How to Communicate With Your Psychiatrist About Medication

In my work with patients who have anxiety and/or depression, I often recommend a consultation with a psychiatrist regarding medication. I believe in the value of psychotherapy; that’s why I became a (non-prescribing) psychologist. However, I find the careful use of psychiatric medications as a helpful aid to psychotherapy. For best results, you must communicate closely and assertively with your psychiatrist about your experience as you try new medications.

It is important to note that I am not a psychiatrist and do not prescribe medication, but I have worked closely alongside psychiatrists in many different settings. I continue to work with patients during the intervals between psychiatry visits. I am intimately familiar with the experiences they have when starting medication. I frequently coach my patients to communicate more with their psychiatrists.

Psychiatric Medicine: an Inexact Science

The selection of an appropriate psychiatric medication is a less exact science than is the choice of medications for other problems. If you have a particular bacterial infection, the specific antibiotic indicated for that infection should work for most people – for example, penicillin for strep throat. However, a medication that works well for one person’s depression may not work for another’s. Unfortunately, we don’t know why that is. Today, there is luckily a large arsenal of medication options from which to choose.  Because some medications work for some and not others, often it takes trial and error to determine which medication works for a particular patient.

Furthermore, the classes of psychiatric medications that are most commonly used for anxiety and mood disorders do not take full effect immediately but rather build up to a therapeutic dose in one’s brain over time. There can be side effects that many people experience before the curative effects kick in. Often patients are started on a lower dose of medication to determine the lowest effective dose as well as to minimize the severity of potential side effects caused by the medication. Further complicating the process, some patients require a higher dosage than others to experience a therapeutic effect.  For example, some may get a benefit from 20 mg of Prozac while others may need 60 mg.

When choosing specific medications, psychiatrists rely on information from drug manufacturers and research trials as well as their own clinical experience of how clients with diagnostic similarities responded to different medications.  These doctors often try to match medication and its side effects with specific symptoms. For example, someone with depression who is very tired may be prescribed an antidepressant that is more energizing, while someone with depression who is more agitated may be prescribed an antidepressant that has a side effect of calming. The side effects often also determine at what time of day the medication should be taken. More activating agents are generally taken in the morning and more sedating medications at night.

Because of the trial-and-error process of matching patients to medications and the lag time it can take to build up to a therapeutic dose, it can take several months to find the right psychiatric medication for a patient. Unfortunately, I too often see clients stop taking medications before they reach a beneficial effect due to some annoying but mild side effect that would have gone away over time.  I have seen patients giving up on medication altogether if the starting dosage of the first medication tried doesn’t help. It is disappointing when this happens because it might have worked.

If a client does not seem to respond to medication, psychiatrists will often first try increasing the dosage to see if a larger dosage produces a positive effect once it has built up, which can take another few weeks. Then if this seems to have no effect, they will usually recommend patients stop or taper the first medication and switch to a different medication, which will take several weeks to ramp up. And then, if necessary, raise that dosage… and so on. Sometimes patients require combinations of different medications, which multiplies the combinations that must be tested.

As you can see, this can be a slow and frustrating process.  Due to the period of time it takes to test the effectiveness of each medication, this can be unavoidable.

What this Means for Patients

When moving to a new medication, it is critical to follow through with the medication plan and communicate closely with your psychiatrist about both the therapeutic effects and any side effects you experience. Your psychiatrist is not a mind-reader.  I have seen many clients who notice no benefit from their medications, wait until the next appointment, which is sometimes months away, to report on a lack of progress. In doing so, they can waste precious time.

Here are some suggestions for working with your psychiatrist and maximizing your chance at more quickly finding the medications(s) and dosages that work for you.

  • Take the medication exactly as your psychiatrist recommends.
  • Keep to the regular appointments requested by your psychiatrist. They typically time these to coincide with the opportune times to gauge whether your medication is working. However, do not hesitate to call them sooner.
  • Take notes on your symptoms and any side effects so you can remember details.
  • Report any severe side effects or suicidal thoughts to your psychiatrist right away (do not wait until the next appointment).
  • Watch for signs of serotonin syndrome, a rare but potentially life-threatening side effect that can occur in response to psychiatric medications. If you experience these symptoms, call your doctor right away or go to the emergency room.
  • Make note of mild side effects (headache, nausea, dry mouth) and try to wait it out. See if the side effects subside after a few days. If not, report to your psychiatrist.
  • Understand how long your psychiatrist has told you it will take to notice a therapeutic effect from the medication. If it takes longer, report to them even if your appointment is still several weeks away. Psychiatrists can sometimes alter a prescription by phone before seeing you again, or they may suggest you come in sooner.

I hope that this information and tips have felt helpful to you. If you are considering medication, it may not be a cure-all, but it can be an incredibly helpful recovery tool. Key is communication!

 

2017 Spring LACPA Eating Disorder SIG Open (to non-LACPA members) events

Date: Tuesday, March 7 at 7:30 pm.

Title: Thinking Critically and Cautiously About the Phrase “Eating Disorders Are Biologically-Based Mental Illnesses

Presenter:  Michael Levine, Ph.D., FAED

Description: It has become a foundational “truth” among many clinicians, researchers, patients, family members, and advocates that, in accordance with the 2009 position statement of the Academy for Eating Disorders (AED), eating disorders are “biologically-based mental illnesses.” In fact, number 4 of the AED’s “Nine Truths about Eating Disorders” is “Eating disorders are not choices, but serious biologically influenced illnesses.”

Dr. Michael Levine has for many years studied sociocultural factors and their relationship to the prevention of eating disorders and disordered eating. In this talk, Levine offers a critical evaluation of this contention, in so far as one meaning of “critical” is “exercising or involving careful judgment or judicious evaluation” (Mirriam-Webster On-Line Dictionary; www.m-w.com).

Levine begins by addressing important general concepts, such as “illness” and “biologically-based,” as well as “scientific,” “evidence-based,” and “risk factor.” This sets the stage for a description of the Biopsychiatric/Neuroscientific paradigm in the eating disorders field. He will then consider the evidence for “biological causes” in the development of eating disorders, and its implications for two important challenges in the field: prevention and talking with patients, families, and the media. Throughout his presentation, Levine will compare and contrast the Biopsychiatric/Neuroscientific paradigm with the Sociocultural paradigm. Thus, his concluding remarks will consider what if anything is gained (and/or lost) by applying phrases such as “biopsychosocial” and “gene-environment interactions.”

