Internet Mental Health

ANOREXIA NERVOSA






Internet Mental Health Quality of Life Scale

Big 5 Factors Of Mental Illness And Code For This Disorder
(The "6th Big Factor" of Mental Health, "Physical Health", Is Coded Abnormal or Red)

  • Overvalues thinness.

  • Develops a phobia about becoming fat, obsesses about it, and compulsively diets to the point of life-threatening starvation.

Prediction

    Variable duration: few months to many years.

Problems

    Occupational-Economic:

    • When severe, causes academic/vocational impairment.

    Perfectionistic, Overcontrolled (High Conscientiousness):

    • Many have obsessive-compulsive personality traits: strong need to control one's environment, inflexible thinking, limited social spontaneity, perfectionism, overly restrained initiative and emotional expression

    Negative Emotions (Negative Emotion):

    • Pathologically thin, yet obsessed with weight loss, phobic of weight gain, and markedly dissatisfied with own body size and shape

    • Primarily caloric restriction, but also food binging and purging (by self-induced vomiting, laxative abuse, or diuretic abuse)

    • May cycle between having Anorexia Nervosa (caloric restriction), and having Bulimia Nervosa (food binging)

    • Some develop Obsessive-Compulsive Disorder (not related to food).

    • When severe, many develop Major Depressive Disorder, anger, decreased interest in sex, suicide attempts

    Medical:

    • Illness denial is common.

    • Starvation can be life-threatening: 12% mortality rate; hospitalization may be required to prevent death from starvation, suicide, or electrolyte imbalance; medical symptoms are those caused by starvation (e.g., emaciation; cessation of menstruation; abnorally low blood pressure, body temperature, and heart rate; peripheral edema); serious medical conditions can result (e.g., anemia, impaired renal function, cardiovascular problems, dental enamel erosion from self-induced vomiting, and osteoporosis)



Explanation Of Terms And Symbols

Internet Mental Health Quality of Life Scale


Fear, Phobia, Obsession, Compulsion

Fearful avoidance is part of our instinctual "flight" response to adversity.

Our ancestors learned to fear dangerous things (e.g., snakes), and this harm avoidance saved their lives.

However, fear can spiral out of control. For example, an individual can develop a phobia to snakes in which the fear becomes excessive. This phobia can develop into an obsession in which the individual spends much of the time thinking about snakes, and how to avoid them. The obsession can develop into a compulsion in which the individual spends much of the time doing superstitious, compulsive, ritual behaviors aimed at avoiding snakes.

There are stages in the escalation of fear:

  • Fear:
    Fear is normal if it is in proportion to the actual danger posed by the specific object or situation, and this fear doesn't cause significant distress or disability.

  • Phobia:
    If fear about about a specific object or situation becomes excessive, it is defined as a phobia. This phobic fear is out of proportion to the actual danger posed by the specific object or situation, and this phobic fear causes significant distress or disability. In anorexia nervosa, the individual develops a phobia about gaining weight and being fat.

  • Obsession:
    If the individual develops persistent, unwanted thoughts about the phobia; this is defined as an obsession. An obsession is an unwanted, recurrent, persistent, fear-provoking intrusive thought. In anorexia nervosa, individuals have unwanted, intrusive thoughts about their fear of being overweight. Thus their life becomes centered around how to lose more weight.

  • Compulsion:
    A compulsion is a ritual an individual develops to combat an obsession. Thus compulsions are fear-relieving avoidance behaviors. The individual feels driven to perform these compulsions. In anorexia nervosa, the individual develops compulsive weight-reducing behaviors (e.g., compulsive: dieting, exercising, self-induced vomiting, or abuse of laxatives or diuretics). Some of these compulsive rituals may spawn other, illogically related compulsions (e.g., "I must avoid eating red foods"). This irrationality is the hallmark of superstitious learning.



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Click Here For Free Diagnosis

Limitations of Self-Diagnosis

Self-diagnosis of this disorder is often inaccurate. Accurate diagnosis of this disorder requires assessment by a qualified practitioner trained in psychiatric diagnosis and evidence-based treatment.

However, if no such professional is available, our free computerized diagnosis is usually accurate when completed by an informant who knows the patient well. Computerized diagnosis is less accurate when done by patients (because they often lack insight).

Example Of Our Computer Generated Diagnostic Assessment

Anorexia Nervosa 307.1

This diagnosis is based on the following findings:
  • Restriction of food intake leading to a significantly low body weight (still present)
  • Felt 'too fat' even when obviously underweight (still present)
  • Intense fear of gaining weight or becoming fat, even though underweight (still present)

Treatment Goals:

  • Goal: prevent severe restriction of food intake.
    If this problem worsened: This could result in potentially life-threatening medical complications associated with malnutrition. Individuals with anorexia nervosa often do not recognize the serious medical implications of their malnourished state. They frequently either lack insight into or deny the problem.

  • Goal: correct disturbance in self-perceived weight or shape.
    If this problem worsened: Her self-esteem will become highly dependent on her perception of her body shape and weight. Weight loss will become valued as an impressive achievement and a sign of extraordinary self-discipline, whereas weight gain will be perceived as an unacceptable failure of self-control.

  • Goal: prevent intense fear of gaining weight or becoming fat.
    If this problem worsened: Her intense fear of becoming fat usually will not be alleviated by weight loss. In fact, concern about weight gain may increase even as weight falls. Younger individuals with anorexia nervosa, as well as some adults, may not recognize or acknowledge a fear of weight loss. However, the clinician may infer that this fear exists in the absence of another explanation for the significantly low weight.


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Anorexia Nervosa F50.0 - ICD10 Description, World Health Organization

A disorder characterized by deliberate weight loss, induced and sustained by the patient. It occurs most commonly in adolescent girls and young women, but adolescent boys and young men may also be affected, as may children approaching puberty and older women up to the menopause. The disorder is associated with a specific psychopathology whereby a dread of fatness and flabbiness of body contour persists as an intrusive overvalued idea, and the patients impose a low weight threshold on themselves. There is usually undernutrition of varying severity with secondary endocrine and metabolic changes and disturbances of bodily function. The symptoms include restricted dietary choice, excessive exercise, induced vomiting and purgation, and use of appetite suppressants and diuretics.

Anorexia Nervosa - Diagnostic Criteria, American Psychiatric Association

An individual diagnosed with anorexia nervosa needs to meet all of the following criteria:

  • Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.

  • Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.

  • Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

  • Specify whether:

  • Restricting type: During the past 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise.

  • Binge-eating/purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).


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Diagnostic Features

Anorexia Nervosa is characterized by deliberate weight loss most commonly in adolescent girls and young women. The core feature of this disorder is a phobic fear of getting fat, an obsession with thinness, and compulsive self-starvation. A point is reached in dieting when genetic and physiological factors kick in, and food restriction behaviors become compulsive and very difficult to stop. These compulsive behaviors include restricted dietary choice, excessive exercise, induced vomiting and purgation, and use of appetite suppressants and diuretics. There is undernutrition of varying severity with secondary endocrine and metabolic changes and disturbances of bodily function.

Researchers are finding that anorexia nervosa and obsessive-compulsive personality disorder share many common features: perfectionism, inflexibility, having to follow the rules, excessive doubt and caution, and a drive for order and symmetry. As many as three-quarters of those with anorexia nervosa have suffered from an anxiety disorder before their eating disorder began, most commonly social anxiety and OCD.

When exposed to food, a typical individual with anorexia nervosa reported that she suffers from a constant stream of self-loathing: "I can't eat this. I'm going to get fat. I'm ugly. I'm disgusting. I'm weak. I hate myself. I can't do this. I'm so pathetic, just pathetic, a weak pig."

Individuals with anorexia nervosa and bulimia nervosa share many similar features. In both disorders, individuals have an obsession with weight loss, a phobia of weight gain, and marked dissatisfaction with their body size and shape. Both disorders can have self-imposed caloric restriction, food binging and purging (by self-induced vomiting, laxative abuse, or diuretic abuse). Some individuals cycle back and forth between anorexia and bulimia. Anorexic individuals restrict their caloric intake far more than bulimic individuals do; thus anorexics are pathologically thin, whereas many bulimics have a normal weight. Bulimic individuals binge more than anorexic individuals. The risk of onset of anorexia nervosa is highest in late adolescence, with 40% of new cases found between ages 15 and 19 years, and drops significantly after 21 years of age.

There is an argument that Anorexia Nervosa is a form of Obsessive-Compulsive Disorder combined with Body Dysmorphic Disorder in which individuals are obsessed with thinness and their body image, and compulsively diet to change their distorted body image.

Individuals with Anorexia Nervosa view their weight loss as an admirable sign of extraordinary self-discipline, whereas they any view weight gain as a sign of failure of self-control. They seldom appreciate how medically dangerous self-imposed starvation can be. Worse still, there are now pro-anorexia and pro-bulimia support websites that promote and glorify anorexia and bulimia. These websites are medically very dangerous and should be strictly avoided.

Historically, eating disorders were a medical rarity prior to World War I. Then, after fashion magazines were introduced, the incidence of anorexia nervosa shot up. Thus the current epidemic of eating disorders started after World War I in America, spread to Europe, and only after World War II spread to Asia. In Canada's far north, eating disorders were historically unknown in previous generations of aboriginals. The current older aboriginal generation was largely protected from Western influences by a language barrier, but younger aboriginals now speak English. Historically, for the first time, eating disorders are starting to appear in young aboriginals. Thus exposure to Western culture appears to be causal in the development of eating disorders.

Complications

Anorexia Nervosa has a 12% mortality rate from medical complications or suicide. Some develop significant impairment of their functioning at school, job or housekeeping. Others may develop significant social isolation.

Associated Laboratory Findings

No laboratory test has been found to be diagnostic of this disorder. However, there are many physiological disturbances (including amenorrhea and vital sign abnormalities) caused by this self-imposed starvation. Most of the physiological disturbances are reversible with nutritional rehabilitation. However, loss of bone mineral density is not completely reversible. Some individuals with this disorder exhibit no laboratory abnormalities.

Prevalence

The 12 month prevalence of Anorexia Nervosa is 0.4% among young women. This disorder has a 10:1 female-to-male ratio.

Course

Anorexia Nervosa usually starts during adolescence or young adulthood. It rarely begins before puberty or after age 40. The onset is often associated with a stressful event which triggers an individual to start dieting. The course and outcome of this disorder is quite variable. Some individuals recover fully after a single episode; some have recurrent episodes of Anorexia and Bulimia; others experience a chronic course over many years.

Comorbidity

A recent study found reported: "About two-thirds of individuals with anorexia nervosa or bulimia nervosa have one or more lifetime anxiety disorder; the most common is obsessive-compulsive disorder (OCD) [41%] and social phobia [20%]. The majority report the onset of OCD, social phobia, specific phobia, and generalized anxiety disorder in childhood, before they developed their eating disorder. People with a history of an eating disorder who were not currently ill and never had a lifetime anxiety disorder diagnosis still tended to be anxious, perfectionistic, and harm avoidant." Another study reported that the lifetime prevalence of OCD ranged from 9.5 to 62% in patients with anorexia nervosa or bulimia nervosa. Anorexia Nervosa also frequently co-occurs with Mood Disorders (bipolar and depressive), Avoidant Personality Disorder and Substance Use Disorders (alcohol and drugs). Some individuals cycle between episodes of Anorexia Nervosa and Bulimia Nervosa.

Outcome

At least 12% die from medical complications or suicide. Among the surviving patients, less than one-half recover on average, whereas one-third improve, and 20% remain chronically ill. Long-term support is necessary in order to prevent recurrence.

