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: eating disorder treatment

Monday, November 4th, 2013

Summary of Treatment Outcomes

My blog posts from June through November 2013 have been devoted to describing my patients’ treatment outcomes. I’ve been advised that my recent posts have been too data-heavy and too detailed, but hey – that’s how I roll. I like to be thorough, meticulous, and transparent. Prospective patients and their families deserve to have access to this information. But for those who prefer brevity, I’ve summarized my treatment outcomes below. Click on the headings in bold for details.

    Outcomes for Patients with Anorexia Nervosa


Fifty-seven percent of my former patients with Anorexia Nervosa (AN) completed treatment. Of the “treatment completers,” 94% reached full remission and the remaining 6% reached physical remission. Patients required, on average, 28 sessions over the course of 17 months to complete treatment.

Forty-three percent of my former patients with AN did not complete treatment with me. Of the “treatment non-completers,” 23% were referred to other treatment settings which could better meet their needs; 15% moved to other geographic locations during treatment and thus were referred for treatment near their new homes; and the remaining 62% dropped out of treatment prematurely.

    Outcomes for Patients with Bulimia Nervosa and Eating Disorder Not Otherwise Specified


Thirty-three percent of my former patients with Bulimia Nervosa (BN) and Eating Disorder Not Otherwise Specified (EDNOS) completed treatment. One-hundred percent of those who completed treatment reached full remission. On average, patients took 15 sessions over the course of 10 months to complete treatment. Amongst patients with BN, 44% made significant progress prior to discontinuing treatment prematurely. For patients with EDNOS, 17% made significant progress prior to discontinuing treatment prematurely.

    Outcomes for Patients with Mood Disorders


Twenty-nine percent of patients my former patients with primary diagnoses of mood disorders completed treatment. Of the patients who completed treatment, 83% achieved full remission and the remaining 17% made significant progress. On average, patients took approximately 23 sessions over the course of 11 months to complete treatment.

Thirty-eight percent of mood disorder patients quit treatment prematurely, 24% were referred to other treatment providers who could better meet their needs, and 9% moved to other geographic locations during their treatment and were referred for treatment near their new homes.

    Outcomes for Patients with Anxiety Disorders


All of my former patients with primary diagnoses of anxiety disorders 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. Patients with anxiety disorders attended an average of 10 sessions over the course of 6 months.

Amongst those who completed a full course of treatment, 75% achieved full remission and the remaining 25% made significant progress.

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Thursday, July 18th, 2013

A Comparison of Treatment Outcomes: AN, BN, and EDNOS

My previous posts described treatment outcomes and correlates of my patients with various eating disorder diagnoses, including Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Eating Disorder Not Otherwise Specified (EDNOS). Some findings were similar across diagnostic groups:

• The vast majority of patients with any diagnosis who completed treatment achieved full remission.

• The attrition rate, overall, was high.

Family-Based Treatment (FBT) was associated with treatment retention, meaning that patients who participated in FBT were less likely to discontinue treatment prematurely than those receiving individual therapy.

• Patients who paid a reduced rate for services were much less likely to complete treatment and much less likely to achieve remission than those who paid full rate.

• Hospitalization during treatment with me was not related to treatment completion or treatment outcome, regardless of diagnosis.

• History of intensive eating disorder treatment (e.g., residential treatment, day treatment) was related to treatment non-completion and poorer outcome for patients across diagnoses.

Quite surprisingly, the differences among the diagnostic groups outnumbered the similarities:

• Patients with AN who completed treatment attended more sessions, over a longer period of time, than patients with BN or EDNOS. Completing treatment for AN involved an average of 28 sessions over 17 months, whereas completing treatment for BN or EDNOS involved an average of 15 sessions over 10 months.

• Type of treatment had a significant impact on outcome for patients with AN but not for patients with BN or EDNOS. All AN patients who achieved remission did so through FBT. However, patients with BN and EDNOS achieved remission through various means, including individual therapy with no family involvement, individual therapy with family involvement, and FBT.

• Younger age at intake and shorter duration of illness predicted treatment completion and remission for patients with AN. However, neither age nor duration of illness affected treatment outcome for patients with BN or EDNOS.

• All “treatment non-completers” with AN (those who quit prematurely, moved away, or were referred to other treatment settings) discontinued treatment within the first six months. In contrast, a number of “treatment non-completers” with BN or EDNOS remained in treatment for more than a year.

• Among patients with AN, those who completed treatment attended significantly more sessions than those who did not (28 sessions vs. 8 sessions) and remained in treatment for a much longer time than those who did not (17 months vs. 3 months). In contrast, for patients with BN and EDNOS, treatment completers and non-completers both remained in treatment for an average of 10 months, and treatment non-completers actually averaged more sessions than treatment completers (20 sessions vs. 15 sessions). Thus, it appears that for BN and ENDOS, treatment completers did not remain in treatment longer, but rather reached remission more quickly.

• Caucasians with AN were slightly more likely than Hispanics with AN to complete treatment and achieve remission. In contrast, Hispanics with BN or EDNOS were significantly more likely than Caucasians with these diagnoses to complete treatment and achieve remission.

• The presence of a comborbid disorder was not related to treatment completion or treatment outcome for patients with AN. However, the presence of a comorbid disorder was a significant predictor of treatment dropout and poorer outcome for patients with BN and EDNOS.

• History of hospitalization for an eating disorder or related psychiatric issue was related to poorer outcome for patients with BN and EDNOS, but not for patients with AN.

• Taking psychotropic medication during treatment was related to treatment completion and positive outcome for patients with AN but not for patients with BN or EDNOS.

Please bear in mind that these findings are specific to my practice and my patients, and are not intended to be generalized to other treatment settings or other patients.

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Sunday, July 14th, 2013

Correlates of Treatment Outcome for Patients with BN & EDNOS

My previous post described the treatment outcomes of my 21 former patients with diagnoses of Bulimia Nervosa (BN) or Eating Disorder Not Otherwise Specified (EDNOS). Treatment was very successful for these patients, with 100% of those who completed treatment (n = 7) achieving full remission. However, the attrition rate was very high, with two-thirds of patients (n = 14) discontinuing treatment prematurely for various reasons. Nineteen percent (n = 4) of patients were referred to other providers or treatment settings because I was unable to meet their needs, 5% (n = 1) moved to another geographic area, and 43% (n = 9) quit before finishing treatment.

Given that treatment completion always led to full remission, attrition appears to be the biggest challenge for this population. Therefore, my post will focus on the differences between those who completed treatment and therefore achieved full remission (aka “treatment completers”) versus those who did not (“treatment non-completers”).