Bio: Michael P. Levine, Ph.D., is Emeritus Professor of Psychology at Kenyon College in Gambier, Ohio, where he taught 33 years (1979-2012). In the field of eating disorders, his commitment to research, writing, and activism focuses on the intersection between sociocultural risk factors, prevention, community psychology, and developmental psychology. He has authored two books and three prevention curriculum guides, and he has co-edited three books on prevention. In August 2015, as co-editor with his long-time collaborator and colleague Dr. Linda Smolak, he published a two-volume Handbook of Eating Disorders (Wiley & Sons Publishing). He and Dr. Smolak are currently working on a second, updated edition of their 2006 book The Prevention of Eating Problems and Eating Disorders (Erlbaum/Routledge/Taylor & Francis). In addition, he has authored or co-authored approximately 110 articles and book chapters, and he has presented his work throughout the United States, as well as in Canada, England, Spain, Austria, and Australia. He is a member of the advisory councils of The National Eating Disorders Association (NEDA), the Center for Study of Anorexia and Bulimia (CSAB, NY), the Center for Balanced Living (CBL, Columbus, Ohio) and Monte Nido & Affiliates—Eating Disorder Treatment Centers.

Dr. Levine is a Fellow of the Academy for Eating Disorders (AED), which has awarded him their Meehan-Hartley Award for Leadership in Public Awareness and Advocacy (2006), and their Research-Practice Partnership Award (2008). Dr. Levine is also a member of the Founders Council of the National Eating Disorders Association, which awarded him the Lori Irving Award for Excellence in Eating Disorders Prevention and Awareness (2004) and the Nielsen Award for Lifetime Achievement (2013). After living for 37 years in Mount Vernon, OH, with his wife, Dr. Mary A. Suydam, a retired (as of May 2015) Kenyon religious studies and women and gender studies professor, they moved to California in late June 2016, to live near UC Santa Barbara, where they both obtained all their degrees.

Location: The office of Dr. Lauren Muhlheim (4929 Wilshire Boulevard, Suite 245, Los Angeles) – free parking in the lot (enter on Highland)

RSVP to: drmuhlheim@gmail.com

March and April SIG meetings are open to all professionals.   During other months SIG meetings are open to all LACPA members.  Non-members wishing to attend may join LACPA by visiting our website www.lapsych.org


Date: Thursday, April 20 at 7:30 pm.

Title: Medical Complications of Eating Disorders

Presenter:  Margherita Mascolo, MD, ACUTE Medical Director

Description:  Dr. Mascolo is the medical director of ACUTE. She will discuss the medical complications of severe restricting as well as purging. The presentation will include a broad review of the pathophysiology of starvation as well as the organ systems affected. There will be case-based discussion and presentation based on real patients seen on the ACUTE unit. Target audience is mental health professionals, dietitians, and allied professionals who need a broad understanding of the medical complications of restricting and purging.

Bio: Dr. Mascolo is the Medical Director at the ACUTE Center for Eating Disorders at Denver Health, where she has been a member of the ACUTE team since its beginning in 2008. She has trained under Dr. Philip S. Mehler for the past 8 years to become one of the country’s leading experts in the medical care of patients with severe eating disorders and served as Associate Medical Director under Dr. Jennifer Gaudiani for the past 3 years.

Dr. Mascolo completed her undergraduate work at the University of St. Thomas in Houston, Texas and earned her medical degree at the University of Texas Health Sciences Center. She completed her residency in Internal Medicine at the University of Colorado in Denver. She is board certified in Internal Medicine, is an Associate Professor in the Department of Medicine at the University of Colorado. Dr. Mascolo has published multiple peer-reviewed articles on the medical complications of eating disorders and is currently working to complete her Certified Eating Disorder Specialist certification.

Location: The office of Dr. Lauren Muhlheim (4929 Wilshire Boulevard, Suite 245, Los Angeles) – free parking in the lot (enter on Highland)

RSVP to: drmuhlheim@gmail.com

March and April SIG meetings are open to all professionals.   During other months SIG meetings are open to all LACPA members.  Non-members wishing to attend may join LACPA by visiting our website www.lapsych.org

Winter 2017 LACPA Eating Disorders SIG Events

glenys1.  Date: Thursday, January 26 at 7:30 pm

Speaker: Glenys Oyston, RDN

Title: The Dangers of Dieting

Description: Dieting for weight loss is a cultural norm – everyone does it, has tried it, or has been told to do it at one time or another. But is dieting for weight loss truly beneficial, or is it causing more harm than good? Registered Dietitian Glenys Oyston, discusses how intentional weight loss efforts are actually harmful to the physical, social and psychological well-being of people who engage in them, and what to do about it.

Bio: Glenys Oyston is a registered dietitian, size acceptance activist, eating coach, and blogger who runs Dare To Not Diet, a coaching business for long-timer dieters and weight cyclers who want to break free of food restriction and body dissatisfaction. She coaches people online or by phone through one-on-one and group coaching programs. She is based on Los Angeles, CA. You can find her at www.daretonotdiet.com.

Glenys Oyston, RDN

Dare To Not Diet

Dietitians Unplugged Podcast

@glenysoRD on twitter

Facebook

Location: The office of Dr. Lauren Muhlheim (4929 Wilshire Boulevard, Suite 245, Los Angeles) – free parking in the lot (enter on Highland)

RSVP to: drmuhlheim@gmail.com

SIG meetings are open to all LACPA members. Nonmembers wishing to attend may join LACPA by visiting our website www.lapsych.org

 

abby22. February 10 at 11 am – LACPA Office (in conjunction with Sport and Performance Psychology SIG)

The LACPA Sport & Performance and Eating Disorders SIGs are pleased to announce our jointly held meeting for February, 2017:

Date: Friday, February 10, 2017

Time: 11:00 AM – 12:30 PM

Location: the LACPA Office, Encino

6345 Balboa Blvd. Building 2, Suite 126

Topic: When an Athlete Gets an Eating Disorder

Speaker: Abby McCrea, LMFT

More about our topic and speaker:

Clinical eating disorders cause significant problems for more than 40% of athletes. Subsequently, the subtleties between “good athlete” and “eating disorder” mindsets can become particularly tricky to discern after the onset of an eating disorder. Knowing the risks, possible causes, and how to support athletes with eating problems is essential for developing and sustaining athletic wellbeing. 

