Rachel Lawson Acting Clinical Head Project Leader Eating Disorders The Werry Centre ED and SUDS in Adolescence Background Research is limited Prevalence about a third Vast majority of those will have Bulimia Nervosa Some Anorexia nervosa binge purge subtype Most commonly used substances Alcohol, cigarettes and cannabis Most common reason for use anger release (mostly cigarettes), avoidance of eating (cigarettes and alcohol), escape from problems (cannabis) and relax/ feel good (all these substances) Part of general pattern of impulsivity Bulimia Nervosa Diagnostic Criteria Recurrent episodes of binge eating Eating, in a discrete period of time an amount of food that is definitely larger than most people would eat during a similar period of time and under similar episodes A sense of lack of control over eating during the episode E.g., the experience is like a ball rolling down a hill. Recurrent inappropriate compensatory behaviour in order to prevent weight gain Vomiting, excessive exercise, amphetamines, laxatives, diuretics and over the counter diet pills Bulimia Nervosa Diagnostic Criteria Both behaviours must occur at least twice a week for three months For binges at least once a month for three months Compensatory behaviour lower threshold of symptom severity Self evaluation is unduly influenced by body shape and weight The disturbance does not occur exclusively during episodes of anorexia nervosa Bulimia nervosa is divided into two subtypes: non purging and purging subtype Central Cognitive Elements Self Evaluation I am now going to ask you a rather hard question you may not have thought about this before. Over the past four weeks has your weight/shape been important in influencing how you feel about think yourself as a person? For example, friend who plays the piano Self Evaluation Client's Current Self-Evaluation Pie Chart Relationship Family Friends School Weight and Shape 1
Client's Ideal Self-evaluation Pie Chart Family Friends Relationship School Wgt/Shape Hobbies Central Cognitive Elements Disturbance of Body Concept How she feels about her body? If she likes/dislikes it? Do her feelings differ for different parts of her body? Body checking practices, including weighing Fear of fatness How would you feel if you gained a kilo? What might you do about that? Eating Disorder Not Otherwise Specified (EDNOS) Failure to meet the full criteria for either anorexia nervosa or bulimia nervosa Individuals receive the diagnosis of the disorder their symptoms appear to match to the closest Binge eating disorder (BED) Recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviors characteristic of bulimia nervosa Physical Risk All patients with eating disorders are at some degree of physical risk Managing the risk GP as part of the care team Physical Assessment Weight and Height BMI = weight (kg)/height(m)² Children and Adolescents: % weight for height scales Bloods Urea and Electrolytes: To assess for electrolyte imbalance, dehydration, kidney function Liver Function tests: To assess for damage to liver secondary to low weight/ and or alcohol misuse Full Blood Count: To assess for bone marrow suppression secondary to low weight Thyroid stimulating hormone (TSH): To exclude thyroid abnormalities for weight loss (NB thyroid s may be reduced in low weight individuals or in people on very restrictive diets) Physical Assessment ECG To assess effect of extreme state of starvation on the heart May see ECG changes with low potassium; heart muscle needs potassium to beat properly and regulate blood pressure Temperature Squat Test To assess proximal muscle weakness and whether extensive muscle failure has occurred Pulse and blood pressure (lying and standing) To assess stress on cardiac systems and the effects of dehydration 2
Treatment Good research CBT for BN adults Adaption for adolescents Research on treatment of co morbid eating and substance use disorders is bleak Clinically Case by case basis Substance dependence Initial detoxification and treatment for substance abuse followed by specialist eating disorders treatment Substance abuse Treatment that targets both problems simultaneously Goal Encourage patients to recognise any connections between the two problems Formulation A road map to treatment A shared understanding of the patient s problem Helps patient to develop metacognitive awareness. i.e., an understanding of their thoughts, feelings and behaviours Predisposing Precipitating Triggers Cognitions Make a mistake Core beliefs Disorder Specific (eating, weight & shape) I am a piece of shit Carbs willmake me fat If I am fat then I am a not attractive CBT for bulimia nervosa: I Phase 1 Engagement and motivation Psychoeducation e.g., role of vomiting; set point theory; energy requirements; value of regular meals Waller et al (2007) CBT for Eating Disorders: A comprehensive treatment guide. Cambridge University Press. Emotions Sad, angry, anxious Short term decrease Long term enhancement Behaviours Alcohol Cigarettes Dieting Binge Vomit Weighing Body Checking Formulation Basics of self monitoring food diaries and other behaviours in session weighing patient predicts weight first; plotted jointly on graph Hyperglycaemic /binge Normal/ recommended Upper Energy s (carbohydrate) Lower Hypoglycaemic /semi-starvation / preoccupied with food Behavioural Experiment Weight Graph The energy graph Upper Breakfast Lunch Hyperglycaemic /binge Dinner D 65 60 Rita's weight chart Upper normal weight band Typical in the eating disorders Energy s (carbohydrate) Lower A Hypoglycaemic /semi-starvation / preoccupied with food B C Weight (kg) 55 50 45 Lower normal weight band Very underweight Breakfast coffee only Lowcarbohydrate lunch Binge 40 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Week 3
CBT for bulimia nervosa: II Phase 2 Continue regular eating Begin to make links between cognitions, emotions and behaviours develop understanding of function of behaviours downward arrowing to get to the central cognitions Challenging beliefs regarding eating, shape and weight and core beliefs cognitive restructuring behavioural experiments CBT for bulimia nervosa: III Phase 3 Looking at broader problems problem solving skills Emotional regulation Body image work Relapse prevention Planning the future CBT for Bulimia Nervosa for adolescents Increased intensity of contact early in treatment to build treatment alliance Education and involvement of parents and others significant friends Flexibility in the use of homework and self monitoring logs Flexibility in the use of treatment time to examine other issues (developmental problems, crises with friends) Engagement and Motivation Motivational Interviewing Techniques Pros and cons Friend or foe letter Pie charts Life Plans Miracle question Values Card Sort Maslow s Hierarchy of Needs Problems and goals Life Plans Lots of energy put in surviving day to day Restrictive eating, bingeing and purging, substance use Focus on here and now rather than long term consequences of behaviour In order to help the client think more broadly Ask the client to consider where they want to be in terms of a specific event e.g., start of new school term, family holiday What will this event be like if they still have the eating disorder and SUDs? How do they want to be remembered in their school year book? Self evaluation Pie Chart Say: Most of us judge ourselves on aspects of our lives. For example, I have a friend who plays the piano and when they play well they feel good about themselves. What do you judge yourself on? What are the things that make you feel good about yourself if they re going well, or bad about yourself if they re not going well?...i am going to draw a circle on the board, like a pie chart, and then we ll fill it in with the things you have suggested. What do you want to start with and what amount should we allocate to that? Create ideal pie Use two side by side to think how they could move from one to the other Useful to acknowledge how much current identity is taken by E, S and w issues and substance use issues What could replace this element if the client were to consider change? Repeat through therapy 4
Teen Values Card Sort Sort through cards, pick top 3 5 values for each of very important to me; Important to me; Not important to me Main focus very important category; Elaborate and reflect on each value; What I would like you to do now is take each of these and tell me whether you think what s going on in your life now is having a positive/negative / or neutral impact on that value? 27 Values Good student; disciplined; and fit; respected at school; strong; in control; on top of things etc Maslow s Hierarchy of Needs Group Exercise Fulfilling life 1 x 2 x personal identity and achievement 3 x belonging (love, affection, being part of a group) 4 x Safety and Security 5 x Survival Substances? Questions E mail: rachel.lawson@cdhb.govt.nz Workforce development Special interest groups Online community Nurses, Dietitians Under construction OTs Clinical Psychologists Medical Staff E learning 5