Working with Eating Working with Eating Disorder Patients Disorder Patients

Elise Curry Psy.D.Elise Curry Psy.D.Clinical PsychologistClinical Psychologist

Private PracticePrivate PracticeSan Diego, CASan Diego, CA

Anorexia NervosaAnorexia Nervosa

Most homogenous Most homogenous psychiatric disorderpsychiatric disorder

90-95% female90-95% female Onset teenage years – Onset teenage years – puberty puberty

Monotonous puzzling Monotonous puzzling symptoms symptoms

Poor response to treatmentPoor response to treatment Highest mortality rate Highest mortality rate 50% to 80% contribution of 50% to 80% contribution of genes genes

DSM IV Criteria for Anorexia DSM IV Criteria for Anorexia NervosaNervosa

Preoccupation with body shape, Preoccupation with body shape, weight/sizeweight/size

<85% ideal BW<85% ideal BW Fear of becoming fat despite low Fear of becoming fat despite low weightweight

Loss of 3 consecutive periods in Loss of 3 consecutive periods in womenwomen

Types: Types: restricting,binge/purge,purgerestricting,binge/purge,purge

DSM IV criteria for Bulimia DSM IV criteria for Bulimia NervosaNervosa

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

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

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

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

Diagnostic challenges in EDs Diagnostic challenges in EDs (ED NOS)(ED NOS)

BN vs. AN: binge/purge typeBN vs. AN: binge/purge type Sandy is 5 ft tall and weighs is 80 Sandy is 5 ft tall and weighs is 80 lbs. She has regular periods and no lbs. She has regular periods and no body distortion. She is 16 yrs old.body distortion. She is 16 yrs old.

Sally purges normal meals, but does Sally purges normal meals, but does not binge.not binge.

Tom thinks he needs to gain weight. He Tom thinks he needs to gain weight. He uses exercise to purge. He binges 2 uses exercise to purge. He binges 2 times per week and then goes running.times per week and then goes running.

Shelly chews and spits her food Shelly chews and spits her food several times a dayseveral times a day

Compulsive ExerciseCompulsive Exercise

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

2. Exercising in 2. Exercising in spite of injury spite of injury or sickness.or sickness.

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

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

5. Exercise is 5. Exercise is done in secret. done in secret.

6. Exercise done 6. Exercise done mostly to burn mostly to burn calories. calories.

Possible Signs of an Eating Possible Signs of an Eating Disorder Disorder

Preoccupation with Preoccupation with food/weightfood/weight

Dramatic weight Dramatic weight loss or gainloss or gain

Chronic dietingChronic dieting Feels cold all the Feels cold all the timetime

Dental problemsDental problems History of ballet, History of ballet, wrestling, or wrestling, or modelingmodeling

Disgusted by red Disgusted by red meat or dessertsmeat or desserts

Has difficulty Has difficulty eating with peopleeating with people

Cuts out food Cuts out food groups groups

Becomes Becomes vegetarian/vegan as vegetarian/vegan as a teena teen

Uses bathroom after Uses bathroom after mealsmeals

Wears baggy clothes Wears baggy clothes or layersor layers

Cooks for other Cooks for other excessivelyexcessively

Excessive exerciseExcessive exercise

Scope of The ProblemScope of The Problem

Prevalence increasingPrevalence increasing AN: .5-2%AN: .5-2% BN: 3-4%BN: 3-4% AN BN More common westernized AN BN More common westernized culturescultures

10% of eating disordered individuals 10% of eating disordered individuals in treatment are malein treatment are male

5% per decade of AN patients die 5% per decade of AN patients die (disorder or suicide)(disorder or suicide)

Scope of the problem: Scope of the problem: continuedcontinued

One of the highest death rates from One of the highest death rates from any mental health condition (AN) 10%any mental health condition (AN) 10%

Increasing incidence in elementary Increasing incidence in elementary age children (8-11 year old)age children (8-11 year old)

The incidence of bulimia in 10-39 The incidence of bulimia in 10-39 year old women TRIPLED between 1988 year old women TRIPLED between 1988 and 1993. and 1993.

There has been a rise in incidence There has been a rise in incidence of anorexia in young women 15-19 in of anorexia in young women 15-19 in each decade since 1930. each decade since 1930.

Ethnic Diversity in EDsEthnic Diversity in EDs

Minnesota Adolescent Health Study Minnesota Adolescent Health Study found that dieting was associated found that dieting was associated with weight dissatisfaction, with weight dissatisfaction, perceived overweight, and low body perceived overweight, and low body pride in all ethnic groups (Story et pride in all ethnic groups (Story et al, 1997). al, 1997).

Among the leanest 25% of 6th and 7th Among the leanest 25% of 6th and 7th grade girls, Hispanics and Asians grade girls, Hispanics and Asians reported significantly more body reported significantly more body dissatisfaction than did white girls. dissatisfaction than did white girls. Robinson et al (1996)Robinson et al (1996)

Cultural IssuesCultural Issues More common in Westernized SocietiesMore common in Westernized Societies Historically self starvation reported prior Historically self starvation reported prior to 19to 19thth century (religious/spiritual century (religious/spiritual “reasons”)“reasons”)

Cultural importance placed on “thinness”Cultural importance placed on “thinness” Less common in cultures where roundness is Less common in cultures where roundness is sign of fertility, health, prosperitysign of fertility, health, prosperity

Hong kong, India : AN w/o fear of fat.Hong kong, India : AN w/o fear of fat. ““Many individuals in our culture, for a number of Many individuals in our culture, for a number of

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

Media StatsMedia Stats The average young adolescent watches 3 to 4 The average young adolescent watches 3 to 4 hours of TV per day (Levine, 1997).hours of TV per day (Levine, 1997).

A study of 4,294 network television A study of 4,294 network television commercials revealed that 1 our of every 3.8 commercials revealed that 1 our of every 3.8 commercials send some sort of “attractiveness commercials send some sort of “attractiveness message,” telling viewers what is or is not message,” telling viewers what is or is not attractive (as cited in Myers et al, 1992). attractive (as cited in Myers et al, 1992). These researchers estimate that the average These researchers estimate that the average adolescent sees over 5,260 “attractiveness adolescent sees over 5,260 “attractiveness messages” per year.messages” per year.

Another study of mass media magazines Another study of mass media magazines discovered that women’s magazines had 10.5 discovered that women’s magazines had 10.5 times more advertisements and articles times more advertisements and articles promoting weight loss than men’s magazines did promoting weight loss than men’s magazines did (as cited in Guillen & Barr, 1994).(as cited in Guillen & Barr, 1994).

