Day # 2

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

6. 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.

7. 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)

9. 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

10. Group Therapy and Integrated Treatment • Goal setting • Structured on-site meals • Meditation/Mindfulness • Cognitive-behavioral therapy • Process group • Art therapy • DBT • Nutritional counseling

11. 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 don’t purge • Challenge foods: have a piece of cheesecake • Foods are not good or bad: incorporate desserts into the meal plan

12. Process Group

14. Treatment considerations based on age • Children (preteen) • Adolescents • Adults • Chronic AN/BN

15. Important considerations • Age of onset • Time of low weight, linear history • Developmental phase • Involvement of other’s (family, spouse, children, parents, etc)

16. What about the kids? • Pre-pubertal Eating Disorder • Childhood Onset Eating Disorder • Early Onset Eating Disorder

17. 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

18. Anorexia NervosaDSM-IV • Refusal to maintain body weight above a minimally normal weight for age and height. <85% of IBW • Intense fear of gaining weight or becoming fat • Disturbance in the way one’s body weight or shape is experienced • Amenorrhea: absence of at least three consecutive menstrual cycles

19. Weight Loss vs Weight Maintenance • DSM-IV criteria excludes children who have not reached the critical level of <85% • Malnutrition can lead to poor growth

20. Body Image • May be more tricky to assess • How can it be evaluated? • Children’s expression of body image • Standard tools • Clinical Interview • Somatic symptoms • Abdominal pain or discomfort • Feeling of fullness • Nausea • Loss of appetite

21. 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

22. 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”

23. 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.

24. Related ED Behaviors in Children • Anorexia nervosa • Food avoidant emotional disorder • Selective eating • Functional dysphagia • Bulimia nervosa • Pervasive refusal syndrome

25. Early behavioral risk factors for EDs • PICA – BN • Picky Eater – BN, some AN • Digestive problems – AN • Subsyndromal symptoms of EDs can predate

26. 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

27. WHY?

28. 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 Biological

29. Psychological • Personality traits • Anxious • Obsessional • Perfectionistic • Susceptibility factors • Obsessions • Perfectionism • Symmetry • Exactness • Negative affect, harm avoidance • Preoccupations with weight, body image and food

30. SOCIAL

31. 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 (<11 years) • Depression during the illness • Disturbed family life and one parent families • Families in which one or both parents had been married before

33. Family therapy • Family Video and discussion • Maudsley Family Therapy for Adolescents • Systemic Family Therapy

34. Family Dynamics: Video and Discussion

35. 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.

37. 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.

38. Session 2: Family Meal • Instructions to parents: bring a meal that would be appropriate for your child’s 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.

39. Case Example: BFT • Madaline age 14 • Family members: mom, dad, sister, patient • Patient’s weight history • Taking control back from patient. • Patient reaction to loss of control. • Rewards and consequences • Patient weight progress over time.

40. 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).

41. 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.

42. 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

44. Meals/Dietitian

45. Handout nutritional assessment

49. Handout exercise plan