This talk is designed to help you:

  1. Explain how and why athletes get eating problems
  2. Recognize the subtle differences between a “good athlete” and an “eating  disorder” mindset
  3. Create ways to support athletes with eating problems

Abby McCrea is a Licensed Marriage and Family Therapist who has a private practice in Sierra Madre, CA. She graduated from Fuller Theological Seminary with a Master’s of Science degree and a clinical focus on the integration between psychology and spirituality. 

With over 13 years of experience in a variety of mental health settings including inner city gang rehab community programs, college counseling centers, and eating disorder residential centers, she brings a depth of understanding, experience, respect, and compassion to her work. In her private practice she specializes and works to empower teens, adults, and families that recovery from an eating disorder is possible.  Additionally, she is passionate about developing research and treatment for athletes with eating problems, and helps clients, families, and coaches in her practice to navigate and manage the delicate balance between life, sport, and recovery.

 Abby speaks nationally on the topics of eating disorders and athletes, eating disorder education, deconstructing social ideals of body image, spirituality and the rituals of eating problems, and identity development among teenagers in life transitions.

Please RSVP and/or direct any questions to Sari Shepphird at drshepp@msn.com

LACPA SIG Meetings are a LACPA member benefit and are open to all LACPA Members. For more information about LACPA Membership, SIG’s and other events, visit the LACPA events calendar: www.lapsych.org

Parking Information:

The LACPA office address is THE ENCINO OFFICE PARK, 6345 Balboa Blvd, Building 2, Suite 126, Encino, CA 91316 – second building from Balboa Blvd., conveniently located near ample free daytime/weekday street parking on Balboa Blvd, south of Victory Blvd.  Both sides of Balboa have all day free parking.  There is also plenty of free parking at the Sepulveda Basin Sports Complex on the west side of Balboa, south of Victory, 6201 Balboa Blvd. (2nd driveway past the Busway). 2-3 minute walk to the office door.  Wherever you park, please check the signs. 

Parking at The Encino Office Park lot between the hours of 9 a.m. – 6:30 p.m. is restricted to building tenants only.  Do not park in the lot at the building. 

 

Checking Our Own Weight Biases as Parents

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Weight bias is a preference for thinness. In the words of psychologist Ashley Solomon, Psy.D., CEDS, “Weight bias is insidiously interwoven into the fabric of our culture.”

Like many of us, I grew up in a family that possesses a great deal of weight bias. When I gained weight just before puberty my mother put me on diets. My paternal grandfather bribed me to lose weight with the offer of a car. I realize my family members meant well. They stated at the time they were worried I would not be well-liked if I was overweight. At 101 years of age, my maternal grandmother still weighs herself daily and credits the diet she started in high school as the cause of my grandfather falling in love with her.

I have already recounted how I helped my older daughter gain weight when she fell off her weight curve at the age of 12—despite her pediatrician’s misplaced admiration, “You’re just how we all want to be,” (75%ile for height and 25%ile for weight [= thin for your height])” My son and younger daughter gained weight before their growth spurts, which led to that same pediatrician warning me about weight gain and risk of obesity for the two of them. This succinctly illuminates our culture’s weight bias: obesity is a far greater concern than anorexia nervosa.

Now let’s fast-forward to 2 years after the obesity warning for my younger daughter. Nearing the end of her height growth spurt, she has fallen off her weight curve. What is an FBT-trained professional therapist and enlightened mother to do?

She is about 10 pounds below where she should be according to the weight graphs (ignoring the single spurious plot point when I got the obesity warning). She is definitely slender. She does take a medication that could reduce appetite. However, even when she doesn’t take it, she has a small appetite. She does not show any other signs of weight or body concern, eats a range of foods, and is not very active (unlike her older sister when I intervened on her behalf to restore weight).

I notice my admiration for her current shape. I notice the temptation to leave her alone and let her remain on the thin side. After all, my son has gained weight now that he is no longer in high school sports. I notice a stronger urge to react to his food choices than I did when he was thinner. And with some larger relatives in their genetic heritage, I have had the fleeting thought that I would rather keep my daughter thin. WHAT?! I caught my thoughts unconsciously falling into programmed family and societal beliefs that I do not actually agree with on an aware and conscious level.

I examine my feelings and beliefs about what weight gain means for my daughter. I quickly recognized my over-valuing of her slenderness and my own projected anxiety about her potentially being larger. After questioning her pediatrician, who is, not surprisingly, unconcerned, and obtaining a print-out of her growth and weight curves, together we (my daughter and I) settled on adding a daily liquid supplement and mild encouragement to eat more. And, my daughter seems to feel it is a fun challenge.

I do what I ask the families I work with do, which is challenge the bias that thin is better and focus on keeping my daughter on track on her own weight curve, which I know is healthiest for her long term.

November 2016 LACPA Eating Disorder SIG events

The Los Angeles County Psychological Association Eating Disorders SIG will be hosting 2 events in November 2016

Tuesday, November 1 – 7 – 8:30 pm in LACPA Office (Encino) – DBT for Eating Disorders 

Speaker: Charlotte Thomas, LCSW, Program Manager of Portland DBT’s Pathways to Mindful Eating Program

Talk Description: charlotte

Dialectical Behavior Therapy (DBT) is an evidence based treatment developed by Marsha M. Linehan, PhD for complex multi-diagnostic individuals with pervasive emotion dysregulation and high risk suicidal behavior. Over the past two and a half decades, research has consistently demonstrated DBT as being effective for patients with a variety of complex problems such eating disorders and substance abuse disorders, where emotion dyscontrol is at the core of the patient’s issues and often interfere with treatment and long-term maintenance of therapeutic progress. This presentation will use a session- to-session birds eye view of the implementation of DBT with complex eating disorders in order to demonstrate use of DBT principles and skills in a concrete, “real world” manner. My hope is to communicate my excitement for DBT, share outcomes commonly generated by DBT, and to generate curiosity among individuals participating in the training.

