CU-MA-PSY-SEM-IV-Child Psychopathology-II

 Prevalence: The percentage of people in a population that has a mental disorder or can be viewed as the number of cases per some number of people  Prevalence rates: The representation of incidence by duration of a particular disorder.  Psychotherapy: The use of psychological techniques to treat psychological disturbances.  Psychological model:Psychological model includes personality, learning, stress, self- efficacy, cognition and early life experiences and the way in which they affect mental illness  Psychological tests: Psychological tests are used for assessment of different attributes personality, social skills, intelligence, cognitive abilities, emotional responses, behavioral responses and interests. They can be administered either individually or to groups using pen and paper or oral method.  Psychopathology: The scientific study and research on psychological disorders  Public stigma: When people in a society approve negative stereotypes towards a person with a mental disorder and discriminate against them. 10.9 LEARNING ACTIVITY 1. Explain the process of assessment undertaken in order to diagnose a child with feeding disorder? ___________________________________________________________________________ ___________________________________________________________________________ 2. Explain the process of treatment provided to a child with feeding disorder? ___________________________________________________________________________ ___________________________________________________________________________ 10.10 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. What is the incidence for feeding disorders? 2. What is the prevalence for feeding disorders? 3. What is the process of assessment for feeding disorder by state regulation? 4. What is the process of assessment for feeding disorder by Poor Care Giver–Infant Reciprocity? 5. What is the process of assessment for Sensory Food Aversions? 6. What is the process of assessment for feeding disorder by infantile Anorexia? 151 CU IDOL SELF LEARNING MATERIAL (SLM)

7. What is the process of assessment for Post Traumatic Feeding Disorder? Long Questions 1. What is the prognosis for feeding disorders? 2. What is the Treatment for feeding disorder by state regulation? 3. What is the Treatment for feeding disorder by Poor Care Giver–Infant Reciprocity? 4. What is the Treatment for Sensory Food Aversions? 5. What is the Treatment for feeding disorder by infantile Anorexia? 6. What is the Treatment for Post Traumatic Feeding Disorder? B. Multiple Choice Questions 1. Treatment can be directed toward the infant, toward the mother, and toward the mother– infant interaction for ____________ a. Poor Care Giver–Infant Reciprocity b. Sensory Food Aversions? c. feeding disorder by state regulation d. Post Traumatic Feeding Disorder 2. Hospitalization may be suggested in _________________ a. Poor Care Giver–Infant Reciprocity b. Sensory Food Aversions c. Infantile Anorexia d. Post Traumatic Feeding Disorder 3. The major goal in ________________ of the intervention is to “facilitate internal regulation of eating” by the infant. a. Poor Care Giver–Infant Reciprocity b. Sensory Food Aversions c. Infantile Anorexia d. Post Traumatic Feeding Disorder 4. Repeated exposures to new foods helps in _______________ a. Poor Care Giver–Infant Reciprocity b. Sensory Food Aversions c. feeding disorder by infantile Anorexia d. Post Traumatic Feeding Disorder 5. Desensitization is used for Treatment for _______________ a. Poor Care Giver–Infant Reciprocity b. Sensory Food Aversions c. feeding disorder by infantile Anorexia 152 CU IDOL SELF LEARNING MATERIAL (SLM)

d. Post Traumatic Feeding Disorder Answers 1-c, 2-a, 3-c, 4-b, 5-d 10.11 REFERENCES Textbooks  Ahuja N (2002). A short text book of Psychiatry. (5th edn). New Delhi: Jaypee Brothers Medical. Publishers (pvt) Ltd.  American PsychiatricAssociation (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-Hil, 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-Hil, New Delhi.  Robert. A. Baron, Psychology, (2008) Prentice Hall India. Reference books  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.  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.  Hufton IW and Oates RK (1977) Nonorganic failure to thrive: A long term follow-up. Pediatrics 59, 73–77. 153 CU IDOL SELF LEARNING MATERIAL (SLM)

 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.  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. 154 CU IDOL SELF LEARNING MATERIAL (SLM)

UNIT 11 – EATING DISORDER PART I STRUCTURE 11.0 Learning Objectives 11.1 Introduction 11.2 Eating Disorders 11.3 DSM Criteria 11.4 ICD 10 Criteria 11.5 Causes of Eating Disorder 11.6 Types of Eating Disorder 11.7 Summary 11.8 Key Words 11.9 Learning Activity 11.10 Unit End Questions 11.11 References 11.0 LEARNING OBJECTIVES After studying this unit, you will be able to,  Describe Eating Disorders  Explain the nature and symptoms of Eating Disorders  Explain the DSM criteria of Eating Disorders  Explain the ICD 10 criteria of Eating Disorders  Describe the causes of Eating Disorders 11.1 INTRODUCTION When Ms. A was first evaluated for admission to apatient eating disorders program, she had been restrictingher food intake for approximately 5 years and had beenamenorrheic for 4 years. At the time of her admission, this24-year-old, single, white woman weighed 71 lb. at a heightof 5 feet 1.5 inches. In 12th grade, Ms. A menstruated forthe first time and also developed “very large” breasts. Shehad a difficult first year at college, where she gained toher maximum weight of 120 lb. The following year, Ms. A transferred to a smaller college, became a vegetarian “forethical reasons”, and began to significantly restrict her foodintake. She limited herself to a total of 700 to 800 cal/day,with a maximum of 200 calories per meal and graduallylost weight in the next 5 years. Ms. A did not binge, vomit,abuse laxatives, or engage in excessive exercise. 155 CU IDOL SELF LEARNING MATERIAL (SLM)

Sheconsidered herself to be “obsessed with calories” andobserved a variety of rituals regarding food and foodpreparation (e.g., obsessively weighing her food). Although Ms. A excelled academically, she had noclose friends and had never been involved in a romanticrelationship. She was quite close to her mother and sisterand had always been dependent on her parents. Aftergraduating (with honors) from college, Ms. A worked at aseries of temporary jobs but was unemployed and livingat home with her mother at the time of admission. Shehad been in outpatient psychotherapy with two differenttherapists during the previous 2 years. The first therapistdid not address her eating disorder, and Ms. A continued tolose weight, from 90 to 80 lb. Although her second therapistconfronted her about her anorexia nervosa and started heron desipramine at 20 mg/day for depressive symptoms, Ms. A continued to lose weight. During her first 5-month hospitalization, Ms. A wastreated with a multimodal program (behavioral weight gain protocol, individual and family therapy, fluoxetine at60–80 mg for obsessive–compulsive traits and depressivesymptoms) and gained to a weight of 98 lb. At discharge,she was maintaining her weight on food but remainedconcerned about her weight and was particularlyfrightened of reaching “the triple digits” (i.e., 100 lb.). After leaving the hospital, Ms. A continued with outpatientpsychotherapy and fluoxetine for several months. Shewas then seriously injured in a car accident and, duringa prolonged convalescent period, discontinued treatmentfor her eating disorder. Ms. A remained unemployed, eventually moved in with her sister and her sister’s family,and gradually lost weight. About 3.5 years after discharge, at age 27 years, Ms. A again sought inpatient treatment. At admission, sheweighed 83 lb. but still felt “fat”. During hospitalization,she steadily gained weight and was prescribed sertralineat 100 mg/day for feelings of low self-esteem, anxietyand obsessional thinking. When she was discharged5 months later, at a weight of 108 lb., she noted menstrualbleeding for the first time in more than 7 years. Afterleaving the hospital, Ms. A continued taking medicationand began outpatient cognitive–behavioral psychotherapy. For the next year, she continued to struggle with eatingand weight issues but managed to maintain her weightand successfully expand other aspects of her life byindependently supporting herself with a full-time job,making new friends and becoming involved in her firstromantic relationship. 11.2 EATING DISORDERS Although clinical descriptions of eating disorders can be traced back many years, particularly for anorexia nervosa, these disorders appeared in the DSM for the first time in 1980 as one subcategory of disorders beginning in childhood or adolescence. Eating disorders became a distinct category in DSM-IV, reflecting the increased attention they had received from clinicians and researchers. In DSM-5, eating disorders will likely be in a category called “Feeding and Eating Disorders” that also includes childhood disorders such as pica (eating 156 CU IDOL SELF LEARNING MATERIAL (SLM)

nonfood substances for extended periods) and rumination disorders (repeated regurgitation of foods). Unfortunately, eating disorders are also likely to be stigmatized. In one recent study, college students were presented vignettes depicting fictional women with different disorders and were then asked to rate these fictional women on a number of dimensions. Participants rated the women depicted with eating disorders as self-destructive and responsible for their conditions. Men in the study were particularly likely to believe that eating disorders were easy to overcome. In another study, participants were randomly assigned to read a vignette about a woman with an eating disorder or a woman with depression. Participants who read about the woman with the eating disorder viewed her as more responsible, more fragile, and more likely to be trying to get attention with her disorder compared to participants who read about the woman with depression. These types of attitudes and beliefs are not consistent with the current research on eating disorders. According to the DSM-5 (APA, 2013), eating disorders are characterized by a persistent disturbance in eating behavior. No doubt you have heard about anorexia nervosa and bulimia nervosa. Within the DSM these are considered to be separate syndromes, and they reflect two types of adult eating disorders. However, disordered eating is not their only striking feature. At the heart of both disorders is an intense fear of becoming overweight and fat and an accompanying pursuit of thinness. This pursuit is relentless and sometimes deadly. 11.3 DSM CRITERIA 11.3.1 DSM Criteria for Anorexia Nervosa A. weight at or above a minimally normal weight Refusal to maintain body for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected). B. or becoming fat, Intense fear of gaining weight even though underweight. C. one’s body Disturbance in the way in which weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight. D. In post menarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.) Specify type: Restricting type: during the current episode of anorexia nervosa, the person has not regularly engaged in bingeeating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). 157 CU IDOL SELF LEARNING MATERIAL (SLM)

Binge-eating/purging type: during the current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). 11.3.2 DSM Criteria for Bulimia Nervosa A. binge-eating. An episode Recurrent episode of binge-eating is characterized by both of the following: (1) eating in a discrete, period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances. (2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating). Recurrent B. compensatory behavior in order to prevent weight gain, inappropriate such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise inappropriate compensatory. C. The binge-eating and behaviors both occur, on average, at least twice a week for 3 months. D. Influenced by body Self-evaluation is unduly shape and weight exclusively. E. The disturbance does not occur during episodes of anorexia nervosa. Specify type: Purging type: during the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas. No purging type: during the current episode of bulimia nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas. 158 CU IDOL SELF LEARNING MATERIAL (SLM)

Fig. 11.1 Specify type: 11.3.3. DSM Criteria for Binge Eating A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances. 2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating). B. The binge-eating episodes are associated with three (or more) of the following: 1. Eating much more rapidly than normal. 2. Eating until feeling uncomfortably full. 3. Eating large amounts of food when not feeling physically hungry. 159 CU IDOL SELF LEARNING MATERIAL (SLM)

