Eating Disorders and Non-Suicidal Eating Disorders and Non-Suicidal Self-Injury: The Role of TraumaSelf-Injury: The Role of Trauma

• Stephen Wonderlich, Ph.D.Stephen Wonderlich, Ph.D.• University of North Dakota School of MedicineUniversity of North Dakota School of Medicine• & Health Sciences& Health Sciences• Neuropsychiatric Research InstituteNeuropsychiatric Research Institute• Sanford HealthSanford Health• Heather Simonich, M.A.Heather Simonich, M.A.• Neuropsychiatric Research InstituteNeuropsychiatric Research Institute• Kathryn Gordon, Ph.D.Kathryn Gordon, Ph.D.• North Dakota State UniversityNorth Dakota State University• Neuropsychiatric Research InstituteNeuropsychiatric Research Institute

Topics for TodayTopics for Today

• Eating DisordersEating Disorders• Non-Suicidal Self-InjuryNon-Suicidal Self-Injury• Borderline PersonalityBorderline Personality• The Role of Trauma in Self-Damaging BehaviorThe Role of Trauma in Self-Damaging Behavior• Clinical Ideas for ED, NSSI, BPD, and TraumaClinical Ideas for ED, NSSI, BPD, and Trauma• Trauma Informed School SystemsTrauma Informed School Systems

Eating Disorder OverviewEating Disorder Overview

DSM-5 Criteria for Anorexia NervosaDSM-5 Criteria for Anorexia NervosaA.A. Restriction of energy intake relative to requirements, leading Restriction of energy intake relative to requirements, leading

to a significantly low body weight in the context of age, sex, to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that normal or, for children and adolescents, less than that minimally expected.minimally expected.

B.B. Intense fear of gaining weight or becoming fat, or persistent Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though at a behavior that interferes with weight gain, even though at a significantly low weight.significantly low weight.

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

DSM-5 Criteria for Bulimia NervosaDSM-5 Criteria for Bulimia NervosaA.A. Recurrent episodes of binge eating. An episode of binge eating is Recurrent episodes of binge eating. An episode of binge eating is

characterized by both of the following:characterized by both of the following:1.1. Eating, in a discrete period of time (e.g., within any 2-hour period), an Eating, in a discrete period of time (e.g., within any 2-hour period), an amount amount of food that is definitely larger than what most individuals would eat in a of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.similar period of time under similar circumstances.

2.2. A sense of lack of control over eating during the episode (e.g., a A sense of lack of control over eating during the episode (e.g., a feeling that one feeling that one cannot stop eating or control what or how much one is cannot stop eating or control what or how much one is eating)eating)

B.B. Recurrent inappropriate compensatory behavior in order to prevent Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, and other medications; fasting; or excessive exercise.diuretics, and other medications; fasting; or excessive exercise.

C.C. The binge eating and inappropriate compensatory behaviors both The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.occur, on average, at least once a week for 3 months.

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

E.E. The disturbance does not occur exclusively during episodes of anorexia The disturbance does not occur exclusively during episodes of anorexia nervosa.nervosa.

DSM-5 Criteria for Binge Eating DisorderDSM-5 Criteria for Binge Eating Disorder

A. Recurrent episodes of binge eating. A. Recurrent episodes of binge eating. B. The binge-eating episodes are associated with three (or more) of the B. The binge-eating episodes are associated with three (or more) of the

following:following:– 1. eating much more rapidly than normal1. eating much more rapidly than normal– 2. eating until feeling uncomfortably full2. eating until feeling uncomfortably full– 3. eating large amounts of food when not feeling physically hungry3. eating large amounts of food when not feeling physically hungry– 4. eating alone because of being embarrassed by how much one is eating4. eating alone because of being embarrassed by how much one is eating– 5. feeling disgusted with oneself, depressed, or very guilty after overeating5. feeling disgusted with oneself, depressed, or very guilty after overeating

C. Marked distress regarding binge eating is present.C. Marked distress regarding binge eating is present.D. The binge eating occurs, on average, at least once a week for 3 months.D. The binge eating occurs, on average, at least once a week for 3 months.E. The binge eating is not associated with the recurrent use of E. The binge eating is not associated with the recurrent use of

inappropriate compensatory behavior and does not occur exclusively inappropriate compensatory behavior and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.during the course of bulimia nervosa or anorexia nervosa.

Epidemiology-Anorexia NervosaEpidemiology-Anorexia Nervosa

• 1% of women in community1% of women in community

• 99% of cases are female99% of cases are female

• Middle to upper classMiddle to upper class

Epidemiology-Bulimia NervosaEpidemiology-Bulimia Nervosa

• 2% of women in community2% of women in community

• 4-5% of college women4-5% of college women

• 90-95% cases are female90-95% cases are female

• Middle to upper classMiddle to upper class•• Broadening to other strataBroadening to other strata

Epidemiology of BEDEpidemiology of BED

3.5% of U.S. women3.5% of U.S. women 2.0% of U.S. men2.0% of U.S. men

• More social and gender diversity than AN More social and gender diversity than AN and BNand BN

• 4.5% of black sample = BED4.5% of black sample = BED

Hudson et al., 2007

Psychiatric Comorbidity/ Associated Psychiatric Comorbidity/ Associated ProblemsProblems

Psychiatric Comorbidity in Bulimic PatientsPsychiatric Comorbidity in Bulimic PatientsN = 46N = 46

CasesCases

No ComorbidityNo Comorbidity 77 (15%)(15%)

AnxietyAnxiety 11 (2%)(2%)

MoodMood 99 (20%)(20%)

Personality Disorder (PD)Personality Disorder (PD) 44 (9%)(9%)

Substance AbuseSubstance Abuse 11 (2%)(2%)

Anxiety/PDAnxiety/PD 22 (4%)(4%)

Mood/PDMood/PD 77 (15%)(15%)

Mood/SubstanceMood/Substance 33 (7%)(7%)

Substance/PDSubstance/PD 11 (2%)(2%)

Mood/Substance/PDMood/Substance/PD 33 (7%)(7%)

Mood/Anxiety/PDMood/Anxiety/PD 22 (4%)(4%)

Mood/Substance/AnxietyMood/Substance/Anxiety 11 (2%)(2%)

Mood/Substance/Anxiety/PDMood/Substance/Anxiety/PD 55 (11%)(11%)

Eating Disorder Risk FactorsEating Disorder Risk Factors

• GenderGender

• AgeAge

• Family History/GeneticsFamily History/Genetics

• Extreme DietingExtreme Dieting

• Weight/shape focused occupation/activitiesWeight/shape focused occupation/activities

Eating Disorder Risk FactorsEating Disorder Risk Factors(cont.)(cont.)

