Two Outpatient Interventions Help Beat Eating Disorders

ANNAPOLIS, MD. – Two treatment strategies appear to be effective in the management of and recovery from eating disorders, according to one eating disorder expert speaking at the annual meeting of the Southern Psychiatric Association.

Dr. Harry A. Brandt said the treatments – family-based treatment (FBT) and Cognitive Remediation Therapy (CRT) – are "really exciting and are ... helping patients a lot."

FBT has been shown to be very effective for adolescents with anorexia and is appropriate for children and adolescents who are medically stable. "The current focus leads to a shift from viewing the family as a cause of an eating disorder to, instead, evaluating family dynamics that might develop in the context of an eating disorder – perhaps functioning in a maintenance or perpetuating way," said Dr. Brandt, director of the Center for Eating Disorders at Sheppard Pratt, Baltimore.

In family-based treatment, no assumptions are made about the origin of the disorder. Instead, the focus is on what can be done. "The parents are engaged as a resource. No blame is directed at the parents or the kids with the eating disorder." Siblings also are involved, play a supportive role, and are protected for the job assigned to the parents.

FBT, an outpatient intervention designed to restore weight, requires a team approach that includes a primary therapist, a pediatrician, and a psychiatrist. Brief hospitalization might be necessary to resolve medical concerns.

Also, parents are viewed as the most useful resource in their child’s treatment under FBT. In fact, the parents play an active role in the recovery process and in restoring their child’s weight, Dr. Brandt said. Therapy is aimed at assisting/supporting the parents in their efforts to help their child recover from anorexia, so that adolescent development can get back on track.

At the start of treatment, the adolescent patient is viewed as incapacitated in terms of eating behaviors with an inability to maintain an optimal weight for age and height.

The therapist’s role is to be a coach or consultant to the parents and to empower them to develop strategies aimed at managing the anorexia and finding ways to help feed the child until weight restoration is achieved. The therapist also encourages sibling support and understanding.

Lastly, the therapist teaches the family to externalize the illness, modeling a no-blame approach with recognition that the eating disorder behaviors are mostly outside the control of the adolescent. "Instead of getting angry at the kid, the therapist helps the parents to get angry at the illness. A parent’s not going to get angry at a kid who develops pneumonia but might get angry at the bacteria that caused it," he said.

FBT works through three phases: weight restoration, returning control of eating to the adolescent, and establishing a healthy adolescent identity. "These are fluid. If we move into phase two and the child stops eating, we might have to go back to phase one for a span of time."

Parents are supported in their efforts to restore their child’s weight and are encouraged to present a united front. Parents monitor meals and snacks, while restricting physical activity.

The therapist reassures the parents that they will succeed. The therapist also conveys to the patient that while she has many fears about weight gain, these fears cannot deflect the parents’ efforts toward weight restoration.

Weight restoration takes precedence over almost any other issue until self-starvation has been reversed. Control can start to be returned to the adolescent when she has reached 90% of ideal body weight and is eating without too much resistance. The process is gradual and age dependent, however, Dr. Brandt said.

Establishing a healthy adolescent identity begins when the adolescent has achieved a healthy weight for age and height. Treatment focuses on general issues of adolescent development and ways in which the eating disorder affected this process. Goals include increased personal autonomy, relationships with peers, or getting ready to leave home for the first time.

The final stages of treatment focus on relapse prevention strategies; the identification and recognition of early warning signs for a developing relapse; and family responses to potential relapse. These responses should be outlined and an action plan should be developed.

Recently, a randomized, controlled trial for adolescents with bulimia compared FBT to supportive individual psychotherapy and showed promising results. Six months after treatment, almost 30% of participants who received family-based treatment were still abstinent from bingeing/purging, compared to only 10% of participants who received supportive psychotherapy, Dr. Brandt said in an interview. "FBT for young adults is still being developed and refined. A small number of trials have shown some positive results, but additional research using randomized controlled trials is necessary to determine if this is the best treatment for this older age group."

