Category: Disorders
Is our biological clock leading us to gain weight?
The role of the circadian system in obesity and disordered eating
By Nicole Mori Psychiatric Mental Health Nurse Practitioner
The circadian system is the body’s endogenous timekeeper, a network of hierarchically-organized structures (“clocks” or “oscillators”) in nucleated cells, which regulates a variety of biological processes (including the cell cycle, metabolism, growth, development and sleep/activity cycles) by generating outputs in a rhythmical manner. The suprachiasmatic nucleus (SCN) in the hypothalamus acts as the “master” pacemaker by generating periodic outputs targeting clocks in peripheral cells. The endogenous SCN period is greater than 24 hours, but it resets every day in response to environmental signals. The main synchronizer for the SCN is the periodical light/dark signal over the course of 24 hours. Additional environmental synchronizers include feeding and social activity. The circadian system enables organisms to adapt to environmental changes and optimize function, playing a central role in the maintenance of health and illness. Research has linked circadian dysregulation to a variety of disorders including cancer, cardiovascular disease, metabolic abnormalities and obesity in humans and animals.
Recent studies support the role of circadian dysfunction in the development and maintenance of obesity. Circadian misalignment can manifest as metabolic abnormalities, sleep disturbances, delayed sleep phase (evening preference), abnormalities in daily rest/activity rhythms and disordered eating patterns. Both endogenous (e.g., genetic) and exogenous factors are involved in circadian dysfunction. External factors include decreased sleep duration, jet lag, frequent snacking and nighttime eating and exposure to bright light. Epidemiological data show shift work is an independent risk factor for obesity and increased metabolic risk. Decreased sleep duration is associated with increased risk for obesity and metabolic disease. Among children, sleep loss is associated with the development of obesity and is a predictor of lifelong obesity. The increasing prevalence of obesity in recent decades has coincided with trends such as shortened sleep duration, light pollution, increased nighttime exposure to bright light and increasing shift work.
Sleep pattern changes affect appetite and eating behaviors and vice versa. Sleep restriction has been associated with changes in circadian hormonal patterns, which result in increased appetite, hunger and food choices such as increased preference for sweets. In turn, alterations in eating patterns have a dysregulating effect on the circadian system. For instance, overeating has been associated with decreased sleep duration, high dietary fat and carbohydrate intake with decreased short wave sleep and high increased nighttime arousal respectively.
The timing of food consumption plays an important role in metabolism and body weight. Nighttime eating leads to increased insulin resistance and worsened glucose tolerance and lipid levels than meals consumed during the daytime. Among bariatric patients, eating late in the day has been associated with less post-operative weight loss. In addition, irregular eating patterns are associated with abnormal weight gain, increased binge eating and greater eating disorder severity. Conversely, appropriate timing of eating and regularization of meal times appear to have a beneficial effect. Animal studies show that time restricted feeding (limiting feedings to a timeframe appropriate to the species’ diurnal/nocturnal pattern) is associated with decreased obesity. Among humans, an app study showed an association between time-restricted feeding and sustained weight loss.
As we have seen, the regulation of metabolism and body weight appear to depend on the optimal function of the circadian system, which requires appropriately timed exposure to synchronizing stimuli. Interventional studies suggest that manipulation of synchronizers may be beneficial in treating disordered eating behaviors, metabolic abnormalities and obesity. Potential interventions for circadian dysfunction would optimize the timing of synchronizers (such as bright light therapy, timing of food intake and time-restricting feeding), regularize rest/activity circadian rhythms (by increasing regular exercise, maintain a consistent waking up schedule), or the administration of medications according to circadian phase. The treatment of circadian dysfunction promises improved outcomes in the prevention and treatment of obesity, but further research is needed. New technologies and methods will enable a thorough characterization of circadian function is obesity and eating disorders and determine whether the circadian system is a potential target for chronotherapeutic interventions.
The Lindner Center of HOPE is conducting a comprehensive study of circadian function in adults with obesity with and without binge eating disorder. For more information, contact Brian or George at (513) 536-0707 or visit http://www.lcoh.info
Bibliography
Broussard, J. L., & Van Cauter, E. (2016). Disturbances of sleep and circadian rhythms: novel risk factors for obesity. Current opinion in endocrinology, diabetes, and obesity, 23(5), 353-359.
Garaulet, M., Gómez-Abellán, P., Alburquerque-Béjar, J. J., Lee, Y. C., Ordovás, J. M., & Scheer, F. A. (2013). Timing of food intake predicts weight loss effectiveness. International journal of obesity, 37(4),
604-611.
self-esteem and self-worth in our youth will bring about numerous long-lasting, positive changes that Cupid’s arrow could only dream of creating.
Promoting Positive Food Habits in Children
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By Elizabeth Mariutto, PsyD, CEDS, Clinical Director of Eating Disorder Services |
“How do I encourage mindful eating for my kids?” I often have patients come in with histories of well-intended parents who promoted diets or restrictive eating in the attempts to help their kids become “healthy.” When they come to me to rewire their brains against the diet culture so prevalent in our society, they feel like they don’t know where to start in promoting more beneficial attitudes towards food in their own kids. Here are ten tips for promoting positive food habits in kids.
