Monday, August 1, 2016

Eating Disorders and Opportunity: Thoughts from a Medical Trainee

Eating Disorders and Opportunity: Thoughts from a Medical Trainee

By Nicole Cifra, MD, MPH
I didn’t start medical school expecting to become so interested in eating disorders. While I always had the feeling I would like working with younger patients, I would have initially guessed that I’d end up doing something along the lines of pediatric oncology. It wasn’t until the end of my second year of medical school, when I was studying for my first set of boards (otherwise known as “Step 1”) that I became aware of the need for professionals in the eating disorders field.
As a part of my tightly adhered to study schedule, I was studiously listening to a friendly psychiatrist give the online behavioral science lectures my school had purchased for us. I received two lectures on eating disorders during my first two years of medical school, so I realized I had quite a bit to learn about this topic.  However, the first words out of the lecturer’s mouth weren’t about the epidemiology or the diagnostic criteria of these diseases, as was the norm for this lecture series. Instead, he began by saying that this was an area of great need, both in terms of treatment and research.
This got my attention. As a then 23-year-old female, I knew eating disorders weren’t exceedingly rare. As the National Eating Disorders Association says, “everybody knows somebody,” or in most cases, at least a few people. I also knew from the lectures I had already received that eating disorders were highly fatal. I found the combination of seriousness and simultaneous lack for resources and expertise very intriguing.
After I took my exam, I became otherwise engaged in a year of public health study following my second year of medical school. But the curiosity lingered, and led me to a yearlong clinical experience in adolescent medicine, a board of directors position with an eating disorders related non-profit, and the Society of Adolescent Health and Medicine annual meeting. The complexity of eating disorders as being both psychiatric and medical, coupled with the influence of environmental and developmental factors, continued to interest me.  As my public health classmates discussed interventions on childhood obesity, I found myself concerned about the opposite end of the spectrum.  I played the devil’s advocate in class when we discussed programs, policies, and beliefs related to obesity, and jokingly referred to myself as the “public health heretic.”
The next year, I brought this newfound knowledge and passion with me to my third year of medical school, where I was surprised by the opportunities available to me because I had this unique interest. As a medical student, it’s hard to feel like you’re contributing to your team, but on many rotations I was able to offer knowledge that directly benefited the care of patients exhibiting eating disordered behaviors.
From my perspective, the field of eating disorders represented an opportunity.  I gave in-service presentations on the new DSM-5 criteria, educated our hospitalist teams about the use of blind weights, and provided information regarding different levels of care when it came time to discharge patients. One of my mentors says “the expert is the person in the room who knows the most on a subject,” but I never would have guessed this person would ever be the medical student, or at least not me.
When I look back at my medical school experience, I’m grateful that my interest in eating disorders was sparked during that time. As trainees, it’s easy to get into the habit of thinking that our time to contribute is in the distant future, when we have acquired a certain amount of knowledge or proficiency. Through my experience, I’ve learned that everyone has something to offer, even those with the most to learn.
I’ve also learned to view eating disorders as not an area where medicine has fallen short, but an area where there is exciting opportunity to move forward.  We, as a medical community, are learning more about how to better prevent and treat these diseases, and in turn improve the lives of our patients. There are few things I can imagine that would be more exciting to be a part of as a trainee.

