Dori Zener, M.S.W., R.S.W Individual, Couple and Family Therapist. April 8, 2014

Transcription

1 Dori Zener, M.S.W., R.S.W Individual, Couple and Family Therapist April 8, 2014

2 I developed an eating disorder when I was just turning eighteen... A lot of things in my life were outside of my control and it was horrifying... I think it started off as control. I wanted to control something in my life - I couldn't work, so I couldn't help with our finances, I couldn't go out because I was scared to explore the city,... I've always been picky about food - the hypersensitivity makes me gag and feel physically sick if I put anything in my mouth a) I don't like the taste of, b) that has a texture I don't like (anything with pulp or bits in it, for example, freaks me out), or c) that consists of too many different textures/tastes (a burger with all the fixin's, a sandwich, curry, most pizzas, salads). Putting new foods in my mouth had always been a touchy subject for me... I'm guessing that if there is a link between AS and anorexia nervosa, it most likely either stems from the hypersensitivity to food, some form of self-harm from self-blame and guilt (it's hard to not know why you have no empathy, or why you can't make friends, or to deal with bullying), or because of needing to control something - anything - in your life. That's from my experience, anyway. (Mayhem, 2010)

3 Autism Spectrum Disorder (ASD) Women on the Spectrum Eating Disorders Overview ASD and Eating Disorders Implications for Treatment Discussion

4 Rudy Simone Temple Grandin Liane Holliday Willey

5

6 Affects 1-3% of women; 5-10% of those affected are male Anorexia nervosa Restricting or Binge/Purge Highest mortality rate of any psychiatric illness People with ASD symptoms are the most treatment resistant Bulimia nervosa Binge/purge Binge eating disorder (new to DSM 5) Compulsive over eating Avoidant/Restrictive Food Intake Disorder (ARFID) (new to DSM 5) Lack of interest in food due to sensory issues or history of negative eating experience No disturbance in way body weight or shape is experienced Typically diagnosed in children

7 Cause: previously viewed as sociocultural Genetics Research began in 1990s Runs in families, high rate in twins, family member with ED 7-12 times increased prevalence in families (Berrettini, 2004) Heritability increases during puberty Demographics: Previously thought to only impact affluent, high achieving Underdiagnosed in miniority populations Comorbidities (Weiner, 2012; Blinder, Cumella & Sanathara, 2006): Depression and anxiety 66% meet criteria across eating disorders, Obsessive Compulsive Disorder - twice as likely in AN restricting and binge purge than bulimiia Bipolar disorder, substance abuse seen in bulimia PTSD greater in binge purge Family mental health alcoholism on father s side, OCD, histories of depression Brain differences

8 When do people seek treatment? ED interferes with day to day life Inpatient & Day patient Goal: medical stabilization, weight gain, normalize eating Increasing exposure: at meals, make choices, planned risks Intensive Group therapy: CBT & DBT Individual therapy option

9

10 ASD overrepresented in AN (12-32%) ASD characteristics Sensory processing Coordination & body awareness issues (Nichols et al., 2009) Gastrointestinal issues (Simone, 2010) Medication side effects

11 Longitudinal Study (Anckarsater et al., 2012 ) Rates of ASD in AN Population n = 51 32% AN+ASD 68% AN-ASD Formal ASD Diagnosis 89% 11% n = 16 Formal Dx No Dx 18 years post treatment : AN + ASD group highest prevalence of personality disorders and lowest Morgan-Russell scores

12 Rigidity in behaviour and thinking Perfectionism Theory of mind deficits (Oldershaw, et al. 2011) Executive functioning challenges Comorbidities - mood and anxiety disorders Elevated systemizing, reduced empathy (Baron-Cohen, et al., 2013)

13

14 Trigger Emotion Dysregulation/Intolerance Binge Eating/Purging Restriction/Laxatives Self-injury/Suicide Substance Abuse Temporary Relief (Reinforcement)

15 Interpersona l Effectivenes s Emotional Regulation Mindfulness Distress Tolerance (Linehan, 1993)

16

17 Group Norms I realize extroverts or other personalities do well with 'free & full' expression, in more free-flowing spontaneous ways. To me, this feels like "the extroverts are hi-jacking" our meeting time. I prefer parameters to be well defined and well understood amongst the group (e.g. segment time limits; what is/isn't appropriate talking/sharing-wise; what would be a 'tangent' that would be best handled in a different time or place) Strategies Norms clearly defined, recorded, posted and enforced Parameters around who can speak, how long, structured turn taking Topics - what is and is not appropriate

18 I think I have a lot to contribute...but I have a hard time organizing, articulating, and presenting my thoughts. I function far better if I can prepare ahead of time, any of my contribution...thus, needing to know ahead of time where we're next going, etc, is very helpful All talking might be overwhelming to process and remember allow/encourage members to write down/take notes and ask for repetition/clarification Strategies Agenda sent prior to meeting to help formulate ideas Provide additional processing time Encourage participants to write during treatment Use multiple teaching techniques: reading, presentations, visuals, video, role play, practice sessions, partners, discussion

