KNP3511 – PSYCHO-SPIRITUAL ASSESSMENT AND

THERAPY

CHAPLAIN RABBI GEOFFREY HABER, BA, BA, MA, DMIN, DD(HON.)

BCC (NAJC), CSPC (CASC), CSE (CASC), CE (ACPE), RP (CRPO)
DIRECTOR, SPIRITUAL CARE, BAYCREST
CERTIFIED SUPERVISOR-EDUCATOR, CLINICAL PASTORAL EDUCATION
ADJUNCT LECTURER, KNOX COLLEGE, TORONTO SCHOOL OF THEOLOGY, UNIVERSITY
OF TORONTO
ASSESSMENTS AND TREATMENTS FOR SOMATIC
& SLEEPING DISORDERS
CONTENTS
 Somatic
 Sleep disorders
 Relaxation training
 Eating disorders
 Body drawing assessment
 Nutrition record
 Eating disorder inventory
 References

3
SOMATIC DISORDERS
SOMATIC DISORDERS

Conversion Disorder and Somatic Symptom Disorder

When a bodily ailment has:
1. Excessive and disproportionate impact on the person
2. Has no apparent medical cause
3. Or is inconsistent with known medical diseases,
physicians may suspect a conversion disorder or a
somatic symptom disorder.

5
SOMATIC DISORDERS

DEFINITIONS:
Conversion Disorder:
 Clients display physical symptoms that affect
voluntary motor or sensory functioning, but the
symptoms are inconsistent with known medical
diseases
 In short, they have neurological-like symptoms—for
example, paralysis, blindness, or loss of feeling—that
have no neurological basis.
 This pattern is called “conversion” disorder because
clinical theorists used to believe that individuals with
the disorder are converting psychological needs or 6
conflicts into their neurological-like symptoms (Ding
& Kanaan, 2017).
SOMATIC DISORDERS

DEFINITIONS:
Conversion Disorder:
 Conversion disorder usually begins between late
childhood and young adulthood; it is diagnosed at least
twice as often in women as in men (Raj et al., 2014).
 It often appears suddenly, at times of extreme stress.
 Rare problem, occurring in at most 5 of every 1,000
persons (Stone & Sharpe, 2018, 2017).
Somatic Symptom Disorder
 People with somatic symptom disorder become
excessively distressed, concerned, and anxious about
bodily symptoms that they are experiencing, and their 7

lives are greatly disrupted by those symptoms

SOMATIC DISORDERS

DEFINITIONS
Somatic Symptom Disorder
 The symptoms last longer but are less dramatic than those
found in conversion disorder.
 In some cases, the somatic symptoms have no known
cause; in others, the cause can be identified.
 Either way, the person’s concerns are disproportionate to
the seriousness of the bodily problems.
 Two patterns of somatic symptom disorder:

1. Somatization pattern: the individual experiences a large

and varied number of bodily symptoms.
8

2. Predominant pain pattern: the person’s primary bodily

problem is the experience of pain.
SOMATIC DISORDERS

DEFINITIONS
Somatic Symptom Disorder
 As many as 4 percent of all people in the United States
may experience a somatization pattern in any given year,
women much more commonly than men (Greenberg,
2016).
 The pattern often runs in families; as many as 20 percent
of the close female relatives of women with the pattern
also develop it.
 It usually begins between adolescence and young
adulthood. 9
SOMATIC DISORDERS

Causes Conversion and Somatic Symptom Disorders

1. Psychodynamic:
 Freud’s theory of psychoanalysis began with his efforts to explain
hysterical symptoms (Electra Complex).
 Sufferers of the disorders have unconscious conflicts carried forth
from childhood that arouse anxiety, and that they convert this
anxiety into “more tolerable” physical symptoms (Levenson, 2018).
2. Cognitive-behavioral:
 Physical symptoms of these disorders yield important benefits to
sufferers.
 In response to such rewards, the sufferers learn to display the bodily
symptoms more and more prominently.
 Communication realm: forms of self-expression, providing a means 10
for people to reveal emotions that would otherwise be difficult for
them to convey (Levenson, 2018).
SOMATIC DISORDERS

Causes Conversion and Somatic Symptom Disorders

3. Multicultural models:
 Most Western clinicians believe that it is inappropriate to
produce or focus excessively on somatic symptoms in
response to personal distress.
 Some theorists believe, however, that this position
reflects a Western bias—a bias that sees somatic reactions
as an inferior way of dealing with emotions (Krupić et al.,
2019; Bagayogo, Interian, & Escobar, 2013; Moldavsky,
2004).
11
SOMATIC DISORDERS
Conversion and Somatic Symptom Disorders Treatments
Psychodynamic:
 Try to help those with somatic symptoms become conscious of and
resolve their underlying fears, thus eliminating the need to convert
anxiety into physical symptoms (Stone & Sharpe, 2018; Kaplan,
2016).
Cognitive-behavioral:
 Use exposure treatments to expose clients to features of the horrific
events that first triggered their physical symptoms, expecting that
the clients will become less anxious over the course of repeated
exposures and more able to face those upsetting events directly
rather than through physical channels (Newby et al., 2018; Tsui et
al., 2017).
Biological:
 Use antidepressant drugs to help reduce anxiety and depression in 12

patients with these disorders (Levenson, 2018; Kurlansik & Maffei,

2016).
SLEEP DISORDERS
SLEEP DISORDERS

DISCUSSION:
 Do you ever have trouble sleeping? What do you think causes
it?
DEFINITION:
 Sleep disorders are a group of conditions that affect the ability
to sleep well on a regular basis.
 A sleep disorder can affect overall health, safety and quality of
life.
 Sleep deprivation can have a negative impact on energy, mood,
concentration, and overall health.
 affect your performance at work, cause strain in relationships,
and impair your ability to perform daily activities. 14
SLEEP DISORDERS

