| DBT for Eating Disorders: Path to Mindful Eating Program
(PME) ::ORIENTATION PACKET:: ::Table of Contents:: Program Overview; Instructions for Obtaining Medical and Nutritional Appointments; Getting Ready; Homework; Agreements in PME; Therapeutic Meal Protocol; Orientation to PME Phone Consultation; Diary Card; Instructions for Completing your Diary Card; PME Food Log; Instructions for Completing your Food Log; Behavioral Chain Analysis of Problem Behavior: Worksheet; Behavioral Chain Analysis of Problem Behavior: Instructions; Behavioral Chain Analysis of Problem Behavior: Example; PME Psychoeducational Principles of Eating Disorders ::Program Overview:: Individual Therapy Session (6 months) - Pretreatment and orientation - Mental health assessment ( 1-2 sessions) - Medical assessment 1. Within a week of completing the mental health assessment 2. Ongoing basis as recommended by the provider - Nutritional assessment 1. Within a week of completing the mental health assessment 2. Ongoing basis as recommended by the provider - Orientation (1-2 sessions) Stage 1: Active Treatment Life-Threatening Behaviors Therapy Interfering Behaviors Eating Disordered Behaviors Other Quality of Life Interfering Behaviors Stage 2: Emotional Avoidance & Identity Issues PTSD/Trauma Body and Self Image Stage 3: Termination/Relapse Prevention Individual therapy sessions are 1-hour long and are conducted weekly (unless otherwise indicated). Sessions involve: 1. Weight status 2. Therapeutic meal 3. Diary card and food log review 4. Chain analysis 5. Exposure exercise Skills Training Group (6 months) 1. Learn Skills 2. Practice Application of Skills 3. Therapeutic Meal Skills training groups are 2-hours long and are conducted weekly. Units are as follows: 1. Orientation/Core Skills (at the start of each unit) 2. Distress Tolerance 3. Emotion Regulation 4. Interpersonal Effectiveness 5. Problem Solving and Relapse Prevention ::Instructions for Obtaining Medical & Nutritional Appointments:: Recommended Medical Provider (Your DBT clinic will recommend someone) 1.Medical appointments must occur within the first month of treatment in the PME program. It is recommended that you call to make an appointment immediately after your first assessment session. 2. To schedule an appointment call (number will typically be given to you) 3. Your specific doctor will check on your insurance and contact you with that information. 4. You will be responsible for your copay or deposit at the time of service. 5. Your therapist will send some basic information. 6. Your first appointment will typically be 90 minutes long. 7. Things to bring to your appointment: - Insurance card - Any labs or medical records from other providers, obtained in the last month. Recommended Nutritionist (Your DBT clinic will recommend someone) 1.Medical appointments must occur within the first month of treatment in the PME program. It is recommended that you call to make an appointment immediately after your first assessment session. 2. To schedule an appointment call (number will typically be given to you) 3. Your specific doctor will check on your insurance and contact you with that information. 4. You will be responsible for your copay or deposit at the time of service. 5. Your therapist will send some basic information. 6. Your first appointment will typically be 90 minutes long. 7. Things to bring to your appointment: - Insurance card - Any labs or medical records from other providers, obtained in the last month. ::PME Getting Ready Homework:: 1. Write down things that you would like to change about your: Thinking, emotions, behavior, relationships. 2. What's good about changing? What's good about staying the same? ::Agreements in PME:: Therapists agree to: 1. Make every reasonable effort to conduct competent and effective therapy 2. Obey standard ethical and professional guidelines. 3. Be available to the client for weekly individual therapy, group therapy, and phone consultation. 4. Respect the integrity and rights of the client. 5. Maintain confidentiality. 6. Work on Problems that arise that interfere with progress in therapy and obtain consultation when needed. Clients agree to: 1. Stay in therapy for the specified time period. 2. Attend scheduled individual and group therapy sessions. 3. Work toward reducing life threatening behaviors as a primary goal of treatment. 4. Work on problems that arise that interfere with the progress of therapy. 5. Work on reducing eating disorder behaviors. 6. Work on other problems that arise that interfere with the quality of life. 7. Attend medical and nutritional appointments as recommended. 8. Comply with recommended weigh in schedule. 9. Abide by any research conditions of therapy and pay agreed upon fees. ___________________________ _________________________ Therapist Signature Client Signature ::PME Therapeutic Meal Protocol:: (Individual therapy and skills group involve therapeutic meals) Guidelines for therapeutic meals: 1. In the interest of time, food needs to be pre-prepared and not require reheating. 