CHAPTER II: PSYCHOLOGICAL DISORDERS ARISING IN …



Abnormal Psychology

The scientific study of abnormal behavior in order to describe, predicts, explain, and change abnormal patterns of functioning.

Goal of course:

Learn theories of abnormal behavior.

Learn scientific based knowledge about abnormal behavior.

1.1. Definitions

Definition of Abnormal Psychology: Abnormal psychology is the scientific study of abnormal thoughts and behavior in order to understand and change abnormal patterns of functioning. The definition of what constitutes 'abnormal' has varied across time and across cultures, and varies among individuals within cultures.

In general, abnormal psychology can be described as an area of psychology that studies people who are consistently unable to adapt and function effectively in a variety of conditions. An individual's ability to adapt and function can be affected by a number of variables, including one's genetic makeup, physical condition, learning and reasoning, and socialization.

1. The definition of abnormality has gone through many dramatic changes through history: Demons, gods: According to Homer (800 B.C.) mental illness was caused by God’s taking a mind away. Many early societies attributed abnormal behavior to the influence of evil spirits I , and magic; bodily fluids (a liquid) and wandering uteruses; astral influences; physical illness are various ways people through history have tried to describe abnormality.

Deviant behavior or psychological dysfunction was viewed as created by the conflict between good and evil, God or Satan.

In this lecture we shall discuss abnormality and abnormal behavior from the nature and cause of abnormal behavior. These shall include:

1) How we conceptualize treatment, the clinician’s role, and the client's role; and

2) (2) What we see in research and treatment, and perhaps more importantly what we don't see.

1.2. Problems with the definitions of abnormality

There are exceptions with each stance, or in other words "counter- examples". Identifying counter-examples is a useful exercise.

A. Statistical deviation

This definition would mean a genius should be termed abnormal because if we use average as a standard, we are saying that: "average person" = "ideal person". Is the average the ideal? Are deviations from the average a sign of abnormality?

In many respects, think how boring life would be if we were all "average" - all basically the same - no dramatic differences. Indeed, many of the wonderful advances made in our history (be it in art, science, culture...) resulted from people who took chances and tried new ways of doing things - people who deviated from what was the average way of doing things. Deviations can lead to flexibility.

Measurement of IQ means we can locate individuals according to their IQ:

– Severe intellectual deficiency IQ = 0-30

– Moderate intellectual deficiency IQ = 30-50

– Moderate mental handicap IQ = 50-70

– Low Intelligence IQ = 70-90

– Moderate Intelligence IQ = 90-110

– Higher Intelligence IQ = 110-130

Intelligence tests provide a measurement of intellectual development that is considered to be extremely vague today.

B. Social norm violation

a) Social reformers, protestors, etc. This definition would require that we label all social reformers as abnormal, for example feminist leaders, human right activists etc. These are people who want social rules changed - they reject the norms of society.

b) Cultural relativism

As natural and absolute the norms of our society seem to us, Sociology and Anthropology have taught us that there is in fact nothing absolute about them. What's abnormal (i.e. "norm violating") in one society may be perfectly normal ("norm consistent") in another. The raw (honest) behavior hasn't changed, but the society has.

Example: Sex and Temperament in New Guinea tribes - research by Margaret Mead (1963): Three tribes, each with very different norms:

1. Arapesh: Both males and females are mild (not severe or strong), parental, and nurturing.

2. Mundugumar: Males and females are fierce (angry and aggressive), oppressive and cannibalistic( a person who eats human flesh).

3. Tchumbuli: Males are catty ( saying unkind things about other people), wear curls ( a small bunch of hair) and pretty clothes, and love to go shopping. Females are energetic, managerial, unadorned (without any decoration).

Each of these cultures is different from the other. By which culture's standards do we judge a behavior to be abnormal?

In addition, even in a single society, there are a myriad of subcultures. Add to this the fact that norms change through the years so that what's normative in one generation, may not be in another. We are left with a single society where there are no clear norms that apply across all individuals. This definitional stance implies that normality is the same as conformity to the mainstream, when in fact there are many streams. The term abnormality thus loses any firm referent.

