Taking New Approaches to Difficult-to-Treat Patients
Reprinted from Eating Disorders Review
July/August 2011 Volume 22, Number 4
At the 10th London International Eating Disorders Conference, held at the University of London late in March, clinicians in concurrent sessions addressed three particularly challenging topics: managing compulsive exercise, treating patients with severe and enduring anorexia nervosa (AN), and treating eating disorders patients who have a history of childhood trauma.
Managing Compulsive Exercise
Drs. Caroline Meyer and Lorin Taranis, of Loughborough University, Leicester, UK, and Dr. Stephen Touyz, of the University of Sydney, Australia, noted that many treatment programs currently prohibit exercise for patients with eating disorders. This practice has largely developed because staff members and clinicians have found it hard to enforce partial exercise programs. In addition, policing such policies creates a battle of wills that only adds more strain to the therapeutic relationship. The panel noted that battles over exercise distract both the patients and the staff from the major goal of therapy, helping patients assume responsibility for themselves.
Dr. Meyer and colleagues believe that a supervised program of exercise is an essential component of treatment of patients with AN and bulimia nervosa. Dr. Meyer noted there is "a basis of misinformation to these patients' behavior, which is just as true for beliefs concerning exercise as it is for distorted views about food." Using cognitive behavioral therapy (CBT), such false beliefs can be challenged by providing accurate information on the type and level of activity necessary for optimal health, along with emphasis on the deleterious effects of excessive exercise in the presence of malnutrition, she said. An important footnote to this is that such sessions must be conducted by professionals with specific expertise in eating disorders and excessive exercise.
Dr. Meyer, who directs Loughborough University's Centre for Research into Eating Disorders, (LUCRED), also described the LEAP program (Loughborough Eating Disorders Activity Therapy Program). The LEAP program applies CBT to counteract excessive exercise among eating disorders patients. As she explained, LEAP is a semi-structured manualized CBT treatment program that is problem-oriented, concerned with the present instead of the past, and that focuses on maintenance. The core principles are to go with and not against the patient, to educate patients about healthy and unhealthy exercise, and, perhaps most importantly, to help patients gain control over exercise, she said. "Control" includes helping patients relearn healthy/non-compulsive attitudes, beliefs, and behaviors about physical activity and excessive exercise. Patients learn the underlying factors that led them to excessively exercise in the first place and also to better understand the connections between compulsive exercise and eating disorders.
The LEAP structure allows for group or individual sessions, and the program includes 8 one-hour sessions that are organized around four core themes: education, guided discovery, skills training, and relapse prevention.(Drs. Meyer, Taranis, and Touyz recently developed The Compulsive Exercise Test (CET) to assess the primary factors that maintain excessive exercise [See Eur Eat Disord Rev 2011 May 19:256].
Treating Severe and Enduring AN
Dr. Bryony Bamford, of St. George's Hospital, University of London, told the audience there is currently no exact definition of severe and enduring AN (SE-AN), but patients do have a distinguishable profile. This profile includes: (1) being consistently ill for 10 years or more, (2) undergoing at least one unsuccessful evidence-based treatment, (3) having severe impairment across a number of life domains, and (4) having a strong motivation to hold onto AN, and thus a reluctance to continue active treatment. In addition, treatment seems risky because when patients do regain their weight, they may drop out of therapy. Often therapists are frustrated because these patients seem disengaged from help and seem hopeless.
Dr. Bamford presented a different model of treatment, one that she said "moves beyond the focus on 'cure' or 'absence of symptoms' to helping individuals build meaningful and valued lives." The focus on quality of life can also be seen in psychological interventions in other fields than the eating disorders field, said Dr. Bamford. And, these patients may be "more motivated to improve the quality of their lives rather than to change their eating patterns or weight status," she said.
Intervention for this group of patients focuses on acceptance, management, reducing risk, and improving quality of life. It is also important to address threats that are of immediate concern to the patient and to treat these separately rather than focusing on the overall illness, she noted. In addition, the emphasis should be on finding ways to cope that address the beliefs about illness rather than focusing on the symptoms of the illness.
