So often, the stigmas surrounding eating disorders are attributed to cisgender, white, female populations when in reality, eating disorders are not bound to race, gender or age. Considering that one study identified that “trans individuals have nearly 5 times the risk of eating disorder symptoms when compared to cisgender heterosexual women,” it is the responsibility of the eating disorder community at large to understand and address the unique challenges associated with providing supportive, effective, and well-informed treatment to the LGBTQ+ population. As we wind down Pride Month, the team at Columbus Park felt it was pertinent to discuss and review some of these unique risk factors and the ways in which they impact the treatments we provide.
We can begin our review with a discussion around prevalence. A 2015 study found that bisexual women are at a higher risk for eating disorders when compared to other sexual minority groups and gay men are at higher risk than men who are straight. A BBC Article titled ‘How Being Gay Can Make Your Body Issues Worse writes “In 2014, the International Journal of Eating Disorders found that gay or bisexual men were three times more likely than straight men to have body image issues.” Additionally, A recent survey in Attitude Magazine reported that in a poll, 84% of respondents said they felt under intense pressure to have a good body. Only 1% considered themselves “very happy” with their appearance. Clinicians must also be aware of body image issues associated with those experiencing Gender Dysphoria within the trans population, as this unique struggle may contribute to compounded difficulties accepting one’s body and body image –a struggle reported by many individuals with eating disorders. This has been noted to contribute to feelings of isolation and discomfort in treatment centers where this confounding variable goes unaddressed.
As LGBTQ+ populations are often underrepresented in larger scale treatment studies, the experience of marginalized populations often cannot be accounted for when evaluating best practices. Considering a great number of research studies are based on college campuses where there are disproportionate numbers of Caucasian, upper-middle class cisgendered young adults involved in studies (referred to as a “sample of convenience” in a recent Psychology Today article) the LGBTQ+ population is understudied. As a result of this, the myths continue to circulate about the ‘typical’ eating disorder sufferer and awareness around the LGBTQ+ populations remains limited.
An easy way to start incorporating more sensitivity to the unique stressors of the LGBTQ+ population in your practice? Start by reading the latest research. A recent study reported that LGBTQ+ youth are at a higher risk for homelessness. Members of the LGTBQ+ community are at a higher risk for being thrown out of their homes, especially trans individuals. Be sure your intake interviews are thorough and supportive. Secondly, as clinicians, we must be mindful of utilizing the correct gender pronouns. We must simply ask our clients at the time of intake what pronouns they prefer. The improper use of pronouns is associated with an increased risk of eating disorder symptoms, along with negative mental health outcomes and feelings of being invalidated in treatment. Meeting your client where they are to understand their unique circumstances will result in more validating, effective and supportive treatment. Learn more about the unique needs of this population here.
3 Ways to Improve How We Support the LGBTQ Community. (n.d.). Retrieved July 1, 2018, from https://www.psychologytoday.com/us/blog/eating-mindfully/201806/3-ways-improve-how-we-support-the-lgbtq-community?eml
Gender Identity and Eating Disorders. (n.d.). Retrieved from https://www.psychologytoday.com/us/blog/eating-mindfully/201603/gender-identity-and-eating-disorders
Arnold, N. (2018, March 06). How being a gay man can make your body issues worse – BBC Three. Retrieved from https://www.bbc.co.uk/bbcthree/article/d9d886e1-b65c-40b3-8e3c-ad0f41aa1ea7
As I field inquiries from people seeking help for their eating struggles, I often hear “I’m not thin enough to have an eating disorder.” The individual might even add something like, “… and I’m probably not sick enough to deserve treatment.” I’ve been running a treatment center for eating disorders for over a decade and consistently, the majority of client population falls within a normal weight range. We do treat restrictive eating disorders (like anorexia) and, in some cases, with restriction, there is extreme weight loss resulting in an obviously emaciated appearance. But there can also be extreme weight loss on a larger frame that results in a normal weight physical presentation. Further we often we see restricted eating – even severe restricted eating – with minimal or no weight loss. So how one looks says nothing about their suffering… and whether or not they need help. In this week’s blog, I want to address Atypical Anorexia, a form of anorexia in which the individual experiences all the core features of anorexia but with weight that is at or above a normal range.
