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Eating disorders are not confined to teens


Posted: Tuesday, May 28, 2013 2:00 am


Eating disorders are not confined to teens


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DEAR DOCTOR K: I’m a woman in my 50s. Ever since my divorce last year, I’ve developed an unhealthy pattern of eating and purging. A friend suggested I might have an eating disorder. Could she be right?


DEAR READER: I understand why you ask the question, as most people think of eating disorders as a teenager’s disease. But eating disorders also affect middle-aged and older women, and even some men.

Experts disagree about what causes eating disorders. There is probably no single, simple answer. Genes seem to play a role. Identical twins are more likely to have eating disorders than non-identical twins, for example.

Eating disorders appear to be more common in people who have dieted frequently in the past and in people who needed to be lean at one point in their lives — because they were competing in certain sports, for example, or dancing.

People with eating disorders appear to be more likely to have psychiatric disorders, particularly obsessive-compulsive disorder, anxiety disorder and substance abuse.

I’m not a psychiatrist, but I’ve always been struck by the parallels between obsessive-compulsive disorder and eating disorders. Both involve irrational behaviors that people cannot control. Eating disorders may be a way of responding to stressful events in life.

There are many reasons why eating disorders may develop or reappear during middle age. With age, for example, you are increasingly likely to lose people you care about. Restricting food or purging can be a way to deal with distressing feelings.

Divorce is another common reason. In addition to grief and loss, the breakup of a marriage can spur a person to view their body unfavorably.

The type of disordered eating you’ve described sounds like bulimia nervosa. People with bulimia go through cycles of binge eating followed by purging. While on a binge, a person with bulimia may eat an entire cake rather than one or two slices, or a gallon of ice cream rather than a bowl. This is followed by a purge: making oneself vomit or using laxatives or diuretics.

Talk to your doctor about your eating patterns.

If you do have bulimia, treatment can help you achieve a healthy weight and eating pattern, eliminate binge eating and purging and address any stressful issues in your life:

n Psychotherapy is the cornerstone of treatment for eating disorders. Cognitive behavioral therapy challenges unrealistic thoughts about food and appearance. It can help you develop more productive thought patterns. Interpersonal and psychodynamic therapy can help you gain insight into issues that may underlie your disordered eating.

n Through nutritional rehabilitation, a dietitian or nutritional counselor can help you learn (or relearn) the components of a healthy diet. He or she can help motivate you to make the needed changes.

n Fluoxetine (Prozac) is the only medication approved to treat an eating disorder. At high doses, it reduces binge eating and vomiting, particularly in combination with psychotherapy. Other antidepressants and the seizure medication topiramate (Topamax) may also be prescribed for bulimia.

With the help of these treatments, you can overcome your eating disorder.

Dr. Komaroff is a physician and professor at Harvard Medical School. Send questions and get additional information at www.AskDoctorK.com.

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Tuesday, May 28, 2013 2:00 am.


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Dr. K

Quelling Anxiety Across the Chesapeake

Driving over the Chesapeake Bay Bridge stirs fear in the hearts of no small number of Baltimore and Washington residents, an anxiety that resumed its seasonal peak over the Memorial Day weekend and the start of the annual pilgrimage to the beach towns and quaint sailing harbors of the Eastern Shore.

“Everyone talks about the fear of crossing the bridge,” said Carolyn Casey, who lives in Washington with her family and has a second home near St. Michaels, Md., across the bridge.

On Friday, she pulled her silver Lexus S.U.V. to the side of the road before the western end of the bridge, which stretches more than four miles. The passenger seat was piled with Whole Foods bags, and two Labrador retrievers were curled in the cargo area. As Ms. Casey climbed into the back seat with her 3-year-old daughter and a nanny, Alex Robinson got in behind the wheel.

“When I told people I’d found someone to drive me over the bridge, they laughed,” said Ms. Casey, 41, a homemaker whose husband is a consultant. “But it all came out — everyone is afraid of the bridge.”

Mr. Robinson, 27, runs Kent Island Express, which charges $25 each way to shuttle people in their own vehicles across a bridge that Travel Leisure magazine ranks as one of the world’s scariest.

As he drove to pick up one customer, he fielded the kind of telephone call he receives all day. “Do you have a lot of people you drive because they’re afraid?” a woman asked, with uneasiness in her voice.

“About 5,800 people use our service,” Mr. Robinson told her.

“Whoa,” the woman said. “That makes me feel better.”

Mr. Robinson’s business, which he took over last year from his mother and stepfather after they had run it for five years, has made him an amateur psychologist. He hires only upbeat drivers so as not to further alarm clients. “Their stress and anxieties feed off of your mood,” he tells employees.

