Eating Disorders: Assessment, Understanding, and Treatment Strategies [Day One]

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Eating Disorders Assessment, Understanding, and
Treatment Strategies Day One

• Elise Curry Psy.D.
• Program Manager
• UCSD IOP
• Terry Schwartz MD
• Medical Director UCSD Eating Disorders Program
• Asst Clinical Professor UCSD

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Structure of 2 day training

• Day 1 Eating Disorders Assessment and
  Psychosocial Treatment Approaches Intro to
  Specific Therapy Modalities for EDS
• Day 2 Eating Disorders Psychiatric/Medical
  Assessment and Treatment Strategies Obesity and
  EDs in special populations

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Nervous Consumption(Morton, 1689)

• Mrs. Dukes daughter, in the eighteenth year of
  her age, fell into a total suppression of her
  monthly courses from a multitude of cares and
  passions of her mind...from which time her
  appetite began to abate. She thus neglected
  herself for two full years. Never did I see one
  conversant with the living, so much wasted, yet
  there was no fever, no distemper of the lungs, or
  signs of preternatural expence of the nutritious
  juices. Only her appetite was diminished.

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Anorexia Nervosa

• Most homogenous psychiatric disorder
• 90-95 female
• Onset teenage years puberty
• Monotonous puzzling symptoms
• Poor response to treatment
• Highest mortality rate
• 50 to 80 contribution of genes

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DSM IV Criteria for Anorexia Nervosa

• Preoccupation with body shape, weight/size
• lt85 ideal BW
• Fear of becoming fat despite low weight
• Loss of 3 consecutive periods in women
• Types restricting,binge/purge,purge

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DSM IV criteria for Bulimia Nervosa

• Recurrent episodes of binge eating, characterized
  by eating an excessive amount of food within a
  discrete period of time and by a sense of lack of
  control over eating during the episode
• Recurrent inappropriate compensatory behavior in
  order to prevent weight gain, such as
  self-induced vomiting or misuse of laxatives,
  diurética, enemas, or other medications
  (purging) fasting or excessive exercise
• The binge eating and inappropriate compensatory
  behaviors both occur, on average, at least twice
  a week for 3 months
• Self-evaluation is unduly influenced by body
  shape and weight

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Diagnostic challenges in EDs (ED NOS)

• BN vs. AN binge/purge type
• Sandy is 5 ft tall and weighs is 80 lbs. She has
  regular periods and no body distortion. She is 16
  yrs old.
• Sally purges normal meals, but does not binge.
• Tom thinks he needs to gain weight. He uses
  exercise to purge. He binges 2 times per week and
  then goes running.
• Shelly chews and spits her food several times a
  day

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Compulsive Exercise

• 1. Having no period isnt healthy, even for an
  athlete.
• 2. Exercising in spite of injury or sickness.
• 3. Individual feels s/he has to exercise to feel
  OK.

• 4. Exercise becomes the way the individual
  organizes his/her life.
• 5. Exercise is done in secret.
• 6. Exercise done mostly to burn calories.

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Possible Signs of an Eating Disorder

• Preoccupation with food/weight
• Dramatic weight loss or gain
• Chronic dieting
• Feels cold all the time
• Dental problems
• History of ballet, wrestling, or modeling
• Disgusted by red meat or desserts

• Has difficulty eating with people
• Cuts out food groups
• Becomes vegetarian/vegan as a teen
• Uses bathroom after meals
• Wears baggy clothes or layers
• Cooks for other excessively
• Excessive exercise

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Body Image

• How you see yourself when you look in the mirror
  or when you picture yourself in your mind.
• What you believe about your own appearance
  (including your memories, assumptions, and
  generalizations).
• How you feel about your body, including your
  height, shape, and weight.
• How you sense and control your body as you more.
  How you feel in your body, not just about your
  body.
• NEDA website

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Negative body image

• A distorted perception of your shape you
  perceive parts of your body unlike how they
  really are.
• You are convinced that only other people are
  attractive and that your body size or shape is a
  sign of personal failure.