Risk Factors and Precipitants

Children with Anxiety Disorders or obsessional traits have an increased risk of developing Anorexia Nervosa. Culture plays a major role in Anorexia Nervosa since this disorder is only present in cultures that over-value thinness. Occupations that over-value thinness (e.g., modeling, ballet dancing) have a very high rate of this disorder.

Familial Pattern

There is an increased risk for both Anorexia Nervosa and Bulimia Nervosa among first-degree biological relatives of individuals with Anorexia Nervosa. It appears that vulnerability to Anorexia Nervosa is genetic. Concordance rates for anorexia nervosa in monozygotic twins are significantly higher than those for dizygotic twins.

Effective Therapies

Family-based treatment has the best evidence base for effectiveness for younger patients. For adults no specific approach has shown superiority and, presently, a combination of renourishment and psychotherapy is recommended. Medication plays a limited role in Anorexia Nervosa (but a major role in Bulimia Nervosa). For Anorexia Nervosa, the most important medicine is food. Hospitalization frequently saves the lives of individuals with Anorexia Nervosa who have life-threatening medical complications. The effectiveness of outpatient psychotherapy for Anorexia Nervosa is inconclusive. However, patients who do not receive psychotherapy (e.g. are in a waiting-list control group or who get 'treatment as usual') do poorly. Cognitive Behavioural Therapy (CBT) for Anorexia Nervosa is not consistently superior to other treatments (including dietary counselling, non-specific supportive management, interpersonal therapy, behavioural family therapy).

Ineffective therapies

Research has shown that nutritional counselling alone has little benefit. In one study, all those in the control group who got only 'dietary advice' dropped out. Vitamins and dietary supplements are only effective during the acute recovery stage following severe starvation. Vitamin or dietary supplement therapy alone is ineffective.

A Dangerous Cult


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Videos

  • Anorexia Nervosa - Google
  • Anorexia Nervosa In Childhood - Child Mind Institute
  • Anorexia Nervosa - Epocrates Online
  • Anorexia Nervosa World Health Organization ICD-10 (2010)
  • Eating Disorders - NIMH
  • Anorexia Nervosa - PubMed Health
  • Anorexia Nervosa - Wikipedia
  • Anorexia Nervosa Genetics Online Mendelian Inheritance in Man
  • Childhood Obsessive-Compulsive Personality Traits in Adult Women With Eating Disorders - This 2003 study found that childhood traits reflecting obsessive-compulsive personality disorder appear to be important risk factors for the development of eating disorders. This study identified five personality traits that increased the risk of developing an eating disorder: perfectionism, inflexibility, having to follow the rules, excessive doubt and caution, and a drive for order and symmetry. These are exactly the same symptoms which define obsessive-compulsive personality disorder.
  • Why it's so difficult to treat adult anorexia - Researchers are finding that anorexia nervosa and obsessive-compulsive personality disorder share many common features. As many as three-quarters of those with anorexia nervosa have suffered from an anxiety disorder before their eating disorder began, most commonly social anxiety and Obsessive-Compulsive Disorder. This article discusses how a family-assisted 5-day intensive treatment program for adults with anorexia nervosa is helping these individuals by using these new insights.

Stories

Rating Scales

You Can Watch A Video Of What Happens To People After 4 Days Of Starvation

Recently there was a 10 day experiment in which 10 individuals agreed to be cavemen and go into the Colorado wildness equipped only with caveman clothing and tools. This experiment quickly became a study of what happens to normal people when they starve.


Psychiatrically, the results were amazing.

The group was able to catch fish on the first day, then they ran out of food. By the fourth day of starvation, the entire group suffered from severe fatigue, insomnia and apathy. Three members of the group became dysfunctional and just spent the day lying down or sitting. One woman, a vegetarian, was very weak and inactive because she couldn't find nutritious vegetarian food. Another female member became very tearful, pessimistic, and emotionally unstable. This woman gave up on the fifth day of starvation, and exited the experiment.
On the sixth day of starvation, a male member of the group just gave up, and said that they had no chance of getting any more food. He then exited the experiment.

Fortunately, on the seventh day of starvation, the four group members that still had the energy and optimism to hunt, actually killed an elk using their caveman spears. To everyone's surprise, the vegetarian woman refused to eat the meat, and - had the experiment run longer than 10 days - would have starved to death.

When you watch the video of this caveman experiment, you can see practically all of the symptoms of major depressive disorder appear. By the fourth day of starvation, all the group had developed severe fatigue, insomnia, hunger, apathy, and half the group developed crippling pessimism. Those that exited the experiment had developed marked loneliness and social withdrawal. In addition, the woman that exited the group had developed emotional instability. The vegetarian's meat-refusal, even if it meant her starvation, could be interpreted as perfectionism and inflexibility. By the 7th day of starvation, 4 group members were still functional (and saved the group by going hunting), and the other 4 remaining members were dysfunctional and so fatigued and apathetic that all they could do is stay in the camp and lie down.

What Did This Experiment Teach Us About Anorexia Nervosa?

Research has repeatedly shown that starvation can trigger Major Depressive Disorder. Thus, it should come as no surprise that self-imposed starvation (Anorexia Nervosa) can also trigger Major Depressive Disorder. What this Caveman Experiment demonstrates is how quickly starvation can trigger uncooperative, oppositional behavior. By the sixth day of this starvation experiment, 6 out of the 10 group members had become so dysfunctional that they couldn't hunt. Two of them became so emotionally upset that they quit the experiment in anger. The other four became so apathetic and oppositional that they refused to hunt. They had lost hope and had given up.

It appeared that the 6 group members that refused to hunt had lost their focus and creativity, and couldn't figure out how to solve their starvation problem. They couldn't see that they would have to be move closer to the elk. All they could do was to become immobilized. Some showed bad judgment by prematurely quitting the experiment. One showed extremely poor judgment by refusing the meat offered to her even though she was starving. Her inflexible vegetarian beliefs would have killed her had the experiment continued.

Thus, in this 10 day experiment in starvation, we can see many of the starvation behaviors that we see in Anorexia Nervosa:

  • Uncooperative, oppositional behavior

  • Socially withdrawn, unfriendly behavior

  • Loss of focus on goal-oriented activity

  • Loss of creativity and impaired problem-solving

  • Poor judgment and inflexible, closed-mindedness

  • Apathy and loss of motivation

  • Inability to work

  • Quickly giving up instead of persisting in the face of adversity

  • Pessimism, expecting the worst

This experiment shows how quickly normal people can develop very dysfunctional behavior during starvation. That is why self-imposed starvation from severe dieting is so dangerous. Self-imposed starvation can trigger powerful dysfunctional behaviors that further reinforce the dieting, potentially leading to tragedy.

Which Behavioral Dimensions Are Involved?

Research has shown that there are 5 major dimensions (the "Big 5 Factors") of personality disorders and other mental disorders. There are two free online personality tests that assess your personality in terms of the "Big 5 dimensions of personality". Although not computerized online, the Big Five Inventory (BFI) is a 44-item test often used in personality research.

This website uses these 5 major dimensions of human behavior to describe all mental disorders. (This website adds one more dimension, "Physical Health", but our discussion will focus on the first 5 major dimensions.)

These major dimensions of human behavior seem to represent the major dimensions whereby our early evolutionary ancestors chose their hunting companions or spouse. To maximize their chance for survival, our ancestors wanted companions who were agreeable, conscientious, intelligent, sociable, emotionally stable, and physically healthy.

    Which Dimensions of Human Behavior are Impaired in Anorexia Nervosa?

    THE POSITIVE SIDE OF THE "BIG 5" PERSONALITY DIMENSIONS THE NEGATIVE SIDE OF THE "BIG 5" PERSONALITY DIMENSIONS DESCRIPTION (Where red = this disorder)
    Agreeableness Antagonism       Agreeableness
    Conscientiousness Disinhibition       Excessive Conscientiousness
    Openness/Intellect Low Openness/Intellect       Openness/Intellect
    Sociability (Extraversion) Detachment       Sociability (Extraversion)
    Emotional Stability Negative Emotion       Negative Emotion


The 5 Major Dimensions of Mental Illness

The Big 5 Factors or dimensions of mental illness each has a healthy side and an unhealthy side. Thus the Big 5 Factors are: (1) Agreeableness vs. Antagonism, (2) Conscientiousness vs. Disinhibition, (3) Openness/Intellect vs. Low Openness/Intellect, (4) Sociability (Extraversion) vs. Detachment (Introversion), and (5) Emotional Stability vs. Negative Emotion.



The Following Pictures Are From The 2/6/2018 SpaceX Falcon Heavy Launch

AGREEABLENESS VS. ANTAGONISM
.
Agreeableness (Agreeable)
.
Description: Agreeableness is synonymous with compassion and politeness. Compassion reflects empathy, sympathy, and caring for others. Politeness reflects respect for others. Agreeable people are interested in others, and they make people feel comfortable. The Agreeableness dimension measures the behaviors that are central to the concept of JUSTICE (fair, honest, and helpful behavior - living in harmony with others, neither harming nor allowing harm). (This dimension appears to measure the behaviors that differentiate friend from foe.)
Descriptors: Compassionate, polite, warm, friendly, helpful, unselfish, generous, modest.
Language Characteristics: Pleasure talk, agreement, compliments, empathy, few personal attacks, few commands or global rejections, many self-references, few negations, few swear words, few threats, many insight words.
Research: Higher scores on Agreeableness are associated with deeper relationships. *MRI research found that Agreeableness was associated with increased volume in regions that process information about the intentions and mental states of other individuals.
"I am helpful and unselfish with others."
"I have a forgiving nature."
"I am generally trusting."
"I am considerate and kind to almost everyone."
"I like to cooperate with others."
"I don't find fault with others."
"I don't start quarrels with others."
"I am not cold and aloof."
"I am not rude to others."
"I feel other's emotions."
"I inquire about others' well-being."
"I sympathize with others' feelings."
"I take an interest in other people's lives."
"I like to do things for others."
"I respect authority."
"I hate to seem pushy."
"I avoid imposing my will on others."
"I rarely put people under pressure."
.
Antagonism (Antagonistic)
.
Description: Antagonism is synonymous with competition and aggression. Antagonistic people are self-interested, and do not see others positively.
Descriptors: Manipulative, deceitful, grandiose, callous, disrespectful, unfriendly, suspicious, uncooperative, malicious.
Language Characteristics: Problem talk, dissatisfaction, little empathy, many personal attacks, many commands or global rejections, few self-references, many negations, many swear words, many threats, little politeness, few insight words.
.
* Callousness:
"It's no big deal if I hurt other people's feelings."
"Being rude and unfriendly is just a part of who I am."
"I often get into physical fights."
"I enjoy making people in control look stupid."
"I am not interested in other people's problems."
"I can't be bothered with other's needs."
"I am indifferent to the feelings of others."
"I don't have a soft side."
"I take no time for others."
.
* Deceitfulness:
"I don't hesitate to cheat if it gets me ahead."
"Lying comes easily to me."
"I use people to get what I want."
"People don't realize that I'm flattering them to get something."
.
* Manipulativeness:
"I use people to get what I want."
"It is easy for me to take advantage of others."
"I'm good at conning people."
"I am out for my own personal gain."
.
* Grandiosity:
"I'm better than almost everyone else."
"I often have to deal with people who are less important than me."
"To be honest, I'm just more important than other people."
"I deserve special treatment."
.
* Suspiciousness:
"It seems like I'm always getting a “raw deal” from others."
"I suspect that even my so-called 'friends' betray me a lot."
"Others would take advantage of me if they could."
"Plenty of people are out to get me."
"I'm always on my guard for someone trying to trick or harm me."
.
* Hostility:
"I am easily angered."
"I get irritated easily by all sorts of things."
"I am usually pretty hostile."
"I always make sure I get back at people who wrong me."
"I resent being told what to do, even by people in charge."
"I insult people."
"I seek conflict."
"I love a good fight."
.
("Agreeableness vs. Antagonism" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.




