Is the (Eating Disorder) Treatment Your Child is Getting FBT?

When new families talk to me about Family-Based Treatment (FBT), I often find that they are confused about what it is and what it isn’t.

FBT is a type of evidence-based treatment for adolescent eating disorders. This treatment was developed at the Maudsley Hospital in London in the 1970s and 1980s; Doctors Lock and Le Grange manualized it into its current form in 2001. Because of its name, FBT is often confused with more general “family therapy.” Be careful, because these are not the same thing—while both involve the family, FBT is a very specific, behaviorally-focused therapy.

While a treatment that includes some elements of FBT—but falls short of the full manualized treatment—may work for some eating disorder cases, it may not work for more difficult cases. When FBT doesn’t work it is important to know whether the child has had an adequate course of the true treatment in its evidence-based form. This can be tricky—in the field of psychotherapy, most therapists identify as eclectic, meaning they adhere to no single therapeutic orientation but combine techniques from several (just scroll through any Psychology Today therapist profile to get a taste for how many different theoretical approaches most therapists endorse). We don’t yet know which elements of FBT are critical to its efficacy and make it such a successful treatment. This would take expensive dismantling studies in which different partial treatments are tested against each other. Except for studies documenting a separated FBT (where only the parents attend sessions), no such study has been cited in the literature. Until we have good evidence that suggests otherwise, treatments that stay true to the original, already-tested treatments are the safest bet.

I once worked with a patient with panic disorder who had had previous treatment. He told me that his previous therapist had conducted cognitive-behavioral therapy (CBT), widely accepted as the best evidence-based treatment for panic disorder. When I dug deeper, I found that his therapy had included no exposure to the sensations of panic—considered to be the core element of CBT treatment for panic disorder.  Instead, the treatment had focused on discussing his anxiety thoughts—a very different protocol. From this experience I learned to inquire carefully about the treatment my patients have previously received before accepting that it cannot work for them.

So it is with Family-Based Treatment. Sometimes parents tell me that they think they tried FBT but are not sure. If your child was treated in an academic center, it’s more likely they got the evidence-based treatment of FBT in its full form. However, some parents who tell me that FBT didn’t work also tell me:

  • They did FBT on their own, with no therapeutic support
  • They had meals with their child, but that the therapist met primarily with the adolescent alone
  • They didn’t supervise all meals because their child resisted it. 

In each of these situations, it is obvious to me that the treatment is not what I would consider FBT. And while it is true that including some aspects of FBT or even a “watered down” FBT may be better than no FBT or parent inclusion at all, it’s important to know whether your child had the real thing or not, especially if they end up needing more or different treatment.

Often, parents who tell me they struggled with renourishing a child on their own find that things go much better once they started working with me or another therapist. That’s not to say that parents should never try to renourish a teen on their own—just that supporting a child with an eating disorder is extremely hard work and best done with the support and guidance of a professional at their side.

Signs Your Child Received FBT

Accordingly, I created the checklist below for parents to determine whether the treatment their child received (or is receiving) is really FBT. To how many of the following statements can you answer “YES” (the more the better)?

  • My therapist received training through the Training Institute for Child and Adolescent Eating Disorders.
    • The basic training is a 2-day workshop. Have they attended one?
    • Have they received or are they receiving clinical consultation or supervision by a staff member of the institute?
    • Are they certified in FBT by the Training Institute (meaning they have completed the 2-day training and received 25 hours of consultation by a staff member around their treatment of 5 patients)?
  • My therapist owns, seems familiar with, and refers to the FBT treatment manual.
  • My therapist refers to and acknowledges the three phases of FBT:
    • Phase 1 —full parental control
    • Phase 2 — a gradual return of control to the teen
    • Phase 3 —establishing healthy independence
  • My therapist is familiar with the work of Drs. James Lock and Daniel Le Grange, developers of the FBT treatment.
  • My therapist adheres to the five principles of FBT:
    • I was specifically told I was responsible for restoring my teen nutritionally and interrupting behaviors that interfere with recovery (including bingeing, purging, and overexercise). I was specifically told I was responsible for planning, preparing, serving, and supervising all meals.
    • I was told we don’t know for sure what causes an eating disorder and it doesn’t matter.
    • Initial attention of treatment focused solely on restoring health including weight gain and stopping eating disorder behaviors.
    • Rather than being given prescriptive tasks, I was empowered to play an active role and to discover those strategies that worked best for my family and the child whom I know best.
    • I was taught to externalize the illness and see it as an outside force that has hijacked my child, threatens his or her life, and makes my child do things he or she wouldn’t normally do. My child did not choose the eating disorder.
  • I have had a family meal at the therapist’s office.
  • My therapist spends most of the time with the full family, meeting only briefly with the adolescent alone at the beginning of the session (or in the case of “separated FBT,” all of the time with parents).
  • My therapist or another member of the treatment team tracks my child’s weight and gives me feedback after every weigh-in on how he or she is doing.
  • I was specifically told I am responsible for supervising all meals and snacks to ensure completion. If purging has been a problem, I was told to supervise the child after eating to prevent purging.
  • If my child has been exercising excessively, I was told to prevent this.
  • After weight was restored and bingeing and purging and other behaviors had ceased, my therapist guided me in gradually returning my teen control over their own eating.
  • I was told it was important to be direct with my teen about eating adequate amounts of food.
  • My therapist discusses the importance of both “state” and weight to recovery—meaning my therapist explains that weight recovery is a step towards psychological recovery, but not an end goal in itself.

