Friday, September 25, 2015

Combating Binge Eating Disorder in Ethnic Minorities

Some promising results from two studies of Black and Hispanic women

Reprinted from Eating Disorders Review
September/October Volume 26, Number 5
©2015 IAEDP
Black and Hispanic women have elevated risks for developing binge eating disorder (BED), perhaps in part because these women also have high rates of obesity. Minority women are also less likely to seek treatment for obesity, and are more likely to drop out of treatment than are women from other ethnic groups. This may be in part because traditional BED treatment approaches may be less acceptable to Black and Hispanic women (World Psychiatry. 2007. 6:142).
In hopes of addressing these trends, researchers at the University of Texas and the University of Southern California designed a lifestyle community intervention program, Health is Power (HIP). The goal of this longitudinal randomized controlled trial was to promote physical activity and improve dietary habits among minority ethnic women (Appetite. 2015. 95:269). Scherezade K. Mama, DrPh, and colleagues recruited 180 African American and Hispanic women in Houston and Austin, TX and randomized them to a physical activity group or a dietary habits intervention group. All the women attended 6 intervention sessions held over 24 weeks. At the beginning, the intervention sessions were held biweekly and then were scheduled monthly. These 60-minute sessions were led by two trained health educators. During the intervention sessions, the women learned about goal-setting, the benefits of being physically active, or eating more fruits and vegetables, self-sufficiency, social support, and ways to prevent relapse. Binge eating and its symptoms were not explicitly discussed or addressed as part of the intervention.
At two time points, before the study began and after it ended, all participants had the following anthropomorphic measurements taken: height, weight, and percent body weight, and these were then used to compute body mass index. Ethnicity, educational level, and household income were measured with the Maternal and Infant Health Assessment Questionnaire. Dietary habits were tallied using the National Cancer Institute Fruit and Vegetable Screener, and dietary fat intake was measured with the Fat Screener. The Fat Screener measures usual dietary fat intake over a year by measuring how often the individual consumes 15 target foods. The Binge Eating Scale was also used. 


The women in this study were of relatively high socioeconomic status, and nearly 75% were Black and roughly 25% were Hispanic. The authors also reported that 72% of the women were non-binge eaters, 22% were binge eaters, and 5% had severe binge-eating symptoms. The women classified as binge eaters reporter higher dietary fat consumption than the non-binge eaters.
At the end of the intervention, the researchers found that 82% of the women were classified as non-binge eaters and 18.3% as binge eaters. That is, 50% of women classified as binge eaters at baseline were classified as non-binge eaters at follow-up. Slightly more women in the physical activity study group were reclassified as non-binge eaters at the follow-up point. 
This study suggests that lifestyle intervention to improve physical activity may be a useful strategy for reducing symptoms of binge eating; according to the authors, it is also the first to address BED among ethnic minority women. The intervention improved daily fruit and vegetable intake by an average of 14%. Body composition did not significantly change even though binge eating symptoms and dietary habits did.
The study did have some limitations. Chiefly, since their study population involved women with relatively high socioeconomic status, it is not clear whether the authors recommend that results can be generalized to other populations such as lower-income minorities, or to men.

A Genetic Link Is Identified for Binge Eating in Adolescence

A positive association is found between a polymorphism in the FTO gene and binge eating.

Reprinted from Eating Disorders Review
September/October Volume 26, Number 5
©2015 IAEDP
Evidence from behavioral genetic studies is increasingly pointing to a genetic link to increased risk of binge eating. However, BED is a more recent addition to the group of recognized eating disorders, and thus few studies before this had traced a possible genetic link specifically for BED.
Dr. Nadia Micali and colleagues at University College and King’s College, London, Harvard Medical School, and the University of Queensland, Australia, hypothesized that higher body mass index (BMI, kg/m2) and binge eating might share a genetic etiology (Obesity. 2015. 23:1729). Dr. Micali and colleagues utilized data from the Avon Longitudinal Study of Parents and Children. During this population-based prospective study of women and their children living in Avon, UK, the teens were assessed at age 14 (n=5958) and again at age 16 (n=4948). During the longitudinal study, binge eating was assessed with a two-part question in which participants were asked about how often in the past year they had eaten a very large amount of food. Those who answered yes were then asked whether they felt “out of control” during the episodes; affirmative answers to both questions yielded a BED diagnosis. The researchers analyzed 32 BMI-associated single nucleotide polymorphisms, or SNPs previously linked to BMI.

The FTO gene and binge eating

The authors reported that the overall mean prevalence of binge eating during adolescence was 5.6% at age 14 and 11.2% at age 16, and binge eating was more common among girls than among boys at both ages (7.4% vs. 3.5% at age 14 and 16.1% vs. 4.4% at age 16). 
The results of Dr. Micali and colleagues’ study suggest a link between a polymorphism in the FTO gene and binge eating in adolescents. This factor may influence food intake, food choices, and control over eating. Girls within or near the FTO locus are seemingly associated with a preference for energy-dense foods, greater intake of food, less sensitivity to cues of satiety, and loss of control eating episodes. 
The authors note that this is the first study to investigate an association between binge eating in adolescence and 32 SNPs that have been associated with BMI, and suggest that as future studies further delineate genetic correlates of obesity, it will be possible to more thoroughly test the mechanisms underlying the relationship between obesity, binge eating, and the FTO gene.

CBT via the Internet: Can It Be Effective?

In a recent study in the Netherlands, Web-based treatment was most effective for those with binge eating disorder.

Reprinted from Eating Disorders Review
September/October Volume 26, Number 5
©2015 IAEDP
A team of Dutch investigators led by Elke D ter Huurne, from the Nijmegan Institute, Nijmegan, Netherlands, has reported that their Web-based cognitive behavior therapy (CBT) approach improved eating disorder psychopathology among participants in a randomized controlled study (J Med Internet Res. 2015; 17: e152). [See also “Update,” in this issue.]
The participants were self-recruited users of the Dutch website, Look at Your Eating, an open-access Internet site that offers psychoeducational content about eating disorders and a forum for peer support. Participants were females at least 18 years of age, with a DSM-IV diagnosis of BN, BED, or EDNOS who had access to the Internet; written referral from a Dutch general practitioner was required. Candidates were ruled out if they were severely underweight, suicidal, or had received psychological or pharmaceutical treatment for any eating disorder within the past 6 months. One-hundred and eight participants were randomized to the web-based CBT program and 106 to the wait-listed group. 