4. Eating alone because of feeling embarrassed by how much one is eating. 5. Feeling disgusted with oneself, depressed, or very guilty afterward. C. Marked distress regarding binge eating is present. D. The binge eating occurs, on average, at least once a week for 3 months. E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nen/osa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa. Specify if: In partial remission: After full criteria for binge-eating disorder were previously met, binge eating occurs at an average frequency of less than one episode per week for a sustained period of time. In full remission: After full criteria for binge-eating disorder were previously met, none of the criteria have been met for a sustained period of time. Specify current severity: The minimum level of severity is based on the frequency of episodes of binge eating (see below). The level of severity may be increased to reflect other symptoms and the degree of functional disability. Mild: 1-3 binge-eating episodes per week. Moderate: 4-7 binge-eating episodes per week. Severe: 8-13 binge-eating episodes per week. Extreme: 14 or more binge-eating episodes per week. 11.4 ICD 10 CRITERIA 11.4.1 ICD 10 Criteria for Anorexia Nervosa Anorexia nervosa is a disorder characterized by deliberate weight loss, induced and/or sustained by the patient. The disorder occurs most commonly in adolescent girls and young women, but adolescent boys and young men may be affected more rarely, as may children approaching puberty and older women up to the menopause. Anorexia nervosa constitutes an independent syndrome in the following sense: (a)the clinical features of the syndrome are easily recognized, so that diagnosis is reliable with a high level of agreement between clinicians; (b)follow-up studies have shown that, among patients who do not recover, a considerable number continue to show the same main features of anorexia nervosa, in a chronic form. For a definite diagnosis, all the following are required: (a)Body weight is maintained at least 15% below that expected (either lost or never achieved), or Quetelet's body-mass index4 is 17.5 or less. Prepubertal patients may show failure to make the expected weight gain during the period of growth. 160 CU IDOL SELF LEARNING MATERIAL (SLM)

(b)The weight loss is self-induced by avoidance of \"fattening foods\". One or more of the following may also be present: self-induced vomiting; self-induced purging; excessive exercise; use of appetite suppressants and/or diuretics. (c)There is body-image distortion in the form of a specific psychopathology whereby a dread of fatness persists as an intrusive, overvalued idea and the patient imposes a low weight threshold on himself or herself. (d)A widespread endocrine disorder involving the hypothalamic - pituitary - gonadal axis is manifest in women as amenorrhea and in men as a loss of sexual interest and potency. (An apparent exception is the persistence of vaginal bleeds in anorexic women who are receiving replacement hormonal therapy, most commonly taken as a contraceptive pill.) There may also be elevated levels of growth hormone, raised levels of cortisol, changes in the peripheral metabolism of the thyroid hormone, and abnormalities of insulin secretion. (e)If onset is prepubertal, the sequence of pubertal events is delayed or even arrested (growth ceases; in girls the breasts do not develop and there is a primary amenorrhea; in boys the genitals remain juvenile). With recovery, puberty is often completed normally, but the menarche is late. 11.4.2 ICD 10 Criteria for Bulimia Nervosa For a definite diagnosis of bulimia nervosa, all the following are required: (a)There is a persistent preoccupation with eating, and an irresistible craving for food; the patient succumbs to episodes of overeating in which large amounts of food are consumed in short periods of time. (b)The patient attempts to counteract the \"fattening\" effects of food by one or more of the following: self-induced vomiting; purgative abuse, alternating periods of starvation; use of drugs such as appetite suppressants, thyroid preparations or diuretics. When bulimia occurs in diabetic patients they may choose to neglect their insulin treatment. (c)The psychopathology consists of a morbid dread of fatness and the patient sets herself or himself a sharply defined weight threshold, well below the premorbid weight that constitutes the optimum or healthy weight in the opinion of the physician. There is often, but not always, a history of an earlier episode of anorexia nervosa, the interval between the two disorders ranging from a few months to several years. This earlier episode may have been fully expressed or may have assumed a minor cryptic form with a moderate loss of weight and/or a transient phase of amenorrhea. 11.5 CAUSES OF EATING DISORDER 11.5.1 Causes of Anorexia Nervosa At present, the etiology of anorexia nervosa is fundamentallyunknown. However, from several sources, such as the epidemiologicaldata just reviewed, it is possible to identify risk factorswhose presence increases the likelihood of anorexia nervosa. Itis also possible to 161 CU IDOL SELF LEARNING MATERIAL (SLM)

describe the course and complications of thesyndrome and to suggest interactions between features of the disorder,for example, between malnutrition and psychiatric illness. Thus, as indicated in figure below, the difficulties that lead to thedevelopment of anorexia nervosa may be distinct from the forcesthat intensify the symptoms and perpetuate the illness once it has begun. Figure11.2 Schematic diagrams illustrating how an interplay of factors may lead to the initiation and persistence of anorexia nervosa. Genetic and Twin Studies Anorexia nervosa occurs more frequently in biological relativesof patients who present with the disorder. The prevalence rateof anorexia nervosa among sisters of patients is estimated to beapproximately 6%; the morbid risk among other relatives rangesfrom 2 to 4%. Some evidence for a genetic component in the etiologyof anorexia nervosa comes from twin studies, which reported substantially higher concordance rates for monozygotic than fordizygotic twin pairs (Klump et al., 2001). However, conclusivedata for genetic transmission of the disorder are not yet available. Family Studies Individual psychiatric disorders in parents, dysfunctional familyrelationships and impaired family interaction patterns havebeen implicated in the etiology of anorexia nervosa. Mothers ofindividuals with anorexia nervosa are often described as overprotective,intrusive, 162 CU IDOL SELF LEARNING MATERIAL (SLM)

perfectionistic and fearful of separation;fathers are described as withdrawn, passive, emotionally constricted,obsessional, moody and ineffectual. Family systemstheorists have suggested that impaired family interactions suchas pathological enmeshment, rigidity, overprotectiveness, anddifficulties confronting and resolving conflicts are central featuresof anorexic pathology. However, few empirical studies havebeen conducted to date, particularly studies that also examinepsychiatrically or medically ill comparison groups. Therefore,the precise role of the family in the development and course ofanorexia nervosa, although undoubtedly important, has not beenclearly delineated. Psychosocial Factors The increased prevalence of anorexia nervosa has been connectedto the current emphasis in contemporary Western society on anunrealistically thin appearance in women. There is substantialevidence that a desire to be slim is common among middle- andupper-class white women and that this emphasis on slimnesshas increased significantly during the past several decades. Inthe USA, anorexia nervosa develops much more frequently inwhite adolescents than in adolescents from other racial groups. It has been suggested that a variety of characteristics may protectAfrican-American girls from having eating disorders, includingmore acceptance of being overweight, more satisfaction withtheir body image and less social pressure regarding weight.It has also been suggested that the emphasis of contemporaryWestern society on achievement and performance inwomen, which is a shift from the more traditional emphasis ondeference, compliance and unassertiveness, has left many youngwomen vulnerable to the development of eating disorders such asanorexia nervosa. These multiple and contradictory role demandsare embodied within the modern concept of a superwoman whoperforms all of the expected roles (e.g., is competent, ambitiousand achieving, yet also feminine, nurturing and sexual) and,in addition, devotes considerable attention to her appearance(Gordon, 1990). Psychodynamic Factors Various psychoanalytic theories have been postulated (e.g., defenseagainst fantasies of oral impregnation; underlying deficitsin the development of object relations; deficits in self- structure),but such hypotheses are difficult to verify. Bruch (1973, 1982)suggested that anorexia nervosa stems from failures in early attachment,attempts to cope with underlying feelings of ineffectivenessand inadequacy, and an inability to meet the demandsof adolescence and young adulthood. These ideas, as well as herconceptualization that the single-minded focus on losing weightin anorexia nervosa is the concrete manifestation of a struggleto achieve a sense of identity, purpose, specialness and control,are compelling and clinically useful. Cognitive–behavioral theoriesemphasize the distortions and dysfunctional thoughts (e.g.,dichotomous thinking) that may stem from various causal factors,all of which eventually focus on the belief that it is essentialto be thin. 163 CU IDOL SELF LEARNING MATERIAL (SLM)

Although the existence of a specific predisposing personalitystyle has not been conclusively documented, certain traitshave commonly been reported among women with anorexia nervosa. Women hospitalized for anorexia nervosa have greaterself-discipline, conscientiousness and emotional caution thanwomen hospitalized for bulimia nervosa and women with no eatingdisorders. In addition, even after they have recovered fromtheir illness, women who have had anorexia nervosa tend to avoidrisks and to exhibit high levels of caution in emotional expressionand strong compliance with rules and moral standards. Developmental Factors Because anorexia nervosa typically begins during adolescence,developmental issues are thought to play an important etiologicalrole. Critical challenges at this time of life include the needto establish independence, a well-defined personal identity, fulfilling relationships, and clear values and principles to governone’s life. Family struggles, conflicts regarding sexuality andpressures regarding increased heterosexual contact are also common. However, it is not clear that difficulties over these issues aremore salient for individuals who will develop anorexia nervosathan for other adolescents. Depression has been implicated as anonspecific risk factor, and higher levels of depressive symptomsas well as insecurity, anxiety and self-consciousness have beendocumented in adolescent girls in comparison with adolescentboys. Similarly, the progression of physical and sexual maturationand the concomitant increase in women’s percentage of bodyfat may have a substantial impact on the self-image of adolescentgirls, particularly because the relationship between self-esteemand satisfaction with physical appearance and body characteristicsis stronger in women than in men. Pathophysiology An impressive array of physical disturbances has been documentedin anorexia nervosa and the physiological bases of manyare understood table below. Most of these physical disturbancesappear to be secondary consequences of starvation, and it is notclear whether or how the physiological disturbances describedhere contribute to the development and maintenance of the psychologicaland behavioral abnormalities characteristic of anorexianervosa. The remainder of this section briefly describesthe major physical abnormalities of anorexia nervosa and what isunderstood about their etiology. Organ Medical Complication Skin Lanugo Cardiovascular system Hypotension Bradycardia Arrhythmias Hematopoietic system Normochromic, normocytic anemia 164 CU IDOL SELF LEARNING MATERIAL (SLM)

Leukopenia- Diminished polymorphonuclear leukocytes Elevated blood urea nitrogen and creatinine Fluid and electrolyte balance concentrations Hypokalemia Hyponatremia Hypochloremia Alkalosis Gastrointestinal system Elevated serum concentration of liver enzymes Delayed gastric emptying Constipation Endocrine system Diminished thyroxine with normal thyroid- stimulating level hormone level Elevated plasma cortisol level Diminished secretion of luteinizing hormone, hormone, estrogen, or testosterone follicle- stimulating Bone Osteoporosis Table: Medical Problems Commonly Associated with Anorexia Nervosa The central nervous system is clearly affected. Computedtomography has demonstrated that individuals with anorexia nervosahave enlarged ventricles, an abnormality that improves withweight gain. The cerebrospinal fluid concentrations of a varietyof neurotransmitters and their metabolites are altered in underweightpatients with anorexia nervosa and tend to normalize asweight is restored. An intriguing exception may be the serotoninmetabolite 5-hydroxyindoleacetic acid, which has been reportedto be elevated in the cerebrospinal fluid of patients with anorexianervosa after they have achieved a normal or near-normal weight. Kaye (1997) has suggested that the elevated 5-hydroxyindoleaceticacid levels may reflect a serotoninergic abnormality that istied to the obsessional traits often observed in anorexia nervosa.Some of the most striking physiological alterations in anorexianervosa are those of the hypothalamic–pituitary–gonadalaxis. In women, estrogen secretion from the ovaries is markedlyreduced, accounting for the occurrence of amenorrhea. In analogousfashion, testosterone production is diminished in men withanorexia nervosa. The decrease in gonadal steroid production isdue to a reduction in the pituitary’s secretion of the 165 CU IDOL SELF LEARNING MATERIAL (SLM)

