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НУТРИЦИОЛОГИЧЕСКОЕ ЛЕЧЕНИЕ НЕРВНОЙ БУЛИМИИ

Марша Херрин, EdD, MPH, RDN, LD, FAED

Киев, Украина

22 сентября 2020 года

День 2

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Ведущая:

Автор книг:

«Руководство для родителей по расстройствам пищевого поведения», 2007
«Нутрициологическое консультирование в лечении расстройств пищевого поведения», 2013

Ведёт частную практику:

Herrin Nutrition Services, Ганновер/Лебанон, штат Нью-Гэмпшир, США
Клинический доцент педиатрии:

Медицинская Школа Гейзеля и Детская больница, Дартмут

Основательница:

Программы профилактики и лечения расстройств пищевого поведения в Дартмутском колледже

Доктор Марша Херрин, EdD, MPH, RD, LD, FAED

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Программа Дня 2:�Нутрициологическое лечение нервной булимии (НБ)�

Исходные данные

Диагностические критерии
История
Генетика
Сопутствующие заболевания
Распространённость заболевания
Описание поведения
Медицинские осложнения

Перерыв (30 минут)

Методы лечения

КПТ, ДПТ, FBT (основанная на семье терапия)
Управление питанием

Планы питания

Работаем с перееданием
Работаем с искусственной рвотой
Регулирование физической активности
Управление весом

Обсуждение (15 минут)

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Диагностические критерии

Съедание значительно большего количества еды, чем съели бы большинство людей при подобных обстоятельствах за подобный период времени

Вызывание рвоты во избежание набора веса

Искусственно вызываемая рвота, злоупотребление слабительными, мочегонными, другими медикаментами, голодание, чрезмерные тренировки

Переедание / искусственная рвота происходят как минимум раз в неделю в течение трех месяцев

Потеря контроля над приемом пищи

Чрезмерное влияние веса и формы тела на самооценку

The DSM-V made two major changes to the way anorexia nervosa—a condition associated with restricted food intake, fear of weight gain, and distorted body image—is diagnosed, broadening its definition:

Bodyweight: In the DSM-IV-TR, a person's weight had to be at or under 85% of the ideal body weight (according to the body mass index, or BMI) to be diagnosed with anorexia nervosa, thus excluding those who were suffering but hadn’t yet lost enough weight to be officially diagnosed. In the update, DSM-V qualifies diagnosis if the person has reached a “significantly low weight,” giving treatment professionals the autonomy to specify the severity of the disorder.²

The low weight criterion was revised to allow more subjectivity and clinical judgment.⁴

This is also an important revision because we know that anorexia nervosa can occur in individuals who are not what would be considered objectively low weight on a BMI chart. The new criteria allows professionals to take into account an individual's unique growth trajectory and weight history. (Criterion A, which included the word "refusal" in terms of weight maintenance and implied willfulness on the part of patients, was changed to focus on behaviors like restricting calorie intake.)

Menstruation: Previously, women had to have three or more skipped periods to be diagnosed with anorexia nervosa. Now, teen girls and women no longer have to have lost their periods (a condition technically called amenorrhea). loss of a menstrual period) was eliminated as a criterion. This is important because it allows males to meet the criteria for anorexia nervosa.³

It also allows official inclusion of the small minority of females who continue menstruating despite extreme weight loss and malnutrition. Many patients who have implanted birth control, on pills will say they have a period.

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Булимия - это новое заболевание

Первый документ опубликован в 1979 году
Считается психиатрическим диагнозом в Классификаторе DSM-III-R, 1987 года
Начинается в подростковом возрасте или в юности
Возникновение заболевания до полового созревания или после достижения 40-летнего возраста маловероятно
Периоды ремиссии свыше 1 года ассоциируются с полным выздоровлением
Значительно повышенный риск смерти (по любой причине + самоубийство)
Переход к нервной анорексии и обратно к булимии

In the 1970s Patients who were referred for treatment of anorexia didn’t fit diagnosis of anorexia. Despite persistant vomiting were of normal weight or near normal weight and usually had normal menses. “The reason I vomit is to get rid of all this food I eat..

In 1976, Christopher Fairburn also saw an early case of bulimia nervosa and began studying by first what is called the Cosmopolitan study’ and the ‘BBC study’, named after the magazine and TV channel, respectively, through which people potentially suffering from bulimia nervosa were found (7,8). first writing a letter to the editors of the European edition of Cosmopolitan asking them to post a notice describing his first patient asking readers to contact him if they also experienced this behaviors.

First described in a published paper 40 years ago by Gerald Russell. Russell G. Bulimia nervosa: an ominous variant of anorexia nervosa. Psychol Med

1979;9(3):429–48.

--------------------

Hail L, Le Grange D. Bulimia nervosa in adolescents: prevalence and treatment challenges. Adolescent health, medicine and therapeutics. 2018;9:11.

Goldstein A, Gvion Y. Socio-demographic and psychological risk factors for suicidal behavior among individuals with anorexia and bulimia nervosa: A systematic review. Journal of affective disorders. 2019 Feb 15;245:1149-67.

Gorrell S, Le Grange D. Update on Treatments for Adolescent Bulimia Nervosa. Child and Adolescent Psychiatric Clinics. 2019 Oct 1;28(4):537-47.

Ahn J, Lee JH, Jung YC. Predictors of suicide attempts in individuals with eating disorders. Suicide and Life‐Threatening Behavior. 2019 Jun;49(3):789-97.

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Булимия - это генетическое заболевание

Близнецовая наследственность (Hübel, 2019)
Эпигенетические факторы:

Возраст, в котором возникает заболевание;
Стресс на ранних этапах жизни;
Детское ожирение;
Раннее половое созревание

Семейное (наследственное) заболевание
Чаще встречается у женщин, чем у мужчин
Текущие исследования в отношении генов-кандидатов

Most genetic research is on anorexia. Neverless IT is confirmed now from early family and twin studies and now genome studies that anorexia, bulimia & binge eating disorder have a significant genetic component. The consensus is that Eating disorders arise from the combined effects of genes & environment factors though

it has also clear that there is not one gene but a variety of genes that creates an ED.

�

Twin-based heritabilities for AN range from 48% to 74%, for bulimia nervosa (BN) from 55% to 62%, and for binge-eating disorder (BED) from 39% to 45%.4 Hübel C, Marzi SJ, Breen G, Bulik CM. Epigenetics in eating disorders: a systematic review. Molecular psychiatry. 2019 Jun;24(6):901-15

--------The genetic research is just beginning and is very exciting. Certain genes are of interest. One of the most interesting finding is the genetic trait of Negative Urgency which is defined with applied to eating disorders as the biological drive to binge when depressed. Makes sense in primitive times, if you are upset it is probably because your survival is being threaten. In this situation it makes sense to feast or binge eat if you have the opportunity.

It is important to acknowledge that the current research

is very sparse, and more than anything the present review

hopes to illustrate the need for further research regarding

the genetic/epigenetic aspects of BN/BSD-BPD. Additional

research is needed not only to validate the current findings,

but also to more fully understand the genetic/epigenetic aetiology

of BN/BSD-BPD. Furthermore, mental health conditions,

including BN/BSD and BPD are often comorbid with

other psychiatric disorders and research is needed to assess

how relevant comorbidities affect the current findings.

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Диагностические маркеры

Электролитные нарушения:

Гипокалиемия (пониженное содержание калия);
Гипохлоремия (пониженное содержание хлора);
Гипонатриемия (пониженное содержание натрия)

Метаболический алкалоз

Повышенный уровень бикарбоната в сыворотке

Метаболический ацидоз
Проблемы с зубами
Опухшие околоушные железы
Мозоли или шрамы на тыльной стороне рук

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Сопутствующие заболевания

Депрессия
Биполярное расстройство
Пограничное расстройство личности

35% (Braun, 1994)
Повышенный риск негативных долгосрочных последствий (McDonald, 2019)

Злоупотребление запрещёнными веществами

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Распространенность

В США медианный возраст начала заболевания составляет 12,4 года
Показатель постоянной зависимости от НБ - 0,9%
Показатель распространенности за 12-месячный период - 0,6%
41,3% сообщили, что вызывали у себя рвоту искусственно

Выздоровление

60% пациентов не удается выздороветь полностью
НБ у подростков изучена недостаточно (4 RTC)

Основные характеристики

Приступообразное переедание
Компенсаторное поведение
Восприятие своего размера и веса большими, чем в действительности

Linardon J, Wade TD. How many individuals achieve symptom abstinence following psychological treatments for bulimia nervosa? A meta‐analytic review. International Journal of Eating Disorders. 2018 Apr;51(4):287-94.

Although the prevalence and incidence of bulimia

nervosa (BN) seem to be declining in recent years,

there is evidence of a shift in incidence, with the

usual age of onset of BN in women changing from 25 to

29 years in the 1980s to 15 to 19 years in the 1990s and now to early adolescence.

A word about recovery rates. I found published papers reporting recovery rates for bulimia varying from 5 to 75% all depending on the definition of recovery. In summary, we need more effective treatments.

-----------

De Young, Kyle P., et al. "Identifying duration criteria for eating‐disorder remission and recovery through intensive modeling of longitudinal data." International Journal of Eating Disorders (2020). 6 months abstinence for recovery.

Bardone-Cone AM, Hunt RA, Watson HJ. An overview of conceptualizations of eating disorder recovery, recent findings, and future directions. Current Psychiatry Reports. 2018 Sep 1;20(9):79.

Murray, Stuart B., et al. "Integrating family-based treatment and dialectical behavior therapy for adolescent bulimia nervosa: preliminary outcomes of an open pilot trial." Eating Disorders 23.4 (2015): 336-344.

Adolescent bulimia nervosa (BN) remains relatively understudied, and the complex �interaction between core eating psychopathology and emotional regulation difficulties �provides ongoing challenges for full symptom remission. In an open pilot trial, we aimed to �investigate the efficacy of a program integrating family-based treatment (FBT) and dialectical �behavior therapy (DBT) in treating adolescent BN, without exclusion criteria. Participants �were 35 adolescents who underwent partial hospital treatment for BN, and outcomes

Characterics

Hail L, Le Grange D. Bulimia nervosa in adolescents: prevalence and treatment challenges. Adolescent health, medicine and therapeutics. 2018;9:11.

Conversely, BN is considered ego-dystonic and aversive to the patient, yet shame and secrecy often inhibit disclosure of symptoms and seeking treatment. In younger populations, developmental concerns, such as the ability to endorse such conceptual symptoms as “undue influence of weight and shape” may further impact the ability to diagnose full-threshold EDs in adolescents.4

The positively skewed distribution of age of onset of EDs, including subthreshold presentations, renders adolescents a target for screening and early intervention before symptoms become severe and enduring,5 and research has supported that early intervention is associated with the most promising treatment outcomes.6 Increasing research has been devoted to the treatment of AN in adolescence, with an increasing number of studies published demonstrating considerable support for family-based treatment (FBT) approaches.7 To date, evidence to guide the treatment of BN in adolescents is limited, with only four published randomized controlled trials (RCTs) of psychological treatments and one open medication trial.8–11

Adolescent Health, Medicine and Therapeutics

Dove Press

Bulimia nervosa in adolescents: prevalence and treatment challenges

Lisa Hail and Daniel Le Grange

Additional article information

Abstract

Bulimia nervosa (BN) is a serious psychiatric illness that typically develops during adolescence or young adulthood, rendering adolescents a target for early intervention. Despite the increasing research devoted to the treatment of youth with anorexia nervosa (AN) and adults with BN, there remains a dearth of evidence for treating younger individuals with BN. To date, there have been four published randomized controlled trials comparing psychosocial treatments, leaving significant room to improve treatment outcomes. Family-based treatment is the leading treatment for youth with AN, while cognitive-behavioral therapy is the leading intervention for adults with BN. Involving caregivers in treatment shows promising results, however, additional research is needed to investigate ways in which this treatment can be adapted further to achieve higher rates of recovery.

Keywords: eating disorders, youth, family-based treatment, cognitive behavioral therapy, psychodynamic therapy, psychopharmacological treatment, evidence based treatment

Introduction

Eating disorders (EDs) are serious psychiatric illnesses that typically develop during adolescence or young adulthood. These disorders are associated with both physical and psychological sequelae and often lead to considerable impairment and distress.1 The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM)2 recognizes eight feeding disorders and EDs, including bulimia nervosa (BN), anorexia nervosa (AN), and subthreshold presentations that are classified under unspecified feeding or ED. While the field has advanced the understanding of treatment approaches for adolescents with AN and adults with BN in particular, evidence to guide the treatment of BN in youth lags behind.

Diagnosis of BN

BN is characterized by recurrent episodes of eating an objectively large amount of food (ie, binge) with an associated loss of control, as well as inappropriate compensatory behavior (eg, self-induced vomiting, misuse of laxatives or diuretics, fasting, or excessive exercise) and overvaluation of shape and weight.2 In the current edition of the DSM, these episodes of binge eating and compensatory behavior must occur at a minimum frequency of once per week over the course of 3 months. In the DSM-IV-TR, the minimum frequency of these episodes of binge eating and compensatory behavior was double (ie, an average of twice per week).3 In studies comparing full and subthreshold presentations of DSM-IV BN, those individuals who were subthreshold reported significantly more subjective binge episodes in which they experienced a loss of control but did not consume an objectively large portion of food.4 Purge frequency across both groups was similar, suggesting that the experience of losing control may be more salient than the amount of food consumed.4 Diagnostic crossover is relatively common, especially among youths, with many who initially present with subthreshold presentations progressing to meet full diagnostic criteria for BN or less commonly AN.4,5 This diagnostic fluidity suggests that clinical management should not differ between sub- and full-threshold BN.

Traditional diagnostic approaches rely on the self-report of symptoms by the patient. While the low body weight characteristic of AN makes it more outwardly visible, AN is considered an ego-syntonic illness, such that it is consistent with the self-concept of the sufferer, making them less open to treatment.5 Conversely, BN is considered ego-dystonic and aversive to the patient, yet shame and secrecy often inhibit disclosure of symptoms and seeking treatment. In younger populations, developmental concerns, such as the ability to endorse such conceptual symptoms as “undue influence of weight and shape” may further impact the ability to diagnose full-threshold EDs in adolescents.4

The positively skewed distribution of age of onset of EDs, including subthreshold presentations, renders adolescents a target for screening and early intervention before symptoms become severe and enduring,5 and research has supported that early intervention is associated with the most promising treatment outcomes.6 Increasing research has been devoted to the treatment of AN in adolescence, with an increasing number of studies published demonstrating considerable support for family-based treatment (FBT) approaches.7 To date, evidence to guide the treatment of BN in adolescents is limited, with only four published randomized controlled trials (RCTs) of psychological treatments and one open medication trial.8–11

Prevalence

Many population-based studies have focused on youths who meet full-threshold criteria for an ED without reporting on the cases who may have clinically significant presentations, but fall below the diagnostic threshold.1 In adults, the prevalence estimates of full-threshold BN are 1%–1.5%,2,12 with 0.1%–2% in youth.13 However, community studies that evaluated disordered eating behavior rather than applying strict DSM criteria found far greater prevalence (ie, 14%–22%) than those applying strict criteria.1,14

In an attempt to estimate the occurrence of EDs in US adolescents better, Swanson et al utilized data from the National Comorbidity Survey replication adolescent supplement.1 These data collected via face-to-face interviews included a representative sample of 10,123 youths aged 13–18 years. The World Health Organization Composite International Diagnostic Interview was used to assess DSM-IV psychiatric disorders, including AN, BN, and binge ED, based on the diagnostic algorithms used with adult populations. Sufficient information was gathered to assess subthreshold presentations of AN using a less stringent weight criterion (ie, less than 90% of median weight for height rather than 85%) and subthreshold binge ED. However, the survey did not include sufficient information to report on subthreshold presentations of DSM-IV BN, such as those who did not meet the duration or frequency criterion or those who experienced only subjective binge episodes.1

In the USA, the median age of onset for DSM-IV BN is quite young: 12.4 years (interquartile range 11.1–13.5 years).1 Within the sample, the lifetime prevalence rate of BN was 0.9% and 12-month prevalence 0.6%. Of adolescents with BN, 41.3% reported purging, while the rest met criteria based on nonpurging compensatory behaviors (ie, excessive exercise, fasting).1 With revised diagnostic criteria reducing the frequency of binge eating and purging from twice per week over 6 months to once per week over 3 months, these numbers obviously underestimate the true prevalence of BN based on current criteria.

Although the prevalence and incidence of bulimia

nervosa (BN) seem to be declining in recent years,

there is evidence of a shift in incidence, with the

usual age of onset of BN in women changing from 25 to

29 years in the 1980s to 15 to 19 years in the 1990s.1

Recovery

Linardon J, Wade TD. How many individuals achieve symptom abstinence following psychological treatments for bulimia nervosa? A meta‐analytic review. International Journal of Eating Disorders. 2018 Apr;51(4):287-94.

Hamadi L, Holliday J. Moderators and mediators of outcome in treatments for anorexia nervosa and bulimia nervosa in adolescents: A systematic review of randomized controlled trials. International Journal of Eating Disorders. 2020 Jan;53(1):3-19.

Family therapies were dominant in the literature. Individual or separated treat- ment appeared superior for families with more difficult relationships, whereas conjoint family treatment appeared to be superior where good family relationships were reported. Where there was greater eating disorder psychopathology in AN, including eating disorder-related obsessions and compulsions, the response was better to a fam- ily approach than to individual therapies. There was some evidence that a family treat- ment was superior for those engaging in purging behaviors in BN. Measures of family relationships, parental self-efficacy, and early change emerged as possible mediators; however, the quality of evidence was mixed and the findings, in some cases, arguably circular. Moderator and mediator analyses were underpowered in all studies, with mul- tiple, and post-hoc, analyses being run, and a broad range of outcome measures used.

Stefini, Annette, et al. "Cognitive-behavioral and psychodynamic therapy in female adolescents with bulimia nervosa: a randomized controlled trial." Journal of the American Academy of Child & Adolescent Psychiatry 56.4 (2017): 329-335.

