By Irina Vanzhula, M.S
Everyone experiences shame and guilt at times. While these emotions can be helpful in guiding our social behavior, they can also bring a lot of discomfort and even trigger depression and other psychological disorders, such as eating disorders. Let’s differentiate between shame and guilt, describe in which situations they can be useful or harmful, and discuss how to cope with them.
Guilt is an unpleasant emotion about something we have done. It is often used synonymously to remorse, meaning that we regret the action, and guilt may involve sadness and empathy towards the person harmed. Guilt is generally seen as a useful emotion that encourages us to follow moral and societal norms. For example, we may feel guilty about lying to a friend or skipping a volunteering shift at the local shelter. Guilt may also occur if we act inconsistently with our personal values. For example, someone who values family above all else may feel particularly guilty about skipping a family holiday dinner.
In contrast to guilt that involves feelings about an act one has done, shame involves negative feelings about oneself. Shame encompasses a feeling of inferiority and perceiving oneself as a small, lesser person, worthless, and a failure. Another way to differentiate guilt and shame is by what the emotion urges us to do: guilt usually triggers a desire to apologize and redeem oneself, while shame may lead to a desire to hide or escape. Although shame can be helpful in some situations (i.e. serious wrongdoing) and is used in programs redeeming violent offenders (Loeffler, 2009), it generally is associated with increased distress and may lead to depression, self-harm, and disordered eating (Muris, 2015).
Feelings of guilt can also be harmful if it is based on an irrational belief, such as feeling guilty for something that was not our fault. For example, if we witness an injustice, we may feel guilty because we think we could have done something to prevent it. Guilt can also transform into shame if a “bad” action is interpreted as having occurred because one is a “bad” person. Example: “I feel guilty that I didn’t visit my family this month” can lead to two different outcomes: 1) Call or visit the family to release the guilt or 2) Feelings of shame because “I am a bad son.” The problem with feeling shame in the second scenario is that it may lead the individual to further avoid visiting family and feeling even more shame.
How then can we cope with guilt and shame? First, check your guilt or shame statement for accuracy. Was it really your fault? Can you think of anyone or anything else that may have contributed to the situation? Make a list of any other possible causes and state how much you think each cause contributed in percentage. Then add up all the percentages and subtract from 100%: How much is left? You may want to do this exercise with someone else who can help you see all the perspectives.
To cope with shame, it can be very helpful to examine the evidence and rewrite shame statements into statements of guilt. For example, if you got frustrated and yelled at your child, does it really mean that you are a bad parent? Generally, we want to change the statement from “There is something wrong with me” to “I have done something wrong.” Most of the time, a guilt reaction is more accurate than shame.
Statement of shame: I yelled at my child again! I am a terrible parent.
Statement of guilt: I feel guilty about yelling at my child.
What if you truly have done something bad and can’t shake the regret or shame? Think back to the situation and answer these questions: What purpose did this action serve to you at the time? What did it help you accomplish? What would have happened if you didn’t make that choice in the moment? It’s easy to see what we did wrong looking back and knowing what we know now; it’s called hindsight bias. Most often, we make the best decision based on what we knew at the time.
Finally, if logic and reason are not helpful in dealing with guilt and shame, practice self-compassion. Most of us are very good at being compassionate towards others, but find it hard to be compassionate to ourselves. Self-compassion entails being warm and understanding toward ourselves when we suffer, fail, or feel inadequate, rather than ignoring our pain or beating ourselves up with self-criticism. Imagine that your close friend or a loved one tells you about their guilt or shame, what would you say to them? Say those words to yourself. You can also find many useful self-compassion exercises on Cristin Neff’s website http://self-compassion.org.
By Shruti Shankar Ram
Consider this: a friend or peer of yours has developed a particular obsession with food – to the point where they count the number of bites they take from their meal, or arrange their food in a specific way every time they eat. They might also have to eat their food in a methodical way and refuse to eat certain foods.
This information alone might make you suspect that they have an eating disorder, but these symptoms could also be seen in another mental illness – obsessive compulsive disorder (OCD).
Obsessive-compulsive disorder is characterized by repetitive, intrusive thoughts, feelings or sensations that cause anxiety, often accompanied by the need to engage in a repeated habit or ritual that serves to reduce this anxiety in the short-term. Similar to eating disorders, there are also various types of OCD, and the obsessions and compulsions can range from a variety of different things – from health to religion and sexual orientation.
