Eating Disorders

Question 1

Anorexia Nervosa

Diagnostic Criteria - DSM-IV TR (APA, 2000)

Answer 1

1. Refusal to maintain body weight over a minimally acceptable weight for age and height (

Question 2

Bulimia Nervosa

Diagnostic Criteria - DSM-IV TR (APA, 2000)

Answer 2

1. Recurrent episodes of binge-eating.
2. Recurrent inappropriate compensatory behaviour in order to avoid weight gain.
3. Minimum average of 2 episodes of binge eating and inappropriate compensatory behaviours per week for the last 3 months.
4. Self-evaluation unduly influenced by body shape and weight.
5. The disturbance does not occur exclusively during periods of anorexia.2 subtypes: purging & non-purging

Question 3

Binge Eating Disorder

Diagnostic Criteria - DSM-IV TR (APA, 2000)

Answer 3

1. Recurrent episodes of binge eating (eating more than others in a discreet time period with a sense of lack of control)
2. BE episode associated with 3+ of
   a) eating more rapidly than usual

    b) 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

3. Marked distress regarding bingeing
4. BE occurs on average on at least 2 days a week for at least 6 mths
5. BE not associated with inappropriate compensatory behaviours and does not occur exclusively during episodes AN or BN

Question 4

Co-morbid Conditions (Davey, 2008)

Answer 4

	AN
	Depression
	OCD
	BN
	Depression
	BPP
	Substance abuse
	BED
	Associated with depression, impaired work and social functioning, low self-esteem and body shape dissatisfaction

Question 5

Patient Perspectives on Causes of AN

Answer 5

 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%

Question 6

Attributions

Answer 6

 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

Question 7

Other Findings

Answer 7

 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

Question 8

4 Components (Prochaska & DiClemente, 1982)

Answer 8

 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

Question 9

Engagement Issues for AN

Answer 9

 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)

Question 10

Halmi et al (2005)

Answer 10

 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

Question 11

Engagement Issues BN

Answer 11

 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

Question 12

Motivational Interviewing

Answer 12

 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)

Question 13

MI Principles

Answer 13

 Express empathy
 Support self-efficacy
 Roll with resistance
 Develop discrepancy

Question 14

MI Approach

Answer 14

 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)

Question 15

Double sided reflections

Answer 15

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)

Question 16

Sidestepping resistance

Answer 16

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)

Question 17

MET

Answer 17

 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)

Question 18

Therapies Tailored for Use with EDs

CBT for Bulimia ( See Davey, 2008 – p337)

Answer 18

	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

Question 19

IPT for Bulimia

Answer 19

 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

Question 20

Outcome Studies

Answer 20

 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)

Question 21

More Recent Models

Answer 21

 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

Question 22

Transdiagnostic Approach

Answer 22

 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

Question 23

Transdiagnostic Trial

Answer 23

 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