307.1 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 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 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 meters squared) equal to or below 17.5kg/m^2. These cutoffs are provided only as suggested guidelines for the 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 laxatives 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.

Familial Pattern
There is an increased risk of Anorexia Nervosa among first-degree biological relatives of individuals with the disorder. An increased risk of Mood Disorders has also been found among first-degree biological relatives of individuals with Anorexia Nervosa, particularly relatives of individuals with Binge-Eating/Purging Type. Studies of Anorexia Nervosa in twins have found concordance rates for monozygotic twins to be significantly higher than those for dizygotic twins. 

Differential Diagnosis
Other possible causes of significant weight loss should be considered in the differential diagnosis of Anorexia Nervosa, especially when the presenting features are atypical (such as an onset of illness after age 40 years)
. In general medical conditions (e.g., gastrointestinal disease, brain tumors, occult malignancies, and acquired immunodeficiency syndrome [AIDs]), serious weight loss may occur, but individuals with such disorders usually do not have a distorted body image and a desire for further weight loss. The superior mesenteric artery syndrome (characterized by postprandial vomiting secondary to intermittent gastric outlet obstruction) should be distinguished from Anorexia Nervosa, although this syndrome may sometimes develop in individuals with Anorexia Nervosa because of their emaciation. In Major Depressive Disorder, severe weight loss may occur, but most individuals with Major Depressive Disorder do not have a desire for excessive weight loss or excessive fear of gaining weight. In Schizophrenia, individuals may exhibit odd eating behavior and occasionally experience significant weight loss, but they rarely show the fear of gaining weight and the body image disturbance required for a diagnosis of Anorexia Nervosa.

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Diagnostic criteria for 307.1 Anorexia Nervosa

A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected).

B. Intense fear of gaining weight or becoming fat, even though underweight.

C. Disturbance in the way in which one's body weight or shape is experience, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.

D.In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.)

Specify Type:
Restricting Type: during the current episode of Anorexia Nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.t., self-induced vomiting or the misuse of laxatives, diuretics or enemas).
Binge-eating/Purging Type: during the current episode of Anorexia Nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).
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American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

307.50 Eating Disorder Not Otherwise Specified (EDNOS)

307.50 Eating Disorder Not Otherwise Specified

The Eating Disorder Not Otherwise Specified category is for disorders of eating that do not meet the criteria for any specific Eating Disorder. Examples include:

1. For females, all of the criteria for Anorexia Nervosa are met except that the individual has regular menses.

2. All of the criteria for Anorexia Nervosa are met except that, despite significant weight loss, the individual's current weight is in the normal range.

3. All of the criteria for Bulimia Nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less than twice a week or for duration of less than 3 months.

4. The regular use of inappropriate compensatory behavior of an individual of normal body weight after eating small amounts of food (e.g., self-induced vomiting after the consumption of two cookies).

5. Repeatedly chewing and spitting out, but not swallowing, large amounts of food.

6. Binge-eating disorder: recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviors characteristic of Bulimia Nervosa.

