Eating Disorders A CBT Approach Beverly Swann MFT

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

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

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

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

Learning Objectives n Learn the DSM criteria for eating disorders (ED) n Understand common themes in ED related to body n n n 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!

Introductions / Expectations Your name Experience/knowledge Eating Disorders and/or Cognitive Behavioral Theory Expectations for the class

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

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/compulsi ve eating Food aversion Orthorexia Diabulimia Night eating

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

DSM-V – ED Proposed Additions (May 2013? ) n Avoidant/Restrictive Food Intake Disorder (food aversion) n Binge Eating Disorder n Feeding and Eating Conditions Not Elsewhere Classified (more defined than NOS) www. dsm 5. org

DSM V: Binge Eating Disorder n Binge eating - Average of 2 times per week for 6 months n No compensatory behaviors n Associated with at least 3 of the following: n n n 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

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

Medical Issues and Complications* - Anorexia Nervosa v v v v 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/neda. Dir/files/documents/handouts/Hlth. Cons. pdf

Medical Issues and Complications Bulimia Nervosa n n n Cardiac issues (bradycardia, tachycardia, orthostasis) Esophageal ruptures/tearing (blood in vomit, cancer) Electrolyte imbalances Elevated CO 2 Edema Sleep disruption Dental/enamel loss Low glucose Low sodium Swollen parotid glands Blood in stool

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

Etiology Genetics loads the gun, and environment pulls the trigger. Craig Johnson, Ph. D

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

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

Neurotransmitters: Development And Maintenance Of Eating Disorders n Dopamine n n n Correlated with harm avoidance Insensitivity to normal rewards (Frank, et al 2005) Serotonin n n n 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)

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

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

Cognitive Behavioral Therapy n Core Concepts 1. Thoughts cause our feelings and behaviors n 2. Time-Limited n 3. Not external factors (people, places, etc. ) Average of 16 to 20 sessions Therapeutic alliance important… but not the answer n Change occurs because client learns how to think differently and, as a result, act differently

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

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

Cognitive Behavioral Therapy n Stages of CBT 1. Identify problems n Prioritize 2. Recognize thoughts, beliefs, feelings about the problem n “Self talk” n Interpretations n Beliefs about self, relationships, situations, etc. 3. Identify faulty thinking n Record physical, emotional and behavioral reactions/responses 4. Challenge faulty thinking § Validity testing… again and again

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

CBT: Important Factors for the Therapist n n n 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

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

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

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

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

Assessment & Diagnosis n Initial Comprehensive History Includes: n n n 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.

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

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

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

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

Co-Occurring Disorders n Binge Eating Disorder n Affective Disorders n n n Major Depression Bipolar Disorder GAD PTSD n Axis II n

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

Co-Occurring Disorders n 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. n 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.

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

Culture n 42% of 1 st-3 rd graders girls want to be thinner n 45% of boys and girls in 3 rd-6 th grades want to be thinner n 37% have already dieted n 51% of 9 -10 year olds feel better about themselves n n 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

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

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: n 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 n Access to treatment n Language barriers

Cultural Considerations Acculturation Socio-economic status – County clients Gender considerations Gay/lesbian populations List of recommended readings: www. nationaleatingdisorders. org/neda. Dir/files/documents/handouts/Incorp. Di. pdf www. nationaleatingdisorders. org/neda. Dir/files/documents/handouts/Women. Col. pdf

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

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

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

The Psychology of Eating Disorders n How Patients Experience Eating Disorders n n n n 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

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

Assessment – Screening Tools n n n n Eating Disorder Questionnaire (EDQ) Obligatory Exercise Scale Addiction Severity Index (ASI) Adult ADHD Self-Report Scale (ASR-v 1. 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)

Assessment Tools n EDI III – based on females aged 13 -53 n n n History 91 items 12 Primary Scales n n n 3 ED specific 9 General psych (but highly relevant to ED) 6 Composites n n n ED Risk Ineffectiveness Interpersonal Problems Affective Problems Overcontrol General Psych Maladjustment Sample evaluation n Context of What You Know About Patient and Family/Loved Ones n

Assessment Tools n Obligatory Exercise Questionnaire n Comparison n Scales n 30 – 40 mild concern n 40 – 50 moderate concern n 50 + serious concern n Sample evaluation n Context of What You Know About Patient and Family/Loved Ones

Assessment Tools n Temperament and Character Inventory n 7 “Personality Dimensions” n 4 Temperament § Harm Avoidance, Novelty Seeking, Reward Dependence, Persistence n 3 Character § Self-directedness, Cooperativeness, Selftranscendence

Assessment Tools n Common combinations: n Anorexia n Temperament § § n High harm-avoidance Low novelty-seeking High reward-dependence High persistence Character § § § Self-directedness varies High cooperativeness Low self-transcendence

Assessment Tools n Common combinations: n Bulimia n Temperament § § n Harm-avoidance varies High novelty-seeking High reward-dependence Low persistence Character § § § Low self-directedness Cooperativeness varies High self-transcendence

