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Working with Eating Disorder Patients Elise Curry Psy.D. Clinical Psychologist Private Practice San Diego, CA Anorexia Nervosa Most homogenous psychiatric disorder 90-95% female Onset teenage years – puberty Monotonous puzzling symptoms Poor response to treatment Highest mortality rate 50% to 80% contribution of genes DSM IV Criteria for Anorexia Nervosa Preoccupation with body shape, weight/size <85% ideal BW Fear of becoming fat despite low weight Loss of 3 consecutive periods in women Types: restricting,binge/purge,purge DSM IV criteria for Bulimia Nervosa Recurrent episodes of binge eating, characterized by eating an excessive amount of food within a discrete period of time and by a sense of lack of control over eating during the episode Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as selfinduced vomiting or misuse of laxatives, diurética, enemas, or other medications (purging); fasting; or excessive exercise The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months Self-evaluation is unduly influenced by body shape and weight Diagnostic challenges in EDs (ED NOS) BN vs. AN: binge/purge type Sandy is 5 ft tall and weighs is 80 lbs. She has regular periods and no body distortion. She is 16 yrs old. Sally purges normal meals, but does not binge. Tom thinks he needs to gain weight. He uses exercise to purge. He binges 2 times per week and then goes running. Shelly chews and spits her food several times a day Compulsive Exercise 1. Having no period isn’t healthy, even for an athlete. 2. Exercising in spite of injury or sickness. 3. Individual feels s/he has to exercise to feel OK. 4. Exercise becomes the way the individual organizes his/her life. 5. Exercise is done in secret. 6. Exercise done mostly to burn calories. Possible Signs of an Eating Disorder Preoccupation with food/weight Dramatic weight loss or gain Chronic dieting Feels cold all the time Dental problems History of ballet, wrestling, or modeling Disgusted by red meat or desserts Has difficulty eating with people Cuts out food groups Becomes vegetarian/vegan as a teen Uses bathroom after meals Wears baggy clothes or layers Cooks for other excessively Excessive exercise Scope of The Problem Prevalence increasing AN: .5-2% BN: 3-4% AN BN More common westernized cultures 10% of eating disordered individuals in treatment are male 5% per decade of AN patients die (disorder or suicide) Scope of the problem: continued One of the highest death rates from any mental health condition (AN) 10% Increasing incidence in elementary age children (8-11 year old) The incidence of bulimia in 10-39 year old women TRIPLED between 1988 and 1993. There has been a rise in incidence of anorexia in young women 15-19 in each decade since 1930. Ethnic Diversity in EDs Minnesota Adolescent Health Study found that dieting was associated with weight dissatisfaction, perceived overweight, and low body pride in all ethnic groups (Story et al, 1997). Among the leanest 25% of 6th and 7th grade girls, Hispanics and Asians reported significantly more body dissatisfaction than did white girls. Robinson et al (1996) Cultural Issues More common in Westernized Societies Historically self starvation reported prior to 19th century (religious/spiritual “reasons”) Cultural importance placed on “thinness” Less common in cultures where roundness is sign of fertility, health, prosperity Hong kong, India : AN w/o fear of fat. “Many individuals in our culture, for a number of reasons, are concerned with their weight and diet. Yet less than half of one percent of all women develop anorexia nervosa, which indicates to us that societal pressure alone isn’t enough to cause someone to develop this disease,” said Kaye. Media Stats The average young adolescent watches 3 to 4 hours of TV per day (Levine, 1997). A study of 4,294 network television commercials revealed that 1 our of every 3.8 commercials send some sort of “attractiveness message,” telling viewers what is or is not attractive (as cited in Myers et al, 1992). These researchers estimate that the average adolescent sees over 5,260 “attractiveness messages” per year. Another study of mass media magazines discovered that women’s magazines had 10.5 times more advertisements and articles promoting weight loss than men’s magazines did (as cited in Guillen & Barr, 1994). Drive for thinness and dieting Girls who diet frequently are 12 times as likely to binge as girls who don’t diet (Neumark-Sztainer,2005). Most fashion models are thinner than 98% of American women (Smolak, 1996). The average American woman is 5’4” tall and weighs 140 lbs. The average model is 5’11” and weighs 117 lbs. 35% of “normal dieters” progress to pathological dieting. Of those, 20-25% progress to partial or full syndrome eating disorders (Shisslak & Crago, 1995). 