Neither age at intake nor duration of illness before intake predicted treatment outcome. Both treatment completers and treatment non-completers averaged approximately 19 years old at intake, with an average duration of illness of 4.5 years.

Patients who completed treatment and achieved full remission did so through a variety of treatment modalities: 43% (n = 3) received individual therapy with no family involvement, 29% (n = 2) received Family-Based Treatment (FBT), 14% (n = 1) received individual therapy with a high level of family involvement, and 14% (n = 1) received individual therapy with moderate family involvement.

Patients receiving FBT (n = 7) were significantly less likely than those receiving individual therapy to quit treatment prematurely. Only 14% of patients receiving FBT (n = 1) quit treatment prematurely. I referred 43% of them (n = 3) to other treatment settings due to my inability to help them progress in treatment. Twenty-nine percent (n = 2) completed treatment with me and 14% (n = 1) moved to another geographic area and continued her treatment there.

Of the 14 patients who received individual therapy, 57% (n = 8) quit treatment prematurely. The remainder of patients either completed treatment and achieved full remission (36%; n = 5) or were referred to other treatment settings (7%; n = 1).

Interestingly, treatment completers did not differ from treatment non-completers on duration of treatment or on number of sessions attended. For treatment completers, duration of treatment ranged from 1-38 months, with an average duration of 10 months. For treatment non-completers, duration of treatment ranged from 1-28 months, with an average duration of 10 months. Treatment completers attended an average of 15 sessions, while treatment non-completers attended an average of 20 sessions. Thus, it appears that treatment completers did not necessarily remain in treatment longer, but rather reached remission more quickly. Anecdotally, I recall that a number of patients who quit treatment prematurely actually did quite well in their first 6-9 months of treatment and nearly reached remission, but then began to regress, got discouraged, and quit.

Rates of treatment completion and treatment outcome differed based on diagnosis. Amongst patients with BN, 22% (n = 2) completed treatment and achieved full remission, while 44% (n = 4) made significant progress prior to discontinuing treatment. For patients with EDNOS, 42% completed treatment and achieved full remission, while 17% (n = 2) made significant progress prior to discontinuing treatment.

Prior history of untreated Anorexia Nervosa (AN) was associated with treatment dropout and poor outcome. Only 18% (n = 2) of those with a prior history of AN completed their BN/EDNOS treatment with me, and both of those patients had been successfully treated for AN years before. None of the patients with a prior history of untreated AN completed their treatment with me.

Patients with a co-morbid disorder were much less likely to complete treatment. While two-thirds of patients in this sample (n = 14) had a co-morbid disorder, only 29% of them (n = 4) completed treatment and achieved remission.

Taking psychotropic medication during treatment was not related to treatment completion. Thirty-six percent of those who took medication during treatment (n = 4) completed treatment and achieved full remission, compared with 30% (n = 3) of those who did not take medication during treatment.

This sample of patients was 71% Caucasian (n = 15), 24% Hispanic (n = 5), and 5% multi-racial (n = 1). Hispanic patients were much more likely to complete treatment and achieve remission than Caucasian patients. Eighty percent (n = 4) of Hispanic patients in this sample completed treatment and achieved remission, compared with only 20% (n = 3) of Caucasian patients.

I work on a sliding fee scale, offering reduced rates based on patient’s ability to pay. Those who paid my full rate were more likely to complete treatment and achieve remission compared with those who paid a reduced rate. Forty-six percent of those who paid my full rate completed treatment (n = 6), compared with 25% of those who paid a reduced rate (n = 2).

Individuals with a history of intensive eating disorder treatment were less likely to complete treatment than those without such a history. Amongst treatment non-completers, 50% (n = 7) had been hospitalized for their eating disorder or a related psychiatric issue, 21% (n = 3) had a history of residential treatment, and 21% had been in partial hospitalization, day treatment, or intensive outpatient programs. Amongst treatment completers, 29% (n = 2) had a prior history of hospitalization, 14% (n = 1) had a history of residential treatment, and none had a history of partial hospitalization, day treatment, or intensive outpatient treatment. The need for hospitalization during treatment with me was not related to treatment completion or treatment outcome.

In sum, the only variables that were related to treatment completion and remission were diagnosis of EDNOS and payment of my full fee for services. The following variables were associated with treatment non-completion: presence of a comorbid diagnosis, history of untreated AN, and prior history of intensive eating disorder treatment. Surprisingly, neither age at intake, duration of illness before intake, type of treatment received, number of sessions attended, duration of treatment, nor need for hospitalization during treatment were related to treatment completion.

These findings are specific to my practice and my patients, and are not intended to be generalized to other clinicians or other populations.

My next post will explore similarities and differences in treatment outcome among patients with AN, BN, and EDNOS.

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Thursday, July 11th, 2013

End of Treatment Outcomes for Patients with Bulimia Nervosa & EDNOS

Since I opened my practice in 2009, I have evaluated 10 patients with a diagnosis of Bulimia Nervosa (BN) and 16 patients with a diagnosis of Eating Disorder Not Otherwise Specified (EDNOS). All patients with a diagnosis of BN or EDNOS who attended an evaluation and at least one treatment session with me, and who are no longer in treatment with me, were included in this sample. Patients I evaluated who did not attend any treatment sessions with me were not included in this sample. Patients who are currently in treatment with me were not included in this sample either. Thus, the sample I will be describing includes a total of 21 patients: 12 with EDNOS and 9 with BN.

As you continue to read, bear in mind that these results are specific to my practice and my patients. These data should not be generalized to other clinicians or other patients.

All patients in this sample were female. Age at intake ranged from 14 – 28, with an average age of 19. Two thirds of the patients (n = 14) had a comorbid disorder, with the most common being Major Depressive Disorder. Sixty-two percent of patients (n = 13) paid my full rate for services, while 38% (n = 8) paid a reduced rate.

For the purpose of calculating duration of illness, the onset of illness was defined as the period of time in which the patient began engaging in behavioral symptoms of eating disorders (e.g., restricting, bingeing, compulsive exercise, purging) as reported by the patient and/or parents. This is an important point to clarify, as symptoms of the illness typically begin long before a diagnosis is made. Length of illness before intake varied considerably, ranging from 6 months to 15 years, with an average of 4.5 years.

Over half of the patients in this sample (n = 11) had a prior history of Anorexia Nervosa (AN). Some of them had been diagnosed with and treated for AN, while others met criteria for AN at one point but were not treated until their illness morphed into BN or EDNOS.

The patients in this sample with EDNOS (n = 12) presented with a range of different symptoms. Half of the patients (n = 6) struggled with some combination of restricting, bingeing, and purging. One quarter of patients (n = 3) presented primarily with binge eating. Seventeen percent (n = 2) had Type I diabetes and withheld insulin (known as “diabulimia”). Eight percent (n = 1) presented with body image distress associated with a history of AN.

