رفتار درمانی شناختی با مواجهه تصویری بدن برای پرخوری عصبی(بویلیما) : یک نمونه مورد

Cognitive behavior therapy (CBT) is an effective treatment for bulimia nervosa (BN). However, among patients with BN, symptom improvement is more pronounced for behavioral eating symptoms (i.e., bingeing and purging) than for body image disturbance, and the persistence of body image disturbance is associated with relapse. The need for more effective body image interventions led to the development of mirror exposure, which focuses on encouraging patients to view themselves in a holistic, nonjudgmental, mindful fashion. Behavioral manifestations of body image disturbance—body checking and avoidance—are also targeted in order to reduce and eliminate such behaviors and their associated preoccupation and distress. A preliminary trial of Body Image Exposure has shown promise, but it has not yet been tested in the context of CBT for BN. The case of “Sara” illustrates the application of this targeted treatment for body image disturbance. Central clinical issues around the perceptual, cognitive, and behavioral components of body image are delineated as they arose in treatment, as are issues of motivation and compliance. Treatment was associated with improvement in eating symptoms, body image, and mood.

Body image disturbance, a core diagnostic feature of anorexia nervosa (AN) and bulimia nervosa (BN) (American Psychiatric Association, 1994), is a robust risk factor for the development of eating disorders (Garner, 2002 and Stice, 2002) and its maintenance is associated with relapse in AN (Rosen, 1990) and BN (Fairburn et al., 1993 and Rosen, 1990). For BN, cognitive behavior therapy (CBT) is less effective in reducing body image disturbance than in improving the behavioral symptoms (e.g., binge eating and purging; Walsh et al., 1997) and the degree of body image change in standard CBT programs has been described as “modest” (Rosen, 1996, p. 339). As a result, there is a growing awareness of the need for more effective body image treatments to produce more clinically significant changes in patients with eating disorders (Fairburn et al., 2003, Rosen, 1996, Rosen, 1997 and Wilson, 1999a). One technique, based on the principle of exposure, involves patients systematically observing themselves in a full-length mirror (Rosen, 1997 and Tuschen-Caffier et al., 2001). Patients with BN react with distress to their body image as if it were a phobic stimulus (Laberg et al., 1991 and Tuschen-Caffier et al., 2003). When viewing their bodies in a mirror, individuals with eating disorders report greater negative emotions and cognitions than non-ED controls, but these negative emotions decrease over the course of the exposure (Vocks, Legenbauer, Wächter, Wucherer, & Kosfelder, 2007). Thus, systematic exposure should reduce the anxiety and the body avoidance that such exposure generates. Further, there is data supporting an attentional bias for weight/shape-related information, especially distressing information, among those with eating disorders. In front of the mirror, individuals with eating disorder symptoms spend more time looking at their self-identified “ugliest