Eating Disorders: Assessment, Understanding, and Treatment

Strategies [Day One]

Elise Curry Psy.D.Program Manager

UCSD IOP

Terry Schwartz MDMedical Director UCSD Eating Disorders Program

Asst Clinical Professor UCSD

Structure of 2 day training

• Day 1: Eating Disorders: Assessment and Psychosocial Treatment Approaches; Intro to Specific Therapy Modalities for EDS

• Day 2: Eating Disorders: Psychiatric/Medical Assessment and Treatment Strategies; Obesity; and EDs in special populations

Nervous Consumption”(Morton, 1689)

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

––

Anorexia Nervosa

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

DSM IV Criteria for Anorexia Nervosa

• Preoccupation with body shape, weight/size

• <85% ideal BW

• Fear of becoming fat despite low weight

• Loss of 3 consecutive periods in women

• Types: restricting,binge/purge,purge

DSM IV criteria for Bulimia Nervosa

Recurrent episodes of binge eating, characterized by eating an excessive amount of food within a discrete period of time and by a sense of lack of control over eating during the episode

Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting or misuse of laxatives, diurética, enemas, or other medications (purging); fasting; or excessive exercise

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

• Self-evaluation is unduly influenced by body shape and weight

Diagnostic challenges in EDs (ED NOS)

• BN vs. AN: binge/purge type• Sandy is 5 ft tall and weighs is 80 lbs. She has

regular periods and no body distortion. She is 16 yrs old.

• Sally purges normal meals, but does not binge.• Tom thinks he needs to gain weight. He uses

exercise to purge. He binges 2 times per week and then goes running.

• Shelly chews and spits her food several times a day

Compulsive Exercise

• 1. Having no period isn’t healthy, even for an athlete.

• 2. Exercising in spite of injury or sickness.

• 3. Individual feels s/he has to exercise to feel OK.

• 4. Exercise becomes the way the individual organizes his/her life.

• 5. Exercise is done in secret.

• 6. Exercise done mostly to burn calories.

Possible Signs of an Eating Disorder

• Preoccupation with food/weight

• Dramatic weight loss or gain

• Chronic dieting• Feels cold all the time• Dental problems• History of ballet,

wrestling, or modeling• Disgusted by red meat or

desserts

• Has difficulty eating with people

• Cuts out food groups • Becomes vegetarian/vegan

as a teen• Uses bathroom after meals• Wears baggy clothes or

layers• Cooks for other

excessively• Excessive exercise

Body Image

• How you see yourself when you look in the mirror or when you picture yourself in your mind.

• What you believe about your own appearance (including your memories, assumptions, and generalizations).

• How you feel about your body, including your height, shape, and weight.

• How you sense and control your body as you more. How you feel in your body, not just about your body.

» NEDA website

Negative body image

• A distorted perception of your shape – you perceive parts of your body unlike how they really are.

• You are convinced that only other people are attractive and that your body size or shape is a sign of personal failure.

• You feel ashamed, self-conscious, and anxious about your body.

• You feel uncomfortable and awkward in your body.

» NEDA website

Positive body image

• A clear, true perception of your shape – you see various parts of your body as they really are.

• You celebrate and appreciate your natural body shape and you understand that a person’s physical appearance says very little about their character and value as a person.

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

• You feel comfortable and confident in your body.

» NEDA website

Distorted Beliefs

• There are “good” foods and “bad” foods. • If I am fat, no one will love me.• If I eat too much, I need to get rid of it by purging.• If I eat this piece of cheesecake, I will be able to see it on my body

tomorrow.• You can never be too rich or too thin.• Thinness equals happiness.• Using laxatives gets rid of all the food.• Purging gets rid of all the food.• My worth is my weight.• It is more important to be thin than anything else.• Everyone hates fat people.• Men like women who are skinny.

Intro to brain function in AN

• Detail vs global

• Set shifting

What are perfectionistic traits?

• Never being satisfied with your achievements or performance

• Ability to see flaws where others do not

• Dread of making mistakes

• Exactness

• Exceedingly high standards

• Very detail focused

• Lack of novelty seeking

• Frequent disappointment with self and others

• Relentless pursuit of perfection

• “I have to be the best at everything I do.”

How can we help pts to reduce perfectionism?

• Identify perfectionism as a personality trait which is unlikely to change

• Help pts to manage their perfectionism by noticing it and doing the opposite (risk taking, trying something new, stop redoing or re-writing)

• Recognize the benefits of this trait. Turn it into an asset, rather than a liability. Being on time, being good at detail oriented tasks, academic achievement, research career etc.

How to deal with resistance to recovery

• 1. Validate pts legitimate needs and help her see how the e.d. serves her

• 2. Use motivational Interviewing: what does she want?

• 3. Normalize her ambivalence

• 4. Help her give a voice to her e.d vs. her recovery voice

• 5. Have her list all the reasons why she wants to recover.

• 6. Have her list all the disadvantages to recovery.

• 7. Be patient. The average recovery rate is 7 years!