Drive for thinness and dietingDrive for thinness and dieting

Girls who diet frequently are 12 times as likely to binge Girls who diet frequently are 12 times as likely to binge as girls who don’t diet (Neumark-Sztainer,2005).as girls who don’t diet (Neumark-Sztainer,2005).

Most fashion models are thinner than 98% of American Most fashion models are thinner than 98% of American women (Smolak, 1996).women (Smolak, 1996).

The average American woman is 5’4” tall and weighs 140 The average American woman is 5’4” tall and weighs 140 lbs. The average model is 5’11” and weighs 117 lbs. lbs. The average model is 5’11” and weighs 117 lbs.

35% of “normal dieters” progress to pathological dieting. 35% of “normal dieters” progress to pathological dieting. Of those, 20-25% progress to partial or full syndrome Of those, 20-25% progress to partial or full syndrome eating disorders (Shisslak & Crago, 1995).eating disorders (Shisslak & Crago, 1995).

95% of all dieters will regain their lost weight in 1 to 95% of all dieters will regain their lost weight in 1 to 5 years (Grodstein, et al., 1996).5 years (Grodstein, et al., 1996).

Americans spend over $40 billion on dieting and diet Americans spend over $40 billion on dieting and diet related products each year (Smolak, 1996). related products each year (Smolak, 1996).

Body ImageBody Image

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

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

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

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

NEDA websiteNEDA website

Negative body imageNegative body image

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

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

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

You feel You feel uncomfortable and uncomfortable and awkward in your awkward in your body.body.

NEDA websiteNEDA website

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

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

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

You feel comfortable You feel comfortable and confident in and confident in your body.your body.

NEDA websiteNEDA website

Childhood Symptoms OC Personality Childhood Symptoms OC Personality Traits: Percentage of Individuals With Traits: Percentage of Individuals With

TraitsTraits

65

77

6272

61

80

50

25

50

0

20

40

60

80

100

Perfectionistic Inflexible Rule Bound

AN (n=26) AN-BN (n=18) BN (n=28)

% o

f Pat

ient

s

Anderluh MB, et al. Am J Psychiatry. 2003;160(2):242-247.

Heritability EstimatesHeritability Estimates

DISORDERDISORDER HERITABILITYHERITABILITY AutismAutism .8 - 1.8 - 1 SchizophreniaSchizophrenia .5 - .9.5 - .9 BipolarBipolar .3 - .8.3 - .8 Anorexia/BulimiaAnorexia/Bulimia .5 - .8.5 - .8 Early MDDEarly MDD .5 - .75.5 - .75 OCDOCD .5 - .7.5 - .7 ObesityObesity .4 - .7.4 - .7

Psychological Correlates of Psychological Correlates of Anorexia NervosaAnorexia Nervosa

Poor self conceptPoor self concept Obsessive compulsive and avoidant Obsessive compulsive and avoidant personality stylepersonality style

Perfectionistic, obsessive, harm avoidant Perfectionistic, obsessive, harm avoidant traitstraits

Family dynamics: enmeshment, anxiety, Family dynamics: enmeshment, anxiety, over-achieversover-achievers Troubles with major life transitionsTroubles with major life transitions an attempt to regress, avoid developmentan attempt to regress, avoid development Difficulty managing and expressing angerDifficulty managing and expressing anger Cognitive distortionsCognitive distortions Ego-syntonic nature of diseaseEgo-syntonic nature of disease

Psychological Correlates of Psychological Correlates of Bulimia NervosaBulimia Nervosa

Poor self conceptPoor self concept Chaotic developmental history, Chaotic developmental history, parental deficitparental deficit

ambiguous communication stylesambiguous communication styles Affective regulation problemsAffective regulation problems Cognitive distortionsCognitive distortions Ego-dystonic nature of diseaseEgo-dystonic nature of disease Impulsivity, substance abuse, self Impulsivity, substance abuse, self harm, sexual acting out, shop liftingharm, sexual acting out, shop lifting

Distorted BeliefsDistorted Beliefs

There are “good” foods and “bad” foods.There are “good” foods and “bad” foods. If I am fat, no one will love me.If I am fat, no one will love me. If I eat too much, I need to get rid of it by If I eat too much, I need to get rid of it by

purging.purging. If I eat this piece of cheesecake, I will be able to If I eat this piece of cheesecake, I will be able to

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

Recovery BeliefsRecovery Beliefs My worth is not my weight.My worth is not my weight. My body is an instrument, not an ornament.My body is an instrument, not an ornament. When I treat my body well, by eating 3 balanced When I treat my body well, by eating 3 balanced

meals per day and exercising moderately, my body meals per day and exercising moderately, my body will find its own set-point weight.will find its own set-point weight.

People come in all kinds of shapes and sizes. I People come in all kinds of shapes and sizes. I don’t have to try to mold my body into a standard don’t have to try to mold my body into a standard set by the media or fashion industry.set by the media or fashion industry.

I need some fat in my diet in order to have soft I need some fat in my diet in order to have soft skin, shiny hair, and be able to become pregnant skin, shiny hair, and be able to become pregnant some day. some day.

I can enjoy having a more curvy body, instead of I can enjoy having a more curvy body, instead of striving for thinness. striving for thinness.

I am unique and special due to my inner qualities.I am unique and special due to my inner qualities. Perfectionism only leads to disappointment, not Perfectionism only leads to disappointment, not

happiness.happiness.

Goal of Psychological TreatmentGoal of Psychological Treatment

Help pt to adjust to their Help pt to adjust to their personality traits/temperamentpersonality traits/temperament

Reduce anxiety through use of Reduce anxiety through use of positive coping skillspositive coping skills

Reduce “eating disorder voice” Reduce “eating disorder voice” and develop a “recovery voice.”and develop a “recovery voice.”

Increase focus on inner Increase focus on inner qualities to define self, rather qualities to define self, rather than physical than physical

traits like thinness.traits like thinness.

