CU-MA-PSY-SEM-IV-Clinical Disorders II (1) Revised

Breathing The main treatment for rumination syndrome is behavioral therapy to stop regurgitation. The behavioral therapy that is usually prescribed for rumination syndrome is diaphragmatic breathing. The diaphragm is a large, dome-shaped muscle located at the base of the lungs. Diaphragmatic breathing is intended to help you relax the diaphragm and use it correctly while breathing to strengthen it. To perform diaphragmatic breathing to help control regurgitation: Lie on your back on a flat surface or in bed, with your knees bent and your head supported. You can use a pillow under your knees to support your legs. Place one hand on your upper chest and the other just below your rib cage. This will allow you to feel your diaphragm move as you breathe. Breathe in slowly through your nose so that your stomach moves out against your hand. Keep the hand on your chest as still as possible. For children, we describe this as “breathing like an opera singer”, with the hand on the belly moving out with each slow breath, and moving in with exhalation. Tighten your stomach muscles, letting them fall inward as you exhale through pursed lips. Keep the hand on your upper chest as still as possible. Treatment depends on the exclusion of other disorders, as well as on age and cognitive ability. Behavior therapy Habit reversal behavior therapy is used to treat people without developmental disabilities who have rumination syndrome. People learn to recognize when rumination occurs and to breathe in and out using the abdominal muscles (diaphragmatic breathing) during those times. Diaphragmatic breathing prevents abdominal contractions and regurgitation. Biofeedback is part of behavioral therapy for rumination syndrome. During biofeedback, imaging can help you or your child learn diaphragmatic breathing skills to counteract regurgitation. For infants, treatment usually focuses on working with parents or caregivers to change the infant's environment and behavior. Medication If frequent rumination is damaging the esophagus, proton pump inhibitors such as esomeprazole (Nexium) or omeprazole (Prilosec) may be prescribed. These medications can protect the lining of the esophagus until behavior therapy reduces the frequency and severity of regurgitation. Some people with rumination syndrome may benefit from treatment with medication that helps relax the stomach in the period after eating. 101 CU IDOL SELF LEARNING MATERIAL (SLM)

4.10 SUMMARY  Infants initially explore their world by mouthing objects and can commonly ingest nonnutritive substances, especially if not well supervised. While it is common for infants to mouth objects, children with pica will repeatedly crave nonnutritive substances on a regular and persistent basis, for at least a month’s duration.  Infants and younger children commonly consume paint, hair, cloth, plaster, and string. Older children typically may eat animal droppings, sand, insects, pebbles, or leaves, while adolescents or adults will eat clay and soil.  The substances ingested differ developmentally with infants and younger children commonly consuming paint, hair, cloth, plaster, and string. Older children typically may eat animal droppings, sand, insects, pebbles, or leaves. Adolescents or adults may consume clay or soil.  Because some cultures sanction ingesting nonnutritive substances, such as soil, a diagnosis of Pica must rule out cultural practice. This eating disorder is most often associated with Mental Retardation or one of the Pervasive Developmental Disorders.  The disorder is most oft en associated with mental retardation or one of the pervasive developmental disorders. The e prevalence rate for adults with severe mental retardation can be as high as 15%.  The DSM reports that it is important to rule out cultural practices in making a diagnosis of pica, since some cultures sanction ingesting nonnutritive substances, such as soil.  The disorder is common in infants and individuals with mental retardation and consists of the repeated regurgitation and rechewing of food. The characteristic feature of this disorder is the repeated regurgitation and rechewing of food.  The disorder is common in infants and those with Mental Retardation. Because the food is regurgitated and not ingested, weight loss, failure to thrive, and even death can result. As many as 25% of infants with Rumination Disorder will die.  Common outcomes include weight loss and failure to thrive. Death may be imminent in as many as 25% of cases. Precipitating factors associated with the disorder include stressful conditions, lack of stimulation or neglect, and strained parent-child relationship. In older children and adults, Mental Retardation is the predisposing factor  Onset is between 3 and 12 months, with stressful conditions, lack of stimulation/neglect, and strained parent/child relationship associated with onset of the disorder. Mental retardation is associated with onset in older children and adults 102 CU IDOL SELF LEARNING MATERIAL (SLM)

4.11 KEY WORDS  Aetiology: The study of the origins of disease: physical, mental or emotional.  Behaviour modification: The deliberate changing of a particular pattern of behaviour by behaviorist methods.  Psychotherapy: The use of psychological techniques to treat psychological disturbances. 4.12 LEARNING ACTIVITY 1. What are the key features of PICA? How does it affect an individual? ___________________________________________________________________________ ___________________________________________________________________________ 2. What are the key features of rumination disorder? How does it affect an individual? ___________________________________________________________________________ ___________________________________________________________________________ 4.13 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. What is PICA? 2. What is rumination disorder? 3. What are the comorbidities of PICA? 4. What are the comorbidities of Rumination disorder? 5. What are the prognosis of PICA? 6. What are the prognosis of Rumination disorder? Long Questions 1. What are the symptoms of PICA? 2. What are the symptoms of Rumination disorder? 3. What are the causes of PICA? 4. What are the causes of Rumination disorder? 5. What are the treatment of PICA? 6. What are the treatment of Rumination disorder? 103 CU IDOL SELF LEARNING MATERIAL (SLM)

B. Multiple Choice Questions 104 1. What is PICA? a. A nonfood eating disorder b. Purging after you eat disorder c. An eating disorder that they don't eat d. A binge eating disorder 2. How do you recognize PICA? a. Intellectual development problems b. Mental health problem c. Malnutrition d. Stress 3. What Is the DSM-V code for PICA? a. 98 b. 307.25 c. 98.3 d. 307.52 4. What are the diagnostic features of PICA? a. intestinal issues, eating disorders, specific culture b. Intellectual disabilities, Mental disabilities, Brain injury c. Eating disorders, Pre diabetic, males d. Underlying heart conditions, males, intestinal issues 5. What do people with Pica crave and eat most? a. dust b. clay c. paper d. All of these CU IDOL SELF LEARNING MATERIAL (SLM)

Answers 1-c, 2-b, 3-d, 4-a, 5-b 4.14 REFERENCES Textbooks  Ahuja N (2002). A short text book of Psychiatry. (5th edn). New Delhi: Jaypee Brothers Medical. Publishers (pvt) Ltd.  American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision: DSM-IV-TR. Washington, DC: American Psychiatric Publishing, Inc.  Clifford Morgan, Richard King, John Weisz, John Schopler (2004) Introduction to Psychology, McGraw-Hill, New Delhi  Domjan Michael (2010). The Principles of Learning and Behavior (6th Edt) Wadsworth, Cengage Learning.  Hergenhahn B R (2008). An introduction to the history of psychology, Wadsworth, Cengage Learning.  Robert S. Feldman (2011) Understanding Psychology, McGraw-Hill, New Delhi.  Robert. A. Baron, Psychology, (2008) Prentice Hall India. Reference books  American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Text Revision.  Chatoor I, Dickson L, Schaefer S et al. (1985) A developmental classification of feeding disorders associated with failure to thrive: Diagnosis and treatment, in New Directions in Failure to Thrive:  Research and Clinical Practice (ed Drotar D). Plenum Press, New York, pp. 235–238.  Chatoor I, Getson P, Menvielle E et al. (1997) A feeding scale for research and clinical practice to assess mother–infant interactions in the first three years of life. Inf Mental Health J 18, 76–91.  Chatoor I, Ganiban J, Hirsch R et al. (2000) Maternal characteristics and toddler temperament in infantile anorexia. J Am Acad Child Adolesce Psychiatry 39, 743– 751.  Dahl M and Sundelin C (1992) Feeding problems in an affluent society: Follow-up at 4 years of age in children with early refusal to eat. Acta Paediatry Scand 81, 575–579. 105 CU IDOL SELF LEARNING MATERIAL (SLM)

 Hufton IW and Oates RK (1977) Nonorganic failure to thrive: A long term follow-up. Pediatrics 59, 73–77.  Main M and Goldwyn R (1991) The Adult Attachment Interview Classification System. Department of Psychology, University of California, Berkeley.  Marchi M and Cohen P (1990) Early childhood eating behaviors and adolescent eating disorders. J Am Acad Child Adolesce Psychiatry 29, 112–117.  Ahuja N (2002). A short text book of Psychiatry. (5th edn). New Delhi: Jaypee Brothers Medical. Publishers (pvt) Ltd.  American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision: DSM-IV-TR. Washington, DC: American Psychiatric Publishing, Inc.  Carson, R. C., Butcher, J. N., & Mineka, S. (2002).Abnormal psychology over time. In Fundamentals of abnormal psychology and modern life. New York: Allyn & Bacon.  Emery, R.E., &Oltmans, T.F. (1998). Abnormal Psychology (2nd ed.). Upper Saddle River, NJ: Prentice-Hall, Inc.  Kay J, Tasman A. (2006) Essentials of Psychiatry, Chichester, John R. Wiley and Sons.  Sadock, Benjamin, J., & Virginia A. (2002). Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (9th ed.). Lippincott Williams &Wilkins.  Sarason I., G & Sarason B. R. (2005). Abnormal psychology: The problem of maladaptive behavior. (11th edn). PHI Learning Private limited.  World Health Organization (1993). The ICD-10 Classification of Mental and Behavioral Disorders Websites  www.simplypsychology.com  http://www.human-memory.net  www.simplypsychology.org  https://psychcentral.com  https://courses.lumenlearning.com  https://www.sparknotes.com 106 CU IDOL SELF LEARNING MATERIAL (SLM)

UNIT 5 – FOOD ADDICTION 107 STRUCTURE 5.0 Learning Objectives 5.1 Introduction 5.2 Food Addiction 5.3 Types of Food Addiction 5.4 DSM Criteria for Food Addiction 5.5 Incidence of Food Addiction 5.6 Prevalence of Food Addiction 5.7Co-morbidity of Food Addiction 5.8 Causes of Food Addiction 5.9 Prognosis of Food Addiction 5.10 Treatment of Food Addiction 5.11 Summary 5.12 Key Words 5.13 Learning Activity 5.14 Unit End Questions 5.15 References 5.0 LEARNING OBJECTIVES After studying this unit, you will be able to,  Explain the nature and symptoms of Food Addiction  Describe the incidence and prevalence of Food Addiction  Explain the co-morbidity of Food Addiction  State the causes of Food Addiction  Explain the prognosis of Food Addiction  State the treatment for Food Addiction 5.1 INTRODUCTION Cathy CU IDOL SELF LEARNING MATERIAL (SLM)