C. Maladaptive behavior

This position ignores the possibility that there may be abnormal situations. That is, perhaps there are situations in which it would be abnormal to adapt.

Example: Germans who were unable to adapt to Nazi Germany; A woman unable to cope with a husband who abuses her. The risk here is that we will end up "blaming the victim".

Eg: John, a 38 male, drinks every day to the point of losing consciousness. He is argumentative with his family and friends, and has gotten into frequent fights at work. Last week he swore at his boss, and as a result has been fired. John does not seem to have any motivation to find further employment. Nevertheless, he spends what little money he has in savings on alcohol and unnecessary items such as candy, video tapes, and whatever else he might want at the moment. John often dwells on how worthless he thinks he is, but also on how others do not treat him properly. When not aggressive, he is frequently depressed.

D. Personal distress

To say that abnormal behavior is behavior that causes a person distress/discomfort is to say that it is normal if there is no discomfort.

Thus, it logically follows that someone like Charles Manson, a mass murderer, is normal: he feels no guilt or discomfort about the killings he is responsible for. Similarly, a psychotic patient who hears voices from his dead mother that makes him happy.

(Psychosis is a general term for a major mental disorder characterized by derangement of personality and loss of contact with reality, often with false beliefs (delusions), disturbances in sensory perception (hallucinations), or thought disorders (illusions). Schizophrenia is both the most common (1% of world population) and the classic psychotic disorder. There are other psychotic syndromes that do not meet the diagnostic criteria for schizophrenia, some of them caused by general medical conditions or induced by a substance (alcohol, hallucinogens,). In the evaluation of any psychotic patient in a primary care setting all of these possibilities need to be considered).

Conversely, distress may not always be a bad thing. Indeed, perhaps people who can easily express their fear, depression, or other forms of distress end up better dealing with their problems. Or some types of distress may actually be very useful: anxiety, for example, can signal you that danger is afoot and that you better prepare for it!

It seems clear that the definition of abnormality must go beyond the limited confines of "distress" and "discomfort", at least in certain situations.

E. Deviation from an ideal

Who is ideal? Who is ideal for the individual? Who is ideal for the species? Who is ideal for the culture? Who is ideal for God? What if the ideal is unrealistic or unobtainable? Ideals, like social norms, are relative across groups and across time, so all the problems discussed above apply here as well.

F. Medical disorder

a) Historically, some hoped that biological causes would be found for all psychological problems. But as we will see, there is a growing body of evidence that certain abnormal behaviors cannot be fully explained without looking at the psychology of the problem.

Example: Conversion hysteria (symptoms such as paralysis, blindness, deafness, which have no physical causes) results from a person's attempt to unconsciously cope with strong unwanted emotions such as anxiety.

b) Implies "health" is absence of disease. According to the World Health Organization, "health" is "a state of complete physical, mental and social well being and not merely the absence of disease and infirmity”.

Using a definition is unavoidable and it is necessary. But choosing one is inherently unscientific - a value judgment in the final moment. When we choose a definition, we do so in part based on feeling, emotion, convenience, custom, appeal, ethics. There is an inherent nonscientific arbitrariness in this choice. The potential result is that psychologist Y and psychologist X could be talking about very different things when using the word "abnormal" confusion and controversy ensues, especially if the definitions remain implicit.

However, as a science, we ideally make our definitions explicit and then attempt to clarify and modify these definitions through scientific/methodological rigor, with an eye always open to the exception and alternative explanations.

Finally, the definition we use in this course is multifaceted - using aspects of each definitional stance. Their individual shortcomings and mutual incompatibilities will create tensions in our discussions that we can use to explore some of the important issues in the study of psychopathology. Or sent to dismal (miserable) institutions called asylums: a hospital where people who were mentally ill could be cared for, often for a long time.

1.3. Classification of Abnormality

Today there are various ways that are used by psychologists and people in general for defining abnormal behavior. These include:

A. Statistical deviation

B. Social norm violation

C. Maladaptive behavior

D. Personal distress

E. Deviation from an ideal

F. Medical disorder

A. Statistical deviation:

The defining characteristic is uncommon behavior - a significant deviation from the average/majority. Many human characteristics are normally distributed.