The NEDA Parent, Family and Friends Netw

By Suzanne Oliver

Visit the NEDA website, attend the organization’s annual conference or participate in a fundraising walksponsored by the National Eating Disorders Association (NEDA), and you will immediately perceive that the focus of this organization is to embrace and support the experiences of both eating disorder sufferers AND their loved ones. NEDA knows that loved ones play a critical role in recovery, and that they need information, a compassionate ear and informed encouragement to help them overcome the sometimes isolating and overwhelming experience of supporting a loved one with an eating disorder.
The Steering Committee of the Parent, Family and Friends Network (PFN) has been comprised of parents and siblings of eating disorders sufferers and has been critical in identifying and creating the resources and programs that support families and loved ones. These include publications like the online Parent Toolkit, the peer-to-peer support of the NEDA Navigators program, the NEDA Conference buddy system and a library of videos (http://www.nationaleatingdisorders.org/webinars) featuring experts discussing topics of relevance to parents and loved ones, such as the levels of care in eating disorders treatment, the role of nutrition therapy in eating disorders treatment and tips on obtaining insurance authorization for eating disorder treatment. NEDA estimates that PFN sponsored videos and publications have reached over 20,000 people. In addition, 288 people have been trained as NEDA Navigators.
The Navigators program is the most hands-on effort of the PFN. Through the NEDA Helpline (800-931-2237), those caring for a loved one struggling with an eating disorder can be connected with a trained Navigator for peer-to-peer online support geared towards offering short-term, goal-oriented assistance. Navigators can help identify treatment options, support groups, websites, books, and next steps on the road to recovery. They offer the wisdom of experience and encouragement, sharing personal stories and listening to the concerns of those who request a Navigator relationship.
Another important effort of the PFN is curating personal stories and relevant resources for families.  The Making Connections magazine was created to reach parents, families and friends of eating disorders sufferers.  Downloads of back issues are available on the NEDA website and include articles such as “The Dilemmas of Men Who Have a Loved One with Eating Disorders”, “ED Lingo 101 for Siblings: Learning to Listen to My Sister As Just My Sister, Not As Her Eating Disorder,” and “The Impact of an Eating Disorder on Siblings.”
Currently the PFN Steering Committee is exploring the best way to bring these kinds of stories and information to the community digitally. These new efforts will complement an already robust collection of existing resources. Through the NEDA website, friends and family members can currently access the Online Eating Disorder Screening Tool, tips on talking to a friend who may be struggling with eating and body image issues (http://www.nationaleatingdisorders.org/family-and-friends) and search treatment providers (http://www.nationaleatingdisorders.org/find-treatment).  Additionally, parents, friends and family are invited to visit NEDA’s online Google Hangout and to view its video library on youtube (https://www.youtube.com/user/NEDANETWORK). I personally wish I had found the NEDA resources much sooner than I did.  Once I discovered them, I bookmarked the NEDA website and have returned often for videos, articles and webinars that have all been enormously valuable to me.

Tuesday, July 5, 2016

Supporting yourself through eating disorder therapy

Supporting yourself through eating disorder therapy

By Leslie Becker-Phelps, PhD
Choosing to enter therapy for your eating disorder means choosing a difficult, though rewarding, path. Whether or not you realize it, you are probably struggling with conflict about the decision. While part of you wants to change, another part of you isn’t ready to be different. It’s still holding tight to those familiar patterns, even though you know that they are also destructive. With each obstacle – whether it is within you or in the “real” world – you will probably feel frustrated and lose patience. You may become harshly critical of yourself – and this can prove to be your biggest problem. When you turn against yourself, you become your own worst enemy and your biggest obstacle to becoming healthier. 
Rather than waging an inner war, try a gentler, more understanding approach. By being kind to yourself and attending to your difficulties in a compassionate manner, you become your own friend, support, and advocate.
To clarify, consider the following scenario: You come across an abandoned child (or dog) in an alley. He cowers fearfully in a corner. And you want to help him. If you approach him as you might approach yourself – with accusations and anger – he will probably respond with pulling back further into the corner or attacking. So, instead, you approach him slowly and with a quiet, reassuring voice. With time and patience, you can probably win his trust and guide him to getting more help. 
This is the same approach that you need to take with yourself.  Using this analogy, do the following:
Identify a self-criticism: Think about a trait or situation that prompts you to be self-critical.  For instance, you might focus on how you tend to be extremely critical about your body. (Limit your time thinking about this. You want to identify your self-critical thoughts, but not get pulled into repeating and reinforcing them.)
Imagine the victim in you. As a third party observer, watch how your ‘inner bully’ criticizes your ‘inner victim.’ See the victim part as a hurt or scared child. Then try to really connect with, and have empathy for, what that victim part of you is feeling.
Practice self-compassion. Choose to be gentle and reassuring with her. You might find it comforting to imagine hugging that part of you, or just placing your hand on her shoulder. If you have trouble doing this, visualize the scene with someone else feeling victimized and approaching that person with compassion. When you’re able to feel compassionately toward that person, you can practice showing the same compassion toward your child self. With practice, you can then develop the ability to feel compassion for your present-day self.
Take time to practice this exercise. Repeat it. And just as you can calm, reassure and embolden a frightened child or stray dog with kindness and patience, you can be the same loving force in your own life. Share your experience of this exercise with your therapist, who can help you build on the developing self-compassion or overcome obstacles preventing you from feeling self-compassion. By nurturing this inner love and support, you will feel better about yourself and will have the resilience to persist in the journey toward a healthier you.
About the author – 
Leslie Becker-Phelps, PhD is a licensed psychologist who treats individuals and couples in her private practice in Basking Ridge, NJ and presents nationally to lay and professional audiences on relationship problems and self-criticism. She is the relationships expert on WebMD’s Relationships and Coping Community; writes for WebMD’s “Relationships” blog; and writes another blog called “Making Change” for Psychology Today. She is the author of Insecure in Love: How Anxious Attachment Can Make You Feel Jealous, Needy, and Worried and What You Can Do About It (New Harbinger Publications), which was released in May 2014. She was also the consulting psychologist for the book Love: The Psychology of Attachment (DK Publishing, 2016). Read more at www.drbecker-phelps.com.