CONSCIENTIOUSNESS VS. DISINHIBITION
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Conscientiousness (Conscientious)
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Description: Conscientiousness is synonymous with being self-disciplined, industrious and orderly. The Conscientiousness dimension measures the behaviors that are central to the concept of SELF-CONTROL - organizing and controlling one's behavior in order to achieve one's goals. (This dimension appears to measure the behaviors that differentiate behavioral order and inhibition from chaos and disinhibition.)
Descriptors: Industrious, self-disciplined, rule-abiding, organized
Language Characteristics: Many positive emotion words (e.g. happy, good), few negative emotion words (e.g. hate, bad), more perspective, careful to check that information is conveyed correctly, straight to the point, formal, few negations, few swear words, few references to friends, few disfluencies or filler words, many insight words, not impulsive.
Research: Higher scores on Conscientiousness predict greater success in school and at work. *MRI research found that Conscientiousness was associated with increased volume in the lateral prefrontal cortex, a region involved in planning and the voluntary control of behavior.
"I do a thorough job. I want everything to be 'just right'. I want every detail taken care of."
"I am careful."
"I am a reliable hard-worker."
"I am organized. I follow a schedule and always know what I am doing."
"I like order. I keep things tidy."
"I see that rules are observed."
"I do things efficiently. I get things done quickly."
"I carry out my plans and finish what I start."
"I am not easily distracted."
.
Rigid Perfectionism (Excessive Conscientiousness)
.
"Even though it drives other people crazy, I insist on absolute perfection in everything I do."
"I simply won't put up with things being out of their proper places."
"People complain about my need to have everything all arranged."
"People tell me that I focus too much on minor details."
"I have a strict way of doing things."
"I postpone decisions."
.
Disinhibition (Disinhibited)
.
Description: Disinhibition is synonymous with being distractible, impulsive and disorganized.
Descriptors: Distractible, impulsive, irresponsible, disorganised, unreliable, careless, forgetful
Language Characteristics: Few positive emotion words, many negative emotion words, less perspective, less careful, more vague, informal, many negations, many swear words, many references to friends (e.g. pal, buddy), many disfluencies or filler words, few insight words, impulsive.
.
* Irresponsibility:
"I've skipped town to avoid responsibilities."
"I just skip appointments or meetings if I'm not in the mood."
"I'm often pretty careless with my own and others' things."
"Others see me as irresponsible."
"I make promises that I don't really intend to keep."
"I often forget to pay my bills."
.
* Impulsivity:
"I usually do things on impulse without thinking about what might happen as a result."
"Even though I know better, I can't stop making rash decisions."
"I feel like I act totally on impulse."
"I'm not good at planning ahead."
.
* Distractibility:
"I can't focus on things for very long."
"I am easily distracted."
"I have trouble pursuing specific goals even for short periods of time."
"I can't achieve goals because other things capture my attention."
"I often make mistakes because I don't pay close attention."
"I waste my time ."
"I find it difficult to get down to work."
"I mess things up."
"I don't put my mind on the task at hand."
.
* Reckless Risk Taking:
"I like to take risks."
"I have no limits when it comes to doing dangerous things."
"People would describe me as reckless."
"I don't think about getting hurt when I'm doing things that might be dangerous."
.
* Hyperactivity:
"I move excessively (e.g., can't sit still; restless; always on the go)."
"I'm starting lots more projects than usual or doing more risky things than usual."
.
* Over-Talkativeness:
"I talk excessively (e.g., I butt into conversations; I complete people's sentences)."
"Often I talk constantly and cannot be interrupted."
.
* Elation:
"I feel much more happy, cheerful, or self-confident than usual."
"I'm sleeping a lot less than usual, but I still have a lot of energy."
.
("Conscientiousness vs. Disinhibition" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.




OPENNESS/INTELLECT vs. LOW OPENNESS/INTELLECT
.
Openness/Intellect (Open-Minded)
.
Description: Openness/Intellect (or "Openness To Experience") is synonymous with being open-minded and creative. The Openness/Intellect dimension measures the behaviors that are central to the concept of WISDOM - having experience, knowledge, and good judgment. (This dimension appears to measure the behaviors that differentiate open-minded from close-minded individuals.) Open-minded people are usually creative, sophisticated, intellectual, curious and interested in art.
Descriptors: Receptive to new ideas, curious, imaginative, creative, unconventional
Language Characteristics: Many positive emotion words (e.g. happy, good), high meaning elaboration, more perspective, politeness, few self-references, complex sentence constructions, few causation words, many inclusive words (e.g. with, and), few third person pronouns, many tentative words (e.g. maybe, guess), many insight words (e.g. think, see), few filler words and within-utterance pauses, stronger uncommon verbs.
Research: Higher scores on Openness/Intellect are associated with greater creativity and general intelligence. *MRI research found that Openness/Intellect did not have any significant correlation with the volume of any localized brain structure.
Relationship To General Intelligence: Research has shown that Openness/Intellect can be separated into 2 factors: Openness and Intellect. Intellect was independently associated with general intelligence (g) and with verbal and nonverbal intelligence about equally. Openness was independently associated only with verbal intelligence.
Example: This video shows how we see what we want to see. What we pay attention to (or what we believe about the world) blinds us to reality. (Exit YouTube after first video.)
"I am original, and come up with new ideas."
"I am curious about many different things."
"I am quick to understand things."
"I can handle a lot of information."
"I like to solve complex problems."
"I have a rich vocabulary."
"I think quickly and formulate ideas clearly."
"I enjoy the beauty of nature."
"I believe in the importance of art."
"I love to reflect on things."
"I get deeply immersed in music."
"I see beauty in things that others might not notice."
"I need a creative outlet."
.
Closed To Experience (Low Openness/Intellect)
.
Description: Low Openness/Intellect (or "Closed To Experience") is synonymous with being closed-minded and uncreative. Low Openness/Intellect is associated with narrow-mindedness, unimaginativeness and ignorance.
Descriptors: Narrow-minded, conservative, ignorant, simple
Language Characteristics: Few positive emotion words, low meaning elaboration, less perspective, less politeness, few positive emotion words, many self-references, simple sentence construction, many causation words (e.g. because, hence), many third person pronouns, few tentative words, few insight words, many filler words and within-utterance pauses, milder verbs.
.
"I prefer work that is routine."
"I have difficulty understanding abstract ideas."
"I think slowly."
"People find it hard to follow my logic or understand my thoughts."
"I avoid philosophical discussions."
"I avoid difficult reading material."
"People find it hard to follow my logic or understand my thoughts."
"I have few artistic interests."
"I seldom notice the emotional aspects of paintings and pictures."
"I do not like poetry."
"I seldom get lost in thought."
"I seldom daydream."
.
Cognitive Impairment
.
* Memory Impairment:
"I have difficulty learning new things, or remembering things that happened a few days ago."
"I often forget a conversation I had the day before."
"I often forget to take my medications, or to keep my appointments."
.
* Impaired Reasoning:
"My judgment or ability to solve problems isn't good."
"I have difficulty understanding abstract ideas."
"I think slowly."
"People find it hard to follow my logic or understand my thoughts."
.
Psychoticism
.
Description: Psychoticism is the state of being psychotic or of being predisposed to develop psychosis.
Descriptors: Unusual beliefs and experiences, eccentricity, perceptual dysregulation.
.
* Eccentricity:
"I often have thoughts that make sense to me but that other people say are strange."
"Others seem to think I'm quite odd or unusual."
"My thoughts are strange and unpredictable."
"My thoughts often don’t make sense to others."
"Other people seem to think my behavior is weird."
"I have several habits that others find eccentric or strange."
"My thoughts often go off in odd or unusual directions."
.
* Unusual Beliefs and Experiences:
"I often have unusual experiences, such as sensing the presence of someone who isn't actually there."
"I've had some really weird experiences that are very difficult to explain."
"I have seen things that weren’t really there."
"I have some unusual abilities, like sometimes knowing exactly what someone is thinking."
"I sometimes have heard things that others couldn’t hear."
"Sometimes I can influence other people just by sending my thoughts to them."
"I often see unusual connections between things that most people miss."
.
* Perceptual Dysregulation:
"Things around me often feel unreal, or more real than usual."
"Sometimes I get this weird feeling that parts of my body feel like they're dead or not really me."
"It's weird, but sometimes ordinary objects seem to be a different shape than usual."
"Sometimes I feel 'controlled' by thoughts that belong to someone else."
"Sometimes I think someone else is removing thoughts from my head."
"I have periods in which I feel disconnected from the world or from myself."
"I can have trouble telling the difference between dreams and waking life."
"I often 'zone out' and then suddenly come to and realize that a lot of time has passed."
"Sometimes when I look at a familiar object, it's somehow like I'm seeing it for the first time."
"People often talk about me doing things I don't remember at all."
"I often can't control what I think about."
"I often see vivid dream-like images when I’m falling asleep or waking up."
.
("OPENNESS TO EXPERIENCE vs. BEING CLOSED TO EXPERIENCE" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.




SOCIABILITY (EXTRAVERSION) vs. DETACHMENT
.
Sociability (Sociable)
.
Description: Sociability (Extraversion) is synonymous with being enthusiastic and assertive. Assertiveness encompasses traits relating to leadership, dominance, and drive. Enthusiasm encompasses both outgoing friendliness or sociability and the tendency to experience and express positive emotion. Extraverts tend to engage in social interaction; they are enthusiastic, risk-taking, talkative and assertive. The Extraversion dimension measures the behaviors that are central to the concept of SOCIABILITY - seeking and enjoying companionship. (This dimension appears to measure the behaviors that differentiate approach from avoidance.)
Descriptors: Sociable, gregarious, reward-seeking, talkative.
Language Characteristics: Many topics, higher verbal output, think out loud, pleasure talk, agreement, compliment, positive emotion words, sympathetic, concerned about hearer (but not empathetic), simple constructions, few unfilled pauses, few negations, few tentative words, informal language, many swear words, exaggeration (e.g. really), many words related to humans (e.g. man, pal), poor vocabulary.
Research: Higher scores on Sociability (extraversion) are associated with greater happiness and broader social connections. *MRI research found that Sociability (extraversion) was associated with increased volume of medial orbitofrontal cortex, a region involved in processing reward information.
"I'm talkative"
"I'm not reserved."
"I'm full of energy."
"I generate a lot of enthusiasm."
"I'm not quiet."
"I have an assertive personality."
"I'm not shy or inhibited."
"I am outgoing and sociable."
"I make friends easily."
"I warm up quickly to others."
"I show my feelings when I'm happy."
"I have a lot of fun."
"I laugh a lot."
"I take charge."
"I have a strong personality."
"I know how to captivate people."
"I see myself as a good leader."
"I can talk others into doing things."
"I am the first to act."
.
Attention Seeking (Excessive Sociability)
.
"I like to draw attention to myself."
"I crave attention."
"I do things to make sure people notice me."
"I do things so that people just have to admire me."
"My behavior is often bold and grabs peoples' attention."
.
Detachment (Detached)
.
Description: Detachment is synonymous with being reserved and quiet.
Descriptors: Withdrawn, anhedonic (pleasureless), intimacy avoiding, Detached, shy, passive, solitary, moody
Language Characteristics: Single topic, doesn't think out loud, problem talk, dissatisfaction, negative emotion words, not sympathetic, elaborated sentence constructions, many unfilled pauses, formal language, many negations, many tentative words (e.g. maybe, guess), few swear words, little exaggeration, few words related to humans, rich vocabulary.
.
* Social Withdrawal:
"I don’t like to get too close to people."
"I don't deal with people unless I have to."
"I'm not interested in making friends."
"I don’t like spending time with others."
"I say as little as possible when dealing with people."
"I keep to myself."
"I am hard to get to know."
"I reveal little about myself."
"I do not have an assertive personality."
"I lack the talent for influencing people."
"I wait for others to lead the way."
"I hold back my opinions."
.
* Intimacy Avoidance:
"I steer clear of romantic relationships."
"I prefer to keep romance out of my life."
"I prefer being alone to having a close romantic partner."
"I'm just not very interested in having sexual relationships."
"II break off relationships if they start to get close."
.
* Anhedonia (Lack of Pleasure):
"I often feel like nothing I do really matters."
"I almost never enjoy life."
"Nothing seems to make me feel good."
"Nothing seems to interest me very much."
"I almost never feel happy about my day-to-day activities."
"I rarely get enthusiastic about anything."
"I don't get as much pleasure out of things as others seem to."
.
* Restricted Emotions:
"I don't show emotions strongly."
"I don't get emotional."
"I never show emotions to others."
"I don't have very long-lasting emotional reactions to things."
"People tell me it's difficult to know what I'm feeling."
"I am not a very enthusiastic person."
.
("Sociability vs. Detachment" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.