SYMPTOMS:
 Some of the signs and symptoms of sleep disorders include:
1. Excessive daytime sleepiness
2. Irregular breathing
3. Increased movement during sleep.
4. Irregular sleep and wake cycle and difficulty falling asleep.

 Most people occasionally experience sleeping problems

due to stress, hectic schedules, and other outside influences,
but when these issues begin to occur on a regular basis and
interfere with daily life, they may indicate a sleeping
disorder.
15
SLEEP DISORDERS

Sleep Disorders Increasingly Common

 More than 1/3 of adults report getting fewer than 7 hours of
sleep in a 24-hour period.
 More than 70% of high school students report getting fewer
than 8 hours of sleep on weeknights.
 Depending on the type of sleep disorder, people may have a
difficult time falling asleep, staying asleep and may feel
extremely tired throughout the day.
 Sleep disorders can be a symptom of another medical or mental
health condition.
 Sleeping problems may eventually go away once treatment is
obtained for the underlying cause. 16
SLEEP DISORDERS

Types of Sleep Disorders:

Insomnia: inability to fall asleep or remain asleep.
 It can be caused by jet lag, stress and anxiety, hormones, or
digestive problems.
 It may also be a symptom of another condition.
 Insomnia can be problematic for overall health and quality of
life, potentially causing:
a. depression
b. difficulty concentrating
c. irritability
d. weight gain
e. impaired work or school performance
 Unfortunately, insomnia is extremely common. Up to 50
17
percent of American adults experience it at some point in their
lives.
SLEEP DISORDERS

Types of Sleep Disorders:

 Insomnia is most prevalent among older adults and women.
 Insomnia is usually classified as one of three types:
1. Chronic: happens on a regular basis for at least 1 month
2. Intermittent: when insomnia occurs periodically
3. Transient: when insomnia lasts for just a few nights at a time

Sleep apnea: characterized by pauses in breathing during sleep.

 Serious medical condition that causes the body to take in less
oxygen.
 Can also cause waking up during the night.
 There are two types:
1. obstructive sleep apnea: flow of air stops because airway space is 18

obstructed or too narrow

2. central sleep apnea: problem in the connection between the brain
SLEEP DISORDERS

Types of Sleep Disorders:

 Parasomnias: class of sleep disorders that cause abnormal
movements and behaviors during sleep.
 They include:
1. sleepwalking
2. sleep talking
3. groaning
4. nightmares
5. bedwetting
6. teeth grinding or jaw clenching

19
SLEEP DISORDERS

Types of Sleep Disorders:

 Restless leg syndrome (RLS): overwhelming need to
move the legs.
 This urge is sometimes accompanied by a tingling
sensation in the legs.
 While these symptoms can occur during the day, they
are most prevalent at night.

 RLS is often associated with certain health conditions,

including:
1. attention deficit hyperactivity disorder (ADHD)
2. Parkinson’s disease 20

 Exact cause isn’t always known.

SLEEP DISORDERS

Types of Sleep Disorders:

 Narcolepsy: characterized by “sleep attacks” that
occur while awake.
 Suddenly feeling extremely tired and fall asleep
without warning.
 The disorder can also cause sleep paralysis,
physically unable to move right after waking up.
 Although narcolepsy may occur on its own, it is
also associated with certain neurological disorders,
such as multiple sclerosis.
21
 SLEEP DISORDERS

Symptoms of Sleep Disorders?

 Symptoms differ depending on the severity and type of sleeping
disorder.
 They may also vary when sleep disorders are a result of another
condition.
 Symptoms include:
1. difficulty falling or staying asleep
2. daytime fatigue
3. strong urge to take naps during the day
4. unusual breathing patterns
5. unusual or unpleasant urges to move while falling asleep
6. unusual movement or other experiences while asleep
7. unintentional changes to your sleep/wake schedule
8. irritability or anxiety
9. impaired performance at work or school
10. lack of concentration 22

11. depression
12. weight gain
 SLEEP DISORDERS

Sleep Disorders Causes:

 There are many conditions, diseases, and disorders
that can cause sleep disturbances.

 In many cases, sleep disorders develop as a result of

an underlying health problem.

1. Allergies and respiratory problems

 Allergies, colds, and upper respiratory infections
 Inability to breathe through the nose can cause
sleeping difficulties.

