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The Disconnected Self: Assessment and Treatment of Eating Disorders Tanja Haaland, LCPC Program Director Eating Disorder Center of Kansas City True or False? You can identify someone with an ED by looking at their appearance and observing what they do or do not eat • • • • Common assumption that only those who are visibly underweight have EDs About 70% of those with bulimia nervosa are normal weight Just because you see a person eat does not mean that they don’t have an ED Individuals struggling with EDs can become very effective at hiding the signs and symptoms Haaland, 2016 Eating Disorder Center of Kansas City True or False? EDs are an attempt to call attention to oneself • • Great lengths are often taken to conceal the ED due to feelings of shame or desire to hold on to the illness and the perceived sense of control it brings. People do not choose to have eating disorders. They are the result of complex biological, psychological, and socio-cultural factors. Haaland, 2016 Eating Disorder Center of Kansas City True or False? EDs are caused by unhealthy, unrealistic images in the media • While these factors can contribute to the development, the causes are multifactorial. • EDs have been documented in the medical literature since the early 1800s, when the “ideal” body shape differed from today. EDs are all about food and body image • Though the illness may start out as a desire to lose weight, they are mental illnesses that have little to do with food, eating, or appearance. • The eating symptoms and preoccupation with thinness are only symptoms of deeper psychological issues. Haaland, 2016 Eating Disorder Center of Kansas City True or False? Dieting is always harmless • Dieting is the #1 risk factor for developing an ED. Most EDs begin with a weight-loss diet. People can recover from an ED through willpower and just eating normally/restoring weight • Specialized ED treatment that incorporates medical, nutritional, and psychological treatment is essential for full recovery. • Early intervention with appropriate care can dramatically improve the outcome. Haaland, 2016 Eating Disorder Center of Kansas City Prevalence • Of patients coming to the attention of mental health professionals 90% female, 10% male • 90% of young women who develop an ED do so between ages of 12-25 • Between 5-20% of college females have eating disorders or disordered eating behaviors • More than 10% of adolescent girls and 3% of boys binge eat or purge at least once a week (Archives of Pediatric and Adolescent Medicine, June 2008) • Shame and secrecy of illness leads to denial, underreporting, misdiagnosis, and inadequate treatment Haaland, 2016 Eating Disorder Center of Kansas City Types of Eating Disorders • • • • Anorexia Nervosa (AN) Bulimia Nervosa (BN) Binge Eating Disorder (BED) Other Specified Feeding & Eating Disorders Haaland, 2016 Eating Disorder Center of Kansas City Anorexia Nervosa • Refusal to maintain body weight at or above a minimally normal weight for the age and height (e.g weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of the expected). • Intense fear of gaining weight or becoming fat, even though underweight. • Disturbance in the way in which one’s shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight. • In postmenarcheal females,amenorrhea, I.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen administration). Haaland, 2016 Eating Disorder Center of Kansas City Anorexia Nervosa • RESTRICTING TYPE: During the current episode of Anorexia Nervosa, the person has not regularly engaged in bingeeating or purge behavior (i.e. self-induced vomiting or the misuse of laxatives, diuretics, or enemas). • BINGE EATING/PURGING TYPE: During the current episode of Anorexia Nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e. self-induced vomiting or the misuse of laxatives, diuretics, or enemas). Haaland, 2016 Eating Disorder Center of Kansas City Prevalence for Anorexia Nervosa • 90% female • .5-1% of women ages 15-35 yrs old • Industrialized countries Haaland, 2016 Eating Disorder Center of Kansas City Course • • • • • Full recovery Relapsing course “Normal Weight Anorexia Nervosa” Chronic deteriorating course Death o Mortality rate >10% for individuals admitted to University hospitals, and >20% on 20 year follow up (Halmi) o Death most commonly results from starvation, suicide, or