The Treatment of Trauma and Eating Disorders

Transcription

1 The Treatment of Trauma and Eating Disorders Jennifer Batson, Psy.D. Primary Therapist Denver - Colorado Springs - Kansas City Updated 5/15/18

2 Objectives Describe overlap between eating pathology and trauma Describe theoretical framework for understanding EDs and trauma Discuss interventions

3 Anorexia Nervosa (AN) Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected. Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight. Restricting Type: This is a subtype that is typically associated with the stereotypical view of anorexia nervosa. The person does not regularly engage in binge eating. Binge-Eating/Purging Type: The person regularly engages in binge eating and purging behaviors, such as self-induced vomiting and/or the misuse of laxatives or diuretics. The binge eating/purging subtype is similar to bulimia nervosa; however, there is no weightloss criterion for bulimia nervosa. As in previous editions of the DSM, anorexia nervosa "trumps" bulimia nervosa, meaning that if a person meets criteria for both anorexia nervosa and bulimia nervosa that anorexia nervosa (binge-eating/purging type) is diagnosed.

4 Bulimia Nervosa (BN) Recurrent episodes of binge eating. An episode of binge eating is characterized by BOTH of the following: Eating in a discrete amount of time (ex: within a 2 hour period) an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances. Sense of lack of control over eating during an episode. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for three months. Self-evaluation is unduly influenced by body shape and weight. The disturbance does not occur exclusively during episodes of anorexia nervosa.

5 Binge Eating Disorder (BED) Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating). The binge-eating episodes are associated with three (or more) of the following: Eating much more rapidly than normal. Eating until feeling uncomfortably full. Eating large amounts of food when not feeling physically hungry. Eating alone because of feeling embarrassed by how much one is eating. Feeling disgusted with oneself, depressed, or very guilty afterward. Marked distress regarding binge eating is present. The binge eating occurs, on average, at least once a week for 3 months. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.

6 Other Specified Feeding and Eating Disorders (OSFED) Atypical Anorexia Nervosa: All of the criteria for anorexia nervosa are met, except that despite significant weight loss, the individual's weight is within or above the normal range. Bulimia Nervosa (of low frequency and/or limited duration): All of the criteria for bulimia nervosa are met, except that the binge eating and inappropriate compensatory behaviors occur, on average, less than once a week and/or for less than 3 months. Binge-Eating Disorder (of low frequency and/or limited duration): All of the criteria for bingeeating disorder are met, except the binge eating occurs, on average, less than once a week and/or for less than 3 months. Purging Disorder: Recurrent purging behavior to influence weight or shape (e.g., self-induced vomiting, misuse of laxatives, diuretics, or other medications) in the absence of binge eating Night Eating Syndrome: Recurrent episodes of night eating, as manifested by eating after awakening from sleep or by excessive food consumption after the evening meal. There is awareness and recall of the eating. The night eating is not better explained by external influences such as changes in the individual's sleep-wake cycle or by local social norms. The night eating causes significant distress and/or impairment in functioning. The disordered pattern of eating is not better explained by binge-eating disorder or another mental disorder, including substance use, and is not attributable to another medical disorder or to an effect of medication.

7 Non-Dominant Hand Writing Activity Write with your non-dominate hand: 1. I feel in trying to write with my non-dominate hand. 2. If I were told I would need to write this way for the rest of my life, it would be for me and I would feel.

8 Non-Dominant Hand Writing Activity How is writing with your non-dominate hand like having an Eating Disorder? Your brain is wired to write with your dominate hand, it is comfortable, natural and easy EDs are brain based The dominate way for a person with an ED is to not eat/binge/purge/over-exercise, etc. In order to become physically healthier, a person with an ED has to override their dominate thoughts and feelings. (similar to this activity, it is awkward and uncomfortable) Recovery takes time, practice, routine to rewire

9 Trauma Defined A wound with a lasting effect Single blow vs. repeated trauma

10 Trauma Defined Emotional Abuse Verbal assaults on person s sense of worth or any humiliating or demeaning behavior directed at someone Physical Abuse Bodily assault that poses a risk of, or result in, injury Sexual Abuse Contact or conduct; explicit coercion is frequent but not necessary feature Emotional Neglect Failure to provide basic psychological and emotional needs (love, encouragement, belonging, support, attention) Physical Neglect Failure to provide basic needs (food, shelter, safety, supervision, health) Exploitation Deception, coercion, and/or force (trafficking, prostitution, labor, financial) Teasing/Bullying Natural disasters

11 The Eye of the Beholder PTSD unique diagnosis because of the importance placed upon etiology. Diagnosis not made unless the person has met the "stressor criterion," meaning exposed to an event considered traumatic Trauma, like pain, is subjective Filtered through cognitive and emotional processes and history Varying thresholds and adaptive capacities for experiences, even of the same traumatic event Bottom line: Psychologically there is overwhelming emotion and a sense of utter helplessness Allen, 2005

12 Complex Trauma Exposure to multiple events often of an invasive, interpersonal nature and the wide-ranging, longterm effects of this exposure Events are severe and pervasive Domains affected: attachment, sensorimotor/somatic development, affect regulation, dissociation, behavioral control, cognition, self-concept, interpersonal relatedness At-risk for additional trauma exposure (Recapitulation) Cook et al., 2005

13 Co-Morbidity The rule rather than the exception. Rare hat ED patients struggle with just disordered eating more commonly will also suffer from mood disorders, anxiety, substance use, somataform disorders, personality disorders, and trauma These are also associated with history of trauma and PTSD Brewerton, 2007