Ninety percent of these patients (n = 19) had a history of some type of psychological treatment prior to meeting with me. The majority had been in individual therapy for their eating disorder at some point. Forty-three percent of the sample (n = 9) had been hospitalized for their eating disorder or for a related psychiatric issue prior to beginning treatment with me. Nineteen percent (n = 4) had a history of residential eating disorders treatment and 24% (n = 5) had a history of partial hospitalization, day treatment, or intensive outpatient treatment.

One-third of the patients in this sample (n = 7) were treated with Family-Based Treatment (FBT). The remaining two-thirds (n = 14) were treated with individual Cognitive-Behavioral Therapy (CBT), with varying degrees of family involvement. Of the individual therapy patients, 21% (n = 3) had a high level of family involvement, meaning that a family member participated in part of each session, shared information and impressions frequently, was kept apprised of weekly goals and progress, and maintained regular phone and email contact with me. Twenty-nine percent of individual therapy patients (n = 4) had a moderate level of family involvement, meaning that a family member participated in some sessions and had occasional phone and email contact with me. Seven percent of individual therapy patients (n = 1) had a low level of family involvement, meaning that a family member attended one or two sessions, and 43% of individual therapy patients (n = 6) had no family involvement whatsoever.

Parents were the most common family members involved in the patient’s treatment. However, some patients had boyfriends, husbands, stepparents, grandparents, siblings, aunts, and uncles involved depending on their living situation and individual circumstances. Whenever family members were involved with treatment, the focus was on providing them with psycho-education about eating disorders and enlisting them as sources of practical and emotional support for the patient at home. Family members were coached in providing meal support and in assisting their loved one in refraining from eating disorder behaviors such as bingeing and purging.

For patients who received individual therapy, my approach was primarily cognitive-behavioral (CBT). In addition, many patients were taught Dialectical Behavior Therapy (DBT) skills such as distress tolerance and emotion regulation, as well as Acceptance and Commitment Therapy (ACT) principles such as thought defusion and values-based living.

Patients in this sample attended between 2 and 54 sessions, with an average of 18 sessions. Duration of treatment with me ranged from 1 month to 38 months, with a mean of duration of 10 months. Slightly more than half of the patients (n = 11) took psychotropic medication while in treatment with me. Three patients had to be hospitalized over the course of their treatment with me.

All patients were assigned an end-of-treatment status describing how they had progressed as of their final session with me. Outcomes were defined as follows:

1. Patient must meet ALL of the following criteria to be classified as in full remission:
a.) Patient gets regular menstrual periods.
b.) Patient is medically healthy, with good vital signs and blood work.
c.) Patient is completely abstinent from eating disorder behaviors, including restricting, binge/purge behaviors, laxatives, and diet pills.
d.) Patient eats regular, balanced meals most of the time or always, as reported by patient and parent (when applicable)
e.) No more than mild preoccupation with food, weight, body image, or fear of weight gain

2. Patient is classified as in physical remission if she meets criteria a, b, c, and d under full remission, but does not meet criteria e under full remission. Essentially, a patient in physical remission is physically well and free of eating disorder behaviors, but continues to be very distressed with her body image and/or preoccupied with thoughts about food and weight.

3. Patient is classified as having made significant progress if:
a.) Patient has made significant improvement in dietary habits (e.g., eats regular, balanced meals and snacks) as reported by patient and parents (when applicable)
b.) Patient is medically healthy, with good vital signs and blood work
c.) Frequency of eating disorder behaviors (e.g., restricting, bingeing, purging) has been reduced to once per week or less.

4. Patient is classified as having made some progress if:
a.) Patient has improved dietary habits somewhat since intake, but needs more improvement
b.) Patient has reduced the frequency of eating disorder behaviors (e.g., restricting, bingeing, purging) since intake, but still engages in these behaviors more than once per week.

5. Patient is classified as having made no progress if she has not improved dietary habits and/or has not reduced the frequency of eating disorder behaviors.

6. Patient is classified as regressed if she meets ANY of the following criteria:
a.) Dietary intake has declined since intake (e.g., more skipped meals, less variety, less nutritional balance)
b.) Frequency of binge/purge behaviors has increased since intake
c.) Patient has become medically unstable

Thirty-three percent of patients (n = 7) completed treatment, 43% (n = 9) quit treatment prematurely, 19% (n = 4) were referred to other providers or treatment settings because I was unable to meet their needs, and 5% (n = 1) moved to another geographic area during treatment.

One-hundred percent of the patients who completed treatment (n = 7) reached full remission. For those who completed treatment, known henceforth as “treatment completers,” duration of treatment ranged from one month to 38 months, with an average duration of 10 months. Number of sessions attended for treatment completers ranged from 3 – 45, with an average of 15 sessions. In other words, the typical patient with BN or EDNOS who completed treatment achieved full remission in 15 sessions over the course of 10 months.

Unfortunately, the attrition rate was very high, so these treatment completers comprised only one-third of the full sample. Of the 14 patients who discontinued prematurely, 43% (n = 6) made significant progress, another 43% (n = 6) made some progress, 7% (n = 1) made no progress, and 7% regressed (n = 1).

My next post will involve a detailed examination of the differences between patients who completed treatment and reached full remission versus those who discontinued treatment prematurely and did not reach full remission.

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Sunday, July 7th, 2013

Correlates of Treatment Outcome for Patients with Anorexia Nervosa

In my last blog post, I described the end-of-treatment outcomes of my former patients (N = 30) with Anorexia Nervosa (AN). In sum, 57% of patients completed treatment (n=17) and 43% of patients (n = 13) did not complete treatment. The former group is referred to as “treatment completers” and the latter as “treatment non-completers.”

As expected, end-of-treatment results differed dramatically between the two groups. By the end of treatment, 94% percent of treatment completers had achieved full remission and 6% (n = 1) had achieved physical remission. In contrast, none of the treatment non-completers achieved remission, although 46% of them made significant progress (n = 6).

Bear in mind that I set the bar very high for my patients in terms of defining remission. In most published studies of AN treatment outcome, the patients whom I categorized as having made significant progress would be categorized as “recovered” or “in remission.” If I used the (completely inadequate) definitions of remission that other studies have used, a full 77% of my sample would have completed treatment and made a full recovery. But I digress.

These data clearly demonstrate that my approach to treating AN is effective. Patients with AN who have completed treatment with me always achieved physical remission and almost always achieved psychological and behavioral remission as well.