• Environmental stress/changeEnvironmental stress/change

• AbuseAbuse

• Personality/self conceptPersonality/self concept

• Depression, anxiety (particularly childhood)Depression, anxiety (particularly childhood)

• Sociocultural influencesSociocultural influences

Stice, 2001Stice, 2001

Jacobi et al., 2002Jacobi et al., 2002

Genetic FactorsGenetic Factors

Biological FactorsBiological Factors

Personality FactorsPersonality Factors

Childhood StressChildhood Stress

Weight & Performance-Related Weight & Performance-Related ActivitiesActivities

Socio-Cultural FactorsSocio-Cultural Factors

NSSI: OverviewNSSI: Overview

Non-Suicidal Self-Injury (NSSI)Non-Suicidal Self-Injury (NSSI)

Socially unaccepted behavior causing intentional and Socially unaccepted behavior causing intentional and direct injury to one’s body tissue without suicidal intent direct injury to one’s body tissue without suicidal intent (e.g., cut, burn, abrade, hit)(e.g., cut, burn, abrade, hit)

Claes & Muehlenkamp (2014)Claes & Muehlenkamp (2014)

DSM 5DSM 5

HandoutHandout

NSSI EpidemiologyNSSI Epidemiology

• Average age of onset – 12-16 yearsAverage age of onset – 12-16 years

• Lifetime prevalence – 18% (teens)Lifetime prevalence – 18% (teens)

• Rates increasing, but recently stabilizedRates increasing, but recently stabilized

• Females > males (slightly)Females > males (slightly)– Type of self harm varies by genderType of self harm varies by gender

Rodham & Hawtone, 2009Rodham & Hawtone, 2009

Muehlenkamp et al., 2012Muehlenkamp et al., 2012

Claes et al., 2010Claes et al., 2010

Types of NSSI BehaviorTypes of NSSI Behavior

• Injury inflicted with a knife, needle, razor Injury inflicted with a knife, needle, razor or sharp object, burn, abrasionor sharp object, burn, abrasion

• Thighs, forearmThighs, forearm

• Series of cuts – 1 or 2 cm apartSeries of cuts – 1 or 2 cm apart

• Blood and scarringBlood and scarring

Overlap of ED and NSSIOverlap of ED and NSSI

• > 70% of ED patients report NSSI> 70% of ED patients report NSSI

• 25-54% of NSSI report disordered eating25-54% of NSSI report disordered eating

• NSSI more strongly associated with binge purge NSSI more strongly associated with binge purge ED than restricting EDED than restricting ED

Claes et al., 2010Claes et al., 2010

Muehlenkamp et al., 2012Muehlenkamp et al., 2012

Golust et al., 2008Golust et al., 2008

Shared Risk for ED and NSSIShared Risk for ED and NSSI

Models to Explain SimilaritiesModels to Explain Similarities

Individual Predisposing FactorsTEMPERAMENT

High Emotional ReactivityNegative Mood Intolerance

PERSONALITYImpulsive

Obsessive-Compulsive TraitsPerfectionism

Social Predisposing FactorsFAMILY ENVIRONMENT

Low Emotional SupportHigh Control & Criticism

Low Connectedness

TRAUMATIC EXPERIENCESEmotional, Physical, Sexual

AbusePeer Bullying

CULTURAL PRESSURESSelf-Objectification

Unrealistic Body StereotypesIndividual Cultural Pressures

Specific Risk FactorsEMOTION DYSREGULATION

Low Distress Tolerance

COGNITIVE DISTORTIONSSelf-Criticism/Guilt

Low Self-EsteemLOW BODY REGARD

Body Esteem/Body DissatisfactionBody Competence

Interceptive Awareness/AlexithymiaBody Integrity

DISSOCIATION

PEER INFLUENCE/CONTAGIONBest Friend/Peer Engagement

Socialization & Selection Efforts

PSYCHIATRIC DisordersMood/Anxiety Disorders

Posttraumatic Stress DisorderSubstance Related DisordersAxis II Personality Disorders

StressfulLife

Event

NSSI&

EatingDisorder

DISTAL FACTORS PROXIMAL FACTORS BEHAVIOR

Models of NSSIModels of NSSI

• Emotional cascadeEmotional cascade– Event – emotion – rumination – behaviorEvent – emotion – rumination – behavior

Selby & Joiner, 2009Selby & Joiner, 2009

• Four Function TheoryFour Function Theory

Nock & Prinstein, 2008Nock & Prinstein, 2008

• Escape TheoryEscape Theory– Failure experience – negative emotion – dissociation – Failure experience – negative emotion – dissociation –

behaviorbehavior

Heatherton & Baumeister, 2001Heatherton & Baumeister, 2001

Causes & Correlates: The Functional Causes & Correlates: The Functional Model of NSSI (Nock)Model of NSSI (Nock)

Interpersonal

Intrapersonal

Positive Reinforcement

Negative Reinforcement

Feel something even if it’s pain

Get a response from someone else

Stop bad feelings

Get out of a situation

Models of NSSI (cont.)Models of NSSI (cont.)

• Emotion DysregulationEmotion Dysregulation– Negative body viewNegative body view– Depression Depression – Emotion dysregulationEmotion dysregulation

Muehlenkamp et al., 2012Muehlenkamp et al., 2012

Gordon et al., 2014Gordon et al., 2014

You Tube - NSSIYou Tube - NSSI

• http://www.youtube.com/watch?v=dZJhJJ-h7Ek&list=PL_F7LS-9PhvsTVSOfs113c09ENQYeRIhQ

Is Trauma Related to ED?Is Trauma Related to ED?

(Miller et al., 1971)

Maltreatment of ChildrenMaltreatment of Children

1.1. Neglect (food, clothing, housing, Neglect (food, clothing, housing, medical)medical)

2.2. Emotional abuse (degrading, Emotional abuse (degrading, demeaning)demeaning)

3.3. Physical abuse (physical pain, Physical abuse (physical pain, coercion, or dominance)coercion, or dominance)

4.4. Witness violenceWitness violence

5.5. Sexual abuse (child used for sexual Sexual abuse (child used for sexual stimulation)stimulation)

Children and AbuseChildren and Abuse

• 10 – 13% of America’s children have been kicked, burned, 10 – 13% of America’s children have been kicked, burned, bit, punched, hit with an object, beaten or threatened with bit, punched, hit with an object, beaten or threatened with weapon by a parentweapon by a parent

• 25% of school children experience a trauma25% of school children experience a trauma

• 20% of traumatized children have a mental health diagnosis 20% of traumatized children have a mental health diagnosis and only 10% of those receive treatmentand only 10% of those receive treatment

• 21 – 32% of U.S. women were sexually abused before age 1821 – 32% of U.S. women were sexually abused before age 18

Kilpatrick, 1996Kilpatrick, 1996

Vogeltanz et al., 1999Vogeltanz et al., 1999NCTSN School committee, NCTSN School committee,

20082008

National WomenNational Womens Study N = 714 Casess Study N = 714 CasesAge at time of RapeAge at time of Rape

<11 years old(29.7%)11-17 years old(32.2%)18-24 years old(22.2%)25-29 years old(7.1%)>29 years old(6.1%)Not sure/refused(3.0%)

22.2%

7.1%

6.1%3.0%

29.7

32.2%

Kilpatrick, 1996

Adverse Childhood ExperiencesAdverse Childhood Experiences1. Child physical abuse.