95% of all dieters will regain their lost weight in 1 to 5 years (Grodstein, et al., 1996). Americans spend over $40 billion on dieting and diet related products each year (Smolak, 1996). Body Image How you see yourself when you look in the mirror or when you picture yourself in your mind. What you believe about your own appearance (including your memories, assumptions, and generalizations). How you feel about your body, including your height, shape, and weight. How you sense and control your body as you more. How you feel in your body, not just about your body. NEDA website Negative body image A distorted perception of your shape – you perceive parts of your body unlike how they really are. You are convinced that only other people are attractive and that your body size or shape is a sign of personal failure. You feel ashamed, self-conscious, and anxious about your body. You feel uncomfortable and awkward in your body. NEDA website Positive body image A clear, true perception of your shape – you see various parts of your body as they really are. You celebrate and appreciate your natural body shape and you understand that a person’s physical appearance says very little about their character and value as a person. You feel proud and accepting of your unique body and refuse to spend an unreasonable amount of time worrying about food, weight, and calories. You feel comfortable and confident in your body. NEDA website Childhood Symptoms OC Personality Traits: Percentage of Individuals With Traits 100 AN (n=26) % of Patients 80 60 65 72 AN-BN (n=18) 77 BN (n=28) 80 62 61 50 50 40 25 20 0 Perfectionistic Inflexible Anderluh MB, et al. Am J Psychiatry. 2003;160(2):242-247. Rule Bound Heritability Estimates DISORDER Autism Schizophrenia Bipolar Anorexia/Bulimia Early MDD OCD Obesity HERITABILITY .8 - 1 .5 - .9 .3 - .8 .5 - .8 .5 - .75 .5 - .7 .4 - .7 Psychological Correlates of Anorexia Nervosa Poor self concept Obsessive compulsive and avoidant personality style Perfectionistic, obsessive, harm avoidant traits Family dynamics: enmeshment, anxiety, over-achievers Troubles with major life transitions an attempt to regress, avoid development Difficulty managing and expressing anger Cognitive distortions Ego-syntonic nature of disease Psychological Correlates of Bulimia Nervosa Poor self concept Chaotic developmental history, parental deficit ambiguous communication styles Affective regulation problems Cognitive distortions Ego-dystonic nature of disease Impulsivity, substance abuse, self harm, sexual acting out, shop lifting Distorted Beliefs There are “good” foods and “bad” foods. If I am fat, no one will love me. If I eat too much, I need to get rid of it by purging. If I eat this piece of cheesecake, I will be able to see it on my body tomorrow. You can never be too rich or too thin. Thinness equals happiness. Using laxatives gets rid of all the food. Purging gets rid of all the food. My worth is my weight. It is more important to be thin than anything else. Everyone hates fat people. Men like women who are skinny. Recovery Beliefs My worth is not my weight. My body is an instrument, not an ornament. When I treat my body well, by eating 3 balanced meals per day and exercising moderately, my body will find its own set-point weight. People come in all kinds of shapes and sizes. I don’t have to try to mold my body into a standard set by the media or fashion industry. I need some fat in my diet in order to have soft skin, shiny hair, and be able to become pregnant some day. I can enjoy having a more curvy body, instead of striving for thinness. I am unique and special due to my inner qualities. Perfectionism only leads to disappointment, not happiness. Goal of Psychological Treatment Help pt to adjust to their personality traits/temperament Reduce anxiety through use of positive coping skills Reduce “eating disorder voice” and develop a “recovery voice.” Increase focus on inner qualities to define self, rather than physical traits like thinness. NEEDS met by the eating