Transcript Day 1

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
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)
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Mrs. Duke’s 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.
Anorexia Nervosa
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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
DSM IV Criteria for Anorexia
Nervosa
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Preoccupation with body shape, weight/size
<85% ideal BW
Fear of becoming fat despite low weight
Loss of 3 consecutive periods in women
Types: restricting,binge/purge,purge
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
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
Compulsive Exercise
• 1. Having no period
isn’t 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.
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
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
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, selfconscious, and anxious
about your body.
• You feel uncomfortable
and awkward in your
body.
» NEDA website
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 person’s
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
Distorted Beliefs
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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.
Intro to brain function in AN
• Detail vs global
• Set shifting
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.”
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.
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!
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 isn’t enough to cause someone to develop this
disease,” said Kaye.
Practice Session
break
Psychiatric co morbidity
PSYCHIATRIC COMORBIDITY: Anorexia
Nervosa
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affective disorders
anxiety disorders
psychotic disorders
personality disorders
Substance abuse
PSYCHIATRIC COMORBIDITY: Bulimia
Nervosa
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affective disorders
anxiety disorders
ICDs/ADD/ADHD
personality disorders
Substance abuse
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 > AN, BN extremes of over- and under-control
Anxiety Disorders (AD)
Lifetime and Premorbid Rates
Study
ED
n
Lifetime AD
AD before ED
Deep 95
AN
24
68%
58%
Bulik 97
AN
68
60%
54%
Bulik 97
BN
116
57%
54%
Godart 00
AN
29
83%
62%
Godart 00
BN
34
71%
62%
AN,BN
672
64%
61%
23% OCD
13% social phobia
Kaye 04
Lifetime OCD Diagnosis in AN, BN
Diagnosis
AN
AN BN
BN
Range
10 – 62%
10 – 66%
0 – 43 %
Percent with Diagnosis
Review of Literature
Godart 2002
Price Foundation Genetic Collaborative Study
Total 1416 subjects
DSM IV, SCID I, Y-BOCS MS/PhD Clinical Interview
N. America, England, Germany
60
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10
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AN (n 619)
AN BN (n 515)
BN (n 282)
General population rate OCD: 1-3% of adults; 2-4% of children
(Grados 97, Riddle 98; Serpell 02)
Obsessive-Compulsive Personality Disorder
(OCPD) Diagnoses in ED
from Clinical Interviewer Assessment
Cassin S, von Ranson K: Personality and eating disorders: a decade in review
Clin Psychol Rev 2005;25(7):895-916
Subjects
RAN
BN
Range of OCPD
2 – 30%
2 – 19%
Starvation study
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 participants:
dramatic 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
Starvation study participants:
Binge Eating
• Serious BED developed in a subgroup
• Followed by self reproach
• Model for BED, EDs, habitual dieters
Starvation Study
participants:emotional 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
Starvation study participants;
social and sexual changes
• Despite being social and gregarious prestudy, the participants became progressively
more withdrawn and isolated
• Decrease in humor
• Feeling socially inadequate
• Dramatic loss of interest in sex
Starvation Study participants;
Cognitive changes
• Reduced concentration, alertness
• Problems in comprehension
• Impaired judgment
Starvation study participants:
physical changes
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Decreased sleep need
Dizzy, headaches
GI discomfort
Hair loss
Thermal sensitivity
Visual, auditory disturbances
Parathesias
Lunch
Third Wave Therapies: CBT, ACT,
and Mindfulness
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
Examples of Distorted Thoughts
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“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 won’t be comfortable in my body if I gain weight.”
“ I can’t stand to be alone, so I binge/purge.”
“I don’t have an eating disorder. It’s not that bad.”
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 doesn’t mean I am fat. Weight
fluctuations are normal.
New feeling and rating: content (50) fear (10)
Thought Record Practice
Event: I ate a whole bag of chips.
Thoughts: I must purge or I will be fat.
Feelings and rating:Fear (99) anger (25)
Body Sensations: heart beating fast, sweaty palms
Distortions:
New thought:
New feeling and rating:
ACT for Anxiety Disorders
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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 client’s
life?
• Humans vs. animals
Eifert,G and Forsyth,J (2005)Acceptance and commitment therapy for
anxiety disorders.
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.
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?
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?
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.
Acceptance of thoughts and
feelings exercise
The use of Metaphor in ACT
• The child in a hole metaphor
• Feeding the anxiety tiger metaphor
• The Chinese finger trap exercise
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
Mindfulness based practice
• What is mindfulness?
• Research on Depression and Mindfulness
• Mindfulness with eating disorders
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.
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
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.
Mindful Eating
• Practice chewing each bite of food with
complete awareness.
• Don’t 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.
Mindfulness exercise
• Need flip chart
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 isn’t something that comes from
outside us. It’s an inside job.
• Seek to become more comfortable with change
and uncertainty.
• Embrace the present moment. It’s all we really
break
Film
• Film and discussion
Q and A