The program’s design

The web-based CBT intervention used a software program developed by a team that includes a psychologist, addiction specialist, psychotherapist, psychiatrist, dietician, as well as registered nurses and social workers, a software development team, and patients and members of a Dutch organization for people with eating disorders. 
Seventeen therapists with either a bachelor’s degree in nursing or social work or a master’s degree in psychology participated in the study. Prior to working with the CBT program, all therapists had 3 months of specialized training, including one day focusing on eating disorders and two days of training in theoretical information and practice-oriented assignments related to the Internet program. They also learned technical aspects of using the intervention, and on CBT and Motivational Interviewing (MI) techniques. 
Study therapists were trained to work with patients with severe eating problems, relapse, or suicidal ideation, and given guidelines for when to contact the individual’s primary care physician. As a further safeguard, all messages from the therapists were checked retrospectively by a multidisciplinary team, and all patient files were regularly checked by the coaches of the Web-based intervention. These coaches were available daily for consultation and advice. 
The CBT intervention included a structured two-part program with at least 21 patient contacts and 10 assignments on a secure Web-based application, according to the authors. These occurred twice weekly, typically for about 20 minutes. Phase 1 analyzed the participants’ eating attitudes and behaviors, while the second part focused on behavior change. 
During the online sessions, participants were instructed about completing homework assignments and registering eating behaviors daily in their online food diaries. They could leave messages in private files, and the therapist always responded within 3 working days. The therapist’s messages were personalized to the individual but also often contained other information and hyperlinks to information on the website, and were based in CBT and MI approaches. When a participant hadn’t responded within 4 weeks, she was considered to have dropped from the study. 

Wait-listed controls 

The control group members each received 7 supportive emails sent by a therapist during the waiting period. These messages included information about the program, as well as details about when participants could begin participating in the intervention, the aim of the supportive messages, and what to do in case they needed urgent help. Further emails described the website, the online forum, and provided basic psychoeducation.
Outcome was primarily measured with the Eating Disorder Examination-Questionnaire. Secondary measures included the Body Attitude Test, the Maudsley Addiction Profile-Health Symptom Scale, and the Rosenberg Self-Esteem Scale.

Results: CBT intervention was more effective

Ninety-four percent of the participants completed the study. Those in the web-based CBT group improved significantly more on eating disorder psychopathology than did those in the wait-listed control group, with lower EDE-Q subscale scores after treatment. The group with BED had the most significantly positive results in changes in eating disorder psychopathology, body dissatisfaction, and mental health. 

The authors noted that during the intervention or wait-listing period, several women in both groups had other sources of support, for example from friends or family or through a self-help program. Some of the women also had in-person contacts with a professional such as a therapist, dietician, or family physician. In all cases this was more common among women in the wait-listed group than in the CBT group. However, this additional support did not seem to provide much treatment value; for the control group, face-to-face contact with a professional improved only one area: body dissatisfaction.

Satisfaction with the program

Overall, participants were satisfied with the Web-based intervention and with their therapists. Most participants evaluated the intervention as rather (46%) or very (35%) useful, particularly for its positive effect upon eating behavior. Notably (for an internet-delivered intervention), one of the components most highly rated by participants was the support of the therapists. The study demonstrates the acceptability of such interventions (satisfaction and treatment retention were high) and adds to the growing literature in this regard.

Thursday, September 24, 2015

Technology, Healthcare and Eating Disorders

Reprinted from Eating Disorders Review

September/October Volume 26, Number 5
©2015 IAEDP

Virtual Communication Offers Bonuses, but also Challenges, for Eating Disorders Patients

One of the highlights at the ICED meeting in Boston was new information about the ways that developing technologies and virtual communication are changing management of eating disorders. These new electronic tools are reaching patients in remote areas, connecting support groups, and offering new treatment options. The overall theme, “Communication: ICED Today and Tomorrow,” was reflected in two sessions in particular.
At a plenary session, “There’s an App for That? How Technology is Changing the face of Eating Disorders Treatment, Research, and Advocacy,” Drs. Lisa Gualtieri, Eric Van Furth, and Margaret Morris weighed the many promises and pitfalls of what they termed the “electronic stampede.” 

Helping patients ‘at the intersection of healthcare and technology’

Dr. Gualtieri teaches methods for integrating technical media into public health at Tufts University School of Medicine, Boston. Her expertise lies in analyzing the ways patients use technology, and she noted there are promises and pitfalls for working “at the intersection of health care and technology.” She added, “Our lives have been profoundly shaped by technology, and sometimes we forget how greatly technology is infiltrating our lives.” 
In this cultural shift, Dr. Gualtieri told the audience, almost everything we do has a technological component. People across all demographics now approach their health care by increasingly relying on the Internet, social media, and their mobile devices. Dr. Gualtieri said that 72% of Internet users currently seek health information online; the only two groups with significantly lower Internet use are those over 65 years of age and people without a high school diploma. This change is taking place in the midst of a cultural shift, where technology has become part of all our lives and where “social capital” has changed, she said. Some of the negative results are cyber bullying, the demise of social interactions, and excessive use of online medical information rather than in-person consultation with a clinician. She warned that the highly variable quality of information on the Internet can put patients at risk; with this information, patients now decide whether they need a doctor because Internet sources can provide "second opinions" online. “Technology can become a prosthetic device—not only are patients not consulting their doctors, but they are relying on their own Internet skills,” she said.
The cure is to put technology in its proper place, said Dr. Gualtieri. Patients are not taught good health literacy skills, for example, how to seek information and what to believe and when to be skeptical. Clinicians can take an active part in changing this by learning to ask about patients’ online research skills, and then helping them improve these skills. The cure also involves better training for health-care providers. According to Dr. Gaultieri, this means giving patients better starting points to help them guide their online searches, using expertise to guide technology use, and becoming better informed about what patients are doing online. Instead of a rush to create smaller and smarter devices, it makes more sense to help people when and where they need it, she said, because health care decisions based on the patient’s own apps can be wrong and can cause incredible harm. Instead, she urged clinicians to understand why patients go online and what they do once they are there. 

Earlier and cheaper electronic treatment interventions

Dr. Eric van Furth, Clinical Director of the Center for Eating Disorders Ursula in Leidschendam, the Netherlands, described two eHealth interventions, Recovery Record and the Dutch information website, Proud to be Me. Both are examples of how electronic approaches can help patients and their families overcome barriers to care and general lack of information about eating disorders, he said. The pervasive denial of illness by anorexia nervosa patients and the shame and fear in those with binge eating disorder or who binge-eat have led to an average delay of 5 years between the onset of illness and patients actually getting care, he noted. 
Recovery Record, an application for smartphone users, is the most downloaded app for eating disorders patients in the world, and now has 300,000-plus users, he said. Forty percent of Recovery Record users never told anyone about their eating disorder prior to using the app, Dr. van Furth added.
Dr. van Furth urged clinicians to expand their knowledge of virtual apps because “we are not reaching the vast majority of people with eating disorders.” For example, he pointed out that 50% to 75% of persons with eating disorders in Europe have no access to treatment. Since a shorter duration of illness translates into better prognosis, why not try to reach individual earlier and more cheaply? EHealth approaches may provide one way to improve early diagnosis and to fast-track people to help. Such approaches also can optimize care for those with chronic illness, and provide cost-effective care.
Proud to Be Me is maintained by two eating disorders survivors, who provide blogs and new emails each day, and the site is linked to all widespread social media, such as Facebook. The website is an alternative to pro-ANA sites and operates from a positive focus that emphasizes recovery, Dr. van Furth said. Proud to Be Me was launched in 2009, and users can register under a pseudonym. The website has three main functions, he said, “breaking the silence, which offers downloadable letters for patients; peer support, where patients meet others online who also have an eating disorder; and it also acts as a guide for finding treatment.” Individuals also have a forum for rating treatment centers on 5 different scales. Visitors can pose questions for clinicians 365 days a year. Chat rooms are arranged by age groups.
Dr. van Furth said that while the Netherlands has only 17.5 million inhabitants, in 2014 Proud to Be Me had 2 million unique visitors and 10,000 to 15,000 unique visits per day. Each day individuals spent an average 5 minutes on the site. There have been 27 million page views. Use of eHealth shows some promising results on bulimic behavior, depression, and anxiety. Dr. van Furth added, “EHealth is about expanding our reach and improving outcome, but also needs to be empirically tested in randomized controlled studies.”

