Dr. Sarah Ravin - Psychologist | Eating Disorders |Body Image Issues | Depression | Anxiety | Obsessive-Compulsive Disorders | Self-Injury
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Dr. Sarah Ravin

Welcome to my professional blog. I am a Florida Licensed Psychologist and trained scientist-practitioner. In 2008, I received my Ph.D. in clinical psychology. A major component of my professional identity is staying informed about recent developments in the field so that I may provide my clients with scientifically sound information and evidence-based treatment. There is a plethora of information on the internet about Eating Disorders, Depression, Anxiety, Psychotherapy. Unfortunately, much of this information is unsubstantiated and some of it is patently false. It is my hope that by sharing my thoughts and opinions on psychological issues, with scientific research and clinical experience sprinkled in for good measure, I can help to bridge the gap between research and treatment.

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Tag: CBT

Monday, November 2nd, 2015

After Weight Restoration: CBT for Body Image

As noted in my previous blog post and the comments that follow, full nutrition and weight restoration will often reduce or eliminate the body image disturbance that plagues so many people with Anorexia Nervosa (AN). This is one of the many reasons why it is essential for AN treatment to require full nutrition and prompt weight restoration.

On the other hand, some people with AN continue to experience intense body dissatisfaction after weight restoration. In these cases, Cognitive-Behavioral Therapy (CBT) can help improve body image and reduce suffering.

In order for CBT to be effective, the patient has to have some motivation to engage in the treatment and some desire to improve her body image. The patient also needs to have the insight to understand that her body itself is not the problem, so changing her body weight or shape is not the solution. Rather, the problem is that she has some negative thoughts, feelings, and behaviors related to her body that cause her to suffer. It is those negative thoughts, feelings, and behaviors that will be the targets for intervention. The insight, motivation, and judgment required for effective body image treatment is yet another reason why this intervention is most effective after full weight restoration.

Many of the CBT-informed interventions for body image are similar to those that are effective in treating anxiety and depression. Consider the following:

Cognitive Restructuring
This involves identifying and challenging distorted automatic thoughts related to one’s body image. Examples of distorted automatic thoughts include: “My thighs are enormous,” “I’m the fattest person in this room,” or “Everyone is staring at me because I’m huge.”

The patient may need some help identifying distorted thoughts because they may seem normal or accurate to her. Once she is able to identify a distorted thought as such, the patient is asked to keep a log of the thoughts as they occur. With the help of the therapist, the patient then learns to identify patterns of distorted thoughts, challenge her own thinking, and generate more rational thoughts to replace the distorted ones.

For example, “Everyone is staring at me because I’m huge” contains distortions of over-generalization and mind-reading. Is EVERYONE really staring at you? No. In a room of 30 people, maybe 2 are looking at you. That isn’t everyone. Do you know for sure that they think you are huge? No, because they didn’t say anything of the sort. Why else might they be looking at you? Maybe they like your shirt.

Exposure and Response Prevention
This involves systematically desensitizing the patient, little by little, to her body image fears for the purpose of improving her quality of life. For example, if the patient loves the beach but can’t bring herself to go because she is ashamed of her body in a bathing suit (this is a frequent scenario in my South Florida-based practice!), the therapist may begin by helping her create a hierarchy or “ladder” of challenges increasing in difficulty. The patient would need to “master” each task before moving on to the next one.

For example:
1.) Go to the beach with your best friend at a time when very few people are there, wearing a shirt and shorts over your swimsuit.
2.) Go to the beach with your best friend at a time when very few people are there, wearing just shorts over your swimsuit.
3.) Go to the beach with your best friend at a time when very few people are there, wearing just a shirt over your swimsuit.
4.) Go to the beach with your best friend at a time when very few people are there, and spend 2 minutes wearing just your swimsuit.
5.) Go to the beach with your best friend at a time when very few people are there, and spend 10 minutes wearing just your swimsuit.
6.) Go to the beach with your best friend at a time when very few people are there, and spend an hour wearing just your swimsuit.
7.) Go to the beach with your best friend when many other people are there, and wear a cover-up.
8.) Go to the beach with your best friend and spend 2 minutes wearing just your swimsuit.
9.) Go to the beach with your best friend when many other people are there, and spend 10 minutes wearing just your swimsuit.
10.) Go to the beach with your best friend when many other people are there, and spend an hour wearing just your swimsuit.
11.) Go to the beach without your best friend and wear a swimsuit the whole time.

