My Name is ED: Diagnosis, Research and Treatment of Eating Disorders

1
My Name is EDDiagnosis, Research and Treatment
of Eating Disorders

• Sharon L.Ward, LPC, NCC
• 104 Maverick Street
• Aledo, Texas 76008
• 817-441-9973
• lpc.ward_at_yahoo.com

2
Todays Objectives

• Review some of the more current statistics and
  literature about eating disorder prevalence,
  etiology and treatment.
• Acquire a fundamental knowledge of signs
  symptoms.
• Identify primary modes of treatment.
• Identify ways you can personally help in the
  fight against Eating Disorders (ED).

3
Signs and Symptoms

• Anorexia
• Bulimia
• Binge or Emotional Eating
• Eating Disorder NOS

4
Anorexia

• Intense Fear of becoming fat
• Refusal or attempted refusal to maintain a normal
  range body weight.
• Distorted body image
• Menstrual period delayed or has ceased in
  females
• (this may be masked by use of birth control
  pills)

5
Bulimia

• Eating amounts of food that are definitely larger
  than what most people would eat in a similar
  period of time.
• Inappropriate behaviour to compensate for food
  eaten
• Self evaluation is unduly influenced by body
  shape/weight
• Note Weight is usually within a normal range.

6
Binge or Emotional Eating(not recognized by
DSM-IV)

• Eating amounts of food that are definitely larger
  than what most people would eat in a similar
  period of time often with a sense of being out
  of control.
• Eating at times when true hunger is not present
  or being unaware when hungry
• Eating past the point of fullness or not being
  aware of the sensation of fullness.

7
Eating Disorder NOS

• Criteria for Anorexia met except individual has
  regular menses
• Criteria met for Anorexia except despite
  significant weight loss, weight is in a normal
  range
• Criteria for Bulimia met except compensatory
  behaviours are less than 2x week.
• Normal weight individual regularly uses
  compensatory behaviours after eating small
  amounts of food.
• Repeatedly chewing or spitting out (but not
  swallowing) food.
• Note current research suggests that the vast
  majority of young adult women with diagnosable
  eating concerns were covered by the EDNOS
  umbrella. (Choate Schwitzer, 2009)

8
Research and Statistics
9
NIMH Statistics Self Report Published February
2007

• NIMH funded study of 2,980 adults
• 1 of women and .3 of men reported having
  anorexia at some time in their lives
• 1.5 of women and .5 of men reported having
  bulimia at some time in their lives
• 3.5 of women and 2 of men reported having
  binge-eating disorder at some time.
• Less than 45 sought specific E.D. treatment. 50
  sought treatment for some kind of emotional
  problem.

10
Numbers in US Population Affected by ED
11
1990s Statistics

• 5 - 10 million girls and women with anorexia or
  bulimia (still supported by NIMH data)
• For every 4 females with anorexia, there is one
  male (NIMH shows slight increase)
• 8-11 females with bulimia there is one male (2001
  data). NIMH now shows 3 to 1 ratio
• 80 of women report dissatisfaction with their
  appearance 40 50 Billion dollars a year is
  spent on dieting and related products

12
More 1990s Statistics

• 42 of 1st - 3rd grade girls say they want to be
  thinner
• 46 of 9 - 11 year olds report dieting
• 35 of "normal dieters" progress to pathological
  dieting. Of those, 20-25 progress to partial or
  full-syndrome eating disorders (Shisslak Crago,
  1995). Maines Data Suggests 38
• 129.6 million (roughly 2/3 of adults) are
  overweight

13
From Margo Maines Article for Medscape 2006

• 20 of women 70 and older are dieting
• In 2003 1/3rd of women admitted to inpatient
  facilities for eating disorders were 30 and older
  (denial fueled by idea that ED is a teen disease)
• 60 of women have engaged in pathogenic weight
  control
• 25 of women reported body dissatisfaction in
  1972, 56 in 1997
• 40 are restrained eaters

14
Margo Maine (cont.)

• 40 are overeaters
• 69 million women in US dieting
• 50 say their eating is devoid of pleasure and
  causes them to feel guilty
• 90 worry about their weight
• ONLY 20 OF WOMEN ARE INSTINCTIVE EATERS

15
Margo Maine (cont.)

• 1998 Survey of more than 80,000 9th and 12th
  graders in the US found
• 56 of 9th grade females and 28 of males are
  engaged in unsafe dieting practices (skipping
  meals, diet pills, laxatives, vomiting, smoking
  for the purpose of weight control, binge eating)
• 57 of females and 31 of males practice
  dangerous dieting with Hispanic and Native
  American students reporting the highest rates.