2. Child sexual abuse.

3. Child emotional abuse.

4. Emotional neglect.

5. Physical neglect.

6. Mentally ill, depressed or suicidal person in the home.

7. Drug addicted or alcoholic family member.

8. Witnessing domestic violence against the mother.

9. Loss of a parent to death or abandonment, including abandonment by parental divorce.

10. Incarceration of any family member for a crime.

(Anda & Felitti, 2009)(Anda & Felitti, 2009)

ACE StudyACE Study

The ACE StudyThe ACE Study(Felitti et al., 1998)

SmokingSmoking

ObesityObesity

DepressionDepression

Suicide GestureSuicide Gesture

AlcoholismAlcoholism

Illicit DrugsIllicit Drugs

Injectable DrugsInjectable Drugs

Sexual PromiscuitySexual Promiscuity

STDSTD

2.22.2

1.61.6

4.64.6

12.212.2

7.47.4

4.74.7

10.310.3

3.23.2

2.52.5

Disease4 or More Adversities

(Odds Ratio)

The ACE StudyThe ACE Study(Felitti et al., 1998)

Heart DiseaseHeart Disease

CancerCancer

StrokeStroke

Bronchitis/EmphysemaBronchitis/Emphysema

DiabetesDiabetes

HepatitisHepatitis

Fair/Poor HealthFair/Poor Health

2.22.2

1.91.9

2.42.4

3.93.9

1.61.6

2.42.4

2.22.2

Disease4 or More Adversities

(Odds Ratio)

ACE STUDYACE STUDY

ACE StudyACE Study

0

5

10

15

20

25

% A

ttem

pti

ng

Su

icid

e

ACE Score

120

3

4+

ACE & SUICIDE ATTEMPTS

The ACE StudyThe ACE Study(Felitti et al., 1998)

• Adverse Childhood Experiences (ACEs) are very commonAdverse Childhood Experiences (ACEs) are very common

• ACEs are strong predictors of adult health risks and diseaseACEs are strong predictors of adult health risks and disease

• ACEs are implicated in the 10 leading causes of death in the ACEs are implicated in the 10 leading causes of death in the United StatesUnited States

ACE Study SummaryACE Study Summary

Is there a relationship betweenIs there a relationship between trauma and disordered eating trauma and disordered eating

in traumatized samples? in traumatized samples?

ED in Incest VictimsED in Incest Victims

Incest (N=38) Control Incest (N=38) Control (N=27)(N=27)

Binge 42% 15%Binge 42% 15%

VomitVomit 24% 4% 24% 4%

Laxative 11% 4%Laxative 11% 4%

(Wonderlich, Donaldson, Carson, Staton, Gertz, Leach, Johnson, 1996)

Trauma and Psychopathology

(Thompson et al., 2002)

How about in traumatized children?How about in traumatized children?

Five Year Prospective Study of CSA Children (8 - 13 years)

0

10

20

30

40

50

60

Extreme Diet Binge Vomit

CSA (n = 68)

Control (n =68)

% w

ith B

ehav

ior

(Swanston et al., 1997)

Prospective Study of CA and EDProspective Study of CA and ED(Johnson et al., 2002)(Johnson et al., 2002)

No CSANo CSA CSACSA Odds RatioOdds Ratio

FluctuationsFluctuations

in weight (%)in weight (%) 1919 4141 3.023.02

Dieting (%)Dieting (%) 1717 5050 4.804.80

Vomiting (%)Vomiting (%) 33 1818 6.596.59

DiagnosisDiagnosis

ED (%)ED (%) 77 2727 5.115.11

Controlling for age, gender, child temperament, Controlling for age, gender, child temperament, eating problemseating problems, , parental psychiatric, other child adversity. Study of 782 families.parental psychiatric, other child adversity. Study of 782 families.

Does trauma influence EDDoes trauma influence EDtreatment response?treatment response?

Impact of Traumatic Experiences andViolent Acts upon Response to Treatment

(Rodriguez et al., 2005)

• 270 women with AN, BN, or BED270 women with AN, BN, or BED

• Entered outpatient tx between January 1997 Entered outpatient tx between January 1997 through July 2003through July 2003

• 160 patients who completed 4 months of tx 160 patients who completed 4 months of tx selected for study sampleselected for study sample

Impact of Traumatic Experiences andViolent Acts upon Response to Treatment

(Rodriguez et al., 2005)

Poor Response Good ResponsePoor Response Good Response

(n=70) (%) (n=90) (%)(n=70) (%) (n=90) (%)

Any type of trauma 53% 37%

Sexual Abuse (repeated) 23% 10%*

Other violent

experiences 47% 30%*

Both Traumas 23% 4%***

SummarySummary

• Trauma is associated with EDTrauma is associated with ED

• Trauma may impact treatment outcomeTrauma may impact treatment outcome

• Trauma is associated with impulsive, Trauma is associated with impulsive, emotionally dysregulated EDemotionally dysregulated ED

So, how may early traumaSo, how may early trauma operate to increase risk? operate to increase risk?

Possible Mediators/MechanismsPossible Mediators/Mechanisms

Trauma ED • Shame

• Dissociation

• Impulse Control

• Anxiety

• Substance Use

• Cognitions

• Mood Instability

(Andrews, 1997; Kent et al., 1999; Hart & Waller, 2002; Murray & Waller, 2002; Wonderlich et al., 2001)

Psychobiological MediationPsychobiological Mediation(Animal Studies)(Animal Studies)

Early Stress Early Stress

Suomi, 1991; Kraemer, 1992; McEwen, 1998; Suomi, 1991; Kraemer, 1992; McEwen, 1998; Meaney et al., 1988; Sapolsky et al., 1986Meaney et al., 1988; Sapolsky et al., 1986

Altered Biological

Stress Response

Behavioral Behavioral ResponseResponse

Suppressed HPA Axis and Trauma (Carpenter et al., 2007)

0

2

4

6

8

10

12

0 15 30 45 60 75 90

Pla

sma

AC

TH

(pm

ol/L

)

Controls

Maltreated

Elapsed Time

Suppressed HPA Axis and Trauma (Carpenter et al., 2007)

0

100

200

300

400

500

600

0 15 30 45 60 75 90

Pla

sma

Cor

tisol

(nm

ol/L

)

Controls

Maltreated

Elapsed Time

Differences in Cortisol for Differences in Cortisol for Abused and Nonabused BNAbused and Nonabused BN

8

10

12

14

16

18

20

22

24

26

0 30 60 90 120

150

180

210

240

Abused Bulimic

Nonabused Bulimic

Abused Normal Eater

Nonabused Normal Eater

Co

rtis

ol

Co

nce

ntr

atio

n (g

/dl)

Time (Minutes)

(Steiger et al., 2001)

Does Child Maltreatment Damage Does Child Maltreatment Damage the Brain?the Brain?

