Integrative Modalities Therapy (IMT) for Eating Disorders

by Tara Deliberto, Ph.D.

Back in March of this year, the approach that Dina Hirsch, PhD, and I created for the treatment of eating disorders was renamed Integrative Modalities Therapy (IMT)!  Here I'll explain the reason for the change as well as the meaning of the new name.

When we started out, our aim was to create a comprehensive collection of evidence-based interventions for patients and families with eating disorders.  For the original plan, we knew that we needed to have an approachable patient-and-family-facing name.  We decided to call the first version of our book "BITE," or Behavioral Interventions, Tips, and Evaluations.  At the time, this name was fitting since the acronym represented the smallest behavioral step a person can take towards recovery (i.e. taking a bite of food) and the fully spelled-out name descriptively explained what was included in the book. It was a go!

Over the years, however, our singular book that brought together interventions, tips, and assessments grew into something much larger: an evidence-based practice treatment approach.  We soon needed to write a treatment manual for clinicians to use alongside the original book for patients and families. Our unpublished manuscript became a resource for clinicians in the trenches who needed a summary of all of the varied evidence-based interventions in one easy place.  Some have called our approach "evidence-based practice in a box."  Recognizing the potential of this type of resource, our goal became to provide clinicians with a comprehensive, practical, flexible, and scalable resource to help navigate the treatment of eating disorders. 

Considering these advancements, prior to both books being published by New Harbinger, it was time for a new clinician-facing name!  We chose to rename our approach Integrative Modalities Therapy (IMT) because it integrates a wide array of evidence-based interventions from gold-standard treatments into the three modalities of individual, group, and family therapy.  In short, the approach is both integrative and can be administered modularly across the three treatment modalities.  As a clinician-facing evidence-based practice approach, we now have the big, hairy, audacious goal of contributing to the efforts of our colleagues by helping to close the eating disorder treatment gap together.

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.

New Autism Theory: "The boy whose brain could unlock autism"

The article "The boy whose brain could unlock autism" from https://medium.com/ is beautiful. It is beautifully written. It is hosted on a beautifully designed site. And most importantly, the non-judgmental theory of autism presented is beautiful.  This theory is also pretty brilliant.

The article presents a theory that reconceptualizes autism as an "intense world syndrome."  This theory suggests that autism is not best thought of as a disorder characterized by a lack of empathy or intelligence, but by the existence of an overload of emotion plus a great capacity to learn.  Further, intense world syndrome suggests that people with autism experience sensations differently.  What an awe-inspiring idea.

There are so many different issues to discuss now!

Let's start with empathy.  Just because it may appear that people with autism lack empathy, doesn't mean this interpretation is correct.  It could be that a person's mind with autism is so overloaded that focusing on someone else is next to impossible.  Over time, this could result in lacking empathy for others.  Further, if people with autism are constantly bombarded with not only intense emotions (e.g. anxiety), but aversive sensory experiences as well (e.g. the act of brushing your teeth produces the internal sensations that nails on a chalkboard would typically evoke), certain consequences can be expected.  We know that spikes in anxiety result in increased calcium release and the encoding of memories.  This process could result in really rigid thinking.  Not to mention, one's focus is really narrowed in those moments.  So if there is constant anxiety, the brain is in a state of rapid-fire learning...on one hand.  On the other hand, it may be difficult to focus on anything but a particular target.  This combination of increased anxiety and rapid fire learning may carve out some pretty "strange" observable behavior patterns over time.  For instance, perhaps a hyper focus on learning calendar dates could result.  Also, the manner of brain processing could leave very little left over for attention on others, hence our current/previous perception of lack of empathy in people on the spectrum.

Speaking of the "spectrum," as a field we are very comfortable examining autism on this spectrum.  But it seems to me that there is still the perception of a dichotomous cutoff whereby some people have autism and others don't.  Right now, once a diagnosis of autism is made, then you are examined on the spectrum as compared to others with this diagnosis.  But what if we viewed every single person as representing a different degree of autism on a full spectrum?  What if the spectrum was thought to encompass all humans?  Well, I think that'd do us a huge service when conceptualizing cases.

Eating disorders, OCD, and self-injury are all jumping into my mind as relevant to this new theory of autism.

