In March, the International Association of Eating Disorders Professionals (IADEP) celebrated its 25th anniversary with a full program of preconference seminars, sessions, keynote presentations, and hands-on workshops. More than 300 professionals attended the symposium, “Behind Closed doors: Face to Face with the Client,” March 11-14, at the Walt Disney Swan Resort in Orlando, FL. Two presentations offered treatment strategies for very ill and suicidal patients.

Managing Very Ill Patients

Drs. Phillip S. Mehler and Jennifer L. Gaudiani of the Denver Health A.C.U.T.E. Center for Eating Disorders, Denver, CO, tackled serious treatment challenges in their presentation, “Becoming More Comfortable Taking Care of the Sickest Patients with Anorexia and Bulimia.” The authors’ treatment center is a 5-bed inpatient unit that treats severely ill patients with anorexia nervosa (AN) and bulimia nervosa (BN). The Center only accepts AN patients who weigh less than 70% of ideal body weight or patients with BN who have severe edema or electrolyte problems.

The clinicians began by stressing that AN results in the highest death rate of any psychiatric disease. Deaths from AN are 5.6 times greater than in the general population, and a third of these deaths are due to cardiac complications. According to Drs. Mehler and Gaudiani, medical complications of BN are directly correlated with the mode and frequency of purging, while in patients with AN they are a direct result of semistarvation and weight loss. Patients with BN face a host of problems, including metabolic, renal, gastrointestinal, cardiac, endocrine, and pulmonary-mediastinal complications. Those with AN often have serious metabolic, gastrointestinal, cardiac, endocrine, and hematologic problems, along with electrolyte dysfunction.

When Should Patients Be Hospitalized?

Drs. Mehler and Gaudiani gave the following guidelines for hospitalizing patients with AN: (1) Seek inpatient care if the patient is below 75% of ideal body weight (IBW), and medical hospitalization when he or she is less than 70% of IBW. (2) Patients should be hospitalized if they have severe organ dysfunction, including cardiac, gastrointestinal, liver, endocrine, electrolyte, and hematologic problems. (3) Worsening weight loss with severely restricted caloric intake, making refeeding complications more likely, is another indication for hospitalization. The goal is to start weight restoration, avoiding and treating refeeding complications.

Among bulimic patients, medical problems are caused by the mode and frequency of purging. Severe fluid and electrolyte shifts can be life-threatening. And, for patients with a history of severe edema, difficult diuretic detoxification, or severe hypokalemia should be managed in a hospital staffed with clinicians experienced in the treatment of people with eating disorders.

The Challenges of Osteoporosis

One example of a challenging endocrine problem in patients with AN is osteoporosis, the Denver clinicians said. The osteoporosis associated with AN is extremely severe and not readily treatable nor reversible. Although it occurs early in life, estrogen replacement therapy does not prevent or treat reduced bone density. Normalized weight is the best indicator of bone density. According to the clinicians, early detection is key because exercise does not protect against bone loss. The duration of amenorrhea and extent of lean body mass are the best predictors of bone density, and it is well to remember that the patient may never fully recover. DEXA should be used as a routine screening device for all anorectic patients who have been amenorrheic longer than 6 months.

Therapy includes weight restoration with resumption of menses, and use of calcium supplements (1200 to 1500 mg/day with vitamin D). Drs. Mehler and Gaudini also noted the importance of measuring 25 (OH) vitamin D levels in these patients. They added that four trials of estrogen therapy showed no benefit on bone mineral density. One positive area may be use of bisphosphonates in patients with AN, but there are some concerns as well; neonates born to mothers who received bisphosphonates show decreased bone weight and incomplete ossification. Other complications of bisphosphonates are that their use does not result in normal bone formation and the bone that is produced may actually be weaker than normal bone. No data for calcitonin or fluoride are yet available, they added.

Dealing with the Refeeding Syndrome

According to the two clinicians, another challenge is the refeeding syndrome, which can be deadly. Phosphorus is the key electrolyte level to watch, they said. The glucose load in food stimulates exuberant insulin release, which shifts phosphate and potassium into the cells, causing serum levels of both to drop sharply. Newly synthesized tissues incorporate phosphorus, potassium, and magnesium, causing serum levels of both to drop sharply. Newly synthesized tissues incorporate phosphorus, potassium, and magnesium, which further depletes serum levels. The main fall in serum phosphorus levels occurs 2 to 3 days after refeeding is started and low levels might last 1 to 2 weeks. Greater than expected amounts of phosphorus repletion may be required, during which time serum phosphorus levels should be monitored daily.

