PSYC 134 - Final Exam
Anorexia Nervosa: Course and Outcome (Cross-Over & Prognosis)
"Diagnostic Drift" - Most women with AN-R will develop symptoms of binge eating and purging over time - Between 2-34% transition to new diagnosis - Prognostic factors - mixed literature! *Longer duration of illness, need for inpatient treatment, and older age associated with worse outcome
Eating Disorder Prevalence
% Male - AN: 0.3 - BN: 0.5 - BED: 2.0 - Total: 2.8 M:F Ratio - AN: 1:3 - BN: 1:3 - BED: 1:1.75 - Total: 1:2
DBT Assumptions about Patients
***1. Patients are doing the best they can 2. Patients want to improve 3. Patients must learn new behaviors in all relevant contexts 4. Patients cannot fail in DBT 5. Patients may not have caused all of their own problems, but they have to solve them anyway ***6. Patients need to do better, try harder, and/or be more motivated to change 7. The lives of suicidal, borderline individuals are unbearable as they are currently being lived
Historical Treatment of Adolescent Anorexia Nervosa
- "Parent-ectomy" (Harper, 1983) *Enmeshment *Overprotective *Rigid *Conflict Avoidant - Parents provided with general psychoeducation - Individual Therapy - Inpatient and Residential Placement
Why Transdiagnostic?
- "What is most striking about AN, BN, and EDNOS is not what distinguishes them but how similar they are" - Diagnostic messiness (e.g., EDNOS as sub-threshold dx, AN/BN overlap) - Temporal migration (AN to BN, BN to AN, etc.)
BED Prevalence
- 1-5% (60% females, 40% males) -Onset typically in early adulthood: AN and BN more frequently seen in adolescence - Correlated with weight status - Health risk overlap with obesity consequences - Associated with depression and poorer quality of life
National Weight Control Registry
- 10,000+ adults (80%) who have successfully lost 30 pounds and kept the weight off for one year - NWCR Statistics: -78% eat breakfast every day -75% weigh self once/week -62% watch less than 10 hours tv/week -90% exercise ~1 hour/day
Historical Overview of ED's in Males
- 1689: Richard Morton: Reported "nervous consumption caused by sadness and anxious cares" in a 16 year-old boy - 1874: Ernest-Charles Lasegue: Described the family dynamics of male patients with anorexia nervosa - 1874: Sir William Gull: Noted that anorexia nervosa occurs in males - 1972: Beumont Beardwood & Russell: "The Occurrence of the Syndrome of Anorexia Nervosa in Make Subjects"
Stage 4 of CBT-E
- 3 appointments, 2 weeks apart - Focused on maintaining progress and reducing risk of relapse - Further problem-solving and relapse prevention planning
Case Example 1
- 32 year old female with long history AN-P, purge via laxatives - 5'2" 88 lbs - Depression, and serious suicidality - Unable to disengage from very toxic relationship - 5-6 treatment facilities, partial weight restoration, but, repeat relapses. - Depression not fully responsive to medication - Antidepressant treatment > improved engagement in program - Married, great guy, kids, ED and depression in complete remission
Obesity Stats
- 35% of adults and 17% of children and adolescents in the US have obesity - Associated with many medical and psychological complications - Est. medical costs: Increases $48-66 billion PER YEAR by 2030
Day Treatment
- 6 days per week - 3-10 hours per day - Several multi family meals - Multi family DBT skills training - Parent Management Training - Learn from other parents - Role of RD
Stage 1 of CBT-E (Weeks 1-4)
- 8 sessions twice/week - Objective = Achieve early change - Psychoeducation about eating and weight control - Establishing pattern of regular eating (3 meals, 2-3 snacks) - Involve significant others - General agenda: 1. In-session weighing (and updating weight graph) 2. Review self-monitoring records/HW
Adolescent Anorexia Nervosa
- AN is a serious psychiatric illness - Prevalence: * Estimated 0.48% among girls age 15-19 * 9 to 10 x more common in girls than in boys - AN becomes a chronic illness for many patients
Emotion Regulation: Reducing Vulnerability to Negative Emotions (ABC PLEASE)
- Accumulate Positives - Build Mastery - Cope Ahead - Treat PhysicaL Illness - Balance Eating - Avoid Mood-Altering Drugs - Balance Sleep - Get Moderate Exercise
Distress Tolerance: Wise Mind ACCEPTS
- Activities - Contributing - Comparisons - Emotions - Pushing Away - Thoughts - Sensations
Pharmacotherapy
- Adjunct to dietary changes, physical activity, and behavior therapy - not a stand alone treatment! - Recommended use within a treatment program only - FDA approval: orlistat, Lorcaserin, Phenterminetopiramate, Naltrexone-bupropion, Liraglutide - Appetite suppressant; inhibits fat absorption - Side effects - Caution: diet pills and off label meds (Extremely dangerous!)
Controversy 1: Involuntary Treatment for AN - What do the data say regarding effectiveness?
- After 2 weeks in treatment, 43% patients admitted involuntarily or under coercion likely to recognize treatment is necessary (Guarda et al., 2007) - No differences in rate of weight gain in hospital for voluntary versus involuntary admission - On the other hand - individuals involuntarily checked into treatment more likely to have poor outcome - Selection bias? - Another recent study demonstrated that at longer-term follow-up, differences in mortality across groups disappears (Ward et al., xxxx) - Individuals involuntarily checked into the hospital: lower weight, more severe symptoms, longer duration of illness, more comorbidities - Individuals reporting higher coercion in general: more likely to be AN and younger
Increasing Responsiveness to Internal Cues
- Appetite Awareness Training - Evaluated in a few small studies - Focus is not on forbidding food, but eating less of it - Monitor and learn about hunger and internal cues to stop eating
Statistics for Co-Occurring Disorders
- Approximately 7.9 million adults have co-occurring disorders (SAMHSA, 2014) - Only 7.4 percent of individuals receive treatment for both conditions with 55.8 percent receiving no treatment at all. - Up to 50% of individuals with an ED are also abusing substances (The National Center on Addiction and Substance abuse (CASA) 2003) - The National Comorbidity Survey Replication Study found that the lifetime co-occurrence of alcohol abuse/dependence and EDs was between 25-34%. Bulimic behaviors (binge-purge subtypes of AN or BN) was the highest risk subgroup.
Bulimia Nervosa: Course and Outcome (Recovery & Relapse)
- Around half of individuals with BN recover and maintain recovery; 30% improve but maintain some symptoms, 20% continue to meet full criteria - Follow-up studies suggest that around 70% achieve remission - Rates of Relapse: 26-55% across follow-up studies - Poor psychosocial functioning and overconcern with shape and weight predict relapse
Controversy 1: Involuntary Treatment for AN - Ethical Issues (APA Ethical Code, 2002)
- Autonomy - Beneficence - Non-Maleficence - Justice - Duty to Protect
Weight-Loss Surgery
- BMI >/= 40 kg/m^2 and/or serious health risks - Two techniques: restrictive and malabsorptive - Weight-loss surgery options: -Adjustable gastric banding -Sleeve gastrectomy -Gastric Bypass surgery (Rous-en-Y) -Biliopancreatic diversion -Maestro rechargeable system - Risk vs. Benefits for Surgical Procedures
Bulimia Nervosa
- BN in makes has received strikingly little attention - Presentation of binge eating may differ - Males endorse lower eating concerns compared to females - Binge episodes versus cheat meals? - Less likely to engage in 'typical' purging behaviors - Exercise is more central to male presentations
Development of Family Based Treatment (FBT) for AN
- Based on family therapy developed at the Maudsley Hospital in London in the 1980's. *Chris Dare; Ivan Eisler - Pulling from other family therapy models: *Strategic FT *Systemic FT
Treatment: Adult Obesity
- Behavioral Weight Loss (BWL): Dietary and physical activity recommendations; behavior change; therapeutic support - Surgical Procedures - Pharamcotherapy - Interventions lack long-term success, with weight regain estimates close to 50% - Our research lab at CHEAR: Impact of memory; attention modification programs; appetite awareness; cue exposure training, executive functioning training
Case Example of DBT
- Bettina: 32 yo high school residence hall advisor. Married and 2 months pregnant. From Berlin, Germany & in USA for 2 years. - Presented for treatment for suicidality, self-harm, Bulimia Nervosa. She stated that she was only coming to treatment because her husband was making her. - History of 2 suicide attempts (prescription medication overdoses), bulimia nervosa, and a marijuana abuse. - At beginning of treatment she had been self-harming with razors several times a week for the past 3 years, and was binge drinking 2-3 times a month. She binge-purged once a week. - Where do you even start?!?!
