*Lecture 16 - Eating Disorders 2: Bulimia Nervosa (BN) Flashcards
What is Bulimia Nervosa?
There are 3 essential features of bulimia nervosa:
- recurrent episodes of binge eating (Criterion A),
- recurrent inappropriate compensatory behaviors to prevent weight gain (Criterion B),
- and self-evaluation that is unduly influenced by body shape and weight (Criterion D).
How is an episode of binge eating characterised?
By both
- Eating, in a discrete period of time (e.g.,within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.
- A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
What are four examples of inappropriate compensatory behaviours in order to prevent weight gain?
- self-induced vomiting
- misuse of laxatives, diuretics, or other medications
- fasting
- excessive exercise
How long must the binge eating and inappropriate compensatory behaviours both occur for it to meet criteria?
On average, at least oncea week for 3 months
What are the full diagnostic criteria for BN?
A: Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
Eating, in a discrete period of time (e.g., within any 2- hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
B: Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
C: The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for 3 months.
D: Self-evaluation is unduly influenced by body shape and weight.
E: The disturbance does not occur exclusively during episodes of anorexia nervosa.
What are the two BN specifiers?
- Remission Status (if appropriate)
- Severity
What are the two remission specifiers for BN?
Specifyif:
In partial remission:After full criteria for bulimia nervosa were previously met, some, but not all, of the criteria have been met for a sustained period of time.
In full remission:After full criteria for bulimia nervosa were previously met, none of the criteria have been met for a sustained period of time.
What is the rating system to specify for severity of BN?
Specifycurrent severity:
The minimum level of severity is based on the frequency of inappropriate compensatory behaviors (see below). The level of severity may be increased to reflect other symptoms and the degree of functional disability.
Mild:An average of 1–3 episodes of inappropriate compensatory behaviors per week.
Moderate:An average of 4–7 episodes of inappropriate compensatory behaviors per week.
Severe:An average of 8–13 episodes of inappropriate compensatory behaviors per week.
Extreme:An average of 14 or more episodes of inappropriate compensatory behaviors per week.
In what decade was BN first noticed by professionals?
1970s
List five comorbidities of BN?
- substance abuse
- depression
- suicidality
- personality disorders
- anxiety disorders
True or False?
BN is often associated with some kind of childhood sexual assault.
False. But this used to be the belief. E.g. The case of Holly Ramona - whose physician asked her assumingly about childhood sexual assault so she made something up.
Name three different assessments for BN?
Garner and Garfinkel, 1979
(Garner, 2004)
(Cooper and Fairburn, 1987)
Eating Attitudes Test - 26
Eating Disorders Inventory - 3
Eating Disorders Examination
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EDI slide 14
Describe the Eating Disorders Examination (EDE)?
semi-structured interview
good reliability and validity
comprehensive
sensitive to change
EDE-Q: self-report questionnaire
Has four subscales:
Restraint
Shape Concern
Eating Concern
Weight ConcernWhich of the 4 subscales of EDE 12.OD does this describe?
restraint over eating avoidance of eating food avoidance dieting rules empty stomach
RESTRAINT
Which of the 4 subscales of EDE 12.OD does this describe?
flat stomach importance of shape preoccupation with shape and weight dissatisfaction with shape fear of weight gain discomfort seeing body avoidance of exposure feelings of fatness
SHAPE CONCERN
Which of the 4 subscales of EDE 12.OD does this describe?
preoccupation with food, eating or calories fear of losing control social eating eating in secret guilt about eating
EATING CONCERN
Which of the 4 subscales of EDE 12.OD does this describe?
importance of weight reaction to prescribed weighing preoccupation with shape and weight dissatisfaction with weight desire to lose weight
WEIGHT CONCERN
According to the EDE 12.OD, what is the RESTRAINT subscale interested in?
restraint over eating avoidance of eating food avoidance dieting rules empty stomach
According to the EDE 12.OD, what is the SHAPE CONCERN subscale interested in?
flat stomach importance of shape preoccupation with shape and weight dissatisfaction with shape fear of weight gain discomfort seeing body avoidance of exposure feelings of fatness
According to the EDE 12.OD, what is the EATING CONCERN subscale interested in?
preoccupation with food, eating or calories fear of losing control social eating eating in secret guilt about eating
According to the EDE 12.OD, what is the WEIGHT CONCERN subscale interested in?
importance of weight reaction to prescribed weighing preoccupation with shape and weight dissatisfaction with weight desire to lose weight
What are some challenges in treatment?
