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.

Easing Post-Meal Stress and Anxiety

Can distraction reduce negative symptoms around meals?

Reprinted from Eating Disorders Review
May/June Volume 27, Number 3
©2016 IAEDP

Assigning verbal, visuospatial, and somatic activities after meals may help counter the anxiety and depression mealtimes can produce among those with eating disorders, according to the results of a small study in London (J Eat Disord. 2016. 4:9).

Dr. Emily Griffiths and her colleagues at the University College London and the Eating Disorders Service, North East London NHS Foundation Trust, London, reported that post-meal symptoms may be increased in inpatients, who are often supervised and their activities restricted after meals. This post-meal distress is still not fully understood, but patients report “feeling fat,” and having negative body image and negative beliefs. The sensation of feeling fat may be a result of misinterpreting emotions such as depression and guilt and bodily sensations of feeling full and bloated after eating, and also fearing rapid weight gain. 

Four post-meal tasks

In their study, the authors asked 25 eating disorders patients to use laptop computers to perform one of three tasks for 15 minutes right after 12 meals of their own choosing (breakfast, lunch, or dinner) within a 2-week period (inpatients) or over 1 month (day treatment patients). The participants were randomly assigned one of four conditions: playing an online computer game (Tetris®), completing a general knowledge quiz, using the fingertips to translate a random list of Braille letters into letters of the English alphabet, and/ or a control task of sitting quietly for 15 minutes. More than two-thirds (69%) of those approached agreed to take part; 11 of 36 who took part completed less than 75% of the post-meal sessions and were subsequently dropped from the study.

After they performed the task, all participants were asked two questions: (1) “To what extent did you experience intrusive body- and fatness-related thoughts during the activity?” and (2) “To what extent did you experience intrusive body and fatness-related images during the activity?” The participants then responded on a Likert-like scale of 1 (very slightly if at all) to 5 (extremely). In addition, the Positive and Negative Affect Scale (PANAS; J Pers Soc Psychol. 1988; 54:1063) was administered at three points: at the beginning of the task, before the specific task was known to the patient, and again after the task.

Post-meal activity produced positive effects

The study results showed that engaging in an activity after meals diminished post-meal distress. All three active tasks increased positive affect, and decreased negative affect, and intrusive thoughts and images. 

(Note: These are thought-provoking results. Distress at meals is a prominent component of, and likely a major impediment to, eating disorders treatment. If one understands exposure as a goal of therapeutic meals, post-meal distraction would be unwanted. Perhaps it is helpful to diminish distress in the early phases of treatment and enhance exposure as treatment proceeds.)

Teens with Chronic Pain

The nature of chronic pain may interfere with detection of a comorbid ED.

Reprinted from Eating Disorders Review
May/June Volume 27, Number 3
©2016 IAEDP

Chronic pain can affect eating patterns in various ways, leading to changes in appetite, erratic meals, vomiting, and decreased activity. Dr. Leslie A. Sim and colleagues at the Mayo Clinic recently reported that eating disorders may be overlooked in teens with chronic pain, leading to a poorer prognosis (J Pediatr Health Care. 2016 doi: 10.1016/j.pedhc.2016.03.001. [Epub ahead of print].

In their study of 34 adolescents with chronic pain and concurrent EDs and 34 age-, gender-, and ED-symptom-matched teens who had an eating disorder but no pain, Dr. Sim and co-workers reported that chronic pain, abdominal pain, autonomic dysfunction, and headache were nearly always diagnosed before the eating disorder was detected. Forty-one percent of the teens with chronic pain reported that their eating disorder developed after their chronic pain, while 35% had ED symptoms before chronic pain developed.

Detection of the eating disorder was delayed in adolescents with chronic pain compared with teens with EDs but no chronic pain. Several factors may account for this. For example, the complaints about the pain may receive more focus. Also, abdominal pain, for example, may give patients with eating disorders a more acceptable excuse for restricting food. Of note, a third of the teens had the postural orthostatic tachycardia syndrome, or POTS, with lightheadedness, headaches, dizziness, fatigue and/or abdominal discomfort, further confusing the picture. The authors offer several steps to help detect eating disorders in these patients.

