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Title: WELCOME TO


1
  • WELCOME TO
  • THE EATING DISORDERS
  • TRAINING

2
EATING DISORDERS ARE NOTABOUT FOOD
  • Eating disorders are primarily a symptom of
    deeper psychological conflict. It serves to
    alleviate and/or protect against psychological
    conflicts and vulnerability.
  • Food/the Eating Disorder is a way to have
    CONTROL, when life feels so out of control.
  • Eating Disorders are diseases of IDENTITY, of
    COPING.
  • Eating Disorders are diseases of FEELINGS
  • 1) Anorexic thinking is such that if I do not
    eat, I do not feel life and emotions slip off
    me like Teflon.
  • 2) Bulimic sufferers often eat and then purge
    away all the negativity they feel to be true
    about themselves, such as self-loathing or
    uncomfortable feelings like anger, shame,
    sadness, longing and neediness.
  • 3) The compulsive eater eats to suppress negative
    emotions and uses food as a comfort.

3
THEY ARE A DISORDERABOUT RELATIONSHIPS
  • Eating disorders are primarily disorders about
    relationships the relationship with oneself and
    with others.
  • Food becomes more reliable and safer than people.
    It doesn't disappoint, reject or hurt the way
    people and relationships can.
  • The food/body acts as a metaphor and is split
    into good versus bad (salad is good, chocolate
    cake is bad). The psychological message expressed
    via this metaphor is that only 'good' feelings
    (like happiness) are acceptable. Other normal
    emotions, such as anger, hurt, envy and sadness,
    are viewed as unacceptable or 'bad.' If I eat
    only 'good' foods, I will feel only 'good'
    feelings. The reality is, however, that just as
    there are no good or bad foods, there are no good
    or bad feelings.

4
INCIDENCE
  • 4 million Americans actively try to lose weight
    each year
  • 90 fail to keep the weight off and often gain
    back more than they lost
  • People spend 30 billion dollars a year on diet
    foods, pills, and special regimens
  • 1/3 of Americans are considered obese
  • 35 of dieters become eating disordered
  • 7 million women and 1 million men suffer from
    anorexia nervosa or bulimia nervosa
  • Men are more apt to conceal their EDs than women.
  • 3-10 of adolescent and college students have a
    severe eating disorder
  • 150,000 American women die each year from
    complications associated with anorexia and
    bulimia

5
SOME FACTS ABOUT TREATMENT
  • Eating disorders start when the person is young,
    can last for years, and cost a great deal of
    money to overcome
  • Almost nine out of 10 individuals with eating
    disorders (86) report that the onset of their
    illness occurred before the age of 20.
  • Three out of four (77) said that the duration of
    their eating disorder ranged from one to 15
    years.
  • It costs 30,000 per month for an inpatient
    treatment program and 100,000 for outpatient
    treatment that includes therapy and medical
    monitoring.

6
4 HARMFUL BEHAVIORS
  • People with eating disorders engage in four
    harmful and destructive behaviorsstarving,
    bingeing, purging, and grazing. They often get
    stuck in cycles of starving and bingeing,
    bingeing and purging, starving and grazing, or
    grazing and purging.

7
Can you spot an eating disorder?
  • Eating disorders are all but impossible to
    recognize in their early stages after all, who
    isnt concerned about looking better, eating
    better, and staying in shape?
  • The symptoms of eating disorders do not readily
    show themselves in a typical physical examination
  • The symptoms can be confusing during the
    adolescent years.
  • Paradoxically, it is often much harder to heal an
    eating disorder once it has progressed to a more
    advanced stage.
  • Educate yourself about eating disorders and be an
    attentive observer

8
Is it an eating disorder?
  • Symptoms can vary dramatically
  • The issue is not WHICH excess you may see in a
    child, but HOW excessive these behaviors are, and
    HOW that excess serves the childs personality
    and lifestyle does the child have voluntary
    control over the behavior? Does it interfere in
    his/her life functions and roles?
  • Watch not necessarily only for behavior, but
    attitudes and thought patterns.
  • Dont rely only on weight to be concerned
  • Be prepared for denial.

9
ANOREXIA NERVOSADiagnostic Criterion
  • Refusal to maintain body weight at or above a
    minimally normal weight for age and height (e.g.,
    weight loss leading to maintenance of body weight
    less than 85 of that expected or failure to
    make expected weight gain during period of
    growth, leading to body weight less than 85 of
    that expected).
  • Intense fear of gaining weight or becoming fat
    even though underweight.
  • Disturbance in the way in which ones body weight
    or shape is experienced, undue influence of body
    weight or shape on self-evaluation, or denial of
    the seriousness of the current low body weight.
  • In postmenarcheal females, amenorrhea, i.e., the
    absence of at least three consecutive menstrual
    cycles. (A woman is considered to have amenorrhea
    if her periods occur only following hormone
    administration, e.g., estrogen).

10
Specify type
  • Restricting Type during the current episode of
    anorexia nervosa, the person has not regularly
    engaged in binge-eating or purging behavior
    (i.e., self-induced vomiting or misuse of
    laxatives, diuretics, or enemas).
  • Binge-Eating/Purging Type during the current
    episode of anorexia nervosa, the person has
    regularly engaged in binge-eating or purging
    behavior (i.e., self-induced vomiting or misuse
    of laxatives, diuretics, or enemas).

11
Differential Diagnosis
  • General Medical Conditions person has a disease
    or illness (i.e., gastrointestinal disease, brain
    tumors, occult malignancies, or AIDS) that causes
    serious weight loss, but the person does not have
    a distorted body image and a desire for further
    weight loss.
  • Superior Mesenteric Artery Syndrome person has
    postprandial vomiting secondary to intermittent
    gastric outlet obstruction. Syndrome can also be
    a result of emaciation in anorexia nervosa.
  • Major Depressive Disorder - person has severe
    weight loss but does not have desire to lose
    weight nor excessive fear of gaining weight.
  • Social Phobia - person feels embarrassed or
    humiliated to be seen eating in public.
  • Obsessive-Compulsive Disorder - person exhibits
    obsessions or compulsions related to food (i.e.,
    food is contaminated).
  • Body Dysmorphic Disorder - person is preoccupied
    with an imagined defect in bodily appearance.
  • Can have major depression, social phobia,
    obsessive-compulsive disorder, and body
    dysmorphic disorder along with anorexia nervosa.
  • Schizophrenia - person exhibits odd eating
    behavior or significant weight loss, but rarely
    shows fear of gaining weight or disturbed body
    image.
  • Bulimia Nervosa - even with bingeing and purging
    (as in some anorexia nervosa, binge-eating/purging
    type), person is able to maintain normal weight.

