2. Sydney’s Background BS in Psychology at Central Michigan University MA and PhD at Wichita State University Worked in a private practice outpatient eating disorder treatment center from 2011 to 2014 Completed an APA accredited pre doctoral internship at a college counseling center and community mental health center in 2014 - 2015 Postdoctoral Fellow at the Inner Door Center since August 2015.

3. DSM-5 Eating Disorder criteria “Eating Disorders are characterized by a persistent disturbance of eating or eating related behaviors that results in the altered consumption of food that significantly impairs psychical health or psychological functioning.” - DSM-5

4. DSM-5 Eating Disorder criteria Anorexia Nervosa Severe restriction of food/calories leading to significantly low body weight Intense Fear of gaining weight Disturbed body image Subtypes Restricting type Binge eating/purging type Severity Mild BMI ≥ 17 kg/m 2 Moderate BMI 16 – 16.99 kg/m 2 Severe BMI 15 – 15.99 kg/m 2 Extreme BMI < 15 kg/m 2

5. DSM-5 Eating Disorder criteria continued Bulimia Nervosa Recurrent episodes of binge eating Recurrent inappropriate compensatory behaviors The above stated behaviors occur once a week on average for at least 3 months Self evaluation is profoundly influenced by body image Behaviors do not occur exclusively during periods of Anorexia Severity Mild: an average of 1-3 episodes of inappropriate compensatory behaviors per week. Moderate: 4-7 episodes per week. Severe: 8-13 episodes a week. Extreme: 14 or more episodes a week.

6. DSM-5 Eating Disorder criteria continued Binge Eating Disorder Recurrent episodes of binge eating Eating a definitively large amount of food in a discrete period of time A sense of lack of control Episodes are associated with three or more of the following Eating more rapidly than normal Eating until uncomfortably full Eating large amounts when not physically hungry Eating alone Feeling disgusted with oneself afterwards

7. DSM-5 Eating Disorder criteria continued Avoidant Restrictive Food Intake Disorder An eating disturbance manifested by persistent failure to meet nutritional needs involving one or more of the following: Weight loss Nutritional deficiency Dependence of enteral feeding or supplements Interference with psychosocial function Does not occur in the context of anorexia or bulimia Not better attributed to by another medical condition

8. DSM-5 Eating Disorder criteria continued Other Specified Atypical Anorexia Bulimia Nervosa (low frequency) Binge Eating Disorder (low frequency) Purging Disorder Unspecified Feeding or Eating Disorder Used in situations in which there insufficient information to make a specific diagnosis. Lesser know ED pathology Orthorexia [12] Diabulimia [10,11]

9. Yes or No? Do the following people have an eating disorder?

17. Eating disorders are not solely about weight. They are about how body weight and image affect a person’s self-worth.

18. How to identify a patient with an eating disorder in an outpatient setting Behaviors such as extreme or sudden weight loss, bingeing and purging are more obvious signs of eating disorder behavior. There are also more subtle behaviors that may indicate an eating disorder. Restricting fluids or bingeing on fluids. Over use of caffeinated beverages. (Coffee or energy drinks) Laxative use. Weighing or measuring food. Weighing and measuring self on a scale or by using “idealized” clothing size. Body checking, feeling one’s body or checking it in the mirror for flaws/size change. Obsession with calories or reading nutrition labels. Over exercise or exercise after eating too much or foods that are viewed as “bad”. Cutting meals into small pieces or using forks for foods like sandwiches. Blotting food with napkins. Unusual food combinations or inappropriate/excessive condiment use.

19. More Discrete Behaviors… Perfectionistic behavior Withdrawal from family, friends, and activities once found interesting Black and White Thinking- all good or all bad Sudden change in eating habits (e.g. becoming vegetarian or vegan) Glands look swollen Paleness and complaints of light headedness Dry, pasty skin, gray Swelling/puffiness in fingers, ankles and face

20. How to assess for an Eating Disorder in your office Things to ask about Family history of eating disorder behaviors? Weight? Weight goals? How often do you weigh yourself? What was weight and eating like as a child? What ways have you tried to lose weight? Why unsuccessful? What is an example of a good day? And a bad day? (ask for specifics!)

21. Assessing for BED If you binge, what is a binge? Frequency? Time of day? How long does it last? Do you feel you can stop once a binge has begun? How often do you feel out of control of your eating during a binge? When bingeing do you feel your rate of eating is more rapid than normal? How often do you eat alone or in secret? Why is that? Are there any factors or circumstances that increase the frequency of your binge eating? Are there any factors that appear to decrease binge eating? What emotions do you experience before, during, and after?

22. Assessing for purging If you purge how? (laxatives, diuretics, exercise, vomiting, restricting) Are there any factors that increase the frequency of your purging behaviors? Factors that decrease this behavior?

23. Assessing for restricting Would you describe an example of the type and amount of foods eaten in a particular day? Any history of dieting? Food rituals? Any trigger factors or situations in your life? When was your last menstrual period? Any mistral irregularities? Do you take any contraceptives? How you found that your periods stop once you stop taking oral contraceptives?

24. The functions of eating disorders from Carolyn Costin’s Eating Disorder Sourcebook (2007) Comfort, soothing, nurturance. Numbing, sedation, distraction. Attention, cry for help (using body in lieu of voice). Discharge tension, anger, rebellion (again using body in lieu of voice). Predictability, structure, identity. Self-punishment or punishment of “the body”. As a ritual to cleanse or purify self. To create a smaller or larger body to provide illusion of protection/safety. Avoidance of intimacy, become asexual when sexuality has been unsafe. Using symptoms to manifest internalized shame (“I’m bad”) instead of blaming abusers. 24

25. Prevalence rates Anorexia Nervosa It is estimated that 1.0% to 4.2% of women have suffered from anorexia in their lifetime [1]. Anorexia has the highest fatality rate of any mental illness [2]. Bulimia Nervosa It is estimated that up to 4% of females in the United States will have Bulimia during their lifetime [3]. 3.9% of these bulimic individuals will die [4]. Binge Eating Disorder 2.8 % of American adults will struggle with BED during their lifetime [5].

26. More Statistics Over 50% of teenage girls and 33% of teenage boys are using restrictive measures to lose weight at any given time [6]. 46% of 9-11 year-olds are sometimes, or very often, on diets, and 82% of their families are sometimes, or very often on a diet [7]. 95% of all dieters will regain their lost weight in 1-5 years [8]. 35% of normal dieters progress to pathological dieting. Of those, 20-25% progress to partial or full criteria for an eating disorder [9]. 25% of American men and 45% of American women are on a diet on any given day [9].