How can you prevent the refeeding syndrome? The speakers advised that a little nutrition support is good, while too much may be lethal—start low, and go slow on calories, paying attention to sodium levels as well, they said.

Managing the Suicidal Patient

Kevin Wandler, MD, Chief Medical Officer at Remuda Ranch, Wickenburg, AZ, told the audience that every 16.6 minutes an American commits suicide, and that suicide is the second leading cause of death for people 20 to 24 years of age. Furthermore, knowledge of suicidal intention and risk of suicide is very important for those treating clients with eating disorders because 50% of psychiatrists face the risk that a patient of theirs will commit suicide during their career, and 20% of psychologists will lose a patient to suicide. When Sullivan conducted a meta-analysis of 42 studies of 178 deaths in 3,006 eating disorders patients, it was learned that 54% died from the complications of eating disorders; 27% from suicide; and 18% from unknown causes. In another study, by Pompili et al., suicide was found to be the major cause of death among individuals with AN, challenging the belief that starvation is the primary cause of death in these patients.

Dr. Wandler pointed out that the challenge for clinicians is predicting which patient with suicidal ideation will go on to harm himself or herself. He noted that even with a thorough suicide assessment, no amount of diligence on the part of the clinician treating such patients can take away another individual’s ability to choose to commit suicide. There are warning signs, however. Psychosocial factors that increase risk for suicide include: recent lack of social support, unemployment, drop in socioeconomic status, poor relationship with family, and domestic partner violence. Childhood trauma, including sexual and physical abuse also increases the risk. He advises considering genetic and familial risk factors, including a family history of suicide (especially in first-degree relatives) and a family history of mental illness, including substance use disorders. Physical illness can also increase the risk, of brain and spinal cord injury, pain syndromes, and diseases of the nervous system.

Factors that can help mitigate the risk include having a sense of responsibility to the family, children in the home, life satisfaction, positive coping skills, positive problem-solving skills and a positive therapeutic relationship.

In Dr. Wandler’s view, in comparison to cognitive behavioral therapy and pharmacology, where improvement rates (reduction of depressive symptoms by half) or remission is very low, dialectical behavioral therapy (DBT) has been very successful. In one study, use of DBT reduced suicide attempts by half, compared with other types of psychotherapy available in the community. DBT teaches life-management skills, he said, and can bring conflicts into awareness, helping patients to make conscious decisions rather than acting out of habit or automatically. He added that more effective compromises are available because the patient sees what he or she is “giving up” in order to “get.”

When Should the Suicidal Patient Be Admitted?

Indications that a patient should be admitted for treatment include the following: (1) when he or she has made a suicide attempt or aborted suicide attempt; (2) if the patient is psychotic, the attempt was violent, premeditated, or near-lethal; (3) if the patient took precautions to avoid rescue or being discovered; (4) if he or she has a persistent plan and or intent, and (5) if distress is increased or the patient regrets surviving the suicide attempt. Additional factors that increase risk are: male gender, age older than 45 years, especially if there has been a new onset of psychiatric illness or suicidal thinking, and if the patient is severely agitated, refuses help, or needs further workup in a structured setting.

Outpatient treatment may be more beneficial than hospitalization in cases where the patient has chronic suicidal ideation and/or self-injury but no prior medically serious attempts at suicide, and where a safe and supportive loving setting is available and outpatient care is ongoing. Dr. Wandler said that suicide contracts are largely useless and only make a clinician feel better. Also, there is a risk that the clinician may become too comfortable, stop listening to the patient, and may overlook warning signs.

“It is our responsibility to conduct and document a reasonable suicide assessment,” he said, but added, “We are not expected to predict suicide and to prevent it.” Instead, Dr. Wandler added, clinicians are expected to identify elevated risks of suicide, and when such risk is identified, they are expected to take reasonable professional steps to reduce the risk and to protect the patient.

Finally, he said, the reality is that some patients will commit suicide, and patients with eating disorders are at high risk. Every patient should be assessed, he said, and it is important to document the assessment, interventions, and recommendations.