Marginalization Multiplied

Marginalization Multiplied

By Kathryn Cortese, LCSW, ACSW, CEDS
As therapists, we learn so much from our clients. When individuals are diagnosed with an eating disorder and are members of a marginalized community, I have learned these persons live lives of “marginalization multiplied.”
According to Miriam-Webster, the simple definition of marginalize is “to put or keep (someone) in a powerless or unimportant position within a society or group.”
http://www.merriam-webster.com/dictionary/marginalize
NEDA in partnership with Reasons Eating Disorders Center has taken on the compelling work of their Marginalized Voices Campaign. The goal of this effort is to challenge “the prevailing myths about who struggles with eating disorders, underscoring that everyone’s experience is equally as valid and deserving of care and recovery.” (To learn more, please go to https://www.nationaleatingdisorders.org/marginalized-voices)
With much gratitude to Lori Price for her commitment to the eating disorders community and her powerful words in the previous article that describe her experience as a marginalized voice, I follow with thoughts on another layer of marginalization with which people with eating disorders co-exist, based on some practice wisdom.
A number of years ago, when sitting with some of my ED clients, I realized that one impact of their eating disorder is what I call “living in the margin.” I would ask my clients to picture a regular sheet of loose-leaf paper. We likened the day-to-day, internal and external processes of living life with an eating disorder as existing in the margin of the loose-leaf. We would use this metaphor to imagine a different life and what it would mean to take up the full page – to be free to find and actualize their true selves. Always, a scary thought, yet, oftentimes quite motivating. No one ever denied living “in the margin.” Some found the safety of the ED margin to be a comfort, yet they also knew their authentic self was being squeezed out of the picture by the compulsions, the rules, the demands, and the commands of the ED. Some felt their voices were powerless against the ED voice and its spewed messages of hate, disparagement, and malicious criticism. Some viewed their position in their world of family, school, and friends as meaningless, insignificant, and worthless. In other words, they lived in “the margin.” Developing the courage to use one’s skills and voice in recovery takes savvy, courage, moxie, grit, persistence, strength to face adversity and setbacks, and determination to be on an equal footing with the rest of humanity – pretty similar to the members of our ED community who also experience marginalization.
These clients’ ability to articulate the potential differences between lives “in the margin” vs. “on the full page” led to some lively discussions about hope, recovery, and their future. Sometimes, this image led to an assignment. I would suggest they simply draw or fill the full space on their loose-leaf paper with colors, abstractions, or collage cutouts for follow-up conversations.
We all “get this.” To complement the work of The Marginalized Voices Campaign, have we taken the time necessary to “see” if we might play a part in marginalizing any of our members of the ED community? How do we challenge the “ideals” culture promotes? Did the previous article by Lori Price strike a chord? Can we all open our minds and hearts and those around us to “get it?” Lori’s is one voice. We know there are many more. Each is valuable and deserves opportunities and access to recovery.
We are all in life on this planet together and, hence, in the pursuit and establishment of equality for every individual. We welcome your comments to this article to offer suggestions for advocacy, education, research, prevention, treatment, the experience of visibility devoid of judgment, and more, so that “marginalization multiplied” is reduced and perhaps extinguished.
About the author –
Kathy Cortese, LCSW, ACSW, CEDS, has worked as a clinician in the eating disorders field since 1989, and now also serves as president and editor-in-chief of the Gürze/Salucore Eating Disorders Resource Catalogue.
Kathryn Cortese, LCSW, ACSW, CEDS, began working with individuals with eating disorders in 1989. She is committed to the beliefs that recovery is real, support is essential, and hope matters. In 2013, along with her son, Michael, Kathy purchased the Gürze Catalogue. They offer the annual Gürze/Salucore Eating Disorders Resource Catalogue, a monthly ENewsletter featuring articles specifically written for this as well as a Book Interview, the edcatalogue.com website, EatingDisordersRecoveryToday.com, the ED Pulse, and in the fall will launch their  podcast, called ED Matters.


