Our patients with anorexia consistently report high anxiety with significant and often irrational food-related fear (akin to phobias), avoidance behaviors, eating rituals, and other maladaptive behaviors that can resemble the various manifestations of OCD. While the connection between anxiety and anorexia was solidified long ago, there has been limited use of established methods for treating anxiety disorders – like exposure and response prevention techniques – in the treatment of AN.
Our esteemed colleagues up at New York State Psychiatric Institute wanted to look more closely at the use of exposure and response prevention interventions specifically for anorexia.
The researchers hypothesized that these interventions would help address underlying fears and rituals that both caused and maintained low caloric intake and weight loss in anorexia.
To evaluate the efficacy of traditional EXRP for AN, a pilot study was carried out over 12 sessions for 17 patients ages 16 to 45. During each of the 12 sessions, 90-minutes of treatment took place. Session one began with the development of a list of patient’s feared eating situations, avoidance behaviors and ritualized behaviors. Psychoeducation was provided to explain the theory behind the study and a distress scale was used to develop a feared eating hierarchy on a scale of 1-100. Each of the subsequent sessions included exposure to the feared eating situation and progressing up their fear ladder. The patient was to experience the anxiety during each hierarchical step, as opposed to avoiding it and in time, habituation of anxiety would occur. Over time, patients would reflect on their experiences and recognize that feared outcomes did not occur. Anxiety was measured with three scales: STAI-S, SUDS, FAH. While this small sample size makes it challenging to generalize results, effect sizes were medium to large. Key to the findings was that there was a decrease in pre-meal anxiety; pre-meal anxiety is particularly important to address in treatment, as it is highly correlated with decreased food intake.
In the Treatment Setting
As with any research protocol, it’s important to think about how valuable findings can translate into practice to benefit patients. At Columbus Park, we target eating anxiety and avoidance both with individual exposure work and also in our supported meal service. In the context of actual dining, we can work with clients to develop food hierarchies and help them deliberately and systematically introduce feared foods back into their food repertories. We pair the exposures with specific skills – like deep breathing and progressive muscle relaxation – to help
our clients manage the distress that comes from confronted and pushing through the fear.
My3square, a virtual meal support program recently launched by the Columbus Park team, is also designed to help participants address food fear, food-related rituals and avoidance. Within the context of group meal support, participants work to increase food variety and adequacy (systematic exposure – steadily introducing feared foods) while concurrently learning and practicing skills for managing the distress associated with the feared situation. Visit us at www.my3square.com to learn more.
Steinglass, J., Albano, A., SImpson,B., Schebendach, J., Attia, E. (2013) Fear of Food as Treatment Target: Exposure and Response Prevention for Anorexia Nervosa in an Open Series. Int J Eating Disorder (45) 615-621
We continue to travel through the Distress Tolerance module (one of the four “chapters” or modules of DBT, each presenting a number of strategies in each skills group) of DBT with the introduction of the “ACCEPTS” skill. Like other skills within the Distress Tolerance module, ACCEPTS help us to manage our responses and emotions during a crisis and prevent escalation of our emotional state. This skill, similarly to TIPS, provides us with tangible tools to use as an alternative to more destructive strategies often accessed during a crisis. ACCEPTS will help us to navigate these emotional states when we may feel desperation or as though the mind is flooded with negative thoughts and the body feels activated. ACCEPTS falls under the category of Distraction.
Distraction is a tool that is commonly used when we must distract ourselves from a distressing situation. Similar to mindfulness practices, the distress tolerance skill of distraction does not suggest that we push away or avoid strong feelings and experiences but rather that we immediately soothe ourselves in an attempt to avoid a response that is “too hot” or “too intense.” With distraction, there is an understanding that the issue will be dealt with at another time.
ACCEPTS is an acronym that is self-explanatory in nature (this makes it easy to remember!) and always accessible!
A-Activity: Engaging in an activity (any activity!) gets us moving, and temporarily distracts us from our feelings of distress. These activities can be as simple as making the bed, organizing your closet, painting a picture, writing a poem, you name it. While in a difficult moment we may not feel motivated to get up and do something, it is often an impactful and immediate intervention.