12
ANOREXIA WARNING SIGNS
  • Loss of a significant amount of weight
  • Continuing to diet even when thin
  • Feeling fat even after losing weight distorted
    experience of body weight and size
  • Intense fear of weight gain their self-esteem is
    highly dependent on body shape and weight.
    Weight loss is an impressive achievement and sign
    of extraordinary self-discipline while weight
    gain is perceived as an unacceptable failure of
    self-control.
  • Loss of monthly menstrual periods
  • Preoccupation with food, calories, fat content
    and nutrition limited foods
  • Preferring to diet in isolation
  • Cooking for others but not eating the food
  • Employ a wide variety of techniques to measure
    body size or weight, including excessive
    weighing, obsessive measuring of body parts, and
    persistently using a mirror to check for
    perceived areas of fat.
  • Typically deny the serious medical implications
    of their malnourished state.
  • Will not generally be forthcoming about their
    behavior. It is thus necessary to ask parents
    and other outside sources to evaluate the degree
    of weight loss and other features of the illness.

13
OTHER WARNING SIGNS
  • Hair loss
  • Cold hands and feet
  • Fainting spells
  • Exercising compulsively
  • Lying about food
  • Depression and anxiety
  • Weakness and exhaustion
  • Periods of hyperactivity
  • Constipation
  • Heart tremors
  • Dry, brittle skin
  • Insomnia
  • Shortness of breath

14
Physical Complications
  • Most medical problems are the direct result of
    starvation. Anorexics weight ranges from
    underweight to emaciation. Listed below are the
    signs, symptoms, and complications of anorexia
    nervosa (Mehler, 1996).
  • Enlarged Cerebral Ventricles and Sulci in the
    Brain
  • Dermatologic
  • Brittle nails
  • Carotenodermia (dry, flaky skin)
  • Lanugolike facial hair (fine hair growth)
  • Pruritus (itchy skin)
  • Thinning scalp hair
  • Cardiovascular
  • Arrhythmias (irregular heart beat)
  • Bradycardia (slowed heart rate, below 60)
  • ECG abnormalities
  • Hypotension (low blood pressure)
  • Left ventricular dysfunction
  • Mitral valve motion irregularities
  • Reduced work capacity
  • Refeeding cardiomyopathy (heart muscle disease
    that can lead to cardiac collapse due to food
    introduction)

15
  • Immunologic
  • Reduced bactericidal capacity of granulocyles
    (reduced ability for white blood cells to fight
    infection)
  • Impaired cell-mediated immunity
  • Reduced granulocyte adherence
  • Reduced number of CD4 and CD8 cells (white blood
    cells)
  • Reduced serum complement levels
  • Hematologic
  • Anemia
  • Leukopenia (reduced white blood cells)
  • Reduced erythrocyte sedimentation rate (reduced
    red blood cell sedimentation rate)

16
  • Endocrine
  • Amenorrhea/hypogonadism
  • Cold sensitivity
  • Diabetes insipidus
  • Euthyroid sick syndrome (bone marrow is producing
    fewer red and white blood cells)
  • Hypoglycemia (low blood sugar levels)
  • Hypothalamic-pituitary-adrenal axis dysfunction
    (work together through hormone interaction so
    body menstruates, has strong bones, and has
    normal thyroid function)
  • Osteopenia/osteoporosis (occurs after six months
    of not menstruating)
  • Gastrointestinal
  • Abdominal pain
  • Constipation
  • Decreased intestinal motility
  • Delayed gastric emptying
  • Duodenal dilation
  • Postprandial fullness (post-eating fullness)
  • Refeeding hepatitis
  • Refeeding pancreatitis

17
  • Metabolic (Electrolyte Imbalance)
  • Hypercholesterolemia (high cholesterol)
  • Hypocalcemia (low calcium)
  • Hypokalemia (low potassium)
  • Hypomagnesemia (low magnesium)
  • Hypophosphatemia (low phosphates-mineral is
    stored in bones so bones are weakened)

18
Recovery Rates
  • 50 of patients recover completely
  • 40 regain normal weight
  • 25 remain emaciated
  • 20 remain thin, although not dangerously so
  • 15 become overweight
  • 10-15 die prematurely due to complications of
    their illness

19
BULIMIA NERVOSADiagnostic Criterion
  • Recurrent episodes of binge eating as
    characterized by
  • Eating, in a discrete period of time (e.g.,
    within any 2-hour period), an amount of food that
    is definitely larger than most people would eat
    during a similar period of time and under similar
    circumstances.
  • A sense of lack of control over eating during the
    episode (e.g., a feeling that one cannot stop
    eating or control what or how much one is
    eating).
  • Recurrent inappropriate compensatory behavior in
    order to prevent weight gain such as self-induced
    vomiting, misuse of laxatives, diuretics, enemas,
    or other medications, fasting, or excessive
    exercise.
  • The binge eating and inappropriate compensatory
    behaviors both occur, on average, at least twice
    a week for 3 months.
  • Self-evaluation is unduly influenced by body
    shape and weight.
  • The disturbance does not occur exclusively during
    episodes of anorexia.

20
Specify type
  • Purging Type during the current episode of
    bulimia nervosa, the person has regularly engaged
    in self-induced vomiting or the misuse of
    laxatives, diuretics, or enemas.
  • Nonpurging Type during the current episode of
    bulimia nervosa, the person has used
    inappropriate compensatory behaviors, such as
    fasting or excessive exercise, but has not
    regularly engaged in self-induced vomiting or the
    misuse of laxatives, diuretics, or enemas.

21
Differential Diagnosis
  • Anorexia Nervosa, Binge-Eating/Purging Type -
    person has lost weight to 85 of what is
    considered normal and has stopped menstruating.
  • Kleine-Levin Syndrome - person has disturbed
    eating behavior but is not overly concerned with
    body shape or weight.
  • Major Depressive Disorder with Atypical Features
    - person overeats but does not binge or engage in
    compensatory behaviors and is not overly
    concerned with body shape and weight.
  • Borderline Personality Disorder binge eating is
    included in impulsive behavior criterion. Both
    diagnoses can be given if bulimic symptoms
    present.
  • Binge First versus Diet First - most people with
    bulimia nervosa began dieting prior to binge
    eating, some started binge eating before they
    dieted. The binge first group more closely
    resembles individuals with binge-eating disorder
    than the group that dieted first (Haiman and
    Devlin, 1999).