- Set up your home to promote balanced nutrition. Buy a variety of produce, serve meals with a balance of proteins, fats, and carbohydrates, and while you can definitely have some sweets and packaged snack foods, having too many of these options can lead to turning to these items often. Serve unfamiliar foods with familiar foods, and introduce new foods multiple times. Encourage family mealtimes at the table without electronics.
- Allow them to trust their bodies. Think about how we feed babies and small children. Every 3 to 4 hours, they cry and tell us they are hungry. We feed them until they stop eating. If children tell you they are full after a meal, don’t force them to finish their plate. This only teaches them that it’s pointless to follow hunger and fullness cues.
- Avoid labeling foods as “good” or “bad” or “healthy” or “unhealthy.” Avoid overtly controlling food messages, such as putting pressure on kids to eat fruits and vegetables or telling them they can’t have sweets, as these practices lead to unhealthy eating habits for kids (Scaglioni, Arrizza, Vecchni, & Tedeschmi, 2011).
- Serve items for meals that you would like kids to eat at regular times, making sure there is something you know they like on the table. Don’t worry about what they end up choosing to eat.
- Avoid rewarding, bribing, or soothing kids with food. Yes, that includes bribing kids for eating their veggies with dessert! Research has found kids consume less of a food and rate them as less tasty if they were presented as instrumental to a goal (Maimaran & Fishback, 2014), and rewarding with food is associated with emotional eating later in childhood (Farrow, Haycraft, & Blisset, 2015). Additionally, teach kids to learn to cope with their emotions in other ways.
- Promote body acceptance. Some kids are naturally smaller, some kids are naturally bigger. And that is ok! Weight-related comments are really not necessary at all, and often harmful. Additionally, avoid holding different standards for children of different sizes. Encourage a balanced, “everything in moderation” approach to eating for all children.
- Practice what we preach! Be a good role model for body acceptance and positive attitudes towards food. Those little ears are listening! Sure, go out for ice cream sometimes. And avoid criticizing your body or telling yourself you have to work out to get rid of the calories from eating that ice cream. Prioritize sitting down to eat and having regular, balanced meals and snacks.
- Encourage healthy activity without tying this to food or weight. Help kids find activities that they truly enjoy, and focus on the value of exercise to help our bodies become stronger, improve our mood, and nourish.
- Teach kids to savor food. Help them be selective in choosing which dessert sounds the best, and demonstrate taking slow bites to truly relish them.
- If they, or you, mess up, treat this with compassion. No one is perfect, and we don’t need to beat ourselves, or others, up about our mistakes.
Farrow, C. V., Haycraft, E., & Blissett, J. M. (2015). Teaching our children when to eat: How parental feeding practices inform the development of emotional eating—a longitudinal experiential design. American Journal of Clinical Nutrition, 101, 908-13.
Jacobsen, M. (2016). How to Raise a Mindful Eater. Middletown, DE: First Printing.
Maimaran, M., & Fishbach, A. (2014). If it’s useful and you know it, do you eat? Preschoolers refrain from instrumental food. Journal of Consumer Research, 41, doi:10.1086/677224
Scaglioni, S., Arrizza, C., Vecchni, F., & Tedeschmi, S. (2011). Determinants of children’s eating behaviors. American Journal of Clinical Nutrition, 94, 6. doi: 10.3945/ajcn.110.001685
Tribole, E. & Resch, E. (2012). Intuitive eating: A revolutionary program that works. New York: St. Martin’s Griffin.
Good Food for Great Mood
Nutritional Psychiatry and Wellness
By Anna I. Guerdjikova, PhD, LISW, CCRC
Director of Administrative Services, Harold C. Schott Foundation Eating Disorders Program
The connection between health in general and the foods we consume has been known since the dawn of human kind, and Hippocrates is credited with the “Let food be thy medicine” saying. The narrower connection between overall diet quality and common mental disorders, in particular depression and anxiety, is a much newer field and the term “nutritional psychiatry” was not coined until the most recent decade. Initially, the focus of this discipline was on researching single foods or nutrients and their role in mental health. Gradually, it has been recognized that proper nutrition for good mental health is a very complex landscape. What we consume and how it affects us cannot be researched in isolation and what we eat in excess can be as important as what we do not eat enough of.
The growing data in the field of nutritional psychiatry is encouraging. A recent systematic literature review derived a list of antidepressant nutrients linked to the treatment and prevention of depression1. The twelve identified antidepressant nutrients included: folate, iron, long-chain omega-3 fatty acids, magnesium, potassium, selenium, thiamine, vitamin A, vitamin B6, vitamin B12, vitamin C, and zinc. The most nutrient-dense individual animal foods to fight depression were oysters, mussels and seafood, all rich in DHA which helps form strong membranes that easily transport nutrients into brain cells, lowers inflammation and raises serotonin levels. From plant-based foods leafy greens, lettuces, peppers, and cruciferous vegetables received the highest score, suggesting that regularly incorporating those veggies in one’s diet might improve mood dysregulation.
