Eating Disorders: An Overview

Eating Disorders: An Overview

• Eating disorders involve severe disruptions in eating behavior and extreme fear of gaining weight.
• They are influenced by sociocultural factors, particularly Westernized views, and have increased in prevalence over the last 45 years.
• The majority (90%) of cases involve young females from wealthy families.
• Anorexia nervosa, bulimia nervosa, and binge-eating disorder are the three major types of eating disorders according to the DSM-5.
• Anorexia has been observed across cultures and throughout history, but the fear of fat may be a more recent development.
• Bulimia has significantly increased in the last 50 years and is closely linked to Western influence.

Bulimia Nervosa: Overview and Defining Features

• Binge eating, defined as consuming excessive amounts of food with a sense of uncontrollability, is a primary characteristic of bulimia.
• Compensatory behaviors, such as self-induced vomiting, misuse of diuretics or laxatives (purging), excessive exercise, or fasting, are used to counteract the effects of binge eating.
• Most individuals with bulimia maintain a normal weight.
• The DSM-5 diagnostic criteria needs binge eating and compensatory behaviors to occur at least once a week for three months.
• Self-evaluation is unduly influenced by weight and body shape.

Associated Features of Bulimia Nervosa

• Medical complications include erosion of dental enamel and electrolyte imbalances, which can lead to kidney failure, cardiac issues, seizures, intestinal problems, colon damage, and, in rare cases, death.
• Psychological features include excessive concern with body shape and weight, fear of gaining weight, and calorie restriction between binges.
• High comorbidity with anxiety, mood disorders, and substance abuse is common.
• Stice's dual-pathway model of bulimic pathology is an important concept.

Anorexia Nervosa: Overview and Defining Features

• Anorexia nervosa is characterized by successful weight loss and restriction of energy intake, leading to significantly low body weight.
• There is an intense fear of obesity, a distorted perception of body shape, and a denial of the seriousness of the low weight.
• The DSM-5 includes restricting subtype (limiting caloric intake) and binge-eating/purging subtype (similar to bulimia but with significant weight loss).
• There's a marked disturbance in body image and high comorbidity with other psychological disorders.

Associated Features and Consequences of Anorexia Nervosa

• Medical consequences include amenorrhea, dry skin, brittle nails and hair, sensitivity to cold, lanugo, and cardiovascular problems.
• Psychological consequences include depression, withdrawal, anxiety, irritability, and reduced sex drive, often secondary to starvation.
• Individuals are never satisfied with their weight and need continuous weight loss to feel comfortable.

Binge-Eating Disorder: Overview and Defining Features

• Binge-eating disorder involves engaging in food binges without compensatory behaviors.
• Key features include a perceived loss of control, rapid eating, eating until uncomfortably full, eating when not hungry, feeling embarrassed about the intake, and feeling disgusted or guilty afterward.
• People with binge-eating disorder are often distressed about their binge eating.
• Many individuals with this diagnosis are normal weight, overweight, or obese

Associated Features of Binge-Eating Disorder

• Individuals with binge-eating disorder tend to be older than those with anorexia or bulimia.
• They experience more psychopathology compared to non-binging obese individuals.
• Binging is often used as a coping mechanism.
• There are no major differences across gender or cultural/racial groups, unlike anorexia and bulimia.

Bulimia and Anorexia: Facts and Statistics

• Bulimia primarily affects females (90% or more) with onset around 16 to 19 years of age.
• Lifetime prevalence is about 1.1% for females and 0.1% for males.
• Anorexia typically develops around age 13 or early adolescence in females from middle to upper-middle-class families.
• Anorexia is more chronic and resistant to treatment than bulimia.
• Both bulimia and anorexia are more prevalent in Westernized cultures, and immigrants may develop symptoms after moving to the West.
• Past lower rates in African American and Asian females is no longer true

Causes of Bulimia and Anorexia: An Integrative Model

• Media and cultural influences emphasize thinness as a marker of success and happiness, leading to dieting.
• Peer groups can reinforce body image concerns and maladaptive coping behaviors.
• Cultural differences no longer serve as protective factors, with equivalent rates across ethnic groups in the U.S.
• LGBTQ+ individuals are associated with higher rates of eating disorders.
• Food insecurity is linked to higher rates of binging.
• Genetics account for approximately 50% of the risk, potentially related to traits like perfectionism or compulsive behavior.
• Common fears include judgment related to weight gain, eating in social situations, disliking body sensations due to weight gain, and feeling tense around food.

