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Working with Eating Disorder Patients

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Ethnic Diversity in EDs ... body pride in all ethnic groups (Story et al, 1997) ... Most fashion models are thinner than 98% of American women (Smolak, 1996) ... – PowerPoint PPT presentation

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Title: Working with Eating Disorder Patients


1
Working with Eating Disorder Patients
  • Elise Curry Psy.D.
  • Clinical Psychologist
  • Private Practice
  • San Diego, CA

2
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

3
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

4
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

5
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
    day

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

7
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

8
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 per decade of AN patients die (disorder or
    suicide)

9
Scope of the problem continued
  • One of the highest death rates from any mental
    health condition (AN) 10
  • 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.

10
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,
    1997).
  • 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)

11
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
    Kaye.

12
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).

13
Drive for thinness and dieting
  • Girls who diet frequently are 12 times as likely
    to binge as girls who dont diet
    (Neumark-Sztainer,2005).
  • 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,
    1995).
  • 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).

14
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
    generalizations).
  • 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
    body.
  • NEDA website

15
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

16
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

17
Childhood Symptoms OC Personality Traits
Percentage of Individuals With Traits
of Patients
Anderluh MB, et al. Am J Psychiatry.
2003160(2)242-247.
18
Heritability Estimates
  • DISORDER HERITABILITY
  • Autism .8 - 1
  • Schizophrenia .5 - .9
  • Bipolar .3 - .8
  • Anorexia/Bulimia .5 - .8
  • Early MDD .5 - .75
  • OCD .5 - .7
  • Obesity .4 - .7

19
Psychological Correlates of Anorexia Nervosa
  • Poor self concept
  • Obsessive compulsive and avoidant personality
    style
  • 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

20
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

21
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.

22
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.

23
Goal of Psychological Treatment
  • Help pt to adjust to their personality
    traits/temperament
  • Reduce anxiety through use of positive coping
    skills
  • Reduce eating disorder voice and develop a
    recovery voice.
  • Increase focus on inner qualities to define self,
    rather than physical
  • traits like thinness.

24
NEEDSmet 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

25
A Major Truth Feelings Follow Thoughts Actions
Thoughts
Actions
Needs
Want Choices
Feelings
Physiology
26
Group Therapy
  • Structured on-site meal
  • Milieu therapy/ use of group
  • CBT/DBT
  • Process group
  • Nutritional counseling
  • Body image group
  • Art Therapy
  • Relaxation, meditation

27
Individual Therapy
  • Affect regulation and tolerance
  • Impulsivity
  • Externalization of self worth
  • Feelings of ineffectiveness, inadequacy
  • Rejection sensitivity
  • DBT
  • PMD and dietitian

28
Family Therapy
  • Required with Adolescents
  • Maudsley Family Therapy
  • Systemic Family Therapy
  • Couples
  • Family involvement to motivate pt for treatment
    (case example)

29
UCSD Eating Disorder IOP(Individual and Family
Therapy by appointment)
30
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

31
Expected IssuesPatients 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

32
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

33
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.

34
Overview of biological underpinnings of EDS
35
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
  •  

36
Genetic Correlates of Bulimia Nervosa
  • Twin studies
  • 5ht2A receptor alteration
  • Family history of affective, anxiety, substance
    abuse d/o

37
Neuroendocrine Correlates of Anorexia Nervosa
  • Serotonin (5HT2A receptor)
  • Dopamine
  • Endogenous opiate response to starvation
  • Hypothalamus dysfunction (satiety, amenorrhea)

38
Neuroendocrine correlates of Bulimia Nervosa
  • Serotonin (5HT1A receptor)
  • Endogenous opiate response to binge purge

39
Neuropsychiatric correlates of Eating Disorders
  • Iowa gambling task AN vs CW Differences seen on
    fMRI
  • 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

40
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
    personality
  • 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
    under-control

41
Important Medical issues in treatment of EDs
42
Physical Complications of Anorexia Nervosa
43
Physical Complications of Anorexia Nervosa Cont.
44
Physical Complications of Anorexia Nervosa Cont.
45
Physical Complications of Bulimia Nervosa
46
Physical Complications of Bulimia Nervosa cont.
47
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
  •  

48
Medical evaluation for Bulimia Nervosa
  • Assess for comorbidity
  • Screening labs electrolytes, Ca, Mg, Phos,
    BUN/Cr, CBC, LFTs, TFTs, UA
  • EKG
  • Dental
  •  
  •  

