IN THIS ISSUE
The Emily Program's Adolescent Intensive Day Program (AIDP) opened at our St. Louis Park, MN location this month. The highly structured program enables us to meet the needs of adolescents and families struggling with eating disorders. To find out more or make a referral, contact us at 1-888-364-5977.
Interested in free CEUs and other continuing education opportunities hosted by The Emily Program?
Check out all of our upcoming events here. Here's what we have coming up soon:
June 26, Berkeley, CA: Neurobiology of Eating Disorders Informs Early Support in Treatment.
Details and registration here.
June 27, Sacramento, CA: Neurobiology of Eating Disorders Informs Early Support in Treatment.
Details and registration here.
July 12, Beachwood, OH. Eating Disorder Are All About Food—Or Are They?
Details and registration here.
Eating disorders (EDs) and substance use disorders (SUDs) frequently co-occur.1, 2, 3 This is a major cause for concern because people struggling with both conditions typically demonstrate worse ED symptoms and poorer outcomes, including increased medical complications, longer recovery times, and higher relapse rates than those with ED alone.4, 5, 6, 7
Prevalence varies based on the type of ED, type of SUD, and population studied, but an estimated range of 17-46% of those diagnosed with an eating disorder also struggle with alcohol or other drugs.4 In adolescents with ED, SUD is 20-40% more likely than in peers without ED.8
SUDs do not co-occur equally among every type of eating disorder. SUDs are particularly prevalent in conjunction with bulimia/binge eating symptoms, and many more individuals diagnosed with bulimia, binge eating, Other Specified Feeding or Eating Disorders (OSFED) and anorexia (binge eating/purging type) experience the co-occurrence than those diagnosed with anorexia (restrictive type).9
Why are eating disorders and substance use disorder often connected?
The etiology of this co-occurring condition is appears to be multifaceted. Research is ongoing, but it is clear that there are several intertwined factors contributing to ED/SUD. Pearlstein (2002)10 cited four major theories:
Addictions model: This is the idea that similarities of symptoms of both disorders, including shared biopsychosocial factors like the interplay of genes, personality traits and cultural influences, may be causing the co-occurrence. Cooper (1989)11 proposed this theory, suggesting that ED and SUD share four typical characteristics: a) Uncontrollable self-destructive behavior b) Initial denial of the extent of the problem and future consequences 3) Deterioration until there is intervention 4) Family involvement, especially early family dysfunction.
Genetic and family heritability: Many researchers have looked at heritability as a possible cause of ED/SUD.10,11 Research has shown that ED and SUD, as separate disorders, can be transmitted genetically, but not cross-transmitted (e.g. if a mother has SUD, it doesn't appear to be more likely that her daughter will have ED).12 This suggests ED and SUD are not manifestations of the same core disorder.
Biological model: This model focuses on the physical effects that ED and SUD share. Evidence suggests that the shared desire to misuse food and substances may be due to an inherently heightened sensitivity to such rewards.13 Both EDs and SUDs are also affected by the dopaminergic system10, 14 Additionally, EDs and SUDs often share physical symptoms, including weight loss, appetite fluctuations, irregular heart rate, muscle weakness, anxiety, and vomiting.