Basically, we're talking about a nice symmetrical bell-shaped curve along which we can rank people: more people fall around the average; the farther away you get from the average, the fewer the people.

Example: Height is a human characteristic. Most people fall around the average height of 5ft. In this example, height can be said to be normally distributed.

Characteristics falling beyond a particular distance from the average values are sometimes seen as abnormal. This distance is defined in terms of "standard deviation units" - these are values that tell the scientist how many people fall beyond the average.

For example: A convention selected (arbitrarily) by scientists is to see people falling beyond 2 standard deviations as abnormal (95.4% falls within the 2 std boundaries).

This is perhaps the most straight forward definition: collect data, calculate averages and standard's.

Example: Intelligence - there is a normal distribution of IQ scores. Those whose scores are 2 standard's below the mean of 100 are, by this definition mentally retarded (ie: abnormal).

B. Social norm violation

Breaking social "rules". Most of our behavior is shaped by norms - cultural expectations about the right and wrong way to do things.

Examples of norms: proper dress, how/what to eat, behavior on the first date, eye contact with strangers, attitude to elders, to parents’ student/instructor, behavior, in fact, all aspects of our lives. Someone who frequently violates these unwritten rules is seen as abnormal. It is seemingly common-sense. Norms are so deeply ingrained they seem absolute.

C. Maladaptive behavior

Two aspects to this:

1) Maladaptive to one's self - inability to reach goals, to adapt to the demands of life.

2) Maladaptive to society - interferes, disrupts social group functioning.

Example: A 35 years old man, drinks every day to the point of losing consciousness. He is argumentative with his family and friends, and has gotten into frequent fights at work. At one time, he fought his boss, and as a result has been fired. That man does not seem to have any motivation to find further employment.

Nevertheless, he spends what little money he has in savings on alcohol and unnecessary items such as make-ups, video tapes, and whatever else he might want at the moment. That man often dwells on how worthless he thinks he is, but also on how others do not treat him properly. When not aggressive, he is frequently depressed.

This is a "practical" definition: it identifies those unable to cope. It is also a "flexible" definition: it takes into account an individual's context, recognizing that maladaptive is a relative term - it depends on the person's life circumstances.

C. Personal distress

Put simply, if the person is content with his/her life, then he/she is of no concern to the mental health field. If, on the other hand, the person is distressed (depressed, usually suspicious of persons, anxious, etc), then those behaviors and thoughts that the person is unhappy about are abnormal behaviors and thoughts.

E. Deviation from an ideal

This perspective requires specification of what the "ideal" personality is. Falling short of this specified ideal is an indication of mental illness. Thus a person may be seen as "abnormal" even if they seem to be functioning alright.

Indeed, from this perspective, we are all striving for some ideal (personal or cultural), and many of us will never reach it. We all at some point deviate from or fall short of the ideal. So, in this sense, we are all abnormal to a certain degree, at least until we reach (if ever) the ideal (whatever that may be).

F. Medical disorder

Abnormality exists when there is a physical disease. Abnormal behavior is a symptom of a physical disorder. This is a biogenic definition. The person is qualitatively different from the unafflicted.

For example: Alzheimer's Disease - The major cause is atrophy of certain regions of the brain, typically occurring during the forties or fifties. The individual suffers from difficulties in concentration, leading to absent-mindedness, irritability and even delusions. Memory continues to deteriorate; and death usually occurs 10-12 years after onset of symptoms.

No one definition is the "correct" or the "best" definition. To a certain extent each one captures a different aspect of the meaning of abnormality. When we talk about Abnormality, or when we study it, or treat those suffering from it, we inevitably invoke one or more of these definitions, either explicitly or implicitly -either we're aware of the definition(s) we're using or we're not. But we do use some definitions. Various people have some definitions in their heads about what psychological abnormality is, whether or not they could clearly state it.

In any event, it is important, especially as scientists, that we make as explicit as possible the definition(s) we use, and acknowledge any limitations. To operate implicitly hinders our ability to develop as a science - our awareness is limited because as long as our definitions are implicit, they remain unchallengeable, we ignore alternatives, we don't "stretch" ourselves. And each definitional stance can certainly be challenged...

