whole person treatment of eating disorders
TRANSCRIPT
Whole Person Treatment of Eating Disorders
Gregory L. Jantz, PhD, CEDSIAEDP‐Certified Eating Disorder Specialist
Approved Supervisor
Gregory L. Jantz, PhD, CEDS
Anorexia Nervosa‐Historical Perspective14th Century – Catherine of Siena practiced an extreme form of
fasting and eventually died of starvation 1868 – Sir William W. Gull names the illness anorexia nervosa –
which means “nervous loss of appetite.” 1870 – Charles Lasègue, without the knowledge of Gull’s work,
described the condition as “L’anorexic hysterique.” 1947 – John Berkman: “Among adolescents the cause for the
psychic upset can often be traced to a parent.” 1973 – Hilde Bruch’s idea that an unhealthy pursuit of thinness was caused by psychological or cultural factors became part of
the common consciousness. Source: James Greenblatt, MD; Dietary Fats in the Prevention and Treatment of Eating Disorders, presented to IAEDP March 22,
2013; used by permission
Gregory L. Jantz, PhD, CEDS
Not Otherwise Specified?
Under DSM‐IV‐TR, the majority of patients were given a diagnosis without specified criteria.
Gregory L. Jantz, PhD, CEDS
Changes to Eating Disorder Criteria between DSM‐IV‐TR & DSM‐V:
Anorexia Nervosa•The core diagnostic criteria for anorexia nervosa are conceptually unchanged from DSM‐IV with one exception: the requirement for amenorrhea has been eliminated. In DSM‐IV, this requirement was waived in a number of situations (e.g., for males, for females taking contraceptives). In addition, the clinical characteristics and course of females meeting all DSM‐IV criteria for anorexia nervosa except amenorrhea closely resemble those of females meeting all DSM‐IV criteria. As in DSM‐IV, individuals with this disorder are required by Criterion A to be at a significantly low body weight for their developmental stage. The wording of the criterion has been changed for clarity, and guidance regarding how to judge whether an individual is at or below a significantly low weight is now provided in the text. In DSM‐5, Criterion B is expanded to include not only overtly expressed fear of weight gain but also persistent behavior that interferes with weight gain.
Source: Highlights of Changes from DSM‐IV‐TR to DSM‐5 (2013) from the American Psychiatric Association, page 12.
Gregory L. Jantz, PhD, CEDS
Changes to Eating Disorder Criteria between DSM‐IV‐TR & DSM‐V:
Bulimia Nervosa•The only change to the DSM‐IV criteria for bulimia nervosa is a reduction in the required minimum average frequency of binge eating and inappropriate compensatory behavior frequency from twice to once weekly. The clinical characteristics and outcome of individuals meeting this slightly lower threshold are similar to those meeting the DSM‐IV criterion.
Source: Highlights of Changes from DSM‐IV‐TR to DSM‐5 (2013) from the American Psychiatric Association, page 12.
Gregory L. Jantz, PhD, CEDS
Changes to Eating Disorder Criteria between DSM‐IV‐TR & DSM‐V:
Binge‐Eating Disorder•Extensive research followed the promulgation of preliminary criteria for binge eating disorder in Appendix B of DSM‐IV, and findings supported the clinical utility and validity of binge‐eating disorder. The only significant difference from the preliminary DSM‐IV criteria is that the minimum average frequency of binge eating required for diagnosis has been changed from at least twice weekly for 6 months to at least once weekly over the last 3 months, which is identical to the DSM‐5 frequency criterion for bulimia nervosa.
Source: Highlights of Changes from DSM‐IV‐TR to DSM‐5 (2013) from the American Psychiatric Association, page 12.
Gregory L. Jantz, PhD, CEDS
Difficulties in Treating Patients with Eating Disorders
Greater than 30% of patients with AN become chronically ill over 10 years
Mortality rates: 10% at 10 years, 20% at 20 yearsHighest risk for suicide among all psychiatric illnesses
Highest number of hospital days of any psychiatric illness
No Advances in the Biological Treatment of Anorexia Nervosa in 50 years.