gonadotropinsluteinizing hormone and follicle-stimulating hormone, which inturn is secondary to diminished release of gonadotropin-releasinghormone from the hypothalamus. Therefore, the amenorrhea ofanorexia nervosa is properly viewed as a type of hypothalamicamenorrhea. It is of interest that in a significant minority amenorrheabegins before substantial weight loss has occurred, suggestingthat factors other than malnutrition, such as psychologicaldistress, contribute significantly to the disruption of the reproductiveendocrine system. In an adult with anorexia nervosa, the status of the hypothalamic–pituitary–gonadal axis resembles that of a pubertalor prepubertal child – the secretion of estrogen or testosterone, ofluteinizing hormone and follicle-stimulating hormone and of gonadotropin-releasing hormone is reduced. This endocrinologicalpicture may be contrasted with that of postmenopausal womenwho have a similar reduction in estrogen secretion but who, unlikewomen with anorexia nervosa, show increased pituitary gonadotropinsecretion. Furthermore, even the circadian patterns ofluteinizing hormone and follicle-stimulating hormone secretionin adult women with anorexia nervosa closely resemble the patternsnormally seen in pubertal and prepubertal girls. Althoughsimilar abnormalities are also seen in other forms of hypothalamicamenorrhea and are therefore not specific to anorexia nervosa,it is nonetheless striking that this syndrome is accompaniedby a physiological arrest or regression of the reproductive endocrinesystem. The functioning of other hormonal systems is also disruptedin anorexia nervosa, although typically not as profoundly as is thereproductive axis. Presumably as part of the metabolic responseto semistarvation, the activity of the thyroid gland is reduced. Plasma thyroxine levels are somewhat diminished, but the plasmalevel of the pituitary hormone and thyroid-stimulating hormone isnot elevated. The activity of the hypothalamic– pituitary–adrenalaxis is increased, as indicated by elevated plasma levels of cortisoland by resistance to dexamethasone suppression. The regulationof vasopressin (antidiuretic hormone) secretion from the posteriorpituitary is disturbed, contributing to the development of partialdiabetes insipidus in some individuals. Anorexia nervosa is often associated with the developmentof leukopenia and of a normochromic, normocytic anemiaof mild to moderate severity. Surprisingly, leukopenia does notappear to result in a high vulnerability to infectious illnesses. Serumlevels of liver enzymes are sometimes elevated, particularlyduring the early phases of refeeding, but the synthetic functionof the liver is rarely seriously impaired so that the serum albuminconcentration and the prothrombin time are usually withinnormal limits. Serum cholesterol levels are sometimes elevatedin anorexia nervosa, although the basis of this abnormality remainsobscure. In some patients, self-imposed fluid restrictionand excessive exercise produce dehydration and elevations of serumcreatinine and blood urea nitrogen. In others, water loadingmay lead to hyponatremia. The status of serum electrolytes is areflection of the individual’s salt and water intake and the natureand the severity of the purging behavior. A common pattern 166 CU IDOL SELF LEARNING MATERIAL (SLM)

ishypokalemia, hypochloremia and mild alkalosis resulting fromfrequent and persistent self- induced vomiting. It has become clear that individuals with anorexia nervosahave decreased bone density compared with age- and sexmatchedpeers and, as a result, are at increased risk for fractures.Low levels of estrogen, high levels of cortisol and poor nutritionhave been cited as risk factors for the development of reducedbone density in anorexia nervosa. Theoretically, estrogen treatmentmight reduce the risk of osteoporosis in women who arechronically amenorrheic because of anorexia nervosa, but controlledstudies indicate that this intervention is of limited, if any,benefit. Abnormalities of cardiac function include bradycardia andhypotension, which are rarely symptomatic. The pump functionof the heart is compromised, and congestive heart failure occasionallydevelops in individuals during overly rapid refeeding. The electrocardiogram shows sinus bradycardia and a number ofnonspecific abnormalities. Arrhythmias may develop, often inassociation with fluid and electrolyte disturbances. It has beensuggested that significant prolongation of the QT interval maybe a harbinger of life- threatening arrhythmias in some individualswith anorexia nervosa, but this has not been conclusivelydemonstrated. The motility of the gastrointestinal tract is diminished,leading to delayed gastric emptying and contributing to complaintsof bloating and constipation. Rare cases of acute gastricdilatation or gastric rupture, which is often fatal, have been reportedin individuals with anorexia nervosa who consumed largeamounts of food when binge-eating. As already noted, virtually all of the physiological abnormalitiesdescribed in individuals with anorexia nervosa are alsoseen in other forms of starvation, and most improve or disappearas weight returns to normal. Therefore, weight restoration is essentialfor physiological recovery. More surprisingly, perhaps, weightrestoration is believed to be essential for psychological recoveryas well. Accounts of human starvation amply document the profoundimpact of starvation on mental health. Starving individualslose their sense of humor, their interest in friends and family fadesand mood generally becomes depressed. They may develop peculiarbehavior similar to that of patients with anorexia nervosa,such as hoarding food or concocting bizarre food combinations.If starvation disrupts psychological and behavioral functioning innormal individuals, it presumably does so as well in those withanorexia nervosa. Thus, correction of starvation is a prerequisitefor the restoration of both physical and psychological health. 11.5.2 Causes of Bulimia As in the case of anorexia nervosa, the etiology of bulimia nervosais uncertain. Several factors clearly predispose individualsto the development of bulimia nervosa, including being an adolescentgirl or young adult woman. A personal or family historyof obesity and of mood disturbance also appears to increase risk.Twin studies have suggested that inherited factors 167 CU IDOL SELF LEARNING MATERIAL (SLM)

are related tothe risk of developing bulimia nervosa, but what these factors areand how they operate are unclear. Many of the same psychosocial factors related to the developmentof anorexia nervosa are also applicable to bulimia nervosa,including the influence of cultural esthetic ideals of thinnessand physical fitness. Similarly, bulimia nervosa primarily affectswomen; the ratio of men to women is approximately 1: 10. It alsooccurs more frequently in certain occupations (e.g., modeling)and sports (e.g., wrestling, running). Although not proven, it seems likely that several factorsserve to perpetuate the binge-eating once it has begun. First, most individuals with bulimia nervosa, becauseof both their concern regarding weight and their worryabout the effect of the binge-eating, attempt to restrict theirfood intake when they are not binge-eating. The psychologicaland physiological restraint that is thereby entailed presumablymakes additional binge-eating more likely. Secondly, even ifmood disturbance is not present at the outset, individuals becomedistressed about their inability to control their eating,and the resultant lowering of self-esteem contributes to disturbancesof mood and to a reduced ability to control impulsesto overeat. In addition, cognitive–behavioral theories emphasizethe role of rigid rules regarding food and eating, and thedistorted and dysfunctional thoughts that are similar to thoseseen in anorexia nervosa. Interpersonal theories also implicateinterpersonal stressors as a primary factor in triggeringbinge-eating. There is no evidence to suggest that a particularpersonality structure is characteristic of women with bulimianervosa. There are also indications that bulimia nervosa is accompaniedby physiological disturbances that disrupt the developmentof satiety during a meal and therefore increase the likelihoodof binge-eating. These disturbances include an enlargedstomach capacity, a delay in stomach emptying and a reductionin the release of cholecystokinin, a peptide hormone secreted bythe small intestine during a meal that normally plays a role interminating eating behavior. All these abnormalities appear topredispose the individual to overeat and therefore to perpetuatethe cycle of binge-eating.It has been suggested that childhood sexual abuse is aspecific risk factor for the development of bulimia nervosa. Scientific support for this hypothesis is weak. The best studies todate have found that compared with women without psychiatricillness, women with bulimia nervosa do indeed report increasedfrequencies of sexual abuse. However, the rates of abuse aresimilar to those found in other psychiatric disorders and occurin a minority of women with bulimia nervosa. Thus, while earlyabuse may predispose an individual to psychiatric problems generally,it does not appear to lead specifically to an eating disorderand most patients with bulimia nervosa do not have histories ofsexual abuse. Pathophysiology In a small fraction of individuals, bulimia nervosa is associatedwith the development of fluid and electrolyte abnormalities thatresult from the self-induced vomiting or the misuse of laxativesor diuretics. The most common electrolyte disturbances are hypokalemia,hyponatremia and hypochloremia. Patients who losesubstantial amounts of 168 CU IDOL SELF LEARNING MATERIAL (SLM)

stomach acid through vomiting may becomeslightly alkalotic; those who abuse laxatives may becomeslightly acidotic. There is an increased frequency of menstrual disturbancessuch as oligomenorrhea among women with bulimia nervosa. Severalstudies suggest that the hypothalamic–pituitary– gonadal axisis subject to the same type of disruption as is seen in anorexia nervosabut that the abnormalities are much less frequent and severe. Patients who induce vomiting for many years may developdental erosion, especially of the upper front teeth.The mechanism appears to be that stomach acid softens theenamel, which in time gradually disappears so that the teeth chipmore easily and can become reduced in size. Some patients developpainless salivary gland enlargement, which is thought torepresent hypertrophy resulting from the repeated episodes ofbinge-eating and vomiting. The serum level of amylase is sometimesmildly elevated in patients with bulimia nervosa because ofincreased amounts of salivary amylase. Most patients with bulimia nervosa have surprisingly fewgastrointestinal abnormalities. As indicated earlier, it appearsthat the disorder is associated with an enlarged gastric capacityand delayed gastric emptying, but these abnormalities are not sosevere as to be detectable on routine clinical examination. Potentiallylife-threatening complications such as an esophageal tearor gastric rupture occur, but fortunately rarely.The longstanding use of syrup of ipecac to induce vomitingcan lead to absorption of some of the alkaloids and to permanentdamage to nerve and muscle. Diagnosis and Differential Diagnosis Phenomenology Bulimia nervosa typically begins after a young woman who seesherself as somewhat overweight starts a diet and, after some initialsuccess, begins to overeat. Distressed by her lack of controland by her fear of gaining weight, she decides to compensate forthe overeating by inducing vomiting or taking laxatives, methodsshe has heard about from friends or seen in media reports abouteating disorders. After discovering that she can successfullypurge, the individual may, for a time, feel pleased in that she caneat large amounts of food and not gain weight. However, the episodesof binge-eating usually increase in size and in frequencyand occur after a variety of stimuli, such as transient depressionor anxiety or a sense that she has begun to overeat. Patients oftendescribe themselves as “numb” while they are binge- eating,suggesting that the eating may serve to avoid uncomfortableemotional states. Patients usually feel intensely ashamed of their“disgusting” habit and may become depressed by their lack ofcontrol over their eating. The binge-eating tends to occur in the late afternoon orevening and almost always while the patient is alone. The typicalpatient presenting to eating disorders clinics has been bingeeatingand inducing vomiting five to 10 times weekly for 3 to10 years. Although there is substantial variation, binges tend tocontain 1000 or more calories and to consist of sweet, high-fatfoods that are normally consumed as dessert, such as ice cream,cookies and cake. 169 CU IDOL SELF LEARNING MATERIAL (SLM)

Although patients complain of “carbohydratecraving”, they only rarely binge-eat foods that are pure carbohydrates, such as fruits. Patients usually induce vomiting or usetheir characteristic compensatory behavior immediately after thebinge and feel substantial relief that the calories are “gone”. Inreality, it appears that vomiting is the only purging method capableof disposing of a significant number of ingested calories. Theweight loss associated with the misuse of laxatives and diureticsis primarily due to the loss of fluid and electrolytes, not calories. When not binge-eating, patients with bulimia nervosa tendto restrict their calorie intake and to avoid the foods usually consumedduring episodes of binge-eating. Although there is somephenomenological resemblance between binge-eating and substanceabuse, there is no evidence that physiological addictionplays any role in bulimia nervosa. 11.5.3 Causes of Binge-Eating Very little is known about the etiology of binge-eating disorder. Binge-eating disorder is clearly associated with obesity, but it is uncertain to what degree the binge-eating is a contributor to and to what degree a consequence of, the obesity. 11.6 TYPES OF EATING DISORDER 11.6.1 Anorexia Nervosa Anorexia nervosa often begins innocently. Typically, an adolescent girl or young woman who is of normal weight or, perhaps, a few pounds overweight decides to diet. This decision may be prompted by an important but not extraordinary life event, such as leaving home for camp, attending a new school, or a casual unflattering remark by a friend or family member. Initially, the dieting seems no different from that pursued by many young women, but as weight falls, the dieting intensifies. The restrictions become broader and more rigid; for example, desserts may first be eliminated, then meat, then any food that is thought to contain fat. The person becomes increasingly uncomfortable if she is seen eating and avoids meals with others. Food seems to assume a moral quality so that vegetables are viewed as “good” and anything with fat is “bad”. The individual has idiosyncratic rules about how much exercise she must do and when, where and how she can eat. Food avoidance and weight loss are accompanied by a deep and reassuring sense of accomplishment, and weight gain is viewed as a failure and a sign of weakness. Physical activity, such as running or aerobic exercise, often increases as the dieting and weight loss develop. Inactivity and complaints of weakness usually occur only when emaciation has become extreme. The person becomes more serious and devotes little effort to anything but work, dieting and exercise. She may become depressed and emotionally labile, socially withdrawn and secretive and she may lie about her eating and her weight. 170 CU IDOL SELF LEARNING MATERIAL (SLM)

