Integrative Approaches in Treating Mood and Anxiety Disorders in Patients with Eating Disorders
Approximately 80 percent of individuals with eating disorders are diagnosed with another psychiatric disorder at some time in their life, most commonly depressive, anxiety and personality disorders (Klump, Haye, Treasure & Tyson, 2009). Untreated alongside the eating disorder, mood and anxiety issues can challenge recovery in even the most committed and well-intentioned patients.
Today, we explore the rationale for thoughtful dual diagnosis programming as well as cutting-edge treatment approaches to heal patients struggling with mood and anxiety issues in addition to a primary eating disorder diagnosis.
Q: Why is acknowledging and treating mood and anxiety issues so important in the eating disorder population?
A: SM: Simply put, mood and anxiety disorders are exceedingly common among patients with eating disorders. Research shows a very high dual diagnosis rate—consider these statistics:
- Of those with Anorexia Nervosa (AN), 48 percent have co-occurring anxiety disorders, 42 percent have co-occurring mood disorders and 31 percent have co-occurring impulse control disorders.
- Of those with Bulimia Nervosa (BN), 81 percent have co-occurring anxiety disorders, 71 percent have co-occurring mood disorders and 64 percent have co-occurring impulse control disorders.
- Of those with Binge Eating Disorder (BED), 65 percent have co-occurring anxiety disorders, 46 percent have co-occurring mood disorders and 43 percent have co-occurring impulse control disorders. (Hudson, Hiripi, Harrison & Kessler, 2007)
- People with eating disorders have a 64 percent lifetime rate of anxiety disorders; the most common diagnoses were Obsessive Compulsive Disorder (41%) and social phobia (20%).
- A substantial majority of eating disorder patients had the onset of OCD, social phobia, specific phobia and Generalized Anxiety Disorder before the emergence of the eating disorder, suggesting that the disordered eating is a successful coping mechanism for those difficult feelings.( Kaye, Bulik, Thorton & Barbarich, 2004)
- Up to 50 percent of individuals with eating disorders also abuse alcohol or illicit drugs, compared with nine percent of the general population. (National Center of Addiction and Substance Abuse at Columbia University, 2003)
What’s interesting and upsetting is that depression, anxiety and emotional dysregulation persist after eating disorder recovery. So often, patients come through an eating disorder program and they fully recover from their eating disorder, but their mood, anxiety and/or substance abuse issues aren’t thoroughly explored. Sometime later, they experience a significant live event or trauma and they develop serious symptoms. Without an understanding of and skills to manage mood, anxiety and substance abuse issues in addition to eating disorder recovery skills, patients find themselves challenged to sustain lasting recovery.
Q: How does level of care impact treatment goals and interventions addressing mood and anxiety issues?
A: SM: Higher levels of care (Residential, Partial Hospitalization) tend to prioritize medical and psychiatric stability and interruption of maladaptive behaviors during the limited time in the structured treatment environment, with some attention to other goals. Outpatient treatment, on the other hand, tends to explore underlying issues in more depth over more time, including exploration of co-occurring diagnoses and how the issues may be intertwined with the eating disorder.
Regardless of level of care, acknowledging a dual diagnosis and creating treatment plans emphasizing long-term goals and behavior expectations can support exploration of co-occurring issues and foster trust and confidence in the treatment relationship.
Treatment plans should consider values, safety planning, behavioral modification plans, daily self-monitoring, trauma-sensitive interventions and exploration of underlying issues. Because abstinence is not always possible, particularly at the higher levels of care, a harm-reduction model and successive approximations may help to minimize the maladaptive behaviors.
Q: What evidence-based approaches target mood and anxiety issues in the eating disorder population?
A: LSE: Dialectical Behavior Therapy, Acceptance and Commitment Therapy and mindfulness-based treatments have been shown to be particularly effective in an integrated approach to treating individuals with this dual diagnosis.
Dialectical Behavior Therapy (DBT) — Our patients want to gain control of their lives, but the more out of control they become the more they use these maladaptive coping skills and it just becomes more chaotic.
DBT is a comprehensive treatment for severe, persistent emotional and behavioral difficulties, including eating, anxiety and mood disorders. Dialectics is the practice of finding the middle ground, while behavioral treatment involves making thoughtful changes. A DBT framework looks at reinforcers and punishers, helping patients to take a step back with humility and accountability. A favorite DBT phrase is “…and how is that working for you?” DBT has several core aspects, including:
- Mindfulness based skills, including both “what” skills (observe, describe and participate) and “how” skills (non-judgmentally, one-mindfully, effectively).
