Psychological

and Physiological

Trauma Research

Seize Your Journeys

_______________________

Traumatic stress is found in many competent, healthy, strong, good people.  No one can completely protect themselves from traumatic experiences.  Many people have long-lasting problems following exposure to trauma.  Up to 8% of persons will have PTSD at some time in their lives. People who react to traumas are not going crazy.  What is happening to them is part of a set of common symptoms and problems that are connected with being in a traumatic situation, and thus, is a normal reaction to abnormal events and experiences.  Having symptoms after a traumatic event is NOT a sign of personal weakness.  Given exposure to a trauma that is bad enough, probably all people would develop PTSD.

By understanding trauma symptoms better, a person can become less fearful of them and better able to manage them. By recognizing the effects of trauma and knowing more about symptoms, a person will be better able to decide about getting treatment.

_______________________

Secure Attachments as a Defense Against Trauma

 “All people mature and thrive in a social context that has profound effects on how they cope with life’s stresses.  Particularly early in life, the social context plays a critical role in fuffering an individual against stressful situations, and in building the psychological and biological capacities to deal with further stresses.  The primary function of parents can be thought of as helping children modulate their arousal by attuned and well-timed provision of playing, feeding, comforting, touching, looking, cleaning, and resting—in short, by teaching them skills that will gradually help them modulate their own arousal.  Secure attachment bonds serve as primary defenses against trauma-induced psychopathology in both children and adults (Finkelhor & Browne, 1984).  In children who have been exposed to severe stressors, the quality of the parental bond is probably the single most important determinant of long-term damage (McFarlane, 1988).”  van der Kolk, Bessel, Alexander C. McFarlane, and Lars Weisaeth, eds.  1996. Traumatic stress: The effects of overwhelming experience on mind, body, and society.  New York and London: Guilford Press. .p. 185

Eating Disorders

 “The Eating Disorders are characterized by severe disturbances in eating behavior.  This section includes two specific diagnoses, Anorexia Nervosa and Bulimia Nervosa.  Anorexia Nervosa is characterized by a refusal to maintain a minimally normal body weight.  Bulimia Nervosa is characterized by repeated episodes of binge eating followed by inappropriate compensatory behaviors such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.  A disturbance in perception of body shape and weight is an essential feature of both Anorexia Nervosa and Bulimia Nervosa.  An Eating Disorder Not Otherwise Specified category is also provided for coding behaviors that do not meet criteria for a specific Eating Disorder.

          Simple obesity is include in the International Classification of Diseases (ICD) as a general medical condition but does not appear in DSM-IV because it has not been established that it is consistently associated with a psychological or behavioral syndrome.  However, when there is evidence that psychological factors are of importance in the etiology or course of a particular case of obesity, this can be indicated by noting the presence of Psychological Factors Affecting Medical Condition.

          Disorders of Feeding and Eating that are usually first diagnosed in infancy or early childhood (i.e., Pica, Rumination Disorder, and Feeding Disorder of Infancy or Early Childhood) are included in the section “Feeding and Eating Disorders of Infancy or Early Childhood.

 Anorexia Nervosa

 Diagnostic Features

The essential features of Anorexia Nervosa are that the individual refuses to maintain a minimally normal body weight, is intensely afraid of gaining weight, and exhibits a significant disturbance in the perception of the shape or size of his or her body.  In addition, postmenarcheal females with this disorder are amenorrheic.  (The term anorexia is a misnomer because loss of appetite is rare.)

          The individual maintains a body weight that is below a minimally normal level for age and height (Criterion A).  When Anorexia Nervosa develops in an individual during childhood or early adolescence, there may be failure to make expected weight gains (i.e., while growing in height) instead of weight loss.