Treatment - Levels of Care n Outpatient – typically once a week therapy n Intensive Outpatient (IOP) – 3 -4 days/week, half-day n Partial Hospitalization (PHP) of Day Treatment – 4 -5 days/week, full-day n Residential – 24/7 treatment, client does not go home n Inpatient – 24/7 medical treatment to stabilize patient medically – usually short-term

Treatment Focus n Medical/Nutrition Stabilization for medically compromised clients n Weight restoration for underweight clients n Neuronal plasticity – brain circuitry is modified by experience – CBT! n Resolve trauma n Develop new habits n Grieve loss of ED n Discover “Who Am I Without ED? ”

Video – Erasing ED Notice: • Co-occurring disorders • Behavioral changes • Thought changes • Belief changes • Possible CBT interventions

Cognitive Behavioral Therapy n Stages of CBT 1. Identify problems n Prioritize 2. Recognize thoughts, beliefs, feelings about the problem n “Self talk” n Interpretations n Beliefs about self, relationships, situations, etc. 3. Identify faulty thinking n Record physical, emotional and behavioral reactions/responses 4. Challenge faulty thinking § Validity testing… again and again

Cognitive Behavioral Therapy n Things to Consider When Identifying the Problem(s) n Gravity/severity of illness n Length of symptoms/situation n Rate of progress made during treatment n Level of stress-tolerance n Support system

CBT – Cognitive Distortions 1) Filtering 2) Black & White Thinking 3) Overgenerlization 4) Jumping to Conclusions 5) Catastrophizing 6) Personalization 7) Control Fallacies 8) Fallacy of Fairness 9) Blaming 10) Shoulds 11) Emotional Reasoning 12) Fallacy of Change 13) Global Labeling 14) Always Being Right 15) Heaven’s Reward Fallacy http: //psychcentral. com/lib/2009/15 -common-cognitive-distortions/

CBT Interventions H = Hungry – am I physically hungry? A = Angry (or other emotion) – am I emotionally hungry? L = Lonely – am I lonely? T = Tired – do I need sleep rather than food?

CBT Interventions n Case Formulation – Vicious Flower n Recording n Food/Mood Log n How Treatment is Going n Identifying Barriers to Change n Identifying “Rules” n Eating rules n Exercise rules n Address impact of events on eating

CBT Case Formulation Belief. Driven http: //www. psychologytools. org/download-therapy-worksheets. html/

CBT Case Formulation Vicious Flower http: //www. psychologytools. org/download-therapy-worksheets. html/

CBT - REBT Ellis’ Rational Emotive Behavior Therapy (REBT) n ABC n n n A = Adversity or activating event B = Belief(s) about the event C = Consequences (dysfunctional emotional and behavioral) n Focus on evaluating B n Look for assumptions and thoughts that are illogical, rigid, unrealistic &/or self-destructive

CBT - REBT assumes that humans have innate rational and irrational tendencies n Irrational tendencies: Self-blame n Criticism n Anger n Depression and anxiety n Avoidance n Addiction n Procrastination How might these show up in an eating disorder client? n

CBT - REBT n Primary goal: You Have A Choice To engage in helpful thoughts or selfdestructive thoughts n Helpful emoting is good – unhelpful is problematic n Ingrain them over time with practice n Major Insights n Irrational beliefs are “root” of issues n People tend to hold on to irrational beliefs, so focus on identifying, questioning and change n Insight alone rarely uproots emotional/psychological issues n

REBT – 3 Core/Common Self. Destructive Beliefs 1. “I absolutely must, under all conditions, perform well and win the approval of others. If I fail… I am a bad, incompetent person, who will probably always fail and deserves to suffer. ” n Contributes to anxiety, panic, feelings of despair, hopelessness, depression and low self-worth 2. “Other people… MUST, under practically all conditions and at all times, treat me nicely, considerately and fairly. Otherwise, it is terrible and they are rotten, bad, unworthy people who will always treat me badly and do not deserve a good life. . . ” n Contributes to anger, rage, vindictiveness 3. “The conditions under which I live absolutely MUST, at all times, be favorable, safe, hassle-free and… enjoyable. If they are not… it’s awful and horrible and I can’t bear it. I can’t ever enjoy myself… my life is impossible and hardly worth living. ” n Contributes to frustration, intolerance, self-pity, procrastination, avoidance and feeling paralyzed.

REBT – Long-Term Goals n Humans are fallible – move toward unconditional self-acceptance n Accepting what they can and cannot change about the world n Assessing skills n Insight is not enough – move toward challenging and changing irrational/selfdestructive beliefs

REBT Core Beliefs n n n Each of the 3 core beliefs have the following in common: n Awfulizing n Frustration intolerance n People depreciation or de-valuing n Over-generalizing n Catastrophizing Each of the 3 core beliefs are dogmatic, rigid and over-use: n Shoulds n Musts n Oughts Often lead to the patient being self-critical - they become aware of these beliefs on some level and become frustrated that they cannot change this quality/dynamic within themselves

REBT Interventions 1. Acknowledging the problem 2. Accepting emotional responsibility 3. Assessing, questioning and ultimately changing 4. Uses various methods, depending on problem n n n Cognitive Emotive Behavioral

