Sunday, January 7, 2018

The Top 25 Articles from Eating Disorders: The Journal of Treatment & Prevention (from 1993–2017)

The Top 25 Articles from Eating Disorders: The Journal of
Treatment & Prevention (from 1993–2017)


Here is a list of the Top 25 Articles from Eating Disorders: The Journal of Treatment & Prevention.  These honorees were selected by Leigh Cohn, Editor-in-Chief; as well as Senior Editors Arnold Andersen, John Foreyt, and Margo Maine. All articles ever published in the journal were eligible and considered. They are listed chronologically.

The Wood-Burning Stove: A Metaphor for Dietary Regulation for Persons With Eating Disorders
by Laura L. Hill (1993)
https://doi.org/10.1080/10640269308248283

The Norwegian Program for the Primary, Secondary and Tertiary Prevention of Eating Disorders
Runi Børresen Gresko & Anna Karlsen (1994)
https://doi.org/10.1080/10640269408249100

Beauty Myth and the Beast: What Men Can Do and Be to Help Prevent Eating Disorders
Michael P. Levine (1994)
https://doi.org/10.1080/10640269408249106

A Three-Year Longitudinal Study of Body Image, Eating Disturbance, and General Psychological Functioning in Adolescent Females
Jill A. Cattarin & J. Kevin Thompson (1994)
https://doi.org/10.1080/10640269408249107

Protective Factors for Eating Disorders in Female #CollegeAthletes
Nancy L. Zucker, Leslie G. Womble, Donald A. Williamson & Lori A. Perrin (1999)
https://doi.org/10.1080/10640269908249286

What Works for Treating Eating Disorders? Conclusions of 28 Outcome Reviews
P. Scott Richards, Bret M. Baldwin, Harold A. Frost, Julie B. Clark-Sly, Michael E. Berrett & Randy K. Hardman (2000)
https://doi.org/10.1080/10640260008251227

Beyond #BodyImage as a Trait: The Development and Validation of the Body Image States Scale
Thomas F. Cash, Emily C. Fleming, Jenny Alindogan, Laura Steadman & Abigail Whitehead (2002)
https://doi.org/10.1080/10640260290081678

The Therapist’s Use of Self-Disclosure in a Relational Therapy Approach for Eating Disorders
Mary Tantillo (2004)
https://doi.org/10.1080/10640260490267760

A Randomized Controlled Study of #CBT and Behavioral #FamilyTherapyfor #Anorexia Nervosa Patients
Jillian Ball & Phillip Mitchell (2004)
https://doi.org/10.1080/10640260490521389

Prevention of Body Dissatisfaction and Disordered Eating: What Next?
Dianne Neumark-Sztainer, Michael P. Levine, Susan J. Paxton, Linda Smolak, Niva Piran & Eleanor H. Wertheim (2006)
https://doi.org/10.1080/10640260600796184

Eating Disorders, #Trauma, and Comorbidity: Focus on #PTSD
Timothy D. Brewerton (2007)
https://doi.org/10.1080/10640260701454311

The Role of #Spirituality in the Treatment of Trauma and #EatingDisorders: Recommendations for Clinical Practice
Michael E. Berrett, Randy K. Hardman, Kari A. O’Grady & P. Scott Richards (2007)
https://doi.org/10.1080/10640260701454394

Diagnosed Eating Disorders in the U.S. #Military: A Nine Year Review
Amanda J. Antczak & Teresa L. Brininger (2008)
https://doi.org/10.1080/10640260802370523

First Aid for Eating Disorders
Laura M. Hart, Anthony F. Jorm, Susan J. Paxton, Claire M. Kelly & Betty A. Kitchener (2009)
https://doi.org/10.1080/10640260903210156

A Feminist Perspective on Risk Factor Research and on the Prevention of Eating Disorders
Niva Piran (2010)
https://doi.org/10.1080/10640261003719435

Family-Based Treatment for Adolescents With #Anorexia Nervosa: A Dissemination Study
Jennifer Couturier, Leanna Isserlin & James Lock (2010)
https://doi.org/10.1080/10640261003719443

Thinking Through the Body: The Conceptualization of #Yoga as Therapy for Individuals With Eating Disorders
Laura Douglass (2011)
https://doi.org/10.1080/10640266.2011.533607

Addiction to Highly Pleasurable Food as a Cause of the Childhood Obesity Epidemic: A Qualitative Internet Study
Robert A. Pretlow (2011)
https://doi.org/10.1080/10640266.2011.584803