Measures of Obesity
- Body Mass Index - DEXA Scan: Dual energy x-ray absorptiometry % fat mass, % fat-free mass - Bod Pod: Air displacement plethysmography - Skin fold measures - Waist circumference (abdominal obesity)
Stage 2 of CBT-E
- Brief- 2 appointments over 2 weeks - Review progress, barriers to change, and revise formulation is necessary - Design stage 3 by identifying problems still need to be addressed
Development of CBT-E
- By late 1990s, CBT was the leading treatment of EDs - However two problems: 1. Note very effective for AN or EDNOS 2. Less than half of patients made full recovery - Fairburn, Cooper, and Shafran examined why some patients did well and others did not *Formulated the "transdiagnostic" view (2003)
BED Treatment Process
- CBT or CBT-gsh is first line - Phase I: Behavioral Self-monitoring, eating pattern, coping skills - Phase II: Cognitive Cognitive distortions and restructuring - Phase III: Maintenance and Relapse Prevention
Important Point!
- CBT-E is NOT traditional "CBT"; but it is based on CBT principles (targeting thoughts, behaviors, and emotions) - CBT-E is NOT focused on cognitive distortions!
BED Treatment
- CBT-based treatment - Empirically-based Treatment Modalities: Cognitive Behavioral Therapy (CBT), Interpersonal Psychotherapy (IPT) - Goal: Reduce binge eating episodes and psychotherapy - Less effective at targeting weight loss: Behavioral Weight Loss (BWL) does not target binge behaviors as well as CBT or IPT in trials
The Ugly of BMI
- Categories can be stigmatizing - Sensitive information
What are Co-Occurring Disorders? (COD)
- Clients with this experience the co-occurrence of one (or more) substance use disorders and (one or more) mental health disorders - A diagnosis of co-occurring disorders occurs when at least one disorder of each type can be established independent of the other and is not simply a cluster of symptoms
CBT Principles
- Collaborative empiricism - Psychoeducation - Self-monitoring - Exposures - Behavioral experiments - Homework
Cognitive Behavioral Therapy (CBT) in general
- Connection between our thoughts, emotions, and behaviors - Change in any of these results in changes in other two - CBT typically places more of an emphasis on thoughts - identifying "cognitive distortions" (common errors or distortions in our thoughts) and replacing them with more accurate thoughts
Muscle Dysmorphia
- Core fear of insufficient muscularity - Compulsive exercise behaviors - Disordered eating practices - Intense anxiety & guilt if exercise or dietary regimen is deviated from - Body shame/checking/avoidance
Anorexia Nervosa in Males
- Core fear of weight gain, and drive for thinness - Cognitive underpinnings may differ in males: Leanness ("six-pack") vs. thinness ("flat stomach") - BMI may not be as low in males - Males seek treatment at later stage of illness - Darcy (2011) males with AN report less 'traditional' symptom severity than females with AN
Distress Tolerance
- Crisis Survival Strategies- tolerating short term pain without using behaviors - Guidelines for Accepting Reality- tolerating long term pain without using behaviors - Pros and Cons of Distress Tolerance
Decreasing Focus on External Cues
- Cue exposure treatment - Focuses on repeated non-reinforced exposures to a stimulus to extinguish the individual's conditioned response, such as a craving, to the stimulus or cue
Research on DBT for Eating Disorders
- DBT for BED: n=44, 89% of women were abstinent from binging/purging after 20 weeks - N-101, found 20 sessions of DBT significantly better than active control group for BED - Case series of 8 women with BN/BED and BPD found significant improvements on all outcomes - n=24 AN/BN+BPD+previous non-response, inpatient stay of 3 mos. 38% AN recovered, 54% BN rec's - DBT Day Treatment: n=55, 24% rec'd, 41% improved, 26% no change, 9% deteriorated
Psychosocial Problems of Obesity
- Decreased quality of life - Body dissatisfaction and self-esteem - Disordered eating behaviors and cognitions - Increased risk of depression
EDs: General Psychopathology
- Depression Symptoms - Anxiety symptoms - Self-harm, substance abuse - Personality disorders - Traits (perfectionism, low self-esteem)
Over-evaluation of shape/weight
- Develop new domains for self-evaluation - Family, Work, Shape/Weight/Eating, Other - Body Checking & Avoidance: *Mirror use, pinching, measuring *Scrutiny creates and maintains dissatisfaction *Avoidance can be just as problematic - Comparisons with others - Strategies: *Identify the behaviors *Educate *Use behavioral experiments
Regulation of Cues Treatment
- Developed by Dr. Kerry Boutelle - Based on Behavioral Susceptibility theory
Ideal Therapy Candidates
- Diagnosis of AN - Younger than age 18 - Living at home with family - Family is able and willing to put significant time commitment into it - "Easier" with intact families
Nutrition Counseling: Beliefs and Process
- Discover & challenge distorted beliefs/fears about food, weight & exercise and how they may enable eating disorder behaviors - Process patient's use of food: emotional eating, self-punishment, sense of communication or control - Process of barriers to progress (internal vs. external) - lack of motivation, underlying issues, lack of structure/planning - Incremental changes to meal plan-consideration of patient's nutritional needs, level of progress and readiness for change
ED Prevention for Males
- Dissonance-Based Interventions - Sexual minority males (Brown * Keel, 2015) - Men regardless of orientation (Brown, Forney, Pinner, & Keel, 2017)
Controversy 3: Private Equity Firms and Residential Eating Disorder Treatment
- Due to managed care, proliferation of residential facilities - Often boasting beautiful resources and setting - Owned by private equity firms; for-profit - Often offer treatments that are not evidence-based - Equine therapy - Limited data on effectiveness - Perks for clinicians that refer their patients to the centers
What are some advantages of BMI?
- Easy to calculate - No machines required - Inexpensive - Provides common language among medical providers - Correlated with: Measures of body fat Diseases Negative health outcomes
Events, Moods, and Eating
- Eating less to gain sense of personal control and identity - Eating less to influence others: e.g., demonstrate feelings of distress, defiance or anger - Overeating as a "treat: - Binge eating and/or purging to cope with negative events/mood
Thought Question: What barriers can you think of that might be preventing individuals from participating in weight-loss treatment?
- Embarrassment - Not affordable - Lack of access to healthy grocery stores, etc.
Things to target in DBT
- Emotions - Urges - Actions - Skill Usage - Goals
Emotion Regulation: What are emotions good for?
- Emotions organize and motivate action - Emotions communicate (and influence) others - Emotions can be self-validating
Models
- Energy Balance Equation - Obesogenic Environment - Behavioral Susceptibility Theory - Cue Reactivity Model: Physiological and psychological reactivity
Transdiagnostic Formulation
- Events and associated mood change - Compensatory vomiting/laxative misuse - Binge eating - Over-evaluation of shape and weight and their control - Strict dieting; non-compensatory weight control behavior - Binge eating - Significant low weight
Treatment: Pediatric Obesity
- Family-based Behavioral Weight Loss Treatment (FBT) - Traffic Light Diet
Nutrition Counseling: Desensitization & Exposure Therapy to increase Flexibility
- Fear Food Challenges - Food Rituals - Social Eating - Dining Out - Grocery Shopping - Cooking
Determining % IBW
- Female - 15 year old - Height: 5'2" - Lifetime highest weight: 100# (age 12) - Onset of eating disorder: age 13 - Goal Weight: 113-117# - Lost menses 2 years ago at onset of ED
Family-Based Behavioral Weight Loss Treatment (FBT): The Art of Behavior Change
- Focus on behavior, it's NOT simply about will power - Will power is temporary, behaviors are long-term - Shift from good intentions -> concrete & specific actions - Effective ways to change behaviors for the long-term: Behavior skills & techniques - Self-Monitoring - Modeling - Positive Reinforcement - Stimulus control
Traffic Light Diet
- Foods are classified as RED, YELLOW or GREEN based on energy density (calories per serving): - GREEN: 0-1 grams of fat/serving, <10% sugar - YELLOW: 2-5 grams of fat/serving, 10-25% sugar - REF: >5 grams of fat/serving or >25% sugar - 5 Fruits and Vegetables/day - 1,000-1,200 kcal for children *Get the most nutrients for the fewest calories
Etiology of Obesity
- Genetic - Environment - Behavioral - Social - Cultural - Psychological - Physiological
BED Characteristics: BED versus Obesity
- Greater weight and shape concerns - More personality disturbance - Greater likelihood of mood/anxiety disorders - Lower quality of life - More executive function deficits
Neurocognitive Deficits of Obesity
- Have been reported for individuals with overweight/obesity - Executive Functioning - Attention - Visuospatial performance - Motor Skills - Mixed results with language, learning, memory, and academic achievement
Obesity and Physical Health
- Heart disease - Hypertension - Dyslipidemia - Stroke - Diabetes - Liver Disease - Cancer Risk *Losing 5-10% body weight can lower risk factors
Over-evaluation of shape/weight: Strategies
- Help patients become more aware of their experience, "What else am I feeling right now?" - Identify triggers and examine their nature - Address underlying emotion or problem-solve situation
Co-Occurring Disorders in Patients with Eating Disorders
- High rates of co-occurring disorders - Complicates treatment, compromises recovery - Neurocircuitry of AN, BN and BED overlap with anxiety and mood disorders - Eating disorders can be "unhealthy attempts at coping" - Impulsivity and eating disorders - Affect dysregulation and eating disorders - Anxiety and eating disorders
Dialectical Behavioral Therapy (DBT)
- Highly organized and structured: specific treatment hierarchy - Behavioral treatment approach: contingency management - Uses dialectical thinking: embraces both validation and change - Non-judgmental stance - Based in emotion regulation theory
Future Directions
- How to minimize disempowerment at higher levels of care - Examine the role of peer support (PAC) - What do we do for the families that FBT doesn't work for?
