Obsessive-compulsive disorder (OCD) is one of the most frequently diagnosed psychiatric disorders in people with eating disorders. It is known to make eating disorders more severe and harder to treat, leading to a longer time until remission is achieved. Recently, more and more researchers are beginning to recognize the significance of the overlap between EDs and OCD, and are trying to develop specific treatments targeted at this population.

A 2004 study by Walter Kaye and colleagues in the American Journal of Psychiatry measured how frequently anxiety disorders (OCD is a type of anxiety disorder) occurred in people with anorexia and bulimia. They found that two-thirds of the ED sufferers had been diagnosed with an anxiety disorder at some point in their life. In general, the onset of the anxiety disorder pre-dated the ED by several years. Of the people with an anxiety disorder, 41% had OCD and 20% had social phobia (social anxiety). The problem, then, is very significant.

The gold standard in treating OCD is a form of cognitive-behavioral therapy known as exposure and response prevention (ERP). You can read more about ERP here. The idea is relatively straightforward: You create a hierarchy of the things you're afraid of that would normally provoke a compulsion. For someone who is afraid of germs, something lower on the list would be touching an unused surgical mask. Higher up might be touching a doorknob at a doctor's office or being coughed on by someone with a cold. Together with a therapist, you would begin to expose yourself to these anxiety-provoking situations and then not engage in any compulsions (like hand-washing) to relieve the anxiety. The point of this is to learn to tolerate the anxiety and that you're not going to die if you happen to inhale a few germs.

Some researchers are beginning to use components of ERP to treat food fears in EDs, especially anorexia nervosa. In a 2011 study in the International Journal of Eating Disorders, researchers at Columbia University first outline a behavioral model for AN that is driven by anxiety and obsessionality (see figure below; the caption is copied from the paper).

Figure 1. Model of Anorexia Nervosa. Traits of high baseline anxiety and obsessionality interact with environmental factors such that patients develop maladaptive behaviors, including food avoidance, and rigid eating patterns (or dieting practices), and they experience high levels of anxiety around eating. These behaviors are interrelated in that rigid dieting leads to increased anxiety about food and vice versa. These behaviors result in a diet that is low fat (low energy density) and limited in variety. This, in turn, promotes weight loss. The low weight state feeds back on the baseline traits and leads to increased levels of anxiety and obsessionality.

Anxiety about eating more and gaining weight consistently interferes with weight gain in AN and with interrupting the binge/purge cycle in BN. The idea is that recovery cannot and will not occur unless these fears are addressed. In a 2012 review article in the European Eating Disorders Review, psychologists hypothesize that one of the reasons family-based treatment is successful for many adolescents is that it forces these exposures. Since the patients can't (theoretically) choose what to eat, they can't choose to avoid "scary" foods. Parents are also coached on how to help stop other food-related rituals

A study published earlier this week addressed the issue of treating OCD and EDs, this time in a residential setting. Published in Cognitive Behaviour Therapy, the researchers treated 56 individuals with AN, BN, or EDNOS in an eating disorder program specific for individuals with co-occurring OCD. Of these patients, 41% were diagnosed with AN, 25% with BN, and 34% with EDNOS. Rates and levels of depression and OCD did not appear to vary by diagnosis. After treatment, the researchers found a significant improvement on scores for OCD, depression, and eating disorders, as assessed by a variety of surveys and self-reports. Patients with AN also significantly increased their body weight.

Which is all well and good, but the problem is that this study (nor any others that I'm aware of) compared the treatment group to anything. Other studies have shown that treating an ED generally improves levels of depression and OCD. Was the improvement seen in this study due to regular eating and the prevention of binge eating and purging? What effect did being in a structured environment have? Would these results have been different if the patients weren't treated for OCD? What about if their OCD was treated and not their ED? I realize that actually conducting a research study in that last scenario would be unethical, especially in a group that qualifies for residential treatment, but it's something that should at least be considered in the discussion.

