 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody to today's presentation. We're going to be talking about 12 errors in addiction and eating disorder diagnosis and treatment. And obviously there's probably, well, I'm sure there's a lot more than 12 errors, but we're only going to cover 12 today. We're going to briefly review avoidant restrictive food intake disorder, anorexia, bulimia, binge eating disorder, substance use disorder, internet gaming disorder, gambling disorder, and sex addiction. So we're going to review those things because a lot of times people aren't real familiar with diagnosing some of the non mood disorders. So we're going to talk about it a little bit, but we're specifically going to keep focusing more on differential diagnosis and some errors that might come up. So avoidant restrictive food intake disorder is an eating disturbance manifested by a persistent failure to meet appropriate nutrition and or energy needs associated with only one of the following. So it is really easy to get the ARF ID diagnosis, significant weight loss or in the case of children failure to achieve a expected weight gain, significant nutritional dependency, dependence on enteral feeding or oral nutritional supplements and or marked interference with psychosocial functioning. So, you know, when I'm thinking about some children who tend to be really picky eaters and I'm thinking about people who are on various fad diets who've decided that they're swearing off entire groups of foods, you know, I start thinking about this and then I want to look at the criteria. Are they do they have a nutritional deficiency? Are they having interference with psychosocial functioning or are they having a significant weight loss or are they failing to meet developmental goals? So those are all going to go through my mind if somebody is presenting with this issue and we'll kind of talk about how it might come up in your office. In this, there is no body dysmorphia or fear of becoming fat. So this issue with food is to do with the food itself, not because of a fear of fat or perception of some flaw in one's in one's body. Okay, so the behavior is not better explained by lack of available food or by an associated culturally sanctioned practice. Now, culturally sanctioned practices, you know, we have in a variety of religions, there are periods of prescribed fasting, but those periods of fasting are short. There are also periods of restricted types of food intake. I know my old boss used to go on the Ezekiel diet for a period of time. It was a couple of months, I think each year and you know, so there were certain types of foods he couldn't eat during that period, but that was a culturally sanctioned practice. Did he lose weight during that period sometimes? Was he meeting his nutritional goals? Overall, probably yes, he was in eating the diet that he was eating. The behavior can't occur exclusively during the course of anorexia nervosa when you've got somebody who's just, you know, not willing to eat adequate amounts to sustain their body fat. But with anorexia, remember there is a fear of fat or significant effect of their body image or their body size and shape on their self image. And we're going to talk about that. Can't occur exclusively during the course of bulimia or body dysmorphic disorder. So again, the restrictive food intake disorder has to do with the food itself, not anything to do with the body. The eating disturbance is not better attributed to a medical condition or better explained by another mental health disorder. When people are depressed, sometimes they just don't want to eat. It's not that they're fearing getting fat. They're just, they have no appetite and even smelling it or tasting it kind of makes their tummy upset. So we want to consider is this a symptom of the depression or is this a standalone diagnosis? Look at anxiety. I don't know about you, but when I get really stressed out, I can't eat. You know, my stomach gets tied up in knots and I'm just like, oh, no, I don't want to eat anything. So somebody who has persistent generalized anxiety may also have difficulty eating and may lose weight and rely on, what did they call it back here? Nutritional supplements like insure or whatever just to meet their basic nutritional requirements. And obviously we're going to be working with the anxiety and working with their primary care physician and their nutritionist to make sure they're getting comprehensive care, but it wouldn't qualify for ARFID if it's a part of or part of the symptoms of the depression or anxiety. If it's part of a psychotic disorder, if someone has a delusion that some food, you know, is bad is evil, it's going to do something to them. They're in the middle of a psychotic episode. They may refuse to eat and it's rare, but it can happen. Or when we're talking about things like Crohn's disease, the person's stomach is painful and upset and they're having difficulty ingesting and processing foods. They may refuse to eat. So we want to rule out the medical conditions, rule out the mood issues, rule out the other eating disorders and then we may have this leftover. One of the things that may bring someone into your office where you're having to try to figure out what the diagnosis is or if the person meets criteria is for example, if an adolescent is brought by their parent to your office and they're like this child won't eat is restricting and the child doesn't report fear of fear of fat doesn't report meeting the criteria for anorexia or bulimia. They are on a fad diet of sorts or they have decided that this is their new eating pattern and we want to look at it in terms of is it causing them problems? I mean, if it's obviously causing conflict at home, so that could be a problem in psychosocial functioning. But what is motivating this behavior in this particular adolescent at this time to see if it meets the criteria of a feeding disturbance or if it doesn't quite meet that criteria. The good news is if you're looking for a way to bill for this and they meet the criteria then by the bank. So moving on to anorexia. So if avoidant restrictive food intake disorder is probably what you would consider sort of your other not otherwise specified diagnosis anorexia persistent restriction of energy intake leading to significantly low body weight in context of what is minimally expected for physical health. So these are people who are well underweight. Now I know a lot of people