Mind-Body Brief Therapy Solutions for Body-dysmorphia in Post-Surgery Bariatric Patients

SC-11 Thursday 8:30-10:00 December 11, 2008

Marc I. Oster, PsyD Carolyn Sauer, PsyD

Milton H. Erickson Foundation San Diego, CA

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BT2008 PPT & Handouts CD

ego-strengthening.

Contents

• Alladin Sympathetic Arousal Script (WORD): hypnotic script aimed at reducing sympathetic over-arousal and • Allen CBT for BDD (Word): journal article.

• Avoidant Behaviors, Weight Loss and Body Image (WORD): journal article conclusion on impact of significant weight loss on body image.

• K. Bailey “Body Dysmorphia: Mind Games After Gastric Bypass Surgery” internet PDF article.

• K. Bailey “Fat Lady in a Thin Body: WLS Patients Feel Like Imposters” internet PDF article.

• “Bariatric Surgery Follow Up” (PDF): journal article American Academy of Family Physicians.

• Bibliography (WORD): Various select presentation references.

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BT2008 PPT & Handouts CD Contents

(continued)

• “Cognitive-Behavioral Treatment of Obesity” (short form) (WORD): summary of journal article.

• “Effects of Weight Loss on Body Image” (WORD): summary of journal article.

• Exercise and Anxiety (WORD): summary/conclusions from journal article.

• Marcus obesity surgery (PDF): “Development of a Model for a Structured Support Group for Patients following Bariatric Surgery” journal article.

• Psych of Body Contouring Surgery (PDF): “Psychological Considerations of the Bariatric • Surgery Patient Undergoing Body Contouring Surgery” journal article.

3 • Rabinowitz Exposure Tx BDD (WORD): summary of journal article.

Carolyn & Marc

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Marc I. Oster, Psy.D., ABPH

Associate Professor

American School of Professional Psychology at Argosy University Schaumburg Campus 999 Plaza Drive, Suite 111 Schaumburg, IL 60173 (847) 969-4944 USA [email protected]

Marc I. Oster, Psy.D., ABPH

Diplomate status with the American Board of Psychological Hypnosis; Fellow of the American Psychological Association; Fellow and Past President of the American Society of Clinical Hypnosis; Board Member of the American Board of Psychological Hypnosis; Consulting Psychologist for the United States Navy Medical Corps, United States Department of Justice Drug Enforcement Administration, and several news organizations; 100 publications and professional presentations; Practice interests include clinical, health, and forensic psychology in the north suburbs of Chicago. 6

Carolyn P. Sauer, Psy.D.

Training and supervision in clinical work with children, adolescents, adults and families; individual, group and family therapy for outpatient and inpatient populations; obstetric hypnosis, empowerment, substance abuse, trauma, and yoga. Certified Diplomate of the National Board of Certified Clinical Hypnotherapists. A graduate of the Teacher Training Program, Iyengar Yoga Institute of San Francisco.

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Perception

• Our presentation is about perception – our perception, others’ perception of the patient, the patient’s perception, and their internalized body image.

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Criteria for Gastric Bypass Surgery

• Approximately 100 pounds overweight • BMI of 40+ or • BMI of 35 plus co-morbid risk factors such as: diabetes, HTN, heart disease, etc • History of failed weight loss/maintenance 9

Obesity-Related Comorbidities

System Comorbidities

Cardiovascular Hypertension, hyperlipidemia, cardiomyopathy, long QT syndrome, atrial fibrillation Pulmonary obstructive sleep apnea, restrictive lung disease Reactive airway disease, Musculoskeletal back pain, immobility Debilitating osteoarthritis, chronic low Psychological depression, body dysmorphic disorder Binge-eating disorder, Dermatologic acanthosis nigricans 10 Intertrigo, venous stasis, decubitus ulcer,

Obesity-Related Comorbidities

(continued)

Endocrine hypoandrogenemia, metabolic syndrome, polycystic ovarian syndrome Diabetes mellitus, Genitourinary Ovarian cancer, uterine cancer, breast cancer, renal cell cancer, dysfunctional uterine bleeding Gastrointestinal Irritable bowel syndrome, nonalcoholic fatty liver disease, gastroesophageal reflux, esophageal cancer, colon cancer Neurologic paresthetica © American Academy of Family Physicians 2006 Ischemic stroke, meralgia 11

What does a BMI = 40+ look like?

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BMI = approx. 47

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Roux-en-Y Gastric Bypass Procedure

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Normal Stomach

© American Academy of Family Physicians 2006 15

Normal Football

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Normal Stomach = Normal Football

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Completed Gastric Bypass

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Coffee Cups

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New Stomach = 4 oz Coffee Cup

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WSL Outcomes

• Weight Loss Surgery Outcomes: Among other things, most notably, significant and rapid weight loss (e.g. 100-

200-280 pounds in 12-18-24 months)

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WSL Outcomes

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Remember this guy?