1.4. History of Abnormal Behavior

Since ancient times, people have attempted to understand and treat mental disorders. Many early societies believed that demons caused abnormal behavior. Later, people came to regard the mentally ill as dangerous people with insufficient self-control. Disturbed individuals were imprisoned or sent to dismal institutions called asylums.

During the late 1700's, the idea that abnormal behavior resulted from serious personal problems began to be investigated. People started treating the mentally ill more humanely. 

During the 1800's, people believed in possible physical reasons for different kinds of mental disorders. A German psychiatrist named Emil Kraepelin became famous for his Lehrbuch der Psychiatre (A Textbook of Psychiatry, 1883). This classified various illnesses according to their specific types of abnormal behaviors. 

In the late 1800's and early 1900's, Sigmund Freud, an Austrian doctor, developed theories about the effects of unconscious drives on behaviour.

Freud and his followers laid the foundations for both the intrapsychic school of psychopathology and psychoanalysis.

The Freudians became especially known for their use of free association to interpret dreams, analyze memories, and make people aware of their unconscious conflicts. 

Later in the 1900's, researchers proposed several other theories and treatments of abnormal psychology.

These proposals centered on the relationship of psychological, physical, and social conditions in the individual and society.

1.5. Theories of Abnormal Psychology

Theories of abnormal psychology describe mental illnesses, suggest possible causes of these illnesses, and propose certain methods of treating them.

These theories can be divided into four main groups or schools: (1) biophysical, (2) intrapsychic, (3) existential, and (4) behavioural. 

1.5.1. Biophysical theories

They emphasize the importance of underlying physical causes of psychological disturbances. Such disturbances include two main groups: (1) those related to a medical condition, such as a disease or injury, and

2) those related to the use of a drug or medication. In these disorders, the condition, drug, or medication is believed to cause mental problems by affecting the brain or other parts of the nervous system.

1.5.2. Intrapsychic theories

They focus on the emotional basis of abnormal behavior.

Intrapsychic theorists believe that conflicts in early childhood cause people to worry or have other unpleasant feelings throughout life. 

Psychologists use the term neurotic to describe people who sometimes behave abnormally but can usually cope with everyday problems. Individuals who lose track of reality are called psychotic.

Some psychotics believe in very unrealistic ideas called delusions.

They may also think perceptions such as "hearing voices" or "seeing visions," called hallucinations, are real. 

A treatment called psychoanalysis is often used to help neurotics and psychotics understand and resolve their conflicts and anxieties.

During psychoanalysis, the patient talks to the therapist, who is called an analyst.

In one technique, called free association, the patient talks to the analyst about whatever thoughts, images, or feelings come to mind. 

Existential theories of abnormal behavior stress the importance of current experiences and the person's view of himself or herself.

Existential therapists try to help patients gain insight into their feelings, accept responsibility for their lives, and fulfill their potential. 

Behavioural theories emphasize the effects of learning on behavior.

Behaviourists use a learning process called conditioning to change abnormal behaviour.

In this process, behaviourists treat disturbed people by teaching them acceptable behavior patterns and reinforcing desired behavior by rewards.

1.6. Causes of behavioural problems

Various factors can explain the behavioural problems for children and teenagers.

These factors can be intrinsic or extrinsic.

The intrinsic factors are personal and connected to the student who has difficulties whereas the extrinsic factors deal with family and school environment (educational and social). 

1. Personal factors are among others:

- Student’s personality (unsuitable behaviour prompted by the individual’s character)

- Hyperactivity

- Academic failure (researches indicated a significant relationship between poor school performance and behavioural problems)

- Sex

The majority of students identified as having behavioural problems are boys.

Research in psychology indicates that boys and girls present different behaviors and that this differentiation intervenes throughout the development since the child is always attracted by the activities of people of his/her sex or the models of his/her sex.

Various researchers attempted to comprehend this differentiation. They relied on genetic variables, on cultural models offered to boys and to girls or to the educational environment. The results indicate that the biological variables explain one part of the difference.