22
WARNING SIGNS OF BULIMIA
  • Eating uncontrollably
  • Purging by vomiting (80-90)
  • Purging by strict dieting, fasting, vigorous
    exercise
  • Abusing laxatives or diuretics (1/3rd of
    population)
  • Using the bathroom frequently after meals
  • Preoccupation with body weight (like anorexics)
  • Depression (often starts before the development
    of bulimia)
  • Mood swings
  • Feeling out of control
  • Swollen glands in neck and face
  • Heartburn
  • Bloating
  • Irregular periods
  • Dental problems
  • Constipation
  • Indigestion
  • Sore throat
  • Vomiting blood
  • Weakness and exhaustion

23
Physical Complications
  • Medical problems are directly related to the
    method and frequency of purging. Because most
    bulimics are within a normal weight range, they
    look healthy, but may have health concerns that
    need to be addressed (Mehler, 1996).
  • Oral
  • Cheliosis (cracking on side of lips due to
    stomach acid)
  • Dental Caries
  • Pharyngeal soreness (sore throat)
  • Sialadenosis (inflammation of salivary glands)
  • Pulmonary
  • Aspiration pneumonia (food gets into lungs
    causing pneumonia)

24
  • Mediastinal
  • Arrhythmias
  • Diet pill toxicity
  • Hypertension
  • Intracerebral hemorrhage
  • Palpitations
  • Hypotension
  • Syrup of Ipecac toxicity
  • Cardiomyopathy (disease of heart muscles)
  • Heart failure
  • Ventricular arrhythmias
  • Mitral valve prolapse
  • Gastroesophageal
  • Barretts esophagus (precancerous cells due to
    stomach acid being in esophagus)
  • Dyspepsia (acid reflux)
  • Dysphagia (pain or difficulty swallowing)
  • Esophageal rupture
  • Esophageal ulcer
  • Esophagitis (inflammation, a precursor to
    Barretts esophagus)

25
  • Gastrointestinal
  • Cathartic colon (irritable bowel)
  • Constipation
  • Diarrhea
  • Hematochezia (blood in the stool)
  • Pancreatitis (inflammation of pancreas)
  • Endocrine
  • Diabetic complications
  • Hypoglycemia
  • Irregular menses
  • Mineralocorticoid excess (excessive adrenal-made
    steroid causes diabetes and increased blood
    pressure)
  • Reproductive
  • Low birth-weight infant
  • Spontaneous abortion
  • Neuromuscular
  • Diet pill toxicity
  • Seizures
  • Syrup of Ipecac toxicity
  • Neuromyopathy (disease of the muscular system)

26
AccompanyingSelf-Destructive Behavior
  • A number of self-destructive behaviors occur
    with bulimia
  • Smoking. Many teenage girls with eating disorders
    smoke because it is thought to help prevent
    weight gain.
  • Impulsive Behaviors. Women with bulimia are at
    higher-than-average risk for dangerous impulsive
    behaviors, such as sexual promiscuity,
    self-cutting, and kleptomania. Some studies have
    reported such behaviors in half of those with
    bulimia.
  • Alcohol and Substance Abuse. An estimated 30 to
    70 of patients with bulimia abuse alcohol,
    drugs, or both. This rate is higher than that of
    the general population and for people with
    anorexia. It should be noted, however, that this
    higher rate of substance abuse may be a
    distortion because studies are conducted only on
    diagnosed patients. Bulimia tends not to get
    diagnosed. And reports of bulimia in the
    community (where the incidence of the eating
    disorder is higher than statistics suggest)
    indicate that substance abuse is actually lower
    than in people with anorexia.

27
Recovery Rates
  • 80 of patients recover
  • 25 of recovered patients retain some abnormal
    eating

28
4. EATING DISORDERS NOT OTHERWISE SPECIFIED
Diagnostic Criterion
  • For females, all the criteria for anorexia
    nervosa except the individual has regular menses.
  • All the criteria for anorexia nervosa are met
    except that, despite significant weight loss, the
    individuals weight is within the normal range.
  • All the criteria for bulimia nervosa are met
    except that the binge eating and inappropriate
    compensatory behaviors are less than twice a week
    or for a duration of less than 3 months.
  • The regular use of inappropriate compensatory
    behaviors by an individual of normal body weight
    after eating small amounts of food (e.g.,
    self-induced vomiting after two cookies).
  • Repeatedly chewing and spitting out, but not
    swallowing large amounts of food.
  • Binge-Eating Disorder recurrent episodes of
    binge eating in the absence of inappropriate
    compensatory behaviors characteristic of bulimia
    nervosa.

29
3. BINGE-EATING DISORDER(EDNOS)
  • Bingeing Repeatedly eating large amounts of food
    can turn into an addictive habit. Some bingers
    have consumed as many as 20,000 calories in one
    sitting. The average binge ranges from 1500 to
    3500 calories (Kaye et al., 1993). Distress comes
    more from loss of control than from quantity
    eaten (Spitzer et al, 1991). If bingeing occurs
    frequently over a period of months, it can turn
    into binge-eating disorder.
  • Grazing This is when someone eats from morning
    to evening or for blocks of time without having
    designated meals. The day becomes one long
    munching event. This style of eating presents
    problems. Grazers don't know how much theyre
    eating and often choose easy-to-grab snack items
    like candy or chips. Weight gain is caused by
    overeating unhealthy foods.

30
  • Recurrent episodes of binge eating. An episode of
    binge eating is characterized by both of the
    following
  • eating, in a discrete period of time (e.g.,
    within any 2-hour period), an amount of food that
    is definitely larger than most people would eat
    in a similar period of time under similar
    circumstances
  • a sense of lack of control over eating during the
    episode (e.g., a feeling that one cannot stop
    eating and control what or how much one is
    eating)
  • The binge eating episodes are associated with
    three (or more) of the following
  • eating much more rapidly than normal
  • eating until feeling uncomfortably full
  • eating large amounts when not feeling physically
    hungry
  • eating alone because embarrassed by how much one
    is eating
  • feeling disgusted with oneself, depressed, or
    very guilty after overeating

31
  • Marked distress regarding binge eating is
    present.
  • The binge eating occurs, on average, at least 2
    days a week for 6 months.
  • Binge eating is not associated with the regular
    use of inappropriate compensatory behaviors
    (i.e., purging, fasting, excessive exercise) and
    does not occur exclusively during the course of
    anorexia nervosa or bulimia nervosa.

