Wednesday, December 13, 2017

Television and Dysfunctional Eating in Teens

Vol. 28 / No. 6  

One gender-related difference emerged in a study in southern Italy.
Adolescence can be a wondrous time of physical growth and exposure to new ideas and experiences, but it may also bring social aspects of everyday life that negatively affect body image. Environmental factors such as teasing by peers and family members and exposure to unattainable ideals of thinness are good examples.
Dr. Barbara Barcaccia and researchers at the University of Sapienza, Rome, and Boston College explored the possible influence of models portrayed on TV on adolescents. The authors sought to examine body image, uneasiness with one’s body, eating-disordered behavior, depression, and anxiety among a group of teens and young adults (Revista Brasileira de Psiquiatria. 2017; doi:10.1590/1516-4446-2016-2200, published online before print). The Italian researchers studied 301 teens 14-19 years of age who were recruited from 13 high schools in southern Italy. The teens filled out a series of questionnaires, including The Body Uneasiness Test (BUT) and the Eating Disorders Inventory-2. The BUT contains 71 questions about weight phobia, body image concerns, and worries about specific bodily parts and functions (Eat Weight Disord. 2006; 11:1). Sample statements include “I avoid mirrors” and “I compare my appearance with others.”
Responses differed by gender
One trend that emerged from the study was gender-based responses to media exposure, highlighting differences in susceptibility to body misperceptions among males and females. Just as reported in previous studies, drive for thinness was impacted more by media exposure in females than males. Perhaps sensitivity to media images helps explain differences in ED prevalence by gender. The authors noted that women do watch more entertainment and image-focused television programs than do men (Eat Behav. 2013. 14:441). They also pointed out that objectification theory states that in Western culture women are specifically objectified and their bodies used to measure self-worth. This then leads to a subconscious tendency for women to compare their body image to others to a greater extent than do men (Psychol Women Q. 1997. 21:173).
Another interesting finding in this study was that the extent to which males’ friends wished to physically resemble TV characters; this was the only statistically significant finding for the males in the study. The authors pondered various possible causes for this trend. While males and females are sensitive to the influence of their friends, in the Italian culture, according to the authors, boys and men interact socially to a greater extent than in other parts of the world.
The results also showed that women were more susceptible to ED behaviors, distorted perceptions of their bodies, and development of depression after exposure to mass media. In contrast, males were more susceptible to distorted perception of their bodies, state and trait anxiety, and depression through indirect comparisons to the mass media through their friends.

A Promising Agent for ED Patients with Severe Behavioral Problems

Vol. 28 / No. 6  

A pilot study used an agent originally designed for patients with epilepsy.
Studies of medications such as SSRIs for individuals with eating disorders have focused on the ED, but many people have co-occurring pervasive severe affective and behavioral problems. A recent trial has offered hope for this subgroup of ED patients.
Some patients with bulimia nervosa (BN) and binge-purge type anorexia nervosa (ANbp) can have many bouts with loss of control eating and compensatory behaviors, such as self-induced vomiting, often with severe medical morbidity. Other comorbid behaviors can include substance abuse, impulsive behaviors such as shoplifting, and self-injury.
Dr. Mary Ellen Trunko and colleagues at the University of California, San Diego, recently reported the results of their pilot study evaluating use of the mood-stabilizing drug lamotrignine (Lamactal®) in a group of patients with ANbp and BN with a range of dysregulated behaviors who had not responded to antidepressants (BPD and Emotion Regulation. 2017; 4:21). The small study group included 9 women with AN or BN-spectrum eating disorders (14 started the trial but 5 did not complete 2 months, for various reasons). All the women were participating in dialectical behavior therapy (DBT) in partial hospital or intensive outpatient treatment settings. Their treatment included 10 hours per day, 6 days per week. As the women improved, they were able to step down to 6 hours of treatment a day and ultimately to 4 hours a day. All participants received a routine lamotrigine titration until a target dose of 100 to 300 mg per day was reached.
Their DBT program included weekly individual sessions, twice-weekly skills training groups using the DBT Skills Manual (Linehan M. DBT Skills Manual, second ed. Guilford Press, New York, 2008), group sessions, and skills coaching via telephone contact or text-messaging outside program hours. The women also underwent emotional and behavior assessments and were studied with a number of questionnaires, including the Eating Disorder Examination Questionnaire (EDEQ). All the DBT therapists met as a team once a week.
An improvement in symptoms was noted
All 9 women who completed the study reported reductions in dysregulated emotions and problems with impulse control. In general BEST and ZAN BPD ratings improved and lamotrignine was said to well-tolerated. One of the women stopped the medication because of a possible rash, a rare but potentially very serious side effect of lamotrigine.
The authors argued for a large-scale rigorous investigation of the drug, with and without DBT or other therapies. This would differ from most med trials in ED in that an inclusive rather than exclusive set of criteria would be used, resulting in a highly comorbid group (of the sort we often see in routine clinical care).