• You feel ashamed, self-conscious, and anxious
  about your body.
• You feel uncomfortable and awkward in your body.
• NEDA website

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Positive body image

• A clear, true perception of your shape you see
  various parts of your body as they really are.
• You celebrate and appreciate your natural body
  shape and you understand that a persons physical
  appearance says very little about their character
  and value as a person.

• You feel proud and accepting of your unique body
  and refuse to spend an unreasonable amount of
  time worrying about food, weight, and calories.
• You feel comfortable and confident in your body.
• NEDA website

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Distorted Beliefs

• There are good foods and bad foods.
• If I am fat, no one will love me.
• If I eat too much, I need to get rid of it by
  purging.
• If I eat this piece of cheesecake, I will be able
  to see it on my body tomorrow.
• You can never be too rich or too thin.
• Thinness equals happiness.
• Using laxatives gets rid of all the food.
• Purging gets rid of all the food.
• My worth is my weight.
• It is more important to be thin than anything
  else.
• Everyone hates fat people.
• Men like women who are skinny.

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Intro to brain function in AN

• Detail vs global
• Set shifting

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What are perfectionistic traits?

• Never being satisfied with your achievements or
  performance
• Ability to see flaws where others do not
• Dread of making mistakes
• Exactness
• Exceedingly high standards

• Very detail focused
• Lack of novelty seeking
• Frequent disappointment with self and others
• Relentless pursuit of perfection
• I have to be the best at everything I do.

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How can we help pts to reduce perfectionism?

• Identify perfectionism as a personality trait
  which is unlikely to change
• Help pts to manage their perfectionism by
  noticing it and doing the opposite (risk taking,
  trying something new, stop redoing or re-writing)
• Recognize the benefits of this trait. Turn it
  into an asset, rather than a liability. Being on
  time, being good at detail oriented tasks,
  academic achievement, research career etc.

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How to deal with resistance to recovery

• 1. Validate pts legitimate needs and help her see
  how the e.d. serves her
• 2. Use motivational Interviewing what does she
  want?
• 3. Normalize her ambivalence

• 4. Help her give a voice to her e.d vs. her
  recovery voice
• 5. Have her list all the reasons why she wants to
  recover.
• 6. Have her list all the disadvantages to
  recovery.
• 7. Be patient. The average recovery rate is 7
  years!

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Cultural Issues

• More common in Westernized Societies
• Historically self starvation reported prior to
  19th century (religious/spiritual reasons)
• Cultural importance placed on thinness
• Less common in cultures where roundness is sign
  of fertility, health, prosperity
• Hong kong, India AN w/o fear of fat.
• Many individuals in our culture, for a number of
  reasons, are concerned with their weight and
  diet. Yet less than half of one percent of all
  women develop anorexia nervosa, which indicates
  to us that societal pressure alone isnt enough
  to cause someone to develop this disease, said
  Kaye.

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Practice Session
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break
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Psychiatric co morbidity
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PSYCHIATRIC COMORBIDITY Anorexia Nervosa

• affective disorders
• anxiety disorders
• psychotic disorders
• personality disorders
• Substance abuse 

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PSYCHIATRIC COMORBIDITY Bulimia Nervosa

• affective disorders
• anxiety disorders
• ICDs/ADD/ADHD
• personality disorders
• Substance abuse

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Psychiatric symptoms in AN and BN

• Premorbid onset
• Best little girl in the world
• Majority have childhood anxiety disorder that
  precedes onset AN, BN
• Childhood negative self-evaluation,
  perfectionism, rule bound, inflexible, obsessive
  personality
• Persistent symptoms after recovery
• Obsessions - body image, weight, food
• Obsessions - perfectionism, symmetry, exactness
• Anxiety, harm avoidance
• Behaviors are exaggerated by malnutrition
• Differences Between AN and BN
• Novelty seeking BN gt AN, BN extremes of over- and
  under-control