Medical and Psychological Treatment of Bulimia Nervosa

• Antidepressants can help reduce binging and purging, but are not a long-term solution.
• Cognitive-behavioral therapy (CBT) is the preferred psychological treatment.
• Treatment components include psychoeducation, scheduled eating, challenging dysfunctional thoughts, and developing coping skills to manage urges to purge.
• Interpersonal psychotherapy's gains are similar to CBT, but takes more time.

Medical and Psychological Treatment of Binge-Eating Disorder

• Sibutramine was used to control hunger in medical treatment.
• CBT is effective for binge-eating disorder.
• Interpersonal psychotherapy is as effective as CBT.
• Self-help techniques can also be effective.

Treatment of Anorexia Nervosa

• There are no medical treatments with demonstrated efficacy.
• The primary initial goal of psychological treatment is weight restoration, often requiring inpatient treatment if the patient is below 70% of expected weight.
• Treatment involves numerous small meals, supervision during eating, and reinforcement for weight gain.
• Confronting self-defeating behaviors and providing psychoeducation about food, weight, nutrition, and health are crucial.
• Treatment likely needs cognitive restructuring.
• Family involvement is also important.
• Long-term prognosis is poorer than for bulimia.

Schizophrenia and Psychosis: An Overview

• Psychosis is a broad term referring to conditions involving hallucinations and delusions.
• Schizophrenia is a specific type of psychosis characterized by disturbed thought, emotion, and behavior.
• Psychosis and schizophrenia are heterogenous conditions with varied causes and presentations.

Psychosis: History and Current Thinking

• Emil Kraepelin used the term "dementia praecox" (premature dementia) to describe what is now known as schizophrenia, focusing on subtypes and recognizing it as a brain disease.
• Eugen Bleuler introduced the term "schizophrenia," emphasizing the "splitting of the mind" and the inability to maintain a consistent train of thought.
• Bleuler described "positive" and "negative" symptoms.

DSM-5 Criteria for Schizophrenia

• Two or more of the following symptoms must be present for a significant portion of time during a 1-month period: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms.
• Social/occupational dysfunction.
• Continuous signs of disturbance for at least 6 months.
• Symptoms are not due to schizoaffective disorder, mood disorder, or substance abuse.

Schizophrenia: The "Positive" Symptom Cluster

• Positive symptoms are active and obvious manifestations of abnormal behavior, involving excesses or distortions of normal behavior.
• Delusions are erroneous beliefs that involve misinterpretations of perceptions or experiences.
• Types of delusions include persecutory, referential, erotomanic, somatic, nihilistic, and grandiose, with persecutory being the most common.
• Hallucinations are sensory experiences without environmental input, which can occur in any sensory mode (auditory, visual, olfactory, gustatory, tactile).
• Auditory hallucinations are the most common, often in the form of voices, with "command" hallucinations being particularly concerning.
• Findings from imaging studies have found structural damage in brain parts involved with auditory processing.

Schizophrenia: The "Negative" Symptom Cluster

• Negative symptoms involve the absence or insufficiency of normal behavior.
• Avolition (or apathy) is a lack of initiation and persistence.
• Alogia is the relative absence of speech, potentially due to a decrease in thought production.
• Anhedonia is the lack of pleasure or indifference.
• Asociality is a limited interest in social interactions.
• Affective flattening involves little expressed emotion, where the face is immobile and unresponsive, but this may not reflect the individual's experienced emotion.

Schizophrenia: The "Disorganized" Symptom Cluster

• Disorganized symptoms include severe and excess disruptions in speech, behavior, and emotion.
• Disorganized speech includes tangentiality and loose associations.
• Word salad and neologisms are common
• Disorganized affect involves inappropriate emotional behavior, (e.g., smiling when speaking about death).
• Disorganized behavior includes unusual behaviors like being disheveled, having an odd appearance, or exhibiting unpredictable behavior.
• Catatonia involves a spectrum of behaviors, including wild agitation, waxy flexibility, and immobility.

