The Link Between Anxiety and Eating Disorders

Hello welcome to this webinar on eating disorders for National Eating Disorders Awareness Week my name is dr. Jill Immanuel I am a senior clinical psychologist at child mind Institute and my colleague here hi I'm dr. Beth McGrath I'm a postdoctoral fellow at the Mount Sinai eating and weed disorders program we're so happy to be here to to partner with the child mind Institute with with NIDA the National Eating Disorders Association for this special webinar on giving you information on eating disorders I myself am a senior like I said a senior clinical psychologist of child mind

Institute a part of the mood and anxiety disorders center here I'm also director of the depression service and DBT program dr. grave is a postdoctoral fellow at Mount Sinai Medical Center she has received specialized training and empirically supported treatments for eating Disorders including cognitive behavioral therapy and the Maudsley method as well as an evidence-based eating disorder prevention program entitled reflections Rebecca completed a clinical externship where she was trained and empirically supported treatments for patients with anxiety disorders and has received extensive training and dialectical behavioral therapy so we'll be talking about a lot of these topics

today so facing the treating eating disorders is Always hard even be more difficult than other mental disorders and health challenges are at play so we're going to talk about the overlap today between eating disorders and anxiety and mood disorders and what the change is about signs symptoms of treatment when they are co-occurring we want hope to give you a lot of good information that you can use in helping not only your family members or friends but being able to see how to reach out to the community and Learn more information alright so and we'll do

this in a question-and-answer format to be able to give you as much precise information as possible so I guess Rebecca it would be really helpful to start with just knowing what are the most common eating disorders what signs and symptoms do we see sure so the three most common disorders are anorexia nervosa bulimia nervosa and binge eating disorder and I can talk about each of them in turn So anorexia nervosa actually out of the three is the least common and there are a few key symptoms that go along with it so the first one is

that you have to have lost a significant amount of weight to the point that you're underweight based on your previous weight trajectory or your previous weight growth patterns essentially the second kind of key criteria is that you need to be afraid of gaining weight despite the fact that you're significantly underweight and Then something else that typically goes along with it is that either you feel fat again despite the fact that you're underweight you're in denial or don't recognize how serious it is that you're underweight and the last one is that it might be extremely important

or kind of the term we often uses over evaluation of shape and weight or body so that a person with anorexia nervosa for them their body is often one of the if not the most important thing in terms of how They feel about themselves okay so we have those those are the three common ones what kind of things do we see in those eating disorders but how do we know that it's that we're seeing an eating disorder great question so in terms of anorexia nervosa one of the key signs of course would be noticing significant

weight loss or rapid weight loss but you might notice other things too for example people might start to cut their food into really small pieces Or have other kind of almost seemingly ritualized behaviors around food you might also start to notice that the person is talking a lot about wanting to lose weight or how they really don't feel good about their body you also might notice things like people might start to pinch parts of their body or weigh themselves really frequently those might all be signs that someone is suffering okay and and what would people

look for in Bulimia great so bulimia nervosa is a disorder in which the person is engaging in binging behavior which has two components to it so you would be eating a large amount of food and while you're doing it you feel like you're losing control over your eating so that basically you couldn't stop once you started and it's followed by we call compensatory behavior or something that you're doing basically to make up for The fact that you overrate the one I think that's typically talked about is vomiting but it can actually be a lot of

other things too so it can be laxatives use or diuretic use it can be excessive or compulsive exercise or it could actually be fasting or you would go for a really long period of time not eating following a binge and those things in order to meet full criteria you'd have to be doing that at least once a week for three months and similar to anorexia Nervosa you also have that overvaluation of shape and weight or shape and weight or really important how you feel about yourself so if we're thinking about kind of signs or symptoms

often what happens with binge eating is that it's actually done in secret because people feel really ashamed so you may not actually see the person binging but there are other symptoms you can look for signs so things like seeing candy wrappers or other food wrappers kind of left in the House or noticing that large amounts of food are kind of inexplicably missing from the house or certainly things like hearing someone vomit in the bathroom smelling vomit or seeing vomit residue on toilets noticing that someone is exercising much more than they used to be certainly finding

something like laxatives all those things could be signs that they're struggling and yet seemingly all these signs but yet a lot of people hide them and don't notice Them right absolutely so parents are our family members often have a really tough time knowing exactly what's going on absolutely and that's part of I think unfortunately what also delays people in getting treatments sometimes and people sometimes feel so ashamed about their symptoms they might either not feel comfortable telling the parent or a friend or anyone and feel like they need to suffer on their own so I'm

hoping that a talk like this and other things Might help people feel more comfortable coming out sure absolutely and then of course we have binge eating disorder which is new to our dsm-5 the Diagnostic and Statistical Manual that just came out last year and it wasn't official disorder before but now we have it as an official disorder is actually pretty common as yes it's the most common of the three disorders that we're talking about and kind of what distinguishes binge eating Disorder from bulimia nervosa is that so notably MiraCosta you're engaging in those binge eating

