Transcript Slide 1

Mind-Body Brief Therapy Solutions for Bodydysmorphia
in Post-Surgery Bariatric Patients
SC-11
Thursday 8:30-10:00
December 11, 2008
Marc I. Oster, PsyD
Carolyn Sauer, PsyD
Milton H. Erickson Foundation
San Diego, CA
1
BT2008 PPT & Handouts CD Contents
• Alladin Sympathetic Arousal Script (WORD): hypnotic script aimed at reducing
sympathetic over-arousal and ego-strengthening.
• Allen CBT for BDD (Word): journal article.
• Avoidant Behaviors, Weight Loss and Body Image (WORD): journal article conclusion
on impact of significant weight loss on body image.
• K. Bailey “Body Dysmorphia: Mind Games After Gastric Bypass Surgery” internet PDF
article.
• K. Bailey “Fat Lady in a Thin Body: WLS Patients Feel Like Imposters” internet PDF
article.
• “Bariatric Surgery Follow Up” (PDF): journal article American Academy of Family
Physicians.
• Bibliography (WORD): Various select presentation references.
• “Body Image and Quality of Life in Post Massive Weight Loss Body Contouring
Patients” (PDF): journal article.
2
BT2008 PPT & Handouts CD Contents (continued)
• “Cognitive-Behavioral Treatment of Obesity” (short form) (WORD): summary of
journal article.
• “Effects of Weight Loss on Body Image” (WORD): summary of journal article.
• Exercise and Anxiety (WORD): summary/conclusions from journal article.
• Marcus obesity surgery (PDF): “Development of a Model for a Structured Support
Group for Patients following Bariatric Surgery” journal article.
• Psych of Body Contouring Surgery (PDF): “Psychological Considerations of the
Bariatric
• Surgery Patient Undergoing Body Contouring Surgery” journal article.
• Rabinowitz Exposure Tx BDD (WORD): summary of journal article.
• Workshop Description Info (WORD): program description, objectives, CE questions,
presenter contact information.
3
Carolyn & Marc
4
Marc I. Oster, Psy.D., ABPH
Associate Professor
American School of Professional Psychology
at Argosy University Schaumburg Campus
999 Plaza Drive, Suite 111
Schaumburg, IL 60173
(847) 969-4944
USA
[email protected]
Marc I. Oster, Psy.D., ABPH
Diplomate status with the American Board of Psychological Hypnosis; Fellow of the
American Psychological Association; Fellow and Past President of the American Society
of Clinical Hypnosis; Board Member of the American Board of Psychological
Hypnosis; Consulting Psychologist for the United States Navy Medical Corps, United
States Department of Justice Drug Enforcement Administration, and several news
organizations; 100 publications and professional presentations; Practice interests include
clinical, health, and forensic psychology in the north suburbs of Chicago.
6
Carolyn P. Sauer, Psy.D.
Training and supervision in clinical work with children,
adolescents, adults and families; individual, group and family
therapy for outpatient and inpatient populations; obstetric
hypnosis, empowerment, substance abuse, trauma, and yoga.
Certified Diplomate of the National Board of Certified Clinical
Hypnotherapists. A graduate of the Teacher Training Program,
Iyengar Yoga Institute of San Francisco.
7
Perception
• Our presentation is about perception – our perception, others’
perception of the patient, the patient’s perception, and their
internalized body image.
