Welcome!

1. Welcome! Parent/Partner Program Sponsored by the Western New York Comprehensive Care Centers for Eating Disorders Feb. 29, 2008

2. Guidelines for participation • Confidentiality. • General questions. • Adjunct to treatment. • The material included may be distressing: please feel free to process this with us and/or your treatment provider(s).

3. Parents/friends are important • All families/loved ones have strengths to contribute to the recovery process. • Even though parents/loved ones are not eating disorder experts they are a necessary part of the healing initiative. • Eating disorders are not intuitively or easily understood: parents/loved ones will have made mistakes; it is best to just move ahead.

4. Role of family and friends What role do family and friends play in coming to this program?

5. Role of family and friends • Support treatment. • Educate. • Facilitate treatment. • Observe the illness. • Improve family relationships. • Research treatment.

6. Mental Health Aspects of Eating Disorders Cris Haltom, PhD Licensed Psychologist Community Education and Prevention Liaison, Eating Disorders Recovery Center of Western NY

7. Treatment team approach • Multidisciplinary approach to treatment. • In addition to parents and the patient on the treatment team there are different professional disciplines represented on treatment team: • Mental health • Nutrition • Physical health and medicine/psychopharmacology

8. Levels of care for eating disorders • Outpatient • Intensive outpatient (IOP) or partial hospital (PHP) • Residential treatment • Inpatient hospitalization • Community resources

9. From normal eating to eating disorders Food/body acceptance Food/body obsessed Disordered eating Eating Disorders Anorexia Bulimia Binge eating disorder

10. Defining eating disorders Three types of eating disorders addressed in this presentation (defined by the American Psychiatric Association, Diagnostic and Statistical Manual) • Anorexia: restricting type and binge eating/purging type • Bulimia • Eating disorder not otherwise specified (EDNOS) including binge eating disorder(BED)

11. Weight loss, loss of menstruation, restrict intake Purge behavior Binge/overeat

12. Cycles in eating disorders: causes are multiple and complex Individual characteristics External/situational stressors Social/cultural messages Behaviors and their consequences Family Biology Power struggles with others

13. Useful facts • 5–10 million women and 1 million men in the U.S. have eating disorders. • Anorexia affects 1% of women and bulimia, 3%. • 3-5% of adolescents have binge eating disorder • 43% of first through third grade girls want to be thinner (Collins 1991). • 57% of teen girls, 33% of teen boys use unhealthy weight control behaviors (e.g., meal skipping, vomiting) (Neumark-Sztainer, 2005) • Vast majority of eating disorders start in childhood (as young as eight years old), adolescence, and young adulthood (Lock and LeGrange, 2005).

14. Recovery rates • Anorexia: among adolescents, • 50–70% recover. • 20% partially recover. • 10–20% develop chronic anorexia (Steinhausen, 2002). • Bulimia: in a six-year treatment study, • 60% had a good outcome. • 29% had an intermediate outcome. • 10% had a poor outcome (Fichter and Quadflieg 1997). • Binge eating disorder, • 50% or more have positive, long-term outcomes (APA Practice Guidelines for 2006).

15. Useful facts (continued) • Average onset age for • anorexia: 14–18. • bulimia: 18–20. • BED: 14, 16, and 18 (most common ages) (Fairburn 1995). • Between 8 and 62% of those with anorexia develop bulimia (Bulik et al. 2005) • Eating disorders start as young as eight years old, possibly younger, and can begin in older age

16. Eating disorder similarities What characteristics do eating disorders have in common?

17. Common characteristics • Body obsession • Body-damaging behavior, e.g., menstrual irregularity • Inappropriate compensatory eating or purging behavior • Inability to tolerate spontaneous response to natural physical hunger and/or satiety • Psychologically driven • Unhealthy eating behavior • Use of food to solve problems/anesthetize feelings • Impairment in cognitive, relationship, work, and/or physical functioning

18. Malnutrition leads to changes in mental health Biology of Human Starvation (Keys 1944): study of effects of starvation on young, healthy men • Strong preoccupations with food. • Emotional and personality changes. • Inflexible eating patterns. • Social withdrawal. • Decreased concentration, comprehension, and judgment. • Binge eating followed by remorse.

19. What is anorexia nervosa? • Inability to maintain even a minimally normal weight for age and height. • Intense fear of gaining weight or becoming fat (irrational fear of altering body through eating). • Disordered perspective of one’s body. • Loss or failure to begin menstrual period (for three consecutive months), known as amenorrhea. • Two types: Restricting and binge eating/purging types (about one-third vomit) (Garner et al. 1993).