Despite the profound disturbances in her view of her weight and of her calorie needs, reality testing in other spheres is intact, and the person may continue to function well in school or at work. Symptoms usually persist for months or years until, typically at the insistence of friends or family, the person reluctantly agrees to see a physician. In general, anorexia nervosa is not difficult to recognize. Uncertainty surrounding the diagnosis sometimes occurs in young adolescents, who may not clearly describe a drive for thinness and the fear of becoming fat. Rather, they may acknowledge only a vague concern about consuming certain foods and an intense desire to exercise. It can also be difficult to elicit the distorted view of shape and weight (criterion C) from patients who have had anorexia nervosa for many years. Such individuals may state that they realize they are too thin and may make superficial efforts to gain weight, but they do not seem particularly concerned about the physical risks or deeply committed to increasing their calorie consumption. 11.6.2 Bulimia Nervosa The salient behavioral disturbance of bulimia nervosa is the occurrence of episodes of binge- eating. During these episodes, the individual consumes an amount of food that is unusually large considering the circumstances under which it was eaten. Although this is a useful definition and conceptually reasonably clear, it can be operationally difficult to distinguish normal overeating from a small episode of binge-eating. Indeed, the available data do not suggest that there is a sharp dividing line between the size of binge-eating episodes and the size of other meals. On the other hand, while the border between normal and abnormal eating may not be a sharp one, both patients’ reports and laboratory studies of eating behavior clearly indicate that, when binge-eating, patients with bulimia nervosa do indeed consume larger than normal amounts of food. Episodes of binge-eating are associated, by definition, with a sense of loss of control. Once the eating has begun, the individual feels unable to stop until an excessive amount has been consumed. This loss of control is only subjective, in that most individuals with bulimia nervosa will abruptly stop eating in the midst of a binge episode if interrupted, for example, by the unexpected arrival of a roommate. After overeating, individuals with bulimia nervosa engage in some form of inappropriate behavior in an attempt to avoid weight gain. Most patients who present to eating disorders clinics with this syndrome report self-induced vomiting or the abuse of laxatives. Other methods include misusing diuretics, fasting for long periods and exercising extensively after eating binges. 11.6.3 Binge eating disorder Beginning in the 1990s, research focused on a group of individuals who experience marked distress because of binge eating but do not engage in extreme compensatory behaviors and therefore cannot be diagnosed with bulimia. These individuals have binge-eating disorder (BED). Currently, Binge eating disorder is in the appendix of DSM-IV-TR as a potential new 171 CU IDOL SELF LEARNING MATERIAL (SLM)

disorder requiring further study, but it will almost certainly be included as a disorder in its own category in DSM-5. Evidence that supports this distinction includes somewhat different patterns of heritability compared to other eating disorders, as well as a greater likelihood of occurring in males and a later age of onset. There is also a greater likelihood of remission and a better response to treatment in Binge eating disorder compared to other eating disorders. Individuals who meet preliminary criteria for BED are often found in weight-control programs. For example, Brody, Walsh, and Devlin (1994) studied mildly obese participants in a weight control program and identified 18.8% who met criteria for Binge eating disorder. In other programs, with participants ranging in degree of obesity, close to 30% met criteria. Binge eating disorder and is associated with more severe obesity. The general consensus is that about 20% of obese individuals in weight-loss programs engage in binge eating, with the number rising to approximately 50% among candidates for bariatric surgery. About half of individuals with Binge eating disorder try dieting before bingeing, and half start with bingeing and then attempt to diet; those who begin bingeing first become more severely affected by Binge eating disorder and are more likely to have additional disorders. It’s also increasingly clear that individuals with Binge eating disorder have some of the same concerns about shape and weight as people with anorexia and bulimia, which distinguishes them from individuals who are obese without Binge eating disorder. It seems that approximately 33% of those with Binge eating disorder binge to alleviate “bad moods” or negative affect. These individuals are more psychologically disturbed than the 6.7% who do not use bingeing to regulate mood. 11.7 SUMMARY  The prevalence of eating disorders has increased rapidly over the last half century. As a result, they were included for the first time as a separate group of disorders in DSM- IV.  There are two prevalent eating disorders. In bulimia nervosa,dieting results in out-of- control binge-eating episodes that areoften followed by purging the food through vomiting or othermeans.  Anorexia nervosa, in which food intake is cut dramatically,results in substantial weight loss and sometimes dangerouslylow body weight.  Bulimia nervosa and anorexia nervosa are largely confined toyoung, middle- to upper- class women in Western cultures whoare pursuing a thin body shape that is culturally mandated andbiologically inappropriate, making it extremely difficult toachieve.  Without treatment, eating disorders become chronic and can,on occasion, result in death.  In addition to sociocultural pressures, causal factors includepossible biological and genetic vulnerabilities (the disorderstend to run in families), psychological factors 172 CU IDOL SELF LEARNING MATERIAL (SLM)

(low self-esteem),social anxiety (fears of rejection), and distorted bodyimage (relatively normal-weight individuals view themselvesas fat and ugly). 11.8 KEY WORDS  Aetiology: The study of the origins of disease: physical, mental or emotional.  Anorexia nervosa (AN): An eating disorder, the main features of which include a refusal to maintain a minimal body weight, a pathological fear of gaining weight and a distorted body image in which sufferers continue to insist they are overweight.  Body image: The picture a person has of how his body appears to other people. This image develops early in life and because of bodily changes it may in later life be markedly inaccurate.  Bulimia nervosa (BN): An eating disorder, the main features of which are recurrent episodes of binge eating followed by periods of purging or fasting.  Psychological debriefing: A type of crisis intervention that requires individuals who have recently experienced a traumatic event to discuss or process their thoughts and feelings related to the traumatic event, typically within 72 hours of the event  Psychological model:Psychological model includes personality, learning, stress, self- efficacy, cognition and early life experiences and the way in which they affect mental illness  Psychological tests: Psychological tests are used for assessment of different attributes personality, social skills, intelligence, cognitive abilities, emotional responses, behavioral responses and interests. They can be administered either individually or to groups using pen and paper or oral method.  Psychopathology: The scientific study and research on psychological disorders  Public stigma: When people in a society approve negative stereotypes towards a person with a mental disorder and discriminate against them. 11.9 LEARNING ACTIVITY 1. Explain with the help of the case study given in the unit, the DSM criteria for eating disorder? ___________________________________________________________________________ ___________________________________________________________________________ 2. Explain with the help of the case study given in the unit, the ICD 10 criteria for eating disorder? ___________________________________________________________________________ ___________________________________________________________________________ 173 CU IDOL SELF LEARNING MATERIAL (SLM)

11.10 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. Define Eating Disorders. 2. What is Anorexia Nervosa? 3. What is Bulimia Nervosa? 4. What is Binge Eating Disorder? 5. What is the DSM diagnostic criteria for Anorexia Nervosa? 6. What is the DSM diagnostic criteria for Bulimia Nervosa? 7. What is the DSM diagnostic criteria for Binge Eating Disorder? 8. What is the ICD diagnostic criteria for Anorexia Nervosa? 9. What is the ICD diagnostic criteria for Bulimia Nervosa? Long Questions 1. Explain the different types of Eating Disorders in detail 2. What are the causes of Anorexia Nervosa? 3. What are the causes of Bulimia Nervosa? 4. What are the causes of Binge Eating Disorder? 5. How does Anorexia Nervosa impact the different organs in our body? B. Multiple Choice Questions 1. What percentage of young women meet the criteria for either anorexia nervosa, bulimia nervosa or eating disorder not otherwise specified? a. 20% b. 30% c. 40% d. 10% 2. According to the DSM, one of the diagnostic criteria for anorexia nervosa is that: a. Individuals have a body weight below 70% of their expected weight for their age and height. b. Individuals have a body weight below 90% of their expected weight for their age and height. c. Individuals have a body weight below 85% of their expected weight for their age and height. d. Individuals have a body weight below 65% of their expected weight for their age and height. 3. Amenorrhea is present in anorexia nervosa. This term means: 174 CU IDOL SELF LEARNING MATERIAL (SLM)

a. Body-image distortion. b. Excessive exercise. c. An intense fear of weight gain. d. Absence of menstrual cycle. 4. Neuropsychological evidence suggests that those with anorexia nervosa have problems with executive function which stem from: a. A dysfunction of the frontal lobe. b. A dysfunction of the occipital lobe. c. A dysfunction of the temporal lobe. d. A dysfunction of the parietal lobe. 5. Bulimia nervosa is characterized by recurrent binge eating and inappropriate use of compensatory behaviours. An example of a compensatory behaviour is: a.Use of laxatives. b.Self-induced vomiting. c.Excessive exercising. d.All of these Answers 1-b, 2-c, 3-d, 4-a, 5-d 11.11 REFERENCES Textbooks  Ahuja N (2002). A short text book of Psychiatry. (5th edn). New Delhi: Jaypee Brothers Medical. Publishers (pvt) Ltd.  American PsychiatricAssociation (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-Hil, 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-Hil, New Delhi.  Robert. A. Baron, Psychology, (2008) Prentice Hall India. Reference books 175 CU IDOL SELF LEARNING MATERIAL (SLM)

 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.  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.  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. 176 CU IDOL SELF LEARNING MATERIAL (SLM)

UNIT 12 – EATING DISORDER PART II STRUCTURE 12.0 Learning Objectives 12.1 Introduction 12.2 Incidence of Eating Disorder 12.3 Prevalence of Eating Disorder 12.4 Assessment of Eating Disorder 12.5 Prognosis of Eating Disorder 12.6 Treatment for Eating Disorder 12.7 Summary 12.8 Key Words 12.9 Learning Activity 12.10 Unit End Questions 12.11 References 12.0 LEARNING OBJECTIVES After studying this unit, you will be able to,  Explain the incidence of Eating Disorders  Explain the prevalence of Eating Disorders  Describe the process of assessment of Eating Disorders  Describe the prognosis of Eating Disorders  Explain the Treatment forEating Disorders 12.1 INTRODUCTION Weighing a mere 88 pounds on her 5-foot-8 frame, Brazilian model Ana Carolina Reston succumbed to a generalized infection on November 15, 2006, while battling anorexia nervosa. She was 21 years old. Having modeled for Armani and Versace and in numerous countries around the world, Carolina was initially hospitalized for kidney failure. Ana Carolina’s anorexia nervosa apparently began after she was criticized for being “too fat” during a casting call in China. At the height of her illness her diet consisted only of tomatoes and apples. Her death highlights the health risks associated with eating disorders. This model’s struggles with anorexia nervosa also reveal the extent to which ideals of beauty are intertwined with thinness. Looking good often means being slim, especially for those in the public eye. Not surprisingly, many celebrities, including Nicole Richie, Mary-Kate Olsen, Victoria Beckham, and the late Princess Diana, have also struggled with eating disorders. After the death in 2006 of Luisel Ramos, a model from Uruguay, some steps were taken by the fashion industry to try to address the situation. The organizers of the Madrid Fashion 177 CU IDOL SELF LEARNING MATERIAL (SLM)