Source: James Greenblatt, MD; Dietary Fats in the Prevention and Treatment of Eating Disorders, presented to IAEDP March 22, 2013; used by permission
Gregory L. Jantz, PhD, CEDS
What is the “Whole‐Person” approach?
•Integration of multiple factors for long‐term recovery of eating disorders
•Emotional•Relational•Intellectual•Medical/Brain‐science•Nutritional•Chemical dependency/Substance Abuse•Dental•Spiritual/Faith‐based
Gregory L. Jantz, PhD, CEDS
Source: James S. Goodwin, MD, Jean M. Goodwin, MD, MHPJAMA May 11, 1984, Vol. 251, No. 18
The TOMATO Effect:Rejection of Highly Efficacious Therapies
Gregory L. Jantz, PhD, CEDS
The TOMATO Effect:Rejection of Highly Efficacious Therapies
•When an efficacious treatment for a certain disease is ignored or rejected because it does not “make sense” in light of accepted
theories of disease•Americans would not eat tomatoes for over 200 years even though they were eaten since the 16th century in Europe•In 1820, there was a public tasting that occurred without
consequencesSource: James Greenblatt, MD; Dietary Fats in the Prevention and Treatment of Eating Disorders, presented to IAEDP March 22, 2013; used by permission
Gregory L. Jantz, PhD, CEDS
Whole‐Person recovery requires an integrated treatment team model
A treatment team approach is the recommended model, including medical personnel (either a physician or a psychiatrist), a
registered dietitian or medical professional who is trained in nutritional rehabilitation, and a mental health clinician. Dental
professionals may also be part of the team.(From Key Elements to a Good Treatment Plan by Cris Haltom, Ph.D., June 26, 2006)
Gregory L. Jantz, PhD, CEDS
Whole‐Person recovery requires an integrated treatment team model
When a patient is managed by an inter‐disciplinary team in an outpatient setting, communication among the professionals is
essential to monitoring the patient’s progress, making necessary adjustments to the treatment plan, and delineating
the specific roles and tasks of each team member.American Psychiatric Association – Practice Guidelines for the Treatment of Patients with Eating Disorders, 3rd
Edition, 2006, Executive Summary (a) Coordinating care and collaborating with other clinicians
Gregory L. Jantz, PhD, CEDS
Whole‐Person recovery requires an integrated treatment team model
The authors of a textbook edited by Grilo and Mitchell (2010) describe therapeutic approaches and reviews supporting evidence on all
aspects of eating disorder treatment, from assessment to nutritional rehabilitation to managing the chronically ill. The authors state that
there is no single treatment for patients with eating disorders. Rather, a diversity of approaches is recommended.
Source: American Psychiatric Association – Guideline Watch (August 2012): Practice Guidelines for the Treatment of Patients with Eating Disorders, 3rd Edition (page 2); The Treatment of Eating Disorders: A Clinical Handbook,
edited by Carlos M. Grilo, PhD and James E. Mitchell, MD.
Gregory L. Jantz, PhD, CEDS
Whole‐Person recovery requires an integrated treatment team model
A team that includes professionals with experience in psychiatry and psychology, internal medicine and nutrition, social work, nursing and even recreation is needed to provide the full range of therapy and treatment to help patients develop the skills necessary to gain
control of destructive eating disorder behavior, improve their support system, increase self‐esteem , and establish a foundation
for long‐term recovery.Source: A “Continuum of Care” Approach to Eating Disorders by Stuart Koman, Ph.D.;
http://www.waldenbehavioralcare.com/pdfs/ContinuumOfCare.pdf
Gregory L. Jantz, PhD, CEDS
Whole‐Person recovery requires an integrated treatment team model
•Approximately 50% of individuals with an eating disorder (ED) abuse or are dependent on alcohol or illicit substances compared with approximately 9% of the general population
Source: (Holderness et al., 1994; The National Center on Addiction and Substance Abuse
(CASA at Columbia University, 2003)
•Of individuals with a substance use disorder, more than 35% report some form of an ED (CASA, 2003) compared to lifetime prevalence estimates of approximately 5% for women in the United States
(Hudson et al., 2007).