Another study followed up with patients for 12 weeks in a randomized controlled design study to examine efficacy of adjunctive dietary intervention in the treatment of moderate to severe depression2. The intervention consisted of seven individual nutritional sessions to support adherence to the recommended diet, encouraging consumption of the following key food groups: whole grains (5–8 servings per day); vegetables (6 per day); fruit (3 per day), legumes (3–4 per week); low-fat and unsweetened dairy foods (2–3 per day); raw and unsalted nuts (1 per day); fish (at least 2 per week); lean red meats (3–4 per week),chicken (2–3 per week); eggs (up to 6 per week); and olive oil (3 tablespoons per day), while reducing sweets, refined cereals, fried food, fast-food, processed meats and sugary drinks (no more than 3 per week). The group receiving dietary support along with therapy or medication, showed significantly greater improvement in depressive symptoms suggesting dietary improvement may provide an efficacious and accessible treatment strategy for the management of depression.
A recent review summarized data from 20 longitudinal and 21 cross-sectional studies and concluded that adhering to a healthy diet, in particular a traditional Mediterranean diet (meals built around plant-based foods like vegetables, fruits, herbs, nuts, beans and whole grains with moderate amounts of dairy, poultry, eggs and seafood), or avoiding a pro-inflammatory diet (deficient in fruits and vegetables and containing excessive amounts of meat, refined grain products, and dessert foods) might confer some protection against depression in observational studies3.
A healthy gut environment (microbiome) supports production of vitamins, helps train the immune system, supports cleansing of the body and helps modulate the nervous system. The microbiome can be influenced by our diet, providing the direct link between the brain and the gut, as 90% of our serotonin receptors are located in the gut. Consuming a diet rich in both prebiotics (the fiber that feeds the probiotics in our gut found in onions, leeks, asparagus, bananas and garlic) and probiotics (good bacteria that are found in fermented foods like sauerkraut, yogurt with active cultures, pickles, kefir, kimchi, kombucha) is recommended for keeping the microbiome well balanced. Probiotics are associated with a significant reduction in depression and anxiety in two recent analyses, reviewing over 30 individual studies4,5. Moreover, overconsumption on ultra-processed food leads to inflammation in the gut and might dysregulate the microbiome, possibly contributing to a plethora of diseases6.
While the field is still working through challenges to identify a clear set of biological pathways and targets that mediate the brain-gut connection, the following few simple recommendations might be helpful as complementary interventions benefiting mild to moderate depression and anxiety:
- Regulated eating habits (3 meals and 1-2 snacks/day) decrease blood sugar variations and helps stabilize moods
- Follow a diet comprising mostly of real foods (Mediterranean diet)
- Probiotic-rich foods and limiting processed food (shopping the “perimeter of the store” preferentially )supports the health of the gut-brain axis and can be beneficial for mood regulation
- LaChance LR, Ramsey D. Antidepressant foods: an evidence-based nutrient profiling system for depression. World J Psychiatry. 2018;8:97-104.
- Jacka F, O’Neil A, Opie R, et al. A randomized controlled trial of dietary improvement for adults with major depression. BMC Med. 2017;15:23.
- Lassale C, Batty GD, Baghdadli A, et al. Healthy dietary indices and risk of depression outcomes; a systematic review and meta-analysis of observational studies. Mol Psychiatry. September 26, 2018
- Ruixue Huang, Ke Wang, Jianan Hu Effect of Probiotics on Depression: A Systematic Review and Meta-Analysis of Randomized Controlled Trials, Nutrients 2016 Aug 6;8(8):483
- Richard T Liu, Rachel F L Walsh, Ana E Sheehan Prebiotics and probiotics for depression and anxiety: A systematic review and meta-analysis of controlled clinical trials Neurosci Biobehav Rev, 2019 Jul;102:13-23.
- Marit K Zinöcker, Inge A LindsethThe Western Diet-Microbiome-Host Interaction and Its Role in Metabolic Disease Nutrients 2018 Mar 17;10(3):365.
When To Seek Treatment For Anxiety
By Angela Couch, RN, MSN, PMHNP-BC
Psychiatric Nurse Practitioner, Lindner Center of HOPE
Anxiety is a common symptom. Anxiety is a part of everyone’s lives, we have all experienced it to one degree or another. Believe it not, anxiety serves some useful purposes. Anxiety can help give you the drive to make a change, or complete task on time.Anxiety can activate the fight or flight instinct, in a “potentially” dangerous situation, giving you the drive to get out of there, or do something to prevent harm. Anxiety can occur when you are enduring multiple stressors, or there is uncertainty, and it’s not entirely unexpected.
For instance, say you hear layoffs are coming in the company, and you’re not sure if your department will be affected. You may experience physical symptoms of anxiety (which could include racing heart, nervous stomach, sweating, tremor, nausea, shortness of breath, and more), and you might also experience worry. COVID-19…yup, that can cause some anxiety, or worry, too! Situational anxiety is a part of life, and often can be managed by rational self-talk, problem-solving, and various positive self-care strategies. (For more on that, see some of our other recent blog articles, for lots of helpful ideas!) So how do we know when the anxiety is more than just “normal” or to be expected, and when to seek help?