Aligning electronic tools with disease management

Margaret Morris, PhD, a clinical psychologist and senior researcher at Intel Corporation, is a pioneer in mobile therapy and making psychotherapy more accessible to patients. Dr. Morris said, “No matter how great your reach is, or how great your insurance, during the last 10 years mobile technologies have become part and parcel of the strategies we use today.”
Dr. Morris reviewed the Mood Phone, the Mobile Digital ScaleTinderCrowd Sourcing, and Crowd Pilot, and described ways that therapists, researchers and individuals are using these devices in everyday life. Mood Phone was originally intended to be used as a personal tool that augmented therapy, particularly as a means for managing anger and personal conflicts. Its most beneficial use has been in what she termed ‘reprisal relationships,’ where it enables the individual to see another’s perspective. The Mobile Digital Scale has been changed in the last few years but still provides behavioral motivation messaging, and data can also be used in caregiving. Tinder, originally a sexual “hookup” tool, has been useful for self-validation, she said, and provides a way to gather and share information. One use encourages women to submit instances of sexual harassment, disclosing the identity of the harasser, and offers new strategies for coping with harassment. Crowd Sourcing, which was designed for disseminating labor, is used instead for getting psychological consultation. Crowd Pilot is a twist on technology that echoes the mood phone, and provides a model for how emotion can be presented and how people can modulate a relationship.

Using blogs, video chats, support groups and apps

In an ICED workshop, four panelists described their experience in creating and using virtual media. There was a consensus that patients are more likely to seek medical information from the Internet first before consulting a physician, and that with careful planning virtual media can be effective. All the speakers, who incidentally met virtually before meeting in person, also stressed the positive and negative realities of online information sites.

Perspective from a former patient

Cate Sangster, MA, a physical education teacher from Melbourne, Australia, has lived with an eating disorder and is using her knowledge and experience to help other patients in recovery. She noted that social media sites such as Facebook allow people to share information about eating disorders and that education is the number-one reason they use Internet sites. She added that, patients also keep themselves safe with social media, because the sites are available 24/7, and “when the tigers come at night” patients they can always find someone who will help. The positive feedback from other patients is beneficial because someone with an eating disorder may be more likely to discuss it with others after researching it online first. Improved mental health literacy is another benefit—the more an individual understands the condition, the more likely he or she is to get help.
Some of the risks of Internet site use include the availability of negative sites such as pro-ANA and pro-MIA sites. Patients may also encounter “trolls,” or individuals who go online only to make trouble. Misinformation may also compete with evidence-based information; to counteract this, she suggested that clinicians tell patients to contact and inform efficacy groups when they encounter false information. There may be a tendency for patients to try to self-diagnose and self-prescribe and social media should never be used to educate patients. Issues of privacy also arise. 
How can clinicians help keep patients safe online? Sangster believes they can take a more active role in giving patients tips for using social media sites such as Twitter, and also can provide a list of trustworthy blogs. Professionals should not allow online relationships to be misunderstood or boundaries to be fuzzy. She said it important for clinicians to protect their own personal information and to maintain professional boundaries while remaining available to patients.

Help for parents

Ten years ago, writer and mental health activist Laura Collins Lyster-Mensh, MS, founded the Around the Dinner Table online forum, a site for parents and patients with eating disorders. On the site, users can select from 14,000 topics related to families and patients. Lyster-Mensh also helped found the websites Maudsley Parents,F.E.A.S.T., and Charlotte’s Helix
Around the Dinner Table allows visitors to be anonymous while the organization is completely transparent, she said. On the site visitors can find stories of parents’ anguish, hope, and ideas. A team of 9 moderators in 4 countries are available so a visitor can get email support within 2 minutes. The site is in English, but future plans call for adding additional languages. Lyster-Mensh said the site helps visitors fight isolation, gain high-quality information, and view examples of successes and mistakes as well. It also promotes empowerment, and can be used to find volunteers for research projects. A few risks she mentioned included unexpected disempowerment when parents read positive stories and become discouraged about their own problems. And, like the trolls described before, some individuals pose as patients or parents ("Munchausen’s by Internet”), and post weird stories or wildly incorrect statistics. The moderators and other visitors correct the misleading information as soon as possible, she said.

Virtual aid for family-based therapy

Psychologist Dr. Sarah K. Ravin, who has a private practice in Coral Gables, FL, became involved in the virtual world when she agreed to write a blog about the F.E.A.S.T. program in 2009. The reaction to her first Internet post was huge, she said, and she learned that parents did not know a great deal about what treatment was available, and there was a definite lack of information available about family-based therapy. Having the virtual presence enabled her to spread the word to a larger audience and to reach out to parents who were seeking services for their children with eating disorders. It also enabled her to connect with other clinicians worldwide. 
Dr. Ravin said that a few of the risks of a virtual presence are that parents may have inflated expectations, and their problems may be very serious and require a different type of care. While new technologies can expand the geographic research of treatment, long-distance care also presents a number of challenges. Dr. Ravin would like to see more outreach to local schools and pediatricians. She also said she hopes for the day when virtual advocacy is obsolete because all patients and their families have the information they need as soon as the diagnosis is made. Greater transparency and parental empowerment, along with evidence-based care, will go far to help parents and patients feel secure that their family is working to recovery.