32
Differential Diagnosis
  • Bulimia Nervosa, Nonpurging Type person with
    binge-eating disorder does not fast or use
    intense physical exercise as compensatory
    behaviors rid the body of food.
  • Major Depressive Disorder person may overeat
    but it is not binge- eating with all the
    associated emotions.
  • Night Eating Syndrome person frequently awakens
    during night and has a compulsion to eat and/or
    drink. Health consequences include obesity,
    diabetes, and hypertension. The reasons people
    give for night eating include (Pietralata et al,
    2000)
  • to combat insomnia by nibbling to kill time.
  • to have a small meal before ending the day and
    going to sleep.
  • waking up once or several times a night to get up
    and eat moderate to excessive amounts of food
    when not hungry.

33
WARNING SIGNS OF BINGEEATING DISORDER
  • Episodes of binge eating
  • Eating when not physically hungry
  • Frequent dieting
  • Feeling unable to stop eating voluntarily
  • Awareness that eating patterns are abnormal
  • Weight fluctuations
  • Depressed mood
  • Feeling ashamed
  • Antisocial behavior
  • Obesity

34
Physical Complications The medical conditions
listed below are found more often and are more
serious in people who are overweight and obese.
  • Dermatologic
  • Yeast/fungal infections
  • Naval infection
  • Rashes
  • Skin ulcers
  • Dermatitis (inflammation of the skin, like
    eczema)
  • Cardiovascular
  • Coronary heart disease
  • Hypertension
  • Circulatory problems
  • Vascular insufficiencies (lack of blood flow to
    legs and feet)
  • Varicosities (bulging veins, like hemorrhoids)
  • Tissue dependencies (accumulation of fat beneath
    skin)

35
  • Gastrointestinal
  • Hiatus hernia (stomach moves into the chest)
  • Esophageal reflux
  • Gall bladder disease
  • Endocrine
  • Diabetes
  • Edema
  • Stein-Leventhal syndrome (polycystic ovarian
    disease)
  • Cushings disease (tumor in adrenal gland
    releases to much steroid causing abnormal hair
    growth and hump on lower part of neck)
  • Reproductive
  • Cancer of breast, uterus, and ovaries
  • Preeclampsia/eclampsia (high blood pressure
    during pregnancy and the dumping of protein
    through the urine)
  • Infertility
  • Irregular menses or amenorrhea
  • Incontinence
  • Respiratory
  • Sleep apnea
  • Obesity hyperventilation
  • Pickwickian syndrome (trouble with breathing)

36
Prevalence and Comorbidity Statistics
  • 0.7-4 of overall population which equals1 to 4
    million Americans (American Psychiatric
    Association, 1994)
  • Females are 1.5 times more likely to have this
    eating pattern than males (American Psychiatric
    Association, 1994)
  • 15-50 (with a mean of 30) of individuals in
    weight-control programs (American Psychiatric
    Association, 1994)
  • 20 or more of overweight or obese individuals
    seeking obesity treatment report significant
    problems with binge-eating (Kinzl et al., 1999)
  • 39.4 indicated they dieted before binge-eating
    46.5 did binge-eating before first attempt to
    diet (Haiman and Devlin, 1999)
  • 53.7 reported onset of binge eating by age 10
    (Abbott et al., 1998)
  • 15.6 report chemical dependency (Santonastaso et
    al., 1999)

37
5. BODY DISMORPHIC DISORDER
  • Although body dismorphic disorder is not
    classified as an eating disorder, a number of
    eating disordered patients also struggle with the
    disorder.
  • Diagnostic Criterion
  • Preoccupation with a defect in appearance. The
    defect is either imagined, or if a slight anomaly
    is present, the individual's concern is markedly
    excessive.
  • The preoccupation must cause significant distress
    or impairment in social, occupational, or other
    important areas of functioning.
  • The preoccupation is not better accounted for by
    another mental disorder (e.g., dissatisfaction
    with body shape and size in Anorexia Nervosa).
  • One or many body parts can be the focus. Most
    individuals describe marked distress over their
    supposed deformity, describing the preoccupation
    as "intensely painful," "tormenting," or
    "devastating." Most find their preoccupation
    difficult to control, make little or no attempt
    to control it, spend hours a day thinking about
    it, and seek excessive reassurance about
    appearance. There is frequent mirror checking,
    use of lighting or magnifying glasses to
    scrutinize the "defect," and/or excessive
    grooming behavior. These behaviors often
    intensify anxiety instead of diminishing it.
    Severe distress can lead to suicidal ideation or
    attempts. Medical, dental, or surgical treatments
    may also be pursued to rectify imagined defects.

38
Other Disordered Eating Behavior You May Encounter
  • Hoarding Food
  • Stealing Food
  • Overeating
  • Hiding Food
  • This is common for children who have been
    neglected, abandoned, or not fed regularly. It
    has do to with inner insecurity and may lessen
    only when the child feels stable and cared for.

39
4 Contributing Factors
  • Four factors contribute to the development
  • of an eating disorder. These factors include
  • 1) Sociocultural
  • 2) Familial
  • 3) Biogenetic
  • 4) Intrapsychic.

40
1) SOCIOCULTURALMEDIA
  • Beauty Standards
  • Advertising
  • Diet Industry
  • Snack and Fast Food Industries
  • Feeding Insecurities

41
SOCIOCULTURALEthnic Factors
  • Most studies of individuals with eating disorders
    have been conducted using Caucasian middle-class
    females. Studies are now reporting, however, that
    minority populations, including Hispanic-
    Americans and African-Americans, are
    significantly affected. There is some indication
    that African-American girls and young women may
    be at particular risk for eating disorders
    because of poor body images caused by cultural
    attitudes that denigrate the physical
    characteristics of minorities.
  • In one study, bulimia was equally common among
    both Caucasian and African American women,
    although the latter were more likely to binge
    recurrently, to fast, and to use laxatives and
    diuretics to control weight. Binge eating may be
    an even more severe a problem in Hispanic
    Americans. A 2000 study on Asian women also
    reported rates of dieting and body
    dissatisfaction that were similar to those in
    other cultures, but Asian women had much lower
    percentages of actual eating disorders.

