Living With Food: The Science Supporting Eating Disorder Treatment

CCED and John Carroll University are hosting, “Dialectical Behavior Therapy Skills Training,” on Friday, May 17, from 9 a.m. to 4 p.m. at JCU’s Lombardo Student Center Conference Room. Join us as we instruct professionals, students, parents and community members alike on how to use creativity to teach DBT skills in therapy.

Prior to the workshop, CCED is hosting a breakfast Eat and Greet at 8 a.m. to mingle with participants, answer questions, and offer resources on DBT skills and eating disorders. Be sure to stop by for a cup of Joe!

CCED clinical psychologist and JCU professor Denise Ben-Porath, PhD, will present in this workshop creative techniques, such as role play, video and experiential exercises, as a way to teach DBT skills. Participants will learn how to structure a DBT group, including providing guidelines to the group and managing group interfering behaviors.

“Change-based” skills, interpersonal effectiveness and emotion regulation will be presented in the morning session. Interpersonal effectiveness skills teach clients how to assert themselves appropriately in interpersonal interactions and emotion regulation skills teach clients how to regulate intense emotions.

In the afternoon, “acceptance-based” skills, mindfulness and distress tolerance will be presented. Distress tolerance skills teach clients how to tolerate a situation without making it worse. Mindfulness skills teach clients how to cognitively defuse from negative thoughts, emotions, and beliefs.

Learn more about this workshop and register today. We hope to see you there!

The cost is $25 for students, parents and community memebers (non-CEUs); $120 for professionals (6 CEUs). All proceeds from this workshop will benefit Eating Disorder Network, a nonprofit organization dedicated to the prevention, treatment, and education of eating disorders.

This workshop provides 6 CEUs approved by Ohio Counselor, Social Worker, and Marriage and Family Therapists Board; the Ohio Board of Nursing; and the Ohio Psychological Association – MCE Program for psychologists.

By, Dr. Mark Warren

Harriet Brown, well known to readers of this blog and to the eating disorder community for her book Brave Girl Eating, recently published an article in the New York Times on why evidence based care is so rarely used in the field of mental health and psychology. Her article is the latest in what has become a very important conversation about the translation of evidence based research into the treatment of mental illness. This topic was also discussed at great length at the recent eating disorder conference in London, organized by Drs Bryan Lask and Rachel Bryant-Waugh. The keynote of this conference, which echos Harriet’s article, shows that the number of practitioners in the community using evidence based care is shockingly low.

Unsurprisingly the response to this article, the presentation in London, and other articles of this nature has been twofold. Many people and clinicians are excited and hopeful that there is effective treatment for historically difficult to treat illnesses. On the other hand, some practitioners are responding by challenging the notion that evidence based care should be the standard of care. The reasons for this vary from the notion that the evidence is weak (possibly, but it is the best we have), to the assumption that the evidence doesn’t apply to every practice (unclear why not), to the criticism that the evidence doesn’t acknowledge cultural and clinical realities (it does). Many criticisms are based on the anecdotal experience of the provider.  One provider referred to the evidence as “weak tea.”

It is very difficult when scientific evidence challenges our own personal experiences and beliefs. However, if you happen to have an eating disorder, or a loved one has an eating disorder, and if you’re aware of the last 20 years of eating disorder treatment, you would want to know that since the advent of evidence based care we have started to get better outcomes.  If I, or a loved one, had an eating disorder, I would far prefer a glass of weak tea to no tea at all.

For more information: Looking for Evidence That Therapy Works 

Should you have any questions please email blog@eatingdisorderscleveland.org

Contributions by Sarah Emerman

By Dr. Mark Warren

A recent article in the International Journal of Eating Disorders by Couturier, Kimber, and Szatmari (2013) adds to the literature on the effectiveness of Maudsley Family Based Therapy (FBT). Their conclusion is that while FBT does not show superiority to other therapies during treatment, there are significant benefits at the 6 -12 month follow up. These benefits reach a level of significance that would cause one to recommend FBT for the treatment of eating disorders in adolescents instead of individual therapy. As they discuss in their article, there are multiple limitations to this study, however research literature has long pointed to the superiority of FBT over individual therapy. This article therefore adds to a growing body of data.