2. Meal time will be 30 minutes 3. The meal you bring should be consistent with your meal plan. You should bring your meal plan to individual and group sessions. 4. You must eat your meal in its entirety. 5. If your meal is not compliant with your meal plan, components will be added from program supplies. 6. If you do not bring a meal you can use a frozen dinner from the program supplies. You will be required to replace it the next week. Considerations for the skills group meal: Eating with others is often anxiety provoking. Becoming comfortable in a social eating environment is an important treatment goal. The therapeutic meal in group is designed to simulate a “normal” social meal, so there are topics to avoid: 1. Eating disordered behaviors 2. What and how much/little someone is eating 3. What and how much/little you are eating 4. Good/bad food 5. Comparing meal plans 6. Comments promoting overconcern with/poor body image 7. Talk related to drugs, alcohol, profanity, sex Some ideas for appropriate meal conversation are: 1. Vacation plans 2. Family 3. Holidays 4. School/work 5. Future aspirations 6. Pop culture/Current events 7. Sporting/social events 8. Hobbies/activities 9. Pets 10. Weather Considerations for the individual therapy meal: Since the time frame is shorter, while eating, an exposure exercise or reviewing the diary card or food log will take place. As recommended, you may be asked to wait for 1-hour in the waiting room after your individual session. ::Orientation to PME Phone Consultation:: The purpose of telephone consultation is to provide coaching to clients in how to apply DBT skills in their outside lives. The classes of telephone consultation situation are as follows: Class I: You are encouraged to use telephone consultation any time you are having difficulty practicing a skill Class II: It can also be used when you are experiencing a problem with your therapist or your skills group facilitator that can’t wait to be discussed at your next individual therapy appointment or group session Class III: You are encouraged to use phone consultation if you are at high risk to engage in your problem eating behavior. Class IV: Finally, telephone consultation can be especially useful to clients when they find themselves in a crisis situation. A crisis is defined as a situation where there is high risk for engaging in a target behavior that is life threatening and assistance in putting the skills to use is needed immediately. If you are experiencing a medical emergency, you should contact your medical provider, call 911 or go to the emergency room. If you are experiencing a mental health issue you should contact your DBT therapist before any other provider and before you go to the emergency room or call a crisis line. The procedure for obtaining phone consultation is as follows: 1. Call your therapist’s voice mail for Class I and II situations. They will try to return your call within 24-48 hours. 2. Call your therapist’s pager for a Class III or IV situation. They will try to return your call within an hour. I you have not heard from your therapist within an hour, call your group skills trainer. If you do not here from your group skills trainer in an hour call the Crisis Line (provided by your DBT clinic). 3. If you are willing to try to implement DBT skills, we will assist you over the phone. However, if you are not wiling (i.e. stating “nothing work” or “yes-butting”) we will not be able to help you. 4. Next meal/snack rule: If it is a class III situation and you have already engaged in your target behavior, you cannot contact your therapist until the next meal/snack if you are tempted with engaging in problem eating behavior. You should record the behavior on your target card. 24 hour rule: If it is a class IV situation and you have already engaged in your target behavior that is not life-threatening do not call for 24 hours after the behavior or wait until your next scheduled individual therapy session. You should record the behavior and any important details on your target card. Again, if you are in need of medical attention, you should call 911 or go to the nearest emergency room ::Diary Card:: (see diary card link) Instructions for Completing Your Diary Card Completing your diary card on a daily basis is an essential component of treatment. “Mindful” completion of the diary card (i.e. paying attention without judging) increases awareness of what is going on for you. Therefore, completing the diary card is a skillful behavior. You will derive the greatest benefit if you complete the diary card on a daily basis. We suggest that you complete it at the end of each day, but if another time is more convenient for you, that is fine. Here’s how you complete your card. Name: For the sake of