Eating Disorders Counselor Certificate Training Part 1


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Part of a 12 part series of courses at resulting in the receipt of a certificate in eating disorders counseling. Addresses bulimia, binge eating, anorexia, obesity. Uses The Body Betrayed by Zerbe and Brief Therapy with Eating Disorders by McDonald in addition to Dr. Snipes clinical experiences.

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Eating Disorders Counselor Certificate Training Part 1

  1. 1. Dr. Dawn-Elise Snipes PhD, LPC, LMHC, CRC, NCC Clinical Director, Unlimited CEUs for $99 per year. Copyright AllCEUs.
  2. 2. <ul><li>Patients with eating disorders whose diagnoses are confirmed by descriptive criteria pose the greatest therapeutic challenge to clinicians. </li></ul><ul><li>Other individuals who may not formally be diagnosed also struggle with feelings about their bodies and eating. In this way we find that the eating disorders actually occur on the spectrum and vary in severity in the general population. </li></ul><ul><li>For the eating-disordered patients, eating disorders may be the one island of mastery and hope for an individual who otherwise feels inadequate to engage life or other people. She is often lonely and struggles to find herself because her life experiences seems too confusing. </li></ul><ul><li>Patients are burdened with overwhelming and shameful body self-hatred which often render them able to confide their symptoms only after months of therapy. </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  3. 3. <ul><li>When rigid diagnostic criteria are used studies show that between 1% and 5% of the population has anorexia and it 2% to 18% had bulimia. These statistics fail to take into account the diagnostic continuum of eating pathologies. </li></ul><ul><li>The eating disorders are variable in their outcome. </li></ul><ul><li>Eating disorders may improve with treatment for sure. But relapse is very high over the long run. </li></ul><ul><li>Those who do regain their body weight or stop bingeing and purging may still be plagued by </li></ul><ul><ul><li>poor interpersonal relationships, sexual concerns, limited independence, depression, anxiety, and impaired attitudes toward eating and weight. </li></ul></ul><ul><li>Research has still not been able to identify with any degree of certainty which patients will consistently benefit from any particular treatment. </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  4. 4. <ul><li>Anorexia, Bulimia and Binge Eating Disorder have several things in common </li></ul><ul><ul><li>Food or control of food are used as a primary coping mechanism </li></ul></ul><ul><ul><li>The person has a morbid fear of obesity </li></ul></ul><ul><ul><li>A preoccupation with weight and appearance </li></ul></ul><ul><ul><li>Low self-esteem </li></ul></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  5. 5. <ul><li>Eating disorders differ from emotional eating and obesity in a couple distinct ways </li></ul><ul><ul><li>Emotional eating involves eating in response to negative feeling states, but does not drastically negatively impact a person’s psyche </li></ul></ul><ul><ul><li>Obesity involves simply overeating, but again does not drastically negatively impact a person’s psyche </li></ul></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  6. 6. <ul><li>Diagnostic Criteria </li></ul><ul><li>Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading or failure to make expected weight gain to maintenance of body weight less than 85% of that expected). </li></ul><ul><li>Intense fear of gaining weight or becoming fat, even though underweight. </li></ul><ul><li>Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight. </li></ul><ul><li>In postmenarcheal females (women who have not yet gone through menopause), amenorrhea (the absence of at least 3 consecutive cycles). </li></ul><ul><ul><li>Restricting Type: during the current episode of Anorexia Nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas) </li></ul></ul><ul><ul><li>Binge-Eating Type or 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) </li></ul></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  7. 7. <ul><li>Prevalance of Anorexia Nervosa: </li></ul><ul><ul><li>Anorexia Nervosa, occurs within the population at approximately .5% to 2%. Or between 1.25 million and 5 million people (Rader Institute) </li></ul></ul><ul><ul><li>A bimodal pattern of onset, occurring in people aged 14 and 18 years. </li></ul></ul><ul><ul><li>The disease is more common in industrialized countries where food is in abundance and emphasis is placed on slender body shape and overall thin appearance. </li></ul></ul><ul><ul><li>Although more common in women, with a female-to-male ratio of 10:1, approximately 15% of cases occur in men. </li></ul></ul><ul><ul><li>Anorexia nervosa is found mainly in the white (>95%) adolescent (>75%) populations of the middle and upper socioeconomic classes, although it can be observed in either sex and in people of any race, age, or social stratum. </li></ul></ul><ul><ul><ul><li>Jennifer DA Liburd, MD , Consulting Staff, Department of Pediatric Emergency Medicine, Bronx Lebanon Hospital Center </li></ul></ul></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  8. 