In a child’s brain elevated catecholamines and In a child’s brain elevated catecholamines and cortisol may lead to:cortisol may lead to:

• Loss of neuronsLoss of neurons• Delays in myelinationDelays in myelination• Deviant pruning processesDeviant pruning processes• Inhibiting of neurogenesisInhibiting of neurogenesis

(Lauder, 1988; Sapolsky, 1990; DeBellis et al., 2002; Dunlop et al., (Lauder, 1988; Sapolsky, 1990; DeBellis et al., 2002; Dunlop et al., 1997; Tanapat et al., 1998; Bremner, 1999)1997; Tanapat et al., 1998; Bremner, 1999)

Biological CorrelatesBiological Correlatesof Trauma in Children with PTSDof Trauma in Children with PTSD

MRI Based VolumeMRI Based Volume Total Brain (Early Onset, Duration)Total Brain (Early Onset, Duration)

Corpus CallosumCorpus Callosum

Prefrontal CortexPrefrontal Cortex

Superior Temporal GyrusSuperior Temporal Gyrus

Hippocampal VolumeHippocampal Volume

CerebellumCerebellum

ØØ PituitaryPituitary

(Teicher et al., 1997; Carrion et al., 2001; DeBellis et al., 1999, 2002a, 2002b; 2004; 2006; Thomas & DeBellis, 2004; Tupler & DeBellis, 2006)

Experience can ChangeExperience can Changethe Brainthe Brain

SummarySummary

Trauma elicits psychobiological changes that may result in increased impulsive dysregulated behavior (i.e., binge, purge, self-harm).

Is Trauma Related to NSSI?Is Trauma Related to NSSI?

Is Child Abuse Related to NSSI?Is Child Abuse Related to NSSI?

CA•Sexual

• Physical

• Dissociation- Somatic

Disconnection• Lack of Emotion

Regulation Skills

NSSI

Muehlenkamp et al., 2010

Yates et al., 2008Gratz & Roemer, 2008

Does Borderline Personality Have Does Borderline Personality Have Any Relevance Here?Any Relevance Here?

Diagnostic Criteria for 301.83 Diagnostic Criteria for 301.83 Borderline Personality DisorderBorderline Personality Disorder

A pervasive pattern of instability of interpersonal relationships, A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by adulthood and present in a variety of contexts, as indicated by five (or more) of the following:five (or more) of the following:

1.1. Frantic efforts to avoid real or imagined abandonmentFrantic efforts to avoid real or imagined abandonment

Note: Do not include suicidal or self-mutilating behavior Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5covered in Criterion 5

2.2. A pattern of unstable and intense interpersonal relationships A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization characterized by alternating between extremes of idealization and devaluationand devaluation

3.3. Identity disturbance; markedly and persistently unstable self-Identity disturbance; markedly and persistently unstable self-image or sense of selfimage or sense of self

Diagnostic Criteria for 301.83Diagnostic Criteria for 301.83Borderline Personality DisorderBorderline Personality Disorder

4.4. Impulsivity in at least two areas that are potentially self-Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.mutilating behavior covered in Criterion 5.

5.5. Recurrent suicidal behavior, gestures, or threats, or self-Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.mutilating behavior.

6.6. Affective instability due to a marked reactivity of mood (e.g., Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)lasting a few hours and only rarely more than a few days)

7.7. Chronic feelings of emptinessChronic feelings of emptiness8.8. Inappropriate, intense anger or difficulty controlling anger Inappropriate, intense anger or difficulty controlling anger

(e.g., frequent displays of temper, constant anger, recurrent (e.g., frequent displays of temper, constant anger, recurrent physical fights)physical fights)

9.9. Transient, stress-related paranoid ideation or severe Transient, stress-related paranoid ideation or severe dissociative symptomsdissociative symptoms

HurtHurt

I hurt myself today, to see if I still feel. I focus on the pain, tthe only thing that's real. The needle tears a hole. The old familiar sting. Try to kill it all away, bbut I remember everything.

What have I become? My sweetest friend, eeveryone I know goes away in the end. You could have it all, mmy empire of dirt. I will let you down, I will make you hurt.

I wear this crown of shit, uupon my liar's chair. Full of broken thoughts I cannot repair. Beneath the stain of time, the feelings disappear. You are someone else, I am still right here.

What have I become? My sweetest friend. Everyone I know goes away in the end.

You could have it all, my empire of dirt. I will let you down, I will make you hurt. If I could start again, a million miles away, I would keep myself, I would find a way.

Clinical Models of BPDClinical Models of BPD

Adler – Etiology/PathogenesisAdler – Etiology/Pathogenesis

• Inadequate Early ExperienceInadequate Early Experience

• Deficit or InsufficiencyDeficit or Insufficiency– Absence of “holding – soothing introjects”Absence of “holding – soothing introjects”

• Search for Caretaking ResponseSearch for Caretaking Response

• Need-Fear DilemmaNeed-Fear Dilemma

Beck – Etiology/PathogenesisBeck – Etiology/Pathogenesis

• Genetic Tendencies and Experience Genetic Tendencies and Experience Shape SchemasShape Schemas– Schemas more continuous than in syndromesSchemas more continuous than in syndromes

• Basic AssumptionsBasic Assumptions– The world is dangerous and malevolentThe world is dangerous and malevolent– I am powerless and vulnerableI am powerless and vulnerable– I am inherently unacceptableI am inherently unacceptable

• Dichotomous ThinkingDichotomous Thinking

Affective Spectrum ModelAffective Spectrum Model(Akiskal, Liebowitz, Klein)(Akiskal, Liebowitz, Klein)

• Primitive Personality = Nonclassical Primitive Personality = Nonclassical Mood DisordersMood Disorders– Subaffective variantsSubaffective variants– Particularly irritable cyclothymiaParticularly irritable cyclothymia

• Bipolar SpectrumBipolar Spectrum

• Tx Focus is on Mood StabilizationTx Focus is on Mood Stabilization

Linehan – Etiology/PathogenesisLinehan – Etiology/Pathogenesis

• Biologically Based Deficit in Emotion Biologically Based Deficit in Emotion RegulationRegulation

• Invalidating EnvironmentInvalidating Environment

• Coping Skills DeficitCoping Skills Deficit

• Borderline “Symptoms” are Efforts to Borderline “Symptoms” are Efforts to Regulate Negative EmotionsRegulate Negative Emotions

PTSD Spectrum ModelPTSD Spectrum Model(Herman, Marmar, Perry)(Herman, Marmar, Perry)

• Significant Proportion of Borderlines Report Significant Proportion of Borderlines Report History of Child AbuseHistory of Child Abuse

• BPD is Adaptation to Traumatic EnvironmentBPD is Adaptation to Traumatic Environment• Instability in Affect, Self-Other Perceptions, Instability in Affect, Self-Other Perceptions,

Relationships Linked to CARelationships Linked to CA• Complex Post-Traumatic Stress Disorder??Complex Post-Traumatic Stress Disorder??• Post-traumatic Personality Disorder??Post-traumatic Personality Disorder??• Tx Attends to Effects of CATx Attends to Effects of CA

Is trauma linked to BPD?? Is trauma linked to BPD??

