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What’s the Difference Between Anorexia Nervosa and Bulimia Nervosa?

signGiven the similarities between bulimia nervosa and anorexia nervosa, binge-eating/purging type, there's room for confusion when making a diagnosis, whether on the ASWB exam or in real life. Let's take a look at what the DSM says about each.

What is anorexia nervosa?

Criteria for anorexia nervosa are as follows:

A. Restriction of energy intake leading to significantly low body weight.

B. Intense fear of gaining weight despite significantly low weight.

C. Disturbance in the way one's body weight or shape is experienced, undue influence of body weight shape on self-evaluation, or persistent lack of recognition of the seriousness of current low body weight.

What are the types of anorexia nervosa?

There are two subtypes in anorexia nervosa:

Restricting type. Weight loss accomplished primarily through dieting, fasting, and/or excessive exercise (not recurrent binging or purging).

Binge-eating/purging type. Recurrent episodes of binge eating or purging (self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

What is bulimia nervosa?

Criteria for bulimia nervosa are as follows:

A. Recurrent episodes of binge eating (overeating in a discrete period of time with a sensed lack of control regarding the eating).

B. Recurrent inappropriate compensatory behaviors to prevent weight gain (e.g., self-induced vomiting, misuse of laxatives, diuretics, or other medications; fasting; excessive exercise).

C. Lasts once a week for three months.

D. Self-evaluation is unduly influenced by body shape and weight.

E. Does not occur exclusively during episodes of anorexia nervosa.

What's the difference between anorexia nervosa, binge/purging-type and bulimia nervosa?

Both anorexia nervosa and bulimia nervosa involve negative self-evaluation of body shape and weight. Both involve behaviors to avoid weight gain such as self-induced vomiting. However, in anorexia nervosa, the disorder leads to significantly low body weight, where bulimia nervosa does not.

The difference is the ways severity is coded for anorexia and bulimia helps highlight the essential difference between the two diagnoses.

For anorexia nervosa, severity is based on body mass index (BMI). For example, "mild" indicates a BMI less than or equal to 17 kilograms per square meter. "Extreme" indicates a BMI of less than fifteen kilograms per square meter.

For bulimia nervosa, severity is based on the frequency of behaviors. For 1-3 episodes per week, a specifier of "mild" is applied. "Extreme" is used for 14 or more episodes per week.

The difference is not the behavior itself, it's the result.

Free ASWB Exam Practice

The ASWB exam often tests to assess knowledge of differentials between commonly occurring DSM disorders like anorexia and bulimia. A sample question:

A 17-year-old client who appears noticeably underweight reports frequently forcing herself to vomit after meals in order to "stay skinny for cheerleading." The MOST likely DSM diagnosis for this client is a type of:

A. Bulimia nervosa

B. Body dysmorphic disorder

C. Rumination disorder

D. Anorexia nervosa

Unless you're caught by the distractors, body dysmorphic disorder (which is not diagnosed when an eating disorder is present) and rumination disorder (not described here), knowing the difference between anorexia and bulimia quickly gets you to the correct answer. The client is "noticeably underweight." You have your essential information. The phrase "a type of" at the end of the question stem is an additional clue. The client is most likely suffering from anorexia nervosa, binge/purging-type. The answer is D.

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Name That Defense Mechanism

defendedHere's a quick quiz that should help you lock down your ease with defense mechanism. What are defense mechanisms? Wikipedia wants to tell you:

A defense mechanism is an unconscious psychological mechanism that reduces anxiety arising from unacceptable or potentially harmful stimuli. Defense mechanisms are not to be confused with conscious coping strategies. Sigmund Freud was one of the first proponents of this construct.

Okay, but which defense mechanism is which? Here's a short list of examples, courtesy of Simply Psychology. You provide the name of the defense mechanism. Good luck!

