Eating Disorders Assessment
Part 2
Instructor: Dr. Dawn-Elise Snipes, PhD, LPC, LMHC
Podcast Host: Counselor Toolbox & Happiness Isnāt Brain Surgery
Objectives
~ Review the prevalence of eating disorders
~ Identify assessment areas
~ Identify risk and protective factors
~ Explore complications
~ Explore potential guidelines for treatment
~ Based on APA Guidelines for Eating Disorders and the NICE Guidelines for Eating Disorder Recognition and Treatment
Goals for Treating Anorexia
~ Restore patients to a healthy weight (associated with the return of menses and normal ovulation in female patients, normal sexual drive and hormone levels in male patients, and normal physical and sexual growth and development in children and adolescents)
~ Treat physical complications
~ Enhance patientsā motivation to cooperate in the restoration of healthy eating patterns and participate in treatment
~ Provide education regarding healthy nutrition and eating patterns
~ Help patients reassess and change core dysfunctional cognitions, attitudes, motives, conflicts, and feelings related to the eating disorder
Goals for Treating Anorexia
~ Treat associated psychiatric conditions, including deficits in mood and impulse regulation and self-esteem and behavioral problems
~ Enlist family support and provide family counseling and therapy where appropriate
~ Prevent relapse.
Anorexia Nutritional Rehabilitation
~ Establish expected rates of controlled weight gain.
~ Realistic targets are 2ā3 lb/week for hospitalized patients and 0.5ā1 lb/week for individuals in outpatient
~ Registered dietitians can help patients choose their own meals and can provide a structured meal plan that ensures nutritional adequacy and that none of the major food groups are avoided.
~ Formula feeding may have to be added to the patientās diet to achieve large caloric intake.
~ Encourage patients with anorexia nervosa to expand their food choices to minimize the severely restricted range of foods initially acceptable to them.
~ Caloric intake levels should usually start at ~1,000ā1,600 kcal/day.
~ Weight gain results in improvements in most of the physiological and psychological complications of semistarvation.
Anorexia Nutritional Rehabilitation
~ It is important to warn patients about the following aspects of early recovery:
~ As they start to feel their bodies getting larger, they may experience a resurgence of mood symptoms, irritability, and suicidal thoughts.
~ Mood symptoms, non-food-related obsessional thoughts, and compulsive behaviors, although often not eradicated, usually decrease with sustained weight gain and weight maintenance.
~ Patients who abruptly stop taking laxatives or diuretics may experience marked rebound fluid retention for several weeks.
~ As weight gain progresses, many patients also develop acne and breast tenderness and become unhappy and demoralized about resulting changes in body shape.
~ Patients may experience abdominal pain and bloating with meals from the delayed gastric emptying that accompanies malnutrition. This may respond to pro-motility agents.
~ Constipation may be ameliorated with stool softeners; if unaddressed, it can progress to obstipation and, rarely, to acute bowel obstruction
Anorexia Psychoeducation
~ The goals of psychosocial interventions are to help patients with anorexia nervosa
~ Understand and cooperate with their nutritional and physical rehabilitation
~ Understand and change the behaviors and dysfunctional attitudes related to their eating disorder
~ Improve their interpersonal and social functioning
~ Address comorbid psychopathology and psychological conflicts that reinforce or maintain eating disorder behaviors.
~ During acute refeeding and while weight gain is occurring, it is beneficial to provide empathic understanding, explanations, praise for positive efforts, coaching, support, encouragement, and other positive behavioral reinforcement
Anorexia Psychoeducation
~ Attempts to conduct formal psychotherapy with starving patients who are often negativistic, obsessional, or mildly cognitively impaired may be ineffective.
~ For children and adolescents, the evidence indicates that family interventions should help the families become actively involved, in a blame-free atmosphere, in helping patients eat more and resist compulsive exercising and purging.
~ Most inpatient-based programs create a milieu that incorporates emotional nurturance and a combination of reinforcers that link exercise, bed rest, and privileges to target weights, desired behaviors, feedback concerning changes in weight, and other observable parameters
Anorexia Psychotherapy
~ Once malnutrition has been corrected and weight gain has begun, psychotherapy can help patients with anorexia nervosa understand
~ Their experience of their illness
~ Cognitive distortions and how these have led to their symptomatic behavior
~ Developmental, familial, and cultural antecedents of their illness
~ How their illness may have been a maladaptive attempt to regulate their emotions and cope
~ How to avoid or minimize the risk of relapse
~ How to better cope with salient developmental and other important life issues in the future.
~ Note that patients may often display improved mood, enhanced cognitive functioning, and clearer thought processes after there is significant improvement in nutritional intake, even before there is substantial weight gain.
Anorexia Psychotherapy
~ Pay attention to cultural attitudes, patient issues involving the gender of the therapist, and possible abuse, neglect, or other developmental traumas.
~ Countertransference reactions to patients with a chronic eating disorder often include exhaustion, demoralization, and excessive need to change the patient.
~ Understand the longitudinal course of the disorder and that patients can recover even after many years of illness.
~ Because of anorexia nervosaās enduring nature, treatment is frequently required for at least 1 year.