Child Abuse in 712 ED Clinic Patients

0

10

20

30

40

50

60

Alcohol Suicide Attempt Shoplifting

None

Sexual

Physical

Both

Fullerton et al., 1995

72 27 0

Personality Disorder in ED PatientsPersonality Disorder in ED Patients

BorderlineBorderline Other PDOther PD No PDNo PD

CSA (%)CSA (%) 7272 2727 00

Wonderlich & Swift, 1990

Relationship of BPD and Childhood Trauma in BN

Childhood Trauma Questionnaire* * *

Wonderlich et al., 2007

Case - Ms. D.Case - Ms. D.

• 40 year old female40 year old female• Diagnosis AN-BP, MDE, BPDDiagnosis AN-BP, MDE, BPD• Three near death suicide gesturesThree near death suicide gestures• History of trauma – CSA – fatherHistory of trauma – CSA – father• 5’ 4” – 70 – 80 lbs.5’ 4” – 70 – 80 lbs.• UnemployedUnemployed• Schedule of life activities:Schedule of life activities:

– 5:00 am – 12:00 pm – sleep5:00 am – 12:00 pm – sleep– 12:00 pm – 5:00 pm – errands, appointments12:00 pm – 5:00 pm – errands, appointments– 7:00 pm – 3:00 am – eat, binge, purge7:00 pm – 3:00 am – eat, binge, purge

Case of Ms. D. (Continued)Case of Ms. D. (Continued)

• TreatmentTreatment– 2 2 years, 2-3x weekyears, 2-3x week– Refused medical evaluationsRefused medical evaluations– Various psychotropic medications - Various psychotropic medications - – Focus of treatmentFocus of treatment

• Binge - unsuccessfulBinge - unsuccessful• Weight gain - unsuccessfulWeight gain - unsuccessful• Trauma - triggeringTrauma - triggering• Suicide – frequent and unsuccessfulSuicide – frequent and unsuccessful• Transference – prominent and complicatedTransference – prominent and complicated

– Mistrust/silence/motionless/angry departuresMistrust/silence/motionless/angry departures– Not understoodNot understood– Hate me/hate selfHate me/hate self– Accept me as I am.Accept me as I am.

Case of Ms. D. (Continued)Case of Ms. D. (Continued)

• Follow-upFollow-up– Referred to ResidentReferred to Resident– Followed Resident to a city 280 miles awayFollowed Resident to a city 280 miles away– Returned 2-3 years laterReturned 2-3 years later

• Up 8 lbs.Up 8 lbs.• WorkingWorking

Clinical topics: Eating Disorders Clinical topics: Eating Disorders and NSSI and NSSI

Treatment ApproachesTreatment Approachesto Eating Disordersto Eating Disorders

How to Find the NICE GuidelineHow to Find the NICE Guideline

www.NICE.org.ukwww.NICE.org.uk

Anorexia NervosaAnorexia Nervosa(NICE Guidelines)(NICE Guidelines)

• Most people with anorexia nervosa Most people with anorexia nervosa should be managed on an outpatient should be managed on an outpatient basis with psychological treatment by a basis with psychological treatment by a service that is competent in giving that service that is competent in giving that treatment and assessing the physical treatment and assessing the physical risk of people with eating disorders.risk of people with eating disorders.

Anorexia NervosaAnorexia Nervosa(NICE Guidelines Cont.)(NICE Guidelines Cont.)

• People with anorexia nervosa requiring People with anorexia nervosa requiring inpatient treatment should be admitted inpatient treatment should be admitted to a setting that can provide the skilled to a setting that can provide the skilled implementation of refeeding with implementation of refeeding with careful physical monitoring careful physical monitoring (particularly in the first few days of (particularly in the first few days of refeeding) in combination with refeeding) in combination with psychosocial interventions.psychosocial interventions.

Anorexia Nervosa Anorexia Nervosa (NICE Guidelines Cont.)(NICE Guidelines Cont.)

• Family interventions that directly Family interventions that directly address the eating disorder should be address the eating disorder should be offered to children and adolescents offered to children and adolescents with anorexia nervosa.with anorexia nervosa.

What is the MaudsleyWhat is the MaudsleyFamily Based Approach?Family Based Approach?

• Outpatient weight restoration treatmentOutpatient weight restoration treatment

• ~ Twenty sessions over 6-12 months~ Twenty sessions over 6-12 months

• Puts PARENTS in charge of weight restoration Puts PARENTS in charge of weight restoration (appropriate control, ultimately relinquished)(appropriate control, ultimately relinquished)

• Contrary to traditional separation of parents and childContrary to traditional separation of parents and child• No assumption about etiology of ANNo assumption about etiology of AN

Maudsley End-of-Outpatient TreatmentMaudsley End-of-Outpatient Treatmentand Five-Year-Follow-Up and Five-Year-Follow-Up

0

20

40

60

80

100P

erc

en

tag

e

Eisler et al 2000 Eisler et al 2003

Good/Int

Poor

Pharmacotherapy and ANPharmacotherapy and AN(Walsh et al., 2006)(Walsh et al., 2006)

• RCT with 93 weight restored AN patientsRCT with 93 weight restored AN patients

• Fluoxetine vs. placebo for 1 yearFluoxetine vs. placebo for 1 year

• No difference in time to relapse or number No difference in time to relapse or number completing 1 year of treatmentcompleting 1 year of treatment

Bulimia NervosaBulimia Nervosa(NICE Guidelines)(NICE Guidelines)

• As a possible first step, patients with As a possible first step, patients with bulimia nervosa should be encouraged bulimia nervosa should be encouraged to follow an evidence-based self-help to follow an evidence-based self-help programme.programme.

Bulimia NervosaBulimia Nervosa(NICE Guidelines cont.)(NICE Guidelines cont.)

• As an alternative or additional first step to As an alternative or additional first step to using an evidence-based self-help using an evidence-based self-help programme, adults with bulimia nervosa programme, adults with bulimia nervosa may be offered a trial of an antidepressant may be offered a trial of an antidepressant drug.drug.

Bulimia Nervosa Bulimia Nervosa (NICE Guidelines cont.)(NICE Guidelines cont.)

• Cognitive behaviour therapy for bulimia Cognitive behaviour therapy for bulimia nervosa (CBT-BN), a specifically adapted nervosa (CBT-BN), a specifically adapted from of CBT, should be offered to adults from of CBT, should be offered to adults with bulimia nervosa. The course of with bulimia nervosa. The course of treatment should be for 16 to 20 sessions treatment should be for 16 to 20 sessions over 4 to 5 months.over 4 to 5 months.

Bulimia Nervosa Bulimia Nervosa (NICE Guidelines cont.)(NICE Guidelines cont.)

• Adolescents with bulimia nervosa may be Adolescents with bulimia nervosa may be treated with CBT-BN, adapted as needed to treated with CBT-BN, adapted as needed to suit their age, circumstances and level of suit their age, circumstances and level of development, and including the family as development, and including the family as appropriate.appropriate.