2. Frequent urination (Nocturia)

23
 Hormonal imbalances and diseases of the urinary tract
may contribute to the development of this condition.
 SLEEP DISORDERS

Sleep Disorders Causes:

3. Chronic pain
 Constant pain can make it difficult to fall asleep or .
wake you up after falling asleep.
 Some of the most common causes of chronic pain
include:
a. arthritis
b. chronic fatigue syndrome
c. fibromyalgia
d. inflammatory bowel disease
e. persistent headaches
f. continuous lower back pain
 In some cases, chronic pain may even be exacerbated
by sleep disorders.
24
 For instance, doctors believe the development of
fibromyalgia might be linked to sleeping problems.
 SLEEP DISORDERS

Sleep Disorders Causes:

4. Stress and anxiety
 Stress and anxiety often have a negative impact on sleep
quality.
 Nightmares, sleep talking, or sleepwalking may also disrupt
your sleep.

5. Other factors include:

 Physical (such as ulcers) & medical (such as asthma).
 Psychiatric (such as depression and anxiety disorders).
 Environmental (such as alcohol).
 Working the night shift (messes up “biological clocks.”)
 Genetics (narcolepsy is genetic).
 Medications (some interfere with sleep).
 Aging (about half of all adults over the age of 65 have some
sort of sleep disorder. It is not clear if it is a normal part of 25

aging or a result of medicines that older people commonly use).

 SLEEP DISORDERS

Sleep Disorders Diagnosis

1. Polysomnography (PSG): This is a lab sleep study that
evaluates oxygen levels, body movements, and brain
waves to determine how they disrupt sleep vs. home sleep
study (HST) that is performed at home and is used to
diagnose sleep apnea.
2. Electroencephalogram (EEG): This is a test that assesses
electrical activity in the brain and detects any potential
problems. It’s part of a polysomnography.
3. Multiple sleep latency test (MSLT): This daytime napping
study is used in conjunction with a PSG at night to help
diagnose narcolepsy.
 These tests can be crucial in determining the right course 26

of treatment for sleep disorders.

 SLEEP DISORDERS

Treatments
1. Medical treatments
 sleeping pills
 melatonin supplements
 allergy or cold medication
 medications for any underlying health issues
 breathing device or surgery (usually for sleep apnea)
 a dental guard (usually for teeth grinding)
2. Lifestyle changes
 Healthy eating
 Reducing stress and anxiety by exercising and stretching
 Regular sleeping schedule
 Drinking less water before bedtime
 Limiting caffeine intake
 Decreasing tobacco and alcohol use
27
 Eating smaller low carbohydrate meals before bedtime
 Maintaining a healthy weight on doctor’s recommendations
 SLEEP DISORDERS

Treatments
3. Cognitive behavioral therapy for insomnia
 CBT-I helps identify and replace thoughts and behaviors
that cause or worsen sleep problems with habits that
promote sound sleep.
 CBT-I helps overcome the underlying causes of sleep
problems.
 CBT-I controls or eliminates negative thoughts and
worries that keep one awake.
 CBT-I helps develop good sleep habits and avoid
behaviors that keep one from sleeping well. 28
 SLEEP DISORDERS

Treatments
CBT-I techniques:

 Stimulus control therapy. Helps remove factors that

condition the mind to resist sleep.
 For example, you might be coached to set a consistent
bedtime and wake time and avoid naps, use the bed only for
sleep and sex, and leave the bedroom if you can't go to sleep
within 20 minutes, only returning when you're sleepy.

 Sleep restriction. Reduces the time you spend in bed,

causing partial sleep deprivation, which makes you more
tired the next night.
29
 Once your sleep has improved, your time in bed is gradually
increased.
 SLEEP DISORDERS

Treatments
CBT-I techniques:

 Sleep hygiene. Changing basic lifestyle habits that

influence sleep, such as smoking or drinking too much
caffeine late in the day, drinking too much alcohol, or not
getting regular exercise.
 It also includes tips that help you sleep better, such as ways to
wind down an hour or two before bedtime.
 Sleep environment improvement. Creates a comfortable
sleep environment, such as keeping the bedroom quiet,
dark and cool, not having a TV in the bedroom, and hiding
the clock from view.
 Relaxation training. Calms the mind and body. 30
 Approaches include meditation, imagery, muscle relaxation
and others.
 SLEEP DISORDERS

Treatments
CBT-I techniques:

 Remaining passively awake. Also called paradoxical

intention, this involves avoiding any effort to fall asleep.
 Paradoxically, worrying that you can't sleep can actually
keep you awake.
 Letting go of this worry can help you relax and make it
easier to fall asleep.
 Biofeedback. Observes biological signs such as heart
rate and muscle tension and shows how to adjust them.
 This information can help identify patterns that affect sleep.

 The most effective treatment approach may combine 31

several of these methods.

RELAXATION TRAINING
 RELAXATION TRAINING

 Relaxation training focuses on becoming aware of

tension within the mind and body.

 Then, systematic relaxation methods (such as

diaphragmatic breathing, progressive muscle relaxation,
guided imagery) are used to reduce tension and to
change the perception of physical pain.

