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Eating Disorders Are Anxiety Disorders:  Why We Should Be Moving Towards Transdiagnostic Conceptualization and Transdiagnostic Treatment

Norman Kim, Ph.D., National Director for Program Development

Norman Kim, P.h.D., graduated from Yale University in 1993. While there, Norman earned a B.A., Distinction in the Intensive Major in Psychology and Pre-Med. He was also awarded the Mellon Fellowship for Research in Psychiatry, Yale Club Foundation Scholar, Yale Directed Studies Program, National Merit Scholarship, U.S. Congress-Budestag Exchange Scholarship.

In 2003, Norman Kim graduated from the University of California at Los Angeles, located in Los Angeles, CA where he earned his P.h.D. in Clinical Psychology. While there, he was awarded The National Research Service Award by National Institutes of Health, University Fellowship, Grants: Advancement to Candidacy Grant, NIMH Autism Diagnostic Interview Training Grant, UCLA Department of Psychology Travel Grant, Nominee for Graduate Teaching Award, Utilized Structural Equation Modeling to develop statistical prediction models of complex, multi-factorial problem behaviors, Dissertation: Multiple pathways to problem behaviors in adolescents: a longitudinal analysis.

PROFESSIONAL AFFILIATIONS: Board of Directors, Eating Disorder Coalition, Eating Disorder Advisory Council, Joint Commission, Advisory Board, Tikvah V’Chizuk, Committee Member, AED Advocacy and Communications Committee, Member, Academy for Eating Disorders, International Association of Eating Disorder Professionals, Residential Eating Disorder Coalition, International Society for the Study of Trauma and Dissociation.

Session Abstract:

There is a growing consensus that the marked level of co-occurrence of eating disorders and anxiety is not just diagnostic overlap, but rather that it represents a more significant, shared underlying diathesis, which predisposition or vulnerability can have multiple phenotypic manifestations. One can certainly see this overlap in the core phenomenology of eating disorders: obsessiveness and compulsivity, the primacy of fear and avoidance, hypervigilance and sensitivity, and prevalence of somatic symptoms that represent both a disconnect from the body as well as a hypersensitivity to somatic sensations and cues. This overlap is also evident in the fact that anxiety symptoms almost always precede eating disorder symptoms, that anxiety disorders are the most common comorbid diagnoses present in eating disorders, and that anxiety symptoms remain long after weight restoration and eating disorder symptoms remission. Ongoing advances in our understanding of the neurobiology and genetics of Eating Disorders and Anxiety further support a more transdiagnostic approach to their conceptualization and treatment.

One such transdiagnostic application is the use of Exposure and Response Prevention (ERP) based approach to eating disorder treatment, for which there is a growing body of evidence. Exposure and Response Prevention is an empirically validated treatment approach based on classical conditioning and learning theory that targets learned fear responses that result in avoidant and compensatory behaviors. ERP is predicated upon learning through experience that feared consequences do not occur, and developing new non-fear associations. Using graded exposures to feared stimuli, exposures are designed to elicit emotional responses in the moment without allowing compensatory behaviors.

We will present the evidence and rationale for an Anxiety based, transdiagnostic approach in conceptualizing and treating eating disorders, and present techniques for developing and using in vivo and imaginal exposures in eating disorder treatment to help patients confront and habituate to feared situations in the safety of planned and structured exposures. We will review how to apply our understanding of neuropsychological functioning in eating disorders and the mechanisms of anxiety in service of healing and overcoming the fear and threat that underlie Eating Disorders.

Educational Learning Objectives:

Participants will apply a transdiagnostic framework to the conceptualization and treatment of eating disorders
Apply the methodology of using exposure and response prevention in eating disorder treatment. Develop and utilize methods for using in vivo and imaginary exposures for use in eating disorders treatment.

Workshop Outline:

I.     Overlap Between Eating Disorders and Anxiety

1. Characteristics and Presentation

2. Psychology

3. Genetic

4. Neurobiology of ED

II.    Transdiagnostic Conceptualization of Eating Disorders
III.   Use of Exposure and Response Prevention (ERP)

1. ERP successful treatment for OCD

2. Expose patients and then prevent from engaging in compulsion

3. Demonstrate the nonoccurrence of the feared consequence

4. Preventing response prolongs exposure

IV.  Why use ERP in Eating Disorders

1. Overlap in phenomenology of ED and Anxiety

2. Anxiety symptoms precede ED symptoms

3. Patients with ED report higher levels of comorbid anxiety

4. Anxiety remains elevated one or more years following weight restoration

V.   Using ERP in Eating Disorder Treatment

1. Break pattern of avoidance

2. Place patient in direct contact with feared stimuli so that there is “habituation”

3. Exposures designed to elicit patient’s emotional experience in the moment

4. Also work on attending to physical feelings

5. Not allow patient to use behaviors to check out or to alleviate anxiety while doing exposure

6. Change rigid patterns (eating in particular order, keeping food separate, keeping rigid schedules)

VI.  Exposure and Response Prevention Protocol

A. Introduce Rationale for ERP and Cog-Beh overview

B. Psychoeducational Component of Anxiety

1. Learn the natural time course of anxiety

2. Anxiety occurring on a scale (not binary, on/off)

3. Fear Hierarchy

C. Exposure In Vivo:

1. Learn that anxiety/distress/urge is temporary and will eventually decrease without use of compensatory behavior

2. SUDS introduced

3. List of triggering stimuli arranged in hierarchy

D. Imaginal Exposure with script and repetition

E. Response Prevention (not allow to engage in compensatory behavior
VII. Therapeutic Application

A. How ERP works to ameliorate symptoms

B. Designing Exposures

C. Case Examples

Audience Level:  Intermediate/Advanced

Disorder: Eating Disorders Demographic/Treatment

Approach: Exposure Therapy

Additional:  Obsessive Compulsive Disorder