“You don’t have to look sick to be sick.” This phrase was aptly penned by a young woman named Lucinda who shared her battle with atypical anorexia on an Australian blog site, My Body and Soul. In atypical anorexia nervosa, sufferers present with the main, core features of anorexia nervosa like restrictive eating behaviors and extreme fear of gaining weight but without the corresponding acute weight suppression (weight loss) that you might see in “typical” AN. As a result of this presentation, many anorexia sufferers go undiagnosed or untreated.
Often, an individual struggling with atypical anorexia nervosa will report severe restrictive eating patterns, ritualized behaviors (such as cutting food into tiny pieces), rigid rules, routines and obsessions. Since the individual may not present with an emaciated or skeletal frame, sufferers themselves may not recognize that they are sick and loved ones may never fear the situation is dire enough to intervene. It is for this reason that this writer, Lucinda, made her case that one does not have to look sick to be sick.
Lucinda hit her rock bottom during college when her restrictive eating patterns and ritualized behaviors took over her life. She did experience weight loss – just not the kind of dramatic weight decrease one would expect with such a restricted diet – and began to struggle with gastrointestinal issues. She writes “I looked thinner than ever and my bowels stopped working properly because of my disordered eating patterns and abuse of laxatives. Mum took me to hospital and I underwent a colonoscopy and an endoscopy, as the doctors thought I had a blockage. Nothing was found and I lived in agony for weeks on end. My mind was also a mess. I was constantly suffering from anxiety attacks and was often frustrated, confused, upset and so petrified of putting on weight.” To Lucinda – and apparently also to those treating her and overlooking the glaring eating disorder driving her suffering – the thought was, “How could I have an eating disorder? I wasn’t nearly skinny enough.”
After more suffering and inconclusive medical tests, Lucinda finally shared with her mother the extent of the emotional torture she had been enduring in relation to food and weight. She was admitted to a treatment facility where she received a diagnosis of PTSD and Anorexia. Lucinda’s treatment focused in on normalizing her eating, stabilizing her weight and helping her to better understand and respond to her emotions. Now, in recovery, Lucinda shares her experience through her passion, writing, and completed her first novel, What’s Eating Lucinda.
For many years, the prevailing fourth edition of the Diagnostic Statistical Manual (the handbook used by healthcare professionals that presents the diagnostic criteria for mental health disorders) grouped all atypical or subclinical disorders under the heading of “Eating Disorder Not Otherwise Specified” (EDNOS). This category covered 6 presentations that did not fold neatly within one of the existing eating disorder like Anorexia or Bulimia. With the publication of the fifth edition of the DSM (the DSM-5), important updates to eating disorder criteria were made. By better integrating varying and different ED presentations, the DSM-5 has created space for disorders of eating that didn’t previously fold so neatly into existing categories and has helped countless individuals better understand their struggles. EDNOS was renamed OSFED (Other Specified Feeding or Eating Disorder) in the DSM-5. With the DSM-5 we also saw the integration of Binge Eating Disorder as a full-fledged diagnosis; previously Binge Eating Disorder was considered another condition under the EDNOS category. The DSM-5 recognized the importance of subthreshold conditions where some but not all criteria may be met and atypical conditions. So there are now five specific OSFED subtypes:
Atypical Anorexia Nervosa (i.e. anorexic features without low weight)
Bulimia Nervosa of low frequency and/or limited duration
Binge Eating Disorder of low frequency and/or limited duration
Night Eating Syndrome
Lucinda’s story reminds us that we must not let perceptions of a diagnosis (e.g. you must be skeletal to suffer from an ED) define our responses. If you or a loved one experiences difficulty around or preoccupation with food or weight, a consultation with a professional is appropriate and necessary – regardless of one’s body size.