16
Co-Morbidity

• 2006 study of 2,436 female inpatients showed
• 94 mood disorders
• 56 anxiety disorders
• 22 substance abuse disorders 2x as likely with
  bulimics
• OCD, PTSD 2x as likely with binge-purge anorexics
• schizophrenia/psychosis 3x more likely with
  restricting anorexics
• More research being done on co-morbidity of
  bi-polar and E.D.

17
Co-Morbidity

• 2004 Study n600 findings
• 2/3rds of individuals with ED had one or more
  lifetime anxiety disorder most often OCD.
• Most participants reported the onset of the
  anxiety disorder prior to the onset of ED.
• From Margo Maine
• 5 times more likely to abuse alcohol or drugs
• Alcohol drug abusing women 11 times more likely
  to have ED

18
Child Maltreatment and Eating Disorders

• 2006 study of 107 outpatient females Norway
• Patients who met criteria for bulimia reported
  far more bullying by peers, coldness and
  overprotection by fathers and more childhood
  physical, emotional and sexual abuse
• 2006 study of 417 US undergrads showed that
  depression is a greater predictor of ED than
  dissociation as the result of childhood abuse.

19
Sexual Trauma ED

• 2004 study of women participating in a study at
  the Harvard Study of Moods and Cycles showed that
  women who reported child physical and sexual
  abuse were 3x more likely to develop ED symptoms
  and nearly 4x more likely to meet DSM-IV criteria
  for ED.
• 2005 study (using 1992 data) taken from a pool of
  14,069 women looked at pregnant women in 3
  districts in Avon, UK. Early sexual abuse was
  found to be a significant independent predictor
  of lifetime eating disorder, shape and weight.
  2005 Senior, Emberson Golding British Journal
  of Psychiatry 2005
• Between 20-50 of women who present with ED have
  experienced previous trauma (includes sexual
  abuse, emotional, physical neglect, abuse,
  separations from caregivers witnessing domestic
  violence) from Margo Maine, 2006

20
Genetics

• Study of 31,406 subjects in Sweden
• monozygotic and dizygotic twins
• Born between 1935 -1958
• Screened for anorexia and other disorders between
  in 1972-1973 and 1999 2002
• Findings
• Genetic factors accounted for 56 of the risk
• 1.2 women, .29 in men (echoes NIMH data)
• Increased rate of anorexia during birth period
• Presence of neuroticism at 1972 screening
  increased likelihood of later anorexia nervosa

21
GeneticsMargo Maine 2006

• Recent review of genetic studies showed 6 risk
  for ED for those who have a first degree relative
  with ED vs. 1 for those who didnt.
• Genetics loads the gun. Environment pulls the
  trigger.

22
Warning Signs and Risk Factors

• Determining if someone has an eating disorder
  requires some detective work

23
Warning Signs Risk FactorsPsychological and
Historical

• Alexithymia difficulty expressing emotions
• Difficulty with self calming
• History of dieting
• History of abuse

• Perfectionism
• Family history of addictive behaviors
• Intelligent, creative
• Obsessive thinking
• Negative body image (beyond weight issue)

24
Warning Signs Risk FactorsPsychological and
Historical (continued)

• Black and White thinking
• Low Self Esteem
• Difficulties within family or other close
  relationships

• Sense of over-responsibility
• Need for conformity
• External Locus of Control

25
Warning Signs Risk FactorsBehavioral

• Complaining of food allergies
• Cooking for others but not eating food prepared
• Fasting
• Frequent weighing

• Excess intake of low-fat or healthy foods
• Wearing oversized clothing
• Avoiding food in social situations (or avoiding
  social situations where food may be present).