confidentiality, we recommend you fill in your first name only or initials. Date: Fill in the date range. How Often Did You Fill Out This Side?: Place a check mark to indicate how frequently you filled in the diary card during the past week. Day and Date: Write in the calendar date (month/day/year) under each day of the week. If you start your card mid-week, “wrap around” the week, so the next seven days are all on one card. Emotion Columns: Refer to the legend1 and choose the number from the scale (0-5) that best represents your highest rating for the day. The key characteristics to consider when making your ratings are intensity (strength of the emotion) and duration (how long it lasted). Urge to Binge: Refer to the legend 1 and choose the number from the scale (0-5) that best represents your highest rating for the day. The key characteristics of the urge to consider when making your rating are intensity (how strongly you felt the urge) and duration (how long the urge lasted). Urge to Purge: Refer to the legend 1 and choose the number from the scale (0-5) that best represents your highest rating for the day. The key characteristics of the urge to consider when making your rating are intensity (how strongly you felt the urge) and duration (how long the urge lasted). Urge to Restrict: Refer to the legend 1 and choose the number from the scale (0-5) that best represents your highest rating for the day. The key characteristics of the urge to consider when making your rating are intensity (how strongly you felt the urge) and duration (how long the urge lasted). Binge Episodes: Write in the number of binge episodes that you had each day. You can also indicate “OBE” or “SBE” to differentiate between objective binge episodes and subjective binge episodes. An objective binge eating episode would be one in which you ate a large amount of food (e.g. a box of cookies and a quart of ice cream) and felt a loss of control while eating. A subjective binge episode refers to binge eating episodes during which you ate a normal or small amount of food (e.g. a candy bar, ½ bag of microwave popcorn) and felt a loss of control while eating. It is key that you experienced a sense of loss of control during the eating in order to count an eating episode as an OBE or SBE. # of Purges: Write in the number of purges for the day. # of Restrictions: Write in the number of times you restricted your intake for the day. This would be evidenced by skipping a prescribed meal or not following the meal plan your treatment team has established. Mindless Eating: Write in the number of mindless eating episodes that you had each day. Mindless eating refers to not paying attention while you are eating, although you do not feel the sense of loss of control that you do during binge episodes. A typical example of mindless eating would be sitting in front of the TV and eating a bag of microwave popcorn without any awareness of the eating (i.e. the popcorn was gone and you were only vaguely aware of having eaten it. However, you didn’t feel a sense of being out of control during the eating.) Food Preoccupation: Refer to the legend 1 and choose the number from the scale (0-5) that best represents your highest rating for the day. Food preoccupation refers to your thoughts or attention being absorbed by or focused on food. For example, your thoughts of a dinner party and the presence of your favorite foods may absorb your attention so much that you have trouble concentrating at work. Apparently Irrelevant Behaviors: Indicate either yes or no (Y or N) depending on whether you did or did not have any AIBs that day. If you did, briefly describe the AIB in the space provided 2. An AIB refers to behaviors that, upon first glance, do not seem relevant to binge eating. You may convince yourself that the behavior doesn’t matter or really won’t affect reaching your goal to stop binging and purging, when in fact the behavior matters a great deal. A typical AIB might be buying several boxes of your favorite girl-scout cookies because you wanted to help out a neighbor’s daughter. Additional Targets: Work with your individual therapist to identify other target behaviors either related to problem eating behaviors (i.e. use of diet pills or laxatives) or other behaviors that are maladaptive responses to emotional dysregulation (i.e. self-harm, spending, gambling, drug/alcohol use/abuse). Used Skills: Refer to the legend and choose the number from the scale (0-5) that best represents your attempt to use the skills each day. When making your rating consider whether or not you thought about using any of the skills that day, whether or not you actually used any of the skills, and whether or not the skills helped. Urge to Quit Therapy: Indicate your urge to quit therapy before the group session and after the group session each week. Both of these ratings should be made for the same group session. It is best to make both