disorder: Safety/Survival: reduction of anxiety Love/Belonging: best friend Freedom: no one can take the e.d. away Power/control/importance: feeling superior, weight loss as an accomplishment Fun/relaxation/release: endorphins released by purging A Major Truth: Feelings Follow Thoughts & Actions Thoughts Actions Needs Want Choices Feelings Physiology Group Therapy Structured on-site meal Milieu therapy/ use of group CBT/DBT Process group Nutritional counseling Body image group Art Therapy Relaxation, meditation Individual Therapy Affect regulation and tolerance Impulsivity Externalization of self worth Feelings of ineffectiveness, inadequacy Rejection sensitivity DBT PMD and dietitian Family Therapy Required with Adolescents Maudsley Family Therapy Systemic Family Therapy Couples Family involvement to motivate pt for treatment (case example) UCSD Eating Disorder IOP (Individual and Family Therapy by appointment) Mon. Tues. Adult and Teen Process Groups Wed. Thurs. Adult Art Therapy Dialectical Behavioral Therapy Meditation Snack Goal Setting Group Dinner Meal and Nutrition Education Treatment Team for all Staff Cognitive Behavioral Therapy Adult Mindfulness Based Stress Reduction Or Teen Art Therapy Goal Setting Dinner Meal Process Meal Goal Setting Fri. Common Management Issues Denial, resistance Lack of insight and motivation for treatment Failure to learn from experience Adolescent – anxious parents, conflicts Adults – family burn out Ambivalence: pt wants to recover, but does not want to gain any weight Expected Issues Patients and Families Obsessive anxiety – much reassurance and discussing details of care Perfectionism – not good enough Stress and conflicts over eating, weight, control, meal plan etc. Over-exercise Undermining treatment: i.e. taking the pt running Countertransference Issues Feeling angry at the patient for not recovering Thinking this is “willful” behavior Blaming the parents Feeling incompetent Giving up hope for the patient Not taking the disorder seriously Coping with Countertransference Issues Practice patient acceptance: The average recovery rate is 7 years. Have compassion for the suffering of the patient. See their behavior as part of the disorder, not personal toward you. Practice good self-care. Overview of biological underpinnings of EDS Genetic Correlates in Anorexia Nervosa Family and twin studies Serotonin receptor gene Variation in Dopamine 2 receptor gene Chrom 1 and 10 Family history of OCD, OCPD, AN Genetic Correlates of Bulimia Nervosa Twin studies 5ht2A receptor alteration Family history of affective, anxiety, substance abuse d/o Neuroendocrine Correlates of Anorexia Nervosa Serotonin (5HT2A receptor) Dopamine Endogenous opiate response to starvation Hypothalamus dysfunction (satiety, amenorrhea) Neuroendocrine correlates of Bulimia Nervosa Serotonin (5HT1A receptor) Endogenous opiate response to binge purge Neuropsychiatric correlates of Eating Disorders Iowa gambling task: AN vs CW: Differences seen on fMRI AN: Neuropsych testing: difficulties with set shifting, flexibility AN: Detail focus, to the point of missing global (Janet Treasure) AN vs BN Use in clinical practice Psychiatric symptoms in AN and BN Premorbid onset “Best little girl in the world” Majority have childhood anxiety disorder that precedes onset AN, BN Childhood negative self-evaluation, perfectionism, rule bound, inflexible, obsessive personality Persistent symptoms after recovery Obsessions - body image, weight, food Obsessions - perfectionism, symmetry, exactness Anxiety, harm avoidance Behaviors are exaggerated by malnutrition Differences Between AN and BN Novelty seeking BN > AN, BN extremes of over- and under-control Important Medical issues in treatment of EDs Physical Complications of Anorexia Nervosa Organ System Symptoms Lab Test Results 1. Whole body Weakness, lassitude Low weight/body mass index, low body fat percentage 2. CNS Apathy, poor concentration CT: ventricular enlargement; MRI: decreased gray and white matter 3. CV Pre-syncope, palps, dyspnea, weakness, cold extremities, chest pain ECG: sinus bradycardia, other arrhythmia, QTc prolongation; cardiac echo (consider): MVP, silent pericardial effusion Physical Complications of Anorexia Nervosa; Cont. Organ System Symptoms Lab Test Results 4. Muscular Weakness, muscle aches Muscle enzyme abnormalities in severe malnutrition 5. Reproductive Prepubertal psychosexually Hypoestrogenemia; prepubertal patterns of LH, FSH 6. Endocrine, metabolic Fatigue, cold intolerance, diuresis, vomiting Elevated cortisol; euthyroid sick; dehydration; electrolyte abnormalities; low phos on refeeding; hypoglyc.