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by: Ronald Freudenberg, Jr., MA, LPCC-S
Outpatient Therapist, Lindner Center of HOPE

Anxiety can take many forms.  Anxiety is also one of the most common reasons one might seek out mental health treatment.  In this blog, we will explore some of the most frequently occurring anxiety disorders, as well as panic attacks, which can be part of a Panic Disorder (but do not have to be, as will be discussed later).  We will also look at effective strategies for preventing, treating, and managing anxiety disorders and symptoms of anxiety.

Regardless of how anxiety may present for one person, the various anxiety disorders all have at least one thing in common…fear.  Whether it is described as worry, nervousness, feeling “on edge,” or something else, the basic emotion of anxiety is fear.  We all experience some anxiety sometimes, and in fact, you may have heard that a little bit of anxiety can be a good thing from time to time.  It serves a protective purpose when it tells us to avoid people, things, or situations which could be dangerous.  Anxiety can also help us by keeping us on our toes and motivating us to perform well under pressure, such as when pulling an all-nighter before an exam, giving a big presentation at work, or playing in the championship game.  Yet, as with any negative emotion, anxiety can become problematic when it becomes too frequent, too intense, lasts for too long, or interferes with our lives and our ability to function well, as can happen in the context of the following types of anxiety disorders.

Types of Anxiety Disorders

Adjustment Disorder

Sometimes, one may feel excessively stressed or anxious about a certain thing or things in one’s life.  People often describe this as “situational”, and the clinical term is an Adjustment Disorder with Anxiety.  (It can also present with depression, or other emotional/behavioral responses.)  An example might be if one would experience something stressful like the loss of a job.  Of course, most people would likely feel some anxiety about this.  However, an adjustment disorder is thought of as when one’s response is out of proportion with what may be typically expected.  With this type of anxiety, once the stressor has resolved, so will the anxiety.  So, when that same individual lands a new job, he/she/they will feel better, simply put.

Generalized Anxiety Disorder

Generalized Anxiety Disorder is very much like it sounds.  This is when a person feels generally anxious, worried, and nervous much of the time (more than half of their days) about any number of different subjects.  In order to meet criteria for the diagnosis, one must experience this type of anxiety for at least six months, find it difficult to control the worry, and present with at least some of the following additional symptoms: restlessness, trouble concentrating, irritability, muscle tension, sleep difficulties, and/or trouble concentrating.  Although every person is unique, classically, a person with GAD may tend toward long-term anxiousness, worry excessively about many things (such as finances, family, work, health, world events, etc.), and lay awake in bed at night doing so.

Phobias

Specific Phobias are another type of anxiety disorder in which a person experiences strong fear and anxiety about a specific thing (object or situation), and actively avoids that thing or endures exposure to it with intense discomfort.  In this writer’s experience it is relatively rare for this to be a person’s main reason for seeking treatment, at least in outpatient settings.  Perhaps that may be because many anxiety-provoking subjects can be pretty easy to avoid.  (When was the last time you unexpectedly came across a snake?)

Social Anxiety Disorder

An exception to anxiety that is easily avoided, is Social Phobia, also known as Social Anxiety Disorder.  Social Phobia exists when the source of a person’s fear is social or performance situations in which one may feel subject to scrutiny or judgment by others.  Social anxiety may arise when one feels uncomfortable mingling with new people at a party, walking through halls of (seemingly) glaring eyes at school, or giving a speech.  From an evolutionary perspective, if anxiety helps us to avoid dangerous things which threaten our survival, being ostracized from one’s tribe and forced to try to survive alone in the wilderness is near the top of that list.  With this in mind, it is little wonder that public speaking is often cited as people’s number one fear.

 

 

 

 

 

Panic Disorder and Attacks

Finally, let us explore the issue of panic.  So, what is a panic attack? Panic Attacks, according to the DSM-5, occur when a person experiences an “abrupt surge” of anxiety which reaches a peak within minutes and includes (at least four of) the following symptoms.

Symptoms of Panic Disorder and Attacks

  • Racing/pounding heart
  • Sweating
  • Shaking
  • Shortness of breath
  • Choking sensations
  • Chest pain
  • Nausea
  • Dizziness or feeling light-headed
  • Chills or heat sensations
  • Numbness/tingling
  • Feeling of unreality or detachment from one’s self
  • Fear of losing control, “going crazy,” or dying

When one develops a fear of having additional panic attacks and exhibits maladaptive behaviors designed to avoid or limit the likelihood of them, this is called a Panic Disorder.  Further, if one’s fear and avoidance includes public situations away from home, open or enclosed crowded spaces from which it would be difficult to escape should panic-like symptoms arise, that is called Agoraphobia (which may, but does not have to, co-occur with Panic Disorder).  Also, according to the most recent edition of the DSM, panic attacks are now thought to be a feature which may occur in the context of a spectrum of other mental health disorders, substance use disorders, and some medical conditions.

Treatment of Anxiety, including Treatment for Panic Disorder and Attacks

When it comes to treatment of anxiety, it is unrealistic for one to expect to live out the rest of their days, anxiety-free.  One can no more be “cured” from anxiety, than from happiness, sadness, or anger.  These are basic human emotions, and there are reasons why we have them.  However, the good news is that anxiety symptoms, whether mild or debilitating, can be effectively prevented, treated and managed, usually by a multi-faceted approach.