From a CCED perspective, we are particularly interested in what happens in those first 6 months and if there is a way to improve the outcome of FBT more rapidly for adolescents. Our clinical experience is that by adding higher levels of care, in particularly partial hospitalization in conjunction with FBT, that we can improve orientation, adherence, and effectiveness of FBT, while still staying in line with the FBT model. Our clinical experience does not meet the criteria of the research considered in this particular article, since it is not a randomized control trial or have a control group associated with it.  However, given the data that we have, we hope to find that the utilization of FBT within a higher level of care may be a more rapid way to help our clients move from anorexia to recovery.  We hope to publish in the next year on the results of our research into this question.

Couturier, J., Kimber, M. and Szatmari, P. (2013), Efficacy of family-based treatment for adolescents with eating disorders: A systematic review and meta-analysis. Int. J. Eat. Disord., 46: 3–11. doi: 10.1002/eat.22042

Should you have questions or comments regarding this post, please email blog@eatingdisorderscleveland.org.

Contributions by Sarah Emerman

Should you have any questions or comments regarding this post please email blog@eatingdisorderscleveland.org

Contributions by Sarah Emerman

 By Dr. Mark Warren

Every year our understanding of the brain and eating disorders improves. However, there are still a limited number of truly evidence based treatment for our patients. The search for evidence based care may feel overwhelming and sometimes futile. Unfortunately, moving in the direction of care that is not evidence based reduces the likelihood that clients will achieve recovery. There are several reasons why providers may offer care not based on the literature or published data:

1. The provider may be trained in only one particular form of therapy. Providers tend to practice in the mode in which they feel most comfortable, even though that type of therapy may be more helpful for some illnesses than others. A patient may therefore receive care that is not evidence based because their provider does not have an orientation to evidence based care.
2. Lack of adherence. Evidence based care can be challenging to sustain. It usually requires a practice that may be manual based, require expensive or difficult to get supervision, and highly specialized training. Clinicians may be aware of and desire to practice evidence based care but may not have the resources to provide it.
3. Bias. Some providers have belief systems about causation, free will, mind, body, culture or multiple other issues that make it difficult for them to believe and accept the literature as it currently exists. Unfortunately belief systems do influence providers practice and may prevent them from gaining most current knowledge.
4. Over-reliance on experience. Study after study has shown that therapists’ experiences with their own successes or lack of success may shape the way they provide treatment. There may be a tendency to reject scientific literature for personal experience, which may not be effective for others.

No provider gets up in the morning not wanting to do their best and every provider wants to help their patients find recovery as best they can. But it is only when this desire is paired with a good understanding of the scientific literature that good evidence based treatment can occur.

Should you  have any questions or comments regarding this post please email blog@eatingdisorderscleveland.org.

Contributions by Sarah Emerman

By, Dr. Mark Warren

An interesting article from the Journal of Adolescent Health was recently profiled in the New York Times. This article challenges traditional methodologies for in-patient re-feeding of teenagers with anorexia nervosa. Historically, the protocol for teens hospitalized for anorexia has been to “start low and go slow” with food. However, this often results in much slower weight gain or even lack of weight gain during the first week of hospitalization and may result in a teen being discharged from the hospital at a significantly lower weight than they would have been if they had been re-fed more aggressively. As we know from other literature, not reaching prior growth curves is thought to be the single greatest factor in relapse for anorexia and hospitalization is often utilized to jump start this vital and necessary weight gain.

While there are still many questions to be answered about the best methodology of feeding individuals in the hospital, the article underlines the basic principles of treatment of eating disorders in adolescents, in particular, those found in Family Based Therapy. Specifically, re-feeding and the cessation of eating disorder behaviors is the most important part of the first phase of treatment. Only after these have been accomplished should other issues involving the eating disorder move to the forefront.

To access this important article please click here.

Should you have any questions or comments regarding this post please email blog@eatingdisorderscleveland.org.