Cultural Issues

• More common in Westernized Societies• Historically self starvation reported prior to 19th century

(religious/spiritual “reasons”)• Cultural importance placed on “thinness”• Less common in cultures where roundness is sign of

fertility, health, prosperity• Hong kong, India : AN w/o fear of fat. • “Many individuals in our culture, for a number of reasons, are

concerned with their weight and diet. Yet less than half of one percent of all women develop anorexia nervosa, which indicates to us that societal pressure alone isn’t enough to cause someone to develop this disease,” said Kaye.

Practice Session

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Psychiatric co morbidity

PSYCHIATRIC COMORBIDITY: Anorexia Nervosa

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

PSYCHIATRIC COMORBIDITY: Bulimia Nervosa

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

Psychiatric symptoms in AN and BN

• Premorbid onset • “Best little girl in the world”• Majority have childhood anxiety disorder that precedes onset AN, BN• Childhood negative self-evaluation, perfectionism, rule bound, inflexible,

obsessive personality

• Persistent symptoms after recovery• Obsessions - body image, weight, food• Obsessions - perfectionism, symmetry, exactness• Anxiety, harm avoidance

• Behaviors are exaggerated by malnutrition• Differences Between AN and BN

• Novelty seeking BN > AN, BN extremes of over- and under-control

Anxiety Disorders (AD)Lifetime and Premorbid Rates

Study ED n Lifetime AD AD before ED

Deep 95 AN 24 68% 58%

Bulik 97 AN 68 60% 54%

Bulik 97 BN 116 57% 54%

Godart 00 AN 29 83% 62%

Godart 00 BN 34 71% 62%

Kaye 04 AN,BN 672 64% 61%

23% OCD

13% social phobia

Lifetime OCD Diagnosis in AN, BN

0

10

20

30

40

50

60

AN (n 619) AN BN (n 515) BN (n 282)

Perc

ent w

ith D

iagn

osis

Price Foundation Genetic Collaborative StudyTotal 1416 subjects

DSM IV, SCID I, Y-BOCS MS/PhD Clinical Interview N. America, England, Germany

Diagnosis Range

AN 10 – 62%

AN BN 10 – 66%

BN 0 – 43 %

Review of LiteratureReview of LiteratureGodart 2002Godart 2002

General population rate OCD: 1-3% of adults; 2-4% of children General population rate OCD: 1-3% of adults; 2-4% of children (Grados 97, Riddle 98; Serpell 02)(Grados 97, Riddle 98; Serpell 02)

Obsessive-Compulsive Personality Disorder (OCPD) Diagnoses in ED

from Clinical Interviewer AssessmentCassin S, von Ranson K: Personality and eating disorders: a decade in review

Clin Psychol Rev 2005;25(7):895-916

Subjects Range of OCPD

RAN 2 – 30%

BN 2 – 19%

Starvation study

Starvation Study

• Univ of Minnesota: Keys et al 1950• 36 young healthy men• Observed behaviors during 3 mos normal

eating, then 6 mos of 50% cal reductions (similar to some diets)

• Many of the experiences that were observed in the participants were similar to those experienced in various EDs

Starvation study participants:dramatic increase in food

preoccupation• One of the most intense changes

• Distracted from usual activities

• Toying with food

• Making “weird concoctions”

• New interest in cookbooks, menus

• Vicarious pleasure in others eating

• Long drawn out eating rituals

Starvation study participants: Binge Eating

• Serious BED developed in a subgroup

• Followed by self reproach

• Model for BED, EDs, habitual dieters

Starvation Study participants:emotional and

personality changes• Recall all were “mentally healthy” prior to study• Most experienced significant emotional

deterioration as a result of semi starvation, often severe

• Depression, mood swings, irritability/outbursts• Anxiety• Apathy, decrease personal hygiene• General disorganization• Persisted during first several weeks of refeeding

Starvation study participants; social and sexual changes

• Despite being social and gregarious pre-study, the participants became progressively more withdrawn and isolated

• Decrease in humor

• Feeling socially inadequate

• Dramatic loss of interest in sex

Starvation Study participants; Cognitive changes

• Reduced concentration, alertness

• Problems in comprehension

• Impaired judgment

Starvation study participants:physical changes

• Decreased sleep need

• Dizzy, headaches

• GI discomfort

• Hair loss

• Thermal sensitivity

• Visual, auditory disturbances

• Parathesias

Lunch

Third Wave Therapies: CBT, ACT, and Mindfulness

Goals of CBT Goals of CBT

Create a safe environment for pts to explore their eating Create a safe environment for pts to explore their eating disorder thoughts and beliefsdisorder thoughts and beliefs

Challenge distorted beliefsChallenge distorted beliefs

Teach cognitive distortionsTeach cognitive distortions

Learn to use thought recordsLearn to use thought records

Assertiveness trainingAssertiveness training

Help pts dispute their ed voiceHelp pts dispute their ed voice

Identify triggers and coping strategiesIdentify triggers and coping strategies

Examples of Distorted Thoughts

• “If I eat this piece of pie, I will be able to see it on my body tomorrow.”

