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Eating Disorders 101: A Basic Guide for Chemical Dependency Professionals


Atkins Diet, South Beach, etc. Yo-Yo dieting. Relationship to Mood Disorders ... 2-3 times more likely to diet. 7 times more likely to binge. Media and Eating ... – PowerPoint PPT presentation

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Title: Eating Disorders 101: A Basic Guide for Chemical Dependency Professionals

Eating Disorders 101 A Basic Guide for Chemical
Dependency Professionals
  • Michelle L. Staub,
  • LPC, CAC Diplomate
  • Caron Treatment Centers
  • Wernsersville, PA, USA

  • Understand diagnostic criteria of eating
  • Understand the relationship to mood disorders
  • Understand the correlation between ED and CD
  • Theoretical Causes of Eating Disorders
  • Understand components of an evaluation

Goals Continued
  • Understand the components of effective treatment
  • Understand the impact of culture on eating
  • Understand the impact of ED on males
  • Sample treatment plans

  • Eating disorder is defined as a persistent
    disturbance of eating or eating related behavior
    that results in the altered consumption or
    absorption of food and that significantly impairs
    physical health or psychological functioning.
  • Brownell Fairburn

Anorexia Nervosa
  • Refusal to maintain body weight at 85
  • Intense fear of gaining weight
  • Disturbance in the way ones body weight is
  • Amenorrhea
  • Subtypes Restricting or Binge-eating/purging
    based on current episode

Anorexia Nervosa
  • Highest mortality rate of all DSM diagnosis 10
  • Starvation causes the brains ventricles to
    increase in size and the cortical mass decreases
  • Gray and white matter of the brain does not
    completely return to normal even after 12 months
    of weight restoration

Anorexia Nervosa
  • .5 1 of the general population
  • 10-20 times more common in females than males
  • 12 - 21 of anorexic women also abuse chemicals
  • Dr. Susan Gordon

Bulimia Nervosa
  • Self evaluation is unduly influenced by body
    shape and weight
  • Does not occur exclusively during episodes of
  • Subtypes include purging type self induced
    vomiting, laxative, diuretics and enemas.
  • non-purging type fasting or exercise

Bulimia Nervosa
  • Eating more food than most people in a similar
    time frame
  • Lack of control over eating
  • Recurrent inappropriate compensatory behavior to
    prevent weight gain can include self-induced
    vomiting, diuretics, laxatives, enema,
    medication, fasting, excessive exercise
  • Occurs minimally twice a week for three months

Bulimia Nervosa
  • 1 3 of women in the general population
  • Twice as common in females than males
  • 9 - 55 of bulimic women also abuse chemicals
  • Dr. Susan Gordon

Binge Eating Disorder
  • Currently under review for separate diagnosis
  • Eating a large amount of food in a discrete
    period of time
  • A sense of lack of control over eating
  • Three or more of the following
  • Eating much more rapidly than normal
  • Eating until uncomfortably full
  • Eating large amounts of food when not physically
  • Eating alone due to embarrassment
  • Feeling disgusted, depressed or guilty after

Binge Eating Disorder (cont.)
  • Occurs minimally twice a week for six months
  • Not associated with the regular use of
    inappropriate compensatory behaviors
  • Often, but not always, overweight or obese
  • 2 of the general population
  • Slightly more common in females than males

Eating Disorder, NOS
  • Meets most of the criteria for Anorexia or
    Bulimia with the exception of one criteria
  • Regular use of inappropriate behaviors after
    ingesting small amounts of food
  • Repeatedly chewing food without swallowing

Disordered Eating
  • Currently, there is not a lot of published
  • Numerous studies are currently being conducted.
  • Theory is an individual may have disordered
    eating which impacts quality of life but not
    diagnosed with an eating disorder.
  • Atkins Diet, South Beach, etc.
  • Yo-Yo dieting

Relationship to Mood Disorders
  • Depressive Disorders
  • Most prevalent to Bulimia
  • 50 of individuals with eating disorders are also
    diagnosed with Major Depressive Disorder
  • Typically, major depression is a consequence of
    the eating disorder
  • Depressive symptoms of ED patients are different
    from other patients with major depressive
  • As the eating disorder improves so does the
    depressive symptoms