UPDATE: NEDA/Obesity Panel

On April 2, the National Eating Disorders Association (NEDA) and the STOP Obesity Alliance hosted a panel discussion to explore ways in which media and society as a whole can more effectively speak about issues of weight and health. NEDA CEO Lynn Grefe said, ‘While eating disorders have the highest death rate of any mental illness, we also know obesity kills.” The panel included representatives from major television networks and popular women’s magazines and from other eating disorders associations. The panel pointed to some of the cultural factors that contribute to the problem, including the recent flood of reality TV programs that focus on extreme weight loss. In addition, even while spending on diet and weight loss products continues to climb, obesity has skyrocketed. The panel also pointed to unrealistic images from the media that contribute to pressures to be thin; the common practice of using body mass index to measure population trends versus individual health were also targeted. Representatives of the eating disorders organizations vowed to track media coverage of both their summit and related topics, and to plan future joint panel discussions involving the media, eating disorders organizations, patients, and other interested parties.

Sleep Disturbances Are Common in Eating Disorders

As many as half of patients with eating disorders may have disturbed sleep. Sleep-related eating disorders have also recently been described as independent clinical syndromes (Birketvedt et al., 1999) [Note: also see the Q&A section in this issue].

Dr. Kyung Ran Kim and colleagues at Yonsei University College of Medicine, Seoul, Korea, interviewed 400 female outpatients diagnosed with anorexia nervosa (AN) or bulimia nervosa (BN) who sought treatment at the Mind & Mind Eating Disorder Clinic and Severance Mental Health Hospital in Seoul. About half (201) of the outpatients interviewed in the study reported having sleep disturbances (Psychiatry Res.2010; 176:88).

Although there were no significant differences in the prevalence of sleep disturbances between those with AN and BN, one dissimilarity did emerge. Patients who binge-ate or purged were more likely to have sleep disturbances than were patients who did not (56.8% versus 34.1%, respectively), regardless of the diagnosis. When the types of disturbances were differentiated, the most common problems were difficulty falling asleep (130 women) and mid-sleep awakening (71 women).

Eating disorder patients with sleep disturbances also had high subscale cores on the Eating Disorders Inventory-2 (EDI-2; Garner, 1991).Among the increased cores were body dissatisfaction, perfectionism, and asceticism; however, these symptoms, which might be more closely associated with restricting symptoms, were not significantly different in the two groups.

The authors proposed several theories about the high comorbidity of sleep disorders and eating disorders. First, emotions common to eating disorders, such as anger, depression, and irritability, may explain these subjective sleep complaints. Second, patients with sleep disturbances might be more prone to behavioral disturbances, such as binge-eating and purging. Third, disturbances in body and weight perception might emerge in the form of other somatic psychological complaints.

Are such disturbances useful clinical markers?

The authors also suggest that their study results show that sleep disturbances might be useful as clinical markers of eating disorders. Dr. Kim and colleagues point to a longitudinal study showing that sleep was particularly fragmented when patients were in the low-weight state but once they returned to normal weight, they slept longer and had fewer nighttime awakenings. Thus, in a way, changes in sleep disturbances might act as a secondary measure of recovery.

Media Literacy Program Fights Shape and Weight Concerns among Young Teens

While recent eating disorders prevention efforts have targeted teens older than 15 years of age, a group felt to be at very high risk for eating disorders, few such programs have been aimed at younger teens. Two Australian researchers recently designed a study to evaluate the effects of a media literacy program aimed at a mixed-sex audience of 8th graders (J Am Acad Child Adolesc Psychiatry. 2009; 48:652).

Psychologists Simon M. Wilksch, PhD and Tracey D. Wade, PhD, of Flinders University, Adelaide, Australia, developed a controlled study of 540 young teens (mean age: 13 years) in which 11 eighth-grade classes (126 girls and 107 boys) received an 8-lesson media literacy program, while 13 comparison classes (147 girls and 160 boys) received normal school lessons. The students were selected from a public school, a Catholic school, and 2 private schools.

The 8 interactive sessions delivered by Dr. Wilksch included two lessons a week in the classroom with the regular teacher present. The literacy program, “Media Smart” (J Am Acad Child Adolesc Psychiatry. 2008; 47:939), was constructed around the key concepts of literacy, activism, and advocacy. All media literacy students received a workbook containing a separate action for each lesson, with a lesson outline, description of learning activities, and a “take-home message.” The program was originally developed to test perfectionism and media literacy. In this study, the primary outcome was concern about shape and weight. The control group had regular class sessions.

Self-report measures evaluated shape and weight concern, dieting, body dissatisfaction, media internalization, perceived pressure and ineffectiveness, depression, and self-esteem. These factors were measured at baseline, immediately after the program ended, and then at 6 months and 30 months after the study.

