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ARFID 101

Earlier today, I was honored to present a webinar on Avoidant-Restrictive Food Intake Disorder (ARFID) for Families Empowered and Supporting Treatment for Eating Disorders (FEAST).

AFRID is a relatively new diagnostic category which was first added to the Diagnostic and Statistical Manual of Mental Disorders – Volume 5 (DSM-5) in 2013. ARFID is characterized by a pattern of avoidant or restrictive eating behaviors which led to significant nutritional, medical, developmental, and/or social-emotional consequences. Individuals with ARFID may restrict their food intake for a variety of reasons. Some individuals are hypersensitive to textures, tastes, and smells and feel comfortable with only a narrow variety of foods. Others don’t experience hunger cues, derive little pleasure or enjoyment from eating, and seem to have little interest in food. Still others begin restricting their food intake abruptly after a food-related trauma, such as choking, vomiting, or having an allergic reaction. Unlike those with Anorexia Nervosa or Bulimia Nervosa, patients with ARFID do not experience drive for thinness, fear of weight gain, or distorted body image.

Treatments for ARFID include Cognitive-Behavioral Therapy (CBT) and Family-Based Treatment (FBT).

My PowerPoint slides from the presentation are available below. The recorded webinar will be available on the FEAST website within the next few days.

ARFID-101 PowerpointDownload

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FIGHT, FLIGHT, FREEZE: The Acute Stress Response in Anorexia Nervosa Recovery

The human body has evolved to protect itself from danger.   The acute stress response, also known as the “fight or flight” response, describes the body’s physiological reaction to a perceived threat.   In response to acute stress or danger, the body’s sympathetic nervous system is activated by the sudden release of hormones.  In turn, the adrenal glands secrete hormones, including adrenaline and norepinephrine, which prepare the body for immediate action to fight off a predator (“fight”) or flee from danger (“flight”).   The “fight or flight” response involves physiological symptoms intended to facilitate fighting or fleeing (e.g., rapid heartrate, increased blood pressure, increased oxygen flow to major muscles, often leading to shaking or muscle tension) as well as an alteration in psychological state associated with the perception of threat (anxiety, panic, aggression, violent impulses).

The third component of the acute stress response involves “freezing,” or defensive immobilization.  This response may occur when a danger is perceived as life-threatening and inescapable.  Think of a deer frozen in the headlights, or a cockroach on its back feigning death.  A human victim of a physical attack or sexual assault may go still and limp rather than fighting back.   The freeze response may, in some cases, allow the victim to survive, and in other cases, the numbness that accompanies it may spare the victim pain in his final moments of life.

Thousands of years ago, in our ancestral environment, we faced daily threats to our survival: saber-tooth tigers, wooly mammoths, cold, hunger, warring tribes.  The acute stress response was essential to our survival.  In today’s world, most triggers for anxiety are more subtle: public speaking, taking the SATs, career uncertainty, financial stressors.  But our bodies don’t know the difference: the physiological and psychological responses are the same today as they were tens of thousands of years ago.

The fight, flight, and freeze responses are activated instantly and without conscious choice.   Remember, these immediate reactions have evolved to protect us from danger in circumstances in which stopping to think could cost us our lives.  We do not choose what our bodies perceive as dangerous or which branch of the acute stress response is activated.  

Most people who suffer from anorexia nervosa have extreme fears of food, weight gain, or both.  People with active anorexia nervosa who have not yet begun the recovery process are able to keep their fears within manageable limits through avoidance: avoiding “fear foods,” avoiding feelings of fullness, avoiding weight gain, avoiding the scale, avoiding the wrath of the anorexic voice by engaging in compensatory behaviors.

Recovery from anorexia nervosa requires sufferers to face these fears head-on multiple times every day.  For these reasons, the bodies of people recovering from anorexia nervosa are locked in a near-constant acute stress response for months.  This is why people recovering from anorexia nervosa usually feel much worse during treatment than they felt while they were acutely ill.   The fight, flight, freeze response also explains most of the extreme and perplexing behaviors that we see in those who are recovering from anorexia nervosa.

The “fight” response is directed at the perceived source of threat.  For a person with anorexia nervosa, the source of threat may be the person who serves him food (e.g., a parent), a treatment provider who requires weight gain (e.g., a therapist, physician, or dietitian), or the person’s own changing body.  Therefore, it is common for people recovering from anorexia nervosa to physically or verbally attack their parents, to lash out at their treatment providers, and to turn their rage inward toward their own bodies as manifested by self-hatred, self-injury, or suicide attempts.   Food itself is also a perceived source of threat.  The fight response towards food may manifest physically as throwing food, cups, or plates; or it may manifest emotionally as a subjective feeling of hatred towards food.

The flight response in anorexia nervosa involves escaping the perceived source of threat.  Many people with anorexia nervosa run away from the table at meal or snack times, lock themselves in their rooms, or run away from home for hours or days at a time to avoid eating.  Some people jump out of moving cars, leave treatment appointments prematurely, or run away from treatment centers.  In a more subtle manifestation of the flight response, many people with anorexia nervosa do their best to avoid the caregiver who is most firm about requiring full nutrition, and gravitate towards caregivers who are more lenient.   