 The foundation of all relaxation techniques is

diaphragmatic breathing.
33
 RELAXATION TRAINING

 The foundation of all relaxation techniques is

diaphragmatic breathing.
 When we are fully asleep or relaxed, we breathe
correctly.
 Our abdomens expand when we inhale and contract
when we exhale.
 Many of us restrict our breathing to our upper chest
when awake or under stress.
 It often helps to repeat a relaxing word, such as “calm”
or “peaceful.”
 Individuals should limit the pace of breathing to 6 to 8
breaths per minute. 34
 RELAXATION TRAINING
Relaxation Techniques
 Progressive muscle relaxation (PMR) is a widely used
method that teaches individuals to relax their muscles
through a two-step process:
1. deliberately apply tension to certain muscle groups
2. stop the tension and notice how the muscles relax as the
tension flows away.
3. Frequently, 14 muscle groups from head to toe are used in
this procedure.
 Breath focus. In this simple, powerful technique, take long,
slow, deep breaths (also known as abdominal or belly
breathing).
1. As you breathe, you gently disengage your mind from
distracting thoughts and sensations.
2. Breath focus can be especially helpful for people with eating 35
disorders to help them focus on their bodies in a more
positive way.
 RELAXATION TRAINING

Relaxation Techniques
 Guided imagery is the use of mental images (such as a
peaceful scene) to create a sense of relaxation and
reduce stress.
1. Individuals decide their destination (such as the beach
or the mountains).
2. They make the image as rich as possible, using all five
senses.
3. For example, if they imagine the beach, they allow
themselves to see the clouds floating in the sky, to hear
the waves rolling in, to feel the warm sand under their
feet, to smell the ocean mist, and to taste the salt on
their tongue.
4. Finally, they are asked to carry this experience with 36

them throughout their day.

 RELAXATION TRAINING
Relaxation Techniques
 Autogenic relaxation is another meditational form of
relaxation, which focuses on specific self-instructions, such
as “My whole body feels comfortable, relaxed, heavy, and
warm” and “I feel quite quiet.”
1. The therapist gives a series of relaxing phrases in the first
person.
2. Individuals repeat the phrase and are given an opportunity to
generate that feeling in their bodies.

 Mindfulness processes include non-defensive, moment-to-

moment, and nonjudgmental awareness.
1. They help individuals pay attention to current experiences of
pain or psychological distress without suppressing or
elaborating those experiences. 37
2. This approach may help decrease over-focus on pain, which
only intensifies the pain and emotional distress.
 RELAXATION TRAINING

Relaxation Techniques
 Yoga, tai chi, and qigong. These three ancient arts
combine rhythmic breathing with a series of postures or
flowing movements.
1. The physical aspects of these practices offer a mental
focus that can help distract you from racing thoughts.
2. They can also enhance your flexibility and balance.
 Repetitive prayer. For this technique, you silently repeat
a short prayer or phrase from a prayer while practicing
breath focus.
 This method may be especially appealing if religion or
spirituality is meaningful to you. 38
 RELAXATION TRAINING
Other Relaxation Techniques
 Massage
 Meditation
 Music and art therapy
 Aromatherapy
 Hydrotherapy
Benefits
 Slowing heart rate
 Lowering blood pressure
 Slowing breathing rate
 Improving digestion
 Maintaining normal blood sugar levels
 Reducing activity of stress hormones
 Increasing blood flow to major muscles
 Reducing muscle tension and chronic pain
 Improving concentration and mood
 Improving sleep quality
 Lowering fatigue 39
 Reducing anger and frustration
 Boosting confidence to handle problems
 RELAXATION TRAINING

Prescribing Relaxation Techniques

When recommending relaxation techniques to patients as
part of their care plan, it is important to select practices in
the context of:
1. not only the patients’ personal health,
2. in relation to their daily lives, families, communities,
3. belief systems.

Following are some questions to raise when discussing

relaxation techniques with patients based on these various
contexts and recommendations based on the answers.
40
RELAXATION TRAINING
Context Questions to Ask
Personal What is your medical
history? Do you prefer being
a part of a group or alone?
What, if any, relaxation
techniques have you tried in
the past?
Daily Life What type of work do you
do? Do you prefer waking up
early or staying up late?
Family How is your relationship with
your partner, children, and/or
extended family? What are
their levels of
interest/previous experience
with relaxation techniques?
Community What schools, studios, and
community centers are
available where you live?
How safe do you feel in your
environment?
Belief What, if any, religious or
Systems spiritual beliefs do you
have?
Recommendations
Consider matching a relaxation technique that has
evidence for a particular medical condition.
Consider tai chi, yoga, qigong, and meditation
classes if a group environment is preferred—
many of these can also be practiced in private
once introductory knowledge is obtained. Be
mindful of the patient’s positive or negative
experiences with certain techniques in the past.
To help make specific and attainable goals
regarding their regular practice of relaxation
techniques, consider the structures of patients’
day-to-day lives.
Consider the level of activity or stress in the home
environment in determining when to practice
relaxation. Involving the family in a regular
practice may also be of benefit in maintaining a
new relaxation routine.
As a clinician, maintain awareness of the local
community and the reputable resources for
learning relaxation techniques in the area. In
areas that are less safe or where it is harder to
find these resources, consider teaching these
techniques in the clinic setting and encourage
regular home practice. 41
Working with a patient’s belief system may
enhance the relaxation experience, e.g., centering
prayer for those with a Christian faith.
EATING DISORDERS
 EATING DISORDERS

Causes of Eating Disorders

 Most of today’s theorists and researchers use a
multidimensional risk perspective to explain
eating disorders.
 They identify several key factors that place a
person at risk for these disorders (Stice &
Desjardins, 2018; Stice et al., 2017).
 Generally, the more of these factors that are
present, the more likely it is that a person will
develop an eating disorder.
43
 EATING DISORDERS

Causes of Eating Disorders

 Psychodynamic Factors—Ego Deficiencies: disturbed
mother–child interactions lead to serious ego
deficiencies in the child (including a poor sense of
independence and control) and to severe perceptual
disturbances that jointly help produce disordered eating
(Treasure & Cardi, 2017; Bruch, 2001, 1991, 1962).

