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Eating Disorders Are Anxiety Disorders: Why We Should Be Moving Towards Transdiagnostic Conceptualization and Transdiagnostic Treatment


Friday, March 24, 2017: 4:00 PM-5:30 PM

Background: He will present the evidence and rationale for an anxiety based, transdiagnostic approach in conceptualizing and treating eating disorders, present techniques for developing exposures, and review how to apply our understanding of the mechanisms of anxiety in service of healing and overcoming the fear and threat that underlie eating disorders.

Objectives: ...the overlap in the phenomenology, epidemiology, and neurobiology of Anxiety and Eating Disorders. ...the rationale and methodology of using a transdiagnostic approach in eating disorder treatment. ...the methods for developing and using in vivo and imaginal exposures for use in eating disorder treatment.

I. Overlap Between Eating Disorders and Anxiety

A. Characteristics

B. Presentation

C. Psychology

D. Genetic

E. Neurobiology of ED

II. Transdiagnostic Conceptualization of Eating Disorders

III. Use of Exposure and Response Prevention (ERP)

  1. ERP successful treatment for OCD
  2. Expose patients and then prevent from engaging in compulsion
  3. Demonstrate the nonoccurrence of the feared consequence
  4. Preventing response prolongs exposure

IV. Why use ERP in Eating Disorders

  1. High relapse rates reflect that weight restoration is only first step
  2. Overlap in phenomenology of ED and Anxiety
  3. Anxiety symptoms precede ED symptoms
  4. Patients with ED report higher levels of comorbid anxiety
  5. Anxiety remains elevated one or more years following weight restoration

V. Using ERP in Eating Disorder Treatment

  1. Break pattern of avoidance
  2. Place patient in direct contact with feared stimuli so that there is “habituation”
  3. Exposures designed to elicit patient’s emotional experience in the moment
  4. Also work on attending to physical feelings
  5. Not allow patient to use behaviors to check out or to alleviate anxiety while doing exposure
  6. Change rigid patterns (eating in particular order, keeping food separate, keeping rigid schedules)

VI. Exposure and Response Prevention Protocol

  1. Introduce Exposure and Response Prevention
    1. Rationale for using
    2. Overview of Cognitive-Behavioral view of sx
  2. Psychoeducational Component of Anxiety
    1. Learn the natural time course of anxiety
    2. Anxiety occurring on a scale (not binary, on/off)
    3. Place fears along scale and identify range of feared consequences
  3. Exposure In Vivo:
    1. Through exposure, learn that anxiety/distress/urge does not last forever and will eventually decrease without use of compensatory behavior
    2. SUDS (Subjective Units of Discomfort/Distress Scale) is introduced
    3. List of triggering stimuli arranged in hierarchy
  4. Imaginal Exposure:
    1. Vividly imagining situation that evoke urges
    2. Volitional repetition of fully imagined scenario results in gradual decrease in distress
    3. Create script
  5. Response Prevention (Not allow to engage in ritual/response)

VI. Dietary and Therapeutic Applications of treatment with ERP

A. How the treatment works to ameliorate symptoms

B. Designing Exposures

C. Case examples

There is a growing consensus that the marked level of co-occurrence of eating disorders and anxiety is not just diagnostic overlap, but rather that it represents a more significant, shared underlying diathesis, which predisposition or vulnerability can have multiple phenotypic manifestations. One can certainly see this overlap in the core phenomenology of eating disorders: obsessiveness and compulsivity, the primacy of fear and avoidance, hypervigilance and sensitivity, and prevalence of somatic symptoms that represent both a disconnect from the body as well as a hypersensitivity to somatic sensations and cues. This overlap is also evident in the fact that anxiety symptoms almost always precede eating disorder symptoms, that anxiety disorders are the most common comorbid diagnoses present in eating disorders, and that anxiety symptoms remain long after weight restoration and eating disorder symptoms remission. Ongoing advances in our understanding of the neurobiology and genetics of Eating Disorders and Anxiety further support a more transdiagnostic approach to their conceptualization and treatment.

One such application is the use of Exposure and Response Prevention (ERP) based approach to eating disorder treatment, for which there is a growing body of evidence. Exposure and Response Prevention is an empirically validated treatment approach based on classical conditioning and learning theory that targets learned fear responses that result in avoidant and compensatory behaviors. ERP is predicated upon learning through experience that feared consequences do not occur, and developing new non-fear associations. Using graded exposures to feared stimuli, exposures are designed to elicit emotional responses in the moment without allowing compensatory behaviors.

Designing appropriate therapeutic and dietary exposures can be challenging. We will present the rationale for using ERP in eating disorder treatment as part of a transdiagnostic approach, and present techniques for developing and using in vivo and imaginal therapeutic and dietary exposures in eating disorder treatment to help patients confront and habituate to feared situations in the safety of planned and structured exposures. We will review how to apply our understanding of neuropsychological functioning in eating disorders and anxiety in the service of providing safety and healing in the midst of threat.

Primary Presenter:
Norman Kim, PhD

Norman completed his B.A. at Yale and his Ph.D. in Clinical Psychology at UCLA, where he was the recipient of an individual National Research Service Award from the NIH. He has developed an expertise in treatment and assessment of psychiatrically complex populations with a particular focus on Eating Disorders, Trauma, and Bipolar Disorder. He is an advocate for eating disorder awareness, and has endeavored to develop a clinical approach that focuses on the exploration of meaning as a path to healing.  Norman is the National Director for Program Development for Reasons Eating Disorder Center and Center for Change in UT.



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