Dr. Sarah Ravin - Psychologist | Eating Disorders |Body Image Issues | Depression | Anxiety | Obsessive-Compulsive Disorders | Self-Injury
Blog
1550 Madruga Ave Suite #225
Coral Gables, FL 33146
305-668-5755 (phone)
305-668-5756 (fax)
info@DrSarahRavin.com
Driving Directions
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.

space

Tag: Psychotherapy

Monday, November 20th, 2017

End of Treatment Outcomes for Patients with Anorexia Nervosa (2009 – 2017)

Description of the Sample

This analysis includes all patients with a primary diagnosis of Anorexia Nervosa (AN) who participated in an evaluation followed by a minimum of one therapy session with me between the start of my practice in 2009 and spring 2017.  Given that this is an analysis of end of treatment outcomes, patients who are currently in treatment with me were not included in this sample.  Patients and families whom I saw only for evaluations or consultations rather than treatment were not included in this sample.

The sample includes 60 individuals (93% female) who ranged in age from 10 – 37 years old, with a median age of 16 and a modal age of 13.  The majority of patients identified as Caucasian (69%) or Hispanic (29%), with less than 3% identifying with other racial/ethnic groups.

Twenty percent of patients in this sample met criteria for the Binge-Purge Subtype of AN, while the remaining 80% had Restricting Subtype.

Half of patients in this sample had a comorbid diagnosis.  The two most common comorbid diagnosis were  ADHD and Major Depressive Disorder, with 13% of patients meeting criteria for each of these disorders.

Duration of illness before beginning treatment with me ranged from 2 months to 21 years, with older patients, on average, having been sick for a longer duration of time.  The mean duration of illness before entering treatment with me was just under 3 years.

Most patients had a history of unsuccessful outpatient treatment with other providers prior to beginning treatment with me.  In addition, 28% percent of patients had a history of hospitalization for AN prior to beginning treatment with me and 15% had a history of residential treatment.

Ten percent of the sample paid a reduced rate for services due to financial need.

What follows is a summary of treatment outcomes.  For a more detailed description of treatment outcomes for patients with AN, click here.

Description of Treatment Received

  • 95% of child and adolescent patients received Family-Based Treatment (FBT).  The remaining 5% received individual therapy.
  • 40% of patients over age 18 received FBT, either alone or in conjunction with individual therapy. The remaining 60% received individual therapy.
  • Some adolescent FBT patients received individual therapy for a co-morbid condition after their course of FBT was complete.
  • All patients received medical monitoring by their physician during treatment with me.
  • 58% of patients took psychotropic medication at some point during their treatment with me.
  • Average number of sessions attended was 23.
  • Average duration of treatment was 13 months.

Reasons for Treatment Ending

  • 50% of patients completed a full course of treatment with me
  • 26% dropped out of treatment prematurely
  • 22% were referred to other providers
  • 3% moved to other geographic locations during treatment

Treatment Completion

  • 97% of patients who completed treatment achieved full recovery. The remaining 3% achieved physical remission.
  • The majority of patients who completed treatment did so in a time frame of somewhere between 7 months and 2 years.
  • A full course of treatment required, on average, 27 sessions over the course of 17 months.
  • Patients with co-morbid conditions required more sessions, on average, than those without co-morbid conditions.

Weight restoration

  • All patients who completed treatment achieved 100% full weight restoration, as indicated by a return to their pre-AN percentile patterns of growth for height and weight.
  • Average time to achieve weight restoration was 3.6 months.
  • Patients who recovered with individual therapy took longer, on average, to achieve weight restoration than those who recovered through FBT.

Treatment Dropout

  • 26% of patients dropped out of treatment prematurely.
  • Patients receiving individual therapy were almost twice as likely as those receiving FBT to drop out of treatment prematurely.
  • For treatment drop-outs, there was a significant correlation between length of time spent in treatment and progress made.
  • All treatment dropouts who were in treatment with me for at least 2 months had made significant progress at the time of drop-out.
  • Patients who dropped out of treatment after one month or less had not made any progress at the time of drop-out.

Status at End of Treatment with Me

Recovery status was assessed for each patient as of his/her final session with me, regardless of the reason for treatment ending.  The statistics listed below are for the entire sample of patients, including those who completed a full course of treatment, those who dropped out prematurely, and those who were referred to other providers due to a geographic move or a need for a different level of care or type of care.

  • 48% had achieved full recovery
  • 2% achieved physical remission
  • 22% made significant progress
  • 5% made some progress
  • 18% made no progress
  • 3% regressed

Predictors of Positive Treatment Outcome

  • Completion of a full course of treatment: 97% of those who completed treatment achieved full remission.
  • Younger age (Children under 13 had the highest rates of full recovery, followed by adolescents ages 13-17).
  • Patients receiving FBT were almost twice as likely as those receiving individual therapy to achieve full recovery.
  • Males were more likely to achieve full recovery than females.
  • Patients with Restricting Anorexia Nervosa were more than twice as likely as those with Binge-Purge Anorexia Nervosa to achieve full recovery.
  • Patients taking psychotropic medication during treatment were somewhat more likely to achieve full recovery than those who did not take psychotropic medication.
  • Patients who paid full rate for treatment were somewhat more likely to achieve full recovery than those who paid a reduced rate due to financial need.
  • Caucasian (non-Hispanic) patients were somewhat more likely than Hispanic patients to achieve full recovery.