electrolyte imbalance Haaland, 2016 Eating Disorder Center of Kansas City Physical Exam Findings Normal response to starvation (famine) Bradycardia Hypotension Hypothermia – cold intolerance Amenorrhea Osteoporosis Low calcium intake and absorption Reduced estrogen secretion • Lanugo hair • Carotenemia • Refeeding Syndrome Phosphorus Liver function Haaland, 2016 Eating Disorder Center of Kansas City Bulimia Nervosa • Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: (1). Eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances. (2). A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating). Haaland, 2016 Eating Disorder Center of Kansas City Bulimia Nervosa • Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise. • The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months. • Self-Evaluation is unduly influenced by body shape and weight. • The disturbance does not occur exclusively during episodes of Anorexia Nervosa. Haaland, 2016 Eating Disorder Center of Kansas City Bulimia Nervosa • Purging Type: During the current episode of Bulimia Nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas. • Non-Purging Type: During the current episode of Bulimia Nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self induced vomiting or the misuse of laxatives, diuretics, or enemas. Haaland, 2016 Eating Disorder Center of Kansas City Prevalance of Bulimia Nervosa • 2-5% of young adult females • 29% of college students Haaland, 2016 Eating Disorder Center of Kansas City Course • Usually begins in late adolescence or early adult life • Often begins during or after a diet • Secretive - may take years to come to medical attention • Intermittent vs. Chronic Haaland, 2016 Eating Disorder Center of Kansas City Physical Exam Findings • • • • • • • Loss of dental enamel Russel’s sign Parotid enlargement “Chipmunk Cheeks” Subconjunctival Hemorrhages Esophagitis/Mallory Weiss Tears Cardiac Arrhythmias Ipecac Sequelae Haaland, 2016 Eating Disorder Center of Kansas City Laboratory Findings • Electrolyte abnormalities o K+, Na, Cl- • Elevated Bicarbonate (metabolic alkalosis) through vomiting • Metabolic Acidosis with laxatives • Elevated Serum Amylase (vomiting) Haaland, 2016 Eating Disorder Center of Kansas City Binge-Eating Disorder • Recurrent episodes of binge eating. An episode characterized by the following: o Eating in a discrete period of time, an amount of food that is larger than most people would eat in a similar amount of time o A sense of lack of control over the eating episode The binge episodes are associated with three or more of the following: • Eating much more rapidly than normal • Eating until comfortably full • Eating large amounts of food when not hungry • Eating alone because embarrassed about how much is being eaten • Feeling disgusted with oneself, depressed, or very guilt afterward Haaland, 2016 Eating Disorder Center of Kansas City Research—Best Practices for BED Patients American Psychiatric Association: • Shows 67% success rate with Cognitive Behavioral Therapy (CBT) therapy guidelines along with dietary support during active treatment. • Best practice is non-diet approach to stop binge eating and treat co-existing mental illness. • A variety of SSRI’s and tricyclic antidepressants have found to be associated with greater decreases in binge frequency. • Medication with CBT and nutritional counseling has significantly more weight loss than either one alone Haaland, 2016 Eating Disorder Center of Kansas City Research—Best Practices for BED Patients Kaiser Permanente Center for Health Research in Portland, OR : • • • Combined CBT, guided self-help with nutritional and therapeutic treatment for BED showed marked improvement over general therapy. 63.5 percent of participants had stopped bingeing. Six months later, 74.5 percent of program participants abstained from bingeing, compared to 44.1 percent in usual care. Haaland, 2016 Eating Disorder Center of Kansas City Binge Eating Disorder-Gastric Bypass Results—Gurze Study • GASTRIC BYPASS-8 YEARS LATER • At least 50% had disordered eating patterns reflective of BED. • Slightly more than half of the patients reported having disordered eating patterns. • 44% stated they required more follow-up to maintain weight loss through psychotherapeutic support and dietary planning. • At 8 year, authors reported successful and unsuccessful patients reported similar