Other Disorders with Psychotic Features

• Schizophreniform disorder involves schizophrenic symptoms for a few months (less than 6; more than 1).
• Schizoaffective disorder involves symptoms of schizophrenia and a mood disorder (bipolar or depressive type).
• Delusional disorder involves the presence of one or more delusions that persist for 1 month or more, with a lack of other positive and negative symptoms.
• Brief psychotic disorder involves one or more positive symptoms of schizophrenia lasting at least 1 day but not longer than 1 month, often precipitated by extreme stress or trauma.
• Schizotypal personality disorder may reflect a less severe form of schizophrenia.

Classification Systems and Their Relation to Schizophrenia

• The process vs. reactive distinction describes the onset of schizophrenia.
• Good vs. poor premorbid functioning focuses on functioning prior to developing schizophrenia.
• Type I schizophrenia involves positive symptoms, good response to medication, and an optimistic prognosis.
• Type II schizophrenia involves negative symptoms, poor response to medication, a pessimistic prognosis, and intellectual impairments.

(Defunct) Subtypes of Schizophrenia

• Paranoid type involves prominent hallucinations and delusions, with relatively intact cognitive skills and affect. Has the best prognosis of all types of schizophrenia
• Disorganized type involves marked disruptions in speech and behavior, with flat or inappropriate affect.
• Catatonic type involves unusual motor responses and odd mannerisms.
• Undifferentiated type is a wastebasket category for major symptoms of schizophrenia that do not meet the criteria for another type.
• Residual type involves a past diagnosis of schizophrenia with an absence of prominent delusions, hallucinations, or disorganized speech and behavior, but the prescence of less extreme residential symptoms such as negative symptoms.

Schizophrenia: Facts and Statistics

• The onset of schizophrenia often develops in early adulthood, with the first psychotic episode occurring in the early to mid-20s for men and late 20s for women.
• Schizophrenia is generally chronic, with many suffering from moderate-to-severe lifetime impairment.
• Positive symptoms are more treatable than negative symptoms.
• Life expectancy with schizophrenia is slightly less than average.
• Schizophrenia affects males and females about equally; women tend to have a better long-term prognosis.
• High comorbidity exists, especially with tobacco use disorder and anxiety disorders.

Causes of Schizophrenia: Findings From Genetic Research

• Schizophrenia has a strong genetic component; individuals inherit a tendency for schizophrenia, not a specific form.
• Risk increases with genetic relatedness.
• Monozygotic twins have a 48% risk.
• Dizygotic twins risk drops to 17%.
• Both parents being schizophrenic results in a 46% risk.
• One schizophrenic parent results in a 16% risk.

Causes of Schizophrenia: Neurotransmitter Influences

• The dopamine hypothesis suggests that drugs that increase dopamine result in schizophrenic-like behavior, and is among the most prominent theories of schizophrenia.
• Current theories emphasize many neurotransmitters, including a higher density of dopamine receptors and excessive stimulation of dopamine D2 receptors in the striatum.
• Deficient stimulation of prefrontal dopamine D1 receptors.
• Enlarged lateral ventricles (50 studies).

Causes of Schizophrenia: Other Factors

• Viral infections during early prenatal development.
• Mothers exposed to influenza in the second trimester may have children more predisposed.
• Cognitive dysfunctions are substantial and linked with functional impairment.
• May be caused by abnormalites in neural density, structure, and interconnections; no sure signs of postnatal injury.

Medical Treatment of Schizophrenia

• Antipsychotic (neuroleptic) medications are the first line of treatment, began in the 1950s.
• Most antipsychotics reduce or eliminate positive symptoms.
• Compliance with medication is often a problem.
• Acute and permanent side effects are common, including extrapyramidal side effects (movement problems).

Causes of Schizophrenia: Neurotransmitter Influences, Continued

• Drugs that decrease dopamine (antagonists) reduce schizophrenic-like behavior but produce side effects similar to Parkinson's disease.
• New "atypical antipsychotics" work with some schizophrenic patients not helped by other drugs and are NOT powerful dopamine antagonists.

