Recognizing Suicide Risk Factors and Warning Signs: Part I of III

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By Aileen Kim, MD

 

Recent current events may be bringing up some thoughts and questions about suicide. This is part I of III of an educational series that addresses some common questions and concerns about suicide.**

What are the differences between suicide risk factors and suicide warning signs?

Risk factors are characteristics or conditions that increase the chance that a person may try to end his or her life. For example, we know that people who try to end their life are more likely to have these variables present:

Health Factors

  • Mental health conditions

    • Depression

    • Substance use problems

    • Bipolar disorder

    • Schizophrenia

    • Personality traits of aggression, mood changes and poor relationships

    • Conduct disorder

    • Anxiety disorders

  • Serious physical health conditions including pain

  • Traumatic brain injury

Environmental Factors

  • Access to lethal means including firearms and drugs

  • Prolonged stress, such as harassment, bullying, relationship problems or unemployment

  • Stressful life events, like rejection, divorce, financial crisis, other life transitions or loss

  • Exposure to another person’s suicide, or to graphic or sensationalized accounts of suicide

Historical Factors

  • Previous suicide attempts

  • Family history of suicide

  • Childhood abuse, neglect or trauma

Warning signs are new or different behaviors in an individual person who might be at risk for ending his or her life in the near future. An individual who demonstrates these signs may be at risk:

Talk

If a person talks about:

  • Killing themselves

  • Feeling hopeless

  • Having no reason to live

  • Being a burden to others

  • Feeling trapped

  • Unbearable pain

Behavior

Behaviors that may signal risk, especially if related to a painful event, loss or change:

  • Increased use of alcohol or drugs

  • Looking for a way to end their lives, such as searching online for methods

  • Withdrawing from activities

  • Isolating from family and friends

  • Sleeping too much or too little

  • Visiting or calling people to say goodbye

  • Giving away prized possessions

  • Aggression

  • Fatigue

Mood

People who are considering suicide often display one or more of the following moods:

  • Depression

  • Anxiety

  • Loss of interest

  • Irritability

  • Humiliation/Shame

  • Agitation/Anger

  • Relief/Sudden Improvement

What causes suicide?

There is no single answer to this question. For any individual whose life ends in suicide, any combination of the risk factors listed above can play a part. People who commit suicide may genuinely believe that their survivors are better off without them or that their death would not have a negative impact on others. Conditions that create risk for suicide can affect a person’s perception, reasoning or judgment.

Is suicide always foreseeable and preventable?

Unfortunately the answer is no. People who attempt suicide can sometimes do so impulsively. They may not necessarily tell others that they want to end their life or intend to do so. Additionally, people with multiple risk factors and warning signs may not attempt suicide. Even when people with risk factors and warning signs seek and receive appropriate treatment, suicide is not always foreseeable and preventable. That doesn’t mean it is futile to try to help someone in your life when you are concerned they might have risk factors or warning signs for suicide, and it does not mean getting help from a professional cannot make a difference.

 

**Disclaimer: The content of this blog is intended as general educational material and is not a substitute for medical evaluation or advice in the context of a healthcare relationship. If you or someone you know is suicidal, call 1-800-273-8255 or seek immediate medical attention by calling 911.

 

References:

https://afsp.org/about-suicide/risk-factors-and-warning-signs/ accessed June 11, 2018

http://www.allianceofhope.org/blog_/2014/07/a-few-weeks-ago-i-noticed-a-young-survivor-who-wrote-in-school-we-are-told-that-suicide-is-100-preventable-but-when-m.html accessed June 11, 2018

Suicide Risk Screening in Healthcare Settings: Identifying Males and Females at Risk

Cheryl A. King, Adam Horwitz, Ewa Czyz, Rebecca Lindsay J Clin Psychol Med Settings. 2017 Mar; 24(1): 8–20.

 

Obsessive-compulsive Disorder (OCD): Frequently Asked Questions

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By: Andrew Hopkins, PA-C

 

What is Obsessive-compulsive Disorder?

Obsessive-compulsive disorder, or OCD, is a mental illness characterized by the presence of obsessions, compulsions, or both.

What are obsessions?

Obsessions are defined as recurrent and intrusive thoughts, images, or urges that causes anxiety or distress. Obsessions are not perceived as enjoyable, nor are they voluntary. Those with OCD attempt to ignore, avoid, or suppress these unwanted and disturbing thoughts. They aim to neutralize or mitigate the distress that obsessions cause through compulsions.

What are compulsions?

Compulsions are repetitive mental or behavioral acts that the individual feels driven to perform, either in relation to an obsession or according to rules he or she believes must be applied rigidly or to achieve a sense of “completeness”. These are often referred to as “rituals”, and include acts such as repetitive washing or checking.

Do I need to experience both obsessions AND compulsions to have OCD?

No, people with OCD can experience obsessions, compulsions, or both. However, the majority of people with OCD often have both.1,2 It is currently unclear whether obsessions lead to compulsions, or compulsions lead to obsessions.3,4

Who can develop OCD?

It is estimated that there is a 2.3% lifetime prevalence.5,6 In adults, women may be slightly more likely to develop OCD compared to men.6,7 Those with Schizophrenia or Schizoaffective disorder, Bipolar disorder, Eating disorders, or Tourette’s disorder appear to experience OCD at a higher frequency than the general population.8-10 The typical age on onset is around 19.5,6  It is unusual to develop OCD after the age of 35.11 Symptoms typically begin gradually over time, but sudden-onset can sometimes occur.

What is the cause of OCD?

There is no known specific cause for OCD. Current evidence suggests it is a combination of genetic, environmental, and neurobiological factors.

How might OCD manifest?

The frequency and severity of symptoms can vary from person to person, varying from mild, minimally interfering symptoms, to severe, incapacitating symptoms. The symptoms often adhere to a “theme’. Some themes include:

  • Cleaning.  Fears of contamination and repetitive cleaning.
  • Symmetry.  Symmetry obsessions and repeating, ordering, and counting compulsions.
  • Taboo thoughts.  Aggressive, sexual, or religious obsessions and related compulsions.

Avoidance behavior is common in OCD. People with OCD may often avoid people, places, or things which may trigger obsessions and/or compulsions. An example of this may be av oidance of public bathrooms for people who have contamination obsessions.

Those with OCD may impose rules on family members because of their symptoms. For example, family members may not be allowed to have visitors to the home for fear of contamination. High levels of family accomodations is often associated with poorer treatment outcomes, high family burden, and poorer quality of life among family members.

May people with OCD experience dysfunctional beliefs, such as:

  • Inflated responsibility and tendency to overestimate threat
  • Perfectionism and intolerance of uncertainty
  • Overvaluing the importance of thoughts and the need to control thoughts

Those with OCD may have varying levels of insight into their symptoms. If an individual recognizes that their OCD beliefs are definitely or probably untrue, then this represents good insight. Contrary, if a person thinks their OCD beliefs are true, this signifies low or poor insight.