8. <ul><li>Predisposing factors include the following factors that make a patient more vulnerable to developing an eating disorder: </li></ul><ul><ul><li>Female sex </li></ul></ul><ul><ul><li>Family history of eating disorders </li></ul></ul><ul><ul><li>Perfectionistic personality </li></ul></ul><ul><ul><li>Difficulty communicating negative emotions </li></ul></ul><ul><ul><li>Difficulty resolving conflict </li></ul></ul><ul><ul><li>Low self-esteem </li></ul></ul><ul><li>Precipitating factors relate most often to developmental tasks. </li></ul><ul><ul><li>10-14 years, this is related to sexual development and menarche, which is associated with a spurt in weight gain. </li></ul></ul><ul><ul><li>15-16 years, precipitating factors stem from independence and autonomy struggles. Ambivalence about growing up is present, and an abnormal transition from dependence to interdependence rather than independence occurs. </li></ul></ul><ul><ul><li>17-18 years, identity conflicts are more common. These patients do not make healthy transitions from leaving home to going to college or getting married. </li></ul></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  9. 9. <ul><li>Perpetuating factors maintain the eating disorder. </li></ul><ul><ul><li>Biologic issues refer to the signs and symptoms of starvation and to the aspects involved in refeeding the malnourished patient. </li></ul></ul><ul><ul><li>Psychologic issues encompass the coping strategies engendered by the eating disorders. </li></ul></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  10. 10. <ul><li>Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: </li></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>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) </li></ul></ul><ul><li>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. </li></ul><ul><li>The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months. </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  11. 11. <ul><li>Self-evaluation is unduly influenced by body shape and weight. </li></ul><ul><li>The disturbance does not occur exclusively during episodes of Anorexia Nervosa . </li></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>Nonpurging 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 </li></ul></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  12. 12. <ul><li>Between 19% and 40% of college age women display bulimic behavior full-blown BN affects about 6% of adolescent girls and 5% of college women </li></ul><ul><li>Of females who participate in gymnastics, dance, diving, as well as track and cross-country, 62% have been reported to have eating disorders. </li></ul><ul><li>Obsessive-compulsive disorder (OCD) is common in patients with bulimia; a dysfunction in the serotonin neurotransmitter system has been implicated in both </li></ul><ul><li>Bulimia is associated with personality disorders, particularly those featuring impulse control issues and rigid thinking (eg. borderline personality disorder). </li></ul><ul><li>Eating disorders usually develop in adolescence, but about 5% of people develop the disorder when they are older than 25 years. Peak onset of BN occurs at 18 years. </li></ul><ul><li>Tammy Foster, MD , Staff Physician, Department of Emergency Services, Mills-Peninsula Medical Center </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  13. 13. <ul><li>Chemical: </li></ul><ul><ul><li>Low serotonin levels. Since serotonin is involved in the development of satiety, these disturbances may contribute to the persistence of binge eating. </li></ul></ul><ul><ul><li>Increased levels of a pancreatic polypeptide PYY, suggesting that these patients have a higher level of appetite, even when given a normal diet. </li></ul></ul><ul><li>Psychiatric: Premorbid psychiatric disorders including affective disorders, anxiety disorders, and substance abuse. </li></ul><ul><li>Psychosocial and environmental </li></ul><ul><ul><li>The strongest risk factor in the development of bulimia is history of dieting. </li></ul></ul><ul><ul><li>Cultural factors: Most cases of BN originate in industrialized countries where food is plentiful and a preoccupation with thinness in women is present. </li></ul></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  14. 14. <ul><li>Obesity is another risk factor for bulimia. </li></ul><ul><li>Family </li></ul><ul><ul><li>A history of sexual abuse </li></ul></ul><ul><ul><li>A family history of eating disorder increases a child's risk from 2-20 times </li></ul></ul><ul><li>Interests and activities </li></ul><ul><ul><li>Certain athletes and activities place a high value upon thinness or weight. The bodies of participants in these activities are often in high-pressure situations, on display in front of crowds or judged in terms of body shape and weight. </li></ul></ul><ul><li>Megan A Moreno, MD, MSEd , Adolescent Medicine Fellow, Department of Pediatrics, Children's Hospital and Regional Medical Center </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  15. 15. <ul><li>Diagnostic Criteria </li></ul><ul><li>Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: </li></ul><ul><ul><li>Eating, in a discrete period of time (eg, within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances; </li></ul></ul><ul><ul><li>A sense of lack of control over eating during the episode (eg, a feeling that one cannot stop eating or control what one is eating). </li></ul></ul><ul><li>The binge eating episodes are associated with at least three of the following: </li></ul><ul><ul><li>Eating much more rapidly than normal </li></ul></ul><ul><ul><li>Eating until feeling uncomfortably full </li></ul></ul><ul><ul><li>Eating large amounts of food when not feeling physically hungry </li></ul></ul><ul><ul><li>Eating alone because of being embarrassed by eating </li></ul></ul><ul><ul><li>Feeling disgusted with oneself, depressed, or guilty after overeating </li></ul></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  16. 