27. Co Occurring Disorders Anxiety and Depression Obsessive Compulsive Disorder Substance Use Disorder Body Dysmorphic Disorder Posttraumatic Stress Disorder Personality Disorders Borderline Dependent Obsessive Compulsive Personality Disorder

28. References 1. The Renfrew Center Foundation for Eating Disorders, Eating Disorders 101 Guide: A Summary of Issues, Statistics and Resources, 2003 2. Crow, S.J., Peterson, C.B., Swanson, S.A., Raymond, N.C., Specker, S., Eckert, E.D., Mitchell, J.E. (2009) Increased mortality in bulimia nervosa and other eating disorders. American Journal of Psychiatry 166, 1342-1346. 3. The National Institute of Mental Health: Eating Disorders: Facts About Eating Disorders and the Search for Solutions. Pub No. 01-4901. Accessed Feb. 2002. www.nimh.nih.gov/health/publications/eating-disorders-new-trifold/index.shtml.) www.nimh.nih.gov/health/publications/eating-disorders-new-trifold/index.shtml 4. Crow, S.J., Peterson, C.B., Swanson, S.A., Raymond, N.C., Specker, S., Eckert, E.D., Mitchell, J.E. (2009) Increased mortality in bulimia nervosa and other eating disorders. American Journal of Psychiatry 166, 1342-1346. 5. Hudson JI, Hiripi E, Pope HG, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry. 2007; 61:348-58.

29. Cont. 6. Neumark Sztainer, D. (2005). I’m, Like, SO Fat! New York: The Guilford Press. pp. 5. 7. Gustafson-Larson, A.M., & Terry, R.D. (1992). Weight-related behaviors and concerns of fourth-grade children. Journal of American Dietetic Association, 818-822. 8. Grodstein, F., Levine, R., Spencer, T., Colditz, G.A., Stampfer, M. J. (1996). Three year follow up of participants in a commercial weight loss program: can you keep it off? Archives of Internal Medicine. 156 (12),1302. 9. Shisslak, C.M., Crago, M., & Estes, L.S. (1995). The spectrum of eating disturbances. International Journal of Eating Disorders, 18 (3), 209219. 10. Rodin G, Olmsted MP, Rydall AC, et al. Eating disorders in young women with type 1 diabetes mellitus. J Psychosom Res. 2002;53(4):943-949. 11. Hunt M. Eating to Lose: Healing from a Life of Diabulimia. New York, NY: Demos Health;2012.

30. Cont. 11. Hunt M. Eating to Lose: Healing from a Life of Diabulimia. New York, NY: Demos Health;2012. 12. https://www.nationaleatingdisorders.org/orthorexia-nervosa https://www.nationaleatingdisorders.org/orthorexia-nervosa

32. Case study A Anorexia Nervosa 62“, 102.4#, BMI 18.8 (low end of normal) Disordered eating pattern characterized by severe restriction, eating only 1-2 times per day, over-exercising and calorie counting. Client engaged in diet pill use, laxative use, and excessive caffeine consumption. Goals In psychotherapy: Improve body image and challenge negative beliefs about food and weight “Not hate food” and consume enough energy to adequately fuel her body outside of PHP. Communicate her needs to family and friends, asking for support when needed. In nutritional therapy: Normalize eating pattern & promote weight gain toward healthy range through meal plan (goal weight of 110-115#) Reduce behaviors or restriction, laxative use, diet pill use, caffeine use and over-exercising through nutrition education. Expand variety of options chosen at meals and snacks. How did things end up? Discharged from program at approximately 112 pounds. Client is maintaining 4 weeks into outpatient therapy. Responded well to use of dialectics, a strong focus on values and personal life goals, and “eating what sounds good!”

33. BREAK…

34. Partial Hospitalization, Intensive Outpatient & Outpatient

35. Assessment Process If presenting with ED concerns… Psychological assessment by our licensed psychotherapist. Psychiatric assessment and consultation by our psychiatrist (medical director). Medical assessment by our PA in conjunction with medical doctor. Nutrition assessment by our registered dietitian. Nursing assessment by our registered medical assistants Assessments will help determine level of care based on severity of symptoms, medical stability, level of motivation

36. Partial Hospitalization Program (PHP) Higher level of care for medically stable individuals seeking ED treatment Often as a transition (“step-down) from a residential facility Specific criteria for determining appropriate level of care (APA Grid) Monday through Friday, 40-45 hours per week Primary diagnosis of ED, commonly treat co-occurring disorders

37. Partial Hospitalization - Typical Day 7:30 - 9:00 am - Vitals, Morning Report along with Physical Assessment and/or Medication Review. Breakfast 9:00 – 10:00 am – Yoga Therapy 10:00 am – 10:30 am -- Snack 10:30 am – 12:00 pm – Two 45 minute groups (Process, Weekend Check-in, Pattern Recognition/Coping Skills, Expressive Arts, Cooking, Self-Esteem, Body Image, Relationships/Boundaries, Weekend Planning) 12:00 – 1:00 pm – Lunch 1:00 – 2:30 pm -- Two 45 minute groups, or one 1.5 hour group (Mediation/mindfulness, Psychodrama, Activity Therapy, Nutrition, Emotion Regulation, Addictive Behaviors, Goal Planning) 2:30 – 3:oo pm -- Snack 3:00 - 5:00 pm - Individual Psychotherapy, Family Therapy, Nutrition Therapy, Occupational Therapy, Yoga Therapy or Physical Assessment/Medication Review

38. PHP, Con’t Primary purpose is reduction of ED behaviors and symptoms Improved or maintained health status Medication management Treat co-occurring disorders that contribute to ED Return to normal functioning in daily life

39. Intensive Outpatient Program - IOP Program for patients who have completed PHP Gradual “step-down” process Acclimating to less structure and return to normal functions of life Reinforces skills and concepts learned in PHP

40. IOP, Con’t Typical Course of IOP Programming Begins at 5 days/week Approximately 18-20 hours/week Lunch and one snack provided Morning yoga therapy and group therapy Individual therapy 1x/week

41. Outpatient – ED services If appropriate for outpatient level of care (less severe symptoms/behaviors, highly motivated, etc.), client’s can begin in outpatient Client’s who complete PHP/IOP often transition to OP Usually, 1-2x/week Continue to track vitals, usually additional supports

42. Binge Eating Disorder (BED) IOP IOP level of care specifically for BED population Created from treatment indications that BED is treated more effectively when not programmed with AN/BN populations 3 days per week, evenings Yoga, dinner, group therapy, snack

43. BED IOP Group Therapy Individual and Family Psychotherapy Medical Nutrition Therapy Yoga Therapy Mealtime Support and Therapy Psychiatric Medication Management and Collaboration with Primary Care Physician

44. Aims and Benefits of BED IOP Improve your relationships with food, self and others Reconnect with your body Establish normalized eating patterns Decrease obsessive thinking Health benefits include improvement in blood pressure and cholesterol levels, along with prevention and/or improvement of diabetes mellitus (studies show 1/3 of those with BED have Type 2 Diabetes)

45. What BED IOP IS NOT BED IOP is not a weight loss program For many, attempts at weight loss and diet approaches have contributed to problem (heavy restriction of calories, food groups, types of food) Weight loss is often a “side effect” once behavioral and psychological change takes place Inner Door encourages people to consume and enjoy food in moderation, not avoid