Why should I be concerned about my OCD?

OCD is associated with a reduced quality of life as well as high levels of social and occupational impairment.12-14 Those with OCD can spend a significant amount of daily time obsessing and acting on compulsions. Frequent avoidance of triggers can result in reduced functioning and ability to satisfy daily needs including eating, bathing, and working. There is a strong link between suicidal thoughts and behaviors and OCD.15

Should I seek treatment?

Without treatment, the likelihood of symptom remission is poor. Remission rates were as low as 20% in patients who went untreated.16  

What treatment options are available for OCD?

Treatment options for OCD include medication and psychotherapy. It is often effective to combine medication and psychotherapy for best outcome.

There is considerable evidence supporting the use of Cognitive Behavioral Therapy, or CBT, for the treatment of OCD.17,18  CBT is typically delivered in a structured program, consisting of: Psychoeducation, cognitive training, mapping OCD, graded exposure and response prevention (ERP), and relapse prevention and generalization training. A patient’s adherence to practicing exposure therapy is one of the strongest predictors for both immediate and long-term outcomes.19-21 CBT is typically considered the first-line treatment when available.

In addition to CBT, or where CBT is unavailable, there are a number of evidence-based medications for OCD. Two classes of antidepressants (SSRI’s and TCA’s) are strongly supported by randomized clinical trials. These medications are generally considered safe, but should be prescribed and monitored under the supervision of a Psychiatrist or Psychiatric Physician Assistant.

Does Potomac Behavioral Solutions offer treatment for OCD?

Yes! If you are suffering from OCD, or are unsure about whether or not you have OCD, consider Potomac Behavioral Solutions as your first step in treatment. Our clinicians can help assess and detail your symptoms history and clarify your concerns. We offer comprehensive treatment for OCD, including medication, CBT and Exposure and Response Prevention (ERP). To gain further information on what OCD treatment would consist of, call (571) 257-3378 today.

 

Work Cited:

  1. Foa EB, Kozak MJ, Goodman WK, et al. DSM-IV field trial: obsessive-compulsive disorder. Am J Psychiatry 1995; 152:90.

  2. Shavitt RG, de Mathis MA, Oki F, et al. Phenomenology of OCD: lessons from a large multicenter study and implications for ICD-11. J Psychiatr Res 2014; 57:141.

  3. Gillan CM, Robbins TW. Goal-directed learning and obsessive-compulsive disorder. Philos Trans R Soc Lond B Biol Sci 2014; 369.

  4. Kalanthroff E, Abramovitch A, Steinman SA, et al. The chicken or the egg: What drives OCD. J Obsessive Compuls Relat Disord 2016; 11:9.

  5. Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62:617.

  6. Ruscio AM, Stein DJ, Chiu WT, Kessler RC. The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Mol Psychiatry 2010; 15:53.

  7. Weissman MM, Bland RC, Canino GJ, et al. The cross national epidemiology of obsessive compulsive disorder. The Cross National Collaborative Group. J Clin Psychiatry 1994; 55 Suppl:5.

  8. Achim AM, Maziade M, Raymond E, et al. How prevalent are anxiety disorders in schizophrenia? A meta-analysis and critical review on a significant association. Schizophr Bull 2011; 37:811.

  9. Pallanti S, Grassi G, Sarrecchia ED, et al. Obsessive-compulsive disorder comorbidity: clinical assessment and therapeutic implications. Front Psychiatry 2011; 2:70.

  10. Kaye WH, Bulik CM, Thornton L, et al. Comorbidity of anxiety disorders with anorexia and bulimia nervosa. Am J Psychiatry 2004; 161:2215.

  11. Grant JE, Mancebo MC, Pinto A, et al. Late-onset obsessive compulsive disorder: clinical characteristics and psychiatric comorbidity. Psychiatry Res 2007; 152:21.

  12. Huppert JD, Simpson HB, Nissenson KJ, et al. Quality of life and functional impairment in obsessive-compulsive disorder: a comparison of patients with and without comorbidity, patients in remission, and healthy controls. Depress Anxiety 2009; 26:39.

  13. Koran LM, Thienemann ML, Davenport R. Quality of life for patients with obsessive-compulsive disorder. Am J Psychiatry 1996; 153:783.

  14. Bobes J, González MP, Bascarán MT, et al. Quality of life and disability in patients with obsessive-compulsive disorder. Eur Psychiatry 2001; 16:239.

  15. Angelakis I, Gooding P, Tarrier N, Panagioti M. Suicidality in obsessive compulsive disorder (OCD): a systematic review and meta-analysis. Clin Psychol Rev 2015; 39:1.

  16. Skoog G, Skoog I. A 40-year follow-up of patients with obsessive-compulsive disorder [see comments]. Arch Gen Psychiatry 1999; 56:121.

  17. Tenneij NH, van Megen HJ, Denys DA, Westenberg HG. Behavior therapy augments response of patients with obsessive-compulsive disorder responding to drug treatment. J Clin Psychiatry 2005; 66:1169.

  18. Simpson HB, Foa EB, Liebowitz MR, et al. A randomized, controlled trial of cognitive-behavioral therapy for augmenting pharmacotherapy in obsessive-compulsive disorder. Am J Psychiatry 2008; 165:621.

  19. Simpson HB, Maher MJ, Wang Y, et al. Patient adherence predicts outcome from cognitive behavioral therapy in obsessive-compulsive disorder. J Consult Clin Psychol 2011; 79:247.

  20. Simpson HB, Marcus SM, Zuckoff A, et al. Patient adherence to cognitive-behavioral therapy predicts long-term outcome in obsessive-compulsive disorder. J Clin Psychiatry 2012; 73:1265.

  21. Wheaton MG, Galfalvy H, Steinman SA, et al. Patient adherence and treatment outcome with exposure and response prevention for OCD: Which components of adherence matter and who becomes well? Behav Res Ther 2016; 85:6.

 

New Dialectical Behavior Therapy Research!

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This recently published journal article in the Journal of the American Medical Association of Psychiatry discusses DBT's efficacy for adolescents, based on a randomized clinical trial. We are excited to see continued research supporting DBT!

"Efficacy of Dialectical Behavior Therapy for Adolescents at High Risk for Suicide" by Elizabeth McCauley, PhD1,2; Michele S. Berk, PhD3,4; Joan R. Asarnow, PhD4; et al.

You can read the full article at: https://jamanetwork.com/…/jamapsyc…/article-abstract/2685324

Interview with Dr. Elizabeth Wine

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Interview with Dr. Elizabeth Wine

How did you become interested in the field of psychology?

My aunt practiced as a clinical psychologist, which sparked my interest in this field. I looked up to her and thought it would be neat if I could also help people in the same way. My interest grew as I realized that each individual I treated was very unique, and that through a one-on-one therapeutic relationship, growth can happen. I discovered that I also grow through this process, both professionally and personally.