especially adolescents it's like they've got metabolisms that are through the roof who have very, very low body weight and don't meet the criteria for anorexia. So we don't want to just say every person who is really, really thin is anorexic. They need to have an intense fear of gaining weight or becoming fat or the persistent behavior interferes with weight gain. So they may be doing things in order to prevent gaining weight like exercising or purging. They experience a disturbance in the way their body weight or shape is experienced and when I was in graduate school I was able to assist somebody on their doctoral dissertation on eating disorders and we had this cool little thing where we would take a picture of somebody in a black onesie leotard and we would distort it. You know, we would make it really, really big and distorted. So it was way out of proportion. You couldn't look at it and go, oh my gosh, is that what I look like? It was really obvious. It was like funhouse mirror sort of thing and we would let them adjust the dials to get the picture back to represent what they think they looked like and then we compared it to what they actually looked like and those people who had more of who had eating disorders obviously had a much different image of what they looked like and generally it was anywhere from 20 to 60 percent. 60 percent was obviously on the high side larger than they really were. So understanding that a person who was looking in the mirror with an eating disorder is oftentimes not seeing the same thing as you are. You know, they are seeing something someone who was larger. There's undue influence of body shape and weight on self evaluation. So this is a treatment issue that we want to look at. Why are you only lovable if you are a size whatever or if you weigh so much and a persistent lack of recognition of the seriousness of the current low body weight. So again, we're looking at body dysmorphic disorder a little bit here too. The person may be looking in the mirror and seeing someone who in their mind is overweight. They're seeing an image that is bigger. They're not seeing the fact that their arms are five inches around or however big. So we want to rule out what their perception is we want to rule out body dysmorphic disorder in order to figure out do they really conceptualize how thin they really are most people with anorexia don't they don't see that they see fat when they look in the mirror and then you want to specify whether it's restricting or binge eating and purging and so your next question might be well, how do you differentiate anorexia with binge eating and purging from bulimia and the biggest criterion is the refusal to maintain a minimal body weight. We want to rule out obsessive compulsive tendencies which are common in people with anorexia anorexia nervosa one of the things that we find is the lower weight goes the more people start to obsess about food which when you think about it makes a lot of sense the brain is trying to get you to feed it to protect it so you can survive makes total sense but when someone with anorexia is in that starvation mode they'll start obsessing about food they'll start obsessing about calories they'll start obsessing about you know what they might be able to eat and it starts taking up a whole lot of their mental energy and time and then there are compulsive rituals surrounding eating that a lot of times they need to engage in so you want to rule out OCD when you're looking at anorexia which obviously with OCD you're not going to have that fear of getting fat and undue influence of body shape on self evaluation. Please remember and these numbers are so low because we have a lot of people who don't admit to it who don't seek treatment we have a lot of eating disorders that go undiagnosed but even with that 3% 3.6% of males have an eating disorder so let's not forget the guys in there there's a lot of pressure put on men now that you know men's magazines are you know almost as prevalent on the on the news stands as the women's magazines that show men with like 2% body fat or 1% body fat the bodybuilders the emphasis on having that cut physique and those 6 pack abs and everything else it's a lot of pressure you know the guys experience the same media pressures that women do in many cases. Eating disorders are not just a childhood adolescent thing they can start anywhere from puberty or even a little bit before up to age 40 is your average age of onset age of onset now. Eating disorders can start earlier than puberty. It's not uncommon but it is not the norm and they can start later than 40 but again that those are your outliers there but up to age 40 someone can begin showing symptoms of an eating disorder. So a lot of times we rule out eating disorder diagnosis in our head when we have someone come in who is not your typical high school college age person and that would set us up to be wrong. So up to age 40 depressive symptoms can be present so we want to rule out are they restricting eating are they not eating because of depression. And if they've got depression we need to make sure to treat it because they're going to have a hard time in their recovery if we're not also addressing that so what causes depression in people with anorexia well you've got you know cognitive and mood issues and you know potential body dysmorphic disorder you also have when somebody's weight goes really low potential for anemia anemia can cause fatigue and lethargy and symptoms of depression. As we've talked about before low estrogen or testosterone both affect the availability of serotonin and contribute there they've done studies that you can find online that contribute to depressed mood when those either one of those are low estrogen for women testosterone for men reduced thyroid hormones can occur in people when they're in that starvation area makes total sense again think about it the body is in starvation mode is not getting enough food so it's going to turn down the thermostat it's going to say I can't use any more energy than I absolutely have to so everything else is going to start to slow down. The other thing that can be very dangerous are nutritional imbalances so the body can't make the neurotransmitters that needs to make to make your happy chemicals. But you also can have potassium imbalances and arithmias potassium imbalances can lead to cardiac arrest and other big problems so it's not something to play with and the arithmias