Environmental Alterations
Once a patient is able to recognize patterns in her negative body image thoughts, she can choose to focus her attention on people, places, and activities that promote positive thoughts and feelings, while reducing or eliminating the negative influences. For example, if a patient has a friend who engages in a lot of “fat talk,” the patient may be assertive with this friend and ask her to stop talking this way around her, or she may decide to stop spending time with this particular friend and hang out with more supportive friends instead. Likewise, if following fitness Instagram accounts makes the patient feel badly about her body, she may decide to stop following these accounts.

Along these lines, many patients find it helpful to donate their outgrown, tight-fitting, or unflattering clothes to charity. The feeling of tight clothes on the body, or the sight of too-small clothes hanging in the closet, can be very triggering. Most people feel much more confident wearing comfortable, flattering clothes.

Eliminating Body Image Rituals
Some people engage in “body checking” rituals, which may be anything from measuring their wrist circumference with their fingers, grabbing the flesh of their belly, spending excessive time in front of the mirror, or trying on 10 different outfits before finding one that looks “just right.” These types of rituals may reduce anxiety in the short term, but they end up becoming self-perpetuating and increasing body dissatisfaction in the long-term.

CBT for body image can be done with a CBT-oriented therapist who has experience working with eating disorders and body image concerns. In my practice, I sometimes use CBT for body image in weight-restored patients with AN after their family has completed a course of FBT (only if it is needed and requested, of course!). I also use it in patients with Bulimia Nervosa (BN) or Binge Eating Disorder (BED) after eating patterns have been normalized, and with non-eating disordered patients who suffer from anxiety or depression and also happen to have struggles with body image.

However, improving body image does not necessarily require a therapist’s help. A motivated patient may be able to utilize these interventions on her own, or with the help of a parent, using internet resources or a guided self-help workbook. I often recommend Thomas Cash’s The Body Image Workbook, 2nd Edition.

There are other interventions for body image derived from 3rd wave behavioral therapies such as Dialectical Behavior Therapy (DBT) and Acceptance and Commitment Therapy (ACT). These will be the topic of my next post.

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Thursday, February 6th, 2014

Let’s Get Physical: Exercise in the Treatment of Mood and Anxiety Disorders

As the Olympic Winter Games are commencing tomorrow in Sochi, I feel inspired to write about the role of physical activity in mental health. This post will focus specifically on exercise in the treatment of mood and anxiety disorders.

Numerous studies have shown that regular exercise improves mood in people with mild to moderate depression. For those with severe depression or bipolar disorder, exercise alone is rarely sufficient, but exercise can play an adjunct role in helping patients recover and prevent relapse.

We know from Newton’s law of motion that an object at rest stays at rest unless a force acts upon it, and an object in motion stays in motion unless some force makes it stop. The same is true for human bodies. Paradoxically, sedentary people tend to have less energy and active people tend to have more.

Now, of course this begs the question of the chicken or the egg – it is likely that people become sedentary because they have little energy or stay active because they have a surplus. This is true. People seem to have “set points” for activity level just as they do for weight and mood. That being said, physical activity has an almost immediate effect on mood and energy level. Over time, consistent exercise helps to stabilize moods, improve sleep, reduce stress, and enhance motivation to continue moving.

For these reasons, I strongly encourage my patients who suffer from mood disorders or anxiety disorders to exercise regularly. In my opinion, exercise is every bit as important as therapy, medication, and sleep when it comes to mood and anxiety disorders.

As I have emphasized in previous posts, the mind is a series of conscious functions carried out by the brain, and the brain is part of the body. Physical health and mental health are one in the same. Despite what society, popular wisdom, and health insurance companies may tell us, there is no actual difference between a physical illness and a mental one. When you exercise your body, you are exercising your brain.

Unlike therapy or medication, exercise is cheap or even free. Unlike medication, which can have unpleasant or dangerous side effects, exercise is generally safe so long as you do it sensibly and moderately. Unlike therapy, which requires another person and an appointment, exercise can be done alone if you choose at a time that suits your schedule. Unlike therapy, which is typically one-on-one and indoors, exercise can be enjoyed inside or outside with your family, friends, classmates, or teammates.