Dead giveaways your child did not get FBT

Below are some indicators that your child might not have “gotten FBT” and might be receiving some conflicting messages:

  • I have been told that we, the parents, had caused the eating disorder.
  • My therapist spends the majority of therapy time alone with the teen.
  • My therapist spends a lot of time talking about the past and reasons my child wanted, needed, or otherwise developed the disorder.
  • A dietitian has met alone with my teen and given him or her nutritional recommendations.
  • My child has been given a meal plan.
  • I have been told that it is an option to not supervise all meals or prevent all purging.
  • The FBT therapist has provided individual CBT, DBT, or ACT with the teen during the weight restoration phase.
  • I have been told from the start of treatment to “not be the food police” (in FBT, this might happen toward the end of treatment, or in Phase 2 with an older teen).
  • My child has been in charge of making his or her own meals from the outset of treatment.

Summary

In conclusion, FBT has been proven to be the most effective treatment for adolescents in clinical trials. That said, not every treatment works for everyone. In my opinion, it is best to start with something that has a backing and then try something else if that doesn’t work. When you have sought out an evidence-based treatment, it’s important to make sure you’re getting the treatment in its researched form.

ARFID talk for LACPA Professionals in Los Angeles

ARFID talk LACPA Jennifer Thomas, Ph.D.
Harvard Health Publications, Jennifer Thomas

Date:  Thursday, January 18 at 7:30 PM

Presenter:  Jennifer Thomas, Ph.D.

Title: Avoidant/restrictive food intake disorder: Assessment, neurobiology, and treatment

Description: Avoidant/Restrictive Food Intake Disorder (ARFID) was recently added to the Feeding and Eating Disorders section of DSM-5 to describe children, adolescents, and adults who cannot meet their nutritional needs, typically because of sensory sensitivity, fear of aversive consequences, and/or apparent lack of interest in eating or food. ARFID is so new that there is currently no evidence-based treatment.  This presentation will discuss how to recognize and diagnose ARFID, share preliminary findings from an ongoing NIMH-funded study of its neurobiological underpinnings, and describe a new cognitive-behavioral treatment currently being evaluated in an open trial.  

Bio:  Dr. Jennifer Thomas is the Co-director of the Eating Disorders Clinical and Research Program at Massachusetts General Hospital, and an Associate Professor of Psychology in the Department of Psychiatry at Harvard Medical School. Dr. Thomas’s research focuses on atypical eating disorders, as described in her books Almost Anorexic: Is My (or My Loved One’s) Relationship with Food a Problem? and Cognitive-Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder: Children, Adolescents, and Adults. She is currently principal investigator on several studies investigating the neurobiology and treatment of avoidant/restrictive food intake disorder, funded by the U.S. National Institute of Mental Health and private foundations.  She is also the Director of Annual Meetings for the Academy for Eating Disorders and an Associate Editor for the International Journal of Eating Disorders.

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

 

 

Sleep: Monitoring and treatment of insomnia without drugs

insomnia treatment without drugsBy 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.

 

Condiments, the Final Frontier of Eating Disorder Recovery

By Katie Grubiak, RDN, Director of Nutrition Services

Katherine Grubiak is a Registered Dietitian with a focus on blending Western & Eastern philosophies regarding nutritional healing.

Condiments in Eating Disorder Recovery

In our work with clients with eating disorders, we help them to reintroduce recently eliminated and avoided foods that present as part of the eating disorder. We notice that as clients (both adult and child) reintroduce foods, it is often the condiments and sauces that are the last to be confronted. In some situations, clients never successfully spontaneously reintroduce these foods; we have to strongly encourage them.

“Normal” eaters enjoy ketchup on French fries, mayonnaise on a sandwich, and dressing (with oil) on salads. In fine cooking, sauces such as Hollandaise are elements that complete the dish. Watch any cooking show and you will see how integral the sauces are to the meals.

In addition to adding needed flavor and creaminess to dishes, these sauces and condiments also add the necessary dietary fat that is essential to metabolic function, hormone balance, absorption of fat soluble vitamins (Vitamins A, D, E, K), nerve coating, and ultimately brain healing.  It is said that even after weight restoration, for 6 months the body & brain are still recovering.  Gray matter, which is severely compromised in anorexia, only can be re-layered through the help of essential fatty acids. Recommendations are between 30-40% of total calories coming from dietary fat. How about we rename this macro-nutrient “essential fuels” (EFs) to honor its positive and real use in recovery?