Another question the researchers didn't factor in was the use of psychotropic medication. Eighty-nine percent of patients were on some type of psychiatric medication; the authors said they didn't control for this in their analysis since only 7% started on medication during their treatment. But they didn't mention how many patients' medication was adjusted, increasing or decreasing dose, or changing types and brands of medication. These things can have a significant effect on OCD and depression symptoms (although a recent study indicated that no psychotropic medications appear to be effective for AN)

As well, one of the researchers is the medical director of the treatment center where the research was carried out. This makes me a little skeptical of the results as a matter of course.

The researchers concluded that "Simultaneous treatment of OCD and eating disorders using a multimodal approach that emphasizes ERP techniques for both OCD and eating disorders can be an effective treatment strategy for these complex cases." But how effective? Is it better? How much better? How long did the results last for? There was no follow-up on any of these patients. Improving in a program is great, but the rubber doesn't really hit the road until after discharge.

This study is a start, but it's a small start. Co-occurring EDs and OCD can be very difficult to treat, but many people do go on to develop healthy and productive lives. We desperately need more resarch into the subject, but we need to start making comparisons to help develop the best, most effective treatment possible.

It seems odd, doesn't it.  Medication has side effects--lots of them, in fact.  You can hear them rattled off in the same droning-yet-chipper voice in every pharmaceutical commercial on the air.  But therapy?  How can therapy have side effects?

Time Magazine had a follow-up to a story about a family in Michigan who used a controversial therapy to help treat their autistic children.  And that's when everything unraveled.  The story itself is sad and even frightening, but that's not the point of the blog.  What struck me was a paragraph at the very end:

We don't often consider the "side effects" of nondrug therapies. But the Free Press series shows just how harmful it can be to buy into a technique or therapy that offers nothing but hope. Many things that help can also harm, which is why we need sound science before any new technique is widely adopted — let alone used as evidence in custody or criminal cases.

It struck me that some ED therapies are the same way: they offer hope, perhaps, but no solid results to back up their efficacy.  And that any treatment can have side effects, even if it's not in pill form. 

Eating can be extremely anxiety-provoking for those with EDs, and that anxiety can be expressed in panic attacks, defiance, self-harm, temper tantrums, and more.  But eating can also be thought of as "therapy" for eating disorders, as a type of exposure and response prevention.  The anxiety is a side effect, and sufferers and families should be warned and prepared for this.

The autism story is also a case study in the fact that therapy can, in fact, actually be harmful to patients and families.  Recently, Becky Henry wrote about how parent-blaming in traditional eating disorder treatment tore her family apart. I know lots of examples of lives stunted or lost, of families wrecked because of ineffective and inappropriate treatment.  Going to therapy isn't something we can think, "Well, it can't hurt, can it?"

Actually, yes. It can. 

Therapists and families need to do their homework before just signing up for weekly psychotherapy to make sure that the therapy's benefits outweigh any potential side effects, and that there's good evidence to show that it will help rather than harm.

Seeing as I have finally (!) found a new therapist in my new location (who also accepts my insurance and is only an hour drive away), who I meet with on Saturday, and there have been several good posts about finding a good therapist and effective treatment, I decided a blog post would be appropriate.

Dr. Sarah Ravin has a list of five questions to ask a potential therapist when seeking treatment:

In regards to your question, here are the five important questions (in my opinion) that one should ask a potential therapist when seeking treatment for a serious, long-standing eating disorder:

1.) In your opinion, what causes eating disorders?

(Make sure they have a science-based explanation that involves neurobiology, genetics, personality traits, and the role of malnutrition. It’s OK if she mentions societal pressures for thinness as triggers, so long as that’s not the ONLY thing she mentions.)

2.) Describe your philosophy of treatment for eating disorders.

(Make sure she emphasizes full nutrtion and weight restoration to ideal body weight (for AN) and nutritional stability / cessation of binge-purge behaviors (for BN) as the first step in treatment. Make sure she also emphasizes the acquisition of coping skills, learning to eat healthfully and independently, self-care, treatment of co-morbid conditions, and relapse prevention)

3.) Describe your training and experience in empirically-supported treatments.

(Make sure she has some training and/or experience with CBT, DBT, ACT or other third-wave behavior therapies, and/or Maudsley FBT).

