Gary Strokosch MD Suzanne Martin PsyD MPH Clay Purswell DDS 1994 2000 Reference D iagnostic and S tatistical M anual of Mental Disorders DSM Publication Dates DSMI 1952 ID: 779916
Download The PPT/PDF document "Eating Disorders in Job Corps" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Eating Disordersin Job Corps
Gary Strokosch, MD
Suzanne Martin,
PsyD
, MPH
Clay Purswell, DDS
Slide2--1994--
--2000--
Reference
D
iagnostic and
S
tatistical
M
anual of
Mental
Disorders
Slide3DSM Publication Dates
DSM-I 1952
DSM-II 1968
DSM-III 1980
DSM-III-R 1987DSM-IV 1994DSM-IV-TR 2000
DSM-V* 2013 (May)*www.dsm5.org
Slide4Eating Disorders in Job Corps
Anorexia Nervosa
Bulimia Nervosa
Eating Disorder NOS
Slide5Lifetime Prevalence Estimates
0.3% Anorexia Nervosa
0.9% Bulimia Nervosa
1.6% Binge Eating Disorder
Swanson, et.al., Arch Gen Psychiatry. 2011; 68:714-723
Estimates vary widely
Slide6Feeding and Eating Disorders of Infancy and Early Childhood
Feeding Disorders (307.59)
Pica (307.52)
Rumination Disorder (307.53
)
Conditions Often Confused with Eating Disorders
Slide7Feeding Disorder of Infancy
or Early Childhood
Persistent failure to eat adequately with significant failure to gain weight or significant loss of weight
Slide8Pica
Persistent eating
of nonnutritive
substances
Slide9Rumination Disorder
Repeated
regurgitation and re-chewing
of food
Slide10Conditions Often Confused with Eating Disorders
Obesity (278.00)
Other Disorders
Slide11Obesity
Simple obesity is included in the
International Classification of Diseases
as a general medical condition, but does not appear in the DSM-IV because it has not been established that it is consistently associated with a psychological or behavioral
syndrome
Slide12International Classification
of Diseases
ICD-1 1900
ICD-2 1909
ICD-3 1920
ICD-4 1929ICD-5 1938ICD-6 1948
ICD-7 1955ICD-9* 1975 (in common use)
ICD-10 1989 (in use since 1995)
*http://en.wikipedia.org/wiki/list_of_ICD-9_codes
Slide13Conditions Often Confused with Eating Disorders
Obesity
(278.00)
Binge Eating Disorder
(BED)
DSM-IV / Appendix B
Compulsive Overeating
AKA
Food Addiction
Similar Definition as BED
Other Disorders
Slide14Two Eating Disorders
Anorexia Nervosa
(307.1)
Restrictive Type (the majority)
Binge-Eating/Purging Type
Bulimia Nervosa (307.51)
Purging Type (the majority)
Non-purging Type
Slide15Anorexia Nervosa
Anorexia Nervosa
is characterized by a refusal to maintain a minimally normal body weight
Slide16Bulimia Nervosa
Bulimia Nervosa
is characterized by repeated episodes of binge eating followed by inappropriate compensatory behaviors
Slide17Anorexia Nervosa
Four Diagnostic Criteria DSM-IV
Refusal to maintain normal body weight
Fear of gaining weight or becoming fat
Disturbance in the way one’s body weight or shape is experienced
Amenorrhea
What to Watch for in Job Corps
Slide18For Example…
1 …
weight loss
leading to maintenance of body weight less than 85% of that expected; or
failure to make expected weight gain
during period of growth, leading to body weight less than 85% of that expected.
2 …an individual has a body mass index (wt. kg./ht. m.2) equal to or below
17.5
.
Slide19BMI Percentiles
General Population
5
th 15th 50
th 85th
95
th
16 yrs.
16.37
17.54 20.09 24.74 29.10
17 yrs.
16.59
17.81 20.36 25.23 29.72
18 yrs.
16.71
17.99 20.57 25.56 30.22
19 yrs.
16.87
18.20 20.80 25.85 30.72
20-24 yrs.
