Day

1
Day 2

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

2
Working with Eating Disorder Patients in an
Outpatient Setting

• Elise Curry Psy.D.
• Program Manager
• UCSD IOP

3
Individual Therapy
4
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

5
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

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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.

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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

8
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)

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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

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Group Therapy and Integrated Treatment

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

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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

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Process Group
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Treatment considerations based on age

• Children (preteen)
• Adolescents
• Adults
• Chronic AN/BN

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Important considerations

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

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What about the kids?

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

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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

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Anorexia NervosaDSM-IV

• Refusal to maintain body weight above a minimally
  normal weight for age and height.
• 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

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Weight Loss vs Weight Maintenance

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

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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

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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

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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

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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.

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Related ED Behaviors in Children

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

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Early behavioral risk factors for EDs

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

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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

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WHY?
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Biological

• Genetics
• Higher rate of AN, BN and ED NOS in first degree
  relatives
• Cross-transmitted
• High heritability
• Medication
• Trials suggest serotonin and dopamine systems
  contribute

• Imaging
• Gordon et al, 1997
• 15 girls ages 8-16 with AN
• Regional cerebral blood blow radioisotope scans
• 13/15 had unilateral temporal lobe hypoperfusion
• Lask et al, 2005
• significant association between unilateral
  reduction of blood flow in the temporal region
  and
• impaired visuospatial ability,
• impaired visual memory
• enhanced speed of information processing

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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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SOCIAL
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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 (
• Depression during the illness
• Disturbed family life and one parent families
• Families in which one or both parents had been
  married before

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Family therapy

• Family Video and discussion
• Maudsley Family Therapy for Adolescents
• Systemic Family Therapy

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Family Dynamics Video and Discussion
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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

36
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.

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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.

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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.

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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.

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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).

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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.

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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

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Meals/Dietitian
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Handout nutritional assessment
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Handout exercise plan
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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

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On site meals

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

53
On site meals

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

54
Dealing with meal challenges

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

55
Questions and Answers
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Day 3

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

59
DBT for Eating Disorders
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Why DBT?

• Refine and change
• Behavioral
• Emotional
• Thinking patterns
• That cause suffering and distress.

61
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

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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.

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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.

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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)

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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.

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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)

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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

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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.

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CBT for Eating Disorders
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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.

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The Thin Commandments

• Carolyn Costin MFT

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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.

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Eating Disorders in special populations

• Pregnancy
• Males
• Obesity and Binge Eating disorder

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ED and Pregnancy

• Reduced fertility, even after full 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

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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, C-sections

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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

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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

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Males and EDs

• Athletes/profession with weight requirements
• 110 male to female ratio
• BED similar rates male/female, though women more
  distressed about it, more guilt

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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.

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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

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Binge Eating Disorder

• Recurrent episodes of binge eating (see BN)
• The binge eating episodes are associated with
  three (or more) of the following
• 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
• Marked distress regarding binge eating is present
• 2 days/week for 6 months

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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

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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

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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

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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

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Psychosocial treatments

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

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Medical treatments for BED/obesity

• Sibutramine
• Orlastat
• ? SSRIs, SNRis, TCAs
• ? Topiramate
• ? Zonisamide
• Acomplia
• Gastric Bipass

89
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

90
Treatment issues in Chronic EDs

• Legal aspects
• Case examples

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Final Question and Answer Session