According to Dr. Bamford, rehabilitation programs should include skills training, goal-setting, enhancing "hope," and managing secondary consequences rather than the primary illness. Constantly working on enhancing motivation is another key, she noted. This is coupled with an agreement on minimum steps, and setting firm behavioral goals. Patients will also need training in useful social skills, rather than emphasizing the symptoms of the illness. In addition to all this, the therapeutic alliance requires an emphasis on consistency, reassurance, encouragement, and patience, with a good degree of hope. The alliance must also be collaborative and it also helps to view the patient as an expert in her own care—find out what works and what doesn't work, Dr. Bamford advised. Finally, practical considerations also help, such as setting shorter sessions or taking a slower pace when warranted. Flexibility is also important—for example, finding out when a good time will be to meet, and telephoning the patient before the session, reinforcing the idea that "I would like to see you," said Dr. Bamford.
A Complex Challenge: Childhood Trauma and Disordered Eating
Eating disorder patients who have a history of traumatic experiences or violence during childhood, such as physical or sexual abuse or neglect, are far more likely to respond poorly to treatment than are other patients, according to Stephen Wonderlich, PhD, and Heather Simonich, MA, from the Neuropsychiatric Research Institute, Fargo, ND, and Óyvind Ró, PhD, MD, of Oslo University Hospital, Oslo, Norway. In such cases, the path to an eating disorder may start with trauma, which can lead to shame, dissociation, impulse control, anxiety, substance use, cognitions, or mood instability, and then to an eating disorder.
Eating disorders patients who have undergone trauma in childhood can also develop post-traumatic stress disorder (PTSD). This may take the form of simple PTSD after a single event in adulthood, or complex PTSD, typically after multiple repeated, prolonged traumas during childhood, which may also lead to dissociative syndromes. Patients with eating disorders and PTSD have a number of telltale symptoms, including recurring intrusive images, sleeping difficulties, difficulty concentrating, lack of interest, and social withdrawal. Childhood trauma may be hidden, and reactivated during treatment. Or the trauma may be known but the patient may have detached from it, describing the symptoms as occurring in someone else. Finally, patients may directly seek help for both PTSD and an eating disorder.
The clinical picture is different for patients with eating disorders without PTSD and those with both disorders, said Dr. Rø. For example, in the absence of PTSD, a patient may have a drive to be thin and fear of weight gain. With PTSD due to sexual abuse, a patient may feel disgust, dirtiness, a need for purification, and may develop a fear of thinness/fatness to avoid attracting unwanted attention. "Their symptoms could be understood as a reaction to 'being in extreme danger," he said.
Better understanding will lead to better treatment for these complex patients, according to Dr. Wonderlich. Treatment difficulties are commonly encountered. Staff members are challenged by the risk for overinvolvement or burnout, and with problems of setting boundaries with these patients. Negative transference reactions are also common, where some therapists may appear to be abusive and other therapists may seem to be withholding or failing to protect the patient. Because some patients have experienced a repetitive pattern of being traumatized in close relationships, there is the risk of "re-traumatization" during treatment.
And, to add even more challenge to treating such patients, there may be a close connection between memories of sexual trauma and eating disorders symptoms. That is, food (smell, consistency, color, taste, time of the meal and even the mealtime atmosphere) may trigger memories of trauma. Some strategies to counteract and disrupt the connection between food and trauma include helping the patient become aware of the connection, differentiating between now and then, helping the patient experiment in safe settings, and helping him or her "avoid the avoidance," said Dr. Wonderlich.
Two approaches that are proving helpful for these challenging patients are trauma-focused cognitive behavioral therapy (TF-CBT), first described by Cohen et al. in 2006, and drug therapies. According to Dr. Wonderlich and his colleagues, studies have consistently shown that TF-CBT assignment, improvement in parental support, and improvement in parental distress about the child's victimization predict a better outcome for the child. The best candidates for TF-CBT are children 4 to 18 years of age with a history of single or multiple trauma, prominent trauma symptoms, depression, or anxiety.Children with severe behavioral problems may need alternative interventions. Dr. Wonderlich also pointed out that of all the classes of drugs that have been studied in this group of patients, the SSRIs are considered the drugs of choice; these include sertraline, paroxetine, and fluoxetine.