whole person treatment of eating disorders

Whole Person Treatment of Eating Disorders

Gregory L. Jantz, PhD, CEDSIAEDP‐Certified Eating Disorder Specialist

Approved Supervisor

Gregory L. Jantz, PhD, CEDS

Anorexia Nervosa‐Historical Perspective14th Century – Catherine of Siena practiced an extreme form of

fasting and eventually died of starvation 1868 – Sir William W. Gull names the illness anorexia nervosa –

which means “nervous loss of appetite.” 1870 – Charles Lasègue, without the knowledge of Gull’s work,

described the condition as “L’anorexic hysterique.” 1947 – John Berkman: “Among adolescents the cause for the

psychic upset can often be traced to a parent.” 1973 – Hilde Bruch’s idea that an unhealthy pursuit of thinness was caused by psychological or cultural factors became part of

the common consciousness. Source: James Greenblatt, MD; Dietary Fats in the Prevention and Treatment of Eating Disorders, presented to IAEDP March 22,

2013; used by permission


Not Otherwise Specified?

Under DSM‐IV‐TR, the majority of patients were given a diagnosis without specified criteria.


Changes to Eating Disorder Criteria between DSM‐IV‐TR & DSM‐V:

Anorexia Nervosa•The core diagnostic criteria for anorexia nervosa are conceptually unchanged from DSM‐IV with one exception: the requirement for amenorrhea has been eliminated. In DSM‐IV, this requirement was waived in a number of situations (e.g., for males, for females taking contraceptives). In addition, the clinical characteristics and course of females meeting all DSM‐IV criteria for anorexia nervosa except amenorrhea closely resemble those of females meeting all DSM‐IV criteria. As in DSM‐IV, individuals with this disorder are required by Criterion A to be at a significantly low body weight for their developmental stage. The wording of the criterion has been changed for clarity, and guidance regarding how to judge whether an individual is at or below a significantly low weight is now provided in the text. In DSM‐5, Criterion B is expanded to include not only overtly expressed fear of weight gain but also persistent behavior that interferes with weight gain.

Source: Highlights of Changes from DSM‐IV‐TR to DSM‐5 (2013) from the American Psychiatric Association, page 12.



Bulimia Nervosa•The only change to the DSM‐IV criteria for bulimia nervosa is a reduction in the required minimum average frequency of binge eating and inappropriate compensatory behavior frequency from twice to once weekly. The clinical characteristics and outcome of individuals meeting this slightly lower threshold are similar to those meeting the DSM‐IV criterion.




Binge‐Eating Disorder•Extensive research followed the promulgation of preliminary criteria for binge eating disorder in Appendix B of DSM‐IV, and findings supported the clinical utility and validity of binge‐eating disorder. The only significant difference from the preliminary DSM‐IV criteria is that the minimum average frequency of binge eating required for diagnosis has been changed from at least twice weekly for 6 months to at least once weekly over the last 3 months, which is identical to the DSM‐5 frequency criterion for bulimia nervosa.



Difficulties in Treating Patients with Eating Disorders

Greater than 30% of patients with AN become chronically ill over 10 years

Mortality rates: 10% at 10 years, 20% at 20 yearsHighest risk for suicide among all psychiatric illnesses

Highest number of hospital days of any psychiatric illness

No Advances in the Biological Treatment of Anorexia Nervosa in 50 years.

Source: James Greenblatt, MD; Dietary Fats in the Prevention and Treatment of Eating Disorders, presented to IAEDP March 22, 2013; used by permission


What is the “Whole‐Person” approach?