EMOTIONAL STABILITY VS. NEGATIVE EMOTION
.
Emotional Stability (Emotionally Stable)
.
Description: Emotional Stability is synonymous with being calm and emotionally stable. The Emotional Stability dimension measures the behaviors that are central to the concept of COURAGE - having calm composure and endurance when confronting adversity. (This dimension appears to measure the behaviors that differentiate safety from danger.)
Descriptors: Calm, even-tempered, peaceful, confident
Language Characteristics: Pleasure talk, agreement, compliment, low verbal productivity, few repetitions, neutral content, calm, few self-references, many short silent pauses, few long silent pauses, many tentative words, few aquiescence, little exaggeration, less frustration, low concreteness.
"I am relaxed, and I handle stress well."
"I am emotionally stable, and not easily upset."
"I remain calm in tense situations."
"I rarely get irritated."
"I keep my emotions under control."
"I rarely lose my composure."
"I am not easily annoyed."
"I seldom feel blue."
"I feel comfortable with myself."
"I rarely feel depressed."
"I am not embarrassed easily."
.
Negative Emotion (Negative Emotions)
.
Description: Degree to which people experience persistent anxiety or depression and are easily upset. (This could be thought of as high threat sensitivity or low stress tolerance.)
Descriptors: Emotionally unstable, anxious, separation-insecure, depressed, self-conscious, oversensitive, vulnerable.
Language Characteristics: Problem talk, dissatisfaction, high verbal productivity, many repetitions, polarised content, stressed, many self-references, few short silent pauses, many long silent pauses, few tentative words, more aquiescence, many self references, exaggeration, frustration, high concreteness.
Research: Lower scores on Emotional Stability are associated with unhappiness, dysfunctional relationships, and mental health problems. *MRI research found that Low Emotional Stability (= Negative Emotion or Neuroticism) was associated with increased volume of brain regions associated with threat, punishment, and negative emotions.
.
* Emotional Instability:
"I get emotional easily, often for very little reason."
"I get emotional over every little thing."
"My emotions are unpredictable."
"I never know where my emotions will go from moment to moment."
"I am a highly emotional person."
"I have much stronger emotional reactions than almost everyone else."
"My emotions sometimes change for no good reason."
"I get angry easily."
"I get upset easily."
"I change my mood a lot."
"I am a person whose moods go up and down easily."
"I get easily agitated."
"I can be stirred up easily."
.
* Anxiety:
"I worry about almost everything."
"I'm always fearful or on edge about bad things that might happen."
"I always expect the worst to happen."
"I am a very anxious person."
"I get very nervous when I think about the future."
"I often worry that something bad will happen due to mistakes I made in the past."
"I am filled with doubts about things."
"I feel threatened easily."
"I am afraid of many things."
.
* Separation Insecurity:
"I fear being alone in life more than anything else."
"I can't stand being left alone, even for a few hours."
"I’d rather be in a bad relationship than be alone."
"I'll do just about anything to keep someone from abandoning me."
"I dread being without someone to love me."
.
* Submissiveness:
"I usually do what others think I should do."
"I do what other people tell me to do."
"I change what I do depending on what others want."
.
* Perseveration:
"I get stuck on one way of doing things, even when it's clear it won't work."
"I get stuck on things a lot."
"It is hard for me to shift from one activity to another."
"I get fixated on certain things and can’t stop."
"I feel compelled to go on with things even when it makes little sense to do so."
"I keep approaching things the same way, even when it isn’t working."
.
* Depressed Mood:
"I have no worth as a person."
"Everything seems pointless to me."
"I often feel like a failure."
"The world would be better off if I were dead."
"The future looks really hopeless to me."
"I often feel just miserable."
"I'm very dissatisfied with myself."
"I often feel like nothing I do really matters."
"I know I'll commit suicide sooner or later."
"I talk about suicide a lot."
"I feel guilty much of the time."
"I'm so ashamed by how I've let people down in lots of little ways."
"I am easily discouraged."
"I become overwhelmed by events."
.
("Emotional Stability vs. Negative Emotion" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.



The "Big 5 Factors" of Personality as Shown In Dogs

The same "Big 5 Factors" of personality found in humans can be found in dogs. This makes sense because dogs, like humans, are a social species.



AGREEABLENESS VS. ANTAGONISM
.
Agreeableness ("Friend")
.
Dog is friendly towards unfamiliar people.
Dog is friendly towards other dogs.
When off leash, dog comes immediately when called.
Dog willingly shares toys with other dogs.
Dog leaves food or objects alone when told to do so.
.
Antagonism ("Foe")
.
Dog is dominant over other dogs.
Dog is assertive with other dogs (e.g., if in a home with other dogs, when greeting).
Dog behaves aggressively towards unfamiliar people.
Dog shows aggression when nervous or fearful.
Dog aggressively guards coveted items (e.g., stolen item, treats, food bowl).
Dog is quick to sneak out through open doors, gates.

CONSCIENTIOUSNESS VS. DISINHIBITION
.
Conscientiousness ("Self-Controlled")
.
Dog works at tasks (e.g., getting treats out of a dispenser, shredding toys) until entirely finished.
Dog works hard all day herding or pulling a sleigh (if a "working dog" on the farm or in the snow).*
Dog is curious.
.
Disinhibition ("Disinhibited")
.
Dog is boisterous.
Dog seeks constant activity.
Dog is very excitable around other dogs.

OPENNESS/INTELLECT vs. LOW OPENNESS/INTELLECT
.
Open To Experience ("Open-Minded")
.
Dog is able to focus on a task in a distracting situation (e.g., loud or busy places, around other dogs).
.
Closed To Experience ("Closed-Minded")
.
Dog is slow to respond to corrections.
Dog ignores commands.
Dog is slow to learn new tricks or tasks.

SOCIABILITY (EXTRAVERSION) vs. DETACHMENT
.
Sociability ("Approach")
.
Dog is attention seeking (e.g., nuzzling, pawing or jumping up on family members looking for attention and physical contact).*
Dog seeks companionship from people.
Dog is affectionate.
.
Detachment ("Avoidance")
.
Dog is aloof.
Dog gets bored in play quickly.
Dog is lethargic.

EMOTIONAL STABILITY VS. NEGATIVE EMOTION
.
Emotional Stability ("Safety")
.
Dog tends to be calm.
Dog is relaxed when greeting people.
Dog is confident.
Dog adapts easily to new situations and environments.
.
Negative Emotion ("Danger")
.
Dog is anxious.
Dog is shy.
Dog behaves fearfully towards unfamiliar people.
Dog exhibits fearful behaviors when restrained.
Dog avoids other dogs.
Dog behaves fearfully towards other dogs.
Dog behaves submissively (e.g., rolls over, avoids eye contact, licks lips) when greeting other dogs.
.
Modified from Jones, A. C. (2009). Development and validation of a dog personality questionnaire. Ph.D. Thesis. University of Texas, Austin.

* New items added by Phillip W. Long MD


Personality Difference Between Dogs and Humans

Dogs and humans are strikingly similar on 4 of the "Big 5 Factors" of personality. However, dogs and humans are quite different on the "Conscientiousness" factor - because the canine brain is designed for hunting, not building. That's why dogs don't build dog houses.

The Brain and the "Big-5 Factors" of Personality In A Social Species

The "Big-5 Factors" of personality represent basic brain functions in social species. For example, when a male approaches a female, the female must: (1) decide whether the male is friend or foe ["Agreeableness"], (2) decide if this represents safety or danger ["Emotional Stability"], (3) decide whether to approach or avoid him ["Sociability"], (4) decide whether to be self-controlled or disinhibited ["Conscientiousness"], and (5) learn from this experience ["Openness to Experience"].

The "Big-5 Factors" of Human and Cat Personality

Cats are a social species, but less social than dogs. Nevertheless, cats also show the "Big 5 Factors" of personality.




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Treatment Guidelines

Summary Of Practice guideline for the treatment of patients with eating disorders. - American Psychiatric Association (2006)

Rating Scheme for the Strength of the Recommendations

Each recommendation is identified as falling into one of three categories of endorsement, indicated by a bracketed Roman numeral following the statement. The three categories represent varying levels of clinical confidence:

  • [I] Recommended with substantial clinical confidence.

  • [II] Recommended with moderate clinical confidence.

  • [III] May be recommended on the basis of individual circumstances.

Choice of Specific Treatments for Anorexia Nervosa

The aims of treating anorexia nervosa are to 1) restore patients to a healthy weight (associated with the return of menses and normal ovulation in female patients, normal sexual drive and hormone levels in male patients, and normal physical and sexual growth and development in children and adolescents); 2) treat physical complications; 3) enhance patients' motivation to cooperate in the restoration of healthy eating patterns and participate in treatment; 4) provide education regarding healthy nutrition and eating patterns; 5) help patients reassess and change core dysfunctional cognitions, attitudes, motives, conflicts, and feelings related to the eating disorder; 6) treat associated psychiatric conditions, including deficits in mood and impulse regulation and self-esteem and behavioral problems; 7) enlist family support and provide family counseling and therapy where appropriate; and 8) prevent relapse.

  1. Nutritional Rehabilitation

    The goals of nutritional rehabilitation for seriously underweight patients are to restore weight, normalize eating patterns, achieve normal perceptions of hunger and satiety, and correct biological and psychological sequelae of malnutrition [I]. For patients age 20 years and younger, an individually appropriate range for expected weight and goals for weight and height may be determined by considering measurements and clinical factors, including current weight, bone age estimated from wrist x-rays and nomograms, menstrual history (in adolescents with secondary amenorrhea), mid-parental heights, assessments of skeletal frame, and benchmarks from Centers for Disease Control and Prevention (CDC) growth charts [I].

    For individuals who are markedly underweight and for children and adolescents whose weight has deviated below their growth curves, hospital-based programs for nutritional rehabilitation should be considered [I]. For patients in inpatient or residential settings, the discrepancy between healthy target weight and weight at discharge may vary depending on patients' ability to feed themselves, their motivation and ability to participate in aftercare programs, and the adequacy of aftercare, including partial hospitalization [I]. It is important to implement refeeding programs in nurturing emotional contexts [I]. For example, it is useful for staff to convey to patients their intention to take care of them and not let them die even when the illness prevents the patients from taking care of themselves [II]. It is also useful for staff to communicate clearly that they are not seeking to engage in control battles and have no punitive intentions when using interventions that the patient may experience as aversive [I].

