Eating Disorders Flashcards
Anorexia Nervosa
Diagnostic Criteria - DSM-IV TR (APA, 2000)
- Refusal to maintain body weight over a minimally acceptable weight for age and height (
Bulimia Nervosa
Diagnostic Criteria - DSM-IV TR (APA, 2000)
- Recurrent episodes of binge-eating.
- Recurrent inappropriate compensatory behaviour in order to avoid weight gain.
- Minimum average of 2 episodes of binge eating and inappropriate compensatory behaviours per week for the last 3 months.
- Self-evaluation unduly influenced by body shape and weight.
- The disturbance does not occur exclusively during periods of anorexia.2 subtypes: purging & non-purging
Binge Eating Disorder
Diagnostic Criteria - DSM-IV TR (APA, 2000)
- Recurrent episodes of binge eating (eating more than others in a discreet time period with a sense of lack of control)
- BE episode associated with 3+ of
a) eating more rapidly than usualb) eating until uncomfortably ill c) eating lots when not hungry d) eating alone due to embarrassment e) feelings of guilt disgust or depression after overeating
- Marked distress regarding bingeing
- BE occurs on average on at least 2 days a week for at least 6 mths
- BE not associated with inappropriate compensatory behaviours and does not occur exclusively during episodes AN or BN
Co-morbid Conditions (Davey, 2008)
AN Depression OCD BN Depression BPP Substance abuse BED Associated with depression, impaired work and social functioning, low self-esteem and body shape dissatisfaction
Patient Perspectives on Causes of AN
Nilsson et al (2007)
Swedish study; interviewed people who had accessed C & A psychiatric clinics 8 & 16 yrs after initial assessment (median age 15 yrs)
Responses subjected to content analysis
At 8 yr follow-up recovery rate = 68%
At 16 yr follow-up recovery rate = 85%
Attributions
8 yr follow-up
13% had no explanation
High own demands/perfectionism most common
16 yr follow-up
1.5% had no explanation
High own demands/perfectionism most common
More answers related to family causes e.g. illness, expectations, disputes
Other Findings
Frequency of causal attributions to sports requirements, peer relationships, developmental tasks and domestic upheaval stable across follow-ups
No differences in causes identified by those who had recovered compared with those who had not
4 Components (Prochaska & DiClemente, 1982)
Stages of change
See diagram on previous slide
Decisional balance
Pros & cons of behaviour and beliefs
Self-efficacy
Confidence in ability to cope with demands
Processes of change
Cognitive and then behavioural
Engagement Issues for AN
AN
Denial
Not entirely deliberate (Vitousek et al, 1998)
Resistant to treatment
Passive-aggressive (Treasure & Ward, 1997)
AN is egosyntonic & increasingly reinforcing (Halmi et al, 2005)
TA difficult to establish
Risks include premature discharge, punitive treatment and strong helper responses (Vitousek et al, 1998)
Halmi et al (2005)
3 centre study in USA
Ss (122) diagnosed AN, aged 14-50 yrs
Examined dropout, treatment acceptance and treatment completion rates in 3 conditions; CBT, SSRI (fluoxetine) and both combined
Considered predictors
Highest rate of attrition occurred in the first 5 weeks of treatment
Only predictor of completion was self-esteem
Low S-E – 40% completed
High S-E – 80% completed
Concluded need to increase acceptance and self-esteem to reduce dropout, and medication alone unsuitable treatment option
Engagement Issues BN
BN
Usually higher level of motivation
92% BN self-refer vs. 19% AN (Bemis, 1986)
Less resistant to treatment as condition is egodystonic
However ambivalence about relinquishing ideals and loss of coping strategy likely (Vitousek et al, 1998)
Shame acts as a barrier
Motivational Interviewing
Developed by Miller & Rollnick (1991)
Effectiveness demonstrated in alcohol abuse settings
Linked to TTM in literature
However no theoretical or empirical connection exist between the two (Wilson & Schlam, 2004)
Some inconsistencies exist e.g. stages & timing
Considered as an adjunct to therapy but should be part of CBT anyway (Wilson & Schlam, 2004)
MI Principles
Express empathy
Support self-efficacy
Roll with resistance
Develop discrepancy
MI Approach
Increase awareness of importance of change
Increase confidence in ability to deal with change
Use socratic method
Cognitive strategies before behavioural
Be collaborative
Be empathic
Validate client’s experience (Vitousek et al, 1998)
Double sided reflections
Patient: I am not prepared to let my weight go
above 35 kg.