The idea that emotional difficulties can cloud people's’ lives also drew me into this field, because our emotions certainly touch all parts of life - relationships, education, career, hobbies, and physical wellness. Knowing this, I feel privileged and honored to have the opportunity to help individuals improve the quality of their lives.

 

What is your favorite part about being Clinical Director at Potomac Behavioral Solutions?

I enjoy providing consultation and supervision to my colleagues in the office, which is possible since we are in a close setting here. Folks can pop in and out of my office throughout the day for questions related to cases. I appreciate that I get a lot of opportunities to practice flexibility in this way, and doing what is effective in the moment. Providing support to providers as well as clients gives me a lot of job satisfaction. Each day is different and the variety of situations that present themselves is a challenge that I enjoy.

 

Can you identify what your favorite form of self-care is, and why?

My favorite form of taking care of myself is taking walks with my husband and puppy. I enjoy this because I get quality time to connect with my husband, and I know that our puppy appreciates the exercise and the chance to get outside. I also find it easier to be mindful on these kinds of walks, compared to during a busy workday.

 

Describe your favorite thing about Dialectical Behavioral Therapy:

One of my favorite aspects of DBT is how applicable the skills are to everyday life, in that the skills are relevant regardless of what a person might be going through. I really appreciate that I can practice and preach the same things because I feel that I am able to be true to who I am. In particular, I like the ABC skills for emotion regulation, which include accumulating positive experiences, building mastery, and coping ahead. I find that regularly practicing these skills can help my own emotion regulation during stressful situations.

 

Now, for a bit of fun: What is your favorite cuisine?

I love sushi! In particular, I really enjoy the eel and avocado roll. To me, there are few things more enjoyable than a mindful eating experience of savoring and noticing every aspect of sushi.

Tuning into Hunger

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By: Julia Yuskavage, MS, RDN

Many people think that knowing when to eat is a simple and easy process, yet it can be difficult and confusing for some people to know when they are indeed physically hungry. While it is true that some medications and medical conditions can interfere with hunger and fullness cues, many individuals sense physiological hunger by noticing subtle changes in physical sensations which communicate to the body that nutrients will soon be needed. Other people may not be aware of the same physical sensations, which could be a result of chronic dieting among other reasons. In fact, this makes sense since many restrictive diets encourage people to override natural hunger cues with the goal of creating a caloric deficit. Yet others might be unable to detect or identify hunger due to intense emotions that mask feelings of hunger. Can you relate to any of these experiences?

If so, you might be wondering how to know when your body is asking for nourishment. The following are some common indicators of hunger:

  • Hunger pangs

  • Growling or grumbling in the stomach

  • Empty or hollow feeling

  • Gnawing

  • Slight queasy feeling

  • Weakness or loss of energy

  • Trouble concentrating

  • Difficult making decisions

  • Lightheadedness

  • Slight headache

  • Shakiness

  • Irritability or crankiness

  • Feeling that you must eat as soon as possible (1)

Many patients who are in the process of healing their relationship with food and eating learn to “hear” their hunger again by practicing mindfulness of physical sensations, although this process takes varying amounts of time for different people. For instance, checking in with one's body throughout the day to notice what physical sensations arise can help tune in to hunger signals. This can also help prevent waiting too long between meals or snacks to eat. When this does happen, it can lead to feelings of ravenous hunger. For instance, you might find yourself eating any food that is in sight, and craving foods such as those high in sugar since they are quick sources of energy for the body, because your feelings of hungers are so strong. The body works in this way as a survival mechanism and to do its best to prevent starvation from occurring. By honoring your body and its need for nourishment, you meet a basic need for food which allows you to more fully live in the moment and live the life you envision for yourself.

 

  1. Reference: May, Michelle and Anderson, Kari. Eat What You Love, Love What You Eat for Binge Eating. Am I Hungry?, 2014.

 

Basic Nourishment

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By: Julia Yuskavage, MS, RDN

With so many sources of nutrition information readily available in this day and age, it’s no wonder why people might feel confused about what, when, how, and why to eat. Oftentimes, nutrition counseling begins with providing some basic information about the major nutrients that our bodies use. The word “nutrition” is derived from “nourish”, which is from the Latin nutrire, meaning to sustain with food or nutriment; supply with what is necessary for life, health, and growth. There are three macronutrients, which include carbohydrate, protein, and fat. Many people have heard that it is “healthy” to avoid certain macronutrients entirely. However, this is not the case, as each of them serves vital roles in the human body. In fact, eliminating food groups from one's eating pattern can be a risk factor for developing an eating disorder. 

Keep in mind that consuming adequate food and nutrients helps the body (including cells, tissues, and organs) operate optimally and provides the body with the energy it needs to perform daily functions. Sometimes, people may find that they either eat too little or too much food in part due to intense emotions and overwhelming feelings (it can be helpful to talk about such emotions and feelings with a trained mental health clinician). When the human body is deprived of precious fuel and nutrition, both the mind and body can suffer and deteriorate, leading to complications that require medical intervention. The following is a brief description of each macronutrient, some of the functions that each serves, as well as some of the foods that each is found in. 

Carbohydrate

Carbohydrates are a major energy source for humans, and can be compared to the function of gasoline fueling a car. Without adequate fuel, you may find that you are “running on empty”. The brain prefers to use this macronutrient for energy, and it is also used during any physical activity/exercise. By consuming adequate carbohydrate, protein is spared, which preserves lean body mass. The three types of carbohydrates are simple (such as sugars found in fruit or cookies), complex (also known as starch), and fiber (which comes from plants and is indigestible). Foods such as corn, beans, potatoes, yogurt, milk, bread, fruit, and candy all provide some level of carbohydrates which are then broken down into glucose for use by the body.

Protein

Protein can also be used as an energy source, although it will not be used for energy needs if adequate carbohydrates are consumed and/or stored in the body, and if fat is also available for energy metabolism. This leaves protein available for functions such as building, maintaining and repairing muscle, skin, hair, bone, organs, and nails. Proteins are used in the creation of hormones and enzymes, and are needed to form antibodies in order to fight off infections and maintain a strong immune system. Some of the major food sources of protein include chicken, beef, pork, fish, cheese, milk, eggs, tofu, certain grains, and legumes such as soybeans, lentils, and peanuts, which are then broken down into amino acids by the body for use. While animal sources of protein provide all of the necessary amino acids our bodies need, plant-based protein sources lack certain amino acids. For this reason, it is important for vegetarians to be mindful about their food choices, in order to ensure that all essential amino acids are consumed through various foods.

