2020 04 22 practical recommendations in the treatment of ... · practical recommendations: in the...

Practical Recommendations: In the Treatment of Eating Disorders

4/22/2020

Presented by Alyssa H. Kalata, PhD. 1

P R A C T I C A L

R E C O M M E N D A T I O N SI n t h e T r e a t m e n t o f E a t i n g D i s o r d e r s

Welcome, your facilitator will be: Samson Teklemariam, LPC, CPTM

• Director of Training and Professional Development for NAADAC

• NAADAC, the Association for Addiction Professionals

• www.naadac.org/education• [email protected]

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www.naadac.org/webinars

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Using GoToWebinar(Live Participants Only)

Control Panel

Asking Questions

Audio (phone preferred)

Polling Questions

Alyssa Kalata, PhD. • Clinical Psychologist

• Clinical Trainer

• [email protected]

• www.linkedin.com/in/alyssahkalata

NAADAC Webinar Presenter

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Webinar Learning Objectives

Describe at least 2 effective methods for assessing eating disorders and SUDs, and how to use this information to make recommendations for an appropriate level of care

Describe strategies for increasing and sustaining motivation for change

Describe at least three treatment strategies that can be used to effectively treat eating disorders and substance use disorders concurrently

Dispelling Myths

Polling Question 1

Approximately what percentage of the patients with whom you work are diagnosed with an eating disorder?

A. 0-10%

B. 10-20%

C. 20-30%

D. 30-50%

E. 50-100%

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Comorbid EDs and SUDs

• 35% of individuals with a substance use disorder will also meet criteria for an eating disorder (CASA, 2003)

• Individuals diagnosed with a substance use disorder who also have a comorbid eating disorder tend to present with a greater severity of substance use

• 50% of individuals who are diagnosed with an eating disorder will also meet criteria for a substance use disorder (Holderness, et al, 1994)

• Individuals diagnosed with an eating disorder who also have a comorbid substance use disorder tend to present with worse eating disorder symptomology

• Individuals with comorbid eating disorders and substance use disorders also tend to have more severe medical complications, additional and more severe psychiatric comorbidities, and higher rates of suicide and suicide attempts

Prevalence and Severity

SCOFF, Eating Disorder Screen for Primary Care (ESP), The Questionnaire on Eating and

Weight Patterns-5 (QEWP-5)

Alcohol: CAGE, AUDIT (10 Questions), AUDIT-C (3 Questions), TWEAK

Other Substances: Alcohol, Smoking, and Substance Involvement Screening

Test (ASSIST)

ScreeningEating

Disorders

Substance Use

Disorders

SCOFF

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Eating Disorders Examination – Questionnaire (EDE‐Q), Eating Disorder Inventory‐3 (EDI‐3), Diagnostic Survey for Eating Disorders (DSED), Eating Attitudes Test‐26 (EAT‐26), Bulimia Test‐Revised (BUILT‐R), Binge Eating

Disorder Test (BEDT)

Alcohol: Michigan Alcohol Screening Test (MAST), Alcohol Dependence Scale (ADS)

Other Substances: Drug Abuse Screening Test (DAST), Tobacco, Alcohol, Prescription Medication, and Other Substance Tool (TAPS)Withdrawal: Clinical Institute Withdrawal Assessment for Alcohol –

Revised (CIWA‐Ar), Clinical Opiate Withdrawal Scales (COWS)

Quantitative Assessment

Eating Disorders

Substance Use

Disorders

General Recommendations: Urinalysis with toxicology screening, blood chemistry studies, EKG

For More Information: https://psychiatryonline.org/pb/assets/raw/sitewide/practice_g

uidelines/guidelines/eatingdisorders.pdf

General Recommendations: Laboratory tests related to medical consequences of substance use, tests for

infectious diseases

Laboratory Tests

Eating Disorders

Substance Use

Disorders

Qualitative Assessment

• Explore function of ED and SUD

• Behaviors and symptoms to consider asking about:• Restricting (food and fluids); drinking excessive

fluids; purging* (via vomiting or via laxatives); bingeing; use of diuretics, emetics, enemas, and caffeine; frequency, intensity, and type of physical activity; body image distress; body checking; mealtime behaviors (e.g. chewing and spitting, hiding food, cutting up food in to small pieces, difficulties with pacing, food rituals, fear foods)

• Provider qualities when conducting qualitative assessment

• Obtain collateral information when feasible

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The Importance of Multidisciplinary Assessment and Treatment