~ Anorexics and Bulimics Anonymous and Overeaters Anonymous are not substitutes for professional treatment.
~ These programs focus exclusively on abstaining from binge eating, purging, restrictive eating, or excessive exercising without attending to nutritional considerations or cognitive and behavioral deficits
Bulimia and Binge Eating Disorder
~ Bulimia Diagnostic Criteria
~ Recurrent episodes of binge eating
~ Recurrent inappropriate compensatory behaviors (such as self-induced vomiting, misuse of laxatives, fasting, or excessive exercise) in order to prevent weight gain
~ The binge eating and inappropriate compensatory behaviors both occur, on average, at least 1x/week for 3 months.
~ Self-evaluation is unduly influenced by body shape and weight.
~ The disturbance does not occur exclusively during episodes of anorexia nervosa
Binge Eating Disorder
~ The following are some behavioral and emotional signs and symptoms of binge eating disorder:
~ Continually eating even when full
~ Inability to stop eating or control what is eaten
~ Stockpiling food to consume secretly at a later time
~ Eating normally in the presence of others but gorging when isolated
~ Experiencing feelings of stress or anxiety that can only be relieved by eating
~ Feelings of numbness or lack of sensation while bingeing
~ Never experiencing satiation: the state of being satisfied, no matter the amount of food consumed
Goals of Bulimia and Binge Eating Treatment
~ Reduce and, where possible, eliminate binge eating and purging
~ Treat physical complications of bulimia nervosa
~ Enhance patientsā motivation to cooperate in the restoration of healthy eating patterns and participate in treatment
~ Provide education regarding healthy nutrition and eating patterns
~ Help patients reassess and change core dysfunctional thoughts, attitudes, motives, conflicts, and feelings related to the eating disorder
~ Treat associated psychiatric conditions, including deficits in mood and impulse regulation, self-esteem, and behavior
~ Enlist family support and provide family counseling and therapy where appropriate
~ Prevent relapse.
Nutritional Treatment for Bulimia and BE
~ Develop a structured meal plan as a means of reducing the episodes of dietary restriction and the urges to binge and purge.
~ Including addressing disinhibition
~ Adequate nutritional intake can help prevent craving and promote satiety.
~ It is important to assess nutritional intake for all patients, even those with a normal body weight (or normal BMI), as normal weight does not ensure appropriate nutritional intake or normal body composition.
~ Among patients of normal weight, nutritional counseling can be a useful part of treatment and helps reduce food restriction, increase the variety of foods eaten, and promote healthy but not compulsive exercise patterns.
Psychotherapeutics
~ Antidepressants are effective as one component of an initial treatment program for most bulimia nervosa patients
~ SSRI treatment having the most evidence for efficacy and the fewest difficulties with adverse effects.
~ To date, fluoxetine is the best studied.
~ Sertraline is the only other SSRI that has been shown to be effective.
Treatment
~ Individual CBT-ED programs for adults with eating disorders should:
~ Typically consist of up to 40 sessions over 40 weeks, with twice-weekly sessions in the first 2 or 3 weeks
~ Aim to reduce the risk to physical health and any other symptoms of the eating disorder
~ Encourage healthy eating and reaching a healthy body weight
~ Cover nutrition, cognitive restructuring, mood regulation, social skills, body image concern, self-esteem, and relapse prevention
~ Create a personalized treatment plan based on the processes that appear to be maintaining the eating problem
~ Explain the risks of malnutrition and being underweight
~ Enhance self-efficacy
~ Include self-monitoring of dietary intake and associated thoughts and feelings
~ Include homework, to help the person practice in their daily life what they have learned.
Treatment
~ MANTRA (Maudsley Model) for adults should:
~ Typically consist of 20 sessions, with:
~ Weekly sessions for the first 10 weeks, and a flexible schedule after this
~ Up to 10 extra sessions for people with complex problems
~ Base treatment on the MANTRA workbook
~ Motivate the person and encourage them to work with the practitioner
~ Be flexible in how the modules of MANTRA are delivered and emphasized
~ When the person is ready, cover nutrition, symptom management, and behavior change
~ Encourage the person to develop a ‘non-anorexic identity'
Treatmentā MANTRA Sessions
~ Module 1: Getting started
~ Exploration of motivation to change through readiness rulers, imagining a future with or without AN, casting oneās mind backward to life before AN, identification of pro-AN beliefs and the function of AN in the personās life, use of externalization, and exploration of personal values and how AN has changed these
~ Module 2: Working with support
~ Identifying potential support persons, taking the perspective of others, identifying helpful and unhelpful interactions with others, planning for involving others
Treatmentā MANTRA Sessions
~ Module 3: Nutrition
~ Assessment of medical risk, othersā assessment of risk and ability to change, daily calorie needs for maintaining weight and for gaining weight, education about the consequences of starvation, what to eat/healthy eating, bingeing/overeating, a day in the life of my stomach, supports and blocks to safeguarding nutritional health, nutritional change plan
~ Module 4: My anorexia: why, what, and how?
~ This module allows patients to build a case conceptualization of how their AN developed and is maintained.
