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Discussion: The Complexity of Eating Disorder Recovery in the Digital Age

Discussion: The Complexity of Eating Disorder Recovery in the Digital AgeDiscussion: The Complexity of Eating Disorder Recovery in the Digital AgeThrough this week’s Learning Resources, you become aware not only of the prevalence of factors involved in the treatment of eating disorders, but also the societal, medical, and cultural influences that help individuals develop and sustain the unhealthy behaviors related to an eating disorder. These behaviors have drastic impacts on health. In clinical practice, social workers need to know about the resources available to clients living with an eating disorder and be comfortable developing interdisciplinary, individualized treatment plans for recovery that incorporate medical and other specialists.Discussion: The Complexity of Eating Disorder Recovery in the Digital AgeFor this Discussion, you focus on guiding clients through treatment and recovery.To prepare:Review the Learning Resources on experiences of living with an eating disorder, as well as social and cultural influences on the disorder.Read the case provided by your instructor for this week’s Discussion.By Day 3Post a 300- to 500-word response in which you address the following:ORDER A PLAGIARISM-FREE PAPER HEREProvide the full DSM-5 diagnosis for the client. Remember, a full diagnosis should include the name of the disorder, ICD-10-CM code, specifiers, severity, and the Z codes (other conditions that may be a focus of clinical attention). Keep in mind a diagnosis covers the most recent 12 months.Explain the diagnosis by matching the symptoms identified in the case to the specific criteria for the diagnosis.Explain why it is important to use an interprofessional approach in treatment. Identity specific professionals you would recommend for the team, and describe how you might best utilize or focus their services.Explain how you would use the client’s family to support recovery. Include specific behavioral examples.Select and explain an evidence-based, focused treatment approach that you might use in your part of the overall treatment plan.Discussion: The Complexity of Eating Disorder Recovery in the Digital AgeExplain how culture and diversity influence these disorders. Consider how gender, age, socioeconomic status, sexual orientation, and/or ethnicity/race affect the experience of living with an eating disorder.Note: You do not need to include an APA reference to the DSM-5 in your response. However, your response should clearly be informed by the DSM-5, demonstrating an understanding of the risks and benefits of treatment to the client. You do need to include an APA reference for the treatment approach and any other resources you use to support your response.The Case of ShannelIntake Date: August 2021DEMOGRAPHIC DATA: This was a voluntary intake for this 28-year-old single African American female. Shannel lives with a 24-year-old female roommate in New York City. She has a bachelor’s degree in Art History and is employed by a major New York museum. Shannel was born and raised in Virginia and moved to New York 4 years ago for employment.Discussion: The Complexity of Eating Disorder Recovery in the Digital AgeCHIEF COMPLAINT: “My roommate suggested I go to therapy. I do not agree. I can handle my life, but she threatened to move out and I cannot afford the apartment by myself.” HISTORY OF PRESENT ILLNESS: Shannel admitted to purging and frequent use of laxatives to try and keep her weight down. Shannel reported her weight was being monitored by a nutritionist and she had lab work done to be sure she remained healthy. Shannel reports that she was much heavier as a teenager and wants to confirm she doesn’t get like that again. Shannel reported that she has a very stressful job. She stated that approximately one month ago she started to have difficulty concentrating at work. She had several altercations with coworkers as well. Several weeks ago Shannel reported that a coworker “said something nasty and I lost it.” Shannel reported that she was angry and “hit everything I knew I could—but that did not help.” Shannel also reported being under stress due to applying for her master’s degree in art history and difficulties with her boyfriend. Shannel complained of depression with insomnia and sleeping only a few hours per night, feeling confused, decreased concentration, irritability, anger, and frustration. She admitted to suicidal ideation. She complained of feeling paranoid over the past few weeks and believed the police were after her and that she heard them outside her door. This was another reason her roommate wanted her to seek treatment. Shannel reported she was emotionally abused as a child and suffered from post-traumatic stress disorder, but she denied a history of flashbacks or nightmares or any avoidance of the person who she says emotionally abused her..Shannel noted that at times over the past year she has very strange experiences of being overwhelmed with fear. At these times she begins sweating, has chest pains and chills, and thinks she is going crazy. It concerns her terribly that these may happen at inappropriate times. Reluctantly, Shannel admitted to