The 43% attrition rate is disheartening, given that patients are likely to achieve remission if they remain in treatment long enough. Attrition is a major problem in AN treatment in general, and in AN treatment for adults in particular. The validity of most AN treatment outcome studies is compromised by the high rates of attrition. It is not surprising that many adults discontinue AN treatment prematurely, given that treatment is very difficult, anxiety provoking, and lengthy.

This raises the question of what is “long enough” in terms of AN treatment? In my opinion, “long enough” is as long as it takes to bring the patient to full remission, which varies considerably based on individual differences. Among the treatment completers, the length of time to full remission ranged from 2 months to 4 years, with a mean of 17 months. The number of sessions attended by treatment completers ranged from 3 – 82, with a mean of 28 sessions. There were a handful of the young patients who achieved full remission in 12 sessions or less, although this was not the norm.

The rates of treatment completion versus non-completion in my sample beg the question of how these two groups differed. What was it that made treatment completers stick it out until the end, while the treatment non-completers either quit or regressed to the point that they required more intensive treatment? Cause and effect cannot be determined from this type of study. However, a careful examination of the similarities and differences between treatment completers and non-completers may yield useful information and hypotheses which can be tested in future studies.

The patients who completed treatment and reached remission differed in several important ways from those who discontinued treatment prematurely.

Variables That Had a Significant Impact on Treatment Outcome:

1.) Type of Treatment

In my practice, all children and adolescents under age 18 with AN receive FBT (Family-Based Treatment, also known as the Maudsley Method). Some adolescents also receive individual therapy as an adjunct to FBT after weight restoration. Some children and adolescents transition to individual therapy with me after FBT is complete; this may be the case for those who have comorbid disorders or other ongoing issues. Patients over 18 with AN are strongly encouraged to do FBT whenever appropriate, although it is not always possible for logistical reasons, and some young adults are staunchly opposed to it. In my sample, 66.7% of patients (n = 20) received FBT alone, 16.7% (n = 5) received FBT plus individual therapy, and 16.7% (n = 5) received individual therapy alone.

In my sample, all of the patients who received individual therapy alone were 20 or older. Six of the 11 young adults in my sample (n = 55%) participated in FBT, either alone or in conjunction with individual therapy. All of the patients under age 18 received FBT, and two of these patients also received individual therapy.

One-hundred percent of treatment completers (n = 17) received FBT, either by itself (n = 15) or in conjunction with individual therapy (n = 2). In other words, all patients who achieved remission did so through FBT. One-hundred percent of the patients who did individual therapy alone (n = 5) ended treatment prematurely, either because they moved (n = 2), they quit (n = 2), or I referred them to a higher level of care (n = 1). In other words, individual therapy by itself never resulted in treatment completion or remission.

2.) Subtype of AN

This sample contained 5 patients with the Binge-Purge subtype of AN (AN – BP) and 25 patients with the Restricting subtype of AN (AN – R). One-hundred percent of treatment completers had a diagnosis of AN-R. None of the AN-BP patients completed treatment.

Among the AN-BP patients, 2 were referred to higher levels of care after regressing during treatment with me. One patient moved to another state after making some progress in treatment with me. Two patients quit treatment prematurely after making significant progress with me.

The patients in my sample with AN-BP were more likely to have a history of impulsivity, self-injury, and suicidal gestures compared to those with AN-R. I hypothesize that this cluster of symptoms made these patients more difficult for me to treat effectively as an outpatient solo practitioner, and more likely to benefit from a more structured, comprehensive treatment approach such as day treatment or residential treatment.

3.) Age

On average, those who completed treatment and achieved remission were significantly younger at intake than those who did not complete treatment (p <.01). Treatment completers ranged in age from 10 – 24 at intake, with a median age of 14. Treatment non-completers ranged in age from 10 – 37, with a median age of 20. However, it is important to note that there was a broad range of ages in both groups, with some young adults achieving full remission and some children and adolescents discontinuing treatment prematurely. 4.) Fee Paid for Services I believe that neither finances nor insurance issues should prevent people from accessing high-quality healthcare services. Therefore, I do not participate on any insurance panels. I am flexible with my fees and I work on a sliding scale based on a patient's ability to pay. If a family’s financial status changes during the course of treatment, I will change my fee for them accordingly. I work with many patients for very low hourly fees. Thus, I can only assume that the patients who discontinued treatment prematurely did not do so for financial reasons. Among the patients in this AN sample, 87% (n = 26) paid my full fee and 13% (n = 4) paid a reduced rate. The rate of reduced-pay patients in this sample is significantly lower than in my other diagnostic groups. I hypothesize that this may be due to the fact that the majority of patients in this sample received family-based treatment and had at least one parent who was a working professional, or who at least was employed full-time. In contrast, many of my patients with other diagnoses were college students supporting themselves, who were therefore eligible for a low fee. In this sample of AN patients, those who paid a reduced rate were significantly less likely to complete treatment compared to those who paid a full rate. Only 25% of reduced fee patients (n = 1) completed treatment, versus 62% of full fee patients (n = 16). It is unclear why reduced rate patients were less likely to complete treatment. However, the reduced rate patients differed from the full rate patients in several important ways. First, and most obviously, they had lower incomes, and likely dealt with the host of stressors that accompany being of lower socio-economic status. Second, they were all over the age of 18, which statistically reduces their likelihood of full recovery. Third, they were more likely to receive individual therapy than the full-rate patients. All of the low-rate patients received individual therapy, either alone (n = 2) or in combination with FBT (n = 2). Observing my patients with other diagnoses, I have noticed that those who pay full rate are much more likely to attend all of their sessions and to complete treatment, whereas those who pay lower rates are more likely to cancel sessions, no-show for sessions, and drop out prematurely. While I’m sure that the reasons for these differences are complex, I can’t help but wonder if people who pay more for something tend to value it more and take it more seriously. Variables That Had a Minor Impact on Treatment Outcome:

1.) Length of illness before intake.

Among treatment completers, length of illness before intake ranged from 3 months to 13 years (mean = 27 months). Amongst treatment non-completers, length of illness before intake ranged from 3 months to 21 years (mean = 67 months). However, this difference was not statistically significant (t = 1.63; p = 0.11).

2.) Use of Medication During Treatment

Individuals who took psychotropic medication during treatment with me were somewhat more likely to complete treatment and achieve remission. Fifty-nine percent of treatment completers (n = 10) took medication during treatment, compared with 38% of treatment non-completers (n = 5).

3.) Ethnicity

This sample of 30 patients was comprised of 60% White Non-Hispanic individuals (n = 18) and 40% White Hispanic Individuals (n = 12). These percentages are roughly similar to the ethnic makeup of Coral Gables, Florida, the Miami Suburb in which my office is located. The treatment completers group was comprised of 71% White Non-Hispanic individuals (n = 12) and 29% White Hispanic individuals (n = 5). The treatment non-completers group included 46% White Non-Hispanics (n = 6) and 54% White Hispanics (n = 7). Therefore, White Non-Hispanics were slightly more likely to complete treatment and achieve full recovery than White Hispanics.