8
Criteria for Gastric Bypass Surgery
• Approximately 100 pounds overweight
• BMI of 40+ or
• BMI of 35 plus co-morbid risk factors such as: diabetes, HTN,
heart disease, etc
• History of failed weight loss/maintenance
9
Obesity-Related Comorbidities
System
Comorbidities
Cardiovascular
Hypertension, hyperlipidemia, cardiomyopathy, long
QT syndrome, atrial fibrillation
Pulmonary
Reactive airway disease, obstructive sleep apnea, restrictive
lung disease
Musculoskeletal
Debilitating osteoarthritis, chronic low back pain, immobility
Psychological
dysmorphic disorder
Dermatologic
nigricans
Binge-eating disorder, depression, body
Intertrigo, venous stasis, decubitus ulcer, acanthosis
10
Obesity-Related Comorbidities (continued)
Endocrine
Diabetes mellitus, hypoandrogenemia, metabolic syndrome,
polycystic ovarian syndrome
Genitourinary
Ovarian cancer, uterine cancer, breast cancer, renal cell cancer,
dysfunctional uterine bleeding
Gastrointestinal
Irritable bowel syndrome, nonalcoholic fatty liver disease,
gastroesophageal reflux, esophageal cancer, colon cancer
Neurologic
Ischemic stroke, meralgia paresthetica
© American Academy of Family Physicians 2006
11
What does a BMI = 40+ look like?
12
BMI = approx. 47
13
Roux-en-Y Gastric Bypass Procedure
14
Normal Stomach
© American Academy of Family Physicians 2006
15
Normal Football
16
Normal Stomach = Normal Football
17
Completed Gastric Bypass
18
Coffee Cups
19
New Stomach = 4 oz Coffee Cup
20
WSL Outcomes
• Weight Loss Surgery Outcomes:
Among other things, most notably, significant and rapid weight
loss (e.g. 100-200-280 pounds in 12-18-24 months)
21
WSL Outcomes
22
23
24
25
Remember this guy?
(2004)
26
Here he is again in 2006. His BMI=47
“In this photo Phil, the
guy on the left, was about
half my size. I have now
lost about half of my
original body weight.
Now Phil and I are the
same size – shirts, pants,
and weight!”
27
WSL Outcomes, part 2
In addition to the significant weight loss and improvements in
overall health, these patients experience a variety of emotional
concerns as they adjust to their new life.
Of interest here is the dramatic, or sometimes traumatic, alterations
in body image also knows as dysmorphia. This is similar in
many respects to the dysmorphia experienced by anoretic
patients.
28
What is Dysmorphia?
Diagnostic Features
excessive preoccupation with a defect in appearance; causing significant distress or
impairment….
find their preoccupations difficult to control; make little or no attempt to resist
them;
spend hours a day thinking about their “defect;” these thoughts may dominate
their lives; may lead to avoidance of work or public situations….
29
Associated Features
alternate between periods of excessive mirror checking and avoidance, frequent requests for
reassurance about the “defect,” compare their “ugly” body part with that of others….
avoidance of usual activities may lead to extreme social isolation, may leave their homes
only at night, when they cannot be seen, or become housebound, may drop out of
school, avoid job interviews, work at jobs below their capacity, or not work at all,
few friends, avoid dating and other social interactions, have marital difficulties, or get
divorced, may be associated with Major Depressive Disorder, Delusional Disorder,
Social Phobia, and Obsessive-Compulsive Disorder.
30
Our Premise
As the surgeons say, “I did the surgery on your stomach, not your
head. You will still have to fix that problem for your surgery to
be successful.”
In other words, WLS patients still have to address their psychology
or the dissonance created by the surgery (thin body, fat body
image) will be resolved by weight gain.
31
Many of the studies cited in the references section that looked at
body image, body dissatisfaction, disparagement, etc, attended to
the lack of satisfaction with and the effect on the patient’s
quality of life resulting from the excessive skin following massive
weight loss. Indeed, the physical and social impact of such a
dramatic, and perhaps traumatic change in one’s appearance can
be quite devastating.
32
What these studies fail to address is perhaps a second order form
of this body image disruption. That is the shock, discomfort,
and growing unfamiliarity this patient has with their new body
and how it or they fit into the world around them.
For example….