42
SOCIOCULTURALSOCIOECONOMIC FACTORS
  • Living in any economically developed nation on
    any continent appears to pose more of a risk for
    eating disorders than belonging to a particular
    population group. Symptoms remain strikingly
    similar across high-risk countries.
  • Income Levels. Oddly enough, within developed
    countries there appears to be no difference in
    risk between the rich and the poor. Some studies
    suggest that those in lower economic groups may
    be at higher risk for bulimia.
  • Urban Life. City living is a risk factor for
    bulimia but it has no effect on the risk for
    anorexia.
  • Intelligence. In one sample, people with eating
    disorders scored significantly higher than
    average on IQ tests. People with bulimia, but not
    anorexia, had higher nonverbal than verbal scores.

43
SOCIOCULTURALSports
  • Athletes are more likely than nonathletes to
    exhibit abnormal eating attitudes and behaviors
    when theyre involved in sports that place
    emphasis on leanness, body image, being scantily
    clad. High achieving people are more likely to
    compulsively exercise and diet than people who
    are less achievement oriented.

44
  • SPORTS (Cont)
  • Female Athletes and Dancers. Women in
    "appearance" sports, including gymnastics and
    figure skating, and in endurance sports, such as
    track and cross-country, are at particular risk
    for anorexia. Success in ballet also depends on
    the development of a wiry and extremely slim
    body. Estimates for episodes of eating disorders
    among such athletes and performers range from 15
    to over 60.
  • Male Athletes. Male wrestlers and lightweight
    rowers are also at risk for excessive dieting.
    One-third of high school wrestlers use a method
    called weight-cutting for rapid weight loss. This
    process involves food restriction and fluid
    depletion by using steam rooms, saunas,
    laxatives, and diuretics. Although male athletes
    are more apt to resume normal eating patterns
    once competition ends, studies show that the body
    fat levels of many wrestlers are still well below
    their peers during off-season and are often as
    low as 3 during wrestling season.
  • Of concern is a recently recognized body-image
    disorder, referred to as muscle dysmorphia, which
    occurs mostly in men who are preoccupied with
    weight lifting and who perceive themselves as
    puny.

45
SOCIOCULTURALPeers
  • Teasing and bullying affect many children and
    teens. Appearance is one of the most common
    reasons for teasing, with weight being a major
    target. Young people understand that thin is
    pretty and fat is ugly.
  • 81 of 10 year olds are afraid of being fat.
    Children who are taunted feel self-conscious and
    bad about how they look. Some vow to lose the
    weight no matter what. This can lead to dieting
    or restricting calories, intense exercising, use
    of diet pills or street drugs, bingeing after a
    period of restricting, and purging in some form
    to prevent weight gain.
  • Some teens can also be influenced by their
    friends unhealthy habits, observing how the
    friend manipulates weight by engaging in eating
    disordered behavior.

46
2) FAMILIAL FACTORS
  • Families also have a powerful influence on
    beliefs people hold about themselves, other
    people, and the world in general. Whatever their
    families value, its likely they do to. For
    instance, if parents find education important so
    do their children. If parents rate making money
    as the highest goal, so will their offspring.
    This is similarly true for being thin and
    attractive.

47
Familial factors/dynamics15 most salient factors
  • Parent(s) expect their children to be successful
    and achievement oriented
  • Parent(s) push their children to be perfect in
    attitude and appearance
  • Parent(s) chronically criticize their children
    and/or each other
  • There are a great many conflicts without the
    ability to resolve them
  • The expression of painful or negative emotions
    is discouraged
  • Children feel disconnected from one or both
    parents
  • Parent(s) are either overinvolved or
    underinvolved with children
  • Parent(s) are controlling
  • Parent(s) emphasize weight and thinness
  • There is a family history of eating disorders
    (i.e., parent(s) diet use food to cope are
    obsessed with their size, shape, or weight talk
    about weight concerns express body hate judge
    people with weight problems etc.)
  • Children are given food to soothe painful
    feelings
  • There is physical, emotional, and/or sexual abuse
    (Studies have reported sexual abuse rates as high
    as 35 in women with bulimia.)

48
FAMILIAL FACTORSInsecure Infancy.
  • Some experts theorize that parents who fail to
    provide a safe and secure foundation in infancy
    may foster eating disorders. In such cases,
    children experience so-called insecure
    attachments. They are more likely to have greater
    weight concerns and lower self-esteem than are
    those with secure attachments.

49
SPECIFIC TO FAMILIES OF ANOREXICS
  • Although research has yet to find
    characteristics that are specific to families of
    anorexics, Strober (1991) has found that these
    factors below apply. There is
  • A limited tolerance of disharmonious affect or
    psychological tension
  • An emphasis on propriety and rule-mindedness
  • An overdirection of the child or subtle
    discouragement of autonomous strivings
  • Poor conflict resolution due to ineffective
    skills

50
SPECIFIC TO ANOREXICSProblems Surrounding Birth
  • In some studies people with anorexia have
    reported a higher than average incidence of
    problems during the mother's pregnancy or after
    birth. These problems include the following
  • Infection.
  • Physical trauma.
  • Seizures.
  • Low birth weight.
  • Older maternal age.
  • Some experts believe that such patients
    experienced an injury to the brain while in the
    womb that predisposed them to eating problems in
    infancy and to subsequent eating disorders later
    in life. Studies have suggested that people with
    anorexia often had stomach and intestinal
    problems in infancy.

51
SPECIFIC TO FAMILIES OF BULIMICS
  • Research suggests that three factors are
    unique to the families of individuals with
    bulimia nervosa (American Psychiatric
    Association, 1993). These include a family
    history of
  • Substance abuse (e.g., parent(s) use substances
    to deal with lifes problems)
  • Obesity and/or migraines People with bulimia are
    more likely than average to have an obese parent
    or to have been overweight themselves during
    childhood.
  • Affective disorders (i.e., depression)

52
Consequences of family dynamics
  • Girls (90 of eating disordered population) and
    boys (10) who come from families with the
    characteristics listed above are more likely to
    develop a negative belief system.
  • Harsh feedback along with parental role-modeling
    make it difficult for them to create a positive
    self-image.
  • Their desire to be loved, cared for, and accepted
    by their parents and to fit into the familys
    paradigm fuels their drive for perfection and the
    need to be in control of themselves and their
    emotions.
  • When they dont measure up, they become
    self-critical (in ways similar to how their
    parents were critical of them). They wind up
    feeling worthless, inadequate, or defective,
    unable to accept their flaws.
  • They will do just about anything to feel good
    about themselves, often resorting to changing
    things outside themselves (i.e., weight,
    appearance, grades, friends, etc.) to feel okay
    on the inside.