19 I think practice eating sessions or videos, sort of like social stories, might help some individuals. I need to see practical applications repeatedly to buy in to changes that are difficult. Difficulty multitasking...[listen + write + socialize + new task]. New tasks will be more overwhelming and harder to do when doing other things (even talking) at the same time Strategies Break down step by step (First...then...) Provide visuals of sequence video, images of steps Practice the skills in a supportive environment Video or photograph individual engaged in the steps Social Story Positive reinforcement

20 Strategies Warnings for transitions and changes to routine Soft classical music, nature sounds in background Movement breaks stretching, yoga, walking, jumping Fidget toys

21 Socializing Clear expectations about socializing outside of group time group or online forum to share ideas Resources Lending library Quiet room/snoezelen room Accommodations Modified treatment schedule Combined individual and group treatment

22 Screen for ASD characteristics Make group treatment ASD friendly Increase cognitive flexibility Introduce new special interests and systemizing areas Understand role of sensory sensitivities in eating behaviour

23

24 Anckarsäter H, Hofvander B, Billstedt E, Gillberg IC, Gillberg C, Wentz E, Råstam M. (2012). The sociocommunicative deficit subgroup in anorexia nervosa: autism spectrum disorders and neurocognition in a community-based, longitudinal study.psychological Medicine, 42, Baron-Cohen, S., Wheelwright, S., Skinner, R, Martin, J. (2001). The Autism-Spectrum Quotient (AQ): Evidence from Asperger Syndrome/High-Functioning Autism, Males and Females, Scientists and Mathematicians. Journal of Autism and Developmental Disorders 31, Baron-Cohen, S., Jaffa, T., Davies, S., Auyeung, B., Allison, C. Wheelwright, S. (2013). Do girls with anorexia nervosa have elevated autistic traits? Molecular Autism, 4:24. Berrettini, W. The Genetics of Eating Disorders. Psychiatriy. 1(3): Blinder, B.J., Cumella, E.J., & Sanathara, V.A. (2006).Psychiatric comorbidities of female inpatients with eating disorders. Psychosomatic Medicine, 68(3): Gillberg, C., Gillberg, I.C., Rastam, M., Wentz, E. (2001). The Asperger Syndrome (and High-Functioning Autism) Diagnostic Interview (ASDI): A Preliminary Study of a New Structured Clinical Interview. Autism 5, Kearns Miller, J. (2003) Women From Another Planet? Our Lives in the Universe of Autism. Linehan, M. (1993). Skills Training Manual for Treating Borderline Personality Disorder. NY: The Guildford Press.

25 Mayhem (2010). Re: Eating Disorders. Retrieved January 10, 2013, from Nichols, S. (2009). Girls Growing up on the Autism Spectrum: What Parents and Professionals Should Know about the Pre-Teen and Teenage Years. London, U.K.: Jessica Kingsley Publishers. Novotney, A. (2009) New Sollutions: Psychologists are developing promising new treatments and conducting novel research to combat eating disorders. American Psychological Association. Vol. 40 No. 4. Oldershaw, A., Treasure, J., Hambrook, D., Tchanturia, K. and Schmidt, U. (2011), Is anorexia nervosa a version of autism spectrum disorders?. Eur. Eat. Disorders Rev., 19: Simone, R. (2010). Aspergirls: Empowering Females with Asperger Syndrome. London, U.K.: Jessica Kingsley Publishers. Stoddart, K., Burke, L., and King, R. (2012). Asperger Syndrome in Adulthood A Comprehensive Guide for Clinicians. New York, N.Y.: W.W. Norton & Company Inc. The National Professional Development Center on Autism Spectrum Disorders. Evidence-based Practice Briefs. Retrieved from: Weiner K. (2012). Comorbid Diagnoses: When Other Illnesses Occur Alongside an Eating Disorder. Huffington Post. Posted: 08/10/2012 6:14 pm

26 An individual must meet criteria A, B, C and D: A. Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by all 3 of the following: Deficits in social-emotional reciprocity; ranging from abnormal social approach and failure of normal back and forth conversation through reduced sharing of interests, emotions, and affect and response to total lack of initiation of social interaction. Deficits in nonverbal communicative behaviors used for social interaction; ranging from poorly integratedverbal and nonverbal communication, through abnormalities in eye contact and body-language, or deficits in understanding and use of nonverbal communication, to total lack of facial expression or gestures. Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers); ranging from difficulties adjusting behavior to suit different social contexts through difficulties in sharing imaginative play and in making friends to an apparent absence of interest in people B. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following: Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases). Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change; (such as motoric rituals, insistence on same route or food, repetitive questioning or extreme distress at small changes). Highly restricted, fixated interests that are abnormal in intensity or focus; (such as strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests). Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment; (such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects). C. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities) D. Symptoms together limit and impair everyday functioning