episodes but there's no compensatory behavior afterwards and again as we were kind of starting to talk about there's a lot of things that often go along with binge eating so eating more rapidly than normal eating when you're not physically hungry eating until you're so full that you feel physically uncomfortable often eating the secret because you're so Ashamed and then feeling really guilty and depressed after these episodes right and we're going to be talking certainly more about depression as they're going along yeah I think what's really would be helpful to for people to know is what

are some of the common misconceptions that people have about eating disorders because there's a lot of the mouth arrow and imagine absolutely um you know I think probably one of the mean ones is the idea that you endorse orders really Only affect women what we know is that it is more common in women about three times more common but it absolutely exists among men and I think part of you know what goes along with this idea that men don't suffer with the users that they're also not seeking treatment for it and so it's really important

for people you know if you see signs or symptoms that you know in a male that it is really possible that they're suffering sure I think another one or Another common misperception is that to have bulimia nervosa that you absolutely have to be vomiting from and as we talked about before there's actually a lot of other kind of compensatory behaviors that you can use so it'd be laxatives excessive exercise so just because someone isn't isn't purging or vomiting doesn't mean that they don't have bulimia okay that's really helpful to know some of those things because

I think a lot of People have conceptions there's also I think there's something that someone who's anorexic really has to be like super bony thin and and you have to be seeing almost their skeleton to some degree and yeah I think that that's not necessarily the case is that correct absolutely so it's really based on your previous weight trajectory so you know some people just naturally have always been say in the 85th percentile for weight and so they could lose a Can amount a weight and still not look amazing but they would still meet criteria

for the disorder and they're absolutely still sick um and you know kind of going along with that there's actually another kind of class of eating disorders known as the other specified eating disorder sure and what goes along with that or kind of some atypical presentations of eating disorders and so a typical interaction nervosa is when you've lost a significant amount of Weight and despite that you're still not underweight and so again even without being a me see that those people are still suffering and kind of going along with that scene with bulimia and binge eating

disorder there's also a typical variations of those and four to meet criteria for that it just means that you have to be engaging in the behaviors less than once a week so I don't want anyone to think that because they're not doing it as often as once a week that They shouldn't be seeking help or that they're not suffering um absolutely they should still seek oh okay no it's really important fact I think we also learned a couple of things and thinking about eating disorder in terms of race and ethnicity and one of the things

I've learned recently is that it's seemingly the research shows that that recent ethnicity Caucasian women are the ones that seemly present with eating disorders when most but there's actually Some research to suggest that it's actually more common in ethnic minorities than we know yeah in part because there's a cultural um little thought or movement to that that not to see treatment yeah that correct yes I think you know the research in terms of kind of differences in prevalence rates among Caucasian individuals first others is mixed so some research says maybe it is more prevalent some

says it is it but absolutely what you were saying I think That attitudes towards seeking mental health treatment do differ um and that can really impact whether or not someone is getting help right um and so again you know I think if there's like one thing or one message that we can really convey her it's that you know anyone who is struggling deserves to be able to get help and that there are really good resources out there for people absolutely the other thing that I also I think isn't talked about enough In the media is

that eating disorders are prevalent in lesbian gay bisexual and transgendered populations as well and what I learned recently is is that they it's in part due to the coming-out process I'm realizing that you're gay and coming and coming out to your fans and family but also harassment bullying that you experienced it working home and it we're going to be talking about this comorbid with anxiety and mood disorders slowly And how that then comes across how they were not seen for treatment a lot of the time is not her yes that and I'm not as familiar

with literature it sounds as you are but I absolutely could see how you know stresses and issues around identity you know could coincide with eating right in fact you know what's really interesting is is that I saw a statistic that said that you know um we talked about men having eating disorders yeah actually disproportionately gay men Actually have president with eating disorders mm-hmm which which we can understand given the circumstance of what we're talking about mm-hmm all right so I think it would be important since we're gonna talk about comorbidity with anxiety and mood disorders

to actually talk about anxiety mood disorder so I figure I'm gay so I can give you a break so what is anxiety exactly anxiety is a normal reaction to a stressful situation And it helped in during our you know during our lifetime it helps us experience different things and it helps us actually give us information and emotions give us information anxiety is helps us to get out of harm's way anxiety helps us to prepare for an event such as like making a public speech and it helps us to be able to take action if we

need to but what happens is anxiety becomes persistent uncontrollable and we can't manage our anxiety then they can Start to disrupt our daily lives and what we do know is that anxiety disorders are some of the most prevalent mental health disorders and issues that we deal with in fact Americans just personally suffer from them and is also one-third of people who have anxiety disorders just one-third get help that means two thirds of people are not getting help for anxiety sores and they are treatable and we have a lot of good treatments for them which we'll

be Talking about my so I'm going to talk a little bit about just some basic anxiety disorders that we treat and are generally seen for treatments so there's generalized anxiety disorder which is kind of a general term but what are we talking about here it's a person with generalized anxiety disorder has persistent and uncontrolled worry and they're not able to control the worry so someone may just be going to the store And say oh I have to pick this up and have to pick this up but then what happens they go and they go what

if I don't get the oh I forgot this but what if I what if I can't get home on time and then if I can't pick my kid up what's going to happen and the worry starts to spin out of control and disrupts their life and so the generalized anxiety disorder is also a hallmark of it is feeling tension a lot of physical pain and and not being able To really function in your daily life because you're so caught up with the worries so what that's one type of anxiety disorder that we're talking about and

