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“ Acceptance and Commitment Therapy in eating disorders. Clinical practice with complex case.” Katia Manduchi, Psy D, Giovambattista Presti MD, Giovanni.

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Presentation on theme: "“ Acceptance and Commitment Therapy in eating disorders. Clinical practice with complex case.” Katia Manduchi, Psy D, Giovambattista Presti MD, Giovanni."— Presentation transcript:

1 “ Acceptance and Commitment Therapy in eating disorders. Clinical practice with complex case.” Katia Manduchi, Psy D, Giovambattista Presti MD, Giovanni Miselli Psy. D & Elisa Rabitti Psy. D 1

2 Case presentation: G. a woman with disordered eating problems, depression and chronical illness… can we make the difference in her life??? G. is 36 years old. Her neurologist suggested her to doing a psychotherapy with me because, after lots of hospitals, for Multiple Sclerosis, recurrent nephrotic syndromes, lupus and their collateral effects, she developed a disordered eating with food restriction and hyperactivity. Contemporary the psychiatrist that work in team with the neurologist, suggested that her diagnosis was complicated from a form of medium depression. Her BMI at the first session was of 15.

3 (1) Her self definition is: “It would be better for my daughter and husband if I’ll died”; “I’m unworthy”; “I can’t express my suffering and my worries for my healthy” (2) Unacceptance of: Body weight and size that started before the illness period; unacceptance of the medical situation and of the physical symptoms (3) Fused with hopelessness and with the fear of dying (4) Food restriction; hyperactivity; anxiety symptoms (5)Family and the daughter relationship; thinnes; having perfect legs. (6) She hasn’t any contact with the present moment but she’s always thinking to her food intake and the physical activity she “needs” to do ACT Question

4 In the first session I have to choose: can I believe in “Wilson wager”??? My answer was…..

5 And then she had to copy with… Her fear of gain weight And she felt so little

6 Assessment In self monitoring diaries we noticed that she was having a food restriction and hyperactivity, daily; BIAAQ: 48 (with the score 7 at items 1 e 2) VLQ: Intensitivity 88; consistence 70; combined 61,3. AAQ2: 41 BDI 2: 10

7 BUT: GSI 1,67; WP 1,5; BIC 1,5; A 1,8; CSM 2; D 1,6 PSD 105; PSDI 3,1 EDI 2 PM 8; IN 7; IS 7; SI 10; BU 0; P 2; IC 3; I 2; IM 13; CE 10; ASC 7

8 TREATMENT During the first 7 months we have had weekly sessions while she started a nutritional training with a doctor that works in team with me and was taking a remedy for the depression under the control of the team for the medical illness;

9 The psychotherapeutic work in this phase Defusion on specifical thoughts: for example we used the “milk milk milk” exercise on the thougths “I’LL DIE SOONER” and “FORBIDDEN FOODS MAKE ME BECAME FAT”;

10 MINDFULNESS as an exercise for reconnect her with her body and the physical sensations from it. After the period of illness G. developed lots of “thoughts avoided” bacause was used to feel really bad sensation when she take an observed position with the body.

11 IMAGERY TECNIQUES: for reinforce the vision of a future, more realistic even if with her chronical illness. Was really important working with G. from the beginning on develope a larger flexibility in her values in this way.

12 Her Values work

13 Next phase…till now…. From January to now we made 6 sessions; In this sessions we had work on the reinforce of the strategies learned during the treatment and in doing this emerged a thought from her adolescence on her thights“My thights are a mess”; this emerged when she arrived to a BMI of 20, a weight she never had in her life.

14 So… an exposure with the mirror So we both decided in a session to explore the thoughts that emerged in the moment in which she was exposing herself to the mirror for 5 minutes. In doing this….

15 What are your thoughts about your body while you’re looking in the mirror?

16 She start to recognize thoughts and bodily sensations: “My thights are disgusting”, “I hate my legs”, and in the same time she reported sensations of muscle contraction in her breast. Than, while she start to defuse her self….she start to cry…and said “I think even…that their mine and I need to accept them as they are” and than embrace me.

17 Now BMI 20 In this mounth the Sclerosis had an aggravation but she cope with this asking me to do a longer period of follow up; asking more support with the medical teams and with her family; developing more bodily awareness as a resource for inform her team.

18 (1) She define herself “A woman that now is taking care of her, her body and her life” (2) More acceptance of shape and weight and acceptance of her clinical situation (3) Strategies learned during the therapy and mindfullnes (4) She is a “disciplined” patient and takes some rest when she need it; she’e really aware of the actual medical situation (5)Family, being a mother, being a good friend, finding some pleasure activities, apreciating some rest, having a “compassioned” relationship with her illness (6) Collaborative with all the teams figures she lives a “normal” life in her family ACT Question

19 Re- test BDI 13 VLQ: Intensity 90; consistence 77; combined 62,9. AAQ2 52.

20 BIAAQ: tot 48 without any high score for specifical items; BUT: GSI 1,2; WP 1,80; BIC 1,22; A 1,33; CSM 1,20; D 0,83; PSD 35; PSDI 0,9 EDI 2 IM 9; BU 1; IC 8; IN 7; P 3; SI 8; CE 4; PM 5; ASC 6; I 2; IS 2.