Using Recovery Record

Lori Lieberman, RD, MPH, CDE, LDN, a registered dietician from Boston, described her experience using Recovery Record, the online record-keeping app described earlier. She has found the app to be especially useful for extending client care between sessions for selected and motivated patients. She stressed the importance of carefully selecting participants; in her practice clients participating in the program are mostly adults and young adults who are also seen in face- to-face sessions weekly or at least at regular sessions. Expectations are clearly stated, and she charges a fee for this service. Lieberman stressed that the online program is definitely not a substitute for regular office visits. 
Lieberman reported seeing increased accountability from her clients, and has found that they value the professional relationship in a way that an anonymous therapist could not achieve. She has also seen the online program help patients move away from a distorted perspective about their eating, and professionals can respond to concerns in a timely fashion. There are no calorie counts or expectations or limitations, she said, and the virtual interactions make live sessions more efficient. Families are reassured and can be quickly engaged in discussions. Even with minimal feedback, participants report feeling “someone is fighting the illness with them,” she said

As all the workshop panelists noted, with a virtual system such as this there is a danger of patients selecting and using ‘snippets of information,’ and thus clinicians and support professional must carefully choose words and feedback, to avoid providing inadvertently negative feedback. Other drawbacks include the possibility that clients may not have the money to enroll; also, the service has the potential to be abused when a patient reaches out to the online source and not to a direct help line. Much depends on the patient’s self-assessment, honesty, and willingness to engage.
What is clear, Lieberman said, is that apps, video chats, and other Internet-based programs can provide incredible benefits for patients with eating disorders. One caveat is that professionals working with virtual media need to be well informed about the emerging technology and aware that “technology is changing faster than the law.” Because of this, serious issues need to be continually addressed, including changes in licensure, HIPAA compliance, and malpractice insurance as well.

Tuesday, September 22, 2015

AFRID: Avoidant/Restrictive Food Intake Disorder: a commentary by Ellyn Satter

Here is the definition of ARFID from the American Psychiatric Association DSM 5  Diagnostic and Statistical Manual.1
Avoidant/Restrictive Food Intake Disorder replaces and extends the DSM-IV diagnosis of feeding disorder of infancy or early childhood. ARFID is an eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:
1. Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
2. Significant nutritional deficiency.
3. Dependence on enteral feeding or oral nutritional supplements.
4. Marked interference with psychosocial functioning.
In some individuals, food avoidance or restriction may be based on the sensory characteristics or qualities of food, such as extreme sensitivity to appearance, color, smell, texture, temperature, or taste. Such behavior has been described as ‘restrictive eating,’ ‘selective eating,’ ‘choosy eating,’ ‘perseverant eating,’ ‘chronic food refusal,’ and ‘food neophobia’ and may manifest as refusal to eat particular brands of foods or to tolerate the smell of food being eaten by others.
Concerns raised by ARFID
As demonstrated by our story, the public hears about this diagnosis, which uses common language to describe eating and feeding problems, and sees the diagnosis as offering a solution to those problems. The media heightens concern with horror stories about adults who only eat French fires or waffles and children who only eat chicken nuggets or peanut butter sandwiches. How are we to interpret and work with this diagnosis?
Diagnosing may catastrophize. Diagnosing variants of normal as being pathological makes the problem seem far worse than it really is. Unfortunately, in today’s feeding and eating world, such variants are all too common. In repeated studies,2-5 more than half of adults test low in Eating Competence,6 meaning they do not feel positive  about their eating, are not reliable about feeding themselves, hesitate to let themselves eat food they enjoy, and are unlikely to pay attention to their hunger and fullness in guiding how much to eat. In fact, only 40% of people admit they enjoy eating, down from 50% 20 years ago. Almost all parents of preschoolers make feeding errors, including limiting menus to foods their children readily accept, then bribing and pressuring them to eat.8  Despite the national hysteria about child overweight, over 90% of parents say they don't believe their children indications of fullness and encourage them to eat more.8,9 Such pressure doesn’t work: pressured children eat less well and behave badly at mealtime.10
Inclusion in DSM implies that this is a psychiatric disorder. In most cases, problems with eating and feeding are not psychiatric disorders. They are problems, and, as such, they can be addressed by education or brief intervention conducted knowledgeably. In my view, to qualify for a psychiatric diagnosis, “marked interference with psychosocial functioning” (optional in the above definition) is essential.  For any eating malady to be a psychiatric disorder, a significant distortion in eating or feeding has to be precipitated/exacerbated/interactive with underlying psychosocial distortion. For children with feeding disorders, the underlying psychosocial distortion lies in the relationship with the parent.  
The feeding literature is not considered. The DSM states that ARFID-related problems “most commonly develop in infancy or early childhood and may persist in adulthood.” However, DSM shows no evidence of awareness of the rich feeding literature which outlines the detail of distorted parent/child feeding interactions that precipitate and/or fail to extinguish food disorders.
Disorders are considered in isolation. Child psychosocial problems are always part of a distorted relationship with parents/primary care providers. Severe feeding problems must be considered that context, and in the context of the child’s medical and developmental history.11 Affected adults carry internalized distortions from those early relationships. Even when children contribute to “food intake disorders” by being irritable, having medical and/or oral-motor problems, developing atypically, or showing extreme food regulation patterns (e.g. don’t eat much or eat a great deal), the parent-child feeding relationship is paramount. 
The ARFID diagnosis implies cures that may or may not be delivered. Certainly, people need help with their feeding and eating. However, that help must be in proportion to the problem at hand, and it must be provided by people who truly understand eating and feeding. As a mental health professional myself, I have observed that, like the authors of DSM 5, mental health professionals are generally not familiar with research and optimum practice around feeding and eating. They  tend to take the sledgehammer approach advocated by the author of the Medscape article.
The take-home message: Correcting such a preponderance of problems with eating and feeding means there is plenty of work to go around. However, that work must be in proportion to the problem at hand, and it must be done by people who truly understand eating and feeding.
For more about addressing child eating problems from a Feeding Dynamics perspective, read Intervening with Pediatric Feeding Disorders. For more about addressing adult distortions in eating attitudes and behaviors, read Secrets of Feeding a Healthy Family.  
For help and direction relative to your feeding/eating problem, join us on Facebook.
  1. Association AP. Feeding and Eating Disorders DSM-5: DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, FIFTH EDI T ION American Psychiatric Association; 2013:329-354
  2. Quick V, Byrd-Bredbenner C, White AA, et al. Eat, Sleep, Work, Play: Associations of Weight Status and Health-Related Behaviors Among Young Adult College Students. Am J Health Promot. Dec 20 2013.
  3. Lohse B. Facebook is an effective strategy to recruit low-income women to online nutrition education. J Nutr Educ Behav. Jan-Feb 2013;45(1):69-76.
  4. Lohse B, Bailey RL, Krall JS, Wall DE, Mitchell DC. Diet quality is related to eating competence in cross-sectional sample of low-income females surveyed in Pennsylvania. Appetite. 2011;58:645-650.
  5. Lohse B, Satter E, Horacek T, Gebreselassie T, Oakland MJ. Measuring Eating Competence: psychometric properties and validity of the ecSatter Inventory. J Nutr Educ Behav. 2007;39 (suppl):S154-S166.
  6. Satter EM. Eating Competence: definition and evidence for the Satter Eating Competence Model. J Nutr Educ Behav. 2007;39:S142-S153.
  7. Taylor P, Funk C, Craighill P. Pew Research Center; 2006.
  8. Sherry B, McDivitt J, Birch L, et al. Attitudes, practices, and concerns about child feeding and child weight status among socioeconomically diverse white, Hispanic, and African-American mothers. J Am Diet Assoc. 2004;104:215-221.
  9. Orrell-Valente JK, Hill LG, Brechwald WA, Dodge KA, Pettit GS, Bates JE. "Just three more bites": an observational analysis of parents' socialization of children's eating at mealtime. Appetite. 2007;48:37-45.
  10. Galloway AT, Fiorito LM, Francis LA, Birch LL. 'Finish your soup': counterproductive effects of pressuring children to eat on intake and affect. Appetite. May 2006;46(3):318-323.
  11. Davies WH, Satter E, Berlin KS, et al. Reconceptualizing feeding and feeding disorders in interpersonal context: The case for a relational disorder. J Fam Psychol. 2006;20:409-417.
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What is the Anna Westin Act?