Numerous times, I have been amazed at how much exercise improves my patients’ mental health. This is especially true for people who have historically been sedentary and embark on a new exercise routine as part of their treatment plan. For example, I am working with a 15-year-old girl whom I’ll call Elsa who suffered from severe depression and crippling anxiety. When I met Elsa last year, she hated exercise and barely had the energy to get out of bed. After months of encouraging her to try different enjoyable physical activities, she finally started biking with her mom and jogging with her neighbor. She is now in full remission from her depression, making excellent progress in tackling her anxiety, and training for her first 5K. She now wakes up at 7:00 am with plenty of energy and really enjoys exercising. I am so proud of her.

One of the more challenging aspects of incorporating exercise into a patient’s treatment plan is that sometimes the mental illness itself is part of the reason why the patient is inactive. Depressed people tend to lose interest in activities they once enjoyed. They feel unmotivated and chronically exhausted. Clearly, it is a challenge for them to do essential things like get dressed and go to school, let alone something “extra” and “optional” like exercise.

For these patients, I use a behavioral technique called behavioral activation. Here’s how it works: we agree upon a small, realistic exercise goal such as walking for 10 minutes three evenings a week. [Elsa’s initial idea was to do the Insanity DVDs she saw on an infomercial. Given that she hadn’t exercised in years, I told her that this idea was, frankly, insane, and I suggested something more moderate.] I have the patient choose an activity they enjoy (or at least one that they don’t hate) and a time of day when they’re likely to follow through (for example, not at 5:00 AM if they aren’t a morning person).

When possible and feasible, I encourage patients to exercise socially by attending a class, joining a sports team, taking lessons, or doing something active outdoors with their families. We make this activity part of their weekly schedule, writing it down (or, often, putting it in their smart phone) as if it were any other appointment or commitment. Most of the time, the patient achieves their initial goal because it is small, realistic, specific, and planned.

Achieving this initial exercise goal creates a feeling of success and personal satisfaction and enhances the person’s motivation to keep going. In addition, they experience a bit of a mood boost from the activity itself. Once the patient achieves the initial exercise goal, it is increased a little bit in frequency or duration.

Using the example above, the patient may walk for 20 minutes during the second week and 30 minutes during the third week. This gradual increase in frequency and duration continues for a number of weeks or months. Eventually, the patient has incorporated regular exercise into her lifestyle. The stress reduction, mood enhancement, and improvement in fitness level enhance her internal motivation to continue exercising.

Anxiety can also interfere with a patient’s plans to exercise. Many people who experience panic attacks are afraid of the physical sensations that result from exercise (rapid breathing, increased heartbeat, sweating), which closely resemble those of a panic attack.

Patients who have social anxiety may shy away from joining sports teams, taking dance classes, or going to gyms because they worry about being judged or making a fool of themselves. For example, Elsa had enjoyed dance classes and swimming in elementary school but later became socially anxious and self-conscious about wearing a leotard or swimsuit in front of her peers. For this reason, she chose to do biking and jogging which did not require such revealing attire. And now, for the record, Elsa does wear a swimsuit with only mild anxiety when she goes to the beach or the pool with her friends. Did I mention how proud of her I am?

For patients with eating disorders, exercise is altogether a different story. That will be the topic of my next blog post.

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Wednesday, December 11th, 2013

Sleep and Mood Disorders: Implications for Mental Health Care

Getting enough sleep is important for everyone. Well-rested bodies and brains are healthier, more resilient, and more energetic. For those with depression and other mood disorders, getting plenty of sleep must be a priority. In fact, research has demonstrated that people with insomnia are ten times more likely to develop depression than those who get sufficient sleep. Further, new research has shown that sleep disturbances can trigger psychiatric illnesses in those who are vulnerable.

Sleep is every bit as important as medication and therapy in the treatment of mood disorders. For this reason, I make a point of discussing and monitoring sleep patterns with my patients, and I integrate sleep hygiene into their treatment plans.

A recent study financed by the National Institute of Mental Health and published in The New York Times found that a psychological treatment called CBT-I (Cognitive-Behavioral Therapy for Insomnia) doubled the effectiveness of antidepressant medication in the treatment of depression.

This was not surprising to me. I was trained in CBT in graduate school and I have seen cognitive-behavioral techniques work wonders in many of my patients. But the implications of this study, and the fact that the results have made it into the popular media, are quite significant.

One of the most disturbing and unfortunate trends in mental health care in recent years has been the overuse of psychotropic medication and the corresponding underuse of behavioral and psychological interventions. This trend is especially bothersome to me because I am keenly aware – thanks to my training and experience as a psychologist – that certain evidence-based psychological treatments are as effective, if not more effective, than medication for treating certain illnesses.