49
Pharmacology for AN
  • SSRIs
  • Atypical antipsychotic medications
  • Meds tried and failed for appetite enhancement
  • GI meds to aid physical symptoms

50
Pharmacology for BN
  • Serotonin re-uptake inhibitors
  • AEDs (topiramate, ?zonisamide)
  • Antipsychotics
  • Mood stabilizers
  • reglan, H2 blockers

51
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

52
Integrated treatment programs
  • Multidisciplinary treatment team
  • Program manager
  • Psychiatrist
  • Therapists with ED training
  • Registered Dietitian
  • Internist/Pediatrician

53
AN Hospital vs Outpatient TreatmentFrom
American Psychiatric Association Guidelines for
the Treatment of Eating Disorders
54
Referral to Higher level of care
  • Pt is failing lower level.
  • Pts weight loss is continuing in spite of
    treatment
  • Pt is unable to stop bingeing/purging.
  • Pts physical symptoms warrant greater
    supervision (fainting, dehydration, heart
    palpitations)
  • Pt is resisting current level of care

55
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

56
Diagnostic Practice
  • See hand-out for interview questions

57
Dual Diagnostic Issues
  • (Psychiatric co-morbidity)

58
PSYCHIATRIC COMORBIDITY Anorexia Nervosa
  • affective disorders
  • anxiety disorders
  • psychotic disorders
  • personality disorders
  • Substance abuse 

59
PSYCHIATRIC COMORBIDITY Bulimia Nervosa
  • Affective disorders
  • Anxiety disorders
  • Impulse Control Disorders
  • Personality disorders
  • Substance abuse

60
Anxiety Disorders (AD)Lifetime and Premorbid
Rates
61
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,
Germany
Review of Literature Godart 2002
General population rate OCD 1-3 of adults 2-4
of children (Grados 97, Riddle 98 Serpell 02)
62
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
63
Factor-Analysis of OCD12 studies, 2000
patientsMataix-Cols, Rosario-Campos, Leckman,
AJP 2005
  • OCD is clinically heterogeneous
  • 4 symptom dimensions
  • Symmetry/ordering
  • Hording
  • Contamination/cleaning
  • Obsessions/checking
  • Associated with distinct patterns of comorbidity,
    genetic transmission, neural substrates,
    treatment response

64
Prevalence of E.D. and S.U.D.
  • 20 of women with a substance abuse/dependence
    have a current or past history of BN or bulimic
    behaviors
  • 21.4 of women with BN have a current or past
    history of drug abuse, and 17 of BN women report
    a current or past history of substance abuse or
    dependence.
  • Theories of shared etiology vs. causal etiology

65
Shared Etiology vs. Causal Etiology
  • Shared both disorders share a common
    predisposition and include the personality,
    family history, developmental, and endogenous
    opiods hypothesis.
  • Causal Having one of these disorders puts an
    individual at risk for developing another
    disorder.
  • Self-medication theory
  • Wolfe and Maisto (2000)

66
Results of Baker, Mazzeo, Kendler Study 2007
  • BN was associated with a lifetime history of
    major depression, neuroticism,conduct disorder,
    CSA, DUD, and a parental history of alcoholism.
  • The results of this study lend support to both
    the personality and self-medication hypotheses.
  • Having higher neurotic tendencies may be the
    underlying reason why women with BN are more
    likely to develop DUD and vice versa.
  • Some of these variables (depression, neuroticism,
    and CSA) may have an impact on whether or not a
    woman with BN is at increased risk of developing
    another disorder like DUD.

67
DBT Heirarchy
  • 1. Life threatening behaviors
  • 2. Therapy interfering behaviors
  • 3. Quality of life issues
  • Marsha Linehan

68
Life threatening behaviors
  • Suicide
  • Starving
  • Binge-purge
  • Etoh poisoning
  • Fatal car crashes
  • Domestic violence
  • Over dose with drugs
  • Others?