 

Tags: , , , , , , ,

Monday, November 6th, 2017

End of Treatment Outcomes for Patients with Mood Disorders (2009 – 2017)

 

Description of the Sample

This analysis includes all patients with a primary diagnosis of a mood disorder who participated in an evaluation followed by a minimum of one therapy session with me between the start of my practice in 2009 and spring 2017.  Given that this is an analysis of end of treatment outcomes, patients who are currently in treatment with me were not included in this sample.

The sample includes 34 individuals (29 females and 5 males) who ranged in age from 12 – 59 years old, with a median age of 20.  The majority of patients in this sample (65%) had a primary diagnosis of Major Depressive Disorder.   Other primary diagnoses included Unspecified Depressive Disorder, Bipolar Disorder, Mood Disorder Not Otherwise Specified, and Persistent Depressive Disorder (formerly known as Dysthymia).

More than half of these patients (56%) had a secondary diagnosis.  The most common secondary diagnoses were anxiety disorders. Other secondary diagnoses in this sample included ADHD, eating disorders, and PTSD.

Approximately 30% of the sample had a history of psychiatric hospitalization, most commonly for suicide attempts or suicidal ideation, prior to staring treatment with me.

Description of Treatment Received

The length of treatment varied dramatically, from one week to 3.7 years.  Number of sessions attended also varied dramatically, from 1 session to 135 sessions.  The broad range of treatment duration and sessions attended reflects the reality that some individuals decided not to proceed with treatment after one or two sessions, whereas other individuals attended sessions off and on, as needed, for the duration of their high school or college years.  The average duration of treatment was 11.9 months and the average number of sessions attended was 28.  So, a typical patient with a mood disorder attended approximately 28 sessions over the course of one year.

The type of treatment received was tailored to the individual patient, based on his or her presenting symptoms, circumstances, age, and preferences.  Forty-one percent of patients received Cognitive-Behavioral Therapy (CBT), 18% received a Dialectical Behavior Therapy (DBT) skills-based approach (NOT a comprehensive DBT program), 30% received integration of CBT and supportive counseling, and 11% interpersonal psychotherapy or supportive counseling.

Level of family involvement varied depending on the patient’s age, presenting symptoms, preferences, and living circumstances.  For the purposes of this assessment, high level of family involvement means that at least one family member attended all or most sessions with the patient.  Moderate level of family involvement means that family members attended some sessions and maintained ongoing communication with me throughout treatment.   Low level of family involvement means that at a family member was involved in the evaluation and/or at least one session, but most sessions were individual.  Among all patients in this sample, 18% had a high level of family involvement, 21% had a moderate level of family involvement, 18% had a low level of family involvement, and 44% had no family involvement.  Degree of family involvement was higher, in general, for adolescent patients than for adult patients, with all patients under age 18 having at least some family involvement in their treatment.  Fifty percent of adolescent patients (under age 18) had a high level of family involvement, while 42% had a moderate level of family involvement and the remaining 8% had a low level of family involvement.

Nearly ¾ of patients saw a psychiatrist and took psychotropic medications during treatment.  Nearly ¼ of patients were hospitalized during treatment, most commonly for suicidal ideation or suicidal gestures.

Treatment Completion and Recovery Rates

Of all patients who began treatment with me for a mood disorder, 15% achieved complete recovery, 24% made significant progress, 41% made some progress, 15% made no progress, and 6% regressed.  For a detailed description of what terms such as “complete recovery” and “significant progress” mean, please see this blog post from 2013.

Eighteen percent of patients completed a full course of treatment with me.  Completing a “full course of treatment” was defined as a mutual ending in which the patient, his/her family (in cases where family was involved) and I mutually agree that treatment goals have been met and treatment is no longer needed.  Of these “treatment completers,” 83% achieved full recovery and the remaining 17% made significant progress towards treatment goals.

The length of time required to complete a full course of treatment varied dramatically from person to person, depending on symptom severity and progress in treatment.  Time required to complete treatment ranged from 1 month to 3 years, with a mean of 16.6 months.  Likewise, number of sessions required to complete treatment varied dramatically between individuals.  Number of sessions attended for treatment completers ranged from 4 – 96 sessions, with an average of 23 sessions.  So, on average, individuals who were most successful in treatment (e.g., those who completed treatment and achieved full remission from their mood disorders) attended an average of 23 sessions over the course of 16 months.

Fifteen percent of patients moved to another geographic location during their treatment (either to attend college or to live elsewhere permanently), prior to completing a full course of treatment with me.  As of their last session with me, 60% of these “movers” had made significant progress in their treatment and the remaining 40% had made some progress.  These individuals were referred to other treatment providers in near their universities or new homes for continued treatment.

The dropout rate for patients with mood disorders was fairly high: 50% of patients discontinued treatment with me prematurely.  As of their last session with me, 18% of these “discontinuers” had made significant progress towards treatment goals, 59% had made some progress, and 24% had made no progress.   On average, individuals who discontinued treatment sooner made less progress, while those who remained in treatment longer made more progress towards their treatment goals.   Three quarters of the individuals who made no progress dropped out of treatment after just one or two sessions, and the remaining one quarter dropped out after 5 sessions.  In contrast, those who made significant progress prior to dropping out of treatment attended an average of 20 sessions.