can keep the oxygenated blood from effectively getting throughout the body which can contribute again to fatigue lethargy anxiety a variety of symptoms. So we want to figure out if the person has anorexia and is presenting with depressive symptoms again what is causing them what is what is the etiology of those depressive symptoms and there's probably multiple but we can't I can't emphasize enough how important it is to have a medical doctor on the treatment team with someone even with if you can conceptualize mild anorexia even somebody who's only like 5 or 10% below the norm. We really want to get a doc in there. Common co-occurring disorders are depression and anxiety so again differentiate anorexia from obsessed obsessive compulsive disorder don't forget men don't discount the late onset make sure we refer for a medical evaluation when somebody comes in and reports a history of you know restrictive dieting yoyo dieting you know anything that might perk up your spidey senses a little bit that may say this person is nutritionally deficient which is going to negatively impact any other recovery we try to address because if their body can't make the neurotransmitters and stay balanced and regulated we're fighting an uphill battle and rule out body dysmorphic disorder as the primary binge eating disorder now this is kind of interesting when we look at it binge eating is characterized by both of the following eating in a discrete period of time within any two hour period is generally the rule window you'd they give you an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances so you know I'm thinking to myself. Well what does that mean in our society I've seen people go to a restaurant and eat a big meal and put down five six thousand calories and you know I've seen people who are you know having a bad day eating entire pizza or you know a large amount of ice cream or half a chocolate cake now is that healthy. No but is it when we're looking at what most people would do in a similar time frame under similar circumstances if somebody else was really really stressed and they were self soothing with food. You know. You know is this behavior all that uncommon is it healthy no we're not saying that but we want to kind of look at normalizing what's going on and figuring out how often these binges occur. So next criteria that has to be there is a sense of lack of control over eating during the episode a feeling that they can't stop eating or control how much they're eating and I find a lot of clients get some relief from this when I'm working with them if they instead of eating out of the bag when they have eating potato chips or Oreos or whatever it is put it on a plate put it on a small plate force yourself to sit down you know changing some of their eating habits can help them get more control over their eating because mindless eating is very common in our society and so you may say okay last chip I'm not going to have any more than the bags just still sitting there. And you may eat again and then the person can start feeling like they don't have any control or any willpower. So we want to give them a sense of self efficacy and we want to help them establish sort of ground rules so they can start controlling how much they eat but this is not necessarily going to make the binges go away so we want to look at what's precipitating those binges what function is the binge serving when we're talking about treatment. Binge episodes are associated with three of the following eating much more rapidly than normal. Now again I don't know about you but me if I've gone all day long and I skip lunch and it's 6 o'clock at night and it's been like you know 12 hours since I've eaten or something. I'm probably going to inhale food and then worry about tasting it later when my son was little he used to have gastric reflux really bad and if we got 15 minutes without crying it was it was good. So anytime I would make food I would kind of eat it as quickly as I could because I knew I was going to have to pick the baby up in short order. Yes there are probably other ways to deal with that yada yada but anyhow. So there are times when I would eat much more rapidly than normal but does it qualify as a binge. Eating until feeling uncomfortably full now we're coming up on Thanksgiving and how many people do you know who after Thanksgiving meal kind of undoes their belt a little bit like oh my gosh I ate way too much. We all do it occasionally so we're normalizing eating large amounts of food when not feeling physically hungry. I think we've all done that occasionally. Eating alone because of feeling embarrassed by how much one is eating. So that's one of those indicators that people are embarrassed to eat in public. But we also want to look when I see that one I start thinking let's rule out bulimia here because a lot of times people with bulimia their self evaluation is very strongly based on their body shape and size. So they feel like people are judging them when they're out eating no matter how much they're eating. So you know we're looking at binge eating disorder obviously with binge eating disorder you don't have the compensatory mechanisms that you do in bulimia. And a binge eat episode can be characterized by feeling disgusted with oneself depressed or very guilty afterwards when you're looking at the bag and you're like I ate an entire bag of M&Ms. You know and again sometimes we do that and when I'm talking to clients and trying to figure out what's going on. Most of the time I don't want them to get all that hung up on making a diagnosis. I want to look at what symptoms are bothering them and let's just deal with those. But we do talk about the fact that you know sometimes people do people do occasionally binge. I mean even people without binge eating disorder. What does that mean to them? What does that mean about them? If they occasionally binge. What do they think about their best friend who may occasionally binge? You know what does that mean? And we also look at society and you know how much society kind of encourages us to eat so often. Binge eating disorders characterized by marked distress regarding binge eating. So if they're embarrassed about it if there's marked distress if they feel like they're spending way too much money on the food that they're binge eating on if they're having significant health problems because of their weight because of the binge eating then we might start looking at that binge