Distress Tolerance: IMPROVE the Moment
- Imagery - Meaning - Prayer - Relaxation - One Thing at a Time - Vacation - Encouragement
TREATMENT OF CO-OCCURRING PSYCHIATRIC DISORDERS IN PATIENTS WITH EATING DISORDERS
- Important to treat both disorders together, not in parallel or sequential (Interacting Disorders, often impact outcome of each other) - Need to Differentiate ED related psychiatric symptoms versus independent co-occurring psychiatric illness
Obesogenic Environment
- Increased access to highly palatable foods AND decreased emphasis on physical activity - > 5,000 steps per day = sedentary lifestyle - Negative health outcomes: -Heart attack -Loss of lean muscle -Faster bone loss -Increased risk of color and breast cancer -Type 2 Diabetes (every 2 hours of tv=14% increase)
Structure of Traditional DBT
- Individual therapy - Group skills training: two hours a week, for one year - Consultation team - Telephone coaching - "Optional" parent training/family therapy for adolescents
Why do you do Eating Disorder/Substance Abuse/Self-Harm behaviors?
- It's hard for me to explain but I do behaviors to numb out emotion and to feel better about myself (15 yo, ED) - I used the behavior to relieve my feelings (16 yo, SH) - To numb emotions, to deal with unwanted feelings (15 yo, SA) - I did it because it made me feel mentally and emotionally good (17 yo, SH) - Because it suppressed all of the emotions I didn't want to deal with. It's an escape. It was a way to torture and sabotage myself because I hated myself so much (17 yo, ED) - I used it because it's an escape from feeling my emotions that I get tired of feeling (17 yo, SA)
Regular Eating
- Key intervention for all patients - Gives structure to the patient's eating habits - Addresses one form of dieting - Reduces frequency of binge eating
Categories of Commonly Used Substances: 10) Over the Counter
- Laxatives: Abusers take 50 to 100x the prescribed dose. Causes constipation, dehydration, edema, bleeding, electrolyte abnormalities, impaired bowel function - Diuretics: 10% of ED patients use daily. Causes GI upset, palpitations, neuropathy, cardiac impairment, electrolyte imbalance, kidney damage - Diet Pills: 25% of ED patients use 1+/day. Tolerance can build. Causes elevated blood pressure, tachycardia, depression, neurological problems, renal and liver failure, seizures
Where to go from here to address ED in Males...
- Less than 1% of ED research focuses specifically on males!!! - Males with EDs still heavily stigmatized - Are we asking the right questions? - Diagnostic criteria - Measures of ED symptoms
Common Characteristics of Co-Occurring Disorders
- Life threatening disorder - Increased risk for suicide - Frequent relapses - Low self-esteem - Impulsive and other at-risk behaviors - Mood and anxiety disorders - Frequent hospitalizations - Medical complications - Early mortality
BED in Children
- Loss of control eating (LOC): Sense of not being able to control what or how much you are eating, regardless of amount of food actually consumed - 9-30% non-treatment-seeking children - 20-36% overweight treatment-seeking children - Disordered eating, depression, anxiety, poorer psychosocial functioning - LOC-ED criteria in children < 12 years old - Prevention efforts
Stage 3 of CBT-E
- Main body of treatment - 8 weekly sessions - Addressing overevaluation of shape/weight - Addressing Dietary rules - Addressing event-related changes in eating - Addressing clinical perfectionism, low self-esteem, interpersonal problems, and mood intolerance
EDs and Mood Disorders
- Major Depressive Disorder: 50-70% all patients with EDs also have Major Depression - Impact on ED, treatment, relapse - AN vs. BN vs. BED - Bipolar Mood Disorder - Diagnosis BN>BED>AN - Impact on ED, Treatment, Relapse - Psychopharm -> May increase appetite
Myth #1: Eating disorders are exceedingly rare in males
- Male's can't get EDs Males can't fulfill the amenorrhea criterion Dietary restriction is not serious, often secondary to other psychiatric illness (Selvini, 1965) - Males account for less than 10% of eating disorder cases (Fairburn & Beglin, 1990)
FBT Manualized in U.S.
- Manualized with Univ of Chicago (Daniel Le Grange) and Stanford (Jim Lock) in late 1990's: Published in 2001 - Outpatient: *16-20 sessions over 12 months *2/3 of adolescent AN patients are recovered at the end of FBT while 75-90% are fully weight recovered at five-year follow-up
Origins of DBT
- Marsha Linehan did a study on CBT and chronic SI, parasuicide, and self-harm - Found focus on unrelenting change in CBT to be invalidating - Resulted in high treatment dropout - Behavior of therapists reinforced dangerousness of patients - Volume of problems overwhelmed therapy
Body Mass Index (BMI)
- Measure of body fat based on height and weight - (weight kg)/(height m) x (height m) - Categories: Underweight: Below 18.5 kg/m2 Normal weight: 18.5 - 24.9 kg/m2 Overweight: 25.0 - 29.9 kg/m2 Obesity: 30.0 kg/m2 and above - In children, take into account sex and age - Percentiles
Nutrition is Science
- Medical Nutrition Therapy - Nutritional Biochemistry - Chemistry *Organic Chemistry *Biochemistry - Biology - Microbiology & Food Microbiology - Food Science - Anatomy & Physiology
Myth #2: Eating disorders present the same way in males and females
- Men less likely to seek treatment - Later age of onset - Previous history of overweight - Males demonstrate greater psychiatry comorbidity - Differences in expression of body dissatisfaction & specific ED symptoms
Over-evaluation of shape/weight: Feeling "fat"
- Mislabeling certain physical or emotional states - Expression of acute increase in body dissatisfaction
Frequent Co-Occurring Disorders in Patients with Eating Disorders
- Mood Disorders - Anxiety Disorders - Personality Disorders - Substance Use Disorders
BED Characteristics: BED versus non-BED controls
- More frequent parental depression - Greater vulnerability to obesity - More exposure to negative comments about shape, weight, and eating - Greater perfectionism - Negative self-evaluation
BED Etiology
- Multiple influences - Genetic: Aggregates in families (heritability 30-80%) - Biological: Alterations in central and peripheral systems associated with regulation of appetite - Environmental: Childhood Obesity, Family Overeating, Negative Comments about Weight/Body/Eating
Research on DBT for Adolescents with ED
- N=12 adolescents with anorexia or bulimia demonstrated significant improvements in behavioral indices of disordered eating and general psychopathology when it treated with DBT on an outpatient basis - Pilot study for adolescents with bulimia treated N=10 with outpatient DBT and found significantly reduced NSSI, binging and purging - 36/51 adolescents with EDs completed an IOP that was based on FBT and DBT. Significant improvements on EDE-Q but insignificant reduction in behaviors
Binge Eating Disorder (BED)
- New diagnosis added to DSM-5: Previously ED-NOS or undiagnosed - Criteria: Persistent episodes of binge eating (1/week) - Binge eating episodes: - Objectively large amount of food - 2-hour period - Loss of Control
Contraindications
- No data that someone will or won't do well. - Just don't do FBT when active abuse in the family. - No absolute contraindications - Don't expect success if they are adamant that they don't want to do it.