46. Yoga Therapy Utilized in every level of care Emphasis on Chakra system Each week in PHP/IOP is themed around a specific Chakra Focus on mindfulness

47. Outpatient Services Large “general” OP population Individual, family, marital therapy Adults, adolescents, children All clinicians work with PHP/IOP, as well as general OP populations Common presenting concerns: Depression, anxiety, substance abuse, self- harm, adjustment issues, court/probation referrals

48. The Team at Inner Door Center Licensed Psychotherapist Certified Alcohol and Drug Counselor Registered Dietitian Physician (Psychiatrist, Internist and Physician’s Assistant) Occupational Therapist Yoga Therapist Performing Arts and Recovery Coach Medical Assistants Master’s Level Interns HR Specialist Marketing Coordinator Medical Financial Specialist

49. Addiction Recovery & Substance Abuse High comorbidity between SA and ED Complex relationship between ED and SA Inverse relationship/symptom substitution Staff experience treating SA CAADC, training and experience Difficulties treating ED with untreated SA

50. Community Support Groups ANAD (Anorexia Nervosa & Associated Disorders): Weekly, ongoing, open support group for eating disorders Free of charge, every Tuesday evening from 7-8 PM Supportive environment, recovery oriented discussion and interventions DBT Skills Group Weekly group running for 16 weeks Work through DBT modules and learn DBT skills Mindfulness, Emotion Regulation, Distress Tolerance, Interpersonal Effectiveness

51. Community Support Groups Reconnect With Food Seven week group consisting of yoga and group process ($249) Discover your roots and messages contributing to your thought process, delay impulses, enjoy your body, eat mindfully, heal negative body image Develop self-acceptance, avoid using food or starvation to numb your emotions, integrate techniques into your daily yoga practice

52. Community Support Groups Reconnect With Recovery Every 3 rd Saturday, free of charge Yoga and group support Open to individuals in all phases of recovery (mental health, ED, SA) Connection with local recovery community

53. Treatment Approaches at IDC

54. Treatment Approaches Cognitive Behavioral Therapy (CBT) is based on the idea that thoughts can cause feelings. Pure CBT involves thought stoppage, reframing and extinction of thoughts. Dialectic behavior therapy (DBT), which emphasizes techniques for emotion regulation, concepts of distress tolerance, acceptance and mindful awareness. Acceptance Commitment Therapy (ACT) which uses an approach to embrace the moment fully so clients can gain the skills to re-contextualize and accept their emotions.

55. Aaron Beck, Albert Ellis, et al.

56. CBT - Principles Link between thoughts, feelings, and behaviors

57. CBT - Principles The ABCDE of CBT

58. Negative Automatic Thoughts (NATs) Thoughts that occur spontaneously, are often short-lived, and without us wanting them to occur. Obviously, negative in nature. Can happen nearly instantaneously, be forgotten quickly BUT, they leave emotional impact that can effect feelings, interpretations, and behaviors. Can be experiences like usual thoughts, also like “images” or view from third-person perspective. “Normal”, but more intense and frequent when psychopathology present

59. Cognitive Distortions What is “Irrational” or “Distorted”? All or Nothing (black and white): “If I’m not perfect, than I have failed” “Either I do it right, or not at all” Over Generalizing: Seeing a pattern based upon a single event, or being overly broad in the conclusions we draw “Everything always goes wrong for me” “Nothing good ever happens”

60. Cognitive Distortions Mental Filter: Only paying attention to certain types of evidence Noticing our failures, but not seeing our successes Disqualifying the Positive: Discounting the good things that have happened or that you have done for some reason or another “Yeah, I got that job, but that doesn’t count; they probably just needed someone really badly.”

61. Cognitive Distortions Jumping to Conclusions: Two main types Mind Reading: Imagining we know what others are thinking Fortune Telling: Predicting the future (“I will fail, won’t get the job” etc.) Magnification (catastrophizing) & Minimization: Blowing things out of proportion, or shrinking something to make it seem less important

62. Cognitive Distortions Emotional Reasoning: The assumption that because we feel a certain way, it must be true. “I feel like embarrassed, so I must be an idiot. This feeling is warranted.” “I feel fat.” Should & Must: Using critical words like “should”, “must”, or “ought”, can make us feel guilty, or like we have already failed. If we apply “shoulds” to other people, it often results in frustration.

63. Cognitive Distortions Labelling: Assigning labels to ourselves or other people “I’m a loser.”, “I’m completely useless.”, “They are such an idiot.”. Personalization: Blaming yourself or taking responsibility for something that wasn’t your fault. Conversely, blaming other people for something that was your fault.

64. Maladaptive vs. Adaptive Thoughts Not just about “thinking positively”. Reframing to explore equally likely outcomes or interpretations. “That outcome isn’t impossible, but what else could happen?” “How likely is that?” “That’s one way of looking at it. What’s another?” “How helpful is that interpretation?”

65. CBT - Summary Thoughts cause feelings, not events. Thoughts lead to feelings and behaviors that contribute to and maintain psychopathology. By changing thoughts, we can change how we feel (reduce depression, anxiety, anger, etc.). This leads to behavioral change that can also lead to emotional change, creating positive feedback loop. One of the most studied treatment interventions, effective with a wide range of disorders Widely used

66. Marsha Linehan

67. DBT - Introduction DBT was developed by M. Linehan specifically to treat Borderline Personality Disorder, and the behaviors that often go along with it Self-harm, suicidal ideation/attempts, substance abuse, anger, relational instability Modification of CBT – often referred to as CBT plus “mindfulness” (oversimplification) Empirically supported method of treatment Proven effectiveness with wide range of disorders

68. DBT – Key Assumptions Self-destructive behaviors are viewed as coping skills for intense and negative emotions (“function”). Emotional vulnerability: Some people are “hard-wired” to experience emotions more intensely, leading to need to “cope”. And/or: Trauma leads to biological changes that lead to increased vulnerability Invalidating Environment: Any environment in which a person’s emotional experiences are responded to inappropriately, or are responded to inconsistently. Communicates that emotions are not valid, you’re “crazy” for having them, or that they are “weak” for having them.

69. Four Modules of DBT Mindfulness: a mental state achieved by focusing one's awareness on the present moment, while calmly acknowledging and accepting one's feelings, thoughts, and bodily sensations, used as a therapeutic technique. Non-judgmentally! Emotional Regulation: Skills we need to manage our emotions, instead of them managing us. Reduce our vulnerability to negative emotions, create positive experiences.

