INPATIENT COGNITIVE­ BEHAVIORAL TREATMENT OF EATING DISORDER PATIENTS WITH DISSOCIATIVE DISORDERS Andrew P. Levin, M,D. Edward Spaustcr, Ph.D. Andrew P. Levin, M.D. is Unit Chief of the Adult Partial lier by Torem (1986). Hospital Program,Holliswood Hospital andAssistant Clinical Despite these findings, little has been written address­ Professor of Psychiatry, Columbia University. ing treatment techniques for these ~dually diagnosed" patients. Typical treatment for eating disorders has focused Edward Spauster, Ph.D. is Clinical Director, Holliswood on a cognitive-behavioral therapy (CBT) model (Fairburn, Hospital. eeal., 1991). Although CBT approaches to dissociative patients (DDs) are well-known, (Andreason & Seidel, 1991; For reprints write Andrew P. Levin, M.D., 87-37 Palermo Caddy, 1985; Ross, 1989; Fine 1991a) it is unclear if these Street, Holliswood, N.Y., 11423. techniques are applicable when the patient suflers both dis­ orders. Torem hasdescribedan ego-state therapy (1987; 1989a) ABSTRACT which combines hypnoanalytic and behavioral techniques to reduce disordered eating. Although not specifically Although several investigations have noted an association between focused on the CBT modd, Torem's treatment paradigm eating disorders and dissociative disorders, little work has addressed includesseveral ofthe basic features ofcognitive-behavioral tlu: treatment ofpatients with both conditions. As an inpatient ser­ treatment in its overall scheme. vice focused on severely-ill eating disorder patients, il became nec­ As an inpatient service initially focused on severely-ill' essary to diagnose and treat roncomitant dissociative disorders. We EDs, our treatment program was forced to respond to the describe a cognitive-behavioral inpatient program developed and dissociative pathol0t.'"Y uncovered in this patientpopulation. specifically adapted to treat eating disorder patients with dissocia­ Tn this paper we describe an inpatient CBT program devel­ tive disorders. Patients were identified by self-report measures (the oped to treat the ~dually diagnosed" patient with an eating Eating Disorder Inventory and the Dissociative Experiences Scale) disorder and dissociative pathology. and clinical interoiews. Specific eatingsymptoms linked to post-trau­ Tn their descriptions ofCBT techniques with dissociative matic stress or conversion disorders were approached with stimulus and multiple personality disorder (MPD) patients, Ross control and hierarchical desensitization. individualandgroup cog­ (1989) and later Fine (1991a) highlighted the uncovering nitive thn-apy as well as diary techniques addressed irrational beliefs and correction ofcognitivedistortions. Thesecognitive restruc­ {()mrrwn to both disorders. Skill enhancement through relaxation turing strategies typically focused on issues such as respon­ training, anxiety management, and anger management, initially sibility for past abuse but neither author has described the tailored for the eating disorder patient, required adaptationJor dis­ use of specific techniques such as logging or rehearsal. sociativepatlwlogy. Addressingboth disorders reduced eatingpathol­ Caddy (1985) provideda case report ofCBT with an MPD ogy whereas inattention to dissociative symptoms led to continued including goal-setting, desensitization, self-management, disturbed eating and purging. Identification and treatment ojdis­ and relaxation exercises. Caddy appears to have employed sociative pathology may improve treatment outcome in the treatment­ unmodified CBT techniques developed foranxiety disorders resistant eating disorder patient. because panicandphobicsymptomsdominated in this patient and dissociative episodes did not disrupt the treaunent. It INTRODUCTION is unclear if these techniques would be manageable in a more severelydissociative patient. A briefreportbyAndreason Several recent'reports have focused on the association and Seidel (1991) described the usc of CBT, goal-setting, between eating disorders and sexual abuse (Hall, Tice, and behavionll limits in three patients with MPD, but was Beresford, Wooley, & Hall, 1989; Palmer, Oppenheimer, not specific about techniques that were employed. Dignon, Chaloner, & Howells, 1990) and, more specifical­ Tn addition to the small CBT literature for patients diag­ ly, between dissociative disorders (DDs) and eating disor­ nosed with dissociative disorders, a much larger literature ders (EDs) (Torem, 1990; Demitrack, Putnam, Brewerton, has described CBT techniques in post-traumatic stress dis­ Brandt, & Gold, 1990; Goodwin, Cheeves, & Connell, 1992). order (PTSD) , e.g., nlpe victims, warvetenlns, ordisaster vic­ McCallum, Lock, Kulla, Rorty, and Wetzel (1992) found a tims (see Saigh, 1992), and borderline personality disorder 29% incidence of dissociative disorders in a sample of 38 patients who were abused as children (Linehan, 1993). women with eatingdisorders. Further, McCallum eta\. (1992), Although PTSD is designated an anxiely disorder in DSM-//J­ reported a temporal relationship between dissociative phe­ R, several authors suggest it represents a form of dissocia­ nomena and eating behaviors, an association described ear- tive pathology (Braun, 1984). Conversely, dissociative dis- 178 I)]SSOClAlI0~. Vol. \ II, 11:0. 