The “freeze” response entails some form of inaction or shutting down.  For example, many people exhibit an inability or apparent refusal to speak about food, weight, or anorexia nervosa.  Others have difficulty swallowing food.  Some people freeze at mealtimes, unable or unwilling to pick up a fork or spoon for hours on end.  In some cases, this acute food refusal necessitates spoon feeding or tube feeding.  Some people with anorexia nervosa appear dissociated, “frozen,” or “zoned out” at mealtimes or at other times when the anorexic voice is particularly powerful.  It is common for patients with anorexia nervosa to shut down during therapy appointments, avoiding eye contact and not engaging in conversation with their treatment providers. 

These fight, flight, and freeze behaviors are extremely distressing for sufferers and for the loved ones who are supporting them.   If you are supporting a family member through recovery from anorexia nervosa, please know that your loved one has not chosen to act or feel this way.  These behaviors are extremely common, and temporary, reactions to the severe anxiety brought on by facing one’s worst fears multiple times per day.   The fact that your loved one is exhibiting these acute stress responses is proof that his or her fears are being challenged.  In fact, if the acute stress response is not being activated, there is a good chance that the anorexia nervosa is not being sufficiently challenged, which may result in a protracted course of illness and a delay in recovery.   Remember to stay the course, to continue requiring full nutrition, prompt and complete weight restoration, and psychological support, regardless of the acute stress responses that come about.

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Metamorphosis: Long-Term Therapy with Young Adults

One of the most rewarding aspects of my job is the opportunity to engage with patients in long-term therapy.  In my practice today, I have a number of patients who began treatment with me years ago, in adolescence, and are now in their 20’s.  These patients first presented in my office with their parents during middle school or high school, suffering from severe eating disorders or depression or debilitating anxiety or, in some cases, all of the above.  Some entered treatment kicking and screaming; others reluctant but resigned; still others wanting help and suffering desperately but requiring immense parental support to stay afloat.

 In many cases, these adolescent patients received intensive Family-Based Treatment for six months or a year or more.  In other cases, the teenage patients received individual Cognitive-Behavioral Therapy with active parental involvement.   All of them made substantial progress in treatment.  The majority recovered fully from their initial presenting diagnosis.  Those who have not recovered fully are doing significantly better, living independent, fulfilling lives, but still experiencing symptoms and receiving ongoing care to keep their illness at bay.  Now, years later, some of them continue with weekly therapy sessions.  Others come in once or twice a month, or perhaps biannually like dental cleanings (we call this “mental hygiene”).  Still others elect come in on an “as needed” basis, scheduling a few sessions here and there to help them cope with life events, navigate relationships, manage stress, or deal skillfully with bouts of depression or anxiety. 

What unites these incredible young men and women is the fact that they have taken full responsibility for their well-being.  They have chosen to engage in long-term individual therapy as an act of self-care.  Through their adolescent suffering, they have become acutely aware of their susceptibility to mental illness.  They are choosing to receive therapy not only to prevent relapse of illness but also to pursue optimal health.   Many of these young adults have chosen to abstain from drugs and alcohol, even as their peers regularly smoke pot and drink to excess.  Many of them have adopted consistent home practices of meditation or yoga.  They make conscious, health-promoting choices when it comes to sleep, nutrition, stress management, and physical activity.  When faced with an important decision about which graduate program to pursue, which job offer to take, which city to live in, or even which person to date, they carefully consider the impact of these choices on their quality of life.

Engaging in long-term therapy with patients like these involves a number of gradual but significant transitions for all members of the therapeutic relationship: the patient, the parents, and me.   For the parents and for me, there is the progression from the crisis management of an acutely ill adolescent to the joy of stepping back into a supportive role for young adult in his own quest for greater levels of well-being.  The parents and I often begin our relationship communicating multiple times per week to put out fires and to ensure that we are in lock-step as we form a circle of safety around a suicidal or eating disordered patient.  As the patient gradually assumes responsibility for her own well-being (which often takes several years for those with adolescent-onset mental illness), communication between parents and me subsides into an occasional email or phone call.   The patient is now a much healthier, more mature young adult, and is trusted to schedule, attend, participate meaningfully in her own therapy sessions.  In many cases, she pays for her own treatment as well.

The therapy itself goes through a significant evolution as I shift from being directive and prescriptive, setting firm limits around dangerous or debilitating symptoms, to engaging with the patient in deep psychological work and collaborative goal setting.  For the patient, there is the very welcome shift from being told what she must do, in therapy and at home, to deciding what issues are important to her and taking the initiative to seek support, both therapeutic and familial, in achieving personally relevant goals.    For the patient, this shift brings with it a transformation from a defensive posture (as evidenced by panicking, shutting down, or lashing out in therapy and at home) to a stance of openness and receptivity (as evidenced by increased self-disclosure and self-awareness along with the display of more vulnerable emotions). 