Personality traits and temperamental vulnerabilities model: This model suggests that there are certain personality traits that may make a person more vulnerable to both EDs and SUDs. For example, impulsivity and novelty seeking, which are typically associated with binge eating/purging behaviors, also appear to be associated with ED/SUD co-occurrence.9
Although directionality of ED/SUD co-occurrence is not clearly understood—SUDs can develop before, during or after an ED—studies suggest that one may increase vulnerability to the other. Research shows it is more likely that EDs will influence SUDs than the other way around.15 One theory is that those with EDs may be more likely to use substances because food deprivation alters dopamine in the brain, creating a hyperresponsiveness to novel environmental stimuli. Another theory is that substance use can also cause appetite suppression, which can trigger an ED.9
There are several factors that often occur alongside ED/SUD, and may be related. One potential mediating factor is Attention Deficit Hyperactivity Disorder (ADHD). Studies have reported co-morbidities among ADHD, EDs, and SUDs.16, 17, 18 The strongest associations are seen between ADHD and binge eating.16, 18 Researchers have also identified abuse, trauma, and post-traumatic stress disorder (PTSD) as associated issues.15, 19, 20 Others have hypothesized that impulsivity and emotional instablility are likely core mediators.21, 22
Identification and Treatment
The good news is that co-occurring eating disorder/substance use disorder is highly treatable. Treatment that addresses both EDs and SUDs in an integrated way hold promise to reduce symptoms. Studies show that concurrent treatment for eating disorders and substance use disorder, especially when caught early, is most effective.4, 24 If one condition is identified, it is wise to screen for the other as well.
The Emily Program's Integrated Eating Disorder/Substance Use Disorder program is focused on addressing EDs and SUDs together to achieve the best possible outcome. The personalized, evidence-based program offers substance use assessment, treatment planning, skills-based group therapy, therapeutic meals, medical and psychiatric management, nutrition counseling, care management, family education and support services, and access to mutual peer support, 12-step meetings, and partnerships with sober facilities. To learn more or make a referral, call 1-888-364-5977.
|The Importance of Early Improvement in Treatment||Fitness Trackers and Disordered Eating|
IN THIS ISSUE
Seattle Residential Site Opening April 3rd!
Eating Disorder/Substance Use Disorder Integrated Intensive Outpatient Program (ED-SUD IIOP) Now Open
Young Adult IOP Now Open in St. Paul, MN
Intensive Day Program Launched in Woodbury, MN
Carol Peterson, Ph.D., Chief Training Officer, The Emily Program
Ongoing learning is a fascinating aspect of our work as eating disorder clinicians and professionals. Sometimes, learning is required in the context of formal training requirements for professional licensure. Other times, our employers and supervisors provide educational materials related to our work. Most commonly, our learning pursuits are prompted by our own questions and curiosity in the context of our professional endeavors. These learning experiences help us strengthen our skills and stay up-to-date with knowledge about best practices and scientific advances. What types of educational options are available to professionals in the eating disorders field? Several types of learning opportunities can be pursued, depending on resources, time, continuing education needs, and training goals.
1. Professional Conferences
Several conferences that focus on eating disorders are held regularly in the United States and internationally. These types of conferences typically include speakers, workshops, poster sessions, and other training experiences. Content may focus on research findings, clinical techniques, advocacy, personal recovery, or some combination of topics. Examples include annual eating disorder conferences hosted by the Academy of Eating Disorders, the National Eating Disorders Association, The Renfrew Center Foundation, and the International Association of Eating Disorders Professionals Foundation, as well as the London Eating Disorders Conference (which is held every two years). Regional and local conferences that focus on eating disorders topics are also available.
Books can be an extremely valuable resource for eating disorder professionals. Some books provide specific information and treatment techniques that are useful for both professionals and clients, including Overcoming Binge Eating (second edition) by Christopher Fairburn (Guilford, 2013). Other books are designed specifically for professionals and include scientific information and/or clinical techniques. Some books focus on one specific topic and other books, including edited editions, include book chapters written by different authors. Book resources for eating disorder professionals include Gurze, ED Referral.com, and the Academy of Eating Disorders.
3. Scientific Journal Articles
Articles from scientific journals include the most recent research findings in the eating disorders field. These types of articles include treatment outcome studies as well as summaries of other types of research investigations related to eating disorders. The International Journal of Eating Disorders, Eating Disorders: The Journal of Treatment and Prevention, European Eating Disorders Review and The Journal of Eating Disorders are examples of scientific journals that specifically focus on eating disorders (although article abstract summaries are often available, full articles may be available to subscribers only). For a broader journal selection, PubMed and PsychInfo can be useful for article searches as well as specialty journals in dietetics and medicine. For eating disorder professionals who are interested in regular summaries of recent research, Eating Disorders Review is a particularly helpful and time-efficient resource.