17.38
18.64 21.46 26.14 31.20
Slide20Bulimia Nervosa
Five Diagnostic Criteria DSM-IV
Binge eating episodes
Compensatory purging
Bingeing/purging at least twice a week for three months
Negative self-evaluation via body weight and shape
Not during episodes of Anorexia Nervosa
What to Watch for in Job Corps
(usually vomiting)
Slide21Bulimia Nervosa
Compensatory Purging Behaviors
Self-induced vomiting
Misuse of laxatives, diuretics, enemas, or other medications
Fasting
Excessive exercise
* most common
*
*
Slide22Eating Disorder NOS
If a person is struggling with eating disorder thoughts, feelings or behaviors, but does not have all the symptoms of anorexia or bulimia, that person may be diagnosed with eating disorder
not otherwise specified
(ED-NOS).
For example:
A person could meet all of the diagnostic criteria for bulimia nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less than twice a week or for duration of less than 3 months.Binge-eating disorder is also officially an ED-NOS category (see separate fact sheet for BED): recurrent episodes of binge eating in the absence if the regular use of inappropriate compensatory behaviors characteristic of bulimia nervosa.
Slide23Eating Disorders:
Equal-Opportunity Diseases
Mostly
adolescent and young adult women
Only 5% of patients are male
Occasionally found in children as young as 5 years and people well into their geriatric years
Found in nearly all ethnic and racial groups when exposed to Western culture
Two peak ages of onset: 13 to 14 years and
17 to 18 years (developmental transitions)
Not associated with body weight at onset
Job Corps
Slide24Minorities
Anorexia Nervosa
White > All Minorities
Bulimia Nervosa
Latino > AA > White
Binge Eating Disorder
Latino > AA > White
Job Corps
Marques, et.al.,
Int
J Eat
Disord
2011; 44:412-420
Slide25Eating Disorders Pose a
Medical & Psychological Dilemma
Unexplained weight loss or involuntary vomiting is usually a sign of a serious medical
illness
EDs are classified as a mental disorder but often present as a medical disorder
EDs have the highest mortality of all mental health conditions
Over half of the these deaths are due to medical complications
Effective management of an eating disorder requires well informed multidisciplinary care
Slide26Mortality
NIH reports a wide range of 5-15% life time mortality for anorexia
Others estimate 0.5% annual death rate for anorexia and 0.2% annual death rate for bulimia
Approximately 1 in 5 deaths in anorexia & bulimia are due to suicide
Crow, et.al., Am J Psychiatry 2009; 166:1342-1346
Arcelus, et.al., Arch Gen Psychiatry. 2011;68(7):724-731
Slide27Comorbidities
as possible presenting symptoms
Anxiety
Obsessive-compulsive
s
ymptoms, especially related to eating and weightDepression
Slide28Hurdles to Detection and
Effective Treatment
Patients
hide
their problem out of fear and embarrassment
Patients rarely seek help on their own
There is a
mistaken notion that patients must want help
to get help
Slide29Key Concept
Eating disorders are more about body
weight
than eating!
Body
weight is the key to understanding (and treating) eating disorders
Slide30Slide31Mary and the Amazing Muffins
Eating
Disorder
vs.
Weight
Disorder
Slide32The Muffins
Slide33Amazing Muffins!
0 calories
0 gm fat
1 gm protein
Mary agreed to eat
these
muffins!
Because they would have
no
effect
on her weight.
Slide34The Not So Amazing Muffins!
Mary ate 3-4 muffins per day for several
months
Averaging ~ 2200
Kcals / 24 gm Prot / 120 gm
Fat
Mary maintained,
but did not gain
weight
Mary continued trying to lose weight
Delayed hospitalization through the
summer
Slide35Anorexia
–
failure to gain or maintain adequate body weight
Bulimia
– extreme fluctuations in body weight
Binge Eating Disorder
– bingeing without purging
Body Weight
(Usually
Low
Weight)
(Usually
Normal
Weight)
(Usually
Overweight
)
Slide36However,
emaciation is not necessary for anorexia
Slide37Age = 16-1
Ht
= 63 ½ in.
Max
Wt
= 134
lbs
BMI = 23.4
Age 17-7
Wt
= 117
lbs
BMI = 20.4
Age 17-9
Wt
= 106.5
lbs
BMI = 18.6
August BMI %
ile
= 18th
Max BMI %
ile
= 77th
June BMI %ile = 40th
January BMI %
ile
= 10th
Slide385%
15%
50%
Percentiles of the Normal Curve
85%
95%
Max
Wt
June
Wt
August
Wt
28
lbs
loss or 21% of total body mass
January
Wt
20 mo.