Take a history of eating behavior, and review the symptoms

Obtaining a clear history of eating behavior and evaluating adolescents for ED symptoms are critical for intervention, according to the authors. In the 34 teens with chronic pain and EDs, the most common diagnosis was anorexia nervosa (AN). This contrasted with typical findings from both community and clinical samples, where AN is often the least commonly diagnosed eating disorder. This could mean that AN is more prevalent in patients with chronic pain, but Dr. Sim and colleagues suggest this is more likely to be due to a detection bias. Marked weight loss may draw attention to patients with AN, and may not be a true representation of the relative prevalence of eating disorder diagnoses in the population with chronic pain.

Adding Exercise to Treatment

11 guidelines include a team approach, patient safety, and reasonable limits.

Reprinted from Eating Disorders Review
May/June Volume 27, Number 3
©2016 IAEDP

The pros and cons of adding exercise to treatment for people with EDs are still being debated. Should exercise be a regular part of treatment for an eating disorder? Or, does this perpetuate a dangerous cycle? After an extensive review of the ED literature, a group of eating disorders experts has developed a set of guidelines for adding exercise to treatment regimens. 

Brian Cook, PhD, and colleagues identified 11 core themes and techniques that have been successful in establishing therapeutic exercise programs for people with EDs (Med Sci Sports Exer. 2016; published ahead of print). The authors noted that the 11 guidelines can be applied to some, but not all, ED patients by “empowering individuals to use exercise as a tool for healthy living.” The authors point to previous research suggesting exercise may actually be helpful for people with EDs, mainly by reducing the drive for thinness and bulimic symptoms. Exercise can also decrease body dissatisfaction, help anorexic patients gain weight, and improve overall quality of life for many ED patients.

A team approach that weighs contraindications, screens for psychopathology

Adding an exercise program requires a spectrum of knowledge about exercise, physiology, and nutrition, as well as skill in tailoring the program to medical and psychological factors, according to the authors. Because of this, a multidisciplinary team with expertise in exercise physiology, nutrition, and mental health needs to be involved in tailoring exercise to the individual. Monitoring is needed both for physical safety as well as for driven or pathological exercise. The authors note that these criteria are mostly likely to be met in inpatient settings.

Tools include a written contract, psycho-education, and positive reinforcement

The authors suggest using a written contract that lays out program rules, goals, anticipated outcome, expectations and contingencies. The exercise program should also include psycho-education, key to most ED-specific programs. Availability of exercise should be contingent on compliance with other parts of the treatment program.

Dr. Cook and his colleagues also recommend the careful, incremental use of exercise starting with small amounts of low-intensity exercise. The researchers noted that the type of exercise is important: some successful programs for weight restoration in AN patients include resistance training vs. aerobic exercise for patients with BN. A reasonable upper limit for exercise, following American College of Sports Medicine recommendations, might be 30 to 40 minutes of exercise at 70% to 80% of maximum effort. 

Finally, it is key to include nutritionists with ED knowledge in the activity program. Weight stabilization must precede introduction of exercise, and the nutritional intake must account for activity level. Each patient can benefit from a debriefing, either during the exercise session or afterward. This enables the therapist and patient to evaluate sensations, emotions, and thoughts evoked by the exercise session.

The authors stressed that “safety is the ultimate concern” when an exercise program is being developed for people with EDs and that adding an exercise component to treatment is not appropriate for all ED patients. And, it does seem likely that most people who exercised before ED treatment reintroduce exercise after treatment. Doing so in a healthy fashion while in structured treatment may reduce long-term risks.

Understanding Brain Development Across The Life Cycle To Improve Treatment For Young Patients

Reprinted from Eating Disorders Review
May/June Volume 27, Number 3
©2016 IAEDP

Better understanding of neuro-development and the concept of brain development across the life cycle can help clinicians improve treatment of teens and young adults, according to Dr. Scott E. Moseman, Medical Director, and Leah Graves, RDN, Nutrition Therapy Manager, at the Laureate Eating Disorders Program, Tulsa, OK. 