The bill is named after Anna Westin, a young Minnesotan who committed suicide as a direct result of her battle with anorexia in February 2000.  Since that time, Anna’s family has turned their grief into something positive by founding the Anna Westin Foundation and working to ensure that tragedies such as Anna’s are prevented in the future. For more information on Anna Westin, visit the EDC website.
The legislation is a comprehensive eating disorders bill that will address the “Three T’s” – Training, Treatment and Truth in Advertising.  It will help those affected with eating disorders get the treatment they need and deserve.  Specifically:
  • Training – Using current HHS funds, the bill would help train health professionals, school personnel and the public on how to identify eating disorders, and how to help prevent the development of behaviors that may lead to eating disorders.
  • Treatment – The bill would clarify the mental health parity law to include residential treatment service coverage, affording the same protections as other illnesses.
  • Truth in Advertising – The legislation would require a Federal Trade Commission (FTC) report, studying whether regulation is needed for digitally altered images of humans in advertising, and if so, strategies to achieve such regulation.

Thursday, September 17, 2015

Effects of Eating Disorders on Muscles, Dental Health, and the Body

A shout out to Sadie for sharing this article with us!  Thanks to Imagix Dental for their resource page on eating disorders.  Thank You!
In the United States, eating disorders affect approximately 30 million Americans. These disorders are a type of mental illness in which a person has an extreme and unhealthy relationship with food and a negative body image. It can affect both women and men of all ages. It is important for people to understand the severity of eating disorders and how dangerous they are. They can cause numerous problems such as disrupting one’s social life and physical problems that range from dental issues to organ failure and death. There are three primary eating disorders: anorexia nervosa, bulimia nervosa, and binge eating disorder. Each of these negatively impact the body in various ways.
Anorexia Nervosa 
Anorexia nervosa, or anorexia, is one of the more commonly recognized eating disorders. It is a condition in which a person obsesses over being thin. This obsession creates a distorted view of their weight that causes them to view themselves as overly fat, even if they have become dangerously thin. A person with anorexia will become overly thin to the point of being emaciated because they fear that they are, or will become, fat or overweight. That fear is so strong that they see any body weight, even a healthy body weight, as bad. To prevent weight gain, they may restrict calories by consuming very small portions of food and participate in excessive exercising or fasting. This represents a type of anorexia called restricting-type anorexia. Other people with the condition may binge on and purge out food. The purging may include vomiting or the misuse of laxatives, enemas, or dietary aids. This type of anorexia is called purging-type anorexia.
At the very root of the problem, this eating disorder is not about the food or even body weight. Mental health professionals believe that anorexia stems from other issues such as feelings of deep insecurity, lack of control, depression, or extreme low self-esteem. Some people may have suffered problems during childhood such as anxiety issues or eating problems at a very early age. It is most common in women and often manifests when a person is a teenager or during the pre-teen years. Anorexia affects the body in various ways. Most of the problems that it causes come from a lack of proper nutrients caused by eating too little or from purging. The problems that anorexia can cause include but are not limited to the following:
  • Dental problems such as tooth decay
  • Weakness of the bones and osteoporosis
  • Irregular heart rhythms due to decreased potassium levels
  • Heart failure
  • Dehydration
  • Kidney failure as a result of dehydration
  • Amenorrhea, or lack of menstruation
  • Decreased testosterone in men
  • Hair loss
  • Fatigue and lethargy
  • Muscle loss or wasting
  • Anemia
  • Low blood pressure
  • Damage to the brain
Bulimia Nervosa
With this eating disorder, people are often average-sized or just slightly overweight. They are desperate to lose weight and go on various diets as a result; however, the more rigid the diet, the more intensely they crave food. These cravings cause people with bulimia to secretly consume copious amounts of food in one sitting, which is known as binging. On average, a person who is on a binge may within a one-hour span consume as much as 5,000 calories. After the individual has binged, there are overwhelming feelings of guilt, shame, and fear of weight gain due to the massive amounts of calories consumed. As a result, the individual will try to remove the consumed food from their system to minimize any chances of putting on more weight. To do this, they purge the food by vomiting or using laxatives. Even people who do not physically purge their food may also have bulimia if they participate in excessive exercise or fasting. This condition is typically associated with having a poor self-image or depression, and the behavior typically occurs twice a week for no less than three months.
Eighty percent of bulimia sufferers are women. People who suspect that a friend or loved one has bulimia should look for common signs of bulimia nervosa. Often, these signs are in the form of behavioral changes. People suffering from bulimia may start eating alone or secretly. Another sign is regularly visiting the bathroom after eating. While in the bathroom, they may run water in the sink as a way of covering the sound of vomiting. Additionally, they may cut off social relationships and decrease activities, and they may exercise regularly regardless of weather conditions, health, or injuries. The individual may have bruises or scars on their knuckles from forcing themselves to vomit frequently, and they may smell strongly of vomit as well. People who smell of vomit often try to cover the smell with perfumes or cologne, mouthwash, mints, or chewing gum. Vomiting may make their cheeks look puffy or like “chipmunk” cheeks. While their weight is average to slightly overweight, it may regularly fluctuate by ten pounds in both directions. Health problems caused by bulimia are typically due to chemical imbalances in the body. They are often associated with the digestive system as well, due to the act of purging. Problems caused by bulimia nervosa include the following:
  • Loss of tooth enamel and other problems with dental decay due to frequent vomiting
  • Gum disease
  • Cardiovascular problems ranging from irregular heartbeats to even death. This can be the result of an imbalance in electrolytes due to decreased potassium levels or dehydration.
  • Thinning bones
  • Bowel complications stemming from the overuse of laxatives
  • Dehydration and problems with one’s kidneys
  • Amenorrhea
  • Pancreatitis
  • Depression and anxiety.
  • Rupturing of the esophagus or even the stomach
  • Constipation that is chronic in nature due to the overuse of laxatives
Binge Eating Disorder
The most common type of eating disorder in the United States is Binge Eating Disorder, which is commonly known by its acronym BED, or compulsive eating. There are more people with BED than there are women and men with bulimia and anorexia combined. This condition is defined as regular binge eating that occurs at least once weekly for a minimum of three months, even though the person is not hungry at the time. Often, the eating is associated with one’s emotions, such as sadness, loneliness, or even anger. During these episodes, the person feels as if they have lost control of how or what is being eaten and their ability to stop. Typically, the episodes last approximately two hours and the individual eats until they are full to the point of extreme discomfort and even pain. Unlike other eating disorders, a person with BED will not purge after binging, nor will they engage in excessive exercise. This was first recognized as an official diagnosis in 2013 by the American Psychiatric Association. After the episode of binging, the individual is overcome with feelings of shame due to having eaten so much or feelings of guilt. Additionally, when a person binges, they may also feel depressed or disgusted by their actions.
Although scientists are not certain what the cause of BED is, depression, dieting, biology, and poor coping skills may affect it. Anyone can suffer from BED, regardless of body weight; however, people who are overweight are more likely to be BED sufferers. Additionally, because they do not purge, BED sufferers are also more likely to carry extra weight than people with bulimia or anorexia. Because it causes weight gain and obesity in some, many of the health problems associated with it are associated with obesity. Negative side effects of BED include:
  • Cardiovascular problems, such as heart disease
  • Type 2 diabetes
  • Gallbladder problems
  • High blood pressure
  • Stroke
  • Sleep apnea
  • Irregular menstrual cycles
  • Fatty liver disease
  • Osteoarthritis
  • High cholesterol levels