Source: From the Introduction to Patterns of Comorbidity of Eating Disorders and Substance Use in Swedish Females, Root et al., 2009); http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2788663.
Gregory L. Jantz, PhD, CEDS
Whole‐Person recovery requires an integrated treatment team model
It is the position of the American Dietetic Association that nutritional intervention, including nutritional counseling, by a registered dietitian (RD) is an essential component of the team treatment of patients with anorexia nervosa, bulimia nervosa, and other eating disorders during assessment and treatment
across the continuum of care.
Source: Position of the American Dietetic Association: Nutrition Intervention in the Treatment of Anorexia Nervosa, Bulimia Nervosa, and Other Eating Disorders (J Am Diet Assoc. 2006; 106:20773‐
2082)
Gregory L. Jantz, PhD, CEDS
Whole‐Person recovery requires an integrated treatment team model
Eating disorders arise from a variety of physical, emotional and social issues all of which need to be addressed to help prevent and treat these disorders . . . while eating disorders appear to focus on body image, food and weight, they are often related to many other issues. Referral to healthcare professionals and encouragement to seek treatment is critical as early diagnosis and intervention greatly improve the opportunities
for recovery.Source: American Dental Association, Oral Health Topics, Anorexia Nervosa (Eating
Disorders); http://www.ada.org/2582.aspx?currentTab=2
Gregory L. Jantz, PhD, CEDS
There is no FDA‐approved medication for Anorexia Nervosa . . .
Source: WebMD August 25, 2011‐ http://www.webmd.com/mental‐health/eating‐disorders/anorexia‐nervosa/anorexia‐nervosa‐medications
Standard of Care
. . . Yet, the majority of patients treated are with psychotropics
Polypharmacy is the norm
Gregory L. Jantz, PhD, CEDS
Benefits of a Multiple‐Disciplinary Team Approach to Treatment
Non‐response to SSRI medication in ill AN subjects could be a consequence of an
inadequate supply of nutrients, which are essential to normal serotonin synthesis and
function. [These data suggest that a disturbed serotonin activity may create a vulnerability for the expression of a cluster of symptoms common to both AN and BN and that nutritional factors may affect SSRI response in depression and/or
obsessive‐compulsive disorder.]
Source: Kaye W, Gendall K, Strober M Biol Psychiatry 1998 Nov 1; 44(9):825‐38.
Gregory L. Jantz, PhD, CEDS
Anorexics with low body weight, low BMI, and low serum albumin (the main protein in blood) levels are at increased risk for vitamin
and mineral deficiency. Vitamin abnormalities may contribute to cognitive
difficulties such as poor judgment or memory loss and other psychiatric
conditions. These deficiencies can often be corrected with dietary interventions.
Source: From the University of Maryland Medical Center – “Anorexia Nervosa”; http://www.umm.edu/altmed/articles/anorexia‐nervosa‐
000012.htm
Benefits of a Multiple‐Disciplinary Team Approach to Treatment
Gregory L. Jantz, PhD, CEDS
A Medical Mystery?
Eating disorders are characterized by severe weight loss from self‐
starvation yet signs or symptoms of vitamin, mineral and fat deficiencies are rarely studied or integrated into
treatment.
Pellagra?
Gregory L. Jantz, PhD, CEDS
Incidence of Eating Disorders
A majority of young women diet at some point in time yet only a small fraction develop eating disorders.
Why?
Gregory L. Jantz, PhD, CEDS
Research shows that many nutrients, such as vitamin B12 and iron, are essential to human
brain function and that deficiencies in these nutrients and others can lead to impaired cognitive function and impaired memory and concentration.