Slide3910th
percentile BMI
Slide40Making the Diagnosis
in Job Corps
Anorexia
– the health & wellness staff should recognize symptoms
Bulimia –
fellow students will tattle on their classmates
Binge Eating
–
may be noticed by dorm staff and students may self report
Slide41Some Signs and Symptoms
of Anorexia Nervosa
To Watch for in Job Corps
Slide42Severe
peripheral vasoconstriction and
hypothermia
Slide43Loss of scalp hair
Slide44Dizziness and Syncope
Slide45Arm
Lanugo
Slide46Hypercarotenemia
Yellow Hands
Slide47Bulimia in the Dorms
Empty food wrappers everywhere
Backed-up sink drains
Backed-up shower drains
Emesis around toilet
Sleep disturbancesLoss of motivation
Slide48Loss of
Concentration and Increased Distractibility
Four auto accidents in six months
Slide49Ankle and Foot Edema
Especially with laxative abuse
Slide50Severe parotid gland swelling
Slide51Subconjuctival
Hematomas
Due To Purging
Slide52Russell’s Signs
Slide53Unusual Habits
Slide54Drinking chocolate milk
from
a spoon
Slide55Preoccupation with food
Slide56Reading
Food
and
Cooking Magazines
Slide57Hoarding Food
One Patient’s Saved Food – Just in Case!
Slide58October ‘04
April ‘05
However, Treatment Can Be Successful
Slide59Risks to Keeping Students in Job Corps with Eating Disorders
Missed classes from spending time in the infirmary
Decreased motivation for training
Occasional trips to the ER for dehydration and/or electrolyte imbalance
Possible medical hospitalization for the sickest of the affected students
Slide60Staff Education
Consider having an in-service to make staff aware of an eating disorder and what the approach should be in helping a student complete their training while struggling with this illness
Slide61Management on Center?
Bulimia
students are sometimes helped by SSRI’s
Bulimia
students must decrease their symptoms enough to live in the dorm, stay in class and minimize ER trips
Anorexia
students must be willing to increase their weight to a safe level (est. 17.5 BMI)
Anorexia
students must be able to fully participate in the training and minimize their need for ER trips
Slide62Chronic Health Problems
PRH 6.10 R1.b.4
“Students identified as having chronic health problems…..shall be monitored as directed by the center physician or other appropriate center health care provider.”
Eating Disorders
Slide63Medical Separation
PRH 6.12 R11.b
Significantly interferes with or precludes further training in Job Corps, or
The health problem is complicated to manage, or
The necessary treatment will be unusually costly.”
“Students are medically separated when they are determined to have a pre-existing or acquired health condition that:
Last Resort
Slide64The Psychology Behind Eating Disorders
Slide65Psychological Factors
Sense of self worth based on weight
Use food as a means to feel in control
Black and White thinking
PerfectionismPoor impulse control
Inadequate coping skills
Slide66Troubled family and personal relationships
Difficulty expressing emotions and feelings
History of being teased or ridiculed based on size or weight
History of physical or sexual abuse
Interpersonal Factors
Slide67Social Factors
Cultural pressures that glorify "thinness" and place value on obtaining the "perfect body"
Narrow definitions of beauty that include only women and men of specific body weights and shapes
Cultural norms that value people on the basis of physical appearance and not inner qualities and strengths
Slide68Biological Factors
In some individuals with eating disorders, certain chemicals in the brain that control hunger, appetite, and digestion have been found to be imbalanced. The exact meaning and implications of these imbalances remains under investigation
Slide69Bulimia and the Body
Slide70Anorexia and the Body
Slide71Thoughts and Beliefs
In spite of average or above-average intelligence, the person thinks in magical and simplistic ways, for example, "If I am thinner, I will feel better about myself."
Becomes irrational and denies that anything is wrong. Argues with people who try to help, and then withdraws, sulks, or throws a tantrum. Wanting to be special, s/he becomes competitive. Strives to be the best, the smallest, the thinnest, and so forth.
Has trouble concentrating. Obsesses about food and weight and holds to rigid, perfectionistic standards for self and others.
Is envious of thin people in general and thinner people in particular. Seeks to emulate them.
Slide72Feelings
Has trouble talking about feelings, especially anger. Denies anger, saying something like, "Everything is OK. I am just tired and stressed." Escapes stress by turning to binge food, exercise, or anorexic rituals.