Dr. Moseman told symposium attendees that dividing eating disorders into traits and states can be helpful for understanding the development and maintenance of eating disorders among young patients. Underlying traits are genetically determined and affected by hormonal, developmental, and environmental pressures that eventually lead to illness. The illness is then sustained by intrinsic and environmental states.

Traits leading to risk

Temperament and personality traits that lead to anorexia are well known, including anxiety, negative emotionality and low self-esteem, along with low reactivity to reward, and harm avoidance. Some of the same traits, including negative emotionality and low self-esteem, can put an individual at risk of developing bulimia. The internal and external influences that promote risk include normal changes at puberty (estrogen changes that affect serotonin, corticotropin-releasing hormone [CRH], cortisol, and developmental changes in the frontal and limbic circuits), and body weight increase and distribution (due to leptin and ghrelin changes). Dr. Moseman added that during puberty, psychological and environmental influences activate, including “trauma and stress during sensitive periods to a sensitive brain.” Other elements include separation and individualization in a high-stress environment, coupled with a fat-phobic culture that holds up thinness as an ideal measure of success and that perpetuates high activity and low caloric intake.

Dr. Moseman said that several physiologic realities prevent anorexic patients from stopping their harmful behaviors. The anorexic patient’s brain, now malnourished, is state-dependent to continue the illness. Along with this is a regression to prepubertal gonadal function and excess limbic serotonin. One more element is that starvation causes increased excretion of CRH, leading to dysphoria, hyperactivity, and decreased feeding. 

Serotonin’s role in perpetuating anorexia has become clearer, too, he noted. With dieting, serotonin decreases, improving mood. Then, weight loss decreases CRH, worsening mood, which leads to dieting, and improved mood. For bulimic patients, there is a disconnect between ideal body image and urges to eat. Bulimics get positive reinforcement from stopping harmful behaviors, and this reduces dysphoria. However, the neurobiological model of intermittent excessive behavior may then come into play; this is behavior common to binge eating, drug abuse, alcoholism, and excessive gambling. Dopamine-related systems also power excessive eating.

Age and drug effectiveness

A patient’s age has much to do with the effectiveness of pharmacotherapy, according to Dr. Moseman. For example, he explained that most psychotropic agents act through neurotransmitters such as dopamine, serotonin, and norepinephrine, and their receptors undergo major changes during normal physical development. Receptor density peaks in the preschool years and then gradually declines toward adult levels in the late teens. In the few studies that have been done, results have shown that stimulants are less likely to induce euphoria in children than in adults, while antipsychotics are more likely to produce metabolic effects in younger patients than in adults. Thus, the younger the patient, the lower the tolerance to stimulants. Perhaps the most controversial example is the use of SSRIs and risk of suicide, he said.

Nutritional considerations

Dietitian Leah Graves told attendees that nutritional intervention is essential for healing and for helping patients get back on track with normal growth and development. Puberty brings significant increases in height, weight, bone mass, body composition, and sexual maturation, making nutritional needs greater at this time than at any other stage of development--other than the first year of life. For females, a linear growth spurt occurs prior to menarche and 15% to 25% of final adult height is often reached by menarche. Growth spurt begins later in males, who often gain 2 to 5 inches in height per year. Half of adult weight is gained during puberty, and 50% of bone mass and peak bone mass are reached during adolescence. By the age of 18 most teens have accumulated 90% of their bone mass. 

Graves told the audience that when an eating disorder occurs, food-related behaviors disrupt the availability of the essential energy, vitamins, and minerals needed for normal growth and development. Energy needs are high during these years; for males this can mean 3000 to 4000 kcal per day or more, and for females 2400 to 3000 or more per day. Patients need energy for healing in addition to the energy needed for normal growth and development. Those with restricting-type anorexia nervosa (AN-R) require more energy intake than do all other subgroup, while AN patients who have been obese require less energy in order to gain weight.

Some strategies to improve nutrition

According to Graves, two keys to improving nutrition among these patients are: (1) involving parents or caregivers in meals and (2)establishing a structured and consistent eating pattern for patients. Early weight gain is essential, and clinicians may find that their patients benefit from having fewer food choices at first. More recent studies have also suggested that younger patients tolerate a higher caloric load with larger incremental advances, such as 1500 to 1800 kcal/day, with subsequent daily increases of 120 to 200 kcal. Increased use of energy-dense foods may also improve outcome.