Eating disorders and OCD are often heavily stereotyped in the media. While you may immediately think of a teenage girl with anorexia nervosa when thinking of an eating disorder, or a person excessively washing their hands when thinking of OCD, the reality is that both these disorders affect individuals from both genders from a wide variety of different backgrounds and across all ages. Unfortunately, these stereotypes could keep individuals with both these disorders from realizing that they even have the disorder or recognizing the signs in their peers, and this keeps people from getting the treatment that they need.
Stereotyping aside, OCD and eating disorders actually share a lot of commonalities. There are several parallels that can be drawn between these two mental illnesses. An example of an obsessive behavior that is seen across both these illnesses is checking. While someone with OCD may constantly check their stove or locks in their house, a person with an eating disorder may constantly check themselves in the mirror or weigh themselves frequently.
This is no coincidence, eating disorders and OCD actually co-occur quite frequently (Rubenstein et. al., 1993; Halmi et. al., 2005; Swinbourne and Touyz, 2007) and eating disorder pathology has been shown to be positively associated with obsessive-compulsive symptoms (Davies et. al., 2009; Naylor et. al., 2011). In fact, obsessive-compulsive symptoms have also been associated with higher relapse rates in eating disorders (Carter, et. al., 2012).
Individuals with OCD and eating disorders typically also share two traits in common – high levels of anxiety and perfectionism. In fact, it is quite common for individuals with these disorders to excel in various other areas of their life while silently suffering from the illness. Perfectionism may be seen as a positive trait by some, but it has been shown to mediate the relationship between OCD and eating disorders, and individuals with either or both of these illnesses typically have high levels of trait perfectionism (Bernert et. al., 2013).
Additionally, obsessional anxiety could help maintain both OCD and eating disorder symptoms. This anxiety surrounds possible catastrophic outcomes that may occur if the ritualistic behaviors is not completed – in the case of an eating disorder, this could mean that an individual believes that, unless they heavily restrict, they will gain large amounts of weight and become overweight. In the case of obsessive-compulsive disorder, this could mean that an individual believes that they will die unless they are constantly avoiding germs and washing their hands. This anxiety leads to drawing associations between certain rituals and outcomes – even if they appear irrational to others.
Not only are there common symptoms between eating disorders and OCD, but the treatment can also look similar. Specifically, exposure and response prevention therapy (ERP) is an evidence-based treatment that has been well established as the most effective treatment for OCD (Koskina et. al., 1996), and research is beginning to show that ERP may be effective in treating eating disorders as well (Ambramowtz et. al., 2013). Combining exposure therapy with cognitive-behavioral therapy (CBT) is effective in breaking up these irrational associations between ritualistic behaviors and the reduction of anxiety.
It is important to note that, of course, eating disorders and OCD, are two very different illnesses. The obsessions and compulsions of an individual with OCD can extend far beyond food, and individuals with eating disorders often experience symptoms that are not typically present in OCD, such as body dysmorphia and drive for thinness. However, it is important to understand the relationship between these disorders, particularly as the comorbidity rate is so high. So, if you do question whether a friend or peer has an eating disorder or OCD – consider the possibility that it could be both!
Abramowitz, J. S. (1996). Variants of exposure and response prevention in the treatment of obsessive-compulsive disorder: A meta-analysis. Behavior Therapy, 27(4), 583-600. doi:10.1016/S0005-7894(96)80045-1
Bernert, R. A., Timpano, K. R., Peterson, C. B., Crow, S. J., Bardone-Cone, A. M., le Grange, D., & ... Joiner, T. E. (2013). Eating disorder and obsessive–compulsive symptoms in a sample of bulimic women: Perfectionism as a mediating factor. Personality And Individual Differences, 54(2), 231-235. doi:10.1016/j.paid.2012.08.042
Davies, H., Liao, P., Campbell, I. C., & Tchanturia, K. (2009). Multidimensional self reports as a measure of characteristics in people with eating disorders.Eating And Weight
Disorders,14(2-3), e84-e91. doi:10.1007/BF03327804
Halmi, K. A., Tozzi, F., Thornton, L. M., Crow, S., Fichter, M. M., Kaplan, A. S., et al. (2005). The relation among perfectionism, obsessive–compulsive personality disorder and obsessive–compulsive disorder in individuals with eating disorders. International Journal of Eating Disorders, 38, 371–374.