- Distress tolerance, and accepting that we cannot change, fix, manipulate, avoid or get rid of our present; learning coping skills.
- Emotional regulation to identify, acknowledge, accept and cope with unfamiliar or intense feelings, ie “Do you know what you’re feeling?” Some patients what they’re feeling and why but they don’t know what to do with it, while others know only a few emotions (anxiety, fear, sadness).
- Interpersonal effectiveness, ie. improving our relationships, letting go of hopeless relationships, and asking for what we want or saying no to requests we cannot or do not want to fulfill. This is so important for eating disorder patients—AN patients not only restrict food but also their needs, while those with BN and BED are wonderful and caring people but struggle to say no and take on too much, becoming emotionally spent and burnt out.
Eating disordered individuals enrolled in three weeks of DBT group therapy and weekly individual sessions in an outpatient setting had significantly lower depression and hopelessness ratings on the Beck Depression Inventory (BDI) and Beck Hopelessness Scale (BHS) respectively. (McQuillan et al., 2005)
On the horizon, there is a new wave of treatment that addresses the “over-controlled” personalities common among those suffering with Anorexia Nervosa (heightened threat sensitivity, diminished reward sensitivity, emphasizing mistakes as intolerable, self-control as imperative, defensive arousal, stilted interactions.)
Radically Open DBT (RO-DBT) contends that emotional loneliness—and not emotion dysregulation—presents the core problem for overly- controlled personalities, and it targets loneliness and social isolation, cultivates flexibility and willingness to bring more risk and acceptance into their lives. RO-DBT was associated with significant improvements in weight gain, reductions in eating disorder symptoms, decreases in eating disorder related psychopathology and increases in eating disorder-related quality of life in a severely underweight sample. (Lynch et al., 2013)
Acceptance and Commitment Therapy (ACT) — examines how ineffective behaviors affect one’s life. Everyone has pain in their lives, and avoidance creates suffering out of normal human pain. ACT is rooted in the belief that psychological problems result from trying to avoid or control unpleasant internal thoughts and feelings, and that psychological flexibility can bring us to new places.
An ACT approach makes no attempt to alter/eliminate difficult internal events; instead it promotes acceptance of difficult thoughts and emotions. Avoidance/control strategies are replaced with constructive values-consistent behaviors. Experiential avoidance tends to be high in eating disorder patients. Individuals with eating disorders become hyper-focused on their body and food intake as a means of avoiding feelings of rejection, imperfection, failure, vulnerability and intimacy. (Hayes & Panley, 2002; Keyser et al., 2009; Paxton & Diggens, 1997; Pells, 2006)
Mindfulness-based interventions — have been found to be effective in treating eating, mood and anxiety disorders. Awareness equals change—we cannot change without awareness, and without change we are not aware.
Kabat-Zinn describes mindfulness as “paying attention in a particular way, on purpose, in the present moment, non-judgmentally.” It works because it calms the nervous system, allows the mind and body to connect, helps with emotional regulation, centering and wise thinking, and improves one’s ability to use coping skills.
Mindfulness interventions and meditation practices help facilitate exposure therapy through increased contact with current experience and willingness to experience negative emotional content (Hayes, Wilson, Gifford, Follette & Strosahl, 1996)
Q: What are the benefits to Insight’s mixed milieu model for treating eating disorder patients with mood and anxiety issues?
A: SM: In recognition of the overlap between eating and mood and anxiety disorders and the need to address both conditions to support lasting recovery, Insight offers a mixed milieu to do cutting-edge work with the dual diagnosis population. This innovative approach acknowledges that patients are not that different despite different manifestation of symptoms (ie. the eating disorder is not about the food).
Both eating disorders and mood and anxiety disorders are chronic illnesses with high potential for relapse, and there are many similarities between these populations. They tend to share common temperaments, a history of trauma, self-harm behaviors and a risk of suicide, substance abuse, emotional dysregulation, maladaptive coping skills, an urge to control an out of control disorder and a lack of motivation for help. There are also possible overlapping genetic factors, overlapping environmental triggers and shared risk factors, including low self-esteem, impulsivity, history of sexual or physical abuse, social isolation, avoidant temperament and peer victimization.