(2004)

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Here he is again in 2006. His BMI=47

“In this photo Phil, the guy on the left, was about half my size. I have now lost about half of my original body weight. Now Phil and I are the same size –

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WSL Outcomes, part 2

In addition to the significant weight loss and improvements in overall health, these patients experience a variety of emotional concerns as they adjust to their new life.

Of interest here is the dramatic, or sometimes traumatic, alterations in body image also knows as dysmorphia. This is similar in many respects to the dysmorphia experienced by anoretic patients.

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What is Dysmorphia?

Diagnostic Features excessive preoccupation with a defect in appearance; causing significant distress or impairment….

find their preoccupations difficult to control; make little or no attempt to resist them; spend hours a day thinking about their “defect;” these thoughts may dominate their lives; may lead to avoidance of work or public situations…. 29

Associated Features alternate between periods of excessive mirror checking and avoidance, frequent requests for reassurance about the “defect,” compare their “ugly” body part with that of others….

avoidance of usual activities may lead to extreme social isolation, may leave their homes only at night, when they cannot be seen, or become housebound, may drop out of school, avoid job interviews, work at jobs below their capacity, or not work at all, few friends, avoid dating and other social interactions, have marital difficulties, or get divorced, may be associated with Major Depressive Disorder, Delusional Disorder, Social Phobia, and Obsessive-Compulsive Disorder. 30

Our Premise

As the surgeons say, “I did the surgery on your stomach, not your head. You will still have to fix that problem for your surgery to be successful.” In other words, WLS patients still have to address their psychology or the dissonance created by the surgery (thin body, fat body image) will be resolved by weight gain.

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Many of the studies cited in the references section that looked at body image, body dissatisfaction, disparagement, etc, attended to the lack of satisfaction with and the effect on the patient’s quality of life resulting from the excessive skin following massive weight loss. Indeed, the physical and social impact of such a dramatic, and perhaps traumatic change in one’s appearance can be quite devastating. 32

What these studies fail to address is perhaps a second order form of this body image disruption. That is the shock, discomfort, and growing unfamiliarity this patient has with their new body and how it or they fit into the world around them.

For example….

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“yes, I did have some BDD issues”

• not recognizing myself in the mirror; • my face changed a lot and fairly quickly; • trouble recognizing as mine, parts of my body, including seeing muscle definition I'd never seen before in my life; • seeing the vascular development in my arms and hands; • feeling bones (e.g. my ribs at the sternum and thinking I had holes in my chest); • walking around tables or clothing racks in restaurants or stores because I didn't know I could fit within the aisles; 34 • not "seeing" oneself socially or personality-wise

General Psychological Treatment

• CBT • Exposure and Response Prevention (ERP) ala OCD treatment (see Rabinowitz, 2007) • Support groups (see Marcus & Elkins, 2004) • Individual Psychotherapy • Medications (SSRIs) 35

A Solution “Body Awareness Therapy”

We define Body Awareness Therapy as any activity, presumably therapeutic, that either re-acquaints the patient with their body or acquaints them with their body for the first time.

For example….

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"body awareness activity I've done”

• studying myself in mirrors (with and without clothes); • asking (partner) to point out someone she sees who looks like I did pre- and post-surgery; • trying on lots of clothes; • trying/doing various kinds of exercise (running, karate, conditioning); • therapy; • talking with friends about their experience or observations of me.

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Body Awareness Therapies

These therapies may include: • Counseling/psychotherapy • Physical exercise • Massage • Therapeutic tasks or exercises ala Erickson or Haley • Yoga • Hard or external martial arts: Karate, Judo, etc • Soft or internal martial or healing arts: Tai Chi, Qi Gong, Acupuncture 38

Common Themes and Goals of Bariatric Support Groups

• Uncertainty, helplessness, lack of control • Treatment-related concerns and doctor patient relationships • Self and body image • Effects of illness on the family and social relationships • Prioritizing life values, setting personal goals • Coping with problems • Learning from group members (Marcus & 39

• Beginning at about six months post-op, there is a fundamental shift from an external locus of control imposed upon them by the operation to an internal locus of self-control. Body image issues remain, but may take on a different aspect, becoming more internalized as a function of identity formation rather than just a physical or cosmetic one. (Marcus & Elkins, 2004) 40

• • • • •

Mechanisms Explaining the Effects of Massage

Mechanical mechanisms result essentially from physical forces of compression, stretching, shearing, and broadening of tissues. Mechanical mechanisms occur at the gross level of the physical structure. Physiologic mechanisms of the body (e.g., changes at the cellular, tissue, or organ system level). refer to the organic processes Reflex mechanisms refer to the result of pressure or movement in one body part affecting another body part. Mind-body mechanisms emotion, immunity, physiology, and health or disease processes. refer to the interplay of mind, Energetic mechanisms refer to changes in the body’s flow of energy, a mechanism related to acupuncture points, the meridian system, and the flow of chi (life 41