26
Warning Signs Risk FactorsBehavioral
(continued)

• Criticism of self and others
• Mood swings
• Extracurricular activities which involve a focus
  on body size, weight or shape.

• Repeatedly feeling face, arms, legs for evidence
  of fat.
• Excessive exercising
• Self Injury
• Social Withdrawal
• Counting calories and or fat grams

27
Warning Signs Physical
Chronic, unexplained medical complaints that may
not have responded to medical treatment

• Chronic Sore throat
• Hair loss
• Dry skin / brittle nails
• Recurrent stomach problems
• Dizziness
• Unexplained problems with the cornea/tear
  production and subsequent scarring 1990 Tufts
  Study

• Edema (puffy face, ankles also a concern during
  refeeding)
• Bruising
• Irregular heart beat
• Anemia
• Headaches

28
Warning Signs Physical (continued)

• Heartburn
• Pericardial effusion
• Failure to Heal Properly From Surgery or Injury

• Body aches / pains
• Chronic Constipation and or diarrhea
• Fatigue

29
Warning Signs Physical (continued)

• Endocrine abnormalities
• Frequent Urination
• Amenorrhea
• Cold intolerance
• Osteoporosis/osteopenia
• Salivary gland hypertrophy

• Timing of puberty
• Mitral valve prolapse
• Othostatic hypotension
• Immune system deficiencies

30
Warning Signs Risk Factors for Men and Boys

• Teased for being under or overweight
• Runners, jockeys, wrestlers, body builders,
  gymnasts, divers, swimmers (weight)
• Models, actors (appearance)
• Focus onMirror Muscles 6 pack, biceps and
  upper body and not total strength or aerobic
  conditioning
• Sexual orientation or identity issues
• Distorted view of muscle size (see muscles as
  smaller than they really are)
• Hostility (new study 2005)

31
Recognize Healthy Eating vs. Dieting

• Healthy eating includes all food groups
• Healthy eating emphasizes balance, variety and
  enjoyment

• Diets tend to restrict certain food groups
• Diets limit caloric intake too severely leaving
  the person feeling deprived (which can result in
  eating problems)

32
No, Really. Im a vegetarian

• Becoming a vegetarian or vegan may at times mask
  an eating disorder. Consider the following
• What is the motivation to become vegetarian?
• Did the timing of becoming a vegetarian appear
  with other eating disordered behaviors?
• What foods wont the person eat and why?
• What feelings come with not following the
  vegetarian framework?
• Does vegetarian eating interfere with social
  situations?

33
Treatment

• A Multidisciplinary approach is imperative for
  the treatment of eating disorders.

34
PSYCHIATRIST
PSYCHOTHERAPIST
DIETITIAN
PHYSICIAN
CARDIOLOGIST
Client
SUPPORT SYSTEM
NURSE
DENTIST
HOSPITAL
FAMILY
SCHOOL
35
Triangulation

• While a multidisciplinary approach is imperative,
  the dynamics that interfere with healthy
  communication within the clients primary
  relationships can sometimes interfere with
  communication within the treatment team.

36
Medical Screening Issues

• Basic blood work often is close to or within
  normal range. This often helps someone maintain
  denial.
• A Full cardiac assessment from someone with
  experience with eating disorders is recommended
  (echocardiogram and stress test in addition to
  EKG)
• Pituitary tumor or dysfunction should be ruled
  out.
• ED may appear to be thyroid dysfunction but be
  actually caused by hormone production issues
  caused by ED.
• ED may also appear to be diabetes insipidus.
  Diabetes Insipidus is not the same as diabetes
  mellitus ("sugar" diabetes).   Diabetes Insipidus
  resembles diabetes mellitus because the symptoms
  of both diseases are increased urination and
  thirst. Diabetes Insipidus is divided into four
  types, each of which has a different cause and
  must be treated differently.  The most common
  type of DI is caused by a lack of vasopressin, a
  hormone that normally acts upon the kidney to
  reduce urine output by increasing the
  concentration of the urine. 