I do not have data on what happens to patients after they discontinue treatment, so this is purely speculation, but I believe several factors contribute to the high dropout rate among patients with mood disorders.  First, depression frequently interferes with a person’s motivation and ability to carry out tasks, and tends to make people hopeless and pessimistic.  Individuals with these symptoms may have a more difficult time persisting towards a goal, such as scheduling appointments and continuing with treatment over a number of months, and they may feel less hopeful about having a positive outcome in treatment.  Second, some patients and families may be satisfied with “good enough,” and may drop out of treatment after making good progress but before achieving all treatment goals.  In contrast, I have high standards for my patients: I believe that full recovery is possible for most people, and when full recovery does not seem achievable, then a full and meaningful life with well-managed symptoms is an alternative good outcome.  I work diligently with patients and their families in pursuit of these goals.

Eighteen percent of patients with mood disorders were referred to other clinicians who could better meet their needs.  I made these referrals when a patient was not progressing in treatment, and when it did not appear likely that they would make progress in the near future.  As of their last session with me, 17% of referred patients had made significant progress, 33% had made some progress, 17% had made no progress, and 33% had regressed.

Predictors of Treatment Outcome

Not surprisingly, completion of a full course of treatment emerged as a strong predictor of positive treatment outcome.  83% of individuals who completed treatment achieved full recovery, while the remaining 17% made significant progress towards treatment goals.  None of the individuals who discontinued treatment prematurely achieved full recovery.

Another strong predictor of positive treatment outcome in this sample was referral source.  Eighty percent of individuals who achieved full recovery were self-referred (e.g., they found my practice through an online search), while the remaining 20% were referred by word of mouth (e.g., by a friend).    In contrast, none of the individuals who were referred to my practice by their psychiatrist, pediatrician, or another therapist completed a full course of treatment or achieved full recovery, although a number of them made significant progress.  My interpretation of this finding is that individuals who proactively sought my services of their own volition may be especially dedicated to improving their mental health, more invested in their treatment, and thus more likely to persevere through a full course of treatment and achieve recovery.   In the case of self-referred adolescents, their parents were the ones who actually brought their children to treatment.  These parents, on the whole, were particularly attuned to their child’s needs and struggles, researched their child’s symptoms and the variety of treatment approaches available, sought my services proactively, and were especially motivated to help their child recover.  Perhaps this parental conscientiousness, attunement, and empowerment helped facilitate recovery for their children.

Level of family involvement in treatment predicted treatment completion and full recovery for adolescent patients but not for adult patients.  All of the adolescents who completed treatment and recovered had moderate or high levels of family involvement.  In contrast, 75% of the adults who completed treatment and achieved full recovery had no family involvement in their treatment, while the remaining 25% had a low level of family involvement.

Individuals who took psychotropic medication were somewhat less likely to recover than those who did not: 40% of individuals who achieved full recovery were taking medication during treatment, whereas 76% of individuals who did not achieve full recovery were taking medication during treatment.  It is unlikely that taking psychotropic medication caused patients to have a worse outcome.  I believe the most likely explanation for this finding is that taking psychotropic medication is a marker of severity: individuals with more severe forms of mood disorders (e.g., Bipolar Disorder, Severe Recurrent Major Depressive Disorder) are more likely to need medication and are perhaps less likely to achieve complete remission of symptoms.

Hospitalization during treatment emerged as a predictor of less favorable outcome.  None of the individuals who were hospitalized during their treatment with me completed a full course of treatment or achieved full recovery.  It is unlikely that being hospitalized actually caused patients to quit treatment or caused them to make less progress in their treatment.  It is more likely that hospitalization, like taking psychotropic medication, is a marker of severity, and those individuals with more severe illnesses are less likely to experience complete remission of symptoms.

The following variables did NOT predict treatment outcome: age, gender, ethnicity, duration of illness, diagnosis, presence of co-morbid diagnoses, rate paid for services, type of treatment received, or history of hospitalization prior to starting treatment.

 

 

Tags: , , , , , , , , , , ,

Friday, August 4th, 2017

End of Treatment Outcomes for Patients with Anxiety Disorders (2009-2017)

 

In an effort to improve the quality of services I offer, and in the service of full transparency to those who seek treatment, I am committed to compiling and sharing outcome data every few years on the patients I have treated.   The last time I compiled and shared my treatment outcome data was in 2013, so it is time for another round, this time with a larger sample to describe.

Description of the Sample

This analysis includes all patients with a primary diagnosis of an anxiety disorder who participated in an evaluation followed by a minimum of one therapy session with me at any time between the start of my private practice in 2009 and spring of 2017.  Given that this is an analysis of end of treatment outcomes, patients who are currently in treatment with me were not included in this sample.

This sample includes 16 patients, all female, who ranged in age from 10 – 42 years old, with a median age of 20.

Description of Treatment Received

Seventy-five percent of these patients were treated with Cognitive-Behavioral Therapy (CBT), while the remaining 25% of patients were treated with supportive or client-centered therapy.

Length of treatment and number of sessions attended varied considerably among these individuals.  The vast majority of patients were in treatment with me for somewhere between 2 – 19 months and attended somewhere between 3-17 sessions.   The median duration of treatment was 4.5 months, and the median number of sessions attended was 12.

Degree of family involvement varied based on the patient’s age and living circumstances.  All patients under age 18 had at least a moderate level of family involvement, and 83% of patients under age 18 had a high level of family involvement.  Patients of college age had low- to moderate levels of family involvement, and most adult patients in their 30’s and 40’s had minimal, if any, family involvement.

Forty-four percent of patients were taking psychotropic medication, prescribed by their psychiatrist, during their treatment with me.  None of the patients in this sample were hospitalized during the course of their treatment with me.