We think it is worth pushing these condiments and sauces as one step towards a full recovery for our clients. If you are a person in recovery or a parent of a person in recovery, we hope you will consider the following suggestions:

  • Try one new condiment on a sandwich or side dish per week. This may include: ketchup, mayonnaise, mustard, aioli, etc.
  • Try dipping chips or vegetables in sauces such as Ranch dressing, salsa, or guacamole.
  • Experiment with one new creamy salad dressing (not fat free) on a salad.
  • Eat a meal that has one new sauce, such as a cream sauce on pasta, a sauce on steak, or an Asian curry.

Here are some recipes:

Chimichurri Sauce-with Argentinian roots its used as both a marinade and a sauce for grilled steak. Also try it with fish, chicken, or even pasta (like a pesto). Chimichurri also makes a great dipping sauce for french bread or a yummy spread on a sandwich! 

  • Prep Time: 8-10 minutes
  • Serves 4

Ingredients:

  • 1 cup firmly packed fresh flat-leaf parsley trimmed of stems
  • 3-4 garlic cloves
  • 2 TBSP fresh or 2 TSP dried oregano leaves
  • 1/2 cup olive oil (extra virgin cold pressed)
  • 2 TBSP red or white wine vinegar-maybe a rice vinegar
  • 1 TSP sea salt
  • 1/4 TSP ground black pepper
  • 1/4 TSP red pepper flakes (amount depending on level of heat desired)

Finely chop the parsley, fresh oregano, & garlic or place all in a food processor with just a few pushes. Place in a small bowl. Stir in the olive oil, vinegar, salt, pepper, and red pepper flakes to taste. Serve immediately or refrigerate. Perishable-so avoid keeping longer than two days.

Chili Aoli

Condiments in eating disorder recoveryUse on top of meatloaf, meatballs, or on a sandwich.

Total time: 10 minutes | Makes 1 cup.

  • 1 cup mayonnaise
  • 2 cloves garlic, peeled and minced
  • 3 1/2 tablespoons canola oil
  • 1/2 teaspoon ground cumin
  • 3/4 teaspoon lemon juice
  • 1 1/2 tablespoons dark chili powder
  • 3/4 tablespoon paprika
  • Salt and pepper

In a small bowl, whisk together all ingredients until smooth. Taste and season as desired with salt and pepper.

Trader Joe’s Wasabi Mayo can really spruce up a turkey sandwich!  

OCD and Eating Disorders – LACPA ED SIG Event – March 2016

It’s the time of year when the Los Angeles County Psychological Association SIG events are open to nonmenbers.  So, come try it out.  Details on our next event are as follows:

Thursday, March 3 at 7:30 PM

Presenter: Kimberley Quinlan, LMFT

Title: When OCD and Eating Disorders Collide: Assessment and Treatment Planning for OCD and co-existing Eating Disorders 

Description: Managing Obsessive Compulsive Disorder and a co-existing eating disorder can be quite difficult and require significant attention and prioritizing. A very important goal is to ensure that improvements in the symptomology in one disorder are not due to an increase in compulsivity in another co-existing disorder.

During this presentation, Kimberley will discuss at length how to identify and assess for Obsessive Compulsive Disorder symptoms and how to then prioritize treatment goals and tools in these cases. Participants will learn how to manage clinical time with clients, specifically when their eating disorder has become a part of their OCD compulsions.

Attendees will learn important differentiations between general OCD, OCD food-related obsessions (including Symmetry obsessions and Orthorexia) and Eating Disorder obsessions.   Attendees will learn how to prioritize treatment goals and planning (specifically targeting the use Exposure and Response Prevention and other evidence based treatment tools) when managing OCD and co-existing Eating Disorders. Attendees will also be offered a Q&A for general questions.

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

Bio:

KIMBERLEY QUINLAN is a licensed Marriage and Family Therapist in the State of California. During her training and education, Kimberley dedicated much of her research to the study of Cognitive Behavioral Therapy (CBT) for the treatment of Anxiety Disorders and Eating Disorders.

Kimberley did her internship at the OCD Center of Los Angeles and went on to become the Clinical Director of the OCD Center of Los Angeles. Kimberley currently has a private practice in Calabasas, California. Kimberley provides weekly outpatient, intensive outpatient services, in addition to 2-day Mindfulness Workshops, for those with OCD, Body Focused Repetitive Behaviors’s and other OCD spectrum disorders.

Kimberley has been featured in many world known media outlets, such as LA Times, Wall Street Journal, KCRW public radio, and the Seattle Times, discussing co-existing OCD and eating disorders. Kimberley has also consulted on various mental health issues with programs such as ABC’s 20/20 and Telemundo.