37
Trends in Treatment

• No one treatment mode shows a remarkably high
  level of effectiveness in the research. This may
  be due to a lack of large, well designed studies.
  2006 Cochrane Collaboration Abstract
• May also be related to small sample sizes and
  high dropout rates Agras Robinson 2008
• Some studies show medication as effective, others
  do not. May have to do more with co-morbid
  diagnosis?
• The best treatment for bulimia helps only 35
  40 of women with this diagnosis NIMH Council
  Minutes 2004
• Case study on the use of imagery when used in
  conjunction with CBT interesting!

38
Treatment (cont.)

• Treatment ideally addresses both the eating
  issue, body image and current relationships and
  other psychopathology. Treating one without
  treating the other does not seem to have a good
  outcome.
• Body image distortion seems to typically be one
  of the last things to change. This means it is
  not the best place to start treatment, especially
  on an outpatient basis.

39
Conceptual Framework

• 3 Stages of Eating Disorders
• Preventable
• susceptible - possible or probable
• Intermediate
• symptoms cause some difficulties but do not
  impair daily living
• Entrenched
• diagnosable
• Drum and Lawler (1988) as discussed in the
  article Mental Health Counseling Responses to
  Eating Related Concerns in Young Adult Women A
  Prevention and Treatment Continuum by Laura
  Choate and Alan Schwitzer April 2009

40
Interventions based on Conceptual Framework

• Prevention
• Social/cognitive, media literacy and health
  promotion
• Intermediate
• Short term psychoeducational groups including
  cognitive behavioural and cognitive dissonance
  strategies. Seems to be more effective than
  prevention intervention.

41
Interventions based on Conceptual Framework

• Psychotherapeutic Interventions
• CBT (Cognitive Behavioural Therapy)
• Focus on present and resolution of symptoms by
  enhancing motivation, incremental behavioural
  change and cognitive restructuring.
• IT (Interpersonal Therapy)
• Recommended as alternative to CBT when CBT is not
  effective. Focus on interpersonal issues such as
  conflict, social problem solving.
• DBT (Dialectical Behaviour Therapy)
• Developed for work with Borderline Personality
  disorder but has shown effectiveness with ED
  treatment.

42
Maudsley

• Developed by a team of psychiatrists and
  psychologists at the Maudsley Hospital, London.
• Developed and used primarily with Anorexic
  Adolescents.
• Focus is on refeeding within an emotionally
  supportive environment at home.
• Research outcomes encouraging.
• www.maudsleyparents.org

43
How Does Disordered Eating Develop?
44
Shadow Development
IMAGINATION
PHYSICALLY ACTIVE
GUILT
JOYFUL
CURIOUS
LAUGHING
INTELLIGENT
FORGIVING
CRYING
TRUSTING
FEAR
CREATIVE
NEED FOR SAFETY
AMAZEMENT
VULNERABILITY
ANGER
SADNESS
SPONTANEOUS
HUNGRY
ABILITY TO SAY NO
45
Shadow Development
IMAGINATION
PHYSICALLY ACTIVE
GUILT
JOYFUL
CURIOUS
RULES CONFORM BE THIN DONT FEEL DO MORE
LAUGHING
INTELLIGENT
FORGIVING
CRYING
TRUSTING
FEAR
CREATIVE
NEED FOR SAFETY
AMAZEMENT
VULNERABILITY
ANGER
SADNESS
SPONTANEOUS
HUNGRY
ABILITY TO SAY NO
46
How Does This Disconnect Happen?
CULTURAL PRESSURE
PEERS
STUDENT
INDIVIDUAL VULNERABILTY
FAMILY DYNAMICS
FEELS BAD
MALADAPTIVE BEHAVIOR
GUILT, SHAME (cumulative)
TEMPORARY RELIEF
47
Remember That Disordered Eating is Not About Food

• The disordered eating behavior is a specialized
  language.
• An unlabeled discomfort or complex concern gets
  translated into the Language of Food and/or Fat.