‘Nobody knew I was anorexic… not even me’. (2018, June 18). Retrieved June 22, 2018, from https://www.bodyandsoul.com.au/health/womens-health/nobody-knew-i-was-anorexic-not-even-me/news-story/e1f4696981b39e848ca38f2ba1400da8
Atypical Anorexia Nervosa: What Are The Signs and Symptoms. (2018, February 09). Retrieved from https://www.eatingdisorderhope.com/blog/atypical-anorexia-nervosa-signs-and-symptoms
Blog | Goodbye EDNOS, Hello OSFED | Jenni Schaefer. (2017, February 22). Retrieved June 28, 2018, from https://jennischaefer.com/blog/eating-and-body-image/goodbye-ednos-hello-osfed-subthreshold-and-atypical-eating-disorders-in-dsm-5/
For the past 10 years, teletherapy along with telehealth education, prevention, and awareness programs have started to gain popularity. Treatments provided over the web and via web apps have expanded access to quality treatment for individuals with limited financial means and in even the most remote areas. Clinicians and researchers alike have been collecting data to evaluate the efficacy of these programs; this data has shed light on the potential success of these programs supporting more widespread support for and utilization of telehealth treatment options. Results from a recent study evaluating the quality of the therapeutic alliance developed in videoconference therapy for individuals with PTSD provided new and important data.
The aforementioned PTSD study developed to address a number of concerns expressed by clinicians who are partial to face-to-face interventions. Some clinicians feel that telehealth or videoconferencing therapies are risky, that an unconventional approach to psychotherapy would not allow for a healthy therapeutic alliance. A second argument of the clinical community is that, while video conferencing does allow for a visual experience of treatment, it intervenes with the ‘sense of presence’. The sense of presence refers to the unique and subjective experience of being in a specific place when in reality, the individual is actually physically somewhere else. While it is not hard to understand the concerns of the clinical community, researchers promoting teleconferencing feel they have developed a form of treatment that most closely resembles a traditional face-to-face consultation experience and that the pros outweigh the cons when considering that certain populations may have no other supportive outlet. Prior to this PTSD-specific study, several different psychological conditions had been studied and consistently results demonstrated no significant difference in the quality of the therapeutic alliance formed when comparing face-to-face treatment to videoconferencing treatment. The article published to Liebertpub states “video conferencing does not appear to compromise the scope or depth of the topics discussed in therapy or the emotions that clients feel.” Regardless of these early publications, the topic requires more research to speak to the generalizability of these results.
The PTSD study aimed to evaluate the effectiveness of video conferencing specifically in the treatment of PTSD with CBT as “victims of trauma may sometimes adopt a defensive interpersonal style, characterized by mistrust. The creation of a therapeutic atmosphere that allows trauma victims to feel safe is therefore important in order to foster non-threatening contact, which in turn promotes the healing of relational problems triggered by a traumatic experience.” Given the particular level of importance alliance plays in this specific diagnosis/treatment, a video conferencing program would need to be closely scrutinized to ensure it could be a viable option. 46 Participants received CBT treatment over a period of 16-25 weeks (17 of them by video conference and 29 in person). Therapy consisted of four modules: psychoeducation, training in anxiety management, imaginary and in vivo exposure and strategies to prevent relapse. Results demonstrated that in both face-to-face and teleconferencing conditions, therapeutic alliances developed “similarly and markedly.” Importantly, variables that researchers expected to affect the therapeutic alliance building, such as level of comfort with remote communication, proved to have no major impact on the quality of the alliance formed. Remote treatment offerings did not serve as unsatisfactory aspects of treatment to clients whereas a general defensive attitude toward therapy or lack of preparation did. These results mirror the data collected in earlier studies and are quite promising to the health care system.
The ability to form quality relationships and therapeutic bonds via telehealth and videoconferencing programming will continue to eliminate barriers to entry for individuals without access to face-to-face treatment. While face-to-face treatment is still considered the gold-standard option, individuals with a barrier to entry can rest assured that specialized care can now be just a click away.
Columbus Park offers video-therapy as an option for those who live too far from our offices to attend face-to-face sessions (although patients must be in NY State due to licensing limitations). Further reflective of our belief that video-therapy represents an invaluable development for the mental health field, Columbus Park recently launched a novel videoconference platform called my3square, that offers meal support via video for eating disorder sufferers all over the country. Participants join group sessions by video, sharing the screen – and a meal – with peers who are similarly motivated to work towards eating disorder recovery. Read more about my3square here.