14 Relationship Between EDs and Trauma Childhood sexual abuse (CSA) is a nonspecific risk factor Meta analysis of 53 studies showed association of childhood sexual abuse and increased incidence of EDs Trauma associated with EDs includes variety of forms of abuse and neglect; Link between ED and trauma also found in children/adolescents, boys and men with EDs Subthreshold PTSD may be risk factor for BN and bulimic symptoms Not associated with severity of the ED Associated with greater co-morbidity (including and often mediated by PTSD) Trauma and PTSD must be addressed in order to facilitate ED recovery Brewerton, 2007

15 Rates of PTSD in EDs 40% of women with BN 22% with BED 14% of women with AN Compared to 12% Non-ED women Approx. 40% of women with BN and 35% with BED reported sexual assault 60% of men with BN reported partner violence 26% of men with BED reported childhood abuse Study in residential treatment: 74% of 293 women admitted reported a traumatic event and 52% met PTSD criteria Mitchell et al, 2012; Reyes-Rodriguez et al, 2011

16 Prevalence More common in BN, AN b/p type, BED, and purging disorder than with AN r type or with OSFED not associated with bulimic symptoms Abuse and neglect not associated with ED severity BUT other psychopathological features found at higher rates interpersonal distrust and interoceptive awareness on EDI and levels of dissociation on the Dissociative Experiences Scale

17 Common Features High rates of dissociation and alexithymia Approx. 75% with AN and 50% with BN extreme difficulty describing emotion Emotional dysregulation Subset of ED patients with PTSD characterized by impulsivity. May help explain overlap between Trauma and AN b/p, BN, and BED but not AN-r

18 Mechanisms of the Relationship between EDs and Trauma Disruption in the nervous system which may make it difficult for individuals to manage their emotions and so they turn to ED behaviors to manage discomfort Dysregulation increases vulnerability to psychiatric disorders Sexual trauma can cause body image issues Self-criticism, shame Hatred focused on body Physical manipulation to decrease attractiveness = safety Dunkley et al. 2010

19 Function of the ED Avoid, escape, sedate extremely painful feelings or affect To feel alive/release tension Discharge anger Establish power and predictability Communicate and maintain helplessness Rebel against injustice Express wish to be rescued Reenactment Abuse perspective clever yet destructive means to accomplish distance as well as re-enactment of the past through ED behavior What we call their symptom, they call their salvation Conceptualization critical to inform direction, course, timing and pace of treatment

20 Traumatic Responses Powerlessness Helplessness Grief Terror Self-blame/guilt Hyperarousal Numbing Anger Dissociation Mistrust Dysregulation Confusion Disorganization Avoidance

21 Sense of Self Identity and Self Esteem Defective, ruined, unlovable Self Punishment Containment of fragmentation Attempt to disappear Cleanse or purify the self Create large or small body for protection Avoidance of intimacy Symptoms may prove I am bad Create separation between mind and body Impaired trust with one s body (betrayal) Poor body boundaries

22 Challenges in Trauma Treatment Easily flooded Telling is often prohibitive Avoidance is natural component of post trauma adjustment Trust is impaired Distorted beliefs and sense of safety Profound shame and secrets Increased reliance on ED Tendency to freeze and/or to distract away from moving forward Nutritional rehabilitation Transference and Countertransference Reporting

23 Developing Buy In Emotions are adaptive, organizing, universal, social. We want to work with them, not control them Remembering can help explain previously incomprehensible symptoms create a more cohesive narrative The price of ignoring emotions or body messages is being unable to detect what is truly dangerous as well as what is safe/nourishing Suppressing does not stop stress hormones from mobilizing the body

24 In The Moment Natural and understandable response You could exaggerate the seriousness and suffer unnecessarily, but most suffer unnecessarily because they minimize the seriousness of what they ve been through Remember so you can get on with life

25 In The Moment Focus on the experience, not playing detective or attempting to corroborate the story Teach what happens when the self is under threat the neurobiology of trauma Surviving trauma takes courage and persistence Can shut down your inner compass and rob you of imagination to create something better Smoke detector analogy Express gratitude for how the ED served

26 In The Moment SUDs Will you feel better or worse if you talk about this right now? Safety Objects in room Identifying triggers

27 The Core of Trauma Shame A sense of worthlessness, powerless and helplessness; the emotional experience of another s scorn real or imagined Cognitively disorganizing Core messages (e.g. I am unlovable ) Shame about the body rooted in deeper shame

28 Effects of Shame Reasoning Map of attachment Recapitulations Beliefs what we believe becomes what we see; Painful but familiar

29 Shame Interventions Do not try to persuade with objective information Reflect the good you see and prepare for it to be dismissed Do not attempt to prove that the individual is good Acknowledge the difficulty in being seen differently Interpretations and epistemological approach Do not challenge beliefs directly explore the resistance Hypothesis testing Encourages self-reflection Relational repair empathy, boundaries, collaboration Building hope, reinforcing resiliency, proactive steps

30 References Mitchell K. S, Mazzeo S. E, Schlesinger M. R, Brewerton T. D, Smith B. N. Comorbidity of partial and subthreshold PTSD among men and women with eating disorders in the National Comorbidity Survey-Replication Study. International Journal of Eating Disorders. 2012; 45: Brewerton T. D. Eating disorders, trauma, and comorbidity: Focus on PTSD. Eating Disorders. 2007; 15: Reyes-Rodríguez ML, Von Holle A, Ulman TF, et al. Post traumatic stress disorder in anorexia nervosa. Psychosomatic medicine. 2011;73(6): Cook A, Spinazzola J, Ford J, Lanktree C, Blaustein M, Cloitre M, van der Kolk B. Complex trauma in children and adolescents. Psychiatric Annals. 2005;35:390.

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