For example, concerning aggression, girls would mainly use verbal attacks whereas boys would tend to resort to physical contact. In the school environment, physical attacks disturb more than verbal attacks.

Physical attacks are less tolerated in the learning environment. That is why a great number of boys are found in the category of students identified as having behavioural difficulties.

In addition to biological and genetic variables, researchers tried to understand the phenomenon by using cultural variables. The results indicate that the cultural variables explain a part of the behavioral difference.

There are cultural practices which explain the fact that boys are much more identified as having behavioral problems.

Cultural models tolerate that the boys should defend their rights while the girls are persuaded not to do so. Parents and teachers encourage boys to react whereas the aggressive gestures of girls are repressed.

2. Family related factors

a.Some family related factors would also constitute the origin of behavioural problems. We can list among others misunderstandings in the family, a very underprivileged socio-economic environment, an extended family.

b.Other researches have indicated that students with behavioral problems often come from families with single-parent or female headed households. This research indicates that the absence of the father is a determining factor for the behavioral problems of boys.

Some data indicate for example that the majority of street children have no father.

c.The way in which children are treated in their family can explain their behavioral problems at school, in the family and in society in general.

Studies in social sciences have proved that ill-treatment or carelessness influences the students’ behaviours at school.

3. School environment

Some school practices can cause behavioral problems in students. Research has shown that the methods of communication, of problem solving, of decision-making at school can have an impact on students’ behaviors.

Within the same context, the students’ social relationships with the administration, their sense of belonging to the school, the mode of preparation and the presence of school regulations constitute the determining school factors for the students’ behaviours.Teaching practices, organisation of the school, physical environment, the collaboration with parents and the community are to be added to these variables.

To illustrate the influence of these variables, let us take some examples.

Behavioral problems arise when:

1. Discipline rules are not clearly defined and students are not involved in their elaboration.

2. There are too many regulations, punishments given anyhow, anywhere or without apparent reason.

3. There is an overpopulated class which can increase the problems of discipline, aggression, noise

4. The teacher’s behaviour, his/her expectations towards one or several students can influence the students’ answers. In education, this is called « Pygmalion effect» or « self-fulfilling prophecy».

(The main idea concerning The Pygmalion Effect is that if you believe that someone is capable of achieving greatness, then that person will indeed achieve greatness. In other words, believing in potential simply creates potential.)

4. The relationships between a teacher and a student are characterised by mutual aversion:a feeling of intense dislike . As indicated by Brophy (1985), teachers can have positive or neutral relationships with students having behavioural problems. Such teachers would not personally feel affected by these bad behaviours. They can be on good terms with such students. On the contrary, teachers can maintain very negative relationships with some students, including students with behavioural difficulties.

5. The keystone of these relationships would be a mutual aversion which would be manifested:

- In students through avoidance behaviour

- In the teacher through a lower level of interaction, a higher level of criticism and a tendency to introduce, in class, a student or students as bad students, a persistent refusal to answer their questions, frequent nonverbal communication with negative attitudes.

4. Social environment

Friends can also be causes of behavioral problems. Remember this French expression: “Tell me who your friends are, I will tell you who you are”. Adolescents are often grouped together and live in gangs. The problems of delinquency are often connected to the existence of gangs, which are sometimes well-structured and strong. In schools, there can be gangs which violently confront one another.

1.7. Forms of behavioural problems

In the school environment, the forms of behavioral problems can be numerous. We give you just some of the most general ones. We must note, however, that the forms can vary according to the socio-cultural context of the school.

1.7.1 Disruptive behaviours

In a school environment, a student is identified as having behavioral difficulties when he/she manifests inappropriate behaviors that are not in agreement with the current standards of conduct in the school. There are some others, all depending on the normative requirements of the school. Some can be considered to be serious in school “A” while they are more tolerated in school “B”.

1.7.2. Disturbing behaviours

In a school environment, a student identified as facing behavioral difficulties presents inappropriate behaviors, in disagreement with the current norms. It is necessary to note that it is not the disturbing behavior as such which is considered to be serious, but its accumulation and its repetition which disturb the teacher.