Koskina, A., Campbell, I. C., & Schmidt, U. (2013). Exposure therapy in eating disorders revisited. Neuroscience And Biobehavioral Reviews, 37(2), 193-208. doi:10.1016/j.neubiorev.2012.11.010
Naylor, H. et. al. (2011) Beliefs about excessive exercise in eating disorders: the role of
obsessions and compulsions. European Eating Disorders Review, 19, 226–236, DOI:
Rubenstein, C. S., Pigott, T. A., Altemus, M., L'Heureux, F., Gray, J. J., & Murphy, D. L. (1993). High rates of comorbid OCD in patients with bulimia nervosa. Eating Disorders: The Journal Of Treatment & Prevention, 1(2), 147-155. doi:10.1080/10640269308248282
Swinbourne, J., & Touyz, S. (2007) The co‐morbidity of eating disorders and anxiety disorders: a review. European Eating Disorder Review, 15, 253–274. https://doi.org/10.1002/erv.784
Does this dress make me look fat? - The Importance of Rejecting Fat Talk
By Caroline Christian
“Does this dress make me look fat?” “Oh my, you look so good! Have you lost weight?” “I need to lose a few pounds before spring break if I am going to wear a bikini on the beach.” These are all statements I have heard just within this past week. With the extreme pressure and focus around body shape and weight in our society, conversations like these are extremely common. Most women will hear at least one statement like these every single day. These statements are called fat talk. Below is a short list of fat talk statements that we may hear, or even say, on a daily basis.
Fat talk statements:
“Your arms look so skinny today!”
“If I were her size, I would not want to leave my house.”
“I need to go to the gym so my boyfriend won’t feel my love handles.”
“I could never pull off jeans that tight with my thunder thighs.”
“Why is he with her? She is a whale!”
“If I was that fat, I just wouldn’t eat.”
“I wish I could be as thin as you.”
“If you think you are fat, I must be a cow!”
“I wish I had a bikini body.”
“That dress is cute, but it isn’t very flattering on you.”
“I need to lose weight before we vacation.”
“Oh my gosh, you look amazing! Have you lost weight?”
“Be honest, do I look fat in this?”
“She probably shouldn’t have been wearing that dress, it was way too revealing.”
The important thing to recognize about fat talk is that it isn’t necessarily malicious. In fact, looking at this list of fat talk statements, you can see that many of the more common examples are actually meant to be complimentary. However, regardless of intention, fat talk statements that equate weight and shape with value or beauty, can be very harmful to you and to the people around you.
Fat talk is extremely prevalent in young women, especially around high school and college years, with around 93% of college-aged women admitting to engaging in fat talk (Salk & Engeln-Maddox, 2012). Other studies have shown the impact negative body talk can have on the people around you. In one study by Gapinski, Brownell, and LaFrance (2003), women who listened to another woman saying negative things about her own body reported higher body dissatisfaction than women who listened to the woman speak about a neutral topic. In addition to increases in body dissatisfaction, exposure to fat talk also increases the likelihood of listeners engaging in fat talk (Tucker et al., 2007). Because of this, fat talk tends to have a cascading effect (i.e., if one friend engages in fat talk around 2 friends, those friends may engage in fat talk around 2 more friends, those 4 friends may engage in fat talk around 2 more friends, and so on.)
Given the huge prevalence and negative mental health impacts of fat talk, there is a clear need for change. But because fat talk is so inundating, change can be really difficult. Some universities and organizations around the country have started challenging this societal norm by hosting a Fat Talk-Free Week. This movement was started at Trinity University in 2008, as a part of the Reflections Body Image Program, which was started by Dr. Carolyn Becker and the national sorority Delta Delta Delta. Now Fat Talk-Free Weeks are hosted at universities all across the country. In addition to challenging students not to engage in fat talk and to shut down fat talk when they hear it, many other events happen during this week that promote healthy body image, like smashing a scale or writing a letter to a younger girl about body image. Another common exercise promoted at these events is challenging women to look in a mirror and write down only positive things they like about themself, both internally and externally. Dr. Becker said in reference to this activity, “It's really hard for women to do. Women are used to standing in front of the mirror and trashing themselves.”
Additionally, beyond participating in these big events, there are lots of small ways you can challenge fat talk in your everyday life. One way I commonly like to challenge fat talk is when I hear a friend say something negative about her own body, (instead of joining in with another fat talk comment about myself) I tell her to say three things she likes about her body. At first this may be brushed off with a snide laugh, but actually make them say those three things. Saying things out loud has been shown to have a reinforcing effect on ideas and beliefs. So verbalizing positive self-affirmations may help reinforce a body positive attitude. Another great way to challenge fat talk is to just speak kindly about your own body and others. The same way fat talk can have a cascading effect, positive body talk can also spread like wild fire among young women. Instead of saying things like, “Oh my gosh you look so skinny, I would kill to look like that!” practice saying compliments that are not dependent on weight or shape. Try some on this list for example:
“The color of your shirt matches your bright personality.”
“You have a great sense of style.”
