Posted by Mark Warren on Fri, Jun 18, 2010 @ 04:10 PM
We have long known that people with anorexia nervosa are often likely to also have comorbid depression. Much of the time the depression is not a separate illness but a result of the physical and biological changes that anorexia produces on the brain and body. Tiredness, exhaustion, malnutrition, chronic worry, and obsession with body size and shape can all make someone more depressed. In addition, on a biological level we believe that the brain’s ability to produce neurotransmitters that effect mood are also significantly depleted by malnutrition. Specifically, we know that serotonin production lessens as malnutrition develops, which makes traditional antidepressant medications less effective. We believe that it is likely that almost all neurotransmitters, which can affect a wide variety of brain function, are depleted with malnutrition. This may look like depression, or just a lack of ability to feel any emotions.
This month an exciting new study has added to our knowledge of the biological changes of the brain from malnutrition. In a study led by Christina Roberto, at the Columbia University Center for Eating Disorders, Roberto found that individuals with anorexia suffered a loss of gray matter in the brain (which is the active part of the cortex). So, some of the changes we see may be due not only to neurotransmitters, but actual loss of brain mass. On a positive note, with restoration of weight, there is also restoration of gray matter, meaning that many of the brain changes from anorexia, whether neurotransmitter or gray matter itself, often correct as refeeeding occurs.
As we have discussed in this blog many times before, refeeeding is the most important single step for the treatment for anorexia. This new study adds to that data and makes clear once again that trying to talk someone out of their eating disorder is likely impossible as they may literally have lost the brain power to know whats going on. In terms of evidence based care, when looking for treatment for anorexia be cautious of treatments where refeeding takes a back seat to figuring out the why the eating disorder develops. As this study demonstrates, at the start of one's treatment, nutrition and refeeding should be the primary focus for most people.
For more on Roberto's study click here
Contributions by Sarah Emerman
If you have any questions or comments about this post please email blog@eatingdisorderscleveland.org
Posted by Sarah Emerman on Fri, Jun 04, 2010 @ 07:15 AM
By Dean Malec, Research Assistant, Sarah Emerman, and Dr. Denise Ben-Porath
The Cleveland Center for Eating Disorders has a strong commitment to ongoing research on effective treatment and evidence based care. Currently, CCED is conducting research for program evaluation on our adult, adolescent, and Dialectical Behavioral Therapy (DBT) day treatment, and intensive outpatient programs. Our goal is to ensure that we are offering empirically supported treatment that also best meets the needs of our clients. Several of our questionnaires have behavioral components to them that examine number of behaviors as treatment progresses, as well as emotional characteristics, such as hopelessness and impulsivity. By assessing the behavioral, psychological, and emotional components of eating disorders we are better able to holistically evaluate the impact of treatment and, if needed, make modifications or add adjunctive treatments.
We are currently in the first stages of presenting our findings. Recently, Dr. Anita Federici has shared the research we have gathered at the Society for the Exploration of Psychotherapy Integration conference in hopes to inform practitioners of significant findings we have gathered on our measures. We hope to take our results and utilize the data to better improve our programs, treatment, and experience of our clients as we help them through their recovery. Drs. Lucene Wisniewski and Denise Ben-Porath have also published several articles in the area of DBT, eating disorders, and treatment outcomes.
To read the abstracts of articles published by Drs. Wisniewski and Ben-Porath please click the links below:
Should you have any questions or comments regarding this post please contact blog@eatingdisorderscleveland.org.
Posted by Mark Warren on Sat, May 22, 2010 @ 09:53 AM
Choosing an eating disorder provider is difficult in the best of times and can feel completely overwhelming in the midst of a crisis. This reality, which we have addressed in other ways in the past, came into sharp focus this past week when three separate fathers came to visit us in person to gather information for their ill child. Each was trying to figure out what their next move should be in obtaining care for their loved one who was not in a position to make that decision from themselves. As we spoke to each father and tried to put ourselves in their place, here were some of the questions that we thought we should be answered.
- Do you know what you’re doing? Have you worked with this disorder before? Have you been successful in your treatment of others with eating disorders?
- Do you know what evidence based treatment is? Have you been trained by experts? Are you an expert?
- Do you understand that eating disorders are life threatening and can kill my loved one? Do you have ongoing relationships with medical professionals? Do you do medical screening? Do you make certain and insist that medical treatment occur along with psychological treatment?
- Do you understand levels of care? Do you know that not every patient gets better the same way? Do you know that different people need different things at different times in their treatment?
- If I do treatment here, can I trust that you will tell me the truth? Can I trust that if I’m not getting better you’ll direct me elsewhere? Can I trust that when I get better you’ll continue to work with me? Can I trust that you will include my family and loved ones in treatment?
As a patient, it is hard in an hour and a half assessment to know the answers to all these questions. It is particularly hard to make a decision when different providers tell you different things. When you see a provider before you leave ask them: “What if you’re wrong? What if what you’re telling me turns out not to be true? What will we do then?”
Contributions by Sarah Emerman
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 Mark Warren on Fri, Jan 08, 2010 @ 10:47 AM
By Dr. Jorey Friedman Beegun and Dr. Mark Warren
In Family Based Treatment (also known as the Maudsley method), parents play an active role in refeeding their child with the goal of restoring their child's weight to a range that is appropriate for their age, height and optimal medical and psychiatric functioning (as determined by a team of professionals and tailored specifically to the child). Once that has occurred, the parents gradually return control of eating back to the adolescent in a manner that stabilizes weight and behavior and allows for a focus on adolescent developmental issues that are often thrown off track by the illness.