Week decided to ban models who did not have a body mass index (a measure of a person’s weight relative to height) in the healthy range. In 2010, Victoria Beckham reportedly deemed 23 models “too skinny” and refused to have them be part of her New York Fashion Week runway show. And in France, legislation has been proposed to prohibit media that encourage emaciation, or extreme thinness. What do you think? Should models be required to get a certificate of health from their doctors before being allowed on the catwalks? Should we expect the fashion industry to police itself, or should legislation be involved? Are you ready to see healthier-looking models in the pages of Vogue, or does ultrathin still mean ultrafashionable to you? 12.2 INCIDENCE OF EATING DISORDER 12.2.1 Incidence of Anorexia Nervosa Anorexia nervosa is a relatively rare illness. Even among high-risk groups, such as adolescent girls and young women, the prevalence of strictly defined anorexia nervosa is only about 0.5%. The prevalence rates of partial syndromes are substantially higher. Despite the infrequent occurrence of anorexia nervosa, most studies suggest that its incidence has increased significantly during the last 50 years, a phenomenon usually attributed to changes in cultural norms regarding desirable body shape and weight. 12.2.2 Incidence of Bulimia Nervosa Soon after bulimia nervosa was recognized as a distinct disorder, surveys indicated that many young women reported problems with binge-eating, and it was suggested that the syndrome of bulimia nervosa was occurring in epidemic proportions. Later careful studies have found that although binge eating is frequent, the full-blown disorder of bulimia nervosa is much less common, probably affecting 1 to 2% of young women in the USA. Although sufficient research data do not exist to pinpoint specific epidemiological trends in the occurrence of bulimia nervosa, research suggests that women born after 1960 have a higher risk for the illness than those born before 1960. 12.3 PREVALENCE OF EATING DISORDER 12.3.1 Prevalence of Anorexia Anorexia nervosa usually affects women; the ratio of men to women is approximately 1: 10 to 1: 20. Anorexia nervosa occurs primarily in industrialized and affluent countries and some data suggest that even within those countries, anorexia nervosa is more common among the higher socioeconomic classes. Some occupations, such as ballet dancing and fashion modeling, appear to confer a particularly high risk for the development of anorexia nervosa. Thus, anorexia nervosa appears more likely to develop in an environment in which food is readily available but in which, for women, being thin is somehow equated with higher or special achievement. 178 CU IDOL SELF LEARNING MATERIAL (SLM)

12.3.2 Prevalence of Bulimia Nervosa Evidence suggests an important role of sociocultural influences in the development of bulimia nervosa. For example, the frequency of the disorder has been reported to be increasing among immigrants to the USA and UK from non-Western countries (Hsu, 1990). Although the rate of the disorder appears to be lower among nonwhite and non-Western cultures, the frequency of bulimia nervosa has been reported to be increasing among these groups, especially among the higher socioeconomic classes. Surprisingly, several epidemiological and clinical studies in the USA found no relationship between bulimia nervosa and social class (Kendler et al., 1991). Among patients with bulimia nervosa who are seen at eating disorders clinics, there is an increased frequency of anxiety and mood disorders, especially major depressive disorder and dysthymic disorder, of drug and alcohol abuse, and of personality disorders. It is not certain whether this comorbidity is also observed in community samples or whether it is a characteristic of individuals who seek treatment. 12.3.3 Prevalence of Binge-Eating The epidemiology of binge-eating disorder is uncertain. Cross sectional studies suggest that the prevalence of binge-eating disorder among adults is a few percent and that the prevalence is higher among obese individuals in the community and among obese individuals who attend weight loss clinics. Similarly, the frequency of binge-eating disorder increases with the degree of obesity. In contrast to anorexia nervosa and bulimia nervosa, individuals with binge-eating disorder are more likely to be men (the female to male ratio is roughly 1.5 : 1 compared with approximately 10 : 1 for anorexia nervosa and bulimia nervosa), from minority ethnic groups and middle-aged. 12.4 ASSESSMENT OF EATING DISORDER 12.4.1 Assessment for Anorexia Nervosa Special Issues in Psychiatric Examinationand History In assessing individuals who may have anorexia nervosa, it isimportant to obtain a weight history including the individual’shighest and lowest weights and the weight he or she would like to be now. For women, it is useful to know the weight atwhich menstruation last occurred, because it provides an indicationof what weight is normal for that individual. The patientshould be asked to describe a typical day’s food intake andany food restrictions and dietary practices such as vegetarianism. The psychiatrist should ask whether the patient ever losescontrol over eating and engages in binge-eating and, if so, theamounts and types of food eaten during such episodes. Theuse of self-induced vomiting, laxatives, diuretics, enemas, dietpills, and syrup of ipecac to induce vomiting should also bequeried. 179 CU IDOL SELF LEARNING MATERIAL (SLM)

Probably the greatest problem in the assessment of patientswith anorexia nervosa is their denial of the illness and theirreluctance to participate in an evaluation. A straightforward butsupportive and nonconfrontational style is probably the mostuseful approach, but it is likely that the patient will not acknowledgesignificant difficulties in eating or with weight and will rationalizeunusual eating or exercise habits. It is therefore helpfulto obtain information from other sources such as the patient’sfamily. Physical Examination and Laboratory Findings The patient should be weighed, or a current weight should beobtained from the patient’s general physician. Blood pressure,pulse and body temperature are often below the lower limit ofnormal. On physical examination, lanugo, a fine, downy hair normallyseen in infants, may be present on the back or the face. The extremities are frequently cold and have a slight red–purplecolor (acrocyanosis). Edema is rarely observed at the initial presentationbut may develop transiently during the initial stages of refeeding. The basis for laboratory abnormalities is presented in theearlier section on pathophysiology. Common findings are a mildto moderate normochromic, normocytic anemia and leukopenia,with a deficit in polymorphonuclear leukocytes leading toa relative lymphocytosis. Elevations of blood urea nitrogen andserum creatinine concentrations may occur because of dehydration,which can also artificially elevate the hemoglobin and hematocrit. While observing the patients of eating disorders, we may observe a variety of electrolyte abnormalities. These are seen in the form of hydration, vomiting anddiuretic or laxative abuse. Serum levels of liver enzymes may beusually normal but may occasionally increase during refeeding. Cholesterol levels of these patients may be higher as compared to others.The electrocardiogram typically may also show sinus bradycardiaandoccasionally low QRS voltage and a prolonged QT interval.Atype of arrhythmias has also been observed. Differences in Presentation The symptoms of anorexia nervosa are quite homogeneous. These kind of symptom differences between patients in clinical disordersare seen in very less psychiatric conditions. As mentionedearlier,younger patients may not express the anxiety and fearof fatness or the overconcern with shape and weight openly.Somepatients with longstanding history of anorexia nervosa do express a desireto gain weight however, they are not able to make concrete changes in theirbehavior. It is suggested that in other cultures, the rationalegiven by patients for losing weight differs from the fear offatness characteristic of cases in North America. Men with anorexia nervosa are seen less frequently than women.However, when the syndrome does develop in men the symptoms are similar to that as seen in women.There is a possibility of an increase in frequency of homosexuality amongmen with anorexia nervosa. Differential Diagnosis 180 CU IDOL SELF LEARNING MATERIAL (SLM)

Although depression, schizophrenia and obsessive–compulsivedisorder may be associated with disturbed eating and weight loss,it is rarely difficult to differentiate these disorders from anorexianervosa. Individuals with major depression may lose significantamounts of weight but do not exhibit the relentless drive for thinnesscharacteristic of anorexia nervosa. In schizophrenia, starvationmay occur because of delusions about food, for example, thatit is poisoned. Individuals with obsessive–compulsive disordermay describe irrational concerns about food and develop ritualsrelated to meal preparation and eating but do not describe theintense fear of gaining weight and the pervasive wish to be thinthat characterize anorexia nervosa. A wide variety of medical problems cause serious weightloss in young people and may at times be confused with anorexianervosa. Examples of such problems include gastric outlet obstruction,Crohn’s disease and brain tumors. Individuals whoseweight loss is due to a general medical illness generally do notshow the drive for thinness, the fear of gaining weight and theincreased physical activity characteristic of anorexia nervosa. However, the psychiatrist is well advised to consider any chronicmedical illness associated with weight loss, especially whenevaluating individuals with unusual clinical presentations suchas late age at onset or prominent physical complaints, for example,pain and gastrointestinal cramping while eating. 12.4.2 Assessment for Bulimia The assessment of individuals who may have binge-eating disorderparallels that of individuals who may have bulimia nervosa. Itis important to obtain a clear understanding of daily food intakeand of what the individual considers a binge. As in the assessmentof bulimia nervosa, the interviewer should inquire about theuse of purging and other inappropriate weight control methods. Individuals who describe binge-eating disorder are likely to beobese, and it is important to obtain a history of changes in weightand of efforts to lose weight. The interviewer should also inquireabout symptoms of mood disturbance and anxiety. Physical Examination and Laboratory Findings The salient general medical issue is that of obesity. Individualswith binge-eating disorder who are obese should be followedby a primary care physician for assessment and Treatment for thecomplications of obesity. There is no evidence suggesting thatthe behavioral disturbances characteristic of binge-eating disorderadd to the physical risks of obesity. Whether the presence ofbinge-eating disorder affects the natural history of obesity is anintriguing but unanswered question. Differential Diagnosis As noted above, the most difficult issue in the diagnostic assessmentof binge-eating disorder is determining whether the eatingpattern of concern to the individual meets the proposed definitionof binge-eating. There are numerous varieties of unhealthy eating,such as the 181 CU IDOL SELF LEARNING MATERIAL (SLM)

consumption of high fat foods and the nosologyof these patterns of eating is poorly worked out. Some individuals with atypical depression binge-eat whendepressed; if the individual meets criteria for both binge-eatingdisorder and an atypical depression, both diagnoses should bemade. 12.4.3 Assessment of Binge-Eating Disorder The assessment of individuals who may have binge-eating disorder parallels that of individuals who may have bulimia nervosa. It is important to obtain a clear understanding of daily food intake and of what the individual considers a binge. As in the assessment of bulimia nervosa, the interviewer should inquire about the use of purging and other inappropriate weight control methods. Individuals who describe binge-eating disorder are likely to be obese, and it is important to obtain a history of changes in weight and of efforts to lose weight. The interviewer should also inquire about symptoms of mood disturbance and anxiety. Physical Examination and Laboratory Findings The salient general medical issue is that of obesity. Individuals with binge-eating disorder who are obese should be followed by a primary care physician for assessment and Treatment for the complications of obesity. There is no evidence suggesting that the behavioral disturbances characteristic of binge-eating disorder add to the physical risks of obesity. Whether the presence of binge-eating disorder affects the natural history of obesity is an intriguing but unanswered question. Differential Diagnosis As noted above, the most difficult issue in the diagnostic assessmentof binge-eating disorder is determining whether the eatingpattern of concern to the individual meets the proposed definitionof binge-eating. There are numerous varieties of unhealthy eating,such as the consumption of high fat foods and the nosologyof these patterns of eating is poorly worked out.Some individuals with atypical depression binge-eat whendepressed; if the individual meets criteria for both binge-eatingdisorder and an atypical depression, both diagnoses should bemade. 12.5 PROGNOSIS OF EATING DISORDER As the recognition of binge-eating disorder is quite recent, there is little definitive information about the natural history of this disorder. However, both controlled treatment studies and follow up studies of community samples indicate that there is substantial fluctuation over time in the frequency and severity of the cardinal symptoms of this disorder. 12.5.1 Prognosis of Anorexia Nervosa The course of anorexia nervosa is enormously variable. Some individualshave mild and brief illnesses and either never come tomedical attention or are seen only briefly by their 182 CU IDOL SELF LEARNING MATERIAL (SLM)