eating occurs on average at least once a week for three months. So we want to look at the time criteria. It's not associated with the current use of inappropriate compensatory behaviors. So that helps us rule out bulimia. Understand that binge eating disorder is less common but much more severe than overeating. So it's not just going to a restaurant and having a big meal. It is eating you know several thousand calories in a particular setting you know 10,000 20,000 calories. Binge eating disorder is associated with more subjective distress regarding the eating behavior than just normal overeating people who just overeat you know and it's not a binge. It's not binge eating disorder. They're like oh I'm going to have to do an extra hour at the gym tomorrow or something and they're done with it. You know they don't beat themselves up for the rest of the night about how much they ate or feel bad about it or feel totally disempowered and and defeated. So again we're looking at a continuum. We have overeating over here which is well get back on the screen overeating which is you know normal people do it occasionally and then we've got binge eating which not only tends to have involve more calories in a shorter period of time but it has a lot more distress associated with it. And then bulimia recurrent episodes of binge eating which we just went through an inappropriate compensatory behavior in order to prevent weight gain self induced vomiting. That's one of them misuse of laxatives. That's another issue that we want to consider misuse of diuretics or other medications and and this can include diet pills that they think are going to speed up their metabolism metabolism amphetamines anything like that that they think is going to help them have less of an appetite and speed up their metabolism fasting. So you may see people who binge and then they don't eat for two days and then they binge and they don't eat for two days. Or excessive exercise and so what is excessive mean. We want to look at the average I mean if somebody's in in the gym for an hour that's different than if if they're in the gym for six hours. So paying attention to the excessive exercise and also in terms of how is it affecting their life you know spending occasionally spending a couple hours in the gym isn't that uncommon for some people going on a really long run is not that uncommon for people especially people training for marathons or something is that excessive exercise and when I'm talking with clients I'm looking for things like they're exercising despite the fact that they're starting to have joint problems they they are exercising or their exercise takes precedence over everything else in their life so they give up hobbies they give up spending time with family when it's really important or they set their work schedule around their exercise and they just can't function if they don't exercise that day. So that's what I'm looking at is you know does the anxiety level go through the roof if somebody can't exercise especially after they've been being an inappropriate compensatory behaviors both occur on average at least once a week for three months. Self-evaluation is unduly influenced by body shape and weight just like with anorexia the disturbance doesn't occur exclusively during the episodes of anorexia and and remember the biggest defining feature is the person's body weight whether they are meeting the criteria for anorexia because they refuse to maintain minimum body weight most people with bulimia are average or slightly above average body weight. We also want to rule out histrionic and borderline personality disorder one of the things that we see is as a co-occurring sometimes with bulimia is people having histrionic tendencies histrionic characteristics in their behaviors overly sexualized behaviors there's a strong correlation between trauma especially childhood sexual trauma and the development of bulimia later in life so sometimes we see some histrionic characteristics it may be something that needs to be addressed in treatment in order for the eating disorder to completely remit because if someone is unduly concerned with their shape and body size engaging in overly sexualized behavior in order to get approval then you know we've got to look at what is your body shape mean does it mean you're only lovable if you are a sexual being and the same thing with borderline personality disorder we see that come out a lot in people who've had early childhood sexual trauma so it may be another co-occurring issue that we want to attend to if it's present so you want to take a look at the personality disorders make sure there's not one that also needs to be attended to the current severity of bulimia mild one to three episodes of inappropriate compensatory behaviors per week so moderate is four to seven episodes so we're looking at you know about one a day severe is 18 to 13 8 to 13 episodes per week and extreme is 14 or more episodes of inappropriate compensatory behavior per week I will share with you when I was in college at my sorority purging was sort of a natural or an expected behavior so I would say that the majority of women in my sorority met the moderate criteria because you know after meals the bathrooms would be busy for quite a while so we're looking at anywhere from seven to 14 episodes per week so we want to be cognizant now when we're working with people who are in a community that supports that kind of behavior you know you're going to have a lot of resistance to changing the behavior because it's sort of inculturated in in that particular community so you know something that also probably will pop up as a treatment issue occasionally people with eating disorders very often don't have peers that they share it with but there are those occasional groups that will provide social pressure to the person to maintain the compensatory behaviors okay other common issues in eating disorder treatment that we want to consider from a therapist's point of view nutritional imbalances when someone is coming in whether it's bulimia anorexia even binge eat disorder generally you're not going to binge eat on the healthy things so if somebody is binge eating on you know Krispy Kreme donuts they're not getting their nutritional profile met so we want to look at nutritional imbalances make sure that they're being assessed for nutritional deficiencies by a medical professional to make sure again that they can make the neurotransmitters