Which Criteria for Recovery Are Relevant According to Eating Disorder Patients and Therapists?
Greta Noordenbos (2011)
https://doi.org/10.1080/10640266.2011.618738

Eating Disorders in Men: Underdiagnosed, Undertreated, and
Misunderstood
Eric Strother, Raymond Lemberg, Stevie Chariese Stanford & Dayton Turberville (2012)
https://doi.org/10.1080/10640266.2012.715512

An Overview of Anorexia Nervosa in Males
Tom Wooldridge & Pauline “Polly” Lytle (2012)
https://doi.org/10.1080/10640266.2012.715515

Trading Health for a Healthy Weight: The Uncharted Side of Healthy Weights Initiatives
Leora Pinhas, Gail McVey, Kathryn S. Walker, Mark Norris, Debra Katzman & Sarah Collier (2013)
https://doi.org/10.1080/10640266.2013.761082

Accelerating Progress in Eating Disorders Prevention: A Call for Policy Translation Research and Training
S. Bryn Austin (2016)
https://doi.org/10.1080/10640266.2015.1034056

The Implementation of Evidence-Based Eating Disorder Prevention Programs
Heather Shaw & Eric Stice (2016)
https://doi.org/10.1080/10640266.2015.1113832

Including the Excluded: Males and #GenderMinorities in Eating Disorder Prevention
Leigh Cohn, Stuart Murray, Andrew Walen & Tom Wooldridge (2016)
https://doi.org/10.1080/10640266.2015.1118958

Tuesday, July 18, 2017

Information about the NewYork-Presbyterian Hospital Adult Eating Disorders Partial Hospitalization Program

Hi all,

In the event that anyone needs a referral for an adult with an eating disorder, NewYork-Presbyterian Hospital's Westchester Division has a fairly new partial hospitalization program!

In the eating disorders PHP, we:
- Accept all forms of insurance, including Medicare and Medicaid
- Run Monday-Friday 8:30am -3:15pm
- Provide supported breakfast, snack, and lunch every day
- Teach family members how to support meals and snacks at home
- Encourage family members to attend meals in the program with the patients as much as possible
- Have two skills groups every day
- Have a nutrition group with a dietitian specializing in eating disorders every day
- Incorporate family members into as much of the daily programming as possible
- Have a once per week multi-family group
- Conduct 1-2 individual therapy sessions per week
- Have 1-2 meetings with psychiatrists per week
- Monitor physical health throughout the program

If anyone is interested in learning more about the program, please email or call me at 914-997-5865!

Best,
Dr. D.


Tara Deliberto, Ph.D.

Director, 
Eating Disorders Partial Hospitalization Program,
New York-Presbyterian Hospital

Assistant Professor of Psychology,
Weill Cornell Medical College

Tel: 914-997-5865
Fax: 914-997-8635

Tuesday, January 10, 2017

Anorexia Nervosa & Borderline Personality Disorder

Gold-Standard Treatments at Odds: 
Complications in Treating Combined Anorexia Nervosa & Borderline Personality Disorder


Any clinician can tell you that treating a life-threatening psychological condition such anorexia nervosa or borderline personality disorder is seriously challenging.  Treating a person with both anorexia nervosa and borderline personality disorder, however, is exponentially more difficult than the treatment of either condition alone.  This is largely because the gold-standard treatments for these disorders are at odds with one another: treating one life-threatening disorder exacerbates the other.  This post discusses how this happens and what to do.

To being to understand this problem, let's start with a discussion of why these disorders are life-threatening.  Eating disorders are life-threatening because the bodily impact of eating disordered behaviors such as severe caloric restriction and purging can respectively result in conditions like severe malnutrition and esophageal tears.  Borderline personality disorder is also life-threatening because people are at risk of engaging in impulsive behaviors, self-injury, and suicidal behavior when because they lack skills to regulate intense emotions.  Clearly, both disorders are life-threatening and must be addressed.  But what do you do if someone has both an eating disorder and borderline personality disorder?  Just treating both conditions at the same time seems like the obvious answer. Quickly after the implementation of this approach, however, one quickly discovers that the gold-standard treatments of the two life-threatening conditions are at odds.  

