THERAPIES FOR EATING DISORDERS

THERAPIES FOR EATING DISORDERSBARBARA SMOLER, LMSW

3/17/14

In the DSM-5, the feeding and eating disorders of anorexia nervosa, bulimia nervosa, binge-eating disorder, rumination disorder, and avoidant/restrictive food intake disorder are presented so that

despite a number of common psychological and behavioral features, the disorders differ substantially from each other in clinical course, outcome, and treatment needs.

However, a diagnosis of Pica may be assigned in the presence of any other feeding and eating disorder as a comorbidity. Also, obesity is not included in the DSM-5 as a mental disorder.

The six types of eating disorders listed in the DSM-5 :

1. Anorexia nervosa is characterized by extreme food (energy intake) restriction that leads to dangerously low body weight and possible malnutrition or starvation, among other detrimental physical effects that can be life threatening. A person with anorexia is likely to have a distorted body image, intense fear of gaining weight, and obsessive thoughts about food and weight.

The DSM-5 identifies two subtypes of anorexia: restricting type and binge-eating or purging type. The restricting type is the most common and may include the restricting of types of food ingested, and maintaining extremely low caloric intake, or other rigid restrictions.

The binge-eating or purging type includes severe restriction interspersed with periods of binge-eating or purging that may include compulsive exercising, self-induced vomiting, or misuse of diuretics, enemas, or laxatives. Anorexia affects approximately .6% of the population.

2. Bulimia nervosa is identified as a cycle of binge eating that results in feelings of shame, guilt and remorse, and a sense of loss of control, which further compel a person to compensate for the binge by purging or overexercising

Physical effects include dehydration, chronic sore throat or inflammation of the esophagus, abdominal pain, and bowel problems, among others. Bulimia does not generally result in significantly low body weight, and sometimes a person’s weight may be slightly above average. Bulimia affects approximately .6% of the population.

3. Binge eating is similar to bulimia in that a person will consume excessive amounts of food in a short period of time, followed by feelings of guilt or disgust. Purging, however, is absent from binge eating, though the person may engage in periodic dieting or fasting to compensate for the binge eating episode resulting in a vicious cycle of binge eating and depression, using food to cope with the stress. Binge eating affects approximately 1.2% of the population.

4. Avoidant/Restrictive food intake disorder (ARFID) is characterized by a routine failure to consume adequate nutritional or daily energy needs that results in significant nutritional deficiency, reliance on oral supplements or enteral feeding, significant (or poor weight gain in youth), or severely impaired psychological and social functioning.

5. Rumination disorder is the compulsive regurgitation of food (over a period of at least 1 month) followed by either spitting, re-chewing, or re-swallowing of the food, which does not occur as a part of another eating disorder or as a result of a medication condition.

6. Pica is a relatively rare eating disorder that is characterized by the persistent eating of nonnutritive, nonfood substances such as clay, paper, paste, chalk, mud, soap, or laundry starch over a period of at least 1 month. A person may be drawn to consume such substances due to the texture or flavor of the item, and the action of eating the substance may be self-soothing. Pica is more commonly found among specific populations, including adults with iron deficiency, pregnant women, institutionalized people, and children.

Why do people develop issues with food and eating? Eating and food issues can develop from a wide range of psychological, biological, social, or external factors, and they affect people of all ages, male or female, although adolescents and young women develop eating disorders at higher rates than other groups.

Food and eating issues are ultimately expressions of one’s sense of self and selfworth. People who compulsively starve themselves, purge, eat to excess, or exercise unnecessarily may do so out of feelings of anxiety, inadequacy, needing to please others, or low self-esteem.

They may feel pressure to succeed and achieve perfection, especially those in certain sports and occupations such as gymnastics, figure skating, acting, modeling, dancing, elite athletics (jockeys), and sports with weigh-ins, e.g. boxing and wrestling.

Adolescents may be more susceptible to developing issues with food due to the hormonal, physical, and neural changes they experience; and sometimes stressful events, trauma, or troubled relationships can lead a person to develop an unhealthy relationship with food.

A family history of eating disorders or other mental health conditions may also contribute to a person’s potential for disordered eating.