I cannot begin to describe how rewarding it feels to support a frightened, malnourished, deeply depressed teenager as she blossoms into a healthy, confident, independent young woman who is attending college or graduate school in another state, working at an exciting full-time job, getting married, or giving birth to her first child.  It is fulfilling beyond words to join with young adult patients in the journey of long-term wellness as they clarify their personal values, decide who they want to be in this world, and take concrete steps towards achieving their dreams.

Those of you who have engaged in long-term therapy, either as a therapist, as a patient, know well how deeply personal and meaningful these relationships can be.  There is a level of emotional intimacy that surpasses even that between spouses, between parent and child, or between the best of friends.   In many ways, engaging in long-term therapy with self-motivated young adults is the polar opposite of Family-Based Treatment (FBT) for Adolescent Anorexia Nervosa.   For most patients in my practice, the former would not have been possible without the latter.   

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The 4 P’s of Mental Health Treatment

I like to conceptualize the etiology and treatment of mental illness using the framework of the 4 P’s: predisposing factors, precipitating factors, perpetuating factors, and prognostic factors.

Predisposing Factors are risk factors which create vulnerability to developing a particular illness.  

Examples of predisposing factors:

Why are they important?

Predisposing factors are important in helping individuals and their families understand their vulnerabilities and in alleviating the guilt, shame, blame, and stigma surrounding mental illness. Once families learn that the patient did not choose to develop this mental illness and the parents did not cause it, they have more energy to devote to recovery.

A word of caution: Predisposing factors are probabilistic, not deterministic.  In other words, having one or more predisposing factors for a particular mental illness does not mean that developing that illness is inevitable.  It simply means that vulnerability is heightened.

Precipitating Factors, known more casually as “triggers,” are events or circumstances that immediately precede the development of a disorder.

Examples of precipitating factors:

  • A loss of some sort (e.g., breakup of a romantic relationship, death of a loved one) often precipitates the onset of depression.
  • An energy imbalance (e.g., consuming fewer calories than one expends) almost always precipitates the development of anorexia nervosa or bulimia nervosa
  • A stressful situation (e.g., final exams in high school or college) may precipitate the onset of an anxiety disorder

Why are they important?

Awareness of the factors that have precipitated a mental health diagnosis is an important part of assessment. Relapse prevention planning, which typically happens towards the end of treatment, should help the patient and family develop awareness of the most common precipitating factors for their particular illness(es) so that  they can avoid those precipitating factors when possible, or be prepared to approach them skillfully and mindfully, with ample supports in place, if they are unavoidable.   

A word of cation: Precipitating factors are not the same as causes.  The majority of individuals go through multiple stressors in their lives without developing a mental illness.  A genetic predisposition is necessary, though not sufficient, for the development of a mental illness. 

Another word of caution: Discussion of precipitating factors shouldn’t be a major focus of treatment.  Once a disorder is set in motion by a perpetuating factor, the disorder takes on a life of its own and becomes self-perpetuating.  It ceases to be “about” that precipitating factor.

Perpetuating Factors are events or circumstances that keep an illness in motion, or those things that cause symptoms to continue occurring over a period of time.

Examples of perpetuating factors:

  • Malnutrition, weight suppression, excessive exercise, and binge/purge behaviors perpetuate an eating disorder. 
  • Environmental stressors, such as a highly rigorous academic environment, social exclusion or bullying, or elite athletic training, may perpetuate an anxiety disorder.   
  • All forms of anxiety are perpetuated by heightened physiological arousal and avoidance. 
  • Irregular sleep schedules, social isolation, and habitual use of marijuana are common perpetuating factors for depression.
  • Distorted patterns of thinking perpetuate most mental illnesses.  

Why are they important?

Most successful mental health treatment is focused on identifying and modifying perpetuating factors. Most, though not all, perpetuating factors are modifiable and can be changed through cognitive or behavioral interventions. 

A word of caution: The most powerful perpetuating factors are often those that directly impact physiology and brain function. For example, starvation is a powerful perpetuating factor in anorexia nervosa, and sleep deprivation is a powerful perpetuating factor in depression. A brain that is malnourished or severely sleep deprived is unlikely to respond well to psychological interventions. Cognitive perpetuating factors, which are also important, can be addressed most effectively later in treatment, after basic physiological function has been restored.

Prognostic Factors are factors which help to determine the eventual outcome, or prognosis, of treatment.

Examples of prognostic factors:

  • Early diagnosis and prompt intervention are positive prognostic factors.
  • Receiving evidence-based treatment is likely to shorten the duration of illness and increase the likelihood of achieving full recovery .
  • Dropping out of treatment prematurely reduces the likelihood of full recovery.
  • The presence of strong social support from family and friends increases the likelihood of full recovery and reduces the risk of relapse.
  • Full weight restoration, and maintenance of optimal body weight over time, dramatically improves the prognosis for anorexia nervosa.
  • Relapse prevention planning improves long-term prognosis by reducing the risk of relapse and guiding the type and timing of intervention if the patient begins to struggle again.
  • Practicing consistent self-care habits, including good sleep hygiene, regular exercise, and balanced nutrition, improves the prognosis for most illnesses.

Why are they important?

