This month’s meeting will review the article “Perceived Coercion and Change in Perceived Need for Admission in Patients Hospitalized for Eating Disorders.” The article was published in the American Journal of Psychiatry.
(Am J Psychiatry 2007; 164:108–114) by Angela S. Guarda, M.D.; Angela Marinilli Pinto, Ph.D.; Janelle W. Coughlin, Ph.D.; Shahana Hussain, M.R.C.Psych.; Nancy A. Haug, Ph.D.; and Leslie J. Heinberg, Ph.D.

From the article:

Ambivalence toward treatment is characteristic of eating disorders, and patients are often admitted to inpatient programs under pressure from clinicians, family, friends, educators, or employers. This study evaluated patient perceptions of the admissions process and perceived need for hospitalization and assessed whether these perceptions remain stable in the short term.

Breakfast will be provided. Please RSVP to lschwechel@pathwayclinic.com by Friday, July 23rd, so Rogers Memorial Hospital can plan accordingly for breakfast.

The group will be discussing an article by Melissa Whitelaw, B.App.Sc. (Phys.Ed.), B.App.Sc. (Hlth.Sc.), B.Nutr.Diet., A.P.D, Heather Gilbertson, Adv.A.P.D., Ph.D. Pei-Yoong Lam, M.B.B.S. and Susan M. Sawyer, M.D.

Does Aggressive Refeeding in Hospitalized Adolescents With Anorexia Nervosa Result in Increased Hypophosphatemia? Journal of Adolescent Health 46 (2010) 577–582

Concerns about refeeding syndrome have led to relatively conservative nutritional rehabilitation in malnourished inpatients with anorexia nervosa (AN), which delays weight gain. Compared to other programs, we aggressively refed hospitalized adolescents. We sought to determine the incidence of hypophosphatemia (HP) in 12-18-year-old inpatients in order to inform nutritional guidelines in this group.

A light breakfast will be provided. Please confirm your attendance  so Children’s Hospital can plan accordingly for breakfast. RSVP to Leah Schwechel by Friday, June 18. A copy of the article is available by request.

Journal Club provides an opportunity for members of the greater Milwaukee area’s professional eating disorders treatment community to discuss recent developments or trends in the field and to provide an opportunity for informal networking.

Family involvement is an important part of treatment in the eating disorder programs at Rogers Memorial Hospital and it offers an important opportunity for families to learn these benefits together and leave with a common vision. Thielke encourages the families she works with to venture out and follow the acronym “RECIPE” to begin that road to a more positive dining experience:

• R is for “Repair”- Take time to first repair your own thoughts and habits about food, nutrition, health, and weight. Remember the “practice what you preach” approach; did you eat breakfast today?
• E is for “Example”- Children learn by example, so eat your vegetables. It can take more than 10 times for a child to see a food before they accept it. Give you and your family permission to enjoy food. Don’t label foods as “good” or “bad.”
• C is for “Communication”- Communicate often about food and about life. The dinner table is a great place and time to turn off the TV and talk to each other.
• I is for “Internal”- Focus on the internal body, not the outside (weight, shape, etc). Focus on the internal values (compassion, kindness, and strengths). Ask how family members are doing. Don’t talk about disordered eating, behaviors, food, nutrition, or weight and exercise at the dinner table with those struggling with an eating disorder.
• P is for “Physical Activity”- Make physical activity fun and make it a family affair. It’s all about clearing the mind as well as needed for overall health. Try badminton, basketball, walking the dog. Or Thielke’s favorite: Grow a garden together as a family.
• E is for “Encouraging Healthy Habits”- Increase consumption of fruits, vegetables, and whole grains. Have children grocery shop with you. Include all family members when planning meals and cooking. Increase water consumption, decrease soda and juice consumption to ensure a more nutrient dense meal plan. Don’t use foods as rewards.

According to Thielke, following this “RECIPE” in any family can assist in an overhaul for everyone nutritionally and emotionally. Family members find that eating meals together can provide a time to actually listen to one another, a time to bond and create a healthier nutrient intake throughout the week.
By including the whole family in menu planning it gives them a sense of belonging and ownership and younger members may be more willing to try new foods, even making suggestions for fresh vegetables or requesting new favorites.

“When I was a girl, I had to ask to be excused before I could leave the evening dining table. At the time I didn’t realize that having meals with my family provided an atmosphere that would increase my self-esteem and teach me appropriate behaviors and manners,” Thielke said.

“Children learn from example. This can lead to guilty and shameful feelings for parents who are struggling with an eating disorder. It can also be an encouragement to reach the goals of recovery. Whether someone is struggling with an eating disorder or not, providing the example of good and positive behaviors surrounding food will contribute to an overall healthy atmosphere.”