“Your laugh is so contagious!”
“I love how down-to-earth you are.”
“You are so warm and fun to be around.”
“Your positive attitude brings out the best in me.”
“I love that dress! You look so confident in it!”
“That thing you don't like about yourself is what makes you so interesting.”
“I am proud to be your friend.”
“Your confidence is contagious!”
At first these changes can be uncomfortable and difficult. But after implementing them in my own life, I have seen a huge boost in confidence and self-love among my close friends and family members. Thinking consciously about the way we talk about others and ourselves in front of our sisters, daughters, mothers, and friends makes a huge difference in the way they see themselves and other women. So next time you face fat talk try to be more conscious about the way you respond, and don’t be afraid to fight back with positive compliments!
Gapinski, K. D., Brownell, K. D., & LaFrance, M. (2003). Body objectification and “fat talk”: Effects on emotion, motivation, and cognitive performance. Sex Roles, 48(9-10), 377-388.
Rochman, B. (2010, October 13). Do I Look Fat? Don't Ask. A Campaign to Ban 'Fat Talk'. Retrieved from http://content.time.com/time/nation/article/0,8599,2025345,00.html
Salk, R. H., & Engeln-Maddox, R. (2011). “If you’re fat, then I’m humongous!” Frequency, content, and impact of fat talk among college women. Psychology of Women Quarterly, 35(1), 18-28.
Tucker, K. L., Martz, D. M., Curtin, L. A., & Bazzini, D. G. (2007). Examining “fat talk” experimentally in a female dyad: How are women influenced by another woman's body presentation style?. Body Image, 4(2), 157-164.
Virtual Reality and Eating Disorders: Why Should We Bring VR Therapy to Kentucky?
By: Lisa Michelson
Within recent years, virtual reality has gained popularity in the entertainment industry. This new domain, where entertainment and technology intersect, has transformed games and television, making a whole new experience for the user. Healthcare providers have also noticed, and have begun to take advantage of this whole new world of possibilities for treating their patients.
Here are a few examples of how health professionals, specifically mental health professionals have begun using virtual reality (VR). VR has been used to treat phobias, anxieties, and fears (Garcia-Palacios et al., 2002). In the United States, Duke University has used VR as a form of cognitive behavioral therapy (CBT) for individuals with anxiety disorders (Zielinski et al., 2006). At the University of Southern California, a VR exposure therapy has been developed in order to address PTSD symptoms for individuals returning from military service in Iraq and Afghanistan (Rizzo & Hartholt, 2005). There are VR medical centers, VR clinical trials, and therapies that continue to be developed. In the eating disorder field, virtual reality is being used to implement CBT for individuals who suffer from eating disorder (ED) behaviors and symptoms. The kinds of VR experiences can range from a full body emersion (wearing sensors all over one’s body) to wearing goggles (for the user to see the VR world they have been placed in). Below is a list of some VR scenarios that participants have been placed in for treatment in Bulimia Nervosa (BN) and Binge Eating Disorder (BED) (Regine de Carvalho et al., 2017):
Furthermore, below is a list of some outcomes that have been observed in utilizing VR in ED treatment (Regine de Carvalho et al., 2017):
Although Regine de Carvalho et al. (2017) did a systematic review of VR in the assessment and treatment of BN and BED, the number of studies that utilized VR in the treatment of BN and BED is few. In researching the use of VR in treating Anorexia Nervosa (AN), the number of studies that used VR within the United States was practically non-existent; most of AN and VR research being conducted in Europe, specifically Spain and Italy (Riva et al., 1999; Perpina et al., 1999).
In the previously mentioned studies, utilizing VR in ED treatment has been shown to improve behaviors and symptoms in participants. In other words, what is being done in these treatments IS working. However, the use of VR as exposure therapy for eating disorder treatment is still not only infrequently used, but underutilized and underdeveloped in the United States.
Here, at the EAT Lab, one of my jobs has been to find collaborators and programmers to develop such technology. While it has been a steep learning curve in understanding what technology would be most user-friendly, financially reasonable, and the best for therapy, we continue to learn more about this technology every week. In our own research into VR software development, it has become apparent why this form of therapy rarely exists in the United States; the combination of technology/entertainment and mental health therapy is still an unchartered (yet exciting!) territory. Communicating the wants/needs of what we, the therapists, want in the VR technology to the software development is like talking between two languages. However, through talking with multiple resources, we have hope that we are closer to brining this technology to Louisville and being amongst the first ED research facilities here to provide this cutting edge therapy to our clients.
To address the question that was posed in the title of this article (Why Should We Bring VR Therapy to Kentucky?), we know it can work to improve health outcomes for our clients and we hope that future advancements will provide more insight to our exposure therapy research.