Let's take eating disorders for starters.  I'm too invested in writing this blog post right now to look it up, but I remember learning at this year's International Conference on Eating Disorders in Montreal that autism and eating disorders are related.  This was an internal hypothesis of mine for ages.  When I saw the data, I literally scribbled "I knew it!!!" in my notes.  [P.S. Even though I'm not going to look up the exact presentation I saw, here's a Medical News Today article on the relationship between eating disorders and autism from August 2013.]

Similar to what this new theory of autism posits, people with eating disorders are also in a state of anxiety, which results in rigid thoughts (e.g. "fat is bad"), compulsive behaviors (e.g. calorie counting), and a self-centered focus.  There's also usually an increased level of intelligence in people with eating disorders... or perhaps it's better conceptualized as "fast learners."   Sounds a bit like high-functioning autism, huh?  

Unlike autism though, many times people with eating disorders report desperately wanting the approval of others.  So, even if the behavior is seemingly self-centered (e.g. wanting to look good), I maintain that the function of the behavior is not completely egocentric.  But reconciling this seemingly self-centered focus and a desire to please others is usually not easy for family members of people with eating disorders.  The idea is difficult to grasp that intense anxiety about other's approval ironically results in a "self-centered" disorder. In short, I think it could be really useful to use intense world syndrome concepts in fostering understanding about eating disorders. 

Here are a few last notes before I move on with my Sunday: I think eating disorders relate to autism in the same way OCD is related to autism.  In fact, I conceptualize eating disorders as a specific subtype of OCD.  It appears to me that the process is the same in both disorders, but the content of the worry differs.  And as such, slightly different treatments are needed... but not too different.  I'll publish more on what I've written about this in the future.

And lastly, there is the example of how self-injury may relate to autism.  I've blogged here before about my hypothesis on self-injury's relation to sensory integration issues.  To read, click this link.  The idea that intense emotions can create perceptual disturbances (auditory hallucinations such as hearing voices) is not new in psychology.  But the idea that intense emotions can also lead to sensory disturbances remains an area where we need work.  Taking that a step further, exploring exactly how emotions are moderated with sensory acts like self-injury (or even doing things like soothing oneself with lavender hand lotion) is worth researching.

We need to know the following: is there a dose response relationship between intense anxiety/emotion and 1) sensory disturbances, 2) learning, 3) rigid thinking, 4) compulsive/repetitive behaviors, and 5) a self-centered focus?  If not, is there some relationship?  What mediates/moderates that relationship?

This new idea of conceptualizing autism as "intense world syndrome" clicked a few pieces into place of an enormous puzzle that I have been kicking around in my brain for years.  I very much look forward to learning from research on this theory in the coming years. 

The French Paradox

The French Paradox:

Why The French Eat Fatty Food & Are Skinnier Than Us

It is official.  The French enjoy food more than Americans. And they are thinner with less health issues.  Awesome.

As it turns out, this phenomenon is so well documented,  even has a name - The French Paradox.

But what if it wasn't actually a paradox?  Maybe it all makes perfect sense.

Studies have shown that the French stop eating when they're full.  Americans stop eating when their plate is empty (Wansink,  2006).  Interestingly, the larger a person is, the more likely they were to rely on external cues to stop eating (e.g. portion size).

Frankly, this isn't too surprising.   We all understand that the plate sizes in the States are big, some of us have an inclination to eat everything on the plate, and subsequently, we gain weight.  But this begs a more interesting million dollar question:  If relying on external cues like plate size can cause weight gain, what is the answer to weight stablization?

Well, the answer is resoundingly NOT self-control, restraint, effort, pressuring yourself, and/or punishing yourself.  These methods also rely on external cues or rules that you set for yourself.  These types of eating guidelines are largely ineffective in practice too.  Consider how many times you've tried to restrain your eating, only to eat a ton.  You may even binge after trying to restrict.

I would go so far as to say that restricting food intake with any type of diet may actually be just as much a part of long-term weight gain as overeating.  For so many people, restricting food intake is simply just the first step in a sequence that eventually leads to unstoppable eating.

Take a moment to chew on that concept a bit: restricting is the opening act for a grande finale binge.  If this cycle repeats over time, the overall effect could actually be weight gain.  Shortening the message, restricting may = weight gain for some.