Later, patients can benefit from a variety of selections, including added fats, starchy carbohydrates, and caloric beverages. Graves described a newer approach to help patients deal with eating-related fears during weight restoration. Exposure and Response Prevention for AN (AN-EXRP) uses a technique first presented by Dr. Joanna Steinglass of Columbia University. This approach specifically addresses maladaptive eating behavior by targeting eating-related fears and anxiety during weight restoration (Int J Eat Disord. 2014. 47:174).

Graves advised addressing patients’ eating-related fears, and emphasized that weight restoration should be personalized, starting with the least-fear-producing foods and graduating to those that produce the most fear. When setting goal weights, it is also good to remember that a weight range is a moving target, she said, and should start where growth would be without the interference of the eating disorder. In this light it is helpful to determine an individual’s pattern of growth prior to the onset of his or her eating disorder. Weight expectations increase each year, to keep up with projected growth and development. This pattern is easier to explain to the patient with weight tables from the Centers for Disease Control and Prevention, Graves said. 

How Valid Is That Eating Disorders/Health Website?

Reprinted from Eating Disorders Review
May/June Volume 27, Number 3
©2016 IAEDP

On the Information Superhighway, there are many exits you hope your patients won’t take. Misinformation about supplements, “miracle diets,” and pro-anorexia (pro-ana) websites are just a few of the wrong turns that lead to invalid and sometimes harmful information. Families also report great frustration when they try to obtain clear-cut results from studies reported from individual eating disorder treatment programs. Few websites report data-based outcomes, and the information offered may not be derived from rigorous research. 

Millie Plotkin, MLS, with Craig Johnson, PhD and Carrie Arnold, MPH, from the Eating Recovery Center, Denver, offer some helpful hints for sorting out useful from useless information on the Internet. Plotkin said one positive note is that professionals and consumers alike report seeking information from the websites of professional eating disorders organizations such as BEDA, iaedp, and NEDA. One less positive trend, however, was reflected in a survey showing that more than half (57.58%) of professionals regularly use social media for health information, compared with 76.58% of consumers.

Another factor complicating the process of finding valid information on the Internet is the marked increase in the number of scientific research articles being posted. Plotkin added that results from many studies also seem to contradict one another.

Six guidelines for grading validity

Plotkin offered six guidelines for evaluating the validity of a study. “When you see a study, she said, “first, look at the type of research. Was this a pilot study, a longitudinal study, a case-control study, a case report, or a review?” Next, she advised looking at the size of the study sample, as well as the use of randomization, the statistical analysis, where the study was published and, very importantly, who funded the research.

Judging news stories

Patients can be advised that “not all news stories are created equal,” according to Plotkin, and professionals can advise them to look for certain details within any news story. Some details include: where was the story published, what are the writer’s credentials, who specifically was interviewed, and who was quoted? That is, did the writer talk to people who weren’t involved in the study to get an unbiased opinion about the results? Last, is this a true news story or merely a press release?

Evaluating eating disorders websites

Many of the same details apply when evaluating the validity of information presented on eating disorders websites, Plotkin noted. First, who publishes the website? Check to see when the information was last updated—once placed online, materials can remain for a long time, even if the information becomes outdated. Another good question to ask is, was the information on the website reviewed by professionals? And, is the website trying to sell you something? Finally, does the site give references for the information? Plotkin showed the results of a study by Smith et al. (Adolesc Psychiatr Nurs. 2011. 24:33) showing the percentage of websites that fully describe and include DSM-IV criteria. The highest percentage was 15.8% for bulimia. Criteria for the diagnosis of anorexia nervosa were given on only 13% of websites. In the same study, while 92% of the sites provided options for treating patients with AN/BN, only 36% outlined treatment options for patients with eating disorders not otherwise specified (EDNOS).