I imagine a lot of people with eating disorders struggle with these I think dr. way to try and highlight some of the ones that are really yeah most common absolutely yeah then there's social anxiety disorder people sometimes hear about this as being really the social phobia mm-hmm social phobia is a Real fear of being evaluated by others in any kind of situation sometimes it's a social mainly social situations but also in some sort of public speaking or performance evaluative kind of situation and they are try to avoid the situation as much as possible to avoid

the worry mm-hmm so we're we definitely talked about that we talked about panic disorder panic disorder is people people who experience panic attacks and we hear that word a lot panic attacks they Experience an spontaneous out-of-the-blue anxiety that Peaks within a few minutes but it's difficult to control and we a lot of people say they're having a panic attack but we have a lot of different symptoms of panic attacks that people really do experience and what is a true panic attacks which is uncontrolled breathing or difficulty breathing muscle tension choking fear of dying trembling shaking

all these different Things can be part of the penance Act there's a lot more symptoms and then another thing I understand is very common with eating disorders is OCD absolutely yeah and I went and we will definitely get into that so in OCD people experienced unwanted and intrusive thoughts that prefer that they cannot get out of their heads causes them tremendous anxiety that unwanted intrusive thought is the obsession now if you're having an unwanted an Intrusive thought then I would want to get rid of it so what they do what they do is they then

do some sort of behavior compulsion to get rid of the anxiety um and it can be OCD presents in many different ways but a common thing that's known for example is is that someone has a fear that they might have gotten some sort of like germ on their hands and they're going to get sick as a result they can't get the thought out of their head so they wash their hands Excessively in order to get rid of that those germs that may not really even be there the person in OCD really understands for the most

part in most cases or many cases that this is a irrational thought and it's not real that they can't control it so we can see little tundra how that relates to eating sores as well um there's a number of other anxieties or specific phobia that's just a fear of some specific thing like a dog or a snake or something Like that there's post-traumatic stress disorder which is a an anxious reaction to a traumatic situation um so we've talked about a number of anxiety sores I'll just briefly talk about mood disorders as well which are also

very comorbid and we'll talk about comorbidity what that is as well with eating disorders yes so mood disorders a mood disorder is basically characterized by any disturbance in mood that is outside the Normal range that you experience on a daily basis so you hear a lot about depression you hear a lot about bipolar disorder let's just briefly define what these things are um depression is a in and of itself major depressive disorder is a huge problem in the United States both amongst adults and adolescents one in five adolescents has depression and depression of course associated

with potential suicide behavior and and a lot of people do as a result of very serious Depression suicide in fact suicide is the third leading cause of death amongst adolescents in the United States so it's a very serious problem but what is depression so if people can say they're sad thirds they can say that they're depressed but that doesn't mean they have major depression major depression is really a situation in which your mood is chronically so low that you can't manage and function in life and there's A lot of symptoms associated with major depression including

not being able to concentrate having low energy feeling sad a lot of the time a lot of disturbances and eating and sleeping not being able to be not being interested in activities that you're formerly interested in and so it's a there's a number a number of other symptoms and this can really cause chronic impairment in fact a lot of the adults in the United States that are not working or Often struggling from depression there's a word there's another kind of depression which is called dysthymia or dysthymic disorder which is you know considered a you know

it's commonly known as a low-grade depression but it's still very serious it's a more chronic depression it's you don't see the same level of impairment as you do in a major depressive episode but you see it over a longer period of time and it can be very debilitating and then of course there's Bipolar disorder bipolar disorder also known as manic depression is sort of that has two tiers of it so we had depression is known as unipolar disorder but bipolar disorder has another tier so you can have depression Corsa bipolar disorder but you'll also have

mania and mania is unmodulated emotions that are often seemingly seen as positive and happy but really it's not it's more having excessive energy feeling irritable pressured speech reckless Behavior not being able to control your emotions feeling out of control and it can really cause severe severe severe impairment in functioning so a lot of these disorders are really associated with eating disorders and it's important for us to go over them just so you know where we're going to be headed yes absolutely and so just so kind of everyone is on the same page we talked about

comorbidity we mean kind of other disorders that are occurring at the same Time that the heat disorder is occurring yeah and so as you were talking about anxiety disorders are very commonly comorbid with eating disorders off you know actually almost all anxiety disorders have been found to be kind of increased among the eating disorder population but in particular social phobia OCD GA D those are kind of often the ones that are cited as commonly comorbid right and there might be kind of different reasons for that One way that there might be a shared actually biological

or genetic component among eating disorders and anxiety disorders which actually makes people more vulnerable to kind of becoming anxious about things so whether it be that you know you're anxious about a social situation or you're anxious about eating the food that's in front of you we think there may be kind of a biological predisposition to becoming kind of scared of things more quickly or The kind of fancy psychological term is like rapid aversive conditioning so that might be one reason it also might have to do with the way that people with eating disorders and anxiety

