Posted by Mark Warren on Fri, Mar 05, 2010 @ 09:36 AM
Psychiatry, and by extension all mental health fields, are to some degree reliant on the Diagnostic Statistical Manual of the American Psychiatric Association. This manual, currently in its 4th addition, is now being re-evaluated for the upcoming 5th edition, known as the DSM V. The DSM is critical in multiple areas of mental healthcare. Its primary function is to provide a behavioral basis for diagnosis. In doing so, it provides standards by which a diagnosis can be reasonably made, that are considered valid and useful for the patient who is receiving the diagnosis.
The core feature of effective healthcare is the ability to link various treatments to different diagnoses. One of the most important ways to determine if you are receiving effective care is to know that your diagnosis impacts your treatment. A provider who believes one treatment treats all is unlikely to be providing effective care. In developing the DSM V, the American Psychiatric Association is acknowledging the importance of supporting the need for accurate diagnosis and effective treatment based on that diagnosis.
The process of developing accurate diagnoses is complicated. Early DSM versions are primarily informed by a psychodynamic view of the world and are not behaviorally organized. Starting with the DSM III in 1975, greater emphasis has been placed on behaviors and their treatment. The DSM V will be the most recent attempt to be as specific and clear as possible about true diagnostic categories and how best to understand complex psychological presentations. It is the nature of these diagnoses and definitions that they will not be perfect, final, or complete and that modifications will continue to occur. However, each manual has been an improvement of its predecessor and we believe the DSM V will be as well.
For eating disorders, there are some significant changes proposed for the DSM V. These include:
- The addition of Binge Eating Disorder as separate diagnosis. At this time, Binge Eating Disorder falls under the diagnosis of a non-specified eating disorder. Binge Eating Disorder, however, is likely the most common eating disorder, has significant medical complications, and may have effective behavioral treatment. Thus, patients will benefit by its having its own separate diagnostic category.
- The diagnosis for Anorexia Nervosa has been changed with the removal of the criteria for amenorrhea. This particular criteria has historically been used for research but is not considered to be a specific marker for the illness and it is possible to have anorexia while still having a normal menses. Its removal therefore will enable more patients to receive effective care.
- Bulimia Nervosa has been changed so that the number of episodes per week is no longer a central criteria for a diagnosis. In the DSM IV, the binge/purge cycle had to be present 3-4 times per week. Under the new criteria, the number of episodes per week has been reduced to one. Again, this change will result in more people with BN being able to access effective care.
Next week: The comorbidity between borderline personality disorder and eating disorders
Contributions by Sarah Emerman
Posted by Sarah Emerman on Fri, Feb 26, 2010 @ 04:20 PM
The two letters below were written by our clients to their eating disorders. With their permission, we share these letters to inspire others to seek treatment and fight for recovery.
Letter #1:
ED:
You are no longer welcomed in my life. Your constant companionship has left me nothing but lonely and hollow inside. You fed me lies instead of the food I really needed. You locked up the voice of my wise mind and hid the key from me. You told me that no one would love me unless I was thin.
Well ED, I did what you told me. I became so malnourished that I lost my hair, my sense of feeling, and my sense of self. You led me on a path of destruction that left me alone and confused. As I was physically and emotionally dying, you encouraged me to continue on this path.
I am no longer your "friend" ED. I am standing up for myself. Although you told me that I am worthless and I do not deserve my life, I do. I am taking back control from you ED. I found the key to the voice of my wise mind and I am allowing myself to follow it. I am no longer going to feel isolated and abandoned. I am going to embrace recovery and allow myself to live a life worth living.
Therefore ED, as hard as this may be, I am ending this "bad romance". You have brought me nothing but heartache and sorrow. Goodbye ED. I hope I never hear from you again. If you try to contact me, I will be busy living the life I deserve and have no time for you. Farewell.
Letter #2:
Dear ED,
I know you bought me those jeans but I'm just writing to tell you that I don't want them anymore. You lied and made me believe that they were a gift when really you were playing tricks with the mirror and disregarding my health as you told me how amazing I looked in them.
I may have felt good as I stepped out of the dressing room then but now I know there are more important things in life than my "great" pair of jeans. You never told me those jeans were dangerous, that by just putting them on you would control me. You never told me that my heart muscle was deteriorating, that it beat slower and slower to the point of almost stopping. No, you distracted me by bombarding me with compliments to make me feel amazing.
