Day # 2

Outpatient

for EDS Special Treatment Considerations based on age and developmental stage Family Therapy Dietician and Meals and nutritional planning

Psychosocial Treatment

Working with Eating Disorder Patients in an Outpatient Setting

Elise Curry Psy.D. Program Manager UCSD IOP

Individual Therapy

Anorexia Nervosa Therapy Strategies

Establish rapport Interpret function of symptoms: needs Calculate weight goal (90% IBW) -1 lb per week weight gain in outpatient Encourage direct expression of feelings, especially anger Careful to allow patient true self expression

Anorexia Nervosa Therapy Strategies

Address issues of expectations from others vs individual wants

Explore fears with food and weight gain as having some relationship to emotional experiences

Teach assertiveness skills. Helping patient say no to things other than food. Stimulate adolescent rebellion in other ways, rather than starvation. (green hair, tattoos, R rated movies, teenage clothing etc.) Family, parent therapy esp with adolescents

Case study: Janine

Age 15 Lives with mother Developed anorexia within past year Perfectionistic Make a mistake with a witness at the library Weight contract Weight restoration: 12 lbs.

Therapy strategies for BN

CBT,

IPT, DBT Affect tolerance Engagement in other stress relieving and pleasurable activities Work on sitting with uncomfortable feelings, rather than urge to get rid of feelings Address issues of expectations from others vs individual wants

Therapy strategies for BN

Food/event

diary Normalize eating, watching for deprivation Set goals for # B/P episodes Trauma issues, shame Co morbid BLPD/O (BN)

Case example: Shelly

Age: 25 College Student C/S symptoms (name change) Purged through running Vow to herself at age 13 Lacked age appropriate dating Assertiveness: family phone conference

Group Therapy and Integrated Treatment

Goal

setting Structured on-site meals Meditation/Mindfulness Cognitive-behavioral therapy Process group Art therapy DBT Nutritional counseling

Goal setting

Goal setting: met, part, not met Mistake with a witness (perfectionism) Reducing the symptom: B/P 1 max Letter to ED ED writes back Meal plan: 3 meals plus 3 snacks helps to reduce binge eating Restrict - Binge - Purge (cycle) What can you do instead? Alternatives Binge if you want, but dont purge Challenge foods: have a piece of cheesecake Foods are not good or bad: incorporate desserts into the meal plan

Process Group

Treatment considerations based on age

Children

(preteen) Adolescents Adults Chronic AN/BN

Important considerations
Age

of onset Time of low weight, linear history Developmental phase Involvement of others (family, spouse, children, parents, etc)

What about the kids?

Pre-pubertal Eating Disorder Childhood Onset Eating Disorder Early Onset Eating Disorder

What Are We NOT Talking About?

DSM-IV

Feeding and Eating Disorders of Infancy or Early Childhood

Pica Rumination Disorder Feeding disorder of infancy or childhood

Anorexia Nervosa DSM-IV

Refusal

to maintain body weight above a minimally normal weight for age and height. <85% of IBW Intense fear of gaining weight or becoming fat Disturbance in the way ones body weight or shape is experienced Amenorrhea: absence of at least three consecutive menstrual cycles

Weight Loss vs Weight Maintenance

DSM-IV criteria excludes children who have not reached the critical level of <85% Malnutrition can lead to poor growth

Body Image

May be more tricky to assess How can it be evaluated? Childrens expression of body image Standard tools Clinical Interview Somatic symptoms Abdominal pain or discomfort Feeling of fullness Nausea Loss of appetite

Amenorrhea
Primary vs Secondary Pubertal delay

Evaluation may include pelvic ultrasound

Height Weight Weight/height

ratio Ovarian volume Uterine volume

Conventional target weight and weight/height may be too low to ensure ovarian and uterine maturity

Alternative Criteria for ED in Children: Byant-Waugh and Lask 1995

Alternative classification for the range of eating disorders of childhood Excessive preoccupation with weight or shape and/or food intake which is accompanied by grossly inadequate, irregular or chaotic food intake

Byant-Waugh and Lask 1995

:Criteria for Anorexia Nervosa
Failure to make appropriate weight gains, or significant weight loss Determined weight loss (e.g., food avoidance, self-induced vomiting, excessive exercising, abuse of laxatives). Abnormal cognitions regarding weight and/or shape. Morbid preoccupation with weight and/or shape.