pediatrician orgeneral medical physician. It is difficult to estimate the frequencyof this phenomenon because such individuals are rarely studied. Most of the literature on course and outcome is based onindividuals who have been hospitalized for anorexia nervosa.Although such individuals presumably have a relatively severeillness and adverse outcomes, a substantial fraction, probablybetween one-third and one-half, make full and complete psychologicaland physical recoveries. On the other hand, anorexianervosa is also associated with an impressive long-term mortality. The best data currently available suggest that 10 to 20% ofpatients who have been hospitalized for anorexia nervosa will, inthe next 10 to 30 years, die as a result of their illness. Much of themortality is due to severe and chronic starvation, which eventuallyterminates in sudden death. In addition, a significant fractionof patients commit suicide. Between these two extremes are a large number of individualswhose lives are impaired by persistent difficulties witheating. Some are severely affected maintaining a chronic state ofsemistarvation, bizarre eating rituals and social isolation; othersmay gain weight but struggle with bulimia nervosa and strictrules about food and eating; and still others may recover initiallybut then relapse into another full episode. There is a high frequencyof depression among individuals who have had anorexianervosa and a significant frequency of drug and alcohol abuse,but psychotic disorders develop only rarely. Thus, in general, individualseither recover or continue to struggle with psychologicaland behavioral problems that are directly related to the eatingdisorder. It is of note that it is rare for individuals who have hadanorexia nervosa to become obese. It is difficult to specify factors that account for the variabilityof outcome in anorexia nervosa. A significant body ofexperience suggests that the illness has a better prognosis when it begins in adolescence, but there are also suggestions that prepubertalonset may portend a difficult course. It is likely that theseverity of the illness (e.g., the lowest weight reached, the numberof hospitalizations) and the presence of associated symptoms,such as binge-eating and purging, also contribute to poor outcome.However, it is impossible to predict course and outcome inan individual with any certainty. 12.5.2 Prognosis of Bulimia Over time, the symptoms of bulimia nervosa tend to improve although a substantial fraction of individuals continue to engage in binge-eating and purging. On the other hand, some controlled clinical trials have reported that structured forms of psychotherapy have the potential to yield substantial and sustained recovery in a significant fraction of patients who complete treatment. It is not clear what factors are most predictive of good outcome, but those individuals who cease binge-eating and purging completely during treatment are least likely to relapse. 183 CU IDOL SELF LEARNING MATERIAL (SLM)

12.5.3 Prognosis of Binge-eating As the recognition of binge-eating disorder is quite recent, there is little definitive information about the natural history of this disorder. However, both controlled treatment studies and follow up studies of community samples indicate that there is substantial fluctuation over time in the frequency and severity of the cardinal symptoms of this disorder. 12.6 TREATMENT FOR EATING DISORDER 12.6.1 Treatment for Anorexia Nervosa Goals of Treatment The first gal of treatment is to engage the patient and her orhis family. For most patients with anorexia nervosa, this is challenging.Patients usually minimize their symptoms and suggestthat the concerns of the family and friends, who have often beeninstrumental in arranging the consultation, are greatly exaggerated. It is useful to identify a problem that the patient canacknowledge, such as weakness, irritability, difficulty concentrating,or trouble with binge-eating. The psychiatrist may thenattempt to educate the patient regarding the pervasive physicaland psychological effects of semi starvation and about the needfor weight gain if the acknowledged problem is to be successfullyaddressed. A second goal of treatment is to assess and address acutemedical problems, such as fluid and electrolyte disturbances andcardiac arrhythmias. Depending on the severity of illness, thismay require the involvement of a general medical physician. Theadditional but most difficult and time-consuming goals are therestoration of normal body weight, the normalization of eatingand the resolution of the associated psychological disturbances.The final goal is the prevention of relapse. Treatment A common major impediment to the Treatment for patients withanorexia nervosa is their disagreement with the goals of treatment;many of the features of their illness are simply not viewedby patients as a problem. In addition, this may be compoundedby a variety of concerns of the patient, such as basic mistrust ofrelationships, feelings of vulnerability and inferiority, and sensitivityto perceived coercion. Such concerns may be expressedthrough considerable resistance, defiance, or pseudocompliancewith the psychiatrist’s interventions and contribute to the powerstruggles that often characterize the treatment process. The psychiatristmust try to avoid colluding with the patient’s attempts tominimize problems but at the same time allow the patient enoughindependence to maintain the alliance. Dealing with such dilemmasis challenging and requires an active approach on the part ofthe psychiatrist. In most instances, it is possible to preserve thealliance while nonetheless adhering to established limits and theneed for change. The initial stage of treatment should be aimed at reversingthe nutritional and behavioral abnormalities. Theintensity of the treatment required and the need for partial or 184 CU IDOL SELF LEARNING MATERIAL (SLM)

fullhospitalization should be determined by the current weight, therapidity of weight loss, and the severity of associated medical andbehavioral problems and of other symptoms such as depression.In general, patients whose weights are less than 75% of expectedshould be viewed as medically precarious and require intensivetreatment such as hospitalization. Most inpatient or day treatment units experienced in thecare of patients with anorexia nervosa use a structured treatmentapproach that relies heavily on supervision of calorie intake bythe staff. Patients are initially expected to consume sufficient caloriesto maintain weight, usually requiring 1500 to 2000 kcal/dayin four to six meals. After the initial medical assessment has beencompleted and weight has stabilized, calorie intake is graduallyincreased to an amount necessary to gain 2 to 5 lb./week. Becausethe consumption of approximately 4000 kcal beyond maintenancerequirements is needed for each pound of weight gain, thedaily calorie requirements become impressive, often in the rangeof 4000 kcal/day. Some eating disorder units provide only foodwhile others rely on nutritional supplements such as Ensure orSustacal. During this phase of treatment it is necessary to monitorpatients carefully; many will resort to throwing food awayor vomiting after meals. Careful supervision is also required toobtain accurate weights; patients may consume large amountsof fluid before being weighed or hide heavy articles under theirclothing. During the weight restoration phase of treatment patientsrequire substantial emotional support. It is probably best to addressfears of weight gain with education about the dangers ofsemistarvation and with the reassurance that patients will not beallowed to gain “too much” weight. Most eating disorders unitsimpose behavioral restrictions, such as limits on physical activity,during the early phase of treatment. Some units use an explicitbehavior modification regimen in which weight gain is tiedto increased privileges and failure to gain weight results in bedrest. A consistent and structured treatment approach, with orwithout an explicit behavior modification program, is generallysuccessful in promoting weight recovery but requires substantialenergy and coordination to maintain a supportive and nonpunitive treatment environment. In most experienced treatment units,parenteral methods of nutrition, such as nasogastric feeding orintravenous hyperalimentation, are only rarely needed. Nutritionalcounseling and behavioral approaches can also be effectivein helping patients expand their dietary repertoire to includefoods they have been frightened of consuming. As weight increases, individual, group and family psychotherapycan begin to address other issues in addition to the distressengendered by gaining weight. For example, it is typicallyimportant for patients to recognize that they have come to basemuch of their self- esteem on dieting and weight control and arelikely to judge themselves according to harsh and unforgivingstandards. Similarly, patients should be helped to see how theeating disorder has interfered with the achievement of personalgoals such as education, sports, or making friends. 185 CU IDOL SELF LEARNING MATERIAL (SLM)

At present, there is no general consensusregarding the mostuseful type of psychotherapy or the specific areas that need tobe addressed when treating patients with eating disorders. Most eating disorders programs engagementdifferent typesof psychotherapeutic interventions. Numerous psychiatristsrecommend the use of individual as well as group psychotherapy. They also suggest usingcognitive–behavioral techniques to help modify the irrationaland extreme emphasis on weight. Although most authorities see littlerole for traditional psychoanalytic therapy, individual and grouppsychodynamic therapy can address such problems as insecureattachment, separation and individuation, sexual relationshipsand other interpersonal concerns. There is good evidence supportingthe involvement of the family in the Treatment for youngerpatients with anorexia nervosa. Family therapy can be useful inaddressing fears of family members regarding their illness. The interventionsemphasize parental cooperation, mutual support andconsistency, as well as establishing boundaries regarding the patient’ssymptoms and other aspects of his or her life.Despite the presence of multiple physiological disturbances associatedwith anorexia nervosa, the rolefor medication is not clearly established. The earliest systematic medication trials in anorexianervosa focused on the use of neuroleptics. Theoretically,such agents might help to promote weight gain, to reduce physicalactivity and to diminish the distorted thinking about shapeand weight, which often reaches nearly delusional proportions. Early work in the late 1950s and 1960s using chlorpromazine ledto substantial enthusiasm, but two placebo-controlled trials of theneuroleptics, sulpiride and pimozide, were unable to establishsignificant benefits. In recent years interest has grown in takingadvantage of the impressive weight gain associated with someatypical antipsychotics; however, no controlled data supportingthis intervention have yet appeared. The frequency of depressionco-occurring among patients with anorexia nervosa is very high. However, there isn’t any sufficient evidence to support the use of antidepressant medication in theirtreatment.Unfortunately, although controlled trials have providedsome evidence of benefit, the impact of cyproheptadine, an antihistamine,in anorexia nervosa appears limited. A large proportion of patients suffering from anorexia nervosa remainchronically ill. Almost 30% to 50% of patients can be successfully treated inthe hospital may also require rehospitalization within a year of discharge.Therefore, after hospitalization outpatient treatments are recommendedto prevent relapse and improve overall short termas well as longtermfunctioning. Several studies have attempted to evaluate theefficacy of various outpatient treatments for anorexia nervosaincluding behavioral, cognitive–behavioral and supportive psychotherapy,as well as a variety of nutritional counseling interventions. Although most of these treatments seem to be helpful,the clearest findings to date support two interventions. For patientswhose anorexia nervosa started before age 18 years andwho have had the disorder for less than 3 years, family therapyis effective, and for adult patients, cognitive–behavioral therapyreduces the rate of relapse. Preliminary information suggeststhat 186 CU IDOL SELF LEARNING MATERIAL (SLM)

fluoxetine treatment may reduce the risk of relapse amongpatients with anorexia nervosa who have gained weight, but additionalcontrolled data are required to document the usefulnessof this intervention. Refractory Patients Some patients with anorexia nervosa refuse to accept treatment and thereby can raise difficult ethical issues. If weight is extremelylow or if there are acute medical problems, it may be appropriateto consider involuntary commitment. For patients whoare ill but more stable, the psychiatrist must weigh the short-termutility of involuntary treatment against the disruption of a potentialalliance with the patient. The goals of treatment may need to be modified for patientswith chronic illness who have failed multiple previous attemptsat inpatient and outpatient care. Treatment may be appropriatelyaimed at preventing further medical, psychological and social deteriorationin the hope that the anorexia nervosa may eventuallyimprove with time. 12.6.2 Treatment for Bulimia Nervosa Goals of Treatment The goals of the Treatment for bulimia nervosa are straightforward.The binge-eating and inappropriate compensatory behaviorsshould cease and self-esteem should become more appropriatelybased on factors other than shape and weight. Treatment The power struggles that often complicate the treatment processin anorexia nervosa occur much less frequently in the Treatment for patients with bulimia nervosa. This is largely because thecritical behavioral disturbances, binge-eating and purging, areless ego syntonic and are more distressing to these patients. Mostbulimia nervosa patients who pursue treatment agree with theprimary treatment goals and wish to give up the core behavioralfeatures of their illness. The Treatment for bulimia nervosa has received considerableattention in recent years and the efficacies of both psychotherapyand medication have been explored in numerous controlledstudies. The form of psychotherapy that hasbeen examined most intensively is cognitive–behavioral therapy,modeled on the therapy of the same type for depression. Cognitive–behavioral therapy for bulimia nervosa concentrates on thedistorted ideas about weight and shape, on the rigid rules regardingfood consumption and the pressure to diet and on the eventsthat trigger episodes of binge-eating. The therapy is focused andhighly structured and is usually conducted in 3 to 6 months. Approximately25 to 50% of patients with bulimia nervosa achieveabstinence from binge-eating and purging during a course of cognitive–behavioral therapy and in most, this improvement appearsto be sustained. The most common form of cognitive–behavioraltherapy is individual treatment, although it can be given in eitherindividual or group format. The effect of cognitive–behavioraltherapy is greater than that of supportive psychotherapy andof interpersonal therapy, indicating that cognitive–behavioraltherapy should be the Treatment for choice for bulimia nervosa.The 187 CU IDOL SELF LEARNING MATERIAL (SLM)

