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Working with Eating Disorder Patients


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Title: Working with Eating Disorder Patients

Working with Eating Disorder Patients
  • Elise Curry Psy.D.
  • Program Manager
  • Terry Schwartz MD
  • Medical Director UCSD Eating Disorders Program
  • Asst Clinical Professor UCSD

Structure of 3 day training
  • Day 1 Intro to ED assessment and treatment
  • Day 2 and 3 More specifics how to, therapy
    modalities, special populations

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

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

Scope of The Problem
  • Prevalence increasing
  • AN .5-2
  • BN 3-4
  • AN BN More common westernized cultures
  • 10 of eating disordered individuals in treatment
    are male
  • 5-20 of AN patients die (disorder or suicide)

Primary Causes of Death in Patients with Eating
Scope of the problem continued
  • One of the highest death rates from any mental
    health condition (AN)
  • Increasing incidence in elementary age children
    (8-11 year old)
  • The incidence of bulimia in 10-39 year old women
    TRIPLED between 1988 and 1993.
  • There has been a rise in incidence of anorexia in
    young women 15-19 in each decade since 1930.

Ethnic Diversity in EDs
  • Minnesota Adolescent Health Study found that
    dieting was associated with weight
    dissatisfaction, perceived overweight, and low
    body pride in all ethnic groups (Story et al,
  • Among the leanest 25 of 6th and 7th grade girls,
    Hispanics and Asians reported significantly more
    body dissatisfaction than did white girls.
    Robinson et al (1996)

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

Media Stats
  • The average young adolescent watches 3 to 4 hours
    of TV per day (Levine, 1997).
  • A study of 4,294 network television commercials
    revealed that 1 our of every 3.8 commercials send
    some sort of attractiveness message, telling
    viewers what is or is not attractive (as cited in
    Myers et al, 1992). These researchers estimate
    that the average adolescent sees over 5,260
    attractiveness messages per year.
  • Another study of mass media magazines discovered
    that womens magazines had 10.5 times more
    advertisements and articles promoting weight loss
    than mens magazines did (as cited in Guillen
    Barr, 1994).

Drive for thinness and dieting
  • Girls who diet frequently are 12 times as likely
    to binge as girls who dont diet
  • Most fashion models are thinner than 98 of
    American women (Smolak, 1996).
  • The average American woman is 54 tall and
    weighs 140 lbs. The average model is 511 and
    weighs 117 lbs.
  • 35 of normal dieters progress to pathological
    dieting. Of those, 20-25 progress to partial or
    full syndrome eating disorders (Shisslak Crago,
  • 95 of all dieters will regain their lost weight
    in 1 to 5 years (Grodstein, et al., 1996).
  • Americans spend over 40 billion on dieting and
    diet related products each year (Smolak, 1996).

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

Childhood Symptoms OC Personality Traits
Percentage of Individuals With Traits
of Patients
Anderluh MB, et al. Am J Psychiatry.
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Psychological Correlates of Anorexia Nervosa
  • Poor self concept
  • Obsessive compulsive and avoidant personality
  • Perfectionistic, obsessive, harm avoidant traits
  • Family dynamics enmeshment, anxiety,
  • over-achievers
  • Troubles with major life transitions
  • an attempt to regress, avoid development
  • Difficulty managing and expressing anger
  • Cognitive distortions
  • Ego-syntonic nature of disease

Psychological Correlates of Bulimia Nervosa
  • Poor self concept
  • Chaotic developmental history, parental deficit
  • ambiguous communication styles
  • Affective regulation problems
  • Cognitive distortions
  • Ego-dystonic nature of disease
  • Impulsivity, substance abuse, self harm, sexual
    acting out, shop lifting

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.

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
  • Perfectionism only leads to disappointment, not

Goal of Psychological Treatment
  • Help pt to adjust to their personality
  • Reduce anxiety through use of positive coping
  • Reduce eating disorder voice and develop a
    recovery voice.
  • Increase focus on inner qualities to define self,
    rather than physical
  • traits like thinness.

Important initial assessment/screening
issues/tools in EDS
  • See Screening Handout

Screening Questions
  • How many diets have you been on in the past year?
  • Do you think you should be dieting?
  • Are you dissatisfied with your body size?
  • Does your weight affect the way you think about

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Introduction to Treatment
NEEDS met by the eating disorder
  • Safety/Survival reduction of anxiety
  • Love/Belonging best friend
  • Freedom no one can take the e.d. away
  • Power/control/importance feeling superior,
    weight loss as an accomplishment
  • Fun/relaxation/release endorphins
  • released by purging

Case Study Tom
A Major Truth Feelings Follow Thoughts Actions
Want Choices
Group Therapy
  • Structured on-site meal
  • Milieu therapy/ use of group
  • Process group
  • Nutritional counseling
  • Body image group
  • Art Therapy
  • Relaxation, meditation