Cognitive-Remediation Therapy

"We know that cognitive process is very involved in anorexia," Dr. Brandt noted. This includes learning, reasoning, problem solving, perception, judgment, and concentration. Cognition provides the ability for people to analyze, discriminate, organize, categorize, memorize, and perform other functions that are influenced by emotions and social feelings.

A cognitive deficit is any impairment in the thought process. Cognitive remediation is working on "techniques to develop skills and strategies that maximize the cognitive abilities and compensate deficits with the idea of developing alternative strategies for impaired functioning," he said. The technique has been used successfully in schizophrenia, brain lesions, attention-deficit/hyperactivity disorder, and obsessive-compulsive disorder.

"Can the brain change? We know the brain is a plastic organ, so of course, it can change. ... Can we get our patients practicing skills that might help them with the kinds of distortions that we see in anorexia nervosa," he asked.

CRT has an objective of exercising connections in the brain that hopefully include functioning. "This seemed to have applicability to eating disorders," Dr. Brandt said. The technique also is used to encourage patients to reflect on the exercises, as a way of raising awareness of thinking styles. By using practice, reflection, and guided discovery, a patient’s thinking style can be improved.

CRT is attractive for several reasons. It’s relatively simple, and there’s a very clear specificity of the material. The therapist’s delivery of this treatment should be very motivational. "The therapist really gets involved in this, and our patients love it. The therapist basically plays games with the patient," Dr. Brandt said. "The therapist is open about what his or her thought processes are as he plays these games and the patients play along. "The patient hopefully learns something about their own cognitive style."

Dr. Brandt observed that CRT is different from cognitive-behavioral therapy, or CBT, because the latter focuses on symptoms of illness rather than on the structure of the thinking. CRT uses effectively neutral material targeting the thought processes with the goal of developing new types of thinking. There isn’t a focus on bingeing/purging or weight restoration."

However, "CRT is not meant to be a stand-alone treatment for eating disorders but as a supplement to more traditional therapies such as CBT and dialectical behavior therapy," he said in an interview. In CRT, cognitive processing skills are the target of treatment, while these skills are required for CBT. CBT requires being able to think, while CRT really focuses on improving the quality of the thinking.

"The application of CRT has little to do with a patient’s intelligence level and much to do with a patient’s thinking style. In fact, the goals of CRT are to help individuals learn about how their brains work so that they can develop new problem-solving skills and enhanced cognitive flexibility."

He added, "Patients with anorexia often struggle with rigid thought patterns and an over focus on details that serve to maintain the symptoms of the disorder. These patients are also commonly very resistant to treatment, and CRT’s nontraditional focus also helps provide opportunities to enhance the therapeutic alliance and increase the patient’s motivation to change."

It’s long been known that anorexia involves detail focus or weak central coherence. Patients with anorexia have an excessively detailed information processing style with a neglect of holistic thinking. "They can’t really see the big picture." They are very good at tasks that involve piecemeal information processing.

In addition, these patients tend to be inflexible and poor at set shifting. They are also very rule-bound. Set shifting is the ability to hold two different cognitive frameworks. Anorexia patients have rigid thinking, and applications of rules and habits. It’s important to talk with patients about their thought processes during exercises that attempt to improve flexible thinking.

Flexible thinking exercises are used to encourage switching between different stimuli. These exercises include illusions (seeing two different pictures in the same image), switching attention tasks, embedded word tasks, estimating tasks, and ecological tasks.

The aim of switching attention tasks is to practice switching between two difference pieces of information swiftly and accurately, while also holding in mind a rule that requires remembering the previous answer. Embedded word tasks are designed to practice identifying particular categories of information among irrelevant information. This requires seeing the bigger picture and the detail, increasing flexibility of thinking.

Exercises like these help patient recognize strengths and weaknesses of thinking styles, challenge anxieties related to those styles, build confidence, and acknowledge and appreciate their strengths.