53
Consequences of family dynamics
  • These young people veer in one of two directions
  • Theyll either starve (dieting that has become
    restrictive with calories and food choices) to
    attain a faultless appearance and numb out
    painful emotions.
  • Or theyll turn to food for comfort or
    companionship (food is the buddy that never
    judges).
  • A certain subset of this group will learn to
    purge in order to prevent weight gain and cleanse
    the body not only of food but also of unpleasant
    feelings.

54
Abusive/Neglectful homes
  • Children who come from abusive or neglectful
    homes have developed their own ways to survive.
  • Some become "parents," caring for themselves and
    their siblings. Others are "in-home paramedics,"
    taking care of parents with substance abuse
    problems, mental health issues or physical
    disabilities. Still others learn to raise
    themselves or exist for much of their young lives
    as sources of comfort or pleasure for their
    parents.
  • They usually have unmet dependency needs such as
    inadequate or sporadic attention and physical
    care. They may have gone without basic physical
    necessities or may have received minimal amounts
    of food, attention and shelter.

55
Abused/Neglected Children
  • Many of these children believe they are at fault.
  • They may think they caused their caregivers to
    neglect them.
  • Therefore, they change their behavior, either
    hoping to receive approval and attention or in an
    effort to obtain the necessities they were
    lacking.

56
Abused/Neglected Children
  • They may beg or steal food, hoard food, or
    complain of constant hunger.
  • They may exhibit Hypher-phagia, unable to stop
    eating to the point of vomiting, because of an
    obsession to survive.
  • They may demonstrate neurotic traits and are at
    high risk for substance abuse.
  • They may have difficulty in many relationships,
    including parental, peers, schools

57
TRAUMA Emotional, physical, and sexual trauma
profoundly affects a persons psyche.
  • Trauma occurs within the family when one or
    both parents are hostile, verbally attacking,
    hypercritical, too controlling, uncaring,
    uninvolved, ignoring or withdrawing from child,
    physically violent, or sexually abusive.

58
Traumas Outside the Home
  • Traumatic events like
  • bullying at school
  • being repeatedly humiliated by a teacher
    in front of classmates
  • or molestation by a neighbor happen
    outside the home.

59
CONSEQUENCES OF TRAUMA
  • A person exposed to sustained and/or excessive
    trauma may exhibit symptoms of posttraumatic
    stress disorder with impaired affect modulation
    self-destructive and impulsive behavior
    dissociative symptoms somatic complaints
    feelings of ineffectiveness, shame, despair, or
    hopelessness feeling permanently damaged a loss
    of previously sustained beliefs hostility
    social withdrawal feeling constantly threatened
    impaired relationships with others or a change
    from the individuals previous personality
    characteristics.
  • The effects of trauma have to be treated along
    with the eating disorder.

60
3) BIOGENETIC FACTORS
  • There are a number of biological and genetic
    factors that correlate with the development of
    eating disorders.

61
ANOREXIA NERVOSA
  • There is an increased risk of anorexia nervosa
    among first-degree biological relatives of
    individuals with anorexia
  • An increased risk of mood disorders has been
    found among first-degree biological relatives of
    individuals with anorexia nervosa, particularly
    anorexics with binge-eating/purging type of the
    disorder
  • There is a correlated genetic liability between
    anorexia nervosa and major depression.
  • The heritability of anorexia is estimated to be
    58

62
ANOREXIA NERVOSA
  • Research suggests that anorexia may occur, in
    part because of a chemical malfunction in the
    brain. Individuals with anorexia nervosa have
    increased levels of serotonin which reduces
    appetite, impulsiveness, and aggressiveness but
    may also boost perfectionism, obsessiveness, and
    negative affect. Anorexics may diet in an
    attempt to lower serotonin levels in order to
    decrease anxiety, obsessiveness, and
    perfectionism ). Starving also increases
    endorphins and cortisol, creating an opiate
    response that results in feeling energized when
    starving and tired when eating.

63
BULIMIA NERVOSA
  • Several studies have suggested a higher
    frequency of bulimia nervosa, mood disorders, and
    substance abuse and dependence in first-degree
    biological relatives of individuals with eating
    disorders.
  • - 43 of sisters and 26 of mothers of women
    with bulimia nervosa had an eating disorder
    diagnosis
  • - 22 of bulimics have a first-degree
    biological relative with major depression
  • - 9-33 of bulimics have a first-degree
    biological relative with history of alcohol abuse

64
  • One study suggests that bulimia may also be
    influenced by brain neurochemistry. Lowered brain
    serotonin can trigger some of the clinical
    features of bulimia nervosa in individuals who
    are susceptible to the disorder. Recovered
    bulimics, compared with nonbulimics, suffered
    more from the effects of being deprived of
    tryptophan, an amino acid that is used by the
    body to make serotonin. They showed bigger dips
    in mood, greater worries about body image, and
    more fear of losing control of eating). With
    reduced serotonin, there is increased likelihood
    of overeating, depression, anxiety, obsessions,
    aggressive-impulsive behaviors, suicidality, and
    substance abuse.

65
BINGE EATING DISORDER
  • The rate of obesity (Body Mass Index gt 30) is
    higher in first-degree relatives of females with
    binge-eating disorder (BED) than in those females
    without BED (26.8 vs. 18.7).
  • Morbidly obese subjects are more likely than a
    comparison group to have first-degree relatives
    with a history of depression, bipolar disorder,
    antisocial personality disorder, and other
    psychiatric disorders.
  • In comparing females with and without BED, the
    overall prevalence rates of various psychiatric
    disorders in first-degree relatives are as
    follows.
  • Affective disorders 10.5 (BED), 8 (non-BED)
  • Substance use disorders 18.4 (BED), 15.2
    (non-BED)
  • Anxiety disorders 4 (BED), 2.7 (non-BED)

66
BINGE-EATING DISORDER
  • One study focused on a gene linked to obesity to
    see if it plays a role in binge eating behavior.
    Melanocortin 4 receptor gene makes a protein by
    that name which helps stimulate a persons
    appetite in the brains hunger-regulating
    hypothalamus. Too little protein is made if the
    gene is mutated, which leaves the body feeling
    overly hungry. Of the 469 severely obese
    participants, 25 were binge eaters. Five percent
    of the total group had the mutated gene. All
    members of this subgroup were binge eaters,
    compared with only 14 of the rest of the group
    who did not have the mutated gene (Branson et.
    al., 2003).