Even though you're not going into medicine and I am, it doesn't take a genius to realize that without a functioning heart there would be no one to even put on the jeans. ED, you don't make any sense, and I'm sick of it so take your jeans back. I'm not going to let you hurt and break my heart anymore.
Posted by Sarah Emerman on Thu, Feb 25, 2010 @ 09:41 AM
Take a listen to CCED's Dr. Lucene Wisniewski provide information on eating disorders and empirically based treatment on Cleveland Connection. The interview by Jim McIntyre aired Sunday, February 21st, on WDOK, WNCX, and WQAL.
Click here to stream the interview!
Posted by Sarah Emerman on Tue, Feb 23, 2010 @ 08:50 PM
This letter was written by the mother of a former client who was in our adolescent program. It is published with their permission in hopes that it will be a helpful resource for other families considering treatment. Identifying information has been removed to protect the privacy of our client.
Dear Dr. Wisniewski & Dr. LeGrange,
I would like to take a moment to personally thank you for all you have done to help the development of the Maudsley Approach. At this present time my daughter is weight restored, back in school, and resuming the normal life of a teenage girl (given that there is a normal). It has been * since we discovered my daughter was assaulted and used starvation and bulimia as a coping mechanism to deal with her trauma. After 4 or 5 months of “traditional” treatment and heartache we learned of a program about * hours from our home that specialized in family based therapy. Our family was struggling, but through the Maudsley approach and CCED, not only was my daughter recovering, but we also were able to reestablish family communication, and coming together to fight this battle. We understood that the more aggressive we were in fighting this the better her chances were (are) for a long term recovery. My daughter and I went to The Cleveland Center for Eating Disorders and stayed there during the week, to take back control of her life. Once my daughter realized we were on her side and were willing to go to such drastic measures, such as to leave home, work, and school, she slowly came to realize she did not want to live her life that way any longer (once weight restored) and saw the need to pick up the fight.
The transition back to * was scary, but our therapist was familiar with the Maudsley method and began working with us again to continue recovery. My daughter is doing well at stage III, we still are in the process of following up and monitoring her weight, but we have been tapering off on sessions and she has been holding pretty steady. She knows when she needs to add extra supplements to her diet and we communicate our concerns to one another. The hardest part was probably phase II for me. After centering everything around her eating and being in Cleveland, just the two of us, I had to hold back on tendencies to want to mother or hover too much. I am so thankful that the support was available to help parents with this aspect of the treatment. I am so thankful for a program that allowed parents to be involved and part of the recovery and not isolated or considered the blame. We already had way too much guilt, and I am happy that she has the tools now to deal with difficulties in her life.
I appreciate your time in reading, I am sure, one of the millions of letters that you receive. I am a student, and while working on a project for my psychology class on eating disorders, and correcting my professor when she went down the road of parents being responsible, I realized there still is not a lot of information and resources regarding anorexia and family based therapy. So, while doing my research for my paper, I reflected on how lucky we were to have come across this program and; and this is what prompted my letter to you. I hope that other families are able to benefit as well.
Sincerely,
*
Posted by Sarah Emerman on Sun, Feb 21, 2010 @ 11:52 AM
Posted by Sarah Emerman on Fri, Feb 19, 2010 @ 12:21 PM
By Sarah Emerman and Katie Dent
Eating Disorder Awareness Week is an annual event intended to provide education on the prevention, understanding, and treatment of eating disorders to patients, families, medical professionals and the general public. This year it will be held throughout the week of February 21st. Throughout the week, The National Eating Disorders Association has partnered with various organizations who will be hosting events around Cleveland to raise awareness about eating disorder treatment and prevention. The Cleveland Center for Eating Disorders is committed to our participation in these important events.
On Tuesday, February 23rd, at 6:30 p.m. we will be holding an open house for the general public to view our facility, meet some of our staff, and interact with other families and patients who are suffering from these life-threatening illnesses. It will be an avenue for people to get information, identify resources for treatment, and receive support.
Additionally, one issue that CCED is particularly passionate about is removing barriers to receiving evidence-based care. On Wednesday, Feb 24th, at 6:30 p.m. we will be hosting a seminar intended for patients, families, and medical professionals titled “Identifying and Treating Eating Disorders in the Primary Care Setting”. Dr. Mark Warren and Dr. Lucene Wisniewski will be providing information on early warning signs of eating disorders, re-feeding syndrome, how to access evidence based treatment, important questions to ask your physician, and the medical risks of eating disorders.
If you would like to attend these free events please contact our front desk at (216) 765-0500 to secure your reservation.
