The Role of Occupational Therapy in the Treatment of Eating Disorders

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1 The Role of Occupational Therapy in the Treatment of Eating Disorders Melissa Livingston, OTR/L Ken Reimann, OTR/L Erin Coffey, OTR/L Samantha Thayer, OTR/L Kayla Hampton, OTR/L Cathryn Gibson, OTS

2 Objectives Identify evidence based practices most appropriate in the treatment of eating disorders Explain the role of OT in the treatment of eating disorders Explain the therapeutic value of three OT interventions used in the treatment of eating disorders

3 Melrose Center: Leading the way in eating disorder care Locations in St. Louis Park, Maple Grove and St Paul

4 Eating Disorder Diagnoses

5 Eating Disorder Diagnosis/Classification Anorexia Nervosa Restriction of energy intake relative to requirements; intense fear of gaining weight or of becoming fat; and disturbance in the way in which one s body weight or shape is experienced (APA, 2013)

6 Young women with anorexia are 12 times more likely to die than are other women of the same age that do not have anorexia. (Sullivan,1995) A study in 2003 found that people with anorexia are 56 times more likely to commit suicide than nonsufferers (Keel et al., 2003) Only one third of individuals struggling with anorexia nervosa in the United States will obtain treatment (EDH, 2017)

7 Eating Disorder Diagnosis/Classification Bulimia Nervosa Recurrent episodes of binge eating; recurrent inappropriate compensatory behaviors in order to prevent weight gain; and self-evaluation is unduly influenced by body shape and weight (APA, 2013)

8 An estimated 4 percent of women in the United States will have bulimia in their lifetime; 3.9 percent of these individuals will die; and only 6 percent will obtain treatment (EDH, 2017). A study in 2010 that compared the prevalence and service utilization for eating disorders across ethnic groups in the U.S. found that bulimia was more prevalent among Latinos and African Americans than non-latino Whites (Marques et al., 2010).

9 Eating Disorder Diagnosis/Classification Other Specified Feeding or Eating Disorder (OSFED) Disorders of feeding or eating that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning but do not meet the specific criteria for other eating disorders (APA, 2013)

10 Research indicates the severity of OSFED is similar to that of anorexia or bulimia (NEDA, 2017) Medical complications Eating disorder thoughts and behaviors Mortality rate

11 Eating Disorder Diagnosis/Classification Binge Eating Disorder (BED) Recurrent episodes of binge eating where there is marked distress regarding binge eating and binges are not associated with recurrent use of inappropriate compensatory behavior (APA, 2013).

12 A 2015 research publication indicated a 50% genetic risk for BED and that nearly 50% of BED patients have comorbid mood and anxiety disorders. The same study also identified 1 in 10 BED patients have a comorbid substance abuse disorder with the most prevalent being alcohol use. (Ulfvebrand et al., 2015) In 2007 it was determined that 3.5% of women and 2.0% of men in The United States will suffer from BED. This is more prevalent than AN and BN combined. (Hudson, et al., 2007)

13 Eating Disorder Diagnosis/Classification Avoidant/Restrictive Food Intake Disorder (ARFID) An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs (APA, 2013).

14 Eating Disorder Diagnosis/Classification ARFID cont. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one s body weight or shape is experienced; and the eating disturbance is not attributable to a concurrent medical condition or better explained by another mental disorder (APA, 2013).

15 Those with ARFID are more likely to be young and male Nearly half of children with ARFID report fear of vomiting or choking One-fifth say they avoid certain foods because of sensory issues. One-third of children with ARFID have a mood disorder Three-quarters have an anxiety disorder Nearly 20 percent have an autism spectrum condition (Fisher et al., 2014; Nicely et al., 2014; Ornstein et al., 2013)

16 Melrose data

17 Risk Factors Personal factors Genetic predisposition Neurobiology Environmental factors Sociocultural ideal

18 Co-occurring Psychiatric Diagnoses Depression Anxiety Disorders/Phobias Post Traumatic Stress Disorder (PTSD) Obsessive Compulsive Disorder (OCD) Personality Disorders, esp Borderline Chronic suicidality (Active or passive) Self-harm Substance Use Disorder (SUD)