He knows to talk about anything but the bridge during the 10 to 15 minutes it takes to cross: first, a disconcerting dogleg curve, then a precipitous climb over the initial suspension span; then downhill and over a second span, a cantilever whose boxy sides and roof feel like a suffocating tunnel.

“Most people, when they’re nervous, they babble,” Mr. Robinson said. “They talk about their first boyfriend. Their kids. People will tell you about their entire life story.”

But not everyone. Construction workers have been known to ride in the back seat of their pickup trucks, hats pulled over their eyes and their ears plugged. A woman once rode with a blanket over her head. A man asked to be put in his trunk, an offer that was refused.

The fear of bridges has a name, gephyrophobia. Psychotherapists say it is common and often traces back to a panic attack during a particular crossing, even after years of driving over the same bridge without incident.

Kathleen Busch, who retired from the human resources department of a Baltimore company, said she could cross carefree “when I could wear a bikini.” Her fear began after she was stuck in the Baltimore Harbor Tunnel for hours. (Experts say the fear of bridges and tunnels are sometimes linked.)

Trying to drive through the tunnel later, “everything went white,” Ms. Busch recalled. “I had a full-blown panic attack,” with racing heart and shortness of breath. “I thought I was going to pass out.”

In the two years since she and her husband bought a retirement home on the Eastern Shore, she has not tried to drive on the Bay Bridge for fear of causing an accident.

The bridge, officially the William Preston Lane Jr. Memorial Bridge, is not the only one with a service to help anxious drivers. The five-mile-long Mackinac Bridge in Michigan, one of the world’s longest suspension bridges, offers a free drivers’ assistance program. In the Florida Keys, enterprising college students have been known to wait at either end of the Seven Mile Bridge to drive tourists.

Mental Health Resource

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School mental health services stretch to meet increased need, staff says

With increasingly severe emotional disorders seen among students, resources for mental health services in public schools do not adequately address the county’s needs, according to one school official.


Symptoms of mental illness have grown more intense in recent years and are seen at much younger ages, said Ann Hammond, the county’s supervisor of psychological services and school therapists. But Frederick County Public Schools’ budget restrictions have kept school mental health staff from increasing to accommodate the growing demand.

Nineteen full-time school psychologists served in the county’s 51 public schools during the 2000-2001 school year, Hammond said. Though the county has gained 13 public schools since 2001, only one part-time psychologist position has been added.

“Schools often are the biggest mental health providers for children because they are with us for such a large part of the day,” Hammond said. “We’re not keeping up, and that’s just the honest truth.”

More than 3,000 children in the county have some form of mental illness, Hammond said. The school system does not keep statistics of the number of its students with mental illnesses.

School psychologists and counselors deal most often with students who have anxiety issues such as obsessive-compulsive disorder or separation anxiety; mood disorders such as depression; attention-deficit (hyperactivity) disorder and trauma from abuse, neglect or loss of a loved one, Hammond said.

The increase in mental health problems, particularly anxiety and depression, can be linked to the stresses children face as a result of a shaky economy, she said.

“As people lose jobs and have less money, families become less stable,” Hammond said. “Everybody is more stressed. Families are losing homes, families are moving in together, so there’s a lot of people living together in less space.”

Job stress can cause parents to have less patience with or pay less attention to their children, Hammond said. When families lose health insurance, they are less likely to be able to afford medicine or therapy for children.

The school system provides a number of services to help students cope with mental illness, including in-school psychological consultations, counseling sessions, and group or one-on-one teaching. Outside health care professionals are also brought into schools through partnerships with the county’s departments of social and health services.

School system staff conducted 1,369 student psychological evaluations, 51 student threat assessments and 320 suicide interventions during the 2011-2012 school year, according to school records.

About 240 students in Frederick County have emotional disabilities that require special education services, Hammond said.

However, there are other students with mental disabilities who do not need special education because of adequate medication and support by family and schools, she said.

Janet Shipman, who oversees the county’s school counselors, said her staff has tried to “fine-tune” the counseling process by educating teachers and students on the importance of reporting unusual changes in their peers’ personalities.

This helps school counselors reach out to students who may consider suicide, whether or not they have expressed the desire to harm themselves.

The number of elementary students who say they intend to hurt themselves has increased from 53 during the 2011-2012 school year to 64 to date in the current school year, Shipman said. The number of such cases among middle and high school students in the current school year has dropped from 118 to 113 and 149 to 108, respectively.

Despite the decline of suicide threats in middle schools and high schools so far this school year, Shipman said she has observed a general increase in serious mental health issues.

The current ratio of counselors to students varies based on the school, Shipman said. One counselor may be placed in a school with 500 students, while another works in a school of more than 900.