1. A young man has no conscious awareness of his desire to hurt his father.

2. A smoker refuses to admit to herself that smoking is bad for one's health.

3. A person comes to believe that their anger toward a rival started with the rival's misbehavior toward them.

4. A person frustrated by their boss, goes home and kicks their dog.

5. An angry person feels relief from working long hours.

How'd you do? Answers are in comments.

There are more defense mechanisms where these came from. Read up on the sites linked above and also here:

To get realistic exam questions about defense mechanisms and much more in SWTP's full-length mock exams, sign up!

Good luck on the exam!

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Generalized Anxiety Disorder and the Social Work Exam

coffee (38861808_s)The theme lately has been anxiety disorders. Let's continue now with generalized anxiety disorder (GAD). Criteria for GAD are pretty straightforward:

A. Excessive anxiety and worry occurring more days than not for at least six months, about a number of events or activities.

B. The worry is difficult to control.

C. The worry comes with three or more of these (or just one in children):

   1. Restlessness, feeling keyed up or on edge.

   2. Being easily fatigued.

   3. Difficulty concentrating or mind going blank.

   4. Irritability.

   5. Muscle tension.

   6. Sleep problems.

Plus the usual...

D. Symptoms cause clinically significant distress or impairment.

E. Not substance induced

F. Not better explained by another condition (e.g., panic, OCD, PTSD, anorexia, somatic symptom disorder, body dysmorphic disorder, illness anxiety disorder, schizophrenia, or delusional disorder).

That is, lots of anxiety, lots of the time. Which is simple enough as far as the social work licensing exam goes, until you get to the "e.g." in letter F. All those rule outs. To be able to identify GAD, you have to be able to identify what it isn't. That means you have to have a pretty good idea what all of those other anxiety and related disorders look like. Suddenly, learning GAD for the exam becomes a little more complicated than expected.

On the test, you might see GAD as a frequent distractor (an appealing answer that isn't the correct answer). It's a catch-all for anxiety-related symptoms. How to ready yourself to tell when GAD's a distractor and when it's the answer? Piecing together your own practice question might help. It could go something like this:

A client tells a social worker he's been an "anxious mess" ever since dropping out of college, worrying about a variety of things "all of the time." He reports difficulty falling asleep even though he's usually exhausted early in the day. He has trouble with self-care like reading or meditating--"my mind just keeps going."

If you leave it there, you've got GAD. Worry for more days than not, significant distress, three of the six offered symptoms. But here's a quiz. Imagine there's an added line. What's the MOST likely diagnosis then?

The client reports everything is easier when he drinks fewer than four cups of coffee in a day.

...or...

The client reports he is "obsessed" with how much he weighs. His MD wants him to put on 20 additional pounds--"but he's a quack."

...or...

The client reports he witnessed a suicide in his college dorm room--"I've never been the same since."

Etc. Now you're into something that may not be GAD. Four cups of coffee--sounds like the symptoms may be "attributable to the physiological effects of a substance." Weigh obsession and weight loss--sounds like anorexia nervosa. Witnessed a suicide--sounds like the client's symptoms might be better explained by PTSD.

And so on. You get the idea.

For more reading about generalized anxiety disorder, check out:

For exam-style questions about GAD, anxiety disorders, and lots more, sign up for SWTP full-length practice tests!

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Panic Disorder and the Social Work Exam

panic (3633778_s)Your client reports occasional "freak outs" during which she experiences:

1. Palpitations

2. Sweating

3. Trembling

4. Shortness of breath

5. Choking feelings

6. Chest pain

7. Nausea

8. Dizziness

9. Chills

10. Numbness

11. Feelings of unreality

12. Fear of going crazy

13. Fear of dying

What's she experiencing? That's a panic attack. What's the diagnosis? It's very likely panic disorder. This imaginary client is symptoms in every one of the thirteen categories of symptoms that make up a panic attack. (She only needed to have four to meet initial criteria for a panic disorder diagnosis.) It's as if she entered your office to help you prepare for the ASWB exam. Thanks, client!