Becomes moody, irritable, cross, snappish, and touchy. Responds to confrontation and even low-intensity interactions with tears, tantrums, or withdrawal. Feels s/he does not fit in and therefore avoids friends and activities. Withdraws into self and feelings, becoming socially isolated.
Feels inadequate, fearful of not measuring up. Frequently experiences depression, anxiety, guilt, loneliness, and at times overwhelming emptiness, meaninglessness, hopelessness, and despair.
Slide73Social Behavior
Tries to please everyone and withdraws when this is not possible. Tries to take care of others when s/he is the person who needs care. May present self as needy and dependent or conversely as fiercely independent and rejecting of all attempts to help.
Person tries to control what and where the family eats. S/he consistently selects low-fat, low-sugar non-threatening -- and unappealing -- foods and restaurants that provide these "safe" items.
Relationships tend to be either superficial or dependent. Person craves true intimacy but at the same time is terrified of it.
Slide74Body Image is…
How you see yourself when you look in the mirror or when you picture yourself in your mind.
What you believe about your own appearance (including your memories, assumptions, and generalizations).
How you feel about your body, including your height, shape, and weight.
How you sense and control your body as you move. How you feel in your body, not just about your body.
Slide75Challenges to Treatment
Lack of motivation to change
Intrinsically reinforced by the weight loss, because it feels good to them
May deny the existence of the problem, or the severity of it
Lack of insight
Not really about food more about sense of self
Slide76Eating Disorder Not Otherwise Specified Who develops ED-NOS?
ED-NOS typically begin in adolescence or early adulthood although they can occur at any time throughout the lifespan.
Like anorexia nervosa and bulimia, ED-NOS is far more common in females; however, among those individuals whose primary symptom is binge eating, the number of males and females is more even.
Estimates suggest that ED-NOS accounts for almost three quarters of all community treated eating disorder cases.
Slide77What are the Common Signs of ED-NOS?
For individuals who binge, most notable is the disappearance of large amounts of food, long periods of eating, or noticeable blocks of time when the individual is alone.
This preoccupation and these behaviors allow the person to shift their focus from painful feelings and reduce tension and anxiety.
Slide78What are the Medical Complications?
Individuals with ED-NOS who binge and purge run risks similar to bulimia in that they can severely damage their bodies. Electrolyte imbalance and dehydration can occur and may cause cardiac complications and, occasionally, sudden death.
In rare instances, binge eating can cause the stomach to rupture.
Slide79What Treatment is Recommended?
Cognitive-behavioral therapy, either in a group setting or individual therapy session, has been shown to benefit. It focuses on self-monitoring of eating and purging behaviors as well as changing the distorted thinking patterns associated with the disorder. Cognitive-behavioral therapy is often combined with nutritional counseling and/or antidepressant medications such as
fluoxetine
(Prozac).
Treatment plans should be adjusted to meet the needs of the individual concerned, but usually a comprehensive treatment plan involving a variety of experts and approaches is best. It is important to take an approach that involves developing support for the person with an eating disorder from the family environment or within the patient’s community environment (support groups or other socially supportive environments).
Slide80Slide81Slide82Slide83Slide84Slide8511/4/2011
85
BARBECUE!!!
Slide8611/4/2011
86
Slide87Slide88Slide89Slide90Slide91Slide92Slide93Slide94Slide95Slide96Slide97Slide98Slide99Slide100Slide101Slide102Slide103Slide104Slide105Slide106Slide107Slide108Slide109Slide110Slide111Slide11230 yrs and still sane?
Slide113Eating Disorders and Oral Health
Dr. Clay Purswell, DDS
Dr Clifford Katz DDS, Contributor
Slide114Regular-o-dontics
Slide115Regular-o-dontics
Slide116Hero-dontics
Slide117Hero-dontics
Slide118?- Dontics
Slide119Eating Disorders and Oral Health- What Determines Oral Health?
Slide120What
Determines
Oral
Health?1. Balance of breaking down and building up of tooth structure.
Demineralization
Remineralization
ACID CHALLENGE
Neutralization
Slide121Acid Challenge
Food + Mouth Germs = Acid
Slide122Acid Challenge
OR
Sodas, Sweet Drinks, and Juice = Acid
Slide123Acid Challenge
Stomach Acid = Acid
Slide124Acid Challenge?