When to Consider Higher Levels of Care
- Not gaining 1-2 lbs per week - More skills - Parents may need respite - Increase parents confidence in their ability to help their child - Parental guilt reduces self efficacy - More structure needed - Access to a RD - More family meal coaching
The Role of the Registered Dietitian in ED Treatment
- Nutrition Counseling - Nutrition Education - Medical Nutrition Therapy
Food Cue Reactivity
- Obesogenic environment - Cues -> overeating -> weight gain - Food Cue Reactivity Model 1. Physiological responses 2. Psychological responses 3. Food consumption - Pavlovian conditioning to food stimuli
Mindfulness: Taking Hold of Your Mind: "What" Skills
- Observe - Describe - Participate - Non-Judgmentally - One-Mindfully - Effectively
Maintaining Mechanisms of ED
- Overevaluation of shape/weight - Dietary restriction & dietary restraint - Events, moods, and eating
Structure of FBT
- Parent and child separate groups - Behavioral coaching: Parent and child meet together to set goals with individual therapist - 4 months of weekly meetings - 2 months of biweekly meetings - Follow-up
Diary Cards
- Patient fills out daily and brings to session - Record of goals for treatment and progress towards them - Used to set agenda: Talk about life-threatening behaviors/urges, then treatment-interfering, then quality of life
Binge Eating Disorder (BED) Criteria
- Persistent episodes of binge eating (1/week) - Binge eating episodes associated with 3+: *Eating much more rapidly than normal *Eating until feeling uncomfortably full *Eating large amounts of food when not hungry *Eating alone because of embarrassment *Feeling disgusted, depressed, or guilty after overeating *Marked distress
Energy Balance
- Positive Energy Balance = Calories > Energy Expenditure -> Weight Increases - Negative Energy Balance = Calories < Energy Expenditure -> Weight Decreases
Controversy 1: Involuntary Treatment for AN - Suggested criteria for involuntary hospitalization (Theil & Paul, 2007; Theils, 2008)
- Presence of cardiac arrhythmias - Severe blood chemistry abnormalities - Acute psychiatric or ominous medical symptoms - Suicidal ideation - BMI < 13 - Poor response to prior interventions
Dietary Protocol for AN/FBT
- RD meets individually with patient to review program food rules and guidelines - Within 1 week RD meet with one or both parents for dietary intake - RD and parents will determine beginning calories and how much will be given in program versus how many parents will give at home (discuss how kcals are determined) - RD will join family session when consultation is requested in treatment team. *Nutrition education *Recipes/menu ideas - RD's will act as consultants to therapists and provide feedback on areas for discussion during family therapy meetings
Distress Tolerance: Guidelines for Accepting Reality
- Radical Acceptance - Willingness (willing hands) - Turning the Mind - Observing Your Breath - Half-Smiling - Awareness
Mindfulness: States of Mind
- Reasonable Mind - Wise Mind (Middle) - Emotion Mind
Sedentary Activity Research
- Recent meta-analysis found that REGARDLESS of physical activity, sedentary activity linked to higher: - All cause mortality - Cardiovascular disease - Cancer mortality - Cancer incidence - Type 2 Diabetes
Controversy 1: Treatment for AN
- Recently published meta-analysis of randomized controlled trials of AN - Demonstrated benefit for specialized treatments on weight at discharge from treatment - No differences between specialized treatment and control treatment at follow-up for weight - No differences between treatment and control at either discharge or follow-up for psychological symptoms NO TREATMENT CURRENTLY IS DOING BETTER THAN CONTROL, LONG-TERM FOR AN. Also consider the samples for these RCTs
Self-Monitoring
- Record of all eating behavior and corresponding, contextual factors (situations, thoughts, emotions) - In "real time" - "It is your tool for becoming an expert on your eating problem and how to overcome it" - Help patients distance themselves from processes, thus can recognize and question
Nutrition Counseling
- Resolving the client's relationship with food, not simply restoring weight, is the goal of treatment - Being at a normal weight does not dispel the abnormal eating behaviors or disturbed attitudes about food
Muscularity Oriented Disordered Eating
- Rigid adherence to rule-driven dietary plan: *Protein consumption *Restriction of dietary energy intake *Bulking & cutting phases *Fastidious use of supplements - Anabolic Steroid Use
What are some disadvantages of BMI?
- Screening tool only - Not diagnostic - Does not take into account body composition - Only uses weight - not muscle mass or stature
Significant Others
- See "significant others" if this is likely to facilitate treatment and the patient is willing - Usually the significant others are people who influence the patient's eating - Aim is to create the optimal environment for the patient to change
BED and Obesity
- Seeking treatment for obesity: 30% with self-report 4.2%-18.8% with interview - Undergoing bariatric surgery 2%-49% BED 6%-64% any binge eating - Surgical vs. Non-Surgical Weight-Loss Treatment Higher levels of ED's in surgical group
Decreasing Sedentary Activity
- Shape down to 14 hours per week (outside of homework)
Case Study: Amanda
- She is a 20 year old female, college student and currently in treatment for anorexia nervosa. When she was 13 years old, she was hospitalized for malnutrition, low body weight, and orthostatic vitals. Throughout her teen years, she was in the hospital two more times for the same reasons. In addition to her eating disorder, she experiences general and social anxiety, negative self-talk, and isolation. - She is in treatment for the first time. The pressure of being in college coupled with over-exercising behaviors have caused alarm to both her parents and her doctor.
Case Study: Donna
- She is a 40 year old female veteran. She is currently in treatment for bulimia nervosa. When she was a child, she was sexually assaulted by a relative. At the age of 11, she started drinking and smoking pot. By 14, she began binging and purging behaviors. Throughout her teens and young adulthood, she dabbed in illicit drugs such as cocaine and crystal meth, engaged in at-risk sexual behavior and was assaulted several times. - While in Navy, Donna developed PTSD and alcohol use disorder. She married an abusive man and had four children. She received some treatment for her substance use in her thirties but is in ED treatment now for the first time.
Social Problems of Obesity
- Teasing/Bullying - Stigma - Social Withdrawal - Interpersonal relationships
DSM-V Criteria: Substance Use Disorder
- The DSM-5 defined a substance use disorder as the presence of at least 2 of 11 criteria, which are clustered in four groups: 1. Impaired Control: (1) taking more or for longer than intended, (2) unsuccessful efforts to stop or cut down use, (3) spending a great deal of time obtaining, using, or recovering from use, (4) craving for substance. 2. Social Impairment: (5) failure to fulfill major obligations due to use, (6) continued use despite problems caused or exacerbated by use, (7) important activities given up or reduced because of substance use. 3. Risky Use: (8) recurrent use in hazardous situations, (9) continued use despite physical or psychological problems that are caused or exacerbated by substance use. 4. Pharmacologic Dependence: (10) tolerance to efforts of the substance, (11) withdrawal symptoms when not using or using less.
Phase III: Establish Healthy Adolescent Identity
- To establish that adolescent-parent relationship no longer needs ED sx as way of communicating - Review adolescent issues and model problem solving of those issues - Terminate treatment
Pharamacological Options for BED Treatment
- Topiramate - Sibutramine - Vyvanse
What is a Registered Dietitian?
- Trained Nutrition Professional with the credentials to provide Medical Nutrition Therapy *Counseling on behavioral and lifestyle changes related to diet and exercise for specific diseases and disorders *Medical professional that acts as a liaison between treatment team, doctors & nurses *Trained in motivational interviewing and able to assess readiness for change - Nutrition Science Degree from accredited university - Professional Practice Internship - National Registration Exam - Continuing Education Units
CBT-E (Conitive Behavioral Therapy, Enhanced)
- Transdiagnostic approach to ED treatment - Leading evidence-based treatment for ED in adults (Fairburn et al, 2009; Fairburn et al, 2013) - Has also been shown to be effective in the treatment of younger patients (Dalle Grave et al, 2013) - CBT-E may be used in inpatient and out-patient settings
Foundations of Treatment
- Transdiagnostic formulation - Psychoeducation - Self-monitoring - Regular eating - In-session weighing - Incorporating significant others
ED Treatment for Males
- Treatment response similar to females - Important to address gender bias - Address medical complications: Low testosterone -> bone loss
Treatment Options for Co-Occurring Disorders
- Twelve Step communities (i.e., NA, AA, CODA, Al Anon, etc.) or similar self-help groups (i.e., Smart Recovery) - Motivational Interventions - Contingency Management - Cognitive Behavior Therapy - Dialectical Behavior Therapy - Pharmacological Interventions
Emotion Regulation: Goals of Emotion Regulation Module
- Understand emotions - Change by acting opposite to painful emotions - Reduce emotional vulnerability
Controversy 1: Involuntary Treatment for AN - Legal Considerations
- Varies across states - Patient's ability to provide consent to treatment - Impaired decision-making - Conservatorship/temporary guardianship - Acute risk to self or others - Grave disability - Treatment required to prevent serious harm; reasonable expectations re: effectiveness
Distress Tolerance: Self-Soothe the Five Senses
- Vision - Hearing - Smell - Taste - Touch
Components of Emotions
- Vulnerability Factors - Interpretation of Event - Prompting Event 1 (inside or outside) - Prompting Event 2 - Aftereffects - Brain Change (neurochemical) - Face/Body Change (physical) - Sensing (experience) - Action Urge - Face/Body (e.g., posture, face) - Expression with Words - Action (do something) - Emotion name
Psychoeducation
- What treatment will entail - ED psychopathology - Medical complications associated with ED - Psychological and physical effects of starvation - Dispel myths about food and weight
What is a Nutrition Therapy?