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Anxiety Disorders (AD)Lifetime and Premorbid
Rates
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Lifetime OCD Diagnosis in AN, BN
Price Foundation Genetic Collaborative
StudyTotal 1416 subjects DSM IV, SCID I, Y-BOCS
MS/PhD Clinical Interview N. America, England,
Germany
Review of Literature Godart 2002
General population rate OCD 1-3 of adults 2-4
of children (Grados 97, Riddle 98 Serpell 02)
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Obsessive-Compulsive Personality Disorder (OCPD)
Diagnoses in ED from Clinical Interviewer
AssessmentCassin S, von Ranson K Personality
and eating disorders a decade in review Clin
Psychol Rev 200525(7)895-916
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Starvation study
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Starvation Study

• Univ of Minnesota Keys et al 1950
• 36 young healthy men
• Observed behaviors during 3 mos normal eating,
  then 6 mos of 50 cal reductions (similar to
  some diets)
• Many of the experiences that were observed in the
  participants were similar to those experienced in
  various EDs

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Starvation study participantsdramatic increase
in food preoccupation

• One of the most intense changes
• Distracted from usual activities
• Toying with food
• Making weird concoctions
• New interest in cookbooks, menus
• Vicarious pleasure in others eating
• Long drawn out eating rituals

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Starvation study participants Binge Eating

• Serious BED developed in a subgroup
• Followed by self reproach
• Model for BED, EDs, habitual dieters

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Starvation Study participantsemotional and
personality changes

• Recall all were mentally healthy prior to study
• Most experienced significant emotional
  deterioration as a result of semi starvation,
  often severe
• Depression, mood swings, irritability/outbursts
• Anxiety
• Apathy, decrease personal hygiene
• General disorganization
• Persisted during first several weeks of refeeding

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Starvation study participants social and sexual
changes

• Despite being social and gregarious pre-study,
  the participants became progressively more
  withdrawn and isolated
• Decrease in humor
• Feeling socially inadequate
• Dramatic loss of interest in sex

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Starvation Study participants Cognitive changes

• Reduced concentration, alertness
• Problems in comprehension
• Impaired judgment

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Starvation study participantsphysical changes

• Decreased sleep need
• Dizzy, headaches
• GI discomfort
• Hair loss
• Thermal sensitivity
• Visual, auditory disturbances
• Parathesias

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Lunch
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Third Wave Therapies CBT, ACT, and Mindfulness
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Goals of CBT
Create a safe environment for pts to explore
their eating disorder thoughts and
beliefs Challenge distorted beliefs Teach
cognitive distortions Learn to use thought
records Assertiveness training Help pts dispute
their ed voice Identify triggers and coping
strategies
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Examples of Distorted Thoughts

• If I eat this piece of pie, I will be able to
  see it on my body tomorrow.
• I must be thin to be happy.
• When I eat pasta, I have to purge.
• Being thin is the only way I can be special.
• I wont be comfortable in my body if I gain
  weight.
• I cant stand to be alone, so I binge/purge.
• I dont have an eating disorder. Its not that
  bad.

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How to use Thought Records

• Event I stepped on the scale and saw the number.
• Thoughts I am a fat cow.
• Feelings and rating Fear (75) anger (45)
  disappointment (75)
• Body Sensations stomach hurts, chest is tight
• Distortions over-generalization, black/white
  thinking, catastrophizing
• New thought Just because the scale went up
  doesnt mean I am fat. Weight fluctuations are
  normal.
• New feeling and rating content (50) fear (10)

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Thought Record Practice

• Event I ate a whole bag of chips.
• Thoughts I must purge or I will be fat.
• Feelings and ratingFear (99) anger (25)
• Body Sensations heart beating fast, sweaty palms
• Distortions
• New thought
• New feeling and rating

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ACT for Anxiety Disorders

• Fear vs. Anxiety
• Is anxiety good for anything?
• Are anxiety and fear dangerous?
• How pervasive are problems of fear and anxiety?
• How has anxiety become a problem in the clients
  life?
• Humans vs. animals
• Eifert,G and Forsyth,J (2005)Acceptance and
  commitment therapy for anxiety disorders.