Prognostic factors are important to share with patients and families so that they can work together with treatment providers to create the best possible treatment outcome.  Prognostic factors are relevant at the time of diagnosis (to help patients and their families act swiftly and choose evidence-based treatment), during treatment (to instill hope when treatment gets difficult and inspire everyone to stay the course rather than dropping out prematurely) and at the end of treatment, when relapse prevention plans are created. Prognostic factors are also important after treatment ends, as they relate to sustaining continued recovery and well-being.

A word of caution: prognostic factors, like predisposing factors, are probabilistic, not deterministic. Having positive prognostic factors does not guarantee a good outcome. Positive prognostic factors merely increase the statistical likelihood of long-term recovery and reduce vulnerability to relapse.

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Updated Summary of Treatment Outcomes

Since opening my private practice in 2009, I have been privileged to work with over 300 individuals and families, providing consultation, evaluations, and treatment for a variety of mental health conditions.  I believe in being transparent and straightforward about the services I provide and why I provide them.  Individuals who are seeking mental health services for themselves or for their children have a right to know what treatment with a particular provider will actually be like, how long it will last, what outcomes they can expect, and what factors contribute to a more or less favorable outcome.

To this end, I collect detailed information on my patients’ treatment outcomes and publish the results on my blog.  Here is an updated summary of treatment outcomes for the disorders I most commonly treat.  For more detailed information on the types of treatment provided and treatment outcomes in my practice for each of these disorders, click on the category heading.

Treatment Outcomes for Anorexia Nervosa

  • 50% of patients who entered treatment with me completed a full course of treatment with me. 26% dropped out of treatment prematurely.  22% were referred to other providers who could better meet their needs.  3% moved to other geographic locations during treatment.
  • 97% of patients who completed treatment achieved full remission. The remaining 3% achieved physical remission.
  • The majority of patients who completed treatment did so in a time frame of somewhere between 7 months and 2 years.
  • A full course of treatment required, on average, 27 sessions over the course of 17 months.
  • Patients with co-morbid conditions, such as anxiety disorders or depression, required more sessions, on average, than those without co-morbid conditions.
  • All patients who completed treatment achieved 100% full weight restoration, as indicated by a return to their pre-AN percentile patterns of growth for height and weight.
  • Average time to achieve weight restoration was 3.6 months.
  • Patients who recovered with individual therapy took longer, on average, to achieve weight restoration than those who recovered through Family-Based Treatment (FBT).
  • Patients receiving FBT were almost twice as likely to recover as those receiving individual therapy.
  • Patients receiving individual therapy were almost twice as likely as those receiving FBT to drop out of treatment prematurely.
  • Individuals with restrictive Anorexia Nervosa were twice as likely to achieve full remission as those with binge-purge Anorexia Nervosa.
  • For treatment drop-outs, there was a significant correlation between length of time spent in treatment and progress made. All treatment dropouts who were in treatment with me for at least 2 months had made significant progress towards treatment goals at the time of drop-out.  Patients who dropped out of treatment after one month or less had not made any progress at the time of drop-out.

 

Treatment Outcomes for Bulimia Nervosa

  • Over half of patients with bulimia nervosa (54%) discontinued treatment prematurely after making significant progress towards treatment goals, but prior to achieving full remission.  15% percent of patients were referred to other treatment providers or types of treatment that could better meet their needs, after making little or no progress in treatment with me. 8% of patients moved to other geographic locations and were thus referred to providers near their new homes.  23% of patients completed a full course of treatment with me.
  • Of those who completed a full course of treatment, 100% achieved full remission from their eating disorder.
  • A full course of treatment required, on average, 13 sessions over the course of 5 months.
  • Patients who took Prozac during treatment were more likely to achieve full remission than those who did not take medication.
  • Patients with a prior history of Anorexia Nervosa were less likely to recover from Bulimia than those who did not have a prior history of Anorexia Nervosa.
  • The presence of a comorbid diagnosis was not related to likelihood of achieving full remission from Bulimia.
  • Level of family involvement in treatment was not related to the likelihood of achieving full remission. This finding is in stark contrast to my outcomes for Anorexia Nervosa, in which family involvement was strongly correlated with positive treatment outcome.

Treatment Outcomes for Mood Disorders

  • Only 18% of patients who presented with a primary diagnosis of a mood disorder completed a full course of treatment with me. 50% discontinued treatment prematurely for unknown reasons, 15% moved to other geographic locations, and 18% were referred to other providers who could better meet their needs.
  • Of those who completed a full course of treatment with me, 83% achieved full remission from their mood disorder and the remaining 17% made significant progress towards their treatment goals.
  • Length of time to complete treatment varied dramatically (from 1 month to 3 years) based on individual needs, symptom severity, and progress. On average, a full course of treatment required 23 sessions over the course of 16 months.
  • High levels of family involvement predicted treatment completion and full recovery for adolescent patients but not for adult patients.
  • Patients who were self-referred were more likely to complete treatment and achieve full remission than those who were referred by another professional.
  • Predictors of less favorable treatment outcomes included hospitalization during treatment and taking psychotropic medication during treatment, most likely because these variables are markers for more severe forms of mental illness.
  • The following variables did NOT predict treatment outcome: age at intake, gender, ethnicity, duration of illness, diagnosis (type of mood disorder), presence of co-morbid diagnoses, rate paid for services, type of treatment received with me, or history of hospitalization prior to starting treatment.