What follow-up showed

Girls in the media literacy group generally had higher rates of clinically significant improvement than did the control girls—the most pronounced change was a reduction of concern about shape and weight (media literacy group, 38%; control group, 25%). Another important finding was that the rate of increased risk after the program was higher for the control girls than for the media literacy girls on all risk factors for shape and weight concern (media literacy group, 28%; control group, 44%) and dieting (media literacy group, 32%; control group, 48%).

Among the boys, those in the media literacy group were at significantly lower risk for shape and weight concern than were control boys at the post-program and 6-month follow-ups (both boys and girls in the media literacy group scored significantly lower in feelings of ineffectiveness than did their counterparts at the post-program follow-up).

Encouraging results seen among young adolescent males

The authors note that their study provides evidence that young adolescent males are a worthwhile target for eating disorder prevention programs, despite the fact that most studies do not include males because of a “floor effect in achieving statistically significant improvements.” In this study, post-hoc testing revealed significant benefits specific to boys in the media literacy group at one or more time points for shape and weight concern, dieting, body dissatisfaction, and feelings of ineffectiveness. The boys benefited as least as much as did the girls, and perhaps even more so at the post-program and 30-month follow-up assessments.

There were three limitations to the study, according to the authors. First, the control group did not receive a placebo intervention, so the benefits of the media literacy program could be due to nonspecific effects. Second, disordered eating behaviors and disordered eating were not measured, because of concern expressed by a school principal that such questions might inadvertently provide information about disordered eating, and third, data were missing for 45.9% of participants at the 30-month follow-up.

Gastric Bypass, 8 Years Later

Persons with super-obesity, or a body mass index (BMI) greater than 40 kg/m², have high risk of morbidity, poorer-than-normal quality of life, and some also face premature death. Since the late 1990s, bariatric surgery, particularly Roux-en-Y gastric bypass, has emerged as the best treatment option.

Until now, there has been little information about the long-term outcome of these patients. A group at the School of Health Professions and the University Hospitals of Geneva, Switzerland, has reported their findings after following a cohort of 80 women (mean age: 40 years) who underwent Roux-en-Y bypass between 1997 and 2002 (J Am Diet Assoc. 2010; 110:527). Body composition was measured by bioelectrical analysis and diet was assessed with a food diary. Physical activity was estimated using a pedometer. Questionnaires were used to evaluate eating disorders, psychological factors, and quality of life among the patients. At the last follow-up visit, 8 years after the procedure, Maaike Kruseman, MPh, RD, and colleagues used a semi-structured interview to measure the benefits and difficulties of the surgery, as well as to record the patients’ perceptions of their quality of life.

At least half had disordered eating patterns

The average weight loss was 30.7 kg; excess weight loss of at least 50% was noted in 47 patients, or 59% of the group. Between the baseline visit and the last visit, the relative proportions of fat mass/total body weight decreased and fat-free mass/total body weight increased. The mean energy intake was 2355 kcal at baseline and 1680 kcal at the 8-year mark. Despite their success in losing excess weight, slightly more than half of the patients reported having disordered eating patterns, including episodes of binge eating or the night eating syndrome.

Factors connected to successful outcomes

Younger age at the time of bypass surgery was associated with a weight loss of at least 50% of excess body weight at 8 years. Neither BMI at baseline nor body composition at baseline predicted successful weight loss at 8 years but excess weight loss and body composition 1 year after surgery were associated with at least 50% loss of excess body weight after 8 years.

When patients were asked about their satisfaction with the surgery, 85% said they were satisfied and would undergo the procedure again. Seventy-four percent were satisfied with their postoperative follow-up; however, 35 patients indicated they would have appreciated a more intensive follow-up, particularly if it were accompanied by psychological support. Eleven patients asked for longer and more in-depth dietary supervision, such as cooking classes or a support group. In addition to gastrointestinal difficulties, including dietary restrictions, patients did say that it was easier to eat less and that they now had better control of food intake. Some reported feeling guilty when weight loss stopped or weight increased, and wished they had more overall support from family members and medical staff.

What needs improvement?