- Works as part of a multidisciplinary team - Understands underlying psychological issues *Professional supervision *Continuing education *Understands relationships between psychology & eating *Recognizes when underlying issues need to be worked out in therapy before moving forward - Ability to establish rapport with challenging patients - Communicates nutrition messages appropriately - Develops highly individualized treatment plans
3. Behavior Chain Example
-Actions -Body Sensations -Cognitions -Events -Feelings
Nutrition Counseling: Hunger & Satiety Work & Food Journaling
1-Starving, faint 2-Over hungry, headache 3-Hungry for a meal 4-Hungry for a snack 5-Neutral-not hungry or full 6-Beginning to feel full-like after a snack 7-Satisfied full-like after a meal 8-Two-bites too many (overfull) 9-Uncomfortable full 10-Stuffed- so full need to lay down - Push Away - Physical vs. Emotional hunger - Continually weave in concepts of Normal Eating for enjoyment & wellness - Mindful Eating/Intuitive Eating
5 Fundamental Assumptions
1. Agnostic view of the illness: Neither parents nor adolescent are to blame 2. Non-Authoritarian Therapeutic Stance: Joining with the family 3. Externalization of the Illness: Separation of the child and illness 4. Initial Focus on Symptoms 5. Parents are part of the solution and responsible for weight gain
Model of Emotions and Impulsive Behaviors
1. Cue or trigger 2. Emotion Dysregulation 3. Attempts to reduce or avoid the painful emotion 4. Binge eating, restricting, purging, self-harm, suicidal behavior substance abuse 5. Temporary Relief
DBT Team Agreements
1. Dialectical Agreement: We agree to accept a dialectical philosophy: There is no absolute truth; nor is truth all relative. When caught between two conflicting options, we agree to look for the truth in both positions. 2. Consultation to the Patient Agreement: We agree that the primary goal of this group is to improve out own skills as DBT therapists, and not serve as a go-between for patients to each other. 3. Consistency Agreement: Because change is a natural life occurrence, we agree to accept diversity and change as they naturally come about. 4. Observing Limits Agreement: We agree to observe our own limits. As therapists and group members, we agree to not judge or criticize other members for having different limits from our own. 5. Phenomenological Empathy Agreement: All things being equal, we agree to search for non-pejorative or phenomenologically empathic interpretations of our patients', our own, and other members' behavior. 6. Fallibility Agreement: We agree ahead of time that we are each fallible and make mistakes. We agree that we have probably either done the problematic things we're being accused of, or some part of it, so that we can let go of assuming a defensive stance to prove our competence.
First Session - "Starting well"
1. Engage the patient in treatment 2. Assess the nature and severity of the problem 3. Jointly create a personalized formulation 4. Explain what treatment will involve 5. Establish real-time self-monitoring 6. Assign HW (self-monitoring, review written formulation) 7. Summarize session and schedule next appt.
Contracts
1. Specify overarching goal 2. Identify 2-3 target behaviors 3. Get child's feedback on actual motivators (not parent's belief about motivators) 4. Convert target behavior into concrete rules 5. Assign short-, medium-, and long-term rewards and consequences
How to Monitor Hunger
1. Starving: Your stomach may hurt, you may have a headache, you may feel a little weak, very low energy, a little shaky or jittery 2. Hungry: You stomach is gently growling, you may feel a little low in energy, your stomach feels empty 3. Neutral: You have taken the edge off of your hunger and have more energy but still do not feel satisfied 4. Satisfied: You feel energetic and alert - ready to take on your next task! It takes 20 minutes for the feeling of fullness to reach your brain, so try to have your meal last this long to really be in touch with your fullness. 5. Stuffed: You feel uncomfortable. You feel tired. It may be hard to move. You feel low in energy - not the jittery energy of starving but the show energy if fullness.
Categories of Commonly Used Substances: 11) Performance Enhancers
3% of athletes with ED abuse steroids. May create secondary addiction to opiates to combat effects
Behavior Chain Analysis
A step-by-step description of the chain of events leading up to, during, and after the target behavior. Include: - Target Behavior - Prompting Event - Vulnerability factors - Consequences - Actions, Body Sensations, Cognitions, Events, Feelings
Categories of Commonly Used Substances: 6) Opioids
Also depresses the CNS; dulls physical and emotional pain. Tolerance builds quickly and is highly addictive. Prescription for pain management such as morphine, Vicodin, Oxycodone or on the streets like heroin.
Subgroups of Males at Higher Risk
Athletes: - ED diagnoses in male athletes > non-athletes - Male athletes have also been shown to have higher rates of overall eating pathology as compared to non-athletes - Lean & weight class sports at increased risk Sexual Minorities: - Represent up to 42% of men in tx-seeking samples - Community-based samples of sexual minority males endorse increased drive for thinness, body dissatisfaction, and higher levels of disordered eating and eating disorders Theories: - Sociocultural theories: Single gay males have increased eating pathology - Minority Stress Theory (Meyer, 1995)
ANTI-ANXIETY AND ANTIPSYCHOTIC MEDICATIONS
BENZODIAZEPINES: 1. VALIUM (DIAZEPAM) 2. XANAX (ALPRAZOLAM) 3. ATIVAN (LORAZEPAM) ATYPICAL ANTIPSYCHOTICS: 1. ABILIFY (ARIPIPRAZOLE) 2. ZYPREXA (OLANZEPINE) 3. RISPERDAL (RISPERIDONE) 4. REXULTI (BREXPIPRAZOLE) 5. SEROQUEL (QUETIAPINE)
Nutrition Education
Basic Education on Macronutrients: - Function of Nutrients in the Body - Food Facts & Fallacies Anatomy & Physiology: - Consequences to malnutrition - Understand how the body systems work - Refeeding Process - Weight & Metabolism - Effects of Compensatory Behaviors (purging, laxatives, diuretics, diet pills, exercise, etc.) - Relationship Between Food & Mood -Assist clients in planning menus to meet needs - How to Grocery Shop - How to Cook - Relapse Prevention and transitioning out of the treatment environment
Teach Skillful Behavior to Replace Problem Behavior
Behaviors to Increase: - Mindfulness Skills - Interpersonal Skills - Emotion Regulation Skills - Distress Tolerance Skills Behaviors to Decrease: - Identity Confusion Emptiness Cognitive Dysregulation - Interpersonal Chaos Fears of Abandonment - Labile Affect Excessive Anger - Impulsive Behaviors Suicide Threats Parasuicide
Case Example (continued)
Bettina's goals: 1. Know who I am. (Travel, find values in parenthood, meditate, learning, enlightenment, reading, mindfulness, talking to husband, doing hobbies) 2. Cope better with difficult emotions. (be vulnerable with husband, use PLEASE skills, practical radical acceptance, change interpretations of what people say) 3. Continue prioritizing work and relationships at the same time Stage 1: Behavioral Control - Chain Analysis & the hierarchy Crisis plan (distress tolerance, mindfulness, pros/cons) Coaching calls Contingency management around self-harm Our relationship Environmental Interventions (school) Stage 2: Emotional Experiencing Skills Acquisition (radical acceptance of emotion, mindfulness) Stage 3: Ordinary Happiness & Unhappiness Skills Acquisition (radical acceptance of people, DEAR MAN) Stage 4: Capacity for Joy and Freedom Focus on the positives: her intelligence & charisma Identity development Building a life worth living
Biosocial Theory in ED
Biological Vulnerability: - BN: emotion lability - AN: difficulty with identification/awareness of emotion, extreme avoidance of emotion; inhibited expression of emotion - Nutritional vulnerability: dysregulation of systems that regulate eating behavior Invalidating environment: - Cultural norms & societal; expectations - Dove Evolution of Beauty video
How do we determine obesity?