Cathy, a 25-year-old medical student, came to therapy to address her eating habits. Fellow students have told Cathy they are concerned about her weight loss and lack of a social life. Cathy claims she is simply stressed about school, putting grades ahead of socializing. She has recently lost about 15 pounds. At 5’4” and 96 pounds, her body is underweight. Further questioning reveals Cathy was teased for being chubby in middle school. She had forced herself to vomit after meals for a few years afterward. More recently, she has been cutting back on food portions, eliminating fats from her diet, and avoiding social events that include food. The therapist refers Cathy to a physician for medical monitoring and a dietician to make a meal plan. The therapist also helps Cathy challenge the distorted, anorexia-driven thinking about her body. As Cathy’s eating improves and her brain is better nourished, she acknowledges her fear of being less than perfect. This fear stems in part from her parents' pressure to succeed in school. Cathy says her parents focused more on her academic achievements than her emotions. The therapist helps Cathy access her repressed feelings. Cathy learns to manage painful emotions rather than starving them away. Over time, Cathy grows more comfortable in her body. Yvonne Yvonne, 38, is an elementary school teacher who has always been overweight. Whenever her former husband insulted her looks, Yvonne soothed herself with food. After such a binge, she experienced shame from her perceived lack of willpower. She would vow to be strong and disciplined from then on. Yet the next time she was stressed, she would find herself binge eating again. Yvonne enters therapy because she wants help stopping the cycle. Her therapist explains how food can be misused as an antidote for painful emotions. He provides Yvonne with tools for tuning in to her body’s hunger and fullness signals. Yvonne learns to let her body's needs dictate her eating rather than following a diet. Through therapy, Yvonne recognizes how her father’s alcoholism affected her. As a child, Yvonne formed the habit of reaching for food to comfort herself when her father was drunk and angry. She had learned from her father to stuff painful feelings down. Over many sessions, Yvonne learns to eat according to her body's needs. She also develops greater emotional self- care skills. Eventually her body drops much of the excess weight. 5.2 FOOD ADDICTION Many Western cultures glorify thinness. American pop-culture is filled with weight-loss programs, diet trends, and body-shaming. These messages can provide fertile ground for eating disorders. Some people come to believe thinness makes a person desirable, while fatness makes someone unworthy. In such cases, eating disorders are ultimately concerned with one’s self-worth. People with eating disorders often experience anxiety, low self-esteem, and a strong need to please others. They may feel pressure to achieve perfection, not just with their bodies, but in 108 CU IDOL SELF LEARNING MATERIAL (SLM)

every facet of life. Other individuals are responding to past trauma, using food to regain a sense of control. A family history of eating disorders may also increase a person’s potential for unhealthy behavior. Reports such as these have led some to question whether certain individuals may experience eating as an addiction. At first pass, the concept of food addiction may appear absurd given that food is needed to maintain survival; in a sense, we are all “dependent” on food. In contrast, overconsumption of highly palatable foods and cycles of food restriction coupled with overeating these kinds of foods are not necessary for survival, and these are precisely the habits that are associated with the development of addictive-like eating behavior. The subject of food addiction has been a source of inquiry and debate in the scientific literature for decades. However, recent research using laboratory animal models suggests that overconsumption of certain food ingredients may engender addiction-like behaviors and neural adaptations, prompting a renewed interest in this topic. Food addiction can cause as much suffering and have as many negative health consequences as any other addiction. Although America is the land of plenty — or perhaps because of it— it’s also the homeland of a wide range of eating disorders. Because food is necessary, available, and legal, not many people consider it a source of addiction. But for some people, certain foods can be as addictive as alcohol and cocaine. Food addictions have many physical side effects, including poor concentration, fatigue, diarrhea, constipation, bloating, skin disorders, and fluid retention. They also have powerful emotional and psychological side effects, including anxiety, depression, loss of self-esteem, and poor self-confidence. The most common characteristic of food addicts is that they eat compulsively with no regard for the consequences. They are persistently preoccupied with buying, preparing, and eating food. Sneaking or stealing food, hiding food, hiding signs of eating food—such as discarding empty wrappers in the bottom of the wastebasket—can all be indicators of food addiction. Food addicts may also feel uneasy when food is not available, gobble food quickly with little chewing, obsess about weight, and consistently continue to eat after others have stopped. As with any other addiction, a food addiction can be caused by a biochemical imbalance. A food addict may be unable to quit after one bite of a trigger or “binge” food, just as an alcoholic may be unable to stop drinking after just one sip. The food addict may develop a tolerance so that larger and larger amounts of a food are required to satisfy cravings. When the food supply is cut off, withdrawal symptoms can occur, including chills, dizziness, nausea, headaches, lethargy, and inability to concentrate. Similar to drug and alcohol withdrawal, a person not getting his or her food “fix” may experience flulike symptoms, even to the point of being bedridden. In many cases people who binge on food use laxatives, diuretics, and self-induced vomiting to purge their bodies of the huge quantities they have eaten. Not only are these techniques 109 CU IDOL SELF LEARNING MATERIAL (SLM)

ineffective—most bingeing is done with refined carbohydrates, which are very quickly absorbed—but they can have devastating effects upon the body over the long term. Signs and Symptoms This Eating Disorder can be recognizable by numerous signs and symptoms. The following are possible symptoms of an addiction to food:  Gorging in more food than one can physically tolerate  Eating to the point of feeling ill  Going out of your way to obtain certain foods  Continuing to eat certain foods even if no longer hungry  Eating in secret, isolation  Avoiding social interactions, relationships, or functions to spend time eating certain foods.  Difficulty function in a career or job due to decreased efficiency  Spending significant amount of money on buying certain foods for bingeing purposes  Decreased energy, chronic fatigue  Difficulty concentrating  Sleep disorders, such as insomnia or oversleeping  Restlessness  Irritability  Headaches  Digestive disorders  Suicidal ideations 5.3 TYPES OF FOOD ADDICTION Any addictive process has twin dragons driving the addictive behavior: impulsivity and compulsivity. Impulsivity is the tendency to act quickly without planning or thinking about consequences. Some people do recognize that what they are thinking of doing may be harmful, butthe thrill or excitement they expect outweighs the risk. Compulsivity means that you are awareof the downside of the behavior but you feel drawn to do it anyway, possibly again and again. Factors that can lead to your developing impulsivity or compulsivity include genetics, theenvironment you grew up in, a history of psychiatric problems, and substance use 110 CU IDOL SELF LEARNING MATERIAL (SLM)

disorders. Ifyou tend to have compulsive behaviors, you may have performed those behaviors not so muchfor pleasure, but to reduce tension, emotional pain, or anxiety—such as overeating compulsively when you’re upset, anxious, or stressed. If you tend to be more impulsive, you are morelikely to use your behaviors for pleasure (not just relief from pain), at least in the beginning. There are different motivations inherent in each of these twin dragons. Impulsivity is driven by a desire to obtain pleasure, arousal, or gratification. Compulsivity is driven more by a desire to alleviate anxiety or discomfort (Berlin and Hollander 2008). Both involve changes in the executive function area of your brain, called the prefrontal cortex. The prefrontal cortex controls judgment, decision-making, the ability to “learn by experience,” and the regulation of your emotions. For example, if you’ve had a bad day at work, you may want to tell your boss exactly what you think of her. The prefrontal cortex will help you to use good judgment and inhibit this impulse so you can keep your job. However, in people with addictions, the prefrontal cortex is impaired in its ability to override impulses or control compulsive desires. These changes in the prefrontal cortex are what lead to impulsivity and compulsivity. If you are impulsive, you may just live and act from the present moment without regard to future consequences. If you’re more compulsive, you may feel driven to use food to relieve emotional discomfort. Once you eat that food you’re craving, you will feel a sense of temporary relief. There is some overlap between impulsivity and compulsivity, and some experts view them as opposite ends of the same spectrum. In the exercises that follow, you can determine where you are on the spectrum—more impulsive or more compulsive. 5.3.1 Overeating – pure and simple We are inundated with opportunities to overeat; highly palatable, refined or processed foods – pizza, ice-cream, cakes that are too tempting to ignore. All of us have done it at some point and this is normal and understandable. We reward ourselves for any number of reasons and the treat might be so delicious and mouth-watering, it has to be finished off at once regardless of the portion size. However, whilst this might initially satisfy us, what can follow is an uncomfortable feeling often accompanied by less-than-ideal emotions like guilt and sometimes even shame. This only happens occasionally – it was a treat after all. But what can you do to feel better straight away? Take a short walk for an hour or so to get the food moving through your digestive tract, it will lift your mood too. Make sure your next meal is a healthy and satisfying one. To avoid the danger zone of feast and famine, don’t skip meals. As soon as you eat after a period of starvation, the body stores food as fat, in case there is another shortage. Eat when you are hungry and stop when you are full. 111 CU IDOL SELF LEARNING MATERIAL (SLM)

Sipping water after the event will help flush out some of the sodium consumed. Be mindful around when overeating occurs. Most of us will do it on a whim or as a reward. When it becomes a regular thing, then we have to look at the “what”, the “why”, and the “need”. 5.3.2 Emotional eating It’s the reason why so many diets fail: we don’t always eat just to satisfy hunger. Eating can become the go-to emotional coping mechanism – when the first impulse is to open the refrigerator whenever stressed, upset, angry, lonely, tired, or bored – it’s easy to get stuck in an unhealthy cycle where the real feeling or problem is never addressed. Emotional hunger can’t be filled with food. Eating may feel good in the moment, but the feelings that triggered the eating are still there bubbling under the surface. And we often feel worse than we did before because of the unnecessary foods we’ve just consumed. Emotional hunger often comes on suddenly. Something triggers the urge to eat and needs instant satisfaction. It craves junk food or sugary snacks to provide an instant rush. Emotional eating is often mindless, before you know it the whole tub of ice-cream is eaten, the pizza has been demolished, no thought or awareness has gone into it and there is usually no real enjoyment. The secret to getting back on track to normal healthy eating patterns is to identify emotional triggers. Make a list of what situations, people, places, or feelings make you comfort eat. Most emotional eating is linked to unpleasant feelings, and feelings from the past, that are triggered by events in the moment. Numbing yourself with food, can avoid the difficult emotions you’d rather not feel. Though positive emotions can, on occasion, trigger it too. You may eat simply to give yourself something to do, or as a way to fill a void in your life. You feel unfulfilled and empty, and food is a way to occupy your mouth and your time. In the moment, it fills you up and distracts you from underlying feelings of lack of purpose and dissatisfaction with your life. Stress is emotional and when chronic, as is common in our fast-paced world, our bodies produce high levels of the hormone, cortisol. Cortisol triggers cravings for salty, sweet, and fried foods – foods that give you a burst of energy and pleasure. To stop emotional eating, you need to find other ways to fulfill yourself emotionally. It’s not enough to understand the cycle of emotional eating or even to understand your triggers, although that’s a big step. You need alternatives to food that you can turn to for emotional fulfillment. When feeling low, call someone who always lifts your spirits or better still, make a point of getting out as isolation is dangerous. Changing your focus like reading a good book or watching a comedy, is also a powerful way to change how we feel. 112 CU IDOL SELF LEARNING MATERIAL (SLM)

5.3.3 Compulsive Eating People who binge and compulsively overeat feel compelled to eat when they are not hungry and can’t stop eating when they’ve had enough. Binge eating disorder involves regularly eating large portions of food in one go, without thinking and in a short space of time, until the person feels uncomfortably full, and then often upset or guilty and out of control. The definition of bingeing differs for all, making Binge Eating Disorder difficult to identify and diagnose, one person’s idea of bingeing may simply be a hearty meal to another. People who describe themselves as compulsive eaters feel that they cannot control their eating resulting in eating more than they need, usually struggling to control their weightingCompulsive over-eaters have cravings they cannot control, and may overeat small or large amounts of food, or just graze some of the time. Binge Eating Disorder and Compulsive overeating are almost identical. Compulsive overeaters will say that they cannot control their food intake and feel they are lacking “willpower”. They will also say that they are eating for comfort rather than hunger or physical need. There are always underlying reasons behind this type of behaviour. Perhaps it is the exertion of control, when it seems we are powerless to make effective choices in our lives. Maybe it is to do with negative body image. It can help to see a counselor and discuss these issues. It is not necessary though to ‘get to the bottom’ of any issue, simply to realize that there are underlying reasons. It is not because you are ‘bad’ or ‘weak’ or ‘have no willpower’. It is because of things that have happened, and you CAN learn to do things differently. This may involve a trip to the doctor, or hiring a qualified Food Addiction therapist or other specialist. The point is that whatever the problem, there is a way out. 5.4 DSM CRITERIA FOR FOOD ADDICTION According to 2019 research, three positions summarize the current debate around food addiction:  The addictive potential of certain foods, such as those with high levels of carbohydrates or fat, qualifies food addiction as a substance use disorder.  Researchers have not identified a specific substance that triggers addiction, such as the nicotine in cigarettes, in potentially ‘addictive’ foods. This means that eating addiction is behavioral and not related to a substance.  Neither of the above holds scientific weight, and even if they did, diagnosing compulsive eating as a food addiction would not be clinically helpful. Despite not having a formal diagnosis in DSM-5, some healthcare professionals still use the term ‘food addiction’. 113 CU IDOL SELF LEARNING MATERIAL (SLM)