- acceptability
- attrition rates
- clinical effectiveness
- speed of action
- breadth of effects
- durability of effects
- cost-effectiveness
Outline CBT-E in BN?
usually lasts 20 weeks semi-structured problem-oriented concerned with present and future (rather than past) 3 stages of treatment
In CBT-E in BN, what are the aims of stage 1?
to establish a sound therapeutic relationship
to educate the patient about the cognitive view on the maintenance of BN and to explain the need for both behaviour and cognitive change
to establish regular weekly weighing
to educate about body weight regulation, adverse effects of dieting, physical consequences of binge eating, self-induced vomiting and laxative abuse
to reduce the frequency of overeating by introducing a pattern of regular eating and the use of alternative behaviour
to reduce secrecy and enlist the cooperation of friends and relatives
In CBT-E in BN, what are the aims of stage 2?
tackling dieting
enhancing problem-solving skills
addressing concerns about shape and weight
addressing other cognitive distortions
In CBT-E in BN, what are the aims of stage 3?
3 interviews at 2 week intervals
aim is to ensure that progress is maintained
relapse prevention
focus on the maintenance of change
problematic goal of abstinence
awareness of vulnerability factors
maintenance of skills for dealing with high risk situations (e.g. problem-solving)
plan for dealing with setbacks (e.g. construction of a maintenance sheet)
Which sessions should stage 2 of CBT-E in BN use?
Sessions 9-16
Which sessions should stage 3 of CBT-E in BN use?
How often should sessions occur?
Sessions 17-19
3 interviews at 2 week intervals
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Outline the The Cognitive View of the Maintenance of Bulimia Nervosa.
Low Self-Esteem
Extreme Concerns About
Shape and Weight
Strict Dieting
Binge-Eating
Self-Induced Vomiting
List 5 skills you need as a therapist?
- technical competence
- establishing an effective therapeutic relationship
- nurturing a commitment to change
- maintaining a specific therapeutic focus
- expertise and experience
Name 6 ways, as a therapist, can you foster a good therapeutic relationship?
- be credible
- be caring and non-judgemental
- develop a collaborative relationship
- balance empathy with firmness
- be positive
- be mindful of gender issues
Name 5 ways you can develop a collaborative therapeutic relationship?
- check the patient’s perception of therapist understanding
- adopt a collaborative attitude
- solicit patient input in setting agenda
- actively involve the patient in formulating homework assignments
- use Colombo style
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structure within session slide 29
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structure across sessions slide 30
True or False?
It is relatively ineffective to use vomiting and laxative as a means of weight control.
True, and this should be part of psycho-education, the first part of CBT.
Name 3 ways a therapist can try to eliminate the use of dieting?
- stress the importance of ceasing to diet and provide education about weight gain
- assess food avoidance and systematically introduce avoided foods into planned meals or snacks (therapist-assisted exposure)
- relax other controls over eating
Provide 3 reasons why a prescribed regular eating pattern important.
- it begins to break down dieting
- it restores a sense of control
- it disrupts learned association between urges/triggers (emotional and situational) to eat or binge
What should a prescribed regular eating pattern entail?
eating 3 meals
&
eating 2 snacks
per day
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slide 36
what about forbidden foods?
goal is to empower the patient - to establish that eating normally will not result in loss of control
goal is not to incorporate high risk foods into daily diets
inclusion of forbidden foods into meal pattern should be planned and deliberate
True or False?
The abstinence model, in which patients must stay away for ‘forbidden foods’, is used and encouraged in BN treatment.
(Polivy, Coleman, & Herman, 2005).
False!!!
There is no scientific evidence to suggest that the abstinence model that is so effective in treatment of alcohol abuse or dependence (e.g., Alcoholics Anonymous, Twelve Step Program) has any role to play in treating the binge-eating episodes in BN. BN patients need to confront their “feared or taboo” foods and learn to eat them in moderation, rather than trying to avoid them forever.
In fact, research on food craving suggests that avoiding a particular food is likely to result in eventual overeating of that food.
True or False?
BN patients need to confront their feared foods
True!!
Avoiding foods perceived as fattening or otherwise unacceptable is actually part of the disorder in the eating disorders, so therapy involves reintegrating forbidden foods into the diet.
Outline the Minnesota Starvation Study
(Keys, Brozek, Henschel, Mickelsen, Taylor, 1950)
Who were the participants?
What happened?
What were the consequences?
Participants:
36 young male volunteers (conscientious objectors to the war, this was their alternative)
What happened:
6 months they ate only 1/2 of their normal food intake in an attempt to lose 25 percent of their body weight.
In fact their food intake had to be reduced further because they could not keep losing to the required level (and the mean amount ultimately lost was only about 24 percent).
What were the consequences?
- suffered many of the symptoms now associated with an eating disorder, e.g.
- obsessive thoughts about food,
- studying recipes,
- deciding to become chefs,
- dreaming about food,
- loss of interest in sexual activity (photographs of pin-up girls were replaced by recipes),
- prolonging eating as long as possible,
- cutting their food into little pieces,
- increasing the use of salt and spices,
- rigidity about food preparation,
- gum chewing,
- drinking large amounts of coffee and tea,
- & during refeeding, binge eating followed by vomiting.
Other psychological effects included
- severe depression and mood swings,
- irritability and outbursts of anger,
- compulsive behaviors and
- self-harm (one cut off three fingers).