How to Manage Anxiety, including Managing Panic Disorder and Attacks

Medications can often be a very helpful part of a person’s treatment plan.  Antidepressants, such as SSRIs, and some SNRIs, are commonly used to treat ongoing symptoms of anxiety, while benzodiazepines (such as Xanax, Klonopin, Valium, or Ativan) are sometimes used on a shorter-term or as-needed basis to alleviate acute anxiety or panic.  (Caution is usually advised with the latter due to their addictive potential.)  Some antihistamines, beta-blockers, and anticonvulsants have been shown to be helpful for anxiety as well.

Various forms of talk therapy can be beneficial by providing a safe, supportive experience in which a person can process fears and learn to implement rational coping thoughts to overcome them.  Therapy can also assist one to form new behaviors to mitigate symptoms of anxiety.  Regardless of the specific therapy used, a common element is learning to approach, rather than avoid, that which causes one’s anxiety.  Anxiety and fear lead to avoidance by definition, while summoning the courage to face and overcome our fears cuts them down to size (this is commonly referred to as “exposure”).  Cognitive-Behavioral Therapies (CBT), Dialectical Behavioral Therapy (DBT, as well as Radically Open DBT), and mindfulness-based psychotherapies are common effective treatment approaches.  Mindfulness can help one learn to be in and accept the present, increasing one’s capacity to tolerate feelings of discomfort while reducing anxious thoughts about the future.

Treating and Managing Panic Disorder and Attacks

In the case of panic attacks, it is advised to first rule-out any medical causes of the symptoms which can mimic other medical issues, specifically heart disease.  If another person is present during a panic attack, they provide support and reassurance, helping the person to talk through it or asking what they need that may be helpful.  In addition to medication, there are other helpful strategies for panic symptoms.

Strategies for Managing Symptoms of Panic Disorder and Attacks

  • Breathing or relaxation exercises
  • Physical exercise
  • Mindfulness/grounding exercises (such as a sensory check-in)

Coping Skills for Anxiety, including Panic Disorder and Attacks

Therapy can also help a person develop effective coping skills for preventing and managing anxiety.  These may vary depending on personal preferences, but can include increasing social supports, problem-solving for stressors, journaling, exploring spirituality, exercise/movement, etc.  Practicing healthy self-care habits (such as getting regular exercise and restful sleep, managing health conditions, and minimizing/avoiding alcohol, caffeine and other drugs) and generally trying to live a balanced lifestyle can simultaneously help to reduce the stress one may experience in life, while increasing one’s ability to effectively cope with anxiety.

Summary:  Anxiety is a common human experience, but persistent and debilitating anxiety, is often what causes people to seek treatment. There are a variety of types of anxiety. Panic or Panic Attacks are among the types of anxiety. Learn what are panic attacks, symptoms and causes and treatments for panic attacks and other anxiety disorders.

Learn more about panic attacks and anxiety.

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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.

Radically Open Dialectical Behavior Therapy for Overcontrolled Personality

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.

Radically Open DBT vs DBT

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.

For more information see our Comprehensive Guide to RO-DBT.

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

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By: Anna Guerdjikova, PhD, LISW, CCRC, Director of Administrative Services, Harold C. Schott Foundation Eating Disorders Program, Lindner Center of HOPE 

 

 

 

 

 

Spring is in the air. More often than not during this time of year, we find ourselves determined to clean, declutter and organize. In a way, spring cleaning is very similar to New Year resolutions and the big hurray at the beginning of the school year in August when everything is new and fresh, big decisions of how we will be better are made…but not for long. We find ourselves hyper-focused on new goals and behaviors to quickly abandon them soon after as it is too hard, too slow, too boring, or life comes in the way of our good intentions. Then the guilt of “look at this mess, I should be decluttering” sets in, we continue to buy things to organize the many things we already have and this cycle continues to perpetuate both the mental anguish and the physical clutter.

To be able to consistently change a behavior, it is helpful to understand why we are resistant to the change, even if we know it will make us feel better in the end. Digging into the barriers and the reasons for our self-sabotage can help us be more self-compassionate and to get us a step closer to actually making the changes we intend and hope for.

Decluttering can be difficult and anxiety provoking. Below we summarize some of the issues and possible ideas on how to approach the solutions to avoid self-blame and feelings of failure and to finally get the ball rolling.

Issue: The job is too huge and you don’t know where to start. It gets to be too overwhelming too quickly. 

Solution: Decide on decluttering small bites – a time period to declutter daily/weekly or one surface, drawer, rack, 1/3 closet at a time and don’t overdo it. Keep a very open mind and avoid rigid agenda (ex. be done with the kitchen by Sunday) no matter how tempting this is, as when the job does not get done for some reason as we have planned, we tend to abandon the whole project.

Issue: What if I need this later?

Solution: If you have not used it in 6 months, you are most probably not going to use it now. Most things in our households can be replaced quickly, thus giving yourself the permission to buy new if needed is the “get out of jail free card” that can help battle this problem. In most cases than not you will not have to use the card/buy the item again.

