“Acceptance and Commitment Therapy in eating disorders.

Clinical practice with complex case.”

Katia Manduchi, Psy D, Giovambattista Presti MD, Giovanni Miselli Psy. D & Elisa Rabitti Psy. D

1

Case presentation: G. a woman with disordered eating problems, depression and chronical illness… can we

make the difference in her life???

G. is 36 years old. Her neurologist suggested her to doing a psychotherapy with me because, after lots of hospitals, for Multiple Sclerosis, recurrent nephrotic syndromes, lupus and their collateral effects, she developed a disordered eating with food restriction and hyperactivity. Contemporary the psychiatrist that work in team with the neurologist, suggested that her diagnosis was complicated from a form of medium depression. Her BMI at the first session was of 15.

Self asContext

Contact with the Present Moment

Defusion

Acceptance

Committed Action

Values

(1) Her self definition is: “It would be better for my daughter and husband if I’ll died”; “I’m unworthy”; “I can’t express my suffering and my worries for my

healthy”

(2) Unacceptance of: Body weight and size that started

before the illness period; unacceptance

of the medical situation and of the physical symptoms

(3) Fused with hopelessness and with the fear of

dying

(4) Food restriction; hyperactivity;

anxiety symptoms

(5)Family and the daughter

relationship; thinnes; having perfect legs.

(6) She hasn’t any contact with the

present moment but she’s always

thinking to her food intake and the

physical activity she “needs” to do

ACT Question

In the first session I have to choose: can I believe in “Wilson wager”???

My answer was…..

And then she had to copy with…

Her fear of gain weightAnd she felt so little

Assessment

• In self monitoring diaries we noticed that she was having a food restriction and hyperactivity, daily;

• BIAAQ: 48 (with the score 7 at items 1 e 2)• VLQ: Intensitivity 88; consistence 70; combined 61,3.• AAQ2: 41• BDI 2: 10

BUT: GSI 1,67; WP 1,5; BIC 1,5; A 1,8; CSM 2; D 1,6

PSD 105; PSDI 3,1

EDI 2 PM 8; IN 7; IS 7; SI 10; BU 0; P 2; IC 3; I 2; IM 13; CE 10; ASC 7

TREATMENT

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

The psychotherapeutic work in this phase

• Defusion on specifical thoughts: for example we used the “milk milk milk” exercise on the thougths “I’LL DIE SOONER” and “FORBIDDEN FOODS MAKE ME BECAME FAT”;

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

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

Her Values work

Next phase…till now….

• From January to now we made 6 sessions;• In this sessions we had work on the reinforce

of the strategies learned during the treatment and in doing this emerged a thought from her adolescence on her thights“My thights are a mess”; this emerged when she arrived to a BMI of 20, a weight she never had in her life.

So… an exposure with the mirror

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

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

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

Now

• BMI 20• In this mounth the Sclerosis had an

aggravation but she cope with this asking me to do a longer period of follow up; asking more support with the medical teams and with her family; developing more bodily awareness as a resource for inform her team.

Self asContext

Contact with the Present Moment

Defusion

Acceptance

Committed Action

Values

(1) She define herself “A woman that now is taking care of her, her body and her life”

(2) More acceptance of shape and weight and acceptance of

her clinical situation

(3) Strategies learned during the

therapy and mindfullnes

(4) She is a “disciplined” patient and takes some rest when she need it;

she’e really aware of the actual medical

situation

(5)Family, being a mother, being a good friend, finding some pleasure activities, apreciating some

rest, having a “compassioned”

relationship with her illness

(6) Collaborative with all the teams figures she lives a

“normal” life in her family

ACT Question

Re- test

• BDI 13• VLQ: Intensity 90; consistence 77; combined

62,9.• AAQ2 52.

• BIAAQ: tot 48 without any high score for specifical items;

• BUT: GSI 1,2; WP 1,80; BIC 1,22; A 1,33; CSM 1,20; D 0,83; PSD 35; PSDI 0,9

• EDI 2 IM 9; BU 1; IC 8; IN 7; P 3; SI 8; CE 4; PM 5; ASC 6; I 2; IS 2.

0

10

20

30

40

50

60

May2009

May2010

BUT (GSI)

BIAAQ

AAQ II

Conclusions

Looking at the scores of the different tests we can observe:

Psychological flexibility is increased as we can see from the results of AAQ II;

Body uneasiness sadisfaction in decreased as we can expect;

Body image Acceptance is still at a “border” range: discussin this with the client she reported that she have had an harder relationship with her body expecially in this mounth in which her illness symptoms started to change and let her suffer more;

the BMI is significantly persistent at 20.

This means that she isn’t avoiding life problems but….

And now she feel like a queen of her dragon

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

Thanks a lot for your attention!&

see you in Parma (Italy) 2011 ACBS World Conference

If you want to contact me:

Kmanduchi@hotmail.comwww.act-italia.org

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