    In working to achieve target weights, the treatment plan should also establish expected rates of controlled weight gain. Clinical consensus suggests that realistic targets are 2-3 pounds (lb)/week for hospitalized patients and 0.5-1 lb/week for individuals in outpatient programs [II]. Registered dietitians can help patients choose their own meals and can provide a structured meal plan that ensures nutritional adequacy and that none of the major food groups are avoided [I]. Formula feeding may have to be added to the patient's diet to achieve large caloric intake [II]. It is important to encourage patients with anorexia nervosa to expand their food choices to minimize the severely restricted range of foods initially acceptable to them [II]. Caloric intake levels should usually start at 30-40 kilocalories/kilogram (kcal/kg) per day (approximately 1,000-1,600 kcal/day). During the weight gain phase, intake may have to be advanced progressively to as high as 70-100 kcal/kg per day for some patients; many male patients require a very large number of calories to gain weight [II].

    Patients who require much lower caloric intakes or are suspected of artificially increasing their weight by fluid loading should be weighed in the morning after they have voided and are wearing only a gown; their fluid intake should also be carefully monitored [I]. Urine specimens obtained at the time of a patient's weigh-in may need to be assessed for specific gravity to help ascertain the extent to which the measured weight reflects excessive water intake [I]. Regular monitoring of serum potassium levels is recommended in patients who are persistent vomiters [I]. Hypokalemia should be treated with oral or intravenous potassium supplementation and rehydration [I].

    Physical activity should be adapted to the food intake and energy expenditure of the patient, taking into account the patient's bone mineral density and cardiac function [I]. Once a safe weight is achieved, the focus of an exercise program should be on the patient's gaining physical fitness as opposed to expending calories [I].

    Weight gain results in improvements in most of the physiological and psychological complications of semistarvation [I]. It is important to warn patients about the following aspects of early recovery [I]: As they start to recover and feel their bodies getting larger, especially as they approach frightening, magical numbers on the scale that represent phobic weights, they may experience a resurgence of anxious and depressive symptoms, irritability, and sometimes suicidal thoughts. These mood symptoms, non-food-related obsessional thoughts, and compulsive behaviors, although often not eradicated, usually decrease with sustained weight gain and weight maintenance. Initial refeeding may be associated with mild transient fluid retention, but patients who abruptly stop taking laxatives or diuretics may experience marked rebound fluid retention for several weeks. As weight gain progresses, many patients also develop acne and breast tenderness and become unhappy and demoralized about resulting changes in body shape. Patients may experience abdominal pain and bloating with meals from the delayed gastric emptying that accompanies malnutrition. These symptoms may respond to pro-motility agents [III]. Constipation may be ameliorated with stool softeners; if unaddressed, it can progress to obstipation and, rarely, to acute bowel obstruction.

    When life-preserving nutrition must be provided to a patient who refuses to eat, nasogastric feeding is preferable to intravenous feeding [I]. When nasogastric feeding is necessary, continuous feeding (i.e., over 24 hours) may be better tolerated by patients and less likely to result in metabolic abnormalities than three to four bolus feedings a day [II]. In very difficult situations, where patients physically resist and constantly remove their nasogastric tubes, feeding through surgically placed gastrostomy or jejunostomy tubes may be an alternative to nasogastric feeding [II]. In determining whether to begin involuntary forced feeding, the clinician should carefully think through the clinical circumstances, family opinion, and relevant legal and ethical dimensions of the patient's treatment [I]. The general principles to be followed in making the decision are those directing good, humane care; respecting the wishes of competent patients; and intervening respectfully with patients whose judgment is severely impaired by their psychiatric disorders when such interventions are likely to have beneficial results [I]. For cooperative patients, supplemental overnight pediatric nasogastric tube feeding has been used in some programs to facilitate weight gain [III].

    With severely malnourished patients (particularly those whose weight is <70% of their healthy body weight) who undergo aggressive oral, nasogastric, or parenteral refeeding, a serious refeeding syndrome can occur. Initial assessments should include vital signs and food and fluid intake and output, if indicated, as well as monitoring for edema, rapid weight gain (associated primarily with fluid overload), congestive heart failure, and gastrointestinal symptoms [I]. Patients' serum levels of phosphorus, magnesium, potassium, and calcium should be determined daily for the first 5 days of refeeding and every other day for several weeks thereafter, and electrocardiograms should be performed as indicated [II]. For children and adolescents who are severely malnourished (weight <70% of healthy body weight), cardiac monitoring, especially at night, may be desirable [II]. Phosphorus, magnesium, and/or potassium supplementation should be given when indicated [I].

  1. Psychosocial Interventions

    The goals of psychosocial interventions are to help patients with anorexia nervosa 1) understand and cooperate with their nutritional and physical rehabilitation, 2) understand and change the behaviors and dysfunctional attitudes related to their eating disorder, 3) improve their interpersonal and social functioning, and 4) address comorbid psychopathology and psychological conflicts that reinforce or maintain eating disorder behaviors.

    1. Acute Anorexia Nervosa

      During acute refeeding and while weight gain is occurring, it is beneficial to provide anorexia nervosa patients with individual psychotherapeutic management that is psychodynamically informed and provides empathic understanding, explanations, praise for positive efforts, coaching, support, encouragement, and other positive behavioral reinforcement [I]. Attempts to conduct formal psychotherapy with starving patients who are often negativistic, obsessional, or mildly cognitively impaired may be ineffective [II].

      For children and adolescents, the evidence indicates that family treatment is the most effective intervention [I]. In methods modeled after the Maudsley approach, families become actively involved, in a blame-free atmosphere, in helping patients eat more and resist compulsive exercising and purging. For some outpatients, a short-term course of family therapy using these methods may be as effective as a long-term course; however, a shorter course of therapy may not be adequate for patients with severe obsessive-compulsive features or nonintact families [II].

      Most inpatient-based nutritional rehabilitation programs create a milieu that incorporates emotional nurturance and a combination of reinforcers that link exercise, bed rest, and privileges to target weights, desired behaviors, feedback concerning changes in weight, and other observable parameters [II]. For adolescents treated in inpatient settings, participation in family group psychoeducation may be helpful to their efforts to regain weight and may be equally as effective as more intensive forms of family therapy [III].

    1. Anorexia Nervosa after Weight Restoration

      Once malnutrition has been corrected and weight gain has begun, psychotherapy can help patients with anorexia nervosa understand 1) their experience of their illness; 2) cognitive distortions and how these have led to their symptomatic behavior; 3) developmental, familial, and cultural antecedents of their illness; 4) how their illness may have been a maladaptive attempt to regulate their emotions and cope; 5) how to avoid or minimize the risk of relapse; and 6) how to better cope with salient developmental and other important life issues in the future. Clinical experience shows that patients may often display improved mood, enhanced cognitive functioning, and clearer thought processes after there is significant improvement in nutritional intake, even before there is substantial weight gain [II].

      To help prevent patients from relapsing, emerging data support the use of cognitive-behavioral psychotherapy for adults [II]. Many clinicians also use interpersonal and/or psychodynamically oriented individual or group psychotherapy for adults after their weight has been restored [II]. For adolescents who have been ill <3 years, after weight has been restored, family therapy is a necessary component of treatment [I]. Although studies of different psychotherapies focus on these interventions as distinctly separate treatments, in practice there is frequent overlap of interventions [II].

      It is important for clinicians to pay attention to cultural attitudes, patient issues involving the gender of the therapist, and specific concerns about possible abuse, neglect, or other developmental traumas [II]. Clinicians need to attend to their countertransference reactions to patients with a chronic eating disorder, which often include beleaguerment, demoralization, and excessive need to change the patient [I]. At the same time, when treating patients with chronic illnesses, clinicians need to understand the longitudinal course of the disorder and that patients can recover even after many years of illness [I]. Because of anorexia nervosa's enduring nature, psychotherapeutic treatment is frequently required for at least 1 year and may take many years [I].

      Anorexics and Bulimics Anonymous and Overeaters Anonymous are not substitutes for professional treatment [I]. Programs that focus exclusively on abstaining from binge eating, purging, restrictive eating, or excessive exercising (e.g., 12-step programs) without attending to nutritional considerations or cognitive and behavioral deficits have not been studied and therefore cannot be recommended as the sole treatment for anorexia nervosa [I]. It is important for programs using 12-step models to be equipped to care for patients with the substantial psychiatric and general medical problems often associated with eating disorders [I].

      Although families and patients are increasingly accessing worthwhile, helpful information through online web sites, newsgroups, and chat rooms, the lack of professional supervision within these resources may sometimes lead to users' receiving misinformation or create unhealthy dynamics among users. It is recommended that clinicians inquire about a patient's or family's use of Internet-based support and other alternative and complementary approaches and be prepared to openly and sympathetically discuss the information and ideas gathered from these sources [I].

    1. Chronic Anorexia Nervosa

      Patients with chronic anorexia nervosa generally show a lack of substantial clinical response to formal psychotherapy. Nevertheless, many clinicians report seeing patients with chronic anorexia nervosa who, after many years of struggling with their disorder, experience substantial remission, so clinicians are justified in maintaining and extending some degree of hope to patients and families [II]. More extensive psychotherapeutic measures may be undertaken to engage and help motivate patients whose illness is resistant to treatment [II] or, failing that, as compassionate care [I]. For patients who have difficulty talking about their problems, clinicians have reported that a variety of nonverbal therapeutic methods, such as the creative arts, movement therapy programs, and occupational therapy, can be useful [III]. Psychosocial programs designed for patients with chronic eating disorders are being implemented at several treatment sites and may prove useful [II].

  1. Medications and Other Somatic Treatments
    1. Weight Restoration

      The decision about whether to use psychotropic medications and, if so, which medications to choose will be based on the patient's clinical presentation [I]. The limited empirical data on malnourished patients indicate that selective serotonin reuptake inhibitors (SSRIs) do not appear to confer advantage regarding weight gain in patients who are concurrently receiving inpatient treatment in an organized eating disorder program [I]. However, SSRIs in combination with psychotherapy are widely used in treating patients with anorexia nervosa. For example, these medications may be considered for those with persistent depressive, anxiety, or obsessive-compulsive symptoms and for bulimic symptoms in weight-restored patients [II]. A U.S. Food and Drug Administration (FDA) black box warning concerning the use of bupropion in patients with eating disorders has been issued because of the increased seizure risk in these patients. Adverse reactions to tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs) are more pronounced in malnourished individuals, and these medications should generally be avoided in this patient population [I]. Second-generation antipsychotics, particularly olanzapine, risperidone, and quetiapine, have been used in small series and individual cases for patients, but controlled studies of these medications are lacking. Clinical impressions suggest that they may be useful in patients with severe, unremitting resistance to gaining weight; severe obsessional thinking; and denial that assumes delusional proportions [III]. Small doses of older antipsychotics such as chlorpromazine may be helpful prior to meals in very disturbed patients [III]. Although the risks of extrapyramidal side effects are less with second-generation antipsychotics than with first-generation antipsychotics, debilitated anorexia nervosa patients may be at a higher risk for these than expected. Therefore, if these medications are used, it is recommended that patients be carefully monitored for extrapyramidal symptoms and akathisia [I]. It is also important to routinely monitor patients for potential side effects of these medications, which can result in insulin resistance, abnormal lipid metabolism, and prolongation of the QTc interval [I]. Because ziprasidone has not been studied in individuals with anorexia nervosa and can prolong QTc intervals, careful monitoring of serial electrocardiograms and serum potassium measurements is needed if anorexic patients are treated with ziprasidone [I]. Antianxiety agents used selectively before meals may be useful to reduce patients' anticipatory anxiety before eating [III], but because eating disorder patients may have a high propensity to become dependent on benzodiazepines, these medications should be used routinely only with considerable caution [I]. Pro-motility agents such as metoclopramide may be useful for bloating and abdominal pains that occur during refeeding in some patients [II]. Electroconvulsive therapy (ECT) has generally not been useful except in treating severe co-occurring disorders for which ECT is otherwise indicated [I].