Issue: The guilt of life not lived. Textbooks we bought to study something we never got to, the hiking shoes to walk the Appalachian trail, the super expensive multicooker and many others representing the life we hoped to have or wished to live but never actually implemented.

Solution: Consider radically accepting yourself for who youare truly at the present moment in life instead of who you wished you were. Get rid of the expensive hiking shoes you have never put on. If you decide to hike the Appalachian trail, you will have to start by hiking the local parks and this can be done in regular sneakers for a while, then if needed you can buy some new fancy hiking shoes.

Issue: Change is hard and decluttering does not solveother issues.

Solution: Take it slow and give your brain and body time to process the change. If you get rid of a rug, the room will feel empty and sad and the most common reaction is to go buy another rug immediately. Try to give the new look time to settle, this will allow you to see the space with new eyes and can spark creativity and true change. If in a while you still feel you need the rug, go for it.

Give approaching decluttering with curiosity and self-compassion a try this spring. It is not fatal if it does not get done and beating yourself over what “should be finished” is not helpful in moving forward. Finally, decluttering our physical and digital spaces might make us more aware and mindful of our habits, but is not the “fix for our lives”. Clutter can be seen as a result of some struggles that we deal with and starting to tackle it might bring to light a plethora of challenges and this is one of the reasons why this process can be so anxiety provoking. Kindness to self, giving it all time and space to unfold and paying attention to the mental load behind the physical possessions might be helpful in promoting sustainable change.

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By Jennifer Farley, PsyD,
Lindner Center of HOPE, Staff Psychologist

There are a number of reasons someone may undergo a psychological evaluation or assessment. The type of testing that is done depends on the individual’s functioning and the setting in which testing may be pursued. This article will look at the different settings of mental health assessments.

Types of Mental Health Assessment Settings

  • Outpatient
  • Inpatient
  • Residential
  • Children’s Assessments

Psychological Assessment in an Outpatient Setting

Testing from a clinical psychologist in a clinical outpatient setting can be pursued on their own or they may be referred from another clinician (such as a primary care physician or psychiatrist). This type of assessment is for patients with non-immediate mental health concerns. In this case, testing is pursued with the referral question in mind (such as whether someone has Attention Deficit/Hyperactivity Disorder, depression, anxiety, a learning disorder, dementia, cognitive problems due to a medical condition, etc). The psychologist tailors the tests to help determine the person’s functioning in the areas that could be affected by a cognitive or emotional disorder. Tests can range from intellectual assessments to personality measures to behavioral questionnaires (which can be completed by the patient themselves, parents, and/or teachers) to academic achievement measures. Clinicians such as neuropsychologists and developmental psychologists can do all these tests and then add additional measures specific to their specialization (such as when documenting problems related to a head injury or when evaluating for Autism Spectrum Disorder). The psychologist can use this information to make a diagnosis and provide recommendations for treatment of the condition. Often, such as for school-age or college-age patients, recommendations for academic accommodations are also provided.

Psychological Assessment In An Acute Inpatient Unit

Sometimes, psychological testing is completed for patients during an acute inpatient psychiatric hospitalization (when the patient is in a mentally unstable condition). In these cases, testing is often used for diagnostic elucidation to help guide decisions about types of medication to use. Recommendations may also be made about additional assessments or resources to pursue following one’s discharge from the hospital. The clinical psychologist completes these evaluations within a short time, since these acute hospitalizations last (on average) about 7 days, and there are usually just a few measures that are administered. Tests are specific to the question about the individual’s diagnosis and may only include emotional/personality measures.

Psychological Assessment in a Residential Setting

Another setting in which psychological testing may occur is within a residential psychiatric setting. This setting is for patients who are experiencing psychological distress that is not severe enough to warrant an acute inpatient hospitalization. Length of stay in a residential setting can vary from 10 days to several months, depending on the purpose of the stay (i.e., evaluation and/or treatment). The purpose of testing in a residential setting is to help comprehensively understand – by way of several different measures – one’s personality functioning, cognitive functioning (which can include neurocognitive skills such as attention, memory, and executive functioning), and other factors (such as external stressors, substance use, medical conditions, etc.) that have contributed to the patient’s condition(s). The patient’s internal strengths and weaknesses are explored, with the intention of making recommendations for how treatment can be tailored to work with the patient’s strengths to compensate for their weaknesses. The clinical psychologist works closely with the other members of the treatment team (such as the psychiatrist, social worker, and the therapists) to understand the patient, develop a treatment plan, and (if a longer stay) to begin implementing the recommendations. The patient’s progress is then monitored and, if needed, further testing can be done to help assess changes in the patient’s functioning as a result of the treatment.

Psychological Assessment in Childhood

In childhood, early observations of potential problems may come from teachers. Teachers may observe struggles in behavior such as impulsivity, talking or interrupting others during times when there is an age-appropriate expectation of silence, and/or oppositional behaviors towards others. Teachers may also be the first to wonder if a child has an underlying learning or attention disorder. If the teacher’s attempts to help the child are unsuccessful, the teacher may recommend testing in the form of a Multi-Factored Evaluation (MFE). Psychological testing may be part of this evaluation and can include intellectual testing and academic achievement testing by a school psychologist. Parent and teacher questionnaires may also be included in the MFE. Depending on the nature of the child’s observed difficulties, others (such as speech and language therapists and physical therapists) may do their own screening. If findings reveal that the student experiences problems that would make learning difficult, accommodations are then recommended and interventions and/or accommodations are then put in place through a 504 Plan or an Individualized Education Plan. It is noteworthy that clinical diagnoses are NOT made from this type of evaluation and findings and recommendations are specific to helping the child learn better.