Wednesday, September 2, 2015

When the Eating Disorder Client Is Suicidal

By Nicole Siegfried, Ph.D, CEDS
Trigger warning/Stress warning: Triggers can be unique, inconsistent and unpredictable. Content in this article may be “triggering.” Content warning: self-harm, suicide
The information contained in this website is for general information purposes only. In no event is Gurze/Salucore liable for any loss or damage, including without limitations, indirect or direct or consequential loss or damage, or any loss or damage whatsoever arising from the use of this website. Use of the information posted is at your own risk.
Eating disorders are associated with extremely elevated mortality rates (Chesney, Goodwin, & Fazel, 2014). Although many of these deaths are related to medical complications from the disorder (e.g., arrhythmia, stroke), a significant percentage are due to suicide (Arcelus, Mitchell, Wales, & Nielsen, 2011; Crisp, Callender, Halek, & Hsu, 1992; Fedorowicz et al., 2007; Harris & Barraclough, 1997). In fact, individuals with anorexia are 31 times more likely to make a fatal suicide attempt than the general population (Arcelus et al., 2011; Chesney, et al., 2014; Preti, Rocchi, Sisti, Camboni, & Miotto, 2011), and individuals with bulimia nervosa are seven and a half times more likely to die by suicide than the general population (Arcelus et al., 2011; Chesney et al., 2014; Preti et al., 2011). Additionally, rates of death by suicide among individuals with eating disorders are elevated compared to other mental health disorders, including depression, bipolar disorder, and schizophrenia (Chesney et al., 2014).

Conceptualizing Suicide in Eating Disorders

An understanding of suicidality and how it develops in individuals with eating disorders is necessary for clinicians to effectively treat clients with eating disorders. Many clinicians have misconceptions about suicide in eating disorders and mistakenly attribute the high suicide rate to clients’ fragility and compromised medical condition. Other providers have the misconception that individuals with eating disorders develop eating disorders as a death wish or as a way to slowly kill themselves. Clinicians should have a clear understanding of the myths and facts related to suicide and eating disorders to be able to provide effective assessment and intervention (see Table 1). Additionally, clinicians who treat eating disorders need to have a clear understanding of the suicidal mind and a framework for conceptualization of suicidality in eating disorders.

Suicide as Psychache

According to Shneidman (1996), “psychache,” which is defined as an overwhelming psychological pain, is at the root of suicidality. This psychological pain can best be understood as an amalgamation of fear, shame, anxiety, rejection, guilt, sadness, burdensomeness, disconnection, hopelessness, and other negative emotions. The profound pain associated with psychache results in an inability to effectively problem-solve, seek alternate solutions, or imagine a future. Psychache is also associated with difficulty eating, sleeping, working, and soliciting help from others (Schneidman, 1993). Psychache is so debilitating that the person experiencing it would rather endure the physical pain of death to relieve the psychological pain of psychache.
Interpersonal Psychological Theory of Suicide
Expounding on Schneidman’s theory of psychache, Joiner (2005) proposed The Interpersonal Psychological Theory of Suicide (IPTS). According to Joiner’s theory, psychological pain results from a combination of perceived burdensomeness and thwarted belongingness, which result in suicidal desireSuicidal capability is the result of an acquired sense of fearlessness toward death and tolerance of physical pain. The intersection of suicidal desire (burdensomeness, thwarted belongingness) and suicidal capability (fearlessness toward death and pain tolerance) creates a perfect storm that can lead to a fatal outcome (see Figure 1).
The IPTS model provides a compelling framework for understanding suicide in eating disorders, and has received preliminary empirical support in various studies (Crow et al., 2008; Selby et al., 2010; Smith et al., 2013). Individuals with eating disorders may develop perceived burdensomeness based on their perception of the impact of their disorder on their families. Carrying the psychological pain associated with psychache can also create a level of burdensomeness for individuals with eating disorders. Finally, clients with eating disorders often report burdensomeness based on the demands of treatment and recovery. For example, gaining weight, working through trauma, or experiencing emotion can create a level of burdensomeness that feels intolerable. Individuals with eating disorders also report thwarted belongingness. They report feeling isolated from others, detached from their identities, and disconnected in mind, body and soul. Capacity for suicide in eating disorders develops through the use of eating disorder behaviors. Based on the lethality and violence associated with vomiting, severe restriction, hard exercise, and/or diuretic/laxative use, eating disorder clients may develop a fearlessness of death while heightening their pain tolerance. Other violent behaviors, such as self-harm and substance abuse, which are common in eating disorders, may further amplify the capacity for suicide. The usefulness of the IPTS model in conceptualizing suicidality in eating disorders may also be helpful in guiding assessment and intervention.

Suicide Risk Assessment

In general, mental health providers are poorly trained to assess suicide risk. The majority of graduate programs provide less than four hours of formalized training in suicide assessment (Schmitz et al., 2012), and a large number of clinicians conduct inadequate suicide assessment or fail to detect suicidal ideation in their clients (Bongar, Maris, Berman, & Litman, 1998; Simon, 2002). Based on the high rate of suicide in eating disorders, lack of training and incompetence in suicide assessment is particularly concerning. To date there are no known investigations of competence in suicide risk assessment for eating disorder clinicians, but it seems reasonable to assume that there is a similar lack of training to that of mental health providers. Based on the high rate of suicide in clients with eating disorders, it is recommended that clinicians treating eating disorders receive specialized training in suicide assessment and intervention.

Suicide Risk Assessment: What Not to Do.

