Play cards, beat anorexia?

What helps patients with eating disorders?

Posted Nov 09, 2009

Play cards, beat anorexia?

Of course not, but researchers at Stanford University are making progress with anorexia patients by having them perform tasks, including a card game, that have nothing to do with food, weight or body image.

And that's the point. These are neutral topics, says Kathleen Kara Fitzpatrick, Ph.D. For any of us, it is much more feasible to change our thinking about non-emotion-laden topics. And then, perhaps, our behavior.

As an example of how the direct approach backfires, Fitzpatrick cites the avocado. She tells the patient all about the nutritional benefits of the avocado. How they have more nutritive potassium than any other fruit, phyto-estrogens for healthy hormone regulation, 300 calories for energy, beta carotene for healthy eyes, and the good kinds of fat, mono and polyunsaturated, a healthy substitute for foods rich in saturated fat. For most with eating disorders, Fitzpatrick says, "You're going to get up and remember only that a Haas avocado has 300 calories."

At issue is the emotional content of food, around which patients have drawn severe boundaries and rules.

"They do not get distracted by the bigger picture, such as how their life is shrunken to merely a preoccupation with food." (Department of Academic Psychiatry, Kings College, London, 2005: "Developing a model of the treatment of eating disorder using neuroscience research to examine the how rather than the what of change.")

In the case of the avocado, the bigger picture is a healthy body.

So, play cards.

The Wisconsin Card Sort Task involves four cards, each with a different color, shape and numerical equivalent. Then you get a new card and, given no direction, are asked to match it with one of the four. In the illustration here, the new card could match 1, 2 or 4. Pick one and you are told whether you have the right match. At some point, though, the rule changes. Suddenly you're doing the same thing and not getting the same result. You have to "set-shift."

Stanford researchers have found adults and adolescents with acute anorexia "continue with previously correct answer even in the face of this no longer being correct."

Cognitive Remediation (or Retraining) Therapy is not just "having fun with therapists," says Fitzpatrick. Nor is it stand-alone therapy. "It's helping people get ready for more intensive therapy." It is a way to practice change.

As a real-life example, an anorexia patient makes two huge leaps after CRT. Her obsessively detailed food logs become less down-to-the-nth degree. She eyeballs portions for a while, and then has days when she doesn't even write in her food log. She breaks her own rules further by calling a friend to set up a social event.

Another benefit from "set-shifting" practice is that it can prepare patients to get more out of therapy. Patients commonly drop out when they feel the therapist doesn't share their goals. But with CRT, they share the task, and the changes it requires, with a therapist.

This dynamic also can help in the frustrating interactions between a parent and an anorexic child, Fitzpatrick explains.

Mother: "I don't get what your saying,' or "I don't agree."

Daughter: "I can't think of another way to express it."

End of conversation.

If the daughter can practice set-shifting in a neutral way, like with cards, perhaps she can learn to express her feelings another way, too.

We learn based on feedback, but anorexics often cut themselves off. (Another example would be, giving directions to someone by saying, "Turn left at Safeway, right at the next signal, left at the park." If that person thinks in terms of street names, she may get lost. If you want the person to get there, you might have to give the directions their way.)

In future posts, we'll look at other exciting, surprising sources of hope for treatment of eating disorders.

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