69
Therapy interfering behaviors
  • Failure to show up
  • Lateness
  • Not being truthful
  • Critical of therapist
  • Coming to session intoxicated
  • Hostility
  • Not talking
  • Not complying with medications
  • Conflict avoidant

70
Quality of life issues
  • Ability to eat meals with others
  • Ability to have food in refridgerator at home
  • Supportive relationships
  • Ability to go out to a restaurant with friends
  • Ability to think about topics other than food,
    weight, and body size

71
Eating Disorders and SUD
  • Which to treat first?
  • Access severity of SUD 12 step, de-tox,
    inpatient?
  • Come up with a mutally agreed upon contract
    sobriety, controlled drinking/using, etc.
  • Make connections btw the ED and SUD meeting
    certain needs
  • Psychiatric eval if needed

72
E.D. and O.C.D.
  • Refer pt for psychiatric evaluation for
    medications
  • Refer pt to OCD specialist for individual
    therapy. Have good communication with this
    therapist.
  • Case Example Danny

73
Working with E.D. and Personality Disorders
  • Borderline Traits
  • Dependent Personality
  • Histrionic Personality
  • Obsessive Compulsive Pers. D/0
  • Narcissistic Traits

74
Individual Therapy with Eating Disorder Patients
75
Psychotherapies for Anorexia Nervosa (McIntosh,
2005)
  • 20 sessions over a 20 week period
  • 56 AN women were randomly assigned to 3
    treatments (35 completed treatment)
  • 1. Cognitive Behavioral Therapy
  • 2. Interpersonal Psychotherapy
  • 3. Non-specific supportive clinical management

76
Which treatment was the best?
  • Interpersonal was the least effective of the 3
    therapies.
  • Successful treatment outcome was achieved by 17
    of the interpersonal psychotherapy patients, 42
    of the CBT patients, and 82 of the non-specific
    supportive clinical management patients.

77
Non-specific Supportive Clinical Management
  • Education, care, and support
  • Fostering a therapeutic relationship that
    promotes adherence to treatment
  • Assist the pt through use of praise, reassurance,
    and advice.
  • Encourage resumption of normal eating and weight
    restoration
  • Provided info on weight maintenance strategies,
    energy requirements, and relearning to eat
    normally
  • Info was provided verbally and through hand-outs.

78
Treatment Strategies for Bulimia Nervosa
  • 1. Meal plan
  • 2. Delay the binge
  • 3. Binge, but dont purge
  • 4. Throw away your scale
  • 5. Challenge distorted beliefs (CBT)
  • 6. Teach anxiety reduction skills
  • 7. Develop support system
  • 8. Write in a journal
  • 9. Set goals each week (1 B/P Max)
  • 10. Use externalization (Life w/o Ed)
  • 11. Teach set-point theory (Making Peace with
    Food book)
  • Chain Analysis (example)

79
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
    want?
  • 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
    recover.
  • 6. Have her list all the disadvantages to
    recovery.
  • 7. Be patient. The average recovery rate is 7
    years!

80
Candy CroverCandy is 23 year old college drop
out who works as a waitress. She drinks alcohol
every weekend and has had more than 20 black
outs. She also binges and purges once a day. She
has done this since age 16 which is the same
year her father died of cancer. Candy tends to
restrict her intake during the day and then
binges and purges at night on the left-overs she
brings home from work. Her weight fluctuates from
140 to 155 lbs.
  • She is 5 ft 10. As a teen, she used to cut on her
    thighs because she thought they were too fat. She
    is coming to you for individual therapy because
    she is worried about her health. She recently
    fainted after a binge-purge episode. Her
    boyfriend found her on the bath room floor and
    rushed her to the E.R. She received 3 bags of
    I.V. fluid due to dehydration

81
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84
Case Example Annie
  • 30 year old B.S. biology
  • Binge/purge for 5 years
  • Weekly individual therapy
  • Identify trigger parents house, skipping meals

85
Case Example Karen
  • 22 year old college graduate
  • Anorexic mother
  • Residential treatment, IOP, PHP, Individual
    therapy
  • 5 2 93lbs
  • Highest weight 120
  • Lowest weight 88
  • Got period back at 105lbs.
  • Doesnt want her thighs to touch
  • Identify binge/purge triggers (grandpas house)


86
When is individual therapy not enough?
87
HBO Special
  • THIN
  • Discussion


88
Questions and Answers about Day I
  • Comments or suggestions for Day II?

89
Life without ED
  • What Jenni Schaefer has to teach us
  • Externalization of the eating disorder

90
What are perfectionistic traits?
  • Never being satisfied with your achievements or
    performance
  • 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.

91
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.

92
Goals and Benefits of Group Therapy
  • Breaks down isolation
  • Provides peer support
  • Learning from others, not just group leader.
  • Shame reduction
  • Problem solving
  • Interpersonal Skill Building
  • Helps to replace e.d.
  • Better resource allocation

93
Why are groups so important for eating disorder
pts?
  • Many of them have social phobia
  • Many of them are isolated
  • Many of them have problems with reading people.
  • Like autism, some people with anorexia have
    difficulties with theory of mind.
  • Group can help them see how they come across to
    others.
  • Many of them have problems with interpersonal
    effectiveness, like assertiveness. Group gives
    them a safe place to practice new skills.