Dr. Brandt reported that he has no relevant financial relationships.

ANNAPOLIS, MD. – Two treatment strategies appear to be effective in the management of and recovery from eating disorders, according to one eating disorder expert speaking at the annual meeting of the Southern Psychiatric Association.

Dr. Harry A. Brandt said the treatments – family-based treatment (FBT) and Cognitive Remediation Therapy (CRT) – are "really exciting and are ... helping patients a lot."

FBT has been shown to be very effective for adolescents with anorexia and is appropriate for children and adolescents who are medically stable. "The current focus leads to a shift from viewing the family as a cause of an eating disorder to, instead, evaluating family dynamics that might develop in the context of an eating disorder – perhaps functioning in a maintenance or perpetuating way," said Dr. Brandt, director of the Center for Eating Disorders at Sheppard Pratt, Baltimore.

In family-based treatment, no assumptions are made about the origin of the disorder. Instead, the focus is on what can be done. "The parents are engaged as a resource. No blame is directed at the parents or the kids with the eating disorder." Siblings also are involved, play a supportive role, and are protected for the job assigned to the parents.

FBT, an outpatient intervention designed to restore weight, requires a team approach that includes a primary therapist, a pediatrician, and a psychiatrist. Brief hospitalization might be necessary to resolve medical concerns.

Also, parents are viewed as the most useful resource in their child’s treatment under FBT. In fact, the parents play an active role in the recovery process and in restoring their child’s weight, Dr. Brandt said. Therapy is aimed at assisting/supporting the parents in their efforts to help their child recover from anorexia, so that adolescent development can get back on track.

At the start of treatment, the adolescent patient is viewed as incapacitated in terms of eating behaviors with an inability to maintain an optimal weight for age and height.

The therapist’s role is to be a coach or consultant to the parents and to empower them to develop strategies aimed at managing the anorexia and finding ways to help feed the child until weight restoration is achieved. The therapist also encourages sibling support and understanding.

Lastly, the therapist teaches the family to externalize the illness, modeling a no-blame approach with recognition that the eating disorder behaviors are mostly outside the control of the adolescent. "Instead of getting angry at the kid, the therapist helps the parents to get angry at the illness. A parent’s not going to get angry at a kid who develops pneumonia but might get angry at the bacteria that caused it," he said.

FBT works through three phases: weight restoration, returning control of eating to the adolescent, and establishing a healthy adolescent identity. "These are fluid. If we move into phase two and the child stops eating, we might have to go back to phase one for a span of time."

Parents are supported in their efforts to restore their child’s weight and are encouraged to present a united front. Parents monitor meals and snacks, while restricting physical activity.

The therapist reassures the parents that they will succeed. The therapist also conveys to the patient that while she has many fears about weight gain, these fears cannot deflect the parents’ efforts toward weight restoration.

Weight restoration takes precedence over almost any other issue until self-starvation has been reversed. Control can start to be returned to the adolescent when she has reached 90% of ideal body weight and is eating without too much resistance. The process is gradual and age dependent, however, Dr. Brandt said.

Establishing a healthy adolescent identity begins when the adolescent has achieved a healthy weight for age and height. Treatment focuses on general issues of adolescent development and ways in which the eating disorder affected this process. Goals include increased personal autonomy, relationships with peers, or getting ready to leave home for the first time.

The final stages of treatment focus on relapse prevention strategies; the identification and recognition of early warning signs for a developing relapse; and family responses to potential relapse. These responses should be outlined and an action plan should be developed.

Recently, a randomized, controlled trial for adolescents with bulimia compared FBT to supportive individual psychotherapy and showed promising results. Six months after treatment, almost 30% of participants who received family-based treatment were still abstinent from bingeing/purging, compared to only 10% of participants who received supportive psychotherapy, Dr. Brandt said in an interview. "FBT for young adults is still being developed and refined. A small number of trials have shown some positive results, but additional research using randomized controlled trials is necessary to determine if this is the best treatment for this older age group."