70. Distress Tolerance: Marsha Linehan: "DBT emphasizes learning to bear pain skillfully. The ability to tolerate and accept distress is an essential mental health goal for at least two reasons. First, pain and distress are a part of life; they cannot be entirely avoided or removed. The inability to accept this immutable fact itself leads to increased pain and suffering. Second, distress tolerance, at least over the short run, is part and parcel of any attempt to change oneself; otherwise, impulsive actions will interfere with efforts to establish desired changes.” Interpersonal Effectiveness: Quality of our relationships significantly impact quality of life. Quality of relationships and communications can be increased through skills offered in DBT. Objective effectiveness, Relationship effectiveness, Self-respect effectiveness

71. Mindfulness Mindfulness is used as a way to gain awareness of and to accept emotions. Developing these skills makes it easier to manage our responses to distressing situations. Largely derived from Eastern traditions (Buddhist, Yogic). Empirically shown to be helpful with variety of disorders

72. Mindfulness Skill – 5 things This is a simple exercise to center yourself, and be mindful of the present. Look around, and notice five things you can see. Observe, with curiosity, these objects. Describe what you are seeing to yourself. Listen carefully, and notice five things you can hear. How does paying attention change your awareness of it? Notice five things you can feel in contact with your body. Notice the chair providing support to your legs and back, the feel of a pen in your hand, the smoothness of a piece of paper.

73. Emotion Regulation Understand how our emotions work (function and purpose). Skills we need to manage our emotions instead of being managed by them. Reduce how vulnerable we are to negative emotions. Build positive emotional experiences.

74. Reducing Vulnerabilities P.L.E.A.S.E. PL: Treat Physical Illness E: Eat Healthy A: Avoid mood altering substances S: Sleep hygiene E: Exercise (+/- 20 min/day)

75. Opposite Action When we experience an emotion, a behavior often results. This behavior can maintain or exacerbate negative emotions and situations. Ex: Sad  Withdrawal; Angry  Yell/Fight Is this effective? Does this contribute to quality of life? Engaging in the opposite action can result in behaviors that decrease negative emotions and increase quality of life. Ex: Sad  Interact with friends; Angry  Listen

76. Distress Tolerance Helpful when we can’t control the situation, but we need to manage distress in a healthy way. Focused on “Radical Acceptance”: Acknowledging that the situation is what it is, without focusing on “how it should be” Non-acceptance leads to anger, sadness, anxiety, etc. Ex: Not getting the promotion. “This isn’t fair, I did everything I needed to do. They’re blind!” “I understand they made the decision based on what they thought was right.” Acceptance does not equal “liking” or “condoning”.

77. Self-Soothe with 5 Senses Vision: Look at pleasing images, the sky, nature. Hearing: Listen to something enjoyable. Touch: Take a bath, get a massage. Taste: Have a small, enjoyable treat. Smell: Find some flowers, perfume, aromatherapy.

78. A.C.C.E.P.T.S. Distressing feelings WILL decrease over time, even if you do nothing. Activities: Do something that requires thought, concentration. Contributing: Focus on someone else; volunteer; good deed. Comparisons: Compare to a “worse” situation, either something you’ve gone through or even a world event. (Not always helpful!) Emotions: Do something that will create opposite emotion. Pushing Away: Imagine writing problems down, crumbling it up, throwing it away. Thoughts as leaves on a stream. Thoughts: When emotions take over, focus on thoughts. Count, read a poem, memorize phone book. Sensations: Use SAFE physical sensations. Hold an ice cube, eat something sour or spicy.

79. Interpersonal Effectiveness DEARMAN: Using objective effectiveness GIVE: Focus on maintaining/improving relationship FAST: Maintain self-respect

80. D.E.A.R.M.A.N. Describe the situation; facts, w/o judgment. Express your feelings, without blaming. Assert yourself by stating exactly what you want. Reinforce why it would be good for both parties. Mindful of your feelings, thoughts, behaviors. Appear confident; eye contact, tone of voice, etc. Negotiate by being willing to compromise, have a plan B ready.

81. G.I.V.E. Gentle manner even if angry, with respect. Interested in others points. Active listening. Validate their thoughts and feelings. Show how it makes sense to you. Easy manner in communicating. Relaxed body language, tone of voice.

82. F.A.S.T. Fair in negotiations. Mutually beneficial. (No) Apologies: Don’t apologize for saying no if it contradicts your own beliefs. Stick to Values: Determine your values and stick to them. Truthful communication. Strive for honesty and authenticity.

83. DBT Summary Some people “hard-wired” to experience emotions more intensely. Self-destructive behaviors viewed as having “function”. DBT strives to increase effective, healthy coping skills. (long vs short term) Not necessarily about change, more about acceptance. Building “a life worth living”.

84. Pronounced as the word “ACT” -- Hayes

85. ACT – Key Assumptions Traditional view is “Healthy Normality”: By nature, human’s are psychologically healthy. Suffering is caused by pathological processes, trauma, irrational thoughts, etc. We need to understand these processes, and change them ACT: Destructive Normality: “Ordinary human psychological processes can themselves lead to extremely destructive and dysfunctional results and can amplify or exacerbate unusual pathological processes.” “The single most remarkable fact about human existence is how hard it is for humans to be happy.” Hayes, Strosahl & Wilson (1999)

86. Goals and Aims of ACT Symptom reduction is not a DIRECT goal. Goal is an improved relationship with our distress. Goal is to remove barriers towards “moving in a valued direction”. Being able to “sit with” unpleasant emotions and thoughts, while still engaging in behavioral change based on values. Behavioral change leads to “positive spiral”, where one is experiencing positive experiences and often practicing “exposure”. Goal is PSYCHOLOGICAL FLEXIBILITY

87. What Causes Suffering? -- F.E.A.R. Fusion with your thoughts. Evaluation of experience. Avoidance of your experience (experiential avoidance). Reason giving for your behavior. These lead to, and exacerbate, distress.

88. Healthy Alternatives to F.E.A.R.? Accept your reactions and be present. Choose a valued direction. Take action.

89. Cognitive Fusion Fusion: Getting caught up in our thoughts and allowing them to dominate our behavior. Viewing thoughts as facts/truth; “I feel this, so it’s true”. Sometimes, the more we try to change a thought, the more we thinking about. “Don’t think about a purple zebra.” Fusion limits our ability to be present and respond reflexively.

90. Defusion Separating or distancing from our thoughts, letting them come and go. Looking at thoughts, rather than from thoughts. Noticing thoughts, rather than being caught up in them. Letting thoughts come and go, rather than holding on to them. Thoughts are just that, thoughts; words, pictures that are simply in response to things in the environment.

91. Defusion Techniques Put a negative self-statement into a sentence… “I am a loser.” Now fuse with that thought; get caught up in it, believe it as much as you can. Now replay the thought, adding “I’m having the thought that…” Replay one more time. Add, “I notice I’m having the thought that…” What happened?

92. Defusion Techniques Using Humor: Pick a negative self-thought (i.e., “I’m stupid”), and sing it to the tune of Happy Birthday. Imagine (or say out loud) saying that thought in the voice of your favorite cartoon character, movie character, sports commentator, etc. What happens?

93. Defusion Techniques “Letting Go” Metaphors Passing cars, driving past you on the porch Clouds drifting across the sky People walking on the other side of the street Suitcases on a conveyor belt Bubbles rising to the surface of a pond Waves washing up to shore Birds flying across the sky Trains arriving and leaving the station

94. “Making Room” for Distress Pick a difficult thought or feeling… Notice any urges to avoid it, change it, fight it, etc. Now imagine it as an object, and “let it” sit next to you. Notice how it is there, yet you are able to function and act in the way you need to.

