MSBH 7001, 2004/05

1. MSBH 7001, 2004/05 Individual Presentation By Poon Man Kay

2. Enjoy eating.

3. Enjoy eating?

4. I cannot control from eating!

5. A young lady who ate a lot A 25-year-old clerical worker could not help her from stopping eating for eight years.

6. When she was 17-year-old, she prepared for the HKCEE and she terminated the relationship with her boyfriend. • After that, she considered herself obese. • Her body weight was 56.8 kg with body height 1.55 m. BMI=23.6

7. She attempted dieting and exercise to reduce her body weight. • Without the usage of medication, including Western or herbal medicine. • Her body weight decreased to 50 kg. BMI=20.8 • Very successful! Every lady might envy her. • Then, what happen?

8. She could not resist the urge to eat because she was too hungry. That was “normal”. • She continued with this pattern of eating.

9. Gradually, She developed the urge to eat even thought she was NOT hungry. • She knew that she was in trouble. • She tried to resist the urge to eat, but she could not tolerate the discomfort generated. • Eating a lot could bring her joy of eating and help her from relieve stress and loneliness.

10. Gradually, she found that eating was disgusting as she ate two to three lunch sets in one setting, completed within one hour (binge eating). • She worried she would be obese after eating. • “Luckily”, she was very clever that she could compensate the weight gain by exercise and repeated regurgitation. • Urge binge eating purging, exercise

11. Repeated regurgitation made her too weak to perform exercise (due to electrolyte imbalance, dehydration). • She was under the control of the urge to eat. No social activity, but only eating alone! • Her life fixed onto food. Nutrient was NOT her consideration.

12. Self-control of not to eat failed repeatedly. • She was frustrated. She felt hopeless and helpless. She considered herself as total personal failure. • She explained her condition to her family and family physician. She felt nobody understand her. As a result, her problem could not be solved. • One day, her chance of “recovery” came! (in fact, it should be remission). • What was it?

13. She was referred to Centre of Behavioral Health. • The diagnosis was Bulimia nervosa (BN), purging type (DSM-IV-TR). • Differential diagnosis: Anorexia nervosa, major depressive disorder, anxiety disorders.

14. Bulimia Nervosa • Adapted DSM Criteria: • A. Recurrent episodes of binge eating: (1) Eating, in a discrete period of time, an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances. (2) A sense of lack of control during the episode. • B. Inappropriate behavior to compensate. • C. Eating and compensation at least twice a week for 3 months. • D. Self-evaluation is unduly influenced by body shape and weight. • E. Not due to anorexia nervosa. • Two types: purging and non-purging type.

15. She was invited to attend the PC in Action. • The interview was targeted on the aspects of eating behavior, loneliness, assertion, expectation from others, interpersonal relationship, low self-esteem, low self-image, and her fragile and weak self. • To normalize her eating condition. It was a eating control problem, not a disease (i.e. to save her face, to decrease her guilty and shame).

16. To find out her strength to fight against BN. The strength included she want to get marriage and she want herself well. • The PC in Action group validated her “symptoms” and empower her. • She had to discuss, agree and accept those methods suggested by the group before implementation. • To learn to enjoy eating, rather than suffering from eating.

17. Behavioral strategies were designed • To let her trusted persons to know her condition and difficulties. To seek support from people. • On the urge to eat, she agreed to perform other activities such as talking to people, walking away and being occupied by other event instead of eating (i.e. to interrupt the chain of behavior). • To brush and clean her mouth as a full-stop signal of eating when she felt the urge. This method was considered most useful by her. • Once she could not help her from eating, she was advice to eat and chew the healthy food such as carrot sticks slowly.

18. Follow up visit • Two follow-up consultations afterward. • In the sessions, to find out her difficulties and work out the solutions with her. • To find out her “dysfunctional thought”. • To maintain her gain. To show her people were taking care of her. She needed not to conform to people. • Six weeks later, She could control her eating problem and showed great clinical improvement.

19. Clinical result • No more binge eating. • Better inter-personal relationship. • More self-fulfillment, more sense of mastery, more self-efficacy, improved self-esteem. • Improved general health. • Group support and courage were important for success.

20. She believed that every BN patient should not lose confidence. • She continued to aware not to engage in binge eating again. • She would be enthusiastic to help other BN clients.

21. Points to learn • This case demonstrated the powerfulness of conducting interview in this PC in Action group setting. • Behavioral methods in controlling BN were effective. • To handle the inner self of client was also important in management of BN.

22. Suggestions • To work out her past developmental history and attachment pattern. To conform other may be relevant to the Chinese Psychology in the relational self. • Difference in the prevalence rate of BN between Western and Chinese societies? • Usually, BN patient show some problems in these aspects. • To invite her family members to the interview will be appropriate. • To prevent her from relapse, we should find out the cause why she adopt binge eating as defense. • That is CBT alone is not the only answer to her.

23. Medication can be considered if patient is associated with depressive features that are common and psychotherapy alone failed. • To study the efficacy of CBT in this PC in Action group setting, CBT in traditional group setting and CBT in individual basis may be useful to find out the effectiveness of PC in Action group setting in Counseling and Psychotherapy. • Interpersonal psychotherapy (ITP) is another option of psychological treatment. ITP does not focus on BN symptoms.

24. Slimming industry is suspected leading to more eating disorder cases. Eating disorder management is going to be a big business.

25. Bulimia Nervosa • Individual with bulimia may be of normal or low body weight. • 90% are female. • Typically begins in adolescence or young adult. • Usually begins after dieting. • Persists for several years. • Can be chronic or intermittent with periods of remission alternating with binging.

26. Common Comorbidities • Major depressive disorder • Dysthymic disorder • Social phobia • Anxiety disorders • Substance use disorder • Medical complications

27. Thank you! Questions welcome