      Although no specific hormone treatments or vitamin supplements have been shown to be helpful [I], supplemental calcium and vitamin D are often recommended [III]. Zinc supplements have been reported to foster weight gain in some patients, and patients may benefit from daily zinc-containing multivitamin tablets [II].

    1. Relapse Prevention

      Some data suggest that fluoxetine in dosages of up to 60 mg/day may help prevent relapse [II]. For patients receiving cognitive-behavioral therapy (CBT) after weight restoration, adding fluoxetine does not appear to confer additional benefits with respect to preventing relapse [II]. Antidepressants and other psychiatric medications may be used to treat specific, ongoing psychiatric symptoms of depressive, anxiety, obsessive-compulsive, and other comorbid disorders [I]. Clinicians should attend to the black box warnings in the package inserts relating to antidepressants and discuss the potential benefits and risks of antidepressant treatment with patients and families if such medications are to be prescribed [I].

    1. Chronic Anorexia Nervosa

      Although hormone replacement therapy (HRT) is frequently prescribed to improve bone mineral density in female patients, no good supporting evidence exists either in adults or in adolescents to demonstrate its efficacy [II]. Hormone therapy usually induces monthly menstrual bleeding, which may contribute to the patient's denial of the need to gain further weight [II]. Before estrogen is offered, it is recommended that efforts be made to increase weight and achieve resumption of normal menses [I]. There is no indication for the use of bisphosphonates such as alendronate in patients with anorexia nervosa [II]. Although there is no evidence that calcium or vitamin D supplementation reverses decreased bone mineral density, when calcium dietary intake is inadequate for growth and maintenance, calcium supplementation should be considered [I], and when the individual is not exposed to daily sunlight, vitamin D supplementation may be used [I]. However, large supplemental doses of vitamin D may be hazardous [I].

Treatment


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Self-Help Resources For Bulimia Nervosa


Improving Positive Behavior

Philosophers for the past 2,500 years have taught that it is very beneficial to start the day with goal-setting, and end the day with a brief review.

This habit of planning your day in the morning, and reviewing your day in the evening, is a time-proven technique for more successful living.

Note: When each of the following videos finishes; you must exit YouTube (by manually closing the window) in order to return to this webpage.



Morning Meditation (5-Minute Video)



Evening Meditation (5-Minute Video)



Life Satisfaction Scale (Video)



Healthy Social Behavior Scale (Video)



Mental Health Scale (Video)

Why We All Need to Practice Emotional First Aid



The Philosophy Of Stoicism (5 minute video)

Stoicism 101 (52 minute video)



The Roman emperor and Stoic philosopher Marcus Aurelius ruled from 161 to 180 A.D.

Inspirational Videos

  • His Holiness Pope Francis is one of the few world leaders that champions universal love, brotherhood, and peace (TED talk)

    Life Is About Interactions (His Holiness Pope Francis)

    Quite a few years of life have strengthened my conviction that each and everyone's existence is deeply tied to that of others: life is not time merely passing by, life is about interactions.

    As I meet, or lend an ear to those who are sick, to the migrants who face terrible hardships in search of a brighter future, to prison inmates who carry a hell of pain inside their hearts, and to those, many of them young, who cannot find a job, I often find myself wondering: "Why them and not me?" I, myself, was born in a family of migrants; my father, my grandparents, like many other Italians, left for Argentina and met the fate of those who are left with nothing. I could have very well ended up among today's "discarded" people. And that's why I always ask myself, deep in my heart: "Why them and not me?"

    First and foremost, I would love it if this meeting could help to remind us that we all need each other, none of us is an island, an autonomous and independent "I," separated from the other, and we can only build the future by standing together, including everyone. We don’t think about it often, but everything is connected, and we need to restore our connections to a healthy state. Even the harsh judgment I hold in my heart against my brother or my sister, the open wound that was never cured, the offense that was never forgiven, the rancor that is only going to hurt me, are all instances of a fight that I carry within me, a flare deep in my heart that needs to be extinguished before it goes up in flames, leaving only ashes behind.

    Many of us, nowadays, seem to believe that a happy future is something impossible to achieve. While such concerns must be taken very seriously, they are not invincible. They can be overcome when we don't lock our door to the outside world. Happiness can only be discovered as a gift of harmony between the whole and each single component. Even science – and you know it better than I do – points to an understanding of reality as a place where every element connects and interacts with everything else.

    Social Inclusion (Solidarity)

    And this brings me to my second message. How wonderful would it be if the growth of scientific and technological innovation would come along with more equality and social inclusion. How wonderful would it be, while we discover faraway planets, to rediscover the needs of the brothers and sisters orbiting around us. How wonderful would it be if solidarity, this beautiful and, at times, inconvenient word, were not simply reduced to social work, and became, instead, the default attitude in political, economic and scientific choices, as well as in the relationships among individuals, peoples and countries. Only by educating people to a true solidarity will we be able to overcome the "culture of waste," which doesn't concern only food and goods but, first and foremost, the people who are cast aside by our techno-economic systems which, without even realizing it, are now putting products at their core, instead of people.

    Solidarity is a term that many wish to erase from the dictionary. Solidarity, however, is not an automatic mechanism. It cannot be programmed or controlled. It is a free response born from the heart of each and everyone. Yes, a free response! When one realizes that life, even in the middle of so many contradictions, is a gift, that love is the source and the meaning of life, how can they withhold their urge to do good to another fellow being? In order to do good, we need memory, we need courage and we need creativity. Good intentions and conventional formulas, so often used to appease our conscience, are not enough. Let us help each other, all together, to remember that the other is not a statistic or a number. The other has a face. The "you" is always a real presence, a person to take care of.

    Compassion

    There is a parable Jesus told to help us understand the difference between those who'd rather not be bothered and those who take care of the other. I am sure you have heard it before. It is the Parable of the Good Samaritan. When Jesus was asked: "Who is my neighbor?" - namely, "Who should I take care of?" - he told this story, the story of a man who had been assaulted, robbed, beaten and abandoned along a dirt road. Upon seeing him, a priest and a Levite, two very influential people of the time, walked past him without stopping to help. After a while, a Samaritan, a very much despised ethnicity at the time, walked by. Seeing the injured man lying on the ground, he did not ignore him as if he weren't even there. Instead, he felt compassion for this man, which compelled him to act in a very concrete manner. He poured oil and wine on the wounds of the helpless man, brought him to a hostel and paid out of his pocket for him to be assisted.

    The story of the Good Samaritan is the story of today’s humanity. People's paths are riddled with suffering, as everything is centered around money, and things, instead of people. And often there is this habit, by people who call themselves "respectable," of not taking care of the others, thus leaving behind thousands of human beings, or entire populations, on the side of the road. Fortunately, there are also those who are creating a new world by taking care of the other, even out of their own pockets. Mother Teresa actually said: "One cannot love, unless it is at their own expense." We have so much to do, and we must do it together. But how can we do that with all the evil we breathe every day? Thank God, no system can nullify our desire to open up to the good, to compassion and to our capacity to react against evil, all of which stem from deep within our hearts. Now you might tell me, "Sure, these are beautiful words, but I am not the Good Samaritan, nor Mother Teresa of Calcutta." On the contrary: we are precious, each and every one of us. Each and every one of us is irreplaceable in the eyes of God. Through the darkness of today's conflicts, each and every one of us can become a bright candle, a reminder that light will overcome darkness, and never the other way around.

    Hope

    To Christians, the future does have a name, and its name is Hope. Feeling hopeful does not mean to be optimistically naïve and ignore the tragedy humanity is facing. Hope is the virtue of a heart that doesn't lock itself into darkness, that doesn't dwell on the past, does not simply get by in the present, but is able to see a tomorrow. Hope is the door that opens onto the future. Hope is a humble, hidden seed of life that, with time, will develop into a large tree. It is like some invisible yeast that allows the whole dough to grow, that brings flavor to all aspects of life. And it can do so much, because a tiny flicker of light that feeds on hope is enough to shatter the shield of darkness. A single individual is enough for hope to exist, and that individual can be you. And then there will be another "you," and another "you," and it turns into an "us." And so, does hope begin when we have an "us?" No. Hope began with one "you." When there is an "us," there begins a revolution.

    Tenderness

    The third message I would like to share today is, indeed, about revolution: the revolution of tenderness. And what is tenderness? It is the love that comes close and becomes real. It is a movement that starts from our heart and reaches the eyes, the ears and the hands. Tenderness means to use our eyes to see the other, our ears to hear the other, to listen to the children, the poor, those who are afraid of the future. To listen also to the silent cry of our common home, of our sick and polluted earth. Tenderness means to use our hands and our heart to comfort the other, to take care of those in need.

    Tenderness is the language of the young children, of those who need the other. A child’s love for mom and dad grows through their touch, their gaze, their voice, their tenderness. I like when I hear parents talk to their babies, adapting to the little child, sharing the same level of communication. This is tenderness: being on the same level as the other. God himself descended into Jesus to be on our level. This is the same path the Good Samaritan took. This is the path that Jesus himself took. He lowered himself, he lived his entire human existence practicing the real, concrete language of love. Yes, tenderness is the path of choice for the strongest, most courageous men and women. Tenderness is not weakness; it is fortitude. It is the path of solidarity, the path of humility. Please, allow me to say it loud and clear: the more powerful you are, the more your actions will have an impact on people, the more responsible you are to act humbly. If you don’t, your power will ruin you, and you will ruin the other. There is a saying in Argentina: "Power is like drinking gin on an empty stomach." You feel dizzy, you get drunk, you lose your balance, and you will end up hurting yourself and those around you, if you don’t connect your power with humility and tenderness. Through humility and concrete love, on the other hand, power – the highest, the strongest one – becomes a service, a force for good.

    The future of humankind isn't exclusively in the hands of politicians, of great leaders, of big companies. Yes, they do hold an enormous responsibility. But the future is, most of all, in the hands of those people who recognize the other as a "you" and themselves as part of an "us." We all need each other. And so, please, think of me as well with tenderness, so that I can fulfill the task I have been given for the good of the other, of each and every one, of all of you, of all of us.

  • The Surgeon General’s prescription of happiness (TEDMED talk)

    The Surgeon General’s prescription of happiness (Dr. Vivek Murthy)

    Disagreement With This Video (By Editor, Phillip W. Long MD)

    I have been trained in public health as well as psychiatry, and I strongly disagee with those in public health, like the U.S. Surgeon General, who fail to mention that our greatest public health emergency is climate change. I believe that it is absurd to suggest, as the U.S. Surgeon General has, that severe public health problems (like childhood poverty causing poor academic achievement) can be fixed by simply teaching students gratitude and meditation. The Surgeon General mentions that this approach was tried at San Francisco's Visitacion Valley Middle School, and it was a great success. This is incorrect. Currently, 80% of San Fransisco's middle schools academically perform better than this school. I invite you to watch this video by the Surgeon General, then compare it to the next video given by Dr. Courtney Howard.

    Happiness Increases Health

    If there was a factor in your life that could reduce your risk of having a heart attack or stroke, that could increase your chances of living longer, that would make your children less likely to engage in crime or use drugs, and that would even increase your success in losing weight, what would that factor be?

    It turns out, it would be happiness.

    By happiness, I don't mean the feeling that comes from indulgence or hedonism, I mean the long-term emotional well-being that comes from fulfillment, purpose, connectedness and love.

    Happiness affects us on a biological level. Happy people have lower levels of cortisol, a key stess hormone. They have more favorable heart rates and blood pressures. They have stronger immune systems, and they have lower levels of inflammatory markers, like c-reactive protein which has been linked to coronary heart disease.

