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As mentioned, the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) has changed the context of how disorders are examined, especially from a life-span developmental perspective. One of the examples is the new section titled “Feeding and Eating Disorders.” The DSM-5 new chapter incorporates eating disorders with disorders that were first diagnosed in infancy, childhood, and adolescence such as pica (ingesting nonfood items) and rumination (regurgitation and rechewing of food). Also new in this chapter is the inclusion of binge eating disorder alongside other eating disorders such as anorexia nervosa and bulimia nervosa (American Psychiatric Association, 2013a). Researchers have provided evidence that the onset and prevalence of eating disorders can be contributed to several factors (Levine & Murnen, 2009; Stice, Marti, & Rohde, 2013) including social, environmental, genetic, biological, and psychological factors (National Institute of Mental Health, 2014).
Previously (as in DSM-IV) binge eating disorder wasn’t considered a specific disorder, being mentioned as an area of consideration in the DSM-IV appendix. Binge eating is now considered a disorder according to DSM-5. The basic symptoms for binge eating disorder include the following (American Psychiatric Association, 2013a, p. 350):
Eating more food in a discreet period of time than most people would eat in the same amount of time
Lack of control of eating during that time
Eating large amounts of food even when not hungry
Eating alone due to the embarrassment of how much is eaten
Feeling disgusted or very guilty with oneself due to the eating
Marked distress regarding binge eating
Binge eating occurs on average at least one time per week for three months
Other than the compulsive-like nature of binge eating, what stands out about the disorder seems to be the psychological distress caused by the disorder. The individual is aware that he or she is binge eating but lacks the ability to stop which causes significant distress.
What is the cause of anorexia nervosa? This is not a simple question. As mentioned, eating disorders in general have several factors that contribute to their onset, including environmental, genetic, biological, as well as physiological factors. One factor that has recently been examined is family dynamics and the similarities between anorexia nervosa and an addiction disorder. Research has shown that there is a lack of social self-confidence and family disturbances for people diagnosed with anorexia nervosa or drug addiction (Doba, Nandrino, Dodin, & Antoine, 2014). Individuals diagnosed with anorexia nervosa have a need to be thin and the pursuit of being thin is significantly exaggerated in their actions, such as restricted eating and extreme physical activity. All of this is associated with the individuals’ perception of body-image (seeing themselves as obese even though they may be extremely thin), as well as self-esteem issues. Chronic symptoms that can develop include brittle hair and nails, muscle wasting/weakness, dry and yellow skin, thinning of the bones (i.e., osteoporosis), heart damage, and brain damage (National Institute of Mental Health, 2014). Hudson, Hiripi, Pope, and Kessler (2007) reported that anorexia nervosa is a relatively rare disorder; however, there is a high incidence of comorbidity with other mental disorders (e.g., depression and anxiety).
Treatment for anorexia nervosa is often complicated and difficult. Individuals suffering from anorexia nervosa rarely go for treatment voluntarily. It is more likely other people, either family or friends, or people in their environment, notice their physical appearance and beg or drag them to seek medical help. When individuals do access medical help, the first step is for medical personnel to ascertain the level of the patients’ physical health. Once medically stabilized, treatment is most effective when it engages the individuals and their families.
One thing that makes the treatment of this disorder so complicated is the difficulty in convincing individuals that they need treatment. Most individuals do not see their disordered relationship with food as being problematic because they want to lose more weight, and they do not want to gain weight. Any attempts to convince the person to agree to the treatment are typically met with extreme resistance. If a therapist does gain the participation of the individuals, having their family involved is additionally challenging because there is a high incidence of family dysfunction among individuals with eating disorders.
While true, full-blown anorexia is rare, many individuals show symptoms without meeting the full criteria. The line between dieting, fasting, and disordered eating can be very thin. You might get to work with clients who report they have normal eating habits, only to discover this is not the case, as is shown by the following case:
Unlike anorexia nervosa, individuals having bulimia nervosa are more likely to find it disturbing enough to seek treatment on their own. Bulimia seems to be a see-sawing pattern of purging unwanted calories and then a build up of anxiety, which then, very temporarily, is calmed by binging. As previously noted, the term “binging” is often used incorrectly.
While there are many methods of purging calories gained, exercise seems to be increasing in popularity among individuals with bulimia. For example, some people exercise for four to five hours, seven days a week, until they have burned off the number of calories they believe they consumed.
With the exception of over-exercising and immediate vomiting, individuals with bulimia often appear to be of average weight to overweight. The reason is as soon as the food is swallowed, calories begin to be absorbed by the body. The longer the food remains in the body (for example, while waiting for a diuretic or laxatives to work), the more calories are absorbed. However, purging via over-exercising and immediate vomiting prohibits the body from absorbing the nutrients in the food.