Contributions by Sarah Emerman

By, Dr. Mark Warren 

A recent study by Dr. Janet Treasure, one of the world’s most prominent eating disorder researchers, has demonstrated the significant importance of early and aggressive treatment for anorexia nervosa. In her study, regardless of the treatment mechanism, patients who had been ill for longer than three years had significantly worse outcomes after treatment then those who had been ill for less time. Give the lack of evidence based treatment available until ten years ago, we do not know if current treatment mechanism may be more effective for those who have been ill longer. However, we can certainly say that based on this study, the faster someone gets into treatment and the more aggressive the treatment, clients are faster into recovery and less likely to relapse.

This study supports previous data from Drs Lock and LeGrange, showing the effectiveness of family based treatment for those under age 18 who had been ill for less than three years. The accumulation of data over time continues to support the necessity of not ignoring, downplaying or minimizing eating disorder behaviors, or hoping that patients will get better on their own without aggressive behaviorally based treatment.

We do not want to discourage hope in those who have been ill longer than three years or those who have started treatment later. Treatment continues to get better as providers and agencies are utilizing evidence based treatment models to treat their clients. Nonetheless, a reading of the current data strongly suggests that no matter where you are, where your loved one is in their eating disorder, the faster they get into aggressive treatment for weight restoration and behavioral cessation the greater their lifelong chance of recovery.

Should you have any questions or concerns regarding the post please email blog@eatingdisorderscleveland.org

Contributions by Sarah Emerman

Please take a look at this post on the F.E.A.S.T. website on information for families of newly diagnosed adolescents. First steps are crucial as you seek out effective treatment and support to begin your journey towards recovery and health.The post provides information on evidence based treatment, facts on eating disorders, support for parents, and success stories of those who have moved into recovery.

Help For Parents of Newly Diagnosed Patients

Should you have any questions or comments regarding this post please email blog@eatingdisorderscleveland.org.

By Dr. Mark Warren

One of the most exciting presentations at this year’s international AED conference was given by Dr. Brian Lask, a scientist from England. His presentation focused on how brain structure may be related to the development of anorexia. This work is exciting for multiple reasons. One reason is that historically, behavioral illnesses have thought to be related to brain neurotransmitters, that is, the chemicals that transmit impulses between nerves in the brain. For illnesses such as depression, bipolar disorder, or schizophrenia, the medications used to treat these illnesses all affect these neurotransmitters, meaning serotonin, dopamine, and norepinephrine. Dr Lask’s work suggests there are structural, rather than chemical abnormalities in clients with anorexia, which may explain how the disorder develops and expresses itself. The work is also important since it rests on understanding the development of brain structures, which are primarily genetically determined, may also be impacted by environmental influences and experiences.

Dr Lask has identified the areas of the brain where various parts of eating disorder symptoms are located. These areas include parts of the cortex involved with body dysmorphia, hunger, sensory perception, eating, the ability to self-measure and evaluate one’s environment and one’s health. Researchers and mental health providers have become aware that these parts of the brain are widely distributed throughout the brain and there can be no single anatomical abnormality that explains all parts of anorexia. Instead, a section of the brain, called the Insula, which is involved with communicating sensations and feelings to higher level cortical functioning is hypothesized to be where the abnormality occurs. His hypothesis is that by losing the central connections of feelings and perceptions to thoughts and behaviors that the multiple diagnostic features of anorexia may arise. This understanding, which still needs significant testing for verification, is a new and hopeful way to look at anorexia. By seeing the illness in terms of anatomical development we can also then see how early intervention and treatment may provide an opportunity for development and growth of this section of the brain so that the illness can be resolved. It also suggests why early intervention in adolescents, whose brains are not fully developed, may have better outcomes than older individuals who may have had structural changes in brain that will require significant re-wiring and re-connection for recovery to occur.

Should you have any questions or comments regarding this post please email blog@eatingdisorderscleveland.org.

Contributions by Sarah Emerman

This entry has been re-posted in honor of Eating Disorder Awareness Week. 

By Dr. Mark Warren

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 for eating disorders 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. 

Should you have any questions or comments regarding this post, please email blog@eatingdisorderscleveland.org.

Contributions by Sarah Emerman