Goals:

Upon completion of this presentation, participants will:

  • Learn about the first 7 sessions of treatment using a composite client with a complex Eating Disorder
  • Understand the biosocial model of DBT as applied to a composite client
  • Learn about the timing and use of strategies such as dialectics, behavioral chain analysis, and diary cards

Speaker bio:

Charlotte Thomas, LCSW

Charlotte received her master’s degree in Social Science Administration (MSSA) at Case Western Reserve University in Cleveland, OH and trained with Lucene Wisniewski PhD, FAED and Mark Warren MD, FAED for the following 4 years in the evidence based treatment of eating disorders. She is now a licensed clinical social worker in the state of Oregon. Charlotte’s professional interest is in treating eating disorders and associated needs including borderline personality disorder, depression and anxiety. She has experience in private practice mental health settings, providing individual, family, and group services for teens and adults. At Portland DBT Institute, Charlotte is the Program Manager for the Pathways to Mindful Eating program and provides direct service to clients, supervision to staff, and serves on the management board for the clinic helping to inform general clinic policy.

 Friday, November 4 – 12 to 1:30 pm in LACPA Office (Encino) in conjunction with the Couples SIG – Panel Discussion: The Impact of Particular Addictive/Compulsive Behaviors on a Couple’s Relationship, and How to Help – Hoarding, Gambling, and Eating Disorders

3 speakers include:

  1. Regina F. Lark, PhD: Family Stuff
  2. Cristin Runfola, PhD:  Uniting Couples in the Treatment of Eating Disorders.
  3. Margaret Altschul, MBA, MA, LMFT: Win, Lose or Draw:  What happens to couples when one partner is a problem gambler?

Speaker bios and talk descriptions below:

Regina F. Lark, PhD: Family Stuff: The impact of compulsive hoarding on relationships with family and friends, creates as much dysfunction as the “stuff” piled around the room. Dealing with it effectively “takes a village” and a strategic plan to calm the relationships between loved ones and the physical environment. Dr. Lark’s presentation will explore the effects of the hoarding disorder and chronic disorganization on the family dynamic, and present strategies for finding clarity amidst the chaos.

Dr. Lark is the owner of A Clear Path: Professional Organizing and Productivity. As a Certified Professional Organizer she specializes in working with people with chronic disorganization, ADHD, and hoarding. She is also a relocation specialist, helping families move or downsize from one home to the next. She is a featured speaker and educator, and is the author Psychic Debris, Crowded Closets: The Relationship between the Stuff in your Head and What’s Under your Bed, Second Edition, (Purple Books, 2014). She serves on the Board of the National Association of Professional Organizers, and is a member of the National Speakers’ Association. She earned a  Ph.D. in History at the University of Southern California.

Cristin Runfola, PhD: Uniting Couples in the Treatment of Eating Disorders. Dr. Runfola will describe recently developed couple-based interventions for eating disorders, including how core cognitive-behavioral couple therapy interventions can be applied and integrated with individual CBT principles for these disorders. Further, she will present data from recent pilot studies conducted with couples affected by anorexia nervosa (UCAN) or binge-eating disorder (UNITE), which yield promising results.

Cristin Runfola, PhD, is a clinical instructor at Stanford University who specializes in the treatment and research of eating disorders. Dr. Runfola’s primary research interest is in developing and testing the efficacy of clinical interventions designed to improve outcome for eating disorders. She underwent extensive training in cognitive-behavioral couples therapy and worked with colleagues at UNC-CH to develop and test manualized protocols for treating anorexia nervosa and binge-eating disorder in a couple context. She is the recipient of various awards, such as the AED Clinician Scholarship Award and NIMH/AED Early Career Investigator Travel Fellowship Award, for her work.

Margaret Altschul, MBA, MA, LMFT: Win, Lose or Draw: What happens to couples when one partner is a problem gambler?

Imagine discovering that your joint bank accounts are gone, your credit cards are charged to the max, and your car is about to be repossessed. This is often the scenario confronting couples when one person is a problem gambler. Problem gambling by one partner brings to a relationship all of the chaos, fear and betrayal of addictions and affairs combined. This presentation will help you gain awareness and understanding about Problem Gambling and learn how you can help couples dealing with the unique challenges this addiction creates.

Margaret Altschul, MBA, MA, is a Licensed Marriage and Family Therapist with a background in education and business. In addition to working with couples, Ms. Altschul applies her training and experience in using EFT and Gottman methods to help adults improve difficult relationships with parents, siblings and people at work. Margaret is authorized by the CA Office of Problem Gambling to provide counseling (at no cost to the client) to people with gambling addiction as well as family members affected by gambling.  She is Director of the Wagner Program at American Jewish University where she trains human services volunteers in basic counseling skills

* LOCATION for both events: LACPA ADDRESS and PARKING INSTRUCTIONS: 6345 Balboa Blvd, Bldg 2, Suite 126, Encino 91316. The buildings are on the south-west corner of Victory and Balboa, and Bldg 2 is the second building from Balboa. If you come from the Westside, take the 405 to the 101 and exit going north on Balboa to just before Victory (park on the street or in the Sepulveda Basin Sports Complex (6201 Balboa Blvd.) on the west side of Balboa, just south of Victory).  Or take the 405 to Victory (past the 101 if you are coming from the Westside) and exit West onto Victory.  Take it to Balboa and turn left, now heading south. On your right, you will see the buildings. Go a bit past the parking lot for the building (we are not allowed to park there during the day), past the Army’s center to the next driveway, which is for the Sepulveda Basin Sports Complex (2nd driveway past the Busway), and park in there. Or park on the street just south of the entrance for the sports complex parking lot. Both sides of Balboa have all day free parking. Allow a 3 – 5 minute walk to the buildings. Walk into the building’s parking area and go to the second building. The LACPA office is right by the entrance off the parking lot, on the left if you walk in from the parking area. Wherever you park, please check the signs

Parking at The Encino Office Park lot between the hours of 9am – 6:30 pm is restricted to building tenants only. We can park there in the evening and on weekends, but not 9 – 6:30 weekdays.

RSVP to: drmuhlheim@gmail.com

SIG meetings are open to all LACPA members. Nonmembers wishing to attend may join LACPA by visiting our website www.lapsych.org 

Sleep: Monitoring and treatment of insomnia without drugs

sleepBy Elisha Carcieri, Ph.D.