Fighting the Stigma, Increasing Awareness and Education: Advocating for Eating Disorders in Kentucky
Fighting the stigma, increasing awareness and education: Advocating for eating disorders in Kentucky
By Leigh C. Brosof
Fighting stigma, increasing awareness, and educating our communities about eating disorders are essential for early detection and treatment of these disorders; and we know that the earlier we catch an eating disorder, the more likely an individual is likely to recover. In the state of Kentucky, there is no officially recognized awareness efforts or state-sponsored educational programs about eating disorders. That is why today (February 5, 2018), myself, Dr. Levinson, and Melissa Cahill, an eating disorder advocate in Louisville, traveled to Frankfort, KY to meet with our legislators to discuss how we can get the state involved in the fight against eating disorders.
We had meetings with Representative Ken Fleming, who is also the executive director of the Kilgore Counseling Center, and Senator Ernie Harris about sponsoring a resolution in the Kentucky House of Representatives and Senate, respectively, to officially recognize February 26-March 4th as Eating Disorder Awareness Week in the state of Kentucky.
We also spoke with them about what other states have done to further the cause of supporting eating disorder awareness. In Missouri, the local government created an eating disorder coalition dedicated to awareness and providing education to health providers about treatment standards. In Pennsylvania, the legislature passed a bill requiring all middle and high schools to provide a fact sheet on eating disorder detection and what to do if you think someone has an eating disorder. These efforts show that state support really can make a difference in the fight against eating disorders, and we hope that Kentucky will follow these examples.
Indeed, in addition to meeting with Representative Fleming and Senator Harris about the resolution, we also asked about longer-term plans to get legislation passed in order to increase awareness and education about eating disorders in Kentucky. Both were immensely supportive in helping us understand the steps in order to get such a bill developed. We were briefly introduced to Representative Kimberly Moser and Senator Julie Raque Adams, who both serve on the Health and Welfare Committee, through which the legislation would be drafted.
Our ultimate goal is to see a coalition created similar to the one in Missouri: one that spreads awareness and education, provides training to health care providers in eating disorder care, and establishes treatment recommendation guidelines for best care. In the meantime, we are thrilled to see that our legislators are listening to the need for state support of eating disorders in Kentucky and to recognize Eating Disorder Awareness Week, which will be the first piece of legislation including eating disorders ever passed (hopefully) in the state. We are also excited to continue to advocate for eating disorder awareness in Kentucky.
Overall, it was a fun and encouraging day, and we are grateful to our legislators for taking the time out of their day to meet with us. This was my first experience with formal advocacy work with legislators, and I look forward to continuing to work toward our goals. But it’s also important to remember that advocacy takes many forms, and it doesn’t always take a trip to Frankfort to make a real difference.
Post on social media. Attend a walk. Put posters up around a school or work building. Bring in a speaker or attend a lecture. That’s all it takes to start advocating for eating disorder awareness in our community. Louisville has come such a long way in the short time I’ve been here, and I’m excited to see how we can advocate for a better future for every individual with a diagnosis of an eating disorder.
Read the full article here:
Avoidance versus Exposure: The Importance of Facing Your Fears
By Caroline Christian
What are you afraid of? We are all afraid of something. Fear is not only normal, it is healthy! The tinge of fear you get when a large blur crosses your periphery when you are walking in the woods is the same fear that has kept humans alive for hundreds of thousands of years. Fear helps us to recognize and escape when we are in dangerous situations. The problem with fear is that we can become afraid of things that can’t really hurt us, such as taking a test, giving a presentation, or eating certain foods. These fears may stop us from doing things we like to do or from having meaningful relationships, potentially spiraling into more stress, anxiety, and even isolation.
The good news is that there are things we can do to reduce these fears. There are basically two options: you can avoid the thing you fear or you can face the fear head on. To see these two strategies in action, let’s look at an example. Say you are afraid of talking to new people:
1) You can avoid putting yourself in a situation where you may have to talk to new people. This would likely mean avoiding grocery stores, job interviews, dating, holiday parties, traveling, doctors’ appointments, etc. The benefit of this is that never facing your fear can provide a brief sense of relief, and may lessen your anxiety in the short term because the fear is not imminent. However, the problem with this method is that avoidance can intensify the fear in the long term, because by never experiencing this irrational fear, you never see that it isn’t as bad as you thought it would be.