Related ED Behaviors in Children

Anorexia

nervosa Food avoidant emotional disorder Selective eating Functional dysphagia Bulimia nervosa Pervasive refusal syndrome

Early behavioral risk factors for EDs

PICA

BN Picky Eater BN, some AN Digestive problems AN Subsyndromal symptoms of EDs can predate

Incidence and Demographics

Anorexia

in this age range is considered to be rare Males may constitute a higher proportion of cases in childhood as opposed to in adolescence or adulthood
19-30% of childhood cases 5-10% of adolescent or adult cases

Biological

Psychological

Social

Biological

Genetics
Higher rate of AN, BN and ED NOS in first degree relatives Cross-transmitted High heritability

Imaging
Gordon et al, 1997

Medication
Trials suggest serotonin and dopamine systems contribute

15 girls ages 8-16 with AN Regional cerebral blood blow radioisotope scans 13/15 had unilateral temporal lobe hypoperfusion significant association between unilateral reduction of blood flow in the temporal region and
impaired visuospatial ability, impaired visual

Lask et al, 2005

Psychological

Personality traits
Anxious Obsessional Perfectionistic

Susceptibility factors
Obsessions
Perfectionism Symmetry Exactness

Negative affect, harm avoidance Preoccupations with weight, body image and food

Prognosis

Long term follow up of patients with early onset anorexia nervosa (Bryant-Waugh et al, 1987)
30 children with anorexia nervosa followed for mean duration of 7.2 years Mean age at onset 11.7 years
19/30

(60%) with a good outcome 10/30 remained moderately to severely impaired Poor prognostic factors included
Early age at onset (<11 years) Depression during the illness Disturbed family life and one parent families Families in which one or both parents had been married before

Family therapy
Family

Video and discussion Maudsley Family Therapy for Adolescents Systemic Family Therapy

Family Dynamics: Video and Discussion

Maudsley Family Therapy

Agnostic toward etiology Involves parents Food is medicine Initial focus on symptoms Parents are responsible for weight restoration. Non-authoritarian therapist stance Separation of child from illness

Maudsley Family Therapy

Phase

I: (sessions 1 - 10) Weight restoration, re-feeding focus. Phase II: (sessions 11 - 16) Transfer control back to adolescent gradually. Phase III: (sessions 17 - 20) Focus on adolescent developmental issues, termination.

Maudsley Family Therapy

Session 1: Funeral session Goals: engage the family, obtain history of how AN came to be, find out how AN has affected each family member, assess family functioning, reduce blame, raise anxiety concerning AN. Interventions: Greet family in sincere but grave manner, externalize the AN, orchestrate intense scene, charge parents with the task of re-feeding.

Session 2: Family Meal Instructions to parents: bring a meal that would be appropriate for your childs nutritional needs. Goals: assess family structure as it may affect ability of parents to re-feed patient, provide an opportunity for parents to successfully feed patient, assess family process during meal. Interventions: bring the symptom alive and present in the room, one more bite, align patient with siblings for support.

Case Example: BFT

Madaline

age 14 Family members: mom, dad, sister, patient Patients weight history Taking control back from patient. Patient reaction to loss of control. Rewards and consequences Patient weight progress over time.

Systemic Family Therapy

Underlying

belief: if you fix the system, the symptom will no longer be needed. The eating disorder is serving a function in the family. The symptom bearer is trying to help the family (unconsciously).