Most weight loss occurred shortly after surgery; more than half of patients regained at least 5 kg between the first and eighth year, and many expressed feelings of guilt and shame about this. At baseline, one year after surgery and at the eighth year follow-up, dietary intake was suboptimal, according to the authors. Energy intake decreased, as expected, but carbohydrate intake fell below the recommended 40% to 65% of total energy intake, whereas fat intake was above the recommended 20% to 35% of total energy intake recommended by the Institute of Medicine and the USDA Dietary Guidelines. This pattern changed little between the first year after surgery and the 8-year follow-up point, suggesting that even basic dietary changes are difficult to achieve in this population. Fifty percent of the sample did not reach the recommended protein intake level: protein intake dropped from 1.5 gm at baseline to an average of 0.8 gm recorded at the final visit.

During follow-up, the authors reported that eating behaviors and psychological state did not improve significantly. Successful and unsuccessful patients alike reported similar rates of problematic eating behaviors, depression and anxiety. Such patterns can be easily overlooked by family and caregivers because the patient’s weight loss is the usual measure of success. Thus, patients may successfully lose weight but still feel like failures. Some patients said they ‘felt alone with their new body, their scar, and their fears.’ The authors stressed the importance of periodic follow-up screening to detect disordered eating patterns and underlying psychological disorders in this patient population.

A 12-Week Intervention for Binge Eating

A short-term intervention program for binge eating that combines cognitive behavioral therapy (CBT) and guided self-help can be effective and also cost-saving for patients with recurrent binge eating, according to the results of a recent study (J Consult Clin Psychol, April 2010, released before print).

Dr. Ruth Streigel-Moore and her colleagues conducted the study at the Kaiser-Permanente Medical Center, Portland, OR, and in southwest Washington State. Dr. Lynn DeBar of Kaiser-Permanente reported that this combined treatment approach allowed more patients to remain free of binge-eating episodes at one year follow-up than a group that received usual care alone, without the guided self-help (64.2% versus 44.6%, respectively). In addition, Dr. Debar noted that the combined therapy appears to be a viable first-line treatment option for most patients with recurrent binge-eating who do not meet the diagnostic criteria for bulimia nervosa (BN) or anorexia nervosa (AN).

The study group included 123 persons with recurrent binge eating in the absence of BN or binge-eating disorder (BED). Half were assigned to the combined CBT-therapy-guided self-help intervention and half received standard care, which involved using any available services at the HMO that they wished. Those in the intervention group could also use any of the center’s services.

The CBT-self-help intervention was delivered in eight sessions over 12 weeks by master’s level therapists with a background in use of CBT for depression, but not for eating disorders. The first session lasted 60 minutes, while the remainder ran for from 20 to 25 minutes each. Participants were instructed to read and follow instructions from the self-help book, Overcoming Binge Eating, by Christopher Fairburn, MD, of the University of Oxford, UK, with assistance from the therapist. The mean age of the participants was 37 years; 92% were female and 97 % were Caucasian. Mean body mass index (BMI) was 31.27 kg/m2.

Throughout the 12 weeks of the study, the use of medications and services to treat eating disorders, mental health problems, and other conditions at the HMO did not differ between the two groups.

Long-term results

After 12 weeks, 63.5% of participants had stopped binge-eating, compared to 28.3% of the control group. By six months, abstinence from binge-eating was greater in the intervention group than in the regular care group (74.5% versus 44.1%, respectively). By 12 months, the advantages for the intervention group were not as marked, but they were still greater than in the regular-care group, and 64% of the intervention participants were binge-free, compared to 45% in the comparison group. The individuals who had had the combined treatment also had better improvement in eating-related psychopathology, depression, and social adjustment than did the regular-care group.

Throughout the year, Dr. DeBar reported, patients who received the intervention had 25.2 more binge-free days than did the controls, resulting in a cost savings of $427 over the other group, when healthcare services, medications, intervention costs, and patient care costs were considered. Changes in weight were similar between the two groups, although those in the combined intervention group who stopped binge-eating lost weight and those who continued to binge-eat gained weight. Two limitations of the study were insufficient power for testing predictors or moderators of treatment outcome, as well as the homogeneity of the study participants,

Excessive Exercise Among Anorexia Nervosa Patients

Researchers exploring excess exercise among patients with anorexia nervosa (AN) have added some new insights. For example, AN patients who use excessive exercise to manage their weight can be distinguished from the two DSM-IV categories of restricting-type and binge-purge type AN, according to the results of one of three studies (Eat Weight Disord. 2009; 14:199).