5.5 INCIDENCE OF FOOD ADDICTION  More than 5% of the population may suffer from food addiction, according to one study.10  Food addiction occurs in almost 7% in women and 3% in men.10  Food addiction occurs in 2% of under/normal weight people and 8% of overweight/obese people. 10  Women between 45-64 years old have an 8.4% prevalence rate, while those between 62-88 years old have a 2.7% prevalence rate. 5.6 PREVALENCE OF FOOD ADDICTION Up to 50% of individuals with eating disorders also present with substance use disorders, and up to 35% of individuals with substance use disorders also present with eating disorders, bulimia nervosa being most commonly linked to substance abuse. 5.7CO-MORBIDITY OF FOOD ADDICTION According to the Centers for Disease Control, 35 percent of the adults in the U.S. are considered obese, which indicates that overeating is a serious problem nationally. Not everyone who suffers from food addiction is overweight, however. Regardless of whether a food addict is obese or not, this is a serious disorder that can have some lasting consequences. Obesity and poor nutrition can lead to such issues as type 2 diabetes, increased risk of heart disease, and digestive issues. Bulimia can cause heart failure, tooth decay, and damage to the esophagus. These are just the physical complications. Often a food addict also suffers from depression, anxiety, and may even have family or financial troubles associated with overeating. Up to 50% of individuals with eating disorders also struggle with substance use disorders and up to 35% of individuals with substance use disorders also have eating disorders; Bulimia Nervosa being most commonly linked to substance abuse. The findings of the National Center on Substance Abuse indicate both have shared risk factors and characteristics. More specifically, recent studies have pointed towards shared defective neurobiological mechanisms as well as frequent comorbidities between FA, eating disorders, mood disorders, anxiety disorders and substance-related and addictive disorders. 5.8 CAUSES OF FOOD ADDICTION Food addiction is likely the culmination of several factors that interplay in the overall cause of this disorder. A man or woman may develop an addiction as a result of biological, 114 CU IDOL SELF LEARNING MATERIAL (SLM)

psychological, or social reasons. Biological causes that may influence the progression of this eating disorder might include hormonal imbalances, abnormalities in various brain structures, side effects from the use of certain medications, or having family members with this type of addiction issues. It also might also be the result of psychological factors. Factors included in this category might include emotional or sexual abuse, being a victim or survivor of a traumatic event, having an inability to healthily cope with negative situations, chronic low-self-esteem, or experiencing grief or loss. Psychological factors such as these can influence an individual to use food as a coping mechanism to relieve the painful emotions that may have resulted. Lastly, there are social implications that may be involved with food addiction, including factors such as disturbances in family function, pressure from peers or society, social isolation, child abuse, lack of social support, and stressful life events. An addiction to food can also be associated with other co-occurring disorders, such as eating disorders or substance abuse. Because food addiction is a complex mental health issue that can have serious complications if left untreated, it is highly recommended that professional help be sought to effectively heal from this disorder. The Arousal Cycle No one is born with a crack pipe or a cookie in her mouth. There is a process that evolves over time and begins with use, progresses to abuse, and finally escalates to addiction. For a food addict, it may start with something as simple as your parents using food as a reward for good behavior or using food to comfort you when you’re upset. You may then start rewarding your-self with food when you’ve done something you’re proud of or when you feel the need to celebrate. You may progress further to using food to help you feel better when you’re down. Over time, food then becomes your primary coping mechanism for all sorts of situations. If you have a food addiction, you may have recognized yourself in Jenn’s story at the beginning of the chapter. One of the components of Jenn’s food addiction is the arousal cycle, or how she reacts to certain foods. (Here, “arousal” refers to general stimulation, not specifically to sexual excitement.) The arousal cycle consists of three phases (Koob 2009):  Preoccupation or anticipation phase: In this phase, you can’t wait to get your hands on your food fix. You look forward to it with great anticipation.  Getting high on your food fix: You are enjoying the experience of eating your food fix. Sometimes your food fix can put you into a state of excitement or into a trance like state. 115 CU IDOL SELF LEARNING MATERIAL (SLM)

 Withdrawal or let-down phase: In this phase you are feeling low, disgusted, shameful, or guilty. You may also have some physical aftereffects of indulging in your food fix—such as bloating, digestive problems, joint aches, or generalized fatigue. If you think back on it, you may notice that in the early stages of your addiction, you ate and obsessed about certain foods primarily because you loved the way your food fix made you feel. (This is the impulsive aspect of food addiction.) As time went on, your food fix may have been used more often to reduce anxiety, stress, or depression. (This is the compulsive part of the food addiction spectrum.) This is similar to what happens with other forms of addiction. When people first start using heroin, for example, they are feeling all the joys of the euphoria and escape that heroin use provides. In the next phase of the arousal cycle, their use increases. Over time, as they get more and more addicted—both physically and mentally— they will tell you that they are using to keep from getting sick. If they don’t use, they become anxious or restless, they have low moods, or they have physical signs of withdrawal and severe cravings. In the latter stage of addiction, they want to use to avoid the pain of not having their fix, rather than for the joy and anticipation of the “high.” In your own experience of food addiction, you may notice that one stage stands out more strongly than the others. For example, with nicotine dependence in smokers, the getting high phase is not that prominent. The third stage, however, is very noticeable. Nicotine addiction is one of the more difficult addictions to get over because of the negative withdrawal symptoms that many people experience—such as severe anxiety, irritability, and feeling just uncomfortable in their skin. Emotions and stress. People who become addicted to food may eat to enhance positive emotions and to reduce negative emotions. For example, you might eat a pizza to “reward yourself” for an accomplishment, but you might also eat a pizza because something bad happened and “you deserve it.” This is classic addictive thinking. Brain chemistry. Foods that are rich in fat and sugar can alter the reward centers of the brain in the same way as drugs and alcohol. The presence of high-sugar foods reduced self-administration of cocaine and heroin in rats trained to press a lever to receive intravenous drugs. The rats preferred the “natural” high from sugar to the high from drugs. This study shows that sugar might actually have a stronger effect on the brain’s reward system than these drugs. Hormones and Food Addiction Hormones are chemical messengers that work in complex, interrelated ways to control just about every process in your body, from appetite, food cravings, and metabolism to stress and emotions. There are many hormones that relate to eating: ghrelin, made in your stomach, 116 CU IDOL SELF LEARNING MATERIAL (SLM)

which stimulates appetite; leptin, made in the brain, which tamps down appetite; and neuropeptide Y, which makes you feel hungry—to name a few. Insulin Insulin is the hormone responsible for regulating blood sugar. It is also an important hormone when it comes to deciding whether the energy in the food you eat gets used up right away or, if not, is stored as fat. When food is stored as fat, the fatty tissue doesn’t just remain dormant. Other hormones that affect appetite, cravings, and food intake are made directly by that fatty tissue. Most of the food you eat is turned into glucose (sugar) in the body. Normally, the pancreas secretes enough insulin to clear glucose from the bloodstream. When glucose is too high on a consistent basis, or when the pancreas can no longer secrete enough insulin to clear the glucose, you may be diagnosed as prediabetic or diabetic. Thyroid Hormones The thyroid gland is located at the base of your neck, above your collarbone. The thyroid essentially regulates your metabolism and body weight. Its other functions include regulation of menstrual cycles, body temperature, cholesterol levels, heart rate, and more. The thyroid gland can either under produce thyroid hormone, causing weight gain and other symptoms, or overproduce, causing weight loss and other symptoms. Symptoms that may indicate a problem with your thyroid are fatigue; weakness; weight gain or difficulty losing weight; coarse, dry hair; hair loss; frequent muscle aches; constipation; and depression. Sex Hormones Estrogen, progesterone, and testosterone are the sex hormones. These hormones have an impact on your appetite, weight, and food intake. Estrogen may help in regulating your appetite by stimulating the production of serotonin, which makes you feel full or satiated. Many women have changes in their appetite and food preferences around the time of their menstrual cycles that can be related to an imbalance between estrogen and progesterone, triggering food cravings. Testosterone affects weight and muscle mass. If you are female and are deficient in testosterone because of poor nutrition or perimenopause, you will not be able to build muscle as easily as someone with adequate testosterone. This deficiency can also affect your ability to burn calories and lose weight. The same can happen to men who have low testosterone levels that lead to a less muscular physique and a higher level of body fat. If you eat a very low-fat diet, you will not have adequate levels of the sex hormones that rely on intake of fat and cholesterol, the building blocks of all the sex hormones. Stress Hormones Emotional stress has a number of direct and indirect effects on your eating, weight, and health. Stress influences your overall health because it affects a very important system in the 117 CU IDOL SELF LEARNING MATERIAL (SLM)

body—the neuroendocrine immune (NEI) system, which includes the brain, metabolism, and the immune system. When one part of the NEI is out of balance, it can affect all three. Emotions actually stimulate parts of the brain that affect the release of neurotransmitters (such as serotonin, dopamine, and norepinephrine) and also the production of certain hormones—some of which govern eating and weight. If you have a high level of emotional stress, you may experience anxiety, anger, fatigue, low mood, food cravings, weight gain, addiction, and difficulty sleeping. You may also have frequent colds or flu symptoms or recurrent infections, signaling that your immune system is not functioning properly. If your stress becomes chronic, the immune system produces inflammatory molecules called cytokines that increase inflammation in the body, causing further imbalances in the NEI system. Stress can contribute to obesity by leading to “comfort” food eating or emotional overeating, lack of sleep that is associated with weight gain, impulsive behaviors, and overeating of highly palatable foods high in sugar, fat, and salt. Emotional stress leads to the activation of the body’s stress system and the release of the stress hormones adrenaline, noradrenaline, and cortisol. Once your body’s stress system is activated and you go into “fight-or-flight” mode, these stress hormones have their own negative effects on the body and can lead to the development of central obesity (apple figure), insulin resistance, and metabolic syndrome (characterized by high blood pressure, high cholesterol and triglycerides, and diabetes) Genetics. Another food addiction cause may be genetics. A 2002 study found that women with a family history of alcoholism had a 49% higher chance of obesity than those without a family history. Although not everyone with obesity has a food addiction, this suggests that there may be a relationship between alcohol addiction and food addiction. Trauma A study of women with PTSD found that women with the greatest number of PTSD symptoms had more than twice the prevalence of food addiction as women with no PTSD symptoms or no history of trauma. When the trauma and onset of PTSD symptoms happened at an earlier age, the relationship to food addiction was even stronger. This suggests that women who experienced a childhood trauma may be at greater risk of food addiction. 5.9 PROGNOSIS OF FOOD ADDICTION Some eating disorders are too complex to treat with outpatient therapy alone. In these cases, a residential treatment center or inpatient hospital may be the best option. A person may live at the facility for one month or longer, getting full-time treatment and support. There are a wide range of rehab programs for eating disorders. Residential centers often include mental health therapy and alternative therapies in their programs. These could include 118 CU IDOL SELF LEARNING MATERIAL (SLM)