Unfortunately, most people outside the field of psychology don’t know this. Americans are bombarded daily with advertisements for psychotropic medication on television, online, and in print. It’s only natural, then, that consumers who are suffering from depression or anxiety would request medications from their doctors, even when they have a problem that can be successfully treated by other means.

Don’t get me wrong – I am by no means anti-medication. I am thankful that we have effective, relatively safe medications on the market now that can help people effectively manage serious illnesses which were once disabling. Indeed, psychotropic medication can be extremely helpful – even life-saving – for many people. My concern is that psychotropic medications are prescribed too frequently to people who may not need them, often without the necessary monitoring, and often without the corresponding psychological and behavioral interventions that have been proven effective.

As a psychologist who practices said psychological and behavioral interventions, rather than a psychiatrist who prescribes said medications, am I biased? Well, obviously. I believe in what I do and I chose this profession for a reason. But still.

My hope is that, with articles such as this one, the general public will learn that evidence-based psychological treatments exist which can reduce their suffering and improve their quality of life. I would like people to be fully informed about their options when it comes to mental health treatment. I look forward to the day when people experiencing psychiatric symptoms routinely ask their primary care physicians for referrals to psychologists who practice evidence-based treatments, rather than, or in addition to, asking for prescriptions.

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Friday, November 1st, 2013

End of Treatment Outcomes for Patients with Anxiety Disorders

Since opening my practice in 2009, I have evaluated 14 patients who presented with a primary diagnosis of an anxiety disorder. All former patients who attended at least one treatment session with me following their evaluation were included in this sample (n = 9). Those who are currently still in treatment with me were not included in this sample. Please bear in mind that the results described below are specific to my practice and my patients, and should not be generalized to other therapists or other patient populations.

The sample described includes nine female patients who ranged in age from 10 to 42 years old (median age = 22). The patients’ primary diagnoses were Panic Disorder (n = 3), Anxiety Disorder Not Otherwise Specified (n = 2), Acute Stress Disorder (n = 2), Hypochondriasis (n = 1), and Generalized Anxiety Disorder (n = 1). One-third of the patients (n = 3) had a comorbid diagnosis: one had Social Anxiety Disorder, one had Major Depressive Disorder, and one had Depressive Disorder Not Otherwise Specified.

Duration of treatment ranged from one month to 11 months, with a mean duration of 5.6 months. Number of sessions attended ranged from 1 session to 18 sessions, with a mean of 10 sessions.

The primary treatment model used was individual Cognitive Behavioral Therapy (CBT). The children in this sample (n = 2) each had a high degree of family involvement, with a parent participating in part of each session. All of the college-aged patients in this sample (n = 3) were treated individually but had some degree of family involvement, with a parent participating in at least one session over the course of treatment. Amongst the adult patients in this sample (n = 4), half had no family involvement and half had some family involvement, with a loved one attending one session over the course of treatment.

None of the patients in this sample had a history of psychiatric hospitalizations before beginning treatment with me, and none of them needed to be hospitalized while in treatment with me. Forty-four percent (n = 4) of these patients took psychotropic medication during treatment. Approximately 56% of patients (n = 5) paid a reduced rate for my services based on their financial situation, and the remaining 44% (n = 4) paid my full rate.

For the purposes of this study, “full remission” was defined as complete absence of anxiety disorder symptoms in the past two weeks, along with good social, occupational, and academic functioning. “Significant progress” was defined having substantially less severe and less frequent anxiety symptoms compared to intake, along with significant improvement in social, occupational, and academic functioning. “Some progress” was defined as having somewhat less severe and frequent anxiety symptoms compared to intake, along with fair social, occupational, and academic functioning.

Forty-four percent (n = 4) of the patients in this sample completed treatment. The remaining 56% (n = 5) quit treatment prematurely. Seventy-five percent of the patients who completed treatment (n = 3) achieved full remission, and the remaining 25% (n = 1) made significant progress.

Patients who quit treatment prematurely attended an average of 12 sessions before quitting. Amongst patients who quit treatment prematurely, 80% (n = 4) had made significant progress at the time of the last session they attended, and the remaining 20% (n = 1) had made some progress. Importantly, the only individual who did not make significant progress quit treatment after attending only an evaluation and one treatment session.

In sum, patients with anxiety disorders responded very well to treatment in a relatively short period of time. All patients who attended more than two sessions experienced substantial improvement in anxiety symptoms as well as significant improvement in functioning, even if they did not complete a full course of treatment.

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