Psychotherapy

-Assessment-Individual Therapy-Family Therapy-Couples’ Therapy-Group Therapy

Nutrition Therapy

-Assessment-Determining EBW-Monitoring Weights-Managing Meal Plan-Dietetic Education-Nutrition Therapy-Exposures

Psychiatry

-Assessment-Risk Management-Medication Management (ED and Comorbid Dx)-Psychotherapy

Primary Care

-Assessment-Monitoring Labs, Weights, and Vitals-Managing Medical Conditions (ED-Related and Non-ED-Related)

Additional Services

-Case Management-Dental Services-Support Groups

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Determining Level of Care• Practice Guideline for the Treatment of Patients With

Eating Disorders (Third Edition):• Assessment of the following domains:

• Medical status• Suicidality• Weight as percentage of healthy body weight• Motivation to recover, including

cooperativeness, insight, and ability to control obsessive thoughts

• Co-occurring disorders (substance use, depression, anxiety)

• Structure needed for eating/gaining weight• Ability to control compulsive exercise• Purging behavior (laxatives and diuretics)• Environmental stress• Geographic availability of treatment program

Current Levels of Care in the Treatment of Eating Disorders

• Medical Acute Crisis

• Inpatient (IP)

• Acute Residential (RES)

• Partial Hospitalization (PHP)

• Intensive Outpatient (IOP)

• Outpatient (OP)

Revision- Guidelines Watch August 2012

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Case Vignette

• Alice is a 27-year-old, Caucasian, cisgender female who works as a server during the breakfast and lunch shift in a fast-paced restaurant. She is single, however has a roommate who works second shift. Alice lives in a major metropolitan area. She has an appointment with her primary care physician today for her annual physical. In reviewing information obtained by nursing staff, her physician notices that Alice has lost 60 pounds since her last annual physical, and she still falls within the “overweight” category per her BMI. In gathering further information, her physician finds that 50 of the 60 pounds Alice has lost have been lost in the past three months. Alice shares with her physician that she has received a lot of compliments about her weight loss, and fully intends to continue to lose weight. Her physician reviewed other vitals taken by the nursing staff, and notices that her blood pressure is 85/55 mgHg. Her physician decides to ask further questions and finds that Alice is drinking Diet Coke throughout her shift, and at most, will have a garden salad with fat free balsamic vinaigrette, if she has time to eat on her shift. Alice reports that she typically eats a dinner consisting of fish or chicken, either grilled or baked, with salted steamed vegetables, typically broccoli. She reports that sometimes she is too tired after work to cook, and may skip dinner and go straight to bed. Alice’s physician has been prescribing her medications for depression and anxiety. Additionally, her physician is aware of her daily nicotine use (pack of cigarettes daily), however her physician is not aware of her occasional marijuana use (1 bowl 2-3 times per week, which Alice uses to “help her sleep”).

Polling Question 2

What level of care would you guess would be recommended for this patient?

A. Medical Acute Crisis

B. Inpatient (IP)

C. Residential (RES)

D. Partial Hospitalization (PHP)

E. Intensive Outpatient (IOP)

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Concurrent Treatment

Multidisciplinary Approach

Appropriate Level of Care and Length of Stay

Whenever possible, treat the eating disorder and substance use disorder concurrently

Assessment and treatment should be done by a multidisciplinary team

Treat both eating disorders and substance use disorders at the right level of care and use existing guidelines to determine when to change levels of care

Key Take-Home Points on Assessment and Treatment Placement

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Case Conceptualization

• ED Behaviors:

• Restricting• Compulsive Exercise

• Substances:

• Caffeine• Tobacco• Insulin• Thyroid Medications• Stimulants• Laxatives and Diuretics

• ED Behaviors:

• Restricting• Bingeing• Purging • Compulsive Exercise

• Substances:

• Alcohol• Psychoactive Substances

• ED Behaviors:

• Restricting• Bingeing• Purging

• Substances:

• Alcohol• Psychoactive Substances

Function of Behaviors

Increasing Positive AffectWeight Loss Decreasing Negative Affect

Disorders of Undercontrol vs. Disorders of Overcontrol

Examples of UndercontrolBehaviors:

• Bingeing

• Purging

• Substance Use

• Impulsive SIB or Suicide Attempts

• Emotional Lability

Examples of Overcontrol Behaviors:

• Rigidity

• Perfectionistic Behaviors

• Compulsive Planning

• Masking Emotional Expression

• Avoiding Novelty

• Making Social Comparisons

• Avoiding the Limelight

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Polling Question 3

What is your theoretical orientation?