tai chi, equine-assisted therapy, or art therapy. Other centers build their programs around specific models of psychotherapy, like Internal Family Systems (IFS) or dialectical behavior therapy. Just as for any addiction, there are consequences related to food addiction that impact your life and the lives of your friends and family members. People with food addiction often experience depression related to their eating behaviors. If you have a food addiction, you may be more prone to health problems, stress, difficulty sleeping, digestive problems, fatigue, and thoughts of suicide due to hopelessness about your food addiction. You may also have higher risks for high blood pressure, type 2 diabetes, high cholesterol, heart disease, and certain cancers. You may experience pain from arthritis in your joints if you are overweight or obese, and you may also have sleep disorders related to your weight. Many of these health risks are related to life-style more than to weight. You can be healthy at any size if you are able to be physically active and have healthy eating behaviors. More than any medical risks, food addiction is psychologically debilitating. Thoughts about food, eating, your weight, or your size can take over your life and make you feel isolated, hopeless, and unhappy. Your food obsessions may cause low self-esteem, anxiety, or panic attacks. You may feel sad, irritable, or emotionally detached or numb. Your work performance may suffer and you may feel isolated from your friends and family members. Food addicts often avoid social events because of embarrassment about their eating behaviors. It’s important to heal your food addiction to enable you to get back into the life you want. 5.10 TREATMENT OF FOOD ADDICTION If you or a loved one has found yourself stuck in the vicious cycle of an addiction to food, you have likely experienced a roller coaster of emotions, including despair, frustration, and hopelessness. Living with an addiction to food may be preventing you from enjoying a life you once lived, though the possibility for healing always exists. By seeking the appropriate help and care you need, you can find the resources to address your addiction to food in an effective manner. Thankfully, there are specialized food addiction treatment centers that can help you approach this disorder in a holistic and comprehensive manner. Food addiction treatment centers offer multi-specialty treatment that will focus on and address medical issues and nutritional concerns while integrating psychotherapy. There is also a myriad of support groups that you can become involved with, such as Food Addicts Anonymous, Overeaters Anonymous, and Food Addicts in Recovery Anonymous. These groups are 12 step based programs that effectively address this on the physical, emotional, and spiritual aspects, offering much needed support to individuals seeking to heal from their addiction to food. 119 CU IDOL SELF LEARNING MATERIAL (SLM)

Attempting to deal with your addiction to food alone can possibly further draw you into fear or isolation. Having guidance, help and support from an eating disorder center that treats food addiction, specialist, or support group can provide you or your loved one with the tools and resources you need to recover and heal from an addiction to food. 5 Levels of Treatment Level 1—Stopping Superficial Behaviors The first step in recovery is to learn to interrupt these behaviors while at the same time not making them the focus of all your efforts. If you’re not satisfied with your body, doesn’t it make sense to put yourself on a diet? If you don’t trust yourself to eat healthily, doesn’t it make sense to be strict in how you think about food? The fact is these strategies aren’t effective because they don’t address the deeper issues. For instance, the reason diets don’t work is because they focus solely on the level of superficial behaviors. People are made to believe that if they just lose weight, their lives will change, their stress will go away, and they will somehow magically be comfortable around food when the diet ends. If you’re reading this book, you have probably admitted to yourself on some level that dieting only makes things worse. For food addiction, abstinence means no longer practicing the behaviors associated with your eating addiction—such as eating impulsively, obsessing about food, restricting, and all the other behaviors that are part of your specific form of food or eating addiction. Your food addiction behaviors serve as a distraction from dealing with underlying issues in your life and allow you to stay in denial about other issues that you are not addressing. The first step to any change is becoming more aware of your behaviors. In order to develop this awareness in a way that doesn’t create more shame or guilt, it is important to create a sense that this work is sacred. This will help you give yourself permission to avoid self-hatred or self-abuse about whatever you learn during this time. Level 2—Emerging from the Emotional Soup Once you’re aware of the addiction-like behaviors you have around food, it’s time to recognize that these behaviors are being driven by emotions. Essentially, you are using food as a way to cope with feelings. In Lisa’s story, her self-confidence and sense of being safe in the world and being able to keep her daughter safe were marred by her traumatic childhood experience. That experience made her feel the need to be on red alert all the time—especially to keep her daughter safe. Being on red alert is an over activation of your stress response system. Level 3—Embracing the Wisdom of Body Sensations Perhaps you respect yourthoughts but don’t respect the sensations in your body. You may feel your body is not your ally, but a recalcitrant and stubborn enemy that you’re trying to beat in the game of weight loss. You may feel embarrassed by your body or feel your body is 120 CU IDOL SELF LEARNING MATERIAL (SLM)

always throwing you a curve ball with random food cravings and desires, strange sensations that you don’t understand and even stranger needs that may baffle you. By reclaiming a connection with your body and learning your body’s language, you will be able to use your body’s wisdom, which far surpasses anything your mind tells you, to help you heal. The mind and its constant barrage of thoughts, opinions, and judgments are where your food addiction lives. The body is where the healing happens. Level 4—Creating New Core Beliefs A core belief is the lens through which we see ourselves, other people, and the world. Core beliefs are usually formed when we are young. They can also be formed in adulthood, when we’ve experienced a traumatic event or an emotionally distressful time. Core beliefs usually have to do with primal needs, such as the need for safety, attention, love, and approval. Core beliefs usually serve a purpose when they are formed, but often they become problems for us later in life. Once you form a core belief, you probably won’t be consciously aware of it, but it will be one of the driving forces for your behaviors—not just behaviors relating to food, but to many other aspects of your life. Constant vigilance is very stressful and makes it difficult to trust people. That could affect her ability to form relationships. It definitely would affect her eating behaviors, making her feel the need to closely monitor and control her choices about food (and perhaps her daughter’s choices as well). So it’s important to understand what your core beliefs are and how they are operating in your life. Level 5—Finding Soul Satisfaction When you have a food or eating addiction and have obsessive thoughts and uncomfortable behaviors about food, the suffering you experience is related to a difference between what your cravings and emotions are telling you to do and what you feel in your soul is authentic or true for you. Recovery from food addiction is very much about satisfying the true needs of your soul. People find soul satisfaction through a host of practices: meditation, being in nature, going to 12-Step meetings, or being part of any group that gives them positive, uplifting input. These practices can lift your spirits, give you a sense of awe, or simply make you feel good. Treatment for compulsive eating should address the emotional, physical, and psychological needs of the individual.Treatment will focus on breaking the destructive habit of chronic overeating. The goal is to replace dysfunctional eating habits with healthy ones and to address problems, such as depression or anxiety. Treatments that may be effective include: Behavior Therapy: Start by keeping a food journal. Write down everything you eat and drink, from the juice you drink at breakfast to the bite of chocolate you have to help you through the afternoon at work to the pasta and bread you eat for dinner. Tracking 121 CU IDOL SELF LEARNING MATERIAL (SLM)

you’reeating habits can help you be more aware of just how much sugar—in the form of white sugar and simple carbohydrates—you’re consuming. Read labels when you’re shopping. You’ll likely be surprised at how much sugar (of many different varieties) is in the food you’re accustomed to eating. Cut back on your sugar intake gradually so you don’t shock your system. Begin by banishing high-sugar sweets from your home. Start eating more whole grains and fewer pastas and breads made from white flour. When you have a sugar craving in the afternoon, eat a banana or an apple. Use seven-grain bread instead of white. Substitute natural sugars for refined white table sugar. Cognitive behavioral therapy (CBT): This branch of psychotherapy aims to identify and change negative thought patterns, as well as creating new coping mechanisms for food addiction triggers. People can take a course of CBT either individually or in a group session. Medication: A person may take medications to relieve symptoms of depression or anxiety that may underly compulsive eating. Solution-focused therapy: A therapist can help an individual find solutions for specific issues, triggers, and stressors in a person’s life that lead to overeating. Trauma therapy: A psychotherapist helps a person come to terms with the trauma that may have links to trigger compulsive eating. Nutritional counseling and dietary planning: This can help a person develop a healthy approach to food choices and meal planning. To keep your blood sugar levels stable and to minimize sugar cravings, eat foods rich in protein and B vitamins. To break the sugar habit, avoid refined carbohydrates such as white bread, white rice, and pasta; eat more complex carbohydrates such as oatmeal, brown rice, and millet. Eat less salt, and fewer dairy products; they’ll cause you to crave something sweet later. Slow down and savor the natural sweetness in food, noticing the “full” taste rather than the “hollow,” empty-of-nutrients sweetness. Chew all your food slowly and thoroughly. Be present with what you’re eating. Enjoy herbal teas without sweeteners. Lifestyle tips Several lifestyle changes can also help a person manage uncontrollable urges to consume particular foods, including:  replacing processed foods and sweeteners with nourishing or less caloric alternatives, such as swapping out table sugar for stevia or potato chips for lentil chips and popcorn  avoiding caffeine  allowing time for a food craving to subside, which can be 2–5 days or longer (http://foodaddictionresearch.org/question-and-answer/if-im-addicted-to-food-what- can-i-do/) 122 CU IDOL SELF LEARNING MATERIAL (SLM)

 eating three balanced meals a day  drinking plenty of water  mindful eating, which involved sitting down to eat meals, focusing on the taste and texture of the food, and chewing slowly  preparing and sticking to a grocery list of healthful foods  cooking meals at home  exercising regularly  getting enough sleep  reducing stress in social settings and the workplace 5.11 SUMMARY  Foods full of fat and sugar can supercharge the brain’s reward system similarly to the way addictive drugs do. They can override the brain’s normal ability to tell an individual to stop eating. When this happens, a person may want to eat more and more.  Like drug addiction, food addiction can also lead to cravings, tolerance, and even withdrawal. For example, a study using high-tech brain imaging scans looked at the brains of abnormal versus normal eaters when they saw a milkshake.  Researchers found that the addicted eaters responded to the milkshake the same way that alcoholics respond when shown a cold beer.  People overeat and become obese for many reasons. Just like people who drink or smoke marijuana, not everyone becomes addicted.  Recent studies have tried to pinpoint what makes people addicted to food different than people who binge eat. The distinction is an important one, because it directly relates to food addiction treatment.  For example, when addiction is the underlying cause of obesity, traditional treatment with diets that rely on personal responsibility or “willpower” may not be sufficient. Because food stimulates the reward center in the brain, many psychologists believe it must be treated in the same way as any other addiction.  They believe that lifestyle changes and even gastric bypass surgery will have minimal effect unless the underlying addiction is addressed.  A major advancement in the study of food addiction is the Yale Food Addiction Scale (YFAS). This scale was developed to identify people who are exhibiting signs and symptoms of food addiction. 123 CU IDOL SELF LEARNING MATERIAL (SLM)