To further understanding as to why these treatments are at odds, let's first discuss the singular treatment of anorexia nervosa, one type of deadly eating disorder.  In anorexia nervosa, a person becomes underweight following a prolonged period of severe caloric restriction.  This severe caloric restriction is a behavioral strategy used to temporarily decrease the experience of fearing  fatness in a given moment.  In the treatment of this condition, the goal must be weight gain to ensure both physical and psychological recovery.  Further, from a psychological perspective, a person recovering from anorexia nervosa must endure the following exposures: 1) eating a large quantity of food many times per day (upwards of 4,000 calories), 2) eating a variety of high-fear foods every day such as pizza and burgers, 3) enduring a physical feeling of fullness that the eating disordered mind equates with immediate "fatness," 4) actual weight gain slowly occurring all day, every day for what is more often months, rather than weeks, and 5) not engaging in any "safety" behaviors that result in a respite from fear of fatness such as exercising, purging, and taking laxatives.  As such, the treatment of anorexia nervosa involves what can be viewed as a series of multiple, intense, all-day in vivo exposures, that carry on for months.  And because the person is in medical crisis, the intensity of this extended exposure cannot be lessened. There is no luxury of spacing out exposures based on psychological readiness in the treatment of anorexia nervosa.  A person with anorexia nervosa must be thrown into the metaphorical deep end.  As such, I imagine that the series of exposures involved in the treatment of anorexia nervosa are more intense than the treatment of any other disorder.

Now, let's discuss the singular treatment of borderline personality disorder.  In the treatment of borderline personality disorder, we are taught early on in graduate school that it is a bad idea to star therapy by addressing underlying trauma, which of course is normally treated with "prolonged exposure."  The idea is that if someone does not have skills to cope with intense negative emotions that arise when addressing trauma in exposure, they may be at increased risk for impulsive, self-injurious, and suicidal behaviors.  So, rather than implementing exposure in the treatment of borderline personality disorder, we are taught the focus in the treatment must be on skill building.*  Returning to a deep-end metaphor, learning coping skills is the equivalent of learning how to swim.  The skills, of course, are very helpful to know before being thrown into the deep end.  

As such, in the treatment of BPD, teaching skills decreases impulsive behaviors, the life-threatening component of the disorder.  A person with anorexia nervosa, however, is not immediately saved in the same way with skills.  Because the treatment of anorexia nervosa first requires medical & nutritional interventions that are psychologically experienced as exposures, there isn't enough time to teach skills before the interventions begin.  Further, even intelligent people with malnourished brains are much more likely to think inflexibly, and therefore, skills such as flexible & dialectical thinking may not be absorbed even if taught well to smart folks.

Now with a greater understanding of the individual disorders, let's return to the problem: focusing on treatment of an eating disorder in which intense exposure is needed can exacerbate the emotion dysregualtion inherent in borderline personality disorder, increasing the odds for impulsive behavior, self-injurious behavior, and suicide; alternatively, focusing primarily on skill building to treat the borderline personality disorder would does not allow for the rapid weight gain needed to ensure medical stability in the treatment of anorexia nervosa. 

To increase understanding of this problem even further, let's combine the above concepts with understanding a bit about how the brain is impacted by both disorders. A patient with anorexia nervosa has a malnourished brain that will result in inflexible thinking, further obsessionally, increased irritability, and other cognitive deficits.  If this person also has borderline personality disorder, not only is the brain malnourished, but the system in the brain in charge of emotion regulation is malfunctioning.  As such, the brain is malnourished - and needs nourishment to function properly - but the process by which re-nourishment occurs involves intense, all-day, multiple exposures that predictably result in rather severe emotion dysregulation, which is efficiently calmed by the immediate escape of negative emotion through the sabotage of the re-nourishment process (e.g. purging).  Big problem.

The problem is so big, in fact, that I do not think that simply treating someone with both outpatient gold standards of treatment - Family Based Therapy for anorexia nervosa and Dialectical Behavior Therapy for borderline personality disorder - will be helpful.  I do, however, have some strategies for fighting the two-headed monster that is comorbid anorexia nervosa and borderline personality disorder.

When clinicians finally see a patient with anorexia nervosa and borderline personality disorder in treatment, the complex interplay of psychological and physical pathology has already seriously compromised the patient's overall health.  Without any time for fostering full understanding of our rationale, the only thing to do in the moment is push the person into the deep end of the pool.  As clinicians we must also, however, dive in after them.  In the pool, we can hold them up until they learn how to swim.

