* Eating disorders

Lecture 11
*Eating disorders
* Many women and man chronically restrict their
diet and engage in weight loss efforts such as
use of laxatives, cigarette smoking, and
chronic use of diet pills.
* Women from 15-24 are most likely to practice
these behaviours.
* Adolescent girls have chief complains about
anorexia nervosa or bulimia nervosa.
* Mortality rate in eating disorder is 6%
*Anorexia nervosa
* Anorexia nervosa is a disorder which is comprised of
self-starvation.
* In this individual diets and exercise to the point
that body weight grossly low optimum level,
threatening health and potentially leading to death.
* Most sufferers are young women but gay and
bisexual also at risk.
 *Developing anorexia
nervosa
* Genetic factors.
* Specially the genes involved in the serotonin,
dopamine, and estrogen system.
* These systems have been implicated both anxiety and
food control.
* Epigenetics such as: early exposure to stress,
dysregulated biological stress system.
* Cognitive perspective,
* Body image distortions e.g. they see themselves as
over weight while in fact they are below their ideal
weight.
*Developing anorexia
nervosa
* Anorexic girls comes from a family with poor
communication skills dealing with emotions or
conflicts, psychopathology, or alcoholism.
* Mother who are occupied with their own weight
and eating behaviors place their daughters at
the risk of eating problem.
* Eating disorder is more tied to insecure
attachment in relationship i.e. to the
expectations of criticism and rejection from
others.
*Treating anorexia
* Chief target to bring the patient’s weight back
to safe level, a target that can be undertaken in
a residential treatment setting i.e. hospital.
* Most use cognitive behavior approaches .
However, standard principles of cognitive
behavior therapy do not always work with
anorexics.
* Motivational issues are specially important, as
inducing the anorexics to want to change her
behavior is essential.
*Treating anorexia

* Family therapy is important.

* To learn positive methods of communicating emotions
and conflicts
* During the early phases of treatment parents are
assume to take control of the anorexic eating and
diet. When he/she starts to gain weight it is shifted to
patient’s control over their eating.
* Some interventions suggested treatment norms
regarding thinness directly.
* Intervention focused on women perception on ideal
and actual weight.
*Bulimia nervosa
* Characterized by alternative cycles of binge
eating and purging through such techniques
including, vomiting, laxative abuse, extreme
dieting or fasting and drug and alcohol abuse.
* Bingeing appear to be caused at least in part
by dieting. About half the people diagnosed
with anorexia have bulimia.
* Bulimia effects 1-3% of women.
*Developing bulimia
* As many anorexics are thin bulimic are of normal
weight or over weight specially through the hips.
* Binge phase is regarding as the out of control
reaction of the body to restore weight, and the purge
phase as an effort to regain control over weight.
* Women prone to bulimia specially binge eating
appear to have altered stress response specially
atypical hypothalamic-pituitary adrenal diurnal
pattern.
* Cortisol level, specially in response to stress may be
elevated promoting eating.
*Developing bulimia
* Families that place higher value on thinness
and appearance are also likely to have bulimic
daughters.
* Physiological theories on bulimia focus on
hormonal dysfunction.
* Ghrelin and leptin dysfunction
* Hypothalamus dysfunction
* Endogenous opioid system
*Treating bulimia
* Lack of insight
* Psychoeducation that their disorder is life
threatening and intervention can help them to
reduce their outcomes.
* When bulimia becomes compulsive then patient
should be placed in a treatment facility.
* CBT has been moderately successful in treating
bulimia.
* Effective treatment is the combination of
medication and psychotherapy.
*Treating bulimia
* Psychological interventions includes:
* Self-monitoring
* Diary of eating habits (time, place, type of food
consumed)
* Individualized or group CBT programme
* Regular meal
* Intake variety of food
* Impulse control
* Change place and food type everytime
* Relapse prevention
* Identify triggers
* Coping strategies
* Stress management
* Alcoholism and smoking
*Alcohol
* Alcohol use disorder is a pattern of alcohol use that
involves problems controlling your drinking, being
preoccupied with alcohol or continuing to use alcohol
even when it causes problems.
* Alcohol consumption has bee linked to:
* Higher blood pressure
* Stroke
* Liver cirrhosis
* Some form of cancer
* What is substance dependence

* A person said to be dependent on a substance when he or she has

repeatedly administer it, resulting in tolerance, withdrawal and
compulsive behaviour.

Substance dependence include:

* Physical dependence
* When the body adjusted to the substance and incorporate the use of that
substance in to the normal functioning of the body tissue.