rates of problematic ED, depression and anxiety Haaland, 2016 Eating Disorder Center of Kansas City Other Specified Feeding & Eating Disorders Significant eating disorder Does not meet criteria for Anorexia, Bulimia or Binge Eating Disorder Purging Disorder Recurrent purging behavior to influence weight of shape in the absence of binge eating Atypical Anorexia Nervosa All of the criteria for AN are met except that despite significant weight loss, the weight is within the normal range Diabulimia (*not a DSM diagnosis) Diabetics who intentionally omit or manipulate their insulin intake in order to manage their weight Haaland, 2016 Eating Disorder Center of Kansas City Purging via Compulsive Over-exercise • Obligatory exercise to the point that it is unsafe and unhealthy • Some warning signs include: • Constant preoccupation or intrusive thoughts about exercise • Finding time at any cost to exercise • Feeling overly anxious, guilty or angry if unable to exercise • Lack of rest days from exercise even when injured and/or ill • Driven primarily by a desire to control weight, shape and/or body • Exercising as punishment for eating “bad” foods or to purge • Feelings about self become based on quantity and quality of exercise Haaland, 2016 Eating Disorder Center of Kansas City Comorbidity Drug and ETOH abuse Shoplifting Promiscuity Spending Binges Mood Disorders -Unipolar -Bipolar • Personality Disorders • • • • • Haaland, 2016 Eating Disorder Center of Kansas City Co-Morbid Conditions seen with Eating Disorders DIAGNOSIS Depression Obsessive-Compulsive Disorder % CO-MORBIDITY RATES 50-75% 10-13% (up to 25% in AN) Bipolar Disorder 12% Anxiety Disorders 43% Substance Abuse 12-18% (AN), 30-37% (BN) Haaland, 2016 Eating Disorder Center of Kansas City Eating Disorders in Men Bulimic symptoms and obsessive fitness practices more common Body Image in Males • • • • Shape vs. weight focused Compulsive over-exercise more common Desire for thinness and increased muscularity = Double Bind Increasing media messages regarding dieting, ideal of muscularity, and plastic surgery options such as pectoral, calf, and buttock implants (Nemeroff et al., 1994) Haaland, 2016 Eating Disorder Center of Kansas City Eating Disorders in Men • Some Risk Factors • • • Being overweight and being teased as a child Delayed maturation Gay male 12-23 yr olds 7x more likely to report bingeing and nearly 12x more likely to report purging than heterosexual males (Journal of Adolescent Health, September 2009) • Prevalence? • • 10% (Wolf,1991; Fairburn & Beglin, 1990). Less likely to pursue treatment Haaland, 2016 Eating Disorder Center of Kansas City Medical Consequences Dry skin and dehydration Hair loss/thinning Lanugo Low Blood Sugar Electrolyte Imbalance Cramps Impaired renal function/kidney infections Constipation Loss of muscle mass Low heart rate and BP Shortness of Breath Cold extremities Dental problems Rupture of esophagus Swollen glands (“Chipmunk cheeks”) Bloodshot eyes Damage to stomach lining Weakened immune system Loss of menstrual cycle, infertility Loss of bone density, Osteoporosis Heart arrhythmias and heart attack Coma and Death Haaland, 2016 Eating Disorder Center of Kansas City What Could Possibly Go Wrong? Anorexia has the highest mortality risk of any psychiatric disorder • Death rates can equal or higher than that of melanoma, prostate, testicular CA: 10-15%! • Many other serious complications short of death can occur • Yet, medical complications often not prevented or go unrecognized, untreated • Starvation affects every organ system o Nothing is spared • Clinicians should anticipate dysfunction of every organ system and evaluate indicators of those systems Haaland, 2016 Eating Disorder Center of Kansas City Eating Disorders--Definitions -From a medical perspective• Restriction (AN, ED-NOS) has its set of potential medical complications o Cardiac--bradycardia, QTC, PVCs, dysrhythmias, CHF, impaired structure & function, pericardial effusions, etc. o Dehydration, electrolyte disorders, hypothermia o Gastroparesis, SMA syndrome o Osteoporosis/osteopenia/growth delay Haaland, 2016 Eating Disorder Center of Kansas City Eating Disorders--Definitions -From a medical perspective• Purging (including exercise) (BN, AN w/ purging, ED-NOS) has its set of potential medical complications o GI Bleeding (stomach, esophagus, pharynx) o Boorhave’s S., Mallory-Weiss