Self-Report Checklists. Despite the frequent use of self-report suicide risk checklists in clinical settings, they have not been found to demonstrate the comprehensiveness or accuracy to adequately predict suicide risk. As such, they are not recommended to be used in isolation when assessing suicide risk in eating disorder clients. In addition to a self-report checklist, it is necessary to conduct a more comprehensive and integrative clinical assessment with each client to accurately determine suicidal risk.
No-Suicide Contracts. Along similar lines, it is also fairly common for clinicians to routinely utilize no-suicide contracts (Miller, Jacobs, & Gutheil, 1998)which require clients to agree that they will not engage in suicidal behavior. To date, there is no evidence that no-suicide contracts actually prevent suicidal behavior (Joiner, Van Orden, Witte, & Rudd, 2009). In fact, in one study up to 50% of individuals who had died by suicide had signed a no-suicide contract (Kroll, 2000). Additionally, there has been no legal precedent in which a no-suicide contract has protected clinicians in litigation (Simon, 1992). Furthermore, there is evidence that the use of no-suicide contracts creates a false sense of security for clinicians, and interferes with their ability to conduct a comprehensive and accurate suicide risk assessment (Simon, 2002). Based on these findings, other methods of assessment and intervention are recommended.

Suicide Risk Assessment: What to Do.

Comprehensive Suicide Assessment. Several methods of comprehensive suicide risk assessment have been proposed (See Joiner et al., 2009 for a full discussion of these measures). In this article one method of evidence-based risk-level assessment and intervention is presented that may be helpful for clinicians treating eating disorder clients. The Suicide Risk Decision Tree (Joiner, Walker, Rudd, & Jobes, 1999) assesses three main indicators of suicide risk (i.e., past suicidal behavior, current suicidal desire/ideation, and current resolved plans and preparations), as well as additional risk and protective factors. The Suicide Risk Decision Tree (see Figure 2) is a semi-structured integrated interview, which requires appropriate clinical training to appropriately and accurately determine suicidal risk. The risk assessment framework assesses for past suicidal behavior, which has been identified as the most significant predictor of future suicide attempts (e.g., Putnins, 2005) and death by suicide (e.g., Brown, Beck, Steer, & Grisham, 2000). The interview also assesses Suicidal Desire and Ideation (i.e., relatively vague thoughts about wanting to be dead) and Resolved Plans and Preparations (i.e., more specific thoughts about and planning for a suicide attempt). The endorsement of additional risk factors (e.g., stressors, feelings of hopelessness) may increase risk. Protective factors (e.g., increased social support) are also assessed, and may buffer risk for suicide. The information obtained in the clinical interview is utilized to categorize suicidal risk into lowmoderate, and high risk, using the flow chart from Figure 3.
Risk-Level Interventions. The Suicide Risk Assessment Decision Tree provides a fairly straightforward method to assess suicide risk and offers a framework to guide interventions based on risk level (see Figure 4). For clients who are at low or mild risk, it is recommended that the clinician help the client create a coping card or a de-escalation plan to address suicidality that may arise during the course of treatment. A common format includes: “If I should become suicidal, these are the actions I will take and the coping skills I will utilize.”
For individuals who are at moderate risk, the use of a safety plan is recommended. A safety plan (see Figure 5) is typically more detailed and specific than a coping card or de-escalation plan and differs from a no-suicide contract in that it focuses on what the client will do as opposed to what the client will not do. The traditional safety plan can be enhanced by including reduction of access to means. Research shows that reducing access to means is one of the most effective interventions for preventing suicide (Sarchiapone, Mandelli, Iosue, Andrisano, & Roy, 2011). Including reminders of reasons for living can also enrich the safety plan. As a function of the constricted thinking, clients who are suicidal often have difficulty accessing reasons for living. Research has shown that recalling reasons for living during a suicidal crisis can decrease suicide risk (Rudd et al., 2015).
For individuals at high suicide risk, the same methods of safety planning and means reduction that are used for moderate suicide risk are recommended. For individuals at high risk, an assessment of imminent harm is necessary. For those individuals at imminent risk, psychiatric hospitalization may be necessary to provide safety. It is recommended that clinicians seek consultation when making decisions for moderate and high risk clients and that they document reasoning behind which methods of intervention were chosen and not chosen.


Based on the high rate of suicide in eating disorders, it is imperative that eating disorder clinicians have a good understanding of suicide in this population and demonstrate competence in assessing and treating suicidality. Evidence-based suicide risk level determination can guide eating disorder clinicians to appropriately intervene with suicidal clients to provide effective treatment and ultimately save lives.
Table 1. From: Joiner, T. (2010). Myths About Suicide. Cambridge, MA: Harvard University.
Copyright 2010 by the American Psychological Association (APA). Reprinted under APA’s fair use policy.


EDs are really a slow suicide
EDs are characterized by a desire for thinness and to not feel rather than a desire for death.
Individuals with AN are less likely to choose violent methods of suicide because these individuals tend to be harm avoidant
Although individuals with AN demonstrate harm avoidant tendencies, they have become habituated to bodily damage which overrides harm avoidant nature.
Individuals with ED's are more likely to die by suicide because they are medically compromised.
Individuals with EDs are more likely to die by suicide attempt because they utilize more lethal means in an attempt.
Individuals with EDs tend to attempt suicide because they have more selfish traits than individuals with other disorders.
Individuals with or without EDs who attempt suicide tend to do so to relieve their perceived burden on others, rather than as a selfish act.
Individuals with EDs are more impulsive and therefore more likely to make an impulsive decision to die by suicide.
Most suicides are the result of long planning and deliberation - with or without an ED.
The majority of people with or without EDs who have thoughts of suicide will attempt suicide at some point.
The majority of individuals with suicidal thoughts do not attempt or die by suicide.
There is an increase of suicides around the winter holidays.
The most common time of the year for suicides is during the spring.
Suicide attempts are just cries for help or to get attention.
Individuals who attempt suicide are experiencing true psychological pain, and are unable to articulate their pain and ask for help.