Fat

Fat is the most energy-dense macronutrient and can be used as a fuel source. It is used by the body to support brain health, form cell structures, create hormones, regulate inflammation, and absorb fat-soluble vitamins (Vitamins A, D, E and K). Dietary fats create energy reserves for our bodies and protect vital organs. Along with providing insulation to keep one’s body warm enough, dietary fats also keep hair and skin vibrant and healthy. Among other foods, fat is found in oils, nuts, seeds, avocado, beef, salmon, cheese, potato chips, and ice cream. Dietary fats are broken down into free fatty acids and monoglycerides, which the body then uses for various functions. Like essential amino acids, the body also requires certain essential fatty acids, which can be found in plant foods as well as some fish.

 

References:

  1. http://www.dictionary.com/browse/nutrition

  2. https://www.eatrightpro.org/

  3. http://www.diabetes.org/

  4. https://mynutrition.wsu.edu/nutrition-basics/

  5. http://lpi.oregonstate.edu/mic/other-nutrients/

  6. https://www.hsph.harvard.edu/nutritionsource/

 

Treatment of Borderline Personality Disorder

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By: Andrew Hopkins, PA-C

 

What is Borderline Personality Disorder?

Borderline Personality Disorder, or BPD, is a mental illness that is accompanied by many signs and symptoms. Those with BPD may experience abrupt changes in mood, or “mood swings.” They may also have difficulty creating and maintaining relationships. People with BPD may question their self-worth and identity, often leaving them feeling “empty.” These individuals are more likely to be overcome with emotion, making it difficult to make clear and logical decisions. They may be described as “impulsive,” as they may be more likely to take part in risky behaviors with potentially dangerous consequences (i.e. reckless driving, sexual promiscuity, drug use, gambling). In an effort to control emotions and stabilize their mood, individuals with BPD often engage in cutting, or other forms of self-injury. They may also experience frequent thoughts of suicidality, but it is important to note that Borderline Personality Disorder is not the same thing as Depression or Bipolar Disorder.

 

Diagnosing BPD

There is no blood test to diagnose BPD. This diagnosis is only made clinically, meaning that it requires a thorough discussion of symptoms and mood history with a clinical professional (such as a therapist, psychologist, or psychiatrist).If there is suspicion for BPD, referral to a clinician with experience in this field may be helpful to quickly and accurately make a diagnosis. Historical symptoms, observed behavior, and discussion with friends and loved ones may help to diagnose BPD.

 

Am I alone?

The prevalence of BPD is estimated to be between 1.6 and 5.9 % of the general American population.1,2 It appears to affect both men and women equally. Based upon the available evidence, there does not appear to be a strong connection between BPD and ethnicity.1

 

Why do I have BPD?

The exact cause of BPD remains unknown. However, there appear to be a number of important factors which lead to the development of symptoms. Most of the available evidence suggests the development of BPD is due to genetic, neurobiologic, and psychosocial factors.3

Studies on twins suggest an underlying genetic component to BPD.4,5  Other studies suggest structural and chemical abnormalities within the brain as a possible contributing factor.6,7 Further research is needed to determine specific causal risk factors.

 

Is there treatment for BPD?

Psychotherapy is the first-line treatment for individuals with BPD. Specifically, Dialectical Behavioral therapy, or DBT, has been shown to be effective in reducing anger and suicidal thoughts.8 DBT has also been shown to be effective in reducing suicide attempts, use of the Emergency Room and need for Psychiatric Hospitalization.9 While there are various forms of effective Psychotherapy for BPD available, a 2012 systematic review and meta analysis showed that “DBT was the most robustly supported by clinical trials”.8

 

What about medicine?

Psychotherapy remains the first-line treatment for BPD. While medicine can be used in addition to therapy, it should not be considered the as the first step in treatment. Medication for BPD is more likely to achieve reduction of symptoms rather than remission; Therefore, the goal of medicine is to lessen symptoms of BPD while psychotherapy does the “heavy-lifting”.10-17  The use and benefit of medication in BPD, although shown in research, is “off-label.” The Food and Drug Administration (FDA) has not formally approved any medication for the treatment of BPD.

Based upon available evidence, three classes of medication have been shown to be effective for symptoms of BPD: Antidepressants, Mood-Stabilizers, and Anti-Psychotics. There are no head-to-head studies proving superiority amongst these three classes. Choosing which medication class to use relies on carefully evaluating the potential benefits of the medicine versus the potential risks. It is also critical to have a discussion on the limits of what medication can do in BPD, so as not to set unrealistic expectations.

 

Medicine at Potomac Behavioral Solutions

Potomac Behavioral Solutions offers both DBT and Medication for the treatment of BPD. We aim to offer the most effective treatment for BPD, and this includes using medication in certain circumstances. If you are seeking treatment for BPD and you are curious if medication is right for you (or if you are looking to discontinue medication), it may be helpful to schedule an appointment with one of our Medication Providers in order to explore all of your options.

 

Work Cited

  1. Lenzenweger MF, Lane MC, Loranger AW, Kessler RC. DSM-IV personality disorders in the National Comorbidity Survey Replication. Biol Psychiatry 2007; 62:553.

  2. Grant BF, Chou SP, Goldstein RB, et al. Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry 2008; 69:533.

  3. Caspi A, McClay J, Moffitt TE, et al. Role of genotype in the cycle of violence in maltreated children. Science 2002; 297:851.

  4. Torgersen S, Lygren S, Oien PA, et al. A twin study of personality disorders. Compr Psychiatry 2000; 41:416.

  5. Kendler KS, Aggen SH, Czajkowski N, et al. The structure of genetic and environmental risk factors for DSM-IV personality disorders: a multivariate twin study. Arch Gen Psychiatry 2008; 65:1438.

  6. Hansenne M, Pitchot W, Pinto E, et al. 5-HT1A dysfunction in borderline personality disorder. Psychol Med 2002; 32:935.

  7. Soloff P, Nutche J, Goradia D, Diwadkar V. Structural brain abnormalities in borderline personality disorder: a voxel-based morphometry study. Psychiatry Res 2008; 164:223.

  8. Stoffers JM, Völlm BA, Rücker G, et al. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev 2012; :CD005652.

  9. Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry 2006; 63:757.

  10. American Psychiatric Association Practice Guidelines. Practice guideline for the treatment of patients with borderline personality disorder. American Psychiatric Association. Am J Psychiatry 2001; 158:1.

  11. Paris J. The treatment of borderline personality disorder: implications of research on diagnosis, etiology, and outcome. Annu Rev Clin Psychol 2009; 5:277.

  12. National Institute for Health and Clinical Excellence. Borderline Personality Disorder: Treatment and Management. 2009. http://www.nice.org.uk/CG78 (Accessed on February 10, 2010).

  13. Nosè M, Cipriani A, Biancosino B, et al. Efficacy of pharmacotherapy against core traits of borderline personality disorder: meta-analysis of randomized controlled trials. Int Clin Psychopharmacol 2006; 21:345.

  14. Ingenhoven T, Lafay P, Rinne T, et al. Effectiveness of pharmacotherapy for severe personality disorders: meta-analyses of randomized controlled trials. J Clin Psychiatry 2010; 71:14.

