I PSYCHOSOCIAL ISSUES ^445

Communication and counseling skills are an important aspect of women’s health care; psychosocial well-being is an important element of overall health. Some of the psychosocial issues most commonly encountered by obstetrician-gynecologists are discussed here.

Stress

Stress can be a reaction to a short-lived situation or it can be long last­ing and due to relationship problems or other serious situations. Distress occurs when an individual does not adapt well to stress. Stress may inter­fere with a patient’s ability to live a normal life. It may manifest itself in an inability to concentrate, irritability, fatigue, and other physical symptoms.

Stress secondary to partner and relationship problems may manifest as sexual dysfunction. Although stress may be associated with sexual dysfunc­tion and some estimates indicate that up to 43% of women have a form of sexual dysfunction at some point in their life, only 12 % of women report having sexual dysfunction and feeling distressed about it. Similarly, it is unclear whether the stress related to sexual dysfunction is a contributing factor in some of the behaviors and psychosocial disorders described later in this section, or if it is an associated symptom. For example, women who present with various forms of eating disorders were reported to have a higher incidence of sexual dysfunction than women without an eating disorder. In a study of women with various types of eating disorders, those with the restricting type or the binge-eating and purging type of anorexia nervosa had the highest percentage of loss of libido—75% and 74%, respectively. Stress-reduction techniques, such as mindfulness, meditation, yoga, prayer, and progressive muscle relaxation, may reduce fatigue and low-libido symptoms (see also the “Sexual Function and Dysfunction” sec­tion in Part 4).

Feeding and Eating Disorders

A woman’s health is enhanced by maintaining a healthy weight and good eating habits.

Types

Feeding and eating disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders include anorexia nervosa, bulimia nervosa, binge-eating disorder, pica, rumination disorder, and avoidant/ restrictive food intake disorder. The first three types are the disorders most frequently encountered in the age group cared for by obstetrician­gynecologists and are discussed as follows. It is important to note that the patient may move from one category to another during the course of the eating disorder.

Anorexia Nervosa

Anorexia nervosa is defined by three essential features: 1) persistent energy intake restriction, which leads to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health; 2) an intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain; and 3) a disturbance in self-perceived body weight or shape. Notably, “amenorrhea for more than three menstrual cycles” has been eliminated as a diagnostic criterion for anorexia in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. Although amenorrhea or other menstrual irregularity may be a present­ing symptom, it is not an applicable diagnostic criterion in all situations (eg, premenarchal females, oral contraceptive users, and postmenopausal women). In addition, some individuals may meet all other diagnostic requirements for anorexia but still report some menstrual activity.

Individuals with anorexia nervosa commonly control body weight through voluntary starvation, excessive exercise, or other weight control measures, such as diet pills or diuretic drugs. The overwhelming majority of patients (95%) with diagnosed anorexia nervosa are female. Individuals 12-18 years of age are most frequently affected, but anorexia nervosa does occur in older women and has been reported in young children.

Bulimia Nervosa

Bulimia nervosa is defined as recurrent episodes of binge eating accompa­nied by the following: eating, in a discrete period of time (eg, within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circum­stances; and the sense of lack of control over the amount being eaten or the ability to stop. Patients with bulimia nervosa are unduly influenced in their self-evaluation by body shape and weight. These individuals do not deny themselves food but rather engage in excess food consumption and then purge it out of their systems using laxatives, self-induced vomiting,

Box 3-31. Subtypes of Anorexia Nervosa

Binge-eating/purging—During the past 3 months, the patient has engaged in recurrent episodes of binge eating or purging behavior, with purging accom­plished through self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

Restricting—During the past 3 months, the patient has not engaged in recur­rent episodes of binge-eating or purging behavior; weight loss is accomplished through dieting, fasting, excessive exercise, or two or more of these three.

Some patients engage in cycles of binge eating and purging in addition to frequent fasting.

Adapted from American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. 5th ed. Washington, DC: APA; 2013. and other behaviors. Individuals with bulimia nervosa may be of average weight, underweight, or overweight.

Binge-Eating Disorder

Binge-eating disorder is defined as eating large amounts of food in a dis­crete period of time and is characterized by marked distress regarding binge eating and a sense of lack of control. The binge eating occurs, on average, at least once a week for 3 months. In this way, it is a variant of bulimia ner­vosa. However, binge eaters do not routinely engage in purging behaviors or compensatory behaviors, such as excessive exercise or prolonged fasting. Research has shown that dieting (fasting), chronic restrained eating, and excessive exercise may be important triggers for binge-eating disorder.

Health Consequences

Eating disorders can have life-threatening consequences. Anorexia nervosa ranks third among common chronic disorders in adolescents, surpassed only by asthma and obesity. It can cause psychologic, physiologic, endo­crine, and gynecologic problems (see Box 3-32). Medical complications of anorexia nervosa include cardiac abnormalities, dangerously low blood pressure and body temperature, low white blood cell count, chronic constipation, osteoporosis, slowed adolescent growth or development, short stature, loss of menstrual periods, infertility, hair loss, and fingernail destruction. Morbidity may reach 10-15%. Deaths are from causes such as starvation, cardiac arrhythmias, cardiac failure, and suicide.