of these ratings as soon as possible following that day’s group session. Use a 0-5 scale of intensity of the urge with 0 indicating no urge to quit, while 5 indicates the strongest urge to quit. ::Completing the Skills Side of the Diary Card:: How often did you fill out this side? Place a check mark to indicate how frequently you filled out the skills side of the diary card during the past week. Skills Practice: Go down the column for each day of the week and circle each skill that you practiced/used that day. ::PME Program Food Log and Appetite Awareness Tracking:: ( a food log will basically ask you to fill out what you ate, when you ate it, how hungry you were, if it was a binge, if you purged, etc) ::Behavioral Chain Analysis of Problem Behavior:: WORKSHEET What exactly is the major PROBLEM BEHAVIOR that I am analyzing? What prompting event IN THE ENVIRONMENT started me on the chain to my problem behavior? Start day: ___________ What things in myself and my environment made me VULNERABLE? What were the LINKS IN THE CHAIN (Actions, Body Sensations, Cognitions, Feelings & Events) Links -Actual (Not skillful) vs. New Skillful Alternative What exactly were the CONSEQUENCES in the environment? 1st 2nd And in myself? 1st 2nd Ways to reduce my VULNERABILITY in the future: Ways to prevent the PRECIPITATING EVENT from happening again: What HARM did my problem behavior cause? Plans to REPAIR, CORRECT, and OVER-CORRECT the harm: My deepest thoughts and feelings about this: ::Behavioral Chain Analysis of Problem Behavior: INSTRUCTIONS:: What exactly is the major PROBLEM BEHAVIOR that I am analyzing? 1. Describe the specific problem behavior (e.g. binge eating, purging, mindless eating, not weighing weekly, missing a group session, or other targeted behaviors). 2. Be specific and detailed in describing characteristics of the behavior, thoughts, or feelings that are important. 3. Describe the problem behavior in enough detail that an actor or actress in a movie could recreate the behavior exactly. What prompting event IN THE ENVIRONMENT started me on the chain to my problem behavior? Start day: ____________ Describe in detail the specific prompting event in the environment that started the chain reaction, even if it doesn’t seem that the event “caused” the problem behavior. 1. Identify when the sequence of events began. What happened first or started the problem behavior. 2. Describe exactly what was going on in the environment the moment the problem started. 3. Describe exactly what was going on in you (what were you doing, thinking, imagining, feeling) the moment the prompting event started. What things in myself and my environment made me VULNERABLE? 1. Describe vulnerability factors happening before the prompting event. 2. What factors or events made you more vulnerable to a problematic chain? 3. Describe factors in you (e.g. use of ETOH, physical illness, sleep deprivation, emotions (such as anger or fear), behaviors (such as inactivity or procrastination), occurring before the prompting event that made you more vulnerable. 4. Describe factors in the environment (e.g. being alone, tempting foods available, increased demands at home or work) occurring before the prompting event that made you more vulnerable. What were the LINKS IN THE CHAIN (Actions, Body Sensations, Cognitions, Feelings, & Events)? 1. Imagine that the problem behavior is chained to the prompting event. Write out all the links in the chain between the prompting event and the problem behavior. 2. Detail each and every link, using a separate piece of paper if more space is needed. Be very specific, as if you were writing a script for a play or a chapter in a novel. 3. Describe the exact thought, feeling, action, sensation, or event that followed the prompting event. 4. Notice what comes first...the sensation? Feeling? Thought? Describe the links in the sequence in which they occur. 5. Then describe what thought, feeling action, sensation, or event followed that. What followed next? 6. Then next after that, etc. For each link in the chain, ask is there another link that went with it? Was there another thought, feeling, action, sensation, or event that occurred? 7. Describe these additional links. Describe in detail what you could have done differently at each link in the chain of events to avoid the problem behavior. 8. Describe the specific skills you could have used to replace the links and avoid the problem behavior. What exactly were the CONSEQUENCES in the environment? 1. Describe the consequences of the problem behavior. 