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. Nonmembers wishing to attend may join LACPA by visiting our website www.lapsych.org

My work in Shanghai with clients from all over the world

Eight years ago this month, I moved to Shanghai for a 2.5 year assignment.  I have been meaning to share my reflections.  Here they are:

I had been working at Los Angeles County Jail for nearly 10 years when my husband’s business plan for a site-based English Language Learning Children’s business in China got funded by the Walt Disney Company. I was by then more than a little “burned out” and ready for a change.

I know my jail co-workers questioned the legitimacy of my excuse for finally “getting out of jail.” “Really, you’re going to China?” they asked incredulously, as if I were just naming the furthest place I could think of from Los Angeles County Jail. I left my job in November 2007 and became wistful. I wondered if my kids would ever be able to remember having a working mother (they were 10, 8, and almost 6 when we left).

And so, in January 2008, my husband and I packed up our house, 3 kids and a dog, and said goodbye to our family and life in Los Angeles. We arrived in Shanghai during its coldest winter in 20 years.

Within 2 weeks of my arrival, I had coffee with a Dutch psychologist who lived in my compound and supervised the counseling program through the expatriate community center. Knowing of my expertise in eating disorders from my CV, she immediately handed me 2 cases. A friend encouraged me to apply for a job with the Singapore-based Parkway Health, which ran clinics throughout Shanghai staffed by Western-trained doctors, serving a predominantly expatriate clientele. Parkway Health promptly hired me, and within 4 months of my arrival in China I was working two jobs.

My clients were anyone who could speak English. This included clients from every continent with the exception of Antarctica (I never got to treat any penguins!). They ranged in age from children to adults in their 60s. The majority were on expatriate assignments or had children with foreign passports attending international schools. Some were Chinese who had lived abroad and were now living in China while their children attended international school. Others were American-born Chinese who had come to work in China and faced significant cultural issues. Other clients came from the UK, Germany, Brazil, Argentina, Sweden, Canada, Israel, India, South Africa, and Australia.

Map in my office in Shanghai with pins representing hometowns of patients.

Map in my office in Shanghai with pins representing hometowns of patients.

I learned that clients around the world experience very similar problems. Due to my specialty, a significant portion of my clients was seeking treatment for eating disorders. But with a short supply of therapists to treat the large and diverse population of expats in Shanghai, I also saw clients with anxiety, mood disorders, and marital problems.

I found that the stress of being an expat away from one’s family and home, and the clash of living in a foreign culture, added overlays of additional stress to whatever other disorder or issues were already there. I also found that there were a certain number of individuals who had fled their location of origin (sometimes a series of locations) in an attempt to run away from a problem; unfortunately, in these circumstances the problems had merely followed them to China.

A Cognitive Behavior Therapy (CBT) approach provided benefits for clients of diverse ethnic backgrounds. I sought additional training in Emotionally-Focused Therapy for couples and Family-Based Treatment for adolescent eating disorders to enhance my skills.

One of the most exciting aspects of living and working in Shanghai was spearheading the establishment of the Shanghai International Mental Health Association (SIMHA), an organization for therapists serving the international community of Shanghai. Over time, I proactively cultivated relationships with anyone who had been a therapist. This aided me when I needed to consult or refer to another therapist. Unfortunately, although various international schools and organizations serving expatriates retained lists of expatriate therapists, whichever list I consulted of therapists practicing in Shanghai was outdated (and the turnover was relatively rapid). Thus, I reached out to the International Mental Health Practitioners of Japan and sought their advice on forming a similar organization in Shanghai. I then banded together the various and diverse therapists I had identified in Shanghai and together we formed a professional organization of mental health professionals (also from all around the world), adopted an ethics code, and built a website and a community of therapists who could support each other. I am proud that SIMHA still thrives.

Living and working in Shanghai gave me an amazing training in cultural awareness and sensitivity. I love learning about clients’ unique backgrounds and experiencing their worldviews. I particularly enjoy working with clients of diverse backgrounds. I am sensitive to the issues of expatriation and acculturation and generational conflicts around culture. I am also comfortable and enthusiastic about engaging with people from different backgrounds, whether cultural, religious, gender orientation, sexual orientation, or lifestyle.  It is this diversity that makes the texture of life so interesting and my work so rewarding.

For Teens With Bulimia, Family Based Treatment is Recommended

Teens With Bulimia Family Based TreatmentMy original eating disorder training began in 1991 with learning Cognitive Behavioral Therapy (CBT) for bulimia nervosa (BN) under G. Terence Wilson, the co-author with Dr. Christopher G. Fairburn, of the treatment approach that preceded CBT-E. In 2010 I underwent training in Family Based Treatment (FBT) for Adolescent Anorexia Nervosa (AN) and became certified in FBT by the Training Institute for Child and Adolescent Eating Disorders.