•Integration of multiple factors for long‐term recovery of eating disorders

•Emotional•Relational•Intellectual•Medical/Brain‐science•Nutritional•Chemical dependency/Substance Abuse•Dental•Spiritual/Faith‐based


Source: James S. Goodwin, MD, Jean M. Goodwin, MD, MHPJAMA May 11, 1984, Vol. 251, No. 18

The TOMATO Effect:Rejection of Highly Efficacious Therapies


The TOMATO Effect:Rejection of Highly Efficacious Therapies

•When an efficacious treatment for a certain disease is ignored or rejected because it does not “make sense” in light of accepted

theories of disease•Americans would not eat tomatoes for over 200 years even though they were eaten since the 16th century in Europe•In 1820, there was a public tasting that occurred without

consequencesSource: James Greenblatt, MD; Dietary Fats in the Prevention and Treatment of Eating Disorders, presented to IAEDP March 22, 2013; used by permission


Whole‐Person recovery requires an integrated treatment team model

A treatment team approach is the recommended model, including medical personnel (either a physician or a psychiatrist), a

registered dietitian or medical professional who is trained in nutritional rehabilitation, and a mental health clinician. Dental

professionals may also be part of the team.(From Key Elements to a Good Treatment Plan by Cris Haltom, Ph.D., June 26, 2006)



When a patient is managed by an inter‐disciplinary team in an outpatient setting, communication among the professionals is

essential to monitoring the patient’s progress, making necessary adjustments to the treatment plan, and delineating

the specific roles and tasks of each team member.American Psychiatric Association – Practice Guidelines for the Treatment of Patients with Eating Disorders, 3rd

Edition, 2006, Executive Summary (a) Coordinating care and collaborating with other clinicians



The authors of a textbook edited by Grilo and Mitchell (2010) describe therapeutic approaches and reviews supporting evidence on all

aspects of eating disorder treatment, from assessment to nutritional rehabilitation to managing the chronically ill. The authors state that

there is no single treatment for patients with eating disorders. Rather, a diversity of approaches is recommended.

Source: American Psychiatric Association – Guideline Watch (August 2012): Practice Guidelines for the Treatment of Patients with Eating Disorders, 3rd Edition (page 2); The Treatment of Eating Disorders: A Clinical Handbook,

edited by Carlos M. Grilo, PhD and James E. Mitchell, MD.



A team that includes professionals with experience in psychiatry and psychology, internal medicine and nutrition, social work, nursing and even recreation is needed to provide the full range of therapy and treatment to help patients develop the skills necessary to gain

control of destructive eating disorder behavior, improve their support system, increase self‐esteem , and establish a foundation

for long‐term recovery.Source: A “Continuum of Care” Approach to Eating Disorders by Stuart Koman, Ph.D.;

http://www.waldenbehavioralcare.com/pdfs/ContinuumOfCare.pdf



•Approximately 50% of individuals with an eating disorder (ED) abuse or are dependent on alcohol or illicit substances compared with approximately 9% of the general population

Source: (Holderness et al., 1994; The National Center on Addiction and Substance Abuse

(CASA at Columbia University, 2003)

•Of individuals with a substance use disorder, more than 35% report some form of an ED (CASA, 2003) compared to lifetime prevalence estimates of approximately 5% for women in the United States

(Hudson et al., 2007).

Source: From the Introduction to Patterns of Comorbidity of Eating Disorders and Substance Use in Swedish Females, Root et al., 2009); http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2788663.



It is the position of the American Dietetic Association that nutritional intervention, including nutritional counseling, by a registered dietitian (RD) is an essential component of the team treatment of patients with anorexia nervosa, bulimia nervosa, and other eating disorders during assessment and treatment

across the continuum of care.

Source: Position of the American Dietetic Association: Nutrition Intervention in the Treatment of Anorexia Nervosa, Bulimia Nervosa, and Other Eating Disorders (J Am Diet Assoc. 2006; 106:20773‐

2082)



Eating disorders arise from a variety of physical, emotional and social issues all of which need to be addressed to help prevent and treat these disorders . . . while eating disorders appear to focus on body image, food and weight, they are often related to many other issues. Referral to healthcare professionals and encouragement to seek treatment is critical as early diagnosis and intervention greatly improve the opportunities

for recovery.Source: American Dental Association, Oral Health Topics, Anorexia Nervosa (Eating

Disorders); http://www.ada.org/2582.aspx?currentTab=2


The Poly‐Pharmacy Highway

Photo Source: Walden Behavioral Care


There is no FDA‐approved medication for Anorexia Nervosa . . .