2. Describe the consequences that reinforce the problem behavior (i.e. make it more likely to happen again. For example, temporary decrease in emotion intensity, increased sense of power over others, etc.) 3. Describe the consequences in the environment (effects on the environment and others’ reactions) immediately following the problem behavior (1st) and later (2nd). And in myself? Describe the consequences in you (how you felt, what you thought, what you did) immediately following the problem behavior. Ways to reduce my VULNERABILITY in the future Describe in detail ways you can prevent the chain of events from starting by reducing your vulnerability to the chain (for example: Improve sleep habits, don’t purchase large amounts of tempting foods, balance work with relaxation). Ways to stop the PRECIPITATING EVENT from happening again Describe in detail things you can do to prevent the prompting event from happening again (for example: Make agreements with spouse, family members or friends to take a time out before an argument escalates and then follow through on the agreement). What HARM did my problem behavior cause? 1. Describe in detail the damage or harm your problem behavior cause for you and others. 2. What did you just harm by binge eating, purging, mindless eating? (e.g. self esteem, self confidence, belief you can control yourself, relationship with others, etc.?) Plans to REPAIR, CORRECT, and OVER-CORRECT the harm 1. Describe in detail what you will do to repair what you’ve damaged by engaging in the problem behavior. 2. What exactly will you do to correct the harm (e.g. the blow to your self-confidence, the interference in relationships that the problem behavior caused)? My deepest thoughts and feelings about this (THAT I WANT TO SHARE) 1. Spend some time encouraging and allowing your deepest thoughts and feelings to surface about this chain of events and problem behavior. 2. Write down the thoughts and feelings that you want to share. ::Behavioral Chain Analysis of Problem Behavior: EXAMPLE:: What exactly is the major PROBLEM BEHAVIOR that I am analyzing? One-hour binge eating episode. It started with a quart of mint chip ice cream from 7-11. I inhaled it while driving and crying, feeling out of control. Then I ate 3 regular-size “milky way” bars one after the other. Didn’t taste any of it. I thought, “I don’t care anymore. I’ll show my husband. I won’t come home for hours.” Then I drove around to drive through Mexican restaurant and ordered nachos, fajitas, and quesadillas to go. I inhaled it all in 20 minutes as I sat in my car totally out of control, overwhelmed with hurt and anger. What prompting event IN THE ENVIRONMENT started me on the chain to my problem behavior? Start day: Sunday 08/02/00 What started it was a fight with my husband Monday evening when he got home from work. It actually began the night before on Sunday when my husband, Bob, started complaining that his mother would be staying in a nearby hotel rather than in our home over the Thanksgiving holiday. We had already discussed this several times and I had finally after all these years asserted myself that I prefer she not stay in our home this year. We had agreed, but Bob kept bringing it up. Each time he mentioned it, I felt tense, like I should give in. Then when he got home Monday after work, he said he changed his mind and didn’t think his mother staying in a hotel was a good idea. I felt he was pressuring me to change my mind, and I barked at him, I don’t think having your mother come at all is a good idea.” He shouted at me, “Why don’t you go stay in a hotel then, and my mother can stay here.” I shouted back, “Fine. I will.” I stomped out of the house, furious and hurt. I jumped in the car and headed for the 7-11 thinking, “I’ll eat everything in sight. I don’t care.” What things in myself and my environment made me VULNERABLE? I was tense and irritable even before my husband brought up the subject of his mother on Sunday night. It was the weekend before Thanksgiving and I had a long list of things to do to prepare. I probably expected too much from myself such as window cleaning, flower arranging, and polishing the silver in addition to all of the grocery shopping, usual cleaning, and errands. I didn’t ask my husband for any help and resented his not offering. By Sunday night I was exhausted, resentful, and irritable. What were the LINKS IN THE CHAIN (Actions, Body Sensations, Cognitions, Feelings, & Events)? Example 1: LINKS - NOT Skillful Grabbed my purse, knocked it into the chair. Stomped out of the house loudly. Jumped into car. New Skillful Behavior Opposite to emotion action. Move slowly. Be gentle. Act respectfully to self and possessions. Example 2: LINKS - NOT Skillful While driving reviewed what I said. Regretted what I’d said. Wished I hadn’t. New Skillful Behavior Observe. Just notice. “This is a feeling of regret.” Don’t judge. Don’t push it out or hang onto it. Observe and Describe. Example 3: LINKS - NOT Skillful Felt sad as I thought about the holidays. New Skillful Behavior Be mindful of my current emotion. Don’t try to block it. Accept it. Be open to my emotion of sadness. What is the emotion’s function? Example 4: LINKS - NOT Skillful Pulled into 7-11 and imagined stuffing my feelings with ice cream and candy. New Skillful Behavior Self-soothe with pleasing imagery. Distract with activities (e.g. visit a friend). Distract with opposite emotion (e.g. read the funnies). What exactly were the CONSEQUENCES in the environment? 