    It turns out, even when you control for smoking, physical activity and other health behaviors, happy people live longer. There's something about happiness that seems to be protective.

    Now I want to be clear. White happiness is an important factor in improving health, it's certainly not the only one. We know that good nutrition, exercise, and sleep are essential tools for preventing illness. Whether we are living with depression or with diabetes, treatment is essential too. Yet among all these factors for improving health, happiness stands out as a largely untapped and unrecognized resource that has the potential to transform health for individuals and for communities...

    (As a physician) the most common condition I treated was unhappiness. It stems from isolation, from lack of meaning, and from a loss of self-worth... (People) are constantly surrounded by news stories and narratives that only remind them time and time again of all the things they have to be worried about. All this unhappiness is important because unhappiness is a risk factor for illness.

    You may ask yourself does happiness really lead to better health? Isn't it the other way around? Doesn't happiness result from good health and favourable circumstances? We may sometimes think, I'll be happy if only I lose 15 more pounds, or if I get a better job, or if I make just a little more money. But the truth is happiness if far more driven by how we process life events than by the events themselves.

    So if happiness is protective, the key question is, can we create it. The answer is yes, and the way we do that is surprisingly simple, and it largely costs nothing.

    Gratitude

    The research tells us that gratitude exercises, meditation, physical exercise, and social connectedness are just a few of the tools we can use to increase happiness. Take gratitude for example, one study participants and randomized them to three different groups. In one group, the gratitude group, participants were asked to write down five things they were grateful for. In the second group, the hassle group, the participants were asked to write down 5 things that hassled them. In the third group, they were asked to write down five things that happened without a positive or negative slant.

    Now at the end of ten weeks, it turns out the participants in the gratitude group experience a greater level of optimism, and they had a more positive view of their life. But they also exercise by 1.5 hours more on average per week. They also slept better, and they had fewer physical symptoms like pain, nausea, and headaches.

    The simple practice of gratitude had the power to increase their happiness and to change their health behavior and their health outcomes.

    Meditation

    Perhaps one of the most powerful examples of cultivating happiness comes from Visitacion Valley Middle School in San Francisco, California.

    Some years ago, Visitation was struggling. They were struggling with low test scores, with high suspension rates, and with so much community violence that they had to hire a full time grief counselor at the school. They tried all kinds of things to help. They started after-school programs, sports programs, peer counseling programs, but all without much luck.

    Then one day they decided to take a leap of faith. What if, they asked themselves, we use meditation as a tool to reduce stress and increase happiness for our students? So they created two 15-minute quiet time meditation sessions during each school day. They taught the teachers and the students how to meditate. They taught the administrators how to meditate as well.

    Within a year, something incredible happened. Suspension rates dropped by 45%. Teacher absenteeism dropped by 30%. Test scores and grade point averages rose markedly. The students reported they were less anxious and they were sleeping better.

    The self-reported happiness scores of the students went from one of the lower scores in San Francisco to the highest score in the entire district. As one student put it, "our school went from being a place of anger, sadness, and fear, to a place where we could be happy"....

    The Visitacion Valley Middle School model is being replicated at other schools now with comparable results. What is so striking about these tools for increasing happiness, meditation, gratitude, social connection, and exercise, is that they are simple and accessible.

    We have become accustomed to thinking that complex problems require complex solutions. But that's not always the case. Sometimes simple solutions can enable us to take on some of our most intractable problems. That's what happiness can do when it comes to health.

    Creating Happiness In The Lives Of Others

    If you think about it, all of us have the power to create happiness in our lives. But we also have the power to create happiness in the lives of others. If you need proof of this, I'd ask you to join me in a short exercise I learned from the legendary Mr. Rogers (host of a children's show).

    Close your eyes for 10 seconds with me and think about the people who have brought kindness, understanding, and joy into your life over the years - the people you remember that helped you to be happy. [audience pauses 10 seconds to do this]

    I remembered my wife Alice, my mother, my father, my sister. They have brought happiness, joy, and health into my life for so many years. Each of us has the power to touch other people's lives. Sometimes it's just a simple gesture or a kind word.

    Imagine if happiness and emotional well-being were prioritized in our schools as much as test scores and grades. Imagine if cultivating happiness was a priority in our workplaces. Imagine if our policymakers understood emotional well-being to be the fuel that enables us to be healthy, productive, and strong.

    So as we grapple with the challenges of how to create a healthier, stronger world, let us remember that happiness is a powerful tool for health. Let us remember that we can create happiness in our lives, and in the lives of the people around us. Let us call ourselves and each to action to ensure that emotional well-being is part of our policies, part of our institutions, and part of our way of life.

    If we do this, we will create a world that is full of joy, a world that is full of health, the world that our children deserve.

  • Healthy Planet, Healthy People: Dr. Courtney Howard (TED talk)

    This talk puts the previous talk by the U.S. Surgeon General to shame. Dr. Howard correctly states that our greatest public health emergency is climate change. If our environment collapses, and we start to starve, teaching people to count their blessings and to meditate will do little. Dr. Howard lists the many things we can do to decrease climate change. (However, we don't know if it is already too late, but at least we can try. P.S. In April 2018, Cape Town South Africa will run out of water and its citizens may thus be forced to leave. For years, there has been a devastating drought in all of East Africa, most of the Middle East, and from there over to Vietnam. This drought has decimated food production - now many of these nations are on the verge of starvation. All of this is the result of climate change.)

  • What the 1% Don't Want You to Know (Moyers & Company)

    Our society is becoming uglier: increased homelessness, increased poverty, increased drug addiction, deterioration of public education, increased political polarization, and increased income inequality. This video explains how much of this societal ugliness can be traced back to the rapidly increasing concentration of wealth in the hands of a very few, extremely rich oligarchs. This interview is with the economist Paul Krugman, who won the Nobel Prize for Economics. (The fabulously rich oil- and coal-barons are denying climate change and are actively opposing restrictions on the burning of fossil fuels.)

  • Maybe we're dark: Andrew Brash (TEDx talk)

    Ambition can put the blinders on people, and drive us to sacrifice caring for others. Climber, teacher, and author Andrew Brash tells how he gave up his summit of Everest to save another climber's life. Looking back on this, Andrew now realizes the human cost of overarching ambition.

  • Medical miracle on Everest (TED talk)

    What makes this story so inspirational is that it is a story of heroism and self-sacrifice. How one climber could have survived, but instead died while trying to help his friend. How another climber knew that he was freezing to death, but chose to spend his final moments phoning his pregnant wife to say goodbye. How two climbers who were already in safety chose to climb back up Everest to rescue others. How one climber who was left for dead spent 36 hours covered by snow, then decided that he would not die this way, and actually made it down Everest to safety. This story illustrates just how noble people can be when they face death.

  • What keeps us happy and healthy as we go through life? (TED talk)

  • Fulfilling trauma's hidden promise (TEDMED talk)

  • What makes life worth living in the face of death (TEDMED talk)

  • Secrets of Centenarians (NHK Documentary)

    This documentary reports the findings of a scientific study on the factors that allow people to live past 100.

  • 10 ways to have a better conversation (TED talk)

    Ten ways to have a better conversation (Celeste Headlee)

    We've all had really great conversations. We've had them before. We know what it's like. The kind of conversation where you walk away feeling engaged and inspired, or where you feel like you've made a real connection or you've been perfectly understood. There is no reason why most of your interactions can't be like that.

    So I have 10 basic rules. I'm going to walk you through all of them, but honestly, if you just choose one of them and master it, you'll already enjoy better conversations.

    Number one: Don't multitask.

    And I don't mean just set down your cell phone or your tablet or your car keys or whatever is in your hand. I mean, be present. Be in that moment. Don't think about your argument you had with your boss. Don't think about what you're going to have for dinner. If you want to get out of the conversation, get out of the conversation, but don't be half in it and half out of it.

    Number two: Don't pontificate.

    If you want to state your opinion without any opportunity for response or argument or pushback or growth, write a blog.

    Now, there's a really good reason why I don't allow pundits on my show: Because they're really boring. If they're conservative, they're going to hate Obama and food stamps and abortion. If they're liberal, they're going to hate big banks and oil corporations and Dick Cheney. Totally predictable. And you don't want to be like that.

    You need to enter every conversation assuming that you have something to learn. The famed therapist M. Scott Peck said that true listening requires a setting aside of oneself. And sometimes that means setting aside your personal opinion. He said that sensing this acceptance, the speaker will become less and less vulnerable and more and more likely to open up the inner recesses of his or her mind to the listener. Again, assume that you have something to learn.

    Bill Nye: "Everyone you will ever meet knows something that you don't." I put it this way: Everybody is an expert in something.

    Number three: Use open-ended questions.

    In this case, take a cue from journalists. Start your questions with who, what, when, where, why or how. If you put in a complicated question, you're going to get a simple answer out. If I ask you, "Were you terrified?" you're going to respond to the most powerful word in that sentence, which is "terrified," and the answer is "Yes, I was" or "No, I wasn't." "Were you angry?" "Yes, I was very angry." Let them describe it. They're the ones that know. Try asking them things like, "What was that like?" "How did that feel?" Because then they might have to stop for a moment and think about it, and you're going to get a much more interesting response.

    Number four: Go with the flow.

    That means thoughts will come into your mind and you need to let them go out of your mind. We've heard interviews often in which a guest is talking for several minutes and then the host comes back in and asks a question which seems like it comes out of nowhere, or it's already been answered. That means the host probably stopped listening two minutes ago because he thought of this really clever question, and he was just bound and determined to say that. And we do the exact same thing. We're sitting there having a conversation with someone, and then we remember that time that we met Hugh Jackman in a coffee shop.

    And we stop listening. Stories and ideas are going to come to you. You need to let them come and let them go.

    Number five: If you don't know, say that you don't know.

    Now, people on the radio, especially on NPR, are much more aware that they're going on the record, and so they're more careful about what they claim to be an expert in and what they claim to know for sure. Do that. Err on the side of caution. Talk should not be cheap.

    Number six: Don't equate your experience with theirs.

    If they're talking about having lost a family member, don't start talking about the time you lost a family member. If they're talking about the trouble they're having at work, don't tell them about how much you hate your job. It's not the same. It is never the same. All experiences are individual. And, more importantly, it is not about you. You don't need to take that moment to prove how amazing you are or how much you've suffered. Somebody asked Stephen Hawking once what his IQ was, and he said, "I have no idea. People who brag about their IQs are losers."

    Conversations are not a promotional opportunity.

    Number seven: Try not to repeat yourself.

    It's condescending, and it's really boring, and we tend to do it a lot. Especially in work conversations or in conversations with our kids, we have a point to make, so we just keep rephrasing it over and over. Don't do that.

    Number eight: Stay out of the weeds.

    Frankly, people don't care about the years, the names, the dates, all those details that you're struggling to come up with in your mind. They don't care. What they care about is you. They care about what you're like, what you have in common. So forget the details. Leave them out.

    Number nine: Listen.

    I cannot tell you how many really important people have said that listening is perhaps the most, the number one most important skill that you could develop. Buddha said, and I'm paraphrasing, "If your mouth is open, you're not learning." And Calvin Coolidge said, "No man ever listened his way out of a job."

    Why do we not listen to each other? Number one, we'd rather talk. When I'm talking, I'm in control. I don't have to hear anything I'm not interested in. I'm the center of attention. I can bolster my own identity. But there's another reason: We get distracted. The average person talks at about 225 word per minute, but we can listen at up to 500 words per minute. So our minds are filling in those other 275 words. And look, I know, it takes effort and energy to actually pay attention to someone, but if you can't do that, you're not in a conversation. You're just two people shouting out barely related sentences in the same place.