Cognitive-Remediation Therapy

"We know that cognitive process is very involved in anorexia," Dr. Brandt noted. This includes learning, reasoning, problem solving, perception, judgment, and concentration. Cognition provides the ability for people to analyze, discriminate, organize, categorize, memorize, and perform other functions that are influenced by emotions and social feelings.

A cognitive deficit is any impairment in the thought process. Cognitive remediation is working on "techniques to develop skills and strategies that maximize the cognitive abilities and compensate deficits with the idea of developing alternative strategies for impaired functioning," he said. The technique has been used successfully in schizophrenia, brain lesions, attention-deficit/hyperactivity disorder, and obsessive-compulsive disorder.

"Can the brain change? We know the brain is a plastic organ, so of course, it can change. ... Can we get our patients practicing skills that might help them with the kinds of distortions that we see in anorexia nervosa," he asked.

CRT has an objective of exercising connections in the brain that hopefully include functioning. "This seemed to have applicability to eating disorders," Dr. Brandt said. The technique also is used to encourage patients to reflect on the exercises, as a way of raising awareness of thinking styles. By using practice, reflection, and guided discovery, a patient’s thinking style can be improved.

CRT is attractive for several reasons. It’s relatively simple, and there’s a very clear specificity of the material. The therapist’s delivery of this treatment should be very motivational. "The therapist really gets involved in this, and our patients love it. The therapist basically plays games with the patient," Dr. Brandt said. "The therapist is open about what his or her thought processes are as he plays these games and the patients play along. "The patient hopefully learns something about their own cognitive style."

Dr. Brandt observed that CRT is different from cognitive-behavioral therapy, or CBT, because the latter focuses on symptoms of illness rather than on the structure of the thinking. CRT uses effectively neutral material targeting the thought processes with the goal of developing new types of thinking. There isn’t a focus on bingeing/purging or weight restoration."

However, "CRT is not meant to be a stand-alone treatment for eating disorders but as a supplement to more traditional therapies such as CBT and dialectical behavior therapy," he said in an interview. In CRT, cognitive processing skills are the target of treatment, while these skills are required for CBT. CBT requires being able to think, while CRT really focuses on improving the quality of the thinking.

"The application of CRT has little to do with a patient’s intelligence level and much to do with a patient’s thinking style. In fact, the goals of CRT are to help individuals learn about how their brains work so that they can develop new problem-solving skills and enhanced cognitive flexibility."

He added, "Patients with anorexia often struggle with rigid thought patterns and an over focus on details that serve to maintain the symptoms of the disorder. These patients are also commonly very resistant to treatment, and CRT’s nontraditional focus also helps provide opportunities to enhance the therapeutic alliance and increase the patient’s motivation to change."

It’s long been known that anorexia involves detail focus or weak central coherence. Patients with anorexia have an excessively detailed information processing style with a neglect of holistic thinking. "They can’t really see the big picture." They are very good at tasks that involve piecemeal information processing.

In addition, these patients tend to be inflexible and poor at set shifting. They are also very rule-bound. Set shifting is the ability to hold two different cognitive frameworks. Anorexia patients have rigid thinking, and applications of rules and habits. It’s important to talk with patients about their thought processes during exercises that attempt to improve flexible thinking.

Flexible thinking exercises are used to encourage switching between different stimuli. These exercises include illusions (seeing two different pictures in the same image), switching attention tasks, embedded word tasks, estimating tasks, and ecological tasks.

The aim of switching attention tasks is to practice switching between two difference pieces of information swiftly and accurately, while also holding in mind a rule that requires remembering the previous answer. Embedded word tasks are designed to practice identifying particular categories of information among irrelevant information. This requires seeing the bigger picture and the detail, increasing flexibility of thinking.

Exercises like these help patient recognize strengths and weaknesses of thinking styles, challenge anxieties related to those styles, build confidence, and acknowledge and appreciate their strengths.

Dr. Brandt reported that he has no relevant financial relationships.