 Recovery from food addiction is different from recovery from alcoholism or drug addiction in one simple way. You cannot simply refrain from eating all together as a part of your recovery.  Humans need to eat to live, so there has to be some form of behavioral change. One thing is certain. Food addiction is a problem that is unlikely to be solved without help.  There are several food addiction recovery options available if you or a loved are suffering from this eating disorder.  Treatment for food addiction includes therapy, such as cognitive-behavioral therapy (CBT), nutritional therapies, and group support. Contact us to learn more about our food addiction recovery program or to discuss admission options. 5.12 KEY WORDS  Evidence-based practice (EBP): Patient care informed through the integration of clinical expertise and best available clinical evidence from systematic research.  Guilt: A cognitive-affective state that emerges in humans when one perceives a personal wrong-doing; it can be adaptive and helpful in increasing the likelihood that behavior remains consistent with one’s values.  Interventions: The action of coming between persons and their problems to try and help the person face the reality of their problems, especially addictions; for example a family may all sit down and try to make a drug addict admit they have a problem and get them to agree to treatment  Natural recovery: A common recovery pathway in which remission from substance use disorder is achieved without the support or services of professional or non- professional intervention. Also known as self-managed recovery.  Outpatient treatment: A professionally delivered substance use disorder treatment modality that requires daily to weekly attendance at a clinic or facility, allowing the patient to return home or to other living arrangements during non-treatment hours.  Psychosis: A mental state whereby a person does not face reality and may, in fact, suffer from hallucinations, delusions, a lack of insight into the inappropriateness of their thoughts and behaviors, and basic disturbances to thoughts, usually seen by disturbed speech and writing  Psychotherapy: The attempt to help an individual or group come to terms with, accept, and deal with psychological and emotional feelings and ideas  Psychodynamic psychotherapy: A form of talk therapy that focuses on the psychological developmental histories and internal unconscious processes (e.g. needs, 124 CU IDOL SELF LEARNING MATERIAL (SLM)

urges, desires) in the patient’s psyche that may present outwardly in a patient’s behavior.  Recovery: The process of improved physical, psychological, and social well-being and health after having suffered from a substance use disorder.  Relapse: Relapse often indicates a recurrence of substance use. More technically, it would indicate the recurrence and reinstatement of a substance use disorder and would require an individual to be in remission prior to the occurrence of a relapse.  Relapse prevention (RP): Relapse Prevention is a skills-based, cognitive-behavioral treatment approach that requires patients and their clinicians to identify situations that place the person at greater risk for relapse – both internal experiences.  Remission: The complete absence of symptoms or the presence of symptoms but below a specified threshold. An individual is considered to “in remission” if they once met criteria for a substance use disorder, but have not surpassed the threshold number of criteria within the past year or longer. 5.13 LEARNING ACTIVITY 1. People participate in eating championships. DO you think they suffer from food addiction? Justify. ___________________________________________________________________________ ___________________________________________________________________________ 2. Explain the process of treatment provided to a person with food addiction? ___________________________________________________________________________ ___________________________________________________________________________ 5.14 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. What is food addiction? 2. What is emotional eating? 3. What is compulsive eating? 4. What is the incidence of food addiction? 5. What is the prevalence of food addiction? 125 CU IDOL SELF LEARNING MATERIAL (SLM)

Long Questions 1. Explain the symptoms of food addiction? 2. What are the types of food addiction? 3. What are the causes of food addiction? 4. Explain the treatment for food addiction. 5. Write about the five levels of treatment for food addiction B. Multiple Choice Questions 1. Eating quickly until uncomfortably full describes: a. Compulsive eating b. Bulimia c. Food addiction d. Binge eating 2. Distorted body image describes: a. Binge eating b. Bulimia c. Compulsive overeating d. All of these 3. Possible effects are weight gain, high blood pressure, heart disease, and diabetes: a. Compulsive eating b. Bulimia c. Food addiction d. Binge eating 4. Which of the following is an example of repression? 126 a. Stopping others from behaving inappropriately. b. Stopping yourself from behaving the way you want to c. Suppressing bad memories or current thoughts that cause anxiety. CU IDOL SELF LEARNING MATERIAL (SLM)

d. Suppressing your natural instincts 5. Psychoanalysis is an attempt to explain what? a. Normal psychological functioning b. Abnormal psychological functioning. c. Normal and abnormal psychological functioning. d. Childhood ideation Answers 1-a, 2-d, 3-a, 4-c, 5-c 5.15 REFERENCES Textbooks  Ahuja N (2002). A short text book of Psychiatry. (5th edn). New Delhi: Jaypee Brothers Medical. Publishers (pvt) Ltd.  American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision: DSM-IV-TR. Washington, DC: American Psychiatric Publishing, Inc.  Clifford Morgan, Richard King, John Weisz, John Schopler (2004) Introduction to Psychology, McGraw-Hill, New Delhi  Domjan Michael (2010). The Principles of Learning and Behavior (6th Edt) Wadsworth, Cengage Learning.  Hergenhahn B R (2008). An introduction to the history of psychology, Wadsworth, Cengage Learning.  Robert S. Feldman (2011) Understanding Psychology, McGraw-Hill, New Delhi.  Robert. A. Baron, Psychology, (2008) Prentice Hall India. Reference books  American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision: DSM-IV-TR. Washington, DC: American Psychiatric Publishing, Inc. 127 CU IDOL SELF LEARNING MATERIAL (SLM)

 Carson, R. C., Butcher, J. N., & Mineka, S. (2002).Abnormal psychology over time. In Fundamentals of abnormal psychology and modern life. New York: Allyn & Bacon.  Emery, R.E., &Oltmans, T.F. (1998). Abnormal Psychology (2nd ed.). Upper Saddle River, NJ: Prentice-Hall, Inc.  Kay J, Tasman A. (2006) Essentials of Psychiatry, Chichester, John R. Wiley and Sons.  Sadock, Benjamin, J., & Virginia A. (2002). Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (9th ed.). Lippincott Williams &Wilkins.  Sarason I., G & Sarason B. R. (2005).Abnormal psychology: The problem of maladaptive behavior. (11th edn). PHI Learning Private limited.  World Health Organization (1993). The ICD-10 Classification of Mental and Behavioral Disorders Websites  www.simplypsychology.com  http://www.human-memory.net  www.simplypsychology.org  https://psychcentral.com  https://courses.lumenlearning.com  https://www.sparknotes.com 128 CU IDOL SELF LEARNING MATERIAL (SLM)

UNIT 6 – CASE STUDIES STRUCTURE 6.0 Learning Objectives 6.1 Introduction 6.2 Case of Diana 6.3 Case of Maria 6.4 Case of Child with Pica 6.5 Case of Rumination Disorder 6.6 Case of Pica Disorder 6.7 Summary 6.8 Key Words 6.9 Learning Activity 6.10 Unit End Questions 6.11 References 6.0 LEARNING OBJECTIVES After studying this unit, you will be able to,  Describe the symptoms and clinical presentation of Dementia  Describe the symptoms and clinical presentation of Pica and Rumination Disorder  Describe the symptoms and clinical presentation of Delirium 6.1 INTRODUCTION A case study is an intensive study of a person or group. Most case studies combine long-term observations with diaries, tests, and interviews. Case studies can be a powerful research tool. By itself, however, a case study does not prove or disprove anything. The results cannot be generalized to anyone else. The researcher’s conclusions may not be correct. Case studies, though, provide a wealth of descriptive material that may generate new hypotheses that researchers can then test under controlled conditions with comparison groups. Case study research is one of the most important in business research. It is also used as marketing collateral by most businesses to land up more clients. Case study research is conducted to assess customer satisfaction, document the challenges that were faced and the solutions that the firm gave them. Using these inferences are made to point out the benefits 129 CU IDOL SELF LEARNING MATERIAL (SLM)

that the customer enjoyed for choosing their specific firm. Such research is widely used in other fields like education, social sciences, and similar. Case studies are provided by businesses to new clients to showcase their capabilities and hence such research plays a crucial role in the business sector. 6.2 CASE OF DIANA At the age of 45, Diana Friel McGowin was a successful legalassistant, wife, and mother, but she was beginning to experience“lapses.” She writes about developing these problemsjust before a party she was planning for her family.Nervously, I checked off the table appointments on a list retrievedfrom my jumpsuit pocket. Such a list had never beennecessary before, but lately I noticed frequent little episodesof confusion and memory lapses. I had decided to “cheat” on this family buffet and have themeal prepared on a carry-out basis. Cooking was also becomingincreasingly difficult, due to what my children and myhusband Jack teasingly referred to as my “absentmindedness.”In addition to memory difficulties, other problems beganat this time, including brief dizzy spells. Diana wrote of herfamily’s growing awareness of the additional symptoms. Shaun walked past me on his way to the kitchen, and paused.“Mom, what’s up? You look ragged,” he commented sleepily.“Late night last night, plenty of excitement, and then up earlyto get your father off to work,” I answered. Shaun laughed disconcertingly.I glanced up at him ruefully. “What is so funny?”I demanded. “You, Mom! You are talking as though you aredrunk or something! You must really be tired!” In the early stages of her dementia, Diana tended to explainthese changes in herself as temporary, with suchcauses as tension at work. However, the extent of her dysfunctioncontinued to increase, and she had more frighteningexperiences. In one episode, she describes an attempt todrive home from a brief errand.Suddenly, I was aware of car horns blowing. Glancing around,nothing was familiar. I was stopped at an intersection and thetraffic light was green. Cars honked impatiently, so I pulledstraight ahead, trying to get my bearings. I could not read thestreet sign, but there was another sign ahead; perhaps it wouldshed some light on my location. A few yards ahead, there wasa park ranger building. Trembling, I wiped my eyes, andbreathing deeply, tried to calm myself. Finally, feeling readyto speak, I started the car again and approached the ranger station. The guard smiled and inquired how he could assist me.“I appear to be lost,” I began, making a great effort to keep myvoice level, despite my emotional state. “Where do you needto go?” the guard asked politely. A cold chill enveloped me asI realized I could not remember the name of my street. Tearsbegan to flow down my cheeks. I did not know where Iwanted to go. Diana’s difficulties continued. She sometimes forgot thenames of her children, and once she astounded her nephewwhen she didn’t recognize him. If she left home, she almostinvariably got lost. She learned to introduce herself as atourist from out of town, because people would 130 CU IDOL SELF LEARNING MATERIAL (SLM)

give herbetter directions. She felt as if there “was less of me everyday than there was the day before”. During initial medical examinations, Diana didn’t recallthis type of problem in her family history. However, a lookthrough some of her late mother’s belongings revealed thatshe was not the first to experience symptoms of dementia.Then I noticed the maps. After mother’s death I had found mysterious hand drawn maps and bits of directions scribbledon note papers all over her home. They were in her purses, inbureau drawers, in the desks, seemingly everywhere. Too distraughtat the time to figure out their purpose, I simply packedthem all away with other articles in the box. Now I smoothedout each map and scrawled note, and placed them side by side.They covered the bedroom floor. There were maps to everyplace my mother went about town, even to my home and mybrother’s home. As I deciphered each note and map, I beganrecollecting my mother’s other eccentric habits. She would notdrive out of her neighborhood. She would not drive at night. She was teased by both myself and my brother about “memorygoofs” and would become irate with both of her childrenover their loving teasing.Then with a chill, I recalled one day when I approachedmy mother to tell her something, and she did not recognize me. 6.3 CASE OF MARIA “Maria,” a pleasant 80-year-old female subacute rehabilitation patient was referred to me for a psychological evaluation of her depression and anxiety. At the time, Maria had just suffered a right frontal lobe cerebrovascular accident (CVA) with left-sided hemiparesis and worsened urinary incontinence. Although she experienced dramatic deterioration in most areas of functioning, her greatest concern and self-reported origin of most of her anxiety surrounded her urinary incontinence and subsequent changes in privacy. Maria reported that she was never married and had no children. She was an independent and successful woman up until her CVA. She designed preschool programs in her early adulthood and later worked as a social worker for low-income children and families. She went back to school to become a registered home health nurse. After retirement, she raised a therapy dog and visited nursing homes and hospitals. She described her work as her “life mission,” and she found great purpose and meaning in serving others. The biggest blow to her self-esteem was that she now was the patient who relied on others for care, which was an extremely difficult reality for her to face. Her thought process was often focused on her fear of not getting to the restroom in time, sitting in a wet diaper, and/or the possibility of recurrent urinary tract infections (UTIs). Maria reported experiencing worsening urinary frequency and occasional urinary incontinence starting approximately 10 years ago, altering her quality of life. Over the years 131 CU IDOL SELF LEARNING MATERIAL (SLM)

