14: Dr. Brad Smith: OCD and Eating Disorders

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This week Dr. Brad Smith joins us to talk about OCD and eating disorders, specifically anorexia nervosa. Eating disorders often co-occur with other illnesses, and Dr. Smith talks about the intersect of OCD and eating disorders, as well as how debilitating these illnesses can be.

Dr. Smith is the Medical director for eating disorders at Rogers Memorial Hospital.

Full transcript –

Kathy: Hello and welcome to ED Matters. This is Kathy Cortese, your host  and it is my pleasure today to welcome Dr. Brad Smith. Brad E.R. Smith is a full time psychiatrist who is board certified in adult psychiatry and forensic cert psychiatry specializing in the assessment treatment of eating disorders and other complex or multiple health diagnosis. Dr. Smith has specialized in treating individuals with eating disorder since he joined Rogers Behavioral Health in 2011 seeing patients in the in patient, residential and partial hospital programs. Before being named Medical Director of Eating Disorder Services, Dr. Smith directed the Adult Inpatient Eating disorders Program in Oconomowoc, Wisconsion. As the hospitals Medical Director of Eating Disorder Services, Dr. Smith’s goal is to help his patients learn evidence based techniques for building resiliency for recovery. Dr. Smith is a member of the American Psychiatric Association, the American Academy of Psychiatry and the Law, The Wisconsin Psychiatric Association and The Wisconsin Medical Society. He has lectured to professional and community of what answers around the nation on eating disorders and a wide variety of mental health topics including peer selected presentations for the National Eating Disorder Association annual meetings. Dr. Smith also provides residency education for the Medical College of Wisconsin which fortunately requires psychiatry residence to train on an eating disorder inpatient unit and the residential program. Welcome, Dr. Smith.

Dr. Smith: Thank you. It’s very much a pleasure to be here with you, Kathy.

Kathy: Thank you. We are going to delve into a topic that perhaps, you know, I think can sometimes be overlooked and that is the intersection of OCD and anorexia nervosa. On their own, we know eating disorders are remarkably complex yet eating disorders often co-occur with other disorders. So to just sort of get us launched, what can you say about the criteria for anorexia nervosa and then if you could follow that up with a criteria that we all understand contributes to OCD.

Dr. Smith: Sure, I’d be happy to. So for anorexia nervosa the criteria that the diagnostic and statistical manual uses in the 5th edition is three major categories: restriction of energy intake which leads to a significantly low body weight. The next criteria is intense fear of increased weight or development of fat in the body or behavior that interferes with weight gain even if somebody is not agreeing that they’re trying to avoid gaining weight. And then finally a disturbed body image, an undue influence on one’s self evaluation based upon their weight or their body image. Those are the three major categories or criteria in the diagnostic and statistical manual.

The obsessive compulsive disorder at diagnostic criteria is a little bit more involved and I think probably the listeners are more familiar with the diagnostic criteria for anorexia nervosa. Obsessive compulsive disorder first of all requires that someone have both obsessions and compulsions and that they significantly impact on the person’s daily life and as well learn this is a major impact on a person’s life as we will go through this. That person may or may not recognize the significance or the severity or that there’s an excessive nature to their symptoms but I’ll explain obsessions, the criteria for obsessions is some sort of intrusive or persistently repetitive thought, urges or images that someone has that causes them significant distress or fear. This is not just an excessive focus on what we would consider a normal life problem and the person has unsuccessful attempts to suppress or ignore this obsession. And finally, they may or may not recognize that these are thoughts or images that their mind is generating and they’re not an actual threat so in both these categories, the DSM is talking about the level of insight. There are a number of individuals with obsessive compulsive disorder who have significant insight and there are some individuals who have very limited insight about the significance or the impact of it.

And finally, compulsions, the other part of obsessive compulsive disorder, excessive or repetitive ritualistic behaviors that you feel you must perform or something bad will happen. The most common examples would be hand washing, counting rituals, mental activities or checking behaviors and these rituals need to take over an hour per day to be considered a part of the criteria, And then finally these rituals are performed to reduce the anxiety of the obsessive thoughts and there’s often a fairly clear or logical connection such as somebody hand washing to avoid fears of germs but there may not be a clearly logical connection all the time. So those are the main criteria for obsessive compulsive disorder.

Kathy: And the intrusive nature of these thoughts and then how the compulsions will drive that behavior, when you know, you’ve looked at this for quite a bit of your experience, what does the research tell us causes OCD?

Dr. Smith: I think like a lot of mental health issues and maybe even a lot of medical issues, there’s not a single cause that we can identify and so it goes back to what we find a genetic factor for this like many other mental illnesses as well as environmental or stress factors that can play a part in this. So we have a pretty good idea that genetics play a role in this and there’s quite a bit of heredity that occurs in individuals, family members, first degree family members with OCD or some form of anxiety disorder being very common. And environmental stresses may bring this out like environmental stresses can bring out other anxiety disorders as well as some things we might not always think of that are important to consider. There are occasions where certain medications can have side effects that can result in obsessive compulsive symptoms. There are even some suggestions that certain types of infections or certain types of changes in the brain chemistry can lead to obsessive compulsive symptoms as well.

