week 11- eating disorders Flashcards
maslows heirarchy of needs
self-actualisation esteem love/belonging safety physiological
Anorexia Nervosa
The Diagnosis of AN
Refusal to maintain weight of at least 85% of expected weight*
Intense fear of gaining weight, though underweight.
Disturbance in body image perception
*A criteria of a BMI < 17.5 is often also used as part of a cutoff for Anorexia.
The presence of amenorrhea is increasingly recognised as neither useful or relevant in diagnosis of AN (Surgenor et al., 2003)
Anorexia Nervosa
prevalance and course
Prevalence
0.5% lifetime prevalence in females
10x more common in females than males
Course
Onset typically in mid to late adolescence
Highly variable course and outcome
The Body Mass Index
<15 = extreme 15-16 = severe 16-16 = moderate >17 = mild <17.5 uextremely underweight (dx point for AN) 17.5-18.5 = underweight 18.5-25 = normal 25-30 = overweight >30 obese BMI = kg/m^2
Common AN Characteristics
Anorexia Nervosa is often complicated by other traits and psychopathology that complicate the picture.
Depression and anxiety symptoms Obsessional features Perfectionism Low self-esteem Social withdrawal Physical complications Lack of insight into / acceptance of need for treatment
Mortality in Anorexia Nervosa
Crude mortality rates for AN range between 0% and 20%
More sophisticated analyses of mortality estimate rates of 0.56% per year (Sullivan, 1995)
Compare with…
Mortality for females age 15-24 = 0.0045% per year
Mortality for female psychiatric inpatients = 0.021% per year
Suicide rate in general population = 0.00002% per year
Predictors of mortality in AN (Keel et al., 2003)
Severity of alcohol use and substance use were correlated with mortality
A regression model incorporating Duration of Illness, Affective Disorder During Hospitalization, Suicidality, and Severity of Alcohol Abuse was significant in predicting mortality.
CBT Conceptualisation of AN
Earliest application of Beck’s CT principles to AN in early 1980s (Garner & Bemis, 1982)
Vitousek (1997)
-Overvalued ideas about personal implications of body shape and weight originating out of personality variables such as perfectionism, etc.
-Sense of Control (Slade, 1982)
Stressed need for control as central feature of AN
Success in dieting reinforces sense of control
The complex nature of control in AN is elaborated in Surgenor (2002, 2003)
CBT Theory of AN Onset
Onset of the Disorder
Need for self-control in context of low-self esteem, perfectionism, and sense of ineffectiveness
Control over eating is focused on as an experience of success/control
Dietary restriction provides immediate evidence of self-control
Control over body shape/weight especially salient to ascetics
Controlling eating has a strong effect on those in the environment, which may already be clouded with dysfunctional relationships
Controlling eating provides a mechanism of arresting or reversing pubertal changes
Western society values dieting to control shape and weight.
CBT Theory of AN Maintenance
Dietary restriction enhances the sense of being in control
- Amount eaten, types of foods, times of eating
- Success at dietary restriction is a potent reinforcer
- Control over eating as expression of control and worth
Aspects of starvation encourage further dietary restriction
- Hunger perceived as threat to control over eating
- Impaired concentration may heighten sense of chaos/uncontrollability
Extreme concerns about shape and weight encourage dietary restriction
-Especially prominent in Western society
Cognitions in Anorexia Nervosa
core beliefs, attitudes and assumptions about the meaning of body weight, shape, personal competence…” (Bowers, 2001, p293).
Cognitions are known to change in AN in response to CBT (Bowers & Ansher, 2000)
The Pro-Anorexia (“Pro-ana”) / Pro-Bulimia (“Pro-mia”) Movement
The Pro-Anorexia (“Pro-ana”) / Pro-Bulimia (“Pro-mia”) Movement
“Pro anorexia is the desire to remain eating disorder thin without the side effects of ill health or the consequences of an eating disorder. And in some cases, accepting the side effects but attempting to simply stay alive.”
CBT with Anorexia Nervosa
The General approach to treatment of AN
- Medical stabilisation / treatment
- Engaging the patient in treatment and maintaining a therapeutic alliance.
- Weight restoration and re-establishment of health eating habits.
- Promotion of healthy eating attitudes and behaviours, and activity levels
- “Psychotherapeutic treatment.
- Maintaining gains / Relapse prevention
May occur on inpatient or outpatient basis (which appear equivalent in efficacy; Crisp, et al., 1991)
Outpatient treatment may follow inpatient admission as relapse prevention.