CBT is the most effective treatment for adults with bulimia nervosa. It is an individual approach that focuses on reducing dieting and changing unhelpful thinking patterns that maintain the behavior. FBT is the most successful treatment for adolescents with AN. FBT encourages parental control and management of eating disorder behaviors, but does not address distorted thinking regarding shape and weight. Over the last five years, there has been no clear guideline on which treatment I should offer to adolescents with BN.

This changed in September 2015 with the online publication of “Randomized Clinical Trial of Family-Based Treatment and Cognitive-Behavioral Therapy for Adolescent Bulimia Nervosa” by Daniel Le Grange, Ph.D., James Lock, M.D., W. Stewart Agras, M.D., Susan Bryson, M.A., M.S., and Booil Jo, Ph.D. which has been published in the November Journal of the American Academy of Child and Adolescent Psychiatry.

In this study, researchers at the University of Chicago and Stanford randomly assigned 130 teens between the ages of 12 and 18 years old with BN to receive either CBT-A (CBT adapted for adolescents) or FBT-BN (FBT for adolescent bulimia). The teens received 18 outpatient sessions over the course of six months. Assessments were conducted at end of treatment and at six and twelve month follow-ups. After the completion of the treatment, bulimia abstinence rates were 39% for FBT patients and 20% for CBT patients. By the six-month follow up, these rates rose to 44% for FBT patients and 25% for CBT patients. These differences were statistically significant. By 12 month follow up, while the bulimia abstinence rate continued to rise for both populations, the difference was no longer statistically significant.

The researchers concluded,

FBT-BN is likely a better initial treatment option compared to CBT-A for those adolescents with clinically significant bulimia behaviors. FBT-BN leads to quicker and higher sustained abstinence rates that are maintained up to 12 months posttreatment…It appears that, similar to their adolescent peers with AN, adolescents with BN can benefit from an approach that actively involves their families in the treatment process. However, given that there were no statistical differences between these 2 treatments at 12 months post-treatment, CBT-A remains a viable alternative treatment for this patient population, especially for those families who would prefer a largely individual treatment or when there is no family available to be of help.

In interviews about the study, Dr. Le Grange said, “Parents need to be actively involved in the treatment of kids and teens with eating disorders.”

This study reinforces my experience. Although I have employed CBT for bulimia in working with adolescents, rarely do adolescents fully embrace the work required on their part for CBT to be successful. I have found it more effective to use FBT with their family and to supplement with some individual CBT if the adolescent appears ready and motivated for additional independent work. Bingeing and purging are serious symptoms carrying the risk of heart and esophageal problems and death. Thus administering a treatment that brings a faster rate of remission of symptoms is a priority.

Look before you leap: Binge Eating Disorder, Vyvanse, and evidence-based psychotherapies

Binge Eating Disorder, Vyvanse, and evidence-based psychotherapiesGuest post by Elisha M. Carcieri, Ph.D. 

Binge eating disorder (BED) has been making headlines with the recent announcement that the FDA has approved lisdexamfetamine dimesylate (Vyvanse) for the treatment of BED.

So, what is BED, how is it treated, and what does this new treatment option mean for sufferers?

What is Binge Eating Disorder

BED is a condition in which a person engages in recurrent episodes of binge eating at least once a week for three months1. Binge eating episodes typically involve eating rapidly until uncomfortably full, and eating when one is not necessarily hungry. Some individuals with BED report feeling unable to stop the episode, and describe themselves as being out of control during a binge. Binge eaters often binge alone and make efforts to hide their behavior from friends, partners, or family members. Episodes of binge eating often end in feelings of guilt, shame, and depressed mood. Unlike other eating disorders, such as bulimia nervosa, people with BED do not vomit or use other methods of compensation (such as excessive exercise or fasting) to shed calories or lose weight after a binge. It should be clear that this is a very different experience than, say, overeating on Thanksgiving, having a second piece of birthday cake, or eating foods that are outside of your normal pattern while on vacation.

Until 2013, BED was not a diagnosable eating disorder. It was instead grouped in with other unspecified eating disorders that didn’t quite meet criteria to be formally diagnosed. After much research, the most recent iteration of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), has included BED as a specific eating disorder distinct from other diagnoses.

Despite only recently being formally acknowledged, BED is the most commonly occurring eating disorder. Prevalence estimates vary, ranging from 1.6-3.5% of women, 0.8-2% of men, and 1.6% of adolescents.1, 2, 3 BED occurs as commonly among women from racial or ethnic minority groups as for white women, 1 and is often seen in people with severe obesity.1, 4 Up to 30% of people seeking bariatric surgery or other interventions for weight loss are suffering from BED5. While it is more common for women to meet all of the criteria for BED, men tend to engage in binge eating as frequently as women2. Like all eating disorders, the causes of BED are complex. There is evidence for genetic, biological, and environmental risk factors. BED is associated with significant chronic health problems. It is also common for individuals with BED to struggle with other mental health disorders at the same time, including depression, anxiety, and substance use disorders.