I don't believe there is much hope of recovering from comorbid anorexia nervosa and borderline personality disorder without massive amounts of support.  Inherent in the disorder of anorexia nervosa, the person with this diagnosis cannot reach the conclusion that consuming large volumes of food and gaining weight will result in recovery.  We have to show them this.  As such, an outpatient level of care is very rarely enough.  It makes sense to me that most people who are severely underweight with anorexia nervosa and borderline personality disorder must be hospitalized on a psychiatric unit with staff and structure that can limit dangerous behaviors.  Because re-nourishment will inevitably be an awfully triggering experience, we must be as emotionally supportive as possible  We must also must be practically supportive and help the person learn as many coping skills as possible.  When someone is very underweight, we don't have the medical luxury of spending time focusing on skills, nor is it likely that most people can effectively learn the skills with a malnourished brain and body.  I think we must focus on re-nourishment while mitigating as many destructive behaviors as possible and teaching skills.  Once the person is stabilized, going to a structured program, likely makes the most sense.  

Unfortunately, in 2017 America, people with anorexia nervosa do not stay on inpatient units until they are 100% weight restored, even without the added complications that borderline personality disorder brings.  On a larger scale, I intend to advocate for a return to a time when patients stay until they have truly weight restored, especially if there is co-morbid borderline personality disorder.  In short, a presentation of both anorexia nervosa and borderline personality disorder really seems to call for the highest levels of care that you can get for the longest amount of time that you can get.  Whether you are a provider, patient, or loved one: I urge you to convey the information in this post to foster an understanding of the serious problem the comorbidity that anorexia nervosa & borderline personality disorder presents to advocate for more time in higher levels of care.



*Please note: there is evidence that PTSD & BPD can be treated simultaneously (Harned and colleagues; for more info: http://bit.ly/2cCrbiy).   But let's think about the treatment of borderline personality disorder and co-morbid PTSD v.s. anorexia nervosa a bit more. In the treatment of PTSD, "prolonged exposure" typically refers to about an hour of exposure once per week, the intensity of which is selected based on the psychological readiness of the patient.  From the perspective of someone who has undergone treatment for anorexia nervosa, the term "prolonged" is likely to seem sarcastically adorable.  I can imagine my patients saying "Wait, that is considered prolonged?  Ha!"  Although PTSD might be able to be treated in the context of BPD with careful consideration, the challenge of treatment anorexia nervosa is much greater.

Tuesday, December 13, 2016

Nurse Practitioner Needed for Immediate Start

Hi all,

We're seeking a nurse practitioner for an immediate start in the eating disorders partial hospitalization program that I direct at NewYork-Presbyterian Hospital in White Plains, NY.  Please let me know if you or anyone you know might be interested in the job!  I'm at tad9048@med.cornell.edu.

Here is the official posting:

Make It Possible at NewYork-Presbyterian
Psychiatric Nurse Practitioner – Eating Disorders Program - Westchester Division
Elevate your career at NewYork-Presbyterian Hospital, and discover why we're the nation's #3-ranked center for Psychiatry (U.S. News & World Report). The Partial Hospitalization program provides rapid stabilization of acute psychiatric symptoms for patients transitioning from an inpatient psychiatric unit or to prevent an inpatient admission. Together, we've built a healing haven for patients. Join us, and experience Making It Possible.
As a Nurse Practitioner in the partial hospitalization program you will provide treatment for adult patients with eating disorders. Deliver group, individual and family therapy. Manage medications and provide discharge planning. Here, you'll experience all the reasons why you entered such a rewarding field.
This position will work Monday - Friday from 8:15am - 4:45pm.
Preferred Criteria (Not Required)
3 to 5 years of experience in the treatment of adult patients with eating disorders
Required Criteria
Master’s Degree in Nursing from a Nurse Practitioner program New York State License as a Nurse Practitioner Board Certification as a Psychiatric-Mental Health Nurse Practitioner (PMHNP) Basic Life Support Certification from the American Heart Association
Join a hospital where employee engagement is at an all-time high. Enjoy competitive compensation along with benefits such as tuition reimbursement, hospital retirement contributions, and financial planning assistance. Start your life-changing journey today.
__________________
#1 in New York. #6 in the Nation. - U.S.News & World Report, “America's Best Hospitals 2016-2017”
Discover why we're #1 in New York - an unparalleled pursuit of excellence and the widest array of choices for your career. Learn more about what we can offer you at: nyp.org/careers
NewYork-Presbyterian Hospital is an equal opportunity employer.

Best,
Tara Deliberto, Ph.D.

Sunday, August 28, 2016

Announcement: Intensive Program for Adults with Eating Disorders Now Opened in the NY-Metro Area!