C- Contributing: When strong emotions take over, it is easy to feel as though our problems and worries are all-encompassing, or even the center of the universe! In these moments, it is important to step outside of ourselves. Maybe we contribute by asking a friend how they are doing or by contributing to an important cause.
C-Comparisons: Similar to the theory behind contributing, when we get caught up in ourselves and our emotions, it can be helpful to take a step back and express gratitude for what we do have. Perhaps we compare ourselves to someone residing in poverty, in war etc. In these moments we can write in our gratitude journal and consider what we do have, when our emotions or situations feel unmanageable.
E–Emotions: When caught up in the moment of strong emotion, we may use Opposite Emotion as a tool. In line with the balanced, dichotomous themes of DBT, this tool uses an opposite to bring us back to neutral ground. This technique tells us to engage in the opposite action. For example: Feeling angry? Watch a funny movie. Feeling sad? Listen to upbeat music. Alternatively, the behaviors can be more active, for example, are you lying in bed feeling down and lethargic? Get up and take a walk around the block.
P– Pushing Away: When we become emotionally activated, there is often a desire to hold on to stressful or “loaded” thoughts. When this begins to happen, we want to compartmentalize our thoughts and watch our emotions shrink away! Visualize your anger drifting away or setting it aside for later. Perhaps you need to take action by writing your negative thoughts down and crumpling, ripping or shredding them up. These activities help us demonstrate to ourselves that we are capable of pushing away the thoughts that do not serve a positive purpose while validating their existence.
T-Thoughts: When we are in an intense emotionally state, we are likely in “emotion mind,” an emotional state that is overpowering. On our way to a calmer emotional state, such as “wise mind” we will reach into our bag of tricks and pull out a useful thought! You may have go-to phrases and quotes nearby to read, or a feel-good thought saved to memory. For some, this looks like reading a soothing phrase or prayer or thinking through a breathing exercise.
S-Sensations: Physical sensations can provide us great relief when we are overcome with emotion. Luckily for us, this tool utilizes something we always have with us, our bodies! Splash cold water on your face, smell a soothing scent, apply hand or face cream etc. This tool acts to “bring us back to our senses!”
Through the use of distress tolerance skills, we are better able to endure our pain in a healthier, more productive way. Over the course of the next few blogs, we will discuss how distress tolerance teaches us to distract, calm and cope.
Dijk, S, (2013). Dbt made simple: a step-by-step guide to dialectical behavior therapy. Oakland, California: New Harbinger Publications
Chang, L (2018, February 2nd). Tolerate Distress with A-C-C-E-P-T-S. Retrieved from https://www.mindfulnessmuse.com/dialectical-behavior-therapy/tolerate-distress-with-a-c-c-e-p-t-s
It has been reported that nine percent of college students today screen positive for ED symptoms (Eisenberg, Nicklett, Roeder, & Kirz, 2011). There are a number of factors that may contribute to this rate (read more about the pressure for perfection by Founder Melissa Gerson here https://columbuspark.com/2017/08/03/pressure-perfection-combating-eating-disorders-college-campuses/) though declines in health, academic performance, social functioning and overall quality of life are consistently reported among this population. While mental health services are available on most US college campuses, these services are often difficult to access due to a number of barriers (denial, availability, scheduling, stigma etc.,) and often, students do not present for or receive care consistently (Eisenberg et al., 2011; Eisenberg, Hunt, Speer, & Zivin, 2011; National Research Council, 2015). As studies have demonstrated that a key indicator of long term recovery from an eating disorder is early intervention, these barriers and delays to treatment may contribute to poor prognosis and relapse rates in this population. High-quality, evidence-based, gold-standard treatment options are typically delivered at treatment centers (off-campus) and may be out of budget for undergraduate students and, depending on their geographic area, inaccessible as well. In recent years, Telehealth programming has helped to provide individuals in rural settings increased access to quality treatment options.