Screen Shot 2015-08-28 at 12.16.29 PM
Figure 2. Decision Tree Interview. Adapted From The Interpersonal Theory of Suicide: Guidance for Working with Suicidal Clients, by T. E. Joiner, Jr., K. A. Van Orden, T. K. Witte, and M. D. Rudd, 2009, p. 72. Copyright 2009 by the American Psychological Association (APA). Reprinted under APA’s fair use policy.
Trigger warning/Stress warning: Triggers can be unique, inconsistent and unpredictable. Content in this article may be “triggering.” Content warning: self-harm, suicide
The information contained in this website is for general information purposes only. In no event is Gurze/Salucore liable for any loss or damage, including without limitations, indirect or direct or consequential loss or damage, or any loss or damage whatsoever arising from the use of this website. Use of the information posted is at your own risk.
To be used by a trained clinician only -
Assess History of Suicidal Behavior:
  1. Past suicidal behavior: Have you attempted suicide in the past? How many times? Methods used? What happened (e.g., went to hospital?).
  2. Do you have a history of non-suicidal self-injury? (e.g., burning, cutting, etc.)
Assess Suicidal Desire and Ideation:
  1. Have you been having thoughts or images of suicide?
  2. Do you ever think about wanting to be dead?
  3. Frequency of ideation: How often do you think about suicide?
  4. What reasons do you have for dying? What reasons do you have to continue living?
Assess Resolved Plans and Preparations:
  1. Duration [look for pre-occupation]: When you have these thoughts, how long do they last?
  2. Intensity: How strong is your intent to kill yourself? (0 = not intense at all, 10 = very intense)
  3. Specified plan [look for vividness, detail]: Do you have a plan for how you would kill yourself?
  4. Means and opportunity: Do you have [the pills, a gun, etc.]? Do you think you’ll have an opportunity to do this?
  5. Have you made preparations for a suicide attempt? [e.g., buying pills]
  6. Do you know when you expect to use your plan?
  7. Courage & competence: How scared do you feel about making an attempt? How courageous do you feel about making an attempt? How able do you feel to make an attempt?
Assess “other significant findings”:
  1. Precipitant stressors: Has anything especially stressful happened to you recently?
  2. Hopelessness: Do you feel hopeless?
  3. Impulsivity: When you’re feeling badly, how do you cope? Sometimes when people feel badly, they do impulsive things to feel better. Has this ever happened to you? [e.g., drinking alcohol, running away, binge eating]
  4. Has anyone in your family made a suicide attempt or died by suicide? Relationship to you? Thoughts and feelings about this?
  5. Presence of psychopathology (rated by interviewer)
  6. Thwarted belongingness: Do you feel connected to other people? Do you live alone? Do you have someone you can call when you’re feeling badly? [are supportive relationships completely absent?]
  7. Perceived burdensomeness: Sometimes people think: “The people in my life would be better off if I were gone.” Do you think that? In what ways to you feel like you contribute meaningfully to those around you? (e.g., at work, at home, in the community)
Protective Factors:
  1. Adequate social support (use responses to item 6 (assess “other significant findings”) to assess this)
  2. Responsibility to others (use responses to item 7 (assess “other significant findings”) to assess this)
  3. Good problem-solving ability: When you are experiencing distress, what do you do to resolve it? When you encounter something difficult, do you sometimes feel like you have no idea what to do to get through it?
  4. Cultural and religious beliefs against suicide
Figure 3. Suicide Risk Assessment Decision Tree. Adapted from “Scientizing and Routinizing the Assessment of Suicidality in Outpatient Practice,” by T. E. Joiner Jr., R. L. Walker, M. D. Rudd, & D. A. Jobes, 1999. Professional Psychology: Research and Practice, 30, p. 451. Copyright 1999 by the American Psychological Association. Reprinted under APA’s fair use policy.
Screen Shot 2015-08-28 at 12.18.32 PM
Figure 4. Interventions for each level of suicide risk. Adapted From The Interpersonal Theory of Suicide: Guidance for Working with Suicidal Clients, by T. E. Joiner, Jr., K. A. Van Orden, T. K. Witte, and M. D. Rudd, 2009, p. 106. Copyright 2009 by the American Psychological Association (APA). Reprinted under APA’s fair use policy.
Risk Category (circle one and check off each action taken):
Low Risk (actions taken)
  • Create a coping card with the client that includes a variant of the following, “In the event that you begin to develop suicidal feelings (or if your existing feelings become more intense), here’s what I want you to do:”
  • List at least three pleasant activities that a client could realistically do when feeling distressed (e.g., work on crossword puzzles, listen to soothing music)
  • List two or three people from the client’s support network that could be called (e.g., mother, friend)
  • List emergency numbers (including that for the National Suicide Prevention Lifeline; 1-800-273-TALK and 911)
  • Continue to regularly monitor suicide risk
  • Document all activities in progress notes
Moderate Risk (actions taken)
  • Consult with a supervisor if you are a trainee
  • Create a coping card (see above)
  • Consider midweek phone check-ins to assess suicide risk more frequently
  • Inform about existence of adjunctive treatments (e.g., medication)
  • Increase social support:
  • o   Encourage client to seek support from friends and family
  • o   Plan with client to have someone check in on him or her regularly
  • o   Ask client’s permission for you to contact the person who will be checking in
  • Attempt to remove access to lethal means (e.g., firearms, pills, etc.)
  • Ask for permission to speak with an informant (e.g., family member, romantic partner), with the appropriate release
  • Continue to regularly monitor suicide risk
  • Document all activities in progress notes                       
High Risk (actions taken)
  • Consult with a supervisor if you are a trainee or with a colleague if you are not a trainee
  • Consider emergency mental health options (e.g., hospitalization)
  • Client should be accompanied and monitored at all times
  • If hospitalization is not warranted, use suggestions from the Moderate Risk category
  • Document all activities in progress notes (including documentation that hospitalization was at least considered)
Figure 5. Sample Safety Plan. Adapted from Bartlett, M. & Siegfried, N(April, 2012). Bridging the treatment of eating disorders and suicidality. Workshop presented at the Annual Conference of the American Association of Suicidology in Baltimore, Maryland. 
Safety Plan
  • When I start to feel emotionally distressed or feel like I want to hurt myself or kill myself, five things that I can do to soothe myself and manage my feelings and/or urges are:

  • When I start to feel like I might act on an unsafe behavior (e.g., self-harm, suicidal behavior), five things I can do to prevent the behavior are: 

1. Create a safe environment:

2. Remind myself of at least 2 reasons for living and recovering:
3. ______________________________________________________________________
4. ______________________________________________________________________
5. ______________________________________________________________________
  • I agree that after I have followed through on the above coping skills, if things are still difficult for me and I believe I might hurt myself, I will do the following:
1. If I am at the facility, I will inform a staff member, who will assist me in being safe.
2. If I am away from the facility, I will
Call the National Helpline: 1-800-273-TALK
Or Contact the local police (phone number): ________________________________
Or Go to the nearest emergency room ____________________________________
This article was adapted from a previous article: Bartlett, M. L., Siegfried, N., & Witte, T.K.  (2013).  Best practice clinical interventions for working with suicidal adults.  Alabama Counseling Association Journal Special Edition Suicide Prevention, Intervention, and Postvention with Youth, Adults, and the Elderly, 38, 65-79.  
About the author -
Dr. Nicole Siegfried is a Certified Eating Disorder Specialist (CEDS) and a licensed clinical psychologist. She is the Clinical Director of Castlewood at The Highlands Treatment Center for Eating Disorders in Birmingham, AL. She previously served as an Associate Professor of Psychology at Samford University and is currently Adjunct Associate Professor of Psychology at University of Alabama at Birmingham. She is an international speaker and has published research, magazine articles, and book chapters in the field of eating disorders. Presently, Dr. Siegfried is an investigator on a research study with Dr. Thomas Joiner examining resilience and suicidality in eating disorders. She is president of the Alabama Regional Chapter of IAEDP, which is in the formation stages. She is a member of the Academy of Eating Disorders (AED) and Co-Chair of the Eating Disorders and Suicide Prevention AED Special Interest Group.
References -
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