Download use DBT with ED patients? - St. Joseph Mercy Ann Arbor

Name of Speaker Lucene Wisniewski, PhD, FAED
Affiliation Case Western Reserve University & The Emily
Program
Title of Keynote Address: DBT in the Treatment of Eating
Disorder: How, Why and With Whom?
Dialectic Behavior Therapy (DBT) was originally designed
to treat chronically suicidal patients diagnosed with
borderline personality disorder. Recent empirical evidence
suggests that DBT may be an effective treatment for some
eating disorder (ED) patients. This keynote address will
review the research support, rationale and existing
models for using DBT to treat patients suffering from
disordered eating.
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Lucene Wisniewski, PhD, FAED
Clinical Integrity Officer
The Emily Program
Adjunct Assistant Professor
Case Western Reserve University
DBT in the Treatment of Eating
Disorders:
What?
Why ?
For Whom?
HOW?
What Is DBT?
• Marsha Linehan, PhD
• Originally - suicidal patients
– many suicidal patients diagnosed with borderline
personality disorder
• Combined CBT with mindfulness/acceptance
techniques
• Promising results
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What Is DBT?:
BPD Reorganized
•
•
•
•
•
BPD is a Disorder of Dysregulation:
Emotional
Interpersonal
Self
Behavioral
Cognitive
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Research on DBT:
randomized controlled trials
• Fewer and less severe incidents of suicidal
behavior
• Stay in therapy longer
• Fewer inpatient psychiatric days
• Cost effective
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What is DBT? the unique assumptions
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DBT Assumptions: Patients
• Patients are doing the best they can.
• Patients want to improve.
• Patients must learn new behaviors in all
relevant contexts.
• Patients cannot fail in DBT.
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DBT Assumptions: Patients
• Patients may not have caused all of their own
problems, but they have to solve them
anyway.
• Patients need to do better, try harder, and be
more motivated to change.
• For many patients, their current lives are
unbearable.
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DBT Assumptions: Therapy
• The most caring thing a therapist can do is
help patients change in ways that bring them
closer to their own ultimate goals.
• Clarity, precision, and compassion are of the
utmost importance in the conduct of DBT.
• The therapeutic relationship is a real
relationship between equals.
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DBT Assumptions: Therapy
• Behavioral principles are universal, affecting
therapists no less than patients.
• Therapists need support.
• DBT therapists can fail.
• DBT can fail even when therapists do not.
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• WHAT is the Structure of DBT?
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:
Four Primary Modes of Treatment
• Individual psychotherapy
• Group skills training
• Telephone skills coaching
• Team consultation
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DBT Structure
• Individual therapy
–Reinforce skills
–Motivation
–Year long commitment
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DBT Structure
• Weekly skills group
–Emotion regulation
–Interpersonal effectiveness
–Distress tolerance
–Mindfulness
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DBT Structure
• Telephone consultation
– In vivo skill coaching
– Skill generalization
– Decrease crisis behavior
– Decrease sense of conflict,
alienation, distance with
therapist.
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DBT Structure
• Consultation Team
– Help therapist morale
– Adherence to the treatment
– Adherence to consultation
team agreements (esp.
assumptions)
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WHAT are the Goals of DBT?
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Standard DBT Goals
• To assist patients to move themselves to a “Live
Worth Living”
• Decrease behaviors that interfere with
– Living (e.g. suicide and self-harm)
– Therapy
– Quality of Life
• Increase behavioral skills
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Stages of Treatment:
Dialectical Syntheses
Pre-treatment ►Commitment and Agreement
Stage 1:
Severe Behavioral Dyscontrol ► Behavioral Control
Stage 2:
Quiet Desperation ► Emotional Experiencing
Stage 3:
Problems in Living ► Ordinary Happiness/Unhappiness
Stage 4:
Incompleteness ► Capacity for Joy and Freedom
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WHY use DBT with ED patients?
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WHY is New Treatment Needed for
EDs?
• CBT and IPT:
– Multiple controlled clinical trials indicate
that these treatments are effective for BN
and BED.
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WHY is New Treatment Needed?
• However
• Treatment adherence problems
• Not successful for everyone
• Data for AN is limited
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WHY not just CBT?