Treatment Outcomes for Anxiety Disorders

  • Half of patients who entered treatment for anxiety disorders completed a full course of treatment with me.
  • Of those who completed a full course of treatment, 88% achieved full recovery and the remaining 12% made significant progress towards their treatment goals.
  • Length of time required to complete a full course of treatment varied dramatically from 1 month to 19 months, with a median treatment duration of 3 months.
  • Of those who discontinued treatment prematurely, 63% had made significant progress towards their treatment goals as of their final session with me, and the remaining 37% had made some progress.
  • Predictors of positive treatment outcome included high levels of family involvement in treatment, younger age at intake, shorter duration of illness, being self-referred to my practice, paying full rate for services, and having good attendance at therapy sessions.
  • Predictors of less favorable treatment outcome included presence of a comorbid diagnosis, taking psychotropic medication during treatment with me, and being referred to my practice by a psychiatrist.

General Conclusions

  • Across diagnostic categories, less than half of patients who enter treatment with me complete a full course of treatment with me.
  • I tend to set the bar high for my patients, striving to engage them and help them continue to progress until they reach full remission.
  • Many individuals and families decide to discontinue treatment after making significant progress towards treatment goals, but prior to achieving full remission.
  • I hope that those who discontinue treatment after making significant progress, but prior to achieving full remission, continue to move forward and eventually achieve full remission with the support of their families and/or with other professional supports.  My primary goal in working with families is to empower the parents to help their child.  My goal is to become obsolete for that particular family.   For this reason, when a family reaches a point where the parents are confident that “We’ve got it from here!” and my involvement is no longer necessary, then I have done my job well.    Therefore, dropping out of treatment prematurely, after making significant progress in treatment, may not necessarily be a negative thing.
  • Across all diagnostic categories, patients who complete a full course of treatment with me do very well in recovery. The vast majority achieve full remission from their illness.

 

 

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End of Treatment Outcomes for Patients with Anxiety Disorders (2009-2017)

In an effort to improve the quality of services I offer, and in the service of full transparency to those who seek treatment, I am committed to compiling and sharing outcome data every few years on the patients I have treated.   The last time I compiled and shared my treatment outcome data was in 2013, so it is time for another round, this time with a larger sample to describe.

Description of the Sample

This analysis includes all patients with a primary diagnosis of an anxiety disorder who participated in an evaluation followed by a minimum of one therapy session with me at any time between the start of my private practice in 2009 and spring of 2017.  Given that this is an analysis of end of treatment outcomes, patients who are currently in treatment with me were not included in this sample.

This sample includes 16 patients, all female, who ranged in age from 10 – 42 years old, with a median age of 20.

Description of Treatment Received

Seventy-five percent of these patients were treated with Cognitive-Behavioral Therapy (CBT), while the remaining 25% of patients were treated with supportive or client-centered therapy.

Length of treatment and number of sessions attended varied considerably among these individuals.  The vast majority of patients were in treatment with me for somewhere between 2 – 19 months and attended somewhere between 3-17 sessions.   The median duration of treatment was 4.5 months, and the median number of sessions attended was 12.

Degree of family involvement varied based on the patient’s age and living circumstances.  All patients under age 18 had at least a moderate level of family involvement, and 83% of patients under age 18 had a high level of family involvement.  Patients of college age had low- to moderate levels of family involvement, and most adult patients in their 30’s and 40’s had minimal, if any, family involvement.

Forty-four percent of patients were taking psychotropic medication, prescribed by their psychiatrist, during their treatment with me.  None of the patients in this sample were hospitalized during the course of their treatment with me.

Treatment Completion and Recovery Rates

Of all patients who entered treatment with me for anxiety disorders, 44% percent recovered completely from their anxiety disorder, while 38% made significant progress in terms of reduction of symptoms and improvement in functioning, and 19% made some progress towards recovery.   In sum, all of the patients in this sample made at least some progress towards their treatment goals.  For a detailed description of the criteria used to determine “full recovery,” “significant progress,” and “some progress,” see this blog post from 2013.

Half of the patients who entered treatment with me for anxiety disorders completed a full course of treatment.   Completing a “full course of treatment” was defined as remaining in treatment until the patient, her family (when involved), and I collaboratively agreed that treatment goals had been met and further treatment was not needed.  The number of sessions required to complete a full course of treatment ranged from 3 – 25 sessions, with a median of 4 sessions.  The duration of treatment for those who completed a full course of treatment ranged from 1-19 months, with a median duration of 3 months.  Of those who completed a full course of treatment, 88% achieved full recovery and 12% made significant progress since starting treatment.

The remaining half of patients did not complete a full course of treatment with me, either because they quit treatment prematurely, they moved to another geographic location, or I referred them to another clinician.   Among those who did not complete a full course of treatment, 63% had made significant progress in their recovery at the time they left treatment with me, and the remaining 37% had made some progress.  It is important to note that I do not have data on what happens to patients after they leave my practice, so these treatment outcomes are based on an assessment of the patient’s symptoms and functioning as of the last session they attended with me. It is possible that some individuals who left treatment prematurely achieved full recovery later on their own, or in treatment with another clinician, after leaving my practice.  It is also possible that some individuals experienced a worsening of their condition after leaving treatment.