Healthy Eating Attitudes
The goals of this treatment phase should incorporate the following
Increasing calorific intake Expanding the range of meals Eating discrete meals and snacks Normalising the pace of eating Elimination of purging Elimination of binge eating Avoidance of ‘diet’ foods Eating in the company of others
Measuring Outcome
Eating Diary
Daily records of the time, type and quantity of food eaten can be used to monitor progress.
Ongoing monitoring can reinforce small changes in the gradual recovery.
Weight Taking
A necessary outcome measure
Focus on weight can ‘collaborate’ with aspects of the disorder, leading some authors to recommend discouraging frequent weighing or talking about weight.
Treatment Outcome in AN
CBT for AN has been subjected to few clinical trials to establish its efficacy
Difficulty in recruiting participants
–AN is a low-prevalence disorder
–Patients with AN often do not appreciate need for treatment
Treatment is relatively long in duration, with 6 to 12 month follow-ups required to establish efficacy
Some patients present with physical sequelae that prevent their ethical inclusion in an RCT.
Outcome of Treatment of AN
Steinhausen (2002) Meta-analysis of 119 patient cohorts Total of 5590 patients Variety of different treatment methods. Differences between treatments not assessed
Mean dropout rate of 12.3% across all studies.
recovery ~43%
mortality~5%
chronicity~20%
improvement~32%
outcome tx of an - weight, mentruation, eating behaviour
~ 45-60% of px recover in these areas
Predictors of Outcome
good -
Predictors of Good Outcome
Short duration of symptoms
Good parent-child relationship
Histrionic Personality features
Predictors of Poor Outcome
Predictors of Poor Outcome Vomiting Bulimia Purgatory behaviour Premorbid developmental abnormalities Eating disorders in childhood Chronicity Obsessive Compulsive Personality Disorder
Novel CBT Treatments
Video Feedback (Rushford & Ostermeyer, 1997)
N=18 AN patients compared with N=18 normal controls
Multi-step approach
Subjects dressed in underwear or swimwear.
Videotaped against plain background
Patient videotaped from front, sides and back to increase 3D depth
Subject dresses
Subject watches video with clinical psychologist and is asked to report on their perceptions of their body shape/weight
Therapist assists patient in evaluating beliefs through viewing the videotape and providing corrective information.
Patient encouraged to view image as another person
Reduction in body image distortions seen in AN group but not in normal control subjects.
Bulimia Nervosa
Recurrent episodes of binge eating
- -Eating at one sitting an abnormally large amount of food
- -Perception of lack of control over eating
Recurrent inappropriate compensatory behaviour
Occurring at least twice per week over three months
period
Self-evaluation is unduly influenced by body shape and weight
Not occurring exclusively in context of Anorexia Nervosa.
Bulimia Nervosa - prevalence, course
Prevalence
1-3% lifetime prevalence
10x more common in females than males
Course
Onset typically in late adolescence or early adulthood.
Chronic and intermittent courses seen
The Bulimia Severity Spectrum
less sever - binge eating disorder
moderate = bn without purging
more severe = bn with purging
CBT Conceptualization - BN
Psychosocial influences
–Current cultural milieu
—–Correlation between cultural pressure to be thin and ED prevalence, across and within cultural groups (Hsu, 1990).
Family factors
Vulnerability factors (Fairburn et al., 1997)
CBT Model of BN
see slide 34
society, family comments, vulnerability factors of obesity/spsych and vulnerability to ED > interacti with Rigid standards for control of eating & Overvalued import of shape/weight > disordered chaotic eating
DIsordered chaotic eating
Attempts to diet > hunger > lapse > AVE /No control > binge > increase in distress > puirge > reduced distress
the final two steps = negative reinforcement
leads to a breakdown in normal conditioning processes that regulate eating
The Role of Dieting in BN
Dieting behaviour is a risk factor for BN.
In 15 year-old schoolgirls, those who diet were 8 times more likely to develop an eating disorder within a one-year period than those who did not restrict food intake.
But dieting was not a sufficient factor alone in BN. Only 20% of those dieting went on to develop an ED. (Patton et al., 1990)
Patients consistently report the onset of binge eating behaviour following a period of dieting.
Cognitions and BN
Cooper & Fairburn (1992)
Compared cognitions in BN with dieters and non-dieters
Used Behavioural method in addition to self report
–In front of a full-length mirror, weighing self, eating a small chocolate mint.
BN patient show higher frequency of negative AT re weight and appearance than dieters and non-dieters in the behavioural tasks
Self-report questionnaires did not differentiate BN from dieters.
CBT with BN
Seminal work done in mid-1980s and early 1990s
Fairburn (1985) treatment manual
Fairburn, Marcus & Wilson (1993) revised treatment manual
Usually conducted in outpatient setting
Individual CBT for BN is significantly more effective than group based treatment (Chen et al., 1999).