Prior to any psychological testing, the patient (and/or his/ her family) should understand the purpose of psychological assessment and how it can be useful for guiding treatment and other recommendations.

Find out more information on what psychological assessment is here and why it is a critical step of the process towards finding a diagnosis and treatment plan.

Finding Help and HOPE

If you, or someone you know, is experiencing a mental health crisis, there is help available. The first step would be to consult with a health care provider or mental health care specialist. To see how Lindner Center of HOPE can help you decide on the best mental health assessment setting, reach out to us today. We can help you take the next steps. 

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By Nicole Mori, RN, MSN, APRN-BC, Psychiatric Mental Health Curse Practitioner, Lindner Center of HOPE

Bipolar disorder (BD) is a complex, chronic, progressive and ranks among the leading causes of disability worldwide.  The underlying feature of BPD is mood instability, with alternation of manic/hypomanic and depressive episodes and, commonly, significant subsyndromal symptoms between distinct mood episodes.  Depressive episodes (and residual depressive symptoms in times of remission) are responsible for much of the disability, suicidal behaviors, and exacerbation of comorbid conditions in BD.  Although depression is the predominant presentation and the leading cause of morbidity in BD, it is poorly understood, and the treatment options are limited.  Inadequate treatment of bipolar depression leads to residual symptoms which may drive relapse.  Effective treatment is of great importance, but it depends on accurate diagnosis and appropriate pharmacotherapy.  However, barriers to prompt diagnosis and treatment persist.

Research data suggest that BD is not uncommon among patients with a diagnosis of depression.  In a primary care clinic, 21% of patients screened positive for BD and among these, 2/3 had not received a diagnosis of BD before.  The frequency of BD is believed to be even higher among patients receiving specialty psychiatric care.  In a NIMH study which followed clinical course for at least a year, 25% of participants initially diagnosed with MDD experienced a manic/hypomanic episode which led to a revision in diagnosis to BPD.  These findings suggest that figures may be underestimating true prevalence of BD in the population.  Differentiating between unipolar and bipolar depression is difficult for both primary care and psychiatric providers.  There are no substantial differences in the presentation of depressive episodes between individuals with bipolar disorder and those with unipolar depression.  Misdiagnosis is common due to lack of thorough screening and comprehensive evaluation and history to rule out BD in patients presenting with depression.

Misdiagnosis is a significant barrier to recovery because response to treatment and clinical course largely depends on the selection of appropriate pharmacotherapy that addresses the mood instability underlying bipolar depression.  Antidepressant therapy- in the absence of mood stabilizing medication- has not demonstrated efficacy in bipolar depression.  Current treatment guidelines recommend antidepressant use only as an adjunct to mood stabilizing agents.  In general, data show that antidepressants are not particularly effective in bipolar depression (either as single or adjunctive therapy) and there are safety concerns for cycle acceleration and induction of mania among some patients.  In addition, initiation of ineffective treatments can prolong the time the patient is symptomatic, with impaired function and lower quality of life.

The diagnosis of BD in depressed patients presents unique challenges to healthcare providers.  The depressive phase of bipolar disorder presents many similarities with unipolar depression, and the correct diagnosis can only be made after careful screening and history.  Although there are several validated instruments to diagnose major depressive episodes, the options available to primary care providers remain limited.  The Mood Disorder Questionnaire (MDQ) is a screening questionnaire that can be used in combination with a thorough history, can improve the chances of identifying individuals with BD if used in combination with a through history.  Clinicians should be alert to features suggestive of underlying bipolar disorder such as the presence of subthreshold hypomanic symptoms, a history of multiple failed antidepressant trials, symptoms of ADHD, or comorbid substance abuse (particularly when early in onset).  Validating information from the patients’ family members can aid in accurate diagnosis.

Depressed patients with BD have significant unmet needs.  Residual morbidity and symptoms are quite common, even among treated patients. The treatment of BD often requires complex pharmacotherapeutic regimens.  Most effective mood stabilizing medications are associated with challenging adverse events, which limits their tolerability and requires watchful monitoring.  In addition to the burden of adverse events, patients with BD can experience loss of response or depressive symptoms that fail to improve after multiple medication trials.  Additional medication options are needed.  Research for novel pharmacotherapies should focus on developing potential, better-tolerated treatments for Bipolar depression.

Sources

McIntyre RS, Calabrese JR. Bipolar depression: the clinical characteristics and unmet needs of a complex disorder. Curr Med Res Opin. 2019 Nov;35(11):1993-2005. doi: 10.1080/03007995.2019.1636017. Epub 2019 Aug 5. PMID: 31311335.

Stiles BM, Fish AF, Vandermause R, Malik AM. The Compelling and Persistent Problem of Bipolar Disorder Disguised as Major Depression Disorder: An Integrative Review [Formula: see text]. J Am Psychiatr Nurses Assoc. 2018 Sep/Oct;24(5):415-425. doi: 10.1177/1078390318784360. Epub 2018 Jun 28. PMID: 29952230.