other commonly used mode of treatment that has beenexamined in bulimia nervosa is the use of antidepressant medication. This intervention was initially prompted by the high ratesof depression among patients with bulimia nervosa and has nowbeen tested in more than a dozen double-blind, placebo- controlledstudies using a wide variety of antidepressant medications.Active medication has been consistently found to be superior toplacebo, and although there have been no large “head-to-head”comparisons between different antidepressants, most antidepressantsappear to possess roughly similar antibulimic potency. Fluoxetine at a dose of 60 mg/day is favored by many investigatorsbecause it has been studied in several large trials and appears to be at least as effective as, and better tolerated than, most other alternatives. It is notable that it has not been possible to linkthe effectiveness of antidepressant treatment for bulimia nervosato the pretreatment level of depression. Depressed and nondepressedpatients with bulimia nervosa respond equally well interms of their eating behavior to antidepressant medication. Although antidepressant medication is clearly superior toplacebo in the Treatment for bulimia nervosa, several studies suggestthat a course of a single antidepressant medication is generallyinferior to a course of cognitive–behavioral therapy. However,patients who fail to respond adequately to, or who relapsefollowing a trial of psychotherapy, may still respond to antidepressantmedication. Special Features Influencing Treatment A major factor influencing the Treatment for bulimia nervosa isthe presence of other significant psychiatric or medical illness.For example, it can be difficult for individuals who are currentlyabusing drugs or alcohol to use the treatment methods described,and many psychiatrists suggest that the substance abuse needs tobe addressed before the eating disorder can be effectively treated. Other examples include the Treatment for individuals with bulimianervosa and serious personality disturbance and those with insulin-dependent diabetes mellitus who “purge” by omitting insulindoses. In treating such individuals, the psychiatrist must decidewhich of the multiple problems must be first addressed and mayelect to tolerate a significant level of eating disorder to confrontmore pressing disturbances. Refractory Patients Although psychotherapy and antidepressant medication areeffective interventions for many patients with bulimia nervosa,some individuals have little or no response. There is no clearly establishedalgorithm for the Treatment for such refractory patients.Alternative interventions that may prove useful include otherforms of psychotherapy and other medications such as opiate antagonistsand the serotonin agonist fenfluramine. Hospitalizationshould also be considered as a way to normalize eating behavior,at least temporarily, and perhaps to initiate a more effective outpatienttreatment. 188 CU IDOL SELF LEARNING MATERIAL (SLM)

12.6.3 Treatment for Binge-Eating Goals of Treatment For most individuals with binge-eating disorder, there are threerelated goals. One is behavioral, to cease binge eating. A secondfocuses on improving symptoms of mood and anxiety disturbancewhich frequently are associated with binge-eating disorder. Thethird is weight loss for individuals who are also obese. Treatment Treatment approaches to binge-eating disorder are currently underactive study. There is good evidence that psychological (e.g.,CBT) and pharmacological (e.g., SSRI) interventions which areeffective for bulimia nervosa are also useful in reducing thebinge frequency of individuals with binge-eating disorder andin alleviating mood disturbance. However, it is not clear howhelpful these approaches are in facilitating weight loss. Standardbehavioral weight loss interventions employing caloricrestriction appear useful in helping patients to control bingeeating,but the benefits of such treatment have not been comparedwith those of more psychologically-oriented treatments,such as CBT. 12.7 SUMMARY  Eating disorders are serious conditions related to persistent eating behaviors that negatively impact your health, your emotions and your ability to perform in important areas of life.  The commonly seen eating disorders include anorexia nervosa, bulimia nervosa and binge-eating disorder.  Most of the eating disorders are related to focusing too much on one’s weight, body shape and food which leads to dangerous eating habits and behaviors. Such behaviors can have significant impact on a person’s ability to get appropriate nutrition.  Eating disorders have an impact on the person’s heart, digestive system, bones, as well as teeth and mouth. They also lead to other diseases.  Eating disorders tend to develop in the teen and young adult years.There are instances wherein eating disorders can develop at other ages. With treatment, the patient can return back to healthier eating habits and sometimes even reverse serious complications caused by these eating disorder.  Several psychosocial treatments are effective, including cognitive-behavioral approaches combined with family therapy and interpersonal psychotherapy. Drug treatments are less effective at the current time.  Eating disorders can be difficult to manage or overcome by oneself. Eating disorders can even take over your life. Unfortunately, people with eating disorders do not believe they need treatment. If you're worried about a loved one, urge him or her to talk to a doctor. 189 CU IDOL SELF LEARNING MATERIAL (SLM)

 Teenage girls and young women are more prone to have anorexia or bulimia than teenage boys and young men.However,they can have eating disorders, too. Although eating disorders can occur across a broad age range, they often develop in the teens and early 20s.  Eating disorders result in a wide range of complications, some of which are even life- threatening.  It is important to seek help early for treatment of eating disorders. People with eating disorders are also at higher risk for medical complications as well as suicidal thoughts.  People with eating disorders are often found to have other mental disorders including depression or anxiety or problems related to substance use. IN such cases, complete recovery is also possible.  Psychotherapies include family-based therapy called the Maudsley approach, wherein parents of adolescents diagnosed with anorexia nervosa assume responsibility for feeding their child. This therapyappears to be effective in helping them gain weight as well as improve eating habits and moods.  Evidence suggests that medications like antidepressants, antipsychotics or even mood stabilizers are also found to be helpful for treating eating disorders and other co- occurring illnesses which include anxiety or depression. 12.8 KEY WORDS  Behaviour modification: The deliberate changing of a particular pattern of behaviour by behaviorist methods.  Depression: One of the most common forms of emotional disturbance which can vary in intensity from an everyday attack of 'the blues ' to a psychotic condition of paralyzing hopelessness.  Group therapy: Psychotherapy involving several people at the same time. The assumption is that people can benefit from the experiences and companionship of other people.  Psychotherapy: The use of psychological techniques to treat psychological disturbances.  Psychological model:Psychological model includes personality, learning, stress, self- efficacy, cognition and early life experiences and the way in which they affect mental illness  Psychological tests: Psychological tests are used for assessment of different attributes personality, social skills, intelligence, cognitive abilities, emotional responses, behavioral responses and interests. They can be administered either individually or to groups using pen and paper or oral method.  Psychopathology: The scientific study and research on psychological disorders 190 CU IDOL SELF LEARNING MATERIAL (SLM)

 Public stigma: When people in a society approve negative stereotypes towards a person with a mental disorder and discriminate against them. 12.9 LEARNING ACTIVITY 1. Explain the process of assessment undertaken in order to diagnose a child with eating disorder? ___________________________________________________________________________ ___________________________________________________________________________ 2. Explain the process of treatment provided to a child with eating disorder? ___________________________________________________________________________ ___________________________________________________________________________ 12.10 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. What is the incidence of anorexia nervosa? 2. What is the prevalence of anorexia nervosa? 3. What is the incidence of bulimia nervosa? 4. What is the prevalence of bulimia nervosa? 5. What is the prevalence of binge-eating disorder? Long Questions 1. What is the assessment process for Anorexia Nervosa? 2. What is the assessment process for Bulimia Nervosa? 3. What is the prognosis for eating disorders? 4. What is the treatment for Anorexia Nervosa? 5. What is the treatment for Bulimia Nervosa? B. Multiple Choice Questions 1. Where anorexia nervosa and depression occur together, an appropriate treatment could be: a. Implosion therapy. b. An antidepressant medication such as fluoxetine. c. An antipsychotic medication such as clozapine. d. An antidepressant medication such as fluoxetine. 2. One of the primary goals of any treatment for anorexia nervosa is to: a. Increase weight to normal levels. 191 CU IDOL SELF LEARNING MATERIAL (SLM)

b. Stop the individual exercising. c. Replace binge eating with other behaviours. d. Reduce weight to normal levels. 3. The Maudsley method is: a. A technique of systematic desensitization for bulimia nervosa. b. A technique of family therapy for treating eating disorders. c. The compulsory detainment in hospital of those at risk of death from anorexia nervosa. d. Cognitive behavioral therapy for binge eating disorder. 4. What health complication is often seen in bulimia nervosa? a. Loss of smell. b. Dental erosion c. Loss of taste. d. Hearing loss. 5. Bulimia nervosa is characterized by recurrent binge eating and inappropriate use of compensatory behaviours. An example of a compensatory behaviour is: a.An intense fear of weight gain. b.Absence of menstrual cycle c.Use of laxatives. d.All of these Answers 1-a, 2-a, 3-a, 4-a, 5-a 12.11 REFERENCES Textbooks  Ahuja N (2002). A short text book of Psychiatry. (5th edn). New Delhi: Jaypee Brothers Medical. Publishers (pvt) Ltd.  American PsychiatricAssociation (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-Hil, 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. 192 CU IDOL SELF LEARNING MATERIAL (SLM)

 Robert S. Feldman (2011) Understanding Psychology, McGraw-Hil, New Delhi.  Robert. A. Baron, Psychology, (2008) Prentice Hall India. Reference books  Bruch H (1973) Eating Disorders. Obesity, Anorexia Nervosa, and the Person Within. Basic Books, New York.  Bruch H (1982) Anorexia nervosa: Therapy and theory. Am J Psychiatry 132, 1531.  Fairburn CG and Walsh BT (2002) Atypical eating disorders, in eating disorders and Obesity: A Comprehensive Textbook, 2nd edn. (eds  Brownell KD and Fairburn CG). Guilford Press, New York, p. 171.  Gordon RA (1990) Anorexia and Bulimia: Anatomy of a Social Epidemic. Basil Blackwell, Cambridge, MA.  Hsu KL (1990) Eating Disorders. Guilford Press, New York. Kaye WH (1997) Anorexia nervosa, obsessional behavior, and serotonin. Psychopharmacology Bull 33, 335.  Kendler KS, Maclean C, Neale M et al. (1991) The genetic epidemiology of bulimia nervosa. Am J Psychiatry 148, 1627.  Klomp KL, Kaye W and Strober M (2001) The evolving genetic foundations of eating disorders. Psychiatry Clin N Am 24, 215.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 193 CU IDOL SELF LEARNING MATERIAL (SLM)