4. Online Resources
Some scientific organizations offer online resources at no cost, including information about enhanced cognitive-behavioral therapy and assessment measures from Oxford and self-help materials from the Centre for Clinical Interventions. Conferences and continuing education events sometimes provide online information including webinars and taped sessions that can be viewed afterwards. The TED Talks website can be searched for presentations related to eating disorders and body image. Other resources that can be accessed online include courses (e.g. https://www.iaedp.com) podcasts, blogs, websites (e.g., http://www.eatingdisorderscoalition.org), clinical research trials (e.g. https://www.clinicaltrials.gov/), treatment guidelines (e.g. https://www.ncbi.nlm.nih.gov/books/NBK49304), and online screening tools (https://www.nationaleatingdisorders.org/online-eating-disorder-screening).
In addition to these types of resources, eating disorder professionals often find it helpful to consult with colleagues and other experts when they have questions about eating disorders. Creating a “learning community” with other professionals for case reviews, discussions of books or other readings, and consultation can provide an optimal integration of education and support.
Interested in free CEUs and other continuing education opportunities hosted by The Emily Program? Check out all of our upcoming events here.
Minnesota Women in Psychology and The Emily Program Foundation are hosting a fantastic professional development event on March 30th in St. Paul, MN. See the event page for more information.
IN THIS ISSUE
Young or old, no age group is immune to eating disorders – including women in their childbearing years. In fact, given the overlap in age range during which eating disorders (EDs) are often diagnosed and the time period during which women can reproduce, pregnancy and EDs frequently co-occur.1,2 And unfortunately, research has shown that there is an increased chance of complications when a pregnant woman has been diagnosed with an ED. Considering the serious problems that can result, it is imperative that EDs are properly identified in pregnant women and that precautions are taken to keep both the mother and developing child safe.
Rates of pregnancy and birth in the eating disorder population
Historically, women with anorexia were thought to be unable to conceive due to menstrual irregularities or amenorrhea, a common side effect of the eating disorder.3 This has since proved false; although women with irregular menstrual cycles experience decreased rates of pregnancy (the rate of pregnancy among women with anorexia is less than half the rate of healthy women4) women diagnosed with anorexia and other EDs are able to become pregnant and give birth.3 Still, women with EDs are significantly less likely to have children compared to control groups.4 One reason for this difference is that fertility is compromised in women with lifetime anorexia and lifetime bulimia.5 Adverse reproductive health outcomes, including increased rates of miscarriage and induced abortions, also appear to be factors.4
The elevated risk of miscarriage exists among populations diagnosed with bulimia, anorexia, and binge eating disorder3,4,6-9 This is in line with the general knowledge that miscarriage occurs more frequently in women with extremely high or low BMIs.10,11 One study found that miscarriages were especially common in women with binge eating disorder (46.7% of women with binge eating disorder experienced miscarriages compared to 23% of women in the control group).4 Studies also show that women with bulimia and anorexia are more likely to report that their pregnancies were unplanned 3,12 and also experience increased rates of induced abortion.3,6 Researchers speculate that in women with bulimia, who often carry impulsive personality traits, this may be due to risky sexual behavior and subsequent unplanned pregnancy.4 With anorexia, researchers speculate that the trend may be a result of inadequate use of contraceptives as a result of menstrual absence or irregularity creating a false sense of security.3
Impacts on maternal and fetal health
Given the severe toll EDs can take on an individual’s body, it is perhaps unsurprising that these disorders carry a greater risk of pregnancy complications and adverse health effects for both mother and child. Among the most commonly cited maternal risks are increased rates of cesarean section10,11 suboptimal nutrition14,15 and postpartum depression.13,16 Expectant mothers with anorexia are more likely to experience hyperemesis gravidarum, or severe pregnancy sickness (nearly one third compared to 9% of controls), and be diagnosed with anemia (nearly 50% versus 12% of controls).17