According to the National Comorbidity Study Replication, about 19.1% of U.S. adults will have had an anxiety disorder in the past year, and 31.1% experience an anxiety disorder in their lifetime. In other words, it’s pretty common! There are various types of anxiety disorders, and most have an underlying common thread– difficulty in accepting uncertainty in some form. So how do you know if you may need to seek further assessment or help for anxiety, if it’s really so common? If everyone gets it, is it really a problem that requires treatment? The answer is yes, it might. Some symptoms that may indicate problematic anxiety include:
* Feeling “paralyzed” by fear.
* Anxiety is causing you to avoid things you used to be able to do without anxiety, or things that are important to you (this could include social activities, leaving your house, going to your job, driving, engaging in spiritual activities, etc.).
* You have difficulty staying present “in the moment”, which may repeatedly distract you from attending to conversations, being able to complete work or school tasks because of lack of focus.
* You are having difficulty with sleep or eating due to excessive worry or anxiety.
Anxiety is causing significant physical symptoms.
* You cannot determine a cause for the anxiety and the symptoms are persistent or very bothersome.
* You worry about “everything” or “all the time”.
* The anxiety/worry you are experiencing about situations seem excessive.
* You need to engage in compulsive or repetitive behaviors, or do things in a certain way, in order to avoid significant anxiety/worry.
* Anxiety is causing you to turn to self-medication with alcohol or substances.
So you’ve determined you should seek help, now what? Psychotherapy can be helpful for anxiety, and is a very important component of treatment. Psychotherapy may include several modalities such as cognitive behavioral therapy, addressing faulty beliefs contributing to anxiety, psychoeducation about anxiety and worry, problem-solving, exercise and wellness activities/lifestyle changes, addressing sleep hygiene, skills for time management and stress reduction, or exposure therapy, just to name a few.
How do you know if psychotherapy is enough to manage the symptoms? Medication can be a helpful component in treatment of anxiety, particularly if symptoms are not improving with other psychotherapeutic interventions mentioned above. Medications alone are rarely enough to treat anxiety disorders adequately. Medication can often make it easier to engage in meaningful psychotherapy, to make those helpful lifestyle changes, or try new ways of coping with the anxiety/worry. If you are experiencing suicidal thinking or significant depression, medication should be a consideration. If the anxiety symptoms are preventing you from being able to work or do other essential tasks, medication may be indicated. If your therapist suggests a medication consultation, you should consider it.
The important things to remember are, everyone has some anxiety, not all anxiety is bad, and when anxiety does become problematic or excessive, there are evidence-based treatments to help, so don’t be afraid to reach out for help!
Am I shopping too much?
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By Jessica Kraft, APRN, PMHNP-BC, Psychiatric Mental-Health Nurse Practitioner, Lindner Center of HOPE |
Everyone needs to shop from time to time, but at what point does shopping become a problem? And is this a diagnosis? Compulsive buying disorder (CBD) is a mental health condition characterized by “excessive, impulsive, and uncontrollable purchase of products in spite of severe psychological, social, occupational and financial consequences”. While this diagnosis is not found in the DSM-V, shopping addiction was described and discussed clinically in the early 20th century by Bleuler and Kraepelin (Black, 2007). There is still much to be learned about the causes of CBD or shopping addiction, but several factors thought to be contributing include materialism, social anxiety, a general lack of social support, loneliness, or trauma history (Harnish, Bridges, Gump, & Carson, 2018). It is not uncommon for those with CBD to also struggle with anxiety disorders, mood disorders, substance use disorders, eating disorders, or disorders of impulse control.
Most consumers of goods take value and usefulness into consideration when making a decision about a
purchase and emotion is not often involved in the decision. This has also been referred to as “utilitarian shopping”, where someone only shops when they need something. Those who struggle with CBD more often make purchases in order to improve their mood, cope with stress, gain social approval, or improve their self-esteem. This has been referred to as “hedonic shopping” where the primary purpose of shopping is for entertainment, distraction, or pleasure. Research has shown that CBD has relation to reward sensitivity and the mesolimbic dopamine reward circuit in the brain (Günüç & Doğan Keskin, 2016). Over time this behavior becomes reinforced and can create a pattern similar to those seen with behavioral addictions like gambling, sexual addiction, or internet addiction (Granero et al., 2016).
Some might think that during a global pandemic with economic uncertainty people would be less likely to spend and work towards curbing unhealthy shopping impulses. For some who struggle with CBD, this isn’t necessarily the case. With the emphasis and ease of online ordering and curbside pick-up options combined with the increased stress that many are feeling related to the pandemic, coping with shopping addiction has been more challenging for some. This year credit and debit card use increased by 79% in May compared to April in New Zealand. As shops reopened in Australia over the summer there were “Christmas size crowds”. A recent study in the UK showed that those with underlying mental health conditions (primarily depression and anxiety) were more likely to resort to “panic buying” or compulsive buying in response to the pandemic (Jaspal, Lopes, & Lopes, 2020). Considering that loneliness is a contributing factor to compulsive buying as well as the need to cope with stress it really isn’t very surprising that the pandemic has exacerbated these unhealthy buying behaviors in those who struggle with CBD.