I'm very excited to announce the opening of a new intensive program from adults with eating disorders at NewYork-Presbyterian Hospital!  This program runs from 8:30am-3:00pm, Monday-Friday, and provides adults with eating disorders the opportunity to eat three times per day with the support of caring and well-trained behavioral specialists.  In addition to meal and snack support, patients receive individualized care while having access to a host of groups focusing on goals such as establishing understanding and use of cognitive behavioral therapy skills, mindfulness practice, assertiveness, and the regulation of one’s emotions.   Taken together, the services offered to our patients - including meal and snack support, individual therapy, family therapy, and group sessions - foster both mental and physical recovery from disabling and life-threatening eating disorders.   
Although our eating disorders partial hospitalization program (ED PHP) is new, New York-Presbyterian Hospital has served the community by treating patients in both inpatient and outpatient settings for many years. Our specialized eating disorders inpatient unit helps people psychologically recover from eating disorders, while benefiting from close medical monitoring of physical symptoms resulting from food restriction & avoidance, purging, laxative use, and other eating disordered behaviors.  Additionally, we have outpatient services where people with eating disorders can see licensed mental healthy professionals for 1-2 sessions per week.  Until now, however, patients with any form of insurance in the NY-Metro Area have not been afforded the opportunity to have an intermediate level of care in a hospital setting in which support,psychological services, & medical monitoring are provided consistently throughout the week.
In this new eating disorders partial hospitalization program (ED PHP), patients are treated & supported by staff from the disciplines of nursing, social work, psychology, nutrition, & psychiatry, who work together to help people recover both mentally & physically from the effects of the eating disorder.  Leadership of this new program will include myself, Tara Deliberto, Ph.D., Assistant Professor of Clinical Psychology in Psychiatry at Weill Cornell Medicine, and Director of the Eating Disorders Center’s Partial Hospitalization Program at New York-Presbyterian Hospital, as well as Evelyn Attia, MD, Professor of Psychiatry at Columbia University Medical Center, Professor of Psychiatry at Weill Cornell Medical College, Director of the Eating Disorders Research Program at the New York State Psychiatric Institute, and Director of the Columbia Center for Eating Disorders at Columbia University Medical Center.    
For more general information about the Eating Disorders Center, click here: More info on the ED PHP will be up soon! 

Tuesday, December 15, 2015

A Holiday Facebook Surprise

I just discovered the "Message Requests" section of Facebook: it holds all of the messages from people you're not Facebook friends with. It was so surprisingly wonderful to find a bunch of lovely messages of gratitude from people who have read the posts on this blog over the last several years. What a totally unexpected and wonderful holiday gift.  Thank you so much for reading, sharing, and engaging.   

Happy holidays,
Tara

Saturday, March 14, 2015

Scattergood Foundation Award Nomination for BITE

Dina Hirsch, Ph.D. & I are extremely excited to announce BITE's nomination for the behavioral health Innovation Award from The Thomas Scattergood Foundation! Please check it out here. The more comments the better so please feel free to post on the Scattergood site with any questions or feedback!

Thanks so much,
Tara Deliberto, Ph.D. & Dina Hirsch, Ph.D.


Wednesday, March 11, 2015

Behavioral Integrative Treatment & Evaluation (BITE) for Eating Disorders - Our Mission

I've spent the last year, together with Dr. Dina Hirsch, Ph.D., developing a comprehensive approach to the treatment of eating disorders called Behavioral Integrative Treatment & Evaluation (BITE).   Now, in only 4 short weeks, we're going to be releasing BITE.  In preparation for our launch, we'd like to share something very dear to us: our mission.  We hope you like it: http://www.bite-ed.com/our-mission/.



Sunday, August 3, 2014

Further Musings on Potential Predictors of Suicidal Behaivor

In the last post I discussed thoughts on why certain groupings of physiological measurements may turn out to be a better predictor of suicidal behavior than genes (check out that post here).  On top of that, I have some general ideas as to how this may play out.