Phase I of the Maudsley method in treating anorexia involves a shift of total control of eating from child to parents during which time the parents are responsible for making all choices surrounding food and re-feeding the adolescent. This first phase of treatment is critical because of need for the child to be gaining weight during a time in which their brain is malnourished and the fear of weight gain is acute. Given that many of the thoughts associated with anorexia nervosa are side effects of malnourishment itself, having an individual therapist or family member try to "convince" the adolescent to eat and gain weight is not successful and has no empirical support. What their brain needs is food and Phase I coaches the parent on providing their child the medicine (food) they need.
Phase II commences when a child has been successfully re-fed and parents believe that the child is ready to attempt to re-gain some control over their eating and food choices. Phase II extends from the very first collaborative moment around eating between the parents and child until the point where the child is able to successfully feed him or herself on a regular basis. This does not mean that the child will have no eating disordered thoughts, feelings, or body image issues as the time in which is takes for these to diminish or dissolve entirely is different for each child. However, the child's ability to tolerate and process these feelings is such that they can be working on eating independently in a gradual fashion. Thoughts, feelings, and body image can be successfully addressed in phase III when normal teenage issues move into the forefront.
Phase III begins when the adolescent is able to maintain appropriate body weight and restriction has stopped. The focus shifts to an exploration of how the eating disorder has impacted the formation of a healthy adolescent identity and works to help both the parents and adolescent get back on track in terms of supporting age-appropriate developmental tasks.
It is important to note that the there are differences between the phases in FBT for those struggling with Bulimia Nervosa and Eating Disorder, Not Otherwise Specified given that those adolescents are often weight-restored. The Maudsley Method is more collaborative with these diagnoses, the degree of which is clinically determined during the initial Maudsley sessions.
Contributions by Sarah Emerman
Posted by Mark Warren on Fri, Nov 27, 2009 @ 09:29 AM
One of the questions we are often asked is “how do you prevent an eating disorder?” or “is it even possible to prevent an eating disorder?” While there are no true answers to these questions, we know that many of the things that we think might help in fact have shown not to be effective. There is significant evidence questioning this issue. Parents are legitimately concerned about what their kids are being taught in school about eating disorders and obesity. Many still advocate for this psycho-education to be provided. Others, however, point out that some individuals with eating disorders will pinpoint this education as a mechanism that fueled their eating disorder behaviors and thoughts.
A recent study of eating disorder education in the schools showed that didactic prevention programs demonstrated little to no impact on the future development of an eating disorder. As with the science of eating disorder treatment, there is a need for evidence-based eating disorder education and prevention. One-time lectures about the evils of eating disorders are unlikely to produce the change we would like to see.
There have been recent discussions among eating disorder professionals on how to best educate high school students on eating disorders and their dangers. A recent study in Ireland exposed adolescents to a computerized eating disorder prevention program in which psycho-education was provided to students in the areas of food, mood, body image, self-esteem, media literacy, and personal stories. The program was provided in hopes that it would reduce disordered eating in males and females between the ages of 13 and 17. The researchers found that the program helped educate students on eating disorder behaviors and reduced disordered eating. Unfortunately, this study is not yet published. We look forward to reading more on this prevention program and encourage continued research on this necessary area of study.
Stice, E. & Shaw, H. (2004). Eating disorder prevention programs: A meta-analytic review. Psychological Bulletin, 130, 206-227.
Contributions by Sarah Emerman
Posted by Sarah Emerman on Tue, Oct 13, 2009 @ 07:16 PM
Check out this article by Sharon Begley in this week's Newsweek on why some mental health professionals reject using evidence-based care, and the growing divide among therapists who base their practices off of research and those who don't.
Ignoring the Evidence: Why do psychologists reject science?
Posted by Mark Warren on Fri, Sep 11, 2009 @ 11:53 AM
The term “evidence-based treatment” refers to therapy that has demonstrated statistically significant improvements or changes in behavior. In most kinds of healthcare, the only kind of treatment a person would accept is something that is evidence based. If someone was getting treatment for cancer, diabetes, or another life threatening illness, they would seek out care that had significant evidence that it worked. Unfortunately, the history of psychiatric treatment is filled with ineffective care used because it was marketed well or because there was nothing else available. Luckily this is no longer true.
Evidence-based therapy for the treatment of eating disorders has only existed for the past 15 years. Although various types of therapy have been proven to show progress in some clients, evidence to support any given treatment is not as good as we would like it to be. It is, however, better than it used to be. The major limitations to research are the short length of many trials in what we now know are long term illnesses, and the difficulty of doing randomized controlled clinical trials. Nonetheless, given that there was no effective treatment prior to 15 years ago, what we know now is a significant improvement.
For adults, evidence-based treatments include Cognitive-behavioral therapy, Dialectical-behavioral therapy,and Interpersonal therapy. If you are 18 years or older and are currently suffering from an eating disorder, these are the therapies to try first. If you are under the age of 18 and have anorexia, the Maudsley method is the only treatment that is evidence-based and should therefore be tried prior to any other treatment. We will cover each of these treatments separately over the next few weeks.
Next week: How can I tell if my therapy is working?
Contributions by Sarah Emerman