Therapist: You’re terrified about what will happen if
you start to attend to your nutritional
needs [empathy with the fear of change]
and you know that there are clear signs
that your body is suffering when your
weight is below 40 kg – for example your
blood glucose runs at a dangerously low
level and your bones are continuing to dissolve.
(Treasure, 2004)
Sidestepping resistance
Patient: I’m just going to leave here and lose weight again!
Therapist: You’re angry that after all the work you’ve done as an in-patient things don’t feel much different. I’m sorry that the team haven’t been able to help you be able to recognise the need to nurture yourself. I’m sorry that we’ve been unable to help enough. (In this statement the therapist reflects the anger that underlies the patient’s statement and expands on the meaning behind it, which is that the in-patient team has failed to live up to expectations)
(Treasure, 2004)
MET
Motivation enhancement therapy
Briefer version of MI
Project MATCH (1993) demonstrated equivalence of 4 MET sessions to 12 of CBT or the 12 step approach with alcohol misuse treatment
No difference in readiness to change 4 sessions of MET vs. 4 sessions CBT (Treasure et al, 1994)
MET shown to improve motivation in patients with AN (Feld et al, 2001)
Therapies Tailored for Use with EDs
CBT for Bulimia ( See Davey, 2008 – p337)
CBT – BN (Fairburn et al, 2003) 3 stages over 20 wks Session 1- 8 Cognitive model of BN presented Introduce more stable eating habits Session 9 - 16 Further work on developing healthy eating Eliminate dieting Cognitive work Session 17- 20 Maintenance and relapse prevention
IPT for Bulimia
Developed for use with depression (Klerman & Weissman)
Again 3 phases, 12-16 sessions
Phase 1
Assessment, formulation & treatment orientation
Inventory of IP relationships; problems defined as grief, interpersonal disputes, role transition and social deficit
Phase 2
Patient takes the lead to identify alternative patterns of interaction with others
Phase 3
Fortnightly intervals
Relapse prevention
Outcome Studies
IPT has been shown to be effective for BN, with equal effect to CBT at 12mths, although progress slower and relapse rates higher (Fairburn et al, 1993)
CBT effective for 40-50% of cases with BN (Davey, 2008)
More Recent Models
See Stice et al (1996) and van Strien et al (2005)
Dual pathway model
Recognition that low body esteem reduces affect and interferes with interoceptive awareness, resulting in emotional eating and consequently overeating.
Restrained eating has no significant impact in clinical samples
Transdiagnostic Approach
Fairburn et al (2003) – CBT-E
Emphasises importance of low self-esteem, mood intolerance, clinical perfectionism & interpersonal difficulties as maintaining factors
Explains movement across categories
Develop recommendations for treatment
Specific diagnosis unimportant
Successful treatment requires adjustment of:
The over-evaluation of eating, weight, shape and their control
4 additional maintaining factors; clinical perfectionism, mood intolerance, low self-esteem & interpersonal difficulties
2 versions; 20 & 40 (BMI
Transdiagnostic Trial
Fairburn et al (2009) http://ajp.psychiatryonline.org/cgi/content/abstract/166/3/311
154 Ss, 2002-2005, Oxford & Leicester, UK
38% BN, 61% EDNOS
At 20 wks just > 50% has score on EDE not > I SD above community mean, at 60wks figures rose to 61% for BN and 45% for EDNOS
Transdiagnostic approach (CBT-E) best reserved for those with added maintenance processes
Wellcome Trust funded research for use with AN