Methods for Systemic Family Therapy

Circular

questioning Therapist is curious observer, not expert. Discuss communication patterns within the family. Involve all family members in the discussion, even small children. Do not pathologize family or symptom bearer.

Case Example: SFT

Brianna

age 16 Family members: mom, Gary, sister, patient Family of origin situation Current family living situation Symptoms of anorexia Function of the anorexia Changes in symptom over time

Meals/Dietitian

Handout nutritional assessment

Eating Disorder Nutritional Assessment

(based on personal interview and review of EDI-2) Date: _________

Name_________________________________ MR. #___________________ M / F Age: ____ ED DX: __________________________ Ht:______ Wt:______ %IBW or NCHS %tile:_______ Personal Treatment Goals: (incl. goal wt range) _______________________________________ ______________________________________________________________________________ Previous work with RD/Nutritionist: ________________________________________________ Previous ED Program: ___________________________________________________________ Wt Hx: _______________________________________________________________________ Recent Wt. Change: ___________________________ Personal weighing frequency: ________ Health Hx: Relevant Med/Psych Hx: _________________________________________________________ Laboratory results: date ___________ Protein status: Alb ______ (3.5-5.0) T Pro ________ (6.0-8.5) Prealb ______(19-4 3) Electrolytes: K ______ (3.4-5.0) Na __________ (136-145) Cl _______ (98-108) Iron status: Total Fe _____ (F:60-160,M:80-180) Hgb _____ (F:11.5-15.5,M:14-18) Hct _____(F:33-47,M:39-54) Other: ____________________________________ Current Medications:____________________________________________________________ Vitamins/Minerals/Supplements: Current type, dose:__________________________________ Recent Past (<6 mos.) type, dose:________________________________________________ Signs of nutritional compromise: Decreased energy level/muscle wasting/hair loss/temp. sensitivity/enamel erosion Nutrient-based lesions: _________________________________ Other:__________________ Current GI function: frequency of BMs: ________ loose/hard: ______________ gas: _______ distention: ____________other: _________________________________________________ Eating Disorder Hx: Restricting/Fasting:________________________ Exercise: _____________________________ Bingeing:__________________Vomiting:___________________Epecac Syrup: ____________ Laxatives: _________________ Diuretics: __________________ Diet Pills: ________________ Relevant Family History: _________________________________________________________ Exercise : Typical Food Intake/Bingeing/Purging Patterns: Good Day: Bad Day:

Nutrition Assessment - page 2 Fluid intake: __________________________________________________________________ Alcohol intake: ________________________________________________________________ Caffeine use: __________________________________________________________________ Gum use: ______________________________Smoking: _______________________________ Food Allergies _________________________________________________________________ Food Intolerances:______________________________________________________________ Cultural/Religious Prefs: _________________________________________________________ Safe Foods: ___________________________________________________________________ _____________________________________________________________________________ Social eating patterns: ___________________________________________________________ ______________________________________________________________________________ Assessment /Goals: Present Intake Inadequacies: ______________________________________________________ _____________________________________________________________________________ Signs of Malnutrition: ___________________________________________________________ Calorie/Energy needs to stabilize weight: ____________________________________________ ____________________________________________ to achieve weight goal: _______________________________________ for recommended exercise level of ______________________________ Protein needs: ___________________ @ _________ grams/kg Carbohydrate needs: ______________ @ 50-55% of kcal Fat needs:_______________________ @ 20-30% of kcal Fluid needs:______________________ @ 1 cc / kcal Fiber needs:______________________ @ 20-35 g.day

Meal Plan : PM__ Dairy _____ Starch _____ Protein _____ Veges/Salad _____ Fruit/Juice _____ Fat _____

Breakfast

Lunch

Dinner

Snacks: AM

PM

_________

_________

________

_____

_____

_________

_________

________

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________

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Other ________________________________________________________________________ Nutritional Assessment page 3 Changes in Progress Weight Record: Date Weight Date Weight Date Weight Date Weight ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ________________________________________________________________________ ____________ Follow-up Notes: ________________________________________________________________________

Handout exercise plan

Exercise Plan
Level 1: No exercise except for supervised walks and yoga during program.