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Цикл «ограничение-переедание»

Ограничение питания

Голод с последующим пиршеством (биологически естественный)
Нарушает контроль над едой
Пациент может голодать весь день, чтобы наесться до отвала вечером
Может ограничивать принятие пищи после эпизода переедания, в качестве компенсации
Становится привычкой, чтобы пациент наслаждался свободой, и ел, как ему хочется

Переедание

Приносит удовольствие
Снижает стресс, скуку, депрессию, тревогу, гнев
Помогает при кризисах
Диссоциация
Невосприимчив к сигналам сытости
Пациент чувствует себя не в состоянии контролировать прием пищи

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Цикл «переедание-рвота»

Переедание

Для того, чтобы вызвать рвоту, нужно основательно переесть
При искусственном вызывании рвоты вероятность переедания выше

Рвота

Снижает тревожность и страх набора веса
Эмоциональная разрядка

“кайф”

Пациент чувствует себя хозяином положения, спокойным, организованным
Самонаказание
Плоский живот

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Приступообразное переедание

Триггерные продукты

Еда без границ
Избегание определенных продуктов
Еда, которую легко есть
Продукты с высоким содержанием углеводов

Триггерная обстановка

Одиночество
Телевизор
Компьютер
Учеба
Машина

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Приступообразное переедание

Объективное

переедание

Более 500 калорий/эпизод
В среднем 1000-1500 калорий
Максимум 10500 калорий

Субъективное

переедание

Менее 500 калорий/эпизод

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Рвота

Искусственно вызываемая рвота

Наиболее распространенная
Может происходить после обычных приемов пищи, при легкой сытости, при употреблении «продуктов, от которых полнеют»

Слабительные

Совершенно пустой, вогнутый желудок
Слабительные продаются без рецепта и кажутся безопасными

Мочегонные

Временная потеря жидкости составляет 1-2 кг

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Рвота

Тренировки
Голодание
Злоупотребление тиреоидином, дефицит внимания, лекарства от диабета
Ипекакуана
Таблетки для похудения
Препараты для подавления аппетита
Клизмы
Сплевывание: жевание без глотания
Руминация: выбрасывание пищи из желудка в рот, повторное глотание
Длительное грудное вскармливание

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Медицинские осложнения

Результат вида и частоты рвоты
Некоторые из них связаны с жидкостью и электролитами
Большинство из них обратимы при условии лечения
Физические:

Разрыв пищевода
Повреждения зубов
Заболевания почек (диуретики)
Остановка сердца

Электролиты и обезвоживание

Болеют только при низком уровне калия

Осложнения при прекращении вызывания рвоты:

Зависимость от слабительных
Ложный синдром Бартера

Риск самоубийства

При НБ - в 7 раз выше нормы (Smith, 2018)

There are many different medical complications

of bulimia nervosa. How susceptible someone is depends to all of these complications depends on genetics

and how often and whether the patient self-induces vomiting or uses laxatives or diuretics. Important not to assume that normal lab values means that the patient is not engaged in frequent purging behaviors.

Most acute: Rupture of esophagus due to purging and rupture of stomach due to bingeing

Patients may not worry about the dental damage because they have never had a bad report from their dentist. Because some dentist seem not to want to discuss it. Erosion of dental enamel occurs in 64% of patietns who self-induce vomiting usually in about 6 months (Mehler book, page 211). The loss of of enamel makes the teeth appear shorter and have irregualar edges.

I

A well publicized case in the US of cardiac arrest in bulimia occurred in Boston when a 20 year old ballet dancer was asked by her dance company to go home to California for eating disordered treatment. Her parents decided to take her to Disneyland first. She died of cardiac arrest sleeping in the back seat of her parents’s car on the way to Disneyland.

Since Potassium is lost in vomit, diarrhea, and urine. Low potassium below 3 milliequivalents of solute per litre is very dangerous and puts the patient at risk for muscle breakdown and cardiac risk. The body has an impressive ability to maintain normal potassium despite significant purging. If serum potassium is low, however, it is highly likely that the patient is purging.

Purging makes one chronically dehydrated and volume depleted leading to rebound edema which can be very upsetting and dangerous when they stop purging. Can last several weeks.

It is important to remember that though risk of suicide is lower in bulimic pateints than in anorexic patients, BUT it is still significantly at 7x the rate for normal controls. (AN 18 x more likely)

Although warnings about potential health risks of purging behaviors appear to

have minimal effects on behavioral change, problems related to appearance are

usually of greater interest. We describe how purging can cause: puffiness; sores

around the mouth; red, rough hands; blood shot eyes, red spots around the eyes; swollen face and

neck; and yellow teeth and other unsightly dental problems.

food ingested prior to vomiting may be

causally linked to it.

Effects on Appearance

Although warnings about potential health risks of purging behaviors appear to

have minimal effects on behavioral change, problems related to appearance are

usually of greater interest. We describe how purging can cause: puffiness; sores

around the mouth; red, rough hands; red spots around the eyes; swollen face and

neck; and yellow teeth and other unsightly dental problems.

Managing Purging 251

Edema is the likely explanation for feelings of “puffiness” and abrupt increases

in body weight. We often see patients with painful sores (cheilosis) at the angles

of the mouth, hoarseness, and sore throats. Red, rough abrasions and calluses on

the dorsum of the hand and knuckles (Russell’s sign) is a classic indicator of the

habit of forcibly inserting fingers into the throat to induce vomiting. The strain

of vomiting can cause hemorrhages on the cornea and petechial (tiny red spots)

hemorrhages on the face. While these can be unsightly, they are not of medical

significance. Salivary gland enlargements are common in patients who binge and

vomit. The hypertrophy of these glands gives those afflicted swollen faces and

puffy-looking jaws. The swelling, which is painless and apparently harmless, disappears

when purging stops.

Dental complications are also at the top of the list of appearance concerns

(see Chapter 1: Clinical Features of Eating Disorders, pp. 3–31). We tell our

patients who purge to expect an increased rate of dental caries and other dental

problems. The first sign is slight yellowing of the front teeth. Over time, teeth

appear worn, ragged, chipped, thinning, and discolored as stomach acids wear

away tooth enamel.

-----

One of the most pathophysiologically interesting complications of eating disorders is Pseudo-Bartter syndrome. Patients who engage in purging behaviors may present to healthcare attention with hypovolemia, hypokalemia, and metabolic alkalosis (hence the name Pseudo-Bartter syndrome). This can occur in the setting of diuretic abuse, but can also arise from other forms of purging such as vomiting or laxative/enema abuse. Such purging behaviors lead to a chronically volume depleted state, which stimulates the renin-angiotensin-aldosterone system, and this hyperaldosteronism can persist for up to three weeks after stopping purging behaviors and restoring euvolemia. ��This becomes particularly relevant in patients admitted to the hospital, who are frequently administered IV crystalloid for volume depletion at the same time as the patient ceases their purging behaviors. Hyperaldosteronism leads to a sodium-avid state by increasing sodium reabsorption in the distal nephron, so sodium-containing bolus intravenous fluids can lead to positive fluid balance with peripheral and pulmonary edema. At times this can be severe enough to require endotracheal intubation. Keep in mind that part of these psychiatric disorders is a fear of gaining weight, so fluid overload won’t do your psychiatry colleagues any favors in treating the underlying problem.

The management of Pseudo-Bartter syndrome includes potassium repletion, gradual fluid administration to correct the metabolic alkalosis over 1-2 days, and initiation of an mineralocorticoid receptor antagonist such as spironolactone for 2-3 weeks to manage edema and hypokalemia. Loop or thiazide diuretics should be avoided in such patients, as these will worsen intravascular volume depletion and continue the cycle of aldosterone stimulation, urinary potassium wasting, and sodium chloride reclamation in the distal nephron.

Diuretic use less common.Self-induced vomiting can cause many problems in the

area of the head and face, due to direct toxic effects of

stomach acid to the throat and mouth, as well as consequences

of straining and retching. Pressure elevations that

Reflux of acidic stomach contents into the esophagus

occurs frequently in patients who engage in self-induced

vomiting. Acid exposure can cause esophageal irritation,

esophagitis, esophageal stricture, and in rare cases Barrett’s

esophagus and even esophageal adenocarcinoma

Conclusion Bulimia nervosa is a serious mental health

disorder which has many medical complications associated

with it. Most are reversible with treatment.

There are many different medical complications

of bulimia nervosa which are caused by the mode and

frequency of purging. Some are fluid and electrolyte

alterations from the utilized mode of purging and some are

due to the local damaging effects of purging behaviors on

those body sites.

Conclusion Bulimia nervosa is a serious mental health

disorder which has many medical complications associated

with it. Most are reversible with treatment.

Crow, S. J., Swanson, S. A., Le Grange, D., Feig, E. H., & Merikangas, K. R. (2014). Suicidal behavior in adolescents and adults with bulimia nervosa. Comprehensive Psychiatry, 55, 1534–1539.

Similar trends emerged for the association between BN and self-reported suicidal plans or attempts. Among adults, suicidality was more common in BN than in the no psychopathology group, but not significantly different from the anorexia nervosa (AN), BED, or other psychopathology subgroups.

Conclusion: There is a high risk of suicidal ideation and behavior among those with BN. These results underscore the importance of addressing suicide risk in adolescents and adults with eating disorder symptoms.�© 2014 Published by Elsevier Inc.

Smith AR, Zuromski KL, Dodd DR. Eating disorders and suicidality: what we know, what we don’t know, and suggestions for future research. Current opinion in psychology. 2018 Aug 1;22:63-7

Suicide is the second leading cause of death among individuals

with anorexia nervosa (AN), and suicidal behavior is elevated in

bulimia nervosa (BN) and binge eating disorder (BED) relative to

the general population. This paper reviews the suicidality

literature within each ED, as well as theoretical explanations for

the elevated risk for suicidality among those with EDs.

Approximately one-quarter to one-third of people with AN, BN,

or BED have thought about suicide, and one-quarter to

one-third of people with AN and BN have attempted suicide.

Relative to gender and aged matched comparison groups,

individuals with AN are 18 times more likely to die by suicide,

and individuals with BN are seven times more likely to die by

suicide. However, the majority of the research in this area is

cross-sectional or retrospective, which leaves the timing of the

mortality risk unclear. Longitudinal work that is designed to

examine dynamic and acute fluctuations in suicidality among

ED samples is needed in order to determine meaningful risk

factors.

Sachs K, Mehler PS. Medical complications of bulimia nervosa and their treatments. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity. 2016 Mar 1;21(1):13-8.

17 of 52

Стратегии опосредования медицинских осложнений (Mehler, 2015)

Кислотный рефлюкс

Поднятие изголовья кровати
Минимизация перорального приема пищи за несколько часов до сна
Ингибиторы протонной помпы

Стоматологические

Полоскание фторсодержащей жидкостью для полоскания рта
Легкая чистка зубной пастой на основе фтора

Увеличение слюнных желёз (хомячьи щеки)

Конфетки-тарты, теплые компрессы
Противовоспалительные средства в низких дозах

If patients are complaining about acid reflux, medications may help

We warn patients that brushing their teeth just after purging, a common practice,

can cause permanent damage to tooth enamel made soft and fragile by contact

with stomach acid. To protect tooth enamel, we advise waiting several hours

before brushing. Instead, immediately after a purging episode, patients should

rinse their mouths with a fluoridated mouthwash or baking soda dissolved in

water, or even just plain water, or suck on an antacid (e.g., Tums or Rolaids).

All of these techniques neutralize stomach acid to some extent and permit at least

some remineralization to occur. The best protection, dentists have told us, is to

wear a sports mouthguard sprinkled with baking soda while vomiting. Prior to

purging, rinsing with a fluoridated mouthwash or spreading fluoridated toothpaste

over teeth can make enamel more resistant and tooth roots less sensitive. As

long as vomiting occurs regularly, tooth enamel will remain soft and susceptible

to erosion. Individuals who purge should avoid raw fruit and fruit juice and, at

the very least, wait several hours after consuming fruit or fruit juice before brushing

teeth.

In order to receive the best possible preventive dental care, patients should

inform their dentists about purging behaviors. Early dental damage is subtle and

difficult to assess by an unsuspecting dental professional.

Sialadenosis Sy-alden-no-sis (chipmunk cheeks) benign, non-inflammatory, non-neoplastic. enlargement of salivary glands. Gives the impression of a face that is bigger tand fatter than it really is.

Discussed on next slide. cathartic colon syndrome,(not on slide) wherein their colon

is relegated to an inert tube incapable of propagating fecal

material resulting in severe constipatio

Mehler PS, Krantz MJ, Sachs KV. Treatments of medical complications of anorexia nervosa and bulimia nervosa. Journal of eating disorders. 2015 Dec;3(1):1-7.

Bulimia nervosa

Gastrointestinal

For patients with bulimia nervosa, treatment of their

acid reflux symptoms follows the usual treatment plan

generally used for any patient with this disorder, namely

proton pump inhibitors, head of bed elevation and

minimizing oral intake within a few hours of going to

sleep. Although there are no data to suggest that patients

with bulimia nervosa, who purge via self-induced vomiting,

are at increased risk of esophageal carcinoma, good

practice would be to refer a bulimic patient for upper

endoscopy, if their acid reflux is refractory to standard

therapy or anyone with dysphagia or a history of recurrent

hematemesis; this is to exclude Barrett’s esophagus or

even worse, neoplastic changes. Barrett’s remains a risk

factor for esophageal carcinoma and endoscopic surveillance

is recommended [41]. In addition, treatment of the

dental consequences of self-induced vomiting largely

revolves around ensuring good dental hygiene to reduce

the harmful effects of stomach acid on teeth enamel.

Brushing lightly with a fluoride-based toothpaste soon after

vomiting is the current practice. Also, the sialadenosis

which can often develop with abrupt cessation of selfinduced

vomiting, is treated with sialagogues such as tart

candies, warm packs applied to the sides of the face

multiple times per day and low dose anti-inflammatory

agents such as ibuprofen. For refractory cases, a trial of

prescription pilocarpine (sialogen) should be initiated

before consideration of surgical treatments [42].

For those patients with bulimia nervosa who purge via

stimulant laxative abuse, the treatment challenge which

evolves is how to successfully “detox” them before they

develop the cathartic colon syndrome, wherein their colon

is relegated to an inert tube incapable of propagating fecal

material resulting in severe constipation. There are no

randomized controlled studies to inform how to optimally

achieve cessation of stimulant laxative abuse while

maintaining some degree of normal colonic function.

Nor are there any data which speak to what amount

of stimulant laxative usage is dangerous or over what

duration of usage. Therefore a prudent approach seems to

be one wherein the message delivered to these patients

must be to completely abandon their usage versus simply

reducing the number of stimulant laxatives used each day.

Additionally, adequate fluid intake should be encouraged

18 of 52

Работа с другими видами компенсаторного поведения

Злоупотребление слабительными

Отслеживайте и корректируйте водно-электролитный баланс
Использование слабительных не приводит к значительному уменьшению поглощения калорий
НЕМЕДЛЕННО ОСТАНОВИТЕСЬ
Сократите потребление на 10% в неделю
Больше клетчатки
Адекватное потребление жидкости
Слабительные средства точно прописываются; их применение контролируется

Полиэтиленгликоль порошок

Злоупотребление мочегонными

Отслеживайте и корректируйте водно-электролитный баланс
Снижайте потребление мочегонных постепенно, чтобы снизить риск рикошетного отека

It’s important to monitor and correct fluid and electrolyte balance if they are either purging, or misusing laxatives or diuretics. And also to reduce consumption gradually – from a psychological and physiological point of view.

cathartic colon syndrome, wherein their colon

is relegated to an inert tube incapable of propagating fecal

material resulting in severe constipation and possibly nee

I year of abuse of stimulant laxatives. Which includes Senna which sounds natuarual. TSenna is flowering herb. The leaves and the fruit of the plant are used to make medicine. Senna is an FDA-approved over-the-counter (OTC) laxative. A prescription is not required to purchase senna. It is used to treat constipation and also to clear the bowel before diagnostic tests such as colonoscopy.

he cathartic colon syndrome is a much more serious entity, involving loss of normal colonic peristalsis. These changes arise from inflammation of the mucosa, alterations in the muscular layers of the colon, and degeneration and damage to the enteric and Auer- bach’s plexi caused by a direct toxic effect from

�typically defined on the basis of radiologic findings. Barium enema studies reveal that the colon loses the normal haustral markings and is dilated. These changes arise from inflammation of the mucosa, alterations in the muscular layers of the colon, and degeneration and damage to the enteric and Auer- bach’s plexi caused by a direct toxic effect fro

s a result of these

changes, slowed or absent transit occurs through

some or all segments of the colon, leading to hard,

infrequently passed stools and, occasionally, a state

of totally refractory constipation. The colon is thus

relegated to an inert tube, incapable of propagating

fecal matter with resultant obstipation. There is

marked variation in individual susceptibility to

these effects of stimulant laxatives. With truly pro-

longed abuse of these laxatives, the cathartic colon

syndrome is potentially irreversible. Loss of normal

colonic function can become so severe that surgical

colectomy and insertion of an ostomy bag is

needed to treat intractable constipation. Unfortu-

nately, it is impossible to predict or advise patients

at what point in their history of laxative abuse this

may occur. However, it is known that tolerance to

the effects of stimulant laxatives does occur. Larger

doses are then required to achieve the same desired

effect. Therefore, more exposure occurs that

increases the risk for the cathartic colon syn-

30

duce a more innocuous reflex constipation. This constipation can be bothersome during withdrawal from laxatives, making it difficult to terminate laxa- tive abuse, but it is usually transient. Of note, many patients who abuse laxatives also engage in other

typically defined on the basis of radiologic findings. Barium enema studies reveal that the colon loses the normal haustral markings and is dilated. These changes arise from inflammation of the mucosa, alterations in the muscular layers of the colon, and degeneration and damage to the enteric and Auer- bach’s plexi caused by a direct toxic effect from

The result is a dilated, atonic colon,

drome.�

Mehler PS, Krantz MJ, Sachs KV. Treatments of medical complications of anorexia nervosa and bulimia nervosa. Journal of eating disorders. 2015 Dec;3(1):1-7.

Bulimia nervosa

Gastrointestinal

For patients with bulimia nervosa, treatment of their

acid reflux symptoms follows the usual treatment plan

generally used for any patient with this disorder, namely

proton pump inhibitors, head of bed elevation and

minimizing oral intake within a few hours of going to

sleep. Although there are no data to suggest that patients

with bulimia nervosa, who purge via self-induced vomiting,

are at increased risk of esophageal carcinoma, good

practice would be to refer a bulimic patient for upper

endoscopy, if their acid reflux is refractory to standard

therapy or anyone with dysphagia or a history of recurrent

hematemesis; this is to exclude Barrett’s esophagus or

even worse, neoplastic changes. Barrett’s remains a risk

factor for esophageal carcinoma and endoscopic surveillance

is recommended [41]. In addition, treatment of the

dental consequences of self-induced vomiting largely

revolves around ensuring good dental hygiene to reduce

the harmful effects of stomach acid on teeth enamel.

Brushing lightly with a fluoride-based toothpaste soon after

vomiting is the current practice. Also, the sialadenosis

which can often develop with abrupt cessation of selfinduced

vomiting, is treated with sialagogues such as tart

candies, warm packs applied to the sides of the face

multiple times per day and low dose anti-inflammatory

agents such as ibuprofen. For refractory cases, a trial of

prescription pilocarpine (sialogen) should be initiated

before consideration of surgical treatments [42].