16. <ul><li>Marked distress regarding binge eating. </li></ul><ul><li>The binge eating occurs, on average, at least 2 days a week for 6 months. </li></ul><ul><li>Bingeing is not associated with the regular use of inappropriate compensatory behaviors (eg, purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia or bulimia. </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  17. 17. <ul><ul><li>Using Binges as a way to hide from their emotions, to fill a void they feel inside, and to cope with daily stresses and problems in their lives. </li></ul></ul><ul><ul><li>Binging can be used as a way to keep people away, to subconsciously maintain an overweight appearance to cater to society's sad stigma &quot;if I'm fat, no one will like me,&quot; as each person suffering may feel undeserving of love. </li></ul></ul><ul><ul><li>As with Bulimia, Binging can also be used as self-punishment for doing &quot;bad&quot; things, or for feeling badly about themselves. </li></ul></ul><ul><li>A person suffering with Binge Eating Disorder is at health risk for a heart attack, high blood-pressure and cholesterol, kidney disease and/or failure, arthritis and bone deterioration, and stroke. </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  18. 18. <ul><li> </li></ul><ul><li> Anorexia Stories </li></ul><ul><li> </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  19. 19. <ul><li>Psychoeducational, cognitive-behavioral and psychopharmacologic are of great help to 40 to 50% of all diagnosed anorexic and bulimic patients. </li></ul><ul><li>On the other hand treatment efforts fall short for large subgroup of patients with significant symptomatology. </li></ul><ul><li>Garfinkel and Garner 1982, found: </li></ul><ul><ul><li>at least 30% of the patients with anorexia nervosa were either dead as a consequence of their illness or were still chronically afflicted. </li></ul></ul><ul><ul><li>Even in those patients who had recovered their weight only 17 to 40% for symptom-free. Most continued to have severe obsessive, compulsive, or depressive symptomatology. </li></ul></ul><ul><ul><li>40 to 55% of the sample had persistent family problems </li></ul></ul><ul><ul><li>40% had unsatisfactory sexual lives or poor interpersonal relationships, depression, anxiety, phobias, or obsessive-compulsive disorder. </li></ul></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  20. 20. <ul><li>Some people have referred to eating disorders as psychosomatic disorders that is, at illness caused by psychological factors or stress as opposed organically based. </li></ul><ul><li>Before we explore eating disorders that some consider a psychosomatic disorder, we must first think for a moment about what transpires every day as we go about our business, interacting in the world through our bodies. </li></ul><ul><ul><li>Of all of the objects in the world, the human body has a peculiar status is not only possessed by the person who hasn't it also possesses and constitutes them. Our bodies quite different from on the other things we claim is our own. We can lose money, books, and even possessions and still remain recognizably ourselves, but it is hard to get any intelligible sense to the idea of a disembodied person. The body is the medium of experience in the instrument of action. Through its actions we shape and organize our experiences and establish our perceptions of the outside world from the sensations that arrive within the body itself.“ </li></ul></ul><ul><li>How is it that this statement can help us understand the development of eating disorders? </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  21. 21. <ul><li>Eating-disordered patients often have no way to express their feelings or to reduce inner tensions verbally (they are Alexthymic). </li></ul><ul><li>Complex affective experiences are channeled instead through their bodies. They often &quot;vomit up&quot; their feeling states that they can't talk about in words, or seek to negate their body and their feelings altogether through starvation. </li></ul><ul><li>Because of the early origin of these disturbances we might think of the problems as residing within the body that speaks for the patient in physical rather than verbal ways. </li></ul><ul><li>In what ways does the eating-disordered symptomatology coincide with the primitive Freudian defense mechanisms of displacement and sublimation? </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  22. 22. <ul><li>Symptoms of an eating disorder are techniques for psychic survival and substitute for the patient's inability to express themselves through language, fantasies, or dreams. </li></ul><ul><li>The main tool therapy has to offer them, verbal expression, must confront their Alexthymia. </li></ul><ul><li>Many patients are able to express themselves and they often reveal details of early betrayal and physical and sexual abuse, illicit substance abuse, and the burden of additional psychiatric disorders. </li></ul><ul><li>As they become able to tell their difficult stories we must listen to help them make sense of their distorted perceptions of themselves, their bodies and their worlds, and give words to what previously has been expressed through bodily functions. </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  23. 