Treatment Completion and Recovery Rates

Of all patients who entered treatment with me for anxiety disorders, 44% percent recovered completely from their anxiety disorder, while 38% made significant progress in terms of reduction of symptoms and improvement in functioning, and 19% made some progress towards recovery.   In sum, all of the patients in this sample made at least some progress towards their treatment goals.  For a detailed description of the criteria used to determine “full recovery,” “significant progress,” and “some progress,” see this blog post from 2013.

Half of the patients who entered treatment with me for anxiety disorders completed a full course of treatment.   Completing a “full course of treatment” was defined as remaining in treatment until the patient, her family (when involved), and I collaboratively agreed that treatment goals had been met and further treatment was not needed.  The number of sessions required to complete a full course of treatment ranged from 3 – 25 sessions, with a median of 4 sessions.  The duration of treatment for those who completed a full course of treatment ranged from 1-19 months, with a median duration of 3 months.  Of those who completed a full course of treatment, 88% achieved full recovery and 12% made significant progress since starting treatment.

The remaining half of patients did not complete a full course of treatment with me, either because they quit treatment prematurely, they moved to another geographic location, or I referred them to another clinician.   Among those who did not complete a full course of treatment, 63% had made significant progress in their recovery at the time they left treatment with me, and the remaining 37% had made some progress.  It is important to note that I do not have data on what happens to patients after they leave my practice, so these treatment outcomes are based on an assessment of the patient’s symptoms and functioning as of the last session they attended with me. It is possible that some individuals who left treatment prematurely achieved full recovery later on their own, or in treatment with another clinician, after leaving my practice.  It is also possible that some individuals experienced a worsening of their condition after leaving treatment.

Predictors of Treatment Outcomes

A high level of family involvement in treatment emerged as the strongest predictor of successful treatment outcome.  100% of patients who had high levels of family involvement in treatment completed a full course of treatment and achieved full recovery.

Completion of a full course of treatment was the second strongest predictor of successful outcome. 88% of patients who completed a full course of treatment achieved full recovery from their anxiety disorder.  The remaining 12% of treatment completers had made significant progress since the start of treatment.

Younger age was also a predictor of successful treatment outcome.  Younger age was strongly correlated with both high family involvement and completion of treatment.

Other factors associated with successful treatment outcome include shorter duration of illness, good attendance at therapy sessions, paying full rate for services, and being self-referred to my practice.

Not surprisingly, discontinuing treatment prematurely was associated with less favorable outcomes.   Even so, 63% of individuals who discontinued treatment prematurely had made significant progress since beginning treatment with me, and the remaining 37% had made some progress.  These data indicate that the majority of individuals with anxiety disorders experienced significant benefits from treatment in terms of reduction of symptoms and improvement in functioning, whether or not they completed treatment a full course of treatment.

Other factors strongly associated with a less favorable treatment outcome included the presence of a comorbid diagnosis, taking psychotropic medication during treatment, and being referred to my practice by a psychiatrist.  Interestingly, these three factors were strongly correlated with one another: all of the individuals who were referred to my practice by their psychiatrist were taking psychotropic medication and 80% of individuals referred by their psychiatrist had comorbid diagnoses.

The following factors were modestly associated with less favorable treatment outcomes: older age, longer duration of illness, lower levels of family involvement, poor attendance at therapy sessions, and paying reduced rate for services.  Again, these factors tended to co-occur with one another, and also tended to co-occur with the three negative prognostic factors listed above.

These statistics reflect overall trends, not absolutes.  Some individuals in this sample did achieve full recovery despite being adults with long duration of illness and no family involvement, or having other characteristics typically associated with less favorable treatment outcome.

For a more detailed description and interpretation of these statistics, click here.

Tags: , , , , , ,

Sunday, June 11th, 2017

There’s an App for That!

 

Technology can be used in a variety of ways to enhance mental health and aid in recovery from psychological disorders.   For example, patients can use smart phone apps to help them track moods and symptoms, implement coping strategies, and reach out for help from clinicians and peers when needed.   Most evidence-based, behaviorally-oriented treatments for mental health problems – such as Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), and Mindfulness-Based Cognitive Therapy (MBCT) – require some degree of self-monitoring.  These types of treatments also strongly encourage daily practices to enhance well-being, such as journaling, identifying and challenging negative thoughts, diaphragmatic breathing, or mindfulness meditation.

Most of the teenagers and college students I work with are far beyond the old pen-and-paper logs and worksheets I was trained to use during graduate school.  It seems there’s an app for everything these days, and so many of these apps are relevant to mental health and wellness.  Today’s young people organize their lives on their smart phones anyway, so it is only natural that we would look to the smartphone to help them self-monitor their symptoms, complete their therapy assignments, and keep track of the strategies they use to help themselves.

There are literally hundreds, if not thousands, of apps that are useful to people with mental health conditions.  Here are a few of my favorites:

The Recovery Record app helps patients with eating disorders self-monitor their meals and snacks as well as thoughts, feelings, and urges that arise around food.

The Insight Timer app offers a meditation timer, thousands of free guided meditation tracks, groups for like-minded meditators, and the ability to track quantitative statistics such as how many minutes the user spends each day in meditation.

DBT Diary Card and Skills Coach is an electronic version of the Diary Card used in standard DBT practice, which helps the patient track target behaviors and utilize DBT skills from the modules of Mindfulness, Distress Tolerance, Emotion Regulation, and Interpersonal Effectiveness.