For those patients with bulimia nervosa who purge via

stimulant laxative abuse, the treatment challenge which

evolves is how to successfully “detox” them before they

develop the cathartic colon syndrome, wherein their colon

is relegated to an inert tube incapable of propagating fecal

material resulting in severe constipation. There are no

randomized controlled studies to inform how to optimally

achieve cessation of stimulant laxative abuse while

maintaining some degree of normal colonic function.

Nor are there any data which speak to what amount

of stimulant laxative usage is dangerous or over what

duration of usage. Therefore a prudent approach seems to

be one wherein the message delivered to these patients

must be to completely abandon their usage versus simply

reducing the number of stimulant laxatives used each day.

Additionally, adequate fluid intake should be encouraged

19 of 52

МЕТОДЫ ЛЕЧЕНИЯ

CBT, FBT, DBT

Планы питания

Стратегии управления поведением

20 of 52

Методы лечения

Наиболее эффективны поведенческие методы лечения (30% выздоровления)

Самая изученная – КПТ
Терапия с привлечением ближайших членов семьи (FBT) наиболее предпочтительна для подростков в случаях:

Хороших отношений в семье;
Более низких уровней симптомов РПП;
Склонности к искусственному вызыванию рвоты

По ДПТ мало исследований

Быстрое реагирование, раннее изменение симптомов улучшает результаты

Again the research is limited. limited, with only four published randomized controlled trials (RCTs) of psychological treatments and one open medication as of 2015 The UK National Institute of Health and Care Excellence (NICE) guidance was selected to guide this review as the most up‐to‐date set of recommendations for child and adolescent treatment, including a detailed methodology, which is published in English. Of .

Hamadi L, Holliday J. Moderators and mediators of outcome in treatments for anorexia nervosa and bulimia nervosa in adolescents: A systematic review of randomized controlled trials. International Journal of Eating Disorders. 2020 Jan;53(1):3-19.

Several countries have developed best practice guidelines on the treatment of AN and BN. The UK National Institute of Health and Care Excellence (NICE) guidance was selected to guide this review as the most up‐to‐date set of recommendations for child and adolescent treatment, including a detailed methodology, which is published in English. Of note, all other national guidelines published recommend the use of a family intervention in the treatment of adolescent AN, although the terminology used and the specific form of family intervention recommended does vary. The APA Practice Guideline for the Treatment of Patients with Eating Disorders (third edition, 2006; 2012) reviews other psychological therapies for both AN and BN, but highlights limitations in the available evidence including small sample sizes, short duration, and a focus on symptom relief rather than recovery. Australian (Hay et al., 2014) and British (NICE, 2017) guidelines propose alternatives to family therapy reflecting the inclusion of research evidence supporting these additional treatments.

Conversely, in a study of BN, those with less severe scores had a better outcome when receiving FBT compared to Supportive Psychotherapy (SPT; Le Grange, Crosby, & Lock, 2008).

Another noted that rapid response strongly predicted better outcome, regardless of diagnosis or treatment modality

�

21 of 52

КПТ

Предположение: Поведение, характерное для РПП, вызвано восприятием своего размера, веса и контроля за потреблением пищи большими, чем в действительности; диетическими ограничениями, вызывающими приступообразное переедание; триггерами событие/настроение
Порядок действий: обучение психологической самопомощи, самомониторинг, регулярное питание, анализ поведенческих моделей переедания/искусственной рвоты
Этап 1: Установление контакта и налаживание отношений, разработка формулировки, самомониторинг, контроль веса, регулярное питание
Этап 2: Выявление барьеров, препятствующих изменениям
Этап 3: Работа с механизмом, поддерживающим РПП
Этап 4: При удачном раскладе, разработка стратегий для предотвращения рецидивов
Этап 5: Планирование долгосрочного поддерживающего лечения

analysis to reduce bulimic symptoms (Fairburn,2008 ). A recent enhanced version (CBT-E) incorporatesinformation on additional maintenance mechanisms of theeating disorder psychopathology, including clinical perfec-tionism, core low self-esteem, difficulties coping with moodstates, and interpersonal difficulties

Help patients be interested and intrigued in their problem.

�NICE Individual CBT-ED for adults with bulimia nervosa should:

typically consist of up to 20 sessions over 20 weeks, and consider twice-weekly sessions in the first phase

in the first phase focus on:

engagement and education

establishing a pattern of regular eating, and providing encouragement, advice and support while people do this

follow by addressing the eating disorder psychopathology (for example, the extreme dietary restraint, the concerns about body shape and weight, and the tendency to binge eat in response to difficult thoughts and feelings)

towards the end of treatment, spread appointments further apart and focus on maintaining positive changes and minimising the risk of relapse

if appropriate, involve significant others to help with one-to-one treatment.

This manual organizes CBT into five phases: phase 1 focuses

on exploring problematic behavior, educating patients about

the disorder and the rationale for treatment, and thereby motivating

them by building a reliable working relationship. The focus of phase

2 is on correcting disordered eating behavior and reducing purging

behavior through eating protocols and education about body mass

index (BMI) and the physiological processes associated with eating.

In phase 3, the patient and therapist assess and work on dysfunctional

cognitions and fears concerning eating, weight, and body

shape. In addition to the foci and strategies introduced in phases 1 to

3, phase 4 comprises training in social skills, affect regulation, and

problem solving, as needed, to address the problems underlying and

associated with the eating disorder. The last treatment phase

primarily addresses relapse prevention. Patients’ autonomy and

self-efficacy in regulating eating behavior are stressed, problematic

situations are anticipated, and patients choose skills that they found

helpful during therapy to prepare for these critical situations. In

phases 1 to 4, one or two sessions per phase are held with significant

others, and this is also an option in phase 5.

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Формулировка КПТ

https://www.credo-oxford.com/index.html#topic4

23 of 52

FBT (основанная на семье терапия)

Предположение: Скрытность и чувство стыда, и связанные с ними дисфункциональные привычки в еде негативно влияют на развитие и запутывают и обескураживают родителей.
Порядок действий: Поддерживаем отношения сотрудничества, направленные на изменение поведения, с пациентом и его родителями.
Методы: графики переедания/рвоты, контроль веса, семейные трапезы
Этап 1: Родители взаимодействуют с пациентом, чтобы наладить регулярное питание и прекратить переедания/рвоту
Этап 2: Родители дают пациенту возможность есть самостоятельно, в соответствии с его возрастом
Этап 3: Родители содействуют здоровому развитию личности пациента

Le Grange D, Lock J. Treating bulimia in adolescents: A family-based approach. Guilford Press; 2009 Jun 19.

NICE Guidelines

FT-BN for children and young people with bulimia nervosa should:

typically consist of 18–20 sessions over 6 months

establish a good therapeutic relationship with the person and their family members or carers

support and encourage the family to help the person recover

not blame the person, their family members or carers

include information about: regulating body weight, dieting,

the adverse effects of attempting to control weight with self-induced vomiting, laxatives or other compensatory behaviours

use a collaborative approach between the parents and the young person to establish regular eating patterns and minimise compensatory behaviours

include regular meetings with the person on their own throughout the treatment

include self-monitoring of bulimic behaviours and discussions with family members or carers

in later phases of treatment, support the person and their family members or carers to establish a level of independence appropriate for their level of development

in the final phase of treatment, focus on plans for when treatment ends (including any concerns the person and their family have) and on relapse prevention.

In Phase I, the primary goal is for the parents to re-establish healthy eating in their adolescent and to supervise post-meal time to prevent the occurrence of compensatory behaviours. To be successful, it is crucially important for the parents to work as a team. The adolescent is invited to collaborate in the process. The role of siblings is to uncritically support the adolescent. One of the sessions in Phase I is devoted to a family meal with the therapist that aims to empower the parents in their ability to re-establish healthy eating in their adolescent. Phase II begins only when the adolescent’s eating is normalized. During that second phase, the control of eating is gradually returned to the adolescent, under the parents’ supervision. Phase III starts when the adolescent can eat normally without parental supervision. General (non food-related) adolescent and family issues and termination are then addressed.

Le Grange, Daniel, et al. "Randomized clinical trial of family-based treatment and cognitive-behavioral therapy for adolescent bulimia nervosa." Journal of the American Academy of Child & Adolescent Psychiatry 54.11 (2015): 886-894.

Anderson, Leslie K., et al. "The integration of family-based treatment and dialectical behavior therapy for adolescent bulimia nervosa: philosophical and practical considerations." Eating disorders 23.4 (2015): 325-335.

Family-Based Treatment (FBT) for bulimia nervosa is adapted from FBT for anorexia nervosa and like its predecessor, is designed for adolescents. While there are many types of family therapy, FBT specifically refers to a treatment modality originally developed at the Maudsley Hospital in London, England. FBT for bulimia nervosa is an outpatient intervention typically conducted in 20 sessions over 6 months, although a shorter course is sufficient for some cases while additional sessions may be necessary for others. FBT consists of three phases. In the first phase, parents are placed in charge of helping their child reestablish healthy eating patterns and prevent binge eating and purging episodes from occurring. While this process is collaborative in nature, parental authority is mobilized as necessary in response to the health crisis that the eating disorder poses. The adolescent’s autonomy in other domains (friendships, school) is kept intact, at a level consistent with the patient’s stage of development. In the second phase of treatment, once the acute symptoms have abated and a regular pattern of eating a variety of foods is established, control over eating is returned to the adolescent. The third phase of treatment addresses termination and issues of family structure and normal adolescent development. FBT views the parents of adolescents with bulimia nervosa as a resource for resolving the problem, and corrects misperceptions of blame directed to the parents and to the ill adolescent. Siblings play a supportive role in treatment, and are protected from the job assigned to the parents. The focus of FBT is not on what caused the bulimia nervosa, but on what can be done to resolve this serious disorder.

�Leaving Guilt Behind

A relatively new form of treatment for adolescent bulimia nervosa called Family-Based Treatment (FBT-BN) helps to alleviate the shame, secrecy, and isolation that so often afflict sufferers by encouraging families to discuss and address the illness openly. From the very first session, the clinician emphasizes that parents are not to blame for their teenager’s illness, nor is the teenager herself to blame for having it. This simple but powerful intervention absolves all members of the family of the guilt they have likely been carrying. Once they are freed from their guilt and self-blame, parents and teens can begin working together to overcome bulimia nervosa

In contrast, teens with BN are usually well aware that they have a problem with eating, and they typically present with at least some motivation to stop bingeing and purging. For this reason, FBT-BN empowers parents to work collaboratively with their teenager to interrupt her binge eating and purging.

n Phase I, the therapist empowers the parents to work collaboratively with their teenager to help her establish regular eating patterns and stop bingeing and purging. Re-establishing normal eating typically involves prioritizing balanced, nutritious family meals and supporting the adolescent in eating appropriate portions. The patient’s siblings are encouraged to provide support to their ill sister or brother during and after meals. During this phase, many families find it helpful to engage in family activities, such as walks outside or playing board games, immediately after meals in order to distract the patient from her compulsion to purge.

Phase II begins once the patient is eating normally and is no longer engaging in binge/purge symptoms. At this point, the therapist assists the parents in helping their adolescent eat on her own in an age-appropriate way. This is accomplished gradually, with the teen earning independence little by little as she gains mastery over her eating and demonstrates the ability to refrain from binge eating and purging.

Once the teenager is able to eat normally on her own without bingeing and no longer requires post-meal support, Phase III begins. The goal of Phase III is to help the patient establish a healthy identity and get back on track with typical adolescent development. At this point, any problems that are interfering with normal adolescent development are identified and addressed. For example, if the teenager is experiencing body dissatisfaction, depression, anxiety, or problems with her peers, these issues may be brought to the family’s attention and treated.

Many patients are surprised to learn that their psychological problems, such as depression or anxiety, often improve or even disappear once their eating patterns have normalized. In fact, a recent study demonstrated that adolescents receiving FBT for bulimia nervosa experienced improvements in both depression and self-esteem, comparable to the improvements made by adolescents receiving CBT. However, for some patients, other disorders or mental health concerns persist even after their bulimia has been resolved. In these cases, continued therapy targeting the other condition may be recommended. Fortunately, teens often feel better equipped to deal with their other mental health problems once they have successfully overcome bulimia.

24 of 52

Обычно в «приеме пищи с тренером» нет необходимости
Разрабатывайте стратегии С пациентом
Ведите пациента:

Родители готовят полноценные приемы пищи и перекусы для пациента, и присматривают за его питанием
Родители присутствуют, когда ребенок находится дома
В доме находится ограниченный запас еды
Сейф
Контроль доступа к деньгам
Надзор за ванной комнатой

Стратегии FBT

25 of 52

ДПТ

Интеграция в КПТ: может помочь пациентам, проходящим лечение в стационарах, "ранним слабым респондентам", обучая их навыкам управления эмоциями; комбинирует поведенческие принципы обучения с практикой осознанности и диалектической философией

Интеграция в FBT: обзор семейной карточки-дневника, анализ поведенческой цепочки, план выхода из кризиса, стратегии повышения эффективности межличностных отношений (во время приемов пищи, вызывающих стресс)

Dialectical behavior therapy (DBT) and CBT and FBT are evidence-based interventions that have been applied

in the treatment of bulimia nervosa (BN).

DBT focuses on providing skills for coping with emotion dysregulation

that often co-occurs with BN, CBT and FBT target the normalization

of eating patterns and behaviors. These papers review the conceptual similarities and differences between

CBT and FBT and DBT along with strategies to guide a blended treatment

approach. Given the strengths and limitations of either

independent treatment, DBT and CBT and FBT complement one another

and together can address the range of symptoms and behaviors

typically seen in adolescent BN.

DBT integrated into CBT to improve the outcome of clients with weak initial response treatment. Found to help sustain recovery.

Early weak treatment response is one of the few trans-diagnostic, treatment-agnostic predictors of poor outcome following a full treatment course.

.

Family Diary Card Review

Both FBT-BN and DBT sessions typically commence with a review of symptomatic

behaviors. In an integrated approach, the diary card includes a

record of all target behaviors from the preceding week, and may typically

include dietary restriction, binge-purge frequency, self-harm, and impulsive

behaviors. Parents are encouraged to discuss whether their observations

of behaviors match adolescent reports, and family sessions are structured

according to the behaviors disclosed on the diary card.

Family Behavior Chain Analysis

In DBT, behavior chains are typically used to elicit the sequential steps

preceding engagement in targeted behaviors, paying particular attention to

outlining emotions, thoughts, and actions (Linehan, 1993). In FBT, familywide

sequential analyses are often conducted with a view to identifying

helpful and unhelpful family interactions that may impact target outcomes

(Murray, Wallis, & Rhodes, 2012). In an integrated approach, family-wide

analyses may be used to identify the emotions, thoughts, and actions underpinning

engagement in target behaviors, allowing for the development of

co-constructed alternate points of intervention.

Family Crisis Plan

Patients in DBT typically develop a crisis plan to use when managing intense

urges for impulsive behavior (Linehan, 1993). In integrating the development

of this plan into a family-wide context for target behaviors, family members

are explicitly involved in each step of the crisis plan. Central parental involvement

in this plan allows for a greater degree of accessibility of support for

adolescents, and may provide additional emotional support, validation, and

distraction when needed for the adolescent. For instance, when managing

acute and intense urges to binge or purge, crisis management plans may

encourage adolescents to turn towards parents in assisting with emotional

validation and distraction until urges subside.

Interpersonal Effectiveness Strategies

In DBT, a number of strategies for interacting with people more effectively

are taught to adolescents (Rathus & Miller, 2015). In the context of FBTBN,

using skills can be helpful, particularly around mealtimes when distress

may be most elevated, for both adolescents and family members. Thus, coconstructed

strategies for effective interpersonal communication may assist

parents in effectively intervening into symptomatic behaviors, and may also

help adolescents in accurately conveying to parents how help is required.

Telephone Consultation

Phone coaching to assist in the management of acute emotional crises is a

central feature of DBT, and has been adapted for use with eating disorder

patients (Wisniewski & Ben-Porath, 2005). Additionally with an integrated

approach, the option of phone coaching is extended to parents, who may call

the therapist for assistance in the management of acute emotional crises. This

approach further centralizes and empowers the parents, which is consistent

with FBT-BN, while ensuring that adolescents are able to access swift crisis

management support, which is consistent with DBT.

Parent Training and Contracts

A common occurrence among families in adapting to the presence of

an eating disorder is a reduced range of family interactions, with family

life becoming gradually reorganized around mitigating the eating disorderinduced

anxiety in the afflicted individual (Eisler, 2005). As a result, parental

boundaries may become less firm, as parents often forego calling attention

to ordinary boundary violations in favor of maintaining focus on the extraordinary

circumstances around the eating disorder. From a behavioral learning

perspective, any reduction in natural consequences of problematic behavior,

may serve to inadvertently reinforce the target problematic behavior.

Multifamily Skills Groups

Daniel LeGranges group offers these.

Anderson, Leslie K., et al. "The integration of family-based treatment and dialectical behavior therapy for adolescent bulimia nervosa: philosophical and practical considerations." Eating disorders 23.4 (2015): 325-335.

Chen, E. Y., et al. "An adaptive randomized trial of dialectical behavior therapy and cognitive behavior therapy for binge-eating." Psychological medicine 47.4 (2017): 703-717.

and is highly intensive. DBT was developed for borderline personality disorder (Lieb et al. 2004), and has efficacy for substance use disorders (Linehan et al. 1999, 2002), depression (Lynch et al. 2007; Feldman et al. 2009), bipolar disorder (Van Dijk et al. 2013), BED (Telch et al. 2000, 2001; Safer & Jo, 2010), and BN (Safer et al. 2001). DBT broadly targets emotion dysregulation which is thought to maintain binge-eating and blends behavior learning principles with mindfulness practice and dialectical philosophy.

Murray, Stuart B., et al. "Integrating family-based treatment and dialectical behavior therapy for adolescent bulimia nervosa: preliminary outcomes of an open pilot trial." Eating Disorders 23.4 (2015): 336-344.

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Анализ поведенческой цепочки ДПТ

10:00 вечера: Поведение: рвота; Мысль: Я заслуживаю наказания; Чувство: покой
9:00 вечера: Поведение: обжорство; Мысль: Я так наелся, что болит живот; Чувство: стыд
7:00 вечера: Поведение: изоляция; Мысль: Я не представляю собой ценности; Чувство: отчаяние
5:30 вечера: Поведение: семейное собрание; Мысль: Я всех разочаровываю; Чувство: гнев
10:00 утра: Поведение: работа; Мысль: Все сроки проекта должны быть соблюдены; Чувство: страх
6:00 утра: Поведение: пробуждение; Мысль: Как мне пережить этот день; Чувство: тревога
12:00 ночи: Поведение: сон; Мысль: Я не способен заснуть в разумное время; Чувство: раздражение, рассеянность

�In regards to Bulimia Nervosa, for the sake of this article let’s reduce the multiple causal features often inherent for such disordered behavior to a single lineage. For example, a patient purges at 10:00 pm.