Benefits of a Multiple‐Disciplinary Team Approach to Treatment
Gregory L. Jantz, PhD, CEDS
Benefits of a Multiple‐Disciplinary Team Approach to Treatment
Nutritional deficiencies are also directly related to:
• impaired emotional functioning, i.e., irritability; • apathy;
• withdrawn behavior; • decreased ability to focus; • decreased ability to listen;
• decreased ability to process information;
• and fatigue.
Gregory L. Jantz, PhD, CEDS
•50% of caloric intake of American children is obtained from added fat and sugar•20‐24% of calories for 2‐19 year‐olds come from soft drinks!•<15% of school children consume recommended servings of fruit•<20% of school children consume recommended servings of vegetablesSource: James Greenblatt, MD; Dietary Fats in the Prevention and Treatment of Eating Disorders, presented to IAEDP March
22, 2013; used by permission
Standard American Diet (SAD)
Gregory L. Jantz, PhD, CEDS
The Journal of the Academy of Nutrition and Dietetics published a study where they found that:
•53% of women with eating disorders were vegetarians•12% of healthy women are vegetarians
Source: Jenny Sangler, August 30, 2012
The majority of women with eating disorders are vegetarian
Gregory L. Jantz, PhD, CEDS
Benefits of a Multiple‐Disciplinary Team Approach to Treatment
Decreased food intake, a cyclic pattern of eating, and weight loss are major manifestations of zinc deficiency. Patients with eating disorders may
develop zinc deficiencies for the following reasons:
• lower dietary intake of zinc• impaired zinc absorption
• vomiting• diarrhea
• bingeing on low‐zinc foods
Gregory L. Jantz, PhD, CEDS
Anorexia Nervosa1. Decreased appetite and
meat avoidance2. Decreased taste and smell3. Nausea and bloating during
re‐feeding4. Insomnia and poor sleep
habits5. Depression6. Attention difficulties
Physical Symptoms of AN and Zinc Deficiency
Source: Zinc deficiency and eating disorders. Humphries L, Vivian B, Stuart M, McClain CJ. J Clin Psychiatry 1989 Dec; 50(12):456‐9
Zinc Deficiency1. Decreased appetite and
meat avoidance2. Decreased taste and smell3. Nausea and bloating during
re‐feeding4. Insomnia and poor sleep
habits5. Depression6. Attention difficulties
Gregory L. Jantz, PhD, CEDS
Recommended nutritional therapies for recovery
•Daily multivitamin•Essential fatty acids, such as Omega 3’s•Vitamin C•Coenzyme Q10•5‐HTP•Creatine•Probiotic supplement (Lactobacillus acidophilus)•L‐glutamine•DHEA•MelatoninFrom the University of Maryland Medical Center, accessed 7/8/13
Gregory L. Jantz, PhD, CEDS
•42 patients (40.% y/0) with dietary intake of Omega 3 < 3 gms/day•DBPC 1.8 gms EPA .4 gms DDHA) Omega 3 supplements or placebo BID x 8 weeks•Celexa 20‐40 mg•Higher proportion of patients achieved full remission in Omego 3 group versus the placebo group ‐ 44% verses 18%
Source: Gertsik, L, Poland, RE, Bresee, C, Rapaport, MH. J Clin Psychpharmacol. 2012 Feb;32(1):61:4.