Body Mass Index (BMI)
Categories of Commonly Used Substances: 7) Sedative-Hypnotics or Anxiolytics
CNS depressants that slow brain activity. Used for treating anxiety and sleep disorders. - Benzodiazepines: Valium, Xanax, Serax, Klonopin, Ativan, Halcion, Librium, Restoril are muscle relaxants, anticonvulsants, short acting anxiety agents, sleep aides and used in alcohol withdrawal - Ambien, Imrest, Lunesta, Sonata and Starnoc are primarily used for sleep disorders - Barbituates: Pentothal, Surital, Nembutal, Seconal, Amytal, Butisol, Solfoton are anxiolytics, sedative-hypnotics and anticonvulsants
Categories of Commonly Used Substances: 8) Stimulants
CNS stimulants; increase energy and concentration; decrease appetite and fatigue. Prescription meds include dexedrine and adderrall, ritalin, concreta, vyvanse. Illegal derivatives include cocaine, powder or crystal methamphetamine.
Controversy 2: Weighing Patients in Treatment Controversy & Example
Clinical Controversy: Should we weigh patients in treatment and should they know their weight? - Recommendations for weighing patients in manuals; mixed, but many recommend Case example: Patricia, 27 years old - Onset of anorexia nervosa 6 years ago at age 21 - Successful treatment in intensive outpatient in upstate New York - Presented to treatment for anxiety, reporting being "remitted" from her eating disorder - Does not know her weight, notes that doing so will likely cause a relapse - Over the past 5 years, therapist has never disclosed her weight - BMI in normal or overweight range - Do I need to weigh Patricia? What information fo I need to know?
Controversy 2: Weighing Patients in Treatment
Clinical Controversy: Should we weight patients in treatment and should they know their weight?
Bulimia Nervosa: Course and Outcome (Cross-Over & Prognosis)
Common pattern of crossover: BN to Purging Disorder or Subthreshold BN - Crossover to AN uncommon - 7-10x more likely to remain stable than crossover to AN Mixed findings for prognostic factors: - Longer duration of symptoms before treatment; personality disturbance When looking at outcome for BN over time, may be important to consider course
Categories of Commonly Used Substances: 9) Tobacco
Commonly held belief that nicotine suppresses appetite and aids in weight loss. Prevalence: 52% of AN and 45% of BN
Controversy 1: Involuntary Treatment for AN - Spectrum of treatment pressures (Guarda et al., 2007)
Considerations: - Legal and ethical considerations - Effectiveness of the treatments - both short and long-term - Counterproductive therapeutically? - Is refusing treatment while acutely ill "reasonable"? - Dying with dignity (Lopez, Yoger, & Feinstein, 2010)
Which of the following therapies discussed in class includes an explicit focus on weighing the patient in session? A. Family-Based Therapy B. Cognitive Behavioral Therapy - Enhanced C. Dialectical Behavior Thersapy D. A and B
D. A and B
One Year Health Care Costs Per Patient
DBT is less expensive than TAU (Treatment as Usual)
Interpersonal Effectiveness: Getting Your Objective
DEAR MAN - Describe the current situation - Express feelings and opinions - Assert by asking or saying no - Reinforce the person ahead of time - Mindful of objectives without distraction: Broken Record & Ignoring Attacks - Appear effective and competent - Negotiate alternative solutions: Turn the Tables
Anorexia Nervosa: Course and Outcome (Recovery & Relapse)
Data suggests recovery is often prolonged: - After 2-5 years, recovery around 45% - Treatment seeking samples: around 69% recovered - Overall: around 46% recover, 33% improve but remain symptomatic, and 20% chronically ill Relapse: - Estimates range, as the study designs have been different - Generally, between 30-50% of women will relapse following discharge from treatment
Categories of Commonly Used Substances: 5) Inhalants
Depresses the CNS causing slurred speech, lack of coordination, euphoria and dizziness. Includes sniffing glue, spray paints, nitrites
Medical Nutrition Therapy
Establish Goal Weight Range: - Laboratory Data - Weight History/Growth Curves - Family Weight History - Body Composition Monitor weight changes & educate accordingly: - Fluid Shifts - Refeeding Effects - Natural Weight Cycles Monitor Nutrition-Related Labs & Medical Complications - Comorbidities such as diabetes, GI diseases, allergies (celiac vs. gluten insensitivity) - Ongoing communication & coordination of care with physician - Prescribe Healthy Exercise - Prescribe Meal Plan - Optimize Resting Metabolic Rate
Research on DBT
Evidence Based Treatment: - Gold Standard for borderline personality disorder, suicidality, self-injurious behaviors - Summary of research findings - Also research supporting use with eating disorders, depression, substance use, bipolar disorders, adolescents; in inpatients, forensic residential settings
EFFECTS OF MALNUTRITION (AN, BN)
Examples: - Reduced brain volume - Abnormal neurotransmitter and neuropeptides - Prepubertal hormonal function Brain not retaining information: - Impaired concentration, learning - Exaggerated mood disturbances
Interpersonal Effectiveness: Keeping your Self-Respect
FAST - Fair to myself and others - (No) Apologies for being alive - Stick to values - Truthful without excuses or exaggeration
Evidence-based treatments for EDs
Family-based treatments: - Adolescents with anorexia nervosa - Outpatient Dialectical Behavior Therapy: - Individuals with BN and BED - Outpatients Cognitive Behavior Therapy - Enhanced: - Transdiagnostic population (?) - Some data suggesting can be be adapted for adolescents Studies supporting the use of these treatments are generally randomized controlled trials: - What does that mean for their utility for "real life" settings?
Amanda vs. Donna
First Case: - 20 years old - Hospitalized at 13 - Anorexia Nervosa - Hospitalization x3 - Anxiety, negative self-talk, isolation - First time in treatment Second Case: - 40 years old - Bulimia Nervosa - History of childhood abuse - Impulsive, risk taking behaviors, - Multiple psychiatric hospitalizations - PTSD - Alcohol use disorder - Polysubstance use disorder - Suicidal Ideation - Suicide attempts x 2 - Self Harm - Avoidance behavior such as isolation - OCD - Domestic violence - Limited access to ED treatment - Financial stressors
Model of Eating Pathology for Men
First: - Friend pressure to be mesomorphic - Family pressure to be mesomorphic - Media pressure to be mesomorphic - Partner pressure to be mesomorphic Second: - Internalization of the Mesomorphic Ideal Third: - Dissatisfaction with Muscularity -> Muscularity Enhancement Behaviors - Dissatisfaction with Body Fat -> Disordered Eating Behaviors
Interpersonal Effectiveness; Keeping the Relationship
GIVE - Gentle manner without attack or threat - Interested in the other person - Validate other person without judging - Easy Manner with humor or a "soft sell"
Bulimia Nervosa: Course and Outcome
Given more recent introduction of BED into DSM, fewer studies on course and outcome - One study indicated 85% remission at 4-year follow-up - Another cohort: 67% at 12 year follow-up Relapse occurred in 4-10% people recovered from BED at differing points of follow-up: - Predictors: Male and higher loss of control when eating normal amount of food
Phase II: Return Control to Adolescent
Goals: - Weight at a minimum of 87% IBW - Maintain parental management of ED sx until patient shows she can manage them on her own - Gradually return food and weight control to patient - Explore relationships between adolescent development issues and ED
Anorexia Nervosa: Course and Outcome (Mortality)
Highest risk of premature death: ~5% - 4.0 to 12.0 times the risk of death than in a comparison population, across studies, standardized mortality ratio is around 5.86 - Most often linked to suicide, rather than starvation -> 1 in 5 AN patients commits suicide - Predictors of fatal outcome: low weight, poor psychosocial functioning, and severity of alcohol use disorder - Attempts higher among individuals with purging behaviors, depression, substance abuse, and a history of physical or sexual abuse
Categories of Commonly Used Substances: 2) Caffeine
Highly used by ED patients, mostly because of its appetite suppressant properties. Approx. 26% of AN and 23% of BN meet criteria for caffeine disorder
Dietary Restriction & Restraint
Identify forms of restraint & restriction: - Delayed eating - Avoidance of specific foods - Skipping meals Dietary rules and rituals: - E.g., not eating more than 600 kcals daily - Not eating after X time or before X time - Not eating in front of others Strategies: - Regular eating & exposure to "challenging" foods - Education on consequences of restriction/restraint
Etiology of Obesity: What contributes to the development of obesity?