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Elizabeth Mariutto, PsyD, CEDS

 

 

 

 

When the average person is asked to describe eating disorders, body image concerns are one of the most identified symptoms.  However, not everyone with an eating disorder struggles with body image.  Those with Avoidant and Restrictive Food Intake Disorder (ARFID) avoid or restrict certain foods, but do not do so out of fear of weight gain, desire to lose weight, or body dissatisfaction. Instead, those with ARFID limit their eating based on sensory features of the food, fear of something bad happening when one eats, or a lack of interest in eating (Thomas & Eddy, 2019).

However, ARFID is more than picky eating. Those with ARFID are highly selective in what they eat, and this selectivity leads to some type of impairment in their lives (American Psychiatric Association, 2013). Children or teenagers may not grow as expected, leading to pediatricians being concerned that they have not followed the typical growth curve that had been evidenced earlier in their lives. Those with ARFID may lose a significant amount of weight unintentionally. Others end up needing to rely on oral supplements or nasogastric tube feedings to get in sufficient energy, and those with ARFID may display nutritional deficiencies.  Additionally, many with ARFID struggle socially (American Psychiatric Association, 2013). Many get-togethers, holidays, and celebrations with family and friends revolve around food, which can be anxiety and shame-inducing for those that eat more selectively, often leading to avoidance of such social gatherings and consequently, problems in relationships.

The same factors that lead to the onset of ARFID are worsened by its symptoms, which creates a cyclical pattern. Those who develop ARFID may experience more intense sensory experiences (Thomas & Eddy, 2019). They may be more sensitive to textures and/or may be a “supertaster” and pick up on more subtle variations of flavor than others. However, eating the same few foods repeatedly can lead to sensory-specific satiety, leading to those few foods becoming more aversive with time. Furthermore, if nutritional deficiencies develop, the taste of new foods can be altered, thus leaving someone to feel they have very few tolerable options. Others with ARFID may start out simply not having much interest in eating. When they eat less as a natural result, their fullness cues start kicking in prematurely and hunger cues dissipate, leading to eating even less.  Lastly, those who develop ARFID after having some type of aversive experience around food (i.e., choking) start to avoid the food that led to the negative experience hoping to avoid the same event. This expands into avoidance of similar foods as well.  The avoidance of these foods reinforces the fear, as these individuals do not have recent fear-countering experiences to teach them that they can safely consume these foods. Avoidance leads to increased anxiety, making the fear more entrenched.

ARFID treatment approaches resemble those for other forms of eating disorders but may include some modifications that more closely resemble the exposure treatment that is often used for obsessive compulsive disorder and anxiety disorders.  A treatment provider will likely do a thorough evaluation and case formulation of what factors need addressed in treatment.  First and foremost, patients may require medical stabilization to manage any of the acute health concerns that have risen with malnutrition.  Second, to prevent further medical problems from occurring and to begin the process of nutritional stabilization, clients often need to increase the overall volume of food.

There has not been much research on treatment for ARFID, although a modified version of cognitive behavioral therapy, CBT-AR, is being researched for ARFID and is showing promise (Thomas et al., 2020; Thomas et al., 2021). CBT-AR pulls from existing eating disorder, obsessive compulsive disorder, and anxiety disorder treatments and extensively educates the patient on how the disorder develops and is maintained, nutritional deficiencies and the importance of volume and variety, then gradually helps patients expose themselves to the foods that they have been avoiding (Thomas & Eddy, 2019).  Furthermore, Family-Based Treatment, which is a front-line treatment for adolescents with eating disorders, has been recently modified to address ARFID more specifically, also showing promising results (Lock, Sadeh-Sharvit, & L’Insalata, 2019). This treatment, which addresses the eating behaviors directly and conveys the seriousness of the eating disorder, empowers parents to refeed their child, takes a non-blaming approach to the illness, and helps parents and patients separate the illness from their identity (Lock et al., 2018).

Getting professional support can help patients with ARFID improve medically, nutritionally, psychologically, and socially. While therapists can provide support and teach specific techniques, the patient ultimately has a significant say into what foods to incorporate, when, and how.  With persistence, those with ARFID can eat with much greater variety and flexibility.

References

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Publishing, Inc.

Lock. J., Robinson, A., Sadeh-Sharvit, S., Rosania, K., Osipov, L et al. (2018). Applying family-based treatment (FBT) to three clinical presentations of avoidant/restrictive food intake disorder: Similarities and differences from FBT for anorexia nervosa. International Journal of Eating Disorders, 52, 439-446. doi: 10.1002/eat.22994

Lock, J., Sadeh-Sharvit, S., L’Insalata, A. (2019). Feasibility of conducting a randomized clinical trial using family-based treatment for avoidant/restrictive food intake disorder. International Journal of Eating Disorders, 52, 6, 746-751. doi: 10.1002/eat.23077

Thomas, J. J., Becker, K. R., Kuhnle, M. C., Jo, J. H., Harshman, S. G. et al (2020). Cognitive-behavioral therapy for avoidant/restrictive food intake disorder (CBT-AR): Feasibility, acceptability, and proof-of-concept for children and adolescents. International Journal of Eating Disorders, 53, 10, 1636-1646. doi: 10.1002/eat.23355

Thomas, J. J., Becker, K. R., Breithaupt, L., Burton Murray, H., Jo, J. H., et al. (2021). Cognitive-behavioral therapy for adults with avoidant/restrictive food intake disorder. Journal of Behavioral and Cognitive Therapy, 31, 1, 47-55. doi: 10.1016/j.jbct.2020.10.004

Thomas, J. J., & Eddy, K. T. (2019). Cognitive-Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder: Children, Adolescents, and Adults. Cambridge: University Printing House.