The good news is that there are established treatments that work for BED. Unfortunately, effective psychological interventions for eating disorders don’t get as much press as pharmaceuticals. Nevertheless, those suffering from BED should be aware of what is available.

Treatment for Binge Eating Disorder

Evidence-based psychological treatments are first-line considerations for the treatment of BED. A psychologist or other mental health professional qualified to treat eating disorders usually conducts psychological treatment for BED on an outpatient basis. Cognitive behavioral therapy (CBT) is the most well studied and established treatment for BED with demonstrated effectiveness.6 The treatment involves reducing episodes of binge eating using tools such as establishing regular eating patterns and self-monitoring of food intake and patterns of eating. CBT also addresses concerns about shape and weight, and examines and challenges patterns of thinking that may be keeping a person stuck in a pattern of binge eating. CBT for BED involves discussion and planning of how to maintain progress, and how to recognize and respond to relapse. Studies have demonstrated improvements lasting up to 12 months post-treatment with CBT.7 Interpersonal therapy (IPT) has also been proven effective for BED with strong research support.8 IPT involves more of a focus on interpersonal (relationship) difficulties with an understanding of how these problems may have precipitated BED, or how they might be keeping the BED going. Finally, there is evidence that dialectical behavior therapy (DBT), which focuses on mindfulness, emotion regulation, and distress tolerance, is effective at treating BED.9

Pharmacological Treatments for Binge Eating Disorder

In addition to psychological treatments, some antidepressants and anticonvulsants have proven helpful at reducing the frequency of binge eating in patients with BED.6 The newest and only medication specifically approved by the FDA for BED is Vyvanse, a central nervous system stimulant that has been approved to treat ADHD in children and adults since 2007. The approval for BED came after clinical trials demonstrated that the average number of binge eating days per week among sufferers were decreased in those who took Vyvanse, compared to those who took a placebo.10 Sounds promising…but there are other considerations to keep in mind…side effects, long-term use, and the question of whether a medication can address the complex nature of a serious eating disorder such as BED.

The potential side effects of Vyvanse include decreased appetite, dry mouth, increased heart rate or blood pressure, difficulty sleeping, anxiety, gastrointestinal problems, feeling jittery, and even sudden death among people with heart problems. The drug is also particularly risky for individuals with a history of seizures or mania. Vyvanse may cause psychotic or manic symptoms in people with no history of mental illness, and has a high potential for abuse, dependence, tolerance, and overdose.

Vyvanse appears to decrease symptoms over a short period of time (about three months) while taking the medication. However, it is unlikely that the medication will result in long-term changes in complex binge eating behavior once the drug is stopped, meaning that one might expect to take Vyvanse for the rest of their lives in order to keep BED at bay. This is problematic considering the chronic nature of BED, 2 and the fact that the negative emotion, distress, shame, and weight or shape concerns that are often related to BED would almost certainly remain unaddressed.

While there are no identified side effects to engaging in psychological treatment of BED, these treatments do take time (often around 20 weeks), and not every person will respond to an intervention the same way. It may take some trial and error to find the right therapist or treatment. However, psychological treatments are more equipped than medication alone to address the binge eating behavior itself, and the different ways binge eating relates to other areas of a person’s life and functioning. Rather than simply masking and reducing symptoms in the short term with a medication, completing a course of evidence-based therapy can provide the insight and tools needed for managing the patterns of disordered eating that are characteristic of BED for life. Many people with BED may benefit from trying a psychological approach before initiating treatment with a serious medication like Vyvanse.

Implications for Patients

All of these factors should be carefully considered when making a decision about treatment for BED. With all eating disorders including BED, it is important to get help sooner rather than later. For many people, turning to their primary care doctor is the first step. Patients should keep in mind that these conversations can be sensitive and difficult, and many providers may not be familiar with BED. Other providers may be familiar with the recent approval of a new drug, and will be eager to explore prescription medication options for treatment.

If you aren’t getting anywhere with your doctor, it is always appropriate to ask for a referral to a medical provider who is more familiar with eating disorders. Your doctor may also be able to provide you with a referral to a mental health provider, such as a psychologist, who can provide one of the therapies discussed above, and to a nutritionist or dietician who specializes in eating disorders for even more comprehensive support. Remember that it is important to seek help from professionals qualified to treat eating disorders, and treatment decisions should be tailored to the unique needs of each person.

If you do see a psychiatrist regarding any medication, we have some recommendations.

References

1. American Psychiatric Association. (2013). The Diagnostic and Statistical Manual of Mental Disorders: DSM 5. bookpointUS.

2. Hudson, J. I., Hiripi, E., Pope Jr, H. G., & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological psychiatry, 61(3), 348-358.