bingeing several times per month since she was 17-years-old.Discussion: The Complexity of Eating Disorder Recovery in the Digital AgePAST PSYCHIATRIC HISTORY: Shannel denies any history of psychiatric problems in the past. Shannel admits to using alcohol periodically but rarely to excess. MEDICAL HISTORY: Shannel is allergic to penicillin and has a lactose intolerance. She wears glasses for reading. PSYCHOSOCIAL AND DEVELOPMENTAL HISTORY: Shannel’s parents were married when her mother was 19-years-old, and Shannel was born the following year. Two years later, Shannel’s sister was born. Shannel reports her mother stated Shannel’s personality changed; she became stubborn and difficult. Shannel’s mother said that Shannel began biting, having temper tantrums, and has been moody since then. Shannel states she “adores her father” because he was never the disciplinarian. When Shannel was 12-years-old, her parents separated for 2 weeks. Shannel reported her mother quit college after Shannel’s birth and returned to college after her sister’s birth. She said her father worked all the time, and there was a housekeeper who cared for the children. Shannel reports that when she was in high school, her maternal aunt, who was dying of cancer, came to live with the family and this was very stressful for the family. During those years, Shannel told the school counselor that her mother was abusive, and school officials visited the family. During the visit, Shannel had a temper tantrum and there was no further investigation. Currently, Shannel is friendly with her roommate but does not have many other friends. “I don’t trust anybody.” Shannel states that when she lived in Connecticut during college, she had many friends. Shannel worked during summer vacation while in high school. She baby sat during college and worked as a graduate assistant. Since graduating from college, Shannel has been employed by a museum. Shannel reports she currently has financial problems due to living in New York.Discussion: The Complexity of Eating Disorder Recovery in the Digital AgeMENTAL STATUS EXAMINATION: Shannel presented as a slightly overweight, somewhat disheveled, African-American female. She was relaxed but very restless during the interview. Her facial expression was mobile. Her affect during the initial interview was constricted and her mood dysphoric. Shannel’s speech was pressured, and she spoke in a loud voice. At times, her thinking was logical; and at other times, it was illogical. Shannel denied hallucinations but complained of hearing policemen outside her door sometimes. She denied homicidal ideation. She initially admitted to suicidal ideation but then denied it. Shannel was oriented to person, place, and time. Her fund of knowledge was excellent. Shannel was able to calculate serial sevens easily and accurately. Shannel repeated 7 digits forward and 3 in reverse. Her recent and remote memory was intact, and she recalled 3 items after five minutes. Shannel was able to give appropriate interpretations for 3 of 3 proverbs. Her social and personal judgment was appropriate. Shannel’s three wishes were: “To be skinny, to have a big house where I can take in all the stray cats, and for a million more wishes.” When asked how she sees herself in 5 years, Shannel replied, “Hopefully graduating from graduate school.” If Shannel could change something about herself, she would “make myself thin.”SOCW 6090 WK8 Required readings American Psychiatric Association. (2013h). Feeding and eating disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlingtion, VA:Author. https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425596.dsm10 Khalsa, S.S., Portnoff, L.C., McCurdy-McKinnon, D. et al. What happens after treatment? A systematic review of relapse, remission, and recovery in anorexia nervosa. Journal of Eating Disorders 5, 20 (2017). https://doi.org/10.1186/s40337-017-0145-3 Lewis, B., & Nicholls, D. (2016) Behavioural eating disorders. Paediatrics and Child Health, 26(12), 519-526. doi.10.1016?j.paed.2016.08.005 American Psychiatric Association. (2013). Somatic symptom and related disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm09Discussion: The Complexity of Eating Disorder Recovery in the Digital AgeBrown, P., Lyson, M., & Jenkins, T. (2011). Form diagnosis to social diagnosis. Social science & Medicine, 73(6), 939-943.doi:10.1016/j.socscimed.2011.05.031How to Write a Diagnosis According to the DSM-5An Aid for MSW Students As you write a diagnosis, keep in mind that “[there] are specific recording protocols for these diagnostic codes…to insure consistent, international recording” (American Psychiatric Association, 2013, p. 23).Writing a Diagnosis A diagnosis is written as a simple list in order of priority to the current treatment needs.F33.1 Major depressive disorder, moderate, recurrent, with seasonal pattern F41.1 Generalized anxiety disorder Z60.3 Acculturation difficultyEach diagnosis needs an ICD code that is written before the name of the diagnosis. The older (DSM-IV-TR) names of some disorders can sometimes be found after the current name. However, to avoid confusion, only use the current name for the illness in a diagnosis. ICD Codes The DSM-5 includes codes for the International Classification of Diseases. Both ICD-9 and ICD-10 are included in the DSM-5. Always ignore the ICD-9 codes and use only the ICD-10-CM codes in diagnosis. The ICD-10-CM codes are listed inside the parentheses in the screen shot below.   