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Self-Discipline, by definition, is the ability to listen and to act based on your inner voice, regardless of how you feel, other influences, or the temptations you face. Discipline is the key to self-mastery. So why is this so hard?

So many people struggle with maintaining healthy choices and keeping to their goals. We have misperceptions that we are supposed to be excited and want to be engaged in these wellness practices. The truth is… discipline is hard. It’s rarely anything that we love to do or get super excited about. It’s often something we internally combat and make excuses for. We will find 100 reasons why we should not deliver or more importantly not show up for ourselves. Breaking into a better emotional and behavioral state is work, hard work. We need to accept that this will always be hard work and something that you must employ, daily or regularly, if you want to feel better and be better!

Research shows that people who have a good sense of discipline are less likely to suffer from major mental health issues and more likely to experience overall increased wellness. Some mental health benefits of being disciplined are it increases depressed moods, it creates less anxiety or stress, it combats drugs or alcohol abuse, it decreases potential for develop eating disorders, and it helps manage obsessive compulsive disorders.

Often mental health practitioners will say, “the key to real therapeutic change is when someone finally figures out how to show up for themselves.” It’s the improved habits and disciplines they enforce on themselves that creates positive change. They learn to be healthier and show up successfully.

The benefit of any discipline consistently comes later. It’s not always in the moment of but the sooner or later future. It will show up in the long term and create a new fondness of self. It’s choosing what I want the most. It will get you to the transformative self. Self- discipline creates confidence and motivation. Confidence being the internal stability of self-worth and motivation being the momentum. Momentum will keep the motivation alive. It will increase your focus making you work harder. Discipline creates a drive to succeed and find joy in the success. By being disciplined you will gain tolerance, patience, and a better sense of self-control. All key traits needed for an overall healthy, happy person to be present every day.

Easy steps to create a discipline:

  1. Set clear goals. Clearly outline what your goal means to you and how you intend to achieve it. Meaning is necessary for a discipline to be initiated.
  1. Make a commitment to yourself. You must have meaning and purpose in this. Knowing you are worth the effort and wanting to get back the control of your life.
  1. Make it apart of your daily routine. It is critical to make time each day and figure out where the discipline will fit into your day. Make a place for it, be consistent. Establishing an autopilot routine is essential for the discipline to occur.

Keeping distractions and temptations away will help you to commit and focus on your goals. Being mindful or purposeful of your attention about what your goals are and when your discipline should take place will help you stay on track. Persevering, staying steadfast through hard times will keep you motivated and keep you from self-sabotaging. Executing or carrying the discipline through will keep you in alignment of success and build the journey of your productive self.

Self-discipline is a practice. It is something that you must demonstrate everyday even if you fail or falter. You must put exertion at it and be available to it. You must practice repeatedly until it becomes an automatic behavior and/or thought. Find the courage to put the work in, be patient, and wait with hope.

By: Kristina Tracy, LISW-S

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Julie Foster, LISW-S, RN, MEd

There are many types of eating disorders. The most commonly talked about eating disorders are anorexia nervosa, bulimia nervosa, binge-eating disorder, and avoidant restrictive food intake disorder. National Eating Disorders Awareness Week (NEDAW) is an observance to bring awareness to the seriousness of eating disorders across the United States. It is estimated that over 28 million Americans will have an eating disorder in their lifetime. (https://www.womenshealth.gov/nedaw).

So, what can employers and leaders do to help?

Fatphobia and body shaming are so woven into our workplaces that often it goes unchecked. In fact, it is a microaggression normalized by “wellness” programs in the workplace that encourage weight and calorie tracking, weight loss incentives, and “Biggest Loser” competitions.

There is “evidence that weight stigma is a bigger risk to people’s health than weight itself and what they eat.” (Harrison, 2021)

Weight-loss challenges can actually be one manifestation of a hostile work environment.

And anyway, dieting does not work! 95% of those who diet may lose weight in the short term, but they gain that weight back and more within 1 to 5 years. (Fildes et al., 2015)

Instead of weight loss competitions, how about implementing “No diet/body talk zones” and including weight discrimination in workplace diversity and inclusion efforts. Workplace leaders can start to change the office culture by modeling zero tolerance for body shaming and also by  supporting employees who are actively fighting against diet culture. Leaders can fight weight discrimination by examining their hiring practices and normalize not just Health at Every Size (HAES) but also leaning into the truth that size has no bearing on one’s intelligence or work ethic.

How can you shut down body-shaming? Start with yourself. What kind of things do you say, out loud, at work, about your body and what you are, and are not, eating? Change the narrative and speak up when others are making fatphobic comments. What others are eating or not eating is no one’s business. Commenting on someone’s weight in any fashion is not appropriate any more than commenting on anything else about their body.