95. Why Defusion? The aim of defusion is NOT to feel better or to get rid of unwanted thoughts. The goal IS to reduce the influence of unhelpful cognitive processes upon behavior, and to facilitate being psychologically present and engaged in experience. The aim of defusion is to enable mindful, valued living. Being fused can make it less likely for people to move in valued direction

96. Experiential Avoidance The tendency to avoid any unpleasant internal experience. Thoughts, feelings, memories, sensations. We often avoid negative situations even when harmful in the long term. Ex: Purging to avoid feeling full. Short-term relief wins out over probability of long term ineffectiveness.

97. Consequences of EA ACT is heavily focused on values; values are highly personal and vary from person to person Close interpersonal relationships, health, openness and honesty, trust, travel, income. Acting in pursuit of short-term relief often moves us further away from acting in accordance with values (valuing health but using ED behaviors), and creates further suffering. Emotions (even painful ones) are NORMAL and VALUABLE, often act as indications that something may be wrong. Avoiding them leads us to miss out on this information.

98. To Sum It All Up… All of these approaches, though different, attempt to help us widen the gap between stimulus and response – that is, between an event and how we act in response to it. Event  _____________________________  Response Versus Event  _  Response

99. Referral Process for ED Front office number at Inner Door Center is (248) 336-2968 Office staff will take initial information Battery of assessments Treatment team decides on appropriate level of care Care is implemented ASAP

100. BREAK…

101. Erika’s Background BS in Dietetics WSU 2009 Clinical Dietitian in Oakland & Macomb county long-term care / short- term rehab homes 2009-2014 Volunteered at Inner Door Center® 2009-2012 Inner Door Center’s Reconnect with Food® yoga therapy teacher training 2012-2013 RDN at Inner Door Center® since July, 2014

102. J Am Diet Assoc. 2011;111: 1236-1241.

103. “The complexities of EDs, such as epidemiological factors, treatment guidelines, special populations, and emerging trends highlight the nature of EDs, which require a collaborative approach by an interdisciplinary team of mental health, nutrition, and medical specialists.”

104. Nutrition Care Process at Inner Door Center® Assessment Diagnosis Intervention (AN, BN, BED) Monitoring Evaluation

105. Nutrition Assessment Gather information / evidence Anthropometric measurements Height, weight history, growth chart/growth patterns Interpret biochemical data Nutrition status/risk for refeeding syndrome Evaluate dietary assessment Eating pattern, fear foods, regimens/rules, attitudes towards weight/shape Identify ED symptoms & behaviors Assess maladaptive eating behaviors/patterns Create nutrition Dx, plan, and coordinate with team members

106. Nutrition Diagnosis (PES) Problem – “Disordered eating characterized by…” Intake, clinical, behavioral Etiology – Dx: ED, psychological disorders, comorbid medical conditions Family dynamics Hx of trauma Hx of substance abuse Symptoms – What is the evidence?

107. Nutrition Intervention - Baseline Establish caloric needs for weight/nutrition goals Normalize eating patterns Meal plan Food exchange system Identify areas for nutrition education Restore interoceptive awareness Hunger Satiety Emotions Provide psychosocial support and positive reinforcement

108. Nutrition Services/Interventions at Inner Door Center® Meal and snack-time support 3 meals / 3 snack pattern Hands-on help with food exchanges Weekly group education (Chakra-focused nutrition education) Weekly individual counseling (PHP, IOP) OP individual counseling Experiential restaurant outings Exposure therapy (fear foods, challenge meals)

109. Chakras and Nutrition

110. Monitoring & Evaluation Monitor nutrient intake and adjust as necessary Monitor for potential medical complications Rate of weight gain; once restored, adjust food intake to maintain weight Communicate individuals’ progress with team and make adjustments to plan accordingly Nutrition ED behaviors Physical activity recommendations

111. Care Coordination Provide counsel to team about protocols to maximize tolerance of feeding regimen/nutrition recommendations Refer for continuation of care, as needed Work collaboratively with treatment team – communicate nutrition needs and behavioral challenges along continuum of care Act as resource to health care professionals, family and provide education Advocate for evidence-based treatment and access to care

112. Anorexia Nervosa Common medical complications Refeeding Syndrome (RS) Evaluating for RS Mechanism of RS Preventing RS Monitoring for RS Behavioral characteristics Nutrition therapy approach

113. AN – Common Medical Complications Cardiac arrhythmias, bradycardia (low HR), heart failure Hypothermia (low body temperature) Hypotension (low blood pressure) Hypoglycemia (low blood sugar) *Refeeding Syndrome (potential deadly shift of electrolytes & fluids) Gastroparesis (delayed gastric emptying) Atonic colon/mucosal atrophy (constipation/diarrhea) Osteoporosis (severe bone density loss) Weakness and falls

114. Evaluating Risk for Refeeding Syndrome (NICE) ONE or more of the followingTWO or more of the following BMI < 16BMI < 18.5 Weight loss of > 15% in the previous 3-6 monthsWeight loss of > 10% in the previous 3-6 months Little or no nutritional intake for > 10 daysLittle or no nutritional intake for > 5 days Low levels of K, Ph, or Mg prior to refeedingHistory of alcohol abuse or drugs including insulin, laxatives, or diuretics Refeeding Syndrome defined: severe electrolyte and fluid shifts associated with metabolic abnormalities in malnourished patients undergoing refeeding, whether orally, enterally, or parenterally. The risk for RS is directly correlated with the degree of weight loss which has occurred as a result of the AN

115. Pathophysiology of Starvation Shift from carbohydrate metabolism to protein & fat catabolism Decrease in insulin levels Glycogen stores depleted Glycolysis  Gluconeogenesis With prolonged starvation Protein conserved for enzyme / structural functions Fat as primary fuel source FA  peripheral tissues Ketones  Brain

116. Pathophysiology of Starvation Loss of lean body mass Major organs compromised: heart, lungs, intestines, liver & kidneys Loss of cellular mass Intracellular loss of electrolytes including Ph, K, Mg Loss of body stores of Phosphorous FA oxidation does not require Ph (vs. glycolysis) BMR decreases 20-25% Conservation of protein and organ function

117. Pathophysiology of Refeeding Syndrome Shift from protein/fat catabolism to carbohydrate metabolism Gluconeogenesis  Glycolysis Insulin secretion increased Increases water and Na retention Increase in cellular uptake of glucose, phosphate, potassium, magnesium Shift back to glycolysis Decreased extracellular concentrations of Phosphorous, Mg, and K Phosphorous deficit for the phosphorylation of glucose Leads to decreased ATP (cellular energy currency)