Predictors of Treatment Outcomes

A high level of family involvement in treatment emerged as the strongest predictor of successful treatment outcome.  100% of patients who had high levels of family involvement in treatment completed a full course of treatment and achieved full recovery.

Completion of a full course of treatment was the second strongest predictor of successful outcome. 88% of patients who completed a full course of treatment achieved full recovery from their anxiety disorder.  The remaining 12% of treatment completers had made significant progress since the start of treatment.

Younger age was also a predictor of successful treatment outcome.  Younger age was strongly correlated with both high family involvement and completion of treatment.

Other factors associated with successful treatment outcome include shorter duration of illness, good attendance at therapy sessions, paying full rate for services, and being self-referred to my practice.

Not surprisingly, discontinuing treatment prematurely was associated with less favorable outcomes.   Even so, 63% of individuals who discontinued treatment prematurely had made significant progress since beginning treatment with me, and the remaining 37% had made some progress.  These data indicate that the majority of individuals with anxiety disorders experienced significant benefits from treatment in terms of reduction of symptoms and improvement in functioning, whether or not they completed treatment a full course of treatment.

Other factors strongly associated with a less favorable treatment outcome included the presence of a comorbid diagnosis, taking psychotropic medication during treatment, and being referred to my practice by a psychiatrist.  Interestingly, these three factors were strongly correlated with one another: all of the individuals who were referred to my practice by their psychiatrist were taking psychotropic medication and 80% of individuals referred by their psychiatrist had comorbid diagnoses.

The following factors were modestly associated with less favorable treatment outcomes: older age, longer duration of illness, lower levels of family involvement, poor attendance at therapy sessions, and paying reduced rate for services.  Again, these factors tended to co-occur with one another, and also tended to co-occur with the three negative prognostic factors listed above.

These statistics reflect overall trends, not absolutes.  Some individuals in this sample did achieve full recovery despite being adults with long duration of illness and no family involvement, or having other characteristics typically associated with less favorable treatment outcome.

For a more detailed description and interpretation of these statistics, click here.

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There’s an App for That!

Technology can be used in a variety of ways to enhance mental health and aid in recovery from psychological disorders.   For example, patients can use smart phone apps to help them track moods and symptoms, implement coping strategies, and reach out for help from clinicians and peers when needed.   Most evidence-based, behaviorally-oriented treatments for mental health problems – such as Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), and Mindfulness-Based Cognitive Therapy (MBCT) – require some degree of self-monitoring.  These types of treatments also strongly encourage daily practices to enhance well-being, such as journaling, identifying and challenging negative thoughts, diaphragmatic breathing, or mindfulness meditation.

Most of the teenagers and college students I work with are far beyond the old pen-and-paper logs and worksheets I was trained to use during graduate school.  It seems there’s an app for everything these days, and so many of these apps are relevant to mental health and wellness.  Today’s young people organize their lives on their smart phones anyway, so it is only natural that we would look to the smartphone to help them self-monitor their symptoms, complete their therapy assignments, and keep track of the strategies they use to help themselves.

There are literally hundreds, if not thousands, of apps that are useful to people with mental health conditions.  Here are a few of my favorites:

The Recovery Record app helps patients with eating disorders self-monitor their meals and snacks as well as thoughts, feelings, and urges that arise around food.

The Insight Timer app offers a meditation timer, thousands of free guided meditation tracks, groups for like-minded meditators, and the ability to track quantitative statistics such as how many minutes the user spends each day in meditation.

DBT Diary Card and Skills Coach is an electronic version of the Diary Card used in standard DBT practice, which helps the patient track target behaviors and utilize DBT skills from the modules of Mindfulness, Distress Tolerance, Emotion Regulation, and Interpersonal Effectiveness.

The nOCD app helps patients with Obsessive Compulsive Disorder implement their exposure and response prevention treatment while compiling objective, real-time data on their experience.

I am a firm believer that what transpires in the therapist’s office is only a fraction of the treatment package.  Most of the healing process results from consistent changes that patients and their families make on a daily basis at home, at school, and in various social settings.   Thanks to modern technology, individuals who are committed to improving their well-being are now able to hold new tools, literally, in the palms of their hands.

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Fighting Stigma: The Gift of a New Generation

Somehow, sometime in the past several years, I crossed some invisible line from “young adult” to simply “adult.”  Polite strangers call me “ma’am” at least as often as they call me “miss.”  Shopping at Forever 21 now seems scandalously inappropriate.  And I can’t remember the last time I was still awake to watch Saturday Night Live.  Now that I seem to be old enough to complain about the younger generation (They think women’s empowerment is posting bikini-clad selfies!  They use social media excessively! Their pivotal relationship conversations take place over text message!), it seems only fair that I also recognize the strengths of this cohort.  And they do have tremendous strengths.