94
Types of Groups
  • Groups according to diagnosis
  • Ongoing vs. time-limited
  • Psychoeducational groups
  • Process groups
  • Skill building groups DBT, CBT
  • Body Image group Cindy
  • AN, BN groups at UCSD
  • Art Therapy group
  • Relapse Prevention

95
Goals of CBT Group
  • 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 strategies

96
CBT groups for Bulimia
  • Research by Mitchell et al 2005 showed that
    Social Support Seeking 1 month after a 12 week
    CBT group predicted the outcome at 6 months.
  • Those group members who utilized their support
    systems 1 month after the group had a better
    outcome.
  • Use of positive coping skills at the end of
    treatment did not predict the outcome at 6
    months.
  • This study highlights the importance of social
    support to maintain treatment goals.

97
Process Group
  • Get topics from each member (Axis II)
  • Divide the time so everyone can share.
  • Group leader intervenes when e.d. thoughts are
    presented as true
  • Let members give support before you do. Its best
    if coming from them.
  • Encourage group participation. Help connect group
    members to each other.
  • Create a safe environment of non-judgemental
    feedback.
  • Help to establish positive group norms.

98
Goals for Body Image Group
  • Create a safe environment for pts to explore body
    image issues
  • Teach about our culture and how we get negative
    messages about body size and shape.
  • Help group members to share their body image
    struggles with each other
  • Help to dispel body image distortions
  • Set body image goals each week
  • Resources

99
Relapse Prevention Group
  • Provide a support group for those in recovery
  • Encourage pts to share their coping strategies
    with each other
  • Problem solve difficulties with staying in
    recovery.
  • Use lapses as learning experiences
  • Prevent relapse through accountability

100
Problems in Groups
  • The monopolizer
  • The advice giver
  • The yes, but
  • Quiet groups
  • Unexpressed anger
  • Poor attendance of certain members
  • Lateness
  • Anorexia vs Bulimia
  • Lack of recovery in the group
  • Cliques between certain members
  • Rejection of members
  • Poor screening of potential group members

101
Goal Setting
  • Set attainable and measurable goals.
  • Examples include 1 B/P Max, 1 Self-sooth, write
    in journal about feelings I had before engaging
    in my eating disorder, eat meal plan, do food
    log, limit exercise to half hour per day, have
    husband hide my scale, body check only 1 time per
    day, eat a challenge food 1 time, make a mistake
    with a witness, write a letter to ed., have ed
    write back, no self-harm, call for support. (see
    flip chart)

102
Group Therapy Practice Large Group
  • Needed 2 leaders and 7 members

103
Reactions to large group exercise
  • What did you learn?

104
1st Session of a new group
  • Introduce the leaders and purpose of the group
  • Go over group rules contact outside group,
    confidentiality, off limits topics, gum chewing,
    water, outside food, length of group (12 weeks),
    dress code
  • Have members tell their story history of the e.d
    and treatment

105
Group Therapy Practice in Small Groups
  • Break into groups of 8 2 leaders and 7 consumers
  • The leader will lead the 1st session by having
    each member tell their story as an introduction.
    S/he will also go over the group rules no
    talking about numbers (Calories, sizes, weights,
    miles ran etc.), confidentiality, no outside food
    allowed, no gum chewing, outside contact
    encouraged for support but not crisis management.

106
Reactions to practice session
  • What was hard for the group leaders?
  • Were you able to explain the group rules and
    answer questions?
  • How did it feel to lead this group?
  • How did members feel in this group?
  • Did it feel safe?
  • Feedback for leaders

107
HBO Special Thin
  • Part II

108
How to set up a group and get it started?
  • Do a needs assessment of your patient population
  • Choose the type of group and the
    inclusion/exclusion criteria
  • Decide on group leadership
  • Design format or curriculum
  • Create a flyer, contact therapists, marketing
  • Conduct interviews
  • Set a start date

109
Brainstorming Session
  • What kinds of groups do we need in our community?
  • What are consumers asking for?
  • How do we get started?

110
What kinds of groups are needed in your community?
  • What is your plan of action?
  • Who will volunteer to get a group started?
  • What resources will you need?
  • Plan your next follow up meeting

111
Questions and Answers
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