* Tolerance:
* The process by which the body increasingly adapt the use of a substance,
requiring the larger and larger doses of it to obtain the same effect.
* What is substance dependence
* Craving:
* A strong desire to engage in a behavior or consume a substance .

* Results from physical dependence and conditioning process: as the

substance is paired with the environmental cues.

* Addiction occurs when a person becomes physically and

psychologically dependent on a substance following repeated
use over-time.

* Withdrawal
* Refers to the unpleasant symptoms, both physical and
psychological that people experience when they stopped using a
substance on which they have dependent
* Alcoholism and drinking

* Problematic drinking and alcoholism are the substance

dependence disorders that defines following behaviors:

* Need for daily use of alcohol

* Inability to cut down on drinking
* Repeated efforts to control drinking
* Binge drinking
* Occasional consumption of large amount of alcohol
* Loss of memory while intoxicated (blackouts)
* Continue drinking despite of known health problems
*Alcoholism and drinking
Drinking and stress:
* People who have a lot of life events, experience chronic stressors,
and have little social support are more likely to become
problematic drinker then those who have not these problems.

* Alienation from work

* Low job autonomy
* Lack of decision making
* Financial strain
* Depression, anxiety, low self-esteem
* Enhance or escape from negative emotions to feel positive ones.
* To maintain social life
*Conti…

Two conditions are vulnerable:

* In between age range of 12-21 chemical dependence

occurs.

* In late middle age alcohol becomes coping mechanism and

managing emotions.

* Late onset drinking are more likely to control their

drinking on their own or be successfully treated, compared
with people who have more long-term drinking
* Treatment of alcohol abuse

For hard-core alcoholics the treatment program includes:

* Detoxification
* Alcohol detoxification (detox) is defined as the natural process
that occurs in the body as it attempts to rid the system of waste
products and toxins from excessive, long-term alcohol
consumption. Alcohol detox in a treatment setting is usually
accompanied by medication, medical observation, and
counseling.

* Detoxification is a period of medical treatment, usually including

counseling, during which a person is helped to overcome physical
and psychological dependence on alcohol.
 *Conti….
Cognitive behavior treatment:

* The goal of CBT is to reduce the reinforcement properties of alcohol.

* To teach people new behavior inconsistent with alcohol.

* To modify environment to reinforce activities that do not include alcohol.

* Learning coping techniques to deal with stress and relapse prevention.

* Motivation enhancement (motivational interview) are important because this entirely

rely on patient.

* Stress management techniques

* Assertive training

* Relapse identification
*Conti….
Relapse prevention:
* Practicing coping skills and social skills for high risk
for relapse prevention.
* Relaxation activities other then alcohol
* Controlled drinking:
* Placebo effect (use of non-alcoholic beverges)
* Smoking
*Smoking
* Smoking is one of the risk factor for lung cancer.
* 80-90% of lung cancer are due to smoking.
* Also increases the risk of:
* Chronic bronchitis

* Emphysemia

* Respiratory disorders

* Lower birth weight in offspring

* Retarded fetal development

Dangers of smoking are not only related to smokers only.

* It also effect second hand smokers including spouse, family members, and
coworkers are at a risk for a variety of health disorder.
* Synergistic effect of smoking

Enhances detrimental effects of other risk factors.

* E.g. smoking and higher level of alcohol produce higher rate of heart
disease as compared to persons who does not smoke.

* Stress and nicotine also interact in dangerous way. e.g. in man nicotine
can increase heart rate reactivity to stress. While in women smoking
can reduce heart rate but increase blood pressure reactivity to stress.

* Weight and smoking can interact to increase mortality. E.g. smokers

who are thin are more vulnerable for mortality as compared to average-
weight smokers.

* Synergistic effect of smoking with depression increase risk for cancer.

* Factors associated with
smoking in adolescents
* 70 % of adolescent smokers are due to Peer pressure

* Social contagion process through contacts with those who smoke.

* if parents are smokers then adolescents are more likely to smoke at early
ages.

Self-identity and smoking:

* Low self-esteem

* Dependency

* Feelings of powerlessnes

* Social isolation

* Feelings of self-efficacy and good self-control skills help adolescents resist

temptation to smoking.
* Interventions to reduce
smoking

Changing attitude towards smoking:

* Antismoking media messages have been effective.
* Focus on negative consequences of smoking through mass
media.
Nicotine replacement therapy:
* Nicotine patches
* Significantly increase initial smoking ceasation.
* Interventions to reduce smoking

Therapeutic approach to the smoking problem:

* Attention retaining (re-orient the attention from smoker to non-smoker
activities).