Source: WebMD August 25, 2011‐ http://www.webmd.com/mental‐health/eating‐disorders/anorexia‐nervosa/anorexia‐nervosa‐medications

Standard of Care

. . . Yet, the majority of patients treated are with psychotropics

Polypharmacy is the norm


Benefits of a Multiple‐Disciplinary Team Approach to Treatment

Non‐response to SSRI medication in ill AN subjects could be a consequence of an

inadequate supply of nutrients, which are essential to normal serotonin synthesis and

function. [These data suggest that a disturbed serotonin activity may create a vulnerability for the expression of a cluster of symptoms common to both AN and BN and that nutritional factors may affect SSRI response in depression and/or

obsessive‐compulsive disorder.]

Source: Kaye W, Gendall K, Strober M Biol Psychiatry 1998 Nov 1; 44(9):825‐38.


Anorexics with low body weight, low BMI, and low serum albumin (the main protein in blood) levels are at increased risk for vitamin

and mineral deficiency. Vitamin abnormalities may contribute to cognitive

difficulties such as poor judgment or memory loss and other psychiatric

conditions. These deficiencies can often be corrected with dietary interventions.

Source: From the University of Maryland Medical Center – “Anorexia Nervosa”; http://www.umm.edu/altmed/articles/anorexia‐nervosa‐

000012.htm



A Medical Mystery?

Eating disorders are characterized by severe weight loss from self‐

starvation yet signs or symptoms of vitamin, mineral and fat deficiencies are rarely studied or integrated into

treatment.

Pellagra?


Incidence of Eating Disorders

A majority of young women diet at some point in time yet only a small fraction develop eating disorders.

Why?


Research shows that many nutrients, such as vitamin B12 and iron, are essential to human

brain function and that deficiencies in these nutrients and others can lead to impaired cognitive function and impaired memory and concentration.



Impaired Cognitive Function

Used by permission of Dr. Daniel Amen


You don’t see whatI see!

Is This a Struggle for CONTROL?



Nutritional deficiencies are also directly related to:

• impaired emotional functioning, i.e., irritability; • apathy;

• withdrawn behavior; • decreased ability to focus; • decreased ability to listen;

• decreased ability to process information;

• and fatigue.


•50% of caloric intake of American children is obtained from added fat and sugar•20‐24% of calories for 2‐19 year‐olds come from soft drinks!•<15% of school children consume recommended servings of fruit•<20% of school children consume recommended servings of vegetablesSource: James Greenblatt, MD; Dietary Fats in the Prevention and Treatment of Eating Disorders, presented to IAEDP March

22, 2013; used by permission

Standard American Diet (SAD)


The Journal of the Academy of Nutrition and Dietetics published a study where they found that:

•53% of women with eating disorders were vegetarians•12% of healthy women are vegetarians

Source: Jenny Sangler, August 30, 2012

The majority of women with eating disorders are vegetarian



Decreased food intake, a cyclic pattern of eating, and weight loss are major manifestations of zinc deficiency. Patients with eating disorders may

develop zinc deficiencies for the following reasons:

• lower dietary intake of zinc• impaired zinc absorption

• vomiting• diarrhea

• bingeing on low‐zinc foods


Anorexia Nervosa1. Decreased appetite and

meat avoidance2. Decreased taste and smell3. Nausea and bloating during

re‐feeding4. Insomnia and poor sleep

habits5. Depression6. Attention difficulties

Physical Symptoms of AN and Zinc Deficiency

Source: Zinc deficiency and eating disorders. Humphries L, Vivian B, Stuart M, McClain CJ. J Clin Psychiatry 1989 Dec; 50(12):456‐9

Zinc Deficiency1. Decreased appetite and

meat avoidance2. Decreased taste and smell3. Nausea and bloating during

re‐feeding4. Insomnia and poor sleep

habits5. Depression6. Attention difficulties


Recommended nutritional therapies for recovery

•Daily multivitamin•Essential fatty acids, such as Omega 3’s•Vitamin C•Coenzyme Q10•5‐HTP•Creatine•Probiotic supplement (Lactobacillus acidophilus)•L‐glutamine•DHEA•MelatoninFrom the University of Maryland Medical Center, accessed 7/8/13