disorders think about things there may be an overlap in that way to kind of thinking of the world as being dangerous and feeling very vulnerable to kind of that dangerous world and maybe unable to cope so same idea that may be you know a situation might seem really scary a Social situation if you're dealing with social phobia in the same way that then you might think about food as being really scary and so there might be an overlap that way there may also be kind of trait like characteristics that are similar particularly perfectionism and so

you could see how that will kind of manifest in both as well so if you're someone who's professional perfectionistic and as a result you're really concerned about seeing things Inappropriately or you may as a result not go to social situations you may not present in front of people you mean to give a talk like this you know it was it may be really nervous right similarly if you know if you're perfectionist about your body or about eating you can see how that would also kind of transcend into an eating disorder and so that's where we

think that some of this be kind of overlapping as well great and there's even other traits that are Associated I think with eating disorders including so one of the biggest things that we talk about in mood disorders is emotional dysregulation yes absolutely and emotional dysregulation is the idea of a person who cannot really effectively modulate their emotions across a range of situations experiences and so often enough that it comes from we've actually found evidence molds I'll talk about this a little bit later where there's actually a genetic component to Being being able to control your

emotions effectively having experiencing emotions very intensely but also if you don't know how to you know the role model so the environment doesn't teach you to control your emotions effectively you don't know how to modulate them and as a result they're kind of all over the place and so that's affiliated with these disorders as well absolutely and it makes sense you know a lot of times kind Of bingeing behavior for example is used as a strategy to try to cope with emotions so if you're feeling really upset or angry it can be really really hard

to sit with those emotions especially if you're someone who might have kind of genetic loading towards kind of being kind of more up and down to begin with and so a lot of people then find different ways to try to cope and one of those ways might be binging so in the moment it might make you feel A little bit better might distract you though certainly in the long in the larger picture or longer term it ends up causing a lot more problems right so as part of treatment we'll talk more about this later we

try to help people develop other coping mechanisms for when they're experiencing those emotions so that they don't have to use binging right and there's even other what we call non-suicidal self injurious behavior is that people do in order to cope with Some of these symptoms so there's cutting like arms burning scratching these things that are often seen out and especially in adolescent populations - as a way to cope with their emotional pain and be able to in people see it as potentially they're committing suicide or they're they're trying to kill them no they're actually not

trying to necessarily kill themselves it's a song called non-suicidal self-injury my idea is I feeling so much pain that I can't Even cope with it so I'm going to do something that takes away the pain some other pain even fact right that takes away the pain right so similar if I sounds like these are for you know serve similar functions they just look a little different they do yeah absolutely so we talked a little bit about the comorbidity with anxiety disorders and in eating disorders on are there specific any other specific things that we can

talk about in terms of Bulimia or anything um well I think with bulimia a lot of times we often think about depression um certainly also the anxiety disorders but you know what we see often is that actually both in bulimia and anorexia nervosa there's often comorbid depression and it's a lot of times it's secondary to the illness so um with anorexia nervosa it's actually often secondary to starvation so actually starving yourself can make you depressed and so you know what we Find and the good news about that is that often as we get people healthy

and they become weight restored actually the depression often kind of remits along with the eating disorder similarly we often see that also with bulimia nervosa and binge eating disorder that as the binging behavior actually hopefully starts to subside usually depressive symptoms also start to get better as well that's really hopeful yes absolutely and you know it's Not and we'll talk about this more later then we have other strategies certainly that we can use and kind of more specific treatments to address the anxiety or the depression but the good news is that oftentimes we don't have

to yeah and I think that there's a really excellent point because I think a lot of providers when they see someone with multiple problems there they feel like they have to necessarily treat every single problem they don't next and we Didn't know where to start necessarily but what you're actually saying is with some eating disorder pickly with bulimia and depression if you treat one the other may actually get better absolutely so but what hopeful like outcome that could potentially be yes - for one - yeah exactly - for like for people suffering from these disorders

absolutely um okay so I guess it would be a good time to get into treatment at This point sure all right so let's talk a little bit about the typical treatments that are generally employed so I think both were where we both work we're very big on terribly supported treatments treatments that have research efficacy behind them and show that these treatments actually do work absolutely and so what's really interesting about when we're talking about eating disorders and mood and rioting disorders is that they're all Really treatable by something called cognitive behavioral therapy or CBT as

it's often referred to and CBT and in essence is it's just the idea that we have negative thought patterns or ways of thinking about things that are actually not helpful to us so the theory behind CBT is is that we have these negative thought patterns patterns that affect our thoughts our excuse me our emotions which then are affect our behavior so a person may look at a Situation and go something that they have - I can't do this and then they might have the emotion sadness anger even potentially frustration and then they avoid mm-hmm and

what we teach people in CBT is to look at that thought and challenge that thought so we can sit there and go where's the evidence that I can't do this maybe I can do this I have the evidence before that in the past I've done this which leads to emotion of positivity hope is hopefulness and even Potentially happiness and then leads to behavior being done so at its essence that's what CBT is and so these treatments are very effective because a hallmark of all these disorders is these negative thought patterns and unrealistic ways of thinking