Omega‐3 Fatty Acids – Augmentation of Antidepressants
Gregory L. Jantz, PhD, CEDS
AN patients received 1 g EPA/day for 3 months:43% recovered
57% showed improved symptoms in:Weight gain
Reversal of growth retardationImprovement in mood
Improvement in general functioning
Source: Ayton, et al., Prostaglandins, Leukotrienes and Essential Fatty Acids; 2004;71:205‐209
A pilot open case series of Ethyl‐EPA supplementation in the treatment of anorexia nervosa
Gregory L. Jantz, PhD, CEDS
Study participants: 81 adolescents or young adults with sub‐threshold psychosis
Supplementation: 1.2 g omega‐3 fatty acids or placebo for 12 weeks
After 40 weeks:5% (2 out of 41 individuals) in omega‐3 group developed psychosis28% (11 of 40 individuals) in placebo group developed psychosis
Source: Amminger, et al, Archives of General Psychiatry, 2010, 67(2):146‐154
Omega‐3s may have ability to delay or prevent psychosis
Gregory L. Jantz, PhD, CEDS
Dietary intake and information on psychotic‐like symptoms was derived from a food frequency questionnaire among 33,623
women, aged 30‐49 years‐old
Participants were classified into three predefined levels: low, middle and high frequency of symptoms
Findings raise a possibility that adult women with a high intake of fish, omega‐3 or omega‐6 PUFA and vitamin D have a lower
rate of psychotic‐like symptomsSource: Hedelin et al. Dietary intake of fish, omega‐3, omega‐6 polyunsaturated fatty acids and vitamin D and the prevalence of psychotic‐like symptoms in a cohort of 33 000 women from the general population. BMC
Psychiatry 2010, 10:38.
Fatty Acids for Prevention of Psychotic Disorders
Gregory L. Jantz, PhD, CEDS
It takes at least 10 weeks for cerebral membranes’ highly unsaturated fatty acid levels to recover following chronic
deficiency.
Source: Bourre, et al., Prostaglandins LeukotEssent Fatty Acids, 1993
Not a Quick Fix
Gregory L. Jantz, PhD, CEDS
Recommended nutritional therapies for recoveryFrom Complimentary and Alternative Medicine Treatments in Psychiatry; 2012; Stradford, Vickar, Berger, Cass
. . . there is a place for nutritional treatments in mental health treatment. Some patients, due to poor diets or metabolic abnormalities, have unusually high needs for some nutrients – biochemicals that are required for normal physiological function. Supplementation can sometimes fully or partially restore neurological activity that has gone awry. Additionally, some supplements – as lithium has for decades – have a palliative effect on symptoms and, in moderate doses, can improve the patient’s condition with few or no side effects (page 45).
Gregory L. Jantz, PhD, CEDS
Recommended nutritional therapies for recoveryFrom Complimentary and Alternative Medicine Treatments in Psychiatry; 2012; Stradford, Vickar, Berger, Cass
(pg. 51)
Vitamin B6 DeficienciesNervousnessIrritabilityDepression
Difficulty concentratingShort‐term memory loss
Gregory L. Jantz, PhD, CEDS
Recommended nutritional therapies for recoveryFrom Complimentary and Alternative Medicine Treatments in Psychiatry; 2012; Stradford, Vickar, Berger, Cass (pg. 50)
Vitamin B12 DeficienciesConcentration difficulties
ConfusionIrritation
Impaired memoryDementiaIrritabilityDepression
Personality changesPsychosis
Gregory L. Jantz, PhD, CEDS
Recommended nutritional therapies for recoveryFrom Complimentary and Alternative Medicine Treatments in Psychiatry; 2012; Stradford, Vickar, Berger, Cass
(pg. 55)
Vitamin D Deficiencies
Although clinical studies are few, epidemiological studies show
remarkable associations between low Vitamin D and psychiatric disorders, including depression
and bipolar disorder.
Gregory L. Jantz, PhD, CEDS
Recommended nutritional therapies for recoveryFrom Complimentary and Alternative Medicine Treatments in Psychiatry; 2012; Stradford, Vickar, Berger, Cass
(pg. 57)
Calcium/Magnesium DeficienciesDepressive symptoms
ConfusionAnxiety
HallucinationsNervousnessApprehensionNumbness
Gregory L. Jantz, PhD, CEDS
Recommended nutritional therapies for recoveryFrom NIH Osteoporosis and Related Bone Diseases National Resource Center, “What People with Anorexia
Nervosa need to know about Osteoporosis”; January 2012; http://www.niams.nih.gov/Health_Info/Bone/Osteoporosis/Conditions_Behaviors/anorexia_nervosa.asp
Anorexia nervosa has significant physical consequences. Affected individuals can experience nutritional and hormonal problems that negatively impact bone density. Low body weight in females causes the body to stop producing estrogen, resulting in a condition known as amenorrhea, or absent menstrual periods. Low estrogen levels contribute to significant losses in bone density.