1st The immediate consequences in the environment were that when I arrived home I didn’t want to sit down to eat dinner with my husband, allowing me to avoid him. 2nd Later, when I wanted to talk with him, it was more difficult because I felt guilty for avoiding him at dinner, and ashamed about my binge eating. And in myself? 1st After the food was gone, I felt exhausted yet relieved. The thoughts and feelings about the fight with my husband were a distant memory; it didn’t seem important anymore. I just wanted to go home and sleep. 2nd Once I got home, I felt guilty because I didn’t want to do anything but go to bed. My stomach was upset and I felt sick and self-hating. Ashamed. Ways to reduce my VULNERABILITY in the future First, I can decease my level of stress and tension by reducing the demands I place on myself. I can also focus on the pleasure and satisfaction I derive from some of the “tasks” I set for myself. Second, I can ask others for help and communicate feelings rather than expect others to read my mind. Ways to prevent PRECIPITATING EVENT from happening again Discuss with husband the “rules” for discussing areas of conflict and disagreements. For example, when both agree that the timing is okay; genuinely listen to each other’s position; agree to end the discussion and return to it later if it seems to be escalating or has reached an impasse. What HARM did my problem behavior cause? The greatest harm done was to myself. I felt ashamed and worthless after the binge and for not handling the situation in a mature manner. Binge eating also made me feel sick and I withdrew from my husband. I felt less able to communicate honestly about the issue at hand regarding his mother’s visit. Plans to REPAIR, CORRECT, and OVER-CORRECT the harm I will repair the harm done by apologizing to myself and committing to never, ever binge again. I will make a promise from deep within to stop, observe, describe and use all the skills I can the next time a binge chain starts. I will apologize to my husband for my role in the fighting and suggest that we do something together that we enjoy. My deepest thoughts and feelings about this (THAT I WANT TO SHARE) In my heart of hearts, my wise self, I know that this is not how I want to behave or conduct my life. I am reacting rather than taking the time to understand, explore, and examine the thoughts and feelings evoked. I miss out on knowing my own experience, on knowing who I am. I blur my experience with binge eating. This deeply saddens me. I want to stop binge eating. ::PME Psychoeducational Principles of Eating Disorders:: Multiples causes of eating disorders 1. Eating disorders are “multidetermined.” 2. There are three broad categories of predisposing factors: a. Cultural b. Individual (psychological and biological) c. Family 3. These factors interact with each other in different ways to lead to an eating disorder. 4. Precipitating factors are not clear, but strict dieting is thought to be an important element. 5. Starvation symptoms are thought to perpetuate eating disorders. The cultural context of eating disorders 1. The majority of eating disorders are seen in girls and women. This fact is thought to be related to the intense pressure on women to conform with the images portrayed in the popular press. 2. Pressure in the media for thinness leads to dieting. 3. Girls as young as age 7 show fear of fatness and desire to diet. 4. Eating disorders are 15 times more likely to develop in a dieting population than in a non-dieting population. 5. As women from non-western cultures are assimilated into western culture their tendency to diet, fear of fatness, and incidence of eating disorder increases. 6. Athletes in some sports are subjected to added pressure for thinness and incidence of eating disorder are greater in these populations. 7. Part of recovery from an eating disorder is rejecting the cultural message that thinness is required for personal happiness. 8. It is impossible for most women to achieve the shape standard portrayed by the media. - Only 5% of women between ages 20 and 29 were as thin as the average Miss America Pageant winner between 1970 and 1979. 9. Ideal body type has changed dramatically over time. - Miss America contestants and Playboy centerfolds have gotten increasingly thin over the years. - This change has been accompanied by an increase in dieting among average women. 10. The difference between the ideal body weight, as perceived by women, and the actual body weight of American women is becoming more broad. - The current shape standard is not close to the actual shape of the average person. 