19 Co-occurring Medical Issues Electrolyte imbalance Reduced Brain Mass Gastric or esophagus rupture (binging/purging) Kidney Failure, cardiac arrest Osteoporosis/Osteopenia Infertility Refeeding syndrome Periodontal complications Digestion complications Diabetic Ketoacidosis (DKA) Muscle Wasting, lanugo Anorexia Nervosa has the highest mortality rate of any mental illness (Arcelus, Mitchell, Wales, & Nielsen, 2011)

20 Treatment Models at Melrose

21 Treatment Models Cognitive Behavior Therapy (CBT) Dialectical Behavior Therapy (DBT) Radically Open Dialectical Behavior Therapy (RO-DBT) Family Based Therapy (FBT)

22 Cognitive Behavioral Therapy Based on premise that our thoughts, feelings, and behavior all influence each other. Changing maladaptive thinking can lead to a change in behavior and affect.

23 Dialectical Behavior Therapy Combination of cognitive and behavioral therapies Establishes coping mechanisms and skills to implement into everyday routine (Gleissner, 2016) Broken into 4 modules Core mindfulness Interpersonal effectiveness Distress tolerance Emotional regulation (Lenz et al., 2016)

24 Radically Open DBT Targets over controlled emotions and behaviors typically found in individuals diagnosed with anorexia Interventions strive to build traits such as Openness to new experiences Flexible responding Emotional expression and awareness Intimacy and connection (Lynch et al., 2013)

25 Family Based Therapy For adolescents and young people living with parents Based on the premise that parents are best treatment resource for recovery Consist of three phases 1. Interrupting ED symptoms, promoting weight gain 2. Gaining control of food choices 3. Developing identity beyond ED (Krosmerly, 2015)

26 Treatment Approach Eating disorder statistics tell us that in order for treatment to be successful, it must be multifaceted. It must include medical care, mental health care, and nutritional education and counseling.

27 Levels of Care Intake (IA) Outpatient (OP) Intensive Outpatient (IOP) Partial Hospitalization Program (PHP) Residential (Res) Intensive Residential (IR) Require Med Order 1:1 Appts. Require Med Order 1:1 Appts Groups Require Med Order 1:1 Appts. Groups Usually transfer from IR to Res Auto Order 1:1 Appts. Groups Adult and Adolescent Auto Order 1:1 Appts. Groups Assess Safety

28 Treatment Process Referral Evaluation Intervention Goal Assessment

29 Evaluation Initial Occupational Therapy Evaluation Semi structured interview What are your goals while here at Melrose? Additional Evaluation Adult/Adolescent Sensory Profile COPM MOCA/SLUMS CAM ILS OT Group recommendations Individual OT recommendations Ongoing evaluation

30 Treatment Process Intervention

31 Individual Sessions: Intervention Topics Using supports Return to school Body Image Cognition Leisure Employment & Return to work Coping skill use Time management & Routine Life roles Life skills Sensory tools Socialization 31

32 Skill acquisition groups

33 Skill generalization groups

34 Treatment Process Goal Assessment

35 Frames of Reference

36 Frames of Reference Model of Human Occupation (Bruce & Borg, 2002) A holistic model for practice, education, and research A system s perspective that emphasizes the constant transaction of person, task, and environment. Person as an open system Input Throughput Output Feedback Input (etc.) Three subsystems: Volition (personal causation, values, interests) Habituation (habits, routines, life roles) Mind-brain-body performance skills Environmental affords and presses

37 Frames of Reference Cognitive Behavioral a person s cognitive function and beliefs mediate or influence [their] affect and behavior. [ ] The goal of intervention is to change the person s thoughts, which in turn will change the person s behavior, ultimately improving the client s daily function and sense of self efficacy. (Bruce & Borg, 2002) Behavioral Built on experimental inquiry and principles of cognitive, social, and conditioned learning theories These principles are systematically applied through behavioral techniques and procedures that bring about behavior change within the individual, and build performance skills necessary for that individual to function successfully in his or her environment. (Bruce & Borg, 2002)