she increasingly focused on this physical symptom, while her social and professional life suffered, and she withdrew from many activities. She became more self-conscious of her perceived “disability.” Maria recognized that her urinary continence was one of the last areas of functioning she could control and by “letting go” of that fear meant that she was accepting her need for care. While in rehabilitation, Maria interacted with staff and residents, used humor in most social environments, asserted ideas of hope and recovery, and stayed in contact with friends and family members in the community. However, as time progressed she appeared to be more withdrawn, similar to her life pattern prior to her CVA. She isolated in her room between rehabilitation sessions, rarely spoke with other residents, and presented with increased anxiety and depression. She used her call light at least every hour to request to go to the restroom. She often focused her attention on physical symptoms that could be related to a UTI. Even after results from multiple urinalyses were negative for an infection, she continued to question the accuracy of the results. Some staff described her as a “problem resident” as they viewed her frequent requests for assistance as attention-seeking behavior. Once we began talking about her urinary incontinence, common underlying themes were observed in session. She experienced sadness regarding the loss of independence and control in her life. Maria felt as if she were not heard by staff. She acknowledged a decreased desire to interact with other residents and family. She expressed feelings of hopelessness and helplessness, and she displayed a poor self-image. Because she had developed good insight and empathy for others through her professional training and life experiences, she was able to pick up on negative non-verbal cues from the staff members, such as poor eye contact, quick and abrupt body movements, sighs and groans, and rapid speech. She interpreted these cues as an act of not caring. Maria often felt abandoned. As a result of the culminating stress, her concerns about her urinary incontinence and requests for help continued to increase. Treatment plan Therapy was focused on helping Maria connect with her former “successful” self and shift her focus from her losses to her strengths. I also consulted with the staff regarding the patient’s perspective and provided suggestions on how to most effectively interact with her when providing care. I recommended the following suggestions: 1. Always use consistent eye contact and face her when talking. 2. Speak slowly and allow her ample time to respond to questions. 3. Use gentle touches and move slower when transferring her. 4. Listen to each concern empathetically and find a solution to her concern if at all possible. 5. If unable to attend to her needs at that time, provide an estimation of time to return to care for her. 132 CU IDOL SELF LEARNING MATERIAL (SLM)

6. If at all possible, have a conversation when providing care. Ask her about her past work and life experiences. Within a couple of weeks, Maria noticed a change in her care and her overall self-image. She became less focused on her urinary incontinence as she felt she had more control over her environment. She began engaging more in her social life inside and outside of the long-term care facility. Ultimately, she was able to connect with her inner strengths and emotional capabilities because of psychological intervention and training of staff. 6.4CASE OF CHILD WITH PICA A. is a 10-year-old girl of Moroccan origin appearing in pediatric specialist of A.P repeatedly by unspecific stomachache, nausea and vomiting. After several visits to the same reason for consulting an exploratory interview alone with the patient in that regard that “sometimes when calms nervous scratching the walls and eating them” is performed. The mother says intrafamily difficulties. Information reported by the patient's mother confirms next visit also providing pictures on the wall of your room is returned. Referral to child and adolescent mental health is decided. Ingestion of nutrients can occur in the course of other mental disorders (for example, a pervasive developmental disorder, schizophrenia), mental retardation, in the Kleine–Levin syndrome… In these cases, should only be established an additional diagnosis of pica if the feeding behavior is sufficiently severe to warrant independent clinical attention. Pica disorder has been studied by pediatricians, gynecologists, dermatologists, psychiatrists, psychologists, nutritionists, anthropologists, etc., which has been interpreted as a conduct disorder, food, mental illness, poverty, hunger… but really the cause it is unknown. Although morbidity and mortality is unknown and difficult to study, include poisonings, parasitosis and surgical abdomen as serious complications. Finally, like all other eating disorders, the overall management of this entity requires the coordinated intervention of various professionals. 6.5CASE OF RUMINATION DISORDER MS A is a 17-year-old girl from Addis Ababa, Ethiopia. She presented to a private informal setting per personal request with the major complaint of ruminating food for the past year. Various distinct clinical phases could be identified in her clinical history. She reported that her difficulties began a few years ago when she gained 22 lb. (10 kg). Being overweight, Ms. A felt uncomfortable, and she was teased by her classmates, who called her “the fat girl” (overweight phase). As a result, Ms. A attempted to reduce her caloric intake by eliminating the food she had eaten through self-induced emesis (bulimic phase). This process proved effective, and she succeeded in her goal of losing the excess weight. As the frequency of her induced vomiting increased, Ms. A became more capable of inducing vomiting without the assistance of her fingers or other device. Ms. A found that chewing the 133 CU IDOL SELF LEARNING MATERIAL (SLM)

regurgitated food was “tasty” and pleasurable, and this triggered the onset of the rumination symptom (rumination phase). The regurgitation and rumination phase did not supersede the bulimic symptoms. The process of rumination occurs almost continuously throughout the day and follows a fixed pattern: the food is frequently ruminated and then reswallowed; less frequently, the food is spat out, normally after dinner. Ms. A chooses specific combinations of foods based on the taste of the regurgitated substance, but also to ensure that the consistency of the bolus is easily ruminated. She stated, “I cannot think of any food as delicious as the ruminated food.” Ms. A adjusts her daily fluid intake to facilitate and optimize the rumination. Her posture was also determined to be an important element of the rumination. While sitting, Ms. A would have the optimal position to facilitate rumination; standing would make it more difficult, while lying down would make the rumination process uncomfortable, as the regurgitated material would enter the nose. Ms. A had gastroscopies performed 6 and 12 months prior to being seen in the private informal setting. The first investigation was negative, but the subsequent gastroscopy revealed the presence of a small ulcer, which was most likely associated with the frequent vomiting and ruminating. However, there was no evidence of other medical or gastroenterological pathologies that could explain her symptoms. During the bulimic phase, Ms. A’s electrocardiogram displayed irregular beats (arrhythmias). Generally speaking, her bowel habits are regular, with approximately 1 episode of diarrhea per week. In addition, Ms. A often complains about an acute and generalized toothache. Discussion Rumination is considered a disorder of infancy or of persons with developmental disorders. When rumination occurs in adults with normal intelligence, the diagnosis may pose a challenge to clinicians. Furthermore, in an African context, in which, historically, eating disorders are believed to be nonexistent or extremely uncommon, the diagnosis is even more challenging. The diagnostic process for Ms. A was indeed very complicated and lasted for more than a year. She had visited several specialists, including a gastroenterologist, who were unable to diagnose the disorder. She was finally diagnosed by a psychiatrist. Today, Ms. A meets all criteria for rumination syndrome. Rumination syndrome was diagnosed according to the Rome III Diagnostic Criteria for Functional Gastrointestinal Disorders (Table 1).6 She also meets all criteria for bulimia nervosa according to both DSM- IV-TR7 (purging type) and DSM-5 (severity: extreme), which are substantially identical. Ms. A is currently receiving support and psychotherapy on a weekly basis. After the bulimic phase, Ms. A is relatively satisfied with her weight; however, her weight is not stable but 134 CU IDOL SELF LEARNING MATERIAL (SLM)

keeps fluctuating. Ms. A has been referred to a nutritionist, who has given her a diet of 2,000 calories per day. 6.6 CASE OF PICA DISORDER Pica is defined as the repeated and excessive consumption of non-nutritive, non-food substances over the course of 1 month. It can occur secondary to nutritional deficiency or as a form of comfort in people with psychosocial stressors. It is considered as a culturally approved practice and is not always pathological. Here we are reporting a case of a 35 year old female presenting with consumption of cardboard pieces. She was diagnosed to have Xylophagia which is a form of Pica secondary to depression. Mrs. H, a 35-year-old female, Hindu by religion, married with an eight-month-old male baby, studied till degree, currently not working, belonging to middle socio-economic status family, with no family history and no past history of any psychiatric illness or neurodevelopmental delay. She presented to the psychiatry outpatient department with complaints of consuming paper and cardboard whenever she was alone from the past 2 months. The onset of her symptomatology was eight months into her post-partum period, was of an insidious onset and progressive nature. Every time she unpacked toys for her child, she would repeatedly smell the cardboard boxes and had an intense liking for the same. When alone at home, she felt like tasting those cardboard papers and ate a few pieces. There were no negative consequences the first time she ate a few pieces which further reinforced her interest. Gradually over the course of a week, she also started chewing on the ends of pencils and ice- cream sticks. On certain days she would end up consuming two to three A4 size sheets bit by bit. The fear of being caught in the act produced significant distress but when alone it would facilitate aggravated consumption. On further detailed evaluation she reported of low mood consistently for the past 2 months because she felt constrained to her home as she was unable to go for work like she used to previously. She had decreased interest in carrying out daily routine work. She reported that she would feel very tired throughout the day and doing household work was becoming laborious. Previously she used to enjoy going out with her friends and family but since the past two months she always preferred to be alone. She did not feel that it was irrational to consume the paper items and did not find it distressful. She also revealed the truth that this habit of eating cardboard and paper gave her a sense of relaxation and helped her forget her worries. Her physical examination was normal and on MSE she was well kempt and groomed, rapport was established with ease. Her mood was subjectively sad and objectively depressed. There was no thought or perceptual disturbances. Her cognitive functions were found to be normal. Hamilton Rating Scale for Depression was applied and her score was found to be 24. Complete blood count revealed Hemoglobin of 10.8 mg/dl and other blood parameters were 135 CU IDOL SELF LEARNING MATERIAL (SLM)

within normal range. Urine routine examination, X-ray abdomen, Ultrasound abdomen was found to be normal. She was diagnosed with Pica secondary to severe depression without psychotic symptoms according to ICD 10 diagnostic criteria and was started on tab Escitalopram 10 mg together with iron supplements. No significant improvement was noted after a period of two weeks. In the next follow up, patient was started on tab Fluoxetine 20 mg that was increased up to 40 mg. Psychoeducation about the nature of her illness was given to her and her family members. Patient was advised behavioral modification. Her psychosocial stressors were addressed and patient was taught relaxation techniques. Patient reported improvement in her low mood and depressive symptoms on further follow- ups in the next two weeks. Hamilton Depression Rating Scale for Depression applied after 2 weeks was found to be 11. She was abstinent from consumption of paper during this time and for the next two months. She also admitted that she is not having the desire to eat those unwanted substances anymore. She was advised for further follow-ups and educated about treatment adherence. Discussion Pica is sometimes a culturally sanctioned practice and may not be pathological always. Although Pica is the most common eating disorder in individuals with developmental disabilities, in this case there was no history of any neurodevelopmental disorder. Although the etiology of Pica is unknown, more recent cases of Pica have been tied to the obsessive- compulsive spectrum disorder. In this patient, there was no history to suggest obsessions as she did not find it irrational or distressful. Numerous hypotheses like psychosocial, biochemical, cultural, socioeconomic and psychodynamic factors explain the phenomenon of Pica. Deficiencies in iron, calcium, zinc and nutrients including thiamine, niacin, Vitamins B and C have been associated with Pica in children. Pica may be benign but sometimes it may be associated with life-threatening complications. Certain psychosocial stressors have been reported to be significantly associated with pica, including maternal deprivation, joint family, parental neglect, pregnancy, impoverished parent-child interaction, and disorganized family structure. In certain scenarios of ingestion of inedible substances, variable and potentially lethal complications may emerge, depending on the type and amount of material ingested. In this case the patient started the consumption of paper as a stress buster secondary to depression. The fact that the consumption of paper reduced significantly when her mood symptoms improved gave the evidence that it was secondary to depression. In our patient no other adverse effects had occurred and she showed significant response with psychoeducation and anti-depressants. 136 CU IDOL SELF LEARNING MATERIAL (SLM)