118. Pathophysiology of Refeeding Syndrome Potential cardiovascular collapse: Reduced heart mass Increased circulatory blood volume with refeeding Changes in serum levels of Ph, K and/or Mg Depletion of ATP (impairing contractile properties of the heart & diaphragm) Low K/Mg can also cause a host of muscular and neurologic dysfunction cardiac dysfunction dysrhythmias skeletal muscle weakness seizures metabolic acidosis

119. Monitoring for Refeeding Syndrome Weight 2-3# gain per week May be difficult to interpret in first few weeks (edema) Heart Rate AN generally bradycardic (HR < 60 BPM); 50-60 BPM Elevated HR (80-90 BPM) during refeeding Presence of tachycardic (HR > 100 BPM) during refeeding Edema Check shins, ankles, feet May also be a minor complication due to insulin secretion increases which induces sodium retention Low sodium diets may be helpful initially

120. Monitoring for Refeeding Syndrome Biochemical *Ph  drives refeeding syndrome Mg K Na Glucose Thiamine Initially – daily or every other day Decrease monitoring as medical stability increases Weight gain Biochemical measures

121. Clinical Presentation of Refeeding Syndrome Tachycardia Shortness of breath Edema Weakness, numbness, confusion Tetany, tremors, vertigo, ataxia, seizures Coma Death

122. Preventing Refeeding Syndrome RS is usually preventable “Start low, advance slow” Be conservative with EEN* TEE should not be the starting point of caloric repletion 3 weeks cited as safety point of discrepancy between HB & IC After first week, 2-3# weight gain goal per week* 600-1000 kcal/d initially Increase 300-400 kcal every 3-4 days Liquid supplements are helpful

123. Preventing Refeeding Syndrome General rules to prevent RS: TEE should never exceed 2X BEE (remember: conservative) Caloric intake should rarely exceed 70-80% kcal/kg, (35-40 kcal/#) With severely anorectic client, begin at 15-25 kcal/kg Protein intake should not exceed 1.5-1.7 g/kg Generally in 1.0-1.5 g/kg range Weight gain should be 2-3# per week Generally peak at: 70-80 kcal/kg, 3000-5000 kcal/d

124. AN – Behavioral Characteristics Food Rituals / Avoidant Delay the process of eating Take very small bites Cut food into very small pieces Move food around plate Push food to the edges of plate Bargaining / Manipulation “Food allergies” “Gluten intolerance”

125. AN – Behavioral Characteristics Rigid food rules Lack variety Low energy density foods Caloric beverages Fear of carbohydrates Fear of added sugar Fear of dietary fat Vegetarianism Orthorexia

126. AN – Nutrition Therapy Normalize eating pattern Progressive weight gain / nutrition goals Educate about refeeding process & metabolism changes Nutrition education Food exchange system Meal plan Incrementally challenge rigidity / rules Less hedonically driven Align client’s actions with their values

127. AN – Nutrition Therapy Address gastrointestinal complaints Gastroparesis Bloating, early satiety, nausea, reflux, non-self-induced vomiting may occur Improves with weight restoration Low-fiber diet may be indicated for first 4-6 weeks Use of liquid supplements up to 50% of caloric intake may be helpful Liquids prior to solids may be helpful Constipation (atonic colon) Is normal Will improve with weight restoration Normal bowel transit time resumes in 2-4 weeks Diarrhea (mucosal atrophy)

128. Best Practices in AN - Literature offers few guidelines How best to restore weight in AN When to admit to a hospital or IP facility How to define “recovery” from a nutrition standpoint How to talk about weight restoration and meal planning with AN clients How to address the cognitive and affective facets of the disorder while remaining within the scope of the practice

129. “Best Nutrition Practices for the Treatment of Anorexia Nervosa: A Delphi Study” Panel of 21 RD’s who had specialized in ED’s for 5 years or more Consensus Defined as minimum of 85% agreement Describes nutrition counseling approaches applicable to all patients with AN Was not shown for approaches for which there is little evidence Some items that did not achieve consensus reflected approaches for which individual tailoring may be necessary depending on age, stage of illness, and other patient factor

130. 85% Consensus Utilize MI techniques during nutrition counseling sessions Educating clients about the medical consequences of AN is beneficial; (many are not aware of the long-term health effects of AN)

131. 90% Consensus When clients first seek treatment, they should work with goals that are modest and achievable so that they can develop a sense of capacity and success RD’s should let clients know that they understand what is happening to them (the negative health parameters they are experiencing)

132. 95% Consensus Goals should be based on what the client deems is important and those goal should be SMART (Specific, Measurable, Attainable, Relevant, Time-Bound) Meal plan should be based upon what client is already eating and modified for improvement RD’s should encourage clients to think about achieving a healthy state rather than a healthy weight When clients are resistant to recovery, RD’s should find out what they are passionate about, what motivates them, what their long-term goals are and then talk about how the ED affects these Treatment approaches do differ for patients who are different ages because the motivators of change are different for different age groups, and because the age of the client determines growth expectations, the impact of altered eating behaviors, the client’s medical risk, and other factors that impact treatment

133. 100% Consensus Goal weight for children and adolescents should be based upon trends in growth charts A good patient goal setting strategy is to determine what a patient needs in order to be medically stable RD’s should make clients aware of signs of malnutrition that will improve with weight restoration RD’s role is to help clients work through misbeliefs & distortions regarding food, health, metabolism & weight Parents should participate in the initial nutrition evaluation appointment with children; 89% consensus for adolescents Treatment techniques that explore scientific evidence / the biological explanation of ED’s are beneficial for client and parents (temperament, comorbid psych issues, etc. – helps eliminate or reduce guilt and shame)

134. Bulimia Nervosa Common medical complications Behavioral characteristics Nutrition Therapy

135. BN – Common Medical Complications* Hypokalemia (low potassium) Hyponatremia (low sodium) Acid-base abnormalities; seizure from severe alkalosis Severe edema after purging cessation Severe constipation or atonic colon from laxative abuse GERD; inflammation/possible rupture of esophagus (Mallory-Weiss) Dental decay and infections Sialadenosis (acute swelling of parotid glands with purging cessation) Volume depletion (dehydration); may cause syncope (passing out) Cardiac arrhythmias from severe electrolyte abnormalities

136. BN – Behavioral Characteristics Anxiety / guilt with food intake Food judgments about foods / food groups Restriction / Binge-Purge cycle Purges Emesis Compulsive exercise (rigid routines despite weather, fatigue, illness, injury) Laxative use/abuse (saltwater, artificially-sweetened candies) Diet pill use/abuse Diuretic pill use/abuse Caffeine use/abuse

137. BN – Nutrition Therapy Normalize eating pattern Foster openness / honesty about compensatory behaviors Decrease food judgments Increase unconditional permission to eat Nutrition education Meal plan Macronutrients Foods that improve satiety Increase interoceptive awareness Distinguish between physical and emotional hunger Systematic Habituation

138. 10 Principles of Intuitive Eating 1. Reject the diet mentality 2. Honor your hunger 3. Make peace with food 4. Challenge the food police 5. Respect your fullness 6. Discover the satisfaction factor 7. Honor your feelings without using food 8. Respect your body 9. Exercise – feel the difference 10. Honor your health – gentle nutrition