I would imagine that each psychological disorder may end up having its own constellation of physiological factors with predictive power.  For instance, people with major depression without psychotic features would have a different constellation of physiological factors associated with suicidal behavior than people with schizophrenia.   The people in the major depression group may have lots of indicators of very low mood but a certain amount of anxiety / excitement too.  Currently, it is a commonly held belief among clinicians, researchers, and even the general public that a certain amount of energy is required to make a suicide attempt.  Rather than a 1 to 1 correlation between low mood and suicide - i.e. the people w/ the lowest mood are at the highest risk of making an attempt - low mood plus a certain amount of motivation/excitation to attempt is believed to be in the mix.  It's worth noting that the excitation wouldn't necessarily improve one's mood.  Low mood and excitation are not only likely to be separate and valid psychological constructs, but they would represent themselves differently physiological tests.   Speaking in terms of totally made up units of measurement to illustrate a point, a person with major depression may need lower than -100 endorphins (representing low mood) and somewhere between +15 and +30 cortisol (representing excitation) in order to qualify as being at imminent risk for suicide.  On the other hand, a person with schizophrenia may need lower than only -25 endorphins (representing low mood) and higher than +200 cortisol (representing excitation) to be at imminent risk for suicide attempt.  Continuing down the path of this totally fabricated example, high levels of excitation may be more indicative of imminent suicide risk in schizophrenia than in major depression for a couple of reasons.  If someone with schizophrenia attempts suicide, it has a decent likelihood of being because they heard a voice in their head commanding them to do so.  As such, the experience of hearing a scary voice telling them to kill themselves would hypothetically induce a physiologically state of excitation. On the other hand, a relatively low but existent amount of excitation would hypothetically be required for a person with major depressive disorder to attempt suicide.  Concurrently, their mood would presently need to be extremely low to be at risk for such destructive behavior.

Pulling back out of the examples and towards the larger picture, in short, I would imagine that each disorder would have it's own set of physiological risk factors.  Major depression, schizophrenia, bipolar, borderline personality disorder, etc. would all have different high-risk constellations.  Some more thoughts on the specifics to come.





Friday, August 1, 2014

Musings on Potential Predictors of Suicidal Behavior

I was recently asked for my thoughts about blood tests as a genetic predictor of suicide on Twitter.  I tweeted them out, but I thought I'd quickly organize them here as well.  It admittedly may be very flawed, but here's my logic:

1. Completing suicide is one isolated behavior that results from a complex myriad of genetic, biological, environmental, and situational factors.   As such, simply looking to genetics - the building blocks of life - to predict one isolated behavior seems far fetched.

2.  There's also a lot of noise introduced when your outcome is the one isolated behavior of a suicide attempt resulting in death.  Someone who may be prone to suicide, for instance, may die in an accident before they ever have the change to attempt suicide.   Further, people who may be prone to suicide otherwise may lead a charmed life & the thought may never cross their minds.  Alternatively, someone not genetically prone to suicide may have a terrible life, develop a substance abuse habit, and impulsively kill themselves one night while under the influence.  Because the environment and circumstance play such a large role in whether or not someone actually dies by suicide, looking to genetics intuitively doesn't feel right to me.  Studying epigenetic factors, however, may yield something very interesting, but my money isn't on it.  I don't think it will be the silver bullet we want it - or hype it - to be.  Think back to the human genome project. (P.S.  Psychologists will recognize this argument as part of the "low base rate behavior" issue.)

3.  It is true that suicidal behavior is linked with psychological disorders, but is perhaps more important to focus on this: the behavior of completing suicide is intimately tied to the circumstances in the immediate environment.  These immediate circumstances will have an immediate effect not a a person's genetics per se, but on their physiology.

For instance, on any given day, a woman with moderate depression may be at a certain point in her menstrual cycle, on substances, vulnerable from a myriad of factors (e.g. relationship stress, lack of sleep, health condition, etc.), and feeling particularly impulsive.  Lets just say that we add a life tragedy to this vulnerable mix of factors and she gets admitted to an inpatient unit for suicidal thoughts.  Eventually she reports her suicidal thoughts have remitted, she is discharged, and then our hypothetical woman unfortunately makes a suicide attempt.  Some of the aforementioned factors (e.g. menstrual cycle, etc.) have a specific physiological impact.  If we had measurements taken from the inpatient unit of this woman's estrogen/progesterone levels, oxytocin, waking levels of cortisol, toxicity, etc. it would result in a specific constellation of physiological factors.  Over time, scientists can examine which constellation(s) of physiological indicators most often co-occur with recent (serious) suicide attempts / completions.  Determining & using immediate constellations of physiological factors to predict suicidal behavior in the near future seems to me like it will be much more accurate (i.e. have "incremental predictive validity") than our current tools (e.g. self-report questionnaires).  The general idea is that in the future we may be able to divine what people are actually feeling based on physiological measures rather than self-report.