Cognitive Behavior Therapy Cognitive Behavior Therapy (CBT)(CBT)

for Bulimia Nervosafor Bulimia Nervosa

Fairburn, Marcus, & Wilson, 1993

CBT for BNCBT for BN

• 20 sessions/16 weeks20 sessions/16 weeks

• ManualizedManualized

• Reduce dietingReduce dieting

• Increase mealsIncrease meals

• Cognitive restructuringCognitive restructuring

• Problem solvingProblem solving

• Self monitoringSelf monitoring

Antidepressant Treatment of Bulimia Nervosa% Reduction in Binge Frequency

-40 -20 0 20 40 60 80 100

IMI

Brofaromine

Fluoxetine

DMI

Fluoxetine

IMI

Trazadone

Phenelzine

Bupropion

IMI

DMI

AMI

IMI

60 mg20 mg

Hospital Based TreatmentHospital Based Treatment

Continuum of Care Continuum of Care

• Self HelpSelf Help

• OutpatientOutpatient

• Intensive OutpatientIntensive Outpatient

• Partial HospitalPartial Hospital

• ResidentialResidential

• InpatientInpatient

Factors to Consider in needFactors to Consider in needfor Hospitalizationfor Hospitalization

• Medical complicationsMedical complications• SuicidalitySuicidality• Body weightBody weight• Motivation to recoverMotivation to recover• Comorbid disordersComorbid disorders• Impairment in ability to care for selfImpairment in ability to care for self• Purging behaviorPurging behavior• Environmental stressEnvironmental stress• Treatment availabilityTreatment availability

Team Approach to Eating Team Approach to Eating DisordersDisorders

WORKING CLOSELY AND CONSISTENTLY WITH EACH MEMBER OF YOUR TREATMENT TEAM IS AN IMPORTANT PART OF YOUR RECOVERY. EATING DISORDERS ARE TOO COMPLEX AND DIFFICULT TO OVERCOME FOR ANY ONE PROFESSIONAL TO “DO IT ALL.” COLLABORATION IS THE KEY.

PATIENT

• Responsible for making and attending appointments

• Responsible for collaborating with the team and being an active participant in his/her treatment

• Responsible for following recommendations from the treatment team

PSYCHOLOGIST

• Provides initial evaluation and diagnosis

•Conducts individual, family and group therapy to help you and your family to understand and overcome your eating disorder and other related problems like depression or anxiety

•Coordinates your care with the rest of the treatment team

CLINICAL NURSE SPECIALIST OR PSYCHIATRIST

• Provides evaluations to determine if psychiatric medications might be helpful in treating your eating disorder or related problems like depression or anxiety

•Monitors your response to such medications and adjusts or changes them as needed

RECEPTIONIST OR OFFICE SPECIALIST

•Schedules appointments with treatment providers

•Takes telephone messages

•Assists treatment providers in managing paperwork

•Obtains insurance preauthorization; tracks benefits and works with insurance companies to get treatment plans approved

TRIAGE NURSE

•Provides information about programs available at EDI

•Completes phone assessments and sets up first time appointments for the outpatient clinic

•Takes phone calls from patients, significant others or families with questions on the illness,

medications or refills

•Coordinates admissions to the inpatient and partial hospitalization programs

DIETITIAN

•Evaluates and assesses nutritional needs

•Provides nutrition education

•Develops an individualized meal plan

•Guides you in normalizing eating and developing healthy attitudes about eating

MEDICAL DOCTOR

•Conducts a thorough medical examination to find out if there are any urgent health problems related to your eating disorder

•Provides medical treatment for health problems if they are found

•Monitors the changes in your physical health throughout your treatment

EDI TREATMENT TEAM

SOCIAL WORKER

• Contact with community resources

• Collaboration with participating agencies

• Coordination of care

• Educate team on resources in the community

http://www.youtube.com/watch?v=1OQbUZeYAik

Treatment Approaches to NSSITreatment Approaches to NSSI

Negative Affect and BingeNegative Affect and BingeSmyth et.al. 2007Smyth et.al. 2007

30

32

34

36

38

40

-8 -6 -4 -2 0 2 4 6 8

Neg

ativ

e A

ffec

t

Hours Relative to Binge

Example of Emotional AvoidanceExample of Emotional Avoidance

Therapist: “Now, what are we doing here? What I’m noticing is I’m hammering away at this with you and you are holding firm and steady with a hint of curiosity.”

Subject: “Well right, I mean how have I done it up until this time in my life…with alcohol and throwing up. That’s where my serenity, if I’m going to have any, comes from. Just numb me up which means I’m not actually having any serenity in the first place. I’m just numbing the rest of my world out.”

Therapist: “Right, and if you begin to tune into instead of numbing out, so if you use the Palm Pilot to begin to tune into what’s going on inside of you…”

Subject: “That’s going to suck.”

Therapist: “Because?”

Subject: “Because it’s going to be work and who knows what I’m going to see.”

Therapist: “What are you going to see?”

Subject: “I mean, I don’t know.”

Therapist: “I think you have a clue otherwise you wouldn’t be so afraid.”

Subject: “Well probably a lot of things I don’t like.”

Therapist: “Like?”

Subject: “I don’t know.”

Therapist: “Slow down and think about it. What are you so afraid of?

Subject: “I guess probably seeing what’s in there and we’re both pretty certain there is pain in there and probably seeing that. Not only seeing it but having it come out and deal with it. No, no, not only deal with it, but having it come out.

Therapist: “And what will happen if it comes out?”

Subject: “It will be painful. Pain is uncomfortable and there is no room.”

Therapist: “It would swamp what you do. There would be no room for it.”

Subject: “Nope. Well there is no room because I’ve not ever allowed there to be room because the feeling of pain is not something like the feeling of wanting to cry or crying, or if like I’m going to be angry. I just don’t like that feeling. I don’t like the feeling of being hurt. I just don’t and so…and if you are hurt and allow yourself to be hurt that infects the rest of your world.

Subject: “A perfect example is the phone call that I had where I hung up the phone and I was almost immediately in tears because I had felt like such a failure. I took everything told to me by the other teacher so personally that it just overwhelmed me to the point I lost all of my business-like composure and I became emotional - like creeped in without me realizing it was going to. I don’t like that feeling because it a) hurts and b) there is no control.”

Therapist: “So it’s just better to just block it out than try to figure out what it is, try and respond to it?”

Subject: “That’s all I’ve ever known.”