20. Personality/problems associated with anorexia • 25% will be diagnosed with obsessive compulsive disorder in lifetime (Am. Psychiat. Assoc. 2000); 10–60% have co-morbid OCD (Godart et al. 2002) • Social phobia: 55% co-morbid Dx (Godart et al. 2000) • Perfectionist, anxious, harm-avoidant (Kaye et al. 2004) • Depression disorders: 50–75% co-morbid (Am. Psychiat. Assoc. 2000) • Anxiety disorders predated ED: 75% (Godart et al. 2000) • Substance abuse: 27% lifetime history of alcohol use disorder (Franko et al. 2005) • Genetic predisposition for eating disorders

21. Myths about anorexia Myth 1: Achieving normal weight means cure. Myth 2: People with anorexia always look unusually thin. Myth 3: People with anorexia are high-achieving, female adolescents with over-controlling mothers.

22. Introduce video clips • Video clips demonstrate different types of eating disorders. • Our videos are taken from an interview with Cathy. • Cathy experienced different levels of eating disorders and alcohol abuse.

23. Cathy’s story What does Cathy tell us about her battle with anorexia?

24. Cathy and anorexia • ED was very subtle and grew slowly. • Changed her eating habits. • Wanted to be more attractive for dating. • Felt competitive with other girls. • Exercised and purged secretively. • Chewed and spit. • Lost hair and skin was ravaged. • Sleepless because fearful of not burning calories.

25. Cathy and her story:part 2 What else can we say about Cathy’s experiences with anorexia?

26. Cathy: anorexia (continued) • Angry at her body • Limitless pursuit of thinness • Desired perfection • Many phases of eating disorder • Tried to limit herself to 200 calories per day • Felt judged • Withdrew from friends • ED took over her life • Low energy, poor memory and concentration • Alcohol abuse

27. What is bulimia? • Binge eating. • Lack of control over eating. • Inappropriate compensatory behavior. • Binge eating/purging twice a week, over three months minimum (90% vomit, 1/3 use laxatives) (Ben-Tovim et al. 1993). Children and adolescents may not meet these exact criteria (still being researched). • Self-worth based on overemphasis on weight and shape.

28. Myths about bulimia Myth 1: Vomiting and laxative and diuretic use inevitably cause weight loss. Myth 2: People with bulimia eat a lot and are less concerned with being thin or dieting. Myth 3: A person who stops binge eating will stop purging behaviors.

29. Cathy and bulimia Cathy also experiences a phase of bulimia

30. Cathy and bulimia What does Cathy share with us about her experience?

31. Characteristics associated with bulimia • Depression and mood disorders • Anxiety disorders • High rate of substance abuse • Social phobia • Impulsivity in multiple domains: suicide attempts, self-injury, and stealing • Harm avoidance • Identity confusion • Larger body mass to start with (Fairburn, 1997) • Dieting going on in family, including for medical illness • Genetic predisposition for eating disorders

32. EDNOS: binge eating disorder • Eat when not hungry. • Unable to stop or control this behavior. • Sense of lack of control over eating during binge episodes. • May include episodes of binge eating where large amounts of food eaten in a short period of time.

33. Myths about BED Myth 1: All people who are obese have binge eating problems. Myth 2: If people with BED stop bingeing they will be recovered. Myth 3: Because BED doesn’t involve more typical eating disorder symptoms like purging or excessive weight loss, it is not as serious a problem.

34. Sandy • Falsely thought she was overweight at age 18. • Did not stop eating when full or satisfied. • Oblivious to the food she ate. • Food was drug to calm, numb, comfort, and pacify. Didn’t know why she was eating sometimes: disconnect between feelings and thoughts. • Although not the case for Sandy, anorexia and bulimia can migrate into BED and vice versa.

35. Risk factors for binge eating Binge eating related to: • Erratic meal patterns and skipped meals • Dieting: Girls who diet are 12x more likely to binge eat, boys 7x (Neumark-Sztainer, 2006) • Inability to recognize hunger/satiety cues. • Frequent overeating in response to emotions, stress and external cues • Use of electronic media and underactivity • Lack of enjoyment of physical activity: too much or too little physical activity can decrease motivation. • Overweight: body dissatisfaction, weight-related teasing • Genetic predisposition to binge eating disorder

36. Stages of treatment and recovery • Recovery process with stages and levels that may fluctuate—we identify five stages. • Identify criteria for recovery so you know where you and your loved one is headed. • Understand that, without treatment, there is a greater chance your loved one will not recover and/or will relapse. • If your child is living at home and under 18, family contact is an important part of therapy. • Encourage your loved one to stay in treatment beyond partial recovery.

37. Recognition there is a problem What helps people recognize there is a problem and seek recovery? • Life slipping by—misses life without illness—peers are moving on. • Wants to live in the body rather than fight the body. • Feels fake. • Embarrassed by what has happened to the body. • Delayed maturation. • Wants to stop hurting self. • Wants a future beyond the eating disorder. • Tired of appearance-based self-esteem. • Tired of burdensome mental obsessions.