 As a result of ineffective parenting, people with eating

disorders improperly label their internal sensations and
needs, generally feel little control over their lives, and in
turn, want to have excessive levels of control over their
body size, shape, and eating habits. 44
 EATING DISORDERS

Causes of Eating Disorders

 Cognitive-Behavioral Factors: deficiencies contribute
to a broad cognitive distortion that lies at the center of
disordered eating, namely, people with anorexia nervosa
and bulimia nervosa judge themselves—often
exclusively—based on their shape and weight and their
ability to control them (Mitchell, 2018; Fairburn et al.,
2015, 2008).
 This “core pathology,” say cognitive-behavioral
theorists, contributes to all other aspects of the disorders,
including the repeated efforts to lose weight and the
preoccupation with shape, weight, and eating. 45
 EATING DISORDERS
Causes of Eating Disorders
 Depression: Many people with eating disorders,
particularly those with bulimia nervosa, have symptoms of
depression (Klein & Attia, 2017).
 This finding has led some theorists to suggest that
depressive disorders help set the stage for eating disorders.

 Biological factors: certain genes may leave some people

particularly susceptible to eating disorders (Mayhew et al.,
2018; Bulik, Kleiman, & Yilmaz, 2016).
 Consistent with this idea, relatives of people with eating
disorders are up to six times more likely than other people
to develop the disorders themselves.
 Other biological factors such as dysfunctional brain
46
circuits, problematic activity of the hypothalamus, and
disturbances of the body’s weight set point.
 EATING DISORDERS

Causes of Eating Disorders

 Family Environment may play an important role in the
development and maintenance of eating disorders
(Cerniglia et al., 2017).
 Families of people who develop eating disorders are
often dysfunctional to begin with and that the eating
disorder of one member is a reflection of the larger
problem.
 Multicultural Factors: Racial and Ethnic Differences
 Multicultural Factors: Gender Differences
47
 EATING DISORDERS

Eating Disorders
1. Anorexia Nervosa
 Individual purposely takes in too little nourishment,
resulting in body weight that is very low and below that
of other people of similar age and gender.

 Individual is very fearful of gaining weight, or

repeatedly seeks to prevent weight gain despite low
body weight.

 Individual has a distorted body perception, places

inappropriate emphasis on weight or shape in judgments
of herself or himself, or fails to appreciate the serious 48
implications of her or his low weight.
 EATING DISORDERS

Eating Disorders
1. Anorexia Nervosa
 People with anorexia nervosa pursue extreme thinness
and lose dangerous amounts of weight.
 They may follow a pattern of restricting-type anorexia
nervosa or binge-eating/purging-type anorexia nervosa.
 The central features of anorexia nervosa are a drive for
thinness, intense fear of weight gain, and disturbed body
perception and other cognitive disturbances.
 People with this disorder develop various medical
problems, particularly amenorrhea.
 As many as 90 percent of all cases of anorexia nervosa
occur among females. 49
 EATING DISORDERS

Eating Disorders
2. Bulimia Nervosa
 People with bulimia nervosa—a disorder also known as
binge-purge syndrome—engage in repeated episodes of
uncontrollable overeating, or binges.
 A binge episode takes place over a limited period of
time, often two hours, during which the person eats
much more food than most people would eat during a
similar time span.
 In addition, people with this disorder repeatedly perform
inappropriate compensatory behaviors, such as forcing
themselves to vomit; misusing laxatives, diuretics, or
enemas; fasting; or exercising excessively. 50
 EATING DISORDERS

Eating Disorders
2. Bulimia Nervosa
 The binges are often in response to increasing tension
and are followed by feelings of guilt and self-blame.
 Compensatory behavior is at first reinforced by the
temporary relief from uncomfortable feelings of fullness
or the reduction of feelings of anxiety, self-disgust, and
loss of control attached to bingeing.
 Over time, however, sufferers generally feel disgusted
with themselves, depressed, and guilty.
 As many as 90 percent of all cases of bulimia nervosa
occur among females. 51
 EATING DISORDERS

Eating Disorders
3. Binge-Eating Disorder
 Like those with bulimia nervosa, people with binge-
eating disorder engage in repeated eating binges during
which they feel no control over their eating.
 However, they do not perform inappropriate
compensatory behavior.
 As a result of their frequent binges, around half of
people with binge-eating disorder become overweight or
even obese (Forman, 2017; Sysko & Devlin, 2017).
52
 EATING DISORDERS