• “I must be thin to be happy.”• “When I eat pasta, I have to purge.”• “Being thin is the only way I can be special.”• “I won’t be comfortable in my body if I gain weight.”• “ I can’t stand to be alone, so I binge/purge.”• “I don’t have an eating disorder. It’s not that bad.”

How to use Thought Records

Event: I stepped on the scale and saw the number.

Thoughts: I am a fat cow.

Feelings and rating: Fear (75) anger (45) disappointment (75)

Body Sensations: stomach hurts, chest is tight

Distortions: over-generalization, black/white thinking, catastrophizing

New thought: Just because the scale went up doesn’t mean I am fat. Weight fluctuations are normal.

New feeling and rating: content (50) fear (10)

Thought Record Practice

Event: I ate a whole bag of chips.

Thoughts: I must purge or I will be fat.

Feelings and rating:Fear (99) anger (25)

Body Sensations: heart beating fast, sweaty palms

Distortions:

New thought:

New feeling and rating:

ACT for Anxiety Disorders

• Fear vs. Anxiety• Is anxiety good for anything?• Are anxiety and fear dangerous?• How pervasive are problems of fear and anxiety?• How has anxiety become a problem in the client’s

life?• Humans vs. animals

Eifert,G and Forsyth,J (2005)Acceptance and commitment therapy for anxiety disorders.

Purpose of ACT

• Rather than controlling anxiety or reducing anxiety, ACT can help clients to learn and practice new and more flexible ways of responding when they experience anxiety.

• Teach clients to see that “anxiety” is not the problem. Attempts to stop the unwanted body sensations, thoughts, past memories, and worries about the future cause a shift from normal anxiety and fear to disordered anxiety and fear.

Patterns and Workability of Avoidance

• 1. Help the client to evaluate how their methods to manage their anxiety have worked.

• 2. Explore their attempted solutions to the problem of anxiety. Do the starve? Do the binge/purge? Isolate from others?

• 3. What is the cumulative effect of these short-term relief strategies? What will happen if you keep using them?

• 4. Is this how you will create the meaningful life you want to have? Can you reach your long term goals and keep these strategies?

Costs of Avoidance

• What have been the long-term costs of your avoidance patterns?

• What have you given up as a consequence of managing your anxieties/worries?

• What has happened to your life over time? Have you done more or less with your life?

• Have your options increased or has your “life space” narrowed over time?

• What would you do with your time if it were not spent trying to manage anxiety, fear, unsettling thoughts, memories, etc?

Develop Creative Hopelessness

• Helping clients to experience that they have been caught in a self-defeating struggle is important.

• This approach is creative in that it allows for new solutions.

• Giving up on old solutions will end up creating hope as new solutions are found.

• Past solutions are hopeless, not the client.• This emphasis implies that there is hope if the

client chooses to adopt a different approach when anxiety show up.

Acceptance of thoughts and feelings exercise

The use of Metaphor in ACT

• The child in a hole metaphor

• Feeding the anxiety tiger metaphor

• The Chinese finger trap exercise

Acceptance and valued living as alternatives to managing anxiety

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

Mindfulness based practice

• What is mindfulness?

• Research on Depression and Mindfulness

• Mindfulness with eating disorders

Definition of Mindfulness

Mindfulness has been described as “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally.”

Mindfulness provides both the means to change mental gears when disengaging from dysfunctional, “doing related” mind states, and an alternative mental gear, or incompatible mode of mind, into which to switch.

Segal, Z., Williams,G. & Teasdale,J (2002) Mindfulness based Cognitive Therapy for Depression.

Research on Mindfulness

• Mindfulness based cognitive behavioral therapy for depression has empirical evidence supporting its effectiveness in relapse prevention for depression. Segal, Z, Williams, J. and Teasdale J. (2002)

• MBCT prevented relapse/recurrence in pts with a history of 3 or more episodes of depression. 8 week class

Why use mindfulness with eating disorder patients?

• It seems to help them to distract from their constant critical dialog in their minds.

• It helps them have more choices about how to respond to their thoughts or triggering situations.

• It gives them the experience of being calm or free from their usual anxiety.

• It provides a sense of hope.• It is a skill that they can use anywhere.

Mindful Eating

• Practice chewing each bite of food with complete awareness.

• Don’t multi-task while you are eating.

• Taste each bite as if it were your last.

• Put your fork down after each bite.

• Eat in silence.

Mindfulness exercise

• Need flip chart

Mindfulness concepts

• Respond rather than react. Connect your feelings with body sensations. Where do

I feel this feeling? Be curious about your emotions, rather than fighting them.

• Suffering is part of life, not something to be avoided. • Happiness isn’t something that comes from outside

us. It’s an inside job.• Seek to become more comfortable with change and

uncertainty.• Embrace the present moment. It’s all we really have.

break

Film

• Film and discussion

Q and A