Working with Eating Disorder Patients

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Working with Eating Disorder Patients

• Elise Curry Psy.D.
• Clinical Psychologist
• Private Practice
• San Diego, CA

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Anorexia Nervosa

• Most homogenous psychiatric disorder
• 90-95 female
• Onset teenage years puberty
• Monotonous puzzling symptoms
• Poor response to treatment
• Highest mortality rate
• 50 to 80 contribution of genes

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DSM IV Criteria for Anorexia Nervosa

• Preoccupation with body shape, weight/size
• lt85 ideal BW
• Fear of becoming fat despite low weight
• Loss of 3 consecutive periods in women
• Types restricting,binge/purge,purge

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DSM IV criteria for Bulimia Nervosa

• Recurrent episodes of binge eating, characterized
  by eating an excessive amount of food within a
  discrete period of time and by a sense of lack of
  control over eating during the episode
• Recurrent inappropriate compensatory behavior in
  order to prevent weight gain, such as
  self-induced vomiting or misuse of laxatives,
  diurética, enemas, or other medications
  (purging) fasting or excessive exercise
• The binge eating and inappropriate compensatory
  behaviors both occur, on average, at least twice
  a week for 3 months
• Self-evaluation is unduly influenced by body
  shape and weight

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Diagnostic challenges in EDs (ED NOS)

• BN vs. AN binge/purge type
• Sandy is 5 ft tall and weighs is 80 lbs. She has
  regular periods and no body distortion. She is 16
  yrs old.
• Sally purges normal meals, but does not binge.
• Tom thinks he needs to gain weight. He uses
  exercise to purge. He binges 2 times per week and
  then goes running.
• Shelly chews and spits her food several times a
  day

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Compulsive Exercise

• 1. Having no period isnt healthy, even for an
  athlete.
• 2. Exercising in spite of injury or sickness.
• 3. Individual feels s/he has to exercise to feel
  OK.

• 4. Exercise becomes the way the individual
  organizes his/her life.
• 5. Exercise is done in secret.
• 6. Exercise done mostly to burn calories.

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Possible Signs of an Eating Disorder

• Preoccupation with food/weight
• Dramatic weight loss or gain
• Chronic dieting
• Feels cold all the time
• Dental problems
• History of ballet, wrestling, or modeling
• Disgusted by red meat or desserts

• Has difficulty eating with people
• Cuts out food groups
• Becomes vegetarian/vegan as a teen
• Uses bathroom after meals
• Wears baggy clothes or layers
• Cooks for other excessively
• Excessive exercise

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Scope of The Problem

• Prevalence increasing
• AN .5-2
• BN 3-4
• AN BN More common westernized cultures
• 10 of eating disordered individuals in treatment
  are male
• 5 per decade of AN patients die (disorder or
  suicide)

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Scope of the problem continued

• One of the highest death rates from any mental
  health condition (AN) 10
• Increasing incidence in elementary age children
  (8-11 year old)
• The incidence of bulimia in 10-39 year old women
  TRIPLED between 1988 and 1993.
• There has been a rise in incidence of anorexia in
  young women 15-19 in each decade since 1930.

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Ethnic Diversity in EDs

• Minnesota Adolescent Health Study found that
  dieting was associated with weight
  dissatisfaction, perceived overweight, and low
  body pride in all ethnic groups (Story et al,
  1997).
• Among the leanest 25 of 6th and 7th grade girls,
  Hispanics and Asians reported significantly more
  body dissatisfaction than did white girls.
  Robinson et al (1996)

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Cultural Issues

• More common in Westernized Societies
• Historically self starvation reported prior to
  19th century (religious/spiritual reasons)
• Cultural importance placed on thinness
• Less common in cultures where roundness is sign
  of fertility, health, prosperity
• Hong kong, India AN w/o fear of fat.
• Many individuals in our culture, for a number of
  reasons, are concerned with their weight and
  diet. Yet less than half of one percent of all
  women develop anorexia nervosa, which indicates
  to us that societal pressure alone isnt enough
  to cause someone to develop this disease, said
  Kaye.