Benefits of Post-Meal Support Groups in an In-Patient Setting

By Hellen Cappo, LPC, LMFT

Post meal processing is an opportunity for individuals struggling with disordered eating to fully explore the myriad of cognitions and emotions (guilt, shame, anger, fear) that surface in response to nutritional restoration, which is a major goal of early treatment. During this active and experiential processing, patients are able to engage with faulty cognitions related to food, weight, and shape that influence disordered eating habits.  Irrational beliefs about nutrition lead to abnormal eating patterns and are part of the daily struggle for those active in their eating disorder. An advantage of post meal processing, is engaging with the clients’ mealtime experience as the obsessive rumination occurs.

The hours after meal times can produce additional urges for compensatory behaviors. Urges to: purge, exercise, self-harm, or other maladaptive behaviors are often identified by patients as they learn to sit with the emotional and physical discomfort that refeeding in an in-patient setting provokes. Post meal processing is a supportive avenue to promote the use of healthy distraction skills such as: coloring, reading, or listening to music. Encouraging patients to engage in sensory based actives like: using play doh, utilizing scented lotions, or progressive muscle relaxation, enables clients to stay mindful of their physical experience while trying to disengage from distorted beliefs about how their recent meal intake is affecting their weight and shape.

Post meal processing is also crucial after individual nutritional challenges such as incorporating “fear foods” into a patient’s meal plan or completing a food exposure. A dominant feature of Anorexia Nervosa is the severe restriction of food intake and variety. The ability to broaden a variety of food choices into one’s meal plan is a predictor of continued success post discharge from an in-patient treatment setting. For this reason, patients at all levels of Eating Disorder treatment engage in nutrition challenges which provide the opportunity for post-meal reflection on their perceived and actual accomplishments and resilience. Using post-meal processing to increase a patient’s positive view of their new eating habits can increase motivation and hopefulness about their ability to recover.

Group leaders, therapists, and nutritionists act as models for helping individuals relearn normalized, non-guilt inducing responses to eating by providing structure and guidelines for post-meal processing. Setting boundaries on the content of discussed information helps guide patients as they become proficient in distinguishing healthy thinking from distorted thinking. Reframing the meal experience helps patients identify methods used to eat through discomfort and to not focus on meals feeling uncomfortable.  Group leaders also help direct patients in learning how to normalize their discussions about eating by shifting content to focus on the patient’s communication of their meal experience: shying away from focus on negative judgments about food or distorted beliefs about how the meal impacts the patient’s weight or shape.

At The Eating Disorders Treatment Center at River Oaks Hospital, post-meal processing is held in a group format. Open forum allows patients the chance to explore cognitions and emotions triggered during meal time. With peer support, patients challenge Eating Disorder related experiences in the moment that they are occur. Post meal processing groups are led by trained staff members who promote open expression of emotions while encouraging reframing, skills use, and honesty of their intrapsychic experience. Staff members are available to provide structure and guidelines on content that promote a sense of safety for patients in which to honestly engage. Communication regarding the content of meals and post meal processing allows for deeper exploration of triggers or emotions in patients’ individual therapy sessions or during the daily therapeutic Process Group.

Nutrition Therapy at the Beginning of Residential Treatment

By Jodi Krumholz, RD, LDN

When a patient first comes into residential eating disorder treatment, the  dietitian performs a very thorough assessment.  We ask a patient about their ED behaviors as well as their weight history. We also want to know if they engage in food rituals such as cutting their foods up into small pieces or eating foods in certain order.  The assessment is an opportunity to really understand a patient’s history as well as figure out who their main support will be when they return home. As residential dietitians, we work diligently to include family and friends in nutrition sessions.  We educate them on how to support their loved ones nutritionally upon return home.

From the first day of treatment, every patient is started on a well balanced meal plan that includes a variety of food groups at each meal.  For example, a meal might include a turkey sandwich with cheese and mayo as well as a cup of fruit and a side salad with dressing. Residential patients may also be started on snacks or supplements like Boost Plus depending on their caloric needs.  One of the biggest goals is to introduce patients to “normal eating.”  Therefore, we serve a variety of cuisines such as pizza, Mexican, Greek, Asian, etc.  We have all patients eating at least 3 desserts weekly because we want to show patients how desserts can fit into a healthy lifestyle.  We teach what normal portions look like based on the USDA guidelines.  Regardless of whether someone is obese or underweight, the goal is to teach all patients what normal eating looks like and that all foods can fit into a healthy lifestyle.  We will accommodate allergies or special diets as needed.