Causes of Schizophrenia Psychological and Social Influences

• The role of stress includes may activate underlying vulnerability and/or may also increase risk of relapse.
• High expressed emotion (family members being critical, hostile, or emotionally over-involved) is associated with relapse.

Medical Treatment of Schizophrenia: Side Effects

• Parkinsonian symptoms are an extrapyramidal side effect that has symptoms such as expressionless face, slow motor activity, shuffling gait.
• Akathisia is feeling restless and a need to move.
• Dystonia is when there's abnormal muscle tone and muscle spasms.
• Tardive dyskinesia is involuntary movements of the tongue, face, mouth, and jaw , and is usually irreversible.
• Side effects caused by "typical antipsychotics".
• Atypical - less EPS but more weight gain and some can cause life-threatening problems.

Psychosocial Treatment of Schizophrenia

• Psychoanalytic/dynamic approaches addressing early experiences with parents or other traumas have no evidence of efficacy.
• Community care programs provide services in the community, including social/living skills training and behavioral family therapy.
• Psychosocial approaches are a necessary part of medication therapy.

Personality Disorders: Nature and Definition

• Personality is an individual's characteristic patterns of thought, emotion, and behavior, along with the psychological motivations behind those patterns.
• A personality trait is a long-standing pattern of behavior expressed across time and in many different situations.
• Predispositions are inflexible and maladaptive, causing distress and/or impairment.

The Five-Factor Model of Personality

• Openness to experience.
• Conscientiousness.
• Extraversion.
• Agreeableness.
• Neuroticism.

Consequences and General Criteria of Personality Disorders

• Personality disorders are associated with decreased social and occupational functioning, increased risk of substance abuse, depression, anxiety, schizophrenia, and suicide.
• The DSM-IV general criteria state that there needs to be a deviation from cultural expectations, and must be seen in two or more of the following: cognition, affectivity, interpersonal functioning, and impulse control.

Theoretical Issues in Personality Disorders

• Issues include dimensional versus categorical approaches, comorbidity, gender differences, and coverage.
• There is almost unanimous consensus that personality disorders should NOT be used in a categorical manner.

The 10 DSM-5 Personality Disorders: Cluster A ("The Weird")

• Paranoid personality disorder is a pattern of distrust and suspiciousness such that others’ motives are interpreted as malevolent.
• Schizoid personality disorder is a pattern of detachment from social relationships and a restricted range of emotional expression.
• Schizotypal personality disorder is a pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior.

The 10 DSM-5 Personality Disorders: Cluster B ("The Wild")

• Antisocial personality disorder is a pattern of disregard for, and violation of, the rights of others.
• Borderline personality disorder is a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity.
• Histrionic personality disorder is a pattern of excessive emotionality and attention-seeking
• Narcissistic personality disorder is a pattern of grandiosity, need for admiration, and lack of empathy.

The 10 DSM-5 Personality Disorders: Cluster C ("The Worried")

• Avoidant personality disorder is a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.
• Dependent personality disorder is a pattern of submissive and clinging behavior related to an excessive need to be taken care of.
• Obsessive-compulsive personality disorder is a pattern of preoccupation with orderliness, perfectionism, and control.

Narcissistic Personality Disorder: DSM-5 Criteria

• A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by 5 or more of the following.

Assessment Issues in Personality Disorders

• Self-report vs. other report can be used in assessments, which both have problems. Gold Standard? Semi-structured interviews.

Psychopathology in Personality Disorders

• Individuals with personality disorders are often glib and have superficial charm, a grandiose sense of self-worth, are pathological liars, are conning/manipulative, have a lack of remorse or guilt, and are callous/lack empathy.

Antisocial Personality Disorder: Traits

• Includes irresponsibility, early behavior problems, a parasitic lifestyle, and failure to accept responsibility for own actions.

Gender Differences in Personality Disorders

• Meta-analyses of gender differences in personality support that men are lower in Agreeableness and women are higher in Neuroticism.

DSM-5 Section III Approach to Personality Disorders

• Consists of moderate or greater impairment in personality (self/interpersonal) functioning, one or more pathological traits, inflexibility/pervasiveness, and has been longstanding.
• Self traits includes identity and self-direction.
• Interpersonal traits includes empathy and intimacy.