they need to in order to feel happy and calm and all that we also don't want to assume lack of knowledge one of the quickest ways to get someone with an eating disorder to shut down is to start educating them about what healthy eating is and what they need to eat and what carbohydrates are then most of them know that probably better than most registered dietitians they eat sleep and breathe calories macros macros you know it's it's part of what they obsess about as part of what they focus on so we don't want to assume they lack knowledge we want to look at again what's the behavior functioning for what is the basis of the behavior it's not that they don't know how to eat well it's serving a different purpose we also want to look at issues of sleep deprivation someone who is sleep deprived is going to maintain low levels of stress which is going to make it harder for them you know it's going to reduce the amount of available serotonin and all that kind of stuff going back to our HPA axis but we're also going to look at issues of hunger you know if they're hungry it may be keeping them from sleeping or they could be uncomfortable because they've been abusing laxatives because they're hungry because they're malnourished any of those things can negatively impact sleep which is going to negatively impact what we're trying to do and their ability to not only feel happier but also remember and learn those things because if they're focused on food and they're in a group therapy session and all they're thinking about is what can I eat that's within my calorie limit for today they're not hearing what you're saying they're not able to focus on that and retain it so we want to make sure they're getting enough sleep so they can focus they can retain stuff they don't create symptoms of depression we want to treat mood issues with the person that has an eating disorder but most people especially if they present and they say I've got an eating disorder if you tell them we're going to treat you know these other anxiety issues or whatever and once you develop the coping skills you won't need to binge anymore you won't need to restrict anymore so that's just secondary they're also probably going to walk out of your office because they don't feel hurt they're presenting and saying I've got a problem I have I feel like I have no control over this and I need to feel like I've got some sense of control so some people although you know well meaning may minimize the impact of the binging the purging the restricting which will turn off a lot of clients and may make them feel even more hopeless and helpless and isolated and failing to address the rebound effects from laxative and deretic abuse when you've been abusing deretics and you stop a lot of times people experience water retention fluid retention for several days or even a couple of weeks afterwards while the body's trying to adjust to oh wow we've got a lot of fluid coming in here and the person's not using the deretics so we want to pay attention to that now remembering laxative abuse and deretic abuse can also cause problems with internal organs so something that the MD needs to assess laxative abuse can also cause the colon to become lazy if you will and when people stop using laxatives they will become constipated they may have difficulty going to the bathroom which will increase their feelings of gassiness and bloating which will increase their feeling of oh my gosh you know I feel so bloated I can't exist like this if this is what recovery is like I can't do it helping people understand the process of basically getting the body back online and it takes several months helping them make sure to work with a nutritionist and a physician to you know ease that transition to ensure treatment compliance is going to be really important because they start freaking out if this you know if they're constipated the scale is going to go up if the scale goes up markedly you know it's it's a shock it's a huge anxiety trigger so we want to kind of look at working with them to address that so moving on from eating disorders because you know they are really prevalent unfortunately in our society more so than I would like to think so we need to pay attention to what's out there and whether our clients are struggling with an eating disorder substance use disorders now I know that types a little small here but I wanted it all on the same page taking the substance in larger amounts and for a longer period than intended wanting to cut down a quit but not being able to spending a lot of time obtaining the substance craving or a strong desire to use the substance failure to carry out major obligations at work school or home due to use continued use despite persistent or recurring social interpersonal physical psychological problems caused or made worse by use stopping or reducing important social occupational or recreational activities due to use and recurrent use of substances and physically hazardous situations now tolerance is indicated by an increased need for increased amounts of the substance or diminished effect with the use of the same amount and when we when we get down to gambling disorder you will see how these same criteria are basically worded a little bit differently but they're pretty much the same criteria gamblers for example need to gamble more money they need to take bigger risks in order to get the same rush that they got before withdrawal syndrome or or the substance is used to avoid withdrawal so when somebody stops using you know let's take alcohol for example we've talked about alcohol a lot and they start to detox from the alcohol their characteristic signs of alcohol withdrawal including the increase in blood pressure and anxiety or the person may be like no you know I I can't go through withdrawal I'm not going to go with through withdrawal but in order to prevent those symptoms they have to continue to use so you know you may see somebody who hasn't experienced withdrawal because they're not willing to stop long enough for their body to actually cleanse it out of their system now one of the caveats here is this does not apply when the drug is used appropriately under medical supervision so let's think about opiates here you know some people have persistent pain from you know a car accident from you know a wartime injury whatever and nothing else handles their pain they've tried you know gabapentin and some of some of the other medications out