TCPR: Dr. Yager, what is your procedure for evaluating patients with eating disorders?
Dr. Yager: Before I see patients for the first time, I have them fill out several questionnaires. I use the EDQ-9 (the eating disorder questionnaire, version 9), a copy of which we put into the Clinical Manual of Eating Disorders (Yager J and Powers P, APPI, 2007). I also ask people to fill out an elaborate life history questionnaire that I designed about a dozen years ago. This has an extensive family history, a psychodynamic history, an interpersonal history, a cognitive behavioral history, and an assessment of the patient’s beliefs about the nature and causes of their problems. I also obtain some basic screening labs, such as CBC, electrolytes, liver functions, thyroid stimulating hormone, creatinine, and BUN (blood urea nitrogen). Depending on the situation, I might also add lipids, serum amylase level (a crude marker of vomiting activity), magnesium (if there is a concern about laxative use), and, if they have had menstrual irregularity or amenorrhea for six months or more, I will order a bone density scan.
TCPR: How long is your typical evaluation session?
Dr. Yager: I schedule my first visit for two hours. In the case of adolescents, I ask their parents to come as well. I start by spending 15 minutes with the patient and parents, just to make sure that we all have the same goals for the assessment and treatment. Next I see the patient alone for about an hour, then the parents alone for 20 minutes, and then I bring everybody in together for a summary and planning session.
TCPR: We cover the latest evidence on medications for eating disorders elsewhere in this issue. Can you describe your non-pharmacologic approaches to treatment?
Dr. Yager: There are several different components, all of which are necessary to address. First is nutritional rehabilitation. I ask patients a series of questions to get at their attitudes toward food. I want to know “What are you eating? What should you be eating? What prevents you from eating appropriately? What are your obsessions about food and eating? What rituals do you engage in with your food preparation and eating? What underlying core beliefs about foods, eating and the impact of food on your body affect what you do? Are there certain foods that so freak you out that you can’t even come near them? Do you really need to be vegetarian? And is your vegetarianism based on religious or cultural attitudes that existed in your family before you even developed an eating disorder, or is your vegetarianism sort of a front for your eating disorder?”
TCPR: Do you have them monitor their food intake?
Dr. Yager: Yes, but I frame it in terms of asking them to become more self-aware, a kind of “Zen 101.” I’ll ask patients to record what they eat and to bring in a diary so we can estimate both the kind of food and the quantity of food. I show them websites with what are called “metabolic equivalence tables (METs),” which tell them what their caloric expenditure will be for certain kinds of activity and what their nutritional needs are (one is available from the Centers for Disease Control at http://tinyurl.com/ccr8gf).
TCPR: Do you recommend any workbooks for patients to monitor their diet and activity?
Dr. Yager: There are several educational and cognitive-behaviorally oriented books that have a therapist and a patient version so you can work through these issues together. I recommend Overcoming Eating Disorders by Stewart Agras and Robin Apple, Eating Disorders: The Journey to Recovery by Laura Goodman and Mona Villapiano, and, for patients with bulimia nervosa, binge eating disorders and even anorexia nervosa of the binge eating/purging subtype, one by Chris Fairburn called Overcoming Binge Eating. A great website is http://www.gurze.com which is a publishing and distributing company that specializes in eating disorder resources. For patients, I also suggest looking at the National Eating Disorders Association website (www.neda.org). For professionals, there is the Academy of Eating Disorders, and its website, www.aedweb.org, which will identify clinicians in your area who specialize in eating disorders.
TCPR: So what is the next phase of treatment of eating disorders after nutritional rehab?
Dr. Yager: Then I focus on the self-destructive eating disorder behaviors, such as binging, purging, and excessive exercising. I use a basic cognitive behavior therapy approach to modifying these behaviors. I’ll say, “Let’s be honest, and let’s see how often you are doing these things and let’s try to identify some of the triggers.” I’ll typically go through a basic “ABC” behavioral analysis, identifying the Antecedents, the Behavior, and the Consequences.
TCPR: Can you give me an example of a behavioral approach?
Dr. Yager: One of my most successful treatments was with a celebrity in LA. This was a women in her 30s who had had severe anorexia nervosa with binge-purge behavior for 15 years by the time I first met her. She had tried all kinds of treatments with various medications and psychotherapies, but nothing had worked with her. So I did a very rudimentary kind of behavior therapy, similar to what I would do with my grandson to get him potty-trained. I said, “Let’s start out by your committing to one day in the month when, by hook or by crook, you are not going to starve yourself or purge. You are going to white knuckle it through the day and then you are going to give yourself a happy face on the calendar.” She said it was very hard but she knew that the day afterwards she could do anything she wanted with eating and purging, so she was able to do it. And then we simply progressively worked through the weeks by adding more happy faces to her calendar. It took two to three months and she was totally symptom free by that time. It was remarkable. I think you have to sometimes use creative gimmicks in this business to explore various approaches. Some strategies that work with some patients won’t work at all for others, and the trick is individualizing and finding the leverage points for each patient.
TCPR: This is fascinating. Do you have another example?
Dr. Yager: I had one patient, a college student in her 20s, for whom the idea of touching anything containing fat – let alone eating it – induced a panic attack. So I had her bring a little bottle of olive oil into my office. I desensitized her first by just having her fingers rest in olive oil. It may sound silly, but in fact she had this phobic fantasy that her body would soak up olive oil and that the olive oil absorbed through her skin would immediately turn into fat globules in her blood stream. So desensitizing her to that fear then allowed her to imbibe some olive oil, and that step then began to break her eating disorder cycle. I once had another patient, a woman who weighed 86 pounds, who felt comfortable eating only in my office – nowhere else. My office became the only safe place that she experienced. She was actually able to eat ice cream in my office without purging it afterwards. So I had my secretary allow her into my empty office during hours I wasn’t there so that she could come and eat, which she did several times a week, and this practice gradually helped desensitize her so that she could ultimately eat elsewhere without purging as well. The key in all these cases is to discover the “thought chains” and the “fantasy chains” that lead patients to harm themselves and avoid healthy behaviors. Then you design individual behavioral programs to help patients break those chains so they can move ahead.
TCPR: Do you give patients homework assignments?
Dr. Yager: I generally do, but the nature of the assignment varies dramatically. The homework may be to go out and meet somebody, or it may be to do self-monitoring, or to say something five times in front of the mirror, or to be nice to your mother tw days a week so that she doesn’t want to kill you. Or in some cases, when there is a chronically destructive ongoing family dispute, I will ask the patient to get a tape recorder and put it in the middle of the kitchen table. The rule in that intervention is that anybody in the family can turn on the tape recorder at any time, and then they have to bring the tape in so that I can hear it. This assignment has the function of increasing self-monitoring and self-awareness so that people recognize what they sound like and what they are doing to each other. It shows them how the criticism in the family may be destructive and often gets people to own what they are doing to one another.
TCPR: Do you ever give patients assignments to avoid certain things?
Dr. Yager: Yes. For example, there are some patients who continuously reinforce their negative self-image by reading women’s magazines. So my assignment may be: “I want a list of all the magazines that you regularly read and then we are going to put you on a restriction diet, so that you can’t read women’s magazines anymore. And let’s try a week without television at home.” What happens is that the women first become aware that they have this constant interaction with an image that makes them feel bad about themselves. Suddenly their whole way of thinking about themselves and about their bodies may shift and become more free.