Kathy: You mentioned the word anxiety and I would imagine that there’s a fair amount of anxiety present in both OCD and anorexia nervosa. Can you tell us more about that?

Dr. Smith: Absolutely. There is — you know, obsessive compulsive disorder is considered an anxiety disorder. There is also quite a lot of anxiety involved in anorexia nervosa. You know, even the diagnostic criterias talking about the undue influence and the worry, the fear of weight gain. The undue influence of weight and body shape that it causes significant anxiety for individuals and so there is significant anxiety in both disorders. I think another feature that’s important to mention is that most clinicians recognize that there is a significant symptom overlap that occurs here in terms of people with anorexia nervosa often have some form of obsessive compulsive type thoughts. And if they don’t have a separate diagnosis of obsessive compulsive disorder, that may mean that it’s confined, those obsessive compulsive thoughts are confined to food, body image, weight, shape, those sort of things and it may not be until that those thoughts and the obsessions expand to other areas of a person’s life that a diagnosis, a separate diagnosis of obsessive compulsive disorder is considered. But I think most clinicians have long recognized that there are a lot of obsessive compulsive type features in individuals with anorexia nervosa.

Kathy: How challenging is it for someone to assess and then come up with a diagnosis of both you know, co-occurring OCD and anorexia?

Dr. Smith: I think it’s challenging partly because of what we were just describing that there is a lot of symptom overlap and so we may commonly get people at Rogers where I work, where we treat individuals with co-morbid obsessive compulsive disorder and anorexia where if they’re showing up for treatment somewhere else they may be diagnosed very well that they have anorexia nervosa pattern occurring but the obsessive compulsive disorder may not be fully assessed or diagnosed. Partially because there’s so much symptom overlap and so the clinicians may assess that they have all of the symptoms accounted for by the anorexia nervosa and again it wouldn’t be unless somebody describes other types of obsessions that we would likely get into an obsessive compulsive disorder diagnosis.

Kathy: I’m not trying to be a lawyer when I ask this question. This is more for diagnostic purposes and education, how would you describe the inner world of an individual who has these co-occurring disorders?

Dr. Smith: Unfortunately, I’d have to use words like torturous, painful, chaotic and impaired. It’s a very, very difficult situation for individuals who have this combination of illnesses, as you described in the opening either one of these illnesses can be extremely disabling and impairing and completely change somebody’s course in life. And so when we get the combination together it’s I think even can be thought as synergistic type effect on the severity in terms of how much disability someone has, how much functional change that the person has and the impact it has on their life.

Kathy: I’d like us I guess to underscore that word impairment and the disability because I think unfortunately sometimes people can be very glib with their own understanding of OCD and very equally glib with their understanding of anorexia. So when you use words like torturous, it sends the serious message. Can you just speak to what you would like maybe the family and loved ones of people who have this type diagnosis to understand what’s happening to their loved one?

Dr. Smith: I believe that many of the loved ones would see this type of torture and torment that people go through especially when we get to individuals who may spend many hours a day caught up in these thoughts, the compulsions whether they’re about classic obsessive compulsive disorder thoughts and obsessions or whether it’s about their eating disorder thoughts and behaviors. And what I would want family’s to know is that the person is dealing with something that is going to very much feel like it’s somewhat outside of themselves that obsessive compulsive disorder is one of the anxiety disorders that we tend to think of most as being outside of a person’s baseline personality or their thought patterns. As an example, someone with generalized anxiety might be more anxious as a chronic baseline level about things that make sense with their life and their normal worries. Someone with obsessive compulsive disorder, it can feel like these thoughts and the obsessions are just implanted into their brain. So fortunately, I find that most family members have a lot of empathy for these individuals because they see the amount of torment and pain that they’re in. The other message I would want families to know is that there is help available and it can be a little challenging to find because the types of treatment that are best used for especially the obsessive compulsive disorder are a bit challenging to find and they’re not available in at least in a face to face format in many areas of the country.

Kathy: And that’s a great segway for us. So in terms of the different forms of treatment, can we start with the role of medications?

Dr. Smith: Well, there certainly can be a role for medications in the treatment of both these disorders. It may be helpful to talk about them a little bit separately knowing that we’re still dealing with one individual who has both. But for an individual with anorexia nervosa, there’s not a lot of great information to suggest that medications are going to be that helpful in the acute stages of treatment such as to get weight restoration or to even help while somebody is pursuing weight restoration. There is information to suggest that antidepressant medications can be effective at helping somebody maintain recovery and some of the thoughts that I have anecdotally about that include the observation that those medicines seem to help the obsessive type thoughts that are part of the anorexia. When it comes to obsessive compulsive disorder, there is good evidence that medications, primarily the antidepressant medications that deal primarily with the neurotransmitter serotonin so medicines that you hear called selective serotonin, reuptake inhibitors and even one of the older tricyclics imipramine that target serotonin. These medicines have good efficacy for decreasing the frequency and severity of the obsessions and compulsions and so they can be a very important piece of the puzzle for both of these illnesses and when somebody has both at the same time then I as a clinician, I would be much more likely to look for medication to help the person with anorexia if they also have obsessive compulsive disorder whereas if somebody had anorexia and was at the beginning stages of weight restoration, I mean I’d see that there is a high utility for the medication right away.

