WebinarTreatment of Obsessive Compulsive Spectrum Symptoms

and Eating DisordersDecember 7th, 2011

Erin McGinty, LPC, NCCProgram Director, Anxiety Services Coordinator, and Primary Therapist

Castlewood Treatment Center for Eating Disorders800 Holland Road

636-386-6611, ext. 103www.castlewoodtc.com

Prevalence of Co-Occurring Anxiety Disorders with Eating Disorders

Kaye et al. (2004) studied the co-morbidity of anxiety disorders in an eating disorder sample, and found the following:

• Two-thirds of the subjects had one or more lifetime anxiety disorder

• A majority of the subjects reported that their anxiety disorders preceded the onset of the eating disorder

• The most common anxiety diagnoses were obsessive-compulsive disorder (OCD; 41%) and social phobia (20%)

Effects of a Co-Morbid Anxiety Disorder on Eating Disorder Symptomology

Clients with co-morbidity experience both a longer length of stay and an exacerbation of eating disorder symptoms such as:

• Perfectionism

• Obsessionality

• Harm avoidance, including:– Higher degrees of worry, or anticipatory anxiety

– Higher degrees of intolerance of uncertainty

– Higher degrees of fatigue

– Higher degrees of pessimism

• Body image dissatisfaction

• Higher scores on depression inventories

The Importance of Treating Co-Morbid Anxiety Disorders (Steinglass et al., 2010)

• “Studies report that individuals with anorexia nervosa endorse significantly higher levels of anxiety than healthy controls both while underweight and after weight restoration”

• Trait anxiety has been identified as a differentiating factor between patients who remitted from anorexia nervosa– Trait anxiety as measured by the State-Trait Anxiety Inventory (STAI;

Speilberger)

• Symptom substitution

Elements of Clinical Anxiety

Fear Cues: Stimuli and situations that elicit anxiety

Maladaptive Beliefs: Exaggerated estimates of threat• Catastrophizing

• Probability Overestimation

Safety Behaviors: “Actions intended to detect, avoid, or escape a negative or feared outcome” (Abramowitz, 2011)

Elements of Clinical Anxiety

Safety Behaviors (continued; Abramowitz, 2011)

• Passive avoidance

• Checking and reassurance seeking• Checking locks, doors, outlets

• Information seeking

• Reassurance seeking

• Visual checking

• Compulsive rituals• Handwashing

• Repetition of standing up, sitting down

• Praying

Elements of Clinical Anxiety

Safety Behaviors (continued; Abramowitz, 2011)

• Brief, covert (mini) rituals

• Safety signals• Cell phone when leaving house

• Anti-anxiety medication

• Keys

• “Safe” person

Eating Disorders as Obsessive-Compulsive Spectrum Disorders

Fear Cue:“Fear of fat” (Steinglass et al., 2010)

Maladaptive Beliefs: Irrational thoughts regarding food, weight, and shape; overestimation of the likelihood and consequences associated with the threat

Safety Behaviors: Passive avoidance, body checking, restriction, purging, compulsive exercise, calorie counting, food rituals

The Application of Anxiety Treatments to Eating Disorders

Outcome studies suggest that Exposure and Response Prevention Therapy (ERP) is an effective form of treatment for co-morbid eating and anxiety disorders:

“Results indicate that CBT with a primary focus on ERP is a successful treatment approach for treating persons with both obsessive-compulsive disorder and an eating disorder. Significant changes in the severity of obsessive-compulsive symptoms, depressive symptoms, and eating disorder symptoms were noted (Adams, Riemann, Weltzin, & McGinty, 2007).”

Exposure and Response Prevention Therapy

Exposure• Graduated, repetitive, and consistent exposure to situations and

thoughts that provoke anxiety and distress– Situational/In vivo exposure

– Imaginal exposure

• While performing the exposure, the client imagines the feared consequence(s) of the exposure

• The client remains exposed to the cue until the associated anxiety decreases

• Goal is to achieve habituation, or the decrease in anxiety due only to the passing of time– Within-trial habituation

– Between-trial habituation

Exposure and Response Prevention Therapy

Exposure and Response Prevention Therapy

Response Prevention

• Refraining from behaviors that are meant to reduce anxiety– Behavioral rituals

– Mental rituals

– Avoidance

• Clients learn that feared consequences of exposure are irrational

Example: Eat a feared food such as potato chips(exposure), no purging/binging/exercise/restriction (response prevention).

Fear Hierarchy Formation

• Generate a list of external and internal triggers that provoke anxiety and induce urges to engage in behaviors

• Assess feared consequences if client was exposed to a trigger

• Assess responses to feared situations:– Passive avoidance

– Behavioral rituals

– Mental rituals

• Generate a list of feared situations

• Ask the client to provide a subjective unit of distress (SUDS) rating for each situation

Fear Hierarchy Formation

Examples of assignments to generate data:

• Assign clients to create a list of the following:– “Good/bad” foods

– Avoided foods

– Binge foods

• Assign clients to complete a an exhaustive list of their ritual behaviors at the table, and to identify what purpose these rituals serve

• Assign clients to write “A Typical Day…– … in my eating disorder.”

– … in my exercise addiction.”

– … in my OCD.”

Fear Hierarchy Formation

• Assign clients to write “The Worst Day of My Eating Disorder”

• Assign clients to write out their exercise routine in exhaustive detail

Target Symptoms in the Treatment of Obsessive-Compulsive Symptoms and Eating Disorders

Body Image• Clothing avoidance

• Mirror avoidance

• Body checking

• Femininity and sexuality

Food Rituals• Cutting of food

• Mixing of food

• Ordering and arranging of food on plate

• Eating foods in a certain order

• Counting rituals

Target Symptoms in the Treatment of Obsessive-Compulsive Symptoms and Eating Disorders

Exercise Rituals• Ordering of exercises in a particular fashion

• Specific number of calories burned, miles run, time exercised, repetition of weight exercises, etc.

• Rigidity around exercise

Perfectionism• Need for symmetry and exactness

• Ordering and arranging compulsions

• Concern over mistakes and the interpretation of mistakes as failures

• Doubts about the ability to accomplish tasks

Target Symptoms in the Treatment of Obsessive-Compulsive Symptoms and Eating Disorders

Other Eating Disorder Rituals• Calorie counting

• Avoidance– Feared foods

• Binging

• Purging

• Rumination

• Chewing/spitting

• Laxative, diet pills, diuretic, ipecac abuse

• Restriction

Exposure and Response Prevention Therapy

Psychoeducation• Providing a rationale for the model

• Educating the client on the importance of follow-through with self-monitoring and exposure assignments

Self-Monitoring• Ban books

• Exposure and thought records

Cognitive Therapy• Identify cognitive distortions and feared consequences of exposure

• Based on the outcome, identify evidence for/against irrational belief

• Reframing of irrational beliefs