3, September 1994 LEVINjSPAUSTER ,• on:l.erssuch asMPO have beenconceptualizedas PTSD (Spiegel, ation by an attending psychiatrist who develops diagnoses 1984), and PTSD symptoms are usually prominent in the in collaboration with otherteam members. In addition,each MPO patient (Lowenstein. 1991). Borderline perwnality patient receives a medical evaluation, the Eating Disorders pathology hasalsobeen recastasPTSD (Herman. 1992). CBT Inventory (Gamer,Olmsted,& Polivy, 1983),the Dissociative techniques utilized for PTSO patienrssuch as relaxation, desen­ Experiences Scale (Bernstein & PuUlam, 1986), and when siti7.ation, and as,.<;ertiveness trainingshould be applicable to appropriate, hypnotic evaluation ofdissociative symptoms. the complex dissociative patient. Our experience suggests CBT modalities are administered in group and individual­ that these techniques can be effective but require modifi­ ized formats. Specific groups include problem solving strate­ cation for the complex dissociative patient with an eating gies with daily behavioral goal-setting, relaxation training, disorder. hierarchical desensitization, cognitive restructuring, impulse Commonalities in cognitive and behavioral features of control strategies, and skill development for assertiveness eating disorder and dissociative disorder patients also pre­ and anger-management. In addition to CBT, treatment dict applicability of similar techniques. Both groups expe­ modalities include pharmacothentpy, psychosocial evalua­ rience affective dysregulation including anger, depression, tion and briefintervention,individual psychotherapy3-4/wk, and anxiery, as well as the impulsive behaviors which follow, conventionalgroup therapy, hypnotherapy, andTwclveStep e.g., self-mutilation, substance abuse, and binge/purge Alcoholics Anonymous, Narcotic Anonymous, and/or cycles. McCallum et al., (1992) noted that self-mutilation OvereatersAnonymous as appropriate andas tolerated. During was temporally related to dissociative experiences in their the period 1990 • 1993, the average length of stay on the sample of 38 eating-disordered women. Affective dysregu­ BDU was 23 days, but the "dually diagnosed" Ells tended to lation precipitating emotional flooding in both groups stay 2842 days. requires an overall focus on pacing, as described by Fine (l992b) in work with MPDs. Cognitive distortions of over· GOAL SETTING AND THE BECK LOG responsibility, perfectionism, and catastrophi:ting are well described in EDs (See Carner & Garfinkel, 1985) and DDs The techniques of goal-setting in a CBT milieu as (Fine, 199Ia). Skill deficits in time management, self-regu­ described by Levendusky and Berglas (1985) form the orga­ lation, andinterpersonalfunctioningfrequently preventprop­ nizing framework of the BDU program. Patients distill pre· er rolc functioning in these two groups and exacerbate eat­ senting symptoms into a a Problem/Goal/Method frame­ ing and dissociative pathology. work during the Grstthrec to five days ofhospitalization in Recognition ofthese common themes in cognitive and daily group therapy and individual sessions with their ther­ behavioral function enables bom the patientand treatment apists and primary nurses. Problems and goals are stated team to focus on specific goals for inpatient treatment and behaviorally; methodsentailshort-term techniques to be uti­ todeveloplong-range targetsforoutpatientcare.At thesame lized during inpatient treatment and long-tenn strategies time, response patterns and cognitive distortions differ in for aftercare. Examples ofgoals for bulimic and dissociative sevenll ways between uncomplicated EDs and "dually diag­ symptoms are included in Appendix). nosed" eatingdisorder patients. Failure to identifythesedif­ Thegoal-setting technique providesa specificdocument ferences may seriously undermine the treatment of the ED for the patient and therapist to utilize and amend through­ patient with dissociation. outlhe therapy. This represents a concretizationofthe prob­ lem idemification and paLiemeducation described inTorem THE INPATIENT SETIING (198gb) and Fine (1991a) thal arc the foundation for all CBTwork (Beck, Rush, Shaw, & Emery, 1979). By serving as The Behavioral Disorder Unit (fiDU) is a 25-bed locked a roadmap for the treatment, the Problem/Goal/Method