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Sports, Athletics, & Exercise Benefits:

improved academic performance, self confidence, emotional stability, independence, cognitive functioning, memory, mood, perception, body image, self-control, sexual satisfaction, work efficiency, decreased alcohol abuse, anger, anxiety, confusion, depression, dysmenorrhea, headaches, hostility, phobias, stress response, psychotic behavior, tension, and work errors 43

Sport as Transformative Practice

• Regular practice of particular physical movements with the intent to improve them sometimes give rise to spontaneous metanormalities; • Sustained and focused attention can produce a state of mind graced by extraordinary clarity and focus; • Imagery rehearsal catalyzes the reintegration of physical performance. It is a well-controlled copy of experience, a sort of body-thinking (e.g. the Arnold, Jack Nicklaus, & Dwight Stones)

Sport as Transformative Practice

(continued)

• Relinquishing limiting cognitive, volitional, emotional, and sensorimotor patterns abandonment of habitual responses (i.e. quitting) and enduring the nay saying voices inside them, athletes discover new capacities - transformation.

• Practiced detachment from results – those who persevere learn that there is an interior freedom and grace beyond their sport's results.

45 • Long-term commitment – to one’s self.

Sport as Transformative Practice

(continued)

• New integrations of mind and body. We must take our old repertoires apart and reassemble them with new power and beauty.

These transformations occur as a result of effort in areas other than sport. However, sport involves a greater physical-mental transformative experience. 46

Martial Arts

The martial arts derive much of their transformative power from the richness and complexity of their repertoires. The sheer number of movements they demand helps practitioners develop coordination, balance, agility, flexibility, strength, endurance, and speed of hand and foot. 47

They incorporate countless discoveries about our psychophysical potential, which is apparent in the fact that many of them use methods that modern somatic disciplines have only recently discovered. (e.g. Tai-chi promotes alignment and extension of the neck as in the Alexander Technique, and cultivates the soft, pleasurable stretching of Feldenkrais.) The martial arts today embody an immense tacit knowledge about human physiology and movement, much of it derived from Oriental medicine and religious practice. 48

Acupuncture

• A basic tenet of Chinese medicine is the belief that vital energy (qi or chi) flows along specific pathways (meridians) that have about 350 major points (acupoints) whose manipulation corrects imbalances by stimulating or removing blockages to energy flow. • Another fundamental concept is the idea of two opposing energy fields (yin and yang) that must be in balance for health to be sustained.

Acupuncture (

continued)

• The benefits of acupuncture have been validated in a variety of conditions: pain management, postoperative nausea and vomiting, osteoarthritis of the knee, fibromyalgia, and headaches. Other conditions treated include: asthma, dysmenorrhea. cervical pain, insomnia, anxiety, depression, and substance abuse, including smoking cessation.

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Tai Chi Chuan

• Tai chi chuan, or tai chi, is designed to increase the life force in the body through a series of slow circular movements. It is a moving form of meditation and is based on the search for perfect balance between yin and yang energies. • The practitioner performs sequences of movements that last from 5 to 30 minutes. The practitioner is expected to focus on breathing and its precise synchronization with the movements. Tai chi helps stress related conditions including anxiety, 51

Yoga

• Yoga seeks to bring into balance all the disparate aspects of the body, mind, and personality. The west grew familiar with yoga through the practice of Hatha yoga and an emphases on the postures (asana).

• Yoga is used to reduce stress and to treat anxiety, high blood pressure, and musculoskeletal conditions. Studies have indicated its benefits for depression. 52

In yoga, a healthy fulfilling life is based on mastering 8 aspects or "limbs". Each limb supports the acquisition of the next one: 1. Yama: 5 ethical guidelines regarding moral behavior toward 2. Niyama: 5 eithcal guidelines regarding moral behavior toward others oneself 3. Asana (yoga postures) 4. Pranayama (practice of the breath) 5. Pratyahara: withdrawal of the senses 6. Dharana: Concentration, the ability to focus on something without being distracted 7. Dhyana: Meditation 8. Samadhi: Bliss, merging of the self with the universe (enlightenment) 53

The purpose of Asana is to make the fit for the mind and the spirit.

body Pranayama is the science of

control the mind (thoughts).

breath.

rhythmic patterns of breath can sooth the nervous system and reduce cravings. By controlling the breath it is possible to The 54

Cautions

Gas Levels * CO2 Normal Breath O2 * Gasping * Dizziness

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Bibliography

A list of bibliographic resources is provided as a separate handout in your packet/CD.

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Then and Now

2004 /2006 BMI = 47 2008 BMI = ~23

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