Category: Bulimia

training in eating disorders.

5/8/2014

This is not good.

This article from The International Journal of Eating Disorders highlights the lack of systematic training in medical schools in the US to treat the psychiatric illness with the highest mortality rate.

From the abstract:

"Of the 637 responding pro- grams, 514 did not offer any scheduled or elective rotations for EDs. Of the 123 programs offering rotations, only 42 offered a formal, scheduled rotation".

So, if your clinician is not being trained as in Eating Disorders why would you expect them to be able to provide adequate treatment? I'm not sure the situation in Australia is much better.

I would love to hear from The Australian and New Zealand Academy of Eating Disorders and the National Eating Disorder Collaboration about what they are doing to change this situation.

Chris Basten & Chris Thornton will be running some more training and Supervision programs for later this year and throughout next year. Details to follow.

CT

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Facebook doesn't cause anorexia

29/7/2014

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Many parents wonder about the impact of social media, such as Facebook, on their children. One concern is the impact on their self esteem and body image. I have been asked “Does Facebook cause Eating Disorders?” Short answer: No. Longer answer, like a relationship status: It’s complicated.

Researchers from Miami have just published an article in the International Journal of Eating Disorders that begins to highlight the complexities of the interaction between social media, body dissatisfaction, self esteem, and disordered eating.

Some previous studies have found a correlation (not causation) between greater Facebook use and disordered eating and higher levels of weight and shape concerns when compared to users of other internet activities. Posting photos and viewing photo’s is correlated to body image disturbance and an increase rate of body comparision. Importatly, these studies are correlational (those who are high in body comparison and body dissatisfaction may be more likely to look at photos) and do not tell us what might lead to what.

One longitudinal study looked at college women’s tendency to seek out negative feedback and engage in social comparisons predicted bulimic and overeating symptoms at a later date. It was postulated that Facebook use led to body dissatisfaction which led to disordered symptoms.

The Miami study took 185 College students with an average age of 18. Individuals in this study who reported a greater “negative feedback seeking style” were more likely to report an increase in their dietary restraint in their eating a month later if they received a larger number of Facebook comments. However, the "negative feedback seeking style" was measured by only one question “(I sometimes write negative things about myself in my status updates to see if others respond with negative comments about me)". Also the increase in restraint was correlated with the number of comments, some of which would have been positive and reassuring.

Individuals were more likely to report higher shape, weight and eating concerns when they received negative comments in response to personally revealing Facebook comments.

So, posting negative comments about yourself on Facebook, and receiving comments about your post (either negative or positive) did tend to increase restraint in this study, as it has in some other studies. I am not sure in would increase restraint or eating disordered attitudes more than magazines and other media images do. There is a strong body of literature indicating that these sorts of images do increase body dissatisfaction, which increases dieting which is, in turn, a risk factor for eating disorders (particularly bulimia nervosa).

As always comments and thoughts are welcome either on our Facebook page or on the Website below.

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The model or the CLINICIAN: Who comes first?

18/11/2013

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Last week I was asked by the Australian and New Zealand Academy of eating Disorders and by the National Eating Disorders Collaboration lead a discussion on what are the core competencies for someone working in the field of eating disoders. As part of that I gave a presentation entitiled "The Model or The Clinician - Who comes first?" I have attached a link to a PDF of the slides here.

I thought I might just provide some context for some of the slides so it makes some sense.

We start with a brief review of the evidence base in the eating disorders (along with one of my favourite quotes from Christopher Hitchens "What can be asserted without evidence can also be dismissed without evidence".

Slide 3 reminds us we do have Clinical Practice Guidelines to direct us, as well as a more recent Cochrane review and also (slide 4) great review by Bulik (up to 2005) and then Hay (2005-20013). Both published in International Journal of Eating Disorders.

Slide 5 suggests there is the strongest evidence for FBT in the treatment of adolescents with anorexia nervosa, but Slide 6 reminds us that that data (for full recovery - which is the standard to which I hold myself) indicates full remission for 50% of patients. (i.e. it's good but 50% ain't great).

Slide 7 & 8 makes similar point for CBT for BN. Good data suggesting good outcome for most, but again about 50% of patients remain symptomatic at end of treatment. There are also other treatments that are helpful for BN and BED, such as Interpersonal Therapy or DBT. The weight of evidence suggests however a first line treatment for BN should be CBT.

Slide 9 covers adult AN, where our results are poor. Most treatments get about 20% of patients to full remission, and get a substantially higher number to partial remission. 10,11, 12 summarise the latest study from Germany - the ANTOP study. This study again found that the type of treatment (a manualised psychotherapy or CBTE) didn't really matter in terms of outcome. Our treatment manuals aren't guiding us to what we should specifically do with adult patients in AN. I would point out however that the majority of the manuals focus on improving nutrition.