Women with past or active EDs also have a greater risk of delivering infants with low birth weight, smaller-than-average head circumference, and microcephaly.17 And it appears that these infants don’t “catch up” as time goes on; developmental delays in these cases tend to persist throughout the child’s life.18 One phenomenon, seen almost exclusively among women diagnosed with bulimia, is “slimming,” which involves a mother projecting her distorted body image onto her baby, perceiving it as overweight. Mothers in this situation may try to restrict feedings, administer suppositories, or induce vomiting.19
Sometimes pregnancy can also cause changes in ED symptoms, ranging from a complete remission of the disorder to exacerbation of symptoms.20,21 Women who experience symptom reduction – which may be permanent or transient following the birth – often cite the well-being of their baby. These women have better birth outcomes, heavier babies, and higher five-minute Apgar scores 22 (a measure of the physical condition of a newborn infant). A less common outcome is that ED symptoms increase during pregnancy. When this does occur, it is often sparked by an excessive fear of weight gain and changes to the body.20 In contrast to those whose symptoms diminish, women who experience increased symptoms often give birth to smaller babies with lower five-minute Apgar scores.22
It is not always immediately evident that a pregnant woman has an ED. The women themselves, especially teens, may not disclose their condition. Or, healthcare providers may overlook the consideration due to the fact that the woman was able to conceive and was therefore in seemingly good health.23 In order to avoid serious health consequences for both mother and child, EDs should be identified and factored into the care plan for the mother-to-be.23
Healthcare providers can often recognize a history of disordered eating alongside a woman’s reproductive record.23 Assessing menstrual cycle regularity is a good indicator of food restriction and unhealthy body weight. Clinicians should also pay special attention to weight recorded at prenatal visits and ask questions like, “What is it like for you to be weighted at every visit?” or “How are you feeling about your physical changes and weight gain?” in order to detect the presence of an ED.23
If an ED is suspected or identified, the OBGYN care provider should be prepared to collaborate with a multidisciplinary team well-versed in ED management.23 Together, they can provide a proper nutrition plan, discuss a healthy weigh-in procedure, provide fetal development education, and screen for post-partum depression.23 They can also work together to offer encouragement during maternal weight gain to reinforce a positive association with the mother's changing body shape.23 With multidisciplinary, specialized support behind her, the expecting mother will be better prepared to avoid reproductive complications and have a healthy pregnancy and baby.
by Carol Peterson, Ph.D., Chief Training Officer at The Emily Program
According to an oft-repeated Chinese proverb, "learning is a treasure that will follow its owner everywhere." As clinicians working in the mental health field, learning is inherent in our profession, given the privilege of our ongoing education provided to us by our clients as we collaborate with them in their pursuit of recovery. In addition, we have the opportunity to learn formally in the context of organized training and informally from colleagues, supervisors, and mentors. Indeed, many of us were drawn to our work initially–and continue to find it rewarding–because of our intense curiosity. In the context of our demanding schedules, how can continue to develop our skills, deepen our understanding of our work, revel in learning, and expand our knowledge?
1. Join a consultation group: Consultation groups usually consist of clinicians who provide feedback, information, and support to one another. Often, members will present case information or discussion topics on a rotating basis as consultation groups typically meet at regular intervals (e.g., monthly or quarterly).
2. Start a reading group: Interested in reading an article or book on a clinical topic? Consider inviting colleagues, peers, and students to read it too and discuss it as a group. Some reading groups meet once and others meet on an ongoing basis. In addition to clinical and research topics, some reading groups discuss novels that focus on mental health topics. Similarly, "movie groups" view and discuss films with specific themes (e.g., the portrayal of psychiatric and psychological treatment).