6.7 SUMMARY  A case study is an in-depth study of one person, group, or event. In a case study, nearly every aspect of the subject's life and history is analyzed to seek patterns and causes of behavior.  Case studies can be used in a variety of fields including psychology, medicine, education, anthropology, political science, and social work.  A case study can have both strengths and weaknesses. Researchers must consider these pros and cons before deciding if this type of study is appropriate for their needs.  One of the greatest advantages of a case study is that it allows researchers to investigate things that are often difficult to impossible to replicate in a lab.  Researchers may choose to perform a case study if they are interested in exploring a unique or recently discovered phenomenon. The insights gained from such research can then help the researchers develop additional ideas and study questions that might then be explored in future studies.  The hope is that learning gained from studying one case can be generalized to many others. Unfortunately, case studies tend to be highly subjective and it is sometimes difficult to generalize results to a larger population.  There are also different methods that can be used to conduct a case study, including prospective and retrospective case study methods.  Prospective case study methods are those in which an individual or group of people is observed in order to determine outcomes. For example, a group of individuals might be watched over an extended period of time to observe the progression of a particular disease.  Retrospective case study methods involve looking at historical information. For example, researchers might start with an outcome, such as a disease, and then work their way backward to look at information about the individual's life to determine risk factors that may have contributed to the onset of the illness. 6.8 KEY WORDS  Case Study: The collection and presentation of detailed information about a particular participant or small group, frequently including the accounts of subjects themselves.  Case Management: Case Management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through 137 CU IDOL SELF LEARNING MATERIAL (SLM)

communication and available resources to promote patient safety, quality of care, and cost effective outcomes.  Dementia Symptoms: The signs of a progressive decline in adult cognitive functions due to damage or disease in the brain, beyond normal aging. Symptoms include problems with memory, language, problem solving, and attention  Elderly Persons Disorders: A group of mental and emotional problems as they affect primarily older persons, such as depression, grief, and memory impairments  Group Counseling: Discussions or therapy that takes place in a group setting; dealing with multiple individuals at the same time, helping them to help each other during the course of the discussions and personal revelations  Group Therapy: Counseling and discussions whereby group members help each other and themselves by discussing individual problems for the benefit of all  Healthy Living: Approaching life in a balanced way that insures success and well- being in physical, social, psychological, and emotional aspects.  Sex Therapy: Treatment relating to the sexual issues and ideas of an individual, especially as they relate to others and the interactions between two people; treatment for any problems relating to sex between two people  Shame: The feeling of regret or deep embarrassment over an action, words, or a feeling  Spirituality: The feelings, thoughts and beliefs about, or study of, gods or beings greater than human beings; a person’s relationship with religious thought and ideas  Spiritual Counseling: Therapy that deals with a person’s religious ideas and behaviors; can also be therapy done with a spiritual leader such as a pastor, priest or rabbi  Stages of Grief and Loss: An attempt to explain how a person deals with grief or loss (especially death), divided into five stages in order of their use: denial, anger, bargaining, depression, and acceptance; The five stages of coping are abbreviated DABDA  Stress: Any mental, physical, or emotional strain or tension; can be caused by people, events, or physical circumstances  Stress Management: The ability to manage the anxieties and problems inherent in every day human life and it’s daily activities and the problems thereof 138 CU IDOL SELF LEARNING MATERIAL (SLM)

6.9 LEARNING ACTIVITY 1. What were the symptoms of Maria? How did the treatment address those symptoms? ___________________________________________________________________________ ___________________________________________________________________________ 2. Write how treatment helped both the patients with PICA? ___________________________________________________________________________ ___________________________________________________________________________ 6.10 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. What were the initial symptoms of Diana? 2. How did Maria’s memory problems progress? 3. What was the diagnosis given to Maris? 4. What is the difference between diagnosis of Maria and Diana? 5. What would Ms. A prefer to eat? Long Questions 1. What is the difference between symptoms of Maria and Diana? 2. What was the treatment plan for Maria? How did it help her? 3. What would be you plan of action for a child with PICA? 4. What would be you plan of action for an adult with PICA? 5. What are the treatment option you would suggest Ms. A who is suffering from Rumination disorder? B. Multiple Choice Questions 1. In Psychology, Case Studies Are Used To: a. Draw General Conclusions About Behaviour Of The Client b. draw conclusions , about individual behavior on the basis of group finding c. assess heritability of individual 139 CU IDOL SELF LEARNING MATERIAL (SLM)

d. Show Importance of Case Studies. 2. What are the pharmacological treatment options for a patient with Parkinson ’s Disease who has to be on nil per oral? a. Orally disintegrating carbidopa-levodopa b. Transdermal apomorphine c. Transdermal rotigotine d. All of these 3. Comorbidity explains the notion that: a. Depression always happens in the winter. b. \"Differentially defined disorders can co-occur.\" c. Sufferers exhibit a chronic fear of death. d. People suffering with the same psychopathology die at the same time. 4. By definition, a cognitive disorder cannot be caused by a. a medical disease b. substance intoxication or withdrawal. c. a psychiatric disorder. d. an infection. 5. Psychological disorders were only added to the International List of Causes of Death (ICD) in 1939. This was done by: a. The American Psychiatric Association (APA) b. The Ministry of Health (MOH) c. The World Health Organization (WHO) d. The National Health Service (NHS) Answers 1-a, 2-d, 3-b, 4-c, 5-c 140 CU IDOL SELF LEARNING MATERIAL (SLM)

6.11 REFERENCES Textbooks  Ahuja N (2002). A short text book of Psychiatry. (5th edn). New Delhi: Jaypee Brothers Medical. Publishers (pvt) Ltd.  American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision: DSM-IV-TR. Washington, DC: American Psychiatric Publishing, Inc.  Clifford Morgan, Richard King, John Weisz, John Schopler (2004) Introduction to Psychology, McGraw-Hill, New Delhi  Domjan Michael (2010). The Principles of Learning and Behavior (6th Edt) Wadsworth, Cengage Learning.  Hergenhahn B R (2008). An introduction to the history of psychology, Wadsworth, Cengage Learning.  Robert S. Feldman (2011) Understanding Psychology, McGraw-Hill, New Delhi.  Robert. A. Baron, Psychology, (2008) Prentice Hall India. Reference books  American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision: DSM-IV-TR. Washington, DC: American Psychiatric Publishing, Inc.  Carson, R. C., Butcher, J. N., & Mineka, S. (2002).Abnormal psychology over time. In Fundamentals of abnormal psychology and modern life. New York: Allyn & Bacon.  Emery, R.E., &Oltmans, T.F. (1998). Abnormal Psychology (2nd ed.). Upper Saddle River, NJ: Prentice-Hall, Inc.  Kay J, Tasman A. (2006) Essentials of Psychiatry, Chichester, John R. Wiley and Sons.  Sadock, Benjamin, J., & Virginia A. (2002). Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (9th ed.). Lippincott Williams &Wilkins.  Sarasin I., G & Sarason B. R. (2005). Abnormal psychology: The problem of maladaptive behavior. (11th edn). PHI Learning Private limited.  World Health Organization (1993). The ICD-10 Classification of Mental and Behavioral Disorders 141 CU IDOL SELF LEARNING MATERIAL (SLM)

Websites  www.simplypsychology.com  http://www.human-memory.net  www.simplypsychology.org  https://psychcentral.com  https://courses.lumenlearning.com  https://www.sparknotes.com 142 CU IDOL SELF LEARNING MATERIAL (SLM)

UNIT 7 – INTERNET ADDICTION 143 STRUCTURE 7.0 Learning Objectives 7.1 Introduction 7.2 Internet Addiction 7.3 Types of Internet Addiction 7.4 DSM Criteria for Internet Addiction 7.5 Incidence of Internet Addiction 7.6 Prevalence of Internet Addiction 7.7 Co-morbidity of Internet Addiction 7.8 Causes of Internet Addiction 7.9 Prognosis of Internet Addiction 7.10 Treatment of Internet Addiction 7.11 Summary 7.12 Key Words 7.13 Learning Activity 7.14 Unit End Questions 7.15 References 7.0 LEARNING OBJECTIVES After studying this unit, you will be able to,  Explain the nature and symptoms of Internet Addiction  Describe the incidence and prevalence of Internet Addiction  Explain the co-morbidity of Internet Addiction  State the causes of Internet Addiction  Explain the prognosis of Internet Addiction  State the treatment for Internet Addiction CU IDOL SELF LEARNING MATERIAL (SLM)

7.1 INTRODUCTION Mo, 16, comes to therapy with her parents, somewhat reluctantly. She at first resists the therapist's attempts to draw her out while her parents tell the therapist, \"All she does is sit in front of the computer and talk to strangers.\" They tell the therapist Momo hardly eats, sleeps irregularly, has lost weight, and displays no interest in the outside world. They also express concern for her safety. Momo displays signs of irritation, and the therapist asks her parents to step out of the room. Though still resistant, Momo begins to open up slightly in the absence of her parents. The therapist asks her about her life: school. friends, and relationships with family members. After some time, Momo admits that she has been having a difficult time at school. Her best friend recently became friends with a group of girls who Momo does not find it easy to get along with. The rest of her classmates already belong to close-knit friend groups, and it is difficult for her to join in. She reports small instances of bullying, but tells the therapist she's \"lucky\" and \"others have it worse.\" The therapist tells her that no one is \"lucky\" to be bullied in any amount. Momo eventually reveals to the therapist that she has a number of friends online who are experiencing a situation similar to hers, and she feels as if they are the only ones who understand her. Thus, when she is away from them, she feels lonely and isolated, and so she desires to spend more and more time online. The therapist normalizes Momo's desire to spend time, virtual or otherwise, with people who understand what she is going through, but helps Momo see it may not be healthy for her to spend quite so much time online. They attempt to work out a balance between her time online and her time engaging in activities necessary for her life: homework, regular meals, sleep, and other forms of self-care. In therapy, Momo also begins to address her feelings of isolation and loneliness, and after several weeks, her mood begins to improve, and she finds that she is able to spend time talking to her friends without her internet time affecting her life. With the help of her parents, she also begins to schedule safe meetings with some of the people she chats to, and spending time \"in the real world\" with these friends also has a positive effect on her mood. 7.2 INTERNET ADDICTION Do you play video games on the Internet in excess? Are you compulsively shopping online? Can’t physically stop checking Facebook? Is your excessive computer use interfering with your daily life – relationships, work, school? If you answered yes to any of these questions, you may be suffering from Internet Addition Disorder, also commonly referred to as Compulsive Internet Use (CIU), Problematic Internet Use (PIU), or iDisorder. Originally debated as a “real thing,” it was satirically theorized as a disorder in 1995 by Dr. Ivan Goldberg, MD who compared its original model to pathological gambling. Since this 144 CU IDOL SELF LEARNING MATERIAL (SLM)