The nOCD app helps patients with Obsessive Compulsive Disorder implement their exposure and response prevention treatment while compiling objective, real-time data on their experience.

I am a firm believer that what transpires in the therapist’s office is only a fraction of the treatment package.  Most of the healing process results from consistent changes that patients and their families make on a daily basis at home, at school, and in various social settings.   Thanks to modern technology, individuals who are committed to improving their well-being are now able to hold new tools, literally, in the palms of their hands.

Tags: , , , , , , , , , , ,

Monday, January 25th, 2016

Iatrogenic Effects

The year is 1892. Emily, age 14, is the second of six children in a Midwestern farming family. One evening in March, Emily’s mother catches a glimpse of her daughter undressing and is taken aback by how slim she looks. Over the next few days, mother notices that Emily eats very little at family meals. She mostly just pushes her food around the plate and slips pieces of her food under the table to the family’s two dogs.

Later that week, Emily’s older sister, Cora, confides in her mother that Emily is no longer getting her monthly cycles. Now mother is greatly concerned, and she has a talk with her husband, who is equally worried. Both parents sit down with Emily and express their concern over her poor eating habits, weight loss, and absence of menstrual cycles. In response to her parents’ talk, Emily bursts into tears. “I just can’t eat,” she cries. “I just can’t.” Mother and father hug their daughter, comfort her, and let her know that they will be taking her to the family doctor the next morning.

When Dr. Benson examines Emily the following day, he is alarmed by his young patient’s gaunt appearance and flat affect. She is no longer the bubbly, robust young girl he has known since birth. Emily’s pulse is much lower than normal, her muscles have wasted, and her adolescent figure has shrunken to a pre-pubescent one.

“Emily is gravely ill and melancholy,” Dr. Benson tells the worried parents. “She is malnourished, and she will need lots of food and rest to recover. She needs complete bed rest for the next three months, plenty of food at each meal, and six tall glasses of milk per day. I will see her again next week.”

Emily cries heavily all the way home, burying her head in her mother’s skirt. As soon as the family gets back to their house, her mother prepares her a large plate of food with extra bread and butter and a tall glass of milk. Mother sits beside Emily and strokes her daughter’s hair as she stares – terrified – at the heaping plate of food. “You will not be doing any chores this spring,” her father tells her firmly. “Cora will do your indoor chores and Ethan will take over your outdoor chores. You will not be returning to school this year – the 2-mile walk is too strenuous for you in this condition. Cora will speak with your teachers and bring home your assignments. You will study from home. You will return to school and chores when you are well.”

“But Papa…” pleads Emily. “I have to –“

“That’s enough, young lady. You know better than to take that tone with me. This is final.” With that, Emily’s father abruptly leaves the room. Tears stream down Emily’s cheeks as she weeps silently. Mother strokes her back and whispers: “Come on, sweetie. Eat.” Hands shaking, Emily picks up her fork and takes a bite. Mother waits with her at the table for the next two hours as she finishes every last bite of food and every last drop of milk.

19th century family

Dr. Benson makes house calls weekly over the next few months. Emily is always lying on her bed, reading and sipping a glass of milk, when he arrives. He watches the young girl slowly put on weight, regain her strength and stamina, begin to smile again, and then blossom into the cheerful teenager she was meant to be. By the time June rolls around, Emily has resumed her monthly cycle and returned to her normal weight. At this point, Dr. Benson gives her permission to begin doing some light chores around the house.

By September, Emily is eating with gusto. She has had three monthly cycles in a row and has regained her curvy figure. She returns to school and resumes all of her farm chores. Her parents are relieved to have their daughter back.

The vignette above illustrates how Anorexia Nervosa (AN) would have been treated several generations ago. Quite a stark contrast from how AN is treated today, isn’t it? The illness itself has remained basically the same throughout time, but the way that people conceptualize it and respond to it has changed dramatically. Consider the following differences between Emily’s treatment in 1892 and the treatment Emily’s great-great-granddaughter Marissa received in modern times:

1.) Emily’s parents are immediately concerned by her weight loss and dwindling food intake. They view weight loss in a growing adolescent as a sign of illness and take her to the doctor immediately. Marissa’s parents are pleased when they notice her becoming slimmer shortly after her 14th birthday. They praise her for foregoing desserts and snack foods. They encourage her interest in athletics and bring her jogging with them in the morning.

2.) Emily’s family doctor is immediately concerned by his young patient’s weight loss, lack of menses, and changed demeanor. At her 15-year-check-up, Marissa’s pediatrician commends her on her 12-pound weight loss. When Marissa’s mother expresses concern to the pediatrician about her daughter’s low heart rate and absence of menses for the past three months, the doctor explains that it is common for female athletes to lose their monthly cycle, and that Marissa’s low heart rate is also due to being a runner.

3.) The prescribed treatment for Emily – full nutrition and complete bed rest – is commenced immediately and aggressively. Eating more food is not recommended, or even suggested, for Marissa. Marissa continues running with the blessing of her doctor and the encouragement of her coach.

4.) The doctor views Emily’s parents as competent agents to re-feed their starving daughter and enforce bed rest for a prolonged period of time. Marissa’s parents are advised to “stay out of the food business” and admonished not to be the “food police.”

