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)  ½-1 lb per week weight gain in outpatient  Encourage direct expression of feelings. especially anger  Careful to allow patient true self expression  .

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

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.  .

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

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 .

part.Goal setting            Goal setting: met.Binge . but don‟t purge Challenge foods: have a piece of cheesecake Foods are not good or bad: incorporate desserts into the meal plan . 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 .Purge (cycle) What can you do instead? Alternatives Binge if you want.

Process Group .

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Treatment considerations based on age  Children (preteen)  Adolescents  Adults  Chronic AN/BN .

spouse. parents. children. linear history  Developmental phase  Involvement of other‟s (family.Important considerations  Age of onset  Time of low weight. 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 .

<85% of IBW  Intense fear of gaining weight or becoming fat  Disturbance in the way one‟s body weight or shape is experienced  Amenorrhea: absence of at least three consecutive menstrual cycles .Anorexia Nervosa DSM-IV  Refusal to maintain body weight above a minimally normal weight for age and height.

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? – Children‟s 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.  . abuse of laxatives).  Abnormal cognitions regarding weight and/or shape. self-induced vomiting. food avoidance.g..  Morbid preoccupation with weight and/or shape. excessive exercising. or significant weight loss  Determined weight loss (e.

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 .

BN and ED NOS in first degree relatives – Cross-transmitted – High heritability  Imaging – Gordon et al. 2005  .Biological  Genetics – Higher rate of AN. 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.

Psychological  Personality traits – Anxious – Obsessional – Perfectionistic  Susceptibility factors – Obsessions  Perfectionism  Symmetry  Exactness – Negative affect. harm avoidance – Preoccupations with weight. body image and food .

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Prognosis  Long term follow up of patients with early onset anorexia nervosa (Bryant-Waugh et al.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 . 1987) – 30 children with anorexia nervosa followed for mean duration of 7.2 years – Mean age at onset 11.

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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  .

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

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

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

patient  Patient‟s weight history  Taking control back from patient. . dad.  Patient reaction to loss of control.Case Example: BFT  Madaline age 14  Family members: mom. sister.  Rewards and consequences  Patient weight progress over time.

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

even small children.  Involve all family members in the discussion.  Do not pathologize family or symptom bearer.Methods for Systemic Family Therapy  Circular questioning  Therapist is curious observer. .  Discuss communication patterns within the family. not expert.

sister.Case Example: SFT  Brianna age 16  Family members: mom. patient  Family of origin situation  Current family living situation  Symptoms of anorexia  Function of the anorexia  Changes in symptom over time . Gary.

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Meals/Dietitian .

Handout nutritional assessment .

5-15.4-5.5-5. goal wt range) _______________________________________ ______________________________________________________________________________ Previous work with RD/Nutritionist: ________________________________________________ Previous ED Program: ___________________________________________________________ Wt Hx: _______________________________________________________________________ Recent Wt.0-8.Eating Disorder Nutritional Assessment (based on personal interview and review of EDI-2) Date: _________ Name_________________________________ MR.0) Na __________ (136-145) Cl _______ (98-108) Iron status: Total Fe _____ (F:60-160.) type.M:39-54) Other: ____________________________________ Current Medications:____________________________________________________________ Vitamins/Minerals/Supplements: Current type. dose:________________________________________________ Signs of nutritional compromise: Decreased energy level/muscle wasting/hair loss/temp. dose:__________________________________ Recent Past (<6 mos.M:14-18) Hct _____(F:33-47.M:80-180) Hgb _____ (F:11.0) T Pro ________ (6. Change: ___________________________ Personal weighing frequency: ________ Health Hx: Relevant Med/Psych Hx: _________________________________________________________ Laboratory results: date ___________ Protein status: Alb ______ (3.5.5) Prealb ______(19-4 3) Electrolytes: K ______ (3. #___________________ M / F Age: ____ ED DX: __________________________ Ht:______ Wt:______ %IBW or NCHS %tile:_______ Personal Treatment Goals: (incl. sensitivity/enamel erosion Nutrient-based lesions: _________________________________ Other:__________________ Current GI function: frequency of BM’s: ________ 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: .