The medical complications of bulimia nervosa can be life threaten­ing and include electrolyte abnormalities that can lead to heart rhythm disturbances, dehydration, dangerously low blood pressure, menstrual cycle abnormalities, enlarged parotid glands, destruction of dental enamel, dental cavities, and bowel abnormalities. Pulmonary complications of aspiration pneumonia and pneumomediastinum can result from vomiting. Irreversible cardiomyopathy may occur in patients with bulimia who use ipecac to induce vomiting.

Binge-eating disorder has a persistent course and often is associated with comorbid psychopathology (eg, depression), which contributes to medical complications.

Box 3-32. Common Presentations of Eating Disorders ^

Gynecologic presentations

• Amenorrhea

• Menstrual irregularity

• Constipation or abdominal pain

• Sexually transmitted infections

• Contraceptive needs

• Pelvic pain

• Atrophic vaginitis

• Breast atrophy

Other presentations

• Depression

• Weakness

• Sports injuries and fractures

• Mouth sores

• Pharyngeal trauma

• Dental caries

• Heartburn

• Chest pain

• Muscle cramps

• Bloody diarrhea

• Bleeding or easy bruising

• Fainting

• Routine medical care

Reprinted from American College of Obstetricians and Gynecologists. Eating disorders in adolescents. In: Guidelines for adolescent health care [CD-ROM]. 2nd ed. Washington, DC: American College of Obstetricians and Gynecologists; 2011. p. 134-47.

Screening and Assessment

The American College of Obstetricians and Gynecologists recommends that all women be counseled on dietary and nutrition issues on a yearly basis or as appropriate. All adolescents should be screened annually for eating disorders and obesity by determining actual weight and stature, calculating body mass index, and asking about body image and eating patterns. A screening tool, such as the SCOFF questionnaire or the EAT-26 questionnaire, also may be used (see Resources). Vital sign abnormalities, including abnormal blood pressure or pulse rate, may be the initial finding that alerts a clinician to a potential eating disorder.

Women and adolescents should be assessed for organic disease, anorexia nervosa, or bulimia nervosa if any of the following conditions or behaviors is found:

• Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, develop­mental trajectory, and physical health

• Recurrent dieting when not overweight

• Amenorrhea or abnormal menses

• Use of self-induced emesis, laxatives, starvation, or diuretics to lose weight

• Undue influence of body weight or shape on self-evaluation

• Body mass index below the 5th percentile

• Hypotension, bradycardia, cardiac arrhythmia, or hypothermia

• Excessive exercising

• Recurrent constipation or unexplained pelvic abdominal pain

• Marked perianal erythema (may be secondary to laxative abuse)

The clinician who finds indications of an eating disorder in a patient should discuss their concerns with the patient and consider the following diagnostic studies:

• Complete blood count (usually normal; white blood cell count possibly low)

• Thyroid function tests (levels of thyroxine and triiodothyronine usu­ally are low in patients with anorexia)

• Electrocardiography (cardiac abnormalities: eg, slow heart rate or disturbances of heart rhythm)

• Electrolyte evaluation (abnormal findings related to purging)

• Follicle-stimulating hormone and luteinizing hormone tests

Management

Once an eating disorder has been suspected or diagnosed, the clinician should assess his or her ability to identify and manage continuing prob­lems and join with a multidisciplinary team of specialists or refer the patient to another practitioner when needed.

Management of eating disorders may include hospitalization, nutri­tional rehabilitation, psychosocial therapy, medications, the use of the addiction model, or a combination of psychosocial and medication strategies. Patients with anorexia nervosa often have concurrent hypoes- trogenism. Merely providing the patient who has anorexia nervosa with hormones does not treat this complex disease adequately and may exacer­bate patient concerns about weight gain and body image. Other interven­tions, as already indicated, are much more critical to prevent mortality and morbidity.

Nonsuicidal Self-Injury Behavior and Related Disorders

Nonsuicidal self-injury behavior disorder is characterized by repetitive infliction of shallow yet painful injuries to the surface of one’s body with a sharp object with the intent to relieve negative emotions. Patients who repeatedly cut or burn themselves or do other damage to their bodies but lack suicidal intent may be displaying signs of nonsuicidal self-injury behavior. Although tattooing and body piercing has become more popular in today’s society, a compulsive approach to these activities may indicate the need to screen for nonsuicidal self-injury behavior.

Although self-injury behavior can occur in any population, it is more often found in adolescent females with a history of physical, emotional, or sexual abuse. These individuals have a higher incidence of substance abuse and eating disorders. Patients who practice self-injury have often been raised in families that discouraged expression of anger and so they subsequently have a lack of skills to express their emotions, and they may also lack a good social support network.

