Working with Eating Disorder Patients Elise Curry Psy.D. Clinical Psychologist Private Practice San Diego, CA
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 • <85% 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 day
1. Having no period isn’t 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. Compulsive Exercise
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 Possible Signs of an Eating Disorder
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)
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.
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)
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 isn’t enough to cause someone to develop this disease,” said Kaye.
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 women’s magazines had 10.5 times more advertisements and articles promoting weight loss than men’s 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 don’t diet (Neumark-Sztainer,2005). • Most fashion models are thinner than 98% of American women (Smolak, 1996). • The average American woman is 5’4” tall and weighs 140 lbs. The average model is 5’11” 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).
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
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 Negative 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 person’s 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 Positive body image
Childhood Symptoms OC Personality Traits: Percentage of Individuals With Traits % of Patients Anderluh MB, et al. Am J Psychiatry. 2003;160(2):242-247.
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
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
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 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.
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 don’t 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.
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.
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
A Major Truth: Feelings Follow Thoughts & Actions Thoughts Actions Needs Want Choices Feelings Physiology
Group Therapy • Structured on-site meal • Milieu therapy/ use of group • CBT/DBT • Process group • Nutritional counseling • Body image group • Art Therapy • Relaxation, meditation
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 • Family involvement to motivate pt for treatment (case example)
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 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
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.
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 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
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 > AN, BN extremes of over- and under-control
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
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