Eating Disorders
3. Binge-Eating Disorder
 Between 2 and 7 percent of the population have binge-
eating disorder.
 Like sufferers of anorexia nervosa and bulimia nervosa,
people with binge-eating disorder tend to be preoccupied
with food, misperceive their body size, experience body
dissatisfaction, and struggle with negative emotions.
 Unlike anorexia nervosa and bulimia nervosa, most
cases of this disorder begin after the age of 20.
53
 EATING DISORDERS

Eating Disorders Treatments

Treating anorexia nervosa
1. help patients regain weight and return to health, a part of
treatment called nutritional rehabilitation.
2. deal with the underlying psychological and family
problems, often using a combination of education,
cognitive-behavioral approaches, and family therapy.
 As many as 75 % of people who are successfully treated
for anorexia nervosa continue to show full or partial
improvements years later.
 However, some of them relapse along the way.
 Family and friends can also play an important role in
helping to overcome the disorder. 54
 EATING DISORDERS
Eating Disorders Treatments
Treatments for bulimia nervosa
1. focus first on stopping the binge-purge pattern (nutritional
rehabilitation)
2. address the underlying causes of the disorder.
 Often several treatment strategies are combined, including education,
psychotherapy (particularly cognitive-behavioral therapy), and, in
some cases, antidepressant medications.
 As many as 75 percent of those who receive treatment eventually
improve either fully or partially.
 While relapse can be a problem, treatment leads to lasting
improvements in psychological and social functioning for many
people.
 Similar treatments are used to help people with binge-eating disorder. 55

 These individuals, however, may also require interventions to address

their excessive weight.
 EATING DISORDERS
Types of Therapy
1. Cognitive behavioral therapy (CBT) and enhanced cognitive behavioral
therapy (CBT-E)
 CBT aims to identify the thought patterns and beliefs that contribute to the
eating disorder.
 These could include thoughts or beliefs that are associated with things such
as:
a. food
b. weight
c. body shape
d. appearance
 Once these thoughts and beliefs are identified, then learn strategies to modify
them and to help manage them.
 CBT is used for a variety of mental health conditions, and people receiving
CBT for eating disorders experience improvements in other related
symptoms like depression and anxiety. 56

 CBT-E (enhanced) is a type of CBT that’s intended for use in all types of
eating disorders.
 EATING DISORDERS
Types of Therapy
2. Interpersonal psychotherapy (IPT)
 IPT is a type of therapy that’s used to treat eating disorders like binge eating
disorder or bulimia.
 In IPT, your eating disorder is explored in the context of social and
interpersonal relationships.
 Four different “problem areas” are used in IPT:
a. Interpersonal deficits: This often includes feelings of isolation or a lack of close,
fulfilling relationships. The relationships in question don’t have to be romantic,
but can also be related to those with friends or family.
b. Role disputes: This often involves a difference in expectations between self and
one or more important people in life, such as parents, friends, or employers.
c. Role transitions: This is typically concerned with big life changes, such as being
on own for the first time, starting a new job, or being in a new relationship.
d. Grief: This can include feelings of loss due to the death of a loved one or the end
of a relationship. 57
 Develop strategies to improve communication and interpersonal skills to
help reduce symptoms.
 EATING DISORDERS
Types of Therapy
3. Family-based treatment (FBT)
 In FBT, family members are vital parts of the recovery process.
 They’re involved in helping do things like:
a. maintaining healthy eating patterns
b. restoring and maintaining a healthy weight
c. interrupting unhealthy behaviors, such as binge eating or purging
4. Dialectal behavior therapy (DBT)
 DBT focuses on managing difficult emotions.
 DBT teaches skills to change the behaviors associated with eating
disorder.
 Some specific skills that DBT aims to build include:
a. interpersonal skills
b. emotional expression
c. flexibility and openness 58

d. coping with feelings of distress

e. encouraging mindfulness
 EATING DISORDERS

Types of Therapy
5. Acceptance and commitment therapy (ACT)
 ACT focuses on changing actions as opposed to thoughts or feelings.
 A principle of ACT is that the behaviors associated with mental
health conditions come from responses to unpleasant feelings like
anxiety or pain.
 People undergoing ACT are asked to examine for themselves what
their core values are.
 They’re then asked to develop goals that help them better satisfy
these values.
 The aim is to accept all feelings — including the unpleasant ones —
and to commit to changing your actions so they better align with core
values to lead a better life and begin to feel better.
59
 ACT is a viable treatment for eating disorders, but more research is
needed to see if it’s effective as a standalone therapy.
 EATING DISORDERS

Types of Therapy
6. Cognitive remediation therapy (CRT)
 CRT focuses on promoting big-picture thinking and mental
flexibility. It’s currently used in the treatment of anorexia nervosa.
 In CRT, a variety of exercises and tasks are used to help address the
rigid thinking patterns that are often associated with anorexia
nervosa.
 Some examples of such tasks include:
a. drawing shapes or performing motions with the dominant and non-
dominant hand
b. asking to repeatedly switch attention between two topics
c. reading and summarizing increasingly difficult passages
d. finding different ways to navigate a map 60
e. asking to come up with alternative ways to use everyday objects
 EATING DISORDERS

Types of Therapy
7. Psychodynamic psychotherapy
 The overall goal of psychodynamic psychotherapy
is to help understand the underlying cause of
eating disorder.
 This involves diving deep into things such as
internal conflicts and motives.
 Providers of this type of therapy believe that
symptoms are the result of unresolved wants and
needs.
 As such, understanding the root cause of the
disorder can address symptoms and reduce risk of
61
relapse.
BODY DRAWING ASSESSMENT, NUTRITION RECORD & EATING
DISORDER INVENTORY
 BODY DRAWING ASSESSMENT
 Women suffering from anorexia or bulimia draw
themselves with prominently different characteristics
than women who do not have eating disorders and who
are considered of normal weight.