So we have some data to guide us on what may be helpful in the treatment of eating disorders. However, the question is how many practitioners are using the evidence base which suggests some empirically supported treatments exist.

Slide 15 was chosen not because the Tobin study is the best one indicating the Research Practice Gap, but because it has the coolest name (I know what you did last summer ... and it wasn't CBT) and it allowed me to put up a poster of SMG. There is a concerning "What Manual" with 21% of clinicians asked do they use a manual in the treatment of BN. I am more interested in the "flexible" user group, as this is where manual and clinician come together (maybe).

16 is on who uses manuals. Well when I here CBT, research focused and young I tend to think of my Doctor of Clinical Psychology and Master of Clinical Psychology students (some of who are pictured in the slide). When the first graduate the don't have the clinical experience, so should be sticking close to the manualised treatment where ever possible.

17 is some of the reasons people don't use manuals. I am most worried about those who don't know the manual. Slide 18 is an interesting study that indicated that even of those for whom CBT was their treatment of choice, few had formally being trained in the manual. ANZAED and the various state based training organisations must roll out training in evidence based treatment. I know Victoria have done this with FBT, as has NZ, but NSW is far behind.

RCT's dont exclude most patients - its an excuse we use when our results aren't as good as RCT. I have never met an eating disordered clinician who doesn't think they have the toughest patients that have all been excluded from RCT. The evidence generally suggests that treatments do disseminate if you use them.

Maybe our treatment models are "ignorant". I am thinking here of adult anorexia nervosa. Maybe drive for thinness or drive for control just doesn't cut it. I look forward to looking at the data coming out of neuropsychiatry labs like Walter Kaye's and the emerging research on Cognitive Remediation Training that may increase the outcomes for CBT.

The most common reason proffered for not using the Empirically Supported Treatment is that therapy is an art that should not be restrained by a cookbook. Surprisingly I agree with this to some extent. Mainly in the restraints that an RCT puts on the length of treatment. Maybe 40 sessions is not enough for adult anorexia (see the ANTOP studies weight graph that shows people keep getting better after treatment). Sometimes patients may need 30 sessions of FBT rather than stopping at 20 as the manual and RCT protocols suggest.

However, there are ideas in the manuals that help our patients. Our therapies need to reflect this.

As clinicians we need to remember that Evidence Based Practice is a three legged stool. Yes, one leg is Empirically Supported Treatments (our manuals). The other legs are clinical experience and also patients values and preferences.
Each of our camps tend to grab onto on leg of the stool and pull. The stool then looks a bit like a "hitting stick" (Slide 20) to beat people over the head with. Or as Phillipa Hay once wrote in response to our article "tyrannise" people with THE EVIDENCE.

However, as clinicians we need to however be aware of our own humanity and vulnerability to thinking errors - most importantly the confirmation bias (slide 21). This is when we do what we think works and collect evidence that it works and discount evidence it doesn't. This bias can lead us to do things that don't work continually, because we assume they do. It is this that, in my opinion, using manuals grounded in science helps us with.

You know I'm using a boring quote when I use a picture of a cute baby to keep the audience interested. I prefer the quote (from the book "Mistakes were made .... but not by me - which btw is going on my tombstone) about science being 'arrogance control'. Clinicians, and unfortunately I can't exclude myself here, can be some of the most arrogant people I now. We think we know that what we do is right and, if unchecked, our confirmation bias keeps it going.

Im not just bashing clinicians who wont use the evidence base. We need to be aware that as science evolves the evidence base will keep changing and we need to be ready to integrate new evidence into our formulations. For example the evidence for the cognitive behavioural model of BN is not as strong as I thought. I had selectively neglected a body of literature that indicates that dietary restraint may not lead to binge eating - although my clinical experience tells me it does. We all need to keep changing and adapting.

So, Im not bashing flexible manual users (which surprised some in the audience). Indeed I think I am one. The manual keeps me "anchored" to principles that are helpful. I try to integrate the concepts in the manual using my clinical experience - sometimes this is not the order the manual tells me. As clinicians we need to be aware of our tendency to drift into the latest clinical 'fad' or basing out therapy on the latest book we have read or workshop we have attended unless they have data to support them (ACT show me your data please).

Slides 24 & 25 are about the idea that maybe what we do is better than the manualised treatment. I feel all practitioners need to be accountable and to measure (and publish) their outcomes - this is the cornerstone of the generation of Practice Based Evidence. Be able to show what you do works. If it does - teach me what you do (make it disseminate-able).