You wouldn’t agree with   a colleague  making racist or homophobic remarks, so the same should be true if employees are body shaming. Here’s how you could respond:

“Why would you think it’s okay to say something fatphobic like that?” Or, “Why do you think it’s okay to discuss ______’s body?”

Another important part of creating a body-size inclusive culture is to conduct a physical audit of your environment. Are there chairs and workstations to accommodate all sizes of bodies? Are your waiting areas or lobbies welcoming to all sizes of bodies? Do your vending machines sell regular and low-calorie drinks for the same price?

Just like “love is love”, “food is food.” Food is neutral, not good or bad. What you eat does not define you as good or bad or qualify as being good or bad. And it’s no one’s business what or how much someone else is eating, so request employees keep their commentary (which is probably related to their own insecurities) to themselves. It is important for leadership to recognize that it is likely that a percentage of their workforce has, or has had, and eating disorder, and comments about food and size can be very triggering for them. What might seem like a neutral comment (“I can’t believe how bad I was! I ate that whole piece of cake!”) reinforces to someone with an eating disorder that food and eating is bad or shameful.  Or talking about how you haven’t eaten all day as some badge of honor reinforces to others that they are somehow weak or wrong for eating regularly.

It is also important to remember that an eating disorder is a disability, therefore the Equality Act 2010 applies. Eating disorders are the most lethal of all mental illnesses. Managers and colleagues should be aware that individuals with eating disorders, as with any long-term health condition, may have changes their performance.

Reasonable adjustments for those suffering with an eating sidorder could include: flexibility in allowing time off for appointments, working hours or extended lunch or other breaks, consideration of factors such as a place to eat in private or avoiding lunch meetings or other work events involving eating socially.

Compliment people without bringing their weight or bodies into it. Find ways to bond, connect and have conversations with people in the workplace that do not involve food, bodies, or weight loss.

Encourage movement for fun, for change of scenery, for better productivity. Play music, normalize dance breaks.

Why not create a routine where everyone has the opportunity to  get up from their desk at least once every hour and takes a 2 minute walk. But avoid tracking steps or putting a lot of emphasis on competition.

The best way for people to be released from diet culture is to have a community of support. The workplace can become a safe space. If you are concerned an employee may have an eating disorder, there is help at the Lindner Center of Hope 513-536-HOPE.

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Binge eating disorder (BED) is the most prevalent eating disorder but remains largely undiagnosed and untreated.  BED is characterized by recurrent episodes of loss of control and consumption of unusually large amounts of food within a short period of time (<=2h).  Episodes are associated with significant emotional distress but are not followed by purging behaviors (vomiting, misuse of laxatives, etc.), which differentiates BED from Bulimia Nervosa.  In addition to psychological distress, BED is associated with medical complications including accelerated weight gain, metabolic abnormalities, functional impairment, and decreased quality of life.  Untreated BED leads to worse clinical outcomes in a variety of medical and psychiatric conditions and poor treatment response in hypertension, diabetes, dyslipidemia, and obesity, which are commonly seen in primary care.  Patients with BED stand to benefit from increased screening, diagnosis, and treatment, particularly patients with type 2 diabetes mellitus (T2DM).

Screening for BED is particularly important in patients with T2DM.  While the prevalence of BED in the general population is estimated around 3%, prevalence is significantly higher in T2DM, where the prevalence of BED is estimated around thirteen times higher than in the general population.  In fact, eating disorders are frequently encountered among patients with T2DM, with prevalence estimated around 20%.  Diagnosis and treatment are important because the presence of binge eating greatly complicates management and is associated with worsened outcomes such as impaired glycemic control, dyslipidemia, and accelerated weight gain.  BED is associated with decreased response to weight loss interventions (including dietary and bariatric surgical procedures), impaired glycemic control, dyslipidemia, and exacerbation of insulin resistance.  Moreover, common pharmacotherapies for diabetes (such as insulin, sulfonylureas, and dietary restraint) have been implicated in the exacerbation of binge eating.

As we have seen, BED is a barrier to achieving treatment goals in T2DM.  It is important to take binge eating into account when selecting treatment.  Reducing the frequency and severity of binge eating can facilitate the achievement of treatment goals in T2DM.  Primary care providers manage most patients with T2DM, but screening and management of BED is still overlooked.  It is necessary to treat patients to decrease the frequency and severity of binge eating to help patients achieve treatment goals for diabetes.  Optimal outcomes in treatment are not possible with untreated BED.  Primary care providers face the challenge of identifying and initiating treatment for this population with complex needs.

Even though BED is an important comorbidity in T2DM, significant barriers to diagnosis and treatment persist.  First, eating disorders are associated with significant stigma and patients may not readily disclose disordered eating behaviors due to shame.  In many cases, patients are aware that some of their eating behaviors are abnormal, but they do not know that they are suffering from a treatable eating disorder.  In addition, primary care providers may overlook binge eating as a possible factor when patients fail to achieve treatment goals despite intensification of treatment.  In addition, primary care providers face time and financial constraints which limit their ability to diagnose, refer and treat.  Finally, there are not enough trained clinicians who can offer specialized medication management, dietary counselling, and psychotherapy for BED.  Medication options are still limited to an FDA approved agent (lisdexamphetamine), plus a couple of drugs used off-label.  However, providers still have options to start addressing the needs of patients with T2DM and BED, including:

Further research is needed to understand the needs of patients with comorbid T2DM and BED as well as to develop treatments to lessen the occurrence of binge eating episodes clinical care guidelines.

