Introduction
The relationship between eating disorders and obsessive-compulsive disorder as part of a so called 'obsessive-compulsive spectrum' is discussed, with particular emphasis on the relationship between eating disorders particularly bulimia and obsessive-compulsive disorder within its theoretical perspectives. In particular the importance of distinguishing distinctions between repetitive weight controls, physical exercises and purging behaviors of eating disorder patient as the study sought to establish the prevalence of obsessive-compulsive disorder among patient with eating disorder because there is a high prevalence of obsessive-compulsive disorder among patient with bulimia nervosa and the prevalence may be correlated with the severity of the eating disorder. Moreover, some people suffering with an eating disorder may be exhibiting other addictive or self-destructive behaviors as a fact that eating disorder is a reaction to a low self-esteem and a negative means of coping with life and stress that will affect the total well-being of the person who is in a way bulimic and shows OCD symptoms within the process.
Background of the theoretical perspective
Bulimia nervosa (BN) is one of the eating disorders identified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Bulimia nervosa is characterized by frequent episodes of binge eating associated with emotional distress and a sense of loss of control accompanied by compensatory behavioral patterns aimed at preventing weight gain. Compensatory behaviors used by individuals with bulimia nervosa include excessive exercise, episodes of fasting or strict dieting, self-induced vomiting, diuretic abuse, laxative abuse, use of appetite suppressants, and/or medications intended to speed up the metabolism The mere consumption of an unusually large amount of food in a defined period without concomitant perception of loss of control is defined as an overeating episode. Similarly, the consumption of rather minimal amounts of food in a defined period with a perception of loss of control is referred to as a subjective bulimic episode. Eating disorders as a group are characterized by a fear of weight gain and a distorted body image with associated anomalies in mood, perception, response to physical and emotional cues and eating behaviors. Furthermore, Obsessive-compulsive disorder (OCD) is classified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) as an anxiety disorder. It is characterized by distressing intrusive thoughts and/or repetitive actions that interfere with the individual's daily functioning. The DSM-IV criteria for OCD are as follows: The individual expresses either obsessions or compulsions.
Obsessions are defined by the following four criteria:
Recurrent and persistent thoughts, impulses, or images are experienced at some time during the disturbance as intrusive and inappropriate and cause marked anxiety and distress. The thoughts, impulses, or images are not simply worries about real-life problems. The person attempts to suppress or ignore such thoughts, impulses, or images or to neutralize them with some other thought or action. The person recognizes that the obsessional thoughts, impulses, or images are a product of his/her own mind.
Compulsions are defined by the following two criteria:
The person feels driven to perform repetitive behaviors or mental acts in response to an obsession or according to rules that must be applied rigidly. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; these behaviors or mental acts either are not connected in a realistic way with what they are meant to neutralize or prevent clearly excessive during the course of the disorder, the person recognizes that the obsessions or compulsions are excessive or unreasonable. The obsessions or compulsions caused by marked distress are time consuming or significantly interfere with the person's normal routine, occupational or academic functioning or usual social activities or relationships. The disorder is not due to the direct physiologic effects of a substance or a general medical condition and specify with poor insight if the person does not recognize that the symptoms are excessive or unreasonable.
Discussion of experience or observation and the etiology
The bulimic client will come to treatment more readily than the anorexic client. She will have a history of bingeing and purging, which has been present for some time, and she, like the anorexic client, started to diet because she thought she was fat. She may purge by taking laxatives, diet pills, diuretics, self-induced vomiting or strenuous exercise. She generally will be more impulsive and rebellious and may have had one or several suicide attempts. Although the bulimic client generally presents in a less emaciated state than the anorexic client, she can be seriously ill with upper and lower GI problems, be cross-addicted to drugs or alcohol and have family members who are substance abusers (Hsu, 1990). She may have been sexually victimized, as this history tends to be more prevalent in eating disorder clients in general (Sloan & Leichner, 1986; Wooley, 1994). Blouin, Zuro and Blouin (1990), found that bulimic clients perceive their families as being more distressed than do age-matched controls. They also reported that bulimic women perceive their families as less cohesive, less encouraging of independent behavior, less expressive, less oriented toward recreational pursuits, more oriented toward achievement, and more controlling than non-eating-disordered women.