Relationship to Mood Disorders (cont.)
  • Anxiety Disorders
  • Social phobia is common among eating disorder
  • Obsessive Compulsive Disorder also has a high
    prevalence among eating disorder patients --
    Theory OCD symptoms are a consequence of the
    dieting and resulting starvation.
  • Brownell Fairburn

Diagnostic Complications between ED and CD
  • Which is primary?
  • Is chemical use part of the eating disorder or a
    separate diagnosis? Or vice versa?
  • Typical drugs of choice heroin, cocaine,
    alcohol, tobacco, caffeine and stimulants

Common Characteristics between ED and CD
  • Patients are in denial
  • Hide behaviors
  • Chronic and fatal
  • High rates of relapse
  • Effects physical, psychological, social , family
    and overall interactions
  • Eating Disorders are not about food, CD is not
    about the alcohol

Common Characteristics between ED and CD (cont)
  • Easier to think about calories/drinking or using
    than to deal with painful feelings and emotions
  • Treatment needs to be multi-disciplinary and

Common Risk factors between ED and CD
  • Tend to emerge in adolescence
  • Symptoms tend to increase in times of stress
  • Many have a history of physical and/or sexual
  • Co-occur with other psychological diagnosis
    (depression, anxiety)
  • Bulimia is the most common ED diagnosed in CD

Influences During Active Addiction
  • Eating Disorders promote the use of substances
    that enhance eating disorder behaviors
  • Some substances (alcohol and marijuana) produce
    weight gain and trigger ED behaviors in an
    attempt to reduce weight
  • Substances decrease self-control and trigger ED
    behaviors in an attempt to regain control
  • Dr. Susan Gordon

Influences During Treatment
  • Other non-treated co-occurring psychological
    conditions can trigger both CD and ED
  • Weight gained in CD treatment can trigger relapse
    to ED behaviors
  • The loss of ED and/or CD as a coping skill can
    trigger relapse to another untreated disorder
  • Dr. Susan Gordon

Other Misused/Abused Substances
  • Diet Pills
  • Fat Burners
  • Diuretics
  • Ipecac
  • Laxatives

Diet Pills
  • Phenylpropylalanine (PPA) no longer available
    due to high incidence of heart attacks and death
  • Ephedrine (Ma Huang) 10
  • Caffeine 36
  • Combination 54
  • Remuda Ranch July 30, 2004

Ephedrine Abuse Complications
  • Heart Attack
  • Stroke
  • Liver failure
  • Kidney problems
  • Dizziness
  • Increased Heart Rate
  • Headache
  • Nervousness
  • Tremors
  • Insomnia
  • Remuda Ranch July 30, 2004

Fat Burners
  • Most are a combination of ephedra, caffeine and
  • Some also contain diuretics and amino acids
  • These also include the most recent and popular
    carb blockers

Diuretic Abuse
  • Most common over the counter diuretics contain
  • Diuretic/herbal product plus
  • Caffeine
  • Potassium salts (K)
  • Analgesics
  • Salicylates
  • Acetaminophen
  • Remuda Ranch Treatment Centers

Diuretic Abuse
  • Decreased Potassium (K)
  • Decreased Chloride (CI-)
  • Dehydration
  • Magnesium Deficiency (Mg)
  • Hyponatremia (Na)
  • Hypercalcemia (Ca)
  • Remuda Ranch Treatment Centers

  • 28 of bulimic patients had tried at one time
  • 3-4 used regularly
  • Direct action on the gastric lining
  • Some will use to help start vomiting
  • Others use as their gag reflex is reduced
  • Toxic
  • Cardiomyopathy
  • EKG changes
  • Present as palpitations, skipped heart beats,
    dizziness, chest pains, shortness of breath can
    resemble panic attack.
  • Remuda Ranch Treatment Centers

Theoretical Causes of Eating Disorders
  • Family Dynamics and Genetics
  • Perfect family places importance on externals
    (appearance) achievements concerned about how
    they are perceived by others.
  • Over protective family parents are overly
    involved, children confused about own identity
    and have difficulty with individuation and
  • Chaotic family children are victims of abuse,
    rules are inconsistent, distrusting of themselves
    and others