Posted by Mark Warren on Fri, Feb 12, 2010 @ 09:38 AM
Understandably, one of the most difficult moments about beginning therapy for an eating disorder is when you first start treatment. In general, one is in a state of emotional distress during a crisis and is often given advice from multiple sources. With many different therapy options available, it can be difficult to be a truly educated consumer of psychological treatment. Add to this that so many health care providers believe that they hold the key to recovery and one can see how the ability to know if you are getting evidence-based care becomes very elusive. The mere fact that a therapist, physician, or other professional says they believe that a treatment is effective should never be a reason to chose that therapy. One needs something to support that belief.
In the real world we do not have time to review the scientific literature on everything a health care professional might tell us. What then can someone do first to research evidence-based treatment?
- Remember that there are very few evidence-based treatments for eating disorders. If you are not receiving cognitive behavioral therapy, dialectical behavioral therapy, interpersonal therapy, or family based therapy, then the odds are very high that you are not getting evidence-based care.
- Your primary care physician is likely to have experience with patients who have done different types of treatment in your community. Your primary care physician is therefore a critical resource.
- When you are in a provider’s office and they are discussing care options with you, never hesitate to ask for all of the evidence behind what they are saying. At this point in time, all practitioners in eating disorder treatment should be able to back up what they are saying in a straightforward and understandable manner.
- Finally, while doing research on treatment for eating disorders, the Internet, while helpful, may not provide definitive answers (and may be more confusing than anything). There are certain organizations that we feel are trustworthy. We highly recommend NEDA, AED, Maudsley Parents, ED Recovery, The Freed Foundation, Are you eating with your anorexic, The F-Word, NAMI, Life After Recovery, and FEAST as reliable organizations and blogs where you can learn about evidence-based care and communicate with other patients and families that may be struggling with an eating disorder.
Next week: CCED's Commitment to Eating Disorder Awareness Week
Contributions by Sarah Emerman
Posted by Sarah Emerman on Fri, Feb 05, 2010 @ 11:10 AM
By, Julie Norman, Registered Dietitian and Registered Yoga Teacher
Orthorexia is an obsession with "pure", "clean", and "healthy" eating. Ironically, the literal translation of the term "orthorexia" means "correct eating". Preservatives, fats, and animal products are often avoided. Often, orthorexia crosses the line from "healthy" eating to disordered eating when it becomes driven by fear of becoming unhealthy. People with orthorexia will maintain their food rules and rituals even in the face of evidence that it is starting to effect their health and other aspects of their life. Sadly, it is the mistaken belief that one is eating in a "healthy" way that eventually leads to being unhealthy.
Orthorexia is similar to anorexia in many ways.
- Food rules and behaviors have a profound effect on multiple areas of a person's life.
- Individuals may spend hours thinking about food and planning what they will eat in the near future.
- People suffering from orthorexia may avoid social situations involving food for fear of violating their food rules. Suffers may avoid eating at restaurants or allowing others to cook for them so as not to consume "unhealthy" ingredients.
- Malnourishment may occur if individuals do not consume enough nutrients, fat, and calories to sustain their bodies.
- Compulsive exercise and obsession with food become much of their identity and impacts their self-esteem and feelings of self-worth.
In the professional world it is very hard to differentiate between a person who is willing to go to these extremes for health reasons versus a person who has a drive for thinness. Therefore, orthorexia is not currently considered a formal diagnosis in the Diagnostic Statistical Manual and is usually grouped together with anorexia or an unspecified eating disorder by clinicians.
Next week: How do you know if you're getting evidence-based treatment?
Contributions by Sarah Emerman and Dr. Mark Warren
Posted by Mark Warren on Fri, Jan 29, 2010 @ 09:54 AM
The concept of recovery and eating disorders is often a complicated and confusing discussion. Use of the word "recovery" can mean many things to different people. Sometimes by recovery we mean that weight has been restored. Sometimes we mean that all behaviors have ceased. Sometimes we mean that all eating disordered thoughts are gone. Sometimes it means our triggers no longer trigger us and sometimes it means that our lives are back to normal, whatever normal may mean for each of us. So when we talk about recovery, we need to know what we mean, what is reasonable to expect, and how to understand that the process of recovery has many different stages.