about things yes absolutely so um and then for eating disorders what's really amazing to me is that another treatment called dialectical behavior therapy has been actually effective both for mood Disorders and for eating disorders and it's a treatment that you people are starting to talk about more and more and more you're hearing a lot about it with treatment with adults and adolescents so I think it'd be helpful to maybe talk a little bit what DBT is sure so I can talk about that a little bit if that's okay yeah um so the idea so dialectical

behavior therapy or DVT is a treatment that was originally developed for people with a type of mental disorder called Borderline person disorder it is developed by dr. Marsha Linehan at the University of Washington and people with borderline personality disorder throughout their lifetime experienced significant impairment in their relationships in their sense of self in their and their ability to control their impulses and it really wreaks havoc on their lives and they don't know how to manage themselves and really effectively their emotions they Can't manage their emotions so in in the mental health field borderline personality disorder

was seen as a very difficult disorder to treat but what Marshall in hand did was bring it into the forefront where it we say no these people can be helped what the DBT does is define borderline personality disorder as a disorder of emotional dysregulation or more of the emotional dysregulation system so as a result what we're looking at is how to Help people cope with their emotions more effectively and what's wonderful web DBT is is that it's a combination of CBT and also Eastern thought so what we have in DBT is CBT and also mindfulness

meditation which helps people to really exercise their their their muscle to learn how to be in the moment and control their emotions even in the face of great difficulty and there's a lot of different skills that we teach in DBT that are very applicable to eating Disorders including crisis management skills so how do you deal with a crisis how do you deal when your emotion just get really high and then you want to get rid of those emotions with very very very painful emotions by doing something ineffective and so DBT has been shown with some

adaptations to be very effective in eating disorder populations and which is very wonderful and in addition to also being very effective with depression and being effective with Whirling personality disorder and actually a lot of other things too so yes uh um and you personally opposed with their skills that I think anybody honestly truly I use these skills too which is always kind of a nice added benefit really absolutely and it you know we've seen such a rise in people talking about mindfulness there was even a article in Time magazine recently that really highlighted what mindfulness

is and so we're seeing that all over the Place and applying it to different disorders yeah absolutely I'm sure we'll be seeing mindfulness for eating disorders very soon yes and you know like oh you know we do that even now things around mindful eating often times where people are you know and I think we probably all guilty of this to eat in front of the TV you while you're talking on the phone you're not really paying attention to what's going on while you're eating how does it Taste you know what are the different body sensations

you have we often try to really slow that down for people which can really change the way you relate to food and the whole eating process and that's helpful for all of us for sure absolutely yeah absolutely so um but there's also very specific treatments for eating disorders that people should know about that are very important yes and I know you gave a really nice overview of cognitive Behavioral therapy and there's kind of a specific adaptation of it for bulimia nervosa and binge eating disorder as well as for anorexia but we'll kind of save that

and talk about that in a little bit so as you were talking about really the kind of premise behind CBT is that you're focusing on the relationship between someone's thoughts their feelings and their behaviors oftentimes with eating disorders its eating behavior that we're looking at so a Common example might be for someone with bulimia nervosa is that they feel really dissatisfied with their body and they want to lose weight and so in an effort to kind of achieve that they often go on a very strict or severe rigid diet um so it could be things

like going really long periods of time without eating like almost not eating all day and until night it could be things like really trying to reduce overall amount you're eating so having a very low kind of Caloric goal each day or it could also be something like cutting out certain types of foods so common examples would be eliminating carbohydrates or fat or gluten things like that and then what ends up happening is that the person becomes both really physically hungry and also feels really psychologically deprived if you tell yourself you can't have something a lot

of times it actually sets you up to want it more sure as of probably all of us can relate To in some aspect of our life and so ends up happening is as a result people are unintentionally setting themselves up today so they end up eating large quantities of food oftentimes if they cut out certain types of foods it's those foods that they're binging on which makes sense and then they feel awful about it they both feel physically really uncomfortable and emotionally feel extremely guilty and so then and for Someone who has bulimia nervosa they

then try to get rid of that right so then they might do something like vomiting or excessive exercise or laxatives use and so once we've kind of mapped out that pattern for people and we do that collaboratively then we try to really break apart the cycle and the first place we usually start with is the eating behavior itself and so what we would try to do is try to help someone develop a healthy relationship with food Eat regularly throughout the day eat a wide variety of foods eat enough to sustain themselves and this can involve

actually exposure like treatment which is commonly used with anxiety disorders as well where we'd actually be exposing people to foods that either they have deemed forbidden or really scared to eat and so it's not uncommon that people come into our offices and they'll be eating things like brownies or whatever they're feared foods might be and the Learning that they can tolerate that you know that they can tolerate it without then eating 30 brownies that they can handle whatever either psychological or physiological discomfort comes along with that and that it doesn't end up leading to you

know 20 30 pound weight gain which is often a fear associated with it and so once we hope people kind of cut out that part of the pattern usually the binging and the purging stop as a result it's kind of like you pulled Out that piece of the puzzle and now the cycle can't maintain itself and so then the next place we try to hit is really that initial body dissatisfaction or wanting to lose weight which we think has kind of led to the dieting to begin with and so there's two main ways in our