there they're supposed to help and it's just not working for them so they're on opiate based medications so do they need to take the substance in larger amounts over a period of time well yeah they do because their body adjusts to it and they develop a tolerance and a withdrawal to it but what we don't see in people who are using it appropriately under medical use supervision is continued use despite persistent interpersonal social problems using in hazardous situations or the reduction in important social occupational and recreational activities due to use now they may not be doing those things due to pain but they're not doing it due to use so they're not avoiding going to their kids ballgame because they want to stay home and shoot heroin they are not going to their kids ballgame because they're in too much pain even though they're taking the medication as prescribed will people who are taking it appropriately under medical supervision experience cravings sometimes yeah they will especially if they miss a dose will they spend a lot of time obtaining the substance you know probably not unless you know your doctor has a really long wait and is never running on time some people who are on prescribed opiate medications want to cut down but they're not able to do it it's not because it's because the pain is too bad the pain is too severe it's not because of the drug interaction it's because when they start cutting down even when they let their endogenous opioids kick back in there's just too much pain for them to have a quality of life so some people may want to quit that cut down or quit and not be able to do it because the underlying physical issue is just too severe so we want to look at you know not stigmatizing people we also want to look at you know when we start talking about medication assisted therapy methadone buprenorphine suboxone those sorts of things all of those things are also going to be present in in many circumstances so we want to look at is this a substance use disorder or you know are they able to carry out major obligations at work school and home whoops now that they're on methadone when they were shooting heroin they couldn't do that are they continuing to use and while they're using while they're on the medication assisted therapy are they experiencing as a result of the medication assisted therapy recurring social interpersonal physical or psychological problems generally the answer is no my experiences most people once they get on medication assisted therapy and they're in a treatment program they tend to start doing a lot better so just kind of bearing that in mind because in recovery circles and and certain self-help groups and stuff the use of medication assisted therapy is greatly frowned upon and the belief that some people need to be on pain medication for their entire lives for the entire rest of their lives is not accepted by some people so we really want to look at the individual and talk about you know what's going on with them told you we can move up to gambling disorder because that was added in the DSM five so you know we're starting to see the switch the move of the American Psychiatric Association to look at addictions and starting to look at behavioral addictions and the next one we're going to look at is internet gaming disorder that didn't make the cut that is in areas for further study but it did make it into the book so we're starting to see an acceptance or an awareness that there are things other than substances that can cause people significant psychosocial or physical problems and it can also contribute to psychological and mood issues so I think that's an awesome positive step that we're starting to legitimize people suffering if you will and we're saying yeah you know we can see it's a problem instead of there's nothing I can do so gambling disorder we're looking at a 12 month period here and a person needs to have for the criteria needs to gamble with increasing amounts of money for excitement you know if they started out with quarter slots and they're up to the $20 tables or whatever I don't gamble so I'm just kind of swinging it here you know we're seeing an increase is restless or irritable when attempting to cut down or stop gambling so if they can't go bet on the ponies or bet on the sports games or fantasy football or whatever it is they start getting really irritable and cranky cranky and restless and especially if they figure out that they could have won some money they can get really cantankerous have made repeated unsuccessful efforts to control or stop gambling so you know if they're put in a situation maybe they play poker at a buddy's house and they say you know I'm going to stop after I lose $500 or $100 or whatever it is and they keep going and even though they said this is my hard line I'm going to stop here they keep going after that and they are unable to quit the game at that point it qualifies is often preoccupied with gambling when feeling distressed so they start getting anxious whether it's about money or not gambling when you're gambling it takes a lot of mental focus to figure out what you're going to bet on or play the game that you're playing so people can start kind of drifting off and start thinking about gambling when stress gets really high because they're looking for that escape they're looking for that rush after losing money gambling often returns another day to get even so they're chasing the high they're trying to come back they're trying to get even trying to win their money back but they're also trying to get that rush because they left on it on a down if you want to make a parallel with drugs it's like getting a bad hit of something and having a really bad high experience a lot of people will come back and try to do it again going now that's not how it's supposed to be they lie to conceal the extent of involvement with gambling they've jeopardized or lost significant relationships jobs or educational or career opportunities because of gambling you know gambling a lot of times is not during the day it's at night so people stay up really really late so they may be barely conscious when they're at work and they may get terminated they may have difficulty in their relationships because they're always going out gambling instead of staying home or going out with their significant others to do something else likewise people I know people who've gotten in trouble at work gambling they can't even put gambling aside