  15. Lieb K, Völlm B, Rücker G, et al. Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials. Br J Psychiatry 2010; 196:4.

  16. Mercer D, Douglass AB, Links PS. Meta-analyses of mood stabilizers, antidepressants and antipsychotics in the treatment of borderline personality disorder: effectiveness for depression and anger symptoms. J Pers Disord 2009; 23:156.

  17. Herpertz SC, Zanarini M, Schulz CS, et al. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of personality disorders. World J Biol Psychiatry 2007; 8:212.

 

Mindfulness in Meals

By: Julia Yuskavage, MS, RDN

Can you relate to the experience of feeling like you are on “autopilot” in life at times, such as going through the motions of an activity without putting much intentional thought into it? Some might describe this state of being as “mindless”. I would venture to say that almost everyone has felt like this at some point in time. For example, at times mindlessness may be related to a pursuit of busyness and productivity; other times, it may be for protective reasons. I have heard patients describe some eating experiences as mindless, in that they may complete a meal before they really notice that they have even begun. Perhaps you have experienced eating until feeling uncomfortably full due to being unaware. On the other hand, perhaps you have experienced the opposite and have neglected to eat at times.

Let’s look at one definition of the word mindful:

  1. attentive, aware, or careful: mindful of one's responsibilities.

  2. noting or relating to the psychological technique of mindfulness: mindful observation of one's experiences. (1)

Some describe mindfulness as noticing, observing, or simply paying attention on purpose, doing so in the present moment, and doing so without judgement. At first glance, mindfulness might seem like a fairly simple concept to grasp and put into practice. However, mindfulness is a skill that requires practice to master, like many other things in life. Mindfulness can be applied to just about anything in life, and if applied to eating processes, one may gain more awareness and insight into one’s eating habits than ever thought possible.

You might be wondering what some of the benefits of mindful eating are. Mindfulness can increase your awareness of thoughts, feelings, and physical sensations related to food and eating. Over time, increased awareness can lead to the opportunity to form new experiences regarding eating, rather than automatically reacting out of habit and/or impulse.

How can someone apply aspects of mindfulness to eating? 

  • Observe your internal and external experiences while eating, without automatically reacting to them. For example, you might observe that your environment while eating entails a television that has its volume turned up high or that you eat more quickly and your heart beats more rapidly when watching the news on television at a loud volume. You might also notice that the pace of your eating changes if the television is off and soft music is playing in the background instead; perhaps you feel more relaxed and less anxious with this change in environment. Changes in your surroundings can influence your eating experience, and having awareness of this can lead to a more satisfying and pleasant experience.

  • Notice what it is about a meal that speaks to each of your five senses. Is the meal hot? Has the food been sitting out and cooling off? Does the temperature outside seem to influence your desire to eat a hot or cold meal? Does the meal contain crunchy or smooth textured foods? Does the food require a lot of chewing or is it soft in nature? What smells do you notice wafting from the food? Are the foods brightly colored and varied in color, or are they similar colors? Do you taste sweetness, saltiness, tanginess, sourness, or a combination? Noticing what appeals and what does not appeal to each of your senses can help you tune in to what really satisfies you, rather than making food choices based on what you hear that you “should” or “should not” eat from external sources. 

  • Watch your thoughts related to food choices as they come and go, as if they were clouds passing through the sky. For instance, perhaps you encounter a thought such as “this food is bad and unhealthy”. Try to acknowledge your responses to food without applying labels to them, accepting them for what they are and nothing more. You might think to yourself, “I am having a thought that this food is bad”, and visualize the thought floating on a puffy, white cloud through a blue sky. This can help to create space between your perception of a food and the food itself, and lessen judgments and moral convictions that are attached to the food.

  • Pay attention to physical sensations, such as signs of hunger and fullness, or notice the absence of such sensations. Maybe you sense emptiness in your stomach or low energy levels throughout your body. Perhaps you notice that you do not eat until late at night and think of eating only when you are feeling very hungry. This practice can help deepen your mind-body connection as it relates to listening to and nourishing your body.

  • Notice your feelings that arise before, during, and after eating, as if they were leaves floating down a stream. Perhaps you experience a feeling of joy when eating a particular dessert that your grandmother made for you as a child. Maybe you notice feelings of guilt and fear after eating a bacon cheeseburger. You might say to yourself, “there is guilt” or “there is fear” and watch as it floats by on a crisp autumn leaf. Doing so can help take away power and negative associations that certain foods have for you.

Taking a mindful approach to eating can be very different from the approach that many people currently have. If you would like to shift your awareness and perspective on your current eating processes, mindful eating practices can open that door for you.

References:

  1. http://www.dictionary.com/browse/mindful

Complications of Anorexia Nervosa: Why medical evaluation and monitoring is critical

By: Andrew Hopkins, PA-C

In life, food is our friend and starvation is our enemy

The human body is very effective in energy conversion. It breaks down food into the necessary nutrients our cells needs to function. Without food, the body transitions into starvation. As the body starves, it begins to break itself down and converts fat and protein into energy. This is a temporary strategy for the body if you miss lunch or are unable to eat for a few hours. But what if your body can’t count on food? What if your body is being permanently starved?

Missing a meal v. Anorexia nervosa

Individuals with Anorexia intentionally restrict food intake leading to starvation, weight-loss, and a low body weight. There is a fear of weight-gain or a fear of “becoming fat”, despite being profoundly underweight. Individuals with anorexia also demonstrate a distorted perception of body weight and image, and may often deny the medical seriousness of a low body weight.

Starvation is deadly

The rate of death in Anorexia is a staggering 10-12 times higher than the general population.1,2,3 In addition, the rate of suicide in Anorexia is nearly 5 times higher than the general population.4,5,6 Medical complications, including heart attacks and heart failure, account for more than half of all deaths in patients with Anorexia. The two biggest risk factors leading to medical complications include the degree of weight loss and how long food restriction has been present for.

Fats, proteins, and changes within the body

In starvation, the body begins to break itself down to create cellular energy in a process known as catabolism. In Anorexia, where there is long-term starvation, the body turns to a more substantial supply of fat and protein: the vital organs. The body breaks down proteins and fats in the heart, brain, liver, kidneys, and muscle leading to atrophy, or tissue wasting. Atrophy results in poorly functioning organ systems and ultimately, organ failure.


Symptoms and signs

While considerable changes to the body and organs are occuring, symptoms may be vague, misleading, or non-existent. Fatigue, low motivation, and changes in mood are common in the course of Anorexia. More concerning signs may be objectively measured, such as low blood pressure, reduced heart rate and reduced core body temperature. Some organ failure can occur without any warning signs or symptoms. Many patients who experience medical complications due to Anorexia require hospitalization due to severity. This makes medical evaluation and screening critical immediately following the diagnosis of Anorexia.   