2) Or you can actively put yourself in situations where you will have to talk to new people. This could be something like: initiating small talk with a new coworker, asking someone on a date, complimenting a stranger at the store, hosting a party, etc. The downside of exposing yourself to your fear is that it can be difficult at first and may cause some (or a lot of!) anxiety. However, the benefit is that by facing the thing you are afraid of, you get to see that you are strong enough to handle it. Over time if you continue to expose yourself to that fear, the anxiety will lessen and the fear will have less control over your life.
Thus, when it comes to handling fear it may be easier initially just to avoid it, but avoidance in the long-term only serves to worsen the fear. Exposure has the opposite effect: while it may be difficult initially, repeated exposures can lessen the anxiety and make it more bearable. This idea is the basis of exposure therapy, which is a cognitive-behavioral approach that has been shown to be effective in treating anxiety disorders, including specific phobias, PTSD, and OCD. Exposure allows people to confront their fears in a safe and controlled environment, so that when the fears come up in the real world, they have less anxiety and are equipped with the tools to handle it.
In contrast to the many clinicians that utilize exposure to treat anxiety and eating disorders, there are a small number of psychologists that advocate for avoidance methods in therapy. This approach has been spurred by the increased awareness of using politically correct language and avoiding triggering words in our society. Topics that are controversial, or that could be potentially painful for individuals based on their past experiences, typically are avoided in academic or professional settings. Although it may be helpful in some places in our society, this type of avoidance does not have a place in therapy or rehabilitation programs. The problem with avoidance in therapy is the same as avoidance in the real world. By never experiencing the fear, you never see that it isn’t as scary as you imagined. This will cause the anxiety to build up, and then if something happens to trigger these emotions outside of therapy, the anxiety will be even worse. That is why exposure is so important in therapy- talking about things that are scary and anxiety provoking in a safe environment allows for less anxiety when faced in the real world.
Additionally, there are things you can do outside of therapy to implement these strategies to better your own life. Beyond therapy, exposure also can be used to tackle everyday anxieties, like testing anxiety or public speaking. Taking sample tests, practicing with friends and coworkers, and visualization exercises are all exposure-based techniques that can help reduce tension and anxiety, so it doesn’t build up on the big day.
So in conclusion, when it comes to battling your fears (whether they are big or small) choose exposure! Although it is difficult at first, in the long term it will give you more control over your fears. In the EAT lab, we are exploring the use of exposure therapy for eating disorders by exposing people to fears such as gaining weight, losing control, making mistakes, or eating certain foods. If you struggle with an eating disorder and you are interested in participating in these studies, click here!
This article discusses ways in which we use avoidance in every day life, and may not even realize it!
Check out this article on how to implement exposure strategies into your everyday routine.
Reflections from ABCT 2017
By: Cheri A. Levinson, Ph.D.
The EAT lab (pictured to the right) just returned from ABCT 2017 in San Diego, California. To say that this conference was inspiring would be an understatement. I think the entire lab left the conference feeling renewed and excited about all of the immerging research both within the eating disorder field and in clinical psychology as a whole. Here are a few highlights from our trip.
Exposure in eating disorders. There was not one, but *two* symposiums focused on using exposure therapy to treat eating disorders. Given this area has been my passion for more than half of my career (which admittedly has not been that long yet), I am excited to see not only more work on the topic, but a growing interest and excitement within the eating disorder field. There were two talks that especially stood out to me on the impact they can bring to the field. First, Nick Farrell (from Rogers) presented work from his partial hospital program showing how exposure and response prevention can be integrated into a partial program. Second, Jamal Essayli (from Penn State Hershey) began to answer the question ‘Can we use exposure therapy during refeeding?’ The answer seems to be a resounding yes. Food exposure does not cause harm and in fact decreases anxiety around food during refeeding. Some research has proposed that we need to wait to use food expose with eating disorder patients until they are weight restored (e.g., instead of getting them to eat while distracting etc), since exposing them to food does in fact lead to their feared concern of weight gain. This research suggests that no, programs should go ahead and start using exposure even when patients are underweight.
Personalizing Treatment. I was lucky to be part of a fantastic symposium including Aaron Fisher (Berkley), Eiko Fried (U Amsterdam), Anne Roefs (Maastricht U), Sarah Jo David (Texas Tech), and Rich McNally (Harvard) that focused on using network analysis to personalize treatment. We got to hear about how network analysis is being used to lead to personalized treatment of anxiety, depression, eating disorders, and obesity. We also got to learn a bit about how we might use machine-learning to predict behaviors such as smoking. The main take away from this symposium, in my mind, is that technology is taking us to new places where we don’t have to rely on averages and can use data to make each treatment plan the best possible for each person.