For example children who make a noise without an apparent reason; play with objects which are not relevant to the task; do not finish their task; answer the questions at the wrong time, etc.., all this in a repetitive way.

Such behaviors are regarded as disturbing. Studies have proved that children deemed as having behavioral difficulties express themselves verbally three times more than others and that they interact with their teacher four times more than others. These students chat with their peers, play with objects or defy their peers.

As you will remember, the tolerance or the intolerance of these behaviors depends on the teacher, on the type of the learning activity, the nature of class-group and the learning context. Therefore, children can easily move around in some classrooms whereas it is prohibited in others. A behaviour is inappropriate with regard to the established rules. Disturbing behaviours also include inhibition, i.e. the behavior of children who do not communicate, and who do not get involved in the interaction with others.

1.7.3.. Aggressiveness

Every teacher considers aggressiveness as critical. An aggressive student is a student who gets angry, who fights in the classroom or on the playground or who breaks everything in his/her way.

1.7.4. Hyperactivity

The hyperactive student is characterized by a lower level of concentration and a higher rate of motor activity. The hyperactivity is an excessive activity of motor behavior. These children are isolated by their peers; they are neglected or simply rejected. The other students do not choose them as team-mates in learning activities. These are children who can become unhappy.

A child who has got behavioural problems is not a lost child. There are interventions to help him/her to correct his/her behaviours or to help him/her when his/her learning process is disrupted. Some of them are:

1.8.1. Strong discipline

According to some research, an effective intervention is when schools have good discipline, and the staff members establish practices that lead students to be responsible. These students behave in an appropriate way even if they are not supervised by adults.

To get to such a result, various strategies can be applied:

1. Clearly establish the school regulations

2. Enhance the students’ commitment towards these regulations by involving them and their parents in the discussion and application of these rules. In most cases, students are not involved in the elaboration of school regulations. In fact, they do not really feel comfortable with these regulations. They are imposed on them from outside and are not, in fact, their rules. The involvement of students is then considered to be paramount to avoid cases of indiscipline.

3. Elaborate the school regulations in collaboration with all school stakeholders so as to allow them to have the same interpretation. If the regulations are vague, and their interpretation varies from one stakeholder to another, it will be difficult for students to know which behaviour to adopt. It will be difficult to apply these rules correctly.

1.8.2. To create a quality learning environment

In order to prevent behavioral problems, it is necessary to create a quality learning environment. The fact that the courses should be well-structured, interesting and open solves many problems. A quality environment supposes among others, good planning of learning activities, competence from teachers as well as clear teaching instructions.

1.8.3. Dialogue and confident relationship with students

Very often, it is through behaviour that children send messages to adults as well as to their peers. A student who feels rejected tries to send messages to adults to draw their attention to what he/she is experiencing, to break his/her isolation and loneliness perhaps in a tactless way. Before intervening, it is essential to stop and to understand what the child wants to transmit as a message in his/her behaviour.

1.8.4. To work out a personalised intervention plan (PIP) for the student with difficulty

When a child has behavioural difficulties and especially if these difficulties disrupt his/her learning, people responsible for the education of this child must intervene to help him/her. In many countries, educationalists resort to what was agreed to be called a personalised intervention plan. It is so called because it is designed according to the characteristics of the child with difficulty.

It is a genuine action plan. According to Georgette Goupil (1991), “the personalised intervention plan is a planning and consultation tool for meeting the needs of a student with difficulty”. PIP is used to support the setting up of individualized services and interventions and to facilitate the social integration of the student.

In this action plan, we can find various elements:

1. Learning objectives (what are the behaviours to be carried out with regard to the learning activities?).

2. Intervention and learning strategies for each on of the objectives

3. Means and resources necessary for the intervention

4. Schedules of achievement

5. People responsible for the intervention

6. The mechanism of learning assessment (as well as assessment criteria and success conditions).

7. Continuous mechanism of the intervention plan revision

In the elaboration of the intervention plan, there is first of all the evaluation of the strength of the student in difficulty, his/her needs and the nature of his/her difficulties. Thus, the elaboration takes into account the learning assets and potential for the student. It is starting from these assets that the objectives will be written to help the child to develop and to open out. The intervention plan is written in collaboration with the student’s parents, the student if he/she is capable as well as with the various stakeholders (teacher, headmaster or headmistress, etc).