67
INHERITED TRAITS
  • Below are 13 traits that genetic researchers
    believe are inherited

Depression Anxiety Obsessiveness Compulsiveness Inhibitedness/shyness Dissocial behavior/schizoid Lability/emotional disregulation Narcissism Pessimism Worrying Perfectionism Low frustration tolerance Sociopathy
68
4) INTRAPSYCHIC FACTORS
  • There are a number of traits and characteristics
    that make individuals more vulnerable to
    developing an eating disorder.

69
PERSONALITY FEATURES
  • Research has identified a number of specific
    premorbid conditions that a young person exhibits
    prior to the development of an eating disorder
    (Academy of Eating Disorders, 1999).

70
Anorexia Nervosa
  • Perfectionism
  • Overly compliant
  • Obsessive-compulsive
  • Exacting
  • Self-control
  • Harm avoidance
  • Worrier
  • Pessimistic
  • Shy
  • Easily fatigued
  • Low level of novelty seeking
  • Negative affect

71
AVOIDANT PERSONALITY DISORDER
  • Some studies indicate that as many as a third of
    anorexic restrictors have avoidant personalities.
    This personality disorder is characterized by the
    following
  • Being a perfectionist.
  • Being emotionally and sexually inhibited.
  • Having less of a fantasy life than people with
    bulimia or those without an eating disorder.
  • Not being rebellious, or being perceived as
    always being "good.
  • Being terrified of being ridiculed or criticized
    or of feeling humiliated. People with anorexia
    are extremely sensitive to failure, and any
    criticism, no matter how slight, reinforces their
    own belief that they are "no good.

72
The person with both anorexia and an avoidant
personality disorder may develop a behavioral and
eating pattern as follows
  • For such individuals, achieving perfection, with
    all that that involves, is the only way they
    believe they can obtain love.
  • Part of the drive for perfection and love is
    being trouble-free and attaining some ideal image
    of thinness. Eating is also associated with lower
    animal drives, so fasting has been linked
    historically to saintliness. The individual is
    driven to demand nothing, including food.
  • Failure is inevitable, since being loved has
    nothing to do with being perfect. (In fact,
    people who are always seeking perfection often
    alienate others around them.)
  • This failure to achieve love is followed by a
    sense of being even more imperfect (which is
    equivalent to being fat) and a renewed sense of
    striving for perfection (i.e., becoming even
    thinner).

73
ANOREXICSOBSESSIVE-COMPULSIVE
  • Obsessive-compulsive personality defines certain
    character traits (e.g., being a perfectionist,
    morally rigid, or preoccupied with rules and
    order). This personality disorder has been
    strongly associated with a higher risk for
    anorexia. These traits should not be confused
    with the anxiety disorder called
    obsessive-compulsive disorder (OCD), although
    they may increase the risk for this disorder.

74
Bulimia Nervosa
  • High level of novelty seeking
  • Negative affect
  • Affective Instability
  • Low frustration tolerance
  • Low moods
  • Highly variable moods
  • High anxiety
  • Impulsive
  • Low Self-esteem
  • Ineffectiveness
  • Body dissatisfaction
  • Interpersonal sensitivity
  • High achievement
  • Self-critical

75
Borderline Personalities. Studies indicate that
almost 40 of people who are diagnosed with
bulimic anorexia (losing weight by bingeing and
purging) may have borderline personalities. Such
people tend to
  • Have unstable moods, thought patterns, behavior,
    and self-images. People with borderline
    personalities have been described as causing
    chaos around them by using emotional weapons,
    such as temper tantrums, suicide threats, and
    hypochondriasis.
  • Be frantically fearful of being abandoned.
  • Be unable to be alone.
  • Have difficulty controlling their anger and
    impulses. (In fact, between one-quarter and
    one-third of people with bulimia have impulsive
    symptoms.)
  • Be prone to idealize other people. Frequently
    this is followed by rejection and by
    disappointment.
  • Some research has suggested that the severity of
    this personality disorder predicts difficulty in
    treating bulimia, and it might be more important
    than the presence of psychological problems, such
    as depression.

76
Narcissism.
  • Studies have also found that people with
    bulimia or anorexia are often highly narcissistic
    and tend to
  • Have an inability to soothe oneself.
  • Have an inability to empathize with others.
  • Have a need for admiration.
  • Be hypersensitive to criticism or defeat.

77
Accompanying Emotional Disorders
  • Between 40 and 96 of all eating-disordered
    patients experience DEPRESSION AND ANXIETY
    disorders. Depression, anxiety, or both is also
    common in families of patients with eating
    disorders.
  • Childhood anxiety disorder usually starts before
    8 years of age.

78
Obsessive-Compulsive Disorder (OCD).
  • Obsessive-compulsive disorder is an anxiety
    disorder that occurs in up to 69 of patients
    with anorexia and up to 33 of patients with
    bulimia. In fact, some experts believe that
    eating disorders are just variants of OCD.
  • Obsessions are recurrent or persistent mental
    images, thoughts, or ideas, which may result in
    compulsive behaviors (repetitive, rigid, and
    self-prescribed routines) that are intended to
    prevent the manifestation of the obsession.
  • Women with anorexia and OCD may become obsessed
    with exercise, dieting, and food. They often
    develop compulsive rituals (e.g., weighing every
    bit of food, cutting it into tiny pieces, or
    putting it into tiny containers).
  • The presence of OCD with either anorexia or
    bulimia does not, however, appear to have any
    influence on whether a patient improves or not.

79
Other Anxiety Disorders. A number of other
anxiety disorders have been associated with both
bulimia and anorexia.
  • Phobias. Phobias often precede the onset of the
    eating disorder. Social phobias, in which a
    person is fearful about being humiliated in
    public, are common in both types of eating
    disorders.
  • Panic Disorder. Panic disorder often follows the
    onset of an eating disorder. It is characterized
    by periodic attacks of anxiety or terror (panic
    attacks).
  • Post-Traumatic Stress Disorder. One study of 294
    women with serious eating disorders reported that
    74 of them recalled a traumatic event and more
    than half exhibited symptoms of post-traumatic
    stress disorder (PTSD), which is an anxiety
    disorder that occurs in response to
    life-threatening circumstances.