By facilitating a DBT intervention call the Behavioral Chain Analysis (BCA), which reverses in written form, the sequence of events leading to the purge action while identifying the corresponding thoughts and feelings. In treatment, a therapist might discover the following sequential dynamic.

By implementing use of a BCA, the patient can be guided to consider the incremental development through previous behavior with correlating thoughts and feelings, leading to an event of origin such as experiencing poor sleep patterns similar to what has been illustrated above. Having less than adequate sleep affect one’s mood state, memory and their ability to behave in top form.

The experience of poor sleep patterns if habitual combined with stressful events such as a sense of failure, may contribute to an increase in a temperamental sensitivity leaving one vulnerable to impulsive behavior such as a binge episode. Consequently following a significantly large volume binge episode, the subsequent purge episode would reasonably follow suite for a patient who experiences a calming effect from such an action.

Through the use of a BCA, once a patient grasps the concept that their self-care habits and life experiences contribute to various states of emotion regulation or dysregulation, they may choose to learn better ways to manage details such as their sleep habits as a starting point. To gain a more robust foundation from which to improve one’s life, a patient would be taught Mindfulness and Distress Tolerance skills. https://www.eatingdisorderhope.com/dbt-vs-cbt-effective-therapy-for-bulimia-nervosa

10:00 pm: Behavior of Purge; Thought – I deserve punishment; Feeling – calmness

9:00 pm: Behavior of Binge; Thought – I am so full my stomach hurts; Feeling – shame

7:00 pm: Behavior of Isolation; Thought – I am of no value; Feeling – despair

5:30 pm: Behavior of Family gathering; Thought – I disappoint everyone; Feeling – anger

10:00 am: Behavior of Employment; Thought – All project deadlines must be met; Feeling – fear

6:00 am: Behavior of Waking up; Thought – How can I get through this day; Feeling – anxiety

12:00 am: Behavior of Sleep; Thought – I’m not able to get to sleep at a reasonable time; Feeling – irritable, distractible

Using the above scenario, a CBT based approach may initially focus on the thought regarding the action of purging by seeking to alter the corresponding thought of “I deserve punishment.”

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ПЕРЕРЫВ

30 минут

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�План питания �

«Самая эффективная поведенческая интервенция»
«Необходимое предписание»
«Вакцина против РПП»

Внимание! Барабанная дробь

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�Планы питания�

План питания для нормализации обменных процессов у диабетиков https://dtc.ucsf.edu/pdfs/FoodLists.pdf

Используется в большинстве программ по стационарному лечению РПП в США, как в больницах, так и в заведениях домашнего типа
Сложный для осуществления в амбулаторных условиях, как для родителей, так и для пациентов

Моя тарелка http://www.choosemyplate.gov/

Используется в некоторых программах по стационарному лечению РПП в США, в больницах и в заведениях домашнего типа
Много фруктов, поменьше углеводов; используется для контроля веса

Подсчет калорий

В основе всех планов

«Правило Трех» (Herrin, 2013) http://www.eatingdisorderguides.com/HerrinFoodPlan.2013.pdf

3 полноценных приема пищи и до 3х перекусов в день
Обычные порции еды сгруппированы в соответствии с содержанием питательных веществ
Десерты и другая «еда для удовольствия» включены в приемы пищи

The ED field lacks an evidenced-based, standardized food plans.

The Exchange-based system is adapted from as a plan for treating diabetes called the Diabetic Exchanges for Meal Planning, (Geil, 2008), which is a well-accepted method grouping foods according to nutrient & energy content. Serving sizes within food groups are small. For example a moderate protein diet would have 9-12 servings of protein.. Exchange-based plans are usually organized into meals & snacks, or individuals are provided a recommended number of servings per food group per day. It is 7 pages long. Most parents find it confusing.

Only a few programs use the My plate plan developed by the US governing to prevent obesiety. Pictures a plate with 50% of the area devoted to vegetables, 25% for protein and 25% for carbohydrates.

Calorie counting. Difficult to do accurately even with all the apps. Next week we will talk about how calorie needs are very individualzed.

The Rule of Threes system (Herrin & Larkin, 2013) is based on three normal meals & up to three snacks per day. Normal portions of food are grouped according to nutrient content. Desserts & other foods eaten for pleasure are considered a food group and incorporated into meals.

I developed the Rule of Threes system when my early Dartmouth College patients coming from hospital programs and eating disordered clinics told me they hated the exchange system and myplate plans and they didn’t want to count calories.

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План питания, КПТ

https://www.credo-oxford.com/pdfs/T6.2_Patient_handout_on_regular_eating.pdf

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�План питания «Правило трех»�

Регулярные сбалансированные полноценные приемы пищи и перекусы

Еда по часам
Принятие пищи за пределами плана питания не поощряется

Планы питания

3 полноценных приема пищи
0-3 перекуса
Акцент на

Белке
Сложных углеводах
Еде для удовольствия

Адаптируйте к «новым» амбулаторным пациентам

Сотрудничайте с пациентом

Копия Плана: можно дать пациенту, можно не давать

https://marciaherrin.com/rule-of-three-food-plan/

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Еда для удовольствия

Съедается для удовольствия
Сладкая, соленая или жирная
Две порции еды для удовольствия (эквивалент не менее 200–300 калорий на порцию)

Защищает от переедания во время приемов пищи
Экспозиция к еде, которая вызывает страх
«От меня требовалось есть десерты в госпитале - и это помогло мне больше всего, во время лечения»

Эти фотографии неизвестного автора находятся под лицензией CC BY-NC

Patients are most suprpised to see the fun food category. I tell them it is the game changer, the most important strategy to truly overcoming eheir eating disorder., per day help to normalize eating, desensitize to fear foods & protect against overeating. Eating fun foods at the end of the meal puts a natural boundary around the eating episode, i.e., “Fun foods end the meal.” Once dessert is eaten, most normal eaters stop eating, having naturally fulfilled the “I just felt like something sweet & now I am satisfied” feeling. Not surprisingly, in a controlled experiment of binge eat- ers, Gendall, Joyce, & Abbott (1999, p. 312) found that, after meals containing protein, subjects could stop further eating by consuming “sweet-tasting, palatable food.” We say, “You’re probably not going to want to eat more broccoli or mashed potatoes after you have a brownie.”

Gendall, K. A., Joyce, P. R., & Abbott, R. M. (1999). The effects of meal composition on

subsequent craving & binge eating. Addictive Behaviors, 24(3), 305–315.

Coelho, J. S., Polivy, J., & Herman, C. P. (2006). Selective carbohydrate or protein restriction: effects on subsequent food intake & cravings. Appetite, 47(3), 352-360.

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При активных формах расстройств пищевого поведения не применяется

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�Работаем с перееданием�

Обычно стремимся к стабилизации веса / к постепенному набору веса при недостаточном весе
Регулярные полноценные приемы пищи
Перекусы?
На основе питания в настоящий момент
Безопасные продукты
Максимально удовлетворяйте потребность в питательных веществах

Начинаем с

Подробное планирование, обсуждение с другими домашними, дневник питания - заполняется «в режиме реального времени»
Триггерные продукты возвращаются в рацион постепенно и запланированно
Найдите занятия, которыми можно заменить объедание

Поддерживаем с помощью

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�Методы плана питания при переедании �

Планы питания

3 приема пищи
0-3 перекуса
2 порции «еды для удовольствия» в составе приемов пищи

Вернитесь к плану питания

Съешьте следующую запланированную пищу или перекусите

A number of studies show that that most direct cause of binge eating in BN and BED is dietary restraint (Lowe, Thomas, Safer, & Butryn, 2007). Nearly all binge-eating patients enter treatment with a strong desire to lose weight but are profoundly discouraged about their prospects for recovery. Many are perfectionistic and have attempted multiple times to abstain from bingeing only to experience relapses that further erode their confidence. They are ashamed of their eating behaviors and suffer extreme body dissatisfaction and they are trying to diet.

The patient desperately wants help with bingeing. Can’t work on that until you are following a food plan! Assume first and foremost that binge eating is primary triggered by dietary restriction, calories, variety, fun foods

------

Binge eating is defined as eating unusually large amounts of food while experiencing a sense of loss of control over the eating. Patients who binge eat may have a diagnosis of AN, BN or BED. Some are overweight or obese and some not. Binge eating found in over 60% of AN patients delays or inhibits full recovery (Tenconi, Lunardi, Zanetti, Santonastaso, & Favaro, 2006). Entrenched AN, especially if BMI is less than 17.5, almost always includes bouts of binge eating (Lowe et al., 2011). Patients are often oblivious to the potentially immense caloric contribution of a binge. In one study, binges averaged between 1,000 to 2,500 calories per episode, with the largest recorded at 10,500 calories (Alpers & Tuschen-Caffier, 2004). Binges have been differentiated into subjective and objective binges, as both types of binges can result in the compunction to purge. Subjective binges have been tentatively defined as less than 500 calories per episode (Wolfe, Baker, Smith, & Kelly-Weeder, 2009). Some of our patients find this distinction helpful in decreasing purging: “This isn’t really a binge so I don’t have to purge.” Loss of control is assessed by asking, “Did you have a sense of loss of control at the time?” “Could you have stopped eating once you had started?” “Could you have prevented the episode from occurring?” (Wolfe et al., 2009).

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Работаем с искусственной рвотой

Адекватное потребление пищи, чтобы предотвратить переедание

При необходимости, маленькие порции, для предотвращения сытости
Избегайте триггерных продуктов

Поведенческие интервенции

Отложите, отвлекитесь и решите
Навыки стрессоустойчивости

Скользите по порывам, как в серфинге

Переучивание приобретённой реакции на триггерные продукты

Сидя в той же комнате / понюхать / лизнуть / попробовать и выплюнуть триггерную еду (например, шоколад)

Most important is to prevent purging is to, eat enough and often enough to prevent bingeing. At the beginning avoiding foods that trigger purging. I keep a list of these foods as patients mention them and let them know we will work on them later in treatment by incorporating them into food plans or food assignment.

CBT strategy of Delay, distract, decide

Delay the decision to give in to the craving for a set time – 5, 10, 30 or 60 minutes. The craving will pass!

I will delay for (write down number of minutes)

Distract

Do something that will occupy your thoughts and grab your attention. Perhaps do something physical to use the energy of the craving.

List the Things you could do, and how long you will do them for:

After delying and distracting, Decide

After the set time, decide not to do whatever the craving wants you to do (the unhealthy or addictive habit you want to stop doing). Remind yourself of all the...

Advantages of not doing it:

If the patient isn’t successful, focus on the strategies they did well, figure out together what didn’t work and why and revise the plan

�DBT strategies of distress tolerance.

Surfing the urge is effective for purging. Imagine that urges are like ocean waves that arrive, crest and subside. Surfers have to trust that the waves will eventually get smaller and reach the shore even when the waves feel large and overwhelming.

Some facts about urges

Urges rarely last longer than 30 minutes if you don’t “reinforce” them by ruminating, giving them attention, planning to fulfill them, justifying, etc. Urges will pass on their own if we allow them to.

Suppressing a thought, feeling or sensation ultimately increases the urege

When urges grow, it can feel like they are never-ending until you give in to them.

This is when you learn to detach from the actual urge and ride the wave without reacting to it. There are many coping skills to use during this step. The easiest one to turn is deep breathing. This helps relax your central nervous system and “ready” you to ride the wave..

3. Have a Plan: Create a plan of what you can do to help you ride the urge out. It might be leaving your kitchen (this is a must in the beginning), going for a walk, taking a relaxing bath or journaling.

For most people the urge to binge lasts about 20-30 minutes. The urge will have a peak (just like a wave) where it feels the strongest and then will start to dissipate.

Knowing this is very empowering and helps you feel like you have some control over the situation. Have a plan of what you can do for 20 minutes to help ride out the urge. Write out the plan on an index card, along with some affirmation that resonate with you. Tape the index card on your fridge, bathroom mirror, or in your car. Identify spots where the binge is most likely to rise and have your plan ready for you to view.

4.Finish Urge Surfing: Once the urge has passed reflect on what helped you surf it in a journal. What worked? What didn’t work so well

Retraining learned response to trigger foods (delete in next version)

One method to desensitize patients to trigger food is being able to be in same room as their trigger food or you may get them to taste and spit out the trigger food. I find that these methods can backfire if the patient is actually depriving themselves of these foods. I am more likely to suggest that the patient plan to eat a trigger food as part of meal with plenty of support and to do it regularly, 3 x week.

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Искусственная рвота: фактическая информация

Среднее потребление калорий во время эпизодов приема пищи с последующей рвотой составило 1331 ккал, при таком распределении макронутриентов: 51% углеводов, 36% жиров и 14% белков (Alvarenga, 2003)
После рвоты сохраняется 1200 калорий, независимо от того, было ли переедание относительно небольшим (1200 калорий) или значительным (3500 калорий) (Kaye, 1993; Bo-Linn, 1983)

Хотя бы минимум питательных веществ усваивается

Неизвестно, как влияет злоупотребление мочегонными на всасывание калорий или питательных веществ
Слабительные снижали всасывание питательных веществ всего на 12%

Скорее всего, потери питательных веществ будут минимальными

«Вы склонны к частой рвоте?»

Kaye, W., Weltzin, T., Hsu, L., McConaha, C., & Bolton, B. (1993). Amount of calories retained after binge eating and vomiting. American Journal of Psychiatry, 150(6), 969-971.

Bo-Linn, G. W., Santa Ana, C. A., Morawski, S. G., & Fordtran, J. S. (1983). Purging and calorie absorption in bulimic patients and normal women. Annals of Internal Medicine, 99, 14-17.

I discuss the research on the amount of calories retained after purging in detail, patients usually find the information about very compelling such as the typical binge is about 1300 calories and the body in its wisdom keeps 1,200 calories whether the binge was relatively small (1,200 calories) or large (3,500 calories). It is unknown how many calories are retained from normal-sized meals and snacks that are purged, but it is logical to assume that up to 1200 calories are preserved as well.

The fact that frank nutrient deficiencies are rarely, if ever found, in bulimic patients suggests that at least a minimum amount of nutrients are also absorbed though this has not been studied. I. Some patients counter with “well what about the potassium all my doctors are worried about.” Yes, some is lost in vomiting, but most of it is lost in urine as the body tries to maintain acid-base balance that is thrown off by frequent vomiting.

Patients are quite interested when I tell them that a 1,200-calorie diet if very well chosen provides just barely provides the minimum of nutrients necessary for life. Isn’t fascinating that 1200 caloreis exactly the calories that the body holds on to when vomiting and that this is about the same calories as is in a typical binge. This proves yet again how the body is always trying to survive.

But Patients will say, I am sure I lost weight when I first started to purge. At first it seemed that I have discovered this amazing trick that finally I can eat what and much as I want and not gain or usually lose weight. And I feel so empty after purging. I usually eat marker foods first (e.g., carrots, tomatoes, corn)

purging until I see remnants of the marker food. One of my patients said

that after bingeing in the afternoon, she purges until she can see some evidence

of food she ate for breakfast in her vomitus. “Then I know I have got it all up.”

I say I hear that from a lot of patietns. I wish we had studies on how this works for new bulimics but it would be unethical to have study subjects who have never purged to be in a purging study. All the purging studies used experienced bulimics as subjects.

My clinical guess, I tell them, is that at first the is fooled by the purging and it actually works, you do lose calories.. but then the body adapts because it assumes the tribe has to deal with bad water or something similar so and the body adapts and develops the ability to extract calories and nutrients from the food eaten and encourages one to eat a lot just in case. I tell them that the distinct feeling of emptiness after purging seems to be just a passing phenomenon. And that because the stomach’s function is to mix and liquefy food;

whatever food is eaten first, does not necessarily come out last.

I talk about the Research shows that self-induced vomiting, laxatives and diuretics and even high amounts of exercise are relatively

ineffective in eliminating consumed calories. Often the patient wants to see the studies which I am happy to send them and will send to you if you want them. I also refer to the studies about weight and bulimia. That The BMIs of individuals with bulimia nervosa are generally in the normal or high normal range. A number of studies show that patients who binge and purge eventually gain weight, and do not lose weight until they abstain from purging (Carter, Mcintosh, Joyce, Gendall, Frampton, & Bulik, 2004) And after 5 years of bulimia, 25% of [patients who started with a healthy BMI ended up with a BMI in the overweight category..

Add Addicted to the high of purge. Don’t see much mention of this is the clinical research literature, but I hear it often form patients about the high and then the calm that follows a typical binge purge episodes. Have any of you heard this from your pateints? Best I can find in the literature is a nice study by Pamela Keel published in 2011 study Negative affect is greater prior to binge eating, increases following binge episodes, and then decreases after purging. ,

Meta-analyses examined changes in affect before and after binge eating using within-subjects standardized mean gain effect sizes (ES). Results supported greater NA preceding binge eating relative to average affect (ES = .63) and affect before regular eating (ES = .68). However, NA increased further following binge episodes (ES = .50). Preliminary findings suggested that NA decreased following purging in Bulimia Nervosa (ES = −.46). Moderators included diagnosis

Finally, although binge eating does not appear to be reinforced by post-binge reductions in negative affect, it is possible that episodes are positively reinforced by increases in positive affect related to the hedonic aspects of eating highly palatable foods (e.g., Small, Jones- Gotman, & Dagher, 2003). This has not been a central tenet of the affect regulation model for binge eating and was explored in only seven EMA studies. Results of these studies suggested that positive affect decreased after binge eating episodes (see Footnote 3). However, this result does not rule out the possibility that positive affect increases during a binge episode. Given the small number of studies, the role of positive affect in triggering and maintaining binge episodes represents an underdeveloped aspect of the literatur

-----------

Haedt-Matt AA, Keel PK. Revisiting the affect regulation model of binge eating: a meta-analysis of studies using ecological momentary assessment. Psychological bulletin. 2011 Jul;137(4):660.

Kaye, W., Weltzin, T., Hsu, L., McConaha, C., & Bolton, B. (1993). Amount of calories retained after binge eating and vomiting. American Journal of Psychiatry, 150(6), 969-971.

Bo-Linn, G. W., Santa Ana, C. A., Morawski, S. G., & Fordtran, J. S. (1983). Purging and calorie absorption in bulimic patients and normal women. Annals of Internal Medicine, 99, 14-17.

Hudson JI, Hiripi E, Pope HG, Kessler RC: The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry 2007; 61:348–358 Crossref, Medline, Google Scholar

Carter FA, McIntosh VV, Joyce PR, Gendall KA, Frampton CM, Bulik CM: Patterns of weight change after treatment for bulimia nervosa. Int J Eat Disord 2004; 36:12–21.