4.  One last thought about the utility (and sensitivity) of genetic testing for suicide:
Not only do I think that blood tests for genetic factors will not yield reliable predictors of suicide completion, they will likely not be of much practical utility.  Consider this: what course of action must a clinician take with the information that a person is at genetic risk for suicide?  If someone is admitted to a psychiatric inpatient unit because of depression and suicidal thoughts, at some point they report they are not imminently at risk.  At that point, we must then discharge them from the hospital.  We would not be able to detain them longer based on a genetic test.  Correct?  How much longer would we keep someone on an inpatient unit based on a genetic test?  Genetic markers are not what we call sensitive measures - they are not sensitive to change.  They are static.  We would, however, have a more firm basis for detaining someone in the hospital if we had evidence that certain physiological constellations were present in a person & evidence that this type of constellation is associated with imminent risk of suicide.  Over time, we would have an idea about how generally someone would be feeling based on the output of physiological tests. Of course, how accurate or difficult to manipulate these hypothetical physiological constellations may be is unknown.  But if I were a betting woman, I would put my money on the scientists examining circumstantial physiological compositions winning the race of determining the most accurate, useful, & sensitive predictor of suicidal behavior.

In short, a suicide attempt is a behavior, not a disorder.  I'm not so sure that treating suicide attempts like a disorder by examining genetic contributions will produce the best predictors of this behavior.  Exploring physiological factors that represent immediate shifts in a person's internal experience however, intuitively feels more promising to me.

P.S.  This post was in response to this CNN article: link.

Tuesday, June 24, 2014

BITE for Eating Disorders





Hi there,

This is more of an announcement than an actual post!  Here's the big news: Dr. Dina Hirsch & I are cooking up a new treatment manual I think you might like. For updates, follow us at @BITEforEDs.

Details about the BITE manual & website are to come!

Best,
The BITE Therapy Team

Wednesday, June 11, 2014

Letters to a Young Student of Psychology


Letters to a Young Student of Psychology

Background:

I was recently asked by a young student in psychology to answer questions for a report she was writing.  The report was on working with patients who are experiencing problems that hit close to home.  Below are both her questions and my answers. Because I graduated from my last clinical training year today, I thought it would be a nice day to publish this post.

Response:
Dear Young Psychology Student,

In the text below, I've done my best to fully answer your questions about my experience training as a psychologist.

Question 1:
Have you worked with school-aged children and adolescents? Briefly explain in what capacity you have worked with this population. What were the successes? What were the challenges?

Answer 1:

Yes, I am at the very end of my 6th year in a clinical psychology PhD program and I just completed internship at North Shore LIJ Hospital (I came directly from my graduation ceremony to this blog, in fact).  On internship I carried a caseload of child & adolescent patients; however, my prior training was largely with adults.  

For the first six months at North Shore LIJ, I carried a caseload on the locked adolescent inpatient unit at the hospital.  There I treated patients with first-break psychosis, recent suicide attempts, or physically violent behaviors.  During the second six months of my position, I worked with patients medically at risk secondary to severe eating disorders.  My patients were either hospitalized on a medical inpatient unit or attending the eating disorders day program, which is a 8:30am to 5:30pm fully structured hospital program.  Additionally, for this entire year, I carried an outpatient caseload.

I conduct only evidence based treatments (EBTs; e.g. cognitive behavioral therapy). So, in terms of successes: when Evidence Based Treatment is being conducted, a lot of symptoms tend to improve.  Therefore, I get to see a lot of success.  Specifically, I love seeing patients recover from anorexia nervosa.  It is consistently amazing to literally see a great deal of progress made over a short period of time.  For instance, we typically treat people who start off at risk of dying from being so underweight until they gain upwards of 15-20 pounds.  You can see that progress. At LIJ, we have a very strict refeeding program that promotes both physical and mental health.  

The biggest challenges for me are:

A) Working with parents who do not accept diagnoses.  Many times parents of children with certain disorders (e.g. autism or eating disorders) refuse to accept the diagnosis. This can be particularly frustrating when this prevents the child from receiving services during a critical phase of their development or illness.  If the parent doesn't come to accept a diagnosis in time, that child runs the risk of being severely affected for his / her entire life by the parent's lack of acceptance.

B) Calling child protective services (CPS) under some conditions.  In some extreme circumstances, CPS must be legally called when parents are neither abusing nor neglecting their children.  Parents may simply not be equipped to deal with their child’s emotional needs.  For instance, if your patient premeditatively stabs a sibling and threatens to do it again, a CPS call may be made even if the parents are "good" parents.  In a case like this, the issue is that parents are unable to control risk of one of their children seriously injuring / killing another of their children.  If the parent does not take the appropriate measures to ensure the safety of the victimized child by making (sometimes expensive) accommodations for the violent child, CPS may be called.  It's very difficult to be in situations like these.  Although in my experience only very reasonable accommodations are requested, in order for parents to follow through, they must emotionally accept that one of their children is a serious threat.  A well-intentioned parent may have the "he won't intentionally stab his sister again... it will be ok" type of mindset.  Of course, this is unacceptable when a patient has clearly expressed murderous intent.