Teenagers and young adults these days, for the most part, have grown up in an era where it is socially acceptable, even encouraged, to speak openly about mental health issues.  Just about every high school and college student who walks into my office has at least a couple of friends with mental health diagnoses.   Most of my patients have one or more members of their extended family, if not their immediate family, who has dealt with a mental illness.   And they know this because they talk openly about it.

And that excessive use of social media I complained about a minute ago?  Well, social media has allowed famous people to speak candidly to a wide audience about their experiences with mental illness, seeking treatment, and ultimately recovering.   Actress Kristen Bell has struggled with depression.   Writer/producer/actress Lena Dunham has received treatment for OCD.  Singer Demi Lovato has spoken openly about her struggles with bipolar disorder and her recovery from an eating disorder.  John Green, author of The Fault in Our Stars, has chronic anxiety which he is able to control with therapy and medication.  Olympic swimmer Michael Phelps has a diagnosis of ADHD.  These individuals have been extremely successful in their professions and have had the courage to speak publicly about their psychiatric problems.

Even more courageous than these celebrities, though, are the regular people who attend school, play sports, hold down jobs, pay bills, raise families, volunteer in their communities, and maintain friendships while also dealing with mental illness.  These are the people who have a lot to lose from the stigma surrounding mental health issues.  These are also the people who have the most to gain from breaking down the stigma.

The younger generation is fighting this stigma.  Australia’s National Youth Mental Health foundation has created an organization called Headspace dedicated to supporting adolescents and young adults with mental illnesses as well as combating stigma surrounding these issues.  In the UK, Prince William, Princess Kate, and Prince Harry have created Heads Together, a charity dedicated to fighting stigma surrounding mental illness and improving the mental well-being of all citizens.  Here in the US, the National Alliance on Mental Illness (NAMI) is running a Stigma-Free campaign.

The message of these organizations is simple and straightforward: mental illness is common and treatable.  Mental health problems are as much a part of the human condition as any other health problem.  Untreated mental illness can have dire effects on the individual, on the family, on the community, and on society as a whole.  People who have psychiatric diagnoses can overcome them and live fulfilling, successful, meaningful lives.  Learn about it.  Talk about it.  Seek treatment when needed, and support others in doing so as well.  Silence and shame help no one.

I can’t recall ever hearing these messages as a teenager or young adult.  If these messages existed at all back in my day, they were eclipsed by the OJ Simpson trial, overshadowed by the Clinton/Lewinsky scandal, drowned out by the Spice Girls and ignored amidst episodes of Friends.  It is an honor and a privilege for me to treat the teens of this generation, who live their lives with more knowledge, understanding, and acceptance than the generation before them.

If you’d like to read an interesting perspective from a highly experienced clinician from a previous generation who has over 40 years of experience treating anxiety and eating disorders, see Dr. Paula Levine’s blog.

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Let’s Get Physical: Exercise in the Treatment of Mood and Anxiety Disorders

As the Olympic Winter Games are commencing tomorrow in Sochi, I feel inspired to write about the role of physical activity in mental health. This post will focus specifically on exercise in the treatment of mood and anxiety disorders.

Numerous studies have shown that regular exercise improves mood in people with mild to moderate depression. For those with severe depression or bipolar disorder, exercise alone is rarely sufficient, but exercise can play an adjunct role in helping patients recover and prevent relapse.

We know from Newton’s law of motion that an object at rest stays at rest unless a force acts upon it, and an object in motion stays in motion unless some force makes it stop. The same is true for human bodies. Paradoxically, sedentary people tend to have less energy and active people tend to have more.

Now, of course this begs the question of the chicken or the egg – it is likely that people become sedentary because they have little energy or stay active because they have a surplus. This is true. People seem to have “set points” for activity level just as they do for weight and mood. That being said, physical activity has an almost immediate effect on mood and energy level. Over time, consistent exercise helps to stabilize moods, improve sleep, reduce stress, and enhance motivation to continue moving.

For these reasons, I strongly encourage my patients who suffer from mood disorders or anxiety disorders to exercise regularly. In my opinion, exercise is every bit as important as therapy, medication, and sleep when it comes to mood and anxiety disorders.

As I have emphasized in previous posts, the mind is a series of conscious functions carried out by the brain, and the brain is part of the body. Physical health and mental health are one in the same. Despite what society, popular wisdom, and health insurance companies may tell us, there is no actual difference between a physical illness and a mental one. When you exercise your body, you are exercising your brain.

Unlike therapy or medication, exercise is cheap or even free. Unlike medication, which can have unpleasant or dangerous side effects, exercise is generally safe so long as you do it sensibly and moderately. Unlike therapy, which requires another person and an appointment, exercise can be done alone if you choose at a time that suits your schedule. Unlike therapy, which is typically one-on-one and indoors, exercise can be enjoyed inside or outside with your family, friends, classmates, or teammates.