NEEDSNEEDSmet by the eating disorder:met by the eating disorder:

Safety/Survival: Safety/Survival: reduction of anxietyreduction of anxiety

Love/Belonging: Love/Belonging: best friendbest friend

Freedom: Freedom: no one can take the e.d. awayno one can take the e.d. away

Power/control/importance: Power/control/importance: feeling feeling superior, weight loss as an accomplishmentsuperior, weight loss as an accomplishment

Fun/relaxation/release: Fun/relaxation/release: endorphins endorphins

released by purgingreleased by purging

A Major Truth: Feelings A Major Truth: Feelings Follow Thoughts & ActionsFollow Thoughts & Actions

Needs

Thoughts

Want Choices

Feelings

Physiology

Actions

Group Therapy Group Therapy

Structured on-site mealStructured on-site meal Milieu therapy/ use of groupMilieu therapy/ use of group CBT/DBTCBT/DBT Process groupProcess group Nutritional counselingNutritional counseling Body image groupBody image group Art TherapyArt Therapy Relaxation, meditationRelaxation, meditation

Individual TherapyIndividual Therapy

Affect regulation and toleranceAffect regulation and tolerance ImpulsivityImpulsivity Externalization of self worthExternalization of self worth Feelings of ineffectiveness, Feelings of ineffectiveness, inadequacyinadequacy

Rejection sensitivityRejection sensitivity DBTDBT PMD and dietitianPMD and dietitian

Family TherapyFamily Therapy

Required with AdolescentsRequired with Adolescents Maudsley Family TherapyMaudsley Family Therapy Systemic Family TherapySystemic Family Therapy CouplesCouples Family involvement to motivate Family involvement to motivate pt for treatment (case example)pt for treatment (case example)

UCSD Eating Disorder IOPUCSD Eating Disorder IOP(Individual and Family Therapy by appointment)(Individual and Family Therapy by appointment)

Mon.Mon. Tues.Tues. Wed.Wed. Thurs.Thurs. Fri.Fri.Adult and Teen Adult and Teen Process GroupsProcess Groups

Adult Art Adult Art TherapyTherapy

MeditationMeditation

SnackSnack

Dialectical Dialectical Behavioral Behavioral TherapyTherapy

Goal Setting Goal Setting GroupGroup

Cognitive Cognitive Behavioral Behavioral TherapyTherapy

Adult Adult Mindfulness Mindfulness Based Stress Based Stress ReductionReduction

OrOr

Teen Art TherapyTeen Art Therapy

Dinner Meal and Dinner Meal and Nutrition Nutrition EducationEducation

Treatment Team Treatment Team for all Stafffor all Staff

Goal SettingGoal Setting Dinner MealDinner Meal

Process MealProcess Meal

Goal SettingGoal Setting

Common Management IssuesCommon Management Issues

Denial, resistanceDenial, resistance Lack of insight and motivation for Lack of insight and motivation for treatmenttreatment

Failure to learn from experienceFailure to learn from experience Adolescent – anxious parents, Adolescent – anxious parents, conflictsconflicts

Adults – family burn outAdults – family burn out Ambivalence: pt wants to recover, Ambivalence: pt wants to recover, but does not want to gain any but does not want to gain any weightweight

Expected IssuesExpected IssuesPatients and FamiliesPatients and Families

Obsessive anxiety – much reassurance Obsessive anxiety – much reassurance and discussing details of careand discussing details of care

Perfectionism – not good enoughPerfectionism – not good enough Stress and conflicts over eating, Stress and conflicts over eating, weight, weight,

control, meal plan etc.control, meal plan etc. Over-exercise Over-exercise Undermining treatment: i.e. taking Undermining treatment: i.e. taking the pt runningthe pt running

Countertransference IssuesCountertransference Issues

Feeling angry at the patient for Feeling angry at the patient for not recoveringnot recovering

Thinking this is “willful” Thinking this is “willful” behaviorbehavior

Blaming the parentsBlaming the parents Feeling incompetentFeeling incompetent Giving up hope for the patientGiving up hope for the patient Not taking the disorder seriouslyNot taking the disorder seriously

Coping with Countertransference Coping with Countertransference IssuesIssues

Practice patient acceptance: The Practice patient acceptance: The average recovery rate is 7 years.average recovery rate is 7 years.

Have compassion for the suffering Have compassion for the suffering

of the patient.of the patient. See their behavior as part of the See their behavior as part of the disorder, not personal toward you.disorder, not personal toward you.

Practice good self-care. Practice good self-care.

Overview of biological Overview of biological underpinnings of EDSunderpinnings of EDS

Genetic Correlates in Anorexia Genetic Correlates in Anorexia NervosaNervosa

  

Family and twin studiesFamily and twin studies Serotonin receptor geneSerotonin receptor gene Variation in Dopamine 2 Variation in Dopamine 2 receptor genereceptor gene

Chrom 1 and 10Chrom 1 and 10 Family history of OCD, OCPD, ANFamily history of OCD, OCPD, AN  

Genetic Correlates of Bulimia Genetic Correlates of Bulimia NervosaNervosa

Twin studiesTwin studies 5ht2A receptor alteration5ht2A receptor alteration Family history of affective, Family history of affective, anxiety, substance abuse d/oanxiety, substance abuse d/o

Neuroendocrine Correlates of Neuroendocrine Correlates of Anorexia Nervosa Anorexia Nervosa

Serotonin (5HT2A receptor)Serotonin (5HT2A receptor) Dopamine Dopamine Endogenous opiate response to Endogenous opiate response to starvationstarvation

Hypothalamus dysfunction Hypothalamus dysfunction (satiety, amenorrhea)(satiety, amenorrhea)

Neuroendocrine correlates of Neuroendocrine correlates of Bulimia NervosaBulimia Nervosa

Serotonin (5HT1A receptor)Serotonin (5HT1A receptor) Endogenous opiate response to Endogenous opiate response to binge purgebinge purge

Neuropsychiatric correlates of Neuropsychiatric correlates of Eating DisordersEating Disorders

Iowa gambling task: AN vs CW: Iowa gambling task: AN vs CW: Differences seen on fMRIDifferences seen on fMRI

AN: Neuropsych testing: AN: Neuropsych testing: difficulties with set shifting, difficulties with set shifting, flexibilityflexibility

AN: Detail focus, to the point of AN: Detail focus, to the point of missing global (Janet Treasure)missing global (Janet Treasure)

AN vs BNAN vs BN Use in clinical practiceUse in clinical practice

Psychiatric symptoms in AN and BNPsychiatric symptoms in AN and BN

Premorbid onset Premorbid onset ““Best little girl in the world”Best little girl in the world” Majority have childhood anxiety disorder that precedes Majority have childhood anxiety disorder that precedes onset AN, BNonset AN, BN