[Turns out there is this whole psychological component to dieting practically no one has been considering!  But I digress.]

Now, returning to the million dollar question.  The correct answer is this: the opposite of relying on external cues to stop eating is relying on internal cues of hunger and fullness.  In short, if you go by external cues like your plate size, you could be heavier over time.  Conversely, if you go by internal cues, your weight is likely to be more stable over time (e.g. Augustus-Hovarth & Tylka, 2011)

Interestingly, Rozin et al (1999) found that American's associated "chocolate cake" with guilt, while the French associated it with "celebration."  The French can actually enjoy cake and they're still thinner.

After all of that dieting, could it be that thinking more like a hedonist shrinks your waistline?  Tell me what you think with a comment below.

P.S. As usual, this post is only a sliver of my thoughts on the matter.  More generally, not only does one need to start paying attention to hunger/satiety cues, but also 1) decrease fear about weight gain, 2) try to curb the desperate desire to be thin, 3) stop mentally obsesses over calories, 4) curb efforts to compensate for calories, and 5) very importantly, being "thin" doesn't equal good health in the same way being "overweight" doesn't equal bad health.  But these issues are fodder for another post!  We'll get there.

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References

Augustus-Hovarth, C. & Tylka. T.  (2011). The Acceptance Model of Intuitive Eating: A Comparison of Women in emerging adulthood, early adulthood, and middle adulthood. The Journal of Counseling Psychology, 58, 110-125.

Rozin, P., Fischler, C., Imada, S., Sarubin, A., & Wrzesniewski, A. (1999). Attitudes to Food and the Role of Food in Life in the U.S.A., Japan., Flemish Belgium, and France: Possible Implications for the Diet-Health Debate.  Appetite, 1999, 33, 163-180.

Wansink,  B. (2006).  Mindless Eating: Why We Eat More Than We Think.  New York: Bantam Books.

You can read more about The French Paradox here: http://en.wikipedia.org/wiki/French_paradox

That "Gut Feeling" is Actually in Your Gut

I'm spending this particularly sunny Saturday in Manhattan doing some literature reviews near an open window overlooking people eating at an outdoor cafe`on 3rd avenue. Unbeknownst to them, I've been watching and wondering about the connection between the food they're eating, their bellies, and their brains. I know I shouldn't get derailed from finishing my work, but I couldn't resist writing this post.

I just came across a review paper called "Gut feelings: the emerging biology of gut-brain communication." Cool stuff. Apparently, there has been talk since about 1850 of a nervous system I've never heard of before: the enteric nervous system (ENS). Technically, it is considered the 3rd branch of the autonomic nervous system, which I'm certainly familiar with, but still! The ENS seems a bit too important for me to have been enveloped in the field seven years before learning about it. It could just be me... but I'm guessing the folks in psychology are not all that knowledgeable of the ENS.

That being said: the ENS, - or the interaction system between the brain and the gut - is referred to as the 'second brain' because it is similar in complexity to the one we have in our heads. It turns out that the second brain may have a pretty big impact on emotions, motivation, and [get this] intuitive decision making. In other words, the gut is quite literally involved in making gut decisions.

Who would've thought? Actually, the guy who coined the phrase "gut feeling" may have.

Consider the fun little notion that maybe we have been able to identify that intuitive decision making comes from the gut all along, without ever having scientific evidence. I love the idea that purely being mindful of your own physiological sensations can be an accurate source of information. How incredible.

Another interesting piece of knowledge this article has to offer is this: disruption of the ENS is associated with inflammatory gastrointestinal disorders, obesity, and eating disorders. To me, this certainly makes a lot of sense!

Specifically relating to over-eating, the paper proposes that the underlying biological mechanism is the mismatch between the big expected reward from eating food, and the relatively small actual reward experienced. The idea is basically that people keep thinking they are going to really enjoy food, are left unsatisfied, and keep coming back for more. While this may certainly be a big part of the picture, I have some other ideas about this... Something to think about for later.

Reference:
Mayer, E. (2011). Gut feelings: the emerging biology of gut-brain communication. Nature Reviews, 12, 453-466.

Eating Disorder Statistics

Just came across this great resource for eating disorders. Please check out the website for the National Association for Anorexia and Associated Disorders, Inc.