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Media Stats

• The average young adolescent watches 3 to 4 hours
  of TV per day (Levine, 1997).
• A study of 4,294 network television commercials
  revealed that 1 our of every 3.8 commercials send
  some sort of attractiveness message, telling
  viewers what is or is not attractive (as cited in
  Myers et al, 1992). These researchers estimate
  that the average adolescent sees over 5,260
  attractiveness messages per year.
• Another study of mass media magazines discovered
  that womens magazines had 10.5 times more
  advertisements and articles promoting weight loss
  than mens magazines did (as cited in Guillen
  Barr, 1994).

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Drive for thinness and dieting

• Girls who diet frequently are 12 times as likely
  to binge as girls who dont diet
  (Neumark-Sztainer,2005).
• Most fashion models are thinner than 98 of
  American women (Smolak, 1996).
• The average American woman is 54 tall and
  weighs 140 lbs. The average model is 511 and
  weighs 117 lbs.
• 35 of normal dieters progress to pathological
  dieting. Of those, 20-25 progress to partial or
  full syndrome eating disorders (Shisslak Crago,
  1995).
• 95 of all dieters will regain their lost weight
  in 1 to 5 years (Grodstein, et al., 1996).
• Americans spend over 40 billion on dieting and
  diet related products each year (Smolak, 1996).

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Body Image

• How you see yourself when you look in the mirror
  or when you picture yourself in your mind.
• What you believe about your own appearance
  (including your memories, assumptions, and
  generalizations).
• How you feel about your body, including your
  height, shape, and weight.
• How you sense and control your body as you more.
  How you feel in your body, not just about your
  body.
• NEDA website

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Negative body image

• A distorted perception of your shape you
  perceive parts of your body unlike how they
  really are.
• You are convinced that only other people are
  attractive and that your body size or shape is a
  sign of personal failure.

• You feel ashamed, self-conscious, and anxious
  about your body.
• You feel uncomfortable and awkward in your body.
• NEDA website

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Positive body image

• A clear, true perception of your shape you see
  various parts of your body as they really are.
• You celebrate and appreciate your natural body
  shape and you understand that a persons physical
  appearance says very little about their character
  and value as a person.

• You feel proud and accepting of your unique body
  and refuse to spend an unreasonable amount of
  time worrying about food, weight, and calories.
• You feel comfortable and confident in your body.
• NEDA website

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Childhood Symptoms OC Personality Traits
Percentage of Individuals With Traits
of Patients
Anderluh MB, et al. Am J Psychiatry.
2003160(2)242-247.
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Heritability Estimates

• DISORDER HERITABILITY
• Autism .8 - 1
• Schizophrenia .5 - .9
• Bipolar .3 - .8
• Anorexia/Bulimia .5 - .8
• Early MDD .5 - .75
• OCD .5 - .7
• Obesity .4 - .7

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Psychological Correlates of Anorexia Nervosa

• Poor self concept
• Obsessive compulsive and avoidant personality
  style
• Perfectionistic, obsessive, harm avoidant traits
• Family dynamics enmeshment, anxiety,
• over-achievers
• Troubles with major life transitions
• an attempt to regress, avoid development
• Difficulty managing and expressing anger
• Cognitive distortions
• Ego-syntonic nature of disease

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Psychological Correlates of Bulimia Nervosa

• Poor self concept
• Chaotic developmental history, parental deficit
• ambiguous communication styles
• Affective regulation problems
• Cognitive distortions
• Ego-dystonic nature of disease
• Impulsivity, substance abuse, self harm, sexual
  acting out, shop lifting

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Distorted Beliefs

• There are good foods and bad foods.
• If I am fat, no one will love me.
• If I eat too much, I need to get rid of it by
  purging.
• If I eat this piece of cheesecake, I will be able
  to see it on my body tomorrow.
• You can never be too rich or too thin.
• Thinness equals happiness.
• Using laxatives gets rid of all the food.
• Purging gets rid of all the food.
• My worth is my weight.
• It is more important to be thin than anything
  else.
• Everyone hates fat people.
• Men like women who are skinny.