1.8.5. Resource person

The school can also allocate a resource person to the child with learning difficulties to help him/her adapt in the school environment. This may be a psycho-educator. This is a person trained in dealing with problems related to school and social adaptability. His/her role will be to identify and to set up means of stimulating the individual strengths which are paralyzed by socio-economic, emotional, intellectual or physical deficiency

CHAPTER II: PSYCHOLOGICAL DISORDERS ARISING IN CHILDHOOD AND ADOLESCENCE

2.1. Eating disorders

Having an Eating Disorder is much more than just being on a diet. An Eating Disorder is a condition that permeates all aspects of each sufferer's life, is caused by a variety of emotional factors and influences, and has profound effects on the people suffering and their loved ones.

An eating disorder is a compulsion to eat, or avoid eating, that negatively affects both one's physical and mental health. Eating disorders affect every part of the person's life. Feelings about work, school, relationships, and day-to-day activities are determined by what has or has not been eaten. s

Many kids, particularly teens, are concerned about how they look and can feel self-conscious about their bodies. This can be especially true when they are going through puberty, and undergo dramatic physical changes and face new social pressures.

Unfortunately, for a growing proportion of kids and teens, that concern can grow into an obsession that can become an eating disorder.

Eating disorders such as anorexia nervosa or bulimia nervosa cause dramatic weight fluctuation, interfere with normal daily life, and damage vital body functions.

Generally, eating disorders involve self-critical, negative thoughts and feelings about body weight and food, and eating habits that disrupt normal body function and daily activities.

2.1.1. Types of Eating Disorders

2.1.1.1. Anorexia nervosa

Anorexia nervosa is deliberate and sustained weight loss driven by a fear of distorted body image. In other words, anorexia involves loss of appetite while nervosa implies emotional reasons.

Anorexia Nervosa is not to be confused with anorexia, which is its symptomatic general loss of appetite or disinterest in food. It represents the refusal to maintain normal, healthy body weight. Anorexics don’t really lose their appetite, they actually may really want to eat food, but they refrain.

a.To be anorexic, a person must be 15% of his/her ideal weight. Most anorexics weigh 25-30% below their ideal weight. In girls and women who have begun menstruating, the weight loss causes them to stop having their periods (i.e. they get amenorrhea - missing 3 normal periods in a row). This is an indication that their weight is too low, and they may have anorexia.

Also, b.anorexics have an intense fear of gaining weight. Irrespective of continued weight loss, they have a fear that they are overweight, and will gain weight.

Thirdly, c.anorexics have a distorted sense of their body shape, despite being very thin. They often believe that they are fat and still need to lose more weight. Anorexics typically weigh themselves frequently throughout the day, and look at particular body parts, and spend more time gazing at themselves more critically. They often exercise to the point that it is punishing.

Statistical Manual of Mental Disorders (DSM-IV) characterizes Anorexia Nervosa by suggesting the following criteria:

▪ A patient must be 15% below normal weight (average patient with Anorexia Nervosa is 25-30% below normal weight);

▪ An intense fear gaining weight or becoming fat and a preoccupation with body weight and shape;

▪ Distorted sense of body shape.

DSM-IV Subtypes:

a) Restricting type:

She/he tries to prevent food intake to prevent gaining weight, but eats enough to appease family and friends. They seem to be described as having deep feelings of mistrust of others, and a tendency to cope with their problems through denial.

b) Binge/purge type

They have small binges that lead to purging behaviors. This type is generally more pathological; they exhibit more personality disorders, have more impulsive behavior, have more drug and alcohol abuse, and have more suicide attempts than the restricting type. Their course is more chronic than is the restricting type’s.

Anorexics are commonly perfectionists, driven to succeed; yet they set unattainable standards of performance for themselves. When they fail to meet these standards, they look for a part of their lives they can control; food and weight become that “control” for them. Low self-esteem and constant self-criticism cause anorexics to constantly fear losing control, and even consuming a small amount of food could be considered a loss of control.