hoax of sorts, the disorder has rapidly gained ground and has been given serious attention from many researchers, mental health counselors, and doctors as a truly debilitating disorder. Though not officially recognized as a disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), its prevalence in American and European cultures is staggering – affecting up to 8.2% of the general population. However, some reports suggest it affects up to 38% of the general population. The widely variable difference in prevalence rates might be contributed to the fact that no true and standardized criteria has been selected for Internet Addiction Disorder. It is researched differently among scientists and mental health professionals. And, it is researched differently across ethnic cultures. CASES of Internet addiction (IA), also known as problematic Internet use, began to appear in the literature in the early 1990s. Since then, this clinical entity has attracted significant attention from both clinicians and the popular media. In DSM-5 (American Psychiatric Association 2013), Internet gaming disorder is listed as a condition warranting more clinical research and experience (Section III). However, behavioral addiction phenomena encompassing the pervasive experience of the Internet itself, and not just the effects of online gaming, are not listed. Nevertheless, both anecdotal and systematic examinations of this phenomena point to some common, and possibly classifiable, features across different cultures and symptom subtypes. Internet use can be viewed as a multifaceted reinforcing agent. Commonly reinforcing elements of its usage include multiplayer games, Internet pornography and virtual sex, online gambling, online shopping, and online communities such as chat rooms and bulletin boards. These features may interact with other behaviorally reinforcing elements, some of which are further delineated in other chapters in this book, which are not directly part of the Internet but are made more accessible or engaged in through the Internet, such as social networking. The emergence of social networking and other Web 2.0 applications have enhanced the immediacy and responsiveness of the Internet experience, and excessive use of social networking Web sites and applications is of growing concern. Regardless of the behavioral phenomenology, the underlying functional impairment often has several common features: withdrawal from social and occupational activities, increasing use and time spent despite attempts to cut down, and financial and social consequences of use. Clinicians familiar with dealing with substance use disorders will find similar themes within IA. Internet addiction is a behavioral addiction in which a person becomes dependent on use of the Internet, or other online devices, as a maladaptive way of coping with life's stresses. Internet addiction is becoming widely recognized and acknowledged, particularly in countries where it is affecting large numbers of people, such as South Korea, where it has been declared a national health problem.1 Much of the current research on the subject of Internet addiction has been carried out in Asia. It is also a growing concern in developed nations in North America and Europe. 145 CU IDOL SELF LEARNING MATERIAL (SLM)

In 1998, Dr. Kimberly Young developed “The Internet Addiction Test.” It includes a 20-item questionnaire that is administered to the client by a proctor. These items include statements such as:  How often do you find that you stay online longer than you intended?  How often do others in your life complain to you about the amount of time you spend online?  How often do you find yourself anticipating when you will go online again? Clients can answer with one of these 5 responses: Not Applicable, Rarely, Occasionally, And Frequently, Often, and Always. Each answer has a numerical value assigned to it. At the end of the test, all the answer’s values are added together, and a score is calculated and used to determine the presence or severity of an internet addiction. 7.3 TYPES OF INTERNET ADDICTION Internet addiction is a broad term that covers a range of behaviors and impulse-control problems involving internet, personal computer, and mobile technology. While there is yet no officially accepted criterion to diagnose an internet addiction, researchers have identified 5 subcategories of specific types of computer and internet addictions. Cybersex Addiction A Cybersex addiction is one of the more self-explanatory internet addictions. It involves online pornography, adult websites, sexual fantasy/adult chat rooms, and XXX web-cam services among others. An obsession with any of these services can be harmful to one’s ability to form real-world sexual, romantic, or intimate relationships. Treatment options are available for those with cybersex addictions, typically in the form of intervention followed by ongoing inpatient or outpatient therapy. Net Compulsions Net compulsions concern interactive activities online that can be extremely harmful, such as online gambling, trading stocks, online auctions (such as E-bay), and compulsive online shopping. These habits can have a detrimental impact on one’s financial stability and disrupt job-related duties. Spending or losing excessive amounts of money can also cause stress in one’s relationships. With instant and easy access to online casinos and stores, it is easy for those who are already susceptible to a gambling or spending addiction to get hooked online. Cyber (Online) Relationship Addiction Cyber or online relationship addicts are deeply involved with finding and maintaining relationships online, often forgetting and neglecting real-life family and friends. Typically, online relationships are formed in chat rooms or different social networking sites but can occur anywhere you can interact with people online. Often, people who pursue online 146 CU IDOL SELF LEARNING MATERIAL (SLM)

relationships do so while concealing their real identity and appearance – this modern phenomenon led to the creation of the term “catfish.” After being consumed by an online social life and persona, a person may be left with limited social skills and unrealistic expectations concerning in-person interactions. Many times, this leads to an inability to make real-world connections, in turn, making them more dependent on their cyber relationships. Counseling or therapy is typically required to treat this addiction and ensure lasting behavioral changes. Compulsive Information Seeking The internet provides users with a wealth of data and knowledge. For some, the opportunity to find information so easily has turned into an uncontrollable urge to gather and organize data. In some cases, information seeking is a manifestation of pre-existing, obsessive- compulsive tendencies. Commonly, compulsive information-seeking can also reduce work productivity and potentially lead to job termination. Depending on the severity of the addiction, treatment options can range from different therapy modalities – which target changing compulsive behavior and developing coping strategies – to medication. Computer or Gaming Addiction Computer addiction, sometimes referred to as computer gaming addiction, involves on- and offline activities that can be done with a computer. As computers became more widely available, games such as Solitaire, Tetris, and Minesweeper were programed into their software. Researchers quickly found that obsessive computer game playing was become a problem in certain settings. Office employees would spend excessive amounts of time playing these games causing a notable decrease in productivity. Today, not only are these classic games still available, but so are thousands of new ones. Computer addiction is the oldest type of internet/computer addiction, and it is still prevalent and harmful today. 7.4 DSM CRITERIA FOR INTERNET ADDICTION Internet addiction is yet to be listed in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (commonly referred to as the DSM-5). However, a 2-year study funded by The National Institutes of Health may change that. Beginning in August of 2017, the study could deliver sufficient evidence that problems stemming from excessive internet use deserve serious attention from U.S. mental health and psychiatric communities. Professionals that do recognize internet addiction tend to classify it as either an obsessive- compulsive disorder or an impulse control disorder to aid treatment. Internet addiction is also called compulsive computer use, pathological internet use, and internet dependence. Other internet addiction tests have also gained popularity. In 2005, Dr. Keith W. Beard published an article in which he proposed 8 characteristics that described having an internet 147 CU IDOL SELF LEARNING MATERIAL (SLM)

use disorder. If 5 or more of the traits describe the subject, they would be diagnosed with an internet addiction. They are:  Is preoccupied with the internet (thinks about previous online activity or anticipates next online session).  Needs to use the internet with increasing amounts of time in order to achieve satisfaction.  Has made unsuccessful efforts to control, cut back, or stop internet use.  Has stayed online longer than originally intended.  Is restless, moody, depressed, or irritable when attempting to cut down or stop internet use.  Has jeopardized or risked the loss of a significant relationship, job, or educational or career opportunity because of the internet.  Has lied to family members, therapist, or others to conceal the extent of involvement with the internet.  Uses the internet as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression). 7.5 INCIDENCE OF INTERNET ADDICTION Since 2001, the number of internet users has shot up by 1000%. The internet certainly offers a lot of potentially addictive activities: shopping, gambling, chat discussions, online relationships, gaming, information-seeking, and pornography viewing. Most people know what it’s like to get drawn into spending more time online than they had planned, but for some people, it becomes a consuming addiction. While the prevalence of IA is difficult to estimate, broadly inclusive studies across different cultures indicate that a large fraction (3.7%–13% in the United States, 1%–5.2% in Norway, 10.7% in South Korea) of the Internet user population express at least some symptoms of excessive Internet use, and about 1% of Internet users have symptoms significant enough to warrant a diagnosis. 7.6 PREVALENCE OF INTERNET ADDICTION Worldwide, the average person spends about 6 hours a day using the internet. A Pew Research study showed that internet usage is a daily activity for most American adults:  77% of American adults go online every day 148 CU IDOL SELF LEARNING MATERIAL (SLM)

 43% go online several times a day  26% are online almost constantly  8% go online once a day  11% go online a few times a week  11% don’t use the Internet at all Children between the ages of 8 and 10 spend an average of 8 hours a day using various kinds of electronic media, with the internet increasingly dominating that time. Children ages 10–18 spend an average of more than 11 hours per day using electronic media. The effect of all this screen time on the developing brain is currently a topic of intense research. Currently, internet addiction prevalence is only estimated to be between 1.5–8%, which may reflect that internet addiction is underdiagnosed. Examining internet use demographic trends can reveal which groups may be more at risk of unhealthy internet use:  Rates of internet use are about the same for both genders, with 27% of women and 25% of men reporting being near-constant internet users  Education increases the risk, with 34% of college grads reporting being online almost constantly, compared to only 20% of those with a high school education or less  Income increases the risk, with 35% of those who earn $75K or more annually using the internet almost constantly, compared to 24% of those who make less than $30K  Race appears to be a factor, with 37% of blacks using the internet almost constantly, compared to 23% of whites and 30% of Hispanics Worldwide, the prevalence of internet addiction has been estimated at 6%. That’s alarming, considering that only about 39% of the world population has internet access. There seems to be a significant variation in rates of internet addiction between countries. For example — among adolescents — the rate of internet addiction in Italy is estimated to be 0.8%, compared to 8.8% in China. However, it’s important to keep in mind that these statistics may be skewed by limitations in how internet addiction is diagnosed and studied. 7.7CO-MORBIDITY OF INTERNET ADDICTION A number of factors have been identified to be significantly associated with IA, including male gender, younger age, drinking behavior, family dissatisfaction, university education, and recent stressful events. While currently there is no unifying set of criteria for identifying and consolidating this group of patients for large-scale clinical studies, recent progress has been significant in ameliorating this growing global public health problem. Because IA disorder is often complicated by elements of other behavioral addictive phenomena, shame and denial are common and complicate estimates of morbidity. 149 CU IDOL SELF LEARNING MATERIAL (SLM)

Furthermore, systematic reviews point to common psychiatric comorbidities such as depression, anxiety, symptoms of attention-deficit/ hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), and hostility/aggression. Studies have given us an idea of the prevalence of other mental health disorders that co-occur with internet addiction. Some of the most common are:  Attention-deficit hyperactivity disorder (ADHD): 14%  Hypomania: 7%  Generalized anxiety disorder: 15%  Social anxiety disorder: 15%  Obsessive-compulsive disorder: 7%  Borderline personality disorder: 14%  Binge eating disorder: 2% People with internet video game addiction are especially likely to have underlying mental health disorders, such as  Depressive disorder: 57%.  Antisocial traits or antisocial personality disorder: 40%  Other addictions: 27%  ADHD: 13%  Social phobia (agoraphobia): 10% 7.8 CAUSES OF INTERNET ADDICTION The actual cause of Internet addiction is not known, but potential factors are varied. Some researchers have compared it to other conditions involving addiction, such as compulsive buying. Those who experience Internet addiction may experience a “high” when using their computers that is similar to the high those who shop compulsively experience when making a purchase. A genetic component may also make it more likely that some who use the internet in a problematic way will become addicted to it. Familial and social factors may also play a role, as a person might turn to virtual reality more and more often in order to escape negative situations in everyday life. As one uses the internet more frequently and experiences positive feelings and sensations as a result of Internet usage, one may come to depend on the internet in order to feel good or even normal. Like most disorders, it’s not likely to pinpoint an exact cause of Internet Addiction Disorder. This disorder is characteristic of having multiple contributing factors. Some evidence 150 CU IDOL SELF LEARNING MATERIAL (SLM)