Palavras MA, Hay P, Claudino A. The efficacy of psychological therapies in reducing weight and binge eating in people with bulimia nervosa and binge eating disorder who are overweight or obese—a critical synthesis and meta-analyses. Nutrients. 2017 Mar;9(3):299.

Hudson JI, Hiripi E, Pope HG, Kessler RC: The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry 2007; 61:348–358 Crossref, Medline, Google Scholar

Carter FA, McIntosh VV, Joyce PR, Gendall KA, Frampton CM, Bulik CM: Patterns of weight change after treatment for bulimia nervosa. Int J Eat Disord 2004; 36:12–21.

Palavras MA, Hay P, Claudino A. The efficacy of psychological therapies in reducing weight and binge eating in people with bulimia nervosa and binge eating disorder who are overweight or obese—a critical synthesis and meta-analyses. Nutrients. 2017 Mar;9(3):299.

To make these points, we often email or give patients copies of relevant research articles. When we discuss the research on the amount of calories retained after purging in detail, patients find the information about very compelling. Kaye, Weltzin, Hsu, McConaha, and Bolton (1993) found that 1,200 calories are retained after SIV whether the binge was relatively small (1,200 calories) or large (3,500 calories). It is unknown how many calories are retained from normal-sized meals and snacks that are purged, but it is logical to assume that up to 1200 calories are preserved as well.

Our patients are quite interested when we tell them that a 1,200-calorie diet if very well chosen provides the bare minimum of nutrients necessary for life and that is exactly the calories that the body holds on to when vomiting is self-induced and that this is about the same calories as is in a typical binge. The body is always trying to survive.

I make a point of providing patients with facts that counter the belief that

purging protects against weight gain.. The BMIs of individuals with bulimia nervosa are generally in the normal or high normal range. At 5 years, 24% of patients fell into the overweight range (BMI=25–29.9), although mean BMI had been in the healthy range at baseline (BMI=22.7, SD=2.7).

Patients who have gained weight as a result of their bulimia lose weight when they stop binge eating (Agras & Apple, 1997, p. 42). We know that binges are bigger when the person knows they are going to purge. They may even it more to make it easy to purge.

We also know that purging does not guarantee weight loss or empty all stomach contents.

The distinct feeling of emptiness after purging is just a passing phenomenon.

Some patients eat highly colored marker foods first (e.g., carrots, tomatoes, corn)

purging until they see remnants of the marker food. One of my patients said

that after bingeing in the afternoon, she purges until she can see some evidence

of food she ate for breakfast in her vomitus. “Then I know I have got it all up.”

Herrin responded that because the stomach’s function is to mix and liquefy food;

whatever food is eaten first, does not necessarily come out last. Even when we

share relevant information and research studies with patients, many do not accept

this data on face value.

I talk about the Research shows that self-induced vomiting, laxatives and diuretics and even high amounts of exercise are relatively

ineffective in eliminating consumed

The BMIs of individuals with bulimia nervosa are generally in the normal or high normal range. At 5 years, 24% of patients fell into the overweight range (BMI=25–29.9), although mean BMI had been in the healthy range at baseline (BMI=22.7, SD=2.7).

Hudson JI, Hiripi E, Pope HG, Kessler RC: The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry 2007; 61:348–358 Crossref, Medline, Google Scholar

Carter FA, McIntosh VV, Joyce PR, Gendall KA, Frampton CM, Bulik CM: Patterns of weight change after treatment for bulimia nervosa. Int J Eat Disord 2004; 36:12–21.

Palavras MA, Hay P, Claudino A. The efficacy of psychological therapies in reducing weight and binge eating in people with bulimia nervosa and binge eating disorder who are overweight or obese—a critical synthesis and meta-analyses. Nutrients. 2017 Mar;9(3):299.

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�Managing Purging�

News Flash

Stomach rupture
Swallowing a toothbrush
Russell’s sign
Chipmunk cheeks
Bad teeth
Weight gain

Рвота не избавляет

Вас от калорий!

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Риски искусственной рвоты

Обучение психологической самопомощи

Разрыв желудка
Проглатывание зубной щетки
Признак Рассела (мозоли на суставах пальцев или тыльной стороне кисти)
Щеки бурундука
Плохие зубы
Увеличение веса

Psychoeducation regarding the harmful effects of purging and the futility of relying on purging to manage weight can be motivating enough for some patients to stop purging behaviors (Vanderlinden, Norré, & Vandereycken, 1992, p. 92). A good number of patients are unaware that purging can be life threatening and is ineffective in eliminating consumed calories.

Patients who are symptom-free feel immune to the consequences of purging; repeated warnings are usually ineffective in motivating behavior change.

Nevertheless, all patients should be informed about the potential health risks. As I have years of clinical practice, I have many stories of other patients’ experiences to help make our points about the dangers of purging. The dramatic story of Jenny who binged on a large batch of cookie batter is a favorite. After trying without success to purge, the batter expanded in the warmth of Jenny’s stomach. Her father, a physician, knew she had to be rushed to the hospital to have her stomach pumped before it ruptured.

�Sasha a graduate student in Engineering, like many other patients had a weak gag reflex as a result of chronic self-induced vomiting. We describe the weak gag reflex as “a door opened too many times the wrong way.” As a result, Josie, like others resorted to using elongated objects (toothbrushes, spoons) in an increasingly vigorous effort to self-induce vomiting; the toothbrush she swallowed subsequently needed to be surgically removed.

Dental complications are also at the top of the list of appearance concerns. Patients should be advised that as long as they vomit regularly, tooth enamel will remain soft and ---susceptible to erosion. Good advice is to wait several hours after consuming acidic foods like raw fruit or fruit juice before brushing.

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Стратегии

Запланированное обжорство/рвота
Перед перееданием / искусственной рвотой нужно….
Ограниченное количество раз в день
Определение времени и места

«Тунцовое» решение

«Пакет обжорства»

«Деньги на переедание»

«Сейф»

Behavioral Strategies

A number of tactics have been developed to manage the various problems patients are likely to encounter as they work at controlling binge eating. It should be noted that even though these strategies are often effective, few of them are likely to be practiced by normal eaters. These behavior strategies, therefore, should be used prudently and targeted at specific problems, but never at the expense of efforts to normalized food behaviors.

For some patients, the paradoxical approach of programming binges is necessary to achieve a decrease in binge-eating behavior. This approach allows patients to experience success because controlling binge-eating behaviors is usually more feasible than eliminating them altogether. Programmed binges designate the amount and kind of food and times and places, days patients are allowed to binge.

For patients who are incapable of abstaining from bingeing, we also have had patients pick three to four things they must do before allowing themselves to binge.. Still another approach is to suggest patients pick the amount of time they know they can delay before bingeing. For example, wait five to ten minutes, and then longer spans of time, before bingeing. Patients who are bingeing multiple times a day may be able to agree to limit binges to once a day. Other patients may be able to promise to binge every other day in the afternoon, but not in the evening. Designating certain times and places for bingeing is productive. For example, only allowing binge eating if the patient is seated at the kitchen table can be helpful for those who previously binged in bed or sitting in the living room watching television. A specific intervention that many of my patients have found helpful is the “tuna solution.” Patients are instructed to keep cans of tuna available and to eat one can “straight up” (i.e. no bread, crackers, mayonnaise) before they allow themselves to binge. This dose of nearly pure protein reduces biologically urges to binge and as many patients have reported, “I realized that I didn’t want to binge badly enough to do the tuna solution first.”

We occasionally suggest patients to prepare a “binge bag” which is stored in the trunk of the car. Patients are instructed to buy and store in the binge bag 20 dollars of any food. Younger patients can be given an allowance to buy their binge foods; they may keep money they do not spend on binge foods to use as they please. This approach can help ease family tensions that naturally arise when a family member binges regularly. Some patients benefit from a firm approach in which they or their parents make the kitchen off-limits, outside of specified times. Putting binge-provoking foods in a locked cabinet or box helps some patients avoid problems. Some families find that going as far as locking the refrigerator or kitchen is necessary. When such extreme measures are deemed necessary, the possibility that the patient may benefit from higher-level treatment should be considered. Restricting access to money can help decrease the size and frequency of bingeing. We encourage patients to buy themselves something “nice” with the money that would have been spent on binge foods.

We instruct patients who binge because of unpleasant feelings, such as loneliness, restlessness, boredom, anxiety, and the like to substitute other actibities for bingeing. For example, if the patient is lonely, she or he should arrange to be in the company of others or phone a friend. With a touch of humor, we commiserate with patients that very few alternatives are truly incompatible with eating though we have found that knitting, woodworking and oil painting to be just such activities. We help our patients formulate a personalized list of pleasurable, simple, and distracting activities or provide them with a list of alternative activities others have found helpful. We also work on pre-empt binge-eating behaviors by suggesting a commitment to engaging in an alternative activity at specified times of the day. I admit that none of these alternatives will have the zing of a binge purge episode, but also doesn’t have the down sides.

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Работаем с позывами к перееданию /рвоте

Отложите, отвлекитесь и решите (https://www.getselfhelp.co.uk/docs/3Ds.pdf)
Навыки стрессоустойчивости
Формулировка: посмотрите, что приводит к эпизодам переедания / искусственной рвоты
Обучение психологической самопомощи
Постарайтесь создать благоприятную обстановку для поддержания у них стабильного настроения – используйте аббревиатуру HALT (Hunger, Anger, Loneliness, Tiredness) - голод, гнев, одиночество, усталость
Избегайте рискованных ситуаций и триггеров
Затем можно сосредоточиться на других триггерах, касающихся незапланированного приема пищи

Could skip this slide.

This slide is a review. The tools and techniques for managing bingeing and purging are basically the same. The pdf listed here is a nicely done handout for the delay, distract & decide.

The CBT technique of developing a formulation of the problem with the patient increases patient awareness of what is maintaining the problem.

These acronyms work better in English HALT acronym is widely used in treatment of bulimia though it was developed to treat alcohol abuse.

HALT means STOP, so when you feel yourself about to tuck into food, immediately say the words HALT through you head, it stands for the following:

InstructionsStep 1

H = Hungry�Before you binge ask yourself: ‘Am I really hungry?’, If you are not hungry but you feel yourself reaching for food then chances are you are about to eat for another purpose.

Step 2

A = Anxious some use Anger�Research has shown that stress can increase our appetite. When you are about to eat ask yourself if you are feeling stressed or anxious, is this driving you to eat?

If you are anxious then try to do something that relaxes you like going for a walk, painting, taking a hot back or even doing a short breathing exercise. Once stress and anxiety are reduced you should notice a significant decline in binge urges.

Step 3

L = Lonely�Loneliness can cause binging; the reason is that food is used as a comfort and distraction from feeling alone. When you are about to binge ask yourself, "Am I lonely? If you think you are, think of something that you can do to help combat your feelings of loneliness, like calling a friend, emailing your support buddy, tracking your progress, writing your own story, writing a letter to someone, or visiting a relative.

Step 4

T = Tired�Sometimes we can confuse tiredness with hunger, and research shows that we receive a boost of the hormones responsible for hunger when we don't get enough sleep. So when you know you are tired or not quite as alert as you normally are, it is important to check if you are hungry or simply sleepy.

Tips & AdviceOther common triggers for "false hunger" and binge urges are things like boredom, stress, unstructured time and any situation or experience that heightens your emotions.

DBTSTOP Stop. When you feel that your emotions seem to be in control, stop! Don't react. Don't move a muscle. Just freeze especially those muscles around the mouth

You would also try to keep the environment conducive to keeping their mood stable – and it is helpful to use the HALT acronym. Then you can focus on ones in terms of unplanned eating.

Perfect time to use the skill:

S is for Stop. Literally freeze and do not do anything, instead of just reacting as we often do.

T is for Take a step back (maybe even 2 or 3). This is going to put some physical distance between you and what triggered you, maybe even take a deep breath. Once you’ve done this, move on to…

O, which is for Observe. When you take a step back from something, your field of vision changes, you can see more of your environment and take in more information. What is happening around you AND within you? Maybe you’ll see someone bumped into you because someone bumped into them. Maybe they have a bunch of bags they are carrying. Maybe they have mobility issues. Maybe they have kids with them and they are trying to manage some difficult behaviors.

Either way, you’re observing things you wouldn’t have observed if you had just immediately reacted. Don’t forget to observe within yourself too.

How are you feeling?

What are the thoughts going through your head right now? “I feel anger,” “I’m reacting strongly,” or “I’m having a thought that I can’t believe this!” Just notice those things and maybe you can challenge them. Lastly…

P is for Proceed Mindfully. In taking advantage of the space and information you gained from the first 3 steps, make an intentional choice about what to do. Maybe you shrug it off, maybe you have some empathy, maybe you are just less annoyed than when it first happened. There is a special kind of satisfaction that comes with knowing you used a skill effectively to get through a situation. “Hey, I was able to use that STOP skill and I reacted differently than I usually would, I didn’t make anything worse!”

Like most things, this is easier said than done, so practice it when nothing is wrong. Then, when you do need the skill, you can more easily reach for it. You don’t want the first time you’ve tried it to be when you’re in distress. Just imagine a situation, maybe do this with kids too, where you go through each step, or do it with your phone or computer, preparing for those inevitable times when you get an email or text that upsets you. With kids or yourself you can also just use visual guides as reminders, drawing, or putting up a picture of a stop sign perhaps.

�

42 of 52

�Самомониторинг�

Соответствующий пациенту
Идея пациента
Разгадывайте загадки
Предлагайте решения
Смотрите на них!
Бороться не стоит

Предоставьте раздаточные материалы: Анкеты, блокноты, наклейки https://www.getselfhelp.co.uk/docs/FoodDiary.pdf
Дневник выздоровления «Recovery Record»

www.recoveryrecord.com

Воины восстановления «Recovery Warriors»

www.recoverywarriors.com

, our experience shows self-monitoring (via food journals) is only effective if the patient is interested and able to devote time to journaling. Self-monitoring, we point out, provides valuable information about eating problems, making clear binge patterns and triggers, and allows the nutrition counselor to play detective looking for clues to solutions to binge-eating episodes. We also mention that self-monitoring immediately after bingeing makes it less likely that one will dissociate and are more likely to have smaller binges. Patients tell us that just knowing that their nutrition counselor is going to look over their food journal keeps them “on the straight and narrow” and fosters their commitment to follow a food plan. In addition, reviewing journals give the nutrition counselor occasion to provide much needed encouragement to demoralized patients. We make the point of commending patients for completing journals and for any and all constructive behaviors. We discuss with patients how shame about binge-eating behaviors can make self-monitoring difficult while emphasizing that to overcome binge eating, behaviors must be faced head on.

For self-monitoring to be effective, it is important that the patient is both committed to the recovery process as well as interested in using the technique. We assess the patient’s willingness to engage in keeping food journals as monitoring can be time-consuming and can feel irrelevant. ?” We query about any negative past experiences with keeping food records and reassure patients they do not have to keep food journals; we let them make the choice.

If food journals are prescribed, we spend significant time reviewing them early in each session. An effective opening question is, “What did you learn from doing food records this week?” Or, “Walk me through your week using your food journals.” “What worries you?” “Where do you see that you need some assistance?” Ideally, patients rather than counselors do the work of looking for patterns and “causes and effects” in food records. Until the patient is monitoring proficiently, we show more interest in the adequacy of the monitoring than in the patient’s actual food behaviors. Fairburn, Marcus, and Wilson (1993, p. 371) remind practitioners that the quality of a patient’s monitoring is directly related to the degree of attention that the practitioner pays to food records.

Very important that if the patient is doing self monitoring that the records are reviewed in sessions. As I have mentioned earlier, self-monitoring is not worth fighting about. Review records at beginning of each session.

HERRIN:

Still helpful if done at the end of day.

Appreciate how much work they are.

Look at the them with the patient. Touch them

43 of 52

Ключевые символы

Без переедания /рвоты

План питания соблюден

44 of 52

Домашняя работа

Главная роль в достижении изменения поведения

Назначается в конце каждой сессии
Дополнения к плану питания
Попробуйте новое реагирование на ситуации (как эксперимент)
Записи о еде
Страхи, связанные с едой
О тренировках
Литература для чтения

Библиотека с выдачей книг на дом

45 of 52

Выздоровление

Выздоровление = воздержание от переедания и искусственной рвоты

28 дней
3 месяца
1 год постоянного клинического контакта и поддержки

Быстрое реагирование прогнозирует восстановление

3 эпизода в первые 4 недели

Улучшение результатов

Ранняя интервенция
Лечение сопутствующих заболеваний
Многоуровневая система лечения
Комбинированные подходы
Решение проблемы подавления веса

50-60% пациентов НЕ УДАЕТСЯ добиться полного воздержания после научно обоснованного лечения

Recovery from Bulimia is usually defined as abstinence for a month, 3 month. I look at providing some sort of clinical support for a year after abstiance achieved

.

Only reductions in binge purge episodes to 3 episodes in the first four weeks of treatment predicted sustained remission (versus relapse) at 6- and 12-month follow- up. These findings provide an empirically derived definition of RR to intensive eating disorder treatment, and provide further evidence that early change is an important prognostic indicator.

Other predictors of good outcomes are

Early intervention, not waiting to get treatment until the bulimia has become a lifestyle.

Stepped care in treatmnting

Skills in emotion regulation which supports DBT inclusion in CBT

Stepped care in adolescents start with CBT if not successful, then FBT

WE w

-----------

MacDonald DE, Trottier K, Olmsted MP. Rapid improvements in emotion regulation predict intensive treatment outcome for patients with bulimia nervosa and purging disorder. International Journal of Eating Disorders. 2017 Oct;50(10):1152-61.

Individuals with eating disorders who rapidly improve their belief that they can effec- tively modulate negative emotions are more likely to achieve a variety of good treatment outcomes. This supports the formal inclusion of emotion regulation skills early in CBT, and encour- aging patient beliefs that these strategies are helpful.

Linardon J, Wade TD. How many individuals achieve symptom abstinence following psychological treatments for bulimia nervosa? A meta‐analytic review. International Journal of Eating Disorders. 2018 Apr;51(4):287-94.

Abstinence estimates were highest in trials that used behavioral-based treatments (e.g., cognitive–behavioral therapy, behavior therapy). There was also evidence that guided self-help interventions produced the lowest post-treatment abstinence rates, but with no difference at follow-up from clinician-led treatments, and studies that used a shorter timeframe for defining abstinence (i.e., 14 days symptom-free com- pared to 28-days symptom-free) produced the highest abstinence rates. Abstinence estimates at follow-up for both the completer (34.6%; 95% CI 5 29.3, 40.2) and intention-to-treat (28.6%; 95% CI 5 25.1, 32.3) analyses were essentially the same as the post-treatment estimates.

Discussion: Over 60% of patients fail to fully abstain from core BN symptoms even after receiving our most empirically-supported treatments. The present findings highlight the urgency toward improving the effectiveness of psychological treatments for BN.