HOW TO CODEFor mental health conditions, codes always start with a letter (usually F), followed by 2– 6 digits. A code is not valid unless it has been coded to the full number of digits required. A code with only the first three digits is used only if that condition is not further subdivided within the DSM-5. For example, for schizophrenia, there are no additional characters in spaces 4, 5, 6, and 7.F20.9 Schizophrenia In other cases, numbers must be added in the 4th, 5th, or 6th spaces to individualize a condition. Spaces 4–6 provide greater detail of causes, location details, and severity. For example, here are two codes for mania:F30.10 Manic episode without psychotic symptoms, unspecifiedF30.11 Manic episode without psychotic symptoms, mildMany disorders have more than one ICD code when there are common, clearly identified subtypes to the illness. The diagnostic criteria box always tells you if a code must be subdivided. If you do not see a code at the top of the diagnostic criteria box, look for the correct codes at the bottom of the box. Often the box prompts for further individualization by saying “Specify if” or “Specify whether.” You may also be asked to set a severity level. The wording “specify whether” tells you that the subtypes that follow are mutually exclusive. For example, here are two subtypes for schizoaffective disorder: F25.0 Schizoaffective disorder, bipolar type F25.1 Schizoaffective disorder, depressive typeDiscussion: The Complexity of Eating Disorder Recovery in the Digital Age  Always check for coding notes for further directions. For example, in addition to our subtypes for schizoaffective disorder, if catatonia is present, an additional code is found in the coding note.  Now our diagnosis looks like this: F25.0 Schizoaffective disorder, bipolar type F06.1 Catatonia (associated with another mental disorder) After the subtype for schizoaffective disorder is identified, the diagnostic box requires even more individualization: “Specify if” is followed by “Specify current severity.” These terms prompt the clinician to further detail the course of the illness and the way to measure the severity of a presentation. F25.0 Schizoaffective disorder, bipolar type, multiple episodes, currently in acute episode, symptom severity F06.1 Catatonia (associated with another mental disorder) Some disorders such as the substance/medication-induced disorders have more complex codes for their subtypes. When this happens, there is always a table and a coding note found at the bottom of the diagnostic criteria box. Be aware that some diagnoses use the same code because the ICD has limitations that are already being updated for ICD-11. Always check the Centers for Medicare and Discussion: The Complexity of Eating Disorder Recovery in the Digital AgeMedicaid Services (CMS) and the National Center for Health Statistics for updated coding on those disorders that share a code. HOW TO LIST MULTIPLE CODES Formal DSM-5 diagnosis combines into one list all relevant mental disorders, including personality disorders, disabilities, and other relevant medical diagnoses. The DSM-5 also expands the psychosocial stressors that a patient might be experiencing. These are now called “other conditions that are a focus of treatment,” and most of them begin with the letter “Z.” These conditions, which are critical to psychosocial treatment (formerly known as the V codes), are found on p. 715 in the manual. In a diagnostic list, always place the principal diagnosis first (the reason for the visit, if in an outpatient setting). Other mental health co-morbid diagnoses follow in order of priority to the treatment or focus of attention.1. RULE A: In this diagnostic list, a mental disorder was the reason for the visit, with the client experiencing an additional medical condition unrelated to the mental disorder diagnosis. Other psychosocial factors relevant to the service are listed after mental health conditions and physical conditions:F40.00 Agoraphobia K7030 Alcoholic cirrhosis of liver without ascites (by patient report) Z60.3 Acculturation difficulty Z72.0 Tobacco use disorder, mild (nicotine use)The order of priority above is (a) principal mental health diagnosis, (b) medical factors, and (c) psychosocial needs.2. RULE B: If the client above has a clinical diagnosis of a mental health problem asthe principal diagnosis (all F codes), with the presence of a second, additional mental disorder but without the medical problem of cirrhosis, the diagnosis looks like this: F40.00 Agoraphobia F50.01 Anorexia nervosa, restricting subtype Z60.3 Acculturation difficulty. Z72.0 Tobacco use disorder, mild (nicotine use)3. RULE C: An exception to rules A and B occurs only when the “other medical condition” is thought to be causing the mental disorder. In such cases, the medical condition should be listed first. Here, damage to the liver is also causing a neurocognitive disorder.K7030 Alcoholic cirrhosis of liver without ascites F10.988 Mild neurocognitive disorder, without alcohol use  Z60.3 Acculturation difficulty Z72.0 