In addition, the men became isolative and withdrawn, with food and eating taking precedence over interest in sexual and other relationships or other activities.
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slides 43,44
How does one institute a meal plan?
- Decide on times for eating (plan ahead when you’ll eat)
- Decide ahead of time what food to have (don’t wait until you’re starving)
- Stick to the plan
- Avoid “making up” for binges or special meals (no single eating episode will ruin your plan—just keep going, no starving or meal skipping allowed!)
- Resist urges to binge and/or vomit- use distractions and alternate activities (make a list of these to refer to as needed)
- Include all foods, even if in very small quantities (remember, a calorie of lettuce is the same to your body as a calorie of chocolate)
- Enjoy your food—eating is supposed to be pleasurable!
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48
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50
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slide 51
What is a Dysfunctional Thought Record (DTR) and how can it be used in the treatment of BN?
Brings awareness of the thoughts to the surface to allow for cognitive restructuring.
the thought itself should be noted down
arguments and evidence to support the thought should be marshalled
arguments and evidence that cast doubt on the thought should be identified
The patient should reach a reasoned conclusion that should be used to govern behaviour.
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Cognitive restructuring
slide 53
Evidence-based questions:
What is the evidence for and against a belief? Reframe the belief as a hypothesis to be tested.
Alternative-based questions:
Are there alternative explanations for events other than the patient’s self-defeating interpretation of an event?
Implication-based questions:
What are the psychological costs of holding a particular belief?
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Cognitive restructuring
slide 55
didactic versus socratic style
intellectual versus emotional knowledge
active challenging of thoughts versus simple self-statements
written assignments versus mental recitation
a learned skill
What is a technique of problem solving that can be used when a patient feels ‘stuck’?
Giving two extreme options so that the patient decides themselves to brainstorm other ways
slides 56-58
What is a major potential pitfalls in teaching CBT skills?
Can be learnt well, but it is much harder to put them into effect
What is the Levi’s Principle?
Patients with AN are of the firm belief that their weights are governed by the Levi’s Principle ie that (j)eans rather than (g)enes determine their weight. Treasure (1997) encourages her patients to shop at a clothing store that allows you to return clothes that don’t fit. She encourages them to get some size 16 clothes (the average size of a British woman). The clinician then explores with the patient what conclusions she come to when she tries on these larger clothes and question whether she still believes that she is actually bigger than average.
What is the difference between a lapse and a relapse?
In a lapse, symptoms are often much less severe i.e. smaller binges, less frequently or only a few pounds lost (lapse)
than was the case initially which would constitute a true relapse.
What is the RU Category
Instructions: Use a separate curve for each of the following categories a) medical status (M) b) nutritional status (N) c) social functioning (S) d) emotional distress (E) e) weight status (W)
see slides 73-75
How should therapists deal with a lapse?
• “Lapses” may occur
- Both therapist and patient should be prepared
- Its never back to ‘baseline’—there is some improvement retained
- Refer back to monitoring sheets and records that show improvement• Compile a record of strategies to cope with lapses
- Resume monitoring
- Review distraction techniques or other methods used earlier
- Learn from the lapse—what went wrong and why
Discuss the situation(s)
[The antecedents to the binge get discussed in more detail, and then:]
remind them of treatment and how it worked in the past
remind them that it is a lapse, and thats okay, not a relapse which is different
FIX CARD
How should therapists deal with a relapse?
CANT THINK OF A GOOD ANSWER
FIX CARD
adaption process
When people reach future states they are not as emotionally impacted as they believe they will be when contemplating them in advance
Coping with actual weight gain may be less distressing than anticipating it
(slide 86)
List 3 obstacles to acceptance?
- social pressures regarding shape and weight
- low self esteem
- perfectionism
List 4 ways we can facilitate acceptance?
- Education
- Therapeutic relationship
- Validation
- Cognitive restructuring
List 4 aspects of motivational interviewing?
- express empathy
- avoid argumentation
- roll with resistance
- support self efficacy
FIX CARD
Acceptance as self-affirmation
balance analysis of negative sequelae of trying to alter what cannot be changed with a more positive focus
acceptance is an active process of self-affirmation rather than a passive resignation to an unhappy fate
cognitive, affective and behavioural components of the process
(slide 89)
What are the most important parts of BN treatment?
monitoring and regular meal plans
What is systemic therapy?
Family / Friends involved
Note: the entire family does not have to be the focus of systematic treatment
What 3 reasons might it be beneficial to involve the family in the therapy of an eating disorder patient?
- ethical, financial and practical reasons in younger patients
- family members might be responsible, at least in part, for the maintenance of the disorder
- family members can play important roles in the management and modification of the disorder
True or False?
Family counselling in which the parents are treated separately from the patient is as effective as conjoint family therapy in which the whole family is treated together.
(Dare and Eisler, 1995)
True
What are two things that a patient in remission from an eating disorder learn to accept?
- whatever shape and weight changes are produced
2. patients have far less control over body shape and weight than they wish