The school system’s fiscal 2013 budget allocated about $6.4 million for student health services, accounting for slightly more than 1.2 percent of the overall budget.

The fiscal 2014 budget request asks for more than $6.7 million, an increase of 6.1 percent in student health funding.

Stretching resources and personnel to meet the county’s needs can be a struggle, Hammond said.

“It’s been very, very hard because we as a system haven’t seen a lot of increases in funding,” she said. “Working within what we have, we do support kids amazingly. We have good people doing their jobs really well.”

School counselors are only a short-term solution, Shipman said, and schools are fortunate to have connections with community resources.

“I know in working with the health department and working with different agencies, there’s a lot of groups of people who are trying to increase awareness, trying to think outside of the box,” Shipman said. “I don’t foresee things getting worse.”

Follow Rachel S. Karas on Twitter: @rachelkaras.

BY THE NUMBERS

240 students in special education for emotional disabilities

Fiscal 2013 FCPS budget: $6.37 million for student health services

Fiscal 2014 request: $6.76 million

Increase of 6.1 percent

2000-2001 51 schools, 19 psychologists2012-2013 64 schools, 19 full time, 1 part time

2011-12 school year:

1,369 student psychological evaluations51 student threat assessments320 suicide interventions

More than 3,000 children in the county have some form of mental illness

Is Your Relationship Worth Saving

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Goodbye to the DSM-V

By Matthew McKay, PhD, New Harbinger Publications co-founder and publisher

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) is here, and it’s dead on arrival. A few weeks ago, the National Institute of Mental Health (NIMH) announced it will no longer fund research based on DSM symptom clusters — for the simple reason that the DSM is irrelevant to determining the cause and treatment of psychological problems. Here’s why:

A huge disconnect exists between DSM categories and treatment.
Some diagnoses have no viable treatments, some have the same treatment (for example, David Barlow’s unified treatment for emotional disorders), and some have multiple evidence-based treatments. If DSM diagnosis doesn’t inform treatment, what good is it? The answer is one, to facilitate the exchange of money between payers and providers, and two, to create silos for focused research. With the NIMH announcement, scratch number two.

The DSM is a topographical symptom map that doesn’t point to the actual causes — underlying mechanisms — that drive and maintain disorders.
These mechanisms, sometimes called transdiagnostic factors and/or vulnerabilities, are how we now formulate and explain psychological pain. Transdiagnostic factors like experiential avoidance, rumination, and cognitive misappraisal, along with vulnerabilities like intolerance of uncertainty, hyperarousal, and negative schemas create psychological disorders. Our treatments must be aimed at these causative mechanisms rather than outdated symptom clusters.

DSM categories are not discrete.
In other words, the same symptom can show up in many different diagnoses. Sadness/dysphoria is listed as a criterion symptom in more than a dozen disorders. If the DSM categories were useful and distinct, this smearing of symptoms across diagnoses wouldn’t happen. It forces clinicians, who observe anger symptoms for example, to rule out attention deficit hyperactivity disorder, bipolar disorder, borderline personality disorder, narcissistic personality disorder, post-traumatic stress disorder, substance use disorder, grief, intermittent explosive disorder, and six other DSM categories. And if one successfully wades through all these choices, there is still no understanding of why the disorder exists or what to do about it.

The DSM fails to account for comorbidity.
If you have obsessive-compulsive disorder, you’re likely to struggle with other anxiety disorders as well. And depression co-occurs with anxiety 60 percent of the time. All this is unexplained by the DSM. The only way to account for high rates of comorbidity is that many disorders are driven by the same underlying (transdiagnostic) mechanisms. Rumination, for example, is a major driver for both depression and anxiety — that’s why they are so often seen together. Though rumination may focus on different things (e.g., personal failures in depression vs. future catastrophes in anxiety) it is a required target of treatment across both diagnoses.

In light of its failures, one might reasonably ask: why a new DSM? In truth, this fifth edition is just moving a few deck chairs on a sinking ship. Dumping the multiaxial system and Asperger’s disorder while adding binge eating, hoarding, and excoriation disorder (skin picking) has brought us no closer to a classification system that explains what’s wrong and guides evidence-based treatment decisions. Soon we’ll need to finish what the NIMH started — lower the lid, hammer it down, and bury the Diagnostic and Statistical Manual of Mental Disorders.

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How To Set Qualifications For Massage Practitioners

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Skin picking classified as distinct disorder

“I went through years, I just felt so embarrassed and had so much shame,” says Hartlin, 26, who began digging at her skin at about age 13. “I thought I was the only one for years, and I think that is the worst part, that disorders such as this feed into that isolation and make it worse.”

What Is Depression

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