DSM-5 Trait Model

• 5 Domains (25 specific traits) including: negative affectivity, detachment, antagonism, disinhibition, and psychoticism.
• Only 6 disorders would remain: schizotypal, antisocial, borderline, narcissistic, avoidant, and OCPD

Personality Disorders: Statistics

• Prevalence in the general population is about .5% to 2.5% of the general population, 10-30% in inpatient settings, up to 15% in outpatient settings.
• Thought to begin in childhood and are predicted by childhood sexual, physical, emotional abuse, and neglect.
• Runs a chronic course and comorbidity rates are high.
• Runs a chronic course and comorbidity rates are high.

Origins of Paranoid PD

• Biological and psychological contributions are unclear, but early learning that the world is dangerous is theorized.

Treatment Options for Paranoid PD

• Few seek professional help on their own.
• Treatment focuses on development of trust and cognitive therapy to counter negative thinking.

Schizoid PD: Clinical Features and Causes

• Pervasive pattern of detachment from social relationships, little interest in sexual experiences, indifferent to praise or criticism, and a very limited range of emotions in interpersonal situations.
• Etiology is unclear, but potentially caused by preference for social isolation resembles autism or an extreme variant of shyness/introversion.

Schizotypal PD: Clinical Features

• Socially isolated, highly suspicious (paranoid), possesses magical thinking, ideas of reference, and illusions.
• Many meet criteria for major depression.

Antisocial PD: Overview and Clinical Features

• Is noncompliance with social norms, violates rights of others, irresponsible, impulsive, and deceitful.
• Lack empathy and remorse, and lack concern for safety of self or others.
• Must be evidence of conduct disorder before age 15.

Narcissistic Personality Disorder: Causes

• Link with failure to learn empathy as a child because of parents failure to effectively “mirror” a child. (Kohut).
• Grandiosity conceals concerns about defectiveness (Kernberg.
• Appears that overvaluing or undervaluing can cause it; too much or too little attention.

Avoidant Personality Disorder: Overview and Clinical Features

• Extreme sensitivity to the opinions of others.
• Highly avoidant of most interpersonal relationships.
• Interpersonally anxious and fearful of rejection.

Dependent Personality Disorder: Overview and Clinical Features

• Reliance on others to make major and minor life decisions.
• Unreasonable fear of abandonment.
• Clingy and submissive in interpersonal relationships.
• Focused on maintenance of supportive/nurturing relationships.

Obsessive-Compulsive Personality Disorder: Overview and Clinical Features

• Excessive and rigid fixation on doing things the right way
• Frugal
• Highly perfectionistic, orderly, and emotionally shallow

Perspectives on Substance-Related Disorders

• Substance-related disorders involve the use and abuse of psychoactive substances that alter mood and/or behavior.
• Characterized by wide-ranging psychophysiological and behavioral effects and associated with significant impairment and costs.

DSM-5: Substance Use Disorder

• Combines DSM-IV abuse and dependence criteria.
• Severity dimension: 2-3: mild substance use disorder; 4-5: moderate substance use; 6+: severe disorder.

DSM-5: Pathological Gambling

• Pathological gambling involves persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress.
• The new addition to DSM-5 includes need for money to achieve excitement, is restless/irritable, and has made repeated unsuccessful efforts.

Substance Use: Main Categories of Substances

• Depressants: result in behavioral sedation.
• Stimulants: increase alertness and elevate mood.
• Opiates: primarily produce analgesia and euphoria.
• Cannabis.
• Hallucinogens: alter sensory perception.
• Other drugs of abuse: include inhalants, anabolic steroids, medications.

The Depressants: Alcohol Use Disorders

• Central nervous system depressant; reduces physiological arousal.
• Mimics a stimulant because it slows down the inhibitory centers.
• Affects several neurotransmitter systems.
• Can cause intoxication, where the individual exhibits maladaptive behavioral or psychological changes that developed as a result of alcohol use.

Alcohol: Some Facts and Statistics

• 12-month prevalence of alcohol used disorder is 9% in 18 or older.
• 23% report binge drinking in the past month.
• Those living in fraternity and sororities report highest levels
• Rates are highest among Caucasian and Native Americans.
• Makes use and abuse alcohol more than females.
• Violence is associated with alcohol and interacts with trait aggression.