Germain, V., Marchand, A., Bouchard, S., Guay, S., Drouin, M.S. (2010) Assessment of The Therapeutic Acclians in Face-to-Face or Videoconferencing Treatment for Posttraumatic Stress Disorder. Cyberpsychology, Behavior, And Social Networking. 13: 29-35.
Our journey through the Emotion Regulation Module of DBT continues as we travel on to “ABC PLEASE.” This skill gives us tangible tools and skills that can be used to increase our own personal and emotional resilience. If this sounds similar to the principles behind PLEASE MASTER, you’re right! For some clinicians, this skill has replaced PLEASE MASTER and is seen as the more updated approach, and for others, they are simply sister tools. When we increase our emotional resiliency, we are better able to bounce back from small stressors or large roadblocks. If you are a visual person, picture this idea of resilience and prevention like a Bobo Doll toy (remember those dolls that behave like punching bags from way back in childhood?) If our Bobo Doll is filled with air, powerful in its stance, a hit to the chest will only cause a small ripple. The doll will re-emerge and restore itself to its baseline upright position rapidly and safely. If our doll is devoid of much-needed air and strength, one small hit could cause a large shockwave, taking much longer to return to baseline. Let’s explore ABC PLEASE and add one more valuable and accessible tool to our Emotion Regulation tool belt.
As you may have guessed, ABC PLEASE is another acronym central to DBT!
A: Accumulating Positive Experiences
ABC PLEASE teaches us that the more positive experiences we can accumulate, the more likely we will be able to tolerate a setback. If we set attainable short and long-term goals, we will continually be arriving at success check-points, filling our “Bobo Doll” with air & positivity. And if we encounter a negative experience, it will have less of an effect on us. We have already logged and stored many more positive experiences that outweigh the negative!
B: Build Mastery
Similarly to PLEASE MASTER, this skill tells us to keep working on ourselves! Through the process of building mastery, we continue to chip away at developing a new skill or mastering a hobby. The confidence and joy that is developed as we achieve success are paramount to filling ourselves up with strength and resilience.
C: Cope Ahead
More often than not, we can predict when an upcoming situation will make us feel uncomfortable, sad, anxious, etc. before it occurs. Coping ahead teaches us to identify skills and tools we can use to manage our emotions before they arise. For example, a teenage student with test-taking anxiety may prepare by studying, attending a study group, visiting teacher office hours or attending their exam with a fidget toy to reduce test-taking anxiety on the day of the exam. An adult with social anxiety may role-play conversation starters with a friend before attending a social gathering or identify relaxation methods and practice deep breathing in advance.
Please: Treating physical illness, Balanced eating, Avoiding mood-altering drugs (non-prescribed), Balanced sleep, Exercise. “Please,” tells us to take care of our physical wellbeing. When we care for our bodies we are more likely to experience life in a positive way and are less susceptible to negativity.
When we begin to use this skill, we find ourselves more willing and able to incorporate activities that we enjoy in our daily life, increase our positive experiences and fill ourselves up with strength. Our newfound resilience will assist us in preparing for stressors that lie ahead and better tolerating “emotional punches” and unexpected situations as they present themselves. As we move through Emotion Regulation, we hope you have been taking note of the skills that may work for you and incorporating activity and mastery into your daily lives! Check back next week for our final Emotion Regulation Tool—Opposite Action!
Sunrise Residential Treatment Center. (2018, January 16). Take Control of Your Emotions Using These 5 Skills. Retrieved from https://www.sunrisertc.com/dbt-emotion-regulation-skills/#opposite-action just FYI!
An interesting Op Ed was recently published to online publication Redbook Magazine discussing the fine line between body positivity and body obsession. Lisa Fogarty, an adult female who has been recovered from anorexia nervosa for many years, delved into her unique thoughts on the body positivity movement and the way it is both helping and hurting society at large. Fogarty’s piece focuses on how a movement of any kind that surrounds the female body continues to promote discussion of the female form (whether positive or negative) in the mainstream media. Fogarty yearns for the day that bodies aren’t referenced positively… or negatively–simply that body type is not discussed at all.