We finish with the photo's of me cooking a BBQ, Jamie Oliver and Heston Blumenthal. I suggest manuals are a bit like cookbooks (which some take as a criticism). I can't cook. For me to cook chicken pizza - you need to give me a McCain's frozen Pizza that has all the ingredients included with strict instructions on what to do (including remove the plastic, turn on the oven to 180 degrees, place on a tray in the oven, leave in for 25 mins etc. Detailed step by step instructions. Heston may prepare a chicken pizza for you. It wont have chicken, pizza base and may be served as a gas - it is art, but it is not chicken pizza. Jamie however, has some instructions for chicken pizza, He includes a chicken and a pizza base. He can add to that base whatever he likes that might make it better. He doesn't need to be told when to remove the pizza from the oven - he just knows (he could tell you when to though). He uses the key ingredients in an understandable manner. He adds to the recipe in a way as guided by his experience, but his chicken pizza can be replicated by those who want to. When it comes to the treatment of our patients, I think Jamie serves as a model that integrates clinician and model.

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2. Once more with feeling

13/8/2013

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For those who have been to my office in Wahroonga they may recognise my slight obsession with Buffy and this is one of my favourite episodes. It also is a tentative link to my previous post.

This post is about what to do with the feelings that come along in the journey of recovery. To return to the picture that I have put up before..

In this post we are going to focus on this part of the picture. It is a small but crucial part of the picture.

At any giving time we are "stuck with" the thoughts our mind gives us. When our mind gives us thoughts that bad things will happen ("I can't cope"; "If I eat that I'll get fat") then this is going to come with feelings. You don't really get to choose the feelings that arise. If you mind predicts that bad things will happen then you will experience fear and anxiety; if it tells you how bad the world is or things you have lost, you will experience sadness; if it tells you how bad you are you will experience shame. Often the more stuck on your thoughts the stronger the feelings are, but even when you are taking a helicopter stance to your thinking the feelings may be really strong.
If you have an eating disorder you may not be very good at having emotions, they are hard to recognise and name which can make them seem even more overwhelming.
If you are human (and I am going to make that assumption about you) then you probably don't like having really strong uncomfortable emotions. You might have lots of ways to "get rid of" these emotions - this might be one of the reasons that the eating disorder keeps going. It may be a way of trying to avoid these feelings. This comes at a cost - which is usually a "smaller life".
I think a really important part of recovery is accepting that these thoughts and feelings are coming along with you for the journey of having a more meaningful life.
I have never met a patient who wanted to feel terror and panic, sadness and shame. I have however had the privilege to work with countless people who have been "willing" to have these emotions on the journey.
Willingness is about accepting that these difficult emotions are coming along for the ride. It is not about wanting to have them, but deciding to not try to get rid of them by engaging back in old behaviours.
These feelings need to be acknowledged, named (which can be hard at first- but a hint might be don't call them fat), and a space found for them. I often say to patients that it is not about "sitting with" your feelings as this always conjours up images of being in a straight jacket and rocking under a table while you sit with these feelings being dominated by them. Just know they are there and make a conscious and deliberate choice to move in a direction that moves you in the direction of a bigger life no matter what the intensity of the emotion or what your head is telling you to do.
We can talk about some ideas I have about ways to do this in a later post.
Take care of yourselves.

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1. Are you Stuck on thoughts or stuck with thoughts.

2/8/2013

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Sometimes when I work I think, I should write that idea down, maybe it would be helpful for another patient, or maybe I could use that in supervision or teaching. Given that it is not thinking about something that moves you anywhere I thought I would take action and write some of the things I do here. These ideas are just ideas and are in no way a substitute for seeing a real live person to get the help you need.

I was working with a patient of mine who we can call Mary because it isn't her name.We were looking at what was making it hard to move forward in building a "bigger life" including working, compassion and giving to others rather than a "smaller life" of weight control and counting calories.

We ended up with this picture (it goes without saying that I once got kicked out of a high school art class for being an abomination to the art world - harsh but fair btw).

There are actually a lot of different concepts in this picture. I thought that maybe I would break it down over a couple of posts.

This one is about getting stuck on thoughts rather than stuck with thoughts.

Mary had a mind full of thoughts. Her thoughts would both maintain the eating disorder (I cant cope, you dont need it) and more change oriented thoughts (your body is collapsing, it dosen't matter). She could see that these thoughts would just swirl around in her head creating chaos and confusion. She tried to challenge these thoughts but these seemed to get her more paralysed by thoughts. Eventually she would get "stuck on" thoughts - she would act as if they were commands that had to be followed. In the previous week she had been stuck on her eating disordered thoughts and followed them automatically. She had followed them thoughtlessly (without thinking about them) or "mindlessly" (without being that aware that she was following thoughts).

We then drew another picture to indicate another way of 'relating' to thinking.

This represents developing a "helicopter stance" to our thoughts (sometimes called an observing mind). We can learn to look at our thoughts, almost as if they were external to us, and see them as thoughts. We discussed how (at least for the present moments) we are "stuck with" these thoughts. We don't get to choose our thoughts we have in our heads, our minds just produce them. We can't not think, we can't choose to not have certain thoughts. These thoughts are coming with us wherever we go. They are our constant companions, at least for the time being.