Inside the Person: - Disordered Eating - Emotional Coping - Hyper-reactivity to Environmental Food Cues - Heightened Hunger Response - Delayed Satiety - Age-Related Changes - Pathological Sources of Endocrine Dysregulation, etc. Outside the Person: - Environmental/Chemical Toxins - Infection - Weight Gain Inducing Drugs - Smoking Cessation - Sleep Deficits - Stress - Child Maltreatment - Weight Cycling (yo-yo effect) - Consistent Temperature - Increased Sedentary Time - Built Environment, etc.
What is the answer to treat Co-Occurring Disorders?
Integrated Care
DBT...
Is designed for the severe and chronic multi-diagnostic, difficult-to-treat patient with both Axis I and Axis II disorders
Mindfulness: "lighthouse beam"
Learning to be in control of your own mind, instead of letting your mind be in control of you.
Categories of Commonly Used Substances: 4) Hallucinogens
Least prevalent of the SUDs; cause an altered state of consciousness. Disturbances in judgment, orientation, intellect, memory, emotion and level of consciousness. Includes LSD, PCP, MDMA (ecstasy), ketamine.
Standard DBT Skills Training Group Format
Length: 2.0 Hours - Mindfulness: 5 minutes - Homework Review: 50 minutes - Break: 10 minutes - Didactic/New Teaching: 50 minutes
Development of Family Based Treatment
Looking more closely at the role of the family: - Adolescent is part of family - Adolescent lives in the home - Adolescent unable to make good decisions about eating - No evidence that parents cause ED's
How can you describe Binge Eating Disorder (BED)?
Loss of Control
Additional Targets to Address (Broad CBT-E)
Mood Intolerance: - Patients who are sensitive to intense mood states and have difficulty regulating their mood - Use DBT and self-monitoring strategies to address Clinical Perfectionism: - Over-evaluation of striving to achieve; seen in ED behaviors and other areas of life (work, sports, etc.) - CBT-E strategy of addressing over-evaluation may be applied; behavioral experiments Low Self-Esteem: - Highly self-critical, global negative view of themselves - CBT strategies to address this Interpersonal Problems: - Difficulty in interpersonal relationships - Use IPT strategies to enhance interpersonal functioning and resolve interpersonal problems
Orientation to this Topic
Most commonly-asked questions as a clinician: - Am I going to get better? Am I going to gain weight? Course: Path that patients have taken between when they were first encountered and when the outcome is assessed Outcome: How well patients are doing at some point after initial encounter - Can be treatment outcome, or just more generally - Related, but distinct! - Textbook reviews mortality, recovery, relapse, crossover, and prognostic factors
Overlapping Neurotransmitters for Eating Disorders and Other Psychiatric Disorders
Norepinephrine: - Alertness - Concentration - Energy Serotonin: - Obsession - Compulsion - Memory Dopamine: - Reward - Motivation Mixed: - Anxiety, Impulse, Irritability, Cognitive, Function, Appetite, Aggression, Sex, Attention
When a patient first comes in...
Nutrition Assessment: - Meal Plan needs - Weight goals - Exercise recommendations
Emotion Regulation
Opposite Action for unjustified emotions Emotions are justified if they: 1. Fit the facts of the situation 2. Are effective in the situation
Specific ED Psychopathology
Over-evaluation of shape and weight (COGNITIVE) - Different from body shape dissatisfaction or "normative discontent" - Expressed through restricting, bingeing, purging, exercise *Weighing frequently *Preoccupation with trivial changes in weight *Checking and avoiding behaviors *Feeling fat = being fat *Profound effect on social functioning/intimate relationships
FBT Behavior Therapy Components
Parent and Child: - Parenting Skills - Positive Reinforcement - Goal Setting - Stimulus Control - Relapse Prevention - Self-Monitoring
In-Session Weighing
Patients with eating disorders are unusual in their frequency of weighing - Reinforces concern about inconsequential changes in weight, and thereby maintains dieting - Avoidance of weighing is as problematic Knowledge of weight is a necessary part of treatment - Permits examination of the relationship between eating and weight - Facilitates change in eating habits - Necessary for addressing any associated weight problem - One aspect of addressing the over-evaluation of weight
Categories of Commonly Used Substances: 3) Cannabis
Popular among ED patients and highly controversial. Two types include Sativa (uplifting with euphoric highs; often promoted to treat depression and fatigue) and Indica (sedating; claims relief for pain and anxiety)
Controversy 2: Weighing Patients in Treatment - Weighing
Pro-Weighing: - Helps to track behavioral progress - Patient safety - Can provide objective indicator of engagement in behaviors - Generally dictates focus on session - Decreases avoidance of scales Pro-Informing Patient: - Decreases avoidance - Prompts patient to cope with normal fluctuations in weight - Allows patients to "test" beliefs about weight its fluctuations Anti-Weighing: - Increases anxiety - Increases emotion dysregulation - Unnecessary if patient is in their weight ranging or in "normal" range (?) - Issues with therapeutic relationship? Anti-Informing Patient: - Same as above - Prompts greater compliance with meal plan (?) - Prudent to wait until the patient is ready
The Core Strategies in DBT
Problem Solving & Validation
Childhood Obesity Complications
Psychosocial, Pulmonary, Renal, GI, Musculoskeletal, Neurological, Cardiovascular, Endocrine, etc.
Controversies and Future Directions in Eating Disorders Research: Wrap Up - Orientation to this Topic
Putting what we've learned into context; explore controversies - both clinical and research - currently debated by the field State of eating disorders research - Decades behind other areas of psychopathology - only began as a field in the '70s-'80s - Tools to understand biological contributions to eating disorders only have been available for ~15 years or so - Evidence-based treatments for eating disorders - how do they do? *Quite badly - 40-60% recover - Also important to recognize what we mean when we say "evidence-based treatment)
Dialectics Lesson 2:
Reality is not static, but is comprised of internal opposing forces (thesis and antithesis) Treatment Implications: - Search for "what is left out" - Ineffective to focus on part without reference to whole - Function of behavior (within dysfunction there is function) - What is being reinforced?
Controversy 3: Private Equity Firms and Residential Eating Disorder Treatment - Case Study
Renfrew Centers • Prior theoretical orientation: idiosyncratic, psychodynamic, eclectic, "feminist-relational" approach • Can an evidence-based protocol for the treatment of emotional disorders (Unified Protocol) be implementing in a large network of residential treatment centers? • Significant resistance from older clinicians • Individuals receiving the UP demonstrated significantly greater deceases in experiential avoidance and anxiety sensitivity and increases in mindfulness, compared to pre-intervention. • No differences between groups at discharge, but UP group showed greater improvements in eating disorder symptoms and depression at follow-up, and continued improvements in experiential avoidance.
USE OF PSYCHIATRIC MEDICATION IN FOR ED SYMPTOMS
SPECIFICALLY TO TARGET THE ED SYMPTOMS: 1. NO MED SHOWN TO BE EFFECTIVE FOR AN 2. PROZAC (FLUOXETINE) FDA APPROVED FOR BN 3. VYVANSE FDA APPROVED FOR BED 4. CLINICAL EXPERIENCE/CASE REPORTS
MEDICATIONS FOR DEPRESSION AND ANXIETY
Serotonin Reuptake Inhibitors (SSRIs): • Prozac (Fluoxetine • Zoloft (Sertraline) • Lexapro (escitalopram) • Celexa (Citalopram) • Paxil (parozetine) Serontonin Norepinephrine Reuptake Inhibitors (SNRIs): • Effexor (Venlafaxine) • Pristiq (desvenlafaxine) • Cymbalta (Duloxetine)
Integrated Care
Services for patients with comorbid ED and SUD should be organized in a comprehensive and integrated manner which includes the following elements: 1) Comprehensive, evidence based screenings for ED, SUD, other psych disorders, medical conditions and relevant lab tesitng 2) Individualized treatment plans that encompass both ED & SUD 3) Therapists and tx teams that are trained in evidence based treatments for COD 4) Services that are provided in the same location by the same providers in a stepwise, integrated fashion 5) A plan or contract to manage service elsewhere if needed (e.g., methadone maintenance, AA/NA meetings).