What are the symptoms of CBD?
- Urges to make a purchase are strong and the act of purchasing creates a “high” feeling
- Preoccupation with shopping or planning purchases
- Making a trip to the store and purchasing more items than originally intended
- Most purchases made are unnecessary items
- Debt, maxed out credit cards, or spending beyond one’s means
- Hiding purchased items from family members or friends due to guilt
- Feeling unable to stop oneself from shopping or making unnecessary purchases
What can you do to decrease urges to shop?
- Seek professional help. While there are few evidence-based treatments for CBD there has been interest and anecdotal success with antidepressants (SSRIs), cognitive behavioral therapy (CBT), and habit reversal training (HRT)
- Join a support group or surround yourself with understanding and supportive people
- When feeling the urge to purchase something make yourself wait a minimum of 24-hours
- Declutter your space, organize, and get a better idea of what you have and what you love
- Identify and avoid triggering situations – for example, unsubscribe from e-mails from your favorite stores if this has led you to make unnecessary and impulsive purchases in the past
- Be mindful of who you follow on social media and how this influences your shopping behaviors
- When looking at an advertisement ask yourself what they are trying to sell you and how this makes you feel about yourself. For instance, does this company benefit financially from you feeling badly about yourself or wanting a different lifestyle?
Sources:
Black, D. W. (2007). A review of compulsive buying disorder. World Psychiatry, 6(1), 14-18. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1805733/#B1
Granero, R., Fernández-Aranda, F., Mestre-Bach, G., Steward, T., Baño, M., del Pino-Gutiérrez, A., … Jiménez-Murcia, S. (2016). Compulsive Buying Behavior: Clinical Comparison with Other Behavioral Addictions. Frontiers in Psychology, 7(914). https://doi.org/10.3389/fpsyg.2016.00914
Günüç, S., & Doğan Keskin, A. (2016). Online Shopping Addiction: Symptoms, Causes and Effects. Addicta: The Turkish Journal on Addictions, 3(3). https://doi.org/10.15805/addicta.2016.3.0104
Harnish, R. J., Bridges, K. R., Gump, J. T., & Carson, A. E. (2018). The Maladaptive Pursuit of Consumption: the Impact of Materialism, Pain of Paying, Social Anxiety, Social Support, and Loneliness on Compulsive Buying. International Journal of Mental Health and Addiction, 17. https://doi.org/10.1007/s11469-018-9883-y
Jaspal, R., Lopes, B., & Lopes, P. (2020). Predicting social distancing and compulsive buying behaviours in response to COVID-19 in a United Kingdom sample. Cogent Psychology, 7(1). https://doi.org/10.1080/23311908.2020.1800924
How to Treat Psychosis with Cognitive Behavioral Therapy for Psychosis (CBTp)
Many think that psychosis cannot be targeted with cognitive behavioral therapy, but that is not the case. There is a specific form of therapy that was developed for psychosis called CBTp. One important point to mention is that the symptoms are only targeted when they are distressing to the client and they interfere with their functioning or safety, not because one believes them to be untrue or abnormal. The main tenet is to join with the client and build rapport while not directly challenging their psychosis, which is referred to as working within their belief system. Once this is established, gradually helping them think differently about some of their experiences or beliefs is possible, but not in all cases. In some cases, the therapy is used to help them live their life and meet their goals in spite of their experiences or beliefs.
One useful technique with this therapy is to help them feel less stigmatized and normalize some of their experiences. There are specific websites out there that detail stories and list famous people out there who have struggled with psychosis, which can be very helpful for the client to read about. One such website is intervoiceonline.org.
Another very practical technique is helping them set smart and realistic goals. This can be done by asking what their goals are and developing a shared goal that can be accomplished. For example instead of “wanting the voices to stop” a smart goal could be “by the fourth session I will have learned and used two different coping strategies that reduce how much distress the voices cause from 100% to 75%”.
Other strategies that CBTp utilizes are coping strategy enhancement. First you figure out what they already are using to cope and figure out if they need to be refined or improved. Helping them figure out the time of day to use these strategies is important. They are likely to be most helpful when their voices are triggered, such as certain times of the day, a specific place, a certain smell, or certain feeling. Some strategies that can be useful to use before their voices are triggered include progressive muscle relaxation, deep breathing, and practicing mindfulness of the present moment such as identifying things in the room. Strategies that can be helpful once the voices are already triggered include: using an ipod and listening to a feel good songs playlist; playing the look, point and name; using sub vocal speech or singing under one’s breath which can interrupt the voices; focusing on voices (hearing out in order to change relationship with voice); entering into dialogue with them, and setting specific times for listening to voices.