 Research study from University of Haifa, IS found

various differences between the groups in four aspects:
1. The neck: women suffering from anorexia or bulimia
tended to draw a larger neck, a disconnected neck, or
no neck at all;
2. The mouth: this feature was more emphasized in
drawings by women suffering from anorexia or
bulimia;
3. The thighs: women with eating disorders drew wider
thighs than the other groups in the study; 63

4. The feet: women with eating disorders tended to draw

pictures without feet or with disconnected feet.
 BODY DRAWING ASSESSMENT

 The study also revealed that self-figure drawings

can differentiate between anorexic and bulimic
women: those with anorexia tended to omit breasts
from their drawings and drew less defined body
lines and smaller figures relative to the page size.

 Women suffering from eating disorders usually

tend to hide their condition, even from their
professional therapists.

 They often find it difficult to talk about their

problem so a non-verbal and non-intrusive tool
such as a simple request for a self-figure drawing
64
can become an important tool in creative art
therapy
 NUTRITION RECORD

 Successful obesity treatment depends on a

combination of diet modification and increased
physical activity.
 The goal of diet therapy is to instruct people on
long-term modifications that will reduce their
energy intake.
 Frequent clinical encounters with a trained health
professional during the initial 6 months of therapy
facilitate reaching the goals of therapy.
 An important component of these clinical
encounters is assessing dietary intake during
treatment and follow-up. 65
 NUTRITION RECORD

Traditional Dietary Intake Methodologies

 All traditional dietary intake methods rely on
information reported by the subjects themselves.

 The methods include:

1. food records,
2. food frequency questionnaires (FFQs),
3. 24-hour recalls.

 Each method has strengths and weaknesses related

to their intended use, ease of administration, and
validity. 66
 NUTRITION RECORD
Food Records
 Food records are typically obtained for 3 to 7 days.
 This was based on the tactic assumption that the
self-reported information was valid or correct.
 However, with the advent of biomarkers, the food
record is known to have many weaknesses that
limit its use in validation studies.
 Biomarkers are variables measured in body fluids
or tissue that independently reflect intake of a food
component.
 Food records require literate, motivated subjects
and place a high burden on the patients.
 The quality of the record declines in relation to the
number of days recorded. 67

 The actual process of recording food intake can

lead patients to change their food-intake patterns.
 NUTRITION RECORD

FFQs
 FFQs are most commonly used in groups of
people to provide estimates of usual dietary
intake over time (typically 6 months to 1
year).

 They are often used in large cohort studies to

place individuals into broad categories along
a distribution of nutrient intake.

 The FFQ lists specific foods and asks the

subject if they eat them and if so how often
and how much they eat.
68

 Hence, the FFQ must be culture-specific

 NUTRITION RECORD

FFQs
 Both short (60 food items) and long (100 food items)
FFQs have been developed, but neither were designed
to assess current energy intake, an important
component of diet therapy for obesity treatment.

 Modified FFQs were designed for identification of

people with high intake of dietary fat and/or low
intakes of fiber, fruits, and vegetables.

 These questionnaires were developed to identify

potential candidates for enrollment into intervention
research studies
69
 They may also be useful to clinicians seeking to
identify people needing diet counseling.
 NUTRITION RECORD
Twenty-Four-Hour Recall
 The 24-hour recall was designed to quantitatively
assess current nutrient intake.
 The 24-hour recall can be conducted in person or by
telephone with similar results.
 The method is relatively brief (20 to 30 minutes), and
the subject burden is less in comparison with food
records.
 It is appropriate for use with low-literacy populations
because the subjects do not need to read or write to
complete the recall.
 Disadvantages of the 24-hour recall include the
inability of a single day's intake to describe the usual
diet.
 The success of the recall depends on the memory, 70

cooperation, and communication ability of the subject.

 Lastly, a trained interviewer is needed.
 EATING DISORDER INVENTORY

EDI-3
 The Eating Disorder Inventory (EDI) is a
self-report questionnaire
 Used to assess the presence of eating
disorders:
1. anorexia nervosa both restricting and binge-
eating/purging type;
2. bulimia nervosa; and
3. eating disorder not otherwise specified
including binge eating disorder.
 It was designed for use with females ages
13–53 years, and can be administered in 20
minutes. 71
 EATING DISORDER INVENTORY

