Eating Disorders: A CBT Approach

1. Eating Disorders:A CBT Approach Beverly Swann, MFT therapy@beverlyswann.com www.beverlyswann.com 925-705-7036 Jennifer Lombardi, MFT, Content Contributor

2. Let’s Get Started • Logistics • Learning Objectives • Introductions / Expectations • Syllabus / Flow of Class • Disclaimer

3. Please Do: • Ask questions • Bring in material from your clients, taking appropriate measures to protect identity • Ask me to slow down or repeat material if needed • Network with each other during breaks

4. Please Don’t: • Cell phones ringing • Take calls during class • Text during class • Side conversations • Arrive late • Discuss any client information presented in class with anyone outside of class

5. Learning Objectives • Learn the DSM criteria for eating disorders (ED) • Understand common themes in ED related to body image and weight beliefs. • Know the health problems that can occur from ED • Develop knowledge of the biopsychosocial theories about ED • Apply assessment tools and a Cognitive Behavioral Theory (CBT) case formulation to determine level of care needed and appropriate treatment interventions • Develop skills in applying CBT strategies to treat ED • *Learn a lot of resources to learn more!

6. Introductions / Expectations Your name Experience/knowledge Eating Disorders and/orCognitive Behavioral Theory Expectations for the class

7. Why CBT? • ED is complex disorder, commonly w/co-occurring disorders • Have to address behavior as well as emotion • Malnourished clients have difficulty using insight to make long-term change • Provides structure and stability for anxious clients

8. Eating Disorder – DSM IV-TR Anorexia Nervosa • Underweight (at or below 85% ideal) • Disrupted menses • Fear of gaining weight/being fat • Sometimes purging behavior • Body/self-image is distorted • Restricting Type, Binge/Purge Type, Atypical Bulimia Nervosa • Normal or overweight • Binge eating with compensatory behaviors • Fear of gaining weight/being fat • Body/self-image is distorted • Purging Type and Non-Purging Type EDNOS • Anorexia criteria met but still having menses or weight is still in normal range • Atypical eating disorders • Binge eating disorder/compulsive eating • Food aversion • Orthorexia • Diabulimia • Night eating

9. Compensatory Behaviors • 60% Self-induced vomiting • 25% Laxatives • 5% Compulsive Exercise • 5% Diet pills • 5% Diuretics • ? Restricting food

10. DSM-V – ED Proposed Additions (May 2013?) • Avoidant/Restrictive Food Intake Disorder (food aversion) • Binge Eating Disorder • Feeding and Eating Conditions Not Elsewhere Classified (more defined than NOS) www.dsm5.org

11. DSM V: Binge Eating Disorder Binge eating - Average of 2 times per week for 6 months No compensatory behaviors Associated with at least 3 of the following: Eating more rapidly than normal Eating until uncomfortable full Eating large amounts of food when not hungry Eating alone out of embarrassment of how much one eats Feeling disgust, depressed, guilty after overeating

12. More About Binge Eating Disorder • 2-5% of the American population suffers from binge eating disorder • Men constitute 40% of those with BED • Onset usually occurs during late adolescence or in early adulthood

13. Medical Issues and Complications* - Anorexia Nervosa • Cardiac issues (bradycardia, tachycardia, orthostasis) • Problems w/kidney and liver function • Low glucose and/or sodium • Reduction of bone density (osteopenial/osteoporosis) • Muscle loss and weakness • Severe dehydration, which can result in kidney failure; fainting, • fatigue, and overall weakness. • Lanugo – growth of extra body hair on arms, chest, and back • Hair and Nail thinning • Amenorrhea • Edema • Sleep disruption • Dental/enamel loss • Tinitis *www.nationaleatingdisorders.org/nedaDir/files/documents/handouts/HlthCons.pdf

14. Medical Issues and Complications - Bulimia Nervosa • Cardiac issues (bradycardia, tachycardia, orthostasis) • Esophageal ruptures/tearing (blood in vomit, cancer) • Electrolyte imbalances • Elevated CO2 • Edema • Sleep disruption • Dental/enamel loss • Low glucose • Low sodium • Swollen parotid glands • Blood in stool

15. Medical Issues and Complications – EDNOS/BED High blood pressure High cholesterol levels Heart disease as a result of elevated triglyceride levels Type II diabetes mellitus Gallbladder disease Obesity Joint/Muscle pain Cancers Gastrointestinal problems Sleep apnea

16. Etiology Genetics loads the gun, and environment pulls the trigger. Craig Johnson, PhD

17. Five Reasons Why An Eating Disorder Develops • Genetics Loads The Gun: • Biology • Personality Traits/Temperament • And Environment Pulls The Trigger: • Trauma/loss • Family Dynamics • Culture