•42 patients (40.% y/0) with dietary intake of Omega 3 < 3 gms/day•DBPC 1.8 gms EPA .4 gms DDHA) Omega 3 supplements or placebo BID x 8 weeks•Celexa 20‐40 mg•Higher proportion of patients achieved full remission in Omego 3 group versus the placebo group ‐ 44% verses 18%

Source: Gertsik, L, Poland, RE, Bresee, C, Rapaport, MH. J Clin Psychpharmacol. 2012 Feb;32(1):61:4.

Omega‐3 Fatty Acids – Augmentation of Antidepressants


AN patients received 1 g EPA/day for 3 months:43% recovered

57% showed improved symptoms in:Weight gain

Reversal of growth retardationImprovement in mood

Improvement in general functioning

Source: Ayton, et al., Prostaglandins, Leukotrienes and Essential Fatty Acids; 2004;71:205‐209

A pilot open case series of Ethyl‐EPA supplementation in the treatment of anorexia nervosa


Study participants: 81 adolescents or young adults with sub‐threshold psychosis

Supplementation: 1.2 g omega‐3 fatty acids or placebo for 12 weeks

After 40 weeks:5% (2 out of 41 individuals) in omega‐3 group developed psychosis28% (11 of 40 individuals) in placebo group developed psychosis

Source: Amminger, et al, Archives of General Psychiatry, 2010, 67(2):146‐154

Omega‐3s may have ability to delay or prevent psychosis


Dietary intake and information on psychotic‐like symptoms was derived from a food frequency questionnaire among 33,623

women, aged 30‐49 years‐old

Participants were classified into three predefined levels: low, middle and high frequency of symptoms

Findings raise a possibility that adult women with a high intake of fish, omega‐3 or omega‐6 PUFA and vitamin D have a lower

rate of psychotic‐like symptomsSource: Hedelin et al. Dietary intake of fish, omega‐3, omega‐6 polyunsaturated fatty acids and vitamin D and the prevalence of psychotic‐like symptoms in a cohort of 33 000 women from the general population. BMC

Psychiatry 2010, 10:38.

Fatty Acids for Prevention of Psychotic Disorders


It takes at least 10 weeks for cerebral membranes’ highly unsaturated fatty acid levels to recover following chronic

deficiency.

Source: Bourre, et al., Prostaglandins LeukotEssent Fatty Acids, 1993

Not a Quick Fix


Recommended nutritional therapies for recoveryFrom Complimentary and Alternative Medicine Treatments in Psychiatry; 2012; Stradford, Vickar, Berger, Cass

. . . there is a place for nutritional treatments in mental health treatment. Some patients, due to poor diets or metabolic abnormalities, have unusually high needs for some nutrients – biochemicals that are required for normal physiological function. Supplementation can sometimes fully or partially restore neurological activity that has gone awry. Additionally, some supplements – as lithium has for decades – have a palliative effect on symptoms and, in moderate doses, can improve the patient’s condition with few or no side effects (page 45).



(pg. 51)

Vitamin B6 DeficienciesNervousnessIrritabilityDepression

Difficulty concentratingShort‐term memory loss


Recommended nutritional therapies for recoveryFrom Complimentary and Alternative Medicine Treatments in Psychiatry; 2012; Stradford, Vickar, Berger, Cass (pg. 50)

Vitamin B12 DeficienciesConcentration difficulties

ConfusionIrritation

Impaired memoryDementiaIrritabilityDepression

Personality changesPsychosis



(pg. 55)

Vitamin D Deficiencies

Although clinical studies are few, epidemiological studies show

remarkable associations between low Vitamin D and psychiatric disorders, including depression

and bipolar disorder.