33
“yes, I did have some BDD issues”
• not recognizing myself in the mirror;
• my face changed a lot and fairly quickly;
• trouble recognizing as mine, parts of my body, including seeing muscle
definition I'd never seen before in my life;
• seeing the vascular development in my arms and hands;
• feeling bones (e.g. my ribs at the sternum and thinking I had holes in my
chest);
• walking around tables or clothing racks in restaurants or stores because I
didn't know I could fit within the aisles;
• not "seeing" oneself socially or personality-wise as others do.
34
General Psychological Treatment
• CBT
• Exposure and Response Prevention (ERP) ala OCD treatment
(see Rabinowitz, 2007)
• Support groups (see Marcus & Elkins, 2004)
• Individual Psychotherapy
• Medications (SSRIs)
35
A Solution
“Body Awareness Therapy”
We define Body Awareness Therapy as any activity, presumably
therapeutic, that either re-acquaints the patient with their body
or acquaints them with their body for the first time.
For example….
36
"body awareness activity I've done”
• studying myself in mirrors (with and without clothes);
• asking (partner) to point out someone she sees who looks like I did preand post-surgery;
• trying on lots of clothes;
• trying/doing various kinds of exercise (running, karate, conditioning);
• therapy;
• talking with friends about their experience or observations of me.
37
Body Awareness Therapies
These therapies may include:
•
•
•
•
•
•
•
Counseling/psychotherapy
Physical exercise
Massage
Therapeutic tasks or exercises ala Erickson or Haley
Yoga
Hard or external martial arts: Karate, Judo, etc
Soft or internal martial or healing arts: Tai Chi, Qi Gong, Acupuncture
38
Common Themes and Goals of Bariatric Support Groups
•
•
•
•
•
•
•
Uncertainty, helplessness, lack of control
Treatment-related concerns and doctor-patient relationships
Self and body image
Effects of illness on the family and social relationships
Prioritizing life values, setting personal goals
Coping with problems
Learning from group members (Marcus & Elkins, 2004)
39
• Beginning at about six months post-op, there is a fundamental
shift from an external locus of control imposed upon them by
the operation to an internal locus of self-control. Body image
issues remain, but may take on a different aspect, becoming
more internalized as a function of identity formation rather than
just a physical or cosmetic one. (Marcus & Elkins, 2004)
40
Mechanisms Explaining the Effects of Massage
• Mechanical mechanisms result essentially from physical forces of compression,
stretching, shearing, and broadening of tissues. Mechanical mechanisms occur at the
gross level of the physical structure.
• Physiologic mechanisms refer to the organic processes of the body (e.g., changes at
the cellular, tissue, or organ system level).
• Reflex mechanisms refer to the result of pressure or movement in one body part
affecting another body part.
• Mind-body mechanisms refer to the interplay of mind, emotion, immunity,
physiology, and health or disease processes.
• Energetic mechanisms refer to changes in the body’s flow of energy, a mechanism
related to acupuncture points, the meridian system, and the flow of chi (life energy).
41
42
Sports, Athletics, & Exercise
Benefits:
improved academic performance, self-confidence, emotional
stability, independence, cognitive functioning, memory, mood,
perception, body image, self-control, sexual satisfaction, work
efficiency, decreased alcohol abuse, anger, anxiety, confusion,
depression, dysmenorrhea, headaches, hostility, phobias, stress
response, psychotic behavior, tension, and work errors
43
Sport as Transformative Practice
• Regular practice of particular physical movements with the intent
to improve them sometimes give rise to spontaneous
metanormalities;
• Sustained and focused attention can produce a state of mind
graced by extraordinary clarity and focus;
• Imagery rehearsal catalyzes the reintegration of physical
performance. It is a well-controlled copy of experience, a sort of
body-thinking (e.g. the Arnold, Jack Nicklaus, & Dwight Stones)
Murphy, 1992
44
Sport as Transformative Practice (continued)
• Relinquishing limiting cognitive, volitional, emotional, and
sensorimotor patterns - abandonment of habitual responses (i.e.
quitting) and enduring the nay saying voices inside them,
athletes discover new capacities - transformation.