Regardless of primary diagnosis, patients in treatment need camaraderie and understanding (in addition to mixed milieu groups, it is important to also incorporate “like” symptom groups to fulfill this need). In a mixed milieu, patients learn to move away from the narrative of the eating disorder and embrace the underlying issues (the root of the matter). They learn to accept differences while maintaining awareness of their individual needs and the needs of the group at large, fostering compassion, deeper camaraderie and commitment to healing for our patients. Patients end up relating to people they never thought they could relate to. Insight’s mixed milieu combines eating, mood and anxiety disorder patients in groups at all stages of treatment.
Q: How do Insight’s Anxiety Disorders, Trauma and Substance Abuse tracks help patients explore these issues alongside their eating disorder treatment and examine how the two diagnoses are intertwined?
A: LSE: Insight’s Anxiety Disorder track addresses rigidly held beliefs, frequent and debilitating worry, intense fear and avoidance of feared stimuli, obsessive thoughts, compulsive behaviors (weighing counting, measuring, checking, etc.), and resulting impaired functioning.
The treatment approach involves Exposure and Response Therapy (hierarchy, exposure, valued action, tolerance of uncertainty), Dialectical Behavior Therapy (distress tolerance, mindfulness, emotional regulation) and Acceptance and Commitment Therapy (cognitive defusion, values, acceptance, mindfulness). Exposure reduces the power of beliefs over patients’ patterns of anxiety, rituals and avoidance, which tends to improve functioning and reduce distress.
Body work and yoga have been shown to be particularly helpful in the treatment of anxiety—done twice per week, this slow, low impact routine encourages patients to focus on breath, body, position and mind, fostering connection to physiological response and working with the body to reduce the overwhelming stress and anxiety sensations. At the end of three months, women in Insight’s yoga group reported improvements in perceived stress, depression, anxiety, energy, fatigue and well-being, while depression scores improved by 50 percent, anxiety scores by 30 percent and overall well-being scores by 65 percent.
- Activity: Cognitive Defusion Activity—Choose a word, ie “chubby.” The group says the word in different volumes, tones and dialects to create distance. Laughter and a sense of humor reduce shame and fusion with beliefs and attachment to the perceived meaning of the word.
Insight’s Trauma Track is organized around a Trauma Informed Care treatment approach, which focuses on Judith Herman’s tri-phasic treatment model. Treatment fosters work around the three foundational phases of trauma treatment: establish safety, grieving/mourning and reconnection. This approach seeks to understand the trauma’s impact and develop a skill set to cope with traumatic symptoms (avoidant and maladaptive behaviors) and foster connection with others.
The importance of trauma work with eating disorder patients is supported by the research base, which indicates that the vast majority of women and men with AN, BN and BED report a history of interpersonal trauma. Rates of PTSD are significantly higher among men and women with BN and BED, approximately 40 percent of women with BN report a history of rape or sexual assault while as many as 35 percent of women with BED report a history of rape or sexual assault (Mitchell, Mazzeo, Schlesinger, Brewerton & Smith, 2012).
- Activity: Grounding Kit—Creation of a Grounding Kit encourages patients to mindfully use all five senses. Kits will often include a stress ball, Altoids, lotion, a grounding stone, affirmations and notecards with facts (the current date, time location) to help patients struggling with painful emotions from trauma come back to the present and mindfully explore their emotional and physical sensations.
Insight’s Substance Abuse track encourages thorough understanding of patients’ drug and alcohol use. Through psychoeducation and skill building rooted in Motivational Interviewing and the 12-Step philosophy, this programming strengthens motivation for change and fosters insight into the relationship between the eating disorder and drug use. While behavioral abstinence is always the goal, many patients are college-age and not ready to be sober. This cohort generally needs additional support to non-judgmentally explore their use and the true impact on their physical and emotional health and functioning, leading patients to accept abstinence as the successful lifestyle.
- Activity: Cost Benefit Analysis—This activity explores the pros and cons of current substance abuse, encouraging patients to honestly explore their substance use as well as examine the outcomes and consequences. By allowing the patient to identify and acknowledge their issue in a supported environment, this exercise fosters strength in the treatment relationship and promotes support and guidance from clinicians.
Susan McClanahan, PhD, Chief Development Officer is President and Founder of Insight Behavioral Health Centers and Chief Development Officer of Eating Recovery Center and Lara Schuster Effland, LCSW is Senior Director of Clinical Oprations at Insight Behavioral Health Centers with locations in Illinois and Austin, Texas.