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Eating Disorders: Assessment, Understanding, and Treatment Strategies [Day One]


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Title: Eating Disorders: Assessment, Understanding, and Treatment Strategies [Day One]

Eating Disorders Assessment, Understanding, and
Treatment Strategies Day One
  • Elise Curry Psy.D.
  • Program Manager
  • Terry Schwartz MD
  • Medical Director UCSD Eating Disorders Program
  • Asst Clinical Professor UCSD

Structure of 2 day training
  • Day 1 Eating Disorders Assessment and
    Psychosocial Treatment Approaches Intro to
    Specific Therapy Modalities for EDS
  • Day 2 Eating Disorders Psychiatric/Medical
    Assessment and Treatment Strategies Obesity and
    EDs in special populations

Nervous Consumption(Morton, 1689)
  • Mrs. Dukes daughter, in the eighteenth year of
    her age, fell into a total suppression of her
    monthly courses from a multitude of cares and
    passions of her mind...from which time her
    appetite began to abate. She thus neglected
    herself for two full years. Never did I see one
    conversant with the living, so much wasted, yet
    there was no fever, no distemper of the lungs, or
    signs of preternatural expence of the nutritious
    juices. Only her appetite was diminished.

Anorexia Nervosa
  • Most homogenous psychiatric disorder
  • 90-95 female
  • Onset teenage years puberty
  • Monotonous puzzling symptoms
  • Poor response to treatment
  • Highest mortality rate
  • 50 to 80 contribution of genes

DSM IV Criteria for Anorexia Nervosa
  • Preoccupation with body shape, weight/size
  • lt85 ideal BW
  • Fear of becoming fat despite low weight
  • Loss of 3 consecutive periods in women
  • Types restricting,binge/purge,purge

DSM IV criteria for Bulimia Nervosa
  • Recurrent episodes of binge eating, characterized
    by eating an excessive amount of food within a
    discrete period of time and by a sense of lack of
    control over eating during the episode
  • Recurrent inappropriate compensatory behavior in
    order to prevent weight gain, such as
    self-induced vomiting or misuse of laxatives,
    diurética, enemas, or other medications
    (purging) fasting or excessive exercise
  • The binge eating and inappropriate compensatory
    behaviors both occur, on average, at least twice
    a week for 3 months
  • Self-evaluation is unduly influenced by body
    shape and weight

Diagnostic challenges in EDs (ED NOS)
  • BN vs. AN binge/purge type
  • Sandy is 5 ft tall and weighs is 80 lbs. She has
    regular periods and no body distortion. She is 16
    yrs old.
  • Sally purges normal meals, but does not binge.
  • Tom thinks he needs to gain weight. He uses
    exercise to purge. He binges 2 times per week and
    then goes running.
  • Shelly chews and spits her food several times a

Compulsive Exercise
  • 1. Having no period isnt healthy, even for an
  • 2. Exercising in spite of injury or sickness.
  • 3. Individual feels s/he has to exercise to feel
  • 4. Exercise becomes the way the individual
    organizes his/her life.
  • 5. Exercise is done in secret.
  • 6. Exercise done mostly to burn calories.

Possible Signs of an Eating Disorder
  • Preoccupation with food/weight
  • Dramatic weight loss or gain
  • Chronic dieting
  • Feels cold all the time
  • Dental problems
  • History of ballet, wrestling, or modeling
  • Disgusted by red meat or desserts
  • Has difficulty eating with people
  • Cuts out food groups
  • Becomes vegetarian/vegan as a teen
  • Uses bathroom after meals
  • Wears baggy clothes or layers
  • Cooks for other excessively
  • Excessive exercise

Body Image
  • How you see yourself when you look in the mirror
    or when you picture yourself in your mind.
  • What you believe about your own appearance
    (including your memories, assumptions, and
  • How you feel about your body, including your
    height, shape, and weight.
  • How you sense and control your body as you more.
    How you feel in your body, not just about your
  • NEDA website