4.) History of intensive eating disorder treatment.

History of residential, day treatment, or intensive outpatient treatment had a minor impact on treatment outcome. Twelve percent of treatment completers (n = 2) and 23% of treatment non-completers (n = 3) had a history of residential eating disorders treatment prior to beginning treatment with me. Twenty-four percent of treatment completers (n = 4) and 31% of treatment non-completers had a history of partial hospitalization, day treatment, or intensive outpatient eating disorder treatment.

Variables that Had No Impact on Treatment Outcome:

1.) Comorbid disorders

The presence of comorbid disorders did not differ significantly between the two groups. Fifty-three percent of treatment completers (n = 9) had a comorbid diagnosis, as did 46% of treatment non-completers.

2.) Gender.

Given that only 7% of the sample was male (n = 2), I cannot draw any conclusions about gender differences in treatment response. Incidentally, both of the males in my sample achieved full recovery.

3.) Hospitalization before treatment.

Being hospitalized for AN or a related psychiatric issue prior to beginning treatment with me did not have a significant impact on treatment outcome. Thirty-five percent of treatment completers (n = 6) had been hospitalized at least one prior to beginning treatment with me, as had 31% percent of treatment non-completers (n = 4).

4.) Hospitalization during treatment.

The need for hospitalization during the course of treatment with me did not have a significant impact on treatment outcome. Eighteen percent of treatment completers (n = 3) needed to be hospitalized during the course of their treatment, compared with 15% (n = 2) of treatment non-completers.

These data, taken together, suggest that a patient with AN-R who enters treatment with me and receives FBT is very likely to achieve full remission within 28 sessions over the course of 17 months, regardless of gender, comorbid diagnosis, or history of hospitalization. A patient under age 18 has a greater likelihood of achieving full remission, although a patient over 18 is also likely to achieve full remission, provided that he or she is treated with FBT.

Please bear in mind that these results are specific to my practice and my patients. These data are not intended to be generalized to other clinicians or other patient populations.

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Monday, July 1st, 2013

End of Treatment Outcomes for Patients with Anorexia Nervosa

Since opening my practice in 2009, I have evaluated 49 patients with primary diagnoses of Anorexia Nervosa (AN). All patients who attended an evaluation and at least one treatment session with me, and who are no longer in treatment with me, were included in this sample. In addition, there were several patients who have completed their treatment but have elected to see me two or three times per year for check-ins; these patients were included in this sample as well. Patients who are currently in treatment with me were not included. Patients who saw me for an evaluation and / or consultation only, but did not attend any treatment sessions, were not included either. Thirty patients met criteria for inclusion in this sample. The remaining 19 did not meet criteria, either because they saw me for evaluation and consultation only or because they are currently in treatment with me.

Please bear in mind that this is not a randomized, controlled study. The results I am posting are specific to my practice and my patients. They are not intended to be generalized to other clinicians or other patients. While many of my patients are referred to me by their pediatrician or psychiatrist, the majority of my patients are self-selecting. That is, their families researched their treatment options on their and chose to work with me for a specific reason. The self-selecting nature of many of these families also limits the generalizability of the results.

The sample described in this post contains 30 patients. These patients ranged in age from 10 – 37 (median age = 15). Eighty-three percent of these patients (n = 25) met criteria for restricting subtype (AN-R) and the remaining 17% (n = 5) met criteria for binge-purge subtype (AN-BP). Half of these patients (n = 15) had a co-morbid diagnosis, with the most common being Major Depressive Disorder and Depressive Disorder Not Otherwise Specified. Fifty-three percent of patients (n = 16) took some type of psychotropic medication during their treatment with me.

The patients varied widely in terms of length of illness and severity of symptoms. Duration of illness before intake ranged from 3 months to 21 years (median duration = 19 months). Importantly, these figures reflect the duration since the onset of illness, which is typically longer (and often much longer) than the duration since diagnosis. For the purpose of calculating duration of illness, onset of illness was defined as the period of time in which patient began engaging in behavioral symptoms of AN (e.g., restricting, compulsive exercise, purging) as reported by the patient and/or parents.

The majority of these patients arrived at my office with some history of treatment. Seventy percent of patients (n = 21) had already received some type of treatment before beginning therapy with me. As expected, most of those who were new to treatment had a much shorter duration of illness. One-third of patients (n = 10) had been hospitalized for their eating disorder or a related psychiatric issue (e.g., suicide attempt) prior to their evaluation with me. Seventeen percent of the patients (n = 5) had previously been in residential treatment and 27% (n = 8) had previously been in partial hospitalization, day treatment, or intensive outpatient treatment eating disorder treatment.

Duration of treatment with me ranged from one week to 48 months (median duration of treatment = 11 months). Number of treatment sessions with me ranged from 1 – 82. For those whose treatment lasted 18 months or longer, the duration of treatment can be explained by either a relapse after a period of remission or continued treatment to address a comorbid condition, such as anxiety or depression. Seventeen percent of patients (n = 5) had to be hospitalized during their treatment with me.

Prior to reporting end-of-treatment outcomes, it is important to clarify how I defined outcomes. I created the following definitions, each with specific criteria, in order to categorize patient outcomes:

1. Patient must meet ALL of the following criteria to be classified as in full remission:
a.) Patient is 100% weight-restored. Target weights were calculated based on patient’s individual historic growth chart and parent input. Patients under age 20 were expected to return to their historic percentiles for height, weight, and BMI. For patients age 20 and up, target weights were calculated based on the patient’s height, body build, weight history, menstrual history, and parental input (when available).
b.) Patient has started or resumed menstrual periods (for females ages 14 +).
c.) Patient is medically healthy.
d.) Complete abstinence from binge/purge behaviors, laxatives, and diet pills.
e.) Patient eats regular, balanced meals most of the time or always , as reported by patient and parent (when applicable)
f.) For children under 18 – child eats independently in an age-appropriate way most of the time or all of the time. For patients ages 18 and up, patient is able to eat independently while maintaining his/her weight.
g.) No more than mild preoccupation with food, weight, body image, or fear of weight gain

2. Patient is classified as in physical remission if he/she meets criteria a, b, c, d, and e under full remission, but does not meet criteria f or g under full remission. Essentially, a patient in physical remission is physically well and free of eating disorder behaviors, but cannot eat well independently, and/or continues to be preoccupied with thoughts about food, weight, and body image.