Some Surprising Genetic Findings for Individuals with Anorexia Nervosa

Vol. 28 / No. 6  
One discovery was a genetic basis for greater educational achievement.
We know there is an important genetic component to anorexia nervosa, but a recent study points in some surprising directions. This large study by Laramie Duncan, PhD, and colleagues (Am J Psychiatry. 2017; 174:850) not only suggests that AN can be partially heritable, but also that metabolic, weight-related, and inflammatory factors may be some of these inherited components.
A scan of the entire genome for links
In all, 3,495 participants with AN and 10,982 controls took part in this remarkably large study. A genome-wide associate scan was conducted to search the entire genome for links between AN and genetic markers. At least three major findings emerged. First, confirming results from previous studies, AN was shown to be partially inherited, with genes accounting for about 20% of the chance of developing the disorder. Second, there was a strong association between AN and the area on a chromosome near genes for diabetes mellitus and some autoimmune diseases. Third, people with AN had lower body mass indexes, lower insulin and glucose levels, and higher high-density lipid cholesterol levels than those without the disorder. Finally, individuals with AN had higher educational achievement. This is an interesting finding because in the past such accomplishments were assumed to be primarily related to family environment. This study suggests that higher achievements may in fact have a genetic basis.
These findings, if replicated, will greatly broaden our understanding of the phenomenon of AN, to include both metabolic and behavioral components of the disorder.

Self-Admission for Inpatient Treatment

Vol. 28 / No. 6  

A small study found areas that needed improvement for ED patients.
For more than a decade, selected patients with severe psychiatric illnesses, including eating disorders, have been able to admit themselves for inpatient treatment in several European countries (which differs markedly from practice in the US).
Eligible patients can typically admit themselves at will for 3 to 7 days, and may leave the service at any time. To be eligible, patients must maintain constant contact with the adult outpatient unit or day treatment unit. Another requirement is that they must have been treated at least one time in the adult inpatient ward during the past 3 years, and know the framework of and the routines and rules of the specific ward.
Swedish researcher Dr. Mattias Strand and colleagues wanted to examine patient experiences with self-admission during the process of starting a new self-admission program in an eating disorders service at the Stockholm Centre for Eating Disorders (BMC Psychiatry. 2017; 17:343). The Swedish researchers interviewed 16 patients in a self-admission program after 6 months, to learn about their experiences and to get suggestions for improving the program.
Some room for improvement
Most patients were generally satisfied with their experience, but they also had suggestions for improvements. One overarching issue was maintaining the balance between the positive effects of the patient’s sense of autonomy and the difficulties handling the freedom and responsibility involving in self-admission. Some patients were not always confident that they could use the increased accountability in a constructive way. An example of this was problems that arose during the process of reserving a bed in the inpatient center. Although the patient is responsible for checking on the availability of a bed and calling back to check on the status of a bed before admission, this was stressful and proved discouraging to some. Establishing a separate waiting list for the self-admission beds (usually 2 to a unit) was the solution. Other patients found staff rotations unsettling. Because their stay in the hospital was usually brief, they did not always work with the same staff members, and had no single regular contact person. Some felt there was not enough emphasis on long-term goals. One patient summed it up well by saying, “This thing about deciding a lot for yourself—perhaps you need to be a little careful about that because if you get to decide for yourself, very often it will be the illness talking.”
Some changes were made
The authors implemented several changes, including providing more thorough information about the rationale of self-admission and patient accountability. They also provided a single contact staff member for each self-admitted patient. Another very important addition was a thorough discussion of one major drawback of the program: the brief time of admission makes it unlikely that a patient can achieve any long-term treatment goals during a single stay. Instead, the authors stress that self-admissions should be viewed as booster opportunities or brief respites. Finally, according to the authors, patients with an eating disorder may be even more reluctant to seek help than other patients, and this needs to be addressed in the design of future self-admission programs.
This is an intriguing approach. For those with ED, one wonders if it will be highly effective in interrupting symptoms of binge eating and purging, or restricting, or if ultimately it will be too small a dose to be helpful.