48
How to Ask About ED

• Avoid questions that would give tips about new
  ways to practice an eating disorder. Instead
  try
• How much would you think you should weigh?
• How do you feel about your present weight?
• Are you concerned, or is anyone else concerned
  about your eating or exercise habits?
• What have you used (or thought about using) to
  deal with your weight concerns?

49
More Questions You Can Ask

• How has your weight changed over the years?
• How do you manage your weight now?
• What did you eat yesterday? (24 hour recall)
• How much do you worry about weight, body size or
  parts and eating ( or scaling question)
• To whom do you find yourself comparing yourself?

50
Help Clients Learn the Language of Feelings

• Listen
• Validating feelings or body perceptions doesnt
  mean you agree with them. Negating these
  observations contributes to Shadow Development.
• Remind clients that managing feelings is
  different from not having them.

51
Handy Facts about ED to share with Clients

• Weight alone is not a solid indicator of health
  (either physical or emotional)
• ED slows metabolism (because the body is trying
  to conserve itself) and makes it more likely that
  the person will gain weight. It is EDs trick to
  keep you invested in him!
• ED reduces the nutrients going to the brain which
  affects mood, interpersonal effectiveness and
  overall perception.

52
General Tips forFamilies Friends

• Talk to the person in private
• Never confront eating behavior at mealtime
• Get parents or significant others involved.
  Al-Anon is a good, free support resource for
  them.
• Do not bargain, bribe, plead, threaten, nag or
  argue with the sufferer to get them to eat.
• Do not become the food police.
• Discourage other kids from monitoring a child
  they are concerned about.

53
General Tips for Families Friends

• If discussing consequences of Eating Disorders,
  focus on short term long term is often seen as
  irrelevant.
• Reflect concern about specific behavioral changes
  before approaching the eating issue. If other
  students are worried about a friends eating,
  encourage them to focus on behavior/social
  changes, not food.

54
So Now That We Know What to Look For

• What Can We Do To Help?

55
Provide Education about Real Growing and Changing
Bodies

• 40 - 80 of body shape is genetic
• Pre-pubertal girls will typically gain weight
  this is normal and necessary
• Challenge peer norms about weight and dieting
• Dieting (which is not the same as healthy eating)
  can stunt growth and can alter metabolism for life

56
Challenge How You Others Talk About Your Own
Bodies

• Does this make my rear end look big?
• I cant believe I ate that. Ill have to make
  up for it tomorrow!
• I wish I looked like ____
• I wish I could have an eating disorder for just
  a little while!
• Eat that now, because when you get to be my
  age

57
Take the Challenge!

• Try to go for a whole meal with your friends and
  not once talk about food, fat grams, calories,
  carbs, bodies or diets. Challenge each other to
  come up with more interesting topics!
• Limit good food, bad food talk. Food isnt
  good or bad it depends on how we use it.

58
Be Media Literate!

• A person who is Media Literate
• Can describe the role the media plays in their
  life and use it wisely
• Enjoys their use of media in a deliberately
  conscious way by understanding the impact of
  music and photographic special effects which
  prevent them from being unduly credulous or
  becoming unnecessarily frightened
• The media literate person is in control of his or
  her media experiences

59
Help Kids See the Whole Picture

• Not all good or all bad
• Very young children can begin to critique
  advertising what is true, what is a trick etc.
• Take kids on-line to age-appropriate media
  literacy sites.
• Deficiency sells

60
Clients Say These Things Have Been Helpful.

• Encouragement and validation
• Education about the process that leads to eating
  disorders and the recovery process
• Permission to express feelings
• Not talking about food or stressful issues at
  mealtime
• Not commenting on appearance (positive or
  negative)
• Blind weighing reduces obsession with numbers
• Peer support/support groups

61
And There is Hope...

• Every person participating in this webinar will
  either be personally affected by or will be in a
  relationship with someone that has disordered
  eating during their lifetime.
• The time and energy that you have given today is
  a significant step in helping these men, women
  and children. Thank you.