Improving Treatment Is a Focal Point at iaedp 2011

The International Association of Eating Disorders Professionals (iaedp) meeting March 3 to 6 in Phoenix addressed the many challenges clinicians face when treating eating disorders patients, focusing around the theme of “Evidence-based Treatment; Treatment-based Evidence.” The three-day program featured preconference master training sessions, workshops, an art reception and exhibit, as well as a documentary film, “America the Beautiful: Health for Sale,” by filmmaker Darryl Roberts.

Assessing and Treating Eating Disorders Patients in Unfamiliar Settings

Eating disorders professionals are often called upon to treat patients in settings other than their own practice, for example, in emergency rooms, in varying types of treatment centers, and in consultation with primary care physicians. Dr. Pauline Powers, Professor of Psychiatry at the University of South Florida Center for Eating and Weight Disorders, Tampa, and a member of the EDR Editorial Board, guided the audience through the challenges they might encounter in unfamiliar settings.

Dr. Powers reminded the audience that eating disorders are a common and serious problem. Using Maricopa County, AZ, the setting for the iaedp meeting, as an example, she noted that based on national data, the lifetime prevalence of eating disorders in that county would probably affect roughly 186,927 individuals out of the county’s population of 4,256,000. Without treatment—and most patients are not being treated– one-fifth of patients will die prematurely, she said. Even with treatment, after 8 to 25 years, the premature mortality rates are 4% for AN patients, 3.9% for bulimia nervosa (BN) patients and 5.2% for those with eating disorders not otherwise specified, or EDNOS.

Eating disorders patients are usually seen by consulting primary care physicians visiting psychiatric units and specialty programs, by consulting psychiatrists to general hospital units or outpatient settings, in the emergency room, or in an outpatient practice. Persons with eating disorders may be treated in open, closed, or random settings, she noted, and physicians there often have had no training in treating persons with eating disorders. As an example of a closed setting, Dr. Powers described visiting Tampa General Hospital, where signs in the emergency department tell the consultant to ring the bell, and warn that the patients may be waiting at the door for a chance to escape. On the same sign, police are advised to guard their guns.

In such a setting, she advised finding ways to feel more at ease, including introducing oneself to the nursing director and locating the attending physician or medical resident. She also reminded the audience that few eating disorders patients are dangerous to others; most don’t want to die or be disabled.

Patients seen in the emergency department are likely to have a number of physical problems, particularly electrolyte imbalances and dehydration, gastrointestinal problems, arrhythmias, edema, seizures or cognitive disorders, and symptoms related to refeeding, for example. Low potassium is the most common electrolyte imbalance seen and may be associated with pain in the calves, cardiac arrhythmias, or a u-wave pattern on the electrocardiogram. Potassium supplementation should be immediately started. For rumination (regurgitating food after a meal and then re-swallowing), a problem more common than most realize, treatment can be as simple as having the patient eat several tablespoons of peanut butter or chew gum for 15 minutes after a meal.

According to Dr. Powers, most AN patients have been seen in an emergency room before formal treatment begins. They may have syncope, seizures, chest pain, abdominal pain, or broken bones. In this setting, Dr. Powers advised watching for typical symptoms of an eating disorder, including dehydration, electrolyte imbalances, cardiac arrhythmias, and seizure. The SCOFF questionnaire (see box) can be helpful for uncovering undetected eating disorders. An important point is not to reassure the patient. According to Dr. Powers, it’s important to not simply reassure the patient that everything will turn out fine medically and to remember that most often symptoms of the eating disorder are ego-syntonic but the physical complications are not.

Several factors can contribute to emergency department and general medical physicians not knowing what to do when confronted with eating disordered patients. For example, no course work in eating disorders is required in medical schools. Next, the focus on obesity makes it hard to remember that underweight patients have problems, too. Then, there is still the belief that eating disorders are not medical problems but willful behavioral problems. Dr. Powers reminded the audience that patients, especially those with AN, may deny they are ill and those with BN may hide their symptoms. She noted that just as Boris said, what we call their symptoms, they call their salvation (Boris HN: J Psychoanalysis 1984; 65:315). The patients’ denial and secrecy help explain not only the difficulty in engaging people in treatment but studying the impact of various forms of treatment. Even now, she added, some professionals hold the erroneous belief that treatment is futile. In reality, Dr. Powers added, with appropriate treatment, more than 70% of adolescent patients with eating disorders recover after 3 to 5 years.

Recovering from Anorexia Nervosa

During a Master Training Session, Emmett R. Bishop, Jr., MD, Director of Research and Outpatient Centers at the Eating Recovery Center, Denver, compared recovery from AN to escaping a wilderness area. The chronic anxiety these patients experience as a byproduct of temperament is one factor contributing to why patients with AN seem to “get lost in the disease.” Patients often use ineffective strategies in attempts to manage their anxiety—one example is developing an eating disorder. Their lifestyle becomes all about avoiding anxiety and as result energy and vitality are sapped.

