Eating Disorders Flashcards
Anorexia NervosaDiagnostic Criteria - DSM-IV TR (APA, 2000)
- Refusal to maintain body weight over a minimally acceptable weight for age and height (
Bulimia NervosaDiagnostic Criteria - DSM-IV TR (APA, 2000)
- 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
Binge Eating DisorderDiagnostic 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)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 overeating3. Marked distress regarding bingeing4. BE occurs on average on at least 2 days a week for at least 6 mths5. 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 goabove 35 kg.Therapist: You’re terrified about what will happen ifyou start to attend to your nutritionalneeds [empathy with the fear of change]and you know that there are clear signsthat your body is suffering when yourweight is below 40 kg – for example yourblood glucose runs at a dangerously lowlevel 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 EDsCBT 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