3. Patient is classified as having made significant progress if:
a.) Patient has made significant improvement in dietary habits (e.g., eats regular, balanced meals and snacks and has expanded the variety of foods he/she eats) as reported by patient and parents (when applicable)
b.) Patient has restored some weight and is at least 90% of ideal body weight (as defined in criterion a under full remission)
c.) Patient is medically healthy
d.) If patient has a history of bingeing, purging, laxatives, or diet pills, the frequency of these behaviors has been reduced to once per week or less.

4. Patient is classified as having made some progress if:
a.) Patient has improved dietary habits since intake, but needs more improvement
b.) Patient has restored some weight but remains more than 10% below target weight (as defined in criterion a under physical remission).
c.) Patient is a female age 14 or older but is not menstruating
d.) If patient has a history of bingeing, purging, laxatives, or diet pills, he/she has reduced the frequency of these behaviors since intake but still engages in them more than once per week.

5. Patient is classified as having made no progress if he/she has not improved dietary habits, has not restored any weight, and/or has not reduced the frequency of bingeing or compensatory behaviors.

6. Patient is classified as regressed if he/she meets ANY of the following criteria:
a.) Patient has lost weight since starting treatment
b.) Patient has been eating less since intake (in terms of frequency, quantity, and variety)
c.) Frequency of bingeing or compensatory behaviors has increased since intake
d.) Patient has become medically unstable

Fifty-seven percent of patients (n = 17) completed treatment and will be referred to as “treatment completers.” Treatment completers ranged in age from 10 – 24 at intake, with a median age of 14. Duration of treatment for treatment completers ranged from 2 months to 48 months (median duration = 15.5 months).

Ninety-four percent of treatment completers (n = 16) met criteria for full remission at end of treatment. The remaining 6% (n = 1) met criteria for physical remission at end of treatment. For the treatment completers, weight restoration was achieved in an average of 3 months (range = 1 – 7 months). Two of the treatment completers were fully weight-restored (though not in full remission) at the start of treatment with me, having already been in eating disorder treatment elsewhere.

Forty-three percent of patients (n = 13) did not complete treatment and will be referred to as “treatment non-completers.” Treatment non-completers ranged in age from 10 – 37, with a median age of 20. Duration of treatment for the non-completers ranged from one week to six months (median duration = 3 months). Of the treatment non-completers, I referred 23% (n = 3) to other providers because they required something I could not provide (e.g., residential treatment) or my treatment approach was not helping them. Fifteen percent of non-completers (n = 2) moved to other parts of the country during their treatment and thus were referred to other providers near their new homes. Sixty-two percent of treatment non-completers (n = 8) dropped out of treatment prematurely.

Of the treatment non-completers, 46% (n = 6) had made significant progress by their last session with me. Fifteen percent had made some progress, 23% (n = 3) had made no progress, and 15% (n = 2) had regressed.

Stay tuned for my next blog post, in which I will examine and interpret the differences between treatment completers and treatment non-completers.

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Wednesday, March 13th, 2013

Book Review: Food to Eat

There are a number of books that I recommend to the parents of every eating disorder patient I see. When it comes to books for eating disorder sufferers themselves, however, I am much more cautious. Many of the books that are directed at sufferers, while well-intentioned, can be triggering for some patients.

Now all of that has changed. I have finally found a book that I would wholeheartedly recommend to any adult eating disorder patient at any stage of recovery: Food to Eat. I have never read anything quite like this before. Food to Eat, authored by dietician Lori Lieberman and recovering eating disorder patient Cate Sangster, combines practical nutritional advice with quick, easy-to-prepare recipes. The most unique part of Food to Eat is that the pages of recipes and nutritional advice are peppered with dialogue between Lori and Cate. A virtual cognitive restructuring exercise, this dialogue counteracts common eating disorder thoughts with empathic, scientifically-grounded information about nutrition and behavior change.

Food to Eat can be particularly helpful for young adults with eating disorder histories who are transitioning into independent living situations which require them to prepare their own food for the first time. In addition, I would recommend Food to Eat for an adult of any age who is pursuing recovery and wants to develop a certain level of comfort in preparing and eating a variety of foods. Finally, I would recommend Food to Eat for caregivers of eating disorder patients who are responsible for preparing and serving food to the patient, as this book provides unique insight into what the patient is likely thinking when a given recipe is presented.

Full nutrition is the most crucial ingredient of eating disorder recovery. Food to Eat provides a recipe for success in overcoming the cognitive as well as nutritional challenges of eating disorders.

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Wednesday, February 13th, 2013

As Serious As Cancer

There are several parallels between Anorexia Nervosa (AN) and cancer. Both diseases are severe and potentially fatal – the mortality rate of AN is similar to that of the most common form of childhood leukemia. Both can become chronic illnesses characterized by periods of remission and periods of relapse. Early, aggressive intervention is crucial in the treatment of AN as well as the treatment of cancer. Both diseases will grow and metastasize if left unchecked. Neither cancer nor AN is the patient’s choice or the parents’ fault. Chemotherapy is an aversive, painful treatment with unwanted side effects. The same can be said of re-feeding and weight restoration in AN – it is extremely anxiety provoking and difficult for the patient, yet it is necessary in order to eradicate the disease. Patients with AN, like patients with cancer, require a tremendous amount of help and support from caregivers for long periods of time.

Blogger Cameron Von St. James, the husband of Mesothelioma survivor Heather Von St. James, wrote the following essay about caring for his wife during her battle with cancer. I think it may resonate with caregivers of patients with AN.

The Hardest Battle Of Our Lives
by Cameron Von St. James

When my wife and I walked into that doctor’s office on November 21, 2005, we didn’t realize that our lives were about to change forever. Until then, we were your average couple. We both worked full-time jobs and had welcomed our first and only child into the world just 3 months prior. As we sat in the doctor’s office together, we watched our lives transform into a chaos and uncertainty before our very eyes. The doctor read the diagnosis: malignant pleural mesothelioma. Cancer, and an extremely deadly one at that. I knew we were in for a long, difficult struggle.

The doctor told us about treatment options. We could go to a local university hospital, a regional hospital that didn’t even have a specialist to deal with my wife’s form of cancer, or Dr. David Sugarbaker in Boston, a renowned specialist in the treatment of mesothelioma. My wife couldn’t even answer, she was so shocked and terrified. She turned to me as if to cry for help. I answered her silent plea by telling the doctor, “Get us to Boston!” That decision turned out to be one of the most important I’ve ever made in my life.

Being a caregiver my wife was extremely taxing and difficult, but it’s a job that I knew I had to do to the best of my ability. I knew I had to be strong for her and be her rock. Inside, though, my life was in turmoil. My wife had to quit her job and required more and more care each day. As a result, I was working full-time, taking care of our infant daughter, and also taking care of my beloved wife too, whisking her to one doctor appointment after another, making travel arrangements to Boston, and making her comfortable at home. It was a full schedule and there were so many times when I felt like giving up, but I knew I needed to press on.