Stage 1 Primary Targets
Severe Behavioral Dyscontrol -> Decrease/Eliminate Behavior Decrease: 1. Life-threatening behaviors 2. Therapy-interfering behaviors: non-attentive, non-collaborative, and non-compliant behaviors 3. Quality-of-life interfering behaviors Increase behavioral skills: - Mindfulness - Interpersonal Effectiveness - Emotion Regulation - Distress Tolerance
Increasing Physical Activity
Shape up to: - 90 min a day 5/7 days for kids - 60 min a day 5/7 days for parents
Overview of CBT-E
Stage One: - "Start well" (establish the foundations of treatment; achieve early change) Stage Two: - Review progress; identify emerging barriers to change; design Stage Three Stage Three: - Address the main maintaining mechanisms Stage Four: - "End well" (maintain the changed obtained; minimize the risk of relapse)
Bulimia Nervosa: Course and Outcome (Mortality)
Standardized mortality ratio: 1.93 for BN - More than six times as likely to die from suicide than matched controls - Predictors of suicide attempts in BN: history of substance use disorder, laxative abuse, Cluster B personality disorders, and childhood sexual abuse
Dialectics Lesson 1:
Stressed Interrelatedness and wholeness; assumes a systems perspective on reality Treatment Implications: - Disorder is systemic - Development and maintenance of disorder is transactional - Teach biosocial theory of etiology
Commonly Seen Syndromes in Patients with Eating Disorderd
Symptoms directly from the eating disorder: - Abnormal feeding behaviors - GI symptoms - Anxiety/Mood symptoms due to ED Co-occurring disorders (2 or more): - Mood disorders - Anxiety disorders - Affective dysregulation and impulse disorders
Controversy 1: Involuntary Treatment for AN - Alternatives to Involuntary Treatment?
Techniques designed to enhance autonomy - Self-admission to the hospital (Strand et al., 2007) - Motivational Enhancement Techniques - Limited data thus far
Severity
The DSM-5 suggests using the number of criteria met as a general measure of severity, from mild (2-3 criteria) to moderate (4-5 criteria) and sever (6 or more criteria).
Categories Commonly Used Substances: 1) Alcohol
The most abused substance by ED patients. Approximately 28% of ED patients had AUD prior to onset of ED; 38% develop an AUD concurrently with the ED; and 24% develop AUD after onset of ED Early onset drinking (prior to age 15) increases the risk of AUD by 3x vs. an onset drinking of 19+.
Biosocial Theory of Emotion Dysregulation
Theory goes to an Invalidating Environment: - Abuse - Neglect - Inaccurate labeling of emotions - Erratic, inappropriate responses to anger - Poor temperamental fit Goes to-> Pervasive Emotion Dysregulation
Phase I: Weight Restoration
Treatment Goals: - Take history of the illness - Separate the illness from the patient Provide education on the seriousness: - Medical Complications Charge parents with refeeding their child: - To Ideal Body Weight (IBW)
Forms of CBT-E
Two versions: - Focused (the core treatment) - Broad (mood intolerance, clinical perfectionism, low self-esteem and interpersonal difficulties) Two intensities: - 20-session version (BMI > 17.5) - 40-session version (15.0 < BMI > 17.5)
Controversy 1: Involuntary Treatment for AN
What if patients do not want treatment? Relevant across samples: - Severe and enduring anorexia nervosa (AN) - 7 years+ - Medically compromised patients (across diagnoses) - Psychologically compromised patients with low insight Mortality high: - 20 years old - 20% mortality from AN; increases 5-10% every decade after - Can we compel individuals with severe eating disorders to enroll in treatment?
Case Example 5
• 17 YO FEMALE WITH AN-R, FORCED TO COME TO TREATMENT BY PARENTS • VERY ANGRY, FRUSTRATED. NO CLEAR ADDITIONAL PSYCHIATRIC ILLNESS • HAD MAJOR TANTRUMS, REFUSED TO EAT, HYSTERICAL, VIOLENT • CRY, SCREAM FOR 8 HOURS AFTER ATE 5 OREOS • TRIED TO KICK OUT WINDOW OF CAR WHILE MOM DRIVING • ABILIFY -> TO TREAT AGITATION, ANXIETY, PERSEVERATIVE NATURE OF ED
Case Example 3
• 28 YEAR OLD MALE REFERRED FOR ED, SEVERE WEIGHT LOSS • 5'11, 120 LBS. GENERALLY VOMITS WITH ANY FOOD INTAKE, REPORTS INVOLUNTARY • DENIES ALL CLASSIC BODY IMAGE, FEAR OF WT GAIN SYMPTOMS. BUT, UNABLE TO MAINTAIN/REGAIN TO NORMAL WEIGHT • DID REPORT ABILITY TO KEEP SOME FOOD DOWN WITH ETOH • REMERON (ANTIANXIETY/ANIDEPRESSANT) -> RESTORATION 1. MOOD, FUNCTION BETTER 2. ANXIETY MUCH BETTER
Case Example 2
• 30 YO FEMALE WITH BIPOLAR DISORDER • MOOD STATE AND ED SYMPTOMS (BINGE VS COMPULSIVE EXERCISE) • ADHERENCE TO TREATMENT STATE DEPENDENT 1. DEPRESSION, BINGE 2. HYPOMANIA • MEDICATIONS AND APPETITE
Case Example 4
• 9 YEAR OLD GIRL WITH ARFID, NAUSEA, VOMITING, ANXIETY • LOW WEIGHT, HADN'T GROWN OR GAINED WEIGHT IN 2 YEARS • WOULD CRY AT MEALS DUE TO STOMACH PAIN, NAUSEA, VOMIT (INVOLUNTARY AFTER MOST MEALS) • UNABLE TO ATTEND SCHOOL REGULARLY • REMERON (ANTIDEPRESSANT/ANTIANXIETY MED)
ASSESSMENT AND TREATMENT FOR CO- OCCURRING ANXIETY/DEPRESSION IN PATIENT WITH EDS
• ACCURATE DIAGNOSIS (BE SURE NOT DUE TO ED) • TIMELINE TECHNIQUE • DEPRESSION - CAN USE MOST ANTIDEPRESSANTS: SSRIS, SNRIS, AVOID MEDS THAT INCREASE WEIGHT OR ARE IMPACTED BY ED • ANXIETY CAN USE MOST "ANTIDEPRESSANTS": SSRIS, SNRIS, AVOID MEDS THAT INCREASE WEIGHT OR ARE IMPACTED BY ED
CHALLENGES IN DIAGNOSING COMORBIDITY IN EATING DISORDERS
• ED RELATED MOOD SYMPTOMS (BODY IMAGE, STARVATION, BINGE PURGE) • ED RELATED ANXIETY SYMPTOMS • ALEXITHYMIA • SUBSTANCE USE
MOOD STABILIZERS
• LITHIUM • DEPAKOTE • TEGRETOL • ALL ATYPICAL ANTIPSYCHOTIC MEDICATIONS
PSYCHIATRIC MEDICATIONS FOR AN
• MANY MEDICATIONS HAVE BEEN STUDIED FOR TREATMENT IN AN • NONE HAVE CONSISTENTLY SHOWN EFFICACY IN "CONTROLLED" TRIALS • DOPAMINE AND SEROTONIN REGULATING MEDICATIONS 1. SSRIS (GENERAL FOUND TO BE UNHELPFUL IN PURE AN) 2. ATYPICAL ANTIPSYCHOTIC 3. APPETITE STIMULANT
PSYCHOPHARMACOLOGY IN PATIENTS WITH EATING DISORDERS
• MEDICATION TO DIRECTLY TARGET THE EATING DISORDER 1. ABNORMAL FEEDING BEHAVIORS 2. GI SYMPTOMS 3. ANXIETY/MOOD SYMPTOMS DUE TO ED • MEDICATION TO TARGET CO-OCCURRING DISORDERS 1. MOOD DISORDERS 2. ANXIETY DISORDERS 3. AFFECTIVE DYSREGULATION AND IMPULSE DISORDERS
MEDICATION FOR BN AND BED
• PATIENTS WITHOUT CO-OCCURRING DISORDERS • SSRI BN >BED • TOPIRAMATE (ANTICONVULSANT) BED AND BN • VYVANSE BED • OBESITY MEDICATIONS
TIMELINE TECHNIQUE FOR DIFFERENTIATING SYMPTOMS OF ED FROM "TRUE" CO-OCCURRING DIAGNOSIS
• PRE-MORBID VULNERABILITIES • TIMELINE OF SYMPTOMS AND EATING DISORDER • EXTREMES OF EATING BEHAVIORS SERVE TO REDUCE DYSPHORIC MOOD • EXAGGERATED BY MALNUTRITION • WHEN CO-OCCURRING SYMPTOMS PREDATE ED OR PERSIST AFTER EATING SYMPTOMS NORMALIZE: LIKELY CO MORBID DIAGNOSIS
EDS AND ANXIETY DISORDERS
• TYPES 1. OBSESSIVE COMPULSIVE DISORDER (OCD) (AN>BN) 2. SOCIAL PHOBIA 3. GENERALIZED ANXIETY DISORDER (GAD) 4. POST TRAUMATIC STRESS DISORDER (BN>AN) 5. PANIC DISORDER