The Research Institute at the Lindner Center of HOPE is conducting a clinical trial of an experimental medication for Binge Eating disorder.  No prior diagnosis is required.  For additional information, contact us at 513-536-0700 or visit:  https://redcap.research.cchmc.org/surveys/?s=TP3C4TEA8J

Bibliography

Harris SR, Carrillo M, Fujioka K. Binge-Eating Disorder and Type 2 Diabetes: A Review. Endocr Pract. 2021 Feb;27(2):158-164. doi: 10.1016/j.eprac.2020.10.005. Epub 2020 Dec 13. PMID: 33554873.

Keshen A, Kaplan AS, Masson P, Ivanova I, Simon B, Ward R, Ali SI, Carter JC. Binge eating disorder: Updated overview for primary care practitioners. Can Fam Physician. 2022 Jun;68(6):416-421. English. doi: 10.46747/cfp.6806416. PMID: 35701190; PMCID: PMC9197289.

Winston AP. Eating Disorders and Diabetes. Curr Diab Rep. 2020 Jun 15;20(8):32. doi: 10.1007/s11892-020-01320-0. PMID: 32537669.

Nicole Mori, RN, MSN, APRN-BC, Lindner Center of HOPE Psychiatric Nurse Practitioner

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By: Sidney Hays, MSW, LISW, DARTT,

Lindner Center of HOPE Professional Associates, Outpatient Therapist

From wild parties in the massive frat houses to stories finding your soulmate in movies and television, many enter college with bright eyes and big dreams. There are expectations of melting into a friend group, dating, gaining experience, and finding your passion as soon as you get to college. All of this, stepping-stones to graduating with the dream job lined up, a group of best friends you’ll vacation with every summer, and that special someone you just might spend the rest of your life with. You’ve heard about the glory days and the football games and the spring break trips. But, what happens when you get to college and the classes are hard, friendships are complicated, partying comes with consequences, and heartbreak hits you?

Many young adults enter college with high hopes and expectations that seem reasonable Unfortunately, the movies and glory day memories from loved ones miss crucial struggles and obligations that come with college. This often leaves college students feeling like they’re “missing something” or failing, which contributes to poor mental health in an environment already rife with challenges. The struggles of large class sizes, living with strangers, easier access to drugs and alcohol, financial stress, being away from home, and lack of structure tend to tax the delicate wellbeing of young adults who have not been adequately equipped with needed skills and whose brains are not fully developed.

Most 18-year-olds step onto a college campus and it’s the first time they will be spending the majority of their time living away from home. Suddenly they are responsible for most every aspect of their life, with minimal adult supervision. Out from the safety net of coming home to parents and the guidance of coaches and teachers, college freshmen spend the majority of their time exclusively with others their same age, facing the same struggles. They navigate friendships, romantic relationships, and living with strangers as best they can, often struggling with codependency, lack of boundaries, and the pervasive anonymity and distance offered by the internet. This group tends to struggle with interpersonal skills and ability to regulate their own emotions, with little guidance on effective skills to use. Many find themselves feeling lonely and in cycles of unhealthy or unfulfilling relationships.

Accountability is a new concept for many college students. The looser structure of college settings requires more self-determination and discipline than high school. College is a place where students are generally free to make most of their decisions. While this can be liberating and a time of beautiful self-discovery, it can also lead to poor attendance, study habits, and moderation of substances and sleep. The negative physical, academic, and emotional effects of these choices tend to pile up, which is why so many college students begin to struggle with anxiety and depression.

What to tell a college student who isn’t having the best time of their life:

Know that you are not alone.

Mayo Health Clinic reported in July 22 that up to 44% of college students reported symptoms of depression and anxiety. The stressors faced by college students are underplayed and the good times overly glorified. It often takes time to make friends and friend groups naturally change; that’s okay. People are trying to understand what they want to do with the rest of their lives, becoming independent adults, and learning about the world. This will likely lead to many shifts in relationships as well.

Manage expectations.

You are in school to get a degree, learn about yourself, create relationships, and prepare yourself for the workforce. You may not find a group of friends during welcome week or even freshman year. The romantic relationships may not work out. You may not graduate with your dream job lined up. This is a step towards your goals and can still be part of a life worth living, even if you don’t get exactly what you want by graduation.

Get support and develop lasting relationship skills.

College is a great time to connect with a therapist to process the changes and have a support to help you identify your goals and live within your values. Learning skills to set boundaries, prioritize your time, communicate effectively, and regulate your emotions will make a world of difference in college and will carry on through your life.

A great option for learning these skills is Dialectical Behavior Therapy (DBT). DBT is a treatment that helps participants learn and practice skills to regulate emotions, tolerate distress, and effectively navigate interpersonal relationships.

If you are interested in learning more, for yourself or someone else, about DBT or individual therapy to help navigate this beautiful and challenging season, contact the Lindner Center of HOPE.