clinic that we try to approach that one is that we try to address what we call body checking and body avoidance behaviors so I think I talked about this a little bit earlier but oftentimes People with eating disorders will be doing different things to kind of check their bodies so it could be things like pinching the sides of their waists it could be things like having a certain pair of jeans off called skinny jeans that they try on to see if they've gained or lost we could be looking in the mirror at certain parts of

their body it could be weighing themselves really often so that's one kind of way of checking and then the Other thing that people often do sometimes in combination but sometimes flipping back and forth is going to the other extreme of avoiding so that could mean kind of not seeing people because you're afraid that they're going to notice you gained weight it could mean not wearing form-fitting clothing because you're afraid of what people are going to say we not go in places like the beach because you don't have to wear a bathing suit we think both

sides of That coin really keep people thinking a lot about their shape and weight leave them feeling really ashamed of their shape and weight and again that's kind of what's been driving the cycle the whole time so we try to tackle both of those so if you're checking things we try to help you do it less and if you're avoiding things again we try to expose you to them so go see those friends you haven't been seen get that out in the world you know things like that so That's one way we dress it but

then actually another way is that I find out we've developed a treatment called muir exposure treatment this is very exciting which i think is pretty cool grant today I'm a psychologist so basically the idea behind this is that body do we believe that body dissatisfaction is often maintained by two things that a person does when they look in the mirror one is that they're often not looking at the whole body but Rather they're focusing in on one or two what I call hot spots but usually areas they feel really uncomfortable about so common areas are

stomach or thighs but it can really vary from person to person so they're not seeing their whole self they're kind of zooming in on those parts they really dislike and when they zoom in on those parts they're describing it in really judgmental ways so this is fat this is flabby this is ugly and disgusting right so if I was Looking in the mirror every day and I was looking at the parts I hated about myself and I was saying those things I would feel really terrible about myself too and so my boss developed this treatment

called mirror exposure which is supposed to really help people break out of that pattern so you stand in front of a three-pound mirror and what you're asked to do is to describe your entire body so you're no longer just allowed to look at those New parts in non-judgmental language so I'm from DDT exactly it's taken from DBT and they are asked to do their whole body down and then up and while they're doing it we measure their anxiety levels or distress levels um with the idea that as you do it more and more ideal you'll

become less distressed by your body or the very least able to tolerate what happens when you look in the mirror and it's been shown to be a really really effective treatment for body Dissatisfaction not just for people with eating disorders but actually you know body dissatisfaction kind of is just common especially among women but certainly among them too and so it's a really nice treatment that we have that we feel like can reach a really broad range of people it was great what's really interesting to a couple points I was thinking as you were talking

was in terms of treating anxiety disorders with exposure yeah it's it's It's a people often don't understand what you were saying very clearly that it's facing the fear that it really is the fear that you're having the most so and so we do that with anxiety disorders and we do that with eating disorders okay it's a very powerful tool absolutely so we're I think what I want to stress is is that in looking for someone to to work with an anxieties or eating disorder a lot of the time someone with this experience exposure Response prevention

treatment is very important to find yes absolutely talking about that a little bit as well yeah absolutely um and you know that sometimes it it can be hard to find someone or can you have to send someone in in a price range that you're able to afford but the nice and sometimes there's research studies that are being conducted to they can afford free treatments so kind of going off a mere exposure we actually have a study At Sinai right now where you can receive free treatment either you would get a mere exposure treatment or a

different type of body image treatment um so that's a nice option especially for people who might not be able to afford otherwise it's a wonderful option yeah the other thing I was thinking about when we were talking but you know I think we've said this a couple of times now is is that um people benefit from these skills that Were teaching and and so we talk about you know people have mental disorders and they're very disturbed these are all misconceptions that people have then you know any kind of these these illnesses are actually just a

wide range of different types of behavior and so people struggle with things and they don't necessarily have they may not like their body but they may not have an eating disorder they may have experienced a lot of anxiety but they Now have anxiety disorders so sometimes these treatments or these techniques are very very helpful the DBT skills are I believe helpful for as you said for everybody yes so it's very important that you know just even learn some of these things is very it can enhance our lives in a lot of ways absolutely I can't

agree more so this mirror technique is actually something that sounds like people could really use yeah I think so absolutely A lot of application for it going down the road yes for sure so let's talk a little bit about treatment are actually how to get treatment more and what kind of treatments do are in terms of what levels of care are there for people with eating disorders we that's one of our terms levels of care but what what are we looking at we're talking about treatment how intense is it what do people get into in

terms of their wonder looking at this absolutely so you know I Think there's a range of treatment options for people who are suffering with eating disorders and it's based on a number of different factors so you certainly can pursue outpatient treatment which is typically meeting once maybe twice a week with somebody usually a kind of a psychologist or social worker or someone who has a master's who can provide kind of counseling services but then there can also be people like psychiatrists or Nutritionists involved as well then there's also kind of a slightly higher level of

care would be more of a day treatment or sometimes referred to as partial hospitalization and so usually that involves a longer duration of treatment so usually you're meeting several hours a day there might be individual therapy but also group therapy we supervise the meals which can be really helpful and then I think the Other option is in patient care and that's usually used if someone is either medically or psychiatrically unstable so you know unfortunately with eating disorders there are a lot of medical complications and so somebody might have electrolyte imbalances cardiac or heart irregularities things

where they really need someone to be monitoring them and so that might be one reason that they need to go inpatient another might be for psychiatric reasons they're worried That they might hurt themselves or feeling suicidal and so that's another reason that someone might go inpatient I say okay and and also one thing we haven't mentioned is that a lot of eating disorder patients have are often on medication absolutely and what and so when we're talking about medication of maddening we're treating some of the comorbid disorders such as anxiety and depression that go along with

the eating disorders yeah really what we're looking Exactly usually on you know the the kind of empirical basis for using medication specifically for eating disorders unfortunately is not very strong so to treat for example the anorexia nervosa itself or the bulimia nervosa itself there's sometimes evidence for ss4 selective serotonin reuptake inhibitors SSRIs maxilla exactly for those with bulimia nervosa but it's not considered kind of the first line a season but yes often for the comorbidity so the Depression anxiety people are often on medications so that's where psychiatrists certainly would be involved and you know oftentimes

there's kind of a collaborative team approach you know a true nutritionist can be very helpful as well this way we make sure that we're kind of taking care of all that goes into eating disorders right so we're really sometimes talking about a psychologist or a social worker we're talking about a psychiatrist a Nutritionist pediatrician or an adolescent medicine specialist or something along that line that will sort team of people to really help monitor someone that I guess it depends varying degrees on what level how its severe the person is struggling yeah absolutely you know I

would say also kind of going back to the different levels of care there's a specific type of treatment for anorexia nervosa and as the family B's treatment or Maudsley Method which is named after the mods in hospital in London where it was developed and in many ways was kind of developed as an alternative to hospitalization for patients with anorexia as long as they're medically stable and someone is monitoring them and that's actually a treatment we use really commonly at Mount Sinai and basically the idea behind it is that in some ways actually parents kind of

start to take the role of an inpatient staff Almost so they're put in charge of refeeding their child sitting with them at all meals and making sure that they eat enough with the idea that the eating disorder wouldn't allow their child to eat enough even if they wanted to in kind of the way that we do that is that is we talk about really separating out the child or the adolescent and the eating disorder with the idea that right now they're kind of seem to be overlapping and one in the same and that As treatment

progresses that ideally they're kind of pulled apart and so the idea is that parents are kind of guided to be extremely impactful and they're suffering and very firm towards the eating disorder so that basically you're creating an environment where there is zero tolerance for the eating disorder and we found that to be a really effective treatment you know unfortunately sometimes what can happen with anorexia nervosa is that you can be Hospitalized and Reif ed and weight restored and then can be released and and relapse and so one of the great benefits of a family based

treatment is that there's kind of no transition from hospital to real world it's all done in the real world ROM and so that's that's a treatment that that we're particularly I think passionate about and actually kind of speaking to anxiety disorders we've actually taken that treatment and kind of altered it so that it's almost More explicitly an anxiety model so you might find this really interesting it kind of speaks to the overlap I think between a lot of our areas of expertise and so basically again my boss developed and which are oscillating dr. Tom Hildebrand

okay he developed a treatment that is called FB te or exposure based family exposure family and basically what he kind of determined or hypothesis is that actually what's happening and family based treatment is That parents are really exposing their children to food but that's basically what's happening but it wasn't quite as exclusively talked about in traditional family based treatment and so as part of kind of this new treatment he developed basically what we do is that we present an anxiety model so the same way that if you had a spider phobia and you were asked

to be around spiders three to five times a day think about how many meals you have to eat if you ending you know An eating disorder and/or anorexia and you were asked to do that you would feel unbelievably anxious right all the time right and that could look like you would run away it could look like you would cry you could scream you could throw things right any of us I think all of us probably have things were afraid of and if you have to imagine being around that thing all the time and having like

your worst fears come true which might be something like gaining a Lot of weight you would feel really awful too right and so I think the nice one of the nice things about it is that it gives a really kind of clear explanation of what the person with anorexia is going through so that their family members can really understand um and we actually ask every family were to go around and talk about something they're really scared about so that they understand what it might be like for their sibling with their child and then We really

set it up like exposure so we have a kind of list of foods that the person might be scared of when we help them start to eat those foods in order of challenging or difficulty eating them and help them learn again to kind of tolerate the anxiety that comes up for them learn that they they can they can eat you no way that's healthy for them and be okay and so that's kind of a more novel treatment that we're using at Sinai that's really exciting yeah I think it's I mean again I'm biased but I

think mom and our experiences that families seem to really benefit from it too which is the most important thing well I think it just highlights a really important thing that we we really should say is is that when you think about individual therapy for any kind of mental health disorder or anything like that people there's this perception you go into an office you talk and then you Leave and it's so not that especially for children adolescents there's families are highly involved and really an integral part of the process and what we're talking about in dealing

with anxiety disorders and dealing with eating disorders is that the family plays a huge role both in sometimes maintaining disorder and and and keeping it alive in a sense of what I mean by that is sometimes it for example with anxiety if a child is avoiding something The parent may not want them to struggle so they help them to avoid not realizing that it's actually feeding the disorder of course when so as a result and with eating disorders there's a lot of similarities yes we're talking about getting the parents and the families involved to help

the child be able to overcome it but also to break some of the patterns in the family that are not working so well and leading to are helping the disorder to stay alive in a Sense absolutely and I think it's a really empowering message to parents to you know I've seen a lot of people come in and you know might feel extremely guilty about their child's eating disorder other people may have told them that they're the reason that they're eating disorder and you know what an awful experience that isn't so you know letting parents know

that what we believe that they are probably the most important component in their child's Recovery and that they can do this it's such I think a powerful experience for for parents and you know I think again if there's another message I can kind of convey to people as that you know there are treatments out there that can work and there are work with you know families to really help people overcome this you know I've seen it happen many times I'm sure you have too so ya know there is a lot of hope out there even

in the Darkest moments where you know and there's a lot of people out ever want to help and have the expertise to do so so I guess this would be a good point to talk about how do you find the right oh yeah right that's that so that's often tricky yeah people um so we talked a little bit about there's some time earlier on that there were some trials and medical centers for disorders but in general where do people go so um what are your Thoughts on that you know I think looking up in your

area again clinicians who do use empirically supported treatments you know I think that's really key and that can be in multiple different settings I think medical settings you know settings a child mind Institute you know where you know that you're getting kind of the highest level of care possible I think is kind of absolutely a first step absolutely and and and also being able To know that there's different like degree it's not it's not necessarily unaffordable like that insurance companies will pay for these treatments it's sometimes a little tricky to have it happen but it

does they will pay for these treatments so it's not necessarily going to break the banker or put somebody in bankruptcy or anything like that so right absolutely you know what I really would encourage people also to look into the option of clinical Research trials even beyond the mere exposure virtually doing another study at signing but we're looking at the use of a smartphone to help aid treatment for binge eating and bulimia nervosa um and so that offers free treatment as well I imagine that there's lots of different kind of hospitals University settings that might have

similar options so you know it does take some research but usually there's something that can be found out there yeah absolutely and Certainly as we're in New York City we're talking there's a lot of resources here in New York City and there may be some areas in the country where resources aren't necessarily as widely available but they're still people out there who can do treatment and consultant and help out with the situation absolutely and you know again depending on kind of you know individual circumstances there might also be Options for things like Skype sessions or

other ways that can you know if you're in an area where you don't have as much accessibility where you might be able to still get help from someone who's a little more at it g a-- graphically at a distance right now I think another place that people have you know the Internet can be a very scary place to look and find information for sure because there's a lot of sites out there that have a lot of scary not So accurate information so it's important to know what are some of some resources to be able to

go to to get more information on finding treatment and learning more about the disorder so of course the NIDA website yeah is an excellent place to find information on child mine org we have a wonderful host of different available articles information we also have a guide to parent for parents to get in good care for their children and soon enough we're Going to have a specific guide for eating disorders um so that we're really excited about that you also talked about there's a monthly website as well yeah there's a belief there's several there's one called

Maudsley parents org which i've heard very good things about and provides a lot of information about what you know Maudsley treatment looks like i believe it has people have fun through the program also speaking about it so that can be a really nice resource as Well our clinic montana eating a wheat deserts program has information on its website about eating disorders as well so that can be also another useful resource yeah absolutely i'm thinking also maybe Nami the National Alliance for the mentally ill absolutely a National Institute of Health NIH yo-yo clinic they have all

all these different websites have really good information and so there is information out there for people who are looking and Trying to find out how do they help their family member for sure it's the last thing we should talk about is how one of our main emissions at the child my message is talking about how to read to increase mental health care for children but also reduce the stigma talking about mental health care and so how do we do that in how what is your opinion um you know first of all I think it's such

a great mission I fully agree that That's probably one of the main things in the mental health field that we should be focusing on right now you know I think that kind of providing education to people and speaking about eating disorders or whatever other mental illnesses you want to bring to light is key so you know things like this which we're doing right now going to schools and talking about it I think the more people understand what eating disorders are I think the less stigma and shame Often is associated with them and also allows people

I think to get the help that they need there's been some research that the lag time between when someone first has bulimia nervosa I believe and gets treatment is something like seven plus years and that's incredible which is just awesome ya know I think you know that's one of the reasons I think it's so great that's EMI is making it a mission you know we we want to be able to get people in Sooner no one deserves to have to suffer right and I think that's really you know even with anxiety and mood disorders there's

sometimes huge lag time in the amount of time that a disorder is diagnosed bipolar disorder takes years sometimes to diagnose particularly and children and even an adult sometimes so it's there we really just have to continue to get the word out and it's it's very much in line with where we were talking about before you have to Face your fears and be able to look at the what's scaring you the most right in the eye and be able to look at that so yeah through these webinars and things like that and all these websites that

we're talking that there is information out there and let's get it out and talk about how to help these children adolescents and adults yes absolutely I think that's it for us so we're really excited and thankful to be here today absolutely