Patients start out in treatment selecting food from a specific menu and then all meals are portioned out and placed on the table when patients enter the dining room. We have staff present to monitor that patients are completing meals and not acting out on any eating disorder behaviors such as hiding food, restricting, etc.  If patients are engaging in behaviors, they would be moved to a separate dining room where there is closer monitoring.  As patients in treatment are meeting nutrition expectations, they are able to progress to walking  through the serving line and choosing their own meals with the assistance of a dietitian.  They can practice asking for the portions they need as well as serve themselves from our salad bar.

Through the use of food journals we assist residential patients to see that their symptoms (i.e., restricting, binging, purging) are really just a way to avoid uncomfortable  emotions. We work closely with our patients in individual sessions to see how emotional experiences influence behaviors and actions. For example, we might look at how a patient restricting a meal in treatment reduces the anxiety or guilt they experience in the short term.  However, we help them to see that overtime in their attempt to relieve these emotions they end up feeling worse about themselves and staying stuck in a vicious cycle.  Patients journal about their meal and emotions throughout the entire day.  Patients learn a lot about themselves this way and the residential dietitians use these journals in sessions as an important tool in teaching patients how their emotions impact the ED. This is a skill that is very unique to a well trained residential ED dietitian.

As dietitians, we have weight goal expectations for patients who need to gain weight (less than 95% IBW) but we never focus on weight loss.  Patients who have previously binged will naturally lose weight from eating normally, but we keep the focus on normal eating and not weight loss.  We look to teach everyone that all foods can fit into a healthy lifestyle and to take the emphasis off weight. Most of the patients are extremely disconnected from their hunger and fullness and will need to eat “mechanically” and follow a meal plan for a long time to come. As part of their experience, we will begin to take them to restaurants and teach them how to prepare well balanced meals for themselves.  We will also practice grocery shopping and have more advanced residential patients take passes to practice eating out with family and friends.

The residential experience is truly a unique one in that we are working on a variety of skills a patient will need to be successful.  We are also implementing  a  lot of structure around mealtime that we want to have incorporated at home. The dietitians work very closely with other team members to help patients eliminate behaviors and understand the function of these behaviors. We believe this paves the way to a successful recovery!

Providing Emotional Support for Parents of Eating Disordered In-Patients

By Allison L. Hall, MSW, LICSW

“Making the decision to have a child is momentous. It is to decide forever to have your heart go walking around outside your body.” Elizabeth Stone

For many parents, having their child admitted to the hospital is one of the most frightening experiences in their parenting career.  Hospitalization can cause a sense of vulnerability, with reliance on strangers to protect and care for their most valued asset.  Sense of control is taken away, and the natural instinct to be their child’s savior is usurped.  Sleep, diet, self-care, work, other children, and outside responsibilities are generally interrupted.  In brief, the world feels like it has turned upside down.  Similar experiences extend to parents of children hospitalized for medical complications of an eating disorder, although given the unique characteristics of the diagnosis there are additional considerations for this population of caregivers.

Understanding the Parent Perspective

In eating disorder care, parents are the front line of treatment.  While battling an eating disorder is exhausting for everyone involved, treatment providers go home at the end of the day.  On the other hand, at the end of their day, parents are in the position to bring the eating disorder home with them.  Parents are tasked with implementing recommended changes outside of the treatment setting, supporting their child to all indicated appointments, taking control of the food shopping, preparation and presentation, modeling healthy eating, utilizing meal coaching strategies, supporting their child in implementing coping skills, monitoring bathroom use, communicating with the treatment team, and promoting a healthy home environment.  This arduous list of responsibilities is added to the already busy lives of parents who are generally juggling multi-sibling households and career demands.

It is also crucial to acknowledge anticipated emotional responses that are likely to include various combinations of guilt, shame, embarrassment, fear, shock, anger, grief, confusion, frustration, and overall exhaustion.   Findings indicate that carers of children with eating disorders are at especially high risk for psychological distress.  1 ( ——– the 1 needs to be a superscript) By the time children reach the need for hospitalization, parents are likely to feel like they have just run a marathon, but know they are still nowhere near the end of this unwelcome journey.  When asked what she would most like professionals to understand of her experience, one mother states, “It’s overwhelming.  I’m only going to hear 2% of what you tell me.  We are in crisis for a long time, and need providers to have patience.”

