Lecture 5: Treatment of eating disorders

Question 1

DSM5 eating disorders

Answer 1

• pica
• rumination (regurgitation of food that occurs at least once a month: rechewing, reswallowing or spit out. person does not make an effort or be stressed/upset/disgusted)
• avoidant and restrictive food intake disorder ARFID
• anorexia nervosa
• bulimia nervosa
• binge eating disorder
• specified eating disorder
• unspecified eating disorder

Question 2

welke emoties zijn geassocieerd met eten in EDs

Answer 2

anxiety, disgust, fear, wanting to avoid

shame is very important! obesity (others’ opinions), ARFID (eating in front of others, because they eat so few things, selective, dont go to activities)

Question 3

eating problems are part of normal development

Answer 3

small children sometimes have a better taste due to evolution

Question 4

eating disorders in general

Answer 4

• severe and persistent disturbance in eating behaviors
• associated distressing thoughts and emotions
• affecting physical, psychological and social functions

Question 5

DSM 5 anorexia

Answer 5

• Restriction of energy intake relative to requirements, leading to a significant low body weight (less than minimally normal/expected). This criteria is difficult, because sometimes we see all the signs in clinical practice but not yet the extremely low body weight. Then we categorize it as eating disorder not otherwise specified, because it is important to start as early as possible.
• Intense fear of gaining weight or becoming fat or persistent behavior that interferes with weight gain.
• Disturbed by one’s body weight or shape, self-worth influenced by body weight or shape, or persistent lack of recognition of seriousness of low bodyweight. When they look in the mirror, they see things that we dont see, their self-perception is biased. Sometimes they cannot even look in the mirror.

Question 6

DSM 5 criteria ARFID

Answer 6

A. Persistent failure to meet appropriate nutritional and/or energy needs. They are often low body weight, but this does not have to be the case: if they eat only fries, they might be overweight, etc.

B. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.

C. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced. -> When you ask them about their body, this is usually in congruence with how others would perceive them.

D. The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder.

Question 7

types of ARFID

Answer 7

1. Sensory
2. Absence of hunger/thirst
3. Trauma: e.g. tube fed as a child -> can be a trauma to start eating after this tubing, very difficult to start eating normally again

Question 8

what is another differential diagnosis for anorexia, hard to distinguish

Answer 8

OCD.

whenever someone is obsessively counting calories, or when someone is afraid of germs and therefore does not eat.

first treat the OCD, then the ED. you cannot change eating patterns if the obsessions and compulsions are still present.

Question 9

types of anorexia

Answer 9

• purging/binge eating
• restrictive

Question 10

BMI is niet heel reliable, verschillen tussen ethnicities enzo

Answer 10

oke

Question 11

ARFID and AN differences and similarities

Answer 11

Similar:
- restrictive food intake
- risk of underweight
- risk of malnutrition
- food intake is emotionally challenging.

Dissimilar:
- AN typically distorted body image and fear of becoming fat (core beliefs), ARFID realistic body image.
- AN emotions are related to the consequences of food intake, ARFID emotions are related to food intake on itself.

Question 12

wat is lastig aan ARFID treatment

Answer 12

when you start to eat other things during treatment, your body needs to adjust to these changes. when you have eaten the same things for years, you get tummy aches when you start to eat other things. your intestines are expanding a bit so that you can process all the foods. this needs to be explained to the child.

Question 13

COVID anorexia

Answer 13

• 48% increase in hospital admissions
• you cannot speak about your disordered eating, less people have noticed
• this was harmful because early intervention is important

Question 14

risk or maintaining events for EDs

Answer 14

• bullying
• parental preoccupation with dietary intake
• difficulties communicating with parents
• acculturation problems
• female
• body shape
• sexual abuse
• more controlled families (AN)
• more chaotic families (BN)
• confused thinking
• deregulated eating habits and patterns, cognitive distortions
• difficulties with negotiating demands of adolescent lives
• temperament
• personality
• online groups
• sensory sensitivity
• once you start having eating patterns that restrict your energy, this affects your body and the waty that you are thinking

Question 15

two outside influences for AN

Answer 15

• pro-anorexia coaches; groups that reinforce the distorted food intake by sending photos. in these communities are these coaches, older males that present themself as younger females. they groom these children, and reinforce these eating patterns.
• anorexic parents that induce anorexia by proxy. therefore important to check the parents’ relationship with food.

Question 16

comorbidities

Answer 16

AN: depression, OCD, anxiety, autism, gender identity
ARFID; mood, anxiety, autism

Question 17

prevalences

Answer 17

• EDs: 5%
• anorexia: 1%, mean onset 17 yrs
• ARFID: 1%, typically younger age compared to AN

most prevalent: arfid, an, bn, bed

Question 18

girl/boy ratio anorexia and arfid

Answer 18

AN: 9 to 1
ARFID: more males

Question 19

Interventions for EDs: who are involved?

Answer 19

• Somatic – pediatrician/ child psychiatrist
• Mental health – mental health clinician
• Food intake – dietician

ALSO
* Psychomotor therapy (bv. tubefed children need to train their muscles because they are not developed correctly)
* Sensory integration therapist
* Coaches to support families with eating at home or at school
* Speech therapist

Question 20

anorexia trias

Answer 20

psyche
somatic
dietary

Question 21

arfid involved ppl

Answer 21

psyche
somatic (pediatrician)
sensory integration
dietary

Question 22

what is the main message for these interventions

Answer 22

food is medicine, food is really important

Question 23

treatments for anorexia

Answer 23

• behavioral feedback and dietary care and physical exercise
• CBT
• family focused therapy: FFT or FBST (deze vooral in NL)

Question 24

wanneer geen family based doen? en wat dan wel?