Childhood negative self-evaluation, perfectionism, rule Childhood negative self-evaluation, perfectionism, rule bound, inflexible, obsessive personalitybound, inflexible, obsessive personality

Persistent symptoms after recoveryPersistent symptoms after recovery Obsessions - body image, weight, foodObsessions - body image, weight, food Obsessions - perfectionism, symmetry, exactnessObsessions - perfectionism, symmetry, exactness Anxiety, harm avoidanceAnxiety, harm avoidance

Behaviors are exaggerated by malnutritionBehaviors are exaggerated by malnutrition Differences Between AN and BNDifferences Between AN and BN

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

Important Medical issues in Important Medical issues in treatment of EDstreatment of EDs

Physical Complications of Anorexia NervosaPhysical Complications of Anorexia Nervosa

Organ SystemOrgan System SymptomsSymptoms Lab Test ResultsLab Test Results

1. Whole body1. Whole body Weakness, Weakness, lassitudelassitude

Low weight/body mass index, Low weight/body mass index, low body fat percentage low body fat percentage

2. CNS2. CNS Apathy, poor Apathy, poor concentrationconcentration

CT: ventricular CT: ventricular enlargement; MRI: decreased enlargement; MRI: decreased gray and white mattergray and white matter

3. CV 3. CV Pre-syncope, Pre-syncope, palps, palps, dyspnea, dyspnea, weakness, cold weakness, cold extremities, extremities, chest painchest pain

ECG: sinus bradycardia, ECG: sinus bradycardia, other arrhythmia, QTc other arrhythmia, QTc prolongation; cardiac echo prolongation; cardiac echo (consider): MVP, silent (consider): MVP, silent pericardial effusionpericardial effusion

Physical Complications of Anorexia Nervosa; Cont.Physical Complications of Anorexia Nervosa; Cont.

Organ SystemOrgan System SymptomsSymptoms Lab Test ResultsLab Test Results

4. Muscular4. Muscular Weakness, Weakness, muscle muscle achesaches

Muscle enzyme abnormalities Muscle enzyme abnormalities in severe malnutritionin severe malnutrition

5. Reproductive5. Reproductive Prepubertal Prepubertal psychosex-psychosex-ually ually

Hypoestrogenemia; Hypoestrogenemia; prepubertal patterns of LH, prepubertal patterns of LH, FSHFSH

6. Endocrine, 6. Endocrine, metabolicmetabolic

Fatigue, Fatigue, cold cold intoleranceintolerance, diuresis, , diuresis, vomiting vomiting

Elevated cortisol; Elevated cortisol; euthyroid sick; euthyroid sick; dehydration; electrolyte dehydration; electrolyte abnormalities; low phos on abnormalities; low phos on refeeding; hypoglyc.(rare)refeeding; hypoglyc.(rare)

Physical Complications of Anorexia Nervosa; Cont.Physical Complications of Anorexia Nervosa; Cont.

Organ SystemOrgan System SymptomsSymptoms Lab Test ResultsLab Test Results

7. GI7. GI Vomiting, Vomiting, abdom. pain, abdom. pain, bloating, bloating, constipationconstipation

Delayed gastric Delayed gastric emptying; occas. abnl emptying; occas. abnl LFTsLFTs

8. Renal8. Renal Pitting edemaPitting edema Elevated BUN; renal Elevated BUN; renal failurefailure

9. Skeletal9. Skeletal Bone pain w/ Bone pain w/ exerciseexercise

X-ray/bone scan w/ X-ray/bone scan w/ stress fx; DEXA w/ stress fx; DEXA w/ osteopenia or osteopenia or osteoporosisosteoporosis

Physical Complications of Bulimia NervosaPhysical Complications of Bulimia Nervosa

Organ systemOrgan system SymptomsSymptoms Lab Test ResultsLab Test Results

1. Metabolic1. Metabolic Weakness; Weakness; irritabilityirritability

Dehydration; Dehydration; serum serum electrolytes: ↓K+, electrolytes: ↓K+, ↓Cl alkalosis w/ ↓Cl alkalosis w/ vomiting; ↓Mg, vomiting; ↓Mg, ↓K+, ↓Phos w/ ↓K+, ↓Phos w/ laxative abuselaxative abuse

2. GI2. GI Abdom. pain; Abdom. pain; constipation; constipation; bloating; bloating; reflux reflux

Physical Complications of Bulimia Nervosa; cont.Physical Complications of Bulimia Nervosa; cont.

Organ systemOrgan system SymptomsSymptoms Lab Test ResultsLab Test Results

3. Oropharyngeal3. Oropharyngeal Dental decay; Dental decay; swollen swollen cheekscheeks

X-rays confirm X-rays confirm erosion of dental erosion of dental enamel; elevated enamel; elevated serum amylaseserum amylase

4.CV and muscular 4.CV and muscular (in ipecac abusers) (in ipecac abusers)

Palpitations; Palpitations; weaknessweakness

Cardiomyopathy Cardiomyopathy and arrhythmias; and arrhythmias; peripheral peripheral myopathy myopathy

Medical evaluation for Anorexia Medical evaluation for Anorexia NervosaNervosa

Assess for co morbidityAssess for co morbidity Screening labs: electrolytes, Ca+Screening labs: electrolytes, Ca++, Mg+, Phos, BUN/Cr, CBC, LFTs, +, Mg+, Phos, BUN/Cr, CBC, LFTs, TFTs, UATFTs, UA

Bone density (DEXA) Bone density (DEXA) EKGEKG

  

Medical evaluation for Bulimia Medical evaluation for Bulimia NervosaNervosa

Assess for comorbidityAssess for comorbidity Screening labs: electrolytes, Ca++, Screening labs: electrolytes, Ca++, Mg+, Phos, BUN/Cr, CBC, LFTs, TFTs, UAMg+, Phos, BUN/Cr, CBC, LFTs, TFTs, UA

EKGEKG DentalDental  

  

Pharmacology for ANPharmacology for AN

SSRIsSSRIs Atypical antipsychotic Atypical antipsychotic medicationsmedications

Meds tried and failed for Meds tried and failed for appetite enhancementappetite enhancement

GI meds to aid physical GI meds to aid physical symptomssymptoms

Pharmacology for BNPharmacology for BN

Serotonin re-uptake inhibitorsSerotonin re-uptake inhibitors AEDs (topiramate, ?zonisamide)AEDs (topiramate, ?zonisamide) AntipsychoticsAntipsychotics Mood stabilizersMood stabilizers reglan, H2 blockersreglan, H2 blockers