A. Psychoanalytic

B. Cognitive

C. Behavioral

D. Humanistic

E. Other

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Actively address alliance ruptures

Style that is relaxed, playful, responsive, flexible, curious

Patient is treated as an equal

Discuss “butterfly attachment problem”

Create a “just in case” plan

Increase in-between session contact

The Therapeutic Relationship

Anorexia Nervosa

Substance Use

Disorders

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From an ED Standpoint…

From a SUD Standpoint…

For Both EDs and SUDs

Assists in addressing overvaluation of weight, shape, and size (when relevant) through increasing number and significance of other domains for self-evaluation

Helps to address key triggers for substance use, like boredom and loneliness

Sets the stage for developing discrepancy between values and current behavior (part of Motivational Interviewing)

Enhancing Motivation: Values-Based Work

Enhancing Motivation: Commitment Strategies• Evaluating the Pros and Cons

• Playing the Devil’s Advocate

• Foot-in-the-Door/Door-in-the-Face Techniques

• Connecting Present Commitments to Prior Commitments

• Highlighting the Freedom to Choose and the Absence of Alternatives

• Using Principles of Shaping

• Cheerleading

• Agreeing on Homework

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DBT Diary Cards

A tool to help patients self-monitor behaviors, emotions, thoughts, urges, events, and skill use

Tracking in and of itself often leads to positive change

Helps to quickly and effectively set a session agenda

Provides information that can assist with developing hypotheses and increasing insight

A Method of Assessment and Intervention

What are Diary Cards?

Why are Diary Cards Useful?

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Chain Analysis

Solution Analysis

Behavior Analysis

Moment-to-moment review of the emotions, behaviors, bodily sensations, thoughts, and environmental events leading up to and following a target behavior

Identifying and implementing the most effective skills and/or CBT procedures to address controlling variables identified in the chain analysis

Compilation of insights gained about patterns based on multiple chain analyses

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CBT Change Procedures in DBT

Behavioral Skills Training

Exposure-Based Procedures

Cognitive Modification Procedures

Contingency Management

Does the patient have the requisite behavioral skills

to regulate emotions, respond skillfully to

conflict, and manage their own behavior?

Are there patterns of avoidance, or are

effective behaviors inhibited by unwarranted

fears or guilt?

Is the patient unaware of the contingencies operating in the

environment, or are effective behaviors

inhibited by faulty beliefs or assumptions?

Are ineffective behaviors being reinforced, are effective behaviors

followed by aversive outcomes, or are

rewarding outcomes delayed?

Relapse Prevention• Cultivating and Sustaining Motivation (e.g.

Pros and Cons, Connecting With Values)• Maintaining Positive Changes• Building and Maintaining Structure• Addressing current and potential

challenges, including triggers and high-risk situations

• Identifying warning signs• Challenging disordered thinking• Identifying and/or Creating a Support

Network • Addressing Lapses and Relapses

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NEDA

The Alliance

F.E.A.S.T.

National Eating Disorders Association:https://www.nationaleatingdisorders.org/

The Alliance for Eating Disorders Awareness:https://www.allianceforeatingdisorders.com/

Families Empowered and Supporting Treatment for Eating Disorders: https://www.feast-ed.org/

Resources

AED

Academy for Eating Disorders:https://www.aedweb.org/home

iaedp

International Association of Eating Disorders Professionals:http://www.iaedp.com/

Summing It All Up

Assessment

Thorough multidisciplinary assessment is critical for

patients with eating disorders and substance

use disorders

Levels of Care

Multidisciplinary treatment at the right level of care for the appropriate duration of

time, ideally that targets both disorders concurrently,

is key

Treatment Strategies

Many therapeutic strategies from Dialectical Behavior

Therapy (DBT) can be utilized to effectively target

both eating disorder behaviors and substance

use

Polling Question 4

As a result of today’s webinar, I will…

A. Make changes to my current screening and/or assessment process

B. Use the APA guidelines to assist with level of care recommendations

C. Adjust my approach to case conceptualization with patients

D. Try a new treatment strategy that I learned about today

E. Other

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ReferencesArkowitz, H. & Menchola, M. (2003). The efficacy of motivational interviewing: a meta-analysis of controlled clinical trials. Journal of Consulting and

Clinical Psychology, 71(5), 843-861. doi:10.1037/0022-006X.71.5.843

Chou, S., Goldstein, R., Smith, S., Huang, B., Ruan, W., Zhang, H., … Grant, B. (2016). The epidemiology of DSM-5 nicotine use disorder: Results from the national epidemiologic survey on alcohol and related conditions-III. Journal of Clinical Psychiatry, 77(10), 1404-1412. doi:10.4088/JCP.15m10114

Costin, C. & Johnson, C. (2011, August). Tricks of the trade: things we’ve learned along the way. Keynote speech given at the 3rd Annual Rocky Mountain Eating Disorders Conference in Denver, Colorado.