A Better Way to Measure Body Composition?

Vol. 28 / No. 6  

Measuring free fatty mass with BIA equations
Body weight and body mass index (BMI, kg/m2) are two major measurements used to establish body composition and degree of underweight or overweight. However, according to a group of Italian researchers, these gold standards turn to tin with severely malnourished patients, such as those with anorexia nervosa (AN). Dual energy x-ray absorptiometry (DXA) represents a gold standard but is not always available; BIA is more available but seen a less valid. Could better equations to calculate BIAS results help? (Nutr Clin. 2017; http://dx.doi.org/10.1016/ clnu.2017.07.016, published online).
One such technique uses DXA. Dr. Maurizio Marra and colleagues at Frederico II University, Naples, Italy, evaluated several BIA equations to determine how accurately they could estimate body composition among patients with AN. Their study group included 82 AN patients with restrictive-type disease (ANr) who were attending the outpatient clinic at the authors’ university. All underwent whole-body DXA scans with two x-ray beams at different energy levels to measure free fatty mass (FFM, or lean body mass plus bone mineral content) and fat mass (FM). BIA was performed and then various approaches to analyzing the results were examined.
Results: BIA measurements underestimated FFM
On average, all the BIA equations significantly underestimated DXA-derived FFM values. Overall, DXA was more accurate than BIA, which in turn gave a more accurate picture than BMI.   The authors underscore the need to develop disease specific methods for analyzing BIA results as a way to make them more useful.