Methods of TreatmentMethods of Treatment

A.A. Regular Weight restorationRegular Weight restoration• 2 to 3 lbs/wk inpatient2 to 3 lbs/wk inpatient• 1 to 2 lbs/wk day-hospital1 to 2 lbs/wk day-hospital• 1 lb/wk outpatient1 lb/wk outpatient

B.B. Nutritional TeachingNutritional Teaching• Provide patient supportProvide patient support• Prevention from vitamin and mineral Prevention from vitamin and mineral

deficiencydeficiency• Prevention of osteoporosisPrevention of osteoporosis

Aim for high CaAim for high Ca++++ intake intake Vitamin D to aid in CaVitamin D to aid in Ca++++ absorption; absorption;

vegetarians may need supplementsvegetarians may need supplements Eat iron-containing foods, especially Eat iron-containing foods, especially

important for vegetariansimportant for vegetarians

Integrated treatment programsIntegrated treatment programs

Multidisciplinary treatment teamMultidisciplinary treatment team

Program managerProgram manager PsychiatristPsychiatrist Therapists with ED trainingTherapists with ED training Registered DietitianRegistered Dietitian Internist/PediatricianInternist/Pediatrician

AN: Hospital vs Outpatient TreatmentAN: Hospital vs Outpatient TreatmentFrom American Psychiatric Association Guidelines for From American Psychiatric Association Guidelines for

the Treatment of Eating Disorders the Treatment of Eating Disorders

OutpatientOutpatient InpatientInpatient

WeightWeight >85%>85% < 75%< 75%

Medical complicationsMedical complications nonenone HR, BP, K HR, BP, K etcetc

Suicidal, comorbid Suicidal, comorbid psych d.o. psych d.o.

Not presentNot present severesevere

Motivation, insight, Motivation, insight, cooperationcooperation

yesyes nono

Excessive exercise, Excessive exercise, purging, etcpurging, etc

minimalminimal severesevere

Stress, family Stress, family dynamicsdynamics

minimalminimal severesevere

Local ED treatment Local ED treatment resourcesresources

availableavailable nonenone

Referral to Higher level of careReferral to Higher level of care

Pt is failing lower level.Pt is failing lower level. Pt’s weight loss is continuing in Pt’s weight loss is continuing in spite of treatmentspite of treatment

Pt is unable to stop Pt is unable to stop bingeing/purging.bingeing/purging.

Pt’s physical symptoms warrant Pt’s physical symptoms warrant greater supervision (fainting, greater supervision (fainting, dehydration, heart palpitations)dehydration, heart palpitations)

Pt is resisting current level of Pt is resisting current level of carecare

Specific LOC ConsiderationsSpecific LOC Considerations

OP: high motivation, >85% IBWOP: high motivation, >85% IBW IOP: moderate motivation, >80%IBWIOP: moderate motivation, >80%IBW PHP: >75%PHP: >75% RTC: clinical issuesRTC: clinical issues IP: <75% IBW, psych co morbid severe IP: <75% IBW, psych co morbid severe (SI)(SI)

UCSD Intensive Family Therapy UCSD Intensive Family Therapy programprogram

Legal controversyLegal controversy

Diagnostic PracticeDiagnostic Practice

See hand-out for See hand-out for interview questionsinterview questions

Dual Diagnostic IssuesDual Diagnostic Issues

(Psychiatric co-(Psychiatric co-morbidity)morbidity)

PSYCHIATRIC COMORBIDITY: Anorexia PSYCHIATRIC COMORBIDITY: Anorexia NervosaNervosa

affective disordersaffective disorders anxiety disordersanxiety disorders psychotic disorderspsychotic disorders personality disorderspersonality disorders Substance abuse Substance abuse 

PSYCHIATRIC COMORBIDITY: Bulimia PSYCHIATRIC COMORBIDITY: Bulimia NervosaNervosa

Affective disordersAffective disorders Anxiety disordersAnxiety disorders Impulse Control DisordersImpulse Control Disorders Personality disordersPersonality disorders Substance abuseSubstance abuse

Anxiety Disorders (AD)Anxiety Disorders (AD)Lifetime and Premorbid RatesLifetime and Premorbid Rates

StudyStudy EDED nn Lifetime Lifetime ADAD

AD before EDAD before ED

Deep 95Deep 95 ANAN 2424 68%68% 58%58%

Bulik 97Bulik 97 ANAN 6868 60%60% 54%54%

Bulik 97Bulik 97 BNBN 116116 57%57% 54%54%

Godart 00Godart 00 ANAN 2929 83%83% 62%62%

Godart 00Godart 00 BNBN 3434 71%71% 62%62%

Kaye 04Kaye 04 AN,BNAN,BN 672672 64%64% 61%61%

23% OCD23% OCD

13% social 13% social phobiaphobia

Lifetime OCD Diagnosis in AN, Lifetime OCD Diagnosis in AN, BNBN

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

DiagnosiDiagnosiss

Range Range

ANAN 10 – 62%10 – 62%

AN BNAN BN 10 – 66%10 – 66%

BNBN 00 – 43 %– 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 Obsessive-Compulsive Personality Disorder (OCPD) Diagnoses in ED Disorder (OCPD) Diagnoses in ED

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

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

SubjectsSubjects Range of OCPDRange of OCPD

RANRAN 2 – 30%2 – 30%

BNBN 2 – 19%2 – 19%

Factor-Analysis of OCDFactor-Analysis of OCD12 studies, 2000 patients12 studies, 2000 patientsMataix-Cols, Rosario-Campos, Leckman, AJP 2005Mataix-Cols, Rosario-Campos, Leckman, AJP 2005

OCD is clinically heterogeneous OCD is clinically heterogeneous 4 symptom dimensions4 symptom dimensions

– Symmetry/orderingSymmetry/ordering– HordingHording– Contamination/cleaningContamination/cleaning– Obsessions/checkingObsessions/checking

Associated with distinct patterns Associated with distinct patterns of comorbidity, genetic of comorbidity, genetic transmission, neural substrates, transmission, neural substrates, treatment responsetreatment response

Prevalence of E.D. and S.U.D.Prevalence of E.D. and S.U.D.