• Practiced detachment from results – those who persevere learn
that there is an interior freedom and grace beyond their sport's
results.
• Long-term commitment – to one’s self.
45
Sport as Transformative Practice (continued)
• New integrations of mind and body. We must take our old
repertoires apart and reassemble them with new power and
beauty.
These transformations occur as a result of effort in areas other
than sport. However, sport involves a greater physical-mental
transformative experience.
46
Martial Arts
The martial arts derive much of their transformative power from
the richness and complexity of their repertoires. The sheer
number of movements they demand helps practitioners develop
coordination, balance, agility, flexibility, strength, endurance, and
speed of hand and foot.
47
They incorporate countless discoveries about our psychophysical
potential, which is apparent in the fact that many of them use
methods that modern somatic disciplines have only recently
discovered. (e.g. Tai-chi promotes alignment and extension of the
neck as in the Alexander Technique, and cultivates the soft,
pleasurable stretching of Feldenkrais.) The martial arts today
embody an immense tacit knowledge about human physiology
and movement, much of it derived from Oriental medicine and
religious practice.
Murphy, 1992
48
Acupuncture
• A basic tenet of Chinese medicine is the belief that vital energy
(qi or chi) flows along specific pathways (meridians) that have
about 350 major points (acupoints) whose manipulation corrects
imbalances by stimulating or removing blockages to energy flow.
• Another fundamental concept is the idea of two opposing energy
fields (yin and yang) that must be in balance for health to be
sustained.
49
Acupuncture (continued)
• The benefits of acupuncture have been validated in a variety of
conditions: pain management, postoperative nausea and
vomiting, osteoarthritis of the knee, fibromyalgia, and headaches.
Other conditions treated include: asthma, dysmenorrhea. cervical
pain, insomnia, anxiety, depression, and substance abuse,
including smoking cessation.
50
Tai Chi Chuan
• Tai chi chuan, or tai chi, is designed to increase the life force in
the body through a series of slow circular movements. It is a
moving form of meditation and is based on the search for perfect
balance between yin and yang energies.
• The practitioner performs sequences of movements that last from
5 to 30 minutes. The practitioner is expected to focus on
breathing and its precise synchronization with the movements.
Tai chi helps stress-related conditions including anxiety,
depression, muscular tension high blood pressure, and
cardiovascular conditions.
51
Yoga
• Yoga seeks to bring into balance all the disparate aspects of the
body, mind, and personality. The west grew familiar with yoga
through the practice of Hatha yoga and an emphases on the
postures (asana).
• Yoga is used to reduce stress and to treat anxiety, high blood
pressure, and musculoskeletal conditions. Studies have indicated
its benefits for depression.
52
In yoga, a healthy fulfilling life is based on mastering 8 aspects or
"limbs". Each limb supports the acquisition of the next one:
1. Yama: 5 ethical guidelines regarding moral behavior toward others
2. Niyama: 5 eithcal guidelines regarding moral behavior toward oneself
3. Asana (yoga postures)
4. Pranayama (practice of the breath)
5. Pratyahara: withdrawal of the senses
6. Dharana: Concentration, the ability to focus on something without
being
distracted
7. Dhyana: Meditation
8. Samadhi: Bliss, merging of the self with the universe (enlightenment)
53
The purpose of Asana is to make the body fit for the mind and
the spirit.
Pranayama is the science of breath. The rhythmic patterns of
breath can sooth the nervous system and reduce cravings. By
controlling the breath it is possible to control the mind
(thoughts).
54
Cautions
Gas Levels
*
CO2
O2 *
Gasping
Dizziness
Normal Breath
*
55
Bibliography
A list of bibliographic resources is provided as a separate handout
in your packet/CD.
56
Then and Now
2004 /2006 BMI = 47
2008 BMI = ~23
57