Acceptance & Commitment Therapy In The Treatment of Eating Disorders

Acceptance & Commitment Therapy

In The Treatment of Eating Disorders

Emmett Bishop, MDEating Recovery Center, Denver, Colorado

Jennifer Lombardi, MFTEating Recovery Center of California, Sacramento, California

Why ACT?

• Eating Disorders– Highest mortality rate of any mental illness– High non-response and relapse rates– Prevalence of co-morbid anxiety & depression– Temperament

Eating Disorder Treatment

• Inpatient • Residential• Partial Hospitalization/Day Treatment• Intensive Outpatient• Outpatient

How ED “Manages”• Anorexia

– Biology• Serotonergic system overactive – restricting decreases anxiety• Imbalance in dopamine/serotonin systems• Aversive response to DA release with food

– Temperament• Harm avoidance• Novelty seeking• Reward dependence• Self-directedness

– Social• Experiential avoidance• Withdrawal and/or hyper-vigilance related to performance

Temperament and Character Inventory

5

Novelty Seeking Harm Avoidance Reward Dependence Persistance Self-Directedness Cooperativeness Self-Trancendence0

10

20

30

40

50

60

70

80

90

100

AN-R, N=374AN-B/P, N=295EDNOS, N=115BN, N=208All Dx, N=992

How ED “Manages”• Bulimia

– Biology• Endogenous opiate release with purging• Reward circuitry

– Temperament• Harm Avoidance• Novelty seeking• Self-directedness

– Social• Experiential avoidance• Emotion-regulation

Treatment Modalities

• Family-based therapy• CBT• DBT• Initial medical focus

– Followed by behavioral

Why ACT

• Contextual framework– “… families may benefit from using both

practical strategies such a feeding support and also theoretical strategies such as psycho- education about the illness.”

– Reframes the illness in a non-shaming way

(LoTempio, et al, 2013)

Why ACT

• Willingness – Considers what patients say that do not want

from therapist/treatment*• Lack of validation for the ED• Inflexible use of theory• View of patient as ED vs. an individual

– ACT encourages exploration of ED purpose and alternatives to manage

(Gulliksen, et al, 2012; Juarascio et al., 2013)

Why ACT

• Values– Explore life beyond ED– What do ED patients state that they want from

treatment?• Motivational “hooks”*

– Firm empathy– ED is one choice of managing– Weave motivational/values work into treatment

– Committed action connected to values

(Glenn Waller, 2012)

Current Research

• TCI• AAQ-W• BI-AAQ• CAQ

AAQ-WN=521

12

Admission Discharge0

20

40

60

80

100

120

101

78

BI-AAQN=465

13

Admission Discharge0

10

20

30

40

50

60

7065

53

Eating Disorder Index CorrelationsN=833

AAQ-WAffective Problems Composite 0.566Asceticism 0.541Body Dissatisfaction 0.679Drive for Thinness 0.686Eating Disorder Risk Composite 0.698Ineffectiveness Composite 0.646Interoceptive Deficits 0.573Low Self Esteem 0.646Overcontrol Composite 0.546Personal Alienation 0.609

14

BI-AAQBody Dissatisfaction 0.657Drive for Thinness 0.756Eating Disorder Risk Composite 0.680Ineffectiveness Composite 0.525Low SelfEsteem 0.535Overcontrol Composite 0.501

Correlations >0.5 are included

Temperament and Character Inventory Correlations N=857

15

Correlations >0.3 are included

AAQ-WHarm Avoidance 0.533Self Directedness -0.492

BI-AAQHarm Avoidance 0.429Self Directedness -0.358

Case Study• Female patient

– Age 35 at onset of IOP tx – Multiple treatment episodes beginning age 26

• Inpatient psych, residential, PHP, IOP, OP– History of AN & BN beginning at age 14– Co-morbid PTSD, major depressive disorder– Trauma

• Sexual abuse beginning at age 5– College graduate– Social isolation

Case Study• Treatment modalities

– CBT– DBT– Family systems work– Art therapy– Psychodynamic

• Results:– Repeated episodes of gaining weight, social

improvement while in treatment– Relapse, on average, within 6 months

Case Study

• Shift in focus of treatment– Willingness

• Specifically around trauma & involvement of support system

– Acceptance• Limitations of family system, loss of stepfather

– Values• Social connection, career/meaning of work

Case Study• Biology

– Decreased medications – Depressive sx decreased

• Temperament– Increased assertiveness– Ability to engage in self-care– Imperfection in work

• Social– Roommate– Social activities