Depressants: Sedative, Hypnotic or Anxiolytic Substance Use Disorders: An Overview

• Effects are similar to large doses of alcohol.
• Such drugs should not be taken on a long-tern, day to day basis.
• Combining such drugs with alcohol is synergistic.
• All influence the GABA neurotransmitter system.

Stimulants: An Overview

• Examples include amphetamines, cocaine, nicotine, and caffeine.

Stimulants: Amphetamine Use Disorders

• Produce elation, vigor, reduce fatigue, reduce appetite.
• Effects are followed by fatigue and depression.
• All are laboratory-made.
• Amphetamines stimulate CNS by enhancing the release of norepinephrine and dopamine and blocking reuptake
• Use can result in hallucinations and delusions.

Stimulants: Cocaine Use Disorders

• Short-lived (15-30 minutes) sensations of elation, vigor, alertness, reduces fatigue, causes insomnia and loss of appetite.
• Blocks reuptake of dopamine.
• Highly addictive, but addiction develops slowly.
• Can cause cardiac difficulties.

Stimulants: Nicotine Use Disorders

• Results in sensations of relaxation, wellness, pleasure; may diminish negative affect.
• Highly addictive with high relapse rates.
• Psychological symptoms (dysphoria, anxiety, irritability, restlessness) and physiological impacts of use.

Stimulants: Caffeine Use Disorders

• Small doses elevate mood to reduce fatigue.
• Half life of 3 to 6 hours.
• Regular use can result in tolerance and dependence.
• Recent consumption of caffeine can cause restlessness, nervousness, insomnia, diuresis, and gastrointestinal disturbance.

Opioids: Overview

• Includes natural and synthetic variants.
• Often referred to as analgesics.
• Examples include heroin, opium, codeine, and morphine.

Opioids: Effects

• Activate body’s endorphins.
• Low doses cause euphoria, drowsiness, and slow breathing.
• High doses can be fatal.
• Withdrawal symptoms can be lasting and severe.

Opioids: Overview

• Mortality rates are high for opioid addicts via overdose, suicide, homicide.
• 1.6 million had opioid use disorder in last 12 months
• 48k deaths due to synthtic opiods in past 12 months 2020

Hallucinogens: Overview

• Produce delusions, paranoia, hallucinations, and/or altered sensory perception.
• DSM-5 has a "Hallucinogen Persisting Perception Disorder".

Cannabis: Overview

• Most widely used illicit substance, 32% tried it.
• DSM-5 has cannabis intoxication and withdrawal diagnoses.

Drug Administration Routes

• Inhaling - 7 seconds.
• Snorting - 4 minutes.
• Intravenous Injection - 20 seconds.
• Intramuscular Injection - 4 minutes.
• Oral ingestion - 30 minutes.

Causes of Substance-Related Disorders

• Substance abuse has a genetic component, 40-60% of variance in alcohol use.
• Multiple genes are involved in substance abuse.
• Drugs affect the pleasure or reward centers in the brain.
• The pleasure center - dopamine key neurotransmitter.
• Drugs that treat substance abuse may specifically treat those underlying disorders.

Causes of Substance-Related Disorders: Psychological Dimensions

• Most drugs result in some pleasurable effects, which makes it more likely that drug will be used again and animal research supports that.
• Substance abuse as a means to cope with negative affect feel less depressed, less anxious, more confident.
• Expectancies are like "if, then" statements, can be negative or positive.

Causes of Substance-Related Disorders: Social and Cultural Dimensions

• Media, family, peers.
• Substance-abusing parents monitor children less carefully, giving them more opportunities to start their own use.

Biological Treatment of Substance-Related Disorders

• Agonist substitution - Substitute safer drug with a similar chemical composition.
• Antagonistic treatment - Drugs that block or counteract pleasurable drug effects, Mixed success.
• Aversive treatment - Drugs that make use of drugs extremely unpleasant, Limited success…

Psychosocial Treatment of Substance-Related Disorders

• Overall efficacy is comparable between inpatient and outpatient care.
• Controlled use - very controversial (as is total abstinence…), Appears to work as well as complete abstinence.
• Now called “harm reduction”.