Kathy: As oppose to refuting?

Dr. Smith: Correct. So medications can be a very important piece of the puzzle. These medicines, the antidepressant family I think of them as being somewhat preventative. They are trying to prevent the obsessions, the compulsions from getting too severe or too frequent. There are other medicines that I think of as rescue medicines like acute relief of anxiety. Things like benzodiazepines or gabapentin, medicines that can help a person get acute relief of anxiety. These may be helpful in certain circumstances but they’re not necessarily helpful over the long term with obsessive compulsive disorder in terms of decreasing the frequency and severity of symptoms. There are a number of other medications that can be used in what’s called augmenting strategies to help the antidepressants work better and provide more efficacy but we get into quite a different number of medicines that could be used. The main take home message for people listening I think is that medications can be an important piece of the recovery process for these individuals. We’re primarily talking about the SSRIs or clomipramine as the foundation of that medication regimen.

 

Kathy: And now I come to a very meaty subtopic here and that is the different cognitive and behavioral skills. Knowing that we have a limited amount of time in this podcast, what are some of the things you’d like to mention about the cognitive skills that are included in treatment, the behavioral skills, etcetera?

Dr. Smith: I think one of the messages is that a specific type of cognitive behavior therapy using exposure with response prevention is the type of therapy that has been most studied and most effective for the treatment of obsessive compulsive disorder and this type of treatment involves a lot of work on the behavioral skills. And I mention that specifically because a lot of times when se say the term cognitive behavior therapy, most people have been more accustomed to the therapy that focuses on the cognitive arm where you’re doing a lot of thought restructuring, thought challenging, there may be homework assignments that are more written assignments or filling out work sheets. In terms of treating individuals with obsessive compulsive disorder that may still be a part of the picture but there’s a much bigger role that’s played in the behavioral aspect with these exposures, having people do exposures or putting themselves in the situations that they actually are fearing but doing it in a gradual way so they’re starting out with challenges that are thought to be challenging but not overwhelming and gradually habituating to the anxiety effects of that. And at the same time a therapist would work with them on trying to help them prevent themselves from doing the ritualistic behavior. So there’s a response prevention so that an individual will gradually start to have the experience that even if they’re putting themselves in that feared situation, there’s not the catastrophic outcome that their fear was telling them and that they can gradually move up. Literally we make a list of these fears and what we call a hierarchy and they move up the ladder of this hierarchy to harder and harder challenges until they’ve habituated and that is the main therapy modality for obsessive compulsive disorder. We find that that has worked extremely well for the anorexia nervosa types of thoughts and behaviors to such a great extent that we actually have extended that to using that approach with every individual with eating disorders because we’ve seen such a positive improvement in not only the obsessive compulsive disorder symptoms but we’ve seen such a positive improvement in terms of their eating disorder pathology, their symptoms, their thoughts, their behaviors with the eating disorder as well as other measures on their depression which is a way for us to gauge how impactful that person’s illness is when we see their depression scores going down.

Kathy: Thank you. We’re going to veer off just for a second because I think it’s so – it’s such a wonderful decision that your residence are required to be on an inpatient unit — participate in a residential program, I’m just curious what feedback you get from the residence?

Dr. Smith: Well, the psychiatry residence at the Medical College of Wisconsin have given us really positive feedback about this and from a number of different ways. One experience that they value is the chance to work with individuals with eating disorders. There aren’t a lot of experiences in psychiatry residency training programs for individuals to work in a systematized way with individuals with eating disorders. So they may have, you know, a patient here or there that has an eating disorder in their outpatient clinic for example but there aren’t a lot of experiences of working on an inpatient unit or in a residential program with the whole patient population being individuals with eating disorders. So that’s a very good experience that they tell us they have. The other experience that they value is seeing the type of cognitive behavior therapy that’s used for obsessive compulsive disorder in action because it’s delivered in a way that we considered a high dosage of these type of therapy compared to what they could try to practice in their outpatient clinics. It gives them a much better feel for the type of progress someone can make over a few weeks or a month with this type of high dosage cognitive behavior therapy. So they’ve given us excellent feedback and it’s been a great pleasure having them there also. It’s really a gratifying part of the work to be able to get that excitement back from residence because they’re excited to learn something new and we’re excited to be able to share something that is so important.

Kathy: Yes. Closing thoughts, how might you like to conclude today?

Dr. Smith: Probably circle back to one of the initial messages that these illnesses are really significant. They’re illnesses that can change the course of people’s lives by themselves and then if you put them together, they’re even more impactful on a person. And the closing message though is that there is help available. There are good treatment measures available and we encourage all individuals who are struggling with these combinations and family members to seek help because it may be a little difficult to get to it, to find your course through it but there are places that can do this type of work to help the individual or the loved ones to get them help.

Kathy: Thank you so very much for your very rich information that you provided. Our guest today has been Dr. Brad E.R. Smith of Rogers Behavioral Health in Wisconsin. Thank you.

Dr. Smith: Thank you.

 

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