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Purpose of ACT

• Rather than controlling anxiety or reducing
  anxiety, ACT can help clients to learn and
  practice new and more flexible ways of responding
  when they experience anxiety.
• Teach clients to see that anxiety is not the
  problem. Attempts to stop the unwanted body
  sensations, thoughts, past memories, and worries
  about the future cause a shift from normal
  anxiety and fear to disordered anxiety and fear.

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Patterns and Workability of Avoidance

• 1. Help the client to evaluate how their methods
  to manage their anxiety have worked.
• 2. Explore their attempted solutions to the
  problem of anxiety. Do the starve? Do the
  binge/purge? Isolate from others?
• 3. What is the cumulative effect of these
  short-term relief strategies? What will happen if
  you keep using them?
• 4. Is this how you will create the meaningful
  life you want to have? Can you reach your long
  term goals and keep these strategies?

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Costs of Avoidance

• What have been the long-term costs of your
  avoidance patterns?
• What have you given up as a consequence of
  managing your anxieties/worries?
• What has happened to your life over time? Have
  you done more or less with your life?
• Have your options increased or has your life
  space narrowed over time?
• What would you do with your time if it were not
  spent trying to manage anxiety, fear, unsettling
  thoughts, memories, etc?

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Develop Creative Hopelessness

• Helping clients to experience that they have been
  caught in a self-defeating struggle is important.
• This approach is creative in that it allows for
  new solutions.
• Giving up on old solutions will end up creating
  hope as new solutions are found.
• Past solutions are hopeless, not the client.
• This emphasis implies that there is hope if the
  client chooses to adopt a different approach when
  anxiety show up.

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Acceptance of thoughts and feelings exercise
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The use of Metaphor in ACT

• The child in a hole metaphor
• Feeding the anxiety tiger metaphor
• The Chinese finger trap exercise

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Acceptance and valued living as alternatives to
managing anxiety

• Trying to fix ourselves is not helpful because
  it implies struggle and self-denigration. Lasting
  change occurs only when we honor ourselves as the
  source of wisdom and compassion. It is only when
  we begin to relax with ourselves that acceptance
  becomes a transformative process. Self-compassion
  and courage are vital. Staying with pain without
  loving-kindness is just warfare. Pema Chodron

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Mindfulness based practice

• What is mindfulness?
• Research on Depression and Mindfulness
• Mindfulness with eating disorders

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Definition of Mindfulness

• Mindfulness has been described as paying
  attention in a particular way on purpose, in the
  present moment, and nonjudgmentally.
• Mindfulness provides both the means to change
  mental gears when disengaging from dysfunctional,
  doing related mind states, and an alternative
  mental gear, or incompatible mode of mind, into
  which to switch.
• Segal, Z., Williams,G. Teasdale,J (2002)
  Mindfulness based Cognitive Therapy for
  Depression.

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Research on Mindfulness

• Mindfulness based cognitive behavioral therapy
  for depression has empirical evidence supporting
  its effectiveness in relapse prevention for
  depression. Segal, Z, Williams, J. and Teasdale
  J. (2002)
• MBCT prevented relapse/recurrence in pts with a
  history of 3 or more episodes of depression. 8
  week class

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Why use mindfulness with eating disorder patients?

• It seems to help them to distract from their
  constant critical dialog in their minds.
• It helps them have more choices about how to
  respond to their thoughts or triggering
  situations.
• It gives them the experience of being calm or
  free from their usual anxiety.
• It provides a sense of hope.
• It is a skill that they can use anywhere.

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Mindful Eating

• Practice chewing each bite of food with complete
  awareness.
• Dont multi-task while you are eating.
• Taste each bite as if it were your last.
• Put your fork down after each bite.
• Eat in silence.

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Mindfulness exercise

• Need flip chart

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Mindfulness concepts

• Respond rather than react.
• Connect your feelings with body sensations.
  Where do I feel this feeling? Be curious about
  your emotions, rather than fighting them.
• Suffering is part of life, not something to be
  avoided.
• Happiness isnt something that comes from outside
  us. Its an inside job.
• Seek to become more comfortable with change and
  uncertainty.
• Embrace the present moment. Its all we really
  have.

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break
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Film

• Film and discussion

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Q and A