Negative body image
  • A distorted perception of your shape you
    perceive parts of your body unlike how they
    really are.
  • You are convinced that only other people are
    attractive and that your body size or shape is a
    sign of personal failure.
  • You feel ashamed, self-conscious, and anxious
    about your body.
  • You feel uncomfortable and awkward in your body.
  • NEDA website

Positive body image
  • A clear, true perception of your shape you see
    various parts of your body as they really are.
  • You celebrate and appreciate your natural body
    shape and you understand that a persons physical
    appearance says very little about their character
    and value as a person.
  • You feel proud and accepting of your unique body
    and refuse to spend an unreasonable amount of
    time worrying about food, weight, and calories.
  • You feel comfortable and confident in your body.
  • NEDA website

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
  • 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
  • Everyone hates fat people.
  • Men like women who are skinny.

Intro to brain function in AN
  • Detail vs global
  • Set shifting

What are perfectionistic traits?
  • Never being satisfied with your achievements or
  • Ability to see flaws where others do not
  • Dread of making mistakes
  • Exactness
  • Exceedingly high standards
  • Very detail focused
  • Lack of novelty seeking
  • Frequent disappointment with self and others
  • Relentless pursuit of perfection
  • I have to be the best at everything I do.

How can we help pts to reduce perfectionism?
  • Identify perfectionism as a personality trait
    which is unlikely to change
  • Help pts to manage their perfectionism by
    noticing it and doing the opposite (risk taking,
    trying something new, stop redoing or re-writing)
  • Recognize the benefits of this trait. Turn it
    into an asset, rather than a liability. Being on
    time, being good at detail oriented tasks,
    academic achievement, research career etc.

How to deal with resistance to recovery
  • 1. Validate pts legitimate needs and help her see
    how the e.d. serves her
  • 2. Use motivational Interviewing what does she
  • 3. Normalize her ambivalence
  • 4. Help her give a voice to her e.d vs. her
    recovery voice
  • 5. Have her list all the reasons why she wants to
  • 6. Have her list all the disadvantages to
  • 7. Be patient. The average recovery rate is 7

Cultural Issues
  • More common in Westernized Societies
  • Historically self starvation reported prior to
    19th century (religious/spiritual reasons)
  • Cultural importance placed on thinness
  • Less common in cultures where roundness is sign
    of fertility, health, prosperity
  • Hong kong, India AN w/o fear of fat.
  • Many individuals in our culture, for a number of
    reasons, are concerned with their weight and
    diet. Yet less than half of one percent of all
    women develop anorexia nervosa, which indicates
    to us that societal pressure alone isnt enough
    to cause someone to develop this disease, said

Practice Session
Psychiatric co morbidity
  • affective disorders
  • anxiety disorders
  • psychotic disorders
  • personality disorders
  • Substance abuse 

  • affective disorders
  • anxiety disorders
  • personality disorders
  • Substance abuse

Psychiatric symptoms in AN and BN
  • Premorbid onset
  • Best little girl in the world
  • Majority have childhood anxiety disorder that
    precedes onset AN, BN
  • Childhood negative self-evaluation,
    perfectionism, rule bound, inflexible, obsessive
  • Persistent symptoms after recovery
  • Obsessions - body image, weight, food
  • Obsessions - perfectionism, symmetry, exactness
  • Anxiety, harm avoidance
  • Behaviors are exaggerated by malnutrition
  • Differences Between AN and BN
  • Novelty seeking BN gt AN, BN extremes of over- and