Lisa is a 14-year-old female and her teacher consulted with the clinical nurse specialist assigned to work with the school system via a local community mental health center. With an office in the school building, the nurse had easy access to students and to teachers who had concerns or questions about particular students. Mrs. D, Lisa's teacher, sought help from the clinical nurse specialist after noticing a dramatic change in Lisa's weight over the first 10 weeks of the school year. Lisa had begun the year as a somewhat overweight, cheerful youngster with dark hair and bright green eyes who excelled at school and had a reputation as a perfectionist in her work. While Lisa's schoolwork remained exemplary, her mood and appearance had changed dramatically. She preferred to stay in the classroom at recess and read, her social contacts with female peers lessened and Mrs. D noticed that Lisa no longer ate lunch. She was observed giving most of her lunch away and nibbling at a small piece of fruit or vegetable. Mrs. D estimates that Lisa lost between 20 and 30 lb in 10 weeks and was looking very thin and gaunt. Her clothes no longer fit, and her hair appeared dry and strawlike. When questioned, Lisa denied there were any problems at home or in the classroom. Mrs. D called Lisa's mother, who worked as an evening nurse in a local hospital. An only child, Lisa was cared for by a neighbor during the evenings when her mother was at work. Lisa's father had left the home when she was quite young, and she never spoke of him.
Moreover, dieting is common among females in our weight-conscious culture. Forty percent of American women report they are dieting (Eating disorders Part II, 1997). Bulimia nervosa is defined as having two or more episodes of binge eating every week for at least 3 months and the use of inappropriate ways of avoiding weight gain from bingeing (APA, 1994). A binge consists of rapid ingestion of large amounts of food during a specific period of time that is unequivocally more than the average person would consume in the same amount of time and under the same circumstances. In addition, the individual has a sense of being unable to control the bingeing. The binge is followed by some form of inappropriate compensation, such as laxative use, diuretics, self-induced vomiting, excessive exercise, fasting, or enemas to rid the body of unneeded calories so that weight is maintained. The typical eating disorder develops in young females during adolescence; it also may develop before menarche or during adulthood (Heebrink, Sunday, & Halmi, 1995). Bulimia nervosa tends to occur later in adolescence. Once the process of dieting leads to the desired goal, the individual begins to think that maybe just a few more pounds would look even better so she continues the behavior. Although the individual refuses to eat, she continues to have a good appetite at least in the beginning (Eating disorders Part I, 1997).
Etiology
Multiple theories exist about the etiology of anorexia nervosa. It probably is multifactorial in origin. Three types of predisposing factors interact, resulting in anorexia, according to Garner (1993). Steiner and Lock (1998) made the same point, stating that since patients in most eating-disorder studies tended to come from specialized eating-disorder clinics, often the studies had a greater number of seriously ill patients than would be found in a representative sample. Pryor and Wiederman studied personality features of anorexia and bulimia and found that an inhibited or avoidant personality style was found in about half the adolescents with eating disorders, regardless of diagnosis. Anorectic adolescents demonstrated more compulsivity than bulimic teens (Pollice, Kaye, Greeno, & Weltzin, 1997). Eating disorders tend to run in families, as do many other psychiatric disorders. The rate of anorexia among close female relatives of women with anorexia is 2% to 10% (Eating disorders Part I, 1997). When comparing groups of patients with an eating disorder with groups of patients with other psychiatric disorders, the eating-disorders group had a 20 percent chance of having a family member with an eating disorder, while the psychiatric patients with other diagnoses had a 6% chance of having a family member with an eating disorder (Eating disorders Part I). Eating disorders have been shown to involve interrelationships among neurotransmitters and neural pathways are involved in depressive disorders (Irwin, 1993).
Specific family interaction patterns that were observed included overprotectiveness, rigidity, enmeshment and family avoidance of conflict. Some authors believe the notion of female slenderness in western culture has been promoted by various types of media that cast young, slim women as glamorous stars and by sales campaigns that use slim, young women to sell various products, with the underlying theme that being thin results in true happiness (Rothblum, 1994; Vanderlinden, Norre, & Vandereycken, 1992). Young women desiring to be fashionable, successful and happy exercised and dieted to achieve the thin look promoted by the media (Garner & Wooley, 1991). Whatever the cause of an eating disorder, the effects can be damaging if not downright devastating and life threatening. People who weigh at least 15 percent less than the normal weight for their height may not have enough body fat to keep their organs and other body parts healthy. People with bulimia often have constant stomach pain. In fact, bulimia can actually damage a person's stomach and kidneys as a result of constant vomiting. Bulimia can also cause a person's teeth to decay because of the acids that come up into the mouth while vomiting. When a person becomes obsessed with weight, it's hard to concentrate on much else. Many times people with eating disorders become withdrawn and less social. Individuals with bulimia often spend a lot of mental energy on planning their next binge, spend a lot of their money on food and hide in the bathroom for a long time after meals and that eating disorders are not fun, bulimia can lead to feelings of guilt and depression as some individuals with eating disorders begin using drugs and other substances to help mask their feelings, which only makes the situation worse.
Obsessive-Compulsive Disorder refers to the repetitive experience of obsessions and/or compulsions that eventually interfere with daily activities, causing the person with OCD to spend hours each day performing compulsive rituals. A common ritual is for the person to wash their hands a certain amount of times at a certain time in a certain order. For someone with an eating disorder, OCD manifests itself by leading the person to count calories methodically, exercise an exact amount at a specific time every day, cutting food up in a certain order and in specific shapes, having to have everything perfect which includes weight, and so on. Because all of these activities are compulsions, meaning that they cannot be controlled until help is sought, it becomes impossible and unbearable for the person afflicted to try and stop on their own. There were about 3.3 million Americans suffer from Obsessive Compulsive Disorder, or about 2.3 percent of the adult U.S. population in a given year. OCD typically starts during the teenage years or early adulthood, although recent studies have shown that some children develop the illness at earlier ages. Just as with an eating disorder, OCD is not biased it strikes all ethnic groups with males and females equally affected. In terms of personality wise, those who have other psychological problems such as depression, an eating disorder, or bipolar disorder tend to be more prone to developing OCD that others.
The link that causes these disorders to be more prone seems to be the fact that perfectionism runs high in all of these psychological problems. The person with Obsessive-Compulsive Disorder will usually be able to recognize that their actions are senseless, but at other times the person may be so high strung with fear about not completing a ritual that they believe strongly in their validity. For someone that has an eating disorder, OCD is a way of control over the person's body and therefore, life. The OCD controls what kind of food goes in, what shape the food is, the color, the weight, the amount, what the person does in other areas of life, and so on. By completing the compulsions, the person once again feels protected until they have to perform another task again. Often the two problems OCD and eating disorders are linked through the problem of perfectionism. It's been said that the compulsive actions are a response to always feeling that nothing the person does is good enough which has led them to over compensate for things. Although most people with Obsessive-Compulsive Disorder try their hardest to keep their problem from the view of others, inevitably OCD takes over the person's life. It gets to the point where you can't go an hour without performing some kind of compulsive ritual or feeling incredible anxiety and with an eating disorder, the longer a person goes without getting the help they need and deserve, the aggravated the OCD becomes and treatment is needed.
Identify and recommend treatment based upon the theoretical perspective
Weight loss may be a symptom of serious medical problems and may be related to other psychiatric disorders, such as depression or social phobias where the phobia is related to eating in public (Glod, 1998). Before making the diagnosis, the clinical nurse specialist will need to ascertain if Lisa is experiencing a distorted body image/fear of gaining weight which is diagnostic of an eating disorder (Glod, 1998). In order to further assess Lisa's problem, the CNS will need to develop an alliance with Lisa's mother and gain permission from her to work with Lisa. Irwin (1993) stressed the importance of building trust with not only the patient with anorexia but also the family, especially when the patient lives at home. The mother's statement that she was pleased with Lisa's weight loss could potentially set up an adversarial relationship between the teacher and the mother, since Mrs. D is worried about Lisa. Since eating disorders have increased incidence among female family members, it is possible that Lisa's mother has an eating disorder herself and has not recognized the seriousness of Lisa's problem or perhaps, as Huon and colleagues (1988) suggested, her mother had developed a positive image of the disorder and doesn't view Lisa as having any type of problem. Part of the diagnostic process for Lisa will be a physical examination to rule out some of the possible medical conditions identified earlier. The patient's distorted body image related to weight is distinctive to the eating disorder.
A significant weight loss can occur in depression, but the depressed patient is aware of the loss and acknowledges the seriousness of the problem is that she has fallen far below a normal weight. After gaining permission from the mother and after a physical examination, the CNS can arrange to meet with Lisa during the school day to assess the situation and plan out a strategy for her treatment. The neighbors who care for Lisa in the evenings may need to be included in planning for ways to manage Lisa's eating at dinner. The CNS will be able to monitor Lisa's weight as part of the treatment plan and may set up a plan with Mrs. D to monitor her lunchtime eating and that Lisa is quite young and early treatment in young patients shows the greatest success.
Treatment Approaches
Treating the eating-disordered adolescent occurs in many types of programs and settings, such as inpatient, outpatient, partial hospitalization, and intensive outpatient treatment programs. Many of the programs were developed in the late 1980s by hospitals in order to receive insurance reimbursement and to decrease the amount of time a client would need to spend as an inpatient. The majority of eating-disordered individuals in this country are treated now as outpatients because inpatient programs have closed as the result of poor insurance reimbursement. Various treatment approaches have been employed to stop disordered eating patterns and return the client to a premorbid state. Garner, Fairburn, and Davis (1987) found that the majority of treatment programs employed an exclusively cognitive-behavior mode of treatment or selectively combined cognitive-behavior principles with other approaches.
A team approach of healthcare professionals generally is involved in treatment whatever the setting as Garner, Garfinkel and Irvine (1986) suggested that a combination of treatment sequencing include cognitive restructuring therapy, meal planning, the introduction of avoided foods and regular weighing. Cognitive restructuring therapy is aimed at challenging the distorted perceptions about weight and shape that may be tied to cultural values. They concluded that a critical factor in the treatment of disordered eating is achieving a balance between attending to both psychological issues and the biological disturbances brought about by weight loss and disturbed eating patterns (Hoffman & Halmi, 1993). Furthermore, antidepressants also proved useful in the treatment of bulimia nervosa when combined with group and individual psychotherapy or as the primary therapeutic modality. Eating-disordered clients often have associated mental diagnoses such as affective disorders, major depression, obsessive-compulsive disorder as well as substance abuse and (Clarkin-Watts, 1996; Hatsukami, Eckert, Mitchell, & Pyle, 1984; Root et al., 1986) because of the multifaceted nature of bulimia nervosa, a comprehensive psychiatric assessment is essential to developing the most appropriate treatment strategy. Patients should be referred to a mental health professional with specific expertise in this area. The most appropriate course of treatment can be determined on the basis of a thorough evaluation of the patient's medical condition, associated eating behaviors and attitudes, body image, personality and interpersonal relationships. Considerable research has been devoted to identifying the most effective pharmacologic and psychologic treatments for bulimia nervosa, including the effects of different medications and the benefits of different psychotherapy approaches.
Conclusion
Therefore, people with eating disorders can get well and gradually learn to eat normally again. Because anorexia and bulimia involve both the mind and body, medical doctors, mental health professionals, and dietitians will often be involved in a person's treatment and recovery. Therapy or counseling is a critical part of treating eating disorders in many cases, family therapy is one of the keys to eating healthily again. Parents and other family members are important in helping a person see that his or her normal body shape is perfectly fine and that being thin doesn't make anyone happy. The most critical thing about treating eating disorders is to recognize and address the problem as soon as possible like all bad habits, unhealthy eating patterns become harder to break the longer a person takes part in them. If you have an eating disorder, don't wait to get help as bulimia can do a lot of damage to the body and mind if left untreated and worst, eating disorders can kill and at best, they leave a person feeling and looking terrible as people must remember that eating disorders are common among teens and more importantly that treatment is out there. Therefore, for treatment, a combination of cognitive behavioral therapy and the use of anti-depressant medication have been shown to help greatly with treating OCD and eating disorders. The anti-depressants reduce the severity of OCD symptoms and a concomitant reduction of the anxiety and distress that accompanies the obsessions, while the cognitive behavioral therapy helps with the severity and frequency of OCD. More than half of patients have their symptoms relieved by an anti-depressant, but usually if the medication is discontinued the patient will go into relapse and will feel the same obsessions and compulsions.
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