11. The diet industry is a multi-billion dollar industry even though there is no evidence that dieting works in the long term. Set-point theory and physiology of regulation of body weight 1. It is widely thought that body weight is largely stable. 2. Research showed that over a 6-10 week period, body weight only varied by .5% despite more significant variations in caloric intake. 3. The body had physiological mechanisms that work to keep body weight stable despite under or over feeding. - Metabolic rate drops 4. Body has natural set range for weight that is mostly genetic. 66 - 84% of your weight can be explained through genetic loading. Loading increases with age. 5. There is no direct relationship between the number of calories eaten and actual weight. Even if you doubled calories, your weight would eventually return to within 10% of your genetically determined range. 6. Some people who are overweight or obese may actually be at their “ideal” biological weight, and dieting will lead to a chronic state of energy deficit. 7. Trying to loose weight below your biologically determined ideal weight basically pits your well power against the physiological mechanisms that function to keep your weight stable. 8. 90-95% of people who loose weight will regain it within a couple years. 9. Weight loss below the ideal biological weight has been shown to have little impact on body fat levels, but does reduce muscle mass and vital organ tissue such as brain, heart, kidneys and liver. Effects of starvation on behavior 1. Severe and prolonged dietary restriction can lead to serious physical and psychological complications. 2. Some of the symptoms of anorexia are actually the symptoms of starvation. 3. In the late 1940's, during WWII, a group of 36 conscientious objectors agreed to participate in a study to observe the physical and psychological effects of starvation. Subjects were carefully screened for psychological pathology. All subjects who participated in the study were within normal limits on all psychological measures. The study was first published in 1950 by Ansel Keys at the University of Minnesota. 4. Patients participated in a 6-month study where they were on a restricted diet of 1550 Kcal per day. Within a short amount of time, subjects exhibited the following change. a. Behavioral Changes b. Food preoccupation and difficulty concentrating on anything other than food c. Collected recipes and kitchen utensils, pictures of food d. Extensive planning about how to eat food e. Began unusual eating habits (cutting food into small pieces, unusual rituals, hoarding food, eating very slowly, eating in silence) f. Increased use of coffee, tea, spices, chewing gum g. Periods of binge eating h. Reduced physical activity i. After the starvation period extreme overeating 5. Emotional and Personality Changes a. 20% experienced extreme emotional deterioration with an impact on functioning b. Most experienced periods of severe emotional distress c. Depression becoming more severe during the course of the experiment d. Elation observed occasionally e Labiality (sudden swings in mood) f. Anxiety g. Irritability and outbursts of anger h. Apathy i. Psychotic episodes j. Social withdrawal 6. Cognitive Changes a. Decreased concentration, alertness, and comprehension b. Poor judgment 7. Physical Changes a. Sleep disturbance b. Weakness c. Dizziness d. GI disturbances e. Hyper-sensitivity to noise and light f. Edema (swelling) g. Hair loss h. Decreased tolerance for cold i. Visual disturbances j. Parasethias (tingling in extremities) k. Decreased sexual interest l. Decreased body temperature, heart rate, respiration, and basal metabolic rate ::Restoring regular eating patterns:: Restoring regular eating involves meal planning which has five components: 1.Structured Eating 2. Eat according to set times and a predetermined plan. 3. Think of food as a medication to treat extreme food cravings and binge eating. 4. This way of eating takes the decision making out of eating while you are early in treatment until eating can be more naturally regulated by internal cues. 5. It is important that eating behavior not be determined by urges and emotions. Spacing Eating 1.It is recommended to eat three meals and two snacks each day. 2. This type of eating will lessen food cravings, urges to overeat or under eat, and loss of control. Paying attention to the quantity of food 1. Number of calories needed to restore weight depends on current weight, metabolic condition, eating pattern, and ability to tolerate change. 2. Slow increase of calories to achieve a weight gain of 1-2 pounds per week is usually recommended. Paying attention to the quality of food 1. Usually at the beginning of treatment people categorize foods as good or bad, often based on food myths. 2. A meal plan should slowly incorporate previously avoided foods and binge foods into everyday eating. 