ICAT Clinical TargetsICAT Clinical Targets

• Motivational EnhancementMotivational Enhancement• Emotion Identification/Tolerance/ExpressionEmotion Identification/Tolerance/Expression• Meal Planning/Behavioral Activation Meal Planning/Behavioral Activation • Urge ControlUrge Control• Relationship SkillsRelationship Skills• Self Regulation SkillsSelf Regulation Skills• Self Discrepancy Self Discrepancy • Relapse PreventionRelapse Prevention

ICAT Core SkillsICAT Core Skills

Table 2. Core Skills in ICAT

Coping SkillPHASE

Acronym for Skill

Elements in Acronym

Emotion Regulation I FEEL Focus, Experience, Examine & Label

Meal Planning/Behavioral Activation II CARE Calmly Arrange Regular Eating

Urge Control II ACT Adaptive Coping Techniques

Relationship

III

SAID Sensitively Assert Ideas & Desires

Self Regulation SPA Self Protect and Accept

Self Discrepancy and Interpersonal Appraisal

REAL Realistic Expectations Affect Living

Impulse Control and Relapse Prevention

IV WAIT Watch All Impulses Today

Find a quiet place. Let yourself sit for a minute. Pay attention to your body sensations. Try not to worry about how you are doing.

Allow a feeling to come. You may not know what to call it. Try not to leave it. Just stay with it for awhile.

Start to wonder what this is. What do you think this feeling is about?Where is it coming from?

Can you give it a name? Try the name out. Does it fit? Is that all of it, or is there another feeling? If yes, repeat

FEEL.

Shifting to the SEAShifting to the SEA

Shifting to the SEAShifting to the SEA

1.1. S:S: Identify Identify SSituationituation

2.2. E:E: Identify Identify EEmotion(s)motion(s)

3.3. A:A: Identify Identify AAction (e.g., binge) ction (e.g., binge)

Implementing the SEA – Change TechniqueImplementing the SEA – Change Technique

(Three Strategies for Action)(Three Strategies for Action)

SituationSituation EmotionEmotion ActionAction

• Perceived failure Perceived failure at workat work

• SadSad

• AngryAngry

• Self CriticismSelf Criticism

• PurgingPurging

• Avoid Avoid SupervisorSupervisor

• Perceived failure Perceived failure at workat work

• SadSad

• AngryAngry

• Identify FeelingsIdentify Feelings

• Review Self StandardsReview Self Standards

• Talk to SupervisorTalk to Supervisor

• Perceived failure Perceived failure at workat work

• SadSad

• AngryAngry

• Identify FeelingsIdentify Feelings

• Decide to go to movie (Self Decide to go to movie (Self Distract)Distract)

• Discuss situation with friend Discuss situation with friend after movie (Self Protect)after movie (Self Protect)

A Brief Bit on Treatment of TraumaA Brief Bit on Treatment of Trauma

Trauma Focused Cognitive Trauma Focused Cognitive Behavioral TherapyBehavioral Therapy(Cohen, Mannarino & Deblinger, 2006)(Cohen, Mannarino & Deblinger, 2006)

TF-CBT

Who should be considered Who should be considered for TFCBT?for TFCBT?

• Children age 4-18Children age 4-18

• Trauma history – single or multiple, any typeTrauma history – single or multiple, any type

• Prominent trauma symptoms (PTSD, depression, Prominent trauma symptoms (PTSD, depression, anxiety, with or without behavioral problems)anxiety, with or without behavioral problems)

• Children with severe behavior problems may need Children with severe behavior problems may need alternative interventionsalternative interventions

• Caregiver involvement is optimalCaregiver involvement is optimal

• Treatment settings: clinic, residential, home, inpatientTreatment settings: clinic, residential, home, inpatient

Core ComponentsCore Components

PP sychoeducation and Parenting Skillssychoeducation and Parenting Skills

RR elaxationelaxation

AA ffect Expression and Regulationffect Expression and Regulation

CC ognitive Copingognitive Coping

TT rauma Narrative Development and Processingrauma Narrative Development and Processing

II n Vivo Gradual Exposure n Vivo Gradual Exposure

CC onjoint Parent/Child Sessiononjoint Parent/Child Session

EE nhancing Safety and Future Developmentnhancing Safety and Future Development

Processing the Trauma NarrativeProcessing the Trauma Narrative

• Identify maladaptive beliefs and thoughtsIdentify maladaptive beliefs and thoughts

• Promote the notion that thoughts can be changedPromote the notion that thoughts can be changed

• Challenge the maladaptive thoughtsChallenge the maladaptive thoughts

Is it true?Is it true?

Does thinking this lead to positive or negative emotions?Does thinking this lead to positive or negative emotions?

Does thinking this help you feel good about yourself?Does thinking this help you feel good about yourself?

Does thinking this help you in relationships with friends and Does thinking this help you in relationships with friends and familyfamily

Examples of Cognitive & Affective Examples of Cognitive & Affective ProcessingProcessing

• SexualitySexuality““Am I gay?”; “I was abused because I dress sexy.”Am I gay?”; “I was abused because I dress sexy.”

• Body ConcernsBody Concerns““I might die of AIDS”; “I might be pregnant.”I might die of AIDS”; “I might be pregnant.”

• Interpersonal ConcernsInterpersonal Concerns““I tore my family apart”; “My friends think I am a slut.”I tore my family apart”; “My friends think I am a slut.”

• Safety ConcernsSafety Concerns““I will never trust another man.”; “I can’t go anywhere alone.”I will never trust another man.”; “I can’t go anywhere alone.”

• Self ImageSelf Image““I am so stupid.”; “I am unlovable.”I am so stupid.”; “I am unlovable.”

Core ComponentsCore Components

PP sychoeducation and Parenting Skillssychoeducation and Parenting Skills

RR elaxationelaxation

AA ffect Expression and Regulationffect Expression and Regulation

CC ognitive Copingognitive Coping

TT rauma Narrative Development and Processingrauma Narrative Development and Processing

II n Vivo Gradual Exposure n Vivo Gradual Exposure

CC onjoint Parent/Child Sessiononjoint Parent/Child Session

EE nhancing Safety and Future Developmentnhancing Safety and Future Development

http://minnesota.cbslocal.com/video?autoStart=true&topVideoCatNo=default&clipId=7565071

Local Efforts to Intervene Early Local Efforts to Intervene Early with Traumatized Childrenwith Traumatized Children

Treatment Collaborative for Treatment Collaborative for Traumatized Youth (TCTY)Traumatized Youth (TCTY)

Mission:Mission:

•To enhance the availability of evidence-To enhance the availability of evidence-based, trauma specific, mental health based, trauma specific, mental health treatments for traumatized children and treatments for traumatized children and their familiestheir families

•Build a trauma-informed Build a trauma-informed multidisciplinary collaborative network multidisciplinary collaborative network across North Dakotaacross North Dakota

– Implement & evaluate evidence-based Implement & evaluate evidence-based mental health treatmentsmental health treatments

– Develop trauma-focused trainings for Develop trauma-focused trainings for child-serving systemschild-serving systems

– Provide community education about the Provide community education about the impact of trauma on children and familiesimpact of trauma on children and families

• 250 clinicians representing over 40 agencies/centers 250 clinicians representing over 40 agencies/centers

• Over 700 children have received services Over 700 children have received services

• SPARCS, TF-CBT, AF-CBTSPARCS, TF-CBT, AF-CBT

• Native American Adaptation Native American Adaptation

• 66thth Annual Meeting of the TCTY – May 12 Annual Meeting of the TCTY – May 12thth, 2014, 2014