5.) Dr. Benson monitors Emily’s condition weekly and supports the family throughout the recovery process. Emily’s menstrual periods return naturally as she restores a healthy weight. Marissa’s pediatrician does not see her again until she develops a stress fracture 5 months later. Marissa has now lost a total of 20 pounds, and her pediatrician gently suggests that she tries to eat a little more. The pediatrician also refers her to a gynecologist, who prescribes birth control pills to re-start her periods.

6.) Emily is expected to comply with the prescribed treatment, and parents are expected to enforce it. Marissa restricts her food intake even more. She is now eating nothing but fruit, vegetables, and chicken breast. Scared to make matters worse, her parents say nothing.

7.) Emily eats hearty meals with her family every day for breakfast, lunch, and dinner, plus plenty of whole milk in between. Unable to watch her daughter starve herself any longer, Marissa’s mother takes her to a local therapist who was recommended by a neighbor. This therapist begins meeting with Marissa weekly, and also refers them to a family therapist and a dietitian. Marissa is now attending multiple appointments each week and following a 1600-calorie exchange plan created by her dietitian. She prepares her own meals, weighing and measuring everything.

8.) The doctor recommends chamomile tea with honey to soothe Emily’s nerves. Neither Emily nor her parents are blamed for her AN. The etiology of the illness is not discussed with Emily or her family, as it is not known. Marissa’s weight does not change, but her mood deteriorates. The therapist refers Marissa to a psychiatrist, who prescribes Lexapro and Klonopin. The family therapist suggests that Marissa’s AN is a cry for attention, as her father works long hours at his law firm and her mother is very preoccupied caring for her younger son with autism.

9.) Emily’s weight was restored to her normal range within three months of commencing treatment. She remains home with her family throughout and maintains good physical and mental health for the rest of her teenage years. By her 16th birthday, Marissa has lost 4 more pounds (a total loss of 24 pounds in 2 years). Her therapist recommends residential treatment at a well-marketed eating disorder treatment center in another state. Marissa spends 3 months at this residential treatment center. The psychiatrist there prescribes two additional psychotropic medications. Within a month of returning home, Marissa relapses and returns to the center for another 3 months.

10.) Emily maintains good relationships with her parents and siblings. She trusts her family to help her when she needs them. By the time she turns 18, Marissa has had three psychiatric hospitalizations, four stays in residential eating disorder treatment, and is taking five different psychotropic medications in addition to Ambien for sleep and birth control pills to regulate periods. She barely speaks to her parents and refuses to sign consents to allow them to access her healthcare information.

Emily and Marissa developed the same illness at the same age but received very different treatments and thus had very different outcomes. Emily’s AN was completely resolved within 6 months, whereas Marissa remains gravely ill and in intensive treatment four years later. Marissa experienced the iatrogenic effects that are so prevalent in modern eating disorder treatment. Iatrogenic effects are harmful outcomes caused by a medical intervention. In other words, a treatment which is intended to help a patient ends up making her condition worse or creating a new problem that wasn’t there before.

Marissa’s story is all too common. The adults around her – with good intentions – inflicted harm by prolonging her state of semi-starvation, prioritizing her adolescent autonomy above her physical health, disempowering her parents, alienating her from her family, subjecting her to time-consuming, costly, and ineffective therapies, prescribing powerful psychotropic drugs that may not have been necessary, isolating her from her primary support system, and surrounding her with other mentally ill teenagers.

modern girl

Clearly, some teenagers with Anorexia Nervosa have complicated presentations with multiple comorbidities which require a team of professionals and specialized care. But there are also many cases in which a simple and straightforward intervention would be far more effective and efficient than the iatrogenic treatments that so many kids and families endure. This is precisely why Family-Based Treatment (FBT) is so effective: it minimizes the iatrogenic effects of other eating disorder treatments. Mainstream eating disorder treatment often morphs Emilys into Marissas.

What would have happened to Marissa if she had been provided with the same treatment as her great- great-grandmother Emily? Would she, too, have regained full health in a matter of six months, and bounced back into a vibrant adolescent life? It’s impossible to know for sure, but it seems likely that she could have. It’s definitely worth a try. Our 21st century Marissas need and deserve treatment that is AT LEAST as effective as 19th century Emilys.

Tags: , , , , , , , , ,

Friday, January 22nd, 2016

After Weight Restoration: Mindfulness for Body Image

There are some people with Anorexia Nervosa (AN) who continue to struggle with significant body dissatisfaction well after their weight has been fully restored and normal eating patterns have been established. For these individuals, mindfulness can be a powerful tool to help them make peace with their bodies.

Jon Kabat-Zinn, creator of the Mindfulness Based Stress Reduction program for treating depression, defines mindfulness as: “the awareness that emerges through paying attention, on purpose, in the present moment, non-judgmentally, to the unfolding of experience moment by moment.”

Although mindfulness has its roots in ancient Buddhist philosophy, it is not a religious practice in itself. Mindfulness can be practiced formally, through mediation, or informally, by learning to be mindful while performing everyday tasks.

Research has demonstrated that mindfulness can reduce the tendency to react emotionally and ruminate on transitory thoughts. It follows, then, that mindfulness – especially with its focus on acceptance and non-judgment – may help people let go of negative thoughts about their bodies.

Yoga, a mindful form of movement with benefits for both physical and mental health, can help alleviate the mental symptoms of eating disorders. A randomized controlled trial of adolescents undergoing treatment for anorexia nervosa, bulimia nervosa, and other eating disorders found that adding yoga to a teen’s treatment plan helped to reduce food preoccupation, body dissatisfaction, and eating disordered thoughts. In recent years, many treatment centers have added yoga to their programs.