Criterion A provides a guideline for determining when the individual meets the threshold for being underweight.  It suggests that the individual weigh less than 85% of that weight that is considered normal for that person’s age and height (usually computed using one of several published versions of the Metropolitan Life Insurance tables or pediatric growth charts.).  An alternative and somewhat stricter guideline (used in the ICD-10 Diagnostic Criteria for research) requires that the individual have a body mass index (BMI) (calculated as weight in kilograms/height in meters2) equal to or below 17.5kg/m2.  These cutoffs are provided only as suggested guidelines for eh clinician, since it is unreasonable to specify a single standard for minimally normal weight that applies to all individuals of a given age and height.  In determining a minimally normal weight, the clinician should consider not only such guidelines but also the individual’s body build and weight history.

Usually weight loss is accomplished primarily through reduction in total food intake.  Although individuals may begin by excluding from their diet what they perceive to be highly caloric foods, most eventually end up with a very restricted diet that is sometimes limited to only a few foods.  Additional methods of weight loss include purging (i.e., self-induced vomiting or the misuse of laxative or diuretics) and increased or excessive exercise.)

Individuals with this disorder intensely fear gaining weight or becoming fat (Criterion B).  This intense fear of becoming fat is usually not alleviated by the weight loss.  In fact, concern about weight gain often increases even as actual weight continues to decrease.

The experience and significance of body weight and shape are distorted in these individuals (Criterion C).  Some individuals feel globally overweight.  Others realize that they are thin but are still concerned that certain parts of their bodies, particularly the abdomen, buttocks, and thighs are “to fat.”  They may employ a wide variety of techniques to estimate their body size and weight, including excessive weighing, obsessive measuring of body parts, and persistently using a mirror to check for perceived areas of “fat.”  The self-esteem of individuals with Anorexia Nervosa is highly dependent on their body shape and weight.  Weight loss is viewed as an impressive achievement and a sign of extraordinary self-discipline, whereas weight gain is perceived as an unacceptable failure of self-control.  Though some individuals with this disorder may acknowledge being thin, they typically deny the serious medical implications of their malnourished state.

In postmenarcheal females, amenorrhea (due to abnormally low levels of estrogen secretion that are due in turn to diminished pituitary secretion of follicle-stimulating hormone [PSH] and luteinizing hormone [LH]) is an indicator of physiological dysfunction in Anorexia Nervosa (Criterion D.)  Amenorrhea is usually a consequence of the weight loss but, in a minority of individuals, may actually precede it.  In prepubertal females, menarche may be delayed by the illness.

The individual is often brought to professional attention by family members after marked weight loss (or failure to make expected weight gains) has occurred.  If individuals seek help on their own, it is usually because of their subjective distress over the somatic and psychological sequelae of starvation.  It is rare for an individual with Anorexia Nervosa to complain of weight loss per se.  Individuals with Anorexia Nervosa frequently lack insight into, or have considerable denial of, the problem and may be unreliable historians.  It is therefore often necessary to obtain information form parents or other outside sources to evaluate the degree of weight loss and other features of the illness.”  p. 583-584.

 Bulimia Nervosa

 “Diagnostic Features

          The essential features of Bulimia Nervosa are binge eating and inappropriate compensatory methods to prevent weight gain.  In addition, the self-evaluation of individuals with Bulimia Nervosa is excessively influenced by body shape and weight.  To qualify for the diagnosis, the binge eating and the inappropriate compensatory behaviors must occur, on average, at least twice a week for 3 months (Criterion C.)

          A binge is defined as eating in a discrete period of time an amount of food that is definitely larger than most individuals would eat under similar circumstances (Criterion A1.).  The clinician should consider the context in which the eating occurred—what would be regarded as excessive consumption at a typical meal might be considered normal during a celebration or holiday meal.  A “discrete period of time” refers to a limited period, usually less than 2 hours.  A single episode of binge eating need not be restricted to one setting.  For example, an individual may begin a binge in a restaurant and then continue it on returning home.  Continual snacking on small amounts of food throughout the day would not be considered a binge.

