Treatment of eating disorders

Treatment of PICA
• Pica can be difficult to treat. One of the first steps
is to encourage children to eat a healthy,
balanced diet.
• Replacing non-food items that children ingest with
more suitable, nutritious food items is an
important goal.
• Speaking with a dietitian who is familiar with Pica
can be very helpful in coming up with appropriate
and tempting menus.
• Dangerous substances that are possibly ingestible
should be removed from the home (and other
relevant environments) immediately so that they
are not available as temptations.
 Treatment of PICA
• Children with Pica enjoy not only the taste or
texture of whatever substances they chose to eat,
but also the oral stimulation involved.
• Therefore, a plan to decrease Pica should include
alternative ways of obtaining stimulation (oral and
otherwise) that are both positive and reinforcing
(e.g., enjoying safe food items, and engaging in
other highly desirable activities).
• To this end, therapists help parents and
caregivers come up with
developmentally-appropriate stimulation plans.
Toddlers, for example, may be stimulated simply
by playing a game searching for toys.
 Treatment of PICA
• Parents should consider consulting with a behaviorally-trained
mental health clinician, as a comprehensive behavioral plan based
squarely on principles of learning theory (e.g., reinforcement,
discrimination training, and punishment) may be necessary to
manage and ultimately eliminate Pica.
• Reinforcement of healthy eating behaviors increases the likelihood
that children will behave similarly in the future (e.g., they might earn
tokens for each hour they behave appropriately and then turn tokens
in for toys).
• Discrimination training is used to help children understand the
differences between non-food and food items.
• Punishment (sometimes called aversive training) methods, such as
placing children in 'time-out' when they engage in Pica behaviors,
decreases the likelihood that children will engage in these behaviors
in the future. For other examples of how learning principles may be
used to influence behavior, please see our Psychological Self-Help
Tools topic center.
 Treatment of PICA
• Research is unclear with regard to which types of procedures
are most successful (reinforcement vs. punishment) in
helping children to discontinue eating non-food substances.
• Punishment may be a quick way of suppressing such
dangerous and self-destructive behaviors, but the gains may
come with unwanted long-term consequences and emotional
side effects (e.g., the child may become overly anxious about
eating) if the punishments are not carefully chosen and
rigorously implemented. Behavioral clinicians will help design
and modify a behavior modification plan based on the
specific child and family being treated.
• Such a behavior modification plan should be implemented
consistently within all of the child's environments (within
other homes, at school, etc.).
Treatment of Anorexia Nervosa
• Many people with anorexia nervosa find it hard to
acknowledge that they have a problem and are ambivalent
about change. This contributes to their reluctance to engage
with treatment and services.
• A precondition for any successful psychological treatment is
the effective engagement of the patient in the treatment plan.
Health care professionals involved in the treatment of
anorexia nervosa should take time to build an empathic,
supportive and collaborative relationship with patients and, if
applicable, their carers.
• This should be regarded as an essential element of the care
offered. Motivation to change may go up and down over the
course of treatment and the therapist needs to remain
sensitive to this. Special challenges in the treatment of
anorexia nervosa include the highly positive value placed by
people with anorexia nervosa on some of their symptoms,
and their denial of the potentially life-threatening nature of
their disorder.
 Treatment of Anorexia Nervosa
Nutritional rehabilitation
The goals of nutritional rehabilitation for seriously underweight patients
are to restore weight, normalize eating patterns, achieve normal
perceptions of hunger and satiety, and correct biological and
psychological sequelae of malnutrition.
A healthy goal weight for female patients is the weight at which normal
menstruation and ovulation are restored and, for male patients, the
weight at which normal testicular function is resumed.
Refeeding programs should be implemented in nurturing emotional
contexts. Nursing supervised oral refeeding of normal food in
appropriate amounts and composition is preferred.
Forced nasogastric or parenteral feeding can each be accompanied by
substantial dangers. When nasogastric feeding is necessary, clinical
experience suggests that continuous feeding (i.e., over 24 hours)
may be less likely than three to four bolus feedings a day to result in
metabolic abnormalities or patient discomfort and may be better
tolerated by patients. [34] As an alternative to nasogastric feeding, in
very difficult situations where patients physically resist and
constantly remove their nasogastric tubes, gastrostomy or
jejunostomy tubes may be surgically inserted.
 Psychosocial Interventions
• Cognitive behavioral therapy (CBT)
• CBT studies generally used a form of therapy
tailored to anorexia nervosa that focused on
cognitive and behavioral features associated with
the maintenance of eating pathology. Of the three
CBT studies, one followed inpatient weight
restoration and two were done in the underweight
state.
• CBT significantly reduced relapse risk and
increased the likelihood of good outcome
compared to nutritional counseling based on
nutritional education and food exchanges after
inpatient weight restoration. Of those receiving
CBT, a greater number of individuals with good
outcomes also received antidepressant
 Psychosocial Interventions
• Family therapy
• Dare et al. found family therapy to be superior to routine
treatment but equivalent to a focal time-limited
psychodynamic psychotherapy in increasing percentage of
adult body weight, restoring menstruation, and decreasing
bulimic symptoms; overall clinical improvement was modest,
however. Crisp et al. found outpatient individual and family
therapy with variable numbers of sessions to be superior to
referral to a family physician for increased weight at one- and
two-year follow-up.