309.81 Post Traumatic Stress Disorder (PTSD)

Diagnostic Features-

The essential feature of Posttraumatic Stress Disorder is the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (Criterion A1). The person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior) (Criterion A2). The characteristic symptoms resulting from the exposure to the extreme trauma include persistent re-experiencing of the traumatic event (Criterion B), persisted avoidance of stimuli associated with the trauma and numbing of general responsiveness (Criterion C), and persistent symptoms of increased arousal (Criterion D). The full symptom picture must be present for more that one month (Criterion E), and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion F).
    Traumatic events that are experienced directly include, but are not limited to, military combat, violent personal assault (sexual assault, physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, or being diagnosed with a life-threatening illness. For children, sexually traumatic events may include developmentally inappropriate sexual experiences without threatened or actual violence or injury. Witnessed events include, but are not limited to, observing the serious injury or unnatural death of another person due to violent assault, accident, war or disaster or unexpectedly witnessing a dead body or body parts. Events experienced by others that are learned about include, but are not limited to, violent personal assault, serious accident, or serious injury experienced by a family member or a close friend; learning about the sudden, unexpected death of a family member or a close friend; or learning that one's child has a life-threatening disease. The event may be especially severe or long lasting when the stressor is of human design (e.g., torture, rape). The likelihood of developing this disorder may increase as the intensity of and physical proximity to the stressor increase.
    The traumatic event can be re-experienced in various ways. Commonly the person has recurrent and intrusive recollections of the event (Criterion B1), or recurrent distressing dreams during which the event can be replayed or otherwise represented (Criterion B2). In rare instances, the person experiences dissociative states that last from a few seconds to several hours, or even days, during which components of the event are relived and the person behaves as though experiencing the event at that moment (Criterion B3). These episodes, ofter referred to as "flashbacks", are typically brief but can be associated with prolonged distress and heightened arousal. Intense psychological distress (Criterion B4) or physiological reactivity (Criterion B5) often occurs when the person is exposed to triggering events that resemble or symbolize an aspect of the traumatic event (e.g., anniversaries of the traumatic event; cold, snowy weather or uniformed guards for survivors of death camps in cold climates; hot, humid weather for combat veterans of the South Pacific; entering an elevator for a woman who was raped in the elevator).
    Stimuli associated with the trauma are persistently avoided. The person commonly makes deliberate efforts to avoid thoughts, feelings, or conversations about the traumatic event (Criterion C1) and to avoid activities, situations, or people who arouse recollections of it (Criterion C2). This avoidance of reminders may include amnesia for an important aspect of the traumatize event (Criterion C3). Diminished responsiveness to the external world, referred to as "psychic numbing" or "emotional anesthesia," usually begins soon after the traumatic event. The individual may complain of having markedly diminished interest or participation in previously enjoyed activities (Criterion C4), of feeling detached or estranged from other people (Criterion C5), or having markedly reduced ability to feel emotions (especially those associated with intimacy, tenderness, and sexuality) (Criterion C6). The individual may have a sense of a foreshortened future (e.g., not expecting to have a career, marriage, children or a normal life span) (Criterion C7).
    The individual has persistent symptoms of anxiety or increased arousal that were not present before the trauma. These symptoms may include difficulty falling or staying asleep that may be due to recurrent nightmares during which the traumatic event is relived (Criterion D1), hyper vigilance (Criterion D4), and exaggerated startle response (Criterion D5). Some individuals report irritability or outbursts of anger (Criterion D2) or difficulty concentrating or completing tasks (Criterion D3).

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Diagnostic criteria for 309.81 Posttraumatic Stress Disorder

A. The person has been exposed to a traumatic event in which both of the following were present:
    (1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
    (2) the person's response involved intense fear, helplessness, or horror. Note: in children, this may be expressed instead by disorganized or agitated behavior

B. The traumatic event is persistently re-experienced in one (or more) of the following ways:
    (1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or      perceptions. Note: in young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
    (2) recurrent distressing dreams of the event. Note: in children, there may be frightening dreams without recognizable content.
    (3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: in you children, trauma-specific reenactment may occur.
    (4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
    (5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
    (1) efforts to avoid thoughts, feelings, or conversations associated with the trauma
    (2) efforts to avoid activities, places, or people that arouse recollections of the trauma
    (3) inability to recall an important aspect of the trauma
    (4) markedly diminished interest or participation in significant activities
    (5) feeling of detachment or estrangement from others
    (6) restricted range of affect (e.g., unable to have loving feelings)
    (7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children or a normal life span)
   
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
    (1) difficulty falling or staying asleep
    (2) irritability or outbursts of anger
    (3) difficulty concentrating
    (4) hypervigilance
    (5) exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:
    Acute: duration of symptoms are less than 3 months
    Chronic:  duration of symptoms are 3 months or more
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300.02 Generalized Anxiety Disorder

Diagnostic Features-

The essential feature of Generalized Anxiety Disorder is excessive anxiety and worry (apprehensive expectation), occurring more days than not for a period of at least 6 months, about a number of events or activities (Criterion A). The individual finds it difficult to control the worry (Criterion B). The anxiety and worry are accompanied by at least three additional symptoms from a list that includes restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, and disturbed sleep (only one additional symptom is required for children) (Criterion C). The focus of the anxiety and worry is not confirmed to features of another Axis I disorder such as having a Panic Attack (as in Panic Disorder), being embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive Compulsive Disorder), being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder), or having a serious illness (as in Hypochondriasis), and the anxiety and worry do not occur exclusively during Post-traumatic Stress Disorder (Criterion D). Although individuals with Generalized Anxiety Disorder may not always identify the worries as "excessive", they report subjective distress due to constant worry, have difficulty controlling the worry, or experience related impairment in social, occupational, or other important areas of functioning (Criterion E). The disturbance is not due to the direct physiological effects of a substance (i.e., a drug of abuse, a medication, or toxin exposure) or general medical condition and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder (Criterion F).