ANNAPOLIS, MD. – Two treatment strategies appear to be effective in the management of and recovery from eating disorders, according to one eating disorder expert speaking at the annual meeting of the Southern Psychiatric Association.

Dr. Harry A. Brandt said the treatments – family-based treatment (FBT) and Cognitive Remediation Therapy (CRT) – are "really exciting and are ... helping patients a lot."

FBT has been shown to be very effective for adolescents with anorexia and is appropriate for children and adolescents who are medically stable. "The current focus leads to a shift from viewing the family as a cause of an eating disorder to, instead, evaluating family dynamics that might develop in the context of an eating disorder – perhaps functioning in a maintenance or perpetuating way," said Dr. Brandt, director of the Center for Eating Disorders at Sheppard Pratt, Baltimore.

In family-based treatment, no assumptions are made about the origin of the disorder. Instead, the focus is on what can be done. "The parents are engaged as a resource. No blame is directed at the parents or the kids with the eating disorder." Siblings also are involved, play a supportive role, and are protected for the job assigned to the parents.

FBT, an outpatient intervention designed to restore weight, requires a team approach that includes a primary therapist, a pediatrician, and a psychiatrist. Brief hospitalization might be necessary to resolve medical concerns.

Also, parents are viewed as the most useful resource in their child’s treatment under FBT. In fact, the parents play an active role in the recovery process and in restoring their child’s weight, Dr. Brandt said. Therapy is aimed at assisting/supporting the parents in their efforts to help their child recover from anorexia, so that adolescent development can get back on track.

At the start of treatment, the adolescent patient is viewed as incapacitated in terms of eating behaviors with an inability to maintain an optimal weight for age and height.

The therapist’s role is to be a coach or consultant to the parents and to empower them to develop strategies aimed at managing the anorexia and finding ways to help feed the child until weight restoration is achieved. The therapist also encourages sibling support and understanding.

Lastly, the therapist teaches the family to externalize the illness, modeling a no-blame approach with recognition that the eating disorder behaviors are mostly outside the control of the adolescent. "Instead of getting angry at the kid, the therapist helps the parents to get angry at the illness. A parent’s not going to get angry at a kid who develops pneumonia but might get angry at the bacteria that caused it," he said.

FBT works through three phases: weight restoration, returning control of eating to the adolescent, and establishing a healthy adolescent identity. "These are fluid. If we move into phase two and the child stops eating, we might have to go back to phase one for a span of time."

Parents are supported in their efforts to restore their child’s weight and are encouraged to present a united front. Parents monitor meals and snacks, while restricting physical activity.

The therapist reassures the parents that they will succeed. The therapist also conveys to the patient that while she has many fears about weight gain, these fears cannot deflect the parents’ efforts toward weight restoration.

Weight restoration takes precedence over almost any other issue until self-starvation has been reversed. Control can start to be returned to the adolescent when she has reached 90% of ideal body weight and is eating without too much resistance. The process is gradual and age dependent, however, Dr. Brandt said.

Establishing a healthy adolescent identity begins when the adolescent has achieved a healthy weight for age and height. Treatment focuses on general issues of adolescent development and ways in which the eating disorder affected this process. Goals include increased personal autonomy, relationships with peers, or getting ready to leave home for the first time.

The final stages of treatment focus on relapse prevention strategies; the identification and recognition of early warning signs for a developing relapse; and family responses to potential relapse. These responses should be outlined and an action plan should be developed.

Recently, a randomized, controlled trial for adolescents with bulimia compared FBT to supportive individual psychotherapy and showed promising results. Six months after treatment, almost 30% of participants who received family-based treatment were still abstinent from bingeing/purging, compared to only 10% of participants who received supportive psychotherapy, Dr. Brandt said in an interview. "FBT for young adults is still being developed and refined. A small number of trials have shown some positive results, but additional research using randomized controlled trials is necessary to determine if this is the best treatment for this older age group."