Theoretical Causes of Eating Disorders (Cont.)
  • Social Dynamics
  • Major life transitions puberty, illness, death
    of a loved one
  • Societal expectations
  • Mother/daughter connection as it relates to
    body image and dieting
  • Prejudices against obese people
  • Failure at work, school, competitive events
  • Traumatic events

Theoretical Causes of Eating Disorders (Cont.)
  • 31 of 8 year olds feel fat
  • When girls go through puberty, body fat increases
  • 11-14 year old girls normal to gain 40 lbs in
    four years
  • Bulimic philosophy shopping, relationships,
    sex, exercise and work

What can be done in chemical dependency programs
in regards to eating disorders?
  • Assess/Evaluate
  • Motivate
  • Refer

A Thorough Evaluation Should Include
  • Weight history
  • Supplement use
  • Exercise organized and unorganized
  • Dieting history
  • Family eating patterns

Evaluation (Cont.)
  • Need to be able to identify
  • Symptoms mood
  • Severity frequency
  • Cognitive impairments
  • Biological impairments

Evaluation (Cont.)
  • Assess as part of the medical assessment
  • Assessment methods
  • Clinical interviews
  • Standardized screening tools
  • EDI Eating Disorder Inventory
  • EAT Eating Attitudes Test
  • Advantages economical, brief, easily
  • Disadvantages less accurate than an interview

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Goals of Basic Treatment (Motivation)
  • Increase Awareness
  • Educate by identifying symptoms and consequences
  • Increase motivation
  • Identify individual triggers

Objectives for Treatment (in general)
  • Establish/increase motivation for recovery
  • Develop a reason to recover
  • Develop an identity without the eating disorder
  • Legalize food look at food as a source of
    nutrition, not a source of fear

Objectives for Treatment (Cont.)
  • Separate food from feelings by dispelling myths
    about food and weight
  • Develop healthy ways to manage feelings assist
    in overcoming thoughts and emotions and focus
    efforts on recovery

  • In PHP and inpatient, treatment typically
    addresses the effects and stabilize symptoms, but
    does not typically address the actual eating
    disorder pathology.
  • The actual eating disorder pathology is typically
    only addressed in long-term individual

Treatment Components
  • Co-morbidities
  • Weight
  • Body image
  • Readiness for change
  • Coping style
  • Eating Disorder Center of Denver

Issues To Address In Therapy
  • ED is important to sense of self
  • Many refer to the ED as a monster inside the
    individual sees this as a positive influence
  • Without the ED, the individual loses identity
    thereby eliminating a perceived effective coping

Treatment Statistics
  • 80 who stay in treatment make progress
  • 20 drop out and relapse
  • Treatment can take 7-10 years or even longer

  • Has been normalized within society and is a
    cultural norm
  • 35 of normal dieters progress to pathological
  • 20-25 develop eating disorders (NEDA, 2005)

What is the current culture? How does it impact
eating disorders?
A Childs Culture
  • Scraped knee chocolate chip cookie everything
    is ok
  • Barbie dolls 57, 100 pounds, size 2 reality
    54, 140 pounds, size 14

A Teenagers Culture
  • A recent study showed a teenager currently has a
    greater fear of being fat, than he/she does over
    cancer, or losing a parent
  • 50 of 9 year olds and 80 of 10 year olds are on

The Worlds Culture
  • McDonalds burger, fries and coke 1950 590
  • 2002 1550 calories
  • Jean Kilbourne

The Worlds Culture (Cont.)
  • Portions have dramatically increased
  • Since 1990, China has tripled in obesity
  • New modern lifestyle everything is already
    chopped and prepared

University of Minnesota Study
  • The effects of mothers dieting had a greater
    influence over sons than daughters
  • 2-3 times more likely to worry about weight/body
  • 2-3 times more likely to diet
  • 7 times more likely to binge

Media and Eating Disorders
  • Ads normalize eating disorders
  • Ads depicting a woman are usually 4-5 women to
    create one
  • Ads with hands over mouth express themselves in
    other ways not what you say others believe it
    is a symbol not to eat

Media and Eating Disorders (Cont.)
  • Food is replacement for sex good girls say no
    dont eat
  • Television reality shows
  • Swan
  • Extreme Makeover
  • Biggest Loser