Cotton, M., Ball, C., & Robinson, P. (2003). Four simple questions can help screen for eating disorders. J Gen Intern Med, 18(1), 53-56. doi:10.1046/j.1525-1497.2003.20374.x

Courbasson, C., Nishikawa, Y., & Shapira, L. (2011). Mindfulness-action based cognitive behavioral therapy for concurrent binge eating disorder and substance use disorders. Eating Disorders, 19, 17-33. doi:10.1080/10640266.2011.533603

Courbasson, C., Smith, P., & Cleland, P. (2005). Substance use disorders, anorexia, bulimia, and concurrent disorders. Canadian Journal of Public Health, 96(2), 102-106.

CSAT (Center for Substance Abuse Treatment). Enhancing Motivation for Change in Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series 35. DHHS Publication No. (SMA) 99–3354. Rockville, MD: Substance Abuse and Mental Health Services Administration, 1999c.

Dimeff, L & Linehan, M. (2008). Dialectical behavior therapy for substance abusers. Addiction Science in Clinical Practice, 4(2), 39-47. doi:10/1151/ascp08239

Dunn, E., Neighbors, C., & Larimer, M. (2006). Motivational enhancement therapy and self-help treatment for binge eaters. Psychology of Addictive Behaviors, 20(1), 44-52. doi:10.1037/0893-164X.20.1.44

References (Continued)Grant, B., Goldstein, R., Saha, T., Chou, S., Jung, J., Zhang, H. … Hasin, D. (2015). Epidemiology of DSM-5 alcohol use disorder: Results from the

National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry, 72(8), 757-766. doi:10.1001/jamapsychiatry.2015.0584

Grant, B., Saha, T., Ruan, J., Goldstein, R., Chou, P., Jung, J., … Hasin, D. (2016). Epidemiology of DSM-5 drug use disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions-III. JAMA Psychiatry, 73(1), 39-47. doi:10.1001/jamapsychiatry.2015.2132

Gregorowski, C., Seedat, S., & Jordaan, G. P. (2013). A clinical approach to the assessment and management of co-morbid eating disorders and substance use disorders. BMC Psychiatry, 13, 289. doi:10.1186/1471-244X-13-289

Holderness, C. C., Brooks-Gunn, J., & Warren, M. P. (1994). Co-morbidity of eating disorders and substance abuse review of the literature. International Journal of Eating Disorders, 16, 1-34. doi: 10.1002/1098-108x(199407)16:1<1::aid-eat2260160102>3.0.co;2-t

Killeen, T., Brewerton, T.., Campbell, A., Cohen, L., & Hien, D. (2015). Exploring the relationship between eating disorder symptoms and substance use severity in women with comorbid PTSD and substance use disorders. American Journal of Drug and Alcohol Abuse, 41(6), 547-552. doi:10.3109/00952990.2015.1080263

Lynch, T. (2018). Radically open dialectical behavior therapy: Theory and practice for treating disorders of overcontrol. Oakland, CA: New Harbinger.

Morgan, J. F., Reid, F., & Lacey, J. H. (2000). The SCOFF questionnaire a new screening tool for eating disorders. West J Med, 172(3), 164-165. doi: 10.1136/ewjm.172.3.164

Murphy, R., Straebler, S., Cooper, Z., & Fairburn, C. (2010). Cognitive behavioral therapy for eating disorders. Psychiatry Clinics of North America, 33(3), 611-627. doi:10.1016/j.psc.2010.04.004

The National Center on Addiction and Substance Abuse (CASA) at Columbia University (2003). Food for thought: substance abuse and eating disorders. New York, NY: Columbia University.

Sysko, R. & Hildebrandt, T. (2009). Cognitive-behavioural therapy for individuals with bulimia nervosa and a co-occurring substance use disorder. European Eating Disorders Review, 17(2), 89-100. doi:10/1002/erv.906

Wade, T., Keski-Rahkonen, A., & Husdon, J. (2011). Epidemiology of eating disorders. In Tsuang, M.T., Tohen, M., & Jones, P. (Eds). Textbook of Psychiatric Epidemiology (3rd Ed.), John Wiley and Sons LTD, Hoboken, N.J.

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Thank You!Alyssa Kalata, PhD. [email protected]

www.linkedin.com/in/alyssahkalata

A N Y Q U E S T I O N S ?

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2020 04 22 practical recommendations in the treatment of ... · practical recommendations: in the...

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