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 .Nutrition Assessment .

Meal Plan : PM__ Dairy _____ Starch _____ Protein _____ Veges/Salad _____ Fruit/Juice _____ Fat _____ Breakfast Lunch Dinner Snacks: AM PM _________ _________ ________ _____ _____ _________ _________ ________ _____ _____ _________ _________ ________ _____ _____ _________ _________ ________ _____ _____ _________ _________ ________ _____ _____ _________ _________ ________ _____ _____ 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 don’t 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

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Day #3  Role Play training  DBT/CBT  Obesity/binge eating disorder  Ends in Special Populations (pregnancy. males) . athletes.

DBT for Eating Disorders .

.Why DBT?  Refine and change:  Behavioral  Emotional  Thinking patterns  That cause suffering and distress.

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

Frantic attempts to avoid abandonment. Intense. Trouble maintaining relationships  3 panic. anxiety over end of relationships  4. .dread. unstable relationships  2.Interpersonal Chaos  Examples:  1.

Learn to deal with conflicts  2. Learn to say no to unwanted requests/demands  3. Maintain self-respect and other‟s respect.Interpersonal Chaos  Treatment goals:  1. .

Problems with anger (over and under-controlled) .Labile affect : emotional regulation training  Examples:  1. Moodiness. intense emotional reactions  4. Extreme emotional sensitivity  2. Chronic depression  5. Ups and downs  3.

. Enhance emotional control  2. but we can learn to modulate emotions to become a bit more relaxed.Labile affect: Treatment goals  1. Remind members that to some extent we are who we are.

 Treatment goals:  1. shopping. fast driving etc. Problems with drugs.Impulsivity: Distress Tolerance Training Examples:  1. alcohol. food. sex. Learn to tolerate distress  2. Explain connection btw distress and impulsive behavior (often functions to reduce intolerable distress)  .

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

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

CBT for Eating Disorders .

           If I am fat. I will be able to see it on my body tomorrow. I need to get rid of it by purging. If I eat too much. . My worth is my weight. Purging gets rid of all the food. Everyone hates fat people. Men like women who are skinny.Distorted Beliefs  There are “good” foods and “bad” foods. no one will love me. Thinness equals happiness. Using laxatives gets rid of all the food. If I eat this piece of cheesecake. You can never be too rich or too thin. It is more important to be thin than anything else.

The Thin Commandments Carolyn Costin MFT .

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

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Eating Disorders in special populations  Pregnancy  Males  Obesity and Binge Eating disorder .

even after full .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.

prematurity. though often not enough  Risks: low birth weight (and associated features).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”). Csections .

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

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. negative reactions from peers as children . passive.

though women more distressed about it.Males and EDs  Athletes/profession requirements  1:10 male to female ratio  BED similar rates male/female. more guilt with weight .

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

 Body builders are at risk if they deplete body fat and fluid reserves to achieve high definition  . 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.Males and EDs They participate in a sport that demands thinness.

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 .

2% of American adults. but minimal success in treatments for obesity itself  .Obesity BMI > 30  32. increasing in children  Increasing in past 30 years by 50% per decade  Major successful treatment advances in treatment of complications of obesity.

including BED .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.

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

Literature Review: Treatment for BED  International J of EDs May 2007  26 studies reviewed: Med plus behav. behav alone  Meds plus BWL best. meds alone. short term .

Psychosocial treatments  CBT  CBT plus BWL  BWL alone  Group therapy  Indiv therapy  12 step/self help .

SNRis. TCAs  ? Topiramate  ? Zonisamide  Acomplia  Gastric Bipass .Medical treatments for BED/obesity  Sibutramine  Orlastat ? SSRIs.

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 .

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