• Website: tcty-nd.orgWebsite: tcty-nd.org

• Over 50 presentations to various professional organizations and Over 50 presentations to various professional organizations and community groupscommunity groups

• Systems work: Mental Health, Juvenile Justice, Child Protection, Systems work: Mental Health, Juvenile Justice, Child Protection, Foster Care Foster Care andand Schools Schools

TCTY IMPACTTCTY IMPACT

Clinical Centers with TCTY Trained CliniciansClinical Centers with TCTY Trained Clinicians

Belcourt

Devils Lake

Center/Agency with TCTY Trained Clinician(s)

Sentinel Butte

Supporting and Educating Supporting and Educating Traumatized StudentsTraumatized Students

HEATHER SIMONICH, MA, LPCNEUROPSYCHIATRIC RESEARCH INSTITUTE

HSIMONICH@NRIFARGO.COM

• Bush Foundation – St. Paul, Minnesota

• Collaboration with Fargo Public Schools (2012-2014)

• Goals:– Provide professional development on the topic of child traumatic

stress for school staff• Professional Discipline (e.g., administrators, counselors, special education,

early childhood)• Building (e.g., Jefferson, Agassiz, Dorothy Moses - Bismarck)• District-wide (e.g., NDSU continuing education course for graduate credit)• State-wide (e.g., ND Elementary Principals Conference)

– Encourage standardized screening and specialized referrals– Develop a group of “trauma-informed champions” to assure

sustainability

Bush Leadership FellowshipBush Leadership Fellowship

ResourcesResources

• Research demonstrates that children who experience Research demonstrates that children who experience trauma are more likely to have:trauma are more likely to have:

– A lower GPA (Hurt et al., 2001; Beers & DeBellis,2002)A lower GPA (Hurt et al., 2001; Beers & DeBellis,2002)

– Higher rate of school absences (Beers & DeBellis, 2002)Higher rate of school absences (Beers & DeBellis, 2002)

– Higher likelihood of drop-out (Grogger, 1997)Higher likelihood of drop-out (Grogger, 1997)

– More suspensions and expulsions (Eckenrode et al., 1993)More suspensions and expulsions (Eckenrode et al., 1993)

– Decreased IQ and reading ability (Delaney-Black et al., 2003)Decreased IQ and reading ability (Delaney-Black et al., 2003)

– Significant deficits in attention, abstract reasoning, long-term Significant deficits in attention, abstract reasoning, long-term memory for verbal information (Beers & DeBellis, 2002)memory for verbal information (Beers & DeBellis, 2002)

– Special education services (Shonk & Cicchetti, 2001)Special education services (Shonk & Cicchetti, 2001)

Trauma and SchoolTrauma and School

• Children are more likely to access mental health services Children are more likely to access mental health services through primary care and schools than through specialty through primary care and schools than through specialty mental health clinics. (Costello et al., 1998)mental health clinics. (Costello et al., 1998)

• 10% of children that could benefit from mental health 10% of children that could benefit from mental health services actually receive care at a mental health facility.services actually receive care at a mental health facility.

• Schools provide an ideal setting for corrective and Schools provide an ideal setting for corrective and supportive experiences – an enormous opportunity to foster supportive experiences – an enormous opportunity to foster resiliency.resiliency.

Trauma and school (Cont.)Trauma and school (Cont.)

• Trauma is clearly not new – but the extensive research that Trauma is clearly not new – but the extensive research that describes trauma’s effects on the developing child is newdescribes trauma’s effects on the developing child is new

• Not suggesting a new category of disability – this is about Not suggesting a new category of disability – this is about implementing an adaptable framework for addressing implementing an adaptable framework for addressing trauma-related challenges within the school settingtrauma-related challenges within the school setting

• Increase learning and teaching time and decrease time spent Increase learning and teaching time and decrease time spent on disciplineon discipline

Trauma and school (Cont.)Trauma and school (Cont.)

1.1. Defining TraumaDefining Trauma

2.2. Traumatic Stress ReactionsTraumatic Stress Reactions

3.3. Adverse Childhood Experiences StudyAdverse Childhood Experiences Study

4.4. Understanding the Neurobiology of TraumaUnderstanding the Neurobiology of Trauma

5.5. Resiliency Resiliency

6.6. Creating Trauma-sensitive Schools: Learning from the Washington state ModelCreating Trauma-sensitive Schools: Learning from the Washington state Model

7.7. Implementing Trauma-sensitive Strategies in the ClassroomImplementing Trauma-sensitive Strategies in the Classroom– Helping children feel psychologically safeHelping children feel psychologically safe– Teaching relaxation (i.e., belly breathing)Teaching relaxation (i.e., belly breathing)– Emotional development activitiesEmotional development activities– Cognitive triangleCognitive triangle– Relationship coachingRelationship coaching– Maintaining connections/building relationships with familiesMaintaining connections/building relationships with families

8.8. Overview of Evidence-based Mental Health InterventionsOverview of Evidence-based Mental Health Interventions

9.9. Taking Care of Yourself: Secondary Traumatic StressTaking Care of Yourself: Secondary Traumatic Stress

Overview of Proposed Professional Overview of Proposed Professional Development Curriculum (6-12hrs)Development Curriculum (6-12hrs)

• Understanding the experience of traumatic stress Understanding the experience of traumatic stress assists us to develop compassion, patience and assists us to develop compassion, patience and empathy. It is a key intervention in itself.empathy. It is a key intervention in itself.

• Recovery from trauma will occur best in the context Recovery from trauma will occur best in the context of healing relationships.of healing relationships.

Understanding Traumatic StressUnderstanding Traumatic Stress

Ron Hertel, Program SupervisorOffice Superintendent of Public Instruction

Phone: 360-725-4968Email: Ron.Hertel@k12.wa.us

Learning from the State of Washington Learning from the State of Washington

Elementary Implementation Video: http://www.youtube.com/watch?v=A1vbSSQJOHw

So, a Key Question is How to Build So, a Key Question is How to Build Resiliency: The Short List Resiliency: The Short List (Ann Masten, Ph.D)(Ann Masten, Ph.D)

1. What are you currently doing in your classroom that already supports these resiliency factors?

2. What are small changes you could make in your classroom to further boost these systems that drive resilience?

3. What are some of the challenges you face in supporting the systems that drive resilience?

So…How Do We Teach Resilience?So…How Do We Teach Resilience?

SummarySummary

• 1 out 4 children will experience a traumatic event before 1 out 4 children will experience a traumatic event before age 16age 16

• Trauma is associated with numerous mental and Trauma is associated with numerous mental and physical health conditions, in addition to, negative physical health conditions, in addition to, negative educational outcomes.educational outcomes.

• If we are truly invested in supporting our children, we If we are truly invested in supporting our children, we must think about the role of traumatic stress in all child-must think about the role of traumatic stress in all child-serving systems (e.g., schools, child welfare, mental serving systems (e.g., schools, child welfare, mental health)health)