“There have even been studies that show family meals can lower the incidence of depression. There are many advantages to organizing meals throughout the week, so make it a priority to start getting together at least four times a week,” she said. “As one of my current patients phrased it: ‘Dining room tables are not just for centerpieces’.”

“Mindful eating is about listening to hunger, fullness, and tastesatiety cues,”echoes Jean L. Kristeller, PhD,  professor of psychology at Indiana State University and co-founder of The Center for Mindful Eating with fellow co-founder Jennifer Fletcher, MEd, RD. Kristeller is currently in the data analysis process of a study on mindful eating funded by the National Institutes of Health and conducted in partnership with Duke University researcher Ruth Wolever, PhD.

A light breakfast will be provided. Please confirm your attendance. RSVP to Leah via lschwechel@rogershospital.org.
Journal Club provides an opportunity for members of the greater Milwaukee area’s professional eating disorders treatment community to discuss recent developments or trends in the field and to provide an opportunity for informal networking.

 Thought challenging is a supplemental technique used at Rogers Memorial Hospital in the treatment of residents who have co-occurring anxiety and eating disorders in the special dual diagnosis unit. This technique is used to lower the anxiety-producing thoughts which accompany their eating disordered behaviors. Generally, errors in thinking fall into two categories, overestimation and catastrophizing.

A probability overestimation error is when someone overestimates the likelihood of a bad event happening. A catastrophizing error is when someone blows out of proportion, magnifies, or catastrophizes how bad fairly likely events really are. Thought challenging addresses these errors.

Thought challenging has three steps:

• Identifying fears which keep them from engaging in anxiety provoking situations
• Identifying factual evidence which they believe supports the likelihood of their fears occurring, and
• Systematically examining the evidence identified to determine whether it truly supports the occurrence of feared consequences.

Learning to lower anxiety levels

Throughout their stay, residents cite their individual experiences with anxiety and construct their own arguments against feared consequences. The result is individualized and personally believable arguments they can use against their internal anxiety.

Members of Rogers Memorial Hospital’s eating disorders treatment team use thought challenging to target feared foods, binge foods, compulsive exercise, body checking behaviors, body avoidant behaviors, body image dissatisfaction and mealtime ritual behaviors, among other eating disorder symptoms.

Building upon successful experiences

Self-efficacy, or the ability of a person to feel competent and masterful in his or her journey toward the goal of recovery, is an important aspect of relapse prevention. Often this mastery is built upon previous experiences and examples of skillful responses to triggers and anxiety.

As a result of thought challenging, patients are able to feel more confident in their ability to encounter stressful situations and manage their thoughts and urges in a skillful and effective manner.

I had the honor of being a part of the NORMAL in Schools gala in February. It was a new experience for me, as I have not had the chance to speak directly with members of our community about eating disorders and art therapy.

The vast majority of the work I do as an art therapist at The Eating Disorder Center involves working on body image as well as challenging “eating disorder thoughts.” The art display offered an opportunity for gala attendees to get a better understanding about the benefits of art therapy for our patients.

Discovering art therapy

I was asked a lot of interesting questions and heard excellent feedback about the artwork displayed. I answered questions from people who were first learning about art therapy to those who wondered how eating disorders develop. I was pleased to see the level of interest shown by attendees who wanted to learn more about art therapy and eating disorders.

On the flip side, I was astonished by the existing need to better educate the general public about mental health disorders, treatment effectiveness and the types of treatment available. The main question I heard was “How does art therapy help?” As I explained that evening, the answer varies depending on the individual being treated.

Sharing the value of art therapy

Further explanations of the images on display helped gala attendees understand how creating an idea in art form gives individuals a way to see how their eating disorder influences their life. One piece contained an image of an egg resting on a nest. The nest, as protector, was nurturing the egg. When relating it to the eating disorder, it represented how the individual feels protected and nurtured by the eating disorder.

Some patients use artwork as a means to separate themselves from their eating disorder. The artwork is viewed as a separate object, representing the eating disorder, apart from themselves.

Many people were amazed by the resulting impact of the image, as I heard “Wow. That is a powerful image.”

Building awareness

Meeting and talking with so many people who are helping those struggling with eating disorders as well as those who struggle themselves was very moving. A personal highlight was meeting former Miss America Kirsten Haglund and seeing her perform a portion of the musical “Normal.”

My experiences at the gala continue to affect me as I reflect on our community’s enthusiasm to help fight a disorder that affects so many. It is encouraging to see the number of people who are willing to support each other.