Researchers at the University of Abertary Dundee, Scotland, compared 428 AN patients with 19 age- and gender-matched controls. Those with AN were initially categorized according to DSM-IV subtype criteria into restricting (RAN, 198 patients) and binge-purge (BPAN, 230) AN. Dr. K. Kiezebrink and colleagues then administered a series of questionnaires selected to reflect key features of the diagnosis of eating disorders and characteristics of eating and food behavior. In addition, structured clinical interviews were carried out to identify the subgroup of patients who use excessive exercise in order to help control weight (EAN).

The RAN, EAN, and BPAN groups did not differ in age, body mass index, age of onset of AN, or in restrained eating. However, significant differences were noted on the Eating Attitude Test-26, including measures of emotional and external factors, disinhibition and hunger factors, extraversion and neuroticism and self-esteem. Subjects in the EAN group were similar to the RAN group on the majority of variables but showed significant differences in extraversion, neuroticism, self-esteem and disease pathology (EAT-26). Compared with the BPAN group, the EAN subjects had lower disease pathology (EAT-26) scores and scored higher on the Eynsenck Personality Inventory (EPI) , extraversion scale, lower on the neuroticism scale than the BPAN group, and had significantly lower disinhibition and hunger scores (Three-Factor Eating Questionnaire).

To the authors, these results suggested that the EAN group has a mixed profile of characteristics resembling both BPAN and RAN groups. When the EAN group was defined as a separate group, members appeared to be more similar to the RAN group than to the BPAN group. However, when the DSM-IV criteria were applied, the EAN group were almost exclusively classified as BPAN. The results suggest that EAN do constitute an identifiable group than can be distinguished from RAN and BPAN. Consequently, it is likely that excessive exercise should be considered as clinically relevant on the outcome of treatment.

Two other studies

In two Norwegian studies, S. Sanda-Bratland and colleagues examined the role of physical activity in patients with long-term eating disorders (Int J Eat Disord 2010 43: 88) and excessive and nonexcessive exercisers who receiving inpatient treatment (Int J Eat Disord 2010, e-pub ahead of print). The first study evaluated 39 female patients receiving inpatient treatment of AN, BN, or eating disorders not otherwise specified (EDNOS). The authors used accelerometer assessed physical activity, the ex4rcise Dependence Sale, Reasons for Exercise Inventory, Eating Disorders Examination, and the Eating Disorders Inventory.

Physical activity was significantly reduced in non-excessive exercisers during treatment; among excessive exercisers there was a trend toward a reduction of physical activity from admission to discharge. In excessive exercisers, reduced eating disorders psychopathology was correlated with a reduction in exercise affects but not with importance of exercise for weight/appearance. Such associations were not reported in non-excessive exercisers. The authors concluded that excessive exercise in an important issue in longstanding eating disorders and the excessive exercising patients need help to develop alternative strategies to regulate negative affects.

The same authors conducted a second study to examine self-reported versus objectively assessed moderate-to-vigorous physical activity and different reasons given for exercise in patients with longstanding eating disorders, compared to a group of controls. Fifty-nine female inpatients (mean age: 30.1 years) and 53 nonclinical age-matched controls (mean age: 31.3 years) participated in a cross-sectional study. Exercise patterns were measured with an accelerometer, ActiGraph (a small monitor worn by a client that measures physical activity for a given period), and a physical activity diary, Reasons for Exercise Inventory, and the EDE.

Self reports and objective reports of moderate-to-vigorous activity were higher across all patients with eating disorders diagnoses when compared with controls. Patients’ self-reported activity levels were lower than were the objectively assessed levels, and no difference was found among controls. Among patients, exercise was more important for regulating negative affects, not weight and appearance, than among controls. Fitness or health was a less important reason for ex

ercise in patients than in controls.

A Nutrition, Body Image and Exercise Obsession Checklist

At the IADEP meeting in Orlando in March, Page Love, MS, RD, LD, of Nutrifit, Sport, Therapy, Inc., Atlanta, offered the following checklist she provides to eating disorders patients with body image, nutrition, and exercise problems.

Schizophrenia and Eating Disorders

At first glance, schizophrenia and eating disorders might seem to be odd bedfellows. However, according to one group of clinicians, many patients with schizophrenia have disturbances in eating behaviors that cover the entire spectrum of eating disorders (Psychiatr Clin N Am. 2009. 32:809). Dr. Sun Young Yum and colleagues, note that these eating disorders occur concurrently and independently from the severity of the schizophrenic symptoms.