Therapist Variables
–No evidence of differences in effectiveness when delivered by male or female therapist.
Recently, one group have suggested staggering treatment to increase its cost-effectiveness (e.g. Davis et al 1999)
CBT for BN – Typical Treatment
Fairburn (1985), Fairburn et al. (1993)
Individual cognitive behavioural therapy
19 Sessions across 20 weeks
Once per week
–More frequent sessions are only necessary when patients are engaging in multiple binge behaviours each day (Fairburn, 1997)
Problem oriented
Focus is on present and future rather than past events
Three phase approach
CBT for BN – Stage One
Aims of Stage One
To explain the rationale underpinning treatment
To replace binge eating with a stable pattern of regular eating
Explaining the Cognitive View of BN Maintenance
Formulation diagram using patient’s own experiences and words
Education that the problems in BN are more than just the binge eating behaviour
Description of treatment process in BN
CBT for BN – Stage One
self-mionitoring
Monitoring of all food/drink consumed and whether part of a binge.
Monitoring of any purging behaviour
Monitoring of body weight
- Patients are asked to weigh themselves at home, rather than in-session
- Aim is to take the focus away from weight as the central issue
- The Body Mass Index
CBT for BN – Stage One - education
Body weight and its regulation
The Body Mass Index (BMI) and its interpretation
-Calculating the patient’s own BMI
-Natural weight fluctuations and their misinterpretation
-A goal weight range that does not necessitate dieting
-The effects of treatment on weight
The physical effects of binge eating and purging behaviour
- Fluid and electrolyte abnormalities
- Oedema
- Salivary gland enlargement, dental damage
- Menstrual irregularities
- Effects on hunger and fullness cues
Education (Continued)
for cbt for bn
The ineffectiveness of vomiting, laxatives, diuretics in weight control
- Many patients survive on the residue of their binges
- Vomiting only retrieves a proportion of what has been consumed
- Laxatives have little or no effect on calorie absorption
- Diuretics have no effect on calorie absorption
The effects of dieting
- The types of dieting that promote binge eating
- The three types of dieting
- Dietary rules versus dietary guidelines (and dichotomous thinking)
CBT for BN – Stage One
advice regarding eating/purging )(harm minimisation)
Advice regarding eating and purging behaviour
1. Prescription of regular pattern of eating
>Major emphasis on this component
>Three planned meals plus two-three planned snacks
2.Use of an alternative behaviour to delay binges
>Nominating activities that can be done when the patient is at high risk of binge eating behaviour
3.Advice regarding vomiting
>Nominating activities that can be done when the patient is at high risk of purging behaviour
4.Advice regarding laxatives and diuretics
>Nominating activities that can be done when the patient is at high risk of purging behaviour
CBT for BN – Stage Two
Usually approximately eight sessions in Stage Two
Aims
To maintain emphasis on regular eating and alternative behaviour use.
To broaden the focus of therapy to address
>Other dieting behaviours
>Concerns about shape and weight
>Other more general cognitive distortions
CBT for BN – Stage Two
Tackling Other Dieting Behaviours
Aim to reduce or eliminate dieting behaviour that leave the patient vulnerable to future eating disorder
Addressing avoidance of certain food types
- -Identify avoided foods
- -Construction of hierarchy and gradual introduction of new foods to diet
Addressing attempts to maintain low-energy-intake diet
- –Identifying methods of maintaining low-calorie diets
- —Planning intake of at least 1500-1800 kcals per day
Enhancing Problem Solving Skills
CBT for BN – Stage Two
Addressing Concerns About Shape and Weight
Cognitive restructuring is conducted using the procedures used for cognitive therapy in depression, but focusing on BN-relevant cognitions
Behavioural techniques are used in parallel with cognitive skills development
>Behavioural experiments
>Exposure-based treatments
>Reducing weight monitoring / heightened self-monitoring
>Increased awareness of natural body shapes of other women
»_space;Cueing techniques
CBT for BN – Stage Three
Three appointments at fortnightly intervals
Aims
»Focus on relapse prevention and maintenance of treatment gains.
Relapse prevention component follows model of Marlatt & Gordon (1985).
>Identifying High-Risk Situations
>Abstinence Violation Effects
>Seemingly Irrelevant Decisions
CBT for BN – Stage Three model Marlatt & gordon
hihg risk sitch > effective coping response > increased selfefficacy > decreased relapse risk
vs
high risk sitch > ineffective coping > decreased self efficacy & decreased positive outcome expectanceies > lapse > abstinence violation effect (AVE) positive effects of lapse > increased relapse risk
Muscle Dysmorpia
dudes wanting to look big