This month’s meeting will feature an article by Rachel Bryant-Waugh, DPhil; Laura Markham, BSc; Richard E. Kreipe, MD; and B. Timothy Walsh, MD: Feeding and Eating Disorders in Childhood (Int J Eat Disord 2010; 43:98-111)

The club will also  review the literature related to the current DSM-IV-TR diagnostic criteria for feeding disorder of infancy or early childhood; pica; rumination disorder; and other childhood presentations that are characterized by avoidance of food or restricted food intake, with the purpose of informing options for the DSM-V.

A light breakfast will be provided.

Learning to lower anxiety levels increases success in recovery
From their initial assessment through the end of their stay, Rogers Memorial Hospital’s patients identify situations related to their eating and anxiety disorders that provoke intense levels of anxiety and assign an anxiety rating (on a 0-7 scale) to each of these situations. The higher the anxiety rating, the more difficult it is for these patients to encounter that situation.

Exposure in a prolonged and repetitive manner
Treatment teams at Rogers Memorial approach anxiety-provoking situations gradually. When patients are exposed to challenging yet manageable levels of anxiety (denoted by a rating of 3 on the 7-point scale), they are better equipped to resist engaging in harmful eating disorder behaviors such as restricting, bingeing, purging, and compensatory exercise.

Some patients fear certain foods, like pizza or ice cream, and anticipate unrealistic weight gain as a response to the consumption of their feared foods. The treatment team finds ways to build an experience of gradual exposure. Depending on an individual’s level of anxiety, the food may only be present in the room at first, but later is held or on the table.

Ultimately, a patient learns to overcome their fear and incorporate their feared foods into their individualized meal plans using a modified version of the exchange system similar to the one developed by the American Dietetic Association.

Anxiety levels decrease
Rogers Memorial’s patients get used to, or habituate to, their anxiety when they are exposed to that situation in a repetitive manner. Their anxiety levels decrease over time, and they are able to see that what they feared would occur in a given situation did not happen.

This gradual exposure approach is called Exposure and Ritual Prevention Therapy (ERP), which is a specific type of Cognitive-Behavioral Therapy (CBT). ERP has been shown to be the most effective in treating Obsessive-Compulsive Disorder and other anxiety disorders. This therapy is used extensively at Rogers Memorial because it allows patients the opportunity to confront their anxiety at a manageable pace, thereby increasing their self-confidence to continue their treatment.

Inarguably, self-efficacy is one of the best things patients can take with them when they leave treatment and continue with their aftercare.

NORMAL in Schools is an organization dedicated to education about eating disorders. Ticket information and details about the evening’s events are available in a downloadable flier, or by visiting the organization’s Web site.

National Eating Disorders Awareness Week is Feb. 21 through  27, 2010.

Master’s-level art therapists help residents challenge their physical and emotional body image distortions.



 Being in a safe, functioning environment where the expectation is to share your feelings and to get your needs met by asking, brings negative thought patterns to the forefront where they can be addressed.

Some examples of these negative thought patterns:

• I don’t deserve to get what I want or need.
• It doesn’t really make any difference; I really don’t care.
• I should be willing to sacrifice my own needs for others.
• Being emotional means being out of control.
• Letting others know that I am feeling bad is weakness.
• I don’t want to hurt anyone.

Hearing a peer in group therapy share thoughts similar to one’s own pattern of thinking allows the individual in treatment to see how common disordered thought patterns can be separate from their own sense of self. For example, a group member may see the personal qualities of a peer and see how that peer’s perception of self is affected by eating disorder thoughts patterns.

This awareness, along with advice offered to peers, often leads the individual to conclude, “I need to be willing to follow my own good advice.”

Healthy boundaries around emotional and behavioral responsibility are developed. These new experiences support the individual’s ability to change their interpersonal patterns and develop new ways of interacting with others.

Some examples of changing thought patterns:

• My wants and needs are important.
• I really do care, about myself and others.
• When I take care of myself, I have more to give to others.
• Sharing emotions is part of developing intimacy in relationships.
• Letting others know how I am feeling is investing trust in our relationship.
• Being a compassionate person means I am sensitive to how others are feeling but I am not responsible for how they feel.

Many new participants who were initially anxious about group therapy find a sense of safety and support within this environment. It is a place where secret thoughts and behaviors are shared and a sense of understanding and acceptance is discovered. Not only is the diagnosis of illness shared, but the need and the ability to change thoughts and behaviors.

Many within the first few days of treatment in the group therapy model will say, “It is such a relief to know that I am not alone.”