18. Initiating Risk Factors • The brain’s signal for hunger is turned down • Anterior Insula • Posterior Insula • Taste is experienced differently for patients with anorexia • Patients with ED do not experience normal “reward” for eating food – anorexia or binge • Diminished self-awareness of internal body states (dissociation) • Family history of anxiety and/or depression

19. Neurotransmitters:Development And Maintenance Of Eating Disorders Dopamine Correlated with harm avoidance Insensitivity to normal rewards (Frank, et al 2005) Serotonin High level associated with anorexia Low levels associated with bulimia/ binge eating disorder Affect instability Impulsivity Self harming behavior Interpersonal insecurities (Steiger et al, 2006)

20. Video – Erasing ED • Notice: • Environmental factors • Emotional factors • Behaviors • Temperament • Medical complications • Thoughts/beliefs

21. Cognitive Behavioral Therapy “There’s nothing good or bad, but thinking makes it so.” Shakespeare’s Hamlet

22. Cognitive Behavioral Therapy Core Concepts Thoughts cause our feelings and behaviors Not external factors (people, places, etc.) Time-Limited Average of 16 to 20 sessions Therapeutic alliance important… but not the answer Change occurs because client learns how to think differently and, as a result, act differently

23. Cognitive Behavioral Therapy Core Concepts Continued 4. Goal-oriented Collaborative – therapist listens, teaches and helps client implement learning 5. Stoicism Emphasis is on being calm 6. Socratic method Ask questions & encourage client to do the same

24. Cognitive Behavioral Therapy Core Concepts Continued 7. Teach clients how Using specific techniques, structure and foster patient’s skills 8. Education-focused Concept of “unlearning” 9. Inductive method Look at thoughts as “hypotheses” to be explored 10. Homework! Reading assignments and practice, practice, practice!

25. Cognitive Behavioral Therapy Stages of CBT Identify problems Prioritize Recognize thoughts, beliefs, feelings about the problem “Self talk” Interpretations Beliefs about self, relationships, situations, etc. Identify faulty thinking Record physical, emotional and behavioral reactions/responses Challenge faulty thinking Validity testing… again and again

26. CBT: Important Factors for the Patient Therapeutic alliance Honesty Consistency/attendance Expectations – progress varies Won’t work without doing homework Express frustrations

27. CBT: Important Factors for the Therapist Don’t forget about the alliance & empathy Have a clear approach & communicate Go to the core belief(s) about the irrational thoughts Can’t just identify irrational thoughts – have to go the distance to help client find new/replacement thought Talk about the roadmap – but encourage/empower the client to drive

28. Cognitive Behavioral Therapy History Behavioral therapy developed in the early 20th century Jones’ work in “unlearning” fears with children Pavlov’s work in the 1950’s Wolpe’s work with systematic desensitization with animals B.F. Skinner’s “radical behavioralism” with psychiatric disorders

29. Cognitive Behavioral Therapy History Cognitive therapy developed in the mid 20th century “Cognitive revolution” – a reaction to behavioralism Added “mentalistic” thoughts and cognitions Present-focused Albert Ellis’ Rational Therapy First form of cognitive behavioral therapy Aaron T. Beck Cognitive Therapy Discovered through free association Recognized certain thoughts preceding certain emotions

30. Cognitive Behavioral Therapy History Continued In 1980’s Merging of the Two Approaches Occurred Clark and Barlow for panic disorder Arnold Lazarus’ multimodal therapy Included physical sensations Visual imagery Interpersonal relationships Biological factors

31. Homework • Using Assessment Worksheet, analyze one or more clients you currently have or have treated in the past.

32. Assessment & Diagnosis Initial Comprehensive History Includes: Eating disorder behaviors – current and past Substance abuse – current and past Treatment history – including medications Medical complications Social support Temperament Culture History of trauma and loss Family history of mental health, medical issues History of abuse, self injury, suicidality What patient views as causes - Often focuses on social as primary, intrapersonal distress secondary. Rarely recognize biological.

33. Assessment – Collaborating With Other Professionals • Importance of treatment team • Primary Care Physician (PCP) • Psychiatrist • Other therapists • Treatment centers • Dietician • Release of Information forms!