20% of women with a substance 20% of women with a substance abuse/dependence have a current or abuse/dependence have a current or past history of BN or bulimic past history of BN or bulimic behaviorsbehaviors

21.4% of women with BN have a 21.4% of women with BN have a current or past history of drug current or past history of drug abuse, and 17% of BN women report a abuse, and 17% of BN women report a current or past history of current or past history of substance abuse or dependence. substance abuse or dependence.

Theories of shared etiology vs. Theories of shared etiology vs. causal etiologycausal etiology

Shared Etiology vs. Causal Shared Etiology vs. Causal EtiologyEtiology

Shared = both Shared = both disorders share disorders share a common a common predisposition predisposition and include the and include the personality, personality, family history, family history, developmental, developmental, and endogenous and endogenous opiods opiods hypothesis. hypothesis.

Causal = Having one Causal = Having one of these disorders of these disorders puts an individual at puts an individual at risk for developing risk for developing another disorder.another disorder.

Self-medication Self-medication theorytheory

Wolfe and Maisto (2000)Wolfe and Maisto (2000)

Results of Baker, Mazzeo, Results of Baker, Mazzeo, Kendler Study 2007Kendler Study 2007

BN was associated with a lifetime history of BN was associated with a lifetime history of major depression, neuroticism,conduct major depression, neuroticism,conduct disorder, CSA, DUD, and a parental history of disorder, CSA, DUD, and a parental history of alcoholism.alcoholism.

The results of this study lend support to both The results of this study lend support to both the personality and self-medication the personality and self-medication hypotheses. hypotheses.

Having higher neurotic tendencies may be the Having higher neurotic tendencies may be the underlying reason why women with BN are more underlying reason why women with BN are more likely to develop DUD and vice versa.likely to develop DUD and vice versa.

Some of these variables (depression, Some of these variables (depression, neuroticism, and CSA) may have an impact on neuroticism, and CSA) may have an impact on whether or not a woman with BN is at increased whether or not a woman with BN is at increased risk of developing another disorder like DUD.risk of developing another disorder like DUD.

DBT HeirarchyDBT Heirarchy

1. Life threatening behaviors1. Life threatening behaviors

2. Therapy interfering behaviors2. Therapy interfering behaviors

3. Quality of life issues3. Quality of life issues

Marsha LinehanMarsha Linehan

Life threatening behaviorsLife threatening behaviors

SuicideSuicide Starving Starving Binge-purgeBinge-purge Etoh poisoningEtoh poisoning Fatal car Fatal car crashescrashes

Domestic Domestic violenceviolence

Over dose with Over dose with drugsdrugs

Others?Others?

Therapy interfering behaviorsTherapy interfering behaviors

Failure to show Failure to show upup

LatenessLateness Not being Not being truthfultruthful

Critical of Critical of therapisttherapist

Coming to Coming to session session intoxicatedintoxicated

HostilityHostility Not talkingNot talking Not complying Not complying with medicationswith medications

Conflict Conflict avoidantavoidant

Quality of life issuesQuality of life issues

Ability to eat meals with othersAbility to eat meals with others Ability to have food in Ability to have food in refridgerator at homerefridgerator at home

Supportive relationshipsSupportive relationships Ability to go out to a Ability to go out to a restaurant with friendsrestaurant with friends

Ability to think about topics Ability to think about topics other than food, weight, and other than food, weight, and body sizebody size

Eating Disorders and SUDEating Disorders and SUD

Which to treat first?Which to treat first? Access severity of SUD: 12 Access severity of SUD: 12 step, de-tox, inpatient?step, de-tox, inpatient?

Come up with a mutally agreed Come up with a mutally agreed upon contract: sobriety, upon contract: sobriety, controlled drinking/using, etc.controlled drinking/using, etc.

Make connections btw the ED and Make connections btw the ED and SUD: meeting certain needsSUD: meeting certain needs

Psychiatric eval if neededPsychiatric eval if needed

E.D. and O.C.D.E.D. and O.C.D.

Refer pt for psychiatric Refer pt for psychiatric evaluation for medicationsevaluation for medications

Refer pt to OCD specialist for Refer pt to OCD specialist for individual therapy. Have good individual therapy. Have good communication with this communication with this therapist.therapist.

Case Example: DannyCase Example: Danny

Working with E.D. and Working with E.D. and Personality DisordersPersonality Disorders

Borderline TraitsBorderline Traits Dependent PersonalityDependent Personality Histrionic PersonalityHistrionic Personality Obsessive Compulsive Pers. D/0Obsessive Compulsive Pers. D/0 Narcissistic TraitsNarcissistic Traits

Individual Therapy with Individual Therapy with Eating Disorder Eating Disorder

PatientsPatients

Psychotherapies for Anorexia Psychotherapies for Anorexia Nervosa (McIntosh, 2005)Nervosa (McIntosh, 2005)

20 sessions over a 20 week period20 sessions over a 20 week period 56 AN women were randomly assigned to 56 AN women were randomly assigned to 3 treatments: (35 completed treatment)3 treatments: (35 completed treatment)

1. Cognitive Behavioral Therapy1. Cognitive Behavioral Therapy

2. Interpersonal Psychotherapy2. Interpersonal Psychotherapy

3. Non-specific supportive clinical 3. Non-specific supportive clinical managementmanagement

Which treatment was the best?Which treatment was the best?

Interpersonal was the least Interpersonal was the least effective of the 3 therapies. effective of the 3 therapies.

Successful treatment outcome Successful treatment outcome was achieved by 17% of the was achieved by 17% of the interpersonal psychotherapy interpersonal psychotherapy patients, 42% of the CBT patients, 42% of the CBT patients, and 82% of the non-patients, and 82% of the non-specific supportive clinical specific supportive clinical management patients. management patients.

Non-specific Supportive Clinical Non-specific Supportive Clinical ManagementManagement

Education, care, and supportEducation, care, and support Fostering a therapeutic relationship that Fostering a therapeutic relationship that promotes adherence to treatmentpromotes adherence to treatment

Assist the pt through use of praise, Assist the pt through use of praise, reassurance, and advice.reassurance, and advice.

Encourage resumption of normal eating and Encourage resumption of normal eating and weight restorationweight restoration

Provided info on weight maintenance Provided info on weight maintenance strategies, energy requirements, and strategies, energy requirements, and relearning to eat normallyrelearning to eat normally

Info was provided verbally and through Info was provided verbally and through hand-outs. hand-outs.