3. Swanson, S. A., Crow, S. J., Le Grange, D., Swendsen, J., & Merikangas, K. R. (2011). Prevalence and correlates of eating disorders in adolescents: Results from the national comorbidity survey replication adolescent supplement. Archives of General Psychiatry, 68(7), 714-723.

4. Marcus, M. D., & Levine, M. D. (2005). Obese patients with binge-eating disorder. In The management of eating disorders and obesity (pp. 143-160). Humana Press.

5. Kalarchian, M. A., Marcus, M. D., Levine, M. D., Courcoulas, A. P., Pilkonis, P. A., Ringham, R. M., … & Rofey, D. L. (2007). Psychiatric disorders among bariatric surgery candidates: relationship to obesity and functional health status. The American journal of psychiatry, 164(2), 328-334.

6. Brownley, K. A., Berkman, N. D., Sedway, J. A., Lohr, K. N., & Bulik, C. M. (2007). Binge eating disorder treatment: a systematic review of randomized controlled trials. International Journal of Eating Disorders, 40(4), 337-348.

7. Wilson, G. T., Grilo, C. M., & Vitousek, K. M. (2007). Psychological treatment of eating disorders. American Psychologist, 62(3), 199.

8. Wilfley, D. E., Welch, R. R., Stein, R. I., Spurrell, E. B., Cohen, L. R., Saelens, B. E., … & Matt, G. E. (2002). A randomized comparison of group cognitive-behavioral therapy and group interpersonal psychotherapy for the treatment of overweight individuals with binge-eating disorder. Archives of general psychiatry, 59(8), 713-721.

9. Telch, C. F., Agras, W. S., & Linehan, M. M. (2001). Dialectical behavior therapy for binge eating disorder. Journal of consulting and clinical psychology, 69(6), 1061.

10. McElroy S. L., Hudson, J. I., Mitchell, J. E., et al. (2014) Efficacy and Safety of Lisdexamfetamine for Treatment of Adults With Moderate to Severe Binge-Eating Disorder: A Randomized Clinical Trial. JAMA Psychiatry.

Elisha Carcieri, Ph.D., is a licensed clinical psychologist (PSY #26716) practicing in the Los Angeles area. Dr. Carcieri earned her bachelors degree in psychology from The University of New Mexico and completed her doctoral degree in clinical psychology at Saint Louis University. During her graduate training, she conducted research focused on eating disorders and obesity, and was trained in using cognitive behavioral therapy (CBT) for eating disorders and other mental health disorders such as anxiety and depression. Dr. Carcieri completed her postdoctoral fellowship at the Long Beach VA Medical Center, where she worked with Veterans coping with mental illness, disability, significant acute or chronic health concerns, and chronic pain. In addition to cognitive behavioral strategies, she also incorporates alternative evidence-based approaches such as mindfulness, and acceptance and commitment-based strategies, depending on the needs of each client. Dr. Carcieri has experience working with culturally diverse clients representing various aspects of diversity including race/ethnicity, gender, age, disability, and size, and welcomes new clients from all backgrounds. She is a member of the American Psychological Association (APA), the Academy for Eating Disorders (AED), and the Los Angeles County Psychological Association (LACPA). 

Psychological assistant providing low cost treatment for eating disorders

I remain committed to the practice of and dissemination of evidence-based treatments. To that end, I am excited to announce that I have added a registered psychological assistant to my practice in Los Angeles:

Liliana Almeida, M.A, Clinical Psychology Ph.D. Student, PSB-94020579 is no longer with the practice, but we do have a new therapist in training who provides low-cost therapy to patients with eating disorders in Spanish, English, and Portuguese. Learn more about Eliane Spagnoletto, ACSW.

Liliana Almeida, M.A.
Liliana Almeida, M.A.

 

Liliana Almeida, M.A., is a fourth year Clinical Psychology Ph.D. student at the California School of Professional Psychology at Alliant International University in Los Angeles. She received her M.A. from The New School and her B.A. from Rutgers University. During the last 7 years she has researched eating disorders and obesity. Her clinical experience includes working with diverse clients in a community mental health center providing cognitive-behavioral and psychodynamic psychotherapy in English and Spanish.

Liliana will be working under my supervision and is available to work with adult and adolescent clients with eating disorders, anxiety, and depression.  She will provide services in English, Spanish, and Portuguese and will be able to provide some low-cost therapy to those in need.

Portuguese

Eu sou uma assistente de psicologia (PBS-94020579) para Lauren Muhlheim, Psy.D., psicóloga clínica especializada no tratamento cognitivo-comportamental de perturbações alimentares. Como assistente de psicologia, eu forneço psicoterapia cognitivo-compartamental em Português sob a licença da Dra. Muhlheim (PSY 15045) para adolescentes e adultos que sofrem com depressão, ansiedade e pertubações de o comportamento alimentar.