(rare) Physical Complications of Anorexia Nervosa; Cont. Organ System Symptoms Lab Test Results 7. GI Vomiting, abdom. pain, bloating, constipation Delayed gastric emptying; occas. abnl LFTs 8. Renal Pitting edema Elevated BUN; renal failure 9. Skeletal Bone pain w/ exercise X-ray/bone scan w/ stress fx; DEXA w/ osteopenia or osteoporosis Physical Complications of Bulimia Nervosa Organ system Symptoms Lab Test Results 1. Metabolic Weakness; irritability Dehydration; serum electrolytes: ↓K+, ↓Cl alkalosis w/ vomiting; ↓Mg, ↓K+, ↓Phos w/ laxative abuse 2. GI Abdom. pain; constipation; bloating; reflux Physical Complications of Bulimia Nervosa; cont. Organ system Symptoms Lab Test Results 3. Oropharyngeal Dental decay; swollen cheeks X-rays confirm erosion of dental enamel; elevated serum amylase 4.CV and muscular (in ipecac abusers) Palpitations; weakness Cardiomyopathy and arrhythmias; peripheral myopathy Medical evaluation for Anorexia Nervosa Assess for co morbidity Screening labs: electrolytes, Ca++, Mg+, Phos, BUN/Cr, CBC, LFTs, TFTs, UA Bone density (DEXA) EKG Medical evaluation for Bulimia Nervosa Assess for comorbidity Screening labs: electrolytes, Ca++, Mg+, Phos, BUN/Cr, CBC, LFTs, TFTs, UA EKG Dental Pharmacology for AN SSRIs Atypical antipsychotic medications Meds tried and failed for appetite enhancement GI meds to aid physical symptoms Pharmacology for BN Serotonin re-uptake inhibitors AEDs (topiramate, ?zonisamide) Antipsychotics Mood stabilizers reglan, H2 blockers Methods of Treatment A. Regular Weight restoration • • • B. 2 to 3 lbs/wk inpatient 1 to 2 lbs/wk day-hospital 1 lb/wk outpatient Nutritional Teaching • • • Provide patient support Prevention from vitamin and mineral deficiency Prevention of osteoporosis Aim for high Ca++ intake Vitamin D to aid in Ca++ absorption; vegetarians may need supplements Eat iron-containing foods, especially important for vegetarians Integrated treatment programs Multidisciplinary treatment team Program manager Psychiatrist Therapists with ED training Registered Dietitian Internist/Pediatrician AN: Hospital vs Outpatient Treatment From American Psychiatric Association Guidelines for the Treatment of Eating Disorders Weight Medical complications Suicidal, comorbid psych d.o. Motivation, insight, cooperation Excessive exercise, purging, etc Stress, family dynamics Outpatient Inpatient >85% < 75% none Not present HR, BP, K etc severe yes no minimal severe minimal severe Referral to Higher level of care Pt is failing lower level. Pt’s weight loss is continuing in spite of treatment Pt is unable to stop bingeing/purging. Pt’s physical symptoms warrant greater supervision (fainting, dehydration, heart palpitations) Pt is resisting current level of care Specific LOC Considerations OP: high motivation, >85% IBW IOP: moderate motivation, >80%IBW PHP: >75% RTC: clinical issues IP: <75% IBW, psych co morbid severe (SI) UCSD Intensive Family Therapy program Legal controversy Diagnostic Practice See hand-out for interview questions Dual Diagnostic Issues (Psychiatric co-morbidity) PSYCHIATRIC COMORBIDITY: Anorexia Nervosa affective disorders anxiety disorders psychotic disorders personality disorders Substance abuse PSYCHIATRIC COMORBIDITY: Bulimia Nervosa Affective disorders Anxiety disorders Impulse Control Disorders Personality disorders Substance abuse Anxiety Disorders (AD) Lifetime and Premorbid Rates Study ED n Lifetime AD AD before ED Deep 95 AN 24 68% 58% Bulik 97 AN 68 60% 54% Bulik 97 BN 116 57% 54% Godart 00 AN 29 83% 62% Godart 00 BN 34 71% 62% AN,BN 672 64% 61% 23% OCD 13% social phobia Kaye 04 Lifetime OCD Diagnosis in AN, BN Diagnosis AN AN BN BN Range 10 – 62% 10 – 66% 0 – 43 % Percent with Diagnosis Review of Literature Godart 2002 Price Foundation Genetic Collaborative Study Total 1416 subjects DSM IV, SCID I, Y-BOCS MS/PhD Clinical Interview N. America, England, Germany 60 50 40 30 20 10 0 AN (n 619) AN BN (n 515) BN (n 282) General population rate OCD: 1-3% of adults; 2-4% of children (Grados 97, Riddle 98; Serpell 02) Obsessive-Compulsive Personality Disorder (OCPD) Diagnoses in ED from Clinical Interviewer Assessment Cassin S, von Ranson K: Personality and eating disorders: a decade in review Clin