Comprehensive evaluation and medical monitoring

Immediately following the diagnosis of Anorexia nervosa, one should have a comprehensive medical evaluation. This should include an extensive physical exam to evaluate for any objective manifestations of weight-loss and low body weight. Blood work is critical to identify for any nutrient deficiencies, abnormal hormone levels, or early signs internal organ failure. An Electrocardiogram (EKG) is needed to evaluate heart health and rule-out any functional changes related to heart atrophy. In females who have not menstruated for over 9 months, it is common to have a Bone Density Study (or DEXA scan) performed to rule-out early-onset Osteoporosis. Any abnormalities during this initial medical evaluation may require hospitalization to stabilize and correct.

Reversing Complications and Restoring Health

The treatment of Anorexia always involves weight restoration. While medical complications may necessitate urgent medical care, nearly all medical complications of Anorexia nervosa can be effectively reversed with adequate weight-gain. However, weight is not the only marker of recovery. It is appropriate to perform continual medical screenings throughout treatment. In order to vigilantly monitor for medical complications during recovery, frequent screenings involving blood work, vital signs, and a review of systems are routinely incorporated.

What’s next?

Treatment of Anorexia often involves a team of providers. At Potomac Behavioral Solutions, our treatment team will work collaboratively to ensure to the best outcomes. We offer dietitian services, family-based therapy (FBT), and medical monitoring during treatment to improve outcomes. Please contact our intake coordinators for further information on how to get started with our treatment team today!

 

Work Cited:

  1. Löwe B, Zipfel S, Buchholz C, Dupont Y, Reas DL, Herzog W. Long-term outcome of anorexia nervosa in a prospective 21-year follow-up study. Psychol Med. 2001;31(5):881-90.

  2. Keel PK, Dorer DJ, Eddy KT, Franko D, Charatan DL, Herzog DB. Predictors of mortality in eating disorders. Arch Gen Psychiatry. 2003;60(2):179-83.

  3. Herzog W, Deter HC, Fiehn W, Petzold E. Medical findings and predictors of long-term physical outcome in anorexia nervosa: a prospective, 12-year follow-up study. Psychol Med. 1997;27(2):269-79.

  4. Hoang U, Goldacre M, James A. Mortality following hospital discharge with a diagnosis of eating disorder: national record linkage study, England, 2001-2009. Int J Eat Disord. 2014;47(5):507-15.

  5. Suokas JT, Suvisaari JM, Gissler M, et al. Mortality in eating disorders: a follow-up study of adult eating disorder patients treated in tertiary care, 1995-2010. Psychiatry Res. 2013;210(3):1101-6.

  6. Crow SJ, Peterson CB, Swanson SA, et al. Increased mortality in bulimia nervosa and other eating disorders. Am J Psychiatry. 2009;166(12):1342-6.

Dieting: Much More Harm Than Good

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By: Julia Yuskavage, MS, RDN

I think most people can agree that the last few months of 2018 have been filled with weight loss television commercials, radio ads for diet programs, and coupons for herbal products that promise a quick fix for “losing that stubborn body fat”. There is a reason for all of this - the dieting industry continues to profit big time from selling these kinds of products. Many times, people believe that if they were able to lose weight or fit into a smaller clothing size, then they might feel happier about themselves and their lives. However, I wonder how much truth there is in this belief.

What many people don’t know, or don’t want to believe, is that the companies that bombard you with these advertisements have a common goal: to sell you something.

Some of the questionable ideas hidden in these messages might sound like…

  • Lose those last 10 pounds and you will be happier!

  • Stop eating carbs and people will notice you!

  • Reduce your belly fat and your dating life will improve!

  • Give up “bad” foods and you will feel better about yourself!

  • Drop 3 dress sizes and you will have finally accomplished something worthwhile!

In fact, a leader of a weight loss corporation has been quoted as saying that their product is great for business because people who use it will inevitably fail, thus returning for more of it (i.e.: buying it) again and again and again. That makes me feel frustrated for people who are using these systems and working hard to meet their nutritional goals/needs.

The reality is that there is no magical number on the scale or measuring tape that will make you feel whole. What diets often lead to are vicious cycles of food restriction, low energy levels, moodiness, overeating, and feelings of guilt, shame, and failure – that then leads to food restriction all over again.

“If you just tried hard enough and did a better job at dieting, you wouldn’t be a failure” is the message that the diet industry is trying to sell. It’s no wonder that the temptation is so high to try a different diet approach each time you feel like a “failure”. Diets often do not lead to long-term health and happiness; instead, they often lead to disordered eating and even early mortality associated with eating disorders.

We’re here to remind you that it’s okay to love yourself JUST the way you are. Accepting yourself and working through the underlying emotions that fuel your desire to diet and lose weight can be a path to freedom.

So often we see clients who are torn between wanting to end dieting once and for all, yet also wanting to lose weight because they believe doing so will lead to happiness. It can be tough to feel like you are stuck between wanting to follow a non-diet approach, yet also wanting to lose weight. If one is willing, there can be a sense of freedom that comes with giving up self-imposed dietary rules, learning to listen to your body’s hunger and fullness cues (or eating intuitively), and accepting yourself for the unique individual that you are. Intuitive eating is referenced as a “dynamic process – integrating attunement of mind, body, and food”(1). The great news is that you have the skills to eat intuitively inside you already – you were born with them; they just got pushed way down, buried under all the societal pressures and norms that have tried for so long to convince you otherwise. If this is how you are feeling/what you are noticing, it might be time to work on letting that skill resurface and start walking the path towards healing your relationship with food and your body. If you would like to learn more about intuitive eating, or if you have concerns about your current eating habits, we are here to help.

 

References:

  1. Tribole E, Resch E. Intuitive Eating. A Revolutionary Program That Works; 2012:1-344.

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Sarah Fischer, PhD in the News!

Dr. Fischer has been interviewed by several media sources related to her most recent research at George Mason University and Potomac Behavioral Solutions! Thank you to all the participants who volunteered. 

 Sarah Fischer, PhD

Sarah Fischer, PhD

 

FOR IMMEDIATE RELEASE
Monday, July 10, 2017
Contact: Jim Sliwa

(202) 336-5707

jsliwa@apa.org

UNDER STRESS, BRAINS OF BULIMICS RESPOND DIFFERENTLY TO FOOD

Scans suggest food is a form of escape from self-critical thoughts

WASHINGTON -- Magnetic resonance imaging scans suggest that the brains of women with bulimia nervosa react differently to images of food after stressful events than the brains of women without bulimia, according to research published by the American Psychological Association.

In women with bulimia, the researchers found decreased blood flow in a part of the brain associated with self-reflection, compared with increased blood flow in women without bulimia. This suggests that bulimics may be using food to avoid negative thoughts about themselves, the researchers said. 

“To our knowledge, the current study is the first investigation of the neural reactions to food cues following a stressful event in women with bulimia nervosa,” said lead author Brittany Collins, PhD, of the National Medical Center. The research was published in the Journal of Abnormal Psychology.