• CBT designed for unwanted thoughts
• Binge/purge behaviors are usually unwanted
• Restrictive behaviors
– Positive emotional response
– Positive social response
– Sense of satisfaction and purpose
– Cannot assume the client and therapist share the
same outcome goals- weight gain, stopping
behaviors
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WHY DBT?
• ED patients have impaired emotion
regulation
• ED patients have specific problem
that can be targeted
behaviors
–
–
–
–
Restriction
Binge Eating
Purging
Compulsive exercise
•
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WHY DBT?
• Treatment for the treators
–ED patients can elicit strong emotions
• Strategies to reduce recidivism
– may be especially useful with AN
• Targets difficult to treat populations
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• FOR WHOM is DBT Indicated ?
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DBT for mild BN/BED
• DBT skills for BN or BED
– Safer, et al., 2012; Safer, et al., 2010;
– Safer, et al., 2001a, 2001b;
– Telch, et al., 2001; Telch et al., 2000.
Good results for BED: NICE, 2004
& Need more research!
For BN
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But what about multi-diagostic
patients?
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WK?
• Axis I
– Anorexia Nervosa
• Binge/purge
• Treatment History
– Major Depressive Disorder, in
• Axis II
– BPD
• Axis III
– Hypokalemia
– Prolonged QTC
– Bradycardia
– Hypothyroidism
– Eating Disorder
• Inpatient
partial
remission
• Residential
• Day Treatment
• Intensive Outpatient
• Individual Therapy
– Suidality/Depression
• Inpatient
• Day Treatment
• Individual Therapy
– CBT
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Scenario One:
The pt enters standard ED treatment
– Pros: staff is expertly trained to treat ED behaviors
– Cons: Staff not trained/tx protocols not designed to
manage comorbid suicidal/self-injurious behavior and
significant therapy interfering behaviors
Outcome: (1) Multi-diagnostic pts leave tx prematurely, feel
like failures, little therapeutic change (2) staff feel
frustrated, ineffective, burned out.
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Scenario Two:
The pt enters standard DBT for BPD tx
– Pros: staff is expertly trained to treat BPD and therapy
interfering behaviors
– Cons: Staff are typically not trained to manage ED
behaviors & related medical complications.
Outcome: (1) Multi-diagnostic pts may reduce therapy
interfering behaviors but the ED symptoms typically
remain strong (2) staff feel frustrated, ineffective, burned
out with ongoing ED symptoms
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DBT for Complex ED
• Full DBT for BPD with BN or BED
– Chen et al., 2008
• Full DBT for ED with BPD or
previous treatment failure
– Kröger et al., 2010
– Palmer et al., 2003
– Wisniewski et al., 2009
– Federici & Wisniewski, 2013
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When to Consider DBT for
Complex/Co-Morbid ED’s?
• Traditional ED treatment has failed
• Presentation: significant emotional
dysregulation
• Behaviors are treatment interfering
• Co-morbid BPD
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HOW to provide DBT for Complex/COmorbid ED
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• Comprehensive DBT For Complex
EDs:
• Combines CB techniques shown
• to be the cornerstone
• of empirically founded treatments
for EDs with DBT theory and practice.
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What does it mean to provide
Comprehensive DBT?
• Individual DBT psychotherapy
• Group DBT skills training
• Telephone skills coaching
• DBT Team consultation
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Comprehensive DBT for Complex EDs
CBT for EDs
DBT Strategies
Diary cards
Acceptance
Meal planning
BCA
Focus on emotion regulation
In Vivo Food exposure Change
Skills
Phone Coaching
Weight monitoring
Exposure
Non-judgmental stance
ED psychoeduction Cog Mod
Dialectical stance
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Think about this….