* Exercise is also a method of reducing attention bias to smoking related

cues.

* Early intervention is based on stages of change model.

Social support and stress management:

* Ex-smokers are likely to be successful over the short term if they have
supportive partner and non-smoking peers.

* Stress management
* Interventions to reduce smoking

Interventions with adolescents:

* We do intervene with self-determination theory.

* It targets the cognitions that are related to autonomy, self-control, and

shoring up their self-image.

Relapse prevention:

* Relapse prevention is important because ability to remain abstinent

show’s a steady month-by-month decline. Such that within 2 years of

cessation program.

* Relapse prevention technique begin by preparing people for withdrawal

symptoms such as cardiovascular, increase in appetite, urge to smoke.

* Interventions to reduce smoking

* Relapse prevention also focuses on the ability to manage high risk

situation that lead to a craving for ciggrate such as drinking a coffe
or alcohol.

* Some relapse prevention method include contingency contracting,

in which smokers pays a sum of money which is returned on condition
if he cut down or remain abstinent.

* a single lapse reduces self-efficacy and increase negative mood, and

reduces believes that one will be successful in stopping smoking.

* Stress trigger lapses cause relapse.

* Management of
chronic illness
* Quality of life: overview

* Traditional View - Quality of life measured in

terms of
* – Length of survival
* – Signs of disease
* However, patients perceive some illnesses and
treatments as “fates worse than death”
* – They threaten valued life activities too much
* Quality of life: what is quality
of life

* The degree to which a person is able to maximize his or her

* – Physical,

* – Psychological,

* – Vocational, and

* – Social functioning

* It also addresses disease or treatment related symptomatology

* It is an important indicator of recovery from, or adjustment to,

chronic illness.
* Quality of life: why study
quality of life

* Documentation helps improve interventions for those who are

chronically ill

* Research helps pinpoint which problems are likely to emerge for

particular patients

* Impact of unpleasant treatments can be seen and reasons for poor

adherence identified

* Therapies can be compared

* Decision-makers have information about long term survival and quality

of life
* Emotional response of chronic
illness

* Defense mechanism by which people avoid the

implications of an illness

* Denial is a common early reaction to the diagnosis

of a chronic illness

* – This illness is not severe

* – This illness will go away soon
* – There will be few long term implications
* Emotional Responses of Chronic
Illness: Denial

* Immediately after the diagnosis, denial can serve a protective

function

* – Keeps patient from dealing with full range of problems posed by

illness

* – Denial can reduce days in intensive care

* – Denial can reduce side effects of treatment

* During the rehabilitative phase, denial may have adverse effects

* – High deniers at this time show less adherence to treatment regimen
* Emotional Responses of Chronic
Illness: Anxiety

* Anxiety is common after diagnosis:

* It increases when people
* – Are waiting for test results
* – Are anticipating adverse side effects
* – Are awaiting invasive medical procedures
* Anxiety is high when
* – Substantial lifestyle changes are expected
* – People feel dependent on health care professionals
* Anxiety may increase over time
* – Concern about possible complications
* – Concern about implications for the future
* – Concern about the impact of the disease on work and leisure-time
activities
* Emotional Responses of Chronic Illness:
Depression

* When the acute phase of chronic illness has ended

* – Then full implications begin to sink in

* – Depression is common

* – Often is debilitating
* • Assessing depression is problematic

* – Depressive symptoms, such as fatigue or weight loss, are

also symptoms of disease or side effects of treatments
* Personal Issues in Chronic
Disease: Overview

* Self-Concept
* – A stable set of beliefs about one’s personal
qualities and attributes

* • Self-Esteem
* – A global evaluation of one’s qualities and attributes
* – Whether one feels good or bad about one’s
qualities and attributes
* Personal Issues in Chronic Disease:
The Physical Self

* Body Image

* – Perception and evaluation of one’s physical functioning

and appearance

* • Body image plummets during illness

* – Body image can be restored, but it takes time

* • Exceptions: Facial disfigurement and burns – Patients

whose faces are disfigured may never accept their altered
appearance
* Personal Issues in Chronic Disease:
The Achieving Self

* Achievement is important to self-esteem and self-

concept

* – Satisfaction from job/career

* – Pleasure from hobbies/leisure activities

* • Does the chronic illness threaten these?