3. Seek online resources: Educational information is often available online (e.g., YouTube, websites like Khan Academy), especially for academic courses and lectures. In addition, online resources can be found for a number of evidence-based treatments. For example, do you want to learn more about cognitive-behavioral treatment for eating disorders? The Centre for Research on Eating Disorders at Oxford's website (credo-oxford.com) includes information about cognitive-behavioral treatment as well as assessment forms and handouts that can be downloaded for clinical use.
4. Set aside one hour per week for learning and block it in your calendar: Designating time within your schedule to devote to learning can support self-care as well as professional development. Although this time can be allotted for "required" education (e.g., continuing education activities for licensure), consider including learning opportunities that spark passion (even if the topic is outside of your typical expertise).
5. Attend workshops, lectures, and webinars: Structured learning activities can be especially valuable for developing a new skill or understanding a topic more comprehensively from an expert in the field.
6. Take or audit a class: Community education, local and on-line colleges/universities, and learning communities can provide a range of courses.
7. Consider teaching or lecturing: Serving in the teacher role provides an ideal opportunity to strengthen knowledge in the context of course preparation as well as during student interactions.
8. As much as possible, surround yourself with colleagues, students, mentors, supervisors, and teachers who share your passion for learning. Enthusiastic curiosity is often contagious and can serve as a foundation of formal and informal communities.
Appreciating small moments of learning can be especially helpful amidst busy schedules (e.g., at the end of the work day, checking in and asking ourselves to reflect on one experience that provided learning and growth that day). For some of us, education beyond our professional scope of work can be as valuable as work-related training. Learning a new skill (e.g., gardening, car repair) or topic (e.g., art history, astronomy) can be rejuvenating and inspiring to us as clinicians, and as humans.
Interested in free CEUs and other continuing education opportunities? Check out all of our upcoming events here.
- The Emily Program recently welcomed new staff members to our care team in Spokane! Patti Zimmerman, MSN, ARNP, serves as a Medical Nurse Practitioner in our Spokane, WA office. Patti provides medical clearance for programming clients and follows up on issues that need further attention during the treatment recovery process, coordinating care with outside medical providers. Her expertise in women's health care and her calm, supportive manner have been a great addition to the team. Sarah Bergen, PMHNP-BC, serves as a Psychiatric Nurse Practitioner. Sarah provides psychiatric care to all of our programming clients, conducting client assessment, managing medications and coordinating with the rest of the care team and community providers to provide comprehensive care. With her working knowledge of eating disorder treatment and willingness to step in when needed, Sarah is an excellent fit at the Spokane office.
- Jennifer Shannon, M.D., Child and Adolescent Psychiatrist, is expanding her role to spend more time working with our Seattle Adolescent and Family Intensive Program (AFI) and Seattle Residential in 2017.
1.Crow, S.J., Keel, P.K., Thuras, P., Mitchell, J.E. (2004). Bulimia symptoms and other risk behaviors during pregnancy in women with bulimia nervosa. The International Journal of Eating Disorders, 36(2): 220-223.
2. Franko, D.L. & Spurrell, E.B. (2000). Detection and management of eating disorders during pregnancy. Obstetrics & Gynecology, 95: 942-946.
3. Bulik, C.M., Hoffman, E.R., Von Holle, A., Torgersen, L., Stoltenberg, C., Reichbom-Kjennerud, T. (1999). Unplanned pregnancy in women with anorexia nervosa. Obstetrics & Gynecology, 116: 1136-1140.
4. Linna, M. S., Raevuori, A., Haukka, J., Suvisaari J.M., Suokas J.T., and Gissler, M. (2013). Reproductive Health Outcomes in Eating Disorders. International Journal of Eating Disorders, 46(8): 826-33.
5. Easter, A. (2011). Fertility and prenatal attitudes towards pregnancy in women with eating disorders: results from the Avon Longitudinal Study of Parents and Children. International Journal of Obstetrics and Gynecology, 118(12): 1491-1498.