When targeting voices in sessions, there are several main goals. One is to help the client understand how their beliefs and thoughts relate to the voices and influence their feelings, mood, and coping. Another is to help them identify their beliefs about their voices. Helping
them explore evidence for and against their distressing beliefs is important. One can also develop behavioral experiments to test out the reality of their belief. Helping them generate alternative explanations and thoughts about their voices is also helpful. Providing behavioral interventions to reduce distress associated with their voices is key as well. Lastly, helping them change their relationship to their voices is important.
As you can see, there are many strategies that can be useful for this presenting problem.
The key it to present it in a way that is collaborative with the client and doing so in a trusting professional relationship. Meeting the client where they are at is important. It is also helpful to keep in mind that these techniques take some time to work and for the client to be able to use them, so patience is key as well.
Nicole Bosse, PsyD
Staff Psychologist, Lindner Center of HOPE
Binge eating disorder in primary care: Why should I screen my patients?
Binge eating disorder (BED) is the most common eating disorder, with an estimated prevalence of 3% in the US population. It is also the most common eating disorder among men. BED is characterized by regularly recurrent episodes of eating unusual amounts of food within a discrete time frame (usually <2hrs), which are associated with loss of control and significant psychological distress. Unlike people with Bulimia nervosa, those with BED do not engage in purging behaviors (such as fasting, driven exercise or self-induced vomiting). Untreated BED is a risk factor for obesity, metabolic disorders, mental health problems and poor quality of life. Although psychotherapy and medications have demonstrated effectiveness in treating BED symptoms, the vast majority of patients with BED remain undiagnosed and untreated.
Patients with BED face significant barriers to evaluation and treatment. First, there are patient-related barriers such as lack of awareness of BED as a medical condition, where the patient may attribute their loss of control to having no willpower. Moreover, patients may be reluctant to discuss their eating behavior and weight out of shame or fear of being judged. Finally, past experience may lead patients to assume that their primary care provider is unwilling or unable to address their disordered eating. Providers also face challenges in identifying BED in the primary care setting: Some patients with BED may have a normal BMI, which makes providers assume that they do not have an eating disorder. In addition, BED often co-occurs with psychiatric disorders such as depression and anxiety, which can lead to attributing the BED symptoms to the patient’s mental health diagnosis or the effects of psychotropic medications. Finally, lack of knowledge about treatment options and underestimation of the impact of BED on medical conditions, leads many primary care providers to overlook BED as a target for evaluation and treatment.
The reality is that primary care providers have much to offer patients with BED. Screening, education, self-management tools and in some cases, referrals to specialty care or medication. Screening for and treating BED can be advantageous when managing patients with diabetes, where decreasing the frequency of binges can lead to significant improvement in metabolic parameters. A BED diagnosis is useful when selecting psychotropic medications with lesser potential to aggravate binge eating. Finally, diagnosing a patient with BED can alleviate the patient’s distress and stigma. Patients who struggle with BED are often relieved and thankful that they have a treatable medical condition rather than attributing their bingeing to a character flaw and feel empowered and thankful for any help in managing their disorder. Since untreated BED poses a challenge in treating conditions such as diabetes and dyslipidemia, diagnosing and managing BED can benefit all areas of patient health.
Although there are still significant barriers to screening, diagnosis and treatment, primary care providers have the means to improve health outcomes among their patients with binge eating. Primary care is the ideal setting for raising awareness of the problem of binge eating among the general population, to address patient’s disorder eating concerns and start patients on their journey to recovery. First of all, routine procedures such as weighing patients, offer opportunities to ask patients whether they have any concerns about their weight or eating patterns. These questions can also be added to the medical history updates hat patients complete prior to office visits. Routine screening of special populations such as patients with diabetes, those attempting weight loss or receiving psychotropic medication is of great help in managing those comorbidities. The SCOFF questionnaire is a brief screen for eating disorders suitable for primary care*. Providers interested in providing medication management for BED should also screen for psychiatric comorbidities and substance use disorders to guide their medication choices.
In summary, patients with BED are largely undiagnosed and untreated, which complicates the management of their medical and mental health issues. Although access to specialty continues to be a challenge, primary care providers have the means to start patients on their road to recovery and improve overall health outcomes and quality of life.
The Research Institute at the Lindner Center of HOPE is a world leader in Binge eating disorder research. For more information about our current studies, call 513-536-0710.
*The SCOFF questionnaire is available at:
http://cedd.org.au/wordpress/wp-content/uploads/2014/09/The-SCOFF-Questionnaire-SCOFF.pdf
References:
Chao AM, Rajagopalan AV, Tronieri JS, Walsh O, Wadden TA.
Nurs Scholarsh. 2019 Jul;51(4):399-407. doi: 10.1111/jnu.12468. Epub 2019 Mar 1.