Individuals are more likely to binge-eat in the late afternoon or evenings. Over the past several years, a typical individual presenting for treatment with bulimia has been binge-eating and inducing vomiting 5 to 10 times a week for 3 to 10 years.
Individuals with bulimia often report being drawn to carbohydrate and dairy-rich foods since these are easier to vomit. They typically avoid acidic or hard foods such as fruits and chips.
As with anorexia, individuals can do permanent and severe damage to their bodies. The sidebar graphic presents some problems bulimia nervosa can cause the body.
With both anorexia and bulimea, Cognitive Behavioral Therapy (CBT) and, more recently, Dialectical Behavior Therapy (DBT), have seemed most effective for helping individuals to learn adaptive coping strategies and to discontinue their disordered behaviors.
The history of gender disorders (as they were called in previous versions of the Diagnostic and Statistical Manual of Mental Disorders [DSM]) in a way mimics the social norms of the time. In the first edition of DSM, which was published in 1952, homosexuality was considered a mental disorder. In the next edition (DSM-II, published in 1968), homosexuality was classified a sexual deviation. In 1973, the term homosexuality was removed from the DSM as a mental disorder. However, in the DSM-III published in 1980, a new interpretation was considered called ego-dystonic homosexuality. The difference in this disorder is that it leaned more toward psychological distress. The DSM-IV published in 1994 listed gender identity disorder. The main feature of gender identity disorder is a persistent cross gender identification that has caused significant distress in the individual’s life (Drescher, 2010).
Gender identity disorder has been replaced with gender dysphoria. The major reason why the name was changed is best stated as: “It is important to note that gender nonconformity is not in itself a mental disorder. The critical element of gender dysphoria is the presence of clinically significant distress associated with the condition” (American Psychiatric Association, 2013b, para. 3). What this basically states is that it is the stressors that a person may encounter. According to the American Psychiatric Association, the stressors have to be clinically significant impacting the individual’s overall functioning such as social and occupational. Terms like transgender, transsexual, cross-dresser, intersex, and drag performer are not something associated with a disorder. They are terms that could be associated with individuals who may encounter significant stress in their lives that leads to gender dysphoria
Substance Use Disorder
National Institute on Drug Abuse (2012) provides a wealth of information on addiction and drug abuse. They begin with the understanding that addiction is considered a disease because of its effects on the brain and behavior. Basically, a chronic addiction alters the functioning of the brain through changes in brain chemistry. CBS News (Browning & Schienberg, 2012) did a piece on addiction highlighting the work of the National Institute on Drug Abuse.
In the past, substance abuse was viewed as distinct stages such as substance misuse, substance abuse, and substance dependence. A common thread for addictions, especially the substance misuse, is an addiction that is gradual—from occasional use to misuse to dependency. Part of that process is physiological—
the brain chemistry is adapting to the continued substance misuse. The disease model puts more relevance on the physiological and less on the psychosocial and environmental factors. The DSM-5 took a different approach to substance abuse. DSM-5 combined two disorders (substance abuse and substance dependence) into one disorder: substance use disorder. Substance use disorder looks at substance addiction through a continuum or level of severity—mild, moderate, or severe.
The general diagnostic criteria for substance abuse, substance dependence, and substance withdrawal disorders are all very similar. The main discriminating factor is the substance the individual uses. This class of disorders and its treatments have become so specialized many states have a separate licensing process for clinicians who want to work with substance issues (often called a Licensed Substance Abuse Counselor). Substance abuse counseling is a growing field and has been established because addictions show no signs of slowing. Perhaps one of the fiercest debates within the field is regarding the existence of dual diagnoses.
Dual diagnoses refer to the idea that an individual can have a disorder of substance abuse combined with another disorder, such as major depressive disorder or posttraumatic stress disorder (PTSD). There seem to be two opinions on this argument. Some treatment programs acknowledge that dual diagnoses do occur. They may go so far as to say individuals often develop a disorder of substance abuse because of a faulty coping strategy for their primary diagnosis. Therefore, both disorders would be diagnosed simultaneously.
Personality disorders are difficult not only to identify but also to treat, because the disorder is a part of every aspect of that individual’s being. To diagnose a personality disorder is to say the individual is experiencing disordered thinking, disordered feeling, and disordered interactions with others. This constitutes a pretty serious decision.