(pg. 57)

Calcium/Magnesium DeficienciesDepressive symptoms

ConfusionAnxiety

HallucinationsNervousnessApprehensionNumbness


Recommended nutritional therapies for recoveryFrom NIH Osteoporosis and Related Bone Diseases National Resource Center, “What People with Anorexia

Nervosa need to know about Osteoporosis”; January 2012; http://www.niams.nih.gov/Health_Info/Bone/Osteoporosis/Conditions_Behaviors/anorexia_nervosa.asp

Anorexia nervosa has significant physical consequences. Affected individuals can experience nutritional and hormonal problems that negatively impact bone density. Low body weight in females causes the body to stop producing estrogen, resulting in a condition known as amenorrhea, or absent menstrual periods. Low estrogen levels contribute to significant losses in bone density.

In addition, individuals with anorexia often produce excessive amounts of the adrenal hormone cortisol, which is known to trigger bone loss. Other problems, such as a decrease in the production of growth hormone and other growth factors, low body weight (apart from the estrogen loss it causes), calcium deficiency, and malnutrition, contribute to bone loss in girls and women with anorexia. Weight loss, restricted dietary intake, and testosterone deficiency may be responsible for the low bone density found in males with the disorder.


•The Japanese eat very little fat and suffer fewer heart attacks than the British or Americans.

•The French eat a lot of fat and also suffer fewer heart attacks than the British or Americans.

Medical Research


Medical Research

•The Japanese drink very little red wine and suffer fewer heart attacks than the British or Americans.

•The Italians drink excessive amounts of red wine and also suffer fewer heart attacks than the British or Americans.

•The Germans drink a lot of beer and eat lots of sausages and fats and suffer fewer heart attacks than the British or Americans.


Medical Research

Eat and drink what you like.

Speaking English is apparently what kills you.


Faith in the Treatment of Eating Disorders


My eating disorder destroyed my relationship

with God. It blocked me from God and I lost all faith and trust in God. I became very angry with God because I felt like God had abandoned me. Eventually, I just stopped thinking about God. My

eating disorder became my God and my body became

the Devil.From Spirituality and Eating Disorders;

http://www.byui.edu/counseling‐center/self‐help/eating‐disorders


Beneficial effects of faith integration in recovery from eating disorders

Patients who actively engage in making decisions about their care, and who are self‐directed toward meaningful life goals, are far more likely to follow through with treatment and

achieve lasting results.From A Continuum of Care Approach to Eating

Disorders by Stuart Koman, Ph.D.

Faith assists patients to develop meaningful life goals



7 Common Spiritual Issues1. Negative image of God who judges, is

unforgiving and punishing2. Feelings of spiritual unworthiness and shame

resulting in a resistance to asking for God’s help

Many eating disorder patients attempt to compensate for their feelings of unworthiness through perfectionism,

relentlessly striving to meet impossibly high standards –physically, morally, religiously, academically and so forth.

Reference: Lack of Spiritual Well‐Being as a Predictor of Eating Disorders Among College Students by Ghazala Saleem, Department of Psychology, Missouri Western State University, page 265 – http://clearinghouse.missouriwestern.edu/manuscripts/809.aspsubmitted May 6, 2006.



7 Common Spiritual Issues3. Fear of abandonment by God, resulting in a distrust of God’s love4. Guilt and shame about sexuality, sexual activity and promiscuity

5. Reduced capacity to love and serve others6. Difficulty surrendering and having faith due to a belief that only

they are able to control their lives7. Shame about the dishonesty and deception they practice due to

the secrecy of their eating disorder behaviors

Reference: Lack of Spiritual Well‐Being as a Predictor of Eating Disorders Among College Students by Ghazala Saleem, Department of Psychology, Missouri Western State University, page 265 – http://clearinghouse.missouriwestern.edu/manuscripts/809.aspsubmitted May 6, 2006.


Integrated Whole‐Person Treatment Team

Mental health counselors, including those familiar and comfortable with spiritual issues

Chemical dependency professionals

Medical professionals, including dental professionals

Nutritional professionals

www.aplaceofhope.comwww.drgregoryjantz.com


whole person treatment of eating disorders

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