The good news is that from this helicopter stance we can have a choice in where we go, rather than just following thoughts we are "stuck on".

I have found that helping people develop a helicopter stance to their thoughts be a really helpful step in moving towards creating a more meaningful life irrespective of what their head is telling them.

We can talk about the "how" to do this later.

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The Futility of Fighting your Body.

29/12/2011

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I came across a Facebook page called leftoverstogo which in turn directed me to an article which was just published in The New York Times called “The Fat Trap”.

http://www.nytimes.com/2012/01/01/magazine/tara-parker-pope-fat-trap.html?pagewanted=all

The article itself is well worth reading, although there a more statistics in there than in many scientific articles I’ve read so it is not the easiest read.

It reminded me however of the enormous complexity of weight loss and how the body has been programmed to fights against it and defend a weight that is biologically predetermined. The article is written from the perspective of obesity, but applies to anorexia and bulimia as well.

The article discuses how we already know that efforts at weight control trigger metabolic and hormonal changes that work to defend a higher weight. However, newer research showed that...

“a full year after significant weight loss, these men and women remained in what could be described as a biologically altered state. Their still-plump bodies were acting as if they were starving and were working overtime to regain the pounds they lost. For instance, a gastric hormone called ghrelin, often dubbed the “hunger hormone,” was about 20 percent higher than at the start of the study. Another hormone associated with suppressing hunger, peptide YY, was also abnormally low. Levels of leptin, a hormone that suppresses hunger and increases metabolism, also remained lower than expected. A cocktail of other hormones associated with hunger and metabolism all remained significantly changed compared to pre-dieting levels. It was almost as if weight loss had put their bodies into a unique metabolic state, a sort of post-dieting syndrome..’

also ... “researchers have so far confirmed 32 distinct genetic variations associated with obesity or body-mass index”.

If this applies to obesity it also applies to anorexia (in particular given the evidence of genetic contribution to this illness) and also bulimia nervosa. This explains why those suffering from the eating disorders become so preoccupied with food weight and shape during the course of the illness. It is also why continued weight loss becomes harder and harder work with greater suffering leading to less “reward”.

The article describes neurobiological research helping us to understand the link between starving and binge eating.

“Another way that the body seems to fight weight loss is by altering the way the brain responds to food. Rosenbaum and his colleague Joy Hirsch, a neuroscientist also at Columbia, used functional magnetic resonance imaging to track the brain patterns of people before and after weight loss while they looked at objects like grapes, Gummi Bears, chocolate, broccoli, cellphones and yo-yos. After weight loss, when the dieter looked at food, the scans showed a bigger response in the parts of the brain associated with reward and a lower response in the areas associated with control. This suggests that the body, in order to get back to its pre-diet weight, induces cravings by making the person feel more excited about food and giving him or her less willpower to resist a high-calorie treat.

“After you’ve lost weight, your brain has a greater emotional response to food,” Rosenbaum says. “You want it more, but the areas of the brain involved in restraint are less active.”

The struggle against the body is one that is endless and rigged against you. The cost are enormous.

The article tells the story of one person who has successfully maintained her weight loss from obesity, which, as we know is a rare occurrence. Although the woman reports being happy with her daily routine it was hauntingly familiar.

“Janice Bridge, a registry member who has successfully maintained a 135-pound weight loss for about five years, is a perfect example. “It’s one of the hardest things there is,” she says. “It’s something that has to be focused on every minute. I’m not always thinking about food, but I am always aware of food.”

So she never lets up. Since October 2006 she has weighed herself every morning and recorded the result in a weight diary. She even carries a scale with her when she travels. In the past six years, she made only one exception to this routine: a two-week, no-weigh vacation in Hawaii.

She also weighs everything in the kitchen. She knows that lettuce is about 5 calories a cup, while flour is about 400. If she goes out to dinner, she conducts a Web search first to look at the menu and calculate calories to help her decide what to order. ... She writes down everything she eats. At night, she transfers all the information to an electronic record”.

To maintain a normal weight she needs to engage in many of the behaviours patients with eating disorders perform in the same ritualised way. This of course dosent mean that she has an eating disorder but I wonder if there are not more fulfilling things to focus on than measuring food and knowing how many calories you burn off during gardening.

I thought the article worth sharing as knowing about the futility of trying to fight the body may be helpful in evaluating the pro’s and con’s of continuing on in a fruitless battle.

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training in eating disorders.

Facebook doesn't cause anorexia

The model or the CLINICIAN: Who comes first?

2. Once more with feeling

1. Are you Stuck on thoughts or stuck with thoughts.

The Futility of Fighting your Body.

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