I often recommend yoga to my newly weight-restored patients as a means of reconnecting with their bodies, reducing stress, and improving physical fitness. Recovering people frequently enjoy yoga even more than they expected to. As one of my college-aged patients told me: “When I was really sick with Anorexia, I felt like my body was something I had to beat into submission. Now, I feel like my body and I are on the same team.”
That is the essence of yoga – a union of body and mind.

Mindfulness has become very popular in the field of mental health. The newer third wave behavior therapies, including Acceptance and Commitment Therapy (ACT), Dialectical Behavior Therapy (DBT), and Mindfulness-Based Cognitive Therapy (MBCT) all contain a core component of mindfulness. These mindfulness-based treatments have been adapted specifically for targeting body image.

Anyone with a book or a computer can begin practicing mindfulness for body image. It does not require a therapist or other trained professional. There are plenty of self-help books and internet resources on this topic:

ACT For Body Image Dissatisfaction
Living With Your Body and Other Things You Hate
The Free Mindfulness Project

Many of my patients in their late teens and early 20’s find that taking a mindfulness approach to their body image is more helpful than a simple cognitive-behavioral approach. Letting go of the struggle, and accepting their bodies as they are right now, brings a sense of peace and contentment which is quite the opposite of the constant struggle of an eating disorder.

Tags: , , , ,

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.

Tags: , , ,

Sunday, September 7th, 2014

After Weight Restoration: The Role of Insight

One of the hallmark symptoms of Anorexia Nervosa (AN) is anosognosia, or a brain-based inability to recognize that one is sick. For this reason, most patients have little or no insight when they first present for treatment. Even months into effective treatment, most patients with AN continue to demonstrate anosognosia from time to time, if not consistently. The irony here is that most patients with AN do not believe they are sick until after they have gotten well.

I am outspoken in my belief that insight is unnecessary, not to mention unlikely, in early recovery from Anorexia Nervosa (AN). I do not expect my patients to have any insight whatsoever early on in their treatment with me. I expect kids with AN to present in my office denying that they have a problem. Their lack of insight does not delay or undermine treatment one bit.

In Family-Based Treatment (FBT), the patient is not required to demonstrate any insight at all during Phase I (Re-feeding and weight restoration). Phase II (returning control of eating to the adolescent) and even Phase III (establishing a healthy adolescent identity) can be successfully completed with a relatively small amount of insight on the patient’s part.

The re-feeding and weight-restoration components of treatment can be achieved without the patient’s consent or compliance. Through FBT and similar family-centered approaches, parents can feed their children complete, balanced nutrition and ensure that they maintain a healthy weight for as long as necessary. In theory, a patient could exist in an externally-maintained state of physical health forever, which would be far better than suffering the long-term medical and psychological consequences of AN. But this is not recovery.

Children and younger teens tend to lack the maturity to develop good insight even after their AN has been in remission for quite some time. Lack of insight is completely normal at this stage of development, even for kids who have never had a brain disorder. It is not necessarily problematic for recovering adolescents to lack insight as long as they are living safely under their parents’ roof.

For older adolescents and young adults, however, there comes a point later in recovery, after physical health is restored and most mental symptoms have subsided, when a patient does need to develop some insight about their illness and “own their recovery.” Patients do not need insight to get well, but they certainly do need insight in order to live a healthy, fulfilling, independent life.

As a side note here, the type of insight I am referring to here has nothing to do with “discovering the root cause” or “learning to love yourself” or “finding your voice” or any of the other talking points commonly referenced in ED recovery circles. The important insights to gain, in my opinion, are the following:

1.) Acknowledging and accepting that you have (or had) an eating disorder, which is a biologically-based brain illness that you did not choose to have and your parents did not cause

2.) Acknowledging and accepting the possibility of relapse

3.) Ability to recognize eating disordered thoughts, feelings, and behaviors in yourself

4.) Understanding the necessity of maintaining full nutrition, every day, for life

5.) Accepting the necessity of maintaining your ideal body weight in order to reduce the risk of relapse

How do you help a person who is recovering from AN to develop insight? It’s tricky, and it varies considerably based upon the patient’s own unique experience of having AN. Unlike full nutrition and weight restoration, insight cannot be thrust upon someone against their will. The patient must be an active participant in the process.

I find it helpful, as a therapist, to have frank conversations with patients and their parents about the biological basis of AN, potential triggers, vulnerability to relapse, and the importance of practicing good self-care. A single conversation at the start of treatment is rarely sufficient. Instead, I integrate these conversations into most of our sessions to help the patient absorb and internalize this information. For the first few months of treatment, these discussions are primarily for the benefit of the parents, as most kids are too malnourished and shut-down to process this information. However, after weight restoration and brain healing, these discussions can have a powerful impact on recovering kids.

Parents often have these insight-building conversations with their recovering teens at home. Often, teens will get defensive, shut down, or lash out when parents bring up these topics. But sometimes kids actually listen!

Many weight-restored patients go through a phase of romanticizing their AN, longing to return to the days of extreme thinness, perpetual motion, and hyper-focus on academics and athletics. While these feelings are understandable and typical at a certain stage of recovery, they need to be counterbalanced with conversations about the negative impact AN had on their bodies, their minds, and their lives. Otherwise, it is all too easy for recovering people to view AN through “rose-colored glasses.”