Javaras KN, Pope HG, Lalonde JK, et al. Co-occurrence of binge eating disorder with psychiatric and medical disorders. J Clin Psychiatry. 2008;69(2):266-273. doi:10.4088/jcp.v69n021
Nicole Mori RN, MSN, APRN-BC
Nurse Practitioner, Lindner Center of HOPE Disorder Services
An Introduction to Radically Open Dialectical Behavioral Therapy
Radically Open Dialectical Behavioral Therapy (RO DBT) is a treatment developed by Thomas Lynch for those who develop disorders associated with an overcontrolled (OC) personality. OC individuals are often described as reserved and cautious, not very expressive with their emotions, and great at delaying gratification. OC individuals tend to be strong rule followers and feel a high sense of obligation in their lives (i.e., go to a birthday party because they feel they have to rather than wanting to do so). However, at times, they may experience “emotional leakage,” or emotionally breaking down once they are in private after holding it all together all day in public. An OC personality can be really helpful in some ways. These are the people that get their work done no matter what, show up to work on time every day, work through all the nitty, gritty details of a project, and follow through on their word. They can be very organized and methodical, and they are great at planning for long-term gains (i.e., saving to buy a house). However, they can be rigid and inflexible at time (i.e., get very upset if a restaurant lost a dinner reservation and struggle with figuring out where else to go to eat) and may have difficulty receiving feedback. Patients that may benefit from this treatment include those with chronic depression and anxiety, autism spectrum disorders, Obsessive-Compulsive Personality Disorder, and Anorexia Nervosa.
The biosocial theory behind RO DBT explains that OC individuals have brains that zoom in on the negative or threatening aspects of a situation before seeing the positives. This predisposition interacts with being raised in an environment that encourages or praises high levels of self-control in one’s life (i.e., doing homework without one’s parents needing to remind them to do so), performing at a high level (i.e., getting good grades, doing well in sports, receiving accolades), and avoiding making errors. These individuals end up avoiding uncertain situations, hold back their emotions out of fear that others may see them as being out of control, and become guarded in social situations, appearing to others as withdrawn. Their lack of vulnerability and difficulty expressing what they are really feeling leads others to struggle to relate to them, so they end up feeling lonely and isolated. Thus, RO DBT operates under the assumption that increasing connectedness to others can improve psychological functioning, thus targeting emotional expression. Additionally, RO DBT encourages being open to hearing other points of view so that one can learn as well as learning to be flexible in responding to varying situations.
Thomas Lynch describes that the five main behavioral targets of RO DBT include 1) being socially distant or reserved, 2) inflexible, rule-governed behaviors, 3) focusing on the details rather than the big picture of a situation and being overly cautious, 4) demonstrating emotional expressions that are inconsistent with how one is really feeling, and 5) comparing oneself to others, leading to resentment and envy. In RO DBT, patients work with their therapists on identifying personal goals consistent with these behavioral targets, connecting these goals to the problems that brought them into treatment. For instance, a patient may bring up that he/she would like to deepen relationships with others, be more flexible when things don’t go according to plan, or let go of past grudges to help fight depression and anxiety.
Many incorrectly assume that RO DBT and Dialectical Behavior Therapy (DBT) are the same thing. While RO DBT has some similarities with DBT, these are two very different treatments. DBT primarily benefits those who have an undercontrolled (UC) personality. UC traits include being impulsive, sensation-seeking, wearing one’s heart on one’s sleeve, and acting in the here and now. Thus, DBT can be helpful for those that have impulsive control problems, such as those with borderline personality disorder, bulimia nervosa, binge eating disorder, and substance abuse disorders. Both RO DBT and DBT combine individual therapy with skills training classes, involve tracking emotions and behaviors via diary cards, allow for telephone consultation with the individual therapist, and involve consultation teams for the group and individual therapists. However, DBT has a stronger focus on self-regulation to target emotion dysregulation whereas RO DBT is much more focused on helping individuals address social signaling and connectedness with others.
References:
Lynch, T. R. (2018). Radically Open Dialectical Behavior Therapy. New Harbinger Publications.
Lynch, T. R. (2018). The Skills Training Manual for Radically Open Dialectical Behavior Therapy. New Harbinger Publications.
Elizabeth Mariutto, PsyD
Lindner Center of HOPE, Psychologist and Clinical Director of Partial Hospitalization/Intensive Outpatient Adult Eating Disorder Services
Psychological Disorders and Their Impact on Cognition
Fortunately, our culture has recently seen a gradual erosion of the stigma regarding emotional disorders, along with an increased understanding of such conditions. However, a less well-understood aspect of emotional disorders is the impact that they have on the cognitive functioning of those who are afflicted. Disorders such as Major Depression, Bipolar Disorder, Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, and Schizophrenia all tend to interfere with one’s ability to access the full extent of their cognitive abilities, adding to the burden that these conditions create.
Regarding Major Depression, it is the one disorder that the DSM-V lists cognitive difficulties as one of the diagnostic criteria (diminished ability to think or concentrate, or indecisiveness, nearly every day). As a neuropsychologist, I routinely encounter patients who are all too aware that their depression impacts their ability to think clearly, to focus, and to recall everyday interactions. Part of the reason for this is that depression causes a reduction in processing speed, as well as the energy that it takes to attend to conversations and events. Difficulties with maintaining attention, and “keeping up” with things going on around them, these patients experience troubles recalling information, sometimes so profoundly that they begin to fear that they may have dementia. However, as their depression is more effectively treated, they regain full access to their cognitive skills and abilities.