tears o GERD, ?Barrett’s esophagus & CA o Constipation o Intestinal paralysis (from laxative abuse) o Electrolyte disorders, dehydration o Aspiration, pneumothorax o Stress fxs, overuse syndromes w/ poor recovery • Limited “spare parts” for repair Haaland, 2016 Eating Disorder Center of Kansas City Brain/Neurologic Dysfunction • Psychiatric • Emotion--labile, blunted, or unable to describe it • Mood, affect • Personality o More OCD, BPD-like o “Unlike themselves”; “Used to be so pleasant, sweet” • Attention o ?ADD • “Can’t be sure what’s wrong in their head until they’re fed” Haaland, 2016 Eating Disorder Center of Kansas City Abuse-Mediated Vulnerability in the Development and Maintenance of Eating Disorders Extrinsic Factors Child Abuse •Sexual •Physical •Psychological •Other General Family Dysfunction •Chaotic •Conflict Laden •Enmeshed •Rigid Specific Environments •Familial/Peer •Overconcern •Teasing regarding weight •Appearance and Dieting Ongoing Development of Self Concept Temperamental Low resilience, mood labile Other focused Ongoing Vulnerability Deficits in Affect Regulation Eating Disorders Comorbid Conditions Intrinsic Factors Haaland, 2016 Eating Disorder Center of Kansas City Genetic Studies • Individuals with a mother or sister who had suffered from Anorexia Nervosa are: o 12 times more likely to develop Anorexia Nervosa o 4 times more likely to develop Bulimia Nervosa Haaland, 2016 Eating Disorder Center of Kansas City Single Genes vs. Multiple Genes • Anorexia & Bulimia Nervosa are complex disorders • Likely to be caused by multiple genes and environmental factors with varied effects • Similar to obesity • For Anorexia nervosa high risk genes most probably include traits such as: o Perfectionism o Orderliness • Low tolerance for new situations • Maturity fears • Low self-esteem • Overall anxiety Haaland, 2016 Eating Disorder Center of Kansas City Twin Studies Consistently Show: • A substantial genetic contribution to Anorexia Nervosa and Bulimia Nervosa, as well as the traits associated with these disorders • Unique environmental influences (e.g. trauma, participating in sports that emphasize thinness) have more significance than the shared environmental effects (e.g. socioeconomic status, religion, general parenting style) Haaland, 2016 Eating Disorder Center of Kansas City Single Genes vs. Multiple Genes • Anorexia & Bulimia Nervosa are complex disorders • Likely to be caused by multiple genes and environmental factors with varied effects • Similar to obesity • For Anorexia nervosa high risk genes most probably include traits such as: o Perfectionism o Orderliness • Low tolerance for new situations • Maturity fears • Low self-esteem • Overall anxiety Haaland, 2016 Eating Disorder Center of Kansas City However, even if an individual was at high genetic risk she might never develop Anorexia Nervosa if she: o Did not live in a culture such as ours which emphasizes dieting and thinness o Go on a diet herself o Have a high risk environmental influences Haaland, 2016 Eating Disorder Center of Kansas City It’s NOT just about food/body image: Some potential “adaptive” functions EDs function as coping tools for more serious and painful underlying issues and feelings: • Control • Comfort; soothing; nurture: secure attachment • Numbing; sedation; distraction • Discharge of tension; anger; rebellion • Predictability; structure • Self-Punishment • Avoidance of intimacy • Avoiding maturation • Feelings of inadequacy and desire for mastery • Fear of success and/or failure • Unresolved grief • Identity and lack of self-awareness Haaland, 2016 Eating Disorder Center of Kansas City Psychodynamic Functions of ED Symptoms Maine, McGilley, Bunnell, 2010 Rebel against a strict caregiver/superego and express autonomy Test the therapist to see if he or she will respond in the same way Displace anxiety or shame onto fears of weight gain or hatred for the body Avoid recovery because it is perceived as resulting in overwhelming demands for performance Avoid recovery because it is equated with becoming a narcissistic extension of the therapist Substitute self-destructiveness related to the ED for suicide Rid the self of an intrusive and/or abusive caregiver Preserve the relationship with the caregiver Defend against feelings of powerlessness and ineffectiveness Haaland, 2016 Eating Disorder Center of Kansas City Predisposing Factors