Hail L, Le Grange D. Bulimia nervosa in adolescents: prevalence and treatment challenges. Adolescent health, medicine and therapeutics. 2018;9:11.

Bulimia nervosa in adolescents: prevalence and treatment challenges

Lisa Hail and Daniel Le Grange

Additional article information

Abstract

Bulimia nervosa (BN) is a serious psychiatric illness that typically develops during adolescence or young adulthood, rendering adolescents a target for early intervention. Despite the increasing research devoted to the treatment of youth with anorexia nervosa (AN) and adults with BN, there remains a dearth of evidence for treating younger individuals with BN. To date, there have been four published randomized controlled trials comparing psychosocial treatments, leaving significant room to improve treatment outcomes. Family-based treatment is the leading treatment for youth with AN, while cognitive-behavioral therapy is the leading intervention for adults with BN. Involving caregivers in treatment shows promising results, however, additional research is needed to investigate ways in which this treatment can be adapted further to achieve higher rates of recovery.

Keywords: eating disorders, youth, family-based treatment, cognitive behavioral therapy, psychodynamic therapy, psychopharmacological treatment, evidence based treatment

Introduction

Eating disorders (EDs) are serious psychiatric illnesses that typically develop during adolescence or young adulthood. These disorders are associated with both physical and psychological sequelae and often lead to considerable impairment and distress.1 The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM)2 recognizes eight feeding disorders and EDs, including bulimia nervosa (BN), anorexia nervosa (AN), and subthreshold presentations that are classified under unspecified feeding or ED. While the field has advanced the understanding of treatment approaches for adolescents with AN and adults with BN in particular, evidence to guide the treatment of BN in youth lags behind.

Diagnosis of BN

BN is characterized by recurrent episodes of eating an objectively large amount of food (ie, binge) with an associated loss of control, as well as inappropriate compensatory behavior (eg, self-induced vomiting, misuse of laxatives or diuretics, fasting, or excessive exercise) and overvaluation of shape and weight.2 In the current edition of the DSM, these episodes of binge eating and compensatory behavior must occur at a minimum frequency of once per week over the course of 3 months. In the DSM-IV-TR, the minimum frequency of these episodes of binge eating and compensatory behavior was double (ie, an average of twice per week).3 In studies comparing full and subthreshold presentations of DSM-IV BN, those individuals who were subthreshold reported significantly more subjective binge episodes in which they experienced a loss of control but did not consume an objectively large portion of food.4 Purge frequency across both groups was similar, suggesting that the experience of losing control may be more salient than the amount of food consumed.4 Diagnostic crossover is relatively common, especially among youths, with many who initially present with subthreshold presentations progressing to meet full diagnostic criteria for BN or less commonly AN.4,5 This diagnostic fluidity suggests that clinical management should not differ between sub- and full-threshold BN.

Traditional diagnostic approaches rely on the self-report of symptoms by the patient. While the low body weight characteristic of AN makes it more outwardly visible, AN is considered an ego-syntonic illness, such that it is consistent with the self-concept of the sufferer, making them less open to treatment.5 Conversely, BN is considered ego-dystonic and aversive to the patient, yet shame and secrecy often inhibit disclosure of symptoms and seeking treatment. In younger populations, developmental concerns, such as the ability to endorse such conceptual symptoms as “undue influence of weight and shape” may further impact the ability to diagnose full-threshold EDs in adolescents.4

The positively skewed distribution of age of onset of EDs, including subthreshold presentations, renders adolescents a target for screening and early intervention before symptoms become severe and enduring,5 and research has supported that early intervention is associated with the most promising treatment outcomes.6 Increasing research has been devoted to the treatment of AN in adolescence, with an increasing number of studies published demonstrating considerable support for family-based treatment (FBT) approaches.7 To date, evidence to guide the treatment of BN in adolescents is limited, with only four published randomized controlled trials (RCTs) of psychological treatments and one open medication trial.8–11

Prevalence

Many population-based studies have focused on youths who meet full-threshold criteria for an ED without reporting on the cases who may have clinically significant presentations, but fall below the diagnostic threshold.1 In adults, the prevalence estimates of full-threshold BN are 1%–1.5%,2,12 with 0.1%–2% in youth.13 However, community studies that evaluated disordered eating behavior rather than applying strict DSM criteria found far greater prevalence (ie, 14%–22%) than those applying strict criteria.1,14

In an attempt to estimate the occurrence of EDs in US adolescents better, Swanson et al utilized data from the National Comorbidity Survey replication adolescent supplement.1 These data collected via face-to-face interviews included a representative sample of 10,123 youths aged 13–18 years. The World Health Organization Composite International Diagnostic Interview was used to assess DSM-IV psychiatric disorders, including AN, BN, and binge ED, based on the diagnostic algorithms used with adult populations. Sufficient information was gathered to assess subthreshold presentations of AN using a less stringent weight criterion (ie, less than 90% of median weight for height rather than 85%) and subthreshold binge ED. However, the survey did not include sufficient information to report on subthreshold presentations of DSM-IV BN, such as those who did not meet the duration or frequency criterion or those who experienced only subjective binge episodes.1

In the USA, the median age of onset for DSM-IV BN is quite young: 12.4 years (interquartile range 11.1–13.5 years).1 Within the sample, the lifetime prevalence rate of BN was 0.9% and 12-month prevalence 0.6%. Of adolescents with BN, 41.3% reported purging, while the rest met criteria based on nonpurging compensatory behaviors (ie, excessive exercise, fasting).1 With revised diagnostic criteria reducing the frequency of binge eating and purging from twice per week over 6 months to once per week over 3 months, these numbers obviously underestimate the true prevalence of BN based on current criteria.

Comorbidity

The National Comorbidity Survey replication adolescent supplement also evaluated the presence of other DSM-IV diagnoses. The majority of respondents meeting criteria for a DSM ED also met criteria for another lifetime DSM-IV diagnosis. The highest rate of comorbidity (88%) occurred in adolescents with BN, with particularly strong associations with mood (49.9%) and anxiety (66.2%) disorders.1

Especially concerning is the level of suicidality among this group. Adolescents with BN reported suicidality at higher rates than adults with BN and higher rates than youth with any other ED diagnosis. Of adolescents with BN, more than half (53%) endorsed suicidal ideation. Over a quarter of the sample had a plan and more than a third had had a prior attempt (17.1% with multiple past attempts).1,15

Treatment for adolescent BN

A diagnosis of BN is typically associated with high rates of comorbidity and elevated mortality.16 In addition, binge-eating and purging behaviors can lead to a range of medical complications, such as electrolyte imbalance, which can lead to arrhythmia or death, esophageal tears, gastric disruption, problems with fertility, and dental decay.17 With the risk of medical complications, it is imperative to utilize a multidisciplinary team approach, including a clinician who is trained in adolescent health with expertise in EDs to ensure the medical safety of outpatient care.

In adults with BN, there is the substantial literature to support cognitive behavioral therapy (CBT) as the leading treatment approach, with relatively good outcomes for most.18 In addition to CBT, there is evidence to support other approaches, such as interpersonal therapy,18 and newer approaches, such as integrative cognitive-affective therapy.19 Despite the growing evidence base for treatment of adults with BN, there remains a dearth of evidence for treating younger individuals with BN. To date, there has been one open medication trial of fluoxetine in conjunction with therapy over the course of 8

Despite the typical onset during adolescence, there have been only four RCTs published to date evaluating psychosocial treatment for BN in youth. The first three compared FBT approaches against guided self-care CBT, CBT adapted for adolescence (CBT-A), and supportive psychotherapy (SPT). The most recently published study compared CBT and psychodynamic therapy (PDT).

Adolescent Health, Medicine and Therapeutics

Dove Press

Bulimia nervosa in adolescents: prevalence and treatment challenges

Lisa Hail and Daniel Le Grange

Additional article information

Abstract

Bulimia nervosa (BN) is a serious psychiatric illness that typically develops during adolescence or young adulthood, rendering adolescents a target for early intervention. Despite the increasing research devoted to the treatment of youth with anorexia nervosa (AN) and adults with BN, there remains a dearth of evidence for treating younger individuals with BN. To date, there have been four published randomized controlled trials comparing psychosocial treatments, leaving significant room to improve treatment outcomes. Family-based treatment is the leading treatment for youth with AN, while cognitive-behavioral therapy is the leading intervention for adults with BN. Involving caregivers in treatment shows promising results, however, additional research is needed to investigate ways in which this treatment can be adapted further to achieve higher rates of recovery.

Keywords: eating disorders, youth, family-based treatment, cognitive behavioral therapy, psychodynamic therapy, psychopharmacological treatment, evidence based treatment

Introduction

Eating disorders (EDs) are serious psychiatric illnesses that typically develop during adolescence or young adulthood. These disorders are associated with both physical and psychological sequelae and often lead to considerable impairment and distress.1 The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM)2 recognizes eight feeding disorders and EDs, including bulimia nervosa (BN), anorexia nervosa (AN), and subthreshold presentations that are classified under unspecified feeding or ED. While the field has advanced the understanding of treatment approaches for adolescents with AN and adults with BN in particular, evidence to guide the treatment of BN in youth lags behind.

Diagnosis of BN

BN is characterized by recurrent episodes of eating an objectively large amount of food (ie, binge) with an associated loss of control, as well as inappropriate compensatory behavior (eg, self-induced vomiting, misuse of laxatives or diuretics, fasting, or excessive exercise) and overvaluation of shape and weight.2 In the current edition of the DSM, these episodes of binge eating and compensatory behavior must occur at a minimum frequency of once per week over the course of 3 months. In the DSM-IV-TR, the minimum frequency of these episodes of binge eating and compensatory behavior was double (ie, an average of twice per week).3 In studies comparing full and subthreshold presentations of DSM-IV BN, those individuals who were subthreshold reported significantly more subjective binge episodes in which they experienced a loss of control but did not consume an objectively large portion of food.4 Purge frequency across both groups was similar, suggesting that the experience of losing control may be more salient than the amount of food consumed.4 Diagnostic crossover is relatively common, especially among youths, with many who initially present with subthreshold presentations progressing to meet full diagnostic criteria for BN or less commonly AN.4,5 This diagnostic fluidity suggests that clinical management should not differ between sub- and full-threshold BN.

Traditional diagnostic approaches rely on the self-report of symptoms by the patient. While the low body weight characteristic of AN makes it more outwardly visible, AN is considered an ego-syntonic illness, such that it is consistent with the self-concept of the sufferer, making them less open to treatment.5 Conversely, BN is considered ego-dystonic and aversive to the patient, yet shame and secrecy often inhibit disclosure of symptoms and seeking treatment. In younger populations, developmental concerns, such as the ability to endorse such conceptual symptoms as “undue influence of weight and shape” may further impact the ability to diagnose full-threshold EDs in adolescents.4

The positively skewed distribution of age of onset of EDs, including subthreshold presentations, renders adolescents a target for screening and early intervention before symptoms become severe and enduring,5 and research has supported that early intervention is associated with the most promising treatment outcomes.6 (Treasure J, Russel G. The case for early intervention in anorexia nervosa:

theoretical exploration of maintaining factors. Br J Psychiatry.

2011;199(1):5–7.)

Increasing research has been devoted to the treatment of AN in adolescence, with an increasing number of studies published demonstrating considerable support for family-based treatment (FBT) approaches.7 To date, evidence to guide the treatment of BN in adolescents is limited, with only four published randomized controlled trials (RCTs) of psychological treatments and one open medication trial.8–11

Prevalence

Many population-based studies have focused on youths who meet full-threshold criteria for an ED without reporting on the cases who may have clinically significant presentations, but fall below the diagnostic threshold.1 In adults, the prevalence estimates of full-threshold BN are 1%–1.5%,2,12 with 0.1%–2% in youth.13 However, community studies that evaluated disordered eating behavior rather than applying strict DSM criteria found far greater prevalence (ie, 14%–22%) than those applying strict criteria.1,14

In an attempt to estimate the occurrence of EDs in US adolescents better, Swanson et al utilized data from the National Comorbidity Survey replication adolescent supplement.1 These data collected via face-to-face interviews included a representative sample of 10,123 youths aged 13–18 years. The World Health Organization Composite International Diagnostic Interview was used to assess DSM-IV psychiatric disorders, including AN, BN, and binge ED, based on the diagnostic algorithms used with adult populations. Sufficient information was gathered to assess subthreshold presentations of AN using a less stringent weight criterion (ie, less than 90% of median weight for height rather than 85%) and subthreshold binge ED. However, the survey did not include sufficient information to report on subthreshold presentations of DSM-IV BN, such as those who did not meet the duration or frequency criterion or those who experienced only subjective binge episodes.1

In the USA, the median age of onset for DSM-IV BN is quite young: 12.4 years (interquartile range 11.1–13.5 years).1 Within the sample, the lifetime prevalence rate of BN was 0.9% and 12-month prevalence 0.6%. Of adolescents with BN, 41.3% reported purging, while the rest met criteria based on nonpurging compensatory behaviors (ie, excessive exercise, fasting).1 With revised diagnostic criteria reducing the frequency of binge eating and purging from twice per week over 6 months to once per week over 3 months, these numbers obviously underestimate the true prevalence of BN based on current criteria.

Comorbidity

The National Comorbidity Survey replication adolescent supplement also evaluated the presence of other DSM-IV diagnoses. The majority of respondents meeting criteria for a DSM ED also met criteria for another lifetime DSM-IV diagnosis. The highest rate of comorbidity (88%) occurred in adolescents with BN, with particularly strong associations with mood (49.9%) and anxiety (66.2%) disorders.1

Especially concerning is the level of suicidality among this group. Adolescents with BN reported suicidality at higher rates than adults with BN and higher rates than youth with any other ED diagnosis. Of adolescents with BN, more than half (53%) endorsed suicidal ideation. Over a quarter of the sample had a plan and more than a third had had a prior attempt (17.1% with multiple past attempts).1,15

Treatment for adolescent BN

A diagnosis of BN is typically associated with high rates of comorbidity and elevated mortality.16 In addition, binge-eating and purging behaviors can lead to a range of medical complications, such as electrolyte imbalance, which can lead to arrhythmia or death, esophageal tears, gastric disruption, problems with fertility, and dental decay.17 With the risk of medical complications, it is imperative to utilize a multidisciplinary team approach, including a clinician who is trained in adolescent health with expertise in EDs to ensure the medical safety of outpatient care.

In adults with BN, there is the substantial literature to support cognitive behavioral therapy (CBT) as the leading treatment approach, with relatively good outcomes for most.18 In addition to CBT, there is evidence to support other approaches, such as interpersonal therapy,18 and newer approaches, such as integrative cognitive-affective therapy.19 Despite the growing evidence base for treatment of adults with BN, there remains a dearth of evidence for treating younger individuals with BN. To date, there has been one open medication trial of fluoxetine in conjunction with therapy over the course of 8 weeks. There are also four published RCTs comparing psychosocial treatments with significant room for improvement of treatment outcomes.

Psychopharmacological treatment

One open clinical trial was published investigating the feasibility and tolerability of fluoxetine (at an adult dose of 60 mg) in conjunction with psychotherapy over the course of 8 weeks.20 Participants were female adolescents aged 12–18 (mean 16.2, SD 1) years with a DSM-IV diagnosis of BN or ED not otherwise specified (EDNOS). All participants were above the 85th percentile of median weight for height by age.20

The medication was generally well tolerated, and no participants discontinued the trial due to side effects. Of the 13 patients who entered the study, ten received a minimum of 1 week of medication, and results were based on their outcome. Findings were comparable to studies of fluoxetine in adults with BN, with a significant decrease in both binge and purge behavior over the course of the trial. From baseline to the end of treatment (EOT), weekly binges decreased by 67% and episodes of purging by 56%. Despite improvements, three of the ten patients continued to meet criteria for a DSM-IV ED (two BN and one EDNOS) at the end of the trial.20

These findings have not been replicated nor have there been any placebo-controlled trials in adolescents with BN. Therefore, the results remain limited in their generalizability, and additional exploration of psychopharmacological interventions is necessary.

Psychological treatment

Despite the typical onset during adolescence, there have been only four RCTs published to date evaluating psychosocial treatment for BN in youth. The first three compared FBT approaches against guided self-care CBT, CBT adapted for adolescence (CBT-A), and supportive psychotherapy (SPT). The most recently published study compared CBT and psychodynamic therapy (PDT).

Family therapy and CBT-guided self-care

Schmidt et al10 were the first to publish findings from an RCT for the treatment of BN in adolescents. Their study, conducted in the UK, sought to compare the efficacy and cost-effectiveness of two treatments. Participants were 85 adolescents aged 13–20 years with DSM-IV BN or EDNOS. In the UK, guided self-care CBT is recommended as the first-line intervention for adults with BN. This treatment approach utilized a workbook and involved ten weekly sessions and three monthly follow-up sessions with the option of two sessions with a “close other” (eg, parent). The role of the therapist was to motivate the patients and guide them through the workbook. Similar to traditional CBT, self-monitoring was utilized, along with problem-solving and behavioral experiments. The comparison treatment was family therapy adapted from the Maudsley model of treatment for AN, as it has a growing evidence base for the treatment of young people with AN. This treatment provided psychoeducation about BN and was problem-oriented, with a focus on the role of the family in restoring regular eating patterns. In family therapy, patients were offered 13 sessions with a close other in addition to two individual sessions over the course of 6 months.10

The primary outcome variable was abstinence from binge eating and vomiting in the month prior to assessment assessed at EOT (6 months) and follow-up (12 months). When looking at binge episodes and purging as a combined variable, there was no difference between conditions at either time point. However, CBT-guided self-care was more effective at achieving abstinence from objective binge eating (45% versus 25%) at EOT, but this advantage was not maintained at follow-up. The impact on purging did not vary by treatment.10

FBT and SPT

In the same year, Le Grange et al8 published another study comparing FBT and SPT. Participants were 80 youths ages 12–19 (mean 16.1, SD 1.6) years, predominantly female (98%), with a diagnosis of DSM-IV BN or partial BN (ie, binge and purge episodes averaging once per week over 6 months). The duration of treatment was 20 sessions over the course of 6 months. Both treatments involved three phases, and the frequency of sessions decreases over time.8

FBT-BN was adapted from FBT for AN. This treatment takes an agnostic stance about the cause of the ED and assumes a significant negative impact of the illness on the family. FBT-BN also externalizes the illness as something separate from the adolescent, and empowers parents to disrupt the cycle of binge eating and purging. SPT is a nondirective treatment that does not involve specific active therapeutic approaches, such as stimulus control, psychoeducation, systematic problem-solving, or direct input about dietary modifications. SPT serves as a general treatment that might be comparable to what would be received in the community.8 The primary outcome measure was abstinence from binge eating and purging in the month prior to assessment at 6 months (EOT) and 12 months (follow-up). At EOT, FBT-BN had significantly higher rates of abstinence (39% versus 18%). However, the rate of abstinence declined during follow-up across both groups (29% and 10%, respectively).8

FBT and CBT

Following the comparison of FBT-BN to SPT, a control treatment similar to what youth with BN might receive in the community, Le Grange et al compared FBT-BN to CBT, which is the most efficacious approach for adults with BN. Participants were 109 youths aged 12–18 (mean 15.8, SD 1.5) years, predominantly female (94%), with DSM-IV BN or partial BN (same as previously mentioned). Both treatments involved 18 sessions over the course of 6 months.9

FBT was comparable to the FBT-BN delivered in the previous study by Le Grange et al,8 aside from having two fewer sessions. CBT-A was adapted from the treatment developed by Fairburn et al.21 The treatment developed for adults was modified such that there was increased contact with the therapist in early treatment, with the goal of enhancing therapeutic alliance, collateral sessions with caregivers to provide psychoeducation about BN and elicit their support in the treatment process, the use of concrete examples to explain points, and the exploration of typical developmental issues.9

Consistently with the prior studies, the primary outcome was abstinence from binge eating and purging for the 4 weeks prior to assessment at EOT (6 months) and follow-up (12 months). The rate of abstinence was significantly higher for FBT-BN than CBT-A (39.4% versus 19.7%), with continued improvement at 6-month follow-up (44% and 25.4% respectively).9

CBT and PDT

In the most recently published RCT, Stefini et al11 compared CBT and PDT. In Germany, where the study was conducted, 58.9% of psychotherapists for children and adolescents practiced PDT. This study sought to evaluate the gap in knowledge about commonly practiced PDT as a treatment for youth with BN. Participants in this sample were females aged 14–20 (mean 18.7, SD 1.9) years with a DSM-IV diagnosis of BN or partial BN (binge and purge episodes less than twice per week in previous 3 months).