In the publication, Lisa bravely reflects on her history with anorexia, a disease that she struggled with for nearly two decades. Lisa recounted how an element of privilege (being able to afford quality treatment) and a strong support team (a “lioness” mother) provided her with an environment in which she could overcome this potentially devastating disease. As she looks back on her experience from a place of mental wellness, she recounts how celebrities, blogs and influencers highlighted an idealized body image throughout her young adult life, and that while we have made great strides in our discussion of the female form, an evolution of thought needs to happen.
With the rise of the body positivity movement, progress has been made to de-emphasize the importance of a ‘perfect’ female frame, and instead, embrace the true female form—tall, short, skinny, stretch marks, you name it. Fogarty references a number of brands who have taken stances to stomp out the use of photoshop and utilize “real women” in their campaigns. In these campaigns, scantily clad women stand bravely in front of the lens posing, cellulite and all. Fogarty fully supports this movement and promotes that women feel confident in their skin but reports that these campaigns are not representative of all women–not all women feel comfortable in their bodies. She writes “All of these things are a step in the right direction — that is, towards normalizing and celebrating all bodies — and will hopefully someday result in our kids feeling even just a little bit more confident about themselves when they step out into the real world. But there’s another reality here that seems almost wrong to address when everyone is suddenly so gung-ho about their bodies: not all of this inspiring pro-body talk resonates with all women.”
While this has surely initiated a wave of change and has the potential to heal society’s superficial norms, Fogarty feels that this body positive movement continues to put women’s bodies at the forefront. And for women struggling with eating disorders and body image issues, the focus on their news feeds continue to be bodies. Fogarty writes “the only way I’ve found healing from my disorder is by understanding that I don’t have to participate in society’s intense focus on women’s bodies. So, when I stumble upon a #loveyourbody hashtag — regardless of the body size or shape of the woman posing for the photo — I think: that’s great for you. You’re amazing. But when the hell will we be able to stop talking almost exclusively about how women look?”
Fogarty, L. (2018, April 26). The Problem With Body Positivity. Retrieved from https://www.redbookmag.com/body/a13446174/body-positivity-problem/
As we continue our blog series on DBT Skills for coping, we enter the DBT module or chapter called Emotion Regulation. Emotion Regulation skills have three primary goals:
1) to help us better attend to and understand our emotions,
2) to decrease our vulnerability to intense [negative] emotion and
3) to reduce emotional suffering
When we neglect our self-care, we can more easily become overwhelmed with emotions and engage in ineffective or impulsive behaviors. Think about it… you can see how we’re more vulnerable to “losing it” when overstressed, overtired, “hangry”, sick, or under the influence of alcohol or drugs…. In this blog, we’re going to focus on the skill of PLEASE Master, which is an acronym for a series of self-care-oriented skills that foster balance and can leave you physically and mentally more capable of controlling your thoughts and behaviors.
The P & L in PLEASE MASTER stands for “Treat Physical Illness.” This is an important reminder to be on top of medication and health needs. If you have a physical illness that needs attention or a daily medication regimen that needs to be followed, we want to be sure to address this first and foremost, so we are starting each day from our strongest possible place.
E stands for Balanced Eating. What we eat and drink can have an effect on mood, energy and overall sense of physical well-being. Eating regularly throughout the day and with a balance of different nutrients will keep your body and mind well-fueled and most prepared to manage what comes your way. For those who struggle with anxiety or difficulty sleeping, beverages with caffeine are best moderated.
Avoid Mood-Altering Drugs serves as the “A” in PLEASE MASTER. When we are under the influence of any substance, our ability to resist various urges and emotions is negatively impacted (e.g. substances like alcohol can function to make us feel more depressed. If we are feeling low mood or depressed at baseline, we would not want to exacerbate that mood state by using alcohol which also functions to lower our inhibitions). If you do use drugs or alcohol, take notice of how those make you feel and the function they serve. We can then select a more appropriate outlet for support.