Other disorders characterized by self-injury behavior include tricho­tillomania, stereotypic self-injury disorder, excoriation, and borderline personality disorder. Trichotillomania involves self-injurious behavior focused on pulling out one’s hair (commonly from the scalp, eyebrows, or eyelashes) during periods of relaxation. Stereotypic self-injury behavior disorder includes head banging, self-biting, or self-hitting during periods of intense concentration and often is associated with developmental delay. Excoriation disorder is characterized by skin-picking (without an imple­ment) of self-deemed unsightly or blemished sites, typically on the face, arms, and hands. Borderline personality disorder is a serious mental illness characterized by instability in interpersonal relationships and impulsivity. Although self-injury behavior is a common symptom of borderline person­ality disorder, individuals with nonsuicidal self-injury behavior typically do not display the intense bouts of aggressive and hostile behavior that is characteristic of borderline personality disorder.

Recognition of self-injury behavior requires referral to a mental health professional experienced in its diagnosis and treatment. Management includes psychotherapy, group therapy, and pharmacologic agents.

Bibliography

American College of Obstetricians and Gynecologists. Eating disorders in adoles­cents. In: Guidelines for adolescent health care [CD-ROM]. 2nd ed. Washington, DC: American College of Obstetricians and Gynecologists; 2011. p. 134-47.

American Psychiatric Association. Diagnostic and statistical manual of mental dis­orders: DSM-5. 5th ed. Washington, DC: APA; 2013.

Andersen AE, Ryan GL. Eating disorders in the obstetric and gynecologic patient population. Obstet Gynecol 2009;114:1353-67. [PubMed] [Obstetrics & Gynecology] Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999;281:537-44. [PubMed] [Full Text]

Pinheiro AP, Raney TJ, Thornton LM, Fichter MM, Berrettini WH, Goldman D, et al. Sexual functioning in women with eating disorders. Int J Eat Disord 2010;43:123-9. [PubMed] [Full Text]

Rome ES, Ammerman S, Rosen DS, Keller RJ, Lock J, Mammel KA, et al. Children and adolescents with eating disorders: the state of the art. Pediatrics 2003;111: e98-108. [PubMed] [Full Text]

Rosen DS. Identification and management of eating disorders in children and ado­lescents. American Academy of Pediatrics Committee on Adolescence. Pediatrics 2010;126:1240-53. [PubMed] [Full Text]

Resources

American College of Obstetricians and Gynecologists, District II. Finding solutions for female sexual dysfunction. Albany (NY): American College of Obstetricians and Gynecologists, District II; 2010. Available at: http://mail.ny.acog.org/website/ FSDResourceGuide.pdf. Retrieved September 14, 2013.

American College of Obstetricians and Gynecologists. Adolescent visit record and adolescent visit and parent questionnaires. Washington, DC: American College of Obstetricians and Gynecologists; 2010.

American College of Obstetricians and Gynecologists. Annual women's health care.

Available at: http://www.acog.org/wellwoman. Retrieved October 1, 2013.

American College of Obstetricians and Gynecologists. Weight control: eating right and keeping fit. Patient Education Pamphlet AP064. Washington, DC: American College of Obstetricians and Gynecologists; 2013.

American Psychological Association. Psychology topics: sexuality. Available at: http://www.apa.org/topics/sexuality/index.aspx. Retrieved July 31, 2013.

Dell D. Mood and anxiety disorders. In: Clin Update Womens Health Care. 2008. p.1-98.

Eating Attitudes Test (EAT-26). Available at: http://www.eat-26.com/index.php. Retrieved July 31, 2013.

ECRI Institute. Bulimia nervosa resource guide. Available at: http://www.bulimiagu ide.org. Retrieved July 31, 2013.

Herzog DB, Franks DL, Cable P. Unlocking the mysteries of eating disorders: a life­saving guide to your child's treatment and recovery. New York (NY): McGraw-Hill; 2008.

Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: a new screening tool for eating disorders. West J Med 2000;172:164-5. [PubMed] [Full Text]

National Eating Disorders Association. Available at: https://www.nationaleatingdis orders.org/. Retrieved September 14, 2013.

National Institute of Mental Health. Eating disorders. Bethesda (MD): NIMH; 2011. Available at: http://www.nimh.nih.gov/health/publications/eating-disorders/ eating-disorders.pdf. Retrieved September 14, 2013.

National Institutes of Mental Health. Borderline personality disorder. Available at: http://www.nimh.nih.gov/h ealth/publications/borderline-personality-disorder/ index.shtml. Retrieved July 31, 2013.

Sadock BJ, Sadock VA, Ruiz P. Kaplan & Sadock's synopsis of psychiatry: behav­ioral sciences/clinical psychiatry. 11th ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2014.

Sidran Institute. Available at: www.sidran.org. Retrieved September 14, 2013.

Zerbe KJ, Rosenberg J. Eating disorders. In: Clin. Update Womens Health Care. 2008. p.1-86.