3. Accurate knowledge about nutritional facts should be sought out from a nutritionist. Vomiting, laxatives, and diuretics in controlling weight 1. Vomiting is not completely effective at removing all food from the stomach and often perpetuate binge eating by worsening food cravings. 2. Laxatives and diuretics are not effective methods of reducing calorie absorption, they just cause temporary water loss. Determining a healthy body weight 1. Weight tables should not be used to determine the ideal weight for an individual. 2. Ideal weight should be determined individually by each person’s weight history and likely genetic background. 3. The best way to determine one’s “natural body weight” is to eat sensibly, gain control of binge eating, engage in moderate exercise and allow one’s body to find what one should weight. 4. The diet industry has lead us to believe that we can “choose” our body weight, the fact is that like having to accept that one is shorter or taller than average, one may have to accept a body weight that is higher than average. 5. One guideline for determining ideal body weight that has been supported by research is to take 90% of your highest weight prior to the onset of the eating disorder. This is just a guideline and may require modification. 6. Because weight varies on a daily based on water balance and the contents of the digestive track, a five-pound range should be established rather than a specific weight. 7. If weight is a medical concern it should be monitored weekly by your therapist/physician. Physical complications 1. Eating disorders have a number of potential medical complications and can be life threatening. 2. Anorexia has the highest mortality rate of any psychiatric disorder. Electrolyte disturbances - Electrolytes are essential for metabolic functioning and for normal functioning of nerve and muscle cells. Purging, laxative abuse and diuretic abuse can lead to an imbalance in electrolytes. - Imbalances in electrolytes can lead to weakness, tiredness, constipation and depression. More seriously, cardiac arrhythmias can develop and may cause sudden death. Cardiac Irregularities - Death from an eating disorder is most often the result of a cardiac irregularity. - In those with anorexia, bradycardia (heart rate less than 60 beats per minute), tachycardia, hypotension, ventricular arrhythmias, and cardiac arrest are a concern. - Repeated use of ipecac can also cause cardiac arrest. Kidney Dysfunction - Induced by electrolyte disturbances and edema. - Care must be taken in refeeding to minimize kidney problems. Cerebral atrophy - In more than half of patients with anorexia, brain scans show cerebral atrophy. This is also seen in some patients with bulimia. - This does appear to reverse itself with renourishment. Neurological abnormalities - In patients with bulimia, abnormalities in electrical discharges in the brain are common. - This may result in muscle spasms and a tingling sensation in the extremities. Swollen Salivary Glands - Occurs in about 25% of those with bulimia, but can also appear in those with anorexia. - Causes a swelling of the face. - Returns to normal when eating is normalized and vomiting is eliminated. Gastrointestinal Disturbances - Abdominal pain, stomach bloating. - Occasionally, spontaneous regurgitation of food. - Enlargement of the stomach resulting from binge eating. - Rarely, binge eating can lead to stomach rupture and death. - Vomiting can lead to serious tearing of the mouth and throat tissue. - Choking can occur on objects used to induce vomiting or on vomitus itself. - The small intestine, liver and pancreas con also be adversely affected. - Permanent loss of bowel reactivity can be seen with the chronic abuse of laxatives. Dental deterioration - Gastric acid can cause erosion of dental enamel, which can lead to periodontal disease. - Teeth often change to a brown or grey color. - Removal of teeth may be required. Finger clubbing or swelling - Seen in severe cases of laxative abuse. - Gradually reduces once laxative use is discontinued. Edema and dehydration - Dieting, vomiting, laxative and diuretic abuse can lead to alternating periods of dehydration and excessive water retention. - Dehydration can cause swelling. - Water retention is often most severe right after vomiting and laxative abuse often resulting in a weight gain of 5 to 10 pounds, but this gradually reduces with time after the discontinuation of vomiting. Menstrual and reproductive functioning - In anorexia amenorrhea is required, but amenorrhea and menstrual irregularities are also seen in about 50% of those women with bulimia. - Menstrual irregularities and infertility can continue for some despite the return to normal weight. - The chance of prenatal complications is increased in those with eating disorders. Bone abnormalities - Osteoporosis is often seen within two years of the onset of the eating disorder. - Those with eating disorders are also more vulnerable to fractures and often have stunted grow. |