“A ruffled mind makes a restless pillow.” Charlotte Bronte

In our self-obsessed culture, monitoring and tracking heartbeat, steps, exercise, food intake, and sleep is commonplace. My sister has recently been tracking her sleep using an app on her smartphone, and she encouraged me to do it too. My first response was, “Why? I know I’m sleep deprived. I don’t need an app to tell me that.” I was still nursing my baby once a night at the time and I was pretty positive this was negatively impacting my sleep and my ability to function in general. Skeptical, I downloaded the app and started it each night before bed for about a week. The application’s primary measure of sleep quality is called ‘sleep efficiency,’ which is the amount of time you are asleep divided by the amount of time you are in bed, and is represented as a percentage. This is the same measure of progress I use with clients in cognitive-behavioral therapy for insomnia (CBT-I). Typically, sleep efficiency of 85% or higher is considered “normal,” “healthy,” “good” sleep. For example, if you are in bed for 8 hours, asleep for 7.5 of those hours, with 20 minutes to fall asleep and two episodes of waking for 5 minutes each, your sleep efficiency is 94%.

The app uses the microphone on your smart phone to measure whether you are awake or asleep based on movement. Years ago, when I worked as a student clinician at a sleep and pulmonary disorder clinic, we used actigraphy watches which then had to be downloaded, interpreted by hand, and then compared with self-report data. Amazing what smart phones can do!

I was somewhat surprised at what the app told me. Many of the nights I was sure my sleep was poor, “I didn’t sleep a wink last night,” the app indicated that, while I was awake for some of the time (feeding my baby), I was out like a light during the time I was in bed. A user-friendly graph depicted the movement associated with my sleep, and decent average sleep efficiency. I learned from a week of monitoring that I should prioritize getting to bed earlier, because when I am in bed, I’m sleeping. While I am not suffering from insomnia, the little experiment reminded me of the benefits of brief self-monitoring, and inspired me to share some information about insomnia and its treatment.

What is insomnia, anyway?

Most people have bouts of insomnia at some point in their lives, usually in response to a stressful event. These short episodes of sleeplessness usually resolve and don’t require treatment. Chronic insomnia last for months or years and can be characterized by:

  • Difficulty falling asleep
  • Difficulty staying asleep
  • Waking up too early
  • Poor quality sleep

Consequences of insomnia include fatigue, sleepiness, difficulty with thinking (attention, concentration, memory), irritability, headaches, poor work performance, and persistent worry about sleep.

It is thought that insomnia develops as a result of three factors: predisposing factors, precipitating factors, and perpetuating factors. Predisposing factors are risk factors for developing insomnia, such as a highly sensitive biological sleep system or a tendency toward high arousal. Precipitating events are usually stressful events that result in an initial loss of sleep; for example, loss of a loved one, a stressful move, a new job, etc. Most people recover from this initial sleep loss once the stressor resolves. But the perpetuating factors play one of the biggest roles in the development and maintenance of insomnia. Some people become highly focused on their sleep difficulty, which results in heightened anxiety, maladaptive behavioral responses (going to bed early, staying in bed late, avoiding evening activities for fear that it may interfere with sleep, developing sleep rituals, or “crutches”), and unhelpful thoughts, attitudes, and beliefs about the sleep problem. Some examples of these common dysfunctional beliefs are:

“I need 8 hours of sleep to feel refreshed and function well during the day.” 

“When I sleep poorly on one night, I know that it will disturb my sleep schedule for the whole week.”

“When I feel tired, have no energy, or just seem not to function well during the day, it is generally because I did not sleep well the night before.” 

“Medication is probably the only solution to sleeplessness.”

These beliefs tend to perpetuate insomnia by further increasing worry and arousal, focusing attention on negative consequences of lost sleep, and decreasing belief in your ability to control your sleep problem. These patterns of thinking, in addition to the well-intentioned but detrimental behavioral responses to sleep loss are the critical targets of CBT for insomnia.

How is insomnia treated with CBT?

Many people believe that medication is the only answer to chronic insomnia. However, CBT for insomnia (CBT-I) is safe, brief (usually 4-5 sessions), has lasting effects, and is well researched. CBT-I is composed of education about sleep, stimulus control strategies, sleep restriction, relaxation training, and “sleep hygiene.”

Stimulus control strategies address the issue of the bed and sleeping environment becoming associated with wakefulness, rather than sleep. In a nutshell, the recommendations go something like this:

  • Go to bed only when sleepy (not just fatigued or tired)
  • Use the bed and bedroom only for sleep (and sex)
  • If unable to sleep, get out of bed and return to bed only when sleepy
  • Wake up at the same time every day regardless of how much you slept
  • Do not nap

Simply put, implementing stimulus control strategies is not fun. Getting out of bed when not sleeping is annoying and takes work. Also, many people with insomnia have the unfounded belief that if they just stay in bed and “rest,” they will increase their likelihood of falling asleep and will at least get some R&R. In reality, more time spent in bed awake will only perpetuate the insomnia, and rest is not equal to sleep.

Occasionally, a strategy called sleep restriction is used in which the amount of time in bed is restricted to the amount of sleep a person typically needs to feel rested. This process can also be unpleasant as it results in an initial loss of additional sleep. However, after a few days, most people begin to see results.

Relaxation training can help to address the increased anxiety and arousal associated with insomnia and the process of sleep. Learning breathing and muscle relation techniques such as progressive muscle relaxation can be important targets for the management of insomnia. If bothersome thoughts and worries are a major component of insomnia (which is often the case for those who have difficulty falling asleep), taking time out of the day to focus on worries and write them down can be helpful.

Sleep hygiene recommendations are a beneficial add-on to the treatment of insomnia (but are not usually sufficient treatment) and are applicable to most “normal” sleepers. The following are some of the guidelines I’ve found to be the most powerful:

  • Wake up at the same time each day regardless of bedtime – This is part of the stimulus control instructions as well. Bedtime can be more difficult to keep consistent.
  • Avoid naps – Especially in the afternoon, naps reduce your sleep drive and may make it more difficult to get to sleep at bedtime.
  • Get regular, daily exercise – …but not right before bedtime (this can delay sleep onset).
  • Don’t watch the clock!!! – Checking the clock during a normal, middle-of the night waking can trigger many of the negative cognitions associated with insomnia and is likely to promote wakefulness.
  • Keep a quiet and comfortable sleeping space
  • Avoid going to bed hungry
  • Avoid coffee, alcohol, and nicotine – especially in the afternoon and evening.