TYPES OF TREATMENT FOR EATING DISORDERS

There are many types of eating disorders and many different approaches and therapies. The severity of the eating disorder may dictate the treatment method chosen. Help may be found at medical care facilities, through private practitioners, and through community or faith-based groups.

Medical treatment for eating disorders, particularly acute, inpatient admission, is not generally required. The exception is when an eating disorder is so severe that the physical damage must be handled immediately, as in the case of an esophageal tear in a bulimic or in the case of severe starvation in an anorexic.

Medical treatment of an eating disorder that includes prescription medication is needed in cases of severe side effects from the disorder. Medications are prescribed, generally by a psychiatrist and may be intended to help treat the eating disorder itself or any possible co-occurring mental illnesses, such as depression, which is common in those with anorexia or bulimia.

Medications used in the treatment of eating disorders typically include:

Selective serotonin reuptake inhibitors (SSRIs) - the preferred type of antidepressant; to help decrease the depressive symptoms often associated with some eating disorders. Eg. Fluoxetine (Prozac).

Tricyclics (TCAs) – another type of antidepressant thought to help with depression and body image. TCAs are generally only used if SSRIs treatments fail. Eg. Desipramine (Norpramin).

Antiemetics – drugs specifically designed to suppress nausea or vomiting. Eg. Ondansetron (Zofran).

According to Reuters, 3/12/14, recent research by British and Korean scientists suggests oxytocin, a brain chemical known as the “love hormone”, is showing promise as a potential treatment for people with anorexia. Researchers found oxytocin altered the tendencies to become fixated on images of fattening foods and large body shapes, suggesting it could be developed as a treatment to help them overcome unhealthy obsessions with diet, and social difficulties, including anxiety and hypersensitivity to negative emotions.

HOW PSYCHOTHERAPY CAN HELP WITH EATING AND FOOD ISSUES

Typically, recovery from disordered eating is a long and arduous process. Some therapies are relatively short term, requiring approximately four months, but when the process lasts for years, many clients struggle with the motivation and energy required to commit to the work involved.

It is important to recognize that recovery not simply attaining the absence of disordered thoughts and behaviors about food and body, but recovering one’s self: developing a sense of authentic identity, and cultivating self-acceptance and reverence for one’s self.

Many different types of psychotherapy have demonstrated effectiveness in treating eating and food issues, including interpersonal psychotherapy, cognitive-behavioral therapy, family therapy, and dialectical behavioral therapy.

INTERPERSONAL PSYCHOTHERAPY (ITP)

ITP has shown some success for bulimia and for binge eating, but has not proven effective for anorexia nervosa. Unlike ITP for depression, there is a lack of focus on the primary symptoms of the illness, (Fairbanks, Jones, Peveler, Hope, & OConnor, 1993).

“ In ITP-BN the therapist tries to steer discussion away from eating disorder topics and toward their interpersonal context and to explore with the patient the affective and interpersonal problems that may be triggering and maintaining eating disorder symptomology.”

So, “Rather than addressing eating problems head on (like CBT), IPT helps patients improve their interpersonal problems driving their illness, which then leads back to reduction in disordered eating.”

Stress and Self-Hatred Causes Weight Gain – Case Example, ITP

Yvonne, 38, is an elementary school teacher who has been overweight since childhood. She has tried innumerable diets, repeatedly losing weight and gaining it back, and she berates herself for being a “fat pig.” Ashamed of her lack of willpower, Yvonne soothed herself with food when her now-former husband made nasty remarks about her weight.

After such a binge, she experienced remorse and vowed to be strong and disciplined from THEN ON. She enters therapy because she feels defeated by her lack of commitment to herself and wonders if she has a problem with emotional eating, although she fears this might just be an excuse for her weaknesses.

Yvonne’s therapist explains the relationship between painful emotional states and the misuse of food as an antidote and provides Yvonne with tools for tuning into her body’s hunger and satiety signals to dictate her eating, rather than following a weight loss plan. At the same time, the therapist teaches Yvonne to recognize the urge to overeat as a sign of emotional distress left unacknowledged.

Through therapy, Yvonne recognizes the effects of her father’s alcoholism on her family and herself. She had unknowingly learned from her father to stuff painful feelings down. Yvonne developed the habit of reaching for food to comfort herself when her father was drunk and arguing with her mother who was timid and didn’t argue back. As Yvonne’s eating became more in tune with her body’s needs and she developed greater emotional self-care skills, her body dropped much of the excess weight.