23. <ul><li>In treatment it is necessary to allow the patient to address the burdens in a manner that keeps her from becoming unbalanced. </li></ul><ul><li>Simply removing the symptoms at the expense of addressing any of the other issues will cause an imbalance and likely cause the patient to fail. </li></ul><ul><li>It is important to view the eating-disordered patients from a biopsychosocial perspective addressing the Alexthymia, emotional liability, any Axis I or Axis II disorders, medical or biochemical complications, interpersonal relationships, the recovery environment, motivation to change, cognitive impairments et cetera, and to understand how all of these factors play together to maintain homeostasis, as it is, in her world. </li></ul><ul><li>Discuss how these things create homeostasis and important things to consider in treatment planning. </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  24. 24. <ul><li>Sophie was a 17 year-old university student who presented for Bulimia after being in the &quot;pig out club&quot; she felt relieved and calm after occurred in the way she'd never known before. </li></ul><ul><li>Discuss why purging behaviors may produce a sense of calm. </li></ul><ul><li>In many eating-disordered patients purging behaviors are followed by a sense of calm as well as a sense of grief and remorse. To escape from this negative feeling state, eating-disordered patients often resort to bingeing and purging again leading to a negative downward spiral. </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  25. 25. <ul><li>The physiological effects of the eating disorder make the side effects of medication hard to monitor. </li></ul><ul><li>When the patient is actively purging, drugs may not be adequately absorbed so there's little benefit from the medication. </li></ul><ul><li>Binge purge episodes may be reduced in frequency by certain antidepressants. </li></ul><ul><li>Although overt symptoms may be reduced by the correct medication, it is only the beginning of treatment. The patient‘s symptoms are predicated on deeper struggles. </li></ul><ul><li>Discuss the various symptom “choices” and their potential meanings. </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  26. 26. <ul><li>Although clinical studies of depression and Bulimia have consistently linked the two conditions, researchers generally concede that bulimia is not a variant of depression. </li></ul><ul><li>Depression itself is common among ED patients because of </li></ul><ul><ul><li>their accompanying feeling of demoralization about their behavior </li></ul></ul><ul><ul><li>The resulting low self-esteem exacerbates self-hatred to the point that these individuals may feel totally lost, disorganized, and fragmented. </li></ul></ul><ul><ul><li>Although they may appear normal weight and in good health, they may in fact be starving in the face of plentitude leading to biochemical imbalances causing depression. </li></ul></ul><ul><ul><li>Depression can also result from a failure of impulse control and impaired interpersonal relationships. </li></ul></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  27. 27. <ul><li>Much research has demonstrated that as the eating disorder progresses social supports diminish because the individual spends more and more time alone bingeing and vomiting or starving and exercising. </li></ul><ul><li>It is important that everyone involved with the person with an eating disorder look carefully at all of the symptoms including irritability, poor sexual history, petty thievery, suicide attempts, and impaired social supports. As any of these may point the way toward a definitive diagnosis of the comorbid Axis I problem and lead to more effective treatment. </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  28. 28. <ul><li>Therapy should not overestimate or overvalue symptom control alone for these patients. </li></ul><ul><li>1/2 of those diagnosed as having an eating disorder are plagued by unexplained anxieties and are unable to relieve their inner tension, they want to get close to others but are afraid to. Often they will cry out for (but simultaneously reject) interpersonal relationships, even with family members. This contradictory behavior makes it difficult for other people including the therapist to reach out to them consistently. (Borderline-ish) </li></ul><ul><li>The mere management of symptoms cannot be equated with definitive treatment. </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  29. 29. <ul><li>1/3 to one half of all patients seeking treatment for eating disorders can also be diagnosed as having a personality disorder, the most common being borderline personality disorder. </li></ul><ul><li>Some well conducted research suggests that the statistic of 30% is too high and that the impairment in social relationships, destructive behavior, and difficulties with impulsivity usually found among people with BPD are best understood as sequels to the eating disorder itself or to an undiagnosed Axis I problem. </li></ul><ul><li>What does this mean for the clinician and how will it impact treatment? </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  30. 30. <ul><li>Borderline Personality Disorder is defined by the DSM IV as: </li></ul><ul><ul><li>A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following: </li></ul></ul><ul><ul><li>For each of the following criteria, we will discuss </li></ul></ul><ul><ul><ul><li>How these behaviors could come to be for the ED patient </li></ul></ul></ul><ul><ul><ul><li>How ED behaviors mimic BPD </li></ul></ul></ul><ul><ul><ul><li>What causes these behaviors in the ED patient </li></ul></ul></ul><ul><ul><ul><li>In what ways does the ED patient manifest the symptoms. </li></ul></ul></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  31. 