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Recovery Beliefs

• My worth is not my weight.
• My body is an instrument, not an ornament.
• When I treat my body well, by eating 3 balanced
  meals per day and exercising moderately, my body
  will find its own set-point weight.
• People come in all kinds of shapes and sizes. I
  dont have to try to mold my body into a standard
  set by the media or fashion industry.
• I need some fat in my diet in order to have soft
  skin, shiny hair, and be able to become pregnant
  some day.
• I can enjoy having a more curvy body, instead of
  striving for thinness.
• I am unique and special due to my inner
  qualities.
• Perfectionism only leads to disappointment, not
  happiness.

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Goal of Psychological Treatment

• Help pt to adjust to their personality
  traits/temperament
• Reduce anxiety through use of positive coping
  skills
• Reduce eating disorder voice and develop a
  recovery voice.
• Increase focus on inner qualities to define self,
  rather than physical
• traits like thinness.

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NEEDSmet by the eating disorder

• Safety/Survival reduction of anxiety
• Love/Belonging best friend
• Freedom no one can take the e.d. away
• Power/control/importance feeling superior,
  weight loss as an accomplishment
• Fun/relaxation/release endorphins
• released by purging

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A Major Truth Feelings Follow Thoughts Actions
Thoughts
Actions
Needs
Want Choices
Feelings
Physiology
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Group Therapy

• Structured on-site meal
• Milieu therapy/ use of group
• CBT/DBT
• Process group
• Nutritional counseling
• Body image group
• Art Therapy
• Relaxation, meditation

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Individual Therapy

• Affect regulation and tolerance
• Impulsivity
• Externalization of self worth
• Feelings of ineffectiveness, inadequacy
• Rejection sensitivity
• DBT
• PMD and dietitian

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Family Therapy

• Required with Adolescents
• Maudsley Family Therapy
• Systemic Family Therapy
• Couples
• Family involvement to motivate pt for treatment
  (case example)

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UCSD Eating Disorder IOP(Individual and Family
Therapy by appointment)
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Common Management Issues

• Denial, resistance
• Lack of insight and motivation for treatment
• Failure to learn from experience
• Adolescent anxious parents, conflicts
• Adults family burn out
• Ambivalence pt wants to recover, but does not
  want to gain any weight

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Expected IssuesPatients and Families

• Obsessive anxiety much reassurance and
  discussing details of care
• Perfectionism not good enough
• Stress and conflicts over eating, weight,
• control, meal plan etc.
• Over-exercise
• Undermining treatment i.e. taking the pt running

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Countertransference Issues

• Feeling angry at the patient for not recovering
• Thinking this is willful behavior
• Blaming the parents
• Feeling incompetent
• Giving up hope for the patient
• Not taking the disorder seriously

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Coping with Countertransference Issues

• Practice patient acceptance The average recovery
  rate is 7 years.
• Have compassion for the suffering
• of the patient.
• See their behavior as part of the disorder, not
  personal toward you.
• Practice good self-care.

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Overview of biological underpinnings of EDS
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Genetic Correlates in Anorexia Nervosa

•  
• Family and twin studies
• Serotonin receptor gene
• Variation in Dopamine 2 receptor gene
• Chrom 1 and 10
• Family history of OCD, OCPD, AN
•  

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Genetic Correlates of Bulimia Nervosa

• Twin studies
• 5ht2A receptor alteration
• Family history of affective, anxiety, substance
  abuse d/o

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Neuroendocrine Correlates of Anorexia Nervosa

• Serotonin (5HT2A receptor)
• Dopamine
• Endogenous opiate response to starvation
• Hypothalamus dysfunction (satiety, amenorrhea)

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Neuroendocrine correlates of Bulimia Nervosa

• Serotonin (5HT1A receptor)
• Endogenous opiate response to binge purge

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Neuropsychiatric correlates of Eating Disorders

• Iowa gambling task AN vs CW Differences seen on
  fMRI
• AN Neuropsych testing difficulties with set
  shifting, flexibility
• AN Detail focus, to the point of missing global
  (Janet Treasure)
• AN vs BN
• Use in clinical practice

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Psychiatric symptoms in AN and BN