139. Intuitive Eating Create a healthy relationship with food, mind, and body Become the expert of your own body Distinguish between physical and emotional hunger Gain a sense of inherent body wisdom Process of making peace with food Decrease/eliminate constant "food worry" thoughts Knowing that your health and your worth as a person do not change, because you ate a food that you had labeled as "bad" or "fattening”

140. Binge Eating Disorder Common medical complications Behavioral characteristics Nutrition therapy

141. BED – Common Medical Complications Occurs over a wide range of BMI’s; common in overweight/obese Affects approximately 30% of obese people seeking weight loss treatment Related to overweight / obese High BP High cholesterol Heart disease DM2 Gallbladder disease OA / Joint pain Sleep apnea Fatigue

142. Health at Every Size Approach to dietary behavior change Alternative to traditional, restrictive diet programs Better physically & emotionally to be as healthy as you can at any weight HAES philosophy  unrealistic expectations and social stigma are at the root of many individuals’ weight issues Break the yo-yo dieting cycle Improve self-esteem and feelings of self-efficacy Increase self-love and self-acceptance

143. Health at Every Size Requires Extensive counseling Motivational Interviewing Not a license to “eat whatever you want” Healthy lifestyle, not weight is the focus As much as 70% of weight is determined by genetics 90% of people fail on diets 60% end up gaining more than they lost

144. Health at Every Size Healthful behaviors, not weight loss, are the focus Healthful diet (without restriction) Physical activity Proper sleep habits Stress management Finding the joy in life Intuitive eating – honoring hunger cues / mindful eating Body acceptance

145. Health at Every Size A few short-term studies reflect Positively affects eating behaviors Positively affects appetite Sometimes results in a decrease in energy intake Currently no long-term studies that examine the effect of this approach on health

146. Health at Every Size Controversy Health risks associated with HAES may depend on degree of obesity BMI > 35 associated with higher death rate, compared to normal weight BMI 30-35 had no greater risk of death BMI 25-30 had significantly lower death rate, compared to normal weight May depend upon adiposity location (abdominal vs. hips/thighs) Estimated that 35% of obese are “metabolically healthy” Could chronic inflammation be the culprit? If so, HAES could aid in decrease inflammatory response Healthful eating Physical activity Decreased stress response

147. BED – Behavioral Characteristics BED Dx is associated with 3 or more defining characteristics: Eat more rapidly than normal Eat until uncomfortably full Eating large amounts of food when not feeling physically hungry Eating alone because one feels embarrassed by how much one is eating Feeling disgusted with oneself, depressed, or very guilty afterward

148. BED – Nutrition Therapy Eat more rapidly than normal Mindful eating skills Eat until uncomfortably full Increase interoceptive awareness (satiety) Eating large amounts of food when not feeling physically hungry Distinguish between emotional hunger and physical hunger Eating alone because one feels embarrassed by how much one is eating Social setting at clinic and in restaurant outings Feeling disgusted with oneself, depressed, or very guilty afterward Allow space to process feelings

149. BED – Behavioral Characteristics Disruption in normal eating behaviors No planned mealtimes / skip meals Taking small portion of food at regular meals Engaging in sporadic fasting or repetitive dieting Developing food rituals (eliminate entire foods / food groups) Creating lifestyle schedules or rituals to make time for binge sessions

150. BED – Nutrition Therapy Disruption in normal eating behaviors No planned mealtimes / skip meals Taking small portion of food at regular meals Meal plan Food exchanges / Plate method / Visual portion sizes Engaging in sporadic fasting or repetitive dieting Legalize food (permission) Educate about destructive dieting cycle Developing food rituals (eliminate entire foods / food groups) Nutrition education

151. BED – Nutrition Therapy Creating lifestyle schedules or rituals to make time for binge sessions Identify binge foods Acknowledge fears Incorporate binge foods in safe/structured setting (exposure therapy) Systematic Habituation

152. BED – Nutrition Therapy Normalize eating pattern Get away from diet mentality Decrease food judgments; “Good food / bad food” Legalize food Nutrition education Macronutrients Foods that improve satiety Increase interoceptive awareness Distinguish between physical and emotional hunger Establish connection with feelings Mindful eating techniques and practice

153. Mindful Eating

154. Rebuild your relationship with food Make conscious food choices Physical or emotional hunger? Build interoceptive awareness Slow down Tune into your senses Tap into pleasure What thoughts are arising? What feelings are arising? Non-judgment…cultivate self-acceptance

155. “What is Normal Eating?” – Ellen Satter “Normal eating is going to the table hungry and eating until you are satisfied. It is being able to choose food you like and eat it, and truly get enough of it – not just stop eating because you think you should. Normal eating is being able to give some thought to your food selection so you get nutrition food, but not being so wary and restrictive that you miss out on enjoyable food. Normal eating is giving yourself permission to eat sometimes because you are happy, sad, or bored, or just because it feels good. Normal eating is mostly three meals a day, or four, or five, or it can be choosing to much along the way. It is leaving some cookies on the plate because you know you can have some again tomorrow, or it is eating more now because they taste so wonderful. Normal eating is overeating at times, feeling stuffed and uncomfortable. And at times it can be undereating and wishing you had more. Normal eating is trusting your body to make up for your mistakes in eating. Normal eating takes up some of your time and attention, but keeps its place as only one important are of you life. In short, normal eating is flexible. It varies in response to your hunger, your schedule, your proximity to food and feelings.”

156. Advanced Training Seek training in counseling and other techniques (MI, ACT, DBT, CBT) Use advanced knowledge – refeeding syndrome, maintaining appropriate weight, ED behaviors, relapse prevention, body image Seek supervision and case consultation from licensed mental health professional to gain proficiency in ED treatment

157. "I liked designing my own food plan instead of plugging into an existing 'popular diet,' while letting go of the drama and importance I give to food." Alice S. Huntington Woods, MI "This program taught me how my body feels, how to eat mindfully, have a better image, feel emotions and not run from them." Ashley O. West Bloomfield, MI "This was truly insightful, and I find it hard to believe I could be the same again. This has changed me. This was a positive experience. I am glad I gave this gift to myself...mind, body and soul." Ilene H. New York, NY "It is a very family and nurturing atmosphere that can be challenging but in a positive way. Helps bring out the healthiest and best person in each patient. Always nice to know I could cry on the shoulder of anyone here and that it is genuine here." Sammie Royal Oak, MI

158. Contact information Inner Door Center ® Located in Downtown Royal Oak 317 E. Eleven Mile Rd. Royal Oak, Michigan 48067 Phone: 248-336-2868 www.innerdoorcenter.com

159. Resources (1) National Eating Disorder Association website; http://www.nationaleatingdisorders.org/, accessed 2/4/16. http://www.nationaleatingdisorders.org/ (2) Mehler, P. S., Winkelman, A. B., Andersen D. M., Gaudini, J. L. (2010). Nutritional Rehabilitation: Practical Guidelines for Refeeding the Anorectic Patient. Journal of Nutrition and Metabolism, Volume 2010, Article ID 625782, 7 pages. (3) Yantis, M., Velander, R. (2009). How to Recognize and Respond to Refeeding Syndrome. Nursing Critical Care, Volume 4, Number 3, p. 14-20. (4) Crook, M. A., Hally, V., Panteli, J. V. (2001). The Importance of Refeeding Syndrome. Nutrition: 17:632-637.