38 Frames of Reference Dynamic Interactional A restorative cognitive rehabilitation approach used to enhance the functional performance of persons having cognitive impairment. (Bruce & Borg, 2002) Cognitive Disability Describes the nature of cognitive processing impairments that compromise the ability for normal function, and identifies adaptations that will optimize the ability of cognitive disabled persons to function in their everyday world. (Bruce & Borg, 2002) Intervention not focused on cognitive change

39 Frames of Reference Psychodynamic How mental processes, including perceptions, thoughts, and feelings, that are in conscious awareness, as well as those that are not, influence one s selection of, participation in, and satisfaction with occupation. (Bruce & Borg, 2002) Intervention focus: enhancing interpersonal communication, facilitating healthy emotional experiences, enhancing self awareness and self acceptance, and enabling patients to identify and pursue their own skills or interests outside of the ED. Sensorimotor For individuals with difficulty processing sensation, which relates to impoverished body image, confidence, and task or social behavior. (Bruce & Borg, 2002) Goal: improved ability to integrate sensory information

40 Specialty Tracks at Melrose

41 Specialty Tracks Eating Disorder and Substance Abuse - EDSA Substance abuse are 4x more prevalent amongst people that suffer from eating disorders (Harrop & Marlatt, 2010). Eating Disorder and Type 1 Diabetes - ED-T1DM A 14 year longitudinal study indicated 60% of patients with T1DM developed an eating disorder with 27% of them using insulin omission as compensation. (Diabetes Care 2015 Jul; 38(7): ). Melrose is 1 of 5 ED-T1DM programs in the country.

42 Specialty Tracks Family Based Therapy - FBT Statistically more effective than other treatments for adolescents, specifically 2x more effective on 6 and 12 month follow up (Arch Gen Psychiatry. 2010;67(10): ) Family Learning Series FLS 4 week series that includes skill based and experiential groups in conjunction with therapy. Family Learning Day FLD Intensive day that focuses on application of skills in family unit.

43 Specialty Tracks Binge Eating Disorder - BED Currently accounts for over 1/3 of all initial assessments at Melrose Center. 17 week program that includes therapy, RD, OT, PT, MD and psychiatry appointments and support. New in 2017: BED Relapse Prevention Group Structured 16 week program that meets weekly with therapist.

44 Eating Disorder Prevention

45 Can Eating Disorders be prevented? Individual protective factors high self-esteem, confidence and positive body image Family protective factors family connectedness, happiness and healthy eating behaviors Socio-cultural factors a reduced emphasis on weight and physical appearance

46 Eating Disorder Prevention Normal eating is Flexible & Varies Eating foods you like when hungry, until you re satisfied Sometimes over-eating, sometimes under-eating using moderate constraint in food selection, but not being so restrictive you miss out

Eating Disorder Prevention Body positivity is Adopting more forgiving, accepting, & affirming attitudes towards our bodies, regardless of size Focusing on health and wellbeing regardless of size

47 Eating Disorder Prevention Body positivity is Adopting more forgiving, accepting, & affirming attitudes towards our bodies, regardless of size Focusing on health and wellbeing regardless of size Recognizing that all bodies are equally valuable Honoring differences in size, age, race, ethnicity, gender, dis-ability, sexual orientation, religion, class, and other human attributes. -Linda Bacon Body Positivity resources Dove Self Esteem Project (

48 Objectives Identify evidence based practices most appropriate in the treatment of eating disorders Explain the role of OT in the treatment of eating disorders Explain the therapeutic value of three OT interventions used in the treatment of eating disorders