• Premorbid onset
• Best little girl in the world
• Majority have childhood anxiety disorder that
  precedes onset AN, BN
• Childhood negative self-evaluation,
  perfectionism, rule bound, inflexible, obsessive
  personality
• Persistent symptoms after recovery
• Obsessions - body image, weight, food
• Obsessions - perfectionism, symmetry, exactness
• Anxiety, harm avoidance
• Behaviors are exaggerated by malnutrition
• Differences Between AN and BN
• Novelty seeking BN gt AN, BN extremes of over- and
  under-control

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Important Medical issues in treatment of EDs
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Physical Complications of Anorexia Nervosa
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Physical Complications of Anorexia Nervosa Cont.
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Physical Complications of Anorexia Nervosa Cont.
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Physical Complications of Bulimia Nervosa
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Physical Complications of Bulimia Nervosa cont.
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Medical evaluation for Anorexia Nervosa

• Assess for co morbidity
• Screening labs electrolytes, Ca, Mg, Phos,
  BUN/Cr, CBC, LFTs, TFTs, UA
• Bone density (DEXA)
• EKG
•  

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Medical evaluation for Bulimia Nervosa

• Assess for comorbidity
• Screening labs electrolytes, Ca, Mg, Phos,
  BUN/Cr, CBC, LFTs, TFTs, UA
• EKG
• Dental
•  
•  

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Pharmacology for AN

• SSRIs
• Atypical antipsychotic medications
• Meds tried and failed for appetite enhancement
• GI meds to aid physical symptoms

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Pharmacology for BN

• Serotonin re-uptake inhibitors
• AEDs (topiramate, ?zonisamide)
• Antipsychotics
• Mood stabilizers
• reglan, H2 blockers

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Methods of Treatment

• Regular Weight restoration
• 2 to 3 lbs/wk inpatient
• 1 to 2 lbs/wk day-hospital
• 1 lb/wk outpatient
• Nutritional Teaching
• Provide patient support
• Prevention from vitamin and mineral deficiency
• Prevention of osteoporosis
• Aim for high Ca intake
• Vitamin D to aid in Ca absorption vegetarians
  may need supplements
• Eat iron-containing foods, especially important
  for vegetarians

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Integrated treatment programs

• Multidisciplinary treatment team
• Program manager
• Psychiatrist
• Therapists with ED training
• Registered Dietitian
• Internist/Pediatrician

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AN Hospital vs Outpatient TreatmentFrom
American Psychiatric Association Guidelines for
the Treatment of Eating Disorders
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Referral to Higher level of care

• Pt is failing lower level.
• Pts weight loss is continuing in spite of
  treatment
• Pt is unable to stop bingeing/purging.
• Pts physical symptoms warrant greater
  supervision (fainting, dehydration, heart
  palpitations)
• Pt is resisting current level of care

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Specific LOC Considerations

• OP high motivation, gt85 IBW
• IOP moderate motivation, gt80IBW
• PHP gt75
• RTC clinical issues
• IP lt75 IBW, psych co morbid severe (SI)
• UCSD Intensive Family Therapy program
• Legal controversy

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Diagnostic Practice

• See hand-out for interview questions

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Dual Diagnostic Issues

• (Psychiatric co-morbidity)

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PSYCHIATRIC COMORBIDITY Anorexia Nervosa

• affective disorders
• anxiety disorders
• psychotic disorders
• personality disorders
• Substance abuse 

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PSYCHIATRIC COMORBIDITY Bulimia Nervosa

• Affective disorders
• Anxiety disorders
• Impulse Control Disorders
• Personality disorders
• Substance abuse

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Anxiety Disorders (AD)Lifetime and Premorbid
Rates
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Lifetime OCD Diagnosis in AN, BN
Price Foundation Genetic Collaborative
StudyTotal 1416 subjects DSM IV, SCID I, Y-BOCS
MS/PhD Clinical Interview N. America, England,
Germany
Review of Literature Godart 2002
General population rate OCD 1-3 of adults 2-4
of children (Grados 97, Riddle 98 Serpell 02)
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Obsessive-Compulsive Personality Disorder (OCPD)
Diagnoses in ED from Clinical Interviewer
AssessmentCassin S, von Ranson K Personality
and eating disorders a decade in review Clin
Psychol Rev 200525(7)895-916
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Factor-Analysis of OCD12 studies, 2000
patientsMataix-Cols, Rosario-Campos, Leckman,
AJP 2005