Answer 24

divorce, dan CBT of DBT

Question 25

BFST phases

Answer 25

3 phases, first is assessment

Question 26

FFT first phase + difficulties

Answer 26

weight-gain, food-intake autonomy goes to parents. this is extremely difficult, patients want to have autonomy (teenagers mostly), and parents have to regulate them (not everything, just the food intake). they have to be there with every meal, and also after the meals, to prevent them from vomiting. fouten die ouders maken: - logica gebruiken (dit helpt niet, dit zorgt voor alleen maar meer vragen en onzekerheid) show confidence and competence: you are perfectly safe, you need this food, i am an expert, i know this is alright. this reduces the fight or flight modus (during which the child cannot eat because stress eats the working memory -> reduced problem solving)

Question 27

during a normal day, ....% of calories is usd for brainfunctioning

Answer 27

20%

Question 28

what if the calorie intake way less than the needed intake? what happens in the body

Answer 28

* Disruptions in neurotransmitter behavior * An increased risk to develop neurological symptoms in early adulthood * Parts of the brain undergo structural changes and abnormal activity during anorexic states * Reduced heart rate, which could deprive the brain of oxygen * Nerve-related conditions including seizures, disordered thinking, and numbness or odd nerve sensations in the hands or feet * A shrinking in the overall size of the brain, including both gray and white matter * A weakened response in the brain regions that are part of the reward circuitry * An adverse effect on the emotional centers of the brain may lead to depression, irritability, and isolation * Difficulty thinking, switching tasks, and setting priorities -> this means adolescents cannot always understand the whole treatment, because their cognition is impaired. they cannot concentrate for long time. daarom zijn cognitieve technieken misschien niet altijd handig in de eerste fase.

Question 29

FFT phase 2

Answer 29

- weight gain - maintenance - transfer of eating autonomy to adolescence - handling relapses - now we can integrate cbt if needed: exposure, cognitive restructuring, etc. - there can be an increase in emotions after the long period of an absence of emotions! this is really important to alert them on

Question 30

FFT phase 3

Answer 30

autonomy with the youth (the family dynamics need to go back to normal, this autonomy needs to go back. need to repair this rupture), address maintaining variables and relapse prevention

Question 31

ARFID treatment phases

Answer 31

1. increase volume food intake (weight gain) or trauma focused treatment if this is the case 2. increase variety of food intake (behavior experiments, distraction strategies, coping skills), check the generalisation to home environment!! (if someone is not underweight, start here) 3. generalisation, maintenace and relapse prevention for subtypes sensory/thirst hunger: CBT, behavioral experiments

Question 32

current clinical discussions

Answer 32

weighting is part of the AN treatment, because it is imporant, and as a kind of exposure. all of the teammembers are looking at you. * Who should weigh the client? * Is weighing helpful? * Does it impact alliance? * Is alliance relevant? * Why does FFT etc work? Rationale: monitor weight (increase) Discussion: weight does not equal health or progression

Question 33

when termination of treatment

Answer 33

* Weight restoration * Healthy and persistent eating pattern * Consider: return of menstruation * No longer meeting ED criteria Decisions to terminate are generally made in a collaborative process with clients (and pediatrician).

Question 34

outcomes of interventions for EDs

Answer 34

- 50% recovers - 25% improves - 25% poor outcome: includes suicide or starvation

Question 35

prediction of eating disorder outcomes

Answer 35

- Fast weight increase in early treatment phases, - fewer comorbidities, - higher BMI at start, - better family functioning, motivation, - less shape concerns at start, - better emotion regulation, - early trauma (negative predictor) - higher chance on dropout: purging

Question 36

externalizing the eating disorder/shadow model

Answer 36

- Separate the illness from the healthy adolescent. - Anorexia has taken over the adolescent’s life, the healthy adolescent is now barely visible. The person has so many characteristics, hobbies, things that define her. But during the eating disorder part, their families only see the eating disorder. This causes tension, conflict, fragility, strange logic, etc. The ED affects the family dynamics, but also how they perceive them. It is not still their family member, it is the disorder. Therefore differentiate between the disorder and the child. Take away the shadow surrounding it. Also when they have to pressure their child to eat: remember you are taking care of the child, not of the disease.

Question 37

ARFID food intake experiment

Answer 37

sometimes start with smelling. challenge thoughts related to the food. based on the schijf van vijf. behavior experiment: - identification of the maladaptive, anxiety provoking thought. understanding why someone finds something difficult (structure, scent, colour, etc. some adolescents have more sensitive teeth, may be sensitive to swallowing, feel that they cant deal with the emotion, afraid of throwing up (trauma-related)). - cognitive restructuring, formulate an alternative, more realistic thought. 'i can deal with this, if i do it fast it is done' - decide on the credibility of both thoughts - exposure, experiment (taste it, or maybe only smell it, etc) - first: what evidence do you expect if the thought is true? and what if the alternative was true? - experiment - go over the evidence, establish which thought was true. reeally important to look at the anxiety provoking thoughts! it might still feel strange, but could you deal with it? could you bear the feeling? -> focus op de anxiety-provoking thought!!! and really focus on this. - positively reinforce adaptive change: reward any approach behavior, not just eating but also smelling, etc.

Question 38

hoelang duren die treatments

Answer 38

echt wel een jaar, bij AN soms langer