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Target 1
Life threatening behaviors
• Suicide/Non-suicidal self injury
• ED behaviors included when
imminently life threatening
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Imminently Life Threatening
Conditions in ED Clients
• Bradycardia
• Heart rate (e.g., < 40) generally warrants
hospitalization (Sachs et al, 2016)
• Prolonged QTc
• >470 needs daily ECG (Sachs et al, 2016)
• >500 requires hospitalization
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Imminently Life Threatening
Conditions in ED Clients
• Electrolyte Abnormalities (Mehler & Walsh, 2016)
– Hypokalemia (serum potassium <3.6)
– Hyponatremia (serum sodium <120-125)
– Metabolic alkalosis (bicarbonate >28)
• Chronic Ipecac Abuse
• Mallory-Weiss Tear
• Diabetic Keto-Acidosis
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Target II
• Therapy Interfering Behaviors
–Behaviors that interfere with
receiving therapy
–Behaviors that burn out therapists
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Behaviors that Interfere with Receiving
Therapy
• Non-attentive behaviors
– Cancel appointment/drop out
– Getting admitted to hospital
– Inadequate intake resulting in inattention during session
• Non-collaborative behaviors
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–
–
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Inability/refusal to work in therapy
Lying
Manipulating weight
Refusal to work on eating “in vivo”
• Noncompliant behaviors
– Not completing diary cards or homework
– Not bringing in food for therapeutic meal
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Behaviors that Burn Out Therapists
• Pushing the therapist’s personal limits
– Phoning too much
– Continuing to lose weight and refusing to collaborate
on weight maintenance or gain
• Behaviors that push the organizational limits
– Not waiting for therapist in the waiting room
– Vomiting in the lobby restroom
• Behaviors that decrease the therapist’s
motivation
– Slow progress
– Lying about intake
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Therapy-Interfering Behaviors for
Specific to those with ED
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Exercising against medical advice
Restricting intake before treatment
Involuntary vomiting
Misrepresenting weight (e.g., water
loading)
Refusing to be weighed
Weight loss when underweight
Hiding food
Omitting symptoms
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Quality of Life Interfering Behaviors
• ED behaviors when they are NOT life
threatening nor therapy interfering.
• Any other quality of life interfering
behaviors that are not imminently life
threatening
–e.g., unemployment, promiscuity,
prostitution, relationship
issues,substance abuse etc.
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DBT Group Skills Training
• Weekly 90 min group
• Takes 1 year to cover all skills twice
• Four Modules
– Mindfulness
– Distress Tolerance
– Emotion Regulation
– Interpersonal Effectiveness
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The function and context of an ED
behavior will determine in which target
it falls
e.g., restriction prior to a therapy
session
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Increase Behavioral Skills
Core Mindfulness Skills
Interpersonal
Effectiveness Skills
Emotion Regulation Skills
Distress Tolerance Skills
Treats
Identify Confusion & Emptiness
Identify emotions, hunger,
fullness non-judgmentally
Treats
Interpersonal Chaos & Fears of
Abandonment
Inability to identify and gratify needs;
ineffective assertiveness re: food
Treats
Labile Affect & Inappropriate Anger
Vulnerability to emotion mind re: food
Treats
Impulsivity & Suicidal Behavior
Eating disorder behaviors
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DBT Phone Coaching
• Provide contact BEFORE a problem behavior
occurs
– Decrease suicide crisis behaviors
– Decrease ED behaviors
– Increase generalization of DBT skills
– Decrease of conflict & alienation with therapist.
• NOT THERAPY!
Limbrunner, Ben-Porath & Wisniewski, (2011). Cognitive and Behavioral Practice 18, 186-195.
Wisniewski & Ben-Porath, (2005). European Eating Disorders Review, 13, 344-350.
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DBT Consultation Team
• Therapy for the therapists
– Weekly for 90 minutes
• Helps with adherence to model
• Decrease burnout
• Non-judgmental stance
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Data from our program
• Case Series Data (n = 7)
• Significant improvements with respect to the
frequency of:
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–
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–
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Suicidal urges/behaviors
Self-injurious behaviors
ED symptoms
Weight gain and nutritional stabilization
Therapy Interfering Behaviors
Treatment retention
Collaboration
Federici & Wisniewski (2013)
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What our patients have said
• This is the first time I’ve eaten on my own outside of a
hospital.”
• “I learned to notice emotions and decipher them more
clearly, to managing urges from self-destructive behavior,
and to take greater self-responsibility.”
• “This was the first program that made me feel empowered
– all the other treatments took that away from me – they
made decisions for me, made me feel helpless. This
program believed that I could figure out my problems and
be skillful – that was the most important thing for me”
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Where does this leave us?
• Start with adherent CBT
– If unsuccessful…
• Modified DBT: Good for Mild BED/BN
– Use the manual!
• Comprehensive DBT: to be considered for comorbid/complex patients who have not been
helped by EBT for EDs
– Get trained!
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