In addition, individuals with anorexia often produce excessive amounts of the adrenal hormone cortisol, which is known to trigger bone loss. Other problems, such as a decrease in the production of growth hormone and other growth factors, low body weight (apart from the estrogen loss it causes), calcium deficiency, and malnutrition, contribute to bone loss in girls and women with anorexia. Weight loss, restricted dietary intake, and testosterone deficiency may be responsible for the low bone density found in males with the disorder.
Gregory L. Jantz, PhD, CEDS
•The Japanese eat very little fat and suffer fewer heart attacks than the British or Americans.
•The French eat a lot of fat and also suffer fewer heart attacks than the British or Americans.
Medical Research
Gregory L. Jantz, PhD, CEDS
Medical Research
•The Japanese drink very little red wine and suffer fewer heart attacks than the British or Americans.
•The Italians drink excessive amounts of red wine and also suffer fewer heart attacks than the British or Americans.
•The Germans drink a lot of beer and eat lots of sausages and fats and suffer fewer heart attacks than the British or Americans.
Gregory L. Jantz, PhD, CEDS
Medical Research
Eat and drink what you like.
Speaking English is apparently what kills you.
Gregory L. Jantz, PhD, CEDS
My eating disorder destroyed my relationship
with God. It blocked me from God and I lost all faith and trust in God. I became very angry with God because I felt like God had abandoned me. Eventually, I just stopped thinking about God. My
eating disorder became my God and my body became
the Devil.From Spirituality and Eating Disorders;
http://www.byui.edu/counseling‐center/self‐help/eating‐disorders
Gregory L. Jantz, PhD, CEDS
Beneficial effects of faith integration in recovery from eating disorders
Patients who actively engage in making decisions about their care, and who are self‐directed toward meaningful life goals, are far more likely to follow through with treatment and
achieve lasting results.From A Continuum of Care Approach to Eating
Disorders by Stuart Koman, Ph.D.
Faith assists patients to develop meaningful life goals
Gregory L. Jantz, PhD, CEDS
Beneficial effects of faith integration in recovery from eating disorders
7 Common Spiritual Issues1. Negative image of God who judges, is
unforgiving and punishing2. Feelings of spiritual unworthiness and shame
resulting in a resistance to asking for God’s help
Many eating disorder patients attempt to compensate for their feelings of unworthiness through perfectionism,
relentlessly striving to meet impossibly high standards –physically, morally, religiously, academically and so forth.
Reference: Lack of Spiritual Well‐Being as a Predictor of Eating Disorders Among College Students by Ghazala Saleem, Department of Psychology, Missouri Western State University, page 265 – http://clearinghouse.missouriwestern.edu/manuscripts/809.aspsubmitted May 6, 2006.
Gregory L. Jantz, PhD, CEDS
Beneficial effects of faith integration in recovery from eating disorders
7 Common Spiritual Issues3. Fear of abandonment by God, resulting in a distrust of God’s love4. Guilt and shame about sexuality, sexual activity and promiscuity
5. Reduced capacity to love and serve others6. Difficulty surrendering and having faith due to a belief that only
they are able to control their lives7. Shame about the dishonesty and deception they practice due to
the secrecy of their eating disorder behaviors
Reference: Lack of Spiritual Well‐Being as a Predictor of Eating Disorders Among College Students by Ghazala Saleem, Department of Psychology, Missouri Western State University, page 265 – http://clearinghouse.missouriwestern.edu/manuscripts/809.aspsubmitted May 6, 2006.
Gregory L. Jantz, PhD, CEDS
Integrated Whole‐Person Treatment Team
Mental health counselors, including those familiar and comfortable with spiritual issues
Chemical dependency professionals
Medical professionals, including dental professionals
Nutritional professionals