long enough to be at work so they end up getting terminated for that and they rely on others to provide money to relieve desperate financial situations caused by gambling not everybody has to meet this criteria before they meet gambling disorder remember they only have to meet four of these criteria a lot of times people are not going to present for treatment until they get into those situations that are financially desperate but paying attention especially if you're in an area where there is a lot of gambling that's prevalent there's casinos there's those things definitely pay attention to that but even in places where there's not there's always poker games and you know online betting online gambling is huge and if you go to the right sites there are a lot of places that will tempt people and they'll give them the first five hundred dollars worth of chips free so to the gambler they make it on and go well you know what can it hurt because I'm not spending any money but then they lose that five hundred that they got free and then they start putting their own money into it so the online gambling establishment sort of enticed people to get started and then once they get started hope that the person can't stop gambling behavior is not better explained by a manic episode when people are manic and this is not new news they will engage in thrill seeking impulsive behaviors they can be wide open for days on end and sometimes people engage in a lot of gambling during this it's risk-taking it's thrill seeking so we want to rule out is this person in a manic episode you know is there a history of bipolar disorder or could it be the onset of bipolar disorder or is it just gambling when bipolar is not adequately controlled people may engage in gambling behavior during a manic episode which there's there was a recent lawsuit against one of the medications for bipolar disorder claiming that people who took that medication also sometimes developed a gambling problem and my thought was well doesn't that tell you that the medication wasn't very effective because it didn't stabilize the manic episode but that was just me so we want to rule rule that out you want to specify if it's episodic or if it's persistent and persistent means continuous for multiple years because remember we're looking at criteria for a year just for diagnosis and then you can specify whether it's in early remission or sustained remission but for remission it says none of the criteria can have been met for 12 months or longer so you know there's a lot of criteria there that may be met in 12 months so it's hard for people to get in full remission and finally internet gaming well not finally one more after this internet gaming disorder right now repetitive use of internet games causing significant issues with functioning five criteria must be met within a year preoccupation with the games withdrawal when not playing the games tolerance more time is needed to be spent playing the games now if you know anybody back in early 2000s I think it was when world of warcraft became really popular I know people who you know called in sick to work and ended up getting divorced I know two people who ended up getting divorced over their engagement in world of warcraft so you know it can get to be an obsessive kind of behavior tried to stop or curb playing but failed to do so has had a loss of interest in other life activities such as hobbies they just come home get on the computer play until it's time for bed or maybe even for go sleep and we've seen pictures of or media portrayals of gamers who wear adult diapers and have food brought to them they don't even get up to go to the bathroom or eat the person as I continued overuse of internet games even when knowledge of how much they were impacting their life so they may look around to go yeah my wife left me I lost my job but you know whatever they've lied to others about the extent of their internet game use use internet games to relieve anxiety or guilt it's a way to escape and has lost or put at risk and opportunity or relationship because of internet games right now the internet gaming disorder only includes internet games it does not include general use of the internet online gambling that would go under gambling criteria and it does not include social media so for those of you who are hoping there was a diagnosis for somebody who's addicted to Facebook it doesn't exist right now so you know those are things that we're kind of looking at but anytime somebody comes into our office and they evidence these criteria preoccupation withdrawal tolerance inability to stop and two or more problems in life because of their use of whatever it is you know it is a clinically significant issue that needs to be addressed regardless of whether the DSM has a diagnosis for it or not sex addiction has also not made it into the DSM yet despite what all of the internet would have you believe you know because it's on the internet it must be true right sex addiction is not an official diagnosis what they're looking at is hoping to try to get it included in the next version of the DSM as an area for further study but the criteria they're using is similar to the others recurrent failure to resist sexual impulses engaging in sexual behaviors to a greater extent or for longer than intended unsuccessful efforts to stop excessive time spent obtaining sex being sexual or recovering from sexual experiences obsessed with parent preparing for sexual activities frequently engaged in sexual behavior when expected to be fulfilling occupational academic domestic or social obligations I can't tell you how many people I've had to write up for looking at porn while they were at work continued sexual behavior despite knowing it's caused or exacerbated problems in their life increased intensity frequency number or risk of sexual behaviors to achieve the desired effect so sometimes people will go to something that's more shocking which is one of the ways we see the development of you know once they've looked at all of the average run of the mill porn we see people going to more hardcore stuff given up or limited social occupational recreational activities because of the sexual behavior and become upset anxious or restless if unable to engage in the behavior one of the big controversies is that sex is a natural behavior so who are we to say what's normal and what's abnormal what frequency is normal and I think what the proponents of this