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Differences Between Males and Females
  • Onset for males is a a later age 20.5
  • Males focus on waist up
  • Males prefer to purge through fasting and
    exercise rather than vomit

Differences Between Males and Females (Cont.)
  • Male messages focus on body shape/image rather
    than weight
  • 41 of men are dissatisfied with weight, whereas
    70 are dissatisfied with body image

Males and Eating Disorders
  • Primary drug of choice steroids
  • Physical effects of steroid abuse in conjunction
    with compulsive exercise
  • Blurred vision, hallucinations, rage, skin
    problems (acne), high blood pressure, joint pain,
    loss of sex drive

Males and Eating Disorders (cont.)
  • Anorexia recent studies show for every four
    females one male is diagnosed
  • Bulimia for every eight females one male is
  • Many more men are considered compulsive
    overeaters/binge eating disorder appear equally
    among both genders

Males and Eating Disorders (cont.)
  • These statistics may not be accurate as men do
    not seek treatment
  • Only 10 of individuals seeking treatment are
  • This is comparable to womens chemical dependency
    treatment 15 years ago

Male Risk Factors
  • Overweight as a child
  • Family encouraged dieting as a teenager
  • Participates in sports that demands thinness
  • Job or profession that demands thinness
  • Homosexuality

Male Characteristics
  • Low self-esteem perfectionist
  • Avoids conflicts hates everything
  • Puts others ahead of themselves

Sample Treatment Planning
Goals of Body Image Group
  • Provide psychosocial educational information on
    the recovery barriers created by body image
  • Provide an opportunity to share with peers
    specific issues related to body image
  • Develop a relapse prevention plan that addresses
    both chemical dependency and body image

Possible Interventions
  • I will meet with the staff dietician on a weekly
    basis to discuss my progress on my food plan
  • I will cooperate with the medical staff regarding
    lab work
  • I will complete an EAT-26 and discuss the results
    with my counselor
  • I will initiate conversation at the dining table
    that does not involve food or treatment
  • I will participate in weekly blind weights
  • I will keep a journal regarding my feeling before
    each meal, my food intake and my feelings

Possible Interventions (Cont.)
  • I will discuss the secondary gains from my
    purging during the weekly group
  • I will keep a journal including my thoughts,
    feelings, behaviors, and desires to purge and
    discuss in the weekly group
  • I will discuss with my counselor what my purging
    has cost me
  • I will identify my triggers and a relapse
    prevention plan and share in the weekly group and
    with my family

Our Role
  • Start where the client is currently
  • Create a safe enviornment for change, the place
    of truth
  • Provide hope with a vision of recovery
  • Do the work together strategize and educate
  • Address any resistance

  • Therapists need to be aware of his/her own bias
  • Own body image
  • Own concerns over weight
  • Immediate reaction is to respond to the outside
    rather than focus on the inside
  • Food is fuel no more, no less

  • Andersen, A. Anorexia Nervosa 11 Areas of
    Advancement. Eating Disorders Review March/April
  • ANRED. (2002) Treatment and Recovery
  • Boston College Eating Awareness Team (2002).
    Eating Disorders and Men
  • Brownell, K.D. Fairburn, C.G. (1995). Eating
    Disorders and Obesity A Comprehensive Handbook.
    Guildford Press New York, NY.

References Cont.
  • Diagnostic and Statistical Manual of Mental
    Disorder Fourth Edition. Published by the
    American Psychiatric Association. Washington, DC.
  • Gordon, S. (1999). Research Update Eating
    Disorders and Substance Abuse Caron Foundation,
    Wernersville, PA.
  • Gordon, S. (2004). Co-Occurring Disorders
    Understanding Addiction with Relationship to
    Eating Disorders Caron Foundation, Wernersville,
  • Karin Kratina, Nancy King, Dayles Moving Away
    from Diets - 2nd edition, Helm Publishing, Lake
    Dallas, TX (2003).

References Cont.
  • Kilbourne, J. (1999). Cant Buy My Love
    Touchstone New York, NY.
  • Remuda Ranch Substance Misused and Abused
    (2004). IAEDP Conference July, 2004.
  • Weiner, K.L. and Bishop, E.R. (2004). Levels of
    Care for Eating Disorders IAEDP Conference
    July, 2004.