Cognitive-Remediation Therapy

"We know that cognitive process is very involved in anorexia," Dr. Brandt noted. This includes learning, reasoning, problem solving, perception, judgment, and concentration. Cognition provides the ability for people to analyze, discriminate, organize, categorize, memorize, and perform other functions that are influenced by emotions and social feelings.

A cognitive deficit is any impairment in the thought process. Cognitive remediation is working on "techniques to develop skills and strategies that maximize the cognitive abilities and compensate deficits with the idea of developing alternative strategies for impaired functioning," he said. The technique has been used successfully in schizophrenia, brain lesions, attention-deficit/hyperactivity disorder, and obsessive-compulsive disorder.

"Can the brain change? We know the brain is a plastic organ, so of course, it can change. ... Can we get our patients practicing skills that might help them with the kinds of distortions that we see in anorexia nervosa," he asked.

CRT has an objective of exercising connections in the brain that hopefully include functioning. "This seemed to have applicability to eating disorders," Dr. Brandt said. The technique also is used to encourage patients to reflect on the exercises, as a way of raising awareness of thinking styles. By using practice, reflection, and guided discovery, a patient’s thinking style can be improved.

CRT is attractive for several reasons. It’s relatively simple, and there’s a very clear specificity of the material. The therapist’s delivery of this treatment should be very motivational. "The therapist really gets involved in this, and our patients love it. The therapist basically plays games with the patient," Dr. Brandt said. "The therapist is open about what his or her thought processes are as he plays these games and the patients play along. "The patient hopefully learns something about their own cognitive style."

Dr. Brandt observed that CRT is different from cognitive-behavioral therapy, or CBT, because the latter focuses on symptoms of illness rather than on the structure of the thinking. CRT uses effectively neutral material targeting the thought processes with the goal of developing new types of thinking. There isn’t a focus on bingeing/purging or weight restoration."

However, "CRT is not meant to be a stand-alone treatment for eating disorders but as a supplement to more traditional therapies such as CBT and dialectical behavior therapy," he said in an interview. In CRT, cognitive processing skills are the target of treatment, while these skills are required for CBT. CBT requires being able to think, while CRT really focuses on improving the quality of the thinking.

"The application of CRT has little to do with a patient’s intelligence level and much to do with a patient’s thinking style. In fact, the goals of CRT are to help individuals learn about how their brains work so that they can develop new problem-solving skills and enhanced cognitive flexibility."

He added, "Patients with anorexia often struggle with rigid thought patterns and an over focus on details that serve to maintain the symptoms of the disorder. These patients are also commonly very resistant to treatment, and CRT’s nontraditional focus also helps provide opportunities to enhance the therapeutic alliance and increase the patient’s motivation to change."

It’s long been known that anorexia involves detail focus or weak central coherence. Patients with anorexia have an excessively detailed information processing style with a neglect of holistic thinking. "They can’t really see the big picture." They are very good at tasks that involve piecemeal information processing.

In addition, these patients tend to be inflexible and poor at set shifting. They are also very rule-bound. Set shifting is the ability to hold two different cognitive frameworks. Anorexia patients have rigid thinking, and applications of rules and habits. It’s important to talk with patients about their thought processes during exercises that attempt to improve flexible thinking.

Flexible thinking exercises are used to encourage switching between different stimuli. These exercises include illusions (seeing two different pictures in the same image), switching attention tasks, embedded word tasks, estimating tasks, and ecological tasks.

The aim of switching attention tasks is to practice switching between two difference pieces of information swiftly and accurately, while also holding in mind a rule that requires remembering the previous answer. Embedded word tasks are designed to practice identifying particular categories of information among irrelevant information. This requires seeing the bigger picture and the detail, increasing flexibility of thinking.

Exercises like these help patient recognize strengths and weaknesses of thinking styles, challenge anxieties related to those styles, build confidence, and acknowledge and appreciate their strengths.

Dr. Brandt reported that he has no relevant financial relationships.