Graduated Exposure versus Using a Hierarchy. Work from Ryan Jacoby at Mass General suggests that we don’t necessarily need to use an exposure hierarchy to treat OCD/anxiety. Instead, we can randomly choose exposures (regardless of difficulty level) and that this method may in fact maximize intolerance of uncertainty and produce better change (and surprisingly less drop out!).
Push for Open Science. One of the undertones of the conference was a push for Open Science. I have to give credit to Aaron Fisher for his plea during the personalized network symposium encouraging researchers to share their data. The message that I took away is that the more we collaborate and are open about our science, the more likely we are to really help people.
Overall, I felt inspired by the amount of collaboration and willingness of our colleagues to be open and work toward creating science that can have real impact. Thanks ABCT for another great conference- already looking forward to next year!
Eating Disorders Impact People of All Ages
by: Lisa Michelson, M.A.
Eating disorders happen at every age. From preteens to older adults, eating disorders do not discriminate. Previously, there was a long-held view that eating disorders are mental illnesses that mainly affect adolescents and young adults (e.g., Bruch, 1973). Subsequently, much of the eating disorder research has focused on these age groups (Rohde et al., 2015; Allen et al., 2014). However, as instances of eating disorders in older individuals increased, which may be attributed by an increase in awareness rather than an overall increase in eating disorders in older individuals, there became a need to treat this population as well. Unfortunately, eating disorders continue to be poorly understood in middle age and older populations. The comparison between how eating disorders manifest in older adults versus younger adults is even more elusive.
As we have begun to understand more about eating disorders, we have learned that fears and symptoms manifest in a variety of ages and also in a variety of ways. For example, at the onset of menopause, women may begin to alter how they view their body, which can lead to an increase in one’s body dissatisfaction (Gupta, 1990; Peat et al., 2008). In other words, as a woman’s body begins to change due to a decrease in hormonal production, she may become dissatisfied with how she experiences her body.
Conversely, we see body dissatisfaction in younger women may result from media portrayals of the “ideal” female body and femininity (Tiggemann & Stevens, 1999). Granted, older women are also affected by media portrayal of older women, but not to the same degree as younger women. In comparing the two ages, Rand and Wright (2000) found that older women have more realistic cognitive perceptions of their bodies. This literature may provide insight as to why older women are less affected by external factors (i.e. cultural factors) compared to younger women. Thus, it seems plausible that these cognitive, biological, and cultural differences may also manifest in different core fears in eating disorders in younger versus older individuals.
So why is this important? Why is identifying the differences between ages necessary? Therapy improves health outcomes for individuals of all ages in treatment for ED behaviors and fears. Furthermore, it is crucial to understand how etiological differences in various ages may contribute to diverse therapy outcomes. In other words, to treat a younger individual with AN in the same manner as an older individual with AN may lack efficacy. Yes, they both suffer from the same disorder; however, the reasons for engaging in such behaviors may be vastly different. It would be like a mechanic expecting to fix two cars in the same way.
Age may differentially influence how fears impact eating disorder symptoms. In a recent study, we analyzed if age moderated the relationship between the eating disorder symptoms and fear of food. Yes! We found that age moderated the relationship between fear of food and eating disorder symptoms (come see us present this work at ABCT!). Specifically, we found that fear of food is more related to eating disorder symptoms in younger versus older participants.
What does this mean? Older participants and younger participants differ in how food-related anxiety impacts eating disorder symptoms. This specific type of fear (food) may be most relevant in younger adults. This means we still need to figure out what types of eating-related fears are most relevant in older age! It is advantageous for the research community to continue to identify these differences as they may illuminate the most effective way to address eating disorder symptoms and fears between individuals of different ages.
What Mindful Eating is Really About
By: Irina Vanzhula, B.A.
People who come to my mindful eating workshop often say that they want to learn to eat healthier, lose weight, and reduce emotional and stress eating. I help them see that these goals have been imposed on them by society and the diet industry. I also challenge the idea that mindful eating is just another way to diet and then introduce a new way of thinking about their relationship with food. I usually see expressions of disbelief when I announce that emotional and stress eating are not their enemy.
Dieting vs. Mindful Eating
Any diet is by definition restrictive. Dieters deny themselves certain food groups, reduce how much they eat, or both. In addition to hunger, dieting creates a sense of deprivation, which in turn may make us sad or depressed. “I so much want that cupcake, but I can’t have it” (Johnson and Wardle, 2010). Some people may be able to convince themselves that they no longer like sweets and even override their hunger signals, but that takes a lot of mental energy and we can’t sustain it for a long time. Best-case scenario, we can maintain the eating pattern for a while using sheer willpower, but it eventually fails. Worst-case scenario dieting may trigger disordered eating (Stice, 2002) or even lead to weight gain over time.