According to the researchers, who presented a series of cases of schizophrenic patients with disordered eating patterns ranging from ritualistic night eating with purging to rituals relating to eating and body image, it is not uncommon to meet a patient whose first psychotic episode was immediately preceded by preoccupation with body weight/image and periods of fasting. This period is extremely distressing to patients; for some, obsessive-compulsive reactions appear to offer a certain level of comfort.

According to the authors, one of the differences between eating disorder patients without schizophrenia and those with schizophrenia is that while patients with eating disorders alone generally provide “smokescreen” reasons for their behaviors, only a few patients with eating disorders plus schizophrenia can offer any rational-sounding explanations (although they may occasionally offer bizarre delusional ideas). For schizophrenic patients who experience the psychopathology, the combination of schizophrenia and eating disorders is distressing and demoralizing, Repeated past failures in psychiatric treatment or self-attempts of control often leave a sense of demoralization for patients and the treating physician alike.

Sorority Rush: Hazardous to Body Image?

Participating in sorority or fraternity recruitment, or rush, programs is a time-honored tradition on many campuses throughout the country. However, according to the results of a recent study, undergraduate women who go through rush to join a sorority are more likely to judge their own bodies from an outsider’s perspective (self-objectification) than are those who do not take part in sorority rush. As time passes, those women who join the group also show higher levels of body shame.

These are a few findings from a study by Ashley Marie Rolnik, a senior at Northwestern University, Chicago. Rolnik’s study is the first to test objectification theory, a theory that links body dissatisfaction, and shame, eating disorders and associated behaviors to self-objectification. Her study, which was a senior honors thesis, was published online (Sex Roles. 2010. DOI:10.1007/s1119-010-9745-y).

The study surveyed 127 freshmen women aged 17 to 20 years of age. The women were divided into two groups: those who went through the recruitment process and joined a sorority and those who did not take part in rush. At four time points—before rush, a few days into the rush, on the day the bids to join were received, and one month after the rush, participants completed online questionnaires.

Levels of self-objectification were higher among rush participants than among women who did not take part, and this pattern continued throughout the study. One month after rush ended, new members also showed higher levels of body shame. Those with higher body weights were more likely to drop out of the rush process and to feel dissatisfied with it, even though analysis showed that the dropouts were not overweight, but less thin than those who joined the sorority.

BOOK REVIEW: Treating Bulimia Nervosa and Binge Eating

Treating Bulimia Nervosa and Binge Eating An Integrated Metacognitive and Cognitive Therapy Manual Authors: Myra Cooper, Todd Gillian, Adrian Wells 256 pages, $40.00 Order online at Bulimia.com

“Metacognition” usually refers to the variety of processes involved in thinking about how one thinks. These processes include such things as reflecting on the styles of thinking one is likely to deploy under particular circumstances as, for example, when problem-solving, daydreaming, or feeling distressed. Individuals vary in the degree, nature, and capacity of their metacognitive activities, i.e., in how much attention, thought, and reflection they give to actually thinking about their cognitive biases, cognitive styles and other habitual tendencies to think in certain ways (for example, jumping to conclusions, black and white thinking, being preoccupied with details, etc.); how much their stream of attention itself is focused or fragmented; what they think about the origins, purpose and value of their predominant thoughts and schemes; and other self-evaluative cognitive patterns.

Starting with this background, theorists and clinicians have developed a number of strategies focusing on those metacognitive processes believed to regulate the production, intensity and duration of pathological thoughts and pathological thinking processes. Today many types of metacognitive therapy are being used for problems ranging from psychotic illnesses to ADHD. These metacognitive therapies differ considerably from one another--as do the diverse array of cognitive therapies applied to the wide range of psychiatric disorders.

More than two decades ago Adrien Wells, a psychologist who is now at the University of Manchester, and colleagues developed and began to test a theoretical model of metacognitive therapy that they initially applied predominantly to anxious rumination. The primary goals of that therapy included socializing patients to the idea that rumination and attentional monitoring for threat are sources of the problem; helping patients to abandon rumination, including by prescribing the banning of rumination; enhancing flexible control over cognition through the use of attention training; detached mindfulness; challenging both positive and negative metacognitive beliefs about rumination; and modifying negative beliefs about emotion that contribute to rumination/worry and fear of relapse.