Stop Complimenting Me on How I Look

P.S. Here's another observation: extreme discomfort with compliments over time in people with eating disorders. Eventually, it just doesn't feel good to get those addictive compliments any more. Maybe this is a sign of improvement?

I think a recognition that this whole game is dangerous and shallow might precede this phenomenon. At the beginning of a drug addiction, people might think that it is all fun and games. Eventually, they can reach a point of developing an aversion, after all of the consequences come to fruition. I think it is the same for eating disorders.

The drug is achieving incremental goals of deprivation and social approval. In cases I've seen, it appears that the aversion to social approval piece comes first, followed by a disregard for monitoring food intake - but only in people who have truly recovered.

Eating Disorders - Are They Really about Control?

by Tara Deliberto

The concept that eating disorders are all about control never sat well with me.  Specifically, the explanation that people with eating disorders "can't control anything in their lives, so they control food," seems a bit too... poetic.  I understand the general idea, but it seems only to hit the target. I prefer the bull's eye.

Rather than simply increasing control, they way I perceive it, eating disorders seems to be more about the asceticism component. For those unfamiliar with this term, asceticism is the practice of depriving oneself of worldly pleasures. As it applies here, asceticism would involve depriving oneself of things that taste good. While it may not sound like fun, there is definitely a rush that comes along with achieving a goal in line with your values.

If your value is looking good by societal standards (i.e being thin), then you'll feel good about taking that self-depriving step towards trying to lose a bit more weight - e.g. passing on dessert. There is definitely some psychological reward from having this Spartan mentality. On top of this, if you value achievement and hard work, it seems you'll certainly at an increased risk of deriving a lot of pleasure from controlling food intake.

Ok, so we have identified two fundamental components so far:
1. valuing looking good by societal standards (i.e. thinness)
2. putting in lots of effort to achieve a goal

So, moving on!  If you have these values coupled with an environment that is chaotic and/or not rewarding, I'd imagine you'd be really looking for a way to feel good somehow. Because it might be difficult to feel good with a dearth of positive things in your life, you might start to adapt. Maybe you'll start getting your kicks from deprivation rather than your run-of-the-mill pleasures.

Perhaps you decide you want to start looking good because then you'd be happy. Why not try to lose some weight. Ok, so you limit your food. It sure feels good to be in control and achieve a goal.

Fast forward a few weeks. You lose some weight. People start to notice. "Wow, you look great!" Man, those compliments feel good. [And not only that, maybe all those self-esteem killing negative comments about your appearance disappeared too.]

Wham! Eating disorder.

I'd imagine there is a cycle where psychological reinforcement from depriving oneself and looking good feed off each other. The more you deprive yourself, the more compliments you get etc. Over time, depriving oneself is just linked with feeling good. Especially if that is the primary way you can feel positive, I'd imagine this whole deprivation/compliment reinforcement cycle mess is quite addicting. People look to score small amounts of pleasure by depriving themselves, while chasing the big goal of all those compliments and social approval.

While I'd love to speculate more, I have a research proposal to write tonight!

So, to wrap up: it doesn't seem to suffice to say that eating disorders are about "control."  There are certainly other areas to be addressed in treatment, but areas to be targeted rather than simply "control," might be:
1. Valuing what society deems as attractive
2. Valuing extremely perfectionistic work towards achieving goals in line w/ the above value
3. Getting high off of asceticism
4. Getting high off of compliments
5. Potentially not receiving reinforcement and/or deriving pleasure from other areas

In short, this notion that people can't control anything in their environment so they control food, is too poetic for my taste!

Ok, back to writing my research proposal on disordered eating! That's all for today.

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P.S. Note to self: Return at a later date to examine which of the components listed above are:
1. necessary-but-not-sufficient
2. necessary-but-can-be-sufficient
3. not-necessary-nor-sufficient-but-can-pop-up.

Quickly, it appears that valuing what society/someone in particular deems attractive is necessary-but-not-sufficient due to the sharp increase in eating disorders as societal ideals changed. Unless, of course, the disorder developed primarily to look unattractive & functions to protect the person from maturity/ sexual abuse. The second component is probably necessary-but-not-sufficient only in anorexia nervosa - where people end up drastically committing to deprivation. With bulimia nervosa / EDNOS, it could exist, but vacillate, or be complicated by a compulsive nature etc.