Anxiety Disorders (AD)Lifetime and Premorbid
Lifetime OCD Diagnosis in AN, BN
Price Foundation Genetic Collaborative
StudyTotal 1416 subjects DSM IV, SCID I, Y-BOCS
MS/PhD Clinical Interview N. America, England,
Review of Literature Godart 2002
General population rate OCD 1-3 of adults 2-4
of children (Grados 97, Riddle 98 Serpell 02)
Obsessive-Compulsive Personality Disorder (OCPD)
Diagnoses in ED from Clinical Interviewer
AssessmentCassin S, von Ranson K Personality
and eating disorders a decade in review Clin
Psychol Rev 200525(7)895-916
Starvation study
Starvation Study
  • Univ of Minnesota Keys et al 1950
  • 36 young healthy men
  • Observed behaviors during 3 mos normal eating,
    then 6 mos of 50 cal reductions (similar to
    some diets)
  • Many of the experiences that were observed in the
    participants were similar to those experienced in
    various EDs

Starvation study participantsdramatic increase
in food preoccupation
  • One of the most intense changes
  • Distracted from usual activities
  • Toying with food
  • Making weird concoctions
  • New interest in cookbooks, menus
  • Vicarious pleasure in others eating
  • Long drawn out eating rituals

Starvation study participants Binge Eating
  • Serious BED developed in a subgroup
  • Followed by self reproach
  • Model for BED, EDs, habitual dieters

Starvation Study participantsemotional and
personality changes
  • Recall all were mentally healthy prior to study
  • Most experienced significant emotional
    deterioration as a result of semi starvation,
    often severe
  • Depression, mood swings, irritability/outbursts
  • Anxiety
  • Apathy, decrease personal hygiene
  • General disorganization
  • Persisted during first several weeks of refeeding

Starvation study participants social and sexual
  • Despite being social and gregarious pre-study,
    the participants became progressively more
    withdrawn and isolated
  • Decrease in humor
  • Feeling socially inadequate
  • Dramatic loss of interest in sex

Starvation Study participants Cognitive changes
  • Reduced concentration, alertness
  • Problems in comprehension
  • Impaired judgment

Starvation study participantsphysical changes
  • Decreased sleep need
  • Dizzy, headaches
  • GI discomfort
  • Hair loss
  • Thermal sensitivity
  • Visual, auditory disturbances
  • Parathesias

Third Wave Therapies CBT, ACT, and Mindfulness
Goals of CBT
Create a safe environment for pts to explore
their eating disorder thoughts and
beliefs Challenge distorted beliefs Teach
cognitive distortions Learn to use thought
records Assertiveness training Help pts dispute
their ed voice Identify triggers and coping
Examples of Distorted Thoughts
  • If I eat this piece of pie, I will be able to
    see it on my body tomorrow.
  • I must be thin to be happy.
  • When I eat pasta, I have to purge.
  • Being thin is the only way I can be special.
  • I wont be comfortable in my body if I gain
  • I cant stand to be alone, so I binge/purge.
  • I dont have an eating disorder. Its not that

How to use Thought Records
  • Event I stepped on the scale and saw the number.
  • Thoughts I am a fat cow.
  • Feelings and rating Fear (75) anger (45)
    disappointment (75)
  • Body Sensations stomach hurts, chest is tight
  • Distortions over-generalization, black/white
    thinking, catastrophizing
  • New thought Just because the scale went up
    doesnt mean I am fat. Weight fluctuations are
  • New feeling and rating content (50) fear (10)

Thought Record Practice
  • Event I ate a whole bag of chips.
  • Thoughts I must purge or I will be fat.
  • Feelings and ratingFear (99) anger (25)
  • Body Sensations heart beating fast, sweaty palms
  • Distortions
  • New thought
  • New feeling and rating

ACT for Anxiety Disorders
  • Fear vs. Anxiety
  • Is anxiety good for anything?
  • Are anxiety and fear dangerous?
  • How pervasive are problems of fear and anxiety?
  • How has anxiety become a problem in the clients
  • Humans vs. animals
  • Eifert,G and Forsyth,J (2005)Acceptance and
    commitment therapy for anxiety disorders.

Purpose of ACT
  • Rather than controlling anxiety or reducing
    anxiety, ACT can help clients to learn and
    practice new and more flexible ways of responding
    when they experience anxiety.
  • Teach clients to see that anxiety is not the
    problem. Attempts to stop the unwanted body
    sensations, thoughts, past memories, and worries
    about the future cause a shift from normal
    anxiety and fear to disordered anxiety and fear.