Bear in mind that the development of insight can take years. Recovered teens who initially presented for treatment at age 13-14 (the typical age of onset) will often show a blossoming of insight around age 17-18, just as they are preparing to leave home for college. This newfound insight is often the result of a variety of factors, including consistent full nutrition, brain healing, normal adolescent developmental processes, maturity, frontal lobe development, and successful therapy. I have worked with many adolescents for whom this happens beautifully, organically, and right on time. These kids go off to college in other states and thrive.

In other cases, however, the timing may be far less convenient. Those who develop AN at 16 or 17 years of age may not be sufficiently recovered to develop the insight needed to manage their illness independently at that magical age of 18. Similarly, who relapse during their junior or senior year of high school may have a setback in the process of insight development and thus may not be ready for independence right after high school.

In some cases, kids are diagnosed in childhood or early adolescence but don’t receive effective treatment until late adolescence. In these cases, it may take even longer for insight to develop if the illness has become entrenched and emotional maturity lags far behind chronological age.

Further, teens who have suffered through months or years of ineffective treatment may have built up an arsenal of bogus myth-based insight that has nothing to do with the reality of their illness. For example:

• “I developed AN as a way to cope with feeling out of control in life.”

• “I have to want to get better on my own. I have to do this for myself.”

• “Re-feeding doesn’t help us discover the root cause of your illness.”

• “I am enmeshed with my parents and this is keeping me sick. I need to become more independent.”

These myth-based “insights” very often result in parental alienation and protracted illness.

As you can see, all insight is not equal. The insights worth having are those that are based in empirical science, those that empower parents to help their offspring recover, and those that serve to help patients achieve and maintain their physical and mental health while living a full and meaningful life.

Tags: , , , , , , , ,

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.

Tags: , , , , , , , ,

Wednesday, January 29th, 2014

Effective Treatment for Bulimia Nervosa: A Good Start

A randomized controlled trial recently published in the American Journal of Psychiatry found that Enhanced Cognitive Behavioral Therapy (CBT-E) was far more effective than psychoanalytic therapy in the treatment of Bulimia Nervosa (BN).

In this study, 70 adults with BN were randomly assigned to either the CBT-E group or the psychoanalytic therapy group. Those in the CBT-E group received 20 sessions over the course of 5 months, whereas those in the psychoanalytic therapy group received weekly sessions for 2 years.

CBT-E for bulimia nervosa directly targets bulimic symptoms of dietary restriction, binge eating, and purging by modifying self-defeating behaviors, identifying and challenging distorted thoughts and beliefs about food, body shape, and weight, and learning skills to regulate moods and deal with setbacks. For example, patients learn to moderate their food intake by consuming regular, satisfying meals and snacks throughout the day rather than fasting, which often leads to nighttime binges.

In contrast, psychoanalytic therapy helps patients work through emotions and resolve inner conflicts which are believed to be at the root of their eating disorder.

After five months of treatment, 42% of patients receiving CBT-E had stopped bingeing and purging, compared to only 6% of patients in the psychoanalytic therapy group. After two years, 44% of patients in the CBT-E group had remained abstinent from bingeing and purging, compared to 15% of patients in the psychoanalytic group. It is important to note that the 2-year assessment represents a 19-month post-treatment follow-up for patients in the CBT-E group, but an end-of-treatment assessment for the psychoanalytic therapy group. Thus, patients in the CBT-E group had maintained their remission 19 months after treatment ended.

I draw the following conclusions from this study:

1.) Treatments which directly target bulimic symptoms are likely to be much more effective than treatments that deal with underlying emotions and psychic conflicts.

2.) Bulimic patients who receive CBT-E experience symptom relief much more quickly than those who receive psychoanalytic therapy.

3.) CBT-E is more efficient and cost-effective. If a psychologist charges $150 per hour, twenty sessions of CBT-E over the course of 5 months would cost a total of $3000. Weekly psychoanalytic sessions for two years would cost a total of $15,600.

4.) The benefits of CBT-E are long-lasting for those who recover

5.) Psychoanalytic therapy can be effective for a small fraction of bulimic patients

6.) CBT-E should be a front-line treatment for bulimia nervosa because, statistically, patients are much more likely to benefit from it than from other treatment approaches.

Bulimia nervosa wreaks havoc on the brain as well as the rest of the body. Insufficient or erratic nutrition caused by restrictive dieting, fasting, bingeing, laxative abuse, purging, and dehydration have a direct and immediate impact on brain function. I suspect that a primary reason for the superiority of CBT-E is that it targets the symptoms of dieting, bingeing, and purging immediately, thereby helping patients achieve medical stability and brain healing. When a person is receiving consistent balanced nutrition and keeping it down, he or she is better able to process emotions, refrain from impulsive behaviors, and do the hard work that is necessary for full recovery.

Perhaps patients in the psychoanalytic therapy group did not have the tools necessary to recover. It is one thing to gain insight into one’s emotions and beliefs; it is another thing entirely to halt a destructive and addictive cycle of restricting, bingeing, and purging.

The authors of this study conclude that it “provides one of the clearest examples of the superiority of one well-implemented psychological treatment over another.” However, CBT-E is not a magic bullet: more than half of the patients who received CBT-E did not recover. Therefore, we need to improve existing treatments for BN and develop new, more effective treatments for this devastating illness.

Tags: , , , , ,

http://www.drsarahravin.com/img/best-badge-eating-disorder.png
Top 10 Psychologists in Coral Gables 2015

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

Top 10 Psychologists in Coral Gables 2015