Web-Based Aftercare for Women with Bulimia Nervosa

Vol. 28 / No. 6  
Early results were promising, but dropouts were a problem.
Response to treatment for BN is modest, but an important factor is that relapse is common (Psychosom Med. 2011; 73:270). To combat this, a group in Germany recently designed a 9-month manualized CBT Web-based aftercare program for women with BN (J Med Internet Res 2017; 19:e321, published online before print). This is one of the first studies designed to evaluate the efficacy of programs targeting maintenance or improvement of treatment gains achieved during inpatient treatment for BN.
Web-based interventions have several advantages over face-to-face interventions, according to Dr. Corinna Jacobi and her colleagues. Patients’ access to the Internet reduces barriers such as cost, availability of services, waiting time, transportation challenges, and stigma about having an eating disorder. The increased anonymity may also encourage individuals to seek help.
Dr. Jacobi and her fellow researchers conducted a randomized controlled trial of 253 women with DSM-IV diagnoses of BN. Over more than 4 years, patients were screened and recruited from 13 hospitals throughout Germany that offer inpatient treatment for eating disorders. Patients were eligible for the study if they were at least 17 years old and had reduced their binge-eating and compensatory behaviors by at least 50% compared to their levels at hospital admission. Participants were then randomized to treatment with the Internet program, “IN@,” or to treatment as usual.
The Web-based intervention, IN@, included information on eating behaviors and core bulimic symptoms, and advice about healthy exercise, body image, and self-esteem. In addition, the IN@ program included a monitoring log for bulimic symptoms and a personal diary. Three clinical psychologists specially trained in behavior therapy for EDs also provided individualized email feedback and up to 9 monthly real-time individual personal chats of about 1 hour per participant. Women in the treatment-as-usual group were also assessed at all follow-up points, and had the option to take part in any outpatient treatment programs offered by the individual hospitals. Assessments were made at admission, at discharge from the hospital, 9 months after admission, 9 months after the intervention, and 9 months after this. Because the study hospitals were scattered throughout Germany, and the patients returned home to different parts of the country, all interview assessments were done by telephone by trained assessors blinded to patient group assignments.
The authors reported that 15% of the women in the intervention program never logged onto the Internet site after being discharged. The remaining 107 women accessed at least half of the intervention content. Forty-seven women (37%) participated in at least one live chat.
Symptoms and program adherence at study’s end
In general, results were numerically better in the IN@ group, but many othercomparisons were not statistically significant. Binge-eating episodes increased significantly in both groups after discharge from the hospital. However, at the post-intervention follow-up, binge-eating episodes were 27% lower in the intervention group than in the treatment-as-usual group. At follow-up there was no difference between the two groups. At the post-intervention assessment, about 1 in 5 patients reported abstinence from binge eating and lack of compensatory behaviors during the prior 2 months, but the difference between the treatment groups was not significant.
As for the incidence of vomiting at the post-intervention point, it was 46% lower in the intervention group, a statistically significant difference. At follow-up, the frequency of episodes of all compensatory behaviors was 41% lower but the difference was no longer significant. The authors note that even though the intervention did not significantly affect abstinence, the results may have important clinical implications, namely that rates of vomiting in the intervention group were almost half of those among the treatment-as-usual group.
What could improve adherence to a Web-based CBT program? The authors suggest that future programs be directed at adapting interventions to help increase adherence and reduce dropouts because use of the website and live chats was modest.