Stress is considered to be a trigger for binge-eating in patients with bulimia nervosa, but there is little research on how people with bulimia nervosa process and respond to food cues.
 
The researchers conducted two experiments. In the first, 10 women with bulimia and 10 without came to a lab where they all ate the same meal. After waiting for about an hour and becoming familiar with an MRI scanner, they then entered the scanner and were shown a series of neutral pictures, such as leaves or furniture, followed by a series of high fat/high sugar food pictures, such as ice cream, brownies, pizza or pasta with cheese sauce. 

Participants were then asked to complete an impossible math problem, a task designed to induce stress and threaten their ego. They then re-entered the scanner and looked at different photos of high fat/high sugar foods. After every activity in the scanner, the women rated their levels of stress and food cravings. 

“We found that everyone experienced increased stress after the stress task, and that everyone reported that stress went down after seeing the food cues again. Also, every time that participants saw the food cues, they reported that their craving for food went up,” said co-author Sarah Fischer, PhD, of George Mason University.

What was surprising was even though patterns of self-reported results were similar for both groups, the two groups showed very different brain responses on their MRI scans, Fischer said. For women with bulimia, blood flow to a region called the precuneus decreased. For women without the eating disorder, blood flow to this region increased. The precuneus is involved in thinking about the self.

“We would expect to see increased blood flow in this region when someone is engaged in self-reflection, rumination or self-criticism,” said Fischer.

In the second experiment, the researchers asked 17 women with bulimia nervosa to complete the same task as the women in the first study, in order to examine whether the findings could be replicated in a different sample of women.
 
“Our results were the same in the second study,” said Fischer. “Women reported increases in stress following the stress task and increases in food craving after seeing food cues. More important, blood flow to the same region, the precuneus, decreased when viewing food cues following stress.”

Collins believes that this decreased blood flow in bulimics suggests that the introduction of food shuts down self-critical thinking in bulimics and gives them something to focus on instead of the painful prospect of dealing with their own shortcomings.

Psychologists have previously theorized that binge-eating provides bulimic women an alternate focus to negative thoughts about themselves that may be brought on by stress. This research provides support for this theory, according to Collins.

“Our findings are consistent with the characterization of binge-eating as an escape from self-awareness and support the emotion regulation theories that suggest that women with bulimia shift away from self-awareness because of negative thoughts regarding performance or social comparisons and shift focus to a more concrete stimulus, such as food,” said Collins.

The results of these experiments could also suggest a neurobiological basis for the use of food as a distractor during periods of stress in women with the disorder, she said. The researchers called for further studies to confirm their results, which they termed preliminary.

The article is part of a special section of the July 2017 issue of the journal devoted to outstanding contributions by young investigators in the field of eating disorders.

“This issue is dedicated to highlighting the accomplishments of an impressive group of young researchers,” wrote the section co-editors Pamela Keel, PhD, Florida State University, and Gregory Smith, PhD, University of Kentucky, in their introduction. “The papers offer a glimpse into the many and multifaceted forms of progress young researchers are making in the effort to understand and address an extraordinarily important form of psychopathology, dysfunction related to the basic need of food consumption.”

    Article:  “The Impact of Acute Stress on the Neural Processing of Food Cues in Bulimia Nervosa: Replication in Two Samples,” by Brittany Collins, PhD, National Medical Center; Jennifer McDowell, PhD, and L. Stephen Miller, PhD, University of Georgia; and Lauren Breithaupt, MA, James Thompson, PhD, and Sarah Fischer, PhD, George Mason University. Journal of Abnormal Psychology, published July 10, 2017.

    Full text of the article is available from the APA Public Affairs Office and at

    www.apa.org/pubs/journals/releases/abn-abn0000242.pdf

    Contact: Sarah Fischer can be contacted by email at snowaczy@gmu.edu or by phone at (703) 993-5635

     

    The American Psychological Association, in Washington, D.C., is the largest scientific and professional organization representing psychology in the United States. APA's membership includes nearly 115,700 researchers, educators, clinicians, consultants and students. Through its divisions in 54 subfields of psychology and affiliations with 60 state, territorial and Canadian provincial associations, APA works to advance the creation, communication and application of psychological knowledge to benefit society and improve people's lives.

    www.apa.org

    If you do not want to receive APA news releases, please let us know at public.affairs@apa.org or 202-336-5700.

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    Binge Eating Disorder- The cycle that continues to feed itself

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    Binge Eating Disorder- The cycle that continues to feed itself

    By: Annyck Besso, MS, RD

    “I woke up the next morning, in distress, telling myself that I needed to have more control over my eating and then everything would be ok.”  This sentence or a similar one may sound familiar to several individuals. In a society that places a great deal of importance on weight loss and healthy eating, most people believe that the problem is related to their “lack of control," rather than something greater. 


    What is Binge Eating Disorder?: 
    Binge Eating Disorder (BED) was first recognized as an eating disorder in the DSM V, which was published in 2013 (APA, 2017). The diagnostic criteria for BED include, but are not limited to, the perception of loss of control while eating a larger quantity of foods than considered “normal” in a specific period of time in addition to extreme feelings of guilt and shame afterwards.  While diagnostic criteria for BED does not include compensation following a binge (e.g., vomiting, laxative use).

     Figure 1- Common nutritional and emotional pattern that arises in many patients with BED

    Figure 1- Common nutritional and emotional pattern that arises in many patients with BED

    Restriction and the Binge Cycle:
    People with BED often report that they try to make up for the behavior the following day through restrictive eating. This restrictive eating behavior can present itself in several forms, such as using food rules to eat “healthier,” avoiding certain foods or limiting oneself to a certain amount of calories. Sometimes just the idea that tomorrow will be different can keep the binge cycle going. 


    The goal of your dietitian is to target restrictive eating, which normally perpetuates the cycle of feeling overly hungry then bingeing. Messages from social media often seem to condition us to believe that we can control what our bodies want and what they should look like. This battle can have dire consequences on our physical health, our mood and our emotional well-being.

     
    Sandra’s Story

    One example is a client who I will name Sandra. Sandra has always had a very difficult relationship with her body,  creating  food rules to try to control her weight and shape. For years, she attempted several diets, which worked initially, but then she ended up heavier and more demoralized after each one. She became confused as she was following her food rules and eating “healthy,”but was unable to lose any weight. Often, Sandra would come home from a long day of work and describe “zoning out” and eating whatever “forbidden foods” she could find over a period of an hour. When she would finally “snap out of it,” she was filled with feelings of guilt, shame and loathing for herself. She would reassure herself by saying that this was the last time and that she was going to get things under control the following day; she would get rid of all the junk food in her house and start anew. 