34. Common Co-Occurring Disorders Substance Abuse/Dependence Depression Anxiety PTSD Obsessive-Compulsive Disorder

35. Common Co-Occurring Disorders Body Dysmorphic Disorder Borderline Personality Disorder Obsessive-Compulsive Personality Disorder Other Addictions Medical Illnesses

36. Co-Occurring Disorders • Anorexia • Anxiety disorders – often pre-date the ED • Obsessive compulsive disorder • Social phobia • GAD • Major Depression • Axis II? • Bulimia • Affective Disorders • Major Depression • Bipolar Disorder • GAD • Substance Abuse • Alcohol, marijuana

37. Co-Occurring Disorders • Binge Eating Disorder • Affective Disorders • Major Depression • Bipolar Disorder • GAD • PTSD • Axis II

38. Co-Ocurring Disorders – Personality Disorders • ED clients with Borderline Personality Disorder • Prognosis not great • Treatment resistant • Suicide and self-harm concerns • ED clients with Obsessive-Compulsive PD features • Perfectionism • Food Rules • In Anorexia, difficult to differentiate from starvation effects

39. Co-Occurring Disorders • Example 1:Janice is a 19 year old Olympic hopeful swimmer who has just completed 6 weeks of treatment for bulimia. She reports that her daily routine includes coffee at Starbucks and carrot sticks during breaks at practice, and appetizers when she goes out with her friends at night. She likes to go hot-tubbing after hitting the bars. • Example 2:Mari comes to your office after being referred for domestic violence counseling. She weighs approximately 220 pounds and her complexion is very red, especially around the nose and cheek area.

40. Trauma or Loss • Several studies of both ED and PTSD patients have shown: • Estimated 30 to 45 percent have some trauma history • Sexual • Physical/neglect

41. Culture • 42% of 1st-3rd graders girls want to be thinner • 45% of boys and girls in 3rd-6th grades want to be thinner • 37% have already dieted • 51% of 9-10 year olds feel better about themselves when dieting • 9% of 9 year olds have vomited to lose weight • 81% of 10 year olds are afraid of being fat • 78% of 18 year old girls are unhappy with their bodies • The #1 wish for girls 11-17 years old is to lose weight Body Wars, Margo Maine

42. Culture • Society Does Not Cause Eating Disorders • BUT… creates toxic environment “Genetics loads the gun and environment pulls the trigger.” Craig Johnson, PhD

43. Cultural Considerations Research shows that eating disorders are not limited to young, caucasian females. Studies have found rates of ED to be roughly the same in several other ethnic groups. Factors to be aware of: • Likelihood of seeking treatment – Asian and Hispanic populations tend to utilize available treatment at a lower rate than caucasians; African American and Native American populations have a higher rate of utilization • Access to treatment • Language barriers

44. Cultural Considerations Acculturation Socio-economic status – County clients Gender considerations Gay/lesbian populations List of recommended readings: www.nationaleatingdisorders.org/nedaDir/files/documents/handouts/IncorpDi.pdf www.nationaleatingdisorders.org/nedaDir/files/documents/handouts/WomenCol.pdf

45. Temperament • Anxious • Perfectionist • Obsessional • Harm or conflict avoidant • Low Self-directedness • Reward dependent • Impulsivity (BN)

46. Temperament Associated with BED • Perfectionistic • People pleasing • Rigid, inflexible thinking • Difficulties expressing needs and emotions • Conflict or harm avoidant • Impulsivity • Reward dependence

47. Personality Traits/Temperament • Temperament & Character Inventory • Harm Avoidance (AKA: “Peacemakers”) • Low Self-Directedness • Reward Dependence (AKA: Perfectionism) • Novelty Seeking (AKA: Impulsivity)

48. The Psychology of Eating Disorders How Patients Experience Eating Disorders Security (something is constant, stable) Avoidance (emotional numbing, isolating) Mental Strength (finally feeling good at something) Self-Confidence (getting praise) Identity (feeling of invincibility) Elicit Care (from others, without having to ask) Communication (communicating difficulties) Death (passive way to suicide) Nordbo, et al, 2006

49. Types of Assessment Bio-psycho-social Medical evaluation Psychiatric evaluation Nursing assessment Nutrition assessment

50. Assessment – Screening Tools • Eating Disorder Questionnaire (EDQ) • Obligatory Exercise Scale • Addiction Severity Index (ASI) • Adult ADHD Self-Report Scale (ASR-v1.1) • Alcohol Use Disorder Identification Test (AUDIT) • Michigan Alcoholism Screening Test (MAST) • Drug Abuse Screening Test (DAST) • Beck Depression Inventory (BDI) • Beck Scale for Suicide Ideation (BSS) • Beck Anxiety Inventory (BAI) • Brief Symptom Inventory (BSI) • Mood Disorder Questionnaire • URICA (readiness to change) • FRIEL Co-dependency Inventory • Multiscale Dissociation Inventory (MDI)