The use of electronic devices around and up to bedtime and in bed is a problem that is becoming more and more ubiquitous and is associated with poor sleep outcomes. Using a cell phone, tablet, computer, etc so close to bedtime can be problematic for a couple of reasons, listed below:

  • Blue light exposure – Smart phones and other devices emit light that has the potential to disrupt the sleep cycle and the brain’s “understanding” that it’s time for sleep.
  • Alertness/stimulation – Engaging with your device in the bedroom environment, especially in bed, serves to associate bed and the bedroom with alertness, rather than sleep.
  • Worry – Checking email right before bedtime or in the middle of the night can initiate worry and anxious thoughts about the following day, tasks that need to be done, etc.

Remember, if you do not have a sleep problem and “problematic” sleep hygiene-related behaviors are not affecting your sleep in a negative way, don’t worry about it! But these behaviors can be important aspects to consider for those who are suffering from a long-term sleep problem.

There are good self-help resources for insomnia both online and in book form. The Centre for Clinical Interventions (CCI) has some solid information sheets, and the book Quiet Your Mind and Get to Sleep is recommended. It can sometimes be difficult to find a CBT-I provider, but there is a directory of member providers on the Society of Behavioral Sleep Foundation website: www.behavioralsleep.org.

References

Carney, C., & Manber, R. (2009). Quiet Your Mind and Get to Sleep. New Harbinger Publications.

Morin CM; Vallières A; Ivers H. Dysfunctional Beliefs and Attitudes about Sleep (DBAS): Validation of a Brief Version (DBAS-16). SLEEP 2007;30(11):1547-1554.

Spielman AJ, Caruso L, Glovinsky P. A behavioral perspective on insomnia. Psych Clin N Am 1987; 10: 541±553.

 

LACPA Eating Disorder SIG

IMG_6334 2The Eating Disorder SIG (EDSIG) is an active group of Los Angeles County Psychological Association (LACPA) professionals interested in eating disorders, body image, and related issues. The group, founded in 2012,  by Stacey Rosenfeld, Ph.D., is now led by Lauren Muhlheim, Psy.D. Through presentations and discussion, the EDSIG helps LACPA members explore the field of eating disorders and provides them support as they interact with eating-disordered clients, families, and the community.  

To date, the EDSIG has attracted national-level speakers as guests, including Dr. Abigail Saguy (author of What’s Wrong with Fat?), Stephanie Covington Armstrong (author of Not All Black Girls Know How to Eat), and Lisa Kantor, JD, an attorney who won the first published eating disorder decision in California, as well the first federal court ruling that mandated insurance companies to pay for medically necessary treatment for mental illnesses. Other speakers include: Dr. Kathleen Kara Fitzpatrick (Clinical Assistant Professor at Stanford University), Aimee Liu (author of several novels as well as Gaining: The Truth of Life After Eating Disorders and Restoring Our Bodies, Reclaiming Our Lives: Guidance and Reflections on Recovering from Eating Disorders), Ragen Chastain (a thought leader in the fat acceptance movement), Dr. Richard Achiro (author of a recent study on over-the-counter workout supplement use in gym-active men that received international recognition from several news sources), Pia Guerrero, founder of Adios Barbie and body image activist, Dagan VanDemark, founder and policy director of Trans Folx Fighting Eating Disorders, TFFED), Dr. Stephanie Knatz Peck (program director for the Intensive Family Treatment Programs at the UCSD Eating Disorders Treatment and Research Center), Jessica Raymond, founder and director of Recovery Warriors and Rise Up + Recover app.

Equally qualified and exciting speakers have already committed to speaking to our group in the coming year, so watch the listserv for details. EDSIG Meetings are geared toward eating-disorder specialists but many talks are likely to be of interest to the more general psychological community. Meetings are held every 1-2 months, typically on a weekday evening, in the Hollywood area. Events are posted on the LACPA calendar and sent out to the email listserv. For questions or to recommend a speaker or request a topic,  Dr. Muhlheim at drmuhlheim@gmail.com.

SIG meetings are open to all LACPA members. Non-members wishing to attend may join LACPA by visiting our website www.lapsych.org.

For a complete list of topics and speakers to date, see below:

2012

  • January 2012: Introduction to group and topic discussion
  • February 2012: Intuitive Eating — Brooke Glazer, RD
  • March 2012: Psychopharmacological Treatment of EDs — Hope Levin, MD
  • May 2012: Overview of FBT — Lauren Muhlheim, PsyD
  • July 2012: Current Topics in EDs
  • October 2012: The One-Hour Medical School — Linda Schack, MD

2013

  • January 2013: Viewing of the film, Someday Melissa
  • April 2013: What’s Wrong with Fat? — Abigail Saguy, PhD
  • June 2013: Difficulties in the Treatment of Overweight Eating Disorder Patients – Swimming Against the Current — Wendy Rosenstein, MD
  • October 2013: Yoga, Feminism, & Body Image — Melanie Klein, MA

2014

  • February 2014:  Eating Disorders Affect us All: Eating Disorders in Diverse Populations — Stephanie Covington Armstrong
  • March 2014: Yoga, Body Image, and Eating Disorders — Chelsea Roff
  • April 2014: Working with Insurance Companies to Obtain Coverage — Lisa Kantor, JD
  • June 2014: Intuitive Eating with BED — Aaron Flores, RDN
  • August 2014: Does Every Woman Have an Eating Disorder? – Stacey Rosenfeld, Ph.D.
  • September 2014: Pregnancy and Eating Disorders – Maggie Baumann, MFT, CEDS
  • October 2014: Transgender Issues and Eating Disorders – Dagan VanDeMark
  • December 2014: The Stages of Recovery – Aimee Liu

2015

  • February 2015: Adios Barbie: Body Image, Intersectionality, Healing and Advocacy – Pia Guerrero
  • March 2015: E.A.U.T.Y: Paint Me A Soul — Nikki DuBose
  • April 2015: Temperament, neurobiology, and implications for adult eating disorder treatment — Stephanie Knatz, Ph.D.
  • May 2015: Misophonia – Jaeline Jaffe
  • June 2015 – Modernizing Recovery Resources for the Millennial Generation– Jessica Raymond
  • July 2015: Advocacy and the Eating Disorder World:  Why Clinicians Matter– Kathleen MacDonald
  • August 2015: Shift Happens: Cognitive development, flexibility and remediation in eating disorders– Kara Fitzpatrick, Ph.D.
  • September 2015: Full Metal Apron: Fighting Eating Disorders from the Kitchen Table — JD Ouellette
  • November 2015: Medico-Legal Aspects of Eating Disorders Treatment Including Denial of Care — David Rudnick, MD
  • December 2015: When Fit Becomes Foe: Excessive Workout Supplement Use as an Emerging Eating Disorder in Men — Richard Achiro, Ph.D.