Treatment Strategies for Bulimia Treatment Strategies for Bulimia NervosaNervosa

1. Meal plan1. Meal plan 2. Delay the binge2. Delay the binge 3. Binge, but don’t purge3. Binge, but don’t purge 4. Throw away your scale4. Throw away your scale 5. Challenge distorted beliefs (CBT)5. Challenge distorted beliefs (CBT) 6. Teach anxiety reduction skills6. Teach anxiety reduction skills 7. Develop support system7. Develop support system 8. Write in a journal8. Write in a journal 9. Set goals each week (1 B/P Max)9. Set goals each week (1 B/P Max) 10. Use externalization (Life w/o Ed)10. Use externalization (Life w/o Ed) 11. Teach set-point theory (Making Peace with 11. Teach set-point theory (Making Peace with Food book)Food book)

Chain Analysis (example) Chain Analysis (example)

How to deal with resistance to How to deal with resistance to recoveryrecovery

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

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

3. Normalize her 3. Normalize her ambivalenceambivalence

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

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

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

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

Candy Crover

Candy is 23 year old college drop out who works as a waitress. She drinks alcohol every weekend and has had more than 20 black

outs. She also binges and purges once a day. She has done this since age 16 which is the same year her father died of cancer.

Candy tends to restrict her intake during the day and then binges and purges at night on the left-overs she brings home from work.

Her weight fluctuates from 140 to 155 lbs.

She is 5 ft 10. As a teen, she used to cut on her thighs because she thought

they were too fat. She is coming to you for individual therapy because she is worried about her health. She recently

fainted after a binge-purge episode. Her boyfriend found her on the bath room

floor and rushed her to the E.R. She received 3 bags of I.V. fluid due to

dehydration

Axis I. II.

III. IV. V. 1. What is your treatment plan? 2.Which issues will you address first by using the DBT Heirarchy? 3. Will you need to set any limits with this patient?

1st Session Candy begins the session telling you that she feels fat. She weighed herself this morning and she was 155lbs. She is worried that her boyfriend wonÕt be attracted to her anymore. Last night she was very anxious and binged and purged for 2 hours. She did not eat any meals that day.

2nd session Candy begins the session by telling you that she only binged/purged 4 times this past week. Eating 2 meals per day helped her. She also followed your suggestion to get rid of her scale. She wants you to help her to understand why she binges/purges. (do a chain analysis). Help her to find a place to break the chain.

1. I came home from work and I was really hungry. I didnÕt eat any meals

that day.

2. I brought home some food from work and put it in the microwave.

3. I cooked the food and ate it out of the carton really fast.

4. I got anxious about getting fat. I told myself ŅI shouldnÕt have eaten all that

bad food.Ó

5. I thought ŅI must purge.Ó Then I went to the bathroom and threw up.

6. I felt more relaxed and then I went to bed.

Case Example: AnnieCase Example: Annie

30 year old B.S. biology30 year old B.S. biology Binge/purge for 5 yearsBinge/purge for 5 years Weekly individual therapy Weekly individual therapy Identify trigger: parent’s Identify trigger: parent’s house, skipping mealshouse, skipping meals

Case Example: KarenCase Example: Karen

22 year old college graduate22 year old college graduate Anorexic motherAnorexic mother Residential treatment, IOP, PHP, Residential treatment, IOP, PHP, Individual therapyIndividual therapy

5’ 2 93lbs5’ 2 93lbs Highest weight: 120Highest weight: 120 Lowest weight: 88Lowest weight: 88 Got period back at 105lbs.Got period back at 105lbs. Doesn’t want her thighs to touchDoesn’t want her thighs to touch Identify binge/purge triggers Identify binge/purge triggers (grandpa’s house)(grandpa’s house)

When is individual When is individual therapy not enough?therapy not enough?

HBO SpecialHBO Special

THINTHIN

DiscussionDiscussion

Questions and Questions and Answers about Day IAnswers about Day I

Comments or Comments or suggestions for Day suggestions for Day

II?II?

Life without EDLife without ED

What Jenni Schaefer has to What Jenni Schaefer has to teach usteach us

Externalization of the eating Externalization of the eating disorderdisorder

What are perfectionistic traits?What are perfectionistic traits?

Never being Never being satisfied with your satisfied with your achievements or achievements or performanceperformance

Ability to see Ability to see flaws where others flaws where others do notdo not

Dread of making Dread of making mistakesmistakes

ExactnessExactness Exceedingly high Exceedingly high standardsstandards

Very detail focusedVery detail focused Lack of novelty Lack of novelty seekingseeking

Frequent Frequent disappointment with disappointment with self and othersself and others

Relentless pursuit Relentless pursuit of perfectionof perfection

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

How can we help pts to reduce How can we help pts to reduce perfectionism?perfectionism?

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

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

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

Goals and Benefits of Group TherapyGoals and Benefits of Group Therapy

Breaks down isolationBreaks down isolation Provides peer supportProvides peer support Learning from others, not just group Learning from others, not just group leader.leader.

Shame reductionShame reduction Problem solvingProblem solving Interpersonal Skill BuildingInterpersonal Skill Building Helps to replace e.d.Helps to replace e.d. Better resource allocationBetter resource allocation

Why are groups so important for Why are groups so important for eating disorder pts?eating disorder pts?

Many of them have social phobiaMany of them have social phobia Many of them are isolatedMany of them are isolated Many of them have problems with “reading Many of them have problems with “reading people.”people.”

Like autism, some people with anorexia Like autism, some people with anorexia have difficulties with “theory of mind.” have difficulties with “theory of mind.”

Group can help them see how they come Group can help them see how they come across to others.across to others.

Many of them have problems with Many of them have problems with interpersonal effectiveness, like interpersonal effectiveness, like assertiveness. Group gives them a safe assertiveness. Group gives them a safe place to practice new skills.place to practice new skills.

Types of GroupsTypes of Groups

Groups according to diagnosisGroups according to diagnosis Ongoing vs. time-limitedOngoing vs. time-limited Psychoeducational groupsPsychoeducational groups Process groupsProcess groups Skill building groups: DBT, CBTSkill building groups: DBT, CBT Body Image group: CindyBody Image group: Cindy AN, BN groups at UCSDAN, BN groups at UCSD Art Therapy groupArt Therapy group Relapse PreventionRelapse Prevention

Goals of CBT GroupGoals of CBT Group

Create a safe environment for pts to Create a safe environment for pts to explore their eating disorder explore their eating disorder thoughts and beliefsthoughts 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 Identify triggers and coping strategiesstrategies

CBT groups for BulimiaCBT groups for Bulimia

Research by Mitchell et al 2005 showed Research by Mitchell et al 2005 showed that Social Support Seeking 1 month after that Social Support Seeking 1 month after a 12 week CBT group predicted the outcome a 12 week CBT group predicted the outcome at 6 months.at 6 months.