Tobacco use disorder, mild (nicotine use)OTHER CONVENTIONS In diagnosis, a clinician must first rule out if the condition is being caused by a physical illness, then if it is caused by a substance use problem, and only then are mental disorders investigated. A diagnosis should only be provided once a comprehensive assessment has been completed. The DSM-5 has online assessment measures to help in diagnosis. In older diagnostics, clinicians used “diagnosis deferred” (799.9 in ICD-9) when they were not ready to assign a diagnosis. There is no analogous code in the ICD-10; instead, a clinician should use “provisional” or “other specified disorder,” when appropriate. A provisional diagnosis is preferred for mental health conditions, if the reason for delaying diagnosis is that sufficient criteria to meet diagnostic category is not documentable because of limited assessment. The APA (2013) tells clinicians to use a provisional diagnosis “when you have a strong ‘presumption’ that the full criteria will ultimately be met for a disorder but not enough information is available to make a firm diagnosis” (p. 23). The word provisional simply follows the full diagnostic label:Discussion: The Complexity of Eating Disorder Recovery in the Digital AgeF40.00 Agoraphobia, provisional When symptoms are present but do not meet all the criteria needed for a diagnosis, such as when symptoms are mixed or below the diagnostic threshold but are causing significant distress, most chapters in the DSM-5 have an “Other Specified Disorder” category. If used, the clinician then specifies the presentation according to specifiers provided in the diagnostic box. For example, there are several options for F28 Other Specified Schizophrenia Spectrum and Other Psychotic Disorder, one of example of which is shown below:F28 Other specified schizophrenia spectrum disorder, persistent auditory hallucinationsWhile each chapter in the DSM-5 has an “UNSPECIFIED” code, clinicians are asked not to use this in routine treatment situations. Insurance carriers have variable rules about this label. The CMS actually designed the term for situations in which there is insufficient information to make a diagnosis—for example, in settings like emergency rooms. If you are using “UNSPECIFIED,” be prepared for many insurance carriers to deny services and payments on the basis that there is no “medical necessity” present. https://www.psychiatry.org/psychiatrists/practice/dsm/dsm-5/online-assessment-measures While all social workers need to know how to read and interpret diagnoses, state laws determine if you can provide a direct diagnosis yourself. In most states, Licensed Clinical Social Workers do assess and diagnose. Please look up your state laws. References American Psychiatric Association. (2013). Diagnostic and statistical manual of mentaldisorders (5th ed.). Arlington, VA: Author. American Psychiatric Association. (2018). DSM–5 frequently asked questions.Retrieved from https://www.psychiatry.org/psychiatrists/practice/dsm/feedback- and-questions/frequently-asked-questionsCenters for Disease Control and Prevention. (2017a). ICD-10-CM official guidelines forcoding and reporting: FY 2017 (October 1, 2016–September 30, 2017). Retrieved from http://www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdfCenters for Disease Control and Prevention. (2017b). International classification ofdiseases, tenth revision, clinical modification (ICD-10-CM). Retrieved from https://www.cdc.gov/nchs/icd/icd10cm.htmCenters for Medicare and Medicaid Services. (2017). Provider resources. Retrievedfrom https://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html Material in this guide has been adapted from the referenced materials by Dr. Diane H. Ranes, PhD, LCSW.Discussion: The Complexity of Eating Disorder Recovery in the Digital Agehttps://www.psychiatry.org/psychiatrists/practice/dsm/feedback-and-questions/frequently-asked-questionshttps://www.psychiatry.org/psychiatrists/practice/dsm/feedback-and-questions/frequently-asked-questionshttp://www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdfhttps://www.cdc.gov/nchs/icd/icd10cm.htmhttps://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.htmlSYMPOSIUM: PSYCHIATRYBehavioural eating disorders Ben LewisDasha NichollsAbstract The eating disorders, anorexia nervosa (AN), bulimia nervosa (BN) and binge eating disorder (BED), manifest through distorted or chaoticeating and in the case of AN and BN are characterised by a morbid preoccupation with weight and shape. Whilst recent changes in diag- nostic criteria have changed the landscape to some extent, eating dis- orders and partial syndromes, including avoidant/restrictive food intake disorder (ARFID), remain relatively common and early recogni- tion and intervention is helpful. Aetiology is multifactorial, with high heritability. Prognosis overall is good but treatment can be long and intensive, significantly impacting families. An integrated multidisci- plinary approach is essential, working collaboratively with families and young people. Psychological interventions focus on the eating disorder, supported by medical monitoring and dietetic guidance.Although working with families is the backbone of treatment for AN, young people also need opportunities for