Treatmentā MANTRA Sessions
~ Module 5: Goals and experiments
~ Identifying areas of concern or difficulty and aspirations, how to set SMART goals for yourself (specific, measurable, achievable, realistic, tangible), using behavioral experiments to achieve goals
~ Module 6: Exploring thinking styles
~ Thinking about thinking: Am I overly focused on detail at the expense of the bigger picture? Am I finding it hard to be flexible and switch between different thoughts, rules, tasks, and perspectives? What is the impact of this thinking style on my life? The balance between speed and accuracy The impact of anxiety about making mistakes What does your thinking style mean for you? How to make most of your thinking style; strengthening bigger picture thinking, strengthening cognitive flexibility, strengthening being good enough; problem solving
Treatmentā MANTRA Sessions
~ Module 7: The emotional and social mind
~ What are emotions and why do we have them? Emotions in the context of relationships/relationship patterns, becoming an expert on your emotions: listening to your emotions, identifying your beliefs about emotions, and learning to express emotions and needs appropriately; learning to manage extreme and overwhelming emotions; the emotional lives of others: learning to see the world from other peopleās perspective to get a more balanced bigger picture view of interpersonal/ emotionally distressing situations; developing self-compassion
Treatmentā MANTRA Sessions
~ Module 8: Identity
~ Anorexia and my identity; my best possible self, qualities, values, struggles, and coping skills of others, who I admire, developing a new identity beyond AN, who will allow me to develop? Practicing living a new identity
~ Module 9: Moving forward
~ Reflection on how to maintain gains, what else needs doing, what could get in the way; tool kit for keeping well, managing difficult thoughts, feelings, and behaviors during the recovery process; developing mottos for a bigger life
Summary
~ Medical stability and nutritional balance are necessary for effective treatment
~ Once the patient is renourished, even before weight gain, often cognitive abilities will improve and obsessions and mood issues will improve.
~ Psychotherapeutics have not been found to be helpful with anorexia, but sertraline and fluoxetine have been found to be helpful in persons with bulimia
~ MANTRA and cognitive behavioral interventions have been found to be most helpful with this population.
Resources
~ CBT-oriented workbooks Agras WS, Apple RF: Overcoming Eating Disorders: A CognitiveBehavioral Treatment for Bulimia Nervosa and Binge-Eating Disorder. New York, Oxford University Press, 1997 (client workbook) Agras WS, Apple RF: Overcoming Eating Disorders: A CognitiveBehavioral Treatment for Bulimia Nervosa and Binge-Eating Disorder. New York, Oxford University Press, 1997 (therapist workbook) Cash TF: The Body Image Workbook: An 8-Step Program for Learning to Like Your Looks. Oakland, CA, New Harbinger, 1997 Fairburn C: Overcoming Binge Eating. New York, Guilford, 1995 Goodman LJ, Villapiano M: Eating Disorders: The Journey to Recovery Workbook. New York, Brunner-Routledge, 2001 (client workbook) Goodman LJ, Villapiano M: Eating Disorders: Time for Change. Plans, Strategies, and Worksheets. New York, Brunner-Routledge, 2001 (therapist workbook) Schmidt U, Treasure J: Getting Better Bit(e) by Bit(e): A Survival Kit for Sufferers of Bulimia Nervosa and Binge Eating Disorder. East Sussex, UK, Psychology Press, 1993 Other books reported to be helpful by patients/families Bulik CM, Taylor N: Runaway Eating: The 8-Point Plan to Conquer Adult Food and Weight Obsessions. New York, Rodale Books, 2005 Ellis A, Abrams M, Dengelegi L: The Art and Science of Rational Eating. Fort Lee, NJ, Barricade Books, 1992 Goodman LJ, Villapiano M: Eating Disorders: The Journey to Recovery Workbook. New York, Brunner-Routledge, 2001 (client workbook) Hall L: Full Lives: Women Who Have Freed Themselves From Food and Weight Obsessions. Carlsbad, CA, GĆ¼rze Books, 1993 Lock J, le Grange D: Help Your Teenager Beat an Eating Disorder. New York, Guilford, 2005 Michel DM, Willard SG: When Dieting Becomes Dangerous. New Haven, CT, Yale University Press, 2003 Walsh BT, Cameron VL: If Your Child Has an Eating Disorder: An Essential Resource for Parents. New York, Guilford, 2005 Zerbe K: The Body Betrayed: A Deeper Understanding of Women, Eating Disorders, and Treatment. Carlsbad, CA, GĆ¼rze Books, 1995 Books reported to be helpful for male patients Andersen AE, Cohn L, Holbrook T: Making Weight: Menās Conflicts With Food, Weight, Shape and Appearance. Carlsbad, CA, GĆ¼rze Books, 2000 Internet resources for health care professionals Academy for Eating Disorders (http://www.aedweb.org) Internet resources for patients, families, and professionals National Eating Disorders Association (http://www.nationaleatingdisorders.org) National Association of Anorexia Nervosa and Associated Disorders (http://www.anad.org/site/anadweb/) Eating Disorder Referral and Information Center (http://www.edreferral.com) Something Fishy (http://www.something-fishy.org; a well-monitored advocacy site)