An article published in the International Journal of Eating Disorders notes “discrepancies between access to and demands for care suggest the need for novel care delivery models that optimize resource delivery while conserving costs.” Digital health technology that utilizes mobile screening tools and online interventions may assist college campuses in overcoming barriers and closing treatment gaps. This article proposed that a stepped care model for screening & treatment delivery uses online screening to assess risk for ED and offers them an intervention based on severity (e.g. low risk = online self-help intervention, subclinical or clinical ED= guided self-help (GSH), full-syndrome anorexia = referral to in-person care). If individuals do not show symptom reduction via the stepped care model, they are then directed to more intensive intervention.
Researches utilized the stepped care model paired with existing data from an online GSH study as they estimated the costs of implementing a US college-based Telehealth screener & intervention. Researchers estimated a stepped care model would cost less and result in fewer individuals needing in-person psychotherapy (after receiving less-intensive intervention) compared to standard care. The costs were calculated for a population of 1,000 college students and when compared to a standard care model, cost-savings was estimated at $13,862.54. Within this stepped care approach model, 37 individuals with EDs and 77 individuals at risk would need in-person psychotherapy, equating to 114 individuals total. Comparatively, in standard care, 146 individuals would need in-person psychotherapy. While these numbers are mere estimations and a number of components were unaddressed in the study (generalizability to other countries, individuals with AN who need higher levels of care, costs of screening, costs of dissemination etc.,), it was clearly illustrated that there is a need for additional research to fully evaluate the cost-effectiveness of telehealth treatment.
These results also demonstrate the clear benefit of cost-effective, telehealth treatment options for college students at risk for eating disorders. It is an exciting time for the field of eating disorder treatment, as new and effective telehealth treatment options are beginning to gain credibility and demonstrate their efficacy. Be sure to check back in with Columbus Park in the coming weeks as we unveil an innovative Telehealth application, designed to reach well beyond our NYC location.
As we continue our series on accessible skills for coping (DBT Skills), I want to introduce Distress Tolerance Skills. Dialectical Behavior Therapy consists of four “chapters” or modules, each presenting dozens of strategies in each skill group. One of the modules is the all-important Distress Tolerance module. Distress Tolerance skills help us survive and cope when experiencing a crisis or intense escalation of emotion. The skills help us tolerate emotional [and physical] pain and can be used in situations when there are few, if any, alternatives to feel better.
When experiencing intense negative emotion, it’s not uncommon to feel like “this will never end” or “this is how it is.” It’s not surprising that when in this activated – and desperate – state of mind, one might resort to the use of unhealthy coping mechanisms (like binge eating, purging, self-harm) in an effort to self-soothe. DBT founder Marsha Linehan developed distress tolerance skills that are easy to access and straightforward to help people use more adaptive, less destructive strategies when in crisis.
As a Distress Tolerance tool, TIP skills are primary and vital. TIP is an acronym that stands for Temperature, Intense Exercise, Paced Breathing, and Progressive Relaxation. TIP skills ask that we change our body chemistry to regain control of our emotions and behavioral responses.
T: Temperature. Have you heard of the mammalian dive reflex? Try leaning over a sink or surface and placing cold water, ice or a cold pack over the temples, eyes and upper nose region for ~30 seconds. This dive-like stance triggers a reflex that occurs in nature when mammals submerge in cold water. Think back to the last time you dove into a cold pool at the start of summer–you may recall the sensation of slowly cutting through the water with your arms, and a feeling of slowed time as you drifted up toward the surface. As we dive face first into cold water, our heart rate slows and our breathing regulates as the body prepares to conserve energy for survival. We have engaged our parasympathetic nervous system and experience a calming effect. So next time you feel highly activated, distressed, upset, angry think “T for temperature” and try running cold water on your forearms, taking a hot or cold shower, chewing on ice or just holding an ice cube in your hand. When we briefly change our temperature, we ground ourselves in the present moment and refocus.
I: Intense exercise or brief bursts of exercise can be helpful in the grounding process. Think of this process as ‘using up’ some of the energy that may be fueling high-energy emotions like anger or anxiety. When in a low-energy state (e.g. feeling, down, depressed, lethargic) getting the heart rate up will invigorate the individual. It’s important to note that exercise can be a highly sensitive issue for those who struggle with eating disorders. If you’re at a place in your treatment where you need to limit exercise, it would make more sense to try the T or P and P skills.