The duration of the treatment was comparable to the guidelines of clinical practice in Germany, which involved substantially more treatment than the prior studies. Both CBT and PDT took place over 1 year, and participants could receive up to 60 sessions. Similar to Le Grange et al,9 CBT was based on Fairburn et al’s model of CBT for EDs22 with significant modifications, including tripling the number of sessions offered. PDT was manualized specifically for young people with BN. Both treatments share a symptom-focused approach that is specific to BN. However, underlying theoretical assumptions are quite different, and each approach places a different emphasis on emotions, cognitions, and behavior.11

Rather than evaluating abstinence from binge-eating and purging behavior 1 month prior to assessment, Stefini et al evaluated what proportion of participants no longer met the criteria for an ED and found no differences between groups, with 13 participants no longer meeting diagnostic criteria for an ED (33.3% CBT and 30.2% PDT). The rates of remission improved slightly, but not significantly for CBT (38.5%) and were unchanged for PDT at follow-up 1 year after EOT.11

Challenges in treatment

The challenges previously discussed with diagnosis will ultimately impact the ability to screen effectively for EDs and connect with treatment. Shame and secrecy may prevent the detection of BN and may inhibit treatment after symptoms are identified. The family may serve a crucial role in enhanced support to regulate eating behavior between sessions. However, in BN, it may be less obvious when binge episodes or compensatory behavior is taking place, making it difficult for parents to structure the environment fully.

In BN, the high level of comorbidity makes it probable that adolescents may present for treatment of another psychiatric disorder (eg, mood or anxiety disorder) while also struggling with binge eating and purging. Diagnostic assessment and ongoing monitoring of progress may offer opportunities to uncover clinically significant symptoms of BN. At the present time, there are limited data to guide the treatment of BN as a disorder in isolation, and there is no guidance about whether consecutive- or concurrent-treatment approaches for comorbid diagnosis are most appropriate or effective. That said, most RCTs to date have included participants with comorbid psychiatric diagnoses and provided pharmacotherapy for these diagnoses alongside psychosocial treatment for the ED. It also remains unclear why RCTs of treatments for BN within younger populations are lagging behind. Taken together, the limited systematic evaluation and concomitant advancement of treatment approaches for this patient population leaves us with a constrained scope of treatment options.

Schmidt U, Lee S, Beecham J, et al. A randomized controlled trial of

family therapy and cognitive behavior therapy guided self-care for adolescents

with bulimia nervosa and related disorders. Am J Psychiatry.

2007:164(4):591–598.

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Регулирование физической активности при булимии

Спросите о тренировках

Могут быть избыточными
55-66% склонны к компульсивным тренировкам
23% пациентов с НА склонны к компульсивным тренировкам

Предложите сделать перерыв

Новый опыт - жизнь без тренировок
Облегчение
Изящный выход из спорта / от чрезмерных физических нагрузок

Ограничения на тренировки

Переедание/рвота > 4 раз в неделю

Возвращение к соревнованиям

При прекращении переедания/рвоты

Bakland, Maria, et al. "Patients’ views on a new treatment for Bulimia nervosa and binge eating disorder combining physical exercise and dietary therapy (the PED-t). A qualitative study." Eating Disorders 27.6 (2019): 503-520.

Our research group has contributed to an expanding portfolio of evidence-based treatment for BN and BED by developing and testing a new treatment, which combines physical exercise and dietary therapy (PED-t) (Mathisen et al., 2017). This treatment rests on an empirically derived conceptual model of neurobiological, psychosocial and behavioral impacts of physical activity on mental health (Lubans et al., 2016). Physical exercise is associated with a lower mental health burden (Chekroud et al., 2018), and is beneficial in treating other mental disorders like depression (Josefsson, Lindwall, & Archer, 2014; Rosenbaum, Tiedemann, & Ward, 2014) and anxiety disorders (Jayakody, Gunadasa, & Hosker, 2013). Moreover, the rationale for the PED-t rests on findings from systematic reviews (Campbell & Hausenblas, 2009; Cook et al., 2016; Blanchet, Mathieu, Laurent, Fecteau, St-Amour, & Drapeau, 2018) which show that physical activity may reduce both body dissatisfaction and the urge to binge eat. The PED-t treatment is based on a previous randomized controlled trial (RCT) from our research group (Sundgot-Borgen, Rosenvinge, Bahr, & Schneider, 2002), which showed that

1

EXPERIENCES OF A NEW EATING DISORDER TREATMENT

guided physical activity, as well as dietary therapy were on par with cognitive-behavioral therapy in terms of reducing BN-symptoms. In a subsequent set of studies (Mathisen et al., 2018a, b, c), we have shown that the PED-t performs equal to cognitive behavioral therapy in terms of alleviating symptoms of BN and BED.

The training program in the PED-t treatment consisted of three weekly exercise sessions, each lasting 40–60 min. Two sessions were resistance exercise, of which one was supervised. The third session consisted of unsupervised pyramid interval running (Mathisen et al., 2017).

The dietary therapy included three psychoeducative modules “dietary routines and structure” (five sessions), “nutritional knowledge and practical skills” (12 sessions), and “summary and future plans” (three sessions). More details on the nature and rationale of the treatment have been published elsewhere (Mathisen et al., 2017; Pettersen et al., 2018).

Pettersen, G., Sørdal, S., Rosenvinge, J. H., Skomakerstuen, T., Mathisen, T. F., & Sundgot- Borgen, J. (2017). How do women with eating disorders experience a new treatment combining guided physical exercise and dietary therapy? An interview study of women participating in a randomised controlled trial at the Norwegian School of Sport Sciences. BMJ Open, 7(12), e018588.

Pettersen, G., Rosenvinge, J. H., Bakland, M., Wynn, R., Mathisen, T. F., & Sundgot-Borgen, J. (2018). Patients’ and therapists’ experiences with a new treatment programme for eating disorders that combines physical exercise and dietary therapy: the PED-t trial. A qualitative study protocol. BMJ Open, 8(1), e018708.

�

We often tell our college-student patients that they get plenty of exercise walking on campus to and from classes and activities. Permission to return to jogging and other physically strenuous activities should be granted gradually and be contingent on weight gain, medical stability, and menstrual status. Determining an “exercise weight” (the weight at which exercise is allowed) should be done pragmatically and based on each patient’s medical status, progress, and pre-morbid exercise practices and body weights. For patients whose weights are at or below the level that is diagnostic of AN, it is reasonable to consider severe limits on exercise. Very low weight patients (i.e., adult patients who have BMI less than 17 kg/m² or children below the fifth percentile) who experience unremitting weight loss should be barred from anything but limited daily tasks. We also recommend rearranging the home so that extraneous walking or stair-climbing are minimized. For patients who are gaining weight consistently, moderate exercise can help them accept associated body changes (Fairburn, 2008). Other studies show that use of a supervised moderate exercise program, such as non-aerobic yoga, may be beneficial during the weight gain phase (APA, 2006). Bratland-Sanda’s et al. (2010) program used a variety of exercise approaches in 60-minute sessions, four-times per week. Each session included a combination of stretching, posture, yoga, Pilates, partner exercises, strength training, balance, exercise balls, aerobic activity and recreational games. Patients in the exercise group gained 33% more than non-exercisers.

Exercise prescriptions for eating-disordered patients must be individualized. What might be excessive for one patient may not be for another. For example, the patient who is a competitive athlete may have physical capacity for more extensive exercise than would a non-athlete. Presumably, athletes are able to engage in heavier levels of exercise without becoming obsessional or compulsive because their exercise routines are purposeful and overseen by a coach. A reasonable exercise guideline for athletes is: no more exercise than the coach recommends. Yet, for a “non-athletic” patient, two 10-minute walks on weekdays might suffice. Ideally, exercise guidelines should be reasonable and clinically defensible based on health status and or lack of progress with weight restoration.

It is generally not productive to attempt to limit activity unless it is likely the patient will be compliant or the treatment team can control access to the activity, such as permission to participate in school-related activities. Collaborating with patients in devising individualized exercise or activity prescriptions to meet their health and psychological needs are a way around this dilemma. Examples of plans that might be appropriate range from no additional exercise besides that associated with school or work to a 10-minute walk in the evening or 30 minutes of window shopping at the mall two days per week. Other patients may prefer 15 minutes of swimming or exercise biking every other day. Exercise plans are contingent on the patient’s physical condition and successful achievement of weight goals. As treatment progresses we continue to focus on how our patients deal with weight gain and body image changes when exercise is limited. We know that that these concerns the least likely to change and that the urge to excessively and or compulsively exercise may be the last ED behavior to abate (APA, 2006).

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Управление весом

Подавление веса

Разница между максимальным весом пациента когда-либо при его взрослом росте, и весом в настоящий момент

Биологическая потребность возмещения потерянного веса
Прогнозирует увеличение веса во время и после лечения
Прогнозирует частоту эпизодов переедания

Оцените и включите в КПТ и FBT (терапию с привлечением ближайших членов семьи)
Примите во внимание вероятность диагноза «анорексия» и соответствующего лечения

DSM-5: «…существенно пониженный вес тела с учетом возраста, пола, траектории развития и физического здоровья. Существенно пониженный вес определяется как вес ниже минимальной нормы ..., или ниже минимально ожидаемого веса.»

Juarascio, Adrienne, et al. "Addressing weight suppression to improve treatment outcome for bulimia nervosa." Cognitive and behavioral practice 25.3 (2018): 391-401

Need to find Bodell LP, Keel PK. Weight suppression in bulimia nervosa: Associations with biology and behavior. Journal of abnormal psychology. 2015 Nov;124(4):994.

Cognitive behavioral therapy (CBT) is regarded as the gold-standard treatment for bulimia nervosa (BN), yet despite impressive empirical support for its effectiveness, over 50% of patients fail to achieve abstinence from binge eating and purging by the end of treatment. One factor that may contribute to reduced efficacy rates in CBT is weight suppression (WS; the difference between a person's highest weight ever at their adult height and current weight). A growing body of research indicates that WS in patients with BN may have a clinically significant effect on symptomatology and prognosis. However, the current cognitive behavioral framework for BN does not explicitly acknowledge the role of WS in the onset or maintenance of BN symptoms and does not provide guidance for clinicians on how to address WS during treatment. The relationship between WS, biological pressure to regain lost weight, and the maintenance of BN symptoms suggest that current cognitive behavioral models of BN may be improved by considering the role of WS and exploring needed treatment modifications. Indeed, a reconceptualization of existing models may offer insight into potential strategies that can be used to reduce the susceptibility to treatment dropout, nonresponse, and relapse. It is therefore necessary to consider whether, and how, clinicians' consideration of WS during case conceptualization and treatment planning could serve to improve CBT outcomes. The current review explores ways in which high WS could contribute to poor CBT outcomes, provides preliminary clinical recommendations for incorporating WS into existing cognitive behavioral treatments based on extant data and clinical wisdom, and proposes suggestions for future research needed in this domain.

One subgroup of patients who may benefit fromaugmentations to CBT are individuals who are weightsuppressed. Weight suppression (WS) represents the discrep-ancy between the highest weight reached since attainingadult height and current weight. While patients with BN aretypically in the normal weight range when presenting fortreatment, many have lost a large amount of weight duringthe development of their disorder (Lowe, Davis, Lucks,Annunziato, & Butryn, 2006). As described in more detailbelow, intentionally keeping one’sweightfarbelowaprevioushigh point can lead to a host of cognitive, emotional, andbiological consequences thatcan drive continued eatingpathology. For these reasons, WS has consistently been shownKeywords: bulimia nervosa; weight suppression; cognitive andbehavioral treatment; treatment modifications1077-7229/17/© 2018 Association for Behavioral and CognitiveTherapies. Published by Elsevier Ltd. All rights reserved.Available online at www.sciencedirect.comScienceDirectCognitive and Behavioral Practice 25 (2018) 391-401www.elsevier.com/locate/cabp

o predict the onset and maintainance of eating pathology

Consistent with these predictions, WS predicts weight gainin BN patients during and after treatment (Carter et al., 2008;Herzog et al., 2010; Lowe, Davis, et al., 2006). Gwirtsman et al.(1989)found that normal-weight women with BN requirefewer calories to maintain a stable body weight compared towomen without BN, which may be due to the elevated levelsof WS in women with BN. The strong biological pressure toregain lost weight may explain why WS consistently predictsthe frequency of binge eating episodes (Butryn et al., 2011;Lowe et al., 2007; Mitchell et al., 2011)inpatientswithBN.Efforts to maintain WS or counteract weight gain may alsoexplain why WS predicts restrictive dieting and purgingbehaviors (Butryn et al., 2011; Butryn et al., 2006; Garner &Fairburn, 1988; Lavender et al., 2015). Patients with WSappear to be stuck in a“bio-behavioral bind,”because BNpatients high in WS are more susceptible to weight gain (dueto metabolic efficiency and binge eating) but also find weightgain highly threatening, leading to more weight loss attemptsand fueling a self-perpetuating cycle. Importantly, morerecent literature suggests WS is predictive of clinical impair-ment in social, cognitive and personal domains (Hagan,Clark, & Forbush, 2017). It is noted that the associationbetween WS and BN behaviors may also be in part driven byattempts to suppress fears of weight gain. For example,research suggests BN patients engage in thought and/oremotion suppression, or the tendency to avoid negative orunpleasant cognitions (Lavender, Jardin, & Anderson, 2009;Svaldi, Caffier, & Tuschen-Caffier, 2010); fear of weight gainamong weight-suppressed patients could therefore also in-crease the likelihood of engaging in bulimic behaviors.Weight Suppression, Time to Remission, andTreatment OutcomeSeveralstudies have found that WS predicts time toremission and treatment outcome for BN patients (Butrynet al., 2006; Keel & Heatherton, 2010; Lowe et al., 2011).An 8-year longitudinal studyfollowed progression of BNtreatment-seeking patients and found that patients withhigher WS took a longer time to reach full remission (Loweet al., 2011). Keel and Heatherton (2010)also investigatedthe magnitude of WS and found that higher WS predictedsymptom maintenance at 10-year follow-up.Butryn et al.(2006)found WS to be a significant predictor of CBTtreatment outcome, including likelihood of dropout andpersistence of BN symptoms following treatment. It shouldbe noted that despite these associations, findings on WS as apredictor of outcome have beensomewhat inconsistent. For392Juarascio et al.