    While this may seem like a good strategy, this is exactly what I would NOT recommend a client to do. Food rules typically perpetuate the cycle of loss of control(led?) eating. It is not a lack of control that leads to bingeing; it is instead primarily the emotional relationship people have with food and their body (amongst other reasons). 


    Treatment Goals:
    Stopping the cycle: after a binge, do not try to “get back on track”. 
    Reconnecting with your body: try asking yourself how hungry you feel before a meal and how satisfied you feel after a meal. Try to let your body guide your food choices, rather than deciding what it should be having. 


    Accepting all foods: there is no such thing as a good food or bad food. All foods are good and serve different purposes in our lives. Eliminating a food or food group simply makes it novel and more interesting which leads us to become preoccupied with the food. 


    Eliminating mindless eating: if you eat at your desk, in front of the TV or in the car, this one is for you. Take time to just EAT and taste the food you’re putting in your mouth. It will feel much more satisfying. 


    Please note the strategies above are NOT as simple as they may seem. If you can identify with this article or know someone who has an emotional relationship with food, it may be beneficial for them or for you to talk with a Registered Dietitian. Please don’t hesitate to reach out.  
     
     
    References:
    American Psychiatric Association. (2017). DSM History. Retrieved from https://www.psychiatry.org/psychiatrists/practice/dsm/history-of-the-dsm on June 19th, 2017. 


    Binge Eating Disorder Association. (2016). Characteristics of BED. Retrieved from https://bedaonline.com/understanding-binge-eating-disorder/symptoms/ on June 19th, 2017. 
     
     

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    Body Image Acceptance!

     

    Annyck Besso, RD and Joanna Marino, PhD recently volunteered at a local kindergarten to provide education on body image acceptance and loving our bodies!

     

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    The Downside of Missed Periods

     
      Sam Tryon, MS, RD

    Sam Tryon, MS, RD

     

    For some, the idea of not having their period might be cause for celebration.  No cramps, bloating or having to worry about keeping tampons or pads on hand; awesome right?! Unfortunately, not getting your period could be cause for concern.*

    If you are 16 years old and have not yet started your period or if you have missed at least 3, you could be diagnosed with amenorrhea.1 Amenorrhea can be caused by a variety of factors including genetic abnormalities, gland problems, and certain gynecological conditions.1  Amenorrhea may also be due to what you eat and how active you are.

    The roles of nutrition and activity

    Low energy availability is one cause of amenorrhea.  Energy availability is a measure of the energy left for bodily functions (i.e. heart beating, digestion, breathing) after subtracting for energy used during exercise and other activities of daily living (i.e. vacuuming, walking to work, gardening).  Low energy availability means that there is not enough energy for body functions and exercise.

    Low energy availability can be a result of not taking in enough fuel (A.K.A. not eating enough) and/or using too much energy for exercise.  Among other effects, the lack of energy left for bodily functions leads to decreased production of gonadotropin-releasing hormone, a hormone important in reproduction, which causes decreased production of estrogen and progesterone and disruption of the menstrual cycle.2

    Amenorrhea and Bone Health

    Both low energy availability and reproductive hormone changes have negative impacts on bone density.  In addition to not having the available energy and nutrients to maintain bone mass, lack of estrogen is associated with bone loss.  In a healthy body, our bones are constantly being broken down to release minerals like calcium and then rebuilt.  Without estrogen, there is increased breakdown without rebuilding which leads to decreased bone density.  This can progress to osteopenia and osteoporosis, putting a person at risk for fractures.  

    Studies have found that up to 95% of people with Anorexia Nervosa have osteopenia and as many as 40% have the more severe osteoporosis.3 Weight gain is associated with return of menstruation and possible reversal of at least some bone loss.

    Amenorrhea and bone loss are especially concerning in adolescents as peak bone mass is reached during this time. Bone loss from low energy availability during this stage of life may prevent patients from reaching a normal peak bone mass. This can put them at increased risk for fractures later in life.

    Next Steps

    If you have missed 3 or more periods, an appointment with your general physician can help to determine the cause of amenorrhea.  They may recommend a bone density test to look for possible bone loss.  

    If the cause is found to be nutrition related, a dietitian can help you change your diet to make sure you are taking in enough energy to fuel your body. Amenorrhea can occur with or without disordered eating and a dietitian can also help assess for any disordered eating behaviors.  If disordered eating is a problem, a therapist may be added to the team to best tackle these concerns and get you back to the activities you love.  

    *The content of this article is for informational purposes only and does not constitute medical advice, professional diagnosis, or treatment.  See your healthcare provider before making any healthcare decisions or with any questions you have regarding a medical condition.  

    References:

    1. Amenorrhea. Eunice Kennedy Shriver National Institute for Child Health and Human Development; [accessed 2017 May 31]. https://www.nichd.nih.gov/health/topics/amenorrhea/Pages/default.aspx

    2. Mallinson, R and De Souza, M. Current perspectives on the etiology and manifestation of the “silent” component of the Female Athlete Triad. Int J Womens Health. 2014; 6: 451–467

    3. Mehler, P and MacKenzie, T. Treatment of Osteopenia and Osteoporosis in Anorexia Nervosa: A Systematic Review of the Literature. Int J Eat Disord. 2009; 42: 195-201

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    My Loved One has Borderline Personality Disorder -- What now?

    Borderline Personality Disorder is Treatable

    If you have a loved one who experiences symptoms of borderline personality disorder (BPD), you can learn more about how to help.   The National Education Alliance
    for Borderline Personality Disorder
     offers resources to family and friends such as:

    • Up-to-date research articles
    • Family Connections Program 
    • Free Webinars and Videos
    • Call-in series to learn more about BPD

    Join our Friends and Family skill class which is held from 6-7pm Tuesday evenings. The group costs $25 and is open to the public! You will learn more about BPD and Dialectical Behavior Therapy (DBT) 

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    OCD Recovery

    Join Joanna Marino, PhD on June 2nd to learn more about OCD treatment success! 

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    NEDA Walk, Washington, DC: April 2, 2017

     Alexa, Charlie (with Daria!), Joanna, and Rebecca 

    Alexa, Charlie (with Daria!), Joanna, and Rebecca 

     Alexa, Charlie (with Daria!), Joanna, and Rebecca

    Alexa, Charlie (with Daria!), Joanna, and Rebecca

     Evelyn and Alexa- Our WONDERFUL intake staff! 

    Evelyn and Alexa- Our WONDERFUL intake staff! 

     Rebecca and Alexa

    Rebecca and Alexa

     Evelyn and Joanna

    Evelyn and Joanna

     Joanna Marino, PhD giving a keynote speech at the DC NEDA walk!

    Joanna Marino, PhD giving a keynote speech at the DC NEDA walk!

     Alexa ;)

    Alexa ;)

     Our booth at the walk

    Our booth at the walk

     Joanna Marino, PhD giving a keynote speech at the NEDA walk

    Joanna Marino, PhD giving a keynote speech at the NEDA walk

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