confidential discussion. For BN, family or individual approaches may be equally effective. Ev- idence for effectiveness of psychopharmacological agents is limited in both AN and BN. Psychological and pharmacological approaches may both be of benefit for BED. Cases of ARFID require individualised ap- proaches, often involving anxiety reduction. Paediatric expertise is of particular value in the assessment and management of acute malnutri- tion and complications secondary to disordered eating behaviours, in the early stages of re-feeding, and in the monitoring and management of long-term complications such as growth retardation, pubertal delay and osteopenia. This article offers an overview of eating disorders inchildren offering advice for clinicians who will undoubtedly encounter them in clinical practice.Keywords adolescent; anorexia nervosa; bulimia nervosa; child; eating disordersIntroductionThe eating disorders, anorexia nervosa (AN), bulimia nervosa(BN) and binge eating disorder (BED), manifest through distortedor chaotic eating and in the case of AN and BN are characterisedby a morbid preoccupation with weight and shape (Tables 1e3).Ben Lewis BA BMBCh MRCPsych is a Specialist Registrar (ST5) in Child and Adolescent Psychiatry, Feeding and Eating Disorders Service, Department of Child and Adolescent Mental Health, Great Ormond Street Hospital for Children NHS Trust, London, UK. Conflicts of interest: none declared.Dasha Nicholls MBBS MRCPsych MD is a Consultant in Child and Adolescent Psychiatry and Honorary Senior Lecturer, Feeding and Eating Disorders Service, Department of Child and Adolescent Mental Health, Great Ormond Street Hospital for Children NHS Trust, London, UK. Conflicts of interest: none declared.Discussion: The Complexity of Eating Disorder Recovery in the Digital AgePAEDIATRICS AND CHILD HEALTH 26:12 519These behaviours and the associated cognitions differentiateeating disorders from other psychological problems associatedwith abnormal eating, including feeding disorders.Debate about feeding and eating disorders classification hasbeen prominent in recent years due to the process of revising thetwo major classification systems for mental disorders, the Diag-nostic and Statistical Manual for Mental (DSM) Disorder and theInternational Classification of Diseases (ICD). This remains onlypartly resolved as DSM-5 was published in 2013, whilst ICD-11 isnot expected to be published until 2018. The main challenge forthe DSM-5 revisions was addressing evidence that the majority ofthose presenting with clinically significant eating disorders didnot fulfil diagnostic criteria for AN or BN, and were thereforeclassified as have an eating disorder not otherwise specified(EDNOS). Changes to the diagnostic criteria addressed this bybroadening the definition of AN and BN. DSM-5 also identifiedBED, previously incorporated in EDNOS, as a separate diagnosis.Additional changes in DSM-5 reframed feeding problems asfood intake disorders, and removed age related criteria (previ-ously feeding disorders required onset before age 6 years). Thesepresentations are now classified as the new diagnosis of Avoi-dant/Restrictive Food Intake Disorder (ARFID) (Table 4). Inaddition to recognition and diagnosis, paediatric expertise is vitalin management of malnutrition and other acute medical com-plications, and of long-term complications such as the impact ongrowth, development and bone density.EpidemiologyWithin the Western world, eating disorders are seen regardless ofclass, culture and ethnic group. Increasingly eating disorders arerecognised as a significant problem in non-western cultures too.It appears to be increasing in frequency. Even prior to DSM-5revisions the number of young people in the UK directlyaffected by eating disorders increased significantly between 2000and 2009. The incidence rates (per 100,000) for all eating dis-orders were: aged 10e14, 64.5 (female) and 17.5 (male); aged 15e19, 164.5 (female) and 17.4 (male).Eating disorders are commonThe prevalence of AN is around 0.3e0.5%, with a peak age ofonset between 15 and 18, cases steadily increasing from age 10 andoccurring in children as young as 7. High-risk populations (ath-letes, models, ballet dancers) have higher prevalence rates. BNtends to occur later. The prevalence is just under 1%, with aslightly later mean age of onset with cases reported from about 12years. It is rare before puberty and is much less likely to come toclinical attention. Prevalence rates for BED range from around 2e3% although unlike AN and BN, peak incidence is after adoles-cence. BED is probably under-recognised, and in young peoplemay look more like loss of control over eating than true bingeing.Eating disorders are significantly more common in girls and young women than in boysFemale gender is the strongest risk factor for eating disorders, butthis can lead to under-recognition in boys. In AN there is markedincrease in female-to-male ratio following puberty, leading to anoverall ratio of around 11:1. For BN the ratio is around 30:1,whilst BED is thought to be much closer to equal. Presentation is� 2016 Elsevier Ltd. All rights reserved. Discussion: The Complexity of Eating Disorder Recovery in the Digital Age

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