31. <ul><li>These &quot;frantic efforts&quot; can include: </li></ul><ul><ul><li>verbal violence </li></ul></ul><ul><ul><li>sudden exaggeration of physical maladies requiring caretaking </li></ul></ul><ul><ul><li>accusations of abuse </li></ul></ul><ul><ul><li>physical blocking of exit pathways to the partner </li></ul></ul><ul><ul><li>threats to children or intimate bystanders </li></ul></ul><ul><ul><li>suicidal intimations or blatant threats of self-harm </li></ul></ul><ul><ul><li>threats to expose actual damaging information shared in confidence </li></ul></ul><ul><ul><li>threats to expose fictitious damaging information </li></ul></ul><ul><ul><li>threats to destroy, or actual destruction of cherished possessions </li></ul></ul><ul><ul><li>threats of sexual infidelity </li></ul></ul><ul><ul><li>threats of divorce </li></ul></ul><ul><ul><li>compulsive revelation of sexual infidelities </li></ul></ul><ul><ul><li>threats of legal retribution </li></ul></ul><ul><ul><li>physical attack/abuse </li></ul></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  32. 32. <ul><li>A black-and-white pattern of relating to others -- often called the abandonment/engulfment cycle </li></ul><ul><li>intimacy and trust have an inversely proportional relationship </li></ul><ul><li>Unable to retain a balanced view of the other person causes the BPD to “split” the other person </li></ul><ul><li>All arguments begin and end with an assignment of blame to the other participant(s) </li></ul><ul><li>express their emotional ambivalence via withholding or rationing of affection. The &quot;Borderline Sulk&quot; manifests as an age-inappropriate, aggressive walling-off from all communication with loved ones </li></ul><ul><li>Dr. Jekyll/Mr. Hyde persona </li></ul><ul><li>Borderlines primarily split themselves </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  33. 33. <ul><li>Chameleon-like quality consistently seeking external validation of their self-value </li></ul><ul><li>Assimilation into a group with strict guidelines and principles (military, religious or even Greek organizations) can substitute for this acceptance. </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  34. 34. <ul><li>There is some biochemical evidence that the same neural pathways involved in BPD are also those which can render a person prone to addictions of all kinds. </li></ul><ul><li>Eating disorders (in particular) and impulsive behaviors such as spending sprees, shoplifting, gambling or hair-pulling are often comorbid with BPD. </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  35. 35. <ul><li>Direct tissue/bodily self-injury </li></ul><ul><li>Refusal to care for self putting self in harm’s way </li></ul><ul><li>Frequent and excessive plastic surgeries </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  36. 36. <ul><li>It is quite common for someone with BPD to feel literally suicidal one moment, and an hour later feel &quot;fine&quot; and wonder what all the fuss is about. </li></ul><ul><li>There is a marked tendency towards drama and chaos </li></ul><ul><li>The person with BPD is not often capable of identifying their own internal or external triggers </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  37. 37. <ul><li>Borderline &quot;emptiness&quot; is often confused with boredom or depression. </li></ul><ul><li>Lacking a sufficiently mature sense of self, or identity, a person with BPD is highly likely to fall into a lethargic, painful dysphoric state in which nothing and no one seems appealing. </li></ul><ul><li>Borderline &quot;emptiness&quot; is often frantically assuaged with the acquisition of material possessions or money, work/school, adrenalin-seeking behaviors and addictions or eating disorders. </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  38. 38. <ul><li>Only a few &quot;primitive&quot; emotions are easily accessible to someone suffering from BPD---Why??? </li></ul><ul><li>The person with BPD tends to dissociate during periods of rage, during which they are not responding to the current surroundings and situation, but rather to a traumatic incident in their past. </li></ul><ul><li>Rages are in general brought on by a triggered suspicion of abandonment or an intimation of criticism/invalidation </li></ul><ul><li>Rages can be turned inwards as self-destructive behavior </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  39. 39. <ul><li>Chief among these is dissociation, or the subjective re-playing of past traumas in present scenarios. A tone of voice, sound, sight or smell may 'trigger' the dissociation </li></ul><ul><li>Most Borderlines suffer from the belief that people are fundamentally ill-willed towards them and will ultimately betray and abandon them. </li></ul><ul><li>Paranoid ideation can include the temporary conviction that loved ones are poisoning, illicitly harming, or (quite common) committing infidelities behind the Borderline's back -- all despite overwhelming objective evidence to the contrary. </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  40. 40. <ul><li>1. Emotional vulnerability. Individuals with BPD have severe difficulty in regulating negative emotions -- including sensitivity to negative emotional stimuli, emotional intensity, and a slow return to an emotional baseline. 2. Self-invalidation. Individuals with BPD have unrealistically high standards and expectations for self with a tendency to invalidate or fail to recognize emotional responses, thoughts, beliefs, and behaviors. 