    You have to listen to one another. Stephen Covey said it very beautifully. He said, "Most of us don't listen with the intent to understand. We listen with the intent to reply."

    Number 10: Be brief.

    "A good conversation is like a miniskirt; short enough to retain interest, but long enough to cover the subject." -- My Sister

    All of this boils down to the same basic concept, and it is this one: Be interested in other people.

  • An Example Of Mindfulness Meditation (10 minute video)

    In the 5th century BCE, Buddha spent 6 years of his life mastering mindfulness meditation. He then decided to look beyond meditation. Buddha concluded that simply emptying the mind of thought is calming, but otherwise it accomplishes little - since "You return to the same world". Instead, Buddha taught that we should change our world by seeking enlightenment through practicing compassion, and living a calm, peaceful, happy life.

  • 100 People: A World Portrait (TEDMED talk)

  • Mindfulness Training: A simple way to break a bad habit (TEDMED talk)

  • If we can’t cure the patient, can the community do it? (TEDMED talk)

  • What if "it's the environment, stupid"? (TEDMED talk)

Physical Exercise: Vital For Self-Help




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  • The best summary on bad research is given by Laura Arnold in this TEDx lecture. If you read nothing else about research, you owe it to yourself to watch this short video - it is excellent!

  • The power of asking "what if?"

  • The active placebo effect: 2300 years ago, the Greek Stoic philosophers taught that it is not the objective event, but our subjective judgment about the event, that determines our behavior. The active placebo effect bears witness to this ancient wisdom.

  • Criteria For High Quality Research Studies

  • It is troubling that a recent study found that two-thirds of important psychological research studies couldn't be replicated. High quality research must meet the following criteria:

    • Randomized Controlled Trial:
      Ask: Was the trial randomized? Was the randomization procedure described and was it appropriate? The best research design is to have research subjects randomly assigned to an experimental or control group. It is essential that confounding factors be controlled for by having a control group or comparator condition (no intervention, placebo, care as usual etc.).

    • Representative Sample:
      Ask: Do the research subjects represent a normal cross-section of the population being studied? Many psychological research studies using university students are flawed because their subjects are not representative of the normal population since they are all W.E.I.R.D. (White, Educated, Intelligent, Rich, and living in a Democracy).

    • Single Blind Trial:
      Ask: Was the treatment allocation concealed? It is essential that the research subjects are kept "blind" as to whether they are in the experimental or control group (in order to control for any placebo effects).

    • Double Blind Trial (Better Than Single Blind Trial):
      Ask: Were blind outcome assessments conducted? In a double blind study, neither the research subjects nor the outcome assessors know if the research subject is in the experimental or control group. This controls for both the placebo effect and assessor bias.

    • Baseline Comparability:
      Ask: Were groups similar at baseline on prognostic indicators? The experimental and control groups must be shown to be comparable at the beginning of the study.

    • Confounding Factors:
      Ask: Were there factors, that weren't controlled for, that could have seriously distorted the study's results? For example, research studies on the effectiveness of mindfulness cognitive therapy in preventing depressive relapse forgot to control for whether the research subjects were also simultaneously receiving antidepressant medication or other psychological treatments for depression.

    • Intervention Integrity:
      Ask: Was the research study protocal strictly followed? The research subjects must be shown to be compliant (e.g., taking their pills, attending therapy) and the therapists must be shown to be reliably delivering the intervention (e.g., staying on the research protocol).

    • Statistical analysis:
      Ask: Was a statistical power calculation described? The study should discuss its statistical power analysis; that is whether the study size is large enough to statistically detect a difference between the experimental and control group (should it occur) and usually this requires at least 50 research subjects in the study.

      Ask: Are the results both statistically significant and clinically significant? The results should be both statistically significant (with a p-value <0.05) and clinically significant using some measure of Effect Size such as Standardized Mean Difference (e.g., Cohen's d >= 0.33). The summary statistics should report what percentage of the total variance of the dependent variable (e.g., outcome) can be explained by the independent variable (e.g., intervention). In clinical studies, the study should report the number needed to treat for an additional beneficial outcome (NNTB), and the number needed to treat for an additional harmful outcome (NNTH).

        Number Needed To Benefit (NNTB): This is defined as the number of patients that need to be treated for one of them to benefit compared with a control in a clinical trial. (It is defined as the inverse of the absolute risk reduction.) Note: Statistically, the NNTB depends on which control group is used for comparison - e.g., active treatment vs. placebo treatment, or active treatment vs. no treatment.

        Number Needed To Harm (NNTH): This is defined as the number of patients that need to be treated for one of them to be harmed compared with a control in a clinical trial. (It is defined as the inverse of the absolute increase in risk of harm.)

        Tomlinson found “an NNTB of 5 or less was probably associated with a meaningful health benefit,” while “an NNTB of 15 or more was quite certain to be associated with at most a small net health benefit.”

      Ask: Does the researcher accept full responsibility for the study's statistical analysis? The researcher should not just hand over the study's raw data to a corporation (that may have $1,000 million invested in the study) to do the statistical analysis.

    • Completeness of follow-up data:
      Ask: Was the number of withdrawals or dropouts in each group mentioned, and were reasons given for these withdrawals or dropouts? Less than 20% of the research subjects should drop out of the study. The intervention effect should persist over an adequate length of time.

    • Handling of missing data:
      Ask: Was the statistical analysis conducted on the intention-to-treat sample? There must be use of intention-to-treat analysis (as opposed to a completers-only analysis). In this way, all of the research subjects that started the study are included in the final statistical analysis. A completers-only analysis would disregard those research subjects that dropped out.

    • Replication of Findings:
      Ask: Can other researchers replicate this study's results? The research study's methodology should be clearly described so that the study can be easily replicated. The researcher's raw data should be available to other researchers to review (in order to detect errors or fraud).

    • Fraud:
      Ask: Is there a suspicion of fraud? In a research study, examine the independent and dependent variables that are always measured as a positive whole number (e.g., a variable measured on a 5-point Likert-type scale ranging from "1 = definitely false to 5 = definitely true" etc.). For each of these variables, look at their sample size (n), mean (M) and standard deviation (SD) before they undergo statistical analysis. There is a high suspicion of fraud in a study's statistics:

      • If the M is mathematically impossible (online calculator): This is one of the easiest ways to mathematically detect fraud. The mean (M) is defined as "the sum (Sum) of the values of each observation divided by the total number (n) of observations". So: M = Sum/n. Thus: (Sum) = (M) multiplied by (n). We know that, if a variable is always measured as a positive whole number, the sum of these observations always has to be a whole number. For these variables to test for fraud: calculate (M) multiplied by (n). This calculates the Sum which MUST be a positive whole number. If the calculated Sum isn't a positive whole number; the reported mean (M) is mathematically impossible - thus the researcher either cooked the data or made a mistake. A recent study of 260 research papers published in highly reputable psychological journals found that 1 in 2 of these research papers reported at least one impossible value, and 1 in 5 of these research papers reported multiple impossible values. When the authors of the 21 worst offending research papers were asked for their raw data (so that its reliability could be checked) - 57% angrily refused. Yet such release of raw data to other researchers is required by most scientific journals. (Here is an example of a research paper filled with mathematically impossible means.)

      • If the SD is mathematically impossible (online calculator): When researchers fraudulently "cook" their data, they may accidently give their data a mean and standard deviation that is mathematically impossible for a (normally distributed) strictly positive variable (because the "cooked" M and SD would mathematically require the strictly positive variable's range of data to include negative numbers). For a normally distributed sample of size of 25-70, this occurs when the SD is greater than one-half of the M; for a sample size of 70+, this occurs when the SD is greater than one-third of the M [using these formulas].

      • If the SD/M is very small (i.e., the variable's standard deviation is very small compared to the mean suggesting data smoothing).

      • If the SD's are almost identical (i.e., the variables have different means but almost identical standard deviations).

      • If the 4th digit of the values of the variables aren't uniformly distributed - since each should occur 10% of the time (Benford's Law).

      • If the researcher is legally prevented from publishing negative findings about a drug or therapy because that would violate the "nondisclosure of trade secrets" clause in the research contract (i.e., it is a "trade secret" that the drug or therapy is ineffective - hence this can not be "disclosed"). Approximately half of all registered clinical trials fail to publish their results.

      • If the researcher refuses to release his raw data to fellow researchers (so that they can check its validity). In order to be published in most scientific journals, a researcher must promise to share his raw data with fellow researchers. Thus a researcher's refusal to do so is almost a sure indicator of fraud.

      • If the research study's data contradicts the study's own conclusions - surprisingly, this often occurs.

  • Calling Bullshit In The Age of Big Data - "Bullshit is language, statistical figures, data graphics, and other forms of presentation intended to persuade by impressing and overwhelming a reader or listener, with a blatant disregard for truth and logical coherence." Reading the syllabus of this university course should be required reading for every student of mental health. This syllabus is absolutely fantastic!

  • Statistical Methods in Psychology Journals: Guidelines and Explanations - American Psychologist 1999

  • Not All Scientific Studies Are Created Equal - video

  • The efficacy of psychological, educational, and behavioral treatment

  • Estimating the reproducibility of psychological science

  • Psychologists grapple with validity of research

  • Industry sponsorship and research outcome (Review) - Cochrane Library

  • 'We've been deceived': Many clinical trial results are never published - (text and video)

  • Junk science misleading doctors and researchers

  • Junk science under spotlight after controversial firm buys Canadian journals

  • Medicine with a side of mysticism: Top hospitals promote unproven therapies - Are some doctors becoming modern witchdoctors?

  • When Evidence Says No, But Doctors Say Yes


Research Topics

Anorexia Nervosa - Latest Research (2016-2017)

Cochrane Review (The best evidence-based, standardized reviews available)

Some evidence of effectiveness:
  • Family therapy for those diagnosed with anorexia nervosa (2010) (Although there are a number of different forms of family therapy, the current review of 13 trials indicated that the therapy most often tested in trials is family based therapy. The trials included in the review had limitations in the reporting of trial conduct and meaningful outcomes. Overall there was some evidence to suggest family therapy may be effective compared to treatment as usual. However, there is not enough evidence to determine whether family therapy is effective compared to other psychological interventions for rates of remission. There were no differences in relapse rates, symptom scores, weight measures, or the number of drop outs between those treated with family therapy versus any other comparison group. Mortality was not measured or reported sufficiently to determine whether it is reduced for those treated with family therapy compared to other interventions. There were very little data about general or family functioning.)
No evidence of effectiveness:
  • Antidepressants for anorexia nervosa (2009) (The aim of the present review was to evaluate the evidence from randomised controlled trials for the efficacy and acceptability of antidepressant treatment in acute AN. Seven small studies were identified; four placebo-controlled trials did not find evidence of efficacy of antidepressants in improving weight gain, eating disorder or associated symptoms, as well as differences in completion rates. Meta-analysis of data was not possible for most outcomes. However, major methodological limitations of these studies (e.g. insufficient power to detect differences) prevent from drawing definite conclusions or recommendations for antidepressant use in acute AN. )
Not yet possible to draw any definite conclusions due to insufficient evidence:
  • Outpatient psychotherapy for anorexic adults (2009) (This review aimed to assess evidence about the effects of outpatient psychotherapy on older adolescents and adults with anorexia nervosa. Although anorexia nervosa is a severe and disabling disorder, only seven trials were found. The trials used different types of psychotherapy. It was not possible to make firm conclusions about the therapies tested. Participants who did not receive psychotherapy (e.g. were in a waiting-list control group or who got 'treatment as usual') did poorly. In one study, all those in the control group who got only 'dietary advice' dropped out. There is an urgent need for multi-centre, large randomized controlled trials of commonly used psychotherapies in older adolescents and adults with anorexia nervosa.)

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