Patterns and Workability of Avoidance
  • 1. Help the client to evaluate how their methods
    to manage their anxiety have worked.
  • 2. Explore their attempted solutions to the
    problem of anxiety. Do the starve? Do the
    binge/purge? Isolate from others?
  • 3. What is the cumulative effect of these
    short-term relief strategies? What will happen if
    you keep using them?
  • 4. Is this how you will create the meaningful
    life you want to have? Can you reach your long
    term goals and keep these strategies?

Costs of Avoidance
  • What have been the long-term costs of your
    avoidance patterns?
  • What have you given up as a consequence of
    managing your anxieties/worries?
  • What has happened to your life over time? Have
    you done more or less with your life?
  • Have your options increased or has your life
    space narrowed over time?
  • What would you do with your time if it were not
    spent trying to manage anxiety, fear, unsettling
    thoughts, memories, etc?

Develop Creative Hopelessness
  • Helping clients to experience that they have been
    caught in a self-defeating struggle is important.
  • This approach is creative in that it allows for
    new solutions.
  • Giving up on old solutions will end up creating
    hope as new solutions are found.
  • Past solutions are hopeless, not the client.
  • This emphasis implies that there is hope if the
    client chooses to adopt a different approach when
    anxiety show up.

Acceptance of thoughts and feelings exercise
The use of Metaphor in ACT
  • The child in a hole metaphor
  • Feeding the anxiety tiger metaphor
  • The Chinese finger trap exercise

Acceptance and valued living as alternatives to
managing anxiety
  • Trying to fix ourselves is not helpful because
    it implies struggle and self-denigration. Lasting
    change occurs only when we honor ourselves as the
    source of wisdom and compassion. It is only when
    we begin to relax with ourselves that acceptance
    becomes a transformative process. Self-compassion
    and courage are vital. Staying with pain without
    loving-kindness is just warfare. Pema Chodron

Mindfulness based practice
  • What is mindfulness?
  • Research on Depression and Mindfulness
  • Mindfulness with eating disorders

Definition of Mindfulness
  • Mindfulness has been described as paying
    attention in a particular way on purpose, in the
    present moment, and nonjudgmentally.
  • Mindfulness provides both the means to change
    mental gears when disengaging from dysfunctional,
    doing related mind states, and an alternative
    mental gear, or incompatible mode of mind, into
    which to switch.
  • Segal, Z., Williams,G. Teasdale,J (2002)
    Mindfulness based Cognitive Therapy for

Research on Mindfulness
  • Mindfulness based cognitive behavioral therapy
    for depression has empirical evidence supporting
    its effectiveness in relapse prevention for
    depression. Segal, Z, Williams, J. and Teasdale
    J. (2002)
  • MBCT prevented relapse/recurrence in pts with a
    history of 3 or more episodes of depression. 8
    week class

Why use mindfulness with eating disorder patients?
  • It seems to help them to distract from their
    constant critical dialog in their minds.
  • It helps them have more choices about how to
    respond to their thoughts or triggering
  • It gives them the experience of being calm or
    free from their usual anxiety.
  • It provides a sense of hope.
  • It is a skill that they can use anywhere.

Mindful Eating
  • Practice chewing each bite of food with complete
  • Dont multi-task while you are eating.
  • Taste each bite as if it were your last.
  • Put your fork down after each bite.
  • Eat in silence.

Mindfulness exercise
  • Need flip chart

Mindfulness concepts
  • Respond rather than react.
  • Connect your feelings with body sensations.
    Where do I feel this feeling? Be curious about
    your emotions, rather than fighting them.
  • Suffering is part of life, not something to be
  • Happiness isnt something that comes from outside
    us. Its an inside job.
  • Seek to become more comfortable with change and
  • Embrace the present moment. Its all we really

  • Film and discussion

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