3. Unrelenting crises. Individuals with BPD often engage in &quot;parasuicidal&quot; behavior and/or set up scenarios which require they be rescued </li></ul><ul><li>4. Inhibited grieving. Individuals with BPD are often unable to cry or express strong sadness appropriately. 5. Active passivity. Individuals with BPD fail to engage actively in solving their own life problems while actively soliciting problem solving from others. 6. Apparent competence. Individuals with BPD often appear more competent than can be demonstrated through their behavior or accomplishments. </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  41. 41. <ul><li>'One law for me, another for everyone else' </li></ul><ul><li>The BPD will retain an emotional memory of others based solely on the most recent interaction </li></ul><ul><li>&quot;Feelings Create Facts&quot; </li></ul><ul><li>&quot;Attention is a Zero-Sum Game&quot; If someone else receives praise or notice, Borderlines fear that there will be less to go around. </li></ul><ul><li>The intense fear of abandonment, usually applies only to those with whom the Borderline is emotionally intimate , therefore the 'outside world' often sees no irrational behaviors. </li></ul><ul><li>When that person is not physically present, someone with BPD slowly loses an 'sense' of that person's existence. Which leads to calling excessively, to inappropriately &quot;check up&quot; on their loved one's, to keep small physical mementos with them at all times, or to insist that they see the partner in person at frequent intervals. </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  42. 42. <ul><li>This questionnaire provides set of 20 &quot;Assumptions&quot; have been the most commonly affirmed by those diagnosed with BPD: </li></ul><ul><li>How do you think these assumptions came to be in the eating disordered patient and how will they impact your therapeutic relationship? </li></ul><ul><li>1. I will always be alone. 2. There is no one who really cares about me, who will be available to help me, and whom I can fall back on. 3. If others really get to know me, they will find me rejectable and will not be able to love me; and they will leave me. 4. I can't manage by myself, I need someone I can fall back on. 5. I have to adapt my needs to other people's wishes, or they will leave </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  43. 43. <ul><li>6. I have no control of myself. 7. I can't discipline myself. 8. I don't really know what I want. 9. I need to have complete control otherwise things go completely wrong. </li></ul><ul><li>10. I am an evil person and I need to be punished for it. 11. If someone fails to keep a promise, they can no longer be trusted. 12. I will never get what I want. 13. If I trust someone, I run a great risk of getting hurt or disappointed. 14. My feelings and opinions are unfounded. 15. If you comply with other’s requests, you run the risk of losing yourself. 16. If you refuse someone's request, you run the risk of losing that person. </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  44. 44. <ul><li>17. Other people are evil and abuse you. 18. I'm powerless and vulnerable and I can't protect myself. 19. If other people really get to know me they will find me rejectable. 20. Other people are not willing or helpful. </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  45. 45. <ul><li>1. It is a dire necessity for adult humans to be loved or approved by virtually every significant other person in their community. </li></ul><ul><li>2. One absolutely must be competent, adequate and achieving in all important respects or else one is an inadequate, worthless person. </li></ul><ul><li>3. People absolutely must act considerately and fairly and they are damnable villains if they do not. They are their bad acts. </li></ul><ul><li>4. It is awful and terrible when things are not the way one would very much like them to be. </li></ul><ul><li>5. Emotional disturbance is mainly externally caused and people have little or no ability to increase or decrease their dysfunctional feelings and behaviors. </li></ul><ul><li>6. If something is or may be dangerous or fearsome, then one should be constantly and excessively concerned about it and should keep dwelling on the possibility of it occurring. </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  46. 46. <ul><li>7. One cannot and must not face life's responsibilities and difficulties and it is easier to avoid them. </li></ul><ul><li>8. One must be quite dependent on others and need them and you cannot mainly run one's own life. </li></ul><ul><li>9. One's past history is an all-important determiner of one's present behavior and because something once strongly affected one's life, it should indefinitely have a similar effect. </li></ul><ul><li>10. Other people's disturbances are horrible and one must feel upset about them. </li></ul><ul><li>11. There is invariably a right, precise and perfect solution to human problems and it is awful if this perfect solution is not found. </li></ul><ul><li>In what ways do Ellis’ Irrational beliefs coincide with BDP beliefs? </li></ul><ul><li>In what ways do you believe these beliefs motivate the ED/BPD patients behaviors? </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  47. 47. <ul><li>Arbitrary Inference </li></ul><ul><li>Selective Abstraction </li></ul><ul><li>Overgeneralization </li></ul><ul><li>Personalization </li></ul><ul><li>Magnification/Exaggeration </li></ul><ul><li>Polarized Thinking </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  48. 