Anxiety disorders also are accompanied by significant cognitive difficulties, for a couple of reasons. First, when the mind is anxious, most of the brain’s resources (blood flow, oxygen, glucose, etc.) are redirected to the emotional centers of the brain (the limbic system), and away from parts of our brain that mediate higher-level thinking and logic. Secondly, those who are anxious tend to be rather “internally-oriented” in their thinking, and so they are not as attentive to external events. In other words, because they become preoccupied with their fears and worries, the ordinary events of the external world can be largely overlooked. As a result, these ordinary events are not well-encoded into the memories of anxious patients, and therefore they cannot easily be recalled. As with depression, as anxiety becomes better managed, these cognitive issues largely resolve.
Two other diagnoses have profound implications for cognitive functioning. Bipolar disorder has a well-established pattern of cognitive difficulties, including diminished attention, verbal memory, and executive functioning abilities (planning, anticipating, problem-solving, emotional regulation, staying focused and attentive to personal goals, etc.) These difficulties, fortunately, are typically limited to times that these patients are actively experiencing a mood episode, whether it be depression or mania. Regarding those with schizophrenia, they experience similar cognitive difficulties. However, they often continue to experience such cognitive difficulties even when their symptoms of schizophrenia have been well-controlled with treatment. This is why the DSM-V lists “associated features” of schizophrenia specific to these difficulties, explaining that, “Cognitive deficits in schizophrenia are common and are strongly linked to vocational and functional impairments.”
Fortunately, over the past 20 years there have been treatments and interventions to address such cognitive difficulties. Cognitive Enhancement Therapy, or CET, has been developed and implemented for the mentally ill for whom cognitive problems are getting in the way of living independently, maintaining employment, and sustaining meaningful relationships. It has proven to be an effective means to address such difficulties, and for providing a much higher quality of life. It is anticipated that, as the benefits of CET become more evident to those working with the mentally ill, its positive impact will widen in both its breadth and depth.
Managing OCD During a Pandemic
Many who struggle with OCD are probably noticing a spike in their symptoms during these unprecedented times. Stress and uncertainty can often make OCD symptoms flare. Those who struggle with specific types of OCD may be having an even harder time: specifically those with contamination concerns and those concerned with harming others. Another symptom of OCD that may be particularly hard currently are perfectionism tendencies. While it may be harder to fight back against OCD with everything going on right now, it is more important than ever to not give in to compulsions and let them take over your life. One simple step you can take is to stay connected to your therapist, likely via telehealth at the moment. Having regular sessions during this time is key, especially as symptoms flare. Staying connected to others online or through social media options is also important, as the more you are connected to others the less stress you will notice. Another key piece is to continue to do things you enjoy and that bring you pleasure, as this will help lessen stress as well. Keeping a structured routine can be helpful and can help make things to continue to feel more normal. It can be important to try to continue with whatever routine you had going before that you are still able to do, for instance still getting at the same time in the morning and getting ready for work even if you are working from home. Adding consistent exercise into that routine will also be helpful, as this helps create endorphins and naturally lessens anxiety. Lastly, avoid reading the news all day, which will only lead to more stress and anxiety. It is important to limit access to only a couple of trusted sites and not get carried away with reading up on everything all day long.
Some specific OCD related steps you can take will vary depending on the type of OCD you have. For those who struggle with contamination concerns, get familiar with the CDC guidelines for the current pandemic and do not add other steps that are not recommended. For instance, they are recommending only washing hands for 20 seconds after being outside or in public, before eating, after going to the bathroom, and after you’ve coughed/sneezed/blown your nose. If soap and water are not available, they recommend you use hand sanitizer that contains at least 60% alcohol. They also only recommend disinfecting surfaces once per day. This should only take a few minutes per day and they suggest only focusing on the surfaces in your home that are frequently touched. It is also important to think about whether this is truly needed (for example, if you stayed home all day and had no visitors, do you really need to disinfect that doorknob?). It is also important to avoid some news sources that might not offer expert recommendations but rather their own opinions.
For those who struggle with fears of harming others, these symptoms might tackle the current pandemic and cause you to obsess about whether or not you might have infected someone or whether or not you might infect someone in the future. This might be a similar theme to past fears of contamination concerns, but it will still be helpful to alert your therapist to the new content so that new exposures can developed.
For those who struggle with perfectionism tendencies, this might be an especially trying time. The perfectionism could target all of the changes going on and adaptations people are having to make to conduct
their jobs, manage their families etc. It is important to give yourself a break and realize that it is impossible to be perfect in anything we do, but especially now during all of this change and uncertainty. Practice doing one or two things imperfectly on purpose as an exposure.
One important exercise I make sure to encourage all of my patients to do is to keep track of their victories against OCD, whether the victories are big or small. Keeping track of successes and not dwelling on everything that is going wrong is a helpful way to stay on track and to realize everything that you are doing to fight OCD, which is likely a lot. It can sometimes be hard to pick out the successes and often others only notice the failures or slips, but there are victories in there as well that deserve your attention and that can help give you confidence to fight back even harder next time
Nicole Bosse, PsyD
Lindner Center of HOPE, Staff Psychologist