P: Paced breathing allows us to activate our parasympathetic nervous system as we regulate and slow our breath. With paced breathing we breathe deeply into our lungs and diaphragm. As we slow the pace of our in-breaths and out-breaths, we may achieve 5-6 thoughtful breaths per minute. Some people refer to deep breathing as “having a pill in your pocket.” In other words, breathing is a highly accessible skill – available to you at all times no matter where you are – and one that can be very effective to calm and steady you when emotion is riding high.
P: Progressive Muscle Relaxation is paired with paced breathing. With paced breathing we tense and relax muscle groups throughout the body to promote a relaxing effect. If you are feeling extreme emotion, you may try mindfully tensing all of your muscle groups at once… and then dropping your weight back into the ground or into your chair. As you travel from head to toe engaging all of your muscle groups simultaneously or one area at a time, pay close attention to the sensations in your body.
Contact us at Columbus Park today to learn more about DBT and distress tolerance skill building.
While at times we may wish we did not experience strong emotion, emotions serve an important purpose. Emotions are the bodies way of signaling to us what is happening around us and within us. From an evolutionary perspective, the development of an emotional response has helped to ensure our survival (e.g. the development of a fight or flight response). If our emotions become too intense, we find ourselves unable to remain in control, and on the flipside, if our emotions are blunted or we push them away, we are not able to access the messages and information we are being presented with.
Responses to our emotions may be primary (strong feelings that come on quickly, e.g. feeling surprised when winning a contest!) or secondary (our feelings about our feelings, e.g. if we feel angry and yell at a friend, we may then feel guilt as a secondary emotion to anger). Often, a primary reaction can set off a chain of events that cause more pain than the original emotion. For example, an individual may be left with feelings of guilt and shame following a binge eating episode. If you have been dealing with strong emotion for a long time, know that there is hope. DBT Emotion Regulation skills are extremely accessible and effective. DBT teaches about the didactic–accepting yourself without judgment, while simultaneously changing destructive behaviors in the service of living a healthy life (Linehan, 1993a). We are all able to learn to control our responses as long as we choose to cope with our emotions!
Mental Noting: Observe & Describe
We have already learned about the evidenced-based support and theory behind mindfulness- a tool that allows us to connect with ourselves and the world around us in a new, observant way. Today, we will dive deeper into the practice of Observing & Describing in our everyday lives as a tool to monitor and regulate our emotions. Mindfulness teaches us the “What” skills– Observe, Describe and Participate. These skills help us to remain in the present moment and prevent thoughts from spinning.
How can we use this skill of observation when we are taken in a wave of strong emotion? Non-judgmental observation provides us with a window of time in which we can step back from an event or emotion, and observe it through the lens of a camera, or as a “witness.” We will prevent ourselves from judging an experience or emotion as good or bad, avoid getting caught up in the experience and quiet the talkative mind. This experience can be calming in and of itself. This cognitive “space” we have created makes room for healthy decision making and increased flexibility.
– Start by noticing your environment and what is going on around you.
– Begin to attend to your feelings, thoughts and any bodily sensations without reacting to them.
– Non-judgmentally observe your emotional state (observe without trying to change).
– Avoid reacting to your emotion, simply notice it (e.g. I am feeling happiness or I am feeling anxious).
– Do not let the mind slip away, remain alert to each experience.
– Envision your thoughts as rubber, they present themselves and then bounce right back out or watch these thoughts and feelings rise and fall like waves.
– Do not push any sensations away but do not hold on to anything.
– Utilize descriptive words to explain your experiences (e.g. my hands are sweating, my chest is pounding, my temperature is rising).
– If you engage in self-judgment, acknowledge it (e.g. self-judgment has wandered in, stay in this moment).
– Avoid engaging with the content of the thoughts, simply label (I am having a thought about X, I am having a feeling about X).
– Remember to stay present, we are not engaging in the act of pushing away at this time.
– Avoid obsessive thoughts and judgments.
– Avoid questioning yourself and how you are doing at the task.