Balanced Sleep or “S” surrounds the principle that we should plan to get ample and sufficient sleep to prevent feelings of irritability or agitation during the day. The amount of sleep each individual needs varies, but you can plan to incorporate anywhere from 5-10 hours into your daily schedule. When we are well-rested, we are more alert, aware, resilient and capable of navigating challenges that may come our way.
E stands for Exercise. For most people, exercise is an important part of maintaining optimal health. Further, the neurochemicals and endorphins released during exercise function as natural antidepressants and can contribute to reduced anxiety. Regular exercise can occur in many ways, whether it’s a short workout video in your living room or a brisk walk with the dog. For individuals in treatment for eating disorders, exercise is a central and particularly delicate subject so it’s essential to honor your personal treatment guidelines when it comes to exercising safely and in a balanced way.
Building MASTERY is the final component of the PLEASE Master skill set. Building Mastery means that we try to engage in activities each and every day that bring us a sense of accomplishment, joy, and confidence. By doing the things we are good at, we promote feel-good sensations and are reminded of our capabilities and strengths as individuals. When we feel self-confident and strong, we are all the more ready to tackle the day.
As we begin to explore the module of Emotion Regulation, be sure to keep PLEASE Master in mind and observe your daily patterns and habits. Whenever possible, utilize this helpful acronym to ensure you are taking good quality care of yourself.
Dietz, L. (n.d.). Reduce Vulnerability. Retrieved May 25, 2018, from https://www.dbtselfhelp.com/html/reduce_vulnerability.html
As we continue to progress on through the four DBT modules in this blog series, we find ourselves exiting Distress Tolerance and entering Emotion Regulation. This module does just what it says— it teaches us various ways in which we can understand our emotions and better regulate them! This module provides a number of useful tools we can use to regain control over our emotions, so they are no longer in the driver’s seat moving us towards poor decision-making. In order to use the tools in the Emotion Regulation module, let’s first review the a few key terms you may have seen referenced in earlier blogs! These three key terms (the three mind states of DBT) are central to DBT—they are Emotion Mind, Reasonable Mind and Wise Mind.
Emotion Mind: we can think of Emotion Mind as a space in which our thoughts run wild. In this place, emotions run the show and drive our actions and decision-making. It’s very hard to view situations through a rational, objective or factual lens when in Emotion Mind. In this state our decision-making and planning capabilities may be distorted. For an individual who has trouble regulating their emotions, this state is often referred to as being “hot” because emotions are in the driver’s seat and the engine is on overdrive.
Reasonable Mind: contrary to Emotion Mind, when in Reasonable Mind our thoughts are “cool.” We are evaluating situations through a reasonable or logical brain only. One will use facts, statistics, thinking and planning to problem-solve. In this state we may feel as though our attention is focused on the task at hand and we are less aware of our emotions.
Wise Mind: if we think of these mind states as a Venn Diagram, Wise Mind would be that central space in which Reasonable Mind and Emotion Mind overlap. In Wise Mind we are able to use our valuable emotions, while collaborating with rational, logical thought to identify solutions and problem solve. When we access Wise Mind we can honor our gut feelings, intuition and instincts to make choices that are beneficial for ourselves and those around us. While we may not always want to do what our gut knows is best, when we can tap into Wise Mind we can make decisions that are healthy, helpful and productive!
We will revisit these states of mind as we progress through the Emotion Regulation module, so keep an eye out! Over the next few weeks, we will learn to access the skills necessary to help keep us in Wise Mind more often than not. Through the Emotion Regulation module, we will learn to identify and let go of emotions that are causing distress or contributing to moments of poor decision making.
Dietz, L. (2013) Mind States. Retrieved from [https://www.dbtselfhelp.com/html/mind_states.html
Due to the widespread accessibility of cell phones and electronic devices, the mental health field has embraced the likelihood that treatment options could, and very well should expand over the next decade. As a result of this movement, various e-therapies have been developed that can provide immediate and direct treatment intervention to users via smartphone apps and computer-based programs. These e-health initiatives have been growing in popularity despite their early stages and researchers have made great strides in studying their efficacy. As researchers and clinicians feel that e-health programs should be evaluated just as traditional face-to-face therapies are, a meta-analysis published in the journal of Behavior Research and Therapy was performed to review research findings utilizing traditional evaluation methodology employed by the UK’s National Institute for Health and Care Excellence (NICE).