Helping patients become aware of values is an important step in recovery, Dr. Bishop explained. The pillars of recovery that will help the patient with AN emerge from the “wilderness” to recovery from AN are values awareness, “mindsight,” and connectedness, he said. From this perspective, “value action” is one goal in their recovery. The goal is helping patients realize that the usefulness of any action is its workability, which is measured against the patient’s true values (defined as those he or she would maintain if the value were a free choice) living well, not having small sets of “good feelings” or avoiding “bad ones.”

AN patients are also helped by realizing that an eating disorder is just one portion from the whole of their values; other parts are intimate relationships, family, friends, work, and leisure, for example, and they need to work to reclaim these aspects of their lives.

Using Mentalization as a Therapeutic Tool

Mentalization is a useful clinical concept for treating patients with eating disorders, according to Theresa Fassihi, PhD, Program Director and Founder of Houston Eating Disorders Center, and Jeffrey Mar, MD, Medical Director of Valenta Eating Disorders Clinic, Redlands, CA.

During their workshop presentation, Drs. Fassihi and Mar explained that one definition of mentalizing is that it is the process by which we implicitly and explicitly interpret behaviors on the basis of intentional mental states such as desires, beliefs, and feelings. Mentalizing is a form of imaginative mental activity, such as perceiving and interpreting human behavior in terms of intentional mental states. This process enables clinicians and clients to empathetically understand both behavior and feelings and how they’re associated with specific mental states, not just in ourselves, but in others as well. Mentalization is a component in most traditional types of psychotherapy, but it is not usually the primary focus of such therapy approaches. Mentalization-based therapy is a psychodynamic treatment rooted in attachment and cognitive therapy, according to Drs. Fassihi and Mar.

Eating disorders patients often demonstrate mentalizing deficits by such phenomena as insecure attachment patterns, high co-morbidity with illnesses that affect mentalization, a high incidence of past events leading to decreased mentalizing, extremely poor sense of self and self-awareness, and a high incidence of alexithymia and/or emotional avoidance. Despite the fact that most patients are intelligent and potentially insightful, they often have extremely poor mentalization skills. Thus, patients have loss of mentalizing for the self, which to them might signify “I am (nothing but) an object.”

Why is mentalizing useful for treating people with eating disorders? The clinicians noted that “mentalizing improves understanding of our patients; it improves communication with patients; and provides a goal that can be constantly pursued.” The speakers then gave examples of therapeutic mentalizing games that can be played with patients in a group treatment setting. In “Anticipatory Role Playing,” for example, the patient selects a peer and the two of them create a probable upcoming interaction. The group then discusses the interaction. Or, the patients replay a recently difficult interaction, and the partners switch roles in an effort to practice mentalizing. In another exercise, two of the group members act out a situation without using words. The group then discusses what the short role-playing was attempting to communicate. In yet another example, patients list 5 to 6 personality traits, one of which is untrue. The entire group then tries to identify the false trait.

Family Therapy with Ethnic Families

When working with ethnic families, “the initial purpose of the therapist is to master the family’s operating style and make meaning of their world,” Dr. Divya Kakaiya, Clinical Director of Healthy Within, San Diego, told the audience at her morning workshop. After this, the therapeutic process can begin by facilitating communication, clarifying information, and providing support to the family.

Dr. Kakaiya emphasized that therapists will need to break through stereotypes and develop a more intuitive way of working with each family. She also noted that certain family dynamics and a variety of family-related factors can add to risk for eating disorders, including family pathology, immigration status, integration conflicts, wealth and poverty, importing a new diet, genetics, and the role of the media, among others. Two major nations where eating disorders are on the rise due to cultural changes are India and China, she added.

Ethnicity, she noted, can be defined as the story of our connections to our heritage and to the story of our evolutions, as well as patterns of our thinking, feeling, and behavior. It is well to learn about and be aware of cultural differences, she said. For example, eastern cultures define a person as a social being and development is categorized by the individual’s growth in empathy and connection. In contrast, Western culture stresses that the person is an individual and development is categorized by the growth in an individual’s capacity for differentiation.

Dr. Kakayia said that in “culturally competent family therapy” the family is a unique dynamic cultural system. In each case it is important to explore the family’s cultural identity, including its structure, fundamental spiritual identity, the family’s representation of itself, and its values and beliefs concerning marriage and family life. She described five major keys to successful cultural communication: questioning assumptions, listening, controlling reactions, adapting nonverbal communication, and adapting language. The family may have come to treatment to recover from the cultural shock of immigration, industrialization, military occupation of their country, economic recession, and the stresses of westernization. In essence, the family may have come for help while in a state of shock.

To achieve a therapeutic alliance with ethnic families, the therapist must know his or her own culture and avoid an ethnocentric attitude, Dr. Kakaiya said. It also helps to have a touch of humility and to honestly admit lack of knowledge of a particular culture. In addition, the alliance is strengthened when the therapist respects the family’s norms, values and customs. “Be empathetic to the disadvantaged,” she urged. Other suggestions for strengthening the therapeutic alliance with families are to let the family define its own identify and to respect that definition, and after careful consideration, sharing some of  your own experiences with the family.

If the therapeutic process has been successful, the family will be able to “de-bug” itself through the support and guidance of the therapist, she said.

— M.K.S.