Those group members who utilized their Those group members who utilized their support systems 1 month after the group support systems 1 month after the group had a better outcome.had a better outcome.

Use of positive coping skills at the end Use of positive coping skills at the end of treatment did not predict the outcome of treatment did not predict the outcome at 6 months.at 6 months.

This study highlights the importance of This study highlights the importance of social support to maintain treatment social support to maintain treatment goals.goals.

Process GroupProcess Group

Get topics from each member (Axis II)Get topics from each member (Axis II) Divide the time so everyone can share.Divide the time so everyone can share. Group leader intervenes when e.d. Group leader intervenes when e.d. thoughts are presented as truethoughts are presented as true

Let members give support before you do. Let members give support before you do. It’s best if coming from them.It’s best if coming from them.

Encourage group participation. Help Encourage group participation. Help connect group members to each other.connect group members to each other.

Create a safe environment of non-Create a safe environment of non-judgemental feedback. judgemental feedback.

Help to establish positive group norms.Help to establish positive group norms.

Goals for Body Image GroupGoals for Body Image Group

Create a safe Create a safe environment for environment for pts to explore pts to explore body image issuesbody image issues

Teach about our Teach about our culture and how culture and how we get negative we get negative messages about messages about body size and body size and shape.shape.

Help group Help group members to share members to share their body image their body image struggles with struggles with each othereach other

Help to dispel Help to dispel body image body image distortionsdistortions

Set body image Set body image goals each weekgoals each week

ResourcesResources

Relapse Prevention GroupRelapse Prevention Group

Provide a support group for those Provide a support group for those in recoveryin recovery

Encourage pts to share their Encourage pts to share their coping strategies with each othercoping strategies with each other

Problem solve difficulties with Problem solve difficulties with staying in recovery.staying in recovery.

Use lapses as learning experiencesUse lapses as learning experiences Prevent relapse through Prevent relapse through accountabilityaccountability

Problems in GroupsProblems in Groups

The monopolizerThe monopolizer The advice giverThe advice giver The yes, butThe yes, but Quiet groupsQuiet groups Unexpressed angerUnexpressed anger Poor attendance of Poor attendance of certain memberscertain members

LatenessLateness Anorexia vs BulimiaAnorexia vs Bulimia

Lack of recovery Lack of recovery in the groupin the group

Cliques between Cliques between certain memberscertain members

Rejection of Rejection of membersmembers

Poor screening Poor screening of potential of potential group membersgroup members

Goal SettingGoal Setting

Set attainable and measurable goals.Set attainable and measurable goals. Examples include: 1 B/P Max, 1 Self-Examples include: 1 B/P Max, 1 Self-sooth, write in journal about feelings sooth, write in journal about feelings I had before engaging in my eating I had before engaging in my eating disorder, eat meal plan, do food log, disorder, eat meal plan, do food log, limit exercise to half hour per day, limit exercise to half hour per day, have husband hide my scale, body check have husband hide my scale, body check only 1 time per day, eat a challenge only 1 time per day, eat a challenge food 1 time, make a mistake with a food 1 time, make a mistake with a witness, write a letter to ed., have witness, write a letter to ed., have ed write back, no self-harm, call for ed write back, no self-harm, call for support. (see flip chart)support. (see flip chart)

Group Therapy Practice: Large Group Therapy Practice: Large GroupGroup

Needed: 2 leaders and 7 membersNeeded: 2 leaders and 7 members

Reactions to large Reactions to large group exercisegroup exercise

What did you learn?What did you learn?

1st Session of a new group1st Session of a new group

Introduce the leaders and Introduce the leaders and purpose of the grouppurpose of the group

Go over group rules: contact Go over group rules: contact outside group, confidentiality, outside group, confidentiality, off limits topics, gum chewing, off limits topics, gum chewing, water, outside food, length of water, outside food, length of group (12 weeks), dress codegroup (12 weeks), dress code

Have members tell their story: Have members tell their story: history of the e.d and history of the e.d and treatmenttreatment

Group Therapy Practice in Group Therapy Practice in Small GroupsSmall Groups

Break into groups of 8: 2 leaders and 7 Break into groups of 8: 2 leaders and 7 consumersconsumers

The leader will lead the 1st session by The leader will lead the 1st session by having each member tell their story as having each member tell their story as an introduction. S/he will also go over an introduction. S/he will also go over the group rules: no talking about the group rules: no talking about numbers (Calories, sizes, weights, numbers (Calories, sizes, weights, miles ran etc.), confidentiality, no miles ran etc.), confidentiality, no outside food allowed, no gum chewing, outside food allowed, no gum chewing, outside contact encouraged for support outside contact encouraged for support but not crisis management.but not crisis management.

Reactions to practice sessionReactions to practice session

What was hard for the group leaders?What was hard for the group leaders? Were you able to explain the group Were you able to explain the group rules and answer questions?rules and answer questions?

How did it feel to lead this group?How did it feel to lead this group? How did members feel in this group?How did members feel in this group? Did it feel safe?Did it feel safe? Feedback for leadersFeedback for leaders

HBO Special: ThinHBO Special: Thin

Part IIPart II

How to set up a group and get it How to set up a group and get it started?started?

Do a needs assessment of your Do a needs assessment of your patient populationpatient population

Choose the type of group and the Choose the type of group and the inclusion/exclusion criteriainclusion/exclusion criteria

Decide on group leadershipDecide on group leadership Design format or curriculumDesign format or curriculum Create a flyer, contact therapists, Create a flyer, contact therapists, marketingmarketing

Conduct interviewsConduct interviews Set a start dateSet a start date

Brainstorming SessionBrainstorming Session

What kinds of groups do we need What kinds of groups do we need in our community?in our community?

What are consumers asking for?What are consumers asking for? How do we get started?How do we get started?

What kinds of groups are What kinds of groups are needed in your community?needed in your community?

What is your plan of action?What is your plan of action? Who will volunteer to get a Who will volunteer to get a group started?group started?

What resources will you need?What resources will you need? Plan your next follow up Plan your next follow up meetingmeeting

Questions and Questions and AnswersAnswers