Level 2: Minimal Exercise. Examples include walking for 45 minutes 3 times per week, swimming for 20 minutes 2 times per week, gym half an hour per week, yoga with permission, biking 1 hour per week. Total exercise time is 2 hours per week.

Level 3: Moderate exercise: Examples include: gym workout 3 times a week for 1 hour, hiking for 2 hours at a time, running 3 times a week for 45 minutes, swimming laps 30 minutes 3 times a week. Total exercise time spent per week is 4 hours.

I agree to document my exercise (type, amount, duration) on my meal report form.

Exercise addiction: Let staff know if your exercise is becoming addictive. The signs of addictive exercise are: motivation based on weight loss, doing more than the agreed upon amount, feeling depressed on days you dont exercise, lying about your exercise to staff, etc.

I agree to the exercise plan for level _____. Signed ________________ Date _______

Weight Restoration Contract

When

to use Out patient level of care; 0.5 1 lb per week Often includes exercise plan Parent/family/spouse informed

On site meals
Exposure

response prevention Challenge foods Peer support, peer pressure Rules at table

On site meals
Structure

of meal % complete Behaviors to watch for Review of purpose for staff and patients

Dealing with meal challenges

Food

types to try Extinguishing behaviors Boost Limit setting on # of boosts/ not eating meal on site

Questions and Answers

Day #3
Role

Play training DBT/CBT Obesity/binge eating disorder Ends in Special Populations (pregnancy, athletes, males)

DBT for Eating Disorders

Why DBT?
Refine

and change: Behavioral Emotional Thinking patterns That cause suffering and distress.

Targets for Treatment 1. Interpersonal Chaos: interpersonal effectiveness training 2. Labile affect: emotional regulation training 3. Impulsiveness: Distress tolerance training 4. Confusion about self and cognitive dysregulation: Mindfulness training

Interpersonal Chaos
Examples:

1.

Intense, unstable relationships 2. Trouble maintaining relationships 3 panic,dread, anxiety over end of relationships 4. Frantic attempts to avoid abandonment.

Interpersonal Chaos
Treatment

goals: 1. Learn to deal with conflicts 2. Learn to say no to unwanted requests/demands 3. Maintain self-respect and others respect.

Labile affect : emotional regulation training

Examples:

1.

Extreme emotional sensitivity 2. Ups and downs 3. Moodiness, intense emotional reactions 4. Chronic depression 5. Problems with anger (over and under-controlled)

Labile affect: Treatment goals

1.

Enhance emotional control 2. Remind members that to some extent we are who we are, but we can learn to modulate emotions to become a bit more relaxed.

Impulsivity: Distress Tolerance Training

Examples: 1. Problems with drugs, alcohol, food, shopping, sex, fast driving etc.

Treatment goals: 1. Learn to tolerate distress 2. Explain connection btw distress and impulsive behavior (often functions to reduce intolerable distress)

Confusion about self and cognitive dysregulation: mindfulness training

Examples: 1.problems experiencing or identifying a self 2. Pervasive feelings of emptiness 3. Problems maintaining her/his own opinions/feelings when around others 4. Cognitive disturbances: depersonalization, dissociation Treatment goals: 1. Go within to find oneself 2. Learn to observe oneself

Structure of Group Sessions

A. 50% homework, 50% new material, opening mindfulness exercise and wind down. B. Review diary cards C. Each person makes a practice commitment each week - pick a skill to work on and use across a variety of situations or for a recurrent situation.

CBT for Eating Disorders

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.