48. <ul><li>While maintaining the focus on behavioral control of the eating disorder and prescribing appropriate medication for any biological or medical elements, clinicians must still attend to the developmental causes and psychological cost of each of the diagnosed difficulties. </li></ul><ul><li>Treatment for a patient actually begins by </li></ul><ul><ul><li>helping her to avoid fleeing her difficulties </li></ul></ul><ul><ul><li>helping her to learn how to focus on what they are so she can begin to place them in proper perspective. </li></ul></ul><ul><ul><li>Helping her take care of herself </li></ul></ul><ul><li>Such patients are often poor caretakers of themselves. They refuse to follow their meal plans or take necessary medications and place themselves in jeopardy or spoil their successes at work. </li></ul><ul><li>What function does the self sabotaging behavior serve and/ or what motivates this behavior? </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  49. 49. <ul><li>Patients also have difficulty implementing good health practices without feeling selfish or deficient. </li></ul><ul><li>What exactly does this mean? Why do they feel selfish or deficient? And how could you approach it in therapy? </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  50. 50. <ul><li>People learn how to take care of themselves to having a good role model at home. </li></ul><ul><li>Children of parents who are chronically anxious, depressed, or hurtful may be unable to soothe or comfort themselves because they never got that soothing or comfort from their parents and never observed it. </li></ul><ul><li>Those without this modeling grow up looking, in a hit-or-miss fashion for different ways to find inner sense of calmness and relief from the tension and anxiety. </li></ul><ul><li>Without the capacity to feel comfortable with oneself the individual can never form meaningful relationship with others. The individual becomes anxious with a new challenge or irritable at the slightest criticism. Binge purge episodes may be the only times that seem tension free. </li></ul><ul><li>Explain why binge purge episodes may be the only times that seem tension free </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  51. 51. <ul><li>The eating disorder places the individual on a downward spiral metabolically and psychologically, socially, spiritually and environmentally. </li></ul><ul><li>Discuss all the direct and indirect ramifications of an eating disorder </li></ul><ul><ul><li>Emotionally </li></ul></ul><ul><ul><li>Cognitively </li></ul></ul><ul><ul><li>Physically </li></ul></ul><ul><ul><li>Socially/interpersonally </li></ul></ul><ul><ul><li>Legally/financially </li></ul></ul><ul><ul><li>Occupationally </li></ul></ul><ul><ul><li>Environmentally </li></ul></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  52. 52. <ul><li>Friend spouses and parents believe that when they confront the person who has an eating disorder they are hoping that person for their life on a better track &quot;tough love.&quot; </li></ul><ul><li>Untimely confrontations from others can often be disastrous and lead to even more difficulty with the symptoms. </li></ul><ul><li>The reversal occurs because the individual must contain more anxiety and shame and the only way to remedy their feeling is to engage in bingeing and purging. </li></ul><ul><li>Treatment that stresses from the outset other coping mechanisms, even those that may take time to develop and master, are often quite restorative and may be the first step in addressing multiple difficulties in rebuilding the self. </li></ul><ul><li>What is this mean in terms of treatment planning? </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  53. 53. <ul><li>By leaving the person with the one way they have found to survive, i.e. not stripping them of their bingeing and purging behaviors immediately, the person regains hope. </li></ul><ul><li>Why? </li></ul><ul><li>What else can you do to create hope that is not seen as patronizing? </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  54. 54. <ul><li>Impoverished parental relationships lead the patient to lack the capacity to soothe themselves and crave nurturance. </li></ul><ul><li>According to this book, it is recommended to the three sessions per week of group or individual therapy, and during times of stress, the opportunity to call the therapist and using writing a journal as a way to put their thoughts into words. </li></ul><ul><li>In what ways does this particular approach potentially foster dependency issues? </li></ul><ul><li>Can IOP be effective and not establish extreme demands on the therapist? If so, how? </li></ul><ul><li>What needs or functions is the therapist trying to serve? </li></ul><ul><li>Can you think of realistic alternatives to this which, by the way, is not paid for by insurance? </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  55. 55. <ul><li>What is the purpose of discussing the concept of the inner child with the clients? and potentially providing them with a transitional object to use in times of stress (for instance a blanket, stuffed animal, or other object) that can take the place of the therapist. </li></ul><ul><li>The inner child theory is based on the concept that when the child experiences overwhelming crises part of their psyche is stunted at the age at which that crisis occurred. In order to free of the psychic energy the grown person must reconnect with the child inside and act as the parent the child never had in order to assist the child in coping with the trauma. Much of this work can be found in the writings of John Bradshaw. </li></ul><ul><li>Do you believe that providing a transitional object, other than food, is appropriate, and what sorts of objects might you suggest. </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  56. 