Epidemiology of Anorexia Nervosa

90-95% of diagnosed with Anorexia Nervosa are female.

Onset begins in the early to middle teenage years. The onset usually follows after a period of dieting and the co-occurrence of a life stressor (usually an interpersonal life event like parental divorce or separation).

50% recover in 4 years – 30% still have Anorexia Nervosa after 4 years and beyond, and are still 30% under weight.

The death rate is 15%.

Medical consequences:

Cardiovascular Complications:

- Slowness of heart rate

- Irregular heart beat

- Fluid in the sac enclosing the heart

- Heart Failure

Metabolic Complications:

- Yellowing of the skin

Impaired taste:

- Hypoglycemia

Fluid and Electrolyte Complications:

- Dehydration

- Weakness

- Tetanus

Hematological Complications:

- Susceptibility to bleeding

- Anemia

Dental Problems:

- Decalcification

- Tooth decay

Endocrine complications:

- Amenorrhea (missing 3 normal periods in a row).

- Lack of sexual interest

- Impotence

Gastrointestinal Complications:

- Salivary gland swelling

- Acute expansion of the stomach

- Constipation

General Complications:

- Weakness

- Hypothermia

The most serious medical complications of anorexia nervosa are:

- Heart failure

- Acute expansion of the stomach to the point of rupturing

- Kidney damage

2.1.1.2. Bulimia Nervosa

Bulimia nervosa is a cyclical and recurring pattern of binge eating (uncontrolled bursts of overeating) followed by guilt, self-recrimination and over compensatory behavior such as crash dieting, over exercising and purging to compensate for the excessive caloric intake.

Bulimia usually means “ox hunger”. It includes rapid binging. Eating is seen (by the patient) to be out of control. The patient is engaging in purging techniques.

Bulimics often have "binge food," which is the food they typically consume during binges. The binge episode leads the individual to feel guilt, shame, embarrassment, and complete failure. Bulimics try to regain control of themselves and the situation by purging the food–making up for their mistake. This leads to feeling famished and empty again, and therefore, another uncontrollable binge, followed by feeling powerless, and the vicious binge/purge cycle continues.

Bulimics have extreme eating and exercising habits, instead of demonstrating moderation. This compulsive behavior is often echoed in similar destructive behavior such as sexual promiscuity, pathological lying, and shoplifting. Some bulimics not only struggle with the eating disorder, but they have other harmful behaviors as well.

Subtypes of Bulimia Nervosa

a) Purging type:

There is evidence that purging type bulimics are more psychopathological than non-purging bulimics. They have more frequent binging, more co-morbid anxiety and depression than the non-purgers, more entrenched negative attitudes towards eating, and are distinguishable from binge-purge anorexia because the anorexics must be 15% below their normal body weight, where the bulimics don’t have to be 15% below their normal body weight.

b) Non-purging type:

They fast or exercise excessively after binging. Non-purging type involves rapid consumption of enormous amounts of food, often upwards of 2000-4000 calories (twice that required for the normal person in one day). Some people consume 15000 to 20000 calories in one episode.

1.2.2.3. Bulimia Nervosa and DSM-IV

The DSM says that binging has a.to be eating an excessive amount of food within 2 hours. The binging is usually concealed by the person.b. The binging usually continues until the person is uncomfortably full. C.After the binge is over, there are feelings of disgust and discomfort and there is a fear of weight gain. These feelings and fears together lead to purging behaviors. The purging techniques include self-induced vomiting, or using laxatives.

➢ Alternatively, the people exercise excessively (57% of bulimics).

➢ About 57% of college students have binges.

➢ Bulimics must have at least 2 binges per week for 3 months to meet the DSM-IV criteria.

➢ Bulimia nervosa patients are afraid of gaining weight, and their self-esteem is dependent on regulating their weight. They also have a distorted view of their body image – they see themselves as fat, even when their weight is normal.

Epidemiology of Bulimia Nervosa

➢ For women the prevalence rate is 1% while it is ................
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