REBT and Eating Disorders n Useful with Temperament and Character n Irrational tendencies: n n n n Self-blame – High Persistence (perfectionism) Criticism – Low Cooperativeness (blaming) Anger – High Novelty-seeking Depression and anxiety – High Rewarddependence Avoidance – High Harm Avoidance Addiction – High Persistence (social attachment) Procrastination – High Harm Avoidance (fear)

REBT and Eating Disorders n Using the ABC n n A = Adversity or activating event – Body Changed During Puberty B = Belief(s) about the event – § § § n n I can’t trust my body My body will gain weight forever I can’t trust myself with certain foods C = Consequences (dysfunctional emotional and behavioral) – I must always be on a diet to control my body weight (or eventually I need my eating disorder) Focus on evaluating B § Look for assumptions and thoughts that are illogical, rigid, unrealistic &/or self-destructive

Linehan’s Dialectical Behavioral Therapy (DBT) n Originally designed for treating Borderline Personality Disorder n Combines CBT techniques with Mindfulness and Distress Tolerance Uses cognitive challenges around distorted thoughts/beliefs n Mindfulness training as self-soothing skills n Research indicates effectiveness with mood disorders, self-injury, sexual abuse survivors and substance abuse n Therapist is an “ally” n

DBT Basics n Four Basic Modules in DBT Treatment n Mindfulness - “What” and “How” n Distress Tolerance n Emotion Regulation n Interpersonal Effectiveness n 3 Primary Techniques/Tools n Diary Cards n Chain Analysis n Milieu

DBT – Basic Modules 1. Mindfulness – to challenge impulsivity “What” – describe an event w/o taking emotions and thoughts literally n “How” – how patient attends and participates in the event; focus on taking a non-judgmental stance – event is neither “good” nor “bad” 2. Interpersonal Effectiveness n Asking for what one needs n Saying “no” n Coping with interpersonal conflict n

DBT Basic Modules 3. Emotion Regulation Skills n n n Identifying and labeling emotions Identifying obstacles to changing emotions Reduce vulnerability to the “emotional mind” Increasing positive events, mindfulness Taking “opposite action” (doing something nice when you are angry) 4. Distress Tolerance Skills n n n Accepting one’s environment Not placing “demands” on it to be different Experience emotions without trying to stop or change them Observe thoughts/actions without trying to stop/or control them Key component: acceptance of reality is NOT equivalent to approval of reality

DBT Primary Techniques/Tools n Diary Cards Start with Myths Sheets (handout – G) n Move to Diary of day, event, emotion’s function n Chain Analysis n Look at environmental and personal antecedents to event n Consequences of event n At what point(s) could different choice(s) have been made n Milieu n Provides rich learning opportunity to practice skills on regular basis n

DBT Interventions 1. Mindfulness – What & How = challenge 2. 3. 4. impulsivity of behaviors Interpersonal Effectiveness – Saying “no” and coping with conflict = challenges harm avoidance, reward dependence Emotion regulation – reducing vulnerability to emotional states = challenges harm avoidance, high novelty seeking Distress tolerance – accepting/not trying to change environment = challenges novelty seeking, harm avoidance

CBT-E n Created by Christopher Fairburn, associates n An “enhanced” version of CBT n Emphasizes processes that maintain ED psychopathology – not initial development n Goal is to create a “formulation” or hypothesis of the processes that maintain the “Eating Disorder Mindset” - These become the features targeted in treatment

CBT-E Stages n Time-limited: 20 sessions (40 for acute AN) n Four Stages n Stage One – 2 x/week for 4 weeks 1. 2. 3. Establish trust Formulate hypothesis of processes that maintain ED Establish Two Things n n In-session Weighing Regular Eating

CBT-E Stages Stage Two – 1 x/week for 2 weeks 1. Take stock in stability with behaviors, weight 2. Plan stage 3 – tackling mechanisms that maintain ED n Stage Three (the Bulk of Treatment) – 1 x/week for 8 weeks 1. Addressing Shape Checking, “Feeling Fat” and Mindsets n Use pie charts, monitoring records, life chart, 2. Addressing Dietary Rules n Food avoidance list 3. Events, Moods and Eating n Problem solving chart, slowing down/observing and analyzing, pros and cons list for ED, reasons to change list n

CBT-E Stages n Stage Four (Ending Well) – 1 x/every 2 weeks for one month 1. 2. 3. Empowering patient to “do the right thing” and reinforcing competency Distinguishing “lapse” from “relapse” Learning the stages/warning signs for return of the ED mindset

Video – Erasing ED Notice: • What improved in their lives? • Life without ED? • Hope

Local ED Treatment Centers n Casa Serena – IOP, Concord n Cielo House – IOP, PHP, Belmont and San Jose n Herrick/Alta Bates – Inpatient/Outpatient, Berkley n La Ventana – IOP/PHP, San Francisco, San Jose, and Marin (some dual diagnosis treatment) n New Dawn – PHP, San Francisco (some dual diagnosis treatment) n Summit – IOP/PHP/Residential

Wrapping It All Up Question / Answer / Review

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