During this time, I dealt with a multitude of fears that will never leave me. Medical bills piled up. I watched the love of my life endure pain and sickness that no one should ever have to endure. I feared what would happen to our daughter if my wife didn’t survive through this. Would she have to spend the rest of her life without a mother? And with a father that was broke because of all the medical bills? It was the hardest, most painful time I’ve ever lived through, and more than once the stress and pressure forced me to the ground in tears. I had bad days, but I never let my wife see my in my moments of weakness. I knew that she needed me to be strong, and I did my best to give her that.

After months of surgery, radiation and chemotherapy treatments, Heather is cancer-free. She beat mesothelioma against all odds, and I am so proud of her. Two years after her diagnosis, I enrolled in school full-time to study Information Technology. I graduated with honors and am thankful to have been given the stage to give the speech at my graduation. It was there that I was able to see the lessons I learned and communicate my gratitude for the fact that my wife had beat cancer.

My own lessons stay with me even today. I learned that I’m strong enough to take care of someone I love, even if it is scary and often painful. I learned to use my own stubbornness to work to my advantage. Most importantly, I learned that time is precious to us all and we should spend it with the people we love so much. It’s seven years later and Heather is cancer free, and we continue to raise our beautiful daughter with the lessons we both learned. It is our hope that our story of triumph over cancer can inspire others in their own battles.

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Tuesday, December 4th, 2012

A Seat at the Table: Understanding and Helping the Siblings of Eating Disorder Patients

I feel honored to serve on the Professional Advisory Panel for FEAST, a nonprofit organization which provides support and information to the parents and families of people with eating disorders. Last weekend, I had the privilege of presenting at the second annual FEAST conference in Alexandria, VA. I spoke to a group of parents about understanding and helping their other children while also caring for their eating disordered child. Below are some of the major points from my presentation.

Eating disorders can impact the patient’s siblings from various angles:

• Through their parents. When a child is ill with an eating disorder, her siblings often receive less attention from their parents. The parents may be physically absent from the home, traveling to faraway treatment centers and attending many different appointments locally. Parents often feel worried, stressed, and irritable, and these emotions can easily spill over into their relationships with their other children.

• By impacting family life. Family meals with an eating disordered person can be tense or explosive. For this reason, siblings may begin to dread family meals or avoid them altogether. Family trips may be cancelled or ruined by the eating disorder. The financial burden of ED treatment impacts the entire family, including siblings.

• Through their social environment. Parents may not be available to drive siblings to their lessons, sports events, and social activities when they are spending long hours preparing and supervising meals and driving the ill sibling to appointments. Siblings may feel embarrassed to invite friends over when their ill sister or brother is acting particularly bizarre. Siblings may have to deal with gossip from friends and neighbors. They may feel conflicted about telling their friends about their family’s situation, and they have to deal with the stigma of mental illness.

• Through the change in eating habits. Parents are encouraged to serve their anorexic children high-calorie foods to restore their weight. Sometimes siblings over-indulge in these foods and gain unneeded weight.

• Through their genes. Biological siblings of eating disorder patients are 10 times more likely to develop an eating disorder compared to the general population. Additionally, siblings of eating disorder patients may inherit genes that predispose them to other psychiatric illnesses, including depression, OCD and other anxiety disorders, substance abuse, ADHD, and autism.

Brothers and sisters may experience a variety of emotions while their sibling is ill with an eating disorder. They may worry that their sibling will get sicker or die. They may grieve for the loss of their sibling’s true personality while she is consumed by the illness, and they may miss her terribly if she is away from home for a lengthy hospitalization or residential treatment stay. They may worry about their own risk for developing an eating disorder. They may feel angry at their sibling for putting the family through hell or making mealtimes miserable. They may feel jealous because of all of the attention their ill sibling is getting. Siblings may react by withdrawing from friends and family members, having difficulty at school, or acting out. They may feel sad or hopeless. They may have difficulty concentrating. Very young siblings may manifest their distress through physical symptoms (e.g., tummy aches, trouble sleeping).

It may not be possible for parents to shield siblings completely from the impact of the eating disorder. However, there are some steps that parents can take to minimize the damage and help siblings cope:

• Immediately upon diagnosis, provide siblings with age-appropriate information on their sibling’s diagnosis, symptoms, and treatment. Explain that the disorder is biologically-based and that the child did not chose to have it. I have a Sibling reading list, as well as a list of Q & A for siblings of AN patients. Even preschool-age siblings can understand a few basic points: “Your sister has a disease in her brain called anorexia which has made her very sick. She is acting different because of her sick brain; it is not her fault. We need to help her get better. Mommy and Daddy will be very busy taking care of her, but we still love you very much.”

• Be frank with siblings about the seriousness of the eating disorder, including the possibility of death. This honesty helps siblings understand why it is so important that the family intervenes immediately and aggressively, and why other activities have to take a back seat for now.

• Be honest with siblings about the reality of dealing with the eating disorder. Acknowledge that, for a period of time, the whole family will be under stress, family life will change, and you may not be able to spend as much time with them.

• Bring siblings to some Family-Based Treatment (FBT) sessions so that the therapist can explain the eating disorder to them, describe the treatment process, answer their questions, and tell them how they can support their ill sister or brother.

• Make a point of scheduling one-on-one time with each sibling and talking with them about their lives apart from the eating disorder.

• Talk with siblings about their feelings and reactions to the eating disorder. Let them know that it is totally normal and understandable for siblings to feel worried, angry, jealous, resentful, or sad in this type of situation.

• Ensure that siblings remain in a support role, rather than taking on a parent’s role. Lock and LeGrange, authors of the FBT manual, call this process “maintaining intergenerational boundaries.” Siblings can help their ill sister by providing her with distraction before, during, and after meals, by being good listeners and providing empathy, and by engaging her in normal sibling activities. Siblings can help by taking over kitchen chores that the eating disordered person is not well enough to do, such as setting the table or doing the dishes. Do not involve siblings in the actual process of re-feeding or supervising meals, as this can put them in a delicate position of being torn between “loyalty” to their ill sister and the responsibility of reporting ED behaviors to their parents.

An eating disorder can also impact siblings in a positive way. For example, they may grow closer to their ill sibling and value her more after almost losing her. They may feel needed and important in the process of supporting their ill sister or brother. Siblings may become more aware of EDs and other psychiatric illnesses in their friends and try to intervene whenever they see concerning behaviors. They may have improved body image after witnessing the disturbing body image distress of their ill sibling. Often, siblings benefit from having more frequent family meals and structured eating habits. They may grow and mature from the experience, developing more autonomy when parents’ focus is on the eating disorder treatment. Siblings benefit from strengthened parental unity. If a sibling develops an eating disorder or another illness in the future, their parents tend to intervene immediately and are much more equipped to deal with it.