Perhaps one reason why personality disorders are so difficult to treat is that their pervasive nature makes them difficult to pick up on, despite those internal clues we learn to hear. With most disorders, we are identifying a pattern of changed thoughts or behaviors—there are identifiable onsets of the symptoms. However, with personality disorders, we are looking for lifelong patterns of attitudes and behaviors (Morrison, 2007). Beyond that, many would argue our current diagnostic system confuses the issue by grouping together personality disorders and sharing common underlying features:
Cluster A: Odd or eccentric features
Cluster B: Dramatic-emotional features
Cluster C: Anxious or fearful features
Thus, many individuals may meet criteria for more than one personality disorder. Morrison (2007) offers the following list of problems, which beset the diagnosis of a personality disorder:
Contrary to the impression you might get from a casual reading of diagnostic manuals, most people have mixtures of personality traits and personality disorders. Yet clinicians tend to diagnose only one personality disorder, even when patients meet the criteria for two or more.
When more than one personality disorder is diagnosed, what does this actually mean? Surely not that the patient has several personalities. And, how does this help inform treatment?
There is no sharp dividing line between personality disorder and normality.
The three personality disorder clusters currently in use have little basis in objective research.
So far, little work has been reported that would pinpoint the cause of personality disorders.
Personality disorders are especially hard to evaluate. Often, the patient interview alone doesn’t suffice, even when a standardized interview is used; neither does psychological testing. Rather, we need interviews with relatives and others who have known the patient well, at least from late adolescence, to demonstrate that the behaviors in question are both enduring and pervasive. (pp. 258–259)
To add to Morrison’s last point, as a clinician, you rarely have the luxury of obtaining corroborating data from friends and family members of the client. In addition, managed care companies know just how poor the prognoses for personality disorders are, and they do not want to pay for treating them. Therefore, with most insurance companies, if the client is diagnosed with a personality disorder instead of another disorder, they will allow few, if any, sessions to be covered.
Personality Disorders Treatment
As mentioned earlier, clients will rarely come for the treatment of their own personality disorder. Clients notice the maladaptive behaviors they are exhibiting. For example, a borderline client might grow concerned about self-injurious behaviors. However, the client doesn’t typically recognize such behaviors as being part of a larger pattern. It is also common for individuals with personality disorders to come for counseling because of other people’s reactions to them.
For example, once a practitioner had a client, David, with narcissistic personality disorder. David had come for counseling to learn how to help his coworkers. He explained that he had asked out every single coworker for a date and had been turned down by all. During his first session, David explained that there was something wrong with his coworkers. He said, “They simply don’t realize what a good catch I am. I am worried about them and want to help them.”
Explaining what can and cannot be addressed in counseling becomes crucial. Unfortunately, because individuals with personality disorders often lack insight into their patterns, the prognosis is poor.
Treatment of a personality disorder is unlikely to result in the development of a fully healthy or ideal personality structure, but clinically and socially, meaningful change to personality structure and functioning does occur. In fact, given the considerable social, occupational, medical, and other costs created by personality disorders, such as the antisocial and borderline, even marginal reductions in symptomatology can represent quite significant and meaningful public health care and social and clinical benefits (First and Tasman, 2004, p. 1236
In this era of concerns about health, diet, and obesity, there are a multitude of diets and weight loss products (including pills and surgery) on the market. The social norms seem to be shifting to a healthier lifestyle, with obesity being targeted as a major health problem. This leads individuals to seek help in weight loss and obesity. For example, in order to be successful after bariatric surgery (weight loss surgery), a person has to change his or her lifestyle—which often includes monitoring what he or she eats and when.
Explain the difference between a person who has to maintain a strict regimen of healthy living and diet to not be obese and a person who is diagnosed with an eating disorder such as anorexia nervosa.
Review the National Institute of Mental Health’s information regarding eating disorders. Describe the symptoms of anorexia nervosa and provide an explanation of the common factors relating to acquiring the disorder, how it is diagnosed, and its treatment.
Impulse control can be defined as an inability to control the desire for a substance or act. The lack of impulse control is seen as a factor related to substance abuse but it is not the only factor. Research information on addictions and the two types of addictions (substance addictions and behavioral addictions). Choose one substance addiction and one behavioral addiction and answer the following:
Describe each addiction including potential genetic and environmental factors leading to the addiction. Describe the common symptoms, especially those that impact the person both physically and psychologically. Describe the common treatments for the disorders.
Explain why a person with an addiction may have a difficult time accepting he or she has an addiction, seeking treatment, and abstaining from the addiction without relapsing.
Justify your answers with appropriate reasoning and research from your text and course readings. Comment on the postings of at least two peers, and provide an analysis of each peer’s postings while also suggesting specific additions or clarifications for improving the discussion question response.
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