Acknowledging the Stigma

According to a recent publication, research exploring stigmatizing attitudes and beliefs of the public toward individuals with eating disorders suggest prevalence of themes such as personal responsibility, attention-seeking, weakness of character, and an issue that should be easily overcome. 2 (—–this 2 needs to be a superscript) Eating disorders are the 3rd most common illness of adolescence 3(—–this 3 needs to be a superscript), however they continue to be surrounded by stigma, stereotypes, and misconceptions.  Because of this stigma, parents are oftentimes resistant to sharing the diagnosis with their support system, their child’s school, their employers, etc.  This resistance to sharing can lead to isolation and minimizing access to the concrete help and emotional support needed in times of crisis.  For parents who choose to share their child’s eating disorder diagnosis, they are at risk of becoming recipients of negative, blaming comments.  As stigmatizing attitudes and beliefs are not limited to the general public and can extend to health care providers, many parents are on the receiving end of damaging remarks made by the providers who are charged with caring for their children.

Offering Psychoeducation

Sorting through the massive array of literature, information, websites, books, and articles available on the topic of eating disorders is an overwhelming, time consuming task.  Arming parents with the knowledge of diagnostic criteria, epidemiology, common characteristics, indicated treatment, and anticipated challenges is an essential component to preparing them for battle with an eating disorder.  Proper education can also help families identify and cease unhealthy patterns and coping mechanisms that are actively empowering the eating disorder.  Having previewed resources available to parents can save time and stress, as well as ensure that parents are learning from valid sources.  Various forms of education are recommended, such as verbal, written articles, books and pamphlets, and available websites as people tend to learn in various ways.     

Managing Self-Care     

While tending to the needs of a child in the hospital, it is easy for parents to lose sight of self-care.  Their own needs tend to fall by the wayside, which can lead to many forms of exhaustion.  Exhausted parents are not necessarily well-equipped to care for their children upon discharge, a time in which they will need to be at their best to enforce adherence to recommendations in the home setting.  Treatment providers can help support parents in implementing self-care in many ways.  For instance, simply acknowledging the toll that this experience takes on the entire family can bring parent needs to the forefront.  Giving family members permission to take time out of the hospital, sleep at home, and go for a walk or sit down in the cafeteria can alleviate the guilt that may be preventing caregivers from taking a break.  Asking parents what they tend to do to relieve stress and/or relax in their routine life can give providers direction in tools to recommend to parents when indicated.  Suggesting the caregiver consider the option of therapy for themselves during this crisis might also be considered.  Other strategies include exploring the option of sharing shifts at the hospital, and taking friends and family members up on offers to help.  The family support system is frequently eager to provide assistance, and can truly alleviate the day-to-day demands on parents.

Suggestions for Providers

Introduce yourself and your role to parents as soon as possible, and welcome them to the treatment team

Identify what you will request from parents, and when you will need them present

Communicate daily with parents,  involve them in conversations and value their input

Review the treatment models practiced

Offer various forms of psychoeducation

Encourage self-care

Validate their emotional responses

Demonstrate  empathy and compassion

Normalize the need for ongoing support from their team, loved ones, and peers

Suggestions for Parents

Know the treatment team

Ask early on what the expectations for you will be during the admission

Communicate daily with the team

Inquire about the treatment model used

Implement self-care

Provide your cell number to providers to encourage communication when you are not present

A common goal of all involved is to help support the child struggling with the eating disorder in achieving quality of life.  In order to reach this goal, it is essential that parents’ needs are considered and tended to.  Due to the demands placed on parents caring for their eating disordered child, they are at high risk for stress and fatigue.  To help decrease the stress and demands on parents, there are many options for support that can be offered by the remainder of the team.  Interventions given to caregivers in early onset cases may be most effective 4,(—–this 4 needs to be a superscript) therefore, it is crucial that treatment providers are prepared with supports from the initial stages of care.