Friday, May 27, 2016

Targeting a Destructive Cycle of Inferiority

A sense of shame and self-criticism may help perpetuate ED symptoms.

Reprinted from Eating Disorders Review
May/June Volume 27, Number 3
©2016 IAEDP
Many patients with anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder (BED) share a sense of inferiority and severe self-criticism. In addition, several core symptoms “feed” the perpetual cycle of eating psychopathology, according to Dr. Cristiana Duarte and her colleagues at the University of Coimbra, Portugal. The researchers also tested whether self-criticism and social comparisons provided the link between overvaluation and shame as part of a study that traced the similarities and differences among patients with AN, BN, and BED (Comprehensive Psychiatry. 2016. 66:123).
When the researchers attempted to understand how overvaluation of body shape and weight and eating were associated with an increased sense of shame, they found that basing one’s sense of self-worth on eating behavior and physical appearance did not lead to a more valued sense of self, but paradoxically increased self-monitoring and self-correction, and lowered self-esteem. 
Dr. Duarte and colleagues studied 119 adolescent and adult female eating disorders outpatients who were seeking treatment at public hospitals and who had ED diagnoses based on results from the Eating Disorders Examination (EDE). Thirty-four patients were diagnosed with AN, 34 had BN, and 51 had BED. In addition to the EDE, all patients completed a number of questionnaires, including the Other asShamer Scale (Personality and Individual Differences. 1994. 17:719), which asks 18 questions about external shame; the Forms of Self-Criticizing & Self-Reassuring Scale(Clin Psychol Psychother. 2015. 22:153), which measures social comparisons based on physical appearances compared to peers as well as models/actresses/celebrities; and the Depression, Anxiety and Stress Scales (Manual for the depression anxiety stress scales. 2nd ed. Sydney, Australia: Psychology Foundation, 1995).
Dr. Duarte and colleagues reported that the patients’ overvaluation predicted internal shame, but this effect was mediated by unfavorable social comparisons and harsh self-criticism, even after controlling for depressive symptoms. 
The authors’ findings have conceptual and practical implications. High levels of a flawed and diminished sense of self cut across EDs. The authors suggest that the findings highlight the relevance of working with patients to change their self-criticism and sense of inferiority.

Probing Biopsychosocial Risk for Developing an Eating Disorder

Predisposing traits and precipitating factors increase risk, challenge recovery.