It is reasonable to presume that a person's behaviors will stop and that weight will normalize to whatever it should be. At its most basic level, recovery should include both of these expectations. Without these changes, a person is still dealing with having an eating disorder on a daily basis. After weight has normalized and behaviors have ceased, the concept of recovery begins to change. The order of these changes will be different for different people. As discussed above, there will be multiple stages of change, including: how a person thinks, how they feel, how they spend their time, what their comfort level is, and how they get comfortable with their bodies and minds. In general, recovery should be thought of as a journey, not a destination. Eating disorder or not, all of us throughout our lives will be working hard to be as psychologically healthy as we can. No one ever reaches a perfect state of enlightenment, in the same way that no one with an eating disorder should expect that their thoughts and feelings will attain a perfect freedom from their disorder. But it is very possible for eating disorder thoughts and feelings to move far from the center of a person's life. Many individuals reach a state of comfort around triggers, develop a healthy relationship with food, and eventually feel comfortable inside their bodies and minds.
In her book, Gaining, which is one of our favorite books about recovery from an eating disorder, Aimee Liu quotes Dr. Sheila Reindl by stating "Recovery is like a big old house. The anorexic or the bulimic is always going to live there. People sometimes think, I can evict her, I can get rid of that. But you don't develop an eating disorder for no good reason. Its a profound experience. So how could you wipe out that whole piece of your history? I prefer to think of it this way. She was in charge of the kitchen, in charge of everything. Now she still gets to live there and she may still have some of those old fears and vulnerabilities, but she's got only one room in the house and has to make way for more and more occupants as time passes."
Next week: What is orthorexia?
Contributions by Sarah Emerman
Posted by Mark Warren on Fri, Jan 22, 2010 @ 10:39 AM
Medication may be part of successful treatment for bulimia nervosa. In multiple studies, treatment with antidepressants has been shown to be moderately effective in reducing the binge/purge cycle of an individual with bulimia nervosa. Trials have shown that antidepressants are superior to placebos in diminishing overeating, decreasing self-induced vomiting, and increasing the sense of control that someone has over their eating. Other studies show the response for those with bulimia to be similar to the rate of response with depression. Since it takes approximately two weeks to observe changes in depression with medication, it is implied that within two weeks some benefit may be seen in those with bulimia as well. Large scale evaluation of the studies of bulimia suggest that high doses of fluoxetine, generally within the range of 60 mg a day, has been optimum for reduction of behaviors and improvement of sense of control. In general, the rate of response to antidepressant medications, in particular fluoxetine, has been shown to be approximately 50%. To date, no consistent predictors of response have been identified. That is, a level of depression prior to treatment does not predict how well these will work with bulimia, even though they may be indicated for depression.
In no situation should medication be used alone for bulimia. Studies demonstrating the effectiveness of medication are clear that all medications are secondary to primary treatment with Cognitive Behavioral Therapy or Dialectical Behavioral Therapy. As noted above, fluoxetine, a selective serotonin re-uptake inhibitor "SSRI", has been studied more often than other medications. Studies by Walsh et al. suggest that taking an SSRI while undergoing Cognitive Behavioral Therapy can result in a significant reduction of symptoms of bulimia (Walsh, Wilson, Loeb, Devlin, Pike, Roose, Fleiss, & Waternaux, 1997). Studies also tend to show that by three weeks of treatment with an SSRI at an appropriate dosage, patients who will respond to medication have already started to show a response. Therefore, the benefits of SSRI treatment should be quickly experienced.
Of some concern with medication and bulimia is the potential seizure inducing risk of Wellbutrin. Because both bulimia and Wellbutrin have been associated with seizures, in general the use of Wellburtin in patients who have bulimia presents significant risk. It is not fully clear whether this risk is theoretical or has been experienced by a significant number of patients with bulimia, as studies of this question are not available. Given the theoretical risk, we try to avoid this combination whenever possible. There is also a small literature on the use of stimulants in patients with bulimia. These remain case reports and we await more thorough studies on this question. Again, given the potential seizure risk of stimulants, they should be used with caution.
A side note needs to be made concerning Topamax, which has been suggested by some clinicians as being an effective treatment for bulimia. To date, studies have not shown Topamax to be superior to an SSRI. Topamax may be associated with paresthesia (tingling) and cognitive impairment. Although Topamax has been reported to have effects on weight, the literature does not support using Topamx for weight issues with bulimia.
Walsh, B. T., Wilson, G. T., Loeb, K. L., Devlin, M. J., Pike, K. M., Roose, S. P., Fleiss, J., &
Waternaux, C. (1997). Medication and psychotherapy in the treatment of bulimia nervosa.
The American Journal of Psychiatry, 154:4, 523 - 531.
Next week: What does it mean to be in recovery?
Contributions by Sarah Emerman