Incorporating WS Into CBT for BN The current cognitive behavioral framework for BN doesnot explicitly acknowledge the role of WS in the onset or maintenance of BN symptoms. Existing CBT and CBT-E models classify BN as a“cognitive disorder,”suggesting thatthe development of BN symptoms is primarily driven byovervaluation of shape and weight (Fairburn, 2008). Whilethese models do acknowledge the physical effects of weightlossinunderweightpatientsasamechanismofthisdisorderand support rigid dieting as a core maintenance factor inBN, they fail to acknowledge that WS in healthy-weightindividuals can encourage continued BN symptoms. CBTsuggests that the primary effect of dieting on BN symptoms iscognitively mediated; CBT models note a possible influenceof short-term deprivation (e.g., fasting) but do not considerthat the biological aspects of WS could support themaintenance of both binge eating and compensatorybehaviors. The relationship described above between WS,biological pressure to regain lost weight, and the mainte-nance of BN symptoms suggest that current models of BNmay be improved by acknowledging the role of WS andexploring needed treatment modifications. Indeed, areconceptualization of existing models may offer insightinto potential strategies that can be used to reduce thesusceptibility to treatment dropout, nonresponse, andrelapse. In the remainder of this paper, we will providepreliminary clinical recommendations for incorporating WSinto existing cognitive behavioral treatments based onclinical theory and existing data (when available), as well assuggestions for future research to better understand how WScanbeaddressedinCBT.Case Conceptualization/IdentificationGiven evidence that BN patients have elevated premorbidBMIs (Fairburn,Welch,Doll,Davies,&O’Connor, 1997;Garner & Fairburn, 1988; Shaw et al., 2012), and theevidence that degree of WS is related to frequency of bingeeating and compensatory behaviors (Butryn et al., 2011;Butryn et al., 2006; Lavender et al., 2015; Lowe et al., 2007;Mitchell et al., 2011), we believe that clincians should assessfor and incorporate WS into their clinical conceptualizationsfor patients with BN. Below we describe aspects of a patient’sweight history and trajectory that could inform caseconceptualization and treatment planning. A modifiedschematic of the CBT for BN model including factorsrelevant to weight suppression is available inFigure 1.Asnoted below, all additions to this model should beconsidered tentative based on the existing state of research,and additional study is needed to confirm these proposedrelations.Clinical RecommendationsWe recommend that clinicians collect a detailed timeline of weight trajectory early in treatment. Fairburn’sCBTalready recommends that therapists assess for certain aspectsof weight history, including weight before and after theeating disorder, and lowest and highest weight sincedeveloping the eating disorder (Fairburn, 2008). However,this approach assigns little meaning to weight history in thecourse of treatment, providing the majority of patients withthe same information about weight. Further, CBT onlyemphasizes weight gain for patients below a certain weight,and argue that encouraging greater amounts of weight gainis“unrealistic”(p. 159,Fairburn, 2008). In addition to thesevariables, we suggest that clinicians more thoroughly assessweight history and variability, including current weight,multiple past weights (highest, lowest, and relevant fluctua-tions in between), and length of time at each weight, as ameasure of the patient’s weight change. The use of a stan-dardized assessment tool such as the Dieting and WeightHistory Questionnaire (Witt,Katterman,&Lowe,2013),which assesses for relevant weight history, may help tofacilitate collection of this information. A more completeassessment of weight history will help clinicians identifypatterns of weight change and consider the implicationsof a patient’s current WS in the context of other variables.Prior research has demonstrated that WS’simpactonBNsymptomsmayinteractwithotheraspectsofweighthistory,including current BMI (Bodell&Keel,2015;Butrynetal.,2011 ). In addition to the factors of weight history that existingdata suggest interact with WS, there are others that, in theory,could also be relevant for case conceptualization but have yetto be empirically evaluated. For instance, the effects asso-ciated with WS may be more pronounced if the patientwasatherhighestweightforseveralyearsbeforeexperienc-ing BN-related weight loss. Conversely, a patient who hasremained significantly weight suppressed for several yearsfollowing a brief period of weight gain early in college andwhose subsequent weight loss was not due to BN symptomsmay experience less negative effects due to WS. While data arenot currently available to demonstate that the length of WS orperiod of time the patient remained at their highest weightare relevant factors, clinical wisdom suggests that these393Addressing Weight Suppression in Bulimia Nervosa

Carter et al. (2008)Zunker et al. (2011)Butryn et al. (2006)Dawkins, Watson, Egan, & Kane, 2013Fairburn, 2008

In addition to gathering objective information aboutweight history, a patient’s subjective interpretation of weight,such as current and past weight goals and levels of distressassociated with past weight fluctuations, should also beconsidered. For instance, if a patient considers his/her bodyweight to be of supreme importance and has beenhistorically intolerant of minor weight gain, this patientmay react to even a very small weight gain during treatmentwith an increase in maladaptive compensatory behaviors toreduce weight. A patient might also assume that any weightgain means that she is very likely to return to her highestprevious weight, an outcome the patient may greatly fear.As such, this patient may be at risk for dropout or relapsein the event of weight gain, and treatment may need to beaugmentedtoensurethatthispatientdoesnotdropoutduring the introduction of regular eating. While little isknown empirically about the interaction between WS andfears of weight gain during treatment, clinical wisdom wouldsuggest that an interaction between these factors is worthconsidering.Future research.Research is needed to determine whatlevel of WS should be considered clinically significant andlikely to impact symptom maintenance. Although anumber of studies have demonstrated that greater WS isassociated with more bulimic symptoms (Butryn et al.,2011; Butryn et al., 2006; Lavender et al., 2015; Mitchellet al., 2011) and longer time to remission (Lowe et al., 2011),there is currently no recommended value for clinicians to usewhen determining the clinical significance of WS in any oneindividual patient. Part of the challenge in identifying whatlevel of WS should warrant concern is that WS is unlikelyto function purely in isolation, and instead likely interactswith several other facets of weight history (e.g., current BMI;Lavender et al., 2015).Although CBT encourages the collection of some facetsof weight history, additional research is needed to documentwhether a more in-depth assessment of weight history couldimprove case conceptualization and treatment outcomes forBN patients. As described above, while there is someevidence to suggest that WS may interact with other factors(e.g., current BMI) to predict symptom maintenance, wehave yet to empirically evaluate many cognitive (e.g., beliefsabout likelihood of future weight gain or the effectiveness ofcompensatory behaviors in preventing weight gain), affective(fear or anxiety about weight gain), and biological variables(history of weight variability, length of time patient has beenbelow their past high weight, length of time at previous highweight) that clinical wisdom would suggest could be relevantfactors. For example, starting weight or current BMI couldaffect the clinical implications of WS: A weight-suppressedpatient whose highest weight was in a normal BMI range andwhose current weight is in a low BMI range may be moreprone to weight gain than a weight-suppressed patient whoseOver-evaluation of shape and weight and their control Strict dieting; non-compensatory weight-control behaviorBinge eating Compensatory vomiting/laxative misuse Elevated weight suppression Weight gain; fear of weight gain Events and associated mood change* Figure 1.Proposed schematic of current CBT model (fromFairburn, 2008) with additional factors related to weight suppression and weighthistory incorporated. Black represents the original CBT model and gray represents suggested additions. All additions represent considerationsfor future study based on existing research and will require additional research to replicate and confirm these relationships.*events may includeactual weight gain during treatment394Juarascio et al. ighest weight was considered overweight, and whosecurrent weight is on the high end of normal. Additionalresearch is clearly needed to identify the potential moder-ating variables that could inform how WS influences themaintenance of BN symptoms and treatment outcomes.

For example, theclinician could say to the patient,“People who have bulimiatend to lose a lot of weight early on in their disorder.However, the heavy restriction and resulting weight loss caninfluence a person’s ability to keep weight off due to changesin their metabolic rate and changes in their reactions tofood. These factors usually begin to lead to fluctuations inweight, which can be both distressing and eventually result ineventual weight gain. This process shows how the work youare doing to try to lose weight, such as the strict dietary rulesyou try to follow, will likely lead to weight gain in the longterm.”Additionally, clinicians could note that while dieting“successes”(i.e., weight loss) may be temporarily relieving tothe patient, it will likely also make weight regain more likelybecauseoftheeffectsofweightlossonmetabolism(adecrease) and appetite (an increase), thereby inadvertentlyperpetuating the disorder. Here, clinicians could draw thepatient’s attention to the“catch-22”that WS has placed themin, whereby large weight loss causes weight regain, whichincreases distress and perpetuates reliance on eatingdisorder behaviors to achieve dramatic weight loss (seeFigure 2).A visual demonstration of the patient’s individual weighttrajectory over time and corresponding symptom severitymay be helpful in conveying both the patient’smagnitudeofWS and its potential implications. A model of the bio-behavioral bind associated with WS may also be presented asa visual demonstration of the relationship between WS andweight gain (seeFigure 3for a sample demonstration ofpsychoeducation). Discussion of WS as linked to bothreduced metabolic efficiency and higher binge-frequencies and/or size could promote a patient’smotiva-tion for treatment by giving them hope that they may be ableto gain control over a self-perpetuating cycle that has beencontrolling them. Moreover, given that purging is much lesseffective at eliminating calories than most patients assume(Bo-Linn, Santa Ana, Morawski, & Fordtran, 1983; Kaye,Weltzin, Hsu, McConaha, & Bolton, 1993), clinicians shouldadvise that even when followed by purging, the increasedbinge eating associated with WS will still likely contribute to395Addressing Weight Suppression in Bulimia Nervosa

positive energy balance, and subsequent weight gain(Butryn et al., 2006). Therefore, if a patient is highlyconcerned about future weight gain, presentation of thepotential future weight-relatedimplicationsofhercurrentBN symptoms may encourage her to view these habits lessfavorably, and perhaps motivate her desire to identify andengage in other, more adaptive behaviors. In presentingthese findings, clinicians should be careful to introducethese concepts gradually and supportively, perhaps address-ing the shared goal of identifying other, more adaptivebehaviors. Framing this as an attainable goal, one may notonly provide hope to the patient that there are other ways ofmanaging both their weight and their weight concerns, butmay also help to build rapport between clinician andpatient.

Bakland, Maria, et al. "Patients’ views on a new treatment for Bulimia nervosa and binge eating disorder combining physical exercise and dietary therapy (the PED-t). A qualitative study." Eating Disorders 27.6 (2019): 503-520.

Our research group has contributed to an expanding portfolio of evidence-based treatment for BN and BED by developing and testing a new treatment, which combines physical exercise and dietary therapy (PED-t) (Mathisen et al., 2017). This treatment rests on an empirically derived conceptual model of neurobiological, psychosocial and behavioral impacts of physical activity on mental health (Lubans et al., 2016). Physical exercise is associated with a lower mental health burden (Chekroud et al., 2018), and is beneficial in treating other mental disorders like depression (Josefsson, Lindwall, & Archer, 2014; Rosenbaum, Tiedemann, & Ward, 2014) and anxiety disorders (Jayakody, Gunadasa, & Hosker, 2013). Moreover, the rationale for the PED-t rests on findings from systematic reviews (Campbell & Hausenblas, 2009; Cook et al., 2016; Blanchet, Mathieu, Laurent, Fecteau, St-Amour, & Drapeau, 2018) which show that physical activity may reduce both body dissatisfaction and the urge to binge eat. The PED-t treatment is based on a previous randomized controlled trial (RCT) from our research group (Sundgot-Borgen, Rosenvinge, Bahr, & Schneider, 2002), which showed that

1

EXPERIENCES OF A NEW EATING DISORDER TREATMENT

guided physical activity, as well as dietary therapy were on par with cognitive-behavioral therapy in terms of reducing BN-symptoms. In a subsequent set of studies (Mathisen et al., 2018a, b, c), we have shown that the PED-t performs equal to cognitive behavioral therapy in terms of alleviating symptoms of BN and BED.

The training program in the PED-t treatment consisted of three weekly exercise sessions, each lasting 40–60 min. Two sessions were resistance exercise, of which one was supervised. The third session consisted of unsupervised pyramid interval running (Mathisen et al., 2017).

The dietary therapy included three psychoeducative modules “dietary routines and structure” (five sessions), “nutritional knowledge and practical skills” (12 sessions), and “summary and future plans” (three sessions). More details on the nature and rationale of the treatment have been published elsewhere (Mathisen et al., 2017; Pettersen et al., 2018).

Pettersen, G., Sørdal, S., Rosenvinge, J. H., Skomakerstuen, T., Mathisen, T. F., & Sundgot- Borgen, J. (2017). How do women with eating disorders experience a new treatment combining guided physical exercise and dietary therapy? An interview study of women participating in a randomised controlled trial at the Norwegian School of Sport Sciences. BMJ Open, 7(12), e018588.

Pettersen, G., Rosenvinge, J. H., Bakland, M., Wynn, R., Mathisen, T. F., & Sundgot-Borgen, J. (2018). Patients’ and therapists’ experiences with a new treatment programme for eating disorders that combines physical exercise and dietary therapy: the PED-t trial. A qualitative study protocol. BMJ Open, 8(1), e018708.

Witt AA, Katterman SN, Lowe MR. Assessing the three types of dieting in the Three-Factor Model of dieting. The Dieting and Weight History Questionnaire. Appetite. 2013 Apr 1;63:24-30.

(1) frequency ofpast dieting and overeating (i.e., history of dieting), (2) current dieting to lose weight, and (3) weight sup-pression, or the difference between an individual’s current weight and his or her highest previous weight.The purpose of this paper is to (1) describe the Dieting and Weight History Questionnaire (DWHQ), ameasure that we have used for many years to assess these three dimensions of dieting; (2) provide somerecent examples of published research on each type of dieting; (3) discuss some of the nuances of assess-ing these dieting types; and (4) suggest directions for future research

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Определите биологически соответствующий вес

Генетическая предрасположенность

Этническая принадлежность
Пол
Семейный анамнез

История веса

Вес до начала заболевания
Кривые роста для детей и подростков

Колебания

Со дня на день ~3 кг
В пределах одного дня ~2 кг
В зависимости от времени цикла для женщин ~1-2 кг

Легко поддерживается, без поведения, свойственного РПП

Диетические ограничения

Нормальное физическое функционирование
Нормальное психическое функционирование

Reflects pre-morbid weight

Adjusted for height in children & adolescents

Easily maintained without dieting

Normal physical & Psychological function

The major determinant of body weight is genetic (Song et al., 2018). A “biologically appropriate weight” is a weight that is easily maintained without need for dieting or inappropriate food and exercise behaviors, and reflects pre-morbid weight, normal physical and psychological function, genetic predisposition ethnicity, gender, and family history (Herrin & Larkin, 2013).

In young individuals, a “biologically appropriate weight” is associated with normal historical development. In adults, a “biologically appropriate weight” is where weight settles when enough food is consumed to attain all required nutrients, and the person is physically and emotionally satisfied. In individuals who lived in higher weight bodies before the onset of their ED, such as those with atypical anorexia, refeeding and weight restoration should proceed with premorbid usual weight taken into account in determining weight restoration goals. In all people, body weight fluctuates day to day about 5-6 pounds (3 kg) due to level of hydration, contents of bowel and bladder, time of day, and time of month for menstruating females.

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Ссылки

Alvarenga MS, Negrão AB, Philippi ST. Nutritional aspects of eating episodes followed by vomiting in Brazilian patients with bulimia nervosa. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity. 2003 Jun 1;8(2):150-6.
Anderson, Leslie K., et al. "The integration of family-based treatment and dialectical behavior therapy for adolescent bulimia nervosa: philosophical and practical considerations." Eating disorders 23.4 (2015): 325-335.
Bo-Linn, G. W., Santa Ana, C. A., Morawski, S. G., & Fordtran, J. S. (1983). Purging and calorie absorption in bulimic patients and normal women. Annals of Internal Medicine, 99, 14-17.
Bodell LP, Keel PK. Weight suppression in bulimia nervosa: Associations with biology and behavior. Journal of abnormal psychology. 2015 Nov;124(4):994.
Braun DL, Sunday SR, Halmi KA (1994) Psychiatric comorbidity in patients with eating disorders. Psychol Med 24(4):859–867.
Hail L, Le Grange D. Bulimia nervosa in adolescents: prevalence and treatment challenges. Adolescent health, medicine and therapeutics. 2018;9:11.
Hamadi L, Holliday J. Moderators and mediators of outcome in treatments for anorexia nervosa and bulimia nervosa in adolescents: A systematic review of randomized controlled trials. International Journal of Eating Disorders. 2020 Jan;53(1):3-19.Chen, E. Y., et al. "An adaptive randomized trial of dialectical behavior therapy and cognitive behavior therapy for binge-eating." Psychological medicine 47.4 (2017): 703-717.
Hübel C, Marzi SJ, Breen G, Bulik CM. Epigenetics in eating disorders: a systematic review. Molecular psychiatry. 2019 Jun;24(6):901-15.

Alvarenga MS, Negrão AB, Philippi ST. Nutritional aspects of eating episodes followed by vomiting in Brazilian patients with bulimia nervosa. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity. 2003 Jun 1;8(2):150-6.

Anderson, Leslie K., et al. "The integration of family-based treatment and dialectical behavior therapy for adolescent bulimia nervosa: philosophical and practical considerations." Eating disorders 23.4 (2015): 325-335.

Bo-Linn, G. W., Santa Ana, C. A., Morawski, S. G., & Fordtran, J. S. (1983). Purging and calorie absorption in bulimic patients and normal women. Annals of Internal Medicine, 99, 14-17.

Bodell LP, Keel PK. Weight suppression in bulimia nervosa: Associations with biology and behavior. Journal of abnormal psychology. 2015 Nov;124(4):994.

Braun DL, Sunday SR, Halmi KA (1994) Psychiatric comorbidity in patients with eating disorders. Psychol Med 24(4):859–867.

Hail L, Le Grange D. Bulimia nervosa in adolescents: prevalence and treatment challenges. Adolescent health, medicine and therapeutics. 2018;9:11.

Hamadi L, Holliday J. Moderators and mediators of outcome in treatments for anorexia nervosa and bulimia nervosa in adolescents: A systematic review of randomized controlled trials. International Journal of Eating Disorders. 2020 Jan;53(1):3-19.Chen, E. Y., et al. "An adaptive randomized trial of dialectical behavior therapy and cognitive behavior therapy for binge-eating." Psychological medicine 47.4 (2017): 703-717.

Hübel C, Marzi SJ, Breen G, Bulik CM. Epigenetics in eating disorders: a systematic review. Molecular psychiatry. 2019 Jun;24(6):901-15.

Juarascio, Adrienne, et al. "Addressing weight suppression to improve treatment outcome for bulimia nervosa." Cognitive and behavioral practice 25.3 (2018): 391-401.

Kaye, W., Weltzin, T., Hsu, L., McConaha, C., & Bolton, B. (1993). Amount of calories retained after binge eating and vomiting. American Journal of Psychiatry, 150(6), 969-971.

Le Grange D, Lock J. Treating bulimia in adolescents: A family-based approach. Guilford Press; 2009 Jun 19.

Linardon J, Wade TD. How many individuals achieve symptom abstinence following psychological treatments for bulimia nervosa? A meta‐analytic review. International Journal of Eating Disorders. 2018 Apr;51(4):287-94.

MacDonald, Danielle E., et al. "Empirically defining rapid response to intensive treatment to maximize prognostic utility for bulimia nervosa and purging disorder." Behaviour Research and Therapy 68 (2015): 48-53.

McDonald S. Understanding the genetics and epigenetics of bulimia nervosa/bulimia spectrum disorder and comorbid borderline personality disorder (BN/BSD-BPD): a systematic review. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity. 2019 Oct 1:1-6.

Mehler PS, Krantz MJ, Sachs KV. Treatments of medical complications of anorexia nervosa and bulimia nervosa. Journal of eating disorders. 2015 Dec;3(1):1-7.

Smith AR, Zuromski KL, Dodd DR. Eating disorders and suicidality: what we know, what we don’t know, and suggestions for future research. Current opinion in psychology. 2018 Aug 1;22:63-7.

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Ссылки

Juarascio, Adrienne, et al. "Addressing weight suppression to improve treatment outcome for bulimia nervosa." Cognitive and behavioral practice 25.3 (2018): 391-401.
Juarascio, Adrienne, et al. "Addressing weight suppression to improve treatment outcome for bulimia nervosa." Cognitive and behavioral practice 25.3 (2018): 391-401.
Kaye, W., Weltzin, T., Hsu, L., McConaha, C., & Bolton, B. (1993). Amount of calories retained after binge eating and vomiting. American Journal of Psychiatry, 150(6), 969-971.
Le Grange D, Lock J. Treating bulimia in adolescents: A family-based approach. Guilford Press; 2009 Jun 19.
Linardon J, Wade TD. How many individuals achieve symptom abstinence following psychological treatments for bulimia nervosa? A meta‐analytic review. International Journal of Eating Disorders. 2018 Apr;51(4):287-94.
Linardon J, Wade TD. How many individuals achieve symptom abstinence following psychological treatments for bulimia nervosa? A meta‐analytic review. International Journal of Eating Disorders. 2018 Apr;51(4):287-94.
MacDonald, Danielle E., et al. "Empirically defining rapid response to intensive treatment to maximize prognostic utility for bulimia nervosa and purging disorder." Behaviour Research and Therapy 68 (2015): 48-53.
McDonald S. Understanding the genetics and epigenetics of bulimia nervosa/bulimia spectrum disorder and comorbid borderline personality disorder (BN/BSD-BPD): a systematic review. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity. 2019 Oct 1:1-6.