80
  • 5) Other factors

81
Being Overweight
  • A 2002 study reported that among American
    teenagers 18 of overweight girls and 6 over
    overweight boys reported extreme eating disorder
    behaviors, including use of diet pills,
    laxatives, diuretics, and vomiting. With the
    increasing epidemic of obesity in America, such
    behaviors will only compound the health problems
    in obese young people.

82
VEGETERIANISM
  • In general, vegetarianism, with careful planning,
    is a healthy practice for both adults and
    adolescents. Studies report, however, that
    vegetarianism in adolescence may be a risk factor
    for eating disorders in both males and females.
    In one study, while vegetarian teens ate more
    fruits and vegetables, they were also twice as
    likely to diet frequently, four times as likely
    to intensively diet, and eight times as likely to
    use laxatives as their non-vegetarian peers.
  • This study does not mean that being a vegetarian
    equates with having an eating disorder. It does
    suggest, however, that parents with children who
    suddenly become vegetarian, should be sure that
    their children are eating a balanced meal with
    sufficient protein, calories, and important
    minerals, such as calcium. Parents also might
    suspect anorexic behavior in their child under
    certain conditions
  • If the child has stopped eating meat only to
    avoid fat rather than from other motives, such as
    love of animals or to improve health.
  • If vegetarian diet coincides with rapid weight
    loss.
  • If the child avoids important vegetable products
    because of calories (such as whole grains) or
    because of fats and oils (such as tofu, nuts, and
    dairy products).

83
Diabetes or Other Chronic Diseases
  • According to one survey, 10.3 of teenage girls
    and 6.9 of boys with chronic illness, such as
    diabetes or asthma, had an eating disorder. Some
    recent research suggests an endocrinological link
    between obesity, diabetes, and eating disorders.
  • Diabetes. Eating disorders are particularly
    serious problems for people with either type 1 or
    type 2 diabetes.
  • Binge eating (without purging) is most common in
    type 2 diabetes and, in fact, the obesity it
    causes may even trigger this diabetes in some
    people.
  • Both bulimia and anorexia are common in type 1
    diabetes. Some experts report that one-third of
    insulin-dependent patients have an eating
    disorder, most often because diabetic women omit
    or underuse insulin in order to control weight.
    If such patients develop anorexia, their
    extremely low weight may appear to control the
    diabetes for a while. Eventually, however, if
    they fail to take insulin and continue to lose
    weight, these patients develop life-threatening
    complications.

84
Early Puberty
  • There is a greater risk for eating disorders and
    other emotional problems for girls who undergo
    early puberty, when the pressures experienced by
    all adolescents are intensified by experiencing,
    possibly alone, these early physical changes,
    including normal increased body fat. One
    interesting study reported the following
  • Before puberty, girls ate quantities of food
    appropriate to their body weight, were satisfied
    with their bodies, and noted their depression
    increased with lower food intake.
  • After puberty, girls ate about three-quarters of
    the recommended calorie intake, had a worse body
    self-image, and noted their depression increased
    with higher food intake.
  • This study reported on girls without eating
    disorders, but it certainly suggests patterns
    that can lead to eating problems, particularly in
    girls who go through puberty early.

85
THE BIG QUESTION NATURE VS. NURTURE?
  • Genetics and environment work in tandem. People
    are born with certain biological predispositions.
    The environment in which a person grows up either
    enhances these traits or minimizes them. It is as
    if genetics are the ammunition in a gun and the
    environment either pulls the trigger or puts the
    gun down. Genetics and environment (societal and
    familial) lay the foundation for how people
    perceive, feel about, and see themselves as well
    as resiliency during stress, constancy of moods,
    and flexibility to roll with the punches.
  • PS Insurance would cover more treatment were
    eating disorders seen as biological diseases

86
SOME FACTS ABOUT TREATMENT
  • Eating disorders start when the person is young,
    can last for years, and cost a great deal of
    money to overcome
  • Almost nine out of 10 individuals with eating
    disorders (86) report that the onset of their
    illness occurred before the age of 20.
  • Three out of four (77) said that the duration of
    their eating disorder ranged from one to 15
    years.
  • It costs 30,000 per month for an inpatient
    treatment program and 100,000 for outpatient
    treatment that includes therapy and medical
    monitoring.

87
COMPREHENSIVE TREATMENT PLANNING
  • When you treat patients with eating disorders,
    youll need to consider how youre going to
    address all the components of the eating
    disorder, what kind of therapeutic treatment
    modalities youll employ, and how psychotropic
    medications aid in the recovery process. Taking
    these factors into account can increase the
    chances of a successful outcome.

88
OVERALL TREATMENT GOALS
  • Treat/remediate physical complications
  • Restore healthy eating patterns
  • Provide education regarding healthy nutrition and
    eating patterns
  • Correct core eating disorder related
    dysfunctional thoughts, attitudes, and feelings
  • Treat associated Axis I and Axis II
    psychopathology including deficits in mood
    regulation, self-esteem, and behavior
  • Enlist family support and provide family
    counseling and therapy where appropriate
  • Prevent relapse
  • In addition to the above
  • Build coping strategies and self-regulatory
    skills
  • Teach assertiveness and communication skills
  • Address body disturbance
  • Encourage exploration of sexuality fears
  • Instigate steps towards separation and
    individuation
  • Focus on maturity fears

89
TEAM APPROACH
  • It is essential to build a team of allied health
    professionals to help treat patients with eating
    disorders. These specialists are necessary for a
    number of reasons.
  • They address components of the recovery process
    that are beyond your scope of training.
  • They focus on areas that you wont have adequate
    time to cover in one or two sessions a week.
  • They provide authority to support the changes
    youre proposing.

90
1. PHYSICIAN
  • The first recommendation you make is for your
    patient to see a physician for a medical
    evaluation and ongoing monitoring. I prefer that
    the patient see an expert who treats eating
    disorders. Make sure the physician conducts a
    thorough physical along with complete blood tests
    so both of you have an idea of any damage thats
    been done to the patients body.
  • For patients who have a subclinical eating
    disorder or milder symptoms with no associated
    health problems, you can forgo this referral.
    Make the referral if and when it becomes
    necessary.
  • Sometimes, for either financial or loyalty
    reasons, patients want to see their own
    physician. Whether your patient sees the person
    you suggest or her/his own doctor, obtain a
    release so you can talk to the physician before
    and after the exam. Provide information gleaned
    in the
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