6. Abraham, S. Sexuality and reproduction in bulimia nervosa patients over 10 years. (1998). Journal of Psychosomatic Research. 44: 491-502.
7. Bulik, C.M. Sullivan, P.F., Fear, J.L., Pickering, A., Dawn, A. McCullin, M. (2007). Fertility and reproduction in women with anorexia nervosa: A controlled study. Journal of Clinical Psychiatry, 60: 130-135.
8. Micali, N., Simonoff, E. Treasure, J. (2007). Risk of major adverse perinatal outcomes in women with eating disorders. The British Journal of Psychiatry, 60: 130-135.
9. Morgan, J.F., Lacey, J.H., Chung, E. (2006). Risk of postnatal depression, miscarriage, and preterm birth in bulimia nervosa: retrospective controlled study. Psychosomatic Medicine, 68: 487-492.
10. Metwally, M. Ong, K.J., Ledger, W.L., Li, T.C. (2008). Does body mass index increase the risk of miscarriage after spontaneous and assisted conception? A metaanalysis of the evidence. Fertility and Sterility, 90: 714-726.
11. Maconochie, N. Doyle, P., Prior, S. & Simmons, R. (2007). Risk factors for first trimester miscarriage—results from a UK-population-based case control study. British Journal of Obstetrics and Gynaecology, 114 (2),: 170-186.
12. Morgan, J.F., Lacey, J.H., Sedgwick, P.M. (1999). Impact of pregnancy on bulimia nervosa. Br J Psychiatry, 174:153-140.
13. Franko, D.L, Blais, M.A., Becker, A. E., Delinsky, S.S., Greenwood, D.N., Flores, A.T., Ekeblad, E.R., Eddy, K.T., & Herzog D.B. (2001). Pregnancy complications and neonatal outcomes in women with eating disorders. The American Journal of Psychiatry, 158(9), 1461-1466
14. American College of Obstetricians and Gynecologists. Nausea and vomiting of pregnancy. (2004). ACOC Practical Bulletin, 52, 1-15.
15. Roem, K. (2002). Hyperemesis gravidarum—a serious complication of pregnancy. Nutrition & Dietetics, 59, 144-146.
16. Mazzeo, S.E., Slof-Op’t Landt, M.C., Jones, I., Mitchell, K., Kendler, K.S., Neale, M.C., Aggen, S.H. & Bulit, C.M. (2006). The International Journal of Eating Disorders, 39(3), 202-211.
17. Koubaa, S., Hallstrom, T., Lindholm, C., Hirschberg, A.L. (2005). Pregnancy and neonatal outcomes in women with eating disorders. Obstetrics & Gynecology, 105(2), 255-260.
18. Park, R.J., Senior, R. Stein, A. (2003). The offspring of women with eating disorders. European Child and Adolescent Psychiatry, 12 (suppl), 100-119.
19. James, D.C. (2001). Eating disorders, fertility and pregnancy: relationships and complications. The Journal of Perinatal & Neonatal Nursing, 15 36-48.
20. Lemberg, R. & Phillips, J. (1989). The impact of pregnancy on anorexia nervosa and bulimia. International Journal of Eating Disorders, 8, 285-295.
21. Blais, M.A., Becker, A.E., Burwell, R.A., Flores, A.T., Nussbaum, K.M., Greenwood, D.N, et al. (2000). Pregnancy: outcome and impact on symptomatology in a cohort of eating-disordered women. International Journal of Eating Disorders, 27, 140-149.
22. Stewart, D.E., Raskin, J., Garfinkel, P.E., MacDonald, O.L., Robinson, G.E., (1987). Anorexia nervosa, bulimia and pregnancy. American Journal of Obstetrics and Gynecology, 157 (1194-1198).
23. Newton, Mandi S., and Lesa Chizawsky L. K. "Treating Vulnerable Populations: The Case of Eating Disorders during Pregnancy." Journal of Psychosomatic Obstetrics & Gynecology 27.1 (2006): 5-7.