To carry out the review, a number of electronic databases were reviewed via searches for randomized control trials of e-therapy programs. As per the researchers, “No restrictions were placed on the type of sample recruited. The samples included participants from the general population, high-risk groups, and full cases. E-therapies were defined as interventions that were primarily delivered via a computer, mobile phone or tablet, although there could be limited additional therapist contact. The means of delivery included the Internet, downloadable software, CD-ROMs and mobile-device apps.” Ultimately twenty trials were utilized in this meta-analysis.
Suggestive of the work that is currently being done in the world of eating disorder e-treatment, 17 of the 20 studies included evaluated CBT-based interventions. Thirteen of these studies focused on eating disorder prevention and six investigated treatment interventions focused on preventing relapse. To evaluate the quality of the evidence, the GRADE approach was used to evaluate bias and assess the confidence in the effect estimates (quality of evidence) for each outcome. This five-category approach evaluated risk of bias, inconsistency, indirectness, imprecision and publication bias.
ED Prevention Studies: Eight of the 20 randomized control trials surrounded the use of CBT-based interventions to reduce body dissatisfaction among students’ bodies. When outcomes were evaluated, results were mixed:
-Study “Student Bodies” demonstrated a small improvement in the drive for thinness and weight concern at the end of the intervention and at follow-up however the evaluation for weight concern proved to be imprecise. Small effect sizes were noted for shape concerns, dietary restriction and global ED pathology at follow-up. Large improvements were found in cessation rate of binge eating, and purging behaviors (41% of the participants in intervention vs. 17% in control group) which was supported by results at follow-up though results may have been estimated imprecisely.
-Another study demonstrated that when compared with face to face group therapy, CBT-based e-therapy was inconclusive.
-Two studies compared CBT-based e-therapy with a waitlist control condition in the treatment of adults with BED. CBT-based e-therapies were associated with large improvements in the cessation of binge eating at the end of the intervention.
Relapse Prevention Studies: One study identified had investigated an online CBT-based relapse prevention program compared to face-to-face treatment protocols for women with anorexia nervosa who had recently been discharged from an inpatient hospital unit.
-Results demonstrated small improvements in clinician-rated bulimia, global eating disorder pathology at the end of intervention although estimates were imprecise
-Small improvements were noted for the frequency of inappropriate weight control behavior and self-rated bulimia at follow up, although the self-rate scale was imprecise. As such, evidence was inconclusive though confidence in the effect estimates was low to moderate.
In sum, the use of single studies in this meta-analysis contributed to difficulty making specific evaluations and often provided effect estimates that were quite low. While no ‘firm conclusions’ were made from this literature review, positive findings, especially for “Student Bodies” programs did emerge. There is evidence to suggest that CBT-based interventions may be meaningful and impactful, especially to those seeking an alternative to face-to-face therapies. Researchers feel that an additional barrier to outcomes in the aforementioned studies was the use of CD-ROM based programming, as opposed to higher tech devices such as computer apps or cellphone apps. Considering the desire and demand for mobile-based programming, this avenue is one worth exploring further and as per the article “Overall, although some positive findings were identified, the value of e-therapy for eating disorders must be viewed as uncertain. Further research, with improved methods, is needed to establish the effectiveness of e-therapy for people with eating disorders.”
It is an exciting time for the eating disorder community, as new and unique approaches are being further investigated. It is the responsibility of the ED community at large to develop telehealth and e-health programs that are rooted in traditional, gold-standard interventions to open up this inclusive and accessible form of treatment to all.
Loucas CE, Fairburn CG, Whittington C, Pennant ME, Stockton S, Kendall T. E-therapy in the treatment and prevention of eating disorders: A systematic review and meta-analysis. Behaviour Research and Therapy. 2014;63:122-131. doi:10.1016/j.brat.2014.09.011.
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