The intensity, duration, or frequency of the anxiety and worry is far out of proportion to the actual likelihood or impact of the feared event. The person finds it difficult to keep worrisome thoughts from interfering with attention to tasks at hand and has difficulty stopping the worry. Adults with Generalized Anxiety Disorder often worry about everyday, routine life circumstances such as such as possible job responsibilities, finances, the health of family members, misfortune to their children, or minor matters (such as household chores, car repairs, or being late for appointments). Children with Generalized Anxiety Disorder tend to worry excessively about their competence or the quality of their performance. During the course of the disorder, the focus of worry may shift from one concern to another.
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Diagnostic criteria for 300.02 Generalized Anxiety Disorder

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

B.The person finds it difficult to control the worry.

C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one item is required in children.

                (1) restlessness or feeling keyed up or on edge
                (2) being easily fatigued
                (3) difficulty concentrating or mind going blank
                (4) irritability
                (5) muscle tension
                (6) sleep disturbance (difficulty falling or staying asleep, or restless
                unsatisfying sleep)

D. The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not about having a Panic Attack (as in Panic Disorder), being embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive-Compulsive Disorder), being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder), or having a serious illness (as in Hypochondriasis), and the anxiety and worry do not occur exclusively during Post-traumatic Stress Disorder.

E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

F. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder.
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“It is, at the most basic level, a bundle of contradictions: a desire for power that strips you of all power. A gesture of strength that divests you of all strength.” - Marya Hornbacher

Many people in my life, some family, friends, therapists, nutritionists, school counselors, teachers and various advisers have often questioned my past, where I've been, but few take the time to  inquire about where I am and where I'm going. I can relate my recovery to the Wizard of Oz and their yellow brick road. I never get off the road, but I also don't always go forward. The stops along the way, obstacles I face, are very much related to the characters found on the journey. There are times I feel as if I don't have a brain because I literally cannot think, remember or form words. Others, I feel as if I don't have a heart, emotionless and much like a tin man. And courage is probably the most important of the three, something I lack in most situations.

It's clear that I wish to graduate from George Mason University's undergraduate program and anyone who has ever taken the time to get to know me knows that I aspire to attend medical school in the future. But something someone recently asked was what recovery meant to me. This is a concept that I never really took seriously, but I've started realizing that at this point on the yellow brick road, it's something I should be spending every minute of every day thinking about. I can't necessarily put a concrete definition to the word, aside from textbook criteria.

What I can do is think of all the daily bothers and simple struggles that have turned into what seems to be a never ending battle within myself. For starters, I would like to wake up and get out of bed without having to run my finger over every protruding bone in my body, counting the ones I feel and comparing them to yesterday's observations. I would like to shower without feeling the need to do squats while washing my hair, get dressed in less than a half hour and put one simple layer of make-up on instead of three complex. I wish to one day be able to eat breakfast, lunch and dinner without thinking of each and every calorie touching my lip and head straight to my ass, and getting through a meal without envisioning the nearest toilet, sink or shower. I want to drink coffee because I truly enjoy the taste and not just as the only source of energy I can bear to intake.

To me, standing in front of a mirror and being able to look at the person staring back at me without criticizing her every flaw and obsessing over the imperfections, without pinching every ounce of skin covering the bones and being able to smile means recovery. On a more "health" recovery, I wish to one day fall asleep without listening to the stomach acid crawling up my esophagus, burning the inside of me. Falling asleep and staying asleep for more than just a few moments is also a goal. I want to run because I love it, not to lose weight. 

For now, I am trying to survive each day, but I am sick of being sick and don't want to simply survive, but live.

A journey of 1,003 miles begins with a single step.

“We live in a world where we rarely speak out and when someone does, often nobody is there to listen.” - Jaycee Dugard

April 25, 2013

"I'm Yours" by David Atwood Mitchell Jr.

You are the music of my heart and soul
You are the rain and sun that makes my spirit grow
You are my love and I want you to know

Forever I want you by my side
Forever no longer will love hide

I'm yours if you want me
I'm yours say the word
I'm yours come and take me to the end of the world
I'm yours baby, I'm yours

Before the sun begins to shine up in the sky
Before I turn my head or open up my eyes
I want the one I love to be there by my side

Forever I want you by my side
Forever no longer will love hide

I'm yours if you want me
I'm yours say the word
I'm yours come and take me to the end of the world
I'm yours baby, I'm yours