UNIT 13 – ELIMINATION DISORDER PART I STRUCTURE 13.0 Learning Objectives 13.1 Introduction 13.2 Elimination Disorder 13.3 DSM Criteria 13.4 ICD 10 criteria 13.5 Causes of Elimination Disorder 13.6 Types of Elimination Disorder 13.7 Summary 13.8 Key Words 13.9 Learning Activity 13.10 Unit End Questions 13.11 References 13.0 LEARNING OBJECTIVES After studying this unit, you will be able to,  Describe Elimination Disorder  Explain the nature and symptoms of Elimination Disorder  Explain the DSM criteria of Elimination Disorder  Explain the ICD 10 criteria of Elimination Disorder  Describe the causes of Elimination Disorder 13.1 INTRODUCTION John, an 8-year-old boy, was the sixth child in a sibship. He was brought by his mother for Treatment for nocturnal enuresis which was occurring on average five times a week, with no particular pattern. Two of his elder brothers had also wet the bed until the age of 10 and 13 years, respectively, as had his biological father who was no longer living with the family. The mother had become exasperated with John’s wetting and had begun punishing him by forcing him to wash his bedclothes by hand every morning before school. His brothers made fun of him, and peers at school avoided him because he frequently came to school still smelling of stale urine. He was not allowed to have anything to drink after 6 pm, and a star chart was currently being used without much success. No praise was given for the two dry nights per week because his mother was convinced that this meant the enuresis was deliberate. John drew a picture describing the terror and anxiety of having a wet night. His three wishes were to stop wetting, to get a Nintendo machine of his own and to find a real dinosaur fossil. The initial management included an explanation of the condition, 194 CU IDOL SELF LEARNING MATERIAL (SLM)

microbiological analysis of a midstream specimen of urine and instructions on baseline recording using the star chart. Overt punishments were eliminated, although John was expected to help change his sheets, and effort was expended in trying to help his mother praise him for the dry nights he was able to achieve. After a 2-week baseline period, urinalysis results came back negative and the frequency of enuresis remained at four to five nights per week. John and his mother were instructed in the use of a night alarm and were telephoned 2 days later to check on any problems. It appeared that John was not waking with the buzzer, and they were instructed to place the alarm unit on an old cookie tin to amplify the sound. Dry nights were recorded on John’s chart, with verbal praise after each one. An initial target of three dry nights per week was set, with the promise of a trip to the movies for John and the two brothers who shared a bedroom with him. This was achieved the first week, although it took a further 6 weeks before he went a full week without a wet bed. After 2 weeks of continence, the restriction on night-time fluids was relaxed without incident. Six months later he remained dry, and school and home relationships were markedly improved. 13.2 ELIMINATION DISORDER Elimination disorders occur when children who are otherwise old enough to eliminate waste appropriately repeatedly void feces or urine in inappropriate places or at inappropriate times. Elimination disorders all involve the inappropriate elimination of urine or feces and are usually first diagnosed in childhood or adolescence. The two disorders that fall under this category are Enuresis and Encopresis. Elimination disorders manifest in childhood or adolescence as repeated voiding of urine (enuresis) or defecation (encopresis) that is inappropriate for the developmental age. Patients may have a history of other psychiatric disorders or of psychosocial stressors. The diagnosis is established based on enuresis occurring 2 times per week for at least 3 consecutive months and encopresis occurring once per month for at least 3 consecutive months. Management of enuresis consists of psychoeducation, behavioral training, and pharmacologic treatment with desmopressin or imipramine. Management of encopresis involves behavioral training and Treatment for underlying constipation, if present. Both conditions have a good prognosis with high rates of spontaneous remission. 13.3 DSM CRITERIA 13.3.1 DSM criteria for Enuresis A. Repeated voiding of urine into bed or clothes, whether involuntary or intentional. B. The behavior is clinically significant as manifested by either a frequency of at least twice a week for at least 3 consecutive months or the presence of clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning. 195 CU IDOL SELF LEARNING MATERIAL (SLM)

C. Chronological age is at least 5 years (or equivalent developmental level). D. The behavior is not attributable to the physiological effects of a substance (e.g., a diuretic, an antipsychotic medication) or another medical condition (e.g., diabetes, spina bifida, a seizure disorder). Specify whether: Nocturnal only: Passage of urine only during nighttime sleep. Diurnal only: Passage of urine during waking hours. Nocturnal and diurnal: A combination of the two subtypes above. Fig.13.1 DSM criteria for Enuresis 13.3.2 DSM criteria for Encopresis A. Repeated passing of feces in inappropriate places (e.g., clothing, floor), either involuntary or intentional. B. At least one such event to occur each month in the least 3 months. C. Chronological age of the child is at least 4 years (or equivalent to developmental level). D. The behavior is not attributable to any physiological effects of a substance (e.g., laxatives) or any other medical condition except through a mechanism involving constipation. 196 CU IDOL SELF LEARNING MATERIAL (SLM)

With constipation and overflow incontinence: Specify whether: There is enough evidence of constipation on physical examination or during history taking. Without constipation and overflow incontinence: Specify whether: There is no evidence of constipation on physical examination or during history taking. Fig.13.2 DSM criteria for Encopresis 13.4 ICD 10 CRITERIA 13.4.1 ICD 10 criteria for Enuresis There is no clear-cut demarcation between an enuresis disorder and the normal variations in the age of acquisition of bladder control. However, enuresis would not ordinarily be diagnosed in a child under the age of 5 years or with a mental age under 4 years. If the enuresis is associated with some (other) emotional or behavioral disorder, enuresis would normally constitute the primary diagnosis only if the involuntary voiding of urine occurred at least several times per week and if the other symptoms showed some temporal covariation with the enuresis. Enuresis sometimes occurs in conjunction with encopresis; when this is the case, encopresis should be diagnosed. 197 CU IDOL SELF LEARNING MATERIAL (SLM)

Occasionally, children develop transient enuresis as a result of cystitis or polyuria (as from diabetes). However, these do not constitute a sufficient explanation for enuresis that persists after the infection has been cured or after the polyuria has been brought under control. Not infrequently, the cystitis may be secondary to an enuresis that has arisen by ascending infection up the urinary tract as a result of persistent wetness (especially in girls). Includes: Enuresis (primary) (secondary) of nonorganic origin Functional or psychogenic enuresis Urinary incontinence of nonorganic origin Excludes: enuresis NOS (R32) 13.4.2 ICD 10 criteria for Encopresis The crucial diagnostic feature is the inappropriate placement of faeces. The condition may arise in several different ways. First, it may represent a lack of adequate toilet-training or of adequate response to training, with the history being one of continuous failure ever to acquire adequate bowel control. Second, it may reflect a psychologically determined disorder in which there is normal physiological control over defecation but, for some reason, a reluctance, resistance, or failure to conform to social norms in defecating in acceptable places. Third, it may stem from physiological retention, involving impaction of faeces, with secondary overflow and deposition of faeces in inappropriate places. Such retention may arise from parent/child battles over bowel-training, from withholding of faeces because of painful defecation (e.g. as a consequence of analfissure), or for other reasons. In some instances, the encopresis may be accompanied by smearing of faeces over the body or over the external environment and, less commonly, there may be analfingering or masturbation. There is usually some degree of associatedemotional/behavioral disturbance. There is no clear-cut demarcation betweenencopresis with associated emotional/behavioral disturbance and some otherpsychiatric disorder which includes encopresis as a subsidiary symptom. Therecommended guideline is to code encopresis if that is the predominantphenomenon and the other disorder if it is not (or if the frequency of theencopresis is less than once a month). Encopresis and enuresis are notinfrequently associated and, when this is the case, the coding of encopresis shouldhave precedence. Encopresis may sometimes follow an organic condition such asanal fissure or a gastrointestinal infection; the organic condition should be the solecoding if it constitutes a sufficient explanation for the faecal soiling but, if it servesas precipitant but not a sufficient cause, encopresis should be coded (in addition tothe somatic condition). Differential diagnosis. It is important to consider the following: (a)encopresis because of organic disease such as aganglionic megacolon (Q43.1) orspina bifida (Q05.-) 198 CU IDOL SELF LEARNING MATERIAL (SLM)

(b)constipation involving faecal blockage resulting in \"overflow\" faecal soiling ofliquid or semiliquid faeces (K59.0); if, as happens in some cases, encopresisand constipation coexist, encopresis should be coded (with an additionalcode, if appropriate, to identify the cause of the constipation). 13.5 CAUSES OF ELIMINATION DISORDER 13.5.1 Causes of Enuresis Possible biological factors include a structural pathological conditionor infection of the urinary tract (or both), low functionalbladder capacity, abnormal antidiuretic hormone secretion, abnormaldepth of sleep, genetic predisposition and developmental delay. Research has found evidence towards sympathetic hyperactivityas well as delayed organ maturation as seen by delay in ossification. Obstructive lesions of the urinary outflow tract canalso result in urinary tract infection (UTI) as well as enuresis. This has beenthought to be important as a high prevalence of such abnormalitiesseen in children with enuresis referred to urologic clinics. This degree ofassociation is not seen at less specialized pediatric centers, however,and most studies linking urinary outflow obstruction to enuresis aremethodologically flawed (Shaffer et al., 1979). Structural causes forenuresis should be considered the exception rather than the rule. The concept that children with enuresis have low functionalbladder capacities has been widely promoted. Shaffer and colleagues(1984) have come up with a functional bladder capacity which was one standard deviationlower than expected (55%) of a sample of children with enuresis inschool clinics. Although low functional capacity may predispose thechild to enuresis, successful behavioral treatment does not seem toincrease that capacity.Instead the sensation of a full (smaller) bladderpromotes the child to waking up to pass urine so that enuresis can be avoided. Reductionof nocturnal secretion of antidiuretic hormone (ADH) hasbeen seen in a small number of children diagnosed with enuresis. This causesexcessive to production of amounts of diluted urine during the nightand thus overwhelming bladder capacity. Several mechanisms are therefore associatedwith enuresis. These include increase in nocturnal urine volume,smaller nocturnal functional bladder capacity, increase in spontaneousbladder contractions, as well as the inability to get up to the stimulusof a large and/or contracting bladder. This may identify two maingroups of children with enuresis: those who demonstrate nocturnalspontaneous bladder contractions (detrusor dependent enuresis) andthose with nocturnal polyuria (volume dependent enuresis). 13.5.2 Causes of Encopresis Within the first year of life, children can show a tendency towardconstipation, with concordance for constipation being six timesmore frequent in monozygotic than in dizygotic twins. Fecalretention and reduced stool frequency between 12 and 24 monthsof age can predict later encopresis. Encopretic children withconstipation and overflow are found to have 199 CU IDOL SELF LEARNING MATERIAL (SLM)

rectal and colonicdistention, massive impaction with hard feces and a number ofspecific abnormalities of anorectal physiology. These abnormalities,which may be primary or secondary to constipation,include elevated anal resting tone, decreased anorectal motilityand weakness of the internal anal sphincter, and dysfunction ofthe external anal sphincter. Encopresis may occur after an acuteepisode of constipation following illness or a change in diet. Inaddition to the pain caused by attempts to pass an extremely hardstool, a number of specific painful perianal conditions such as anal fissure can lead to stool withholding and later fecal soiling. Stressful events such as the birth of a sibling or attending a newschool have been associated with up to 25% of cases of secondaryencopresis. In nonretentive encopresis, the main theories centeron faulty toilet training. Stress during the training period, coercivetoileting leading to anxiety and “pot phobia”, and failureto learn or to have been taught the appropriate behavior have allbeen implicated. True fecal urgency, which may have a physiologicalor pathological basis, may also be important in a smallproportion of cases (Woodmansey, 1967). 13.6 TYPES OF ELIMINATION DISORDER 13.6.1 Enuresis Functional enuresis is usually defined as the intentional or involuntary passage of urine into bed or clothes in the absence of any identified physical abnormality in children older than 4 years of age. It is often associated with psychiatric disorder and children with enuresis are frequently referred to mental health services for treatment. 13.6.2 Enuresis (Not Due to a Medical Condition) This disorder is characterized by the repeated voiding of urine into clothes or bed at the age of 5 (chronic logically or developmentally) or older for a period of at least twice weekly over three months. Enuresis reflects a significant emotional distress or impairment in social, academic or other important areas of functioning. Enuresis may be either diurnal (during waking hours) or nocturnal (during night-time sleep) or a combination of both. 13.6.3 Encopresis Encopresis is usually defined as the intentional or involuntarypassage of stool into inappropriate places in the absence of anyidentified physical abnormality in children older than 4 years. Itmay not be attributable to a medical condition and must occurat least monthly for a period of three months. The distinction isdrawn between encopresis with constipation (retention with overflow based on history or physical examination) and encopresiswithout constipation. Other classification schemes include makinga primary–secondary distinction (based on having a 1-yearperiod of continence) or soiling with fluid or normal feces. 200 CU IDOL SELF LEARNING MATERIAL (SLM)