38. Treatment and recovery Parents, family, and friends can help set stage for treatment and recovery.

39. Parents/family/friend’s role in setting stage for treatment/recovery • Friends of minors need to tell a responsible adult • Notice peculiar eating habits & health or size obsession • Reduce self-blame • Approach child/loved one directly with empathy and concern while reporting your observations: Use “I” • Loved one needs to be thought of as ill, not wrong • Think of the loved one as separate from the illness • Don’t expect compliance in response to request to overcome ED: the ED is a relied-upon coping mechanism

40. Setting the stage for recovery(continued) • Set a healthy example. • Validate honest communication and expression of feelings. • Place emphasis on internal character building and not external achievement/ appearance. • Be ready to make supportive changes. • Calmly request your loved one receive professional help - insist if loved one is a minor.

41. Approaching a loved one about getting help Sample dialogue about approaching loved ones about problematic disordered eating behavior: Use I statements. Family member/friend: “I am worried about you. I see you skipping lunch. I smelled vomit in the bathroom after you left the bathroom last night. I think you need help with this.” Individual with ED: minimizes or denies your observation. Family member/friend: “I hear what you are saying, but I see things differently. I am concerned about your health and I need you to talk to someone even if you don’t think there is a problem.” Individual with ED: refuses to cooperate Family member/friend: “I understand that you don’t see a problem here. I can understand that you might not want me interfering in your life or bringing in outsiders to help, but sometimes professional help can be very useful.”

42. Pitfalls for parents/loved ones Avoid: • judging your loved one’s refusal to eat. • anger at your loved one’s ED behavior; blame the eating disorder, not the loved one. • repeated nagging about food eaten/purging behavior: leads to resentment for everyone. • power struggles over food/ ED behavior. • bribing loved one to “give up” symptoms. • splitting food into good/bad categories. • discussion of physical appearance, workouts. • “guilting” or chiding your loved one’s lack of progress • blaming yourself: self-blame causes anxiety and defensiveness in parents and loved ones.

43. Cathy and recovery What does Cathy tell us about her recovery?

44. Overall goals of treatment normalize and restore regular, healthy eating reduce/minimize compensatory behaviors, e.g., purge behaviors restore and stabilize healthy weight body acceptance good self-care increased connectedness with family and friends eating disorders no longer the focus of family communications

45. What goes on in treatment?first stage of therapy • Individual and family history • Assessment of eating disorder • Assessment of co-morbid psychological problems/possible need for medications • Collaboration with treatment team to establish a common understanding of the eating disorder and to agree on a treatment approach • Collaboration with eating disordered individual and parents (if a child or adolescent): fully recognize the eating disorder and establish agreed upon treatment plan • Review of initial treatment approach

46. Models of mental health treatments Most therapists use multiple approaches: • Cognitive behavioral therapy (CBT) • Psychodynamic • Psychoeducational • Dialectic behavior therapy (DBT) • Interpersonal/Relational therapy • Family/multifamily therapies • Structural and systems • Maudsley Approach ( • Group therapy: DBT, expressive, body image

47. New Maudsley method for outpatients: • Initial task is nutrition restoration and normalizing eating at home: parents manage the eating disorder 2. Family seen as resource rather than the source of the problem: little evidence that families cause ED’s • Parents take charge of nutrition restoration and disrupt extreme dieting and exercise with anorexia • In the case of bulimia, parents seek collaboration with their child to promote healthy eating and disrupt pathological eating and purging behaviors. 5. Agnostic with regard to causes

48. Second stage of treatment and recovery • Focus on immediate health stabilization and beginning nutrition restoration. • Build treatment team further, if needed. • Once health begins to be restored, take fuller advantage of psychotherapy (Olmstead 2005). • Nutritionist guides and/or consults about nutrition restoration paralleling mental health and medical treatment. • Parents/loved ones collaborate with other treatment team members in developing/implementing treatment plan. Family support is necessary for success. • Individual begins developing alternative coping strategies.

49. Third stage of treatment and recovery • Tackle the social/ psychological underpinnings of ED once food intake, eating habits, compensatory behaviors are modified. • Active symptom interruption continues with therapeutic support. • Treatment professionals, collaborating with family, evaluate and intervene around child’s/loved one’s ability to follow treatment recommendations. • New coping strategies begin. • Additional family therapy intervention done with young people to resolve new and old family problems.

50. Fourth stage of recovery and treatment • Eating problems no longer the focus of family communication • Get on with the task of adolescent development. • Establish autonomy. • Practice self-feeding and self-care. • Improve body image/body acceptance. • Identity formation actively worked on • Have normal relationships with peers. Family supports developing friendships. Social phobia treated, if needed. • Resolve past trauma/significant events. • Establish good boundaries in the family/couple.