The Thin Commandments

Carolyn Costin MFT

Recovery Beliefs

My worth is not my weight. My body is an instrument, not an ornament. When I treat my body well, by eating 3 balanced meals per day and exercising moderately, my body will find its own set-point weight. People come in all kinds of shapes and sizes. I dont have to try to mold my body into a standard set by the media or fashion industry. I need some fat in my diet in order to have soft skin, shiny hair, and be able to become pregnant some day. I can enjoy having a more curvy body, instead of striving for thinness. I am unique and special due to my inner qualities. Perfectionism only leads to disappointment, not happiness.

Eating Disorders in special populations

Pregnancy

Males
Obesity

and Binge Eating disorder

ED and Pregnancy
Reduced

recovery 20% pts at fertility clinics have EDs More likely to lie about ED behaviors during pregnancy High relapse rates after delivery Higher risk for PPD

fertility, even after full

Eating Disorders in Pregnancy

Increase

difficulty with weight gain (psychological and physically) Overall, most studies reveal improvement in behaviors in pregnancy (for the greater good), though often not enough Risks: low birth weight (and associated features), prematurity, Csections

Males and EDs

Less

common than in females, but increasing (approx 10% of EDS occur in men) They have a job or profession that demands thinness. Male models, actors. Cultural pressures to be V shaped

Males and EDS

More

in common with female EDs than differences Lower testosterone may predispose to ED Fears regarding sexuality More common in homosexual men Conflict over sexual identity Avoidant, passive, negative reactions from peers as children

Males and EDs

Athletes/profession

requirements 1:10 male to female ratio BED similar rates male/female, though women more distressed about it, more guilt

with weight

Males and EDs

They

were fat or overweight as children (different than females). They have been dieting. Dieting is one of the most powerful eating disorder triggers for both males and females.

Males and EDs

They participate in a sport that demands thinness. Runners and jockeys are at higher risk than football players and weight lifters. Wrestlers who try to shed pounds quickly before a match so they can compete in a lower weight. Body builders are at risk if they deplete body fat and fluid reserves to achieve high definition

Binge Eating Disorder

Recurrent episodes of binge eating (see BN) The binge eating episodes are associated with three (or more) of the following:

Marked distress regarding binge eating is present 2 days/week for 6 months

Eating much more rapidly than normal Eating until feeling uncomfortably full Eating large amounts of food when not feeling physically hungry Eating alone because of being embarrassed by how much one is eating Feeling disgusted with oneself, depressed, or very guilty after overeating

Obesity
BMI > 30 32.2% of American adults, increasing in children Increasing in past 30 years by 50% per decade Major successful treatment advances in treatment of complications of obesity, but minimal success in treatments for obesity itself

Is Obesity a psychiatric disorder (BED)?

Medical/Metabolic

issues Am J Psych 2007: Issues for DSM V: Should obesity be included as a brain Disorder Major limitation to treatment of obesity is long term behavioral compliance Diets major cause of ED, including BED

BED and Neurochemistry

Serotonin, endogenous opiates, cannabinoids Certain foods impact nucleus accombens: DA, opiate Neuropsych: IGT similar to addicts; ie; follow immed reward over long term results during gambling type tasks 9with excitable reward) Individual biological risks: genetic/heritability

Literature Review: Treatment for BED

International

J of EDs May 2007 26 studies reviewed: Med plus behav, meds alone, behav alone Meds plus BWL best, short term

Psychosocial treatments
CBT

CBT

plus BWL BWL alone Group therapy Indiv therapy 12 step/self help

Medical treatments for BED/obesity

Sibutramine

Orlastat
?

SSRIs, SNRis, TCAs ? Topiramate ? Zonisamide Acomplia Gastric Bipass

Special Assessment and Treatment Strategies for Chronic AN

Problems

accumulate, may become irreversible after as early as 6 mos Poor Prognosis Risk benefit assessment of ED Harm reduction

Treatment issues in Chronic EDs

Legal

aspects Case examples

Final Question and Answer Session