COGNITIVE THERAPY (CBT) – (BECK, A.T., FREEMAN, A., DAVIS, D., & ASSOCIATES, 2004)

Anorexia and bulimia represent a constellation of maladaptive beliefs that revolve around one central assumption: “My body weight and shape determine my worth and/or my social acceptability,” Revolving around this assump-tion are such beliefs as “I will look ugly if I gain more weight,” “The only thing in my life I can control is my weight,” & “If I don’t starve myself I will let go completely and become enormous.”

Anorexics show typical distortions in information processing. They misinterpret symptoms of fullness after meals as signs that they are getting fat. And they misperceive their image in a mirror or photograph as being much fatter that it actually is. (Beck & Weishaar, 2004).

CBT is a collaborative enterprise between the patient and therapist to explore dysfunctional beliefs and interpretations and try to modify them, chiefly through logical examination and behavioral experiments. CBT is evidence based, focused around triggers, behaviors, and consequences of the eating disorder. There is also focus on irrational and harmful beliefs, such as believing they are fat when they are severely underweight.

The therapist asks questions and the patient describes how he or she would like things to be different and what he or she might do to help create change, (Padesky, 1993). The technique is aimed at identifying and correcting errors in information processing, biases and beliefs, and testing out new beliefs to see if they are more accurate and functional. CBT also uses skills training (assertiveness, social skills, behavioral rehearsal) as behavior techniques.

“Perfectionist” Personality Type Leads to Anorexia – Case Example – CBT

Cathy, a 25 year old second-year medical student, came to therapy because some fellow students expressed concerns about Cathy’s extreme weight loss and increasing lack of participation in social events. Cathy maintains that she is simply stressed out about school, putting grades ahead of socializing.

She has recently lost about 15 pounds, and at 5’4” and 96 pounds, her BMI is 16.5. She is menstruating regularly, though very lightly, and has been on birth control pills for the last four years. Furthur questioning reveals that Cathy still has an intense fear of becoming “the fat kid that no one likes,” after having been teased for being chubby in middle school.

. As a teenager, she induced vomiting after meals for a few years, and more recently she has been cutting back on her food portions, eliminating fats from her diet, and avoiding social events that include food, because she doesn’t “know what’s in it.”

In addition to referring her to a physician for medical monitoring and a dietician for help devising an appropriate meal plan, Cathy’s therapist helps Cathy view anorexia an an unwelcome guest who has taken over Cathy’s brain.

She helps Cathy challenge the distorted, anorexia-driven thinking about her body’s needs for nutrients and energy, and as Cathy’s eating improves and her brain is better nourished, she begins to acknowledge her tremendous fear of being less than perfect stems in part from her parents’ intense focus on her academic achievements, rather than her inner emotional experiences.

Cathy learned to ignore her emotional needs after her parents divorced in an effort to please them, as they seemed happier when she did well in school. She also wanted to make sure that she wasn’t a burden or an unhappy reminder of their failed marriage. The therapist helps Cathy access her feelings and learn to manage painful emotions rather than starving them away, and Cathy becomes more comfortable in her body.

PSYCHOTHERAPY

This is the most in-depth eating disorder therapy, delivered one-on-one with a therapist. Eating disorder psychotherapy focuses on past life events (often traumas like abuse), personality issues, eating triggers and initial causes of the eating disorder. It is crucial in cases where the patient has a history of trauma or where the eating disorder is particularly severe or longstanding.

FAMILY THERAPY

This therapy deals with the effects the eating disorder has had on a family. Family therapy may include the parents of the patient, the children of the patient or other family members. It aims to address the damage done by the eating disorder and put into place new, healthy ways of dealing with family stress and creating a healthy family environment.

FINAL THOUGHTS

Eating disorder therapy can be delivered in many formats and while always focusing on the patient, the therapy may focus also on the way eating disorders affect relationships and family as well as patient-specific issues. It is important to take into account the relationships and environment of the patient during therapy for eating disorders, so the work the patient does is not undone by those around her or him.

BibliographyWedding, D., & Corsini, R.J., (2014, 2011.) Current Psychotherapies American Psychiatric Association, (2013) Dsm-5

Acknowledgement WEB MD