Spanish

Soy una asistente de psicología (PBS-94020579) para Lauren Muhlheim, Psy.D., una psicóloga clínica especializada en el tratamiento cognitivo-conductal de los trastornos alimentarios. Como asistente de psicología yo proveo terapia cognitivo-conductal en Español bajo la supervision y licencia de la Dra. Muhlheim (PSY 15045) para adolescentes y adultos que sufren de la depresión, ansiedad y de los trastornos de la conducta alimentaria.

 

AED Tweetchat on Diabulimia

I have to admit that, when a colleague on the Academy for Eating Disorder Social Media Committee that I was co-chairing proposed “diabulimia” as an idea for a tweetchat, I was not particularly excited.  As an eating disorder specialist in outpatient private practice, I have not professionally encountered clients with diabetes and eating disorders.

Since we could not easily identify any experts on the topic who also tweeted, the idea languished until the International Association of Eating Disorder Professionals scheduled an event on the topic in my area.  John Dolores , JD, PhD, a licensed clinical psychologist and Executive Director of Center for Hope of the Sierras, was the guest speaker.

Prior to attending his talk, I had the luck at the FEAST conference to sit next to Dawn Lee-Akers, CFO at Diabulimia Helpline.  Together Dawn and Dr. Dolores educated me on the severity of ED-DTM1 (popularly referred to as “diabulimia”) and the need to draw more professional and public knowledge about this issue (and both agreed to be involved in the chat).

As a result, I was really excited to be involved in helping prepare for the AED twitter chat on the topic this week and to do my part to bring attention to the issue.  It was a great and informative chat and I hope you’ll read the entire transcript available here.

Some highlights of what I have learned:

  • Diabulimia is a media term; many providers prefer ED-DMT1.  It is most commonly the coexistence of Type I diabetes and an eating disorder with manipulation of insulin to lose weight.  In this case, the insulin manipulation is considered an inappropriate compensatory behavior (hence the use of the term diabulimia).  The individual may meet criteria for Bulimia Nervosa or OSFED.  It is also possible to have Type II diabetes and an eating disorder, which may be included in diabulimia if insulin manipulation is involved.  Additionally, some people can have diabetes and an eating disorder that are totally unrelated.
  • Women with Type I diabetes are 2.4 times more likely to develop an eating disorder than their non-diabetic peers.  Statistics vary quite significantly with a reported 45-80% of Type I diabetics reporting binge eating.  Multiple studies show 30%-35% of women with Type I diabetes report restricting or omitting insulin in order to lose weight.
  • Higher rates of eating disorders among people with diabetes are not surprising due to the way diabetes has traditionally been treated.  The traditional diabetes ‘diet’ focuses on low carbs and high protein, which encourages restriction, which in turn can lead to binge eating.  Diabetes management includes a lot of focus on numbers and on control which may feed perfectionism.  Patients with diabetes often lose weight pre-diagnosis, and gain weight when they start insulin, so come to associate insulin with weight increase.  They quickly learn that they can manipulate their weight by under dosing with insulin.
  • The effects of compensation by insulin are even more devastating than other forms of dietary compensation.  Patients with diabulimia are at risk for serious medical consequences.  The most dangerous short-term consequence is diabetic ketoacidosis, which requires immediate hospitalization.  Longer-term consequences include peripheral and autonomic neuropathy, retinopathy, cardiovascular disease, and even renal failure.  Some of the consequences are irreversible.
  • Diabulimia requires a specific and sensitive treatment approach from a coordinated team of professionals with expertise in diabetes and eating disorders.  The team should include nursing, endocrinologist, dietitian, therapist, and diabetes educator.  It is critical that the team use a consolidated approach and not treat the diabetes and eating disorder separately.
  • Intuitive eating, CBT, DBT, & ACT are successful in the treatment for comorbid diabetes and eating disorders.  The treatment of diabulima requires medical oversight, including regular monitoring of blood glucose, management of certain side effects of insulin re-introduction, and treatment of new or worsening diabetes complications.  Eating disorder patients with comorbid diabetes are more likely to be medically unstable and need inpatient treatment.

With diabetes on the rise and numerous prevention efforts aimed at preventing obesity, I was left wondering:  where are the prevention efforts for the even deadlier combination of diabetes and eating disorders?  For such efforts, eating disorder professionals and organizations must work together with diabetes professionals and organizations.  We invited several diabetes organizations to join our chat, and fortunately, a few did.  We must continue to raise attention to this problem and reach out to others outside the eating disorder field.

Resources:

  • The Diabetes Eating Problem Survey (DEPS-R) can be used by providers to assess whether patients with diabetes may have an eating disorder.
  • Diabulimia Helpline maintains a list of US treatment centers that have specialized programs to treat comorbid Diabetes and Eating Disorders.
  • Diabulimia Helpline recommends this video as the best overview on Diabulimia for patients, family and professionals.