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Sunday, July 29th, 2012

Navigating Phase III

Last week, I blogged about navigating Phase II of Maudsley Family-Based Treatment (FBT). Today I present a roadmap for Phase III, which is equal to Phase II in its importance as well as its ambiguity.

A common but ill-informed criticism of FBT is that it only addresses eating and weight. This is a misconception. Phase I focuses on establishing normal eating habits and restoring normal weight and Phase II focuses on helping the patient eat on her own in an age-appropriate way, but Phase III has nothing to do with food or weight at all. A wonderful thing about FBT is that the life-threatening eating disordered behaviors are treated first, which frees up the therapist, the patient, and the family to focus on any remaining issues in Phase III.

The goal of Phase III is establishing a healthy adolescent identity. An eating disorder engulfs an adolescent’s identity, creates extreme stress for the entire family, and strains the relationships between family members. Phase III is about restoring healthy, age-appropriate family relationships and returning the adolescent to normal life. Anything that stands in the way of these goals must be dealt with in order for the patient to recover fully.

Phase III begins when the patient is able to eat normally, with age-appropriate independence, while maintaining a healthy weight and not engaging in any eating disorder behaviors. Essentially, once all food issues have been resolved, the patient is ready for Phase III.

The authors of the FBT manual (Locke & Le Grange, 2001) advise that Phase III entails a handful of sessions scheduled several weeks apart. In my clinical experience, many patients do quite well with just a few sessions in Phase III, but others continue to struggle with anxiety, depression, body image, perfectionism, or other problems. Therefore, I offer to provide patients and families with an extended version of Phase III when I believe it is warranted. Length of illness, severity of illness, and co-morbid conditions all influence whether a patient may benefit from more treatment than the FBT manual prescribes.

In my practice, Phase III typically addresses the following issues:

1.) Returning the patient to normal development.

An eating disorder can interrupt normal adolescent development. Often, when a patient enters Phase III, she is at the same developmental level as when the illness first began. Phase III entails helping the patient develop the maturity and social-emotional skills that were lost as a casualty of ED. Depending on the age of the patient, this may entail returning to sports or other activities, getting a driver’s license, going out with friends, dating, returning to college, or developing new hobbies and interests.

2.) Re-establishing healthy relationships amongst family members.

An eating disorder can wreak havoc on family life. It is not uncommon for spouses to have major marital conflict emerge as a result of ED. Siblings may feel neglected by their parents or jealous of the patient. The patient and her parents may develop a codependent relationship over the course of treatment, which can be advantageous in the first two phases, but must be corrected in Phase III so that the patient and parent can each return to their own lives. Healthy boundaries amongst family members can be damaged by ED, and it is crucial for these boundaries to be re-established at the end of treatment.

3.) Addressing any remaining psychological symptoms of the eating disorder.

There are numerous psychological symptoms related to an eating disorder. For example, body dysmorphia, perfectionism, poor self-esteem, anxiety, and cognitive rigidity may predispose people to AN and perpetuate the illness once it has begun. For many patients, these symptoms abate or resolve on their own during the first two phases. For many others, however, targeted treatment is needed at this phase. Cognitive-behavioral therapy (CBT) can be helpful in this regard.

4.) Working through the trauma of experiencing an eating disorder.

While many treatment programs address traumatic experiences that precipitated an eating disorder, few acknowledge that the experience of having eating disorder is itself very traumatic. Caring for a child with an eating disorder can be almost as traumatic as experiencing one. In many cases, the patient or her parents (or both) experience post-traumatic stress reactions at this point, such as disturbing nightmares, intrusive memories, and avoidance of stimuli associated with the eating disorder.

It is not uncommon for parents, drained and burnt out from the exhausting work of Phase I and Phase II, to have their own breakdowns at this point. Their child is well enough that they are no longer operating in crisis mode and they have some room to breathe. Once the survival instinct is no longer employed on a constant basis, parents have permission to experience their own reactions. Some parents fall into a depression; others feel disillusioned and cynical; still others suffer from extreme anxiety or lash out in anger. These are all normal, expected reactions to the trauma of almost losing a child. It is important for parents to get their own therapeutic support at this juncture if needed.

5.) Addressing grief.

Another often neglected aspect of eating disorder treatment is grieving what the eating disorder has taken. Not all patients and families experience this grief, but some do. I believe that when there is grief associated with the eating disorder, it should be discussed openly and addressed as part of the healing process. Patients often lose friends to their illness. They may have to take a hiatus from their favorite sport, or give it up altogether. Some patients miss a semester of school. Most are isolated from society for some time. At this stage, patients can feel the pain and injustice of losing a piece of their youth irretrievably.

Some parents may mourn the loss of their child’s innocence. They mourn the loss of life as they knew it. Many parents take time off from work and become isolated from their social circle as they help their child recover. Some parents mourn the loss of dreams they once had for their child which have been thwarted by ED.

No one emerges from the hell of an eating disorder unscathed. That said, some people are able to close that chapter in their lives and move forward, whereas others remain trapped by anger, sadness, or bitterness. It is important for patients and parents to work through their grief so that they can move forward in a life unencumbered by ED.

6.) Relapse prevention.

It is important for the patient and her parents to be aware of possible signs of impending relapse and to know what to do if these signs emerge. I find it very useful to discharge patients with a written relapse prevention plan which I have developed in collaboration with the patient and family.

7.) Evaluating the patient for co-morbid conditions.

Many patients with eating disorders experience co-morbid psychiatric conditions. Patients who continue to struggle with emotional or behavioral problems after the eating disorder has been resolved should be evaluated to determine whether they suffer from a comorbid disorder. The most common comorbid disorders are the anxiety disorders (including OCD, generalized anxiety disorder, panic disorder, PTSD, and social anxiety disorder), followed closely by mood disorders (depression and bipolar disorder). Other comorbid conditions may include autism spectrum disorders (such as Asperger’s), ADHD, substance abuse, and personality disorders.

8.) Getting the patient appropriate treatment for co-morbid conditions.

If the patient does indeed suffer from a co-morbid condition, it is important for her to get treatment for it. Treatment for a co-morbid disorder may include individual therapy, psychotropic medication, or a combination thereof. Cognitive behavioral therapy (CBT) in particular has been found to help many people recover from anxiety disorders, mood disorders, and numerous other conditions.

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Sarah Katherine Ravin's Practice is ranked in the top Coral Gables, FL Psychology practices.

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