Psychol Rev 2005;25(7):895-916 Subjects Range of OCPD RAN 2 – 30% BN 2 – 19% Factor-Analysis of OCD 12 studies, 2000 patients Mataix-Cols, Rosario-Campos, Leckman, AJP 2005 OCD is clinically heterogeneous 4 symptom dimensions – Symmetry/ordering – Hording – Contamination/cleaning – Obsessions/checking Associated with distinct patterns of comorbidity, genetic transmission, neural substrates, treatment response Prevalence of E.D. and S.U.D. 20% of women with a substance abuse/dependence have a current or past history of BN or bulimic behaviors 21.4% of women with BN have a current or past history of drug abuse, and 17% of BN women report a current or past history of substance abuse or dependence. Theories of shared etiology vs. causal etiology Shared Etiology vs. Causal Etiology Shared = both disorders share a common predisposition and include the personality, family history, developmental, and endogenous opiods hypothesis. Causal = Having one of these disorders puts an individual at risk for developing another disorder. Self-medication theory Wolfe and Maisto (2000) Results of Baker, Mazzeo, Kendler Study 2007 BN was associated with a lifetime history of major depression, neuroticism,conduct disorder, CSA, DUD, and a parental history of alcoholism. The results of this study lend support to both the personality and self-medication hypotheses. Having higher neurotic tendencies may be the underlying reason why women with BN are more likely to develop DUD and vice versa. Some of these variables (depression, neuroticism, and CSA) may have an impact on whether or not a woman with BN is at increased risk of developing another disorder like DUD. DBT Heirarchy 1. Life threatening behaviors 2. Therapy interfering behaviors 3. Quality of life issues Marsha Linehan Life threatening behaviors Suicide Starving Binge-purge Etoh poisoning Fatal car crashes Domestic violence Over dose with drugs Others? Therapy interfering behaviors Failure to show up Lateness Not being truthful Critical of therapist Coming to session intoxicated Hostility Not talking Not complying with medications Conflict avoidant Quality of life issues Ability to eat meals with others Ability to have food in refridgerator at home Supportive relationships Ability to go out to a restaurant with friends Ability to think about topics other than food, weight, and body size Eating Disorders and SUD Which to treat first? Access severity of SUD: 12 step, detox, inpatient? Come up with a mutally agreed upon contract: sobriety, controlled drinking/using, etc. Make connections btw the ED and SUD: meeting certain needs Psychiatric eval if needed E.D. and O.C.D. Refer pt for psychiatric evaluation for medications Refer pt to OCD specialist for individual therapy. Have good communication with this therapist. Case Example: Danny Working with E.D. and Personality Disorders Borderline Traits Dependent Personality Histrionic Personality Obsessive Compulsive Pers. D/0 Narcissistic Traits Individual Therapy with Eating Disorder Patients Psychotherapies for Anorexia Nervosa (McIntosh, 2005) 20 sessions over a 20 week period 56 AN women were randomly assigned to 3 treatments: (35 completed treatment) 1. Cognitive Behavioral Therapy 2. Interpersonal Psychotherapy 3. Non-specific supportive clinical management Which treatment was the best? Interpersonal was the least effective of the 3 therapies. Successful treatment outcome was achieved by 17% of the interpersonal psychotherapy patients, 42% of the CBT patients, and 82% of the nonspecific supportive clinical management patients. Non-specific Supportive Clinical Management Education, care, and support Fostering a therapeutic relationship that promotes adherence to treatment Assist the pt through use of praise, reassurance, and advice. Encourage resumption of normal eating and weight restoration Provided info on weight maintenance strategies, energy requirements, and relearning to eat normally Info was provided verbally and through handouts. Treatment Strategies for Bulimia Nervosa 1. Meal plan 2. Delay the binge 3. Binge, but don’t purge 4. Throw away your scale 5. Challenge distorted beliefs (CBT) 6. Teach anxiety reduction skills 7. Develop support system 8. Write in a journal 9. Set goals each week (1 B/P Max) 10. Use externalization (Life w/o Ed) 11. Teach set-point theory (Making Peace with Food book) Chain Analysis (example) How to deal with resistance to recovery 1. Validate pts legitimate needs and help her see how the e.d. serves her 2. Use motivational Interviewing: what does she want? 3. Normalize her ambivalence 4. Help her give a voice to her e.d vs. her recovery voice 5. Have her list all the reasons why she wants to recover. 6. Have her list all the disadvantages to recovery. 7. Be patient. The average recovery rate is 7 years! Candy Crover Candy is 23 year old college drop out who works as a waitress. She drinks alcohol every weekend and has had more than 20 black outs. She also binges and purges once a day. She has done this since age 16 which is the same year her father died of cancer. Candy tends to restrict her intake during the day and then binges and purges at night on the left-overs she brings home from work. Her weight fluctuates from 140 to 155 lbs. She is 5 ft 10. As a teen, she used to cut on her thighs because she thought they were too fat. She is coming to you for individual therapy because she is worried about her health. She recently fainted after a binge-purge episode. Her boyfriend found her on the bath room floor and rushed her to the E.R. She received 3 bags of I.V. fluid due to dehydration Axis I. II. III. IV. V. 1. What is your treatment plan? 2.Which issues will you address first by using the DBT Heirarchy? 3. Will you need to set any limits with this patient? 1st Session Candy begins the session telling you that she feels fat. She weighed herself this morning and she was 155lbs. She is worried that her boyfriend wonÕ t be attracted to her anymore. Last night she was very anxious and binged and purged for 2 hours. She did not eat any meals that day. 2nd session Candy begins the session by telling you that she only binged/purged 4 times this past week. Eating 2 meals per day helped her. She also followed your suggestion to get rid of her scale. She wants you to help her to understand why she binges/purges. (do a chain analysis). Help her to find a place to break the chain. 1. I came home from work and I was really hungry. I didnÕt eatany meals that day. 2. I brought home some f ood f rom work and put it in the microwave. 3. I cooked the f ood and ate it out of the carton really f ast. 4. I got anxious about getting f at. I told myself ŅIshouldnÕthave eaten all that bad f ood.Ó 5. I thought ŅImust purge.ÓThen I went to the bathroom and threw up. 6. I f elt more relaxed and then I went to bed . Case Example: Annie 30 year old B.S. biology Binge/purge for 5 years Weekly individual therapy Identify trigger: parent’s house, skipping meals Case Example: Karen 22 year old college graduate Anorexic mother Residential treatment, IOP, PHP, Individual therapy 5’ 2 93lbs Highest weight: 120 Lowest weight: 88 Got period back at 105lbs. Doesn’t want her thighs to touch Identify binge/purge triggers (grandpa’s house) When is individual therapy not enough? HBO Special THIN Discussion Questions and Answers about Day I Comments or suggestions for Day II? Life without ED What Jenni Schaefer has to teach us Externalization of the eating disorder What are perfectionistic traits? Never being satisfied with your achievements or performance Ability to see flaws where others do not Dread of making mistakes Exactness Exceedingly high standards Very detail focused Lack of novelty seeking Frequent disappointment with self and others Relentless pursuit of perfection “I have to be the best at everything I do.” How can we help pts to reduce perfectionism? Identify perfectionism as a personality trait which is unlikely to change Help pts to manage their perfectionism by noticing it and doing the opposite (risk taking, trying something new, stop redoing or re-writing) Recognize the benefits of this trait. Turn it into an asset, rather than a liability. Being on time, being good at detail oriented tasks, academic achievement, research career etc. Goals and Benefits of Group Therapy Breaks down isolation Provides peer support Learning from others, not just group leader. Shame reduction Problem solving Interpersonal Skill Building Helps to replace e.d. Better resource allocation Why are groups so important for eating disorder pts? Many of them have social phobia Many of them are isolated Many of them have problems with “reading people.” Like autism, some people with anorexia have difficulties with “theory of mind.” Group can help them see how they come across to others. Many of them have problems with interpersonal effectiveness, like assertiveness. Group gives them a safe place to practice new skills. Types of Groups Groups according to diagnosis Ongoing vs. time-limited Psychoeducational groups Process groups Skill building groups: DBT, CBT Body Image group: Cindy AN, BN groups at UCSD Art Therapy group Relapse Prevention Goals of CBT Group Create a safe environment for pts to explore their eating disorder thoughts and beliefs Challenge distorted beliefs Teach cognitive distortions Learn to use thought records Assertiveness training Help pts dispute their ed voice Identify triggers and coping strategies CBT groups for Bulimia Research by Mitchell et al 2005 showed that Social Support Seeking 1 month after a 12 week CBT group predicted the outcome at 6 months. Those group members who utilized their support systems 1 month after the group had a better outcome. Use of positive coping skills at the end of treatment did not predict the outcome at 6 months. This study highlights the importance of social support to maintain treatment goals. Process Group Get topics from each member (Axis II) Divide the time so everyone can share. Group leader intervenes when e.d. thoughts are presented as true Let members give support before you do. It’s best if coming from them. Encourage group participation. Help connect group members to each other. Create a safe environment of nonjudgemental feedback. Help to establish positive group norms. Goals for Body Image Group Create a safe environment for pts to explore body image issues Teach about our culture and how we get negative messages about body size and shape. Help group members to share their body image struggles with each other Help to dispel body image distortions Set body image goals each week Resources Relapse Prevention Group Provide a support group for those in recovery Encourage pts to share their coping strategies with each other Problem solve difficulties with staying in recovery. Use lapses as learning experiences Prevent relapse through accountability Problems in Groups The monopolizer The advice giver The yes, but Quiet groups Unexpressed anger Poor attendance of certain members Lateness Anorexia vs Bulimia Lack of recovery in the group Cliques between certain members Rejection of members Poor screening of potential group members Goal Setting Set attainable and measurable goals. Examples include: 1 B/P Max, 1 Selfsooth, write in journal about feelings I had before engaging in my eating disorder, eat meal plan, do food log, limit exercise to half hour per day, have husband hide my scale, body check only 1 time per day, eat a challenge food 1 time, make a mistake with a witness, write a letter to ed., have ed write back, no self-harm, call for support. (see flip chart) Group Therapy Practice: Large Group Needed: 2 leaders and 7 members Reactions to large group exercise What did you learn? 1st Session of a new group Introduce the leaders and purpose of the group Go over group rules: contact outside group, confidentiality, off limits topics, gum chewing, water, outside food, length of group (12 weeks), dress code Have members tell their story: history of the e.d and treatment Group Therapy Practice in Small Groups Break into groups of 8: 2 leaders and 7 consumers The leader will lead the 1st session by having each member tell their story as an introduction. S/he will also go over the group rules: no talking about numbers (Calories, sizes, weights, miles ran etc.), confidentiality, no outside food allowed, no gum chewing, outside contact encouraged for support but not crisis management. Reactions to practice session What was hard for the group leaders? Were you able to explain the group rules and answer questions? How did it feel to lead this group? How did members feel in this group? Did it feel safe? Feedback for leaders HBO Special: Thin Part II How to set up a group and get it started? Do a needs assessment of your patient population Choose the type of group and the inclusion/exclusion criteria Decide on group leadership Design format or curriculum Create a flyer, contact therapists, marketing Conduct interviews Set a start date Brainstorming Session What kinds of groups do we need in our community? What are consumers asking for? How do we get started? What kinds of groups are needed in your community? What is your plan of action? Who will volunteer to get a group started? What resources will you need? Plan your next follow up meeting Questions and Answers