160. Resources (5) Mittnacht, A. M., Bulik, C. M. (2015). Best Nutrition Counseling Practices for the Treatment of Anorexia Nervosa: A Delphi Study. International Journal of Eating Disorders, volume 48: 111-122. (6) Ghoch, M. E., Alberti, M., Capelli, C., Calugi, S., Dalle Grace, R. (2012). Resting Energy Expenditure in Anorexia Nervosa: Measured versus Estimated. Journal of Nutrition and Metabolism, volume 2012, Article ID 652932, 6 pages. (7) Kristellar, J. L., Baer, R. A., Quillian-Wolever, R. (2006). Mindfulness-Based Approaches to Eating Disorders. New York: Guillford Press, p. 74-91. (8) Kristellar, J. L., Quillian-Wolever, R. (2011). Mindfulness-Based Eating Awareness Training for Treating Binge Eating Disorder: The Conceptual Foundation. Eating Disorders, 19:49-61.

161. Resources (9) Harris, C. (2014). Treat Binge Eating Disorder Utilizing Mindful Techniques. SCAN’S PULSE, Vol. 33, No. 3. (10) The essence of normal eating. Reprinted from Secrets of Feeding a Healthy Family (2 nd ed., fig. 2, p. 16), by E. Satter, 2008, Madison, WI: Kelcy Press. (11) Webb, D. (2016). Health at Every Size. Today’s Dietitian, Vol. 18, No. 1:27-28

162. Case Study – AN, Restricting Type Client Jane Doe 23 y.o. Lives with mom, pets Has a supportive boyfriend Dad left at age 13, “day before 8 th grade” Works part time as pharmacy tech Suspended schooling to “work on getting better” Had been “struggling” significantly academically due to malnourishment

163. Previous Medical History MDD – recurrent, moderate Anxiety / panic attacks ADHD (Aderol suspended until weight gain) R/O GAD & Bipolar II Trauma history Sexual molestation Sexual abuse Emotional, physical, & verbal abuse

164. Previous Medical History Suicidal ideation between 8 th -10 th grade with self-harm Inpatient 2X - Forest View (May & October 2012) Inpatient 1X – Beaumont (date unknown) Prior to IDC – OP at Mila Velinova at Blue Water Clinic Multiple ER visits for ED related reasons, including low K No current suicidal ideation or self-harm

165. Anorexia Etiology Reports that ED, depression & anxiety started and have been consistent since age 13 after parents divorce Reports being “pudgy” as a child Reports that her father Monitored what and how she ate Wouldn’t let her eat past 8 pm (though he would) Made her have smoothies in the morning Got the feeling he thought she was fat 9 th grade reports feeling ugly and fat – first boyfriend 10 th grade – cross country, marching band “Started restricting more and more” Only ate one salad all day at band camp

166. Anorexia History 11 th grade – 140# “sitting on butt, smoking weed, studying, & eating PB” Was asked to prom “Wanted to lose weight healthy way” (got down to 133#) Ate nothing during the day After school: ate salmon, light bread, light soup, steamed carrots, apple, broken up pretzel sticks, cup cereal, cut up peaches Cup of yogurt after worked out “Would fake eat with friends”

167. Anorexia History Senior year wouldn't eat all day After school: slice & eat apple, clean home, watch Dr. Oz, Coke Zero Steam 5 carrots in microwave with tiny bit of salt, 1/4 serving pretzel sticks, break it into tiny pieces, workout 2 hours, do homework Maybe eat a piece of lite bread with pc of turkey and 1/4 mozzarella stick; lite soup “I would always make sure I burned more calories than I ate."

168. Anorexia History Had “been able to hide this from my mom for a year” Everything made her sick after she started eating again Would experience ravenous hunger, eat considerably more than the norm, then spontaneously vomit Dropped to 82# (lowest weight) Reports being “way more unhappy then ever been in entire life; emotions all over the place; cardiac unit more than once, K iv's, kidney issues, and lost jobs.”

169. Initial Nutrition Assessment at IDC 68” / 97.0# / 14.8 BMI (extreme malnutrition/underweight status) Expressed goal of “wanting to be healthy, not skinny” Had realistic perception that she was underweight Highly motivated for recovery Had to show she was motivated by gaining weight before PHP started Was drinking Boost Plus Daily Was going to buy Magic Cups to aid in weight gain Was eating near 1,000 kcal/d at this point Yoga restriction to start

170. Diet History Not experiencing hunger/satiety cues Difficulty falling and staying asleep Reports she’s “had stomach problems since she was little” Client reported "trying" to eat throughout the day but feels unable to due to fear of certain foods, including anything "fattening“ Client reported being "allergic or intolerant" to raw onions & "grease“ Claims a "slight" lactose intolerance Especially sensitive to full-fat dairy products (diarrhea & bloating) Severe food restriction history

171. Nutrition Dx Disordered eating pattern characterized by severe oral food restriction with food obsession/intrusive thoughts, distorted body image, and intense fear of gaining weight as evidenced by BMI 14.8 extreme malnutrition/underweight status. Depletion of subcutaneous fat with evident protein-calorie malnutrition and likely depleted glycogen stores with risk for hypoglycemia and refeeding syndrome should renourishment ensue. Altered nutrition-related labs, which are currently being monitored by PCP - client takes K and Mg supplements as directed by PCP. Client reports GI symptoms consistent with anorexic/starvation state of delayed gastric emptying, bloating, difficulty digesting when oral food intake is increased. Client likely in hypometabolic state with potential for hypermetabolic state should re- nourishment ensue. Food and nutrition-related knowledge deficit with harmful beliefs/attitudes about food or nutrition-related topics.

172. Client Progress Started PHP at 100# Initiated diet at 1,000-1,300 kcal/d first week Daily lab monitoring for the first week Reduced lab monitoring to bi-weekly 2 nd full week; weekly thereafter Slow-release iron

173. Client Progress Weight trend: 1 st wk: Gained 2# 1 st wknd: Lost 2# 2 nd wk: Gained 2# (Ensure Plus added daily PHP) 2 nd wknd: Gained 0.5# 3 rd wk: Gained 3.5# 3 rd wknd: Lost 1.5# 4 th wk: Gained 3.5# 4 th wknd: Gained 1.0# 5 th wk: Gained 1.0#, lost 2.0# (started doing more yoga/metabolism) Meal plan increased

174. Client Progress Jane continues to stay highly motivated Struggles with extreme negative thoughts/body image issues Is already willing to deal with some trauma with primary therapist Will hopefully continue on this trend