Preferred Provider WorkshopTreatment of Obsessive Compulsive Spectrum Symptoms

and Eating DisordersSaturday, July 16th

Erin McGinty, LPCCastlewood Treatment Center for Eating Disorders

1260 St. Paul Road636-386-6633

www.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

Co-Occurring Anxiety Disorders and Emotion Regulation

Individuals with anxiety disorders face many struggles in regulating emotion:

• Emotion misidentification

• Impaired understanding of emotions

• Increased negative responses to internal and external cues

As a result, clients make attempts to regulate emotional experiences that exacerbate unwanted emotional states

• Social avoidance

• Experiential avoidance

• Eating disorder and other maladaptive behaviors

Obsessive-Compulsive Symptoms and Eating Disorders

• Preoccupation with weight, shape, and food mirror obsessions

• Eating disorder behaviors may be compulsions

• View of an eating disorder as an obsessive-compulsive spectrum disorder

• Cognitive behavioral therapy (CBT) and exposure and response prevention (ERP) therapy is the treatment of choice for anxiety disorders such as obsessive-compulsive disorder– Initial studies suggest that utilizing ERP in the treatment of eating

disorders is effective in reducing depressive, obsessive-compulsive, and eating disorder symptom severity

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).

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

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

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