Numerous times, I have been amazed at how much exercise improves my patients’ mental health. This is especially true for people who have historically been sedentary and embark on a new exercise routine as part of their treatment plan. For example, I am working with a 15-year-old girl whom I’ll call Elsa who suffered from severe depression and crippling anxiety. When I met Elsa last year, she hated exercise and barely had the energy to get out of bed. After months of encouraging her to try different enjoyable physical activities, she finally started biking with her mom and jogging with her neighbor. She is now in full remission from her depression, making excellent progress in tackling her anxiety, and training for her first 5K. She now wakes up at 7:00 am with plenty of energy and really enjoys exercising. I am so proud of her.

One of the more challenging aspects of incorporating exercise into a patient’s treatment plan is that sometimes the mental illness itself is part of the reason why the patient is inactive. Depressed people tend to lose interest in activities they once enjoyed. They feel unmotivated and chronically exhausted. Clearly, it is a challenge for them to do essential things like get dressed and go to school, let alone something “extra” and “optional” like exercise.

For these patients, I use a behavioral technique called behavioral activation. Here’s how it works: we agree upon a small, realistic exercise goal such as walking for 10 minutes three evenings a week. [Elsa’s initial idea was to do the Insanity DVDs she saw on an infomercial. Given that she hadn’t exercised in years, I told her that this idea was, frankly, insane, and I suggested something more moderate.] I have the patient choose an activity they enjoy (or at least one that they don’t hate) and a time of day when they’re likely to follow through (for example, not at 5:00 AM if they aren’t a morning person).

When possible and feasible, I encourage patients to exercise socially by attending a class, joining a sports team, taking lessons, or doing something active outdoors with their families. We make this activity part of their weekly schedule, writing it down (or, often, putting it in their smart phone) as if it were any other appointment or commitment. Most of the time, the patient achieves their initial goal because it is small, realistic, specific, and planned.

Achieving this initial exercise goal creates a feeling of success and personal satisfaction and enhances the person’s motivation to keep going. In addition, they experience a bit of a mood boost from the activity itself. Once the patient achieves the initial exercise goal, it is increased a little bit in frequency or duration.

Using the example above, the patient may walk for 20 minutes during the second week and 30 minutes during the third week. This gradual increase in frequency and duration continues for a number of weeks or months. Eventually, the patient has incorporated regular exercise into her lifestyle. The stress reduction, mood enhancement, and improvement in fitness level enhance her internal motivation to continue exercising.

Anxiety can also interfere with a patient’s plans to exercise. Many people who experience panic attacks are afraid of the physical sensations that result from exercise (rapid breathing, increased heartbeat, sweating), which closely resemble those of a panic attack.

Patients who have social anxiety may shy away from joining sports teams, taking dance classes, or going to gyms because they worry about being judged or making a fool of themselves. For example, Elsa had enjoyed dance classes and swimming in elementary school but later became socially anxious and self-conscious about wearing a leotard or swimsuit in front of her peers. For this reason, she chose to do biking and jogging which did not require such revealing attire. And now, for the record, Elsa does wear a swimsuit with only mild anxiety when she goes to the beach or the pool with her friends. Did I mention how proud of her I am?

For patients with eating disorders, exercise is altogether a different story. That will be the topic of my next blog post.

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Giving Thanks

In my work as a clinical psychologist, I am faced daily with stories of tragedy, trauma, illness, conflict, and loss. Each therapy session is a window into private suffering.

“Isn’t it hard?” people ask me. “Isn’t it awful to listen to people’s problems all day long? Doesn’t it make you depressed?” My answers to these questions are: “Yes,” “No,” and “Quite the opposite.” It is painful to witness people suffering, but it is endlessly rewarding to help them triumph.

Rather than letting other people’s pain drag me down, I feel honored that they have shared it with me and privileged that I am in a position to help them cope with it. I am intimately aware of the obstacles people face – and overcome – every single day. Being a clinical psychologist provides me with daily opportunities to participate in stories of healing, strength, opportunity, resolution, and empowerment.

As Thanksgiving approaches, many Americans begin to think about expressing gratitude for the things we take for granted the rest of the year. Consider these:

If you get out of bed next Thursday, give thanks.
There are those with depression who cannot do so without herculean effort.

If you are preparing to host relatives in your home, give thanks.
There are those with crippling social anxiety for whom a house full of guests would be unthinkable.

If you are planning to travel across several time zones to spend the holiday with relatives, give thanks.
There are those with mood disorders for whom jet lag can trigger an episode of mania or depression.

If you are looking forward to Thanksgiving dinner, give thanks.
There are those with anorexia nervosa for whom a holiday feast is an object of fear, loathing, and guilt.

If you set the table next Thursday in under five minutes, give thanks.
There are those with OCD who cannot relax unless every napkin, fork, and knife is lined up precisely.

If you sit on the couch after dinner to watch football with your uncles and cousins, give thanks.
There are those with bulimia nervosa who will be pacing around the house, waiting for an opportunity to purge unnoticed.

If you settle into bed with a good book later that evening, give thanks.
There are those who will be cutting their forearms with a razor to numb themselves from the intolerable emotions triggered by the day’s events.

If you go to bed Thanksgiving night satiated and content, give thanks.
There are those whose restless worry keeps them up until sunrise.

If you have never even considered feeling grateful for these ordinary things, give thanks.
Our mental health, and that of our family, should not be taken for granted.