Biological & Psychological Factors: • Genetic Predisposition • Early onset puberty • Increased BMI prior to onset • Co-morbid Psychological Disorders • Traumatic Event • Stressors/change • Temperament Social/Environment Factors: • Family/relationship dynamics • Family hx of severe dieting/exercise, negative body image (modeling) • Competitive academic/social environment • Sports that require a specific body type/weight • Cultural pressures for extreme thinness / hyper-muscular physique • Media messages and dieting culture Haaland, 2016 Eating Disorder Center of Kansas City Treatment Haaland, 2016 Eating Disorder Center of Kansas City SYMPTOM IS FUNCTIONAL SYMPTOM IS THE SOULUTION! Distorted Survival Strategies (Perceived Safety) Haaland, 2016 Eating Disorder Center of Kansas City Challenges in the Treatment of EDs Finding substitute coping strategies to replace eating disorder behaviors Harm avoidant temperament Rigidity and difficulty making shifts in thinking and behaving Alexithymia Identity linked to disorder Need for control Perfectionism interferes with trying new ways Haaland, 2016 Eating Disorder Center of Kansas City Where to begin Where to begin Establishment of trust Get addiction under control not as responsive to psychotherapy when in active addiction Normalizing brain function is necessary for effective psychotherapy and antidepressant efficacy “First we eat, then we talk.” –Walter Vandereycken Refeeding: significantly alleviates mood and anxiety regulation, allows antidepressants to work, and allows psychological issues to rise and be clarified (Brewerton, 2014) Haaland, 2016 Eating Disorder Center of Kansas City Requirements of effective psychotherapy Grossly intact brain function Ability to attend Ability to learn Motivation, willingness/readiness to change Supportive relationship(s) Body-oriented and mindfulness exercises are often a first step (Brewerton, 2014) Haaland, 2016 Eating Disorder Center of Kansas City BEWARE: Symptom substitution! Whack-a-mole! Binge to restrict, restrict to purge, SUD Goal of therapy: Take the rejected and disconnected aspects of the Self, and work to form an authentic whole. Haaland, 2016 Eating Disorder Center of Kansas City • Learning to contract o Power and control/dependence and mastery: avoid becoming the clients external locos of control, and help the client use contracts to selfregulate arousal and impulsivity o Commitments to recovery are more helpful than contracts “to” the therapist o Time-limited contracts are more helpful than general ones o Coping commitments are more helpful o A commitment must always be honored or a new commitment negotiated; ignoring broken commitments is “re-enactment behavior” on both the part of both the client and the therapist Haaland, 2016 Eating Disorder Center of Kansas City Lifetime PTSD in Subjects with Eating Disorders in the National Comorbidity Survey Replication (Huson J, et al., Biological Psychiatry 2007; 61:348) • • • • AN 10% BN 44% BED 25% Other Specified Feeding/ED 16% Brewerton, 2014 Haaland, 2016 Eating Disorder Center of Kansas City Primary or Secondary Trauma Condition? Primary: • The onset of the eating disorder symptoms— restricting, purging, binge eating—follows a traumatic experience • The roots of the eating disorder are directly related to the trauma/abuse Secondary: • The onset of the eating disorder precedes the traumatic experience Haaland, 2016 Eating Disorder Center of Kansas City Trauma Treatment 1) Stabilization and managing responses o Establishing safety (physical and psychological) o Psychoeducation o Managing trauma responses (skills) 2) Processing and grieving traumatic memories o cognitive-behavioral therapy (CBT) o eye movement desensitization reprocessing therapy (EMDR) o body-psychotherapy and Sensorimotor Psychotherapy 3) Reconnecting with the world Haaland, 2016 Eating Disorder Center of Kansas City Trauma Reenactment • Client attempts to work through the trauma because of three specific unrealized objectives (on a subconscious level): 1)Trying to understanding the experience 2)Trying to mastery the experience 3)Trying to distraction or manage mood with a stimulating but less threatening type of similar but controlled trauma (Van der Kolk, 1987) Haaland, 2016 Eating Disorder Center of Kansas City Trauma Reenactment Through ED Behaviors • Bingeing until nauseous or gagging • Threw up after abuse • Engaging in behaviors that feel shameful or secretive • Creating a dissociative experience Haaland, 2016 Eating Disorder Center of Kansas City Common mistakes made by therapists working with self-destructiveness o Not understanding the degree of relief associated with self harm o Not understanding that the care of the body is not a priority: when our body only matters as a vehicle for discharging tension, it’s care becomes meaningless o Not understanding that post-traumatic shame and secrecy make it feel “normal” to hide the extent of the self-harm even from the therapist o Becoming engaged in a struggle with the client around issues of safety in which the therapist becomes the spokesperson in favor of safety and the client the spokesperson in favor of self-harm, thereby neglecting the task of helping the client struggle with her own internal conflict Haaland, 2016 Eating Disorder Center of Kansas City Reframing the meaning of symptoms o Purpose of ED behavior: start with assumption that every symptom is a valuable piece of data o Look for what the symptom is still trying to accomplish: i.e. chronic suicidal feelings might offer comfort or a “bail-out” plan, cutting might help modulate arousal, social avoidance could be an attempt to avoid “danger” o Once it is clear what the symptom is trying to accomplish the therapist and the client can then work together to find other ways to accomplish the same goal in a context that describes the client as an ingenious and resourceful survivor, rather than as a damaged victim Celebrate the symptom! ~Sincere letter of gratitude Haaland, 2016 Eating Disorder Center of Kansas City Narrative Story Telling: NST • Repeated narration o Organization of trauma memory o Fear Reduction through habituation • Meaning analysis/contextualization o Revision of beliefs about self and others (trauma schemas are part of past versus present) o Integration of trauma memory into a life history o Exploration and resolution of feelings other than fear, shame, guilt, anger, and loss Haaland, 2016 Eating Disorder Center of Kansas City Art Therapy o Creates transitional object between self and therapist o Creates concrete awareness of the relationship between the trauma and the disorder eating symptomology o Provides a means to “tell” and externalize shameful material o Provides distance from the traumatic material o Enables identification, expression, and containment of emotions, Haaland, 2016 thoughts, and impulses Eating Disorder Center of Kansas City Difficulty in Assessing ED’s: Not always readily “seen” Normalization of behaviors Functioning well in other areas of their lives Denial, secrecy, lying, and shame Requires ongoing assessment as behaviors may change Careful assessment of self-harm, multi-impulsive behaviors and suicidal ideations (23x more likely to commit suicide) Haaland, 2016 Eating Disorder Center of Kansas City It Takes a Team: Collaboration between Professionals Psychiatry Individual psychotherapy Dietary Medical Family therapy Group therapy Milieu therapists (higher levels of care) Haaland, 2016 Eating Disorder Center of Kansas City Levels of Care • Level 1: Outpatient • Level 2: Intensive Outpatient (IOP)* • Level 3: Partial Hospitalization (PHP)* o 6 days/week, 8-10 hours/day • Level 4: Residential Treatment Center • Level 5: Inpatient Hospitalization • Level 6: Acute Medical ICU *offered at EDC-KC Haaland, 2016 Eating Disorder Center of Kansas City In Closing… • Eating disorders are complex disorders that are often invisible • Accompanied by significant medical and psychosocial costs • Understanding what lies beneath the struggle empowers action • Early intervention is key & recovery is possible with proper treatment Haaland, 2016 Eating Disorder Center of Kansas City EDC-KC is Partial Hospitalization Program o 6 days a week, 8-10 hour days, 2-3 meals a day o Sessions with: • Primary Therapist (2 x week), • Family Therapist (1 x week), • Psychiatrist (1 x week), • Primary Care Physician (1 x week), • Dietitian (1 x week), • Nurse Practitioner (daily), • Cooking Class with Chef, • And 55 hours of programming with MA level clinicians (including Art Therapist and Yoga/Movement Therapy) Apartment available for out of town patients Haaland, 2016 Eating Disorder Center of Kansas City Questions? Tanja Haaland, LCPC Program Director EDC-KC: 844.845.3922 Direct Line: 913.945.1282 [email protected]