          Although the type of food consumed during the binge varies, it typically includes sweet, high-calorie foods such as ice cream or cake.  However, binge eating appears to be characterized more by an abnormality in the amount of food consumed than by a craving for a specific nutrient, such as carbohydrate.  Although individuals with Bulimia Nervosa consume more calories during an episode of binge eating than persons without Bulimia Nervosa consume during a meal, the fractions of calories derived from protein, fat, and carbohydrate are similar.

          Individuals with Bulimia Nervosa are typically ashamed of their eating problems and attempt to conceal their symptoms.  Binge eating usually occurs in secrecy, or as inconspicuously as possible.  An episode may or may not be planned in advance and is usually (but not always) characterized by rapid consumption.  The binge eating often continues until the individual is uncomfortably, or even painfully, full.  Binge eating is typically triggered by dysphoric mood states, interpersonal stressors intense hunger following dietary restraint, or feelings related to body weight, body shape, and food.  Binge eating may transiently reduce dysphoria, but disparaging self-criticism and depressed mood often follow.

          An episode of binge eating is also accompanied by a sense of lack of control (Criterion A2).  An individual may be in a frenzied state while binge eating, especially early in the course of the disorder.  Some individuals describe a dissociative quality during, or following, the binge episodes.  After Bulimia Nervosa has persisted for some time, individuals may report that their binge-eating episodes are no longer characterized by an acute feeling of loss of control, but rather by behavioral indicators of impaired control, such as difficulty resisting binge eating or difficulty stopping a binge once it has begun.  The impairment in control associated with binge eating in bulimia Nervosa is not absolute; for example, an individual may continue binge eating while the telephone is ringing, but will cease if a roommate or spouse unexpectedly enters the room.

          Another essential feature of Bulimia Nervosa is the recurrent use of inappropriate compensatory behaviors to prevent weight gain (Criterion B).  Many individuals with Bulimia Nervosa employ several methods in their attempt to compensate for binge eating.  The most common compensatory technique is the induction of vomiting after an episode of binge eating.  This method of purging is employed by 80%-90% of individuals with Bulimia Nervosa who present for treatment of eating disorders clinics.  The immediate effects of vomiting include relief from physical discomfort and reduction of fear of gaining weight.  In some cases, vomiting becomes a goal in itself, and the person will binge in order to vomit or will vomit after eating a small amount of food.  Individuals with Bulimia Nervosa may use a variety of methods to induce vomiting, including the use of fingers or instruments to stimulate the gag reflex.  Individuals generally become adept at inducing vomiting and are eventually able to vomit at will.  Rarely, individuals consume syrup of ipecac to induce vomiting.  Other purging behaviors include the issue of laxatives and diuretics.  Approximately one-third of those with Bulimia Nervosa misuse laxatives after binge eating.  Rarely, individuals with the disorder will misuse enemas following episodes of binge eating, but this is seldom the sole compensatory method employed.

          Individuals with Bulimia Nervosa may fast for a day or more or exercise excessively in an attempt to compensate for binge eating.  Exercise may be considered to be excessive when it significantly interferes with important activities, when it occurs at inappropriate times or in inappropriate settings, or when the individual continues to exercise despite injury or other medical complications.  Rarely, individuals with this disorder may take thyroid hormone in an attempt to avoid weight gain.  Individuals with diabetes mellitus and Bulimia Nervosa may omit or reduce insulin doses in order to reduce the metabolism of food consumed during eating binges.

          Individuals with Bulimia Nervosa place an excessive emphasis on body shape and weight in their self-evaluation, and these factors are typically the most important ones in determining self-esteem (Criterion D).  Individuals with this disorder may closely resemble those with Anorexia Nervosa in their fear of gaining weight, in their desire to lose weight, and in the level of dissatisfaction with their bodies.  However, a diagnosis of Bulimia Nervosa should not be given when the disturbance occurs only during episodes of Anorexia Nervosa (Criterion E).”  p. 589-591

Diagnostic and statistical manual of mental disorders. 2000. 4^th ed. Washington, D.C.: American Psychiatric Association.