• OCD is clinically heterogeneous
• 4 symptom dimensions
• Symmetry/ordering
• Hording
• Contamination/cleaning
• Obsessions/checking
• Associated with distinct patterns of comorbidity,
  genetic transmission, neural substrates,
  treatment response

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Prevalence of E.D. and S.U.D.

• 20 of women with a substance abuse/dependence
  have a current or past history of BN or bulimic
  behaviors
• 21.4 of women with BN have a current or past
  history of drug abuse, and 17 of BN women report
  a current or past history of substance abuse or
  dependence.
• Theories of shared etiology vs. causal etiology

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Shared Etiology vs. Causal Etiology

• Shared both disorders share a common
  predisposition and include the personality,
  family history, developmental, and endogenous
  opiods hypothesis.

• Causal Having one of these disorders puts an
  individual at risk for developing another
  disorder.
• Self-medication theory
• Wolfe and Maisto (2000)

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Results of Baker, Mazzeo, Kendler Study 2007

• BN was associated with a lifetime history of
  major depression, neuroticism,conduct disorder,
  CSA, DUD, and a parental history of alcoholism.
• The results of this study lend support to both
  the personality and self-medication hypotheses.
• Having higher neurotic tendencies may be the
  underlying reason why women with BN are more
  likely to develop DUD and vice versa.
• Some of these variables (depression, neuroticism,
  and CSA) may have an impact on whether or not a
  woman with BN is at increased risk of developing
  another disorder like DUD.

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DBT Heirarchy

• 1. Life threatening behaviors
• 2. Therapy interfering behaviors
• 3. Quality of life issues
• Marsha Linehan

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Life threatening behaviors

• Suicide
• Starving
• Binge-purge
• Etoh poisoning
• Fatal car crashes
• Domestic violence

• Over dose with drugs
• Others?

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Therapy interfering behaviors

• Failure to show up
• Lateness
• Not being truthful
• Critical of therapist
• Coming to session intoxicated

• Hostility
• Not talking
• Not complying with medications
• Conflict avoidant

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Quality of life issues

• Ability to eat meals with others
• Ability to have food in refridgerator at home
• Supportive relationships
• Ability to go out to a restaurant with friends
• Ability to think about topics other than food,
  weight, and body size

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Eating Disorders and SUD

• Which to treat first?
• Access severity of SUD 12 step, de-tox,
  inpatient?
• Come up with a mutally agreed upon contract
  sobriety, controlled drinking/using, etc.
• Make connections btw the ED and SUD meeting
  certain needs
• Psychiatric eval if needed

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E.D. and O.C.D.

• Refer pt for psychiatric evaluation for
  medications
• Refer pt to OCD specialist for individual
  therapy. Have good communication with this
  therapist.
• Case Example Danny

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Working with E.D. and Personality Disorders

• Borderline Traits
• Dependent Personality
• Histrionic Personality
• Obsessive Compulsive Pers. D/0
• Narcissistic Traits

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Individual Therapy with Eating Disorder Patients
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Psychotherapies for Anorexia Nervosa (McIntosh,
2005)

• 20 sessions over a 20 week period
• 56 AN women were randomly assigned to 3
  treatments (35 completed treatment)
• 1. Cognitive Behavioral Therapy
• 2. Interpersonal Psychotherapy
• 3. Non-specific supportive clinical management

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Which treatment was the best?

• Interpersonal was the least effective of the 3
  therapies.
• Successful treatment outcome was achieved by 17
  of the interpersonal psychotherapy patients, 42
  of the CBT patients, and 82 of the non-specific
  supportive clinical management patients.

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Non-specific Supportive Clinical Management

• Education, care, and support
• Fostering a therapeutic relationship that
  promotes adherence to treatment
• Assist the pt through use of praise, reassurance,
  and advice.
• Encourage resumption of normal eating and weight
  restoration
• Provided info on weight maintenance strategies,
  energy requirements, and relearning to eat
  normally
• Info was provided verbally and through hand-outs.