diagnosis come back with is we're not saying we're looking at frequency for what's normal or abnormal we're looking at how is it impacting the person psychologically occupationally interpersonally is it causing them problems is it forming a major portion of their day where they're obsessing about it and they're giving up other things that they used to like that's what I'm gleaning from the material that I read about the people that are pushing to have this added as a diagnosis as I said it's not currently an area for further study or in the DSM-5 but we're seeing a gradual opening of awareness to behavioral type addictions what do we do how do we treat someone who presents claiming to have sex addiction you know obviously we're not going to go well that's not in the DSM so it's private pay or nothing but a lot of the treatment centers that's what they're doing now they advertise they treat sex addiction and they say that most insurance companies cover addiction treatment what they fail to say is unless you have another addiction that's actually in the DSM insurance ain't going to pay for it in every case that I know now there could be exceptions obviously you want to assess for concurrent diagnoses if somebody presents with sex addiction do they have other things that may be motivating that compulsive behavior are they trying to basically self-medicate are they dealing with adjustment disorder dependent personality depression histrionic personality or PTSD those are you know common diagnoses which you could see co-occurring with sex or pornography addiction so if you're trying to work with somebody who's presented and they're in a great amount of distress and they have you know self-diagnosed sex addiction but they also have other issues going on you know you can code for those issues and get reimbursed for those it may not be enough to sessions to treat the sex addiction but it can get the person started addiction treatment issues we always regardless of what the addiction is or what they proclaim their addiction is examine the reasons of the function of the use to identify areas for intervention what triggers their use is it anxiety is it stress is it sobering up you know we also want to look at when you're using you're disrupting the neurotransmitter balance so you know when you stop using you're probably going to experience some depression and or anxiety and so when the person tries to stop on their own they experience these dysphoric emotions and they're like ah and they may return to use in order to not feel that way so we want to look at what needs to be done to get the person through the initial acute withdrawal period and what other functions is this behavior serving if it's to help them deal with stress anxiety or depression well what's causing those and we want to help people develop distress tolerance skills to deal with urges even after they're in recovery or however you want to say it there are going to be times when they're triggered and they have the desire to use again they think about using again and that can be really scary for somebody who has been addicted to something so we want to help them develop those distress tolerance skills to deal with the urges one analogy I use for some of my clients is thinking about a bumblebee you know assuming you're not deathly allergic to them if a bee lands on your arm your immediate urge is probably to swipe it off you know if a fly lands on me my natural instinct my immediate urge is to wipe it off now if you swat a bumblebee what's going to happen it's probably going to come back and sting you so distress tolerance skills is like dealing with that bumblebee taking a breath and deciding you know what I don't want to get stung so I'm going to tolerate the bee sitting there even though it makes me a little bit uncomfortable I'm going to tolerate it sitting on my arm until it's ready to fly away which will be in a few minutes so in summary whether you're alone or concurrently with mood medical psychotic or personality disorders so we want to make sure to really do a comprehensive assessment because we need to address all of the areas of presentation common errors we want to make sure to differentiate eating disorders from obsessive compulsive disorder you know if they are using it ritualistically if they're having obsessions about it don't forget males in your eating disorder diagnosis or discount late onset for men or women it can have an initial presentation you know as late as 40 years old and that's still within the norm range ensure that we make referrals to physicians for eating disorders alcohol or benzo misuse not even necessarily meeting the criteria for substance use disorder generally you know we should be referring making sure the person's had a physical when they present or anything to rule out physiological causes but alcohol and benzo withdrawal can be life-threatening and eating disorders can put the person in a position where they're damaging their organs and in a life-threatening position rule out body dysmorphic disorder with eating disorders it can co-occur but you want to make sure it's not just BDD emotional eating likely doesn't meet criteria for binge eating so we don't want to assume that address nutritional imbalances send them to a physician get them with a registered dietitian for any people that we're working with whether it's somebody who's got a gambling disorder and they've been up drinking and gambling all the time and they're not eating well or the person with an eating disorder make sure to address sleep deprivation in the treatment plan don't treat a mood issues and expect food issues to spontaneously remit address the rebound effects from laxative and erratic abuse addiction treatment does not apply when the substance is being used appropriately under medical supervision so we don't want to you know necessarily diagnose somebody with an addiction if they're using it appropriately and rule out bipolar disorder specifically a manic episode when we're evaluating somebody for gambling disorder all righty thank you everybody for coming today and if you're here tomorrow I will be remember we don't have class on Thursday because it's Thanksgiving if I didn't um uh if I didn't what I lost my train of thought oh if I don't see you tomorrow have a very happy Thanksgiving and I will see you next week if you enjoy this podcast please like and subscribe either in 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