(Neziroglu, F. The Relationship Between Eating Disorders and OCD: Part of the
... Individuals who suffer from AN commonly diet and exercise excessively,.
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Obsessive Compulsive Disorder and Eating Disorders Who s Driving the Bus? By Guy Oberwise, LCSW Directory of Primary Therapy and Mood Disorders Coordinator Timberline Knolls Residential Treatment Center Lemont, Ill.
Welcome and Background • Timberline Knolls almost seven years • 25+ years as clinician/therapist -‐-‐ down in the trenches • Last two years, more expertise in Mood and Anxiety Disorders • CertiRied in ERP
Table of Contents • Relationship between ED and OCD • OCD Spectrum Disorders • ED Behavior and OCD Thought Process • Crash Course in OCD • Who is Driving the Bus? • Assessment and Treatment Approaches • Exposure and Response Prevention • Treatment Approaches for both ED and OCD
Relationship Between ED and OCD • Common views about eating disorder behaviors: – – – –
performing rituals around food obsessing about what to eat or weight whether food will sit in their stomachs and make them feel ugly preoccupation with body image
• Most people do not think of ED as being part of the OCD spectrum. • In an effort to alleviate their patients suffering, sometimes professionals mistake one for the other. • Since behaviors that result from both OCD and EDs appear similar, it might be difRicult to determine which of the two disorders the patient actually has if both are simultaneously present. • Which disorder is mainly responsible for bringing about the other? (Neziroglu, F. The Relationship Between Eating Disorders and OCD: Part of the Spectrum)
Relationship Between ED and OCD • Since 1939, researchers have speculated on the parallels between OCD and ED. • Numerous studies now show that those with eating disorders have statistically higher rates of OCD (11% -‐ 69%) and vice versa (10% -‐ 17%). • As recently as 2004, Kaye et al. reported that 64% of individuals with eating disorders also possess at least one anxiety disorder, and 41% of these individuals have OCD in particular.
(Neziroglu, F. Relationship between Eating Disorders and OCD: Part of the Spectrum)
Relationship Between ED and OCD • In 1983, Yaryura-‐Tobias and Neziroglu proposed that ED may be considered part of the OCD spectrum; currently, boundaries among AN, BN and OCD remained blurred. • Challenge for clinicians: recognizing whether the condition is a particular form of OCD or an entirely separate, but related, disorder with symptoms that merely have an obsessive-‐compulsive quality to them. – Individuals who suffer from AN commonly diet and exercise excessively, those with bulimia usually develop a vicious cycle of binging and purging. – In both instances, extreme and often life-‐threatening behaviors that consist of either consuming too little or too much food typically stem from intrusive, obsessive thoughts.
(Neziroglu, F. Relationship between Eating Disorders and OCD: Part of the Spectrum)
OCD Spectrum Disorders
OCD Spectrum Disorders Dysphoria
Somatization Body Dysmorphic Disorder
Substance Abuse Paraphilia
Trichotillomania Nail Biting Harm
(Steketee, Gail, Ph.D, Overcoming Obsessive-Compulsive Disorder, Best Practices for Therapy, 1999)
OCD Spectrum Disorders • A variety of conditions have been classiRied as OCD Spectrum disorders, but there is some doubt about their linkage to OCD and appropriateness of ERP for these conditions. • These disorders vary with OCD along two dimensions: impulsive/compulsive behavior and dysphoric/ euphoric mood. • OCD falls into the moderately dysphoric mood range; the feeling of being compelled to engage in rituals because of discomfort is the hallmark of this disorder. (Steketee,Gail, Overcoming Obsessive Compulsive Disorder, Best Practices for Therapy, 1999)
OCD and Bulimia • Most clearly related is bulimia, which is characterized by ingesting excessive amounts of food, an anxious and dysphoric state, followed by purging and/or use of laxatives to relieve discomfort • Bulimia has responded well to treatments similar to those used in OCD, but according to diagnostic criteria for OCD, when obsessive thoughts are focused on food and weight gain, the condition would be considered an eating disorder. • An exception to this rule can be seen in the case of a young woman: – Obsessed about contamination from food, poisoning from chemicals or medications in her food. – Ate little and occasionally forced herself to vomit because of fears. Although she was very thin and possibly malnourished, because of their function, her symptoms were better classed as OCD than an eating disorder.