* – If it does, self-concept may be damaged

* – If not, they may take on new meanings

* Coping with Chronic Illness:
Coping Strategies
* Coping strategies
* – Similar to those employed to deal with other
stressful events
* – One notable difference:Chronically ill report
fewer active coping methods (planning, problem
solving) and instead use more passive coping
methods (positive focus and escape/avoidant)
* Coping with Chronic Illness:
Coping Strategie

* • Avoidant coping is associated with increased

psychological distress

* – Related to poor glycemic control among insulin-dependent

diabetics

* • Active coping efforts are more consistently associated

with good adjustment

* • Multiple Strategies may be helpful when a strategy is

matched to a particular problem
* Coping with Chronic Illness:
Patients’ Belief
* Patients must integrate their illnesses into their lives
* – Develop a realistic sense of the illness
* – Understand restrictions imposed by it
* – Follow the regimen required
* • Patients need to adopt an appropriate model for their
disorder
* – Acute models won’t be effective
* • People develop theories about where their illness came
from
* – Stress
* – Physical injury
* – Bacteria
* – God’s will
* – Self-Blame? Another person? Environment? Fate?
* Rehabilitation and Chronic
Illness: Overview

* Chronic illness raises specific problemsolving tasks

* – Depends critically on patient co-management of the disorder

* – Tasks include

* • Physical problems
* • Vocational problems
* • Problems with social relationships

* • Personal issues concerned with the illness

* Rehabilitation and Chronic
Illness: Physical Problem

* Physical Rehabilitation A program of activities geared

toward helping patients

* – Use their bodies as much as possible

* – Sense changes in the environment so as to make

appropriate physical accommodations

* – Learn new physical management skills

* – Learn a necessary treatment regimen

* – Learn how to control the expenditure of energy

* Rehabilitation and Chronic
Illness: Physical Problems

* Physical problems include those that

* – Arise as a result of the chronic illness

* – Emerge as a consequence of treatment

* • Comprehensive programs may need to include

* – Pain-management programs

* – Training in adaptive devices

* – Behavioral interventions

* • Adherence is essential to consider

* Rehabilitation and Chronic Illness:
Caregiving Role

* Substantial strain on primary caregiver

* – Typical caregiver: Women in her 60s caring for an

elderly spouse

* – Also common: Care for parents and disabled

children

* • Role commonly falls to women • Caregivers are

at risk for – Distress, depression, declining health
* Rehabilitation and Chronic
Illness: Positive Changes

* Chronically ill people may

* – Perceive a narrow escape from death

* – Reorder their priorities
* – Find meaning in smaller activities of life
* • Two studies compared quality of life in cancer patients
with normal samples of people free of disease

* – Cancer samples had greater quality of life than non-ill

samples
* Psychological Interventions and
Chronic Illness: Brief Interventions

* Brief Psychotherapeutic interventions

* – Telling what to expect during treatment

* • Forestalls anxiety

* – Group coping skills training successful

* • Enhances perceptions of control

* Therapy conducted over the telephone

* • Benefits patients by enhancing personal control

* – Music, art, and dance therapies

* • Improve patients’ responses to chronic illness

* Psychological Interventions and Chronic
Illness: Education, Internet, Writing

* Patient Education Programs are designed

* – To inform patients about the disorder and its treatment

* – To train them in methods for coping with the disorder and its
corresponding limitations

* • The Internet
* – Provides information in a cost-effective manner – Patients/Families
access appropriate Web sites

* • Expressive Writing

* – Writing about cancer benefits the terminally ill

* Psychological Interventions and Chronic
Illness: Relaxation and Stress
Management

* • Relaxation training
* – Widely used with the chronically ill

* – Decreases anxiety and nausea from chemotherapy

* – Decreases pain for cancer patients

* – Used with stress management/blood pressure monitoring to treat

essential hypertension

* • MBSR: Mindfulness-based stress reduction

* – Focus on reality of present moment

* – Long-term efficacy unknown, reduces stress

* Psychological Interventions
and Chronic Illness: Exercise

* • Exercise interventions
* – Most commonly undertaken with MI patients
* – May or may not have a direct impact on mood
* – Physical fitness is reliably improved
* – Exercise improves quality of life
* Psychological Interventions and Chronic
Illness: Social Support/Family Support

* Social support resources

* – Influence health outcomes favorably

* – Can be threatened by chronic illness

* • Interventions can teach patients to

* – Recognize potential sources of support

* – Draw on these resources effectively

* • Family support

* – Enhances patient's physical/emotional functioning

* – Promotes adherence to treatment

* Psychological Interventions
and Chronic Illness: Support
Groups

* • Group of individuals who meet regularly

* – Share some common problem or concern

* • Support groups are believed to help people cope because

* – People learn techniques that others have used successfully to combat
problems

* – They provide opportunities to share concerns and exchange

information with similar others

* • Support groups may promote better health and long-term survival