More than a decade ago, Myra Cooper, a psychologist at the University of Oxford who’s focused on cognitive behavioral therapy (CBT) for bulimia nervosa and binge eating disorder, and her colleague, Gillian Todd, at Cambridge University, teamed up with Wells to amalgamate their conceptualizations and approaches regarding metacognitive problems in bulimia nervosa and binge eating disorder. The current volume, built around a prototypical case, is the extremely informative and detailed clinical manual that they have developed for these conditions. The approach is a thoughtful morph–with traditional CBT approaches for BN and BED serving as scaffolding upon which the metacognitive work is built. Although many if not most clinicians have otherwise employed these techniques without specifically calling them “metacognitive,” this term may serve a useful purpose in thinking about just how various psychotherapeutic techniques applied to eating disorders fit together.

For clinicians who value CBT as well as other psychotherapeutic approaches, this book is definitely worth reading. Briefly, the clinical work is structured sequentially around a careful assessment; weekly ratings and evaluations completed by clients of their progress, difficulties, and understanding of these events; motivational analysis regarding their attitudes to BN/BED; and socialization into the model by helping them to develop their own case conceptualization (built around a “case conceptualization pro forma” and several worksheets included in their entirety). Next, training in detached mindfulness is introduced, following which the client is engaged in behavioral experiments and self-reflective observations about the negative thoughts and beliefs generated by binge eating under the acronym of the PETS framework (Prepare, Expose, Test, Summarize). In the next phase, using a Dysfunctional Thought Record, clients identify and deal first with their key beliefs about the negative consequences of their disorders and then with their positive beliefs, core negative and positive self-beliefs, and, ultimately with planning for the future, including relapse prevention training.

While much of this will already be familiar to many CBT therapists, there are novel conceptual and practical additions. The precise methods employed by Cooper et al. are detailed in more than 50 pages of valuable appendices . Included are all of their rating scales, and clinical discussions that describe their use. Whether the application of these strategies will ultimately yield more profound and sustaining results than traditional CBT and/or other treatment approaches for BN and BED, and whether particular types of patients are most likely to benefit from these strategies, are questions that have not yet been adequately addressed. While waiting for answers to those questions, clinicians will find much of value in this book, and may decide to enhance their approaches by employing some its rich thinking and clinical lore.

—J.Y.

Q & A: Could This Be a Case of Night Eating Syndrome?

Q: A patient I’ve been treating for a mood and anxiety disorder who takes divalproex and lorazepam informed me that his wife has been concerned by his increasingly strange nocturnal behavior. For several months his wife tells him he’s had frequent episodes of getting out of bed in the middle of the night and acting “out of it,” during which time he basically sleep-walks to the kitchen and eats large amounts of food before returning to bed. This has happened often enough so that he’s been gaining weight. Is this pattern what is meant by the “night eating syndrome”? Do you have any advice as to how to treat this problem? (C.G., Odessa, TX)

A: Several eating disorder syndromes have been described in association with disturbances in sleep and in circadian patterns. These disorders are usually diagnosed under the DSM-IV EDNOS category (eating disorders not otherwise specified). The eating disorders workgroup for DSM-V is considering whether or not to propose that Night Eating Syndrome (NES) be separately listed in an appendix as a “condition that may be the focus of clinical attention,” and therefore a condition also worthy of further investigation. (http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=26). That said, what you’re describing is less typical of NES per se than of another distinct syndrome in which eating and sleep disturbances have been linked, i.e., sleep-related eating disorder (SRED).

NES and SRED are quite different. NES could be considered an abnormality in the circadian rhythm of meal timing with a normal circadian timing of sleep onset, i.e., with individuals eating a substantial part of their daily intake in the evening after their usual dinnertime, and before they go to sleep. Conversely, the feeding behavior in SRED is characterized by recurrent episodes of eating after an arousal from nighttime sleep, with or without amnesia. In addition to eating other foods, in SRED episodes patients will sometimes eat foods that are ordinarily unpalatable, for example, raw flour and raw bacon.

Both conditions are often relentless and chronic. SRED is frequently associated with other sleep disorders, in particular parasomnias, such as sleep-walking. Case reports have linked some cases of SRED to the use of certain psychotropic medications, including tricyclic antidepressants, anticholinergics, lithium, triazolam, olanzapine, risperidone, and zolpidem. I’ve personally seen cases associated with use of thioridazine, lorazepam and divalproex. Early studies have suggested that the antiseizure medication topiramate may be an effective treatment for SRED (Sleep Medicine Reviews. 2009; 13, 23e34).

—J.Y.