Question 2:  Have you worked with a child that has lost a parent?  What have you found challenging? What have you found to be helpful for the client?

Answer 2:
I haven't worked with a child grieving the death of a parent; however, I have worked with patients grieving the loss of a parent. Specifically, patients in foster care grieve the loss of their parent in a primary care giving roll.  Some parents clearly demonstrated neglectful / abusive behavior, while some parents were not able to protect others from the violent behavior of the patient.

Challenging: It pulls at my heart strings when patients grieving the loss of a parent ask questions about the future.  The question when the child is removed from the home is always “what is going to happen to me?” and I can’t really answer those questions.  While some foster homes and residential settings are wonderful, others are not.  When working with patients in the hospital, I have no idea about the quality of the home where they would be next.  That can be tough.

Helpful: It is helpful not to intervene when a patient is actively grieving.  While on internship, I have had to break very difficult news to patients and have been present at the time the very instant the grieving process started.  In that specific moment, my job isn’t to relate to the patients or actively try and make them feel better.  My job is just sit there with the person and be as fully present to them as possible.  In instances like this, only when the person truly wants to be alone, do you leave them alone.  

In terms of advice, I would say this: knowing when grieving ends and a disorder begins is imperative.  Unfortunately, there are no easy rules to follow about this.  You can't say something like "oh, after two months, this child should be over the death of their parent."  You can, however, assess whether or not the person is emotionally avoidant.  Grieving implies that the person is actually experiencing the emotion of sadness that naturally accompanies loss.  If the person is doing things like drugs etc to avoid feelings of grief, we have a problem.  Once you figure out if/how the patient is avoiding, then rule is this: if the person is actually experiencing grief, sit with the emotion; however, if there is dysfunction secondary to avoidance, then intervene.  I think the ability to skillfully assess and intervene will naturally come with experience.  There's a whole book to write about this.

Question 3:
Is there a population that you see yourself in or relate to on an emotional level? What is that like? What has helped you maintain emotional distance? What has helped you to not “take the work home?”

Answer 3:
I have thought about this a lot, but I’ve never actually talked to anyone about it.  So here we go.  I think that if you really undergo a lot of self-examination over many years across many different experiences, you have the ability to remember even very mild emotional reactions, inclinations, and urges.  If you’re aware of the wide breadth of your own experience, it can be very easy to relate to patients, at least on some level.  In short, understanding yourself helps you understand others.  Because of this, I have found that I relate to every patient about something on an emotional level (to varying degrees of course).  

There have been a few times where I really see myself in a patient.  When this happens, it forces me to look at decisions I have made.  In these circumstances, I internally relate as much as I can to the patient and use genuine sympathy and understanding to build the relationship.  And with a strong relationship, we can facilitate adaptive change together.

I didn’t think it is necessary - or even helpful - to maintain emotional distance.  I don't wall myself off from experiencing my own emotions because that usually ends poorly.  It is helpful to use my emotions in session.  That isn't to say though, that a therapist shouldn't maintain an objective lens.  A good CBT therapist will know how and when to think rationally.  In fact, it is wholly possible to think rationally about a scenario while also experiencing real emotion.

In a way, you should take your work home.  Of course it isn't helpful to be overly involved with your patient's lives, but if a patient's experience was emotionally triggering for you, take home your own emotion about your own life.  Process that.

Question 4:  
Do you have any advice for me?

Answer 4:
I know that the reason why you're asking these questions, Young Student in Psychology, is that you lost a parent and you're worried that having a patient with a similar experience will be too much.  So listen, if you’re working with a patient who lost a parent and it triggers sadness about your own loss, sit with that.  Accept it.  Pay attention to it.  Ignoring this opportunity for your own emotional growth would only be hurting you.  You are going to have strong emotions and that is ok.  In this field, we have the privilege of helping other people through difficult emotions, which also happen to provide us with special opportunities for insight into ourselves.

In terms of advice, I would say this: be genuine and don’t avoid.  If something upsets you, obviously don’t make the session about your problems, but allow yourself to feel emotions about the patient’s pain in session and express your own pain when you get home.  Over time, exposing yourself to what you’re afraid of or emotionally sensitive to will make you stronger than you can anticipate.  Although the hole in your life caused by the death of a parent will never close, it will become easier to manage your emotions about this.  The more opportunities you give yourself to experience those emotions, the better therapist you will become and the stronger you will be.  Make mistakes and put yourself in situations you are not sure you can handle.