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Treatment Strategies for Bulimia Nervosa

• 1. Meal plan
• 2. Delay the binge
• 3. Binge, but dont purge
• 4. Throw away your scale
• 5. Challenge distorted beliefs (CBT)
• 6. Teach anxiety reduction skills
• 7. Develop support system
• 8. Write in a journal
• 9. Set goals each week (1 B/P Max)
• 10. Use externalization (Life w/o Ed)
• 11. Teach set-point theory (Making Peace with
  Food book)
• Chain Analysis (example)

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How to deal with resistance to recovery

• 1. Validate pts legitimate needs and help her see
  how the e.d. serves her
• 2. Use motivational Interviewing what does she
  want?
• 3. Normalize her ambivalence

• 4. Help her give a voice to her e.d vs. her
  recovery voice
• 5. Have her list all the reasons why she wants to
  recover.
• 6. Have her list all the disadvantages to
  recovery.
• 7. Be patient. The average recovery rate is 7
  years!

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Candy CroverCandy is 23 year old college drop
out who works as a waitress. She drinks alcohol
every weekend and has had more than 20 black
outs. She also binges and purges once a day. She
has done this since age 16 which is the same
year her father died of cancer. Candy tends to
restrict her intake during the day and then
binges and purges at night on the left-overs she
brings home from work. Her weight fluctuates from
140 to 155 lbs.

• She is 5 ft 10. As a teen, she used to cut on her
  thighs because she thought they were too fat. She
  is coming to you for individual therapy because
  she is worried about her health. She recently
  fainted after a binge-purge episode. Her
  boyfriend found her on the bath room floor and
  rushed her to the E.R. She received 3 bags of
  I.V. fluid due to dehydration

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Case Example Annie

• 30 year old B.S. biology
• Binge/purge for 5 years
• Weekly individual therapy
• Identify trigger parents house, skipping meals

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Case Example Karen

• 22 year old college graduate
• Anorexic mother
• Residential treatment, IOP, PHP, Individual
  therapy
• 5 2 93lbs
• Highest weight 120
• Lowest weight 88
• Got period back at 105lbs.
• Doesnt want her thighs to touch
• Identify binge/purge triggers (grandpas house)

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When is individual therapy not enough?
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HBO Special

• THIN
• Discussion

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Questions and Answers about Day I

• Comments or suggestions for Day II?

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Life without ED

• What Jenni Schaefer has to teach us
• Externalization of the eating disorder

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What are perfectionistic traits?

• Never being satisfied with your achievements or
  performance
• Ability to see flaws where others do not
• Dread of making mistakes
• Exactness
• Exceedingly high standards

• Very detail focused
• Lack of novelty seeking
• Frequent disappointment with self and others
• Relentless pursuit of perfection
• I have to be the best at everything I do.

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How can we help pts to reduce perfectionism?

• Identify perfectionism as a personality trait
  which is unlikely to change
• Help pts to manage their perfectionism by
  noticing it and doing the opposite (risk taking,
  trying something new, stop redoing or re-writing)
• Recognize the benefits of this trait. Turn it
  into an asset, rather than a liability. Being on
  time, being good at detail oriented tasks,
  academic achievement, research career etc.

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Goals and Benefits of Group Therapy

• Breaks down isolation
• Provides peer support
• Learning from others, not just group leader.
• Shame reduction
• Problem solving
• Interpersonal Skill Building
• Helps to replace e.d.
• Better resource allocation

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Why are groups so important for eating disorder
pts?

• Many of them have social phobia
• Many of them are isolated
• Many of them have problems with reading people.
• Like autism, some people with anorexia have
  difficulties with theory of mind.
• Group can help them see how they come across to
  others.
• Many of them have problems with interpersonal
  effectiveness, like assertiveness. Group gives
  them a safe place to practice new skills.