Cycles of Eating
Many who attempt to forcefully regulate their eating get stuck in a cycle of dieting, overeating, and feeling guilty. Restricting our food intake overall and denying ourselves food we enjoy leads to hunger and intensified sense of craving. As a result, we may end up overeating and eating more of those foods we were trying to avoid in the first place. It is not all about willpower too, in fact, it has very little to do with willpower. When we are very hungry, our bodies are designed to crave fatty and sugary foods because it is a sure way to stock up on enough energy in case there is a shortage of food in the future again (Heshmat, 2011). Overeating is often associated with guilt or what we call “I have blown it” effect. We feel guilty for “breaking the rules” and decide to start all over tomorrow, and the cycle continues. Alternatively, overeating may make us feel depressed and bad about ourselves, which can trigger more emotional eating.
What is the solution? In my workshop, I suggest that my participants abandon food rules and adopt a new set of goals: learn to eat intuitively by recognizing their hunger and fullness signals and satiate their body and mind. The key to achieving those goals is mindfulness. Mindfulness has many definitions and applications, but the one we focus on is awareness. Recent research is discovering that awareness may be the key to successful mindfulness-based interventions for disordered eating (Sala & Levinson, in press). Mindful awareness is paying attention to present moment experiences and is opposite of running on automatic pilot. Many of our eating experiences are indeed automatic. Our eating is a response to multiple environmental cues, such as smells, bowl of candy in the office, snacking while watching television, eating out of boredom or at the social event, and more. Overwhelmed by these stimuli, we lose touch with the true sensations of hunger and fullness, and true taste satisfaction.
Practicing mindful awareness can help us disengage the automatic processes and really tune into our bodies. General meditation practice can help build the skill of paying attention, but mindful eating can be simply slowing down and paying attention to your meal. Next time you are about to eat, pause and take a breath. Notice how you are feeling and what you are thinking. Notice any attitude you have towards this meal you are about to eat. Notice the smell, the colors and shapes on your plate. Also notice sensations of your physical hunger. Hunger may feel different for each person, but in general we get hungry when our energy level is depleted and we need to refill our bodies. Physical hunger may be associated with lower blood sugar, fatigue, stomach empty and growling, and mouthwatering. This is how your body lets you know you need to eat, but how do we know when we are full?
Most people see hunger and fullness as opposite ends of the same scale. If you are no longer hungry, you are full, and vice versa, right? In fact, body fullness and satiety are more complicated concepts. If you were to drink 20 oz of water, your stomach will feel very full, but you will likely still be hungry. Many people describe physical sensations of fullness as feeling bloated, having an extended stomach, feeling heavy, clothes getting tight, and even a lump in the throat. Have you ever eaten very fast when you are hungry and your stomach is full but you still feel hungry? These examples suggest that hunger and fullness are their own concepts and each can be measured on a separate scale. In general, physical hunger is about blood sugar levels, and physical fullness is about filling up the space of your stomach.
Psychological hunger refers to wanting to eat for reasons such as boredom, sadness, food proximity, stress, and habit. You may snack at a party when you are not physically hungry or crave chocolate ice-cream at the end of a difficult day at work. Although we perceive emotional eating negatively, psychological hunger also needs to be satisfied. We call this body satiety. Consider this example: you eat a large portion of bland boiled chicken and rice. Your hunger is down, your fullness is up, but you are still craving dessert. That is because the meal did not satisfy you and you are still low on body satiety. Mindful eating proposes that instead of fighting these feelings, you satisfy them in a mindful way without overeating.
What are you truly hungry for?
The good news is that we don’t need to consume a lot of food to be satisfied. Out taste buds get tired very quickly: third, fourth and later bites won’t taste as good as the first one. This means, that we can satisfy that psychological hunger by having only a small amount of craved food. In addition, it is helpful to ask ourselves: what are we truly hungry for? If we are about to eat out of boredom, maybe we are really hungry for some good company and friendship? And last but not the least is self-compassion. If you do make a choice to satisfy your psychological hunger by eating our favorite food, don’t blame yourself. Be kind to yourself and recognize that this is what you need at that moment.
Mindful eating introduces a completely different relationship with food and navigates you away from food rules. Mindful eating is based on building awareness of external and internal processes that dictate our eating behaviors. Developing eating awareness skills can help you end your battle with food and achieve your behavioral and health goals.
To join our mindful eating group contact us here: http://www.louisvilleeatlab.com/eat.html
To hear more about the negative impact of dieting, watch this TED talk: