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12 Errors in
Addiction and Eating Disorder Diagnosis
Instructor: Dr. Dawn-Elise Snipes, PhD
Executive Director:, Counselor Education and Training
Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery

~ Avoidant/Restrictive Food Intake Disorder
~ Anorexia
~ Bulimia
~ Binge Eating Disorder
~ Substance Use Disorder
~ Internet Gaming Disorder
~ Gambling Disorder
~ Sex Addiction and Gambling
Avoidant/Restrictive Food Intake Disorder (ARFID)

~ An Eating disturbance as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with 1+ of the following:
~ Significant loss of weight (or failure to achieve expected weight gain or faltering growth in children).
~ Significant nutritional deficiency
~ Dependence on enteral feeding or oral nutritional supplements
~ Marked interference with psychosocial functioning
~ Note: There is no body dysmorphia or fear of becoming fat
Avoidant/Restrictive Food Intake Disorder (ARFID)

~ The behavior is not better explained by lack of available food or by an associated culturally sanctioned practice.
~ The behavior does not occur exclusively during the course of
~ Anorexia nervosa
~ Bulimia nervosa
~ Body dysmorphic disorder
~ The eating disturbance is not attributed to a medical condition, or better explained by another mental health disorder.
~ Depression
~ Anxiety
~ Psychotic disorder
~ Chron’s Disease

~ Persistent restriction of energy intake leading to significantly low body weight (in context of what is minimally expected for physical health)
~ Either an intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain (even though significantly low weight).
~ Disturbance in the way one's body weight or shape is experienced
~ Undue influence of body shape and weight on self-evaluation
~ Persistent lack of recognition of the seriousness of the current low body weight.

Restricting type
Binge-eating/purging type
Anorexia Differential and Confounds
~ Obsessive Compulsive tendencies common (R/O OCD)
~ Can occur in males (3.6% males have an ED)
~ Onset during puberty up to age 40
~ Depressive symptoms (primary or secondary)
~ Anemia
~ Low estrogen/testosterone
~ Reduced thyroid hormones
~ Potassium imbalances and arrhythmias
~ Common Co-Occurring Disorders
~ Depression
~ Anxiety

Binge Eating Disorder
~ Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
~ 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.
~ 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).
Binge Eating Disorder
~ The binge eating episodes are associated with 3+ of the following:
~ Eating much more rapidly than normal
~ Eating until feeling uncomfortably full
~ Eating large amounts of food when not feeling physically hungry
~ Eating alone because of feeling embarrassed by how much one is eating
~ Feeling disgusted with oneself, depressed or very guilty afterward

Binge Eating Disorder
~ Marked distress regarding binge eating is present
~ Binge eating occurs, on average, at least once a week for three months
~ Binge eating not associated with the recurrent use of inappropriate compensatory behaviors
~ Note:
~ Binge Eating Disorder is less common but much more severe than overeating.
~ Binge Eating Disorder is associated with more subjective distress regarding the eating behavior
~ Recurrent episodes of binge eating.
~ Recurrent inappropriate compensatory behavior in order to prevent weight gain
~ Self-induced vomiting
~ Misuse of laxatives
~ Diuretics, or other medications
~ Fasting
~ Excessive exercise

~ The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for three months.
~ Self-evaluation is unduly influenced by body shape and weight.
~ The disturbance does not occur exclusively during episodes of Anorexia Nervosa.
~ Rule out histrionic and borderline personality disorder

~ Specify current severity based on the frequency of inappropriate compensatory behaviors
~ Mild: An average of 1-3 episodes of inappropriate compensatory behaviors per week
~ Moderate: An average of 4-7 episodes of inappropriate compensatory behaviors per week
~ Severe: An average of 8-13 episodes of inappropriate compensatory behaviors per week
~ Extreme: An average of14 or more episodes of inappropriate compensatory behaviors per week
Common Issues in Eating Disorder Diagnosis
~ 7. Nutritional imbalances
~ Assuming lack of knowledge
~ 8. Sleep deprivation (hunger, discomfort)
~ 9. Treating mood issues and expecting food issues to spontaneously remit
~ 10. Failing to address the “rebound” effects from laxative and diuretic abuse

Substance Use Disorder
~ A minimum of 2-3 criteria mild, 4-5 is moderate, and 6-7 is severe
~ Taking the substance in larger amounts and for longer than intended
~ Wanting to cut down or quit but not being able to do it
~ Spending a lot of time obtaining the substance
~ Craving or a strong desire to use substances
~ Failure to carry out major obligations at work, school, home due to use
~ Continued use despite persistent or recurring social, interpersonal, physical, psychological problems caused or made worse by use
~ Stopping/reducing important social, occupational, recreational activities due to use
~ Recurrent use of substances in physically hazardous situations
~ *Tolerance: A need for increased amounts or diminished effect with use of the same amount.
~ *Withdrawal syndrome or the substance is used to avoid withdrawal
* 11. Does not apply when used appropriately under medical supervision

Gambling Disorder
~ Persistent and recurrent problematic gambling behavior 4+ of the following in a 12-month period:
~ Needs to gamble with increasing amounts of money for excitement.
~ Is restless or irritable when attempting to cut down or stop gambling.
~ Has made repeated unsuccessful efforts to control, or stop gambling.
~ Is often preoccupied with gambling when feeling distressed
~ After losing money gambling, often returns another day to get even
~ Lies to conceal the extent of involvement with gambling.
~ Has jeopardized or lost a significant relationship, job or educational or career opportunity because of gambling.
~ Relies on others to provide money to relieve desperate financial situations caused by gambling.

Gambling Disorder
~ 12. Gambling behavior is not better explained by a manic episode.
~ Specify if:
~ Episodic: Meeting diagnostic criteria at more than one time point, with symptoms subsiding between periods
~ Persistent: Continuous symptoms, for multiple years.
~ Specify if:
~ In early remission: none of the criteria for gambling disorder have been met for at least 3 months but for less than 12 months.
~ In sustained remission: none of the criteria met for 12 months or longer.
~ Specify current severity:
Mild: 4–5 criteria met
Moderate: 6–7 criteria met
Severe: 8–9 criteria met

Internet Gaming Disorder (AFS)
~ Repetitive use of Internet-based games, causing to significant issues with functioning. 5 criteria must be met within one year:
~ Preoccupation or obsession with Internet games.
~ Withdrawal symptoms when not playing Internet games.
~ Tolerance–more time needs to be spent playing the games.
~ Tried to stop or curb playing, but has failed to do so.
~ The person has had a loss of interest in other life activities, such as hobbies.
~ A person has had continued overuse of Internet games even with the knowledge of how much they impact a person’s life.
~ Lied to others about his or her Internet game usage.
~ Uses Internet games to relieve anxiety or guilt–it’s a way to escape.
~ Has lost or put at risk an opportunity or relationship because of Internet games.

Internet Gaming Disorder (AFS)
~ At this time, the criteria for this condition are limited to Internet gaming and do not include
~ General use of the internet
~ Online gambling
~ Social media

Sex Addiction as a Diagnosis
~ Recurrent failure (pattern) to resist sexual impulses
~ Engaged in sexual behaviors to a greater extent or for longer than intended
~ Unsuccessful efforts to stop, reduce, or control sexual behaviors.
~ Spent excessive time obtaining sex, being sexual, or recovering from sexual experiences
~ Obsessed with preparing for sexual activities
~ Frequently engaged in sexual behavior when expected to be fulfilling occupational, academic, domestic, or social obligations
~ Continued sexual behavior despite knowing it has caused or exacerbated social, financial, psychological, or physical problems
~ Increased the intensity, frequency, number, or risk of sexual behaviors to achieve the desired effect, or experience diminished effect when continuing behaviors
~ Given up or limited social, occupational, or recreational activities because of sexual behavior
~ Become upset, anxious, restless, or irritable if unable to engage in behavior.

Sex and Pornography Addiction
~ Not a diagnosis or AFS in the DSM V
~ DSM V did add gambling disorder as a dx and Internet Gaming disorder as an AFS
~ How do we treat someone who presents claiming to have it?
~ Assess for concurrent diagnoses
~ Adjustment Disorder
~ Anxiety
~ Dependent PD
~ Depression
~ Histrionic PD
Addiction Treatment Issues
~ Examine reasons for/functions of use to identify areas for intervention
~ Develop distress tolerance skills to deal with urges

~ Addictions and eating disorders can occur alone or concurrently with mood, medical, psychotic or personality disorders
~ Common Errors
~ Differentiate eating disorders from OCD
~ Don’t forget males in ED diagnoses
~ Don’t discount late onset
~ Ensure referral to MD (ED/Alcohol/Benzo misuse)
~ Rule out body dysmorphic disorder with eating disorders (can co-occur)
~ Emotional eating likely doesn’t not meet criteria for binge
~ Address nutritional imbalances
~ Address sleep deprivation (hunger, discomfort)
~ Don’t treat mood issues and expecting food issues to spontaneously remit
~ Address the “rebound” effects from laxative and diuretic abuse
~ Addiction dx does not apply when used appropriately under medical supervision
~ Rule out bipolar disorder with gambling disorder