Power of the Group
  • Reduce isolation
  • Enhance accountability
  • Shame reduction
  • Encourage each other
  • Forward momentum of the group
  • Establish healthy group norms
  • How group leader uses group to enhance individual

Individual Therapy
  • Affect regulation and tolerance
  • Impulsivity
  • Externalization of self worth
  • Feelings of ineffectiveness, inadequacy
  • Rejection sensitivity
  • DBT
  • PMD and dietitian

Family Therapy
  • Required with Adolescents
  • Maudsley Family Therapy
  • Systemic Family Therapy
  • Couples

UCSD Eating Disorder IOP (Individual and Family
Therapy by appointment)
Common Management Issues
  • Denial, resistance
  • Lack of insight and motivation for treatment
  • Failure to learn from experience
  • Adolescent anxious parents, conflicts
  • Adults family burn out
  • Ambivalence pt wants to recover, but does not
    want to gain any weight

Expected Issues Patients and Families
  • Obsessive anxiety much reassurance and
    discussing details of care
  • Perfectionism not good enough
  • Stress and conflicts over eating, weight,
  • control, meal plan etc.
  • Over-exercise
  • Undermining treatment i.e. taking the pt running

Countertransference Issues
  • Feeling angry at the patient for not recovering
  • Thinking this is willful behavior
  • Blaming the parents
  • Feeling incompetent
  • Giving up hope for the patient
  • Not taking the disorder seriously

Coping with Countertransference Issues
  • Practice patient acceptance The average recovery
    rate is 7 years.
  • Have compassion for the suffering
  • of the patient.
  • See their behavior as part of the disorder, not
    personal toward you.
  • Practice good self-care.

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Overview of biological underpinnings of EDS
Genetic Correlates in Anorexia Nervosa
  • Family and twin studies
  • Serotonin receptor gene
  • Variation in Dopamine 2 receptor gene
  • Chrom 1 and 10
  • Family history of OCD, OCPD, AN

Genetic Correlates of Bulimia Nervosa
  • Twin studies
  • 5ht2A receptor alteration
  • Family history of affective, anxiety, substance
    abuse d/o

Neuroendocrine Correlates of Anorexia Nervosa
  • Serotonin (5HT2A receptor)
  • Dopamine
  • Endogenous opiate response to starvation
  • Hypothalamus dysfunction (satiety, amenorrhea)

Neuroendocrine correlates of Bulimia Nervosa
  • Serotonin (5HT1A receptor)
  • Endogenous opiate response to binge purge

Neuropsychiatric correlates of Eating Disorders
  • Iowa gambling task AN vs CW Differences seen on
  • AN Neuropsych testing difficulties with set
    shifting, flexibility
  • AN Detail focus, to the point of missing global
    (Janet Treasure)
  • AN vs BN
  • Use in clinical practice

Cognitive Flexibility
  • Anorexia Nervosa
  • ? Perceptual rigidity
  • ? Cognitive rigidity
  • AN Weight recovery
  • No changes
  • AN Full recovery
  • Partial improvement in cognitive flexibility
  • Bulimia Nervosa
  • Slowness in cognitive shifting tasks
  • Fluctuations in Perceptual task

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

  • affective disorders
  • anxiety disorders
  • ICDs
  • 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
Study Total 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
Assessment Cassin S, von Ranson K Personality
and eating disorders a decade in review Clin
Psychol Rev 200525(7)895-916
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Important Medical issues in treatment of EDs
Physical Complications of Anorexia Nervosa
Physical Complications of Anorexia Nervosa Cont.
Physical Complications of Anorexia Nervosa Cont.
Physical Complications of Bulimia Nervosa
Physical Complications of Bulimia Nervosa cont.
Amenorrhea and Osteopenia
  • Most serious complication of prolonged amenorrhea
    is osteopenia, or reduced bone mass
  • Degree of osteopenia depends on age of onset and
    duration of amenorrhea
  • Adolescence is critical time for bone mass
  • Approx 60 of peak bone mass is accrued during
  • Little net gain in bone mass after 2 yrs
  • Peak bone mass achieved by end of second decade

Osteopenia and Osteoporosis
  • Osteopenia refers to decreased quantity of
    normally mineralized bone
  • Osteoporosis is clinical syndrome consisting of
    decreased bone mass, disruption in normal bone
    architecture with decreased bone strength,
    pathological fractures, pain and disability
  • Osteoporosis defined as greater than 2.5 SD below
    the mean for young adult women
  • Osteopenia 1-2.5 SD below young adult ref

Bone Density and Fractures
  • Each SD decrease in bone density doubles the
    fracture risk
  • DEXA is most widely used method for measuring
    bone density
  • May be compared with age-matched children and
    adolescents (Z scores)