While Dialectical Behavioral Therapy (DBT) was initially developed as a treatment for chronic suicidal individuals diagnosed with Borderline Personality Disorder, it has been proven effective as a treatment for a broad range of issues like substance abuse, depression, PTSD and eating disorders. Here at Columbus Park Eating Disorder Center in NYC, we use DBT-ED which is an adaptation of DBT specifically to address eating pathology. For certain patients, particularly a subset of patients with Binge Eating Disorder and Bulimia Nervosa who use food as a coping method for managing emotion, DBT-ED is our treatment of choice. While DBT has been well-studied as a formal treatment for a wide range of mental health conditions, the skills – and there are dozens of them – happen to be incredibly practical and accessible for any individual who wants to increase self-awareness, effective management of emotion and interpersonal effectiveness.
Over the next few weeks, we will be zeroing in on the four DBT Modules – or skill groupings – and will highlight some of our favorite DBT skills. Let’s begin with an important skill: mindfulness. Due to its efficacy and accessible nature, mindfulness has solidified its position as the foundation of DBT. Research has demonstrated that mindfulness can reduce stress, anxiety, depression and lead to an increased ability to enjoy life. In fact, studies have shown that mindfulness can aid us in activating a part of the brain that promotes happiness, optimism and triggers positive feelings (Harvard Health Publications, 2004). Too often, clients will dismiss mindfulness as an “airy-fairy” concept, or assume it is a form of meditation, disregarding its credibility and misinterpreting its intent. Mindfulness is not utilized in an attempt to escape or push away one’s emotions. Rather, it is a practice that promotes acceptance and experiencing the present in a nonjudgmental way.
Mindfulness has a number of benefits:
Taking Control of Your Mind
Mindfulness practice is focused on staying in the present as opposed to the past (which can be experienced as regret, depression, shame) or the future (often experienced as worry, sadness, etc). Let’s use a metaphor and think of emotions like a speeding car. When your car is speeding (because your mind is elsewhere—you are focused on the past or concerned about the future) a small bump or rock could result in a big crash. When practicing mindfulness, we maintain a manageable speed. By focusing only on the present moment, we are aware of what’s happening within us and around us, enhancing our ability to make safe choices as roadblocks come and go along our route.
Increased Behavioral Control
Mindfulness offers us a window of time between experiencing an emotion and reacting to it, to consider our choices and their potential outcomes. The grounding practice of mindfulness may prevent us from acting on an impulsive urge that could have a negative outcome. Perhaps you can relate to the statement “I didn’t have time to think, I just did” or “I lost control over myself.” Over time, mindfulness will teach you to become more aware of your thoughts and feelings, so you can navigate your world with more clarity, control and balance.
While mindfulness exercises are not utilized in DBT as relaxation techniques, relaxation is often noted as a welcomed side-effect. By holding our attention on one thing at a time, our world does not feel as chaotic or hectic. Mindfulness teaches us to observe the present moment, which can have a calming effect when we choose to observe how we feel on a nature walk, while eating a delicious meal, while soaking in the tub, etc. When we are grounded in the present, as opposed to drifting to the future or thinking about the past, we are better able to enjoy life’s special moments as they arise.
Take out your toothbrush and toothpaste and start brushing your teeth (your dentist can thank us).
Now really tune into this activity… fully attend to what you’re doing as you brush. What do you feel, smell, taste, hear? Tapping into all your senses helps you attend to the full experience of the present moment.
It’s natural for our minds to wander. When this happens, simply notice that your attention has shifted and then gently bring your attention back to the activity itself. This last step requires that we accept our mind has wandered. Try not to judge yourself as having done something wrong if your mind wanders. Staying present, drifting and then returning to the present is what mindfulness is all about!
This mindfulness exercise can be practiced with any activity: walking the dog, painting your nails, riding the subway…. The point is that you’re engaging in an activity with full attention and awareness and that you’re refocusing back to the experience every time your mind begins to wander. Practice is essential. Over time, you’ll strengthen your “mindfulness” muscle and will get better and better at tuning out chatter or distracting (or distressing) content and stay present with the task at hand.