Perspectives: Teaching New Math for EDs

By Sandra Wartski, PsyD, CEDS
At the height of their illness, clients with eating disorders are often engaged in ongoing mental math torture. There is usually an exhausting focus on various mathematical calculations, including calories consumed, calorie expenditure, restrictive meal planning, exhaustive menu examination, weight analysis, clothing size scrutiny, and a myriad of other mental gymnastics that undermine concentration and focus upon joyful life activities.
Some of this over-focus on numbers can represent an OCD (Obsessive Compulsive Disorder) and ED overlap; however, unlike some of the other non-ED-OCD behaviors, such as door-tapping or handwashing, the ED numbers focus ends up being much more deeply rooted in meaning, entrenched “stuckness,” and trepidation.   The gold standard of treatment for OCD is more formally known as Exposure Response Prevention (ERP) therapy, and generally involves refraining from giving in to the OCD commands. ERP requires an individual to be exposed to the thoughts, images, and objects that trigger anxiety and then preventing usual responses to this anxiety with compulsions and/or rituals.
ED treatment involves a healthy dose of the ERP approach (even when not labeled as such), because keeping up with food and eating is a daily requirement (unlike some of the pure OCD “pulls” that can be more easily avoided, such as airplanes or cracks in the sidewalk), and is at the core of recovery. But the extra layers of ED meaning imbued upon the numbers means that clinicians may also need to pull in additional skills.
ED treatment is already multifaceted. Part of treatment does involve teaching a new approach involving facing calories, weight, size, and food. We wish for less negative obsession about amounts and numbers but, paradoxically, we also need a reasonable focus on some of this at the start of recovery. We are generally aiming at intuitive eating eventually, where we would hope that selection of a particular snack is based more on availability and taste preference rather than fat grams or calories. Unfortunately, most clients are far from this in the beginning. The majority need guidance in general structure, outlines, and minimums to begin the process of resetting in this confusing process of attending mindfully to hunger and fullness signals.
When negative number crunching or mental math torture is a significant symptom, sometimes creating a surprising or novel approach can help to break rigid routines. Some clients are willing to engage in straightforwardly breaking habits with a more basic exercise such as deliberately creating number confusion. This might involve repeatedly reciting random numbers or counting backwards in Roman numerals when the ED counting commences, but sometimes teaching a more comprehensive “New Math” is what might be needed.
New Math Subtraction
Clients are generally well versed with skills that enable them to cut out or avoid foods. Sneaky subtraction tactics are presented by the ED as logical and necessary but are really duplicitous and devious. New Math Subtraction might involve helping a client to find other things to cut out of his or her current routines instead. We can help clients to consider other things to subtract from their current life. Aside from aiming to diminish the continual math calculations, we can encourage them to consider other, broader-range issues that deserve to get cut out of their lives. We might propose questions about what else needs to be subtracted from current thinking patterns, behavioral interactions, relationships, and life routines in general that would substantially enhance current health and happiness. When ED subtraction begins to take hold, can we stop and switch gears to figure out what else might be subtracted instead? Perhaps this involves cutting out time spent on certain social media sites or with certain competitive friends. Maybe this involves getting out of an old routine of not eating at family dinners and instead cutting out the habit of not speaking up. Rather than avoiding certain taboo foods, is there perchance a need to cut out a false assumption or negative association?   Subtracting and deleting that which truly needs to be deleted is freeing.
New Math Addition
Individuals with EDs also add in ED-inspired behaviors fairly regularly, such as calculated water-loading to manage hunger pangs or secretive over-exercise to undo the anxiety of having added in a snack. Addition anxiety lurks around every bend, allowing the ED to attempt to prevent or “make right” any perceived failing. With New Math Addition, there are multiple add-ins to consider. We might aim to help clients to creatively consider what they need more of in their lives. This requires a broader perspective than the usual ED narrow focus, moving away from “needing” more torment and instead finding ways to add in more joy, fun, and relaxation. What else would they like to be included in their lives? What else has needed to be said or revealed that has been missing from conversations for far too long? What has been absent since the ED took residence and could be added back in? Looking for those add-ins that truly enhance day-to-day living from the inside out creates a whole new dimension of living.
New Math Multiplication
ED multiplication misery comes in various forms, such as repeatedly rounding up calorie estimations, distorted message cycling, and falling into mirror distortion trickery. New Math Multiplication focuses on more authentic ways of maximizing enjoyment.   Helping clients orient to ways of capitalizing on and actively seeking out more of the good is complex at the beginning but becomes increasingly easier as new routines are established. Like learning the times tables, there is effort needed at first but then the calculations become second nature. Can we help clients find a way to practice reviewing the positive experiences and moments of gratitude twice as often as the negative? Are there activities that would be double the fun with a good friend? Can we orient to how the delight of a meal or the comfort of an outfit might be quadrupled? Multiplier effects can create an explosion of positive experiences.
New Math Division
Grapes cut in half, sandwiches into quarters, or brownies into sixths are not uncommon partitioning practices for those struggling with an ED. There is often the concern about how much is too much, and then the derogatory division begins. Instead of cutting the serving in half, can we explore ways of cutting the stress in half? Can divide up the unrealistic work load instead of the next snack? Helping a client to stay in treatment and to feel the support of their treatment team and their support system is likely to be the most essential new math concept in the domain of division. Any workload, fear, anxiety, and confusion are generally reduced significantly when shared with others. Clients have often spent so much time operating secretly and calculating cunningly that this notion of sharing and letting in others will be hard, but ultimately distributes the difficulty so much more effectively. Dividing the things that truly need sharing and balance rather than the nutritional intake needs allows more stable and settled focus overall.
Privileging the Practice
Just as with any new skill, New Math requires practice and repetition. Once we are used to approaching situations in one way, shifting to a new way of thinking takes time and patience. Sometimes, however, a little bit of surprise and lightheartedness can disrupt even the most rigid of routines.