EDI-3
 It contains 91 items divided into twelve
subscales rated on a 0-4 point scoring
system.
 Three items on the EDI-3 are specific to
eating disorders, and 9 are general
psychological scales that are relevant to
eating disorders.
 The inventory yields six composite scores:
eating disorder risk, ineffectiveness,
interpersonal problems, affective problems,
overcontrol, and general psychological
maladjustment. 72
 EATING DISORDER INVENTORY
EDI-3
Subscale scores on the EDI are:
1. Drive for thinness: an excessive concern with
dieting, preoccupation with weight, and fear of
weight gain
2. Bulimia: episodes of binge eating and purging
3. Body dissatisfaction: not being satisfied with one's
physical appearance
4. Ineffectiveness: assesses feelings of inadequacy,
insecurity, worthlessness and having no control over
their lives
5. Perfectionism: the refusal to accept anything short
of perfection
6. Interpersonal distrust: reluctance to form close 73

relationships
 EATING DISORDER INVENTORY
EDI-3
Subscale scores on the EDI are:
7. Interoceptive awareness: "measures the ability of an
individual to discriminate between sensations and
feelings, and between the sensations of hunger and
satiety"
8. Maturity fears: The fear of facing the demands of
adult life
9. Asceticism: reflects the avoidance of sexual
relationships
10. Impulse regulation: shows the ability to regulate
impulsive behavior, especially the binge behaviour
11. Social insecurity: estimates social fears and
insecurity 74

12. Personal Alienation

 EATING DISORDER INVENTORY

EDI-3
 Self-report measures have the advantages of
being relatively economical, brief, easily
administered and objectively scored.
 They are not susceptible to bias from
interviewer-subject interactions and can be
administered anonymously.
 The major disadvantage of self-report
measures is that they are less accurate than
interview methods, when assessing
ambiguous behaviors such as binge-eating.
 They need to be supplemented by symptom
frequency data derivedby interview or a
75
symptom checklist.
REFERENCES
REFERENCES

 Bonnet MH, et al. ( 2016). Treatment of insomnia. http://www.uptodate.com/home.

 Brasure M, et al. Psychological and behavioral interventions for managing insomnia disorder: An evidence report for a
clinical practice guideline by the American College of Physicians. Annals of Internal Medicine. 2016;165:113.
 Buckley, M. et al. (2022). Relaxation training. Behavioral Medicine Clinical Services. Providence, RI: Lifespan Brown
University Alpert Medical School.
https://www.lifespan.org/centers-services/behavioral-medicine-clinical-services/relaxation-training#:~:text=Relaxation%20
training%20focuses%20on%20becoming,the%20perception%20of%20physical%20pain
.
 Buysse DJ. Insomnia. JAMA. 2013;309:706.
 Cleveland Clinic. (2022). Common Sleep Disorders. Cleveland, OH https://
my.clevelandclinic.org/health/articles/11429-common-sleep-disorders
 Cognitive behavioral therapy for insomnia. National Sleep Foundation. https://
sleepfoundation.org/sleep-news/cognitive-behavioral-therapy-insomnia. 77

 Corliss, J. (2022). Six relaxation techniques to reduce stress. Harvard Heart Letter. Cambridge, MA: Harvard Health
Publishing. https://www.health.harvard.edu/mind-and-mood/six-relaxation-techniques-to-reduce-stress
REFERENCES

 Fischer, C. (2011). Simple self-figure drawings aid diagnosis of women with eating disorders. The Behavioral Medicine Report.
Corpus Christi, TX: BMED Report. https://www.bmedreport.com/archives/23495
 Garner, D. M. (2021) Understanding and treatment of eating disorders. Reference Module in Neuroscience and Biobehavioral
Psychology. Amsterdam, NL: Elsevier. https://www.sciencedirect.com/topics/medicine-and-dentistry/eating-disorder-inventory
 Johnson, R. (2002). Dietary intake—how do we measure what people are really eating? Obesity Research 10(1) 63-68. https://
onlinelibrary.wiley.com/doi/abs/10.1038/oby.2002.192
 May Clinic (n.d.) Sleep Disorders. Rochester, MN https://www.mayoclinic.org/diseases-conditions/sleep-disorders/symptoms-causes/
syc-20354018
 Minichiello, V. J. (2018). Integrative Medicine (Fourth Edition), Amsterdam, NL: Elsevier Publishing
 Newsom. R. (2020). Cognitive Behavioral Therapy for Insomnia (CBT-I). The Sleep Foundation. Seattle, WA
https://www.sleepfoundation.org/insomnia/treatment/cognitive-behavioral-therapy-insomnia
 Olson EJ (2016). Insomnia treatment: Cognitive behavioral therapy instead of sleeping pills. Mayo Clinic. Rochester, MN
https://www.mayoclinic.org/diseases-conditions/insomnia/in-depth/insomnia-treatment/art-20046677
78
 Qaseem A, et al. Management of chronic insomnia disorder in adults: A clinical practice guideline from the American College of
Physicians. Annals of Internal Medicine. 2016;165:125.
REFERENCES

 Roddick, J. and Cherney, K. (2020). Sleep disorders. Healthline. San Francisco., CA

https://www.healthline.com/health/sleep/disorders
 Seladi-Schulman, J. (2020). Is therapy an effective treatment for eating disorders? Healthline. San Francisco., CA
https://www.healthline.com/health/sleep/disorders
 Shaughnessy AF. CBT effective for chronic insomnia. American Family Physician. 2016;1:60.
 Trauer JM, et al. Cognitive behavioral therapy for chronic insomnia: A systematic review and meta-analysis.
Annals of Internal Medicine. 2015;163:191.

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