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Types of Groups

• Groups according to diagnosis
• Ongoing vs. time-limited
• Psychoeducational groups
• Process groups
• Skill building groups DBT, CBT
• Body Image group Cindy
• AN, BN groups at UCSD
• Art Therapy group
• Relapse Prevention

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Goals of CBT Group

• Create a safe environment for pts to explore
  their eating disorder thoughts and beliefs
• Challenge distorted beliefs
• Teach cognitive distortions
• Learn to use thought records
• Assertiveness training
• Help pts dispute their ed voice
• Identify triggers and coping strategies

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CBT groups for Bulimia

• Research by Mitchell et al 2005 showed that
  Social Support Seeking 1 month after a 12 week
  CBT group predicted the outcome at 6 months.
• Those group members who utilized their support
  systems 1 month after the group had a better
  outcome.
• Use of positive coping skills at the end of
  treatment did not predict the outcome at 6
  months.
• This study highlights the importance of social
  support to maintain treatment goals.

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Process Group

• Get topics from each member (Axis II)
• Divide the time so everyone can share.
• Group leader intervenes when e.d. thoughts are
  presented as true
• Let members give support before you do. Its best
  if coming from them.
• Encourage group participation. Help connect group
  members to each other.
• Create a safe environment of non-judgemental
  feedback.
• Help to establish positive group norms.

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Goals for Body Image Group

• Create a safe environment for pts to explore body
  image issues
• Teach about our culture and how we get negative
  messages about body size and shape.

• Help group members to share their body image
  struggles with each other
• Help to dispel body image distortions
• Set body image goals each week
• Resources

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Relapse Prevention Group

• Provide a support group for those in recovery
• Encourage pts to share their coping strategies
  with each other
• Problem solve difficulties with staying in
  recovery.
• Use lapses as learning experiences
• Prevent relapse through accountability

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Problems in Groups

• The monopolizer
• The advice giver
• The yes, but
• Quiet groups
• Unexpressed anger
• Poor attendance of certain members
• Lateness
• Anorexia vs Bulimia

• Lack of recovery in the group
• Cliques between certain members
• Rejection of members
• Poor screening of potential group members

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Goal Setting

• Set attainable and measurable goals.
• Examples include 1 B/P Max, 1 Self-sooth, write
  in journal about feelings I had before engaging
  in my eating disorder, eat meal plan, do food
  log, limit exercise to half hour per day, have
  husband hide my scale, body check only 1 time per
  day, eat a challenge food 1 time, make a mistake
  with a witness, write a letter to ed., have ed
  write back, no self-harm, call for support. (see
  flip chart)

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Group Therapy Practice Large Group

• Needed 2 leaders and 7 members

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Reactions to large group exercise

• What did you learn?

104
1st Session of a new group

• Introduce the leaders and purpose of the group
• Go over group rules contact outside group,
  confidentiality, off limits topics, gum chewing,
  water, outside food, length of group (12 weeks),
  dress code
• Have members tell their story history of the e.d
  and treatment

105
Group Therapy Practice in Small Groups

• Break into groups of 8 2 leaders and 7 consumers
• The leader will lead the 1st session by having
  each member tell their story as an introduction.
  S/he will also go over the group rules no
  talking about numbers (Calories, sizes, weights,
  miles ran etc.), confidentiality, no outside food
  allowed, no gum chewing, outside contact
  encouraged for support but not crisis management.

106
Reactions to practice session

• What was hard for the group leaders?
• Were you able to explain the group rules and
  answer questions?
• How did it feel to lead this group?
• How did members feel in this group?
• Did it feel safe?
• Feedback for leaders

107
HBO Special Thin

• Part II

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How to set up a group and get it started?

• Do a needs assessment of your patient population
• Choose the type of group and the
  inclusion/exclusion criteria
• Decide on group leadership
• Design format or curriculum
• Create a flyer, contact therapists, marketing
• Conduct interviews
• Set a start date

109
Brainstorming Session

• What kinds of groups do we need in our community?
• What are consumers asking for?
• How do we get started?

110
What kinds of groups are needed in your community?

• What is your plan of action?
• Who will volunteer to get a group started?
• What resources will you need?
• Plan your next follow up meeting

111
Questions and Answers