22 Conclusions Looking at the scores of the different tests we can observe:  Psychological flexibility is increased as we can see from the results of AAQ II;  Body uneasiness sadisfaction in decreased as we can expect;

23  Body image Acceptance is still at a “border” range: discussin this with the client she reported that she have had an harder relationship with her body expecially in this mounth in which her illness symptoms started to change and let her suffer more;  the BMI is significantly persistent at 20. This means that she isn’t avoiding life problems but….


25 And now she feel like a queen of her dragon

26 …And I’m simply honored to have the chance to being a witness of her strenght….

27 Thanks a lot for your attention! & see you in Parma (Italy) 2011 ACBS World Conference If you want to contact me:

28 BIBLIOGRAFIA Beck, A. T. (1970). Cognitive therapy: Nature and relation to behavior therapy. Behavior Therapy, 1(2), 184-200. Fairburn, C. G. (2008). Eating disorders: The transdiagnostic view and the cognitive behavioral theory. In C. G. Fairburn (Ed.), Cognitive behavior therapy and eating disorders. (pp. 7-22). New York, NY, US: Guilford Press Christopher G. Fairburn, D.M., F.Med.Sci., Zafra Cooper, D.Phil., Dip.Psych., Helen A. Doll, D.Phil., Marianne E. O'Connor, B.A., Kristin Bohn, D.Phil., Dip.Psych., Deborah M. Hawker, Ph.D., D.Clin.Psy., Jackie A. Wales, B.A., and Robert L. Palmer, F.R.C.Psych. Transdiagnostic Cognitive-Behavioral Therapy for Patients With Eating Disorders: A Two- Site Trial With 60-Week Follow-Up. Am J Psychiatry December 15, 2008. Forman, E. M. & Herbert, J. D. (2009). New directions in cognitive behavior therapy: Acceptance-based therapies. In W. O’Donohue & J. E. Fisher, (Eds.), General principles and empirically supported techniques of cognitive behavior therapy (pp. 77-101), Hoboken, NJ: Wiley

29 Hayes, S.C. (2004). Acceptance and commitment therapy, relational frame theory, and the third wave of behavior therapy. Behavior Therapy, 35, 639-665. Hayes, S. C., & Pankey, J. (2002). Experiential avoidance, cognitive fusion, and an ACT approach to anorexia nervosa. Cognitive and Behavioral Practice, 9(3), 243- 247. Hayes, S. C., Strosahl, K., & Wilson, K. G. (1999). Acceptance and Commitment Therapy: An experiential approach to behavior change. New York: Guilford Press. Heffner, M., Sperry, J., Eifert, G. H., & Detweiler, M. (2002). Acceptance and commitment therapy in the treatment of an adolescent female with anorexia nervosa: A case example. Cognitive and Behavioral Practice, 9(3), 232-236. Kristeller, J., Baer, R., & Quillian-Wolever, R. (2006). Mindfulness-based approaches to eating disorders. In R. A. Baer (Ed.). Mindfulness-based Treatment Approaches. San Diego: Elsevier. BIBLIOGRAFIA

30 National Institute for Clinical Excellence. (2004). Eating disorders—Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders (Clinical Guideline No. 9). London: Author. (Available at Sandoz, E.K., Wilson, K.G., & Merwin, R.M. (under review). Assessment of Body Image Acceptance:The Body Image – Acceptance and Action Questionnaire. Vanderlinden, J. (2008). Many roads lead to rome: Why does cognitive behavioural therapy remain unsuccessful for many eating disorder patients? European Eating Disorders Review, 16(5), 329-333. E.D.I. 2 : Eating Disorder Inventory ( Garner 1991) versione italiana a cura di G.Trombini, M.Rizzardi, E. Trombini, ed. O.S.; Cuzzolaro M, Vetrone G, Marano G, Battacchi M. Body Uneasiness Test, BUT, in Conti L., a cura di: Repertorio delle scale di valutazione in psichiatria, vol 3, Firenze, SEE, 2000, pp 1759-1761); BIBLIOGRAFIA

31 Wilson, G., & Fairburn, C. (1993). Cognitive treatments for eating disorders. Journal of Consulting and Clinical Psychology. 61(2), 261-269. Bauer B. & Ventura M. “Oltre la dieta” 1998 ed. Centro Scientifico Dalle Grave R. “Terapia cognitivo-comportamentale dell’obesità” 2001 ed. Positive Press Fairburn C. “Cognitive-behavioral treatment for bulimia” 1985 in D.M. Garner & P.E.Garfinkel “Handbook of psychotherapy for anorexia nervosa and bulimia ed. Guilford Press (NY) pg. 160-162 Garner D. & Garfinkel P. “Hadbook of treatment for eating disorder” 1997 Guilford Press Garner D. & Dalle Grave R. “Terapia cognitivo-comportamentale dei disturbi dell’alimentazione” 1999 ed. Positive Press K Sandoz, E. K. & Wilson, K. G. (2006). Assessing Body Image Acceptance. Unpublished Manuscript. University of Mississippi. Versione Italiana a cura di Presti, G., Miselli, G., Rabitti E., Zaffanella, M., Manduchi, K., e Moderato P. (2009), IESCUM, IULM University, ACBS BIBLIOGRAFIA

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