2016

  • January 2016: Elimination is Oppression: The Ill-Advised War Against Obesity– Ragen Chastain
  • January 2016: Unraveling the Enigma of Male Eating Disorders (CE event) — Stuart Murray, Ph.D.
  • March 2016: When OCD and Eating Disorders Collide: Assessment and Treatment Planning for OCD and co-existing Eating Disorders – Kimberly Quinlan, LMFT
  • April 2016: Medical Complications in Eating Disorder Treatment – Lyn Goldring, RN
  • May 2016: Dieting, stress, and weight stigma – Janet Tomiyama, Ph.D.
  • July 2016: It’s All Relative: Eating Disorders and Genetics – Stephanie Zerwas, Ph.D.
  • November 2016:  DBT for Eating Disorders – Charlotte Thomas, LCSW
  • November 2016: in conjunction with the Couples SIG – Panel Discussion: The Impact of Particular Addictive/Compulsive Behaviors on a Couple’s Relationship, and How to Help – Hoarding, Gambling, and Eating Disorders– Regina F. Lark, PhD, Cristin Runfola, PhD, and Margaret Altschul, MBA, MA, LMFT
  • December 2016: The Healing Power of the Paw: How Animals Can Play a Vital Role in Eating Disorder Recovery — Shannon Kopp

2017

  • January 2017: The Dangers of Dieting – Glenys Oston, RDN
  • February 2017: When an Athlete Gets an Eating Disorder – Abby McCrea, LMFT (in conjunction with the Sports and Performance Psychology SIG)
  • March 2017: Thinking Critically and Cautiously About the Phrase “Eating Disorders Are Biologically-Based Mental Illnesses – Michael Levine, Ph.D., FAED
  • April 2017: Medical Complications of Eating Disorders – Margherita Mascolo, MD

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Book Recommendation: “Dietland” by Sarai Walker

DietlandThis summer I read Dietland, a novel by Sarai Walker. It’s rare to find a novel that is both relevant and sensitive to the concerns of my clients. I found the book so empowering, I’m recommending it to patients.

The book tells the story of Plum Kettle, a young 300-pound woman who lives in New York and works as a ghost-writer answering angsty emails to the editor of a teen magazine. She has been on multiple diets and is planning to have weight loss surgery. While living in the crowded city, she tries hard not to be noticed. Rather than living in the present, her main focus is planning for her future life as a thin person. She orders clothing online that will fit her future thin body.

Walker vividly portrays the stigma and humiliation faced by countless people living in larger bodies. Like many of my larger patients with binge eating disorder, Plum suffers from depression and weight self-stigma. Weight self-stigma is a multidimensional concept involving negative emotions and beliefs about being larger, including shame and fear of being discriminated against in social situations due to one’s weight. Not surprisingly, weight self-stigma is associated with binge eating and reduced quality of life.

Out of fear of being teased about her weight, Plum avoids parties, clubs, bars, beaches, amusement parks, and airplanes and, consequently, spends most of her time alone, either answering emails from the café or at home in her apartment.

Through a series of unconventional events, over the course of the book Plum learns to resist an unrealistic cultural ideal. She turns her anger outward, confronts weight stigma, and stands up to societal pressure. Ultimately Plum finds her voice and becomes empowered. She learns to accept a body that does not fit the thin ideal, stops putting her life on hold, and starts living her life as she is:

It felt good to be free. With unexpected power in my legs, I kept going, racing ahead with the wind and the sun on my face, taking a leap into the wide world, which now seemed too small to contain me.

While the treatment I provide is more traditional than the process through which Plum goes, these are the same transformations that I hope my patients will undergo. In my work with larger clients, I employ CBT for binge eating disorder, but I supplement this evidence-based treatment with additional strategies stemming from Health at Every Size to address weight self-stigma. I try to help clients cultivate a more accepting and compassionate way of relating to their bodies and to turn their anger outward.

My favorite passage in the book is a line of questions I want to ask my clients:

“I want you to consider something, hon. What if it’s not possible for you to ever become thin? What if there is no one day? What if this is your real life right now? What if you’re already living it?”

The book is both fun and inspiring. And, it is being turned into a television show!

Source

Palmeira, L., Pinto-Gouveia, J., & Cunha, M. (2016). The role of weight self-stigma on the quality of life of women with overweight and obesity: A multi-group comparison between binge eaters and non-binge eaters. Appetite105, 782–789. http://doi.org/10.1016/j.appet.2016.07.015

 

December 2016 LACPA Eating Disorder SIG

Shannon-Kopp-Headshot-e1444137530220Date: Wednesday, December 7 at 7:30 pm (Note: new date)

Presenter: Shannon Kopp – Author of Pound for Pound: A Story of One Woman’s Recovery and the Shelter Dogs Who Loved Her Back to Life (HarperCollins Publishers) and Founder of SoulPaws Recovery Project.

Title: The Healing Power of the Paw: How Animals Can Play a Vital Role in Eating Disorder Recovery

With the highest mortality rate of any mental illness and afflicting up to 30 million people in America, eating disorders can have heartbreaking consequences. For eight years, Shannon Kopp battled the silent, horrific, and all-too-common disease of bulimia. Despite a near decade of weekly therapy, medication, loving support from family, and a hospitalization and rehab stay at Rosewood Center for Eating Disorders, she continued to grow progressively sicker.

Then, at twenty-four, she began working with shelter dogs at the San Diego Humane Society, where she felt a deep sense of calm and comfort around the animals. Gradually over time, when Shannon wrestled with anxiety, she began turning to the loving presence of a dog (rather than to the eating disorder). A dog’s ability to live in the present moment helped to pull her out of her head and back down to earth. The dogs grounded her, and they created a vital sense of emotional security.