56. <ul><li>Although many of these patients lack adequate or emotionally available parents, or experienced overwhelming from as early in their life, is it necessary, or even healthy, for the therapists to try to assume this parental role? </li></ul><ul><li>In what ways can you assist the patient in becoming their own parent? </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  57. 57. <ul><li>In therapy the personal cost of the eating disorder and other psychological problems must continually be pointed out these patients. </li></ul><ul><li>The individual constantly relies on the eating disorder as if it is and will for evermore be her identity. </li></ul><ul><li>In what ways does the eating disorder serve a reinforcing purpose? </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  58. 58. <ul><li>Challenging the self construct is extraordinarily difficult. It means a new identity must be found, and mourning the loss of the old self. </li></ul><ul><li>This often mandates a mourning period of a year. </li></ul><ul><ul><li>All important holidays, anniversaries etc. must be traversed at least once for the mourner to adequately work through the loss of an important person—the self. </li></ul></ul><ul><ul><li>Additionally, many ED patients personify their eating disorder and hold fervent loyalty to Mia or Ana. She is their best friend and the only one who has not betrayed her. </li></ul></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  59. 59. <ul><li>In the mourning process, patients must </li></ul><ul><ul><li>Mourn the symptom itself and what it means. (including the personification if appropriate) </li></ul></ul><ul><ul><li>Learn to see the many ways eating disorder helped or even saved their lives </li></ul></ul><ul><ul><li>Identify the ways the disorder has been deceptive in their lives </li></ul></ul><ul><ul><li>Begin to build the strengths that will help them grapple with life more constructively. </li></ul></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  60. 60. <ul><li>Patients with eating disorders often struggle mightily to express their feelings through words. </li></ul><ul><li>To develop their identity they must learn to recognize and name and appropriately express the feeling states. </li></ul><ul><li>Helping the patient create her own &quot;menu of feelings&quot; is one of the foremost tasks of therapy. </li></ul><ul><li>The first forays into naming feelings often come not in verbal modes themselves, but in other ways such as art, collages, painting, music, or movements. </li></ul><ul><li>What are some examples of some themes or activities you could give a patient with an eating disorder to assist her in identifying her feelings, mourning the loss of the pathological self and/or integrating that self within the healthy new self? </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  61. 61. <ul><li>Emphasis on alternative means of expression also enables patients to employ their raw energies in a constructive activity via the defense mechanism of sublimation (the capacity to channel energies into constructive valued work) </li></ul><ul><li>This does not come easily for individuals who may have grown up without a daily routine or schedule, or modeling of appropriate coping skills. </li></ul><ul><li>The normal development of subliminatory channels typically lasts into early adulthood. </li></ul><ul><li>Most of these patients have little idea what they like or do not like. But usually focus on academic achievement honors and never come to terms with the value of having hobbies and using leisure time constructively. </li></ul><ul><li>How can you help patients discover what they like and learn to sublimate? </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  62. 62. <ul><li>Many of these patients experienced strong conditional love and a need to displace aggressive feelings because those at whom they are/were angry were also those were vital to her survival. </li></ul><ul><li>If patients begin to see that their feelings do not harm the therapist, who in fact returns for more sessions, they learn their anger may not be as dangerous as they believed it might be. </li></ul><ul><li>What is a caveat to that statement? (Hint: what would happen if the eating-disordered patients began expressing the anger towards the person at whom it is directed instead of the therapists?) </li></ul><ul><li>How does this ring or BPD symptomatology? </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  63. 63. <ul><li>We have discussed the range of Eating Disorders, touched on some of the basic problems faced by ED patients and, hopefully, “normalized” some of their behaviors for the therapist who can allow themselves into the phenomenological reality of the ED patient. </li></ul><ul><li>Think for a moment and discuss what it must be like growing up with an eating disorder. </li></ul><ul><ul><li>What are some things that you now know about the ED patient’s development? </li></ul></ul><ul><ul><li>Try to describe the “typical” ED patient emotionally, cognitively, physically, socially, occupationally and environmentally </li></ul></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.
  64. 64. <ul><li>Think about this for the upcoming weeks </li></ul><ul><li>Normal Person vs. Barbi </li></ul>Unlimited CEUs for $99 per year. Copyright AllCEUs.