In order to fully meet panic disorder criteria, a panic attack needs to be follow by a month or more of either 1) persistent worry about additional panic attacks or 2) significant maladaptive change in behavior related to the attacks (avoidance bx, that is). Also, as with every last diagnosis, panic disorder can only be diagnosed if it's not better explained by substance use or a medical condition. So watch out for an exam question like this:

A client reports a series of panic attacks during which he experiences an accelerated heart rate, shaking, a sensation of being smothered, and heat sensations. He worries "all the time" about future panic attacks and has stopped dating for fear of a panic attack occurring in the middle of a date. What should the social worker do FIRST to help this client?

Before looking at the answers, think of what yours would be. That's generally a good approach to studying, unless you're pressed for time (e.g., in timed mode on a practice exam). What answers might you expect to see as A-D? Maybe these:

A) Diagnose the client with panic disorder

B) Provide psychoeducation about panic attacks

C) Refer client for a medical evaluation

D) Introduce cognitive behavioral techniques for reducing panic.

What do you say? We're in a diagnostic blog post, so the diagnostic answer is tempting. But it's premature to diagnose the client. First things first: rule out an underlying medical condition that may be causing the client's panic-attacky symptoms (the client's symptoms are just about all the ones left of the DSM list of thirteen above) . The client saying he's having panic attacks doesn't mean that's necessarily what's really going on. He should get a clean bill of health, then receive the diagnosis, then the psychoed and CBT. This simple order of operations--rule outs first!--will help get you through many a social work exam item.

Before moving on to helpful links, there's one more thing to note for the diagnosis: Culture-specific symptoms are sometimes seen. The DSM-5 lists tinnitus, headaches, and "uncontrollable screaming or crying" among them. They count too.

Okay, now some helpful links:

For more exam prep re panic disorder and lots more, try SWTP's full-length practice tests. Sign up to get started!

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Social Anxiety Disorder and the Social Work Exam

judgement (34043230_s)Social anxiety disorder aka SAD aka social phobia is one of those diagnoses, like OCD or PTSD, that many people use casually to describe non-clinical symptoms (eg, "I really don't want to go to that party, my social phobia's kicking in.") But having some anxiety about party-going or spending time in groups of people isn't a disorder. It's just, for many, life--normal, non-clinical worry. Take a look at these (abridged) criteria for SAD:

A. Fear of scrutiny in social situations.

B. Fear of anxiety showing and being negatively evaluated.

C. The social situations almost always provoke anxiety.

D. The social situations are avoided and endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual threat posed.

F. Symptoms are persistent, lasting for 6 months or more.

G. Symptoms cause clinically significant distress or impairment.

H Symptoms are not attributable to the effects of a substance or

I. ...another disorder or...

J. ...a medical condition.

The focus in social anxiety disorder is a fear of scrutiny and negative evaluation. What will people say about me? On the social work licensing exam, look for phrases like that. As soon as you see,  people think I'm a loser, start thinking social anxiety disorder. Then look for the six month duration, intensity, impairment, lack of exceptions, and the absence of other explanations, and you've got your dx!

SAD was by far the most popular choice for the last free practice question. And why not? "A social worker sees a client, an MSW student, who reports feeling anxious in social situations, especially in classes. She says she gets clammy hands, shortness of breath, and can't bring herself to speak at all when called upon." That sounds a lot like social anxiety disorder. The trick there was the client's inability to speak. That's not a SAD symptom. That's selective mutism. Selective mutism was the best primary diagnosis in that case. The client in the vignette may qualify for both diagnoses. So it's sort of a trick question--the kind that will probably not be used for scoring--a tester which will be discarded before appearing as a scored item on the ASWB exam.

Hope this clears things up some. For additional reading about social anxiety disorder, try these:

For more questions about social anxiety disorder, anxiety disorders in general, and lots more, sign up now for SWTP's full-length practice exams.

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