Prevalence of Bone Loss in AN (N130)
(Grinspoon et al, Ann Int Med, 2000)
Mechanisms of Bone Loss in AN
  • Undernutrition
  • Low lean body mass
  • Reduced calcium and Vitamin D intake
  • IGF-I deficiency
  • Hormonal
  • Estrogen deficiency
  • Resistance to growth hormone (GH)
  • Elevated cortisol (stress hormone)
  • Deficiency of other hormones
  • Testosterone
  • Dehydroepiandrosterone (DHEA)

Bone Loss Treatment Strategies
  • No therapies proven effective for bone loss in
    women with AN.
  • Estrogen Decision on estrogen individualized,
    but no convincing data that estrogen alone
    increases bone density in AN population.
  • Potential therapies under study
  • IGF-I
  • DHEA
  • Testosterone
  • Bisphosphonates

Osteoporosis Treatment
  • Weight gain
  • Calcium supplementation improves bone mass
  • Vitamin D
  • Moderate weight-bearing exercise increases bone
  • When medically stable, wt bearing exercises 3-4
    times per week

Is there a benefit to treatment of Amenorrhea
  • Drugs
  • Appearance of normal menses
  • AN abnormalities driven by malnutrition
  • Drugs are NOT substitute for nutrition
  • Illusion that problem is solved
  • ? Ineffective or harmful
  • Menses regulated by complex neuroendocrine

Medical evaluation for Anorexia Nervosa
  • Assess for co morbidity
  • Screening labs electrolytes, Ca, Mg, Phos,
    BUN/Cr, CBC, LFTs, TFTs, UA
  • Bone density (DEXA)
  • EKG

  • Normal food
  • Peripheral edema
  • Bloating or discomfort
  • Reflux
  • Rare gastric dilitation
  • Nasogastric feeding
  • Seldom indicated
  • Nasal, esophageal erosion
  • Central hyperalimentation
  • Rarely indicated
  • Pneumothorax, infection, metabolic disturbances

Nutritional Restoration and Weight Gain in AN
  • Starvation and weight loss ego syntonic
  • Increased dysphoria before and during meals
  • Food and weight obsessions and rituals
  • Stereotypic food choices, ritualized eating,
    calorie counting
  • Delusionary quality
  • Nothing else is more important

Requirements for weight gain in anorexia nervosa
excess calories (over maintenance) to gain 1 kg
Eating behavior in AN After weight restoration
  • Hypermetabolic after weight restoration
  • RAN need 50 to 60 kcal/kg/day
  • BAN need 40 to 50 kcal/kg/day
  • 50 kg women 2000 to 3000 kcal/day
  • Probably normalizes in long term
  • Probable contribution to high rate of relapse

Medical evaluation for Bulimia Nervosa
  • Assess for comorbidity
  • Screening labs electrolytes, Ca, Mg, Phos,
    BUN/Cr, CBC, LFTs, TFTs, UA
  • EKG
  • Dental

Pharmacology for AN
  • SSRIs
  • Atypical antipsychotic medications
  • Meds tried and failed for appetite enhancement
  • GI meds to aid physical symptoms

Pharmacology for BN
  • Serotonin re-uptake inhibitors
  • AEDs (topiramate, ?zonisamide)
  • Antipsychotics
  • Mood stabilizers
  • reglan, H2 blockers

Methods of Treatment
  • Regular Weight restoration
  • 2 to 3 lbs/wk inpatient
  • 1 to 2 lbs/wk day-hospital
  • 1 lb/wk outpatient
  • Nutritional Teaching
  • Provide patient support
  • Prevention from vitamin and mineral deficiency
  • Prevention of osteoporosis
  • Aim for high Ca intake
  • Vitamin D to aid in Ca absorption vegetarians
    may need supplements
  • Eat iron-containing foods, especially important
    for vegetarians

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Integrated treatment programs
  • Multidisciplinary treatment team
  • Program manager
  • Psychiatrist
  • Therapists with ED training
  • Registered Dietitian
  • Internist/Pediatrician

AN Hospital vs Outpatient Treatment From
American Psychiatric Association Guidelines for
the Treatment of Eating Disorders
Referral to Higher level of care
  • Pt is failing lower level.
  • Pts weight loss is continuing in spite of
  • Pt is unable to stop bingeing/purging.
  • Pts physical symptoms warrant greater
    supervision (fainting, dehydration, heart
  • Pt is resisting current level of care

Specific LOC Considerations
  • OP high motivation, gt85 IBW
  • IOP moderate motivation, gt80IBW
  • PHP gt75
  • RTC clinical issues
  • IP lt75 IBW, psych co morbid severe (SI)
  • UCSD Intensive Family Therapy program
  • Legal controversy

Outcome Data for EDs
  • Data mixed results due to design of studies
  • AN 10 yr 50 rec, 20-30 improved but still
    symptomatic, 10-20 chronic, up to 10 mortality
  • BN 10yr 50-70 rec, 30 some improvement, 20

Outcomes for EDS
  • Some studies show ave of 7 years to rec
  • Less than 1 year of treatment has poorer
  • Chronicity, OCPD, purging in AN associated with
    worse outcome