?
Drugs of abuse = ?
Slide125Acid Challenge
Demineralizes
tooth Structure
C
Ca+
PO4+
Ca+
Slide126After 30 min – Neutralizationand Re-mineralization
Re-mineralization
occurs over next
2 hours
Ca+
PO4+
Ca+
Ca+
PO4+
Slide127Frequency Dependent
Eat or Drink< 2hrs
before complete
re-mineralization = net tooth loss
Over time this can lead to decay or erosion.So the more frequent the intake, the more potential for tooth loss, and the more quickly it can occur.
Slide128What Determines Oral Health?
2. Healthy
Periodontium
(Gums and bone)
Good nutritionGood hygiene
Slide129What Determines Oral Health?3. Other Factors
1. Disease
2. Physiologic processes including
Inflammatory
UlcerativeCarcinogenicAuto Immune3. Diet, Habits, and Lifestyle
Slide130Slide131Other “Eating Disorders” And Oral Health
Slide132How Other “Eating Disorders” Influence Oral Health
Obesity/Overeating
Intake frequency
Nutrition
Slide133How Other “Eating Disorders” Influence Oral Health
Coke sipper
Acid exposure
(even sugar free)
Intake frequencyNutritionalAlso Soda Swisher
Slide134How Other “Eating Disorders” Influence Oral Health
Pregnancy Cravings or Food Cravings
Intake frequency
Nutrition
?
Slide135How Other “Eating Disorders” Influence Oral Health
Lemon Sucker
Acid exposure
Also Fruit Mulling
Slide136How Other “Eating Disorders” Influence Oral Health
Drug Influenced Eating
Oral hygiene
Nutrition
Acid exposure?
Slide137“MOLARDRAMA”
Slide138Effects of Anorexia
and Bulimia
Slide139How Eating Disorders Influence
Oral Health
Anorexia
Nutritionally
deprived - All oral tissues at risk
Slide140Anorexia
Nutritional and inflammatory—Would expect poor gingival health, bulging gums, nutritional deficiency diseases like scurvy, poor bone structure like osteoporosis, and poor tooth structure
*May not be present
(Time and home care)
Slide141How Eating Disorders Influence
Oral Health
Bulemia
Acid erosion
Intake frequencyNutritionalInflammatory
Slide142Effects of Bulimia
Erosion of teeth, especially lingual or tongue side, due to purging
Slide143Effects of Bulimia
Reddened Tissues of throat and palate
Slide144Effects of Bulemia
Thermal Sensitivity of Teeth
Slide145Effects of Bulimia
Enlarged Parotid glands (Chipmunk cheeks?)
Slide146Effects of Bulimia
Dry mouth with decreased saliva flow
Reddened, dry, cracked lips with fissures at the angles of the lips
Slide147Picture of Me and Kids in uniforms
Slide148CASE STUDIES
and Warning Flags
Slide149Case 1
Classic Presentation
Slide150Case 1
Classic Presentation
Slide151Case 2
Warning Flags
Slide152Case 3
Slide153Case 3
Slide154Case 4
Slide155Case 5 - The real thing
Slide156Case 5- The real thing
Slide157Dental Management
of
Eating Disorder Patient
Slide158Dental Treatment
Protect -
Fluoride paste or varnish
Slide159Side Note- Fluoride
Remineralization
with Fluoride
3 times resistance
to acid dissolution
Ca+
PO4+
Ca+
PO4+
Fl-
Fl-
Slide160Dental Treatment
Protect
-
MI paste (Calcium and Phosphate)
Slide161Dental Treatment
Protect
-
Oral TissuesOral Hygiene InstructionsDental Cleaning
Slide162Dental Treatment
Restore
-
Form and FunctionEmployability
Slide163Miraculo-dontics
Slide164Miraculo-dontics
Slide165Slide166Refer!
Slide167Case Study
18 year old Latino female
Reports 60 lb weight gain during pregnancy at 16 – never lost
History of childhood sexual trauma (ages 5-14)
Mother died of AIDS when student was 12
BMI = 33.4 (65 inches, 201 lbs.) on arrival
Reports depressed mood and sleep disturbance
RA reports excessive food in dorm
Progressing in Job Corps, but a loner
BMI = 35.1 (211 lbs) after 9 months