49 Questions?

50 Check our website: Melroseheals.com Facebook.com/MelroseCenter Call Melrose for an intake:

51 Reference List Eating Disorder Hope, Eating disorder statistics and research. Retrieved from Gleissner, Grete. "What is DBT." Psychology Today, 28 Sept. 2016, Accessed 6 Nov Lynch, T. R., Gray, K. L., Hempel, R. J., Titley, M., Chen, E. Y., & O Mahen, H. A. (2013). Radically open-dialectical behavior therapy for adult anorexia nervosa: feasibility and outcomes from an inpatient program. BMC psychiatry, 13(1), 293. doi: / x Marques, L., Alegria, M., Becker, A. E., Chen, C., Fang, A., Chosak, A., & Diniz, J. B. (2011). Comparative Prevalence, Correlates of Impairment, and Service Utilization for Eating Disorders across U.S. Ethnic Groups: Implications for Reducing Ethnic Disparities in Health Care Access for Eating Disorders. The International Journal of Eating Disorders, 44(5), doi: /eat Mortality in Anorexia Nervosa. American Journal of Psychiatry, 152(7), National Eating Disorders Association (2017). OSFED overview and statistics. Retrieved from Ulfvebrand, S., Birgegard, A., Norring, C., Nogdahl, L., von Hausswolff-Juhlin (2015). Psychiatric comorbidity in women and men with eating disorders: results from a large clinical database. Psychiatry Research, 230(2), ) Hudson, J. I., Hiripi, E., Pope, H. G., & Kessler, R. C. (2007). The Prevalence and Correlates of Eating Disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3), Kosmerly, S., Waller, G., & Robinson, A. L. (2015). Clinician adherence to guidelines in the delivery of family-based therapy for eating disorders. International Journal Of Eating Disorders, 48(2), doi: /eat Lenz, A. S., Taylor, R., Fleming, M., & Serman, N. (2014). Effectiveness of Dialectical Behavior Therapy for Treating Eating Disorders. Journal Of Counseling & Development, 92(1), doi: /j x Body Respect: What Conventional Health Books Leave out, Get Wrong and Just Plain Fail to Understand about Weight, by Linda Bacon, PhD., and Lucy Aphramor, PhD, RD.

52 Fisher, M. M., Rosen, D. S., Ornstein, R. M., Mammel, K. A., Katzman, D. K., Rome, E. S.,... & Walsh, B. T. (2014). Characteristics of avoidant/restrictive food intake disorder in children and adolescents: a new disorder in DSM-5. Journal of Adolescent Health, 55(1), Nicely, T. A., Lane-Loney, S., Masciulli, E., Hollenbeak, C. S., & Ornstein, R. M. (2014). Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders. Journal of eating disorders, 2(1), 1. Ornstein, R. M., Rosen, D. S., Mammel, K. A., Callahan, S. T., Forman, S., Jay, M. S.,... & Walsh, B. T. (2013). Distribution of eating disorders in children and adolescents using the proposed DSM-5 criteria for feeding and eating disorders. Journal of Adolescent Health, 53(2), Golan M, Hagay N, Tamir S (2013) The Effect of In Favor of Myself : Preventive Program to Enhance Positive Self and Body Image among Adolescents. PLoS ONE8(11): e Lampis, J., Agus, M. & Cacciarru, B. Applied Research Quality Life (2014) 9: x Keel PK, Dorer DJ, Eddy KT, Franko D, Charatan DL, Herzog DB. Predictors of Mortality in Eating Disorders. Arch Gen Psychiatry. 2003;60(2): doi: /archpsyc Sullivan, P. F. (1995). Mortality in anorexia nervosa. American Journal of Psychiatry, 152(7), doi: /ajp American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Retrieved from

53 Discussion Questions How do you envision this information being useful in your current practice/role? Have you ever worked with a client that you thought could benefit from a referral to Melrose? Any personal or professional barriers to making a referral? If you were concerned about a patient how would you approach them?

Avoidant Restrictive Food Intake Disorder (ARFID)

Avoidant Restrictive Food Intake Disorder (ARFID) TABLE OF CONTENTS Introduction................................................3 What Is ARFID?............................................. 4 How Is ARFID