Shannon adopted a dog and began bringing her dog with her to therapy, and soon, Shannon was sharing on a deeper and more honest level than ever before. This marked the beginning of her eating disorder recovery—she will celebrate seven years free from bulimia on August 28th.

Research on the human-animal bond (known as Anthrozoology) has increased steadily over the years. Studies have shown that the presence of an animal may decrease stress levels by lowering blood pressure and creating a sense of general well-being—for the both human and animal!

Today, Shannon offers free animal therapy—SoulPaws Workshops— to those suffering from eating disorders in her community. (Learn More About SoulPaws Workshops Here: http://shannonkopp.com/workshops/)

Location: The office of Dr. Lauren Muhlheim (4929 Wilshire Boulevard, Suite 245, Los Angeles) – free parking in the lot (enter on Highland)

Bio – Shannon Kopp is an eating disorder survivor, animal welfare advocate, and the best-selling author of Pound for Pound: A Story of One Woman’s Recovery and the Shelter Dogs Who Loved Her Back to Life (HarperCollins Publishers). She is also the founder of SoulPaws Recovery Project, offering free animal therapy to those suffering from eating disorders. Shannon’s story has been featured on CNN, Fox News, Huffington Post, Salon, NPR and more. www.shannonkopp.com

http://www.harpercollinsspeakersbureau.com/speaker/shannon-kopp/

RSVP to: drmuhlheim@gmail.com

SIG meetings are open to all LACPA members. Nonmembers wishing to attend may join LACPA by visiting our website www.lapsych.org

Raising the Bar: Competence in Outpatient Eating Disorder Treatment

Lauren and Alli with Charles Portney, MD, who gave us feedback at ICED 2016.
Lauren and Alli with Charles Portney, MD (who enthusiastically gave us feedback) at ICED 2016.

When my friend and colleague, Alli Spotts-De Lazzer, M.A., MFT, LPCC, CEDS, asked me to join her in writing an article on competence for therapists treating eating disorders, I jumped at the opportunity.

Psychotherapists are ethically bound to treat within their scope of competence. Yet how does a psychotherapist determine if he or she is competent to treat eating disorders, the mental disorders with the highest mortality rates? Alli had searched for a guide or brief resource to help clinicians in training to better understand the basic knowledge recommended for treating eating disorders. To our surprise, few documents existed. Furthermore, we have both often heard that patients and families would like to feel better supported in knowing how to verify the credentials of outpatient eating disorder therapists. Many insurance companies do little vetting in choosing which therapists are listed on their panels as eating disorder treatment providers.

So we decided to create what we hoped would be a helpful document.

Alli and I each have extensive experience treating eating disorders in the outpatient setting. We come from different and complementary backgrounds. I received my original training in the 1990s in an evidence-based research lab under the direction of Terry Wilson, Ph.D, a developer of Cognitive Behavioral Therapy for eating disorders, and I have focused on evidence based treatments ever since. Alli aligns with an eclectic approach informed by evidence-based concepts, personal experience with eating disorders, and eating disorder trainings that range from Continuing Education Units to pre-licensed work at Monte Nido Treatment Center under the leadership of Carolyn Costin.

While we acknowledge that there are many possible paths to becoming a psychotherapist who treats eating disorders, we sought to answer questions including:

  • What set of competencies seem necessary for therapists to know in the outpatient setting?
  • What are many of the unique therapeutic needs of patients with eating disorders including anorexia nervosa, bulimia nervosa, and binge eating disorder?
  • What basic knowledge and training might therapists pursue if they desire to treat eating disorders in the outpatient setting?

In addition to a mental health treatment focus, patients with eating disorders also commonly present with nutritional and medical issues that may need attention. While having well trained, collaborative team members covering medical and nutritional disciplines in a patient’s care is desirable, in a real-world outpatient setting, these team members may not always be available. Psychotherapists working in the outpatient setting who do not have well-established protocols, resources, or collaborators can be particularly vulnerable if/when issues of competence arise.

Eating disorders are psychological disorders that often come with physical, medical, or nutritional consequences and/or complications that call for acute or gradual attention. Psychotherapists, therefore, are recommended to have a basic working knowledge of eating disorder-specific domains extending beyond a psychotherapist’s traditional scope of practice and usual training. Furthermore, each major disorder – anorexia nervosa, bulimia nervosa, and binge eating disorder – can present unique treatment needs and levels of risk.

Our review of the literature incorporating both research and practice guidelines, in conjunction with our own clinical experience in treating eating disorders in the outpatient setting determined that the areas of suggested knowledge generally fell into 5 domains:

  • Assessment and Diagnosis
  • Medical Factors
  • Nutrition and Malnutrition
  • Treatment Strategies
  • Multidisciplinary Collaboration and Levels of Care

Our hope is that the paper will:

  • Help therapists treating eating disorders in the outpatient setting by providing accessible information and resources and assist in potentially improving the experiences of and outcomes for patients;
  • Serve as a useful guide for clinicians desiring to specialize in the treatment of eating disorders;
  • Assist patients and families in feeling more supported by knowledge when seeking treatment providers; and
  • Possibly help to influence insurance companies in the realm of eating disorders.

We are grateful to the following colleagues who gave valuable, substantial feedback on drafts of our paper: Jennifer Thomas, Ph.D.; Charles Portney, M.D.; Stacey Rosenfeld, Ph.D.; Laura Collins; Kristine Vazzano, Ph.D.; Nina Savelle Rocklin, Psy.D; and Elisha Carcieri, Ph.D. We received considerable research assistance from eating disorders informationist, Millie Plotkin. We also thank our additional valued colleagues who provided helpful comments.

After an extensive peer-review process, the paper, “Eating Disorders and Scope of Competence for Outpatient Psychotherapists,” was accepted by and published in the American Psychological Association Journal, Practice Innovations, 2016, Vol. 1, No. 2, 89–104. It is available for purchase here for $11.95.

We’ll be presenting on the paper in Los Angeles this fall:

  • Friday, October 7 10:30 am in West LA at IAEDP LA Coffee
  • Tuesday, October 11 at 8 a.m. St. John’s Hospital Eating Disorders Conference, Santa Monica

Join us!

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