Eating Disorders

Cognitive Distortions and Self-Worth in Eating Disorders

  • Clients with eating disorders place an extreme emphasis on their self-worth in relation to their physical appearance.

  • Cognitive distortions are prevalent in these populations. Examples of these maladaptive thoughts include:

    • "Nobody will like me if I'm overweight."

    • "My clothes won't fit if I continue to eat."

  • Occupational therapy is essential because practitioners are skilled at helping clients develop healthy, adaptive, and appropriate ways of coping. This is achieved by incorporating occupation-based activities within a safe and supportive environment.

  • Focus is centered on two primary concepts: food for thought (the relationship between cognition and food) and the family dinner (the role of the support system).

Classifications of Eating Disorders: Anorexia and Bulimia

  • Anorexia Nervosa is characterized by an abnormally low body weight. Clients engage in the avoidance of eating as a purposeful strategy to prevent distressing or distorted thoughts, such as the intense fear of gaining weight.

  • Bulimia Nervosa is characterized by binge eating followed by self-induced vomiting. This cycle is often driven by permissive thoughts, which allow the individual to bypass self-control. Examples of permissive thoughts include:

    • "I'll just have 11 more bite."

    • "I've already started eating so I might as well just keep eating."

    • "I'll start eating better tomorrow."

  • In bulimia nervosa, the lack of control over these thoughts leads directly to impulsive eating behaviors.

Occupational Therapy Interventions for Routines and Cognition

  • Intervention focuses on establishing and practicing healthy routines to address maladaptive behaviors in Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs), specifically cooking, eating, leisure, social activities, and work.

  • Practitioners emphasize specific healthy habits:

    • Maintaining healthy portion sizes.

    • Ensuring consistency in eating schedules.

    • Establishing appropriate levels of engagement in leisure and exercise (addressing both under-activity and excessive/compulsive exercise).

    • Stopping the obsessive counting of calories.

  • The goal is to help the client engage in these activities in a more adaptive way, addressing the underlying cognitive distortions that disrupt their relationship with food.

Psychodynamic and Cognitive Behavioral Approaches

  • Cognitive Behavioral Therapy (CBT) is utilized to challenge or acknowledge cognitive distortions. It helps clients identify these thoughts and develop healthier, more effective ways to respond to them.

  • The psychodynamic approach focuses on healthy and creative expression to build self-esteem and self-awareness regarding body image. Creative activities used in this approach include:

    • Photography

    • Dance

    • Drawing

    • Art

  • Acknowledging the feelings and maladaptive thoughts behind the eating disorder is critical to directing the client toward healthier coping methods.

Discharge Planning and Family Involvement: The Family Dinner Concept

  • Discharge planning is a critical component for preventing relapse. Clients must enter a healthy and supportive environment upon leaving professional care.

  • The psychoeducation model is used to train both the client and their caregivers on how to set up the environment and social situations to ensure the client feels supported.

  • Family therapy approaches incorporate the family and caregivers into the treatment plan, educating them on how to provide a safe and reassuring environment.

  • Reintroduction of food and food preparation tasks must be graded. Just as with any other occupational task, the complexity must increase slowly:

    • Initially, practitioners do not have the client cook a 44-course meal if they have been avoiding all food.

    • In these early stages, caregivers should be the ones preparing the food and selecting the food.

    • The client only transition to selecting and preparing their own food once they have built sufficient autonomy and comfort.

The Grandma Mnemonic for Clinical Practice

  • A visual mnemonic is used to remember the specific dynamics of family involvement in eating disorder recovery. Imagine a family dinner where a grandmother is the one putting food on everyone's plate and calling the shots regarding portion sizes and food selection.

  • This scene represents the necessary shift in control during early recovery: although occupational therapy values autonomy, in the initial stages of eating disorder intervention, the family or caregiver must take charge of portion control and food selection.

  • Over time, this control is gradually returned to the client as they gain the skills for healthy, independent management.

Questions & Discussion

  • Question: An Occupational Therapist (OT) works in a behavioral health facility with teens who have eating disorders. The OT is preparing an activity to help families learn to foster a relapse prevention strategy in the home environment. What activity would best help with this?

  • Options provided were: (A) Engage the group in planning and preparing a balanced meal, (B) suggest medical monitoring to encourage adequate nutrition, (C) identify and discuss safe and reassuring mealtime environments, or (D) use art therapy to facilitate expression of feelings and beliefs.

  • Analysis: While meal planning (A) and art therapy (D) are relevant to OT and eating disorders, they do not specifically target the home environment for families in the context of relapse prevention as effectively as focus on the mealtime atmosphere.

  • Conclusion: The correct answer is (C), identifying and discussing safe and reassuring mealtime environments. This ensures family and friends understand how to provide a non-judgmental environment, which is critical for success in the home setting post-discharge.