Dbt made simple: a step-by-step guide to dialectical behavior therapy
Think back to the last time you experienced feeling “hangry”—irritable, cranky or uncomfortable due to hunger. Perhaps it was when you had gone too long between meals, got held up in a lunch meeting or were engaging in a restrictive diet plan. This uncomfortable and desperate feeling occurs when we are depleted, and our bodies need energy. Interestingly, for an individual struggling with anorexia, the experience of being overly hungry is quite different. Emptiness and energy depletion can actually leave an individual with anorexia feeling better. To understand this phenomenon, renowned researcher Walter Kaye has collaborated with a number of scientists to further understand the neuroscience behind these paradoxical experiences.
When Walter Kaye began his research in the 1980’s he noted being “struck by how homogenous the symptoms [of anorexia] were.” Kaye disagreed with the stance of many medical professionals at the time, who felt that anorexics were selfish, vain, willful, even “petulant teenagers” that simply needed to choose to get better. He recognized early on that something in their biology was causing anorexia and that by identifying underlying biological causes, more informed treatments could be developed. For those suffering with anorexia nervosa, a greater understanding of the neurological processes driving their experiences has helped many to reduce the blame they place on themselves and challenge stigmas associated with the disease. One such individual, “Heather,” who shared her experience in a recent The Atlantic article, recalls the first time the neuroscience of anxiety and anorexia was demonstrated to her in a treatment program. She writes “I realized I wasn’t completely crazy…It was a huge relief. It is real and I’m not making it up and I’m not a complete loser.”
By debunking the myth that anorexia is a matter of personality or willfulness, and evaluating the various neurological practices at play, we can address this disease with greater compassion and understanding.
Dr. Walter Kaye has found that women with a predisposition to anorexia had indicators in their level of cerebrospinal fluid. These individuals had an unusually high level of neurotransmitter serotonin in the cerebrospinal fluid. While we often think of serotonin as a “feel-good neurotransmitter,” too little serotonin is linked to depression and too much serotonin is linked to a chronic state of anxiety and irritability. Three quarters of those diagnosed with anorexia have been known to suffer with anxiety, social anxiety or OCD and related diagnoses prior to their anorexia diagnosis. Kaye believes that this flooding of serotonin makes certain individuals more vulnerable to anorexia.
Serotonin & Tryptophan:
Tryptophan, an amino acid often discussed around the Thanksgiving table, is necessary in the synthesis of serotonin. When you eat less food, your tryptophan levels decrease and thus reduce your body’s serotonin levels. For those individuals with a predisposition to anorexia, starvation will directly reduce the amount of tryptophan and serotonin in the brain, thus reducing anxiety, partially explaining the lack of anxious or ‘hangry’ responses to lower caloric intake. The problem here? The brain will retaliate. Over time, starvation will result in the development of more receptors for serotonin, as the brain tries to “wring out” as much serotonin as possible. This increased sensitivity to serotonin will result in more irritability and anxiety so when eating does occur, there will be a surge of serotonin that results in panic, instability and even rage. The brain has now become hypersensitive and this negative feedback loop has “locked itself into place.” Eating becomes synonymous with anxiety and discomfort.
Motivation & Reward:
Researcher Walter Kaye shares “One reason that people with anorexia are able to starve themselves is that when they get hungry, the parts of the brain that should be driving reward and motivation just aren’t getting activated.” A study researching the brains of women who had recovered from anorexia, discovered that the brain responded less intensely to sugar water than to their healthy control counterparts. These individuals were noted to find sweets less rewarding even when hungry and disinterested in food even when highly palatable food is plentiful. That experience of “yum!” when you bite into a rich piece of chocolate or cake, does not happen for the anorexic brain. The reward area of the brain is quiet while the fear response remains on overdrive. Through fMRI research, Kaye found that “Unlike most people, whose brains respond strongly to rewarding things such as sweets, people with anorexia are generally far more sensitive to punishment (the removal of something pleasant) than reward.”
With greater understanding of these mechanisms, individuals in eating disorder treatment programs are better able to succeed at recovery. Families and loved ones also report feeling a greater sense of compassion after learning about this biologically based brain disorder. As a community, we can do our part to reduce stigmas, prevent invalidating statements such as “just eat!” or “just gain some weight!” and begin to tell our loved ones, “I finally get it!”
Know someone who is suffering from anorexia? Reach out to us at Columbus Park to learn more about our treatment center and gold-standard interventions.
Internet-based eating disorder interventions such as audio/visual communication (tele-therapy) and smartphone applications have demonstrated some promising outcomes in recent studies. Early feedback from E-health research has suggested that Internet-based cognitive behavioral therapy and guided self-help programs have reduced eating disorder psychopathology and have provided greater access for rural and underserved populations.
Initial interest in Telehealth for ED was based on a widespread need for access to quality treatment regardless of geographic location and programs that would assist individuals in overcoming barriers to quality care. While eating disorders have one of the highest mortality rates among mental health conditions and cause marked impairment in an individual’s quality of life, unfortunately, stigmas, shame and financial constraints also prevent many from seeking the treatment they need. One study suggested that more than half of a community-based sample reported on average 1.1 years delay in receiving treatment due to an additional barrier–waitlists. In an attempt to circumvent these barriers to treatment, a number of treatment approaches and strategies have been developed over the past few years in the field of internet-based services.
While smartphone apps are available at just the click of a button, it is important for consumers and clients to understand that these applications were developed to use before, after, or as a supplement to existing treatments–not to replace treatment entirely. Alternatively, these solutions may serve as an adjunct to those who have completed a short intervention program but are still in need of therapeutic support to consolidate and maintain treatment gains. Blended care, which would require face-to-face therapy paired with an online component seems to be the most promising use of the applications and online programming to date. Blended care appears promising since online sessions can reduce costs, travel time, and provide more flexibility. That said, thorough studies investigating blended care for EDs are not plentiful. A stepped care approach is also being evaluated, where guided or un-guided self-help could be offered to individuals who require additional support after completing a treatment program to maintain treatment gains. Additional research is required to better understand how clinics, clinicians and professionals can integrate these tools into their everyday practice procedures.
To evaluate the overall costs associated with an E-based intervention, a number of trials are currently being run to evaluate and substantiate cost effectiveness. Factors such as the cost associated with inclusion of therapist support are also being considered. One such study evaluated a stepped-care approach in which individuals with BN, begin with offline self-help from which patients could step up to more intensive treatment approaches. This stepped-care approach was more effective and less expensive. This suggests that low-intensity stepped approaches that initiate with an online component could lead to reduction of overall costs.
While factors such as cost-effectiveness, e-diagnostic tools and approaches to integrating care are still being researched, E-health is demonstrating strong results and providing access to treatment for many who would have otherwise gone without it.
While the potential for telehealth is great, current findings on efficacy and effectiveness are considered to be just the tip of the iceberg. Researchers are interested in better understanding how the field of eating disorder treatment may optimize E-health solutions within existing health care models, how to blend e-health into their everyday treatment procedures and further realize what role E-health may play in our healthcare delivery systems moving forward.
In the coming months, Columbus Park will be launching an E-health tool in an effort to help more people who struggle with eating. We’ll be using a video platform to reach people well beyond our midtown offices and to create a sense of community amongst those who are working toward recovery. More to come soon!
The importance of early change in eating disorder treatment cannot be over-emphasized. When we say “early change” we mean a significant reduction in ED symptoms like restriction, binge-eating and purging – within the first 6-8 weeks of treatment. Extensive research shows that early change is associated with a significantly improved treatment outcome. In other words, those patients who show a drop in ED symptoms early on in treatment, fare better overall.
A recent research study conducted a unique evaluation of rapid response in Enhanced Cognitive Behavioral Therapy “CBT-E” (the main treatment we use at Columbus Park). The study aimed to identify one specific, single behavioral symptom (such as purging episodes in BN, binge eating episodes in BED, or weight regain in AN) that could be used to assess early response across multiple diagnostic categories. Researchers evaluated a transdiagnostic population of Anorexia, Bulimia and Eating Disorder Not Otherwise Specified “EDNOS,” in a community-based setting using the EDE-Q,16 (a widely used measure of eating disorder pathology) to identify this baseline criterion. Results suggested that baseline differences such as sociodemographic variables, personality factors, eating disorder pathology, related psychopathology nor eating disorder severity were found to distinguish rapid and non-rapid responders. The only clear predictor of a rapid responder was whether or not reliable change was noted on the EDE-Q in the early stages of treatment (on average, 4.6 weeks after commencing treatment).
Despite these inconclusive results, the success rates of rapid responders was reinforced. The International Journal Eating Disorders states, “on average, rapid responders required significantly fewer treatment sessions than non-rapid responders and showed significantly lower scores on EDE-Q post-treatment.” Study participants labeled as rapid responders demonstrated “superior treatment outcomes”, had “lower scores on the EDE-Q global post-treatment” and were “twice as likely to achieve full remission.” Results demonstrated that 53% of rapid responders were labeled as in full remission post treatment as opposed to the non-rapid responders who lagged behind at 23% remission at post-treatment.
Since the research has so consistently supported that early change results in remission and long-term recovery, we at Columbus Park take specific steps to ensure a successful initiation of treatment. First, we are sure to deliver the treatments with accuracy and fidelity to the treatment models; in other words, we deliver the treatments well so that our clients have the best chance of a good treatment response. We also make sure that our clients initiate treatment at a time when they can be consistent and get the proper “dose” of the treatment; we make sure to start at a time when clients don’t have a planned vacation, work trips etc. Consistency helps our clients build momentum which consequently improves patient engagement and bolsters confidence.
At Columbus Park, we use objective measures – specifically our client’s decrease in global distress along with weight (in AN) or binge/purge frequency (in BED/BN) – to assess how our clients are responding to treatment. We track the treatment response closely and make sure that our clients are on track. If they are not, we swiftly make necessary adjustments to the treatment. We’re proud to say that Columbus Park’s outcomes represent our success in helping our clients experience early change and the consequent overall positive treatment response. Please read more about Columbus Park outcomes here and here
Could a commonly used intervention for anxiety & OCD-related disorders be key to curbing post-treatment relapse in adults with anorexia nervosa? Researchers out of New York Psychiatric Institute set out to demonstrate that Exposure & Response Prevention for anorexia nervosa (AN-EXRP) could prevent the return of ritualistic eating behaviors and pre-meal anxiety and promote long term recovery. Research has demonstrated that as many as 30-50% of adults receiving treatment on an inpatient hospital unit will relapse within a year of their program discharge. Longitudinal studies have demonstrated that after achieving weight restoration (the critical first step to recovery) there is a clear reduction in psychological symptoms, although many of the rituals and fears associated with caloric intake and pre-meal anxiety are under addressed post-treatment. Exposure and Response Prevention (AN-EXRP) has been targeted to engage patients in confronting these fears and decreasing anxiety around meal time in the hopes of promoting long-term recovery and decreasing relapse rates.
AN-EXRP research was conducted on a short-term hospital research unit at the New York State Psychiatric Institute (NYSPI) with participants ages 16-45. Once patients achieved weight restoration (quantified at a BLI of >18.5 kg/m2) they were provided 12 sessions of either AN-EXRP or Cognitive Remediation Therapy (an easy-to-use intervention aimed at reducing cognitive inflexibility). Results evaluated the change in caloric intake in a subsequent assessment of eating behavior upon the completion of 12 structured behavioral sessions.
Those participants who received AN-EXRP experienced a 50kcal increase in caloric intake post-treatment as compared to those who received CPT and demonstrated a 77kcal decrease in caloric intake post treatment. Historically, as research has demonstrated, food intake will rapidly decline after discharge from a structured inpatient setting. This 77kcal decrease in CRT recipients may be a potential demonstration of this known phenomenon at play. Initial review of AN-EXRP has demonstrated that it is a credible intervention technique and may been associated with better caloric intake over time. AN-EXRP may serve to promote the continuation of healthy behaviors obtained on the unit, provide recipients with management tools to be used once discharged and contribute to longer term recovery. Considering evaluations have been confined to an inpatient, research-based setting, more research must be done in a generalized setting, such as an outpatient treatment program, to prove whether it will lead to widespread, long-lasting reduction in relapse rates.
At Columbus Park Treatment Center in New York City, we know and practice AN-EXRP and can implement it with AN clients who are nearing weight restoration. We consider exposure work a regular part of our standard practice and an intervention we also use with BN and BED clients. Interested in learning more about the ways in which we utilize AN-EXRP and related treatments here at Columbus Park? Contact us HERE.