4.) How many patients with eating disorders have you treated in the past three years? How many of these patients have fully recovered?

(Make sure she’s seen at least a few other people with EDs, and make sure that the majority of them are fully recovered (or at least well on their way to recovery).

5.) What is your opinion on the involvement of family members and significant others in the treatment of eating disorders?

(If she advocates parentectomies or exclusion of family members, or implies that families cause EDs, this is bad news. If she views family members as potential emotional or nutritional support for the patient, this is good news).

If there is one word in reading about a therapist's history and treatment philosophy that gives me the heebie-jeebies and automatically makes me click "NEXT!" is this: eclectic. I shudder just typing it. To me, eclectic says "I do whatever I feel like doing" or is kind of like commitment-phobia for the potential therapist. You're a professional- tell me what works and why. There's a difference between "eclectic" and "I have been trained in approaches A, B, and C and can help tailor therapy to you and your situation." I have found a combination of CBT, DBT, and FBT to be helpful at various stages in my recovery, so I'm not all-or-nothing about types of therapy. But eclectic? Ick.

The Cleveland Center for Eating Disorders blog "Living With Food" has this advice for seeking evidence-based treatment:

1.Remember that there are very few evidence-based treatments for eating disorders. If you are not receiving cognitive behavioral therapy, dialectical behavioral therapy, interpersonal therapy, or family based therapy, then the odds are very high that you are not getting evidence-based care.

2.Your primary care physician is likely to have experience with patients who have done different types of treatment in your community. Your primary care physician is therefore a critical resource.

3.When you are in a provider’s office and they are discussing care options with you, never hesitate to ask for all of the evidence behind what they are saying. At this point in time, all practitioners in eating disorder treatment should be able to back up what they are saying in a straightforward and understandable manner.

4.Finally, while doing research on treatment for eating disorders, the Internet, while helpful, may not provide definitive answers (and may be more confusing than anything). There are certain organizations that we feel are trustworthy. We highly recommend NEDA, AED, Maudsley Parents, ED Recovery, The Freed Foundation, Are you eating with your anorexic, The F-Word, NAMI, Life After Recovery, and FEAST as reliable organizations and blogs where you can learn about evidence-based care and communicate with other patients and families that may be struggling with an eating disorder.

Off course, point #2 assumes your PCP/GP isn't a total bonehead and doesn't blow off your concerns. Still, they should know something about community resources or have a referral to someone who isn't a total bonehead. When all else fails, go straight to point #4.

There are plenty of other barriers to finding quality ED care, not the least of which are: geography, therapist's availability, insurance coverage, wait lists, finances, you name it.

What criteria do you use when looking for a therapist (or what criteria would you use)? Do you have any words or phrases that are a therapist "turn off"?

There was a brief but interesting research article this past week on Interesting practitioners in training in empirically supported treatments, published in the Journal of Clinical Psychology. Despite a growing recognition of the importance of empirically supported treatments (otherwise known as evidence-based treatments), not all therapists are aware of these treatments or are willing and able to provide them. A good blog post from the Cleveland Center for Eating Disorders explains some of the reasons why.

Of course, all the training in the world isn't useful unless a therapist is interested in receiving that training. Speaking as someone with a research-oriented background, not a clinical one (nor even a psychological one), my first instinct would be to start by showing people the strength of the research base behind the treatment. What this paper found, however, is that most therapists responded more favorably to case studies rather than larger research studies.

Which, when you think about it, does make sense. Most therapists are more oriented towards people than they are towards large research studies (I'm the opposite, which helps explain why I'm not a therapist and never will be). This is neither good nor bad, it's just a general trend I've observed. Furthermore, case studies can provide more practical information in explaining how the therapy is carried out, how the patient responded, and what are some common pitfalls. This isn't to say that case studies should replace large research trials, just that they interest therapists more in empirically supported treatments.

For more information on empirically supported treatments, see both the Psychotherapy Brown Bag blog and this explanation from the American Psychological Association (they have information specifically on empirically supported treatments for eating disorders here).