• Four family therapy studies focused exclusively on
adolescents; and one combined adolescent and adult
patients. Family therapy was more effective for younger
patients with earlier onset than for older patients with a more
chronic course in the United Kingdom trial performed by
Russell et al. and the follow-up by Eisler et al. These studies
did not yield evidence that the specific type of family therapy
administered was helpful for the older more chronic group.
 Medication
• Selective Serotonin Reuptake
Inhibitors:Fluoxetine and Citalopram
• Antipsychotics
• Hormones: Investigators have studied
three hormones in the treatment of AN:
growth hormone (rGH), testosterone, and
estrogen.
Treatment of Binge eating disorders
Cognitive behavioural therapy (CBT)
• If you're offered CBT, it will usually be in group sessions with other
people, but it may also be offered as 1-to-1 sessions with a
therapist.
• You should be offered about 16 weekly sessions over 4 months,
each one lasting about 90 minutes for a group session and 60
minutes for an individual session.
• CBT involves talking to a therapist, who will help you explore
patterns of thoughts, feelings and behaviours that could be
contributing to your eating disorder.
• They will help you:
• plan out the meals and snacks you should have during the day, to
help you adopt regular eating habits
• work out what is triggering your binge eating
• change and manage negative feelings about your body
• stick to your new eating habits so you do not relapse into binge
eating
 Treatment of Binge eating
disorders
• Interpersonal Psychotherapy
Interpersonal psychotherapy (IPT) has been applied to the treatment of BED
based on a strong body of evidence demonstrating a consistent relationship
between poor interpersonal functioning and eating disorderss. The
interpersonal model of binge eating posits that social problems create an
environment in which binge eating develops and is maintained as a coping
mechanism, serving to reduce negative affect in response to unfulfilling social
interactions
. Binge eating may, in turn, worsen interpersonal problems by increasing social
isolation and impeding on fulfilling relationships, thereby maintaining the
eating disorder
. People with BED often present with suppressed affect; so, instead of expressing
negative affect, they eat to cope. IPT helps individuals acknowledge and
express this painful affect so that they can better manage negative feelings
without turning to food. IPT also seeks to reduce binge eating pathology by
supporting the development of healthy interpersonal skills that can replace
maladaptive behaviors and promote a positive self-image .
 Dialectical Behavior Therapy
• The modification of DBT for BED is based on the affect
regulation model of binge eating, which posits that binge
eating occurs in response to intolerable emotional
experiences when more adaptive coping mechanisms are
not accessible.
• Engaging in binge eating is hypothesized to provide
temporary relief from negative affect, reinforcing the
behavior. This model of binge eating has been the focus of
considerable research, and has sparked interest in the use of
DBT as a treatment for BED
• . DBT comprises four focal areas: mindfulness, distress
tolerance, emotion regulation, and interpersonal
effectiveness. The latter component is often omitted in the
study of DBT for BED to avoid overlap with IPT, and to
decrease the length of treatment
• . The main goal of DBT is the development of adaptive
emotional regulation skills and their implementation in daily
life .
 Treatment for Rumination
Disorder
Behavior Therapy
• Diaphragmatic breathing is intended to help you relax the
diaphragm and use it correctly while breathing to strengthen
it.
• To perform diaphragmatic breathing to help control
regurgitation:
• Lie on your back on a flat surface or in bed, with your knees
bent and your head supported. You can use a pillow under
your knees to support your legs. Place one hand on your
upper chest and the other just below your rib cage. This will
allow you to feel your diaphragm move as you breathe.
• Breathe in slowly through your nose so that your stomach
moves out against your hand. Keep the hand on your chest
as still as possible. For children, we describe this as
“breathing like an opera singer”, with the hand on the belly
moving out with each slow breath, and moving in with
exhalation.
• Tighten your stomach muscles, letting them fall inward as
you exhale through pursed lips. Keep the hand on your
 Behavioral Therapies
• Various other behavioral strategies have been reported in
case reports and chart reviews instead of diaphragmatic
breathing [e.g., general relaxation , aversion training , and
distraction (e.g., gum chewing) ], but there is no research to
suggest that they are superior to diaphragmatic breathing.
• In CBT-RD, interventions are selected to target secondary
psychological mechanisms maintaining regurgitations,
including alternate self-soothing strategies, cognitive
strategies to facilitate riding out premonitory urges,
behavioral experiments to test fears (e.g., about using
diaphragmatic breathing in public), and behavioral exposures
(e.g., systematic exposure to stimuli associated with
regurgitations)
• Given current evidence, when patients continue to
experience regurgitations after using diaphragmatic
breathing, we suggest clinicians consider referring patients to
specialists (e.g., behavioral health specialists) to learn
strategies to augment diaphragmatic breathing.