Reprinted from Eating Disorders Review
May/June Volume 27, Number 3
©2016 IAEDP
Dr. Guido K. W. Frank, Director of the Developmental Brain Research Program at the University of Colorado, has proposed a biopsychosocial risk model to explain why patients develop and maintain eating disorders (Front Behav Neurosci. 2016; 10:1). Terming it “The perfect storm,” Dr. Frank proposes that the extremes of eating found in eating disorders “alter normal brain function, in particular dopamine (DA)-related pathways, and create a biological cycle that interferes with recovery.”
Dr. Frank describes a model consisting of the following elements: first, preexisting factors, including personality traits and trait alterations of neurobiology (in this model, changes in DA function) set the stage. Situational factors can occur that significantly increase or decrease food intake; this change in intake then interacts with altered DA function. Similar precipitating effects may be caused by pubertal changes. Yet another kind of precipitating factor is what Frank classifies as psychological factors: family dysfunction, poor self-esteem, and social pressures.
In Dr. Frank’s model, the final step is a self-perpetuating pattern. In AN, restriction sensitizes the DA system, leading to more restriction. In BN and BED, desensitized DA circuits drive binge eating. This model shares certain similarities with others but really highlights the potential role of dopamine function in EDs.

Outpatient Family-Centered Treatment for AN, EDNOS

In this Swedish study, most adolescents improved without need for inpatient care.

Reprinted from Eating Disorders Review
May/June Volume 27, Number 3
©2016 IAEDP
Some adolescent girls with anorexia nervosa (AN) or restrictive eating disorders not otherwise specified (EDNOSr) can be successfully treated as outpatients in a family-based setting, without the need for hospitalization, according to the outcome of a Swedish study (Upsala J Med Sci. 2016. 121:50).
Dr. Agneta Rosling and her colleagues studied the one-year outcomes and analyzed predictors of outcome among a cohort of168 female patients (29 with AN and 112 with restrictive-type EDNOS), 141 of whom were followed for one year after starting treatment in 1991. 
In Sweden, all services for child and adolescent psychiatry services are tax-supported and thus free for patients. Patients are immediately accepted for assessment, following inquiries by parents or referral from school health services. At the Uppsala University Eating Disorders Unit, care is provided by a multidisciplinary team and largely follows American Psychiatric Association recommendations. However, inpatient care is only available in emergency situations and not for weight restoration.

The outpatient program

The first step (weeks 1 to 3) focuses solely on halting weight loss. At the first assessment, parents are advised about their role and how to re-establish normal meals served on a fixed schedule. Patients usually do not attend school, and exercise is not allowed until normal eating patterns have been re-established. Parents and teens attend separate counseling sessions, and the patients are invited to participate in psychoeducational groups.
The second step (weeks 6 to 8) begins once the patient is eating normal meals. At this point, the goal is to restore weight at a rate of 0.5 to 1 kg (1.1 to 2.2 lb) per week. 
The third step begins when the patient has regained a substantial amount of weight and gradually begins attending school once more. This step may take several months, and may still include family meal support.
The final step begins only when eating, attending school, and reassuming daily routines are being “reliably maintained,” according to the authors. Cognitive behavioral therapy (CBT) using a “transdiagnostic” approach to prevent relapse may be added at this point. Hospitalization and pharmacologic treatment (usually with selective serotonin reuptake inhibitors, or SSRIs) are used only in severe cases. For example, the teen may be hospitalized if she is at imminent risk for arrhythmias and/or when she refuses to eat or drink. In such cases, cardiac monitoring and nasogastric intubation may be needed.

168 adolescent participants

At the initial assessment,The 168 teenaged girls were diagnosed with AN (n=31) or EDNOSr (n=137). The girls diagnosed with AN had ED symptoms for about 9 months (range: 1-32 months), while those with EDNOSr had symptoms for about 12 months (range: 1-42 months). Follow-up data were available for 141 of the 168.
At the one-year follow-up point, 73% had been outpatients for the entire year. Among those with AN, 6/29 (21%) were free of an ED. Of those with EDNOS, 48% were free of an ED. Roughly 40% received medication, and 5% were hospitalized. Overall, the majority showed improvement in weight. 

These results support the value of extensive outpatient treatment, particularly for those with EDNOS.