( Steketee, Gail, Overcoming Obsessive Compulsive Disorder, Best Practices for Therapy, 1999)
BDD and OCD • Body Dysmorphic Disorder is close to the compulsive and dysphoric end of spectrum. • The disorder of imagined ugliness – individuals believe that one or more parts of their bodies(e.g., nose, thinning hair) are defective and provoke ridicule or rejection from others. – often seek reassurance and medical intervention to correct the presumed defects. (Steketee, Gail, PhD., Overcoming Obsessive Disorder, best practices for therapy, 1999)
Hypochondriasis and OCD • Hypochondriasis overlaps somewhat with OCD, differing mainly in the greater generality of fears of illness in hypochondriacal clients who are typically concerned about a range of potential diseases. • By Contrast, OCD sufferers report a focused obsession in one main area, as in the case of one woman who sought medical testing and checked her breast repeatedly for cancer (a condition from which her mother died) to the point of physical damage • Anorexia resembles BDD and hypochondriasis, but the focus of anxiety is on body weight. Distinctive to all three conditions is marked lack of insight into the presumed physical Rlaw, illness, or underweight, whereas most OCD sufferers express clear awareness of the excessiveness of their fears ( I know this sounds ridiculous, but… ), and only a minority lack insight. (Steketee, Gail, PhD., Overcoming Obsessive Disorder, best practices for therapy, 1999)
Anxiety and Eating Disorders • Anxiety disorders are common in eating disordered individuals and often declare themselves prior to the onset of the ED (Kaye, Bulik, Thorton, Barbarich, & Masters, 2004) • Although rates of individual AD diagnoses differ among ED subtypes, higher-‐than-‐expected rates of social phobia, obsessive compulsive disorder, panic disorder, agoraphobia, and GAD have been reported in all subtypes (Hudson etal.2007;Kaye et al.,2004).
In Summary • EDs generally implicate phobic elements (e.g., the fear of weight gain), obsessive preoccupations (e.g., over attention to body shape), and compulsive reactions (e.g., the need to purge after eating). • Feasible to frame and work with eating symptoms as variants of anxiety-‐driven behaviors, applying the concepts of phobia, obsessions, and compulsions to weight gain fears, bodily preoccupations, and driven weight loss strategies
(see Barlow, Allen, & Choate, 2004)
ED Behavior and OCD Thought Process
Anorexia Nervosa Diagnostic Criteria • Refusal (or obsession and compulsion) to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected). • Intense fear of gaining weight or becoming fat, even though underweight. (Keel and Mccormick2010)
Anorexia Nervosa Diagnostic Criteria • Disturbance in the way in which one s body weight or shape is experienced, undue inRluence of body weight or shape on self-‐evaluation, or denial of the seriousness of the current low body weight. • In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles.
(Keel and Mccormick2010)
Eating Disorders • Sufferers rely on symptoms to control overwhelming internal feelings, fears, intense pain or other troubling emotions. • High co-‐occurrence with substance abuse • High rates of trauma
Roots of EDs EDs develop in the context of: – Genetic predispositions – Environmental factors – Medical history – Life experiences – The presence of co-‐occurring psychiatric and addictive disorders
ED Clinical Phenomenology • • • • • • • • • •
Loss of control Unsuccessful attempts to stop the ED behaviors Great deal of time spent thinking about or engaging in the behaviors Continuing despite negative consequences Withdrawal symptoms including irritability, restlessness, insomnia, depressed mood, self-‐injury Tolerance Negative impact on social, occupational or recreational activities (disease of isolation) Limited emotion regulation skill Denial/secrecy/shame Body image distortions/dissatisfaction
Food/Weight Related Symptoms • Behaviors associated with ED may include: – Consistent adherence to increasingly strict diets, regardless of weight – Habitual trips to the bathroom immediately after eating – Secretly bingeing on large amounts of food – Stealing food – Hoarding food – Exercising compulsively often several hours per day – Compulsive weighing/body checking
Social, Cognitive and Spiritual Signs • Withdrawal from friends/family • Avoidance of meals or situations where food may be present • Preoccupation with weight, body size and shape • Obsessing over calorie intake or expenditure • Memory and planning difRiculties • Rigid, black and white thought patterns • Disconnection from value system and self
Crash Course in OCD
Diagnostic Criteria For OCD A. Either obsessions or compulsions. – Obsessions are deRined by: •
Repetitive and persistent thoughts, images, or impulses that are experienced at some point, as intrusive and inappropriate and that cause marked anxiety or distress. Thoughts, images or impulses are not worries about real-‐life problems Person tries to ignore or suppress the thoughts, images, or impulses, or neutralize them with some other thought or action Thoughts, images or impulses are recognized as a product of one s own mind and not imposed from without.
(Jonathon Abramowitz, Obsessive-‐Compulsive Disorder2006)
Diagnostic Criteria for OCD – Compulsions are deRined by: • Repetitive behaviors or mental acts that one feels driven to perform in response to an obsession or according to a certain rule • the behaviors or mental acts are aimed at preventing or reducing distress or preventing feared consequences; however the behaviors or mental acts are clearly excessive or are not connected in a realistic way with what they are designed to neutralize or prevent (Jonathon Abramowitz, Obsessive Compulsive Disorder2006)
Diagnostic Criteria for OCD B. At some point during the disorder, the person has recognized that the obsessions or compulsions are excessive and unreasonable. C. The obsessions or compulsions cause marked distress, are time-‐consuming (take more than 1 hour a day), or signi=icantly interfere with usual daily functioning. D. The content or the obsessions or compulsions is not better accounted for by another Axis I disorder (e.g. concern with appearance in the presence of body dysmorphic disorder, or preoccupation with having a serious illness in the presence of hypochondriasis). E. Symptoms are not due to the direct physiological effects of a substance or a general medical condition. ( Jonathan Abramowitz, Obsessive Compulsive Disorder2006)
Obsessions Reported by a Non-‐ Clinical Sample Several studies have clariRied that 85-‐90% of ordinary people experience intrusive thoughts or mental rituals that are quite similar in nature to and content to those of OCD suffers. Such as: – – – – – – – – –
Impulse to hurt or harm someone. Thought of intense anger toward someone, related to a past experience. Impulse to say something nasty and damning to someone. Thought of harm to, or death of, close friend or family member. Thought that something is wrong with your health. Thought whether an accident had occurred to a loved one. Impulse to crash car while driving. Thoughts about accidents or mishaps, usually when about to travel. Thought of harm befalling her children, especially an accident.
Thus, it is not the intrusive quality of obsessions that is atypical, but rather their frequency, intensity, and capacity to disturb the person who experiences them, as well as the difRiculty in getting rid of them.
Common Observed OCD symptoms • Contamination – Obsessions concerning contamination from dirt, germs, body secretions, household items, poisonous materials; washing and cleaning rituals, avoidance • Harming – Obsessions concerning responsibility for injury or harm to others; compulsive checking, seeking assurance, repeating activities to prevent disasters • Incompleteness – Obsessions concerning order, asymmetry, imbalance (perhaps the fear that discomfort will persist indeRinitely); compulsive arranging, ordering, repeating • Unacceptable thoughts – Obsessional thoughts, impulsive images of sex, sacrilege and violence; mental rituals, neutralizing, seeking assurance
Common Obsessions • Thoughts of contamination from germs, dirt, fungus, animals, body waste, or household chemicals. • Persistent fears and doubts that one is (or may become) responsible for harm or misfortunes such as Rires, burglaries, awful mistakes, injuries • Unacceptable sexual ideas (e.g. molestation) • Unwanted sacrilegious thoughts (e.g. desecrating a synagogue) • Need for order, symmetry, completeness • Fear of certain numbers (e.g. 13, 666), colors or words (e.g. murder)
Common Rituals • Washing one s hands 50 times per day or taking multiple (lengthy) showers • Repeatedly cleaning objects or vacuuming the Rloor • Returning several times to check that the door is locked • Placing items in the correct order to achieve balance • Re-‐tracing one s steps • Re-‐reading or re-‐writing things to prevent mistakes • Calling relative or experts to ask for reassurance • Thinking the word life to counteract hearing the word death • Repeated and excessive confessing of one s sins • Repeating a prayer until it is said perfectly
Safety Behaviors in OCD • Passive avoidance – Avoidance of situations and stimuli (e.g., driving, being the last one to leave the house, toilets, 666 ) • Compulsive rituals – Hand washing, checking, seeking assurances, repeating routine activities • Covert neutralizing – Mental rituals (e.g., repeating prayers, good words, or safe phrase), brief mental acts (e.g., canceling out a bad thought with a good thought) • Brief or subtle mini rituals -‐ Use of wipes or paper towels, quick checks of appliances, scrutinizing others behavior or facial expressions.
Prevalence and Course • OCD is quite common, occurring in 2.5 percent of the population (one in forty people) at some point during their lives. • Fourth most common psychiatric disorder • Men and women affected almost equally • Age of onset is a few years younger for males then for females (Gail Steketee, Ph.D., Overcoming Obsessive Compulsive Disorder, Best Practices for Therapy1999)
Similarities OBSESSIVE COMPULSIVE DISORDER
• Individual counts the number of mouthfuls chewed or pieces of food in a meal, according to some Rixed or magical number that is “correct” or EATING DISORDERS “just right.” • Individual repeatedly washes hands, due to a fear of germs, contact with • Individual counts mouthfuls or pieces waste products, or a number of other of food as a means of limiting portions and thus effectively losing sources of possible contamination more weight. that exist. • Individual throws out food in a can • Individual excessively washes hands that has been slightly dented, for fear to remove trace amounts of oil that might cause weight gain if ingested. that it might contain food poisoning and later cause serious illness to • Individual throws out food in a can someone. because it was discovered to contain too many calories after reading the label. (Neziroglu.F. The Relationship Between Eating Disorder and OCD: Part of the Spectrum)
Similarities OBSESSIVE COMPULSIVE DISORDER
• Individual repeatedly asks a waiter in a restaurant about different dishes on menu, doubtful that he or she has • enough knowledge to make the perfect meal decision. • Individual refuses to enter the kitchen in order to eat, due to fear of accidentally mixing the cleaning • items with the food. • Individual repeatedly checks refrigerator, shelves or other parts of house, in order to make sure that every piece of food bought is in its • proper, designated place.
Individual constantly asks same waiter about contents of dishes, so as to stay away from having any butter, oil, or fat. Individual refuses to enter the same room, for it will only lead to the temptation to eat and thus get fat. Individual constantly checks same locations, in search of food to eat in an extensive bulimic binge period.
(Neziroglu.F. The Relationship Between Eating Disorder and OCD: Part of the Spectrum)
So Who is Driving the Bus? • In the case of both anorexia and bulimia, obsessions lead to levels of anxiety that can only be reduced by ritualistic compulsions. • The compulsive behaviors of anorexics can often be seen in their careful procedures of selecting, buying, preparing, cooking, ornamenting, and eventually consuming food.
(Neziroglu,F. Eating disorder and OCD:Part of the Spectrum)
So Who is Driving the Bus? • Just as with OCD, compulsions are commonly strengthened by many other personality traits such as uncertainty, meticulousness, rigidity, perfectionism (Yaryura-‐Tobias et al., 2001) • The common thread linking both anorexia and bulimia to OCD is the overwhelming presence of obsessions and compulsions that eventually affects the individual s daily functioning even to the extent of becoming incapacitated. (Neziroglu,F. Eating disorder and OCD:Part of the Spectrum)
So Who is Driving the bus? • As with an OCD sufferer who can never achieve that just right feeling on a speciRic task, so is a bulimic prevented from ever reaching his or her goals of fullness and emptiness in an endless binge-‐purge cycle. • Lastly, the OCD sufferer who may loose weight excessively and appear anorexic, yet is doing so merely as the result of contamination concerns or time consuming rituals that prevent him or her from eating on a regular basis. • The potential for one disorder to appear as the other is virtually endless….
So Who is Driving the Bus? • When food or eating is the object of fear and worry, anxiety symptoms must be differentiated from an eating disorder. – For instance, patients with a phobia of certain foods (due to a fear of choking or vomiting) may restrict their eating, lose weight, and be difRicult to distinguish form those with anorexia nervosa.
• In addition, eating and anxiety disorders can co-‐occur, as with a woman with anorexia who has also had obsessions that she would absorb calories (and gain weight) by merely touching or looking at food. (John Abramowitz, Exposure Therapy for Anxiety2011)
Considerations for Therapy and Approach • If a patient is underweight, careful consideration should be given to health implications, as well as the potential for cognitive impairment which could prevent learning during exposure. Exposure therapy might be delayed until a healthy weight can be maintained. • In instances where a speciRic phobia (choking on food) has resulted in a signiRicant weight loss that threatens the patient s health, a combined exposure and weight restoration approach may be required.
Assessment and Treatment Approaches
Assessment Tools • Yale-‐Brown Obsessive Compulsive Scale • A symptom checklist and a severity rating scale • Symptom checklist provides deRinitions and examples of obsessions and compulsions
Treatment Approaches Currently, two empirically supported treatments exist for OCD: 1. Cognitive-‐Behavioral Therapy 2. Pharmacotherapy involving serotonin reuptake inhibitors(SRI) medication
Medication for OCD • Anafranil Clomipramine Up to 250mg/day • Zoloft Sertraline Up to 200 mg/day • Prozac Fluoxetine Up to 40 to 80mg • Luvox Fluvoxamine Up to 300 mg/day • Paxil Paroxetine 40 to 60 mg/day • Celexa Citalopram up to 60mg/day (Johathan Abramowitz, Obsessive Compulsive Disroder2006)
Medication for OCD • These agents are thought to reduce OCD by increasing the concentration of serotonin • On average, 20% to 40% improvement in OCD symptoms over a 12 week period
Advantages/Disadvantages Advantages: • Safe and easy to use • Clinically effective: 20 to 40 percent of time
Disadvantages: • • • •
Limited improvement rates About 50% of people do not improve Possible side effects Must be used continuously for improvements
Cognitive Behavioral Therapy (CBT) • Based on understanding of the symptoms • Vital components of CBT include: – Education – Cognitive therapy techniques – Exposure Therapy – Response Prevention
CBT • Entails socializing the patient to the cognitive-‐ behavioral conceptual model and providing rationale for how the treatment techniques are designed to weaken obsessions and compulsions. • CBT techniques for OCD involve rational discussion to help the patient identify and correct mistaken beliefs that underlie obsessional fears, avoidance, and safety-‐ seeking behaviors.
Exposure and Response Prevention • Centerpiece of the treatment program • Exposure entails gradually confronting situations and thoughts that evoke obsessive fears • Accompanied by imagining the feared consequences of exposure • Patient remains exposed until the associated distress decreases on its own, without attempting to reduce the distress by withdrawing form the situation or by performing compulsive rituals • Response prevention component of CBT entails refraining from any behaviors that serve to reduce obsessional anxiety or terminate exposure
Advantages/Disadvantages of CBT/ERP
Advantages: • Clinically effective: 60 to 70% symptom reduction on average • Treatment is fairly brief (usually 15 to 20 sessions) • Long term maintenance of treatment gains Disadvantages: • Patient must work hard to achieve improvements • Involves purposely evoking anxiety during exposure • Trained ERP Therapist not widely available
Developing the Hierarchy • At TK, therapist Rirst interviews the resident carefully to obtain a detailed list of situations that provoke obsessional fears. • Fears are arranged in a hierarchy from least to most difRicult according to the level of discomfort provoked • Discomfort to each situation is rated on a 0 (none) to 100 (maximum) Subjective Units of Discomfort Scale (SUDS) • Based on SUDS rating, each exposure is assigned each week of therapy grouping together those with similar themes, contexts, and associated discomfort level
Direct Exposure • During therapy sessions at TK, the therapist describes and often demonstrates how the resident should engage in the exposure to ensure that she is not avoiding obsessive cues • Therapist inquires about the resident s thoughts and demotions, asking for ratings of discomfort every Rive to ten minutes to ensure that the resident is fully exposed to all aspects of cues for discomfort • If anxiety is relatively low or declines rapidly, the resident will be asked to confront the next item on her hierarchy
Imagined Exposure • Residents can experience catastrophic obsessive thoughts and images that occur spontaneously in their everyday lives; thoughts and images are difRicult to provoke fully during direct exposure. • Therapist constructs imaginary scenes in which these feared obsessions and their catastrophic outcomes (Rire, burglary, running over a pedestrian) occur • Scenes are ordered from least to most discomforting • During sessions, therapist inquires about sensory perceptions, thoughts, and emotional and physiological feelings
Effective Treatment Approaches for Both ED and OCD Symptomology • • • • • • • • • •
DBT CBT ACT Exposure Therapy Medication Expressive Therapies Group Therapy Experiential Therapy Family Systems 12-‐Steps
Summary • Diagnosing clients with both ED and OCD symptoms is not easy! • Use the YBOC s to help diagnose OCD symptoms • Weight restoration takes precedence over OCD symptoms • Exposure Therapy should be done with a trained therapist • Use multiple treatment options and approaches
Hierarchy Examples Contamination fears: SUDS 1 to 7 7 Taking shower 6 Touching shower curtain with hand 5 Touching shower curtain with paper towel 4 Stepping into shower stall 3 Looking at shower, imagine getting in and starting to shower 2 Looking at the shower 1 Thinking about taking a shower
Hierarchy Example • • • • • • •
Need to know or remember Fear of losing things – checking binder, organ. Checking that did not make a mistake Checking that didn t forget something Counting up to 4 and back down Rewriting/rereading homework assignments Fear of not saying just the right thing
Guy Oberwise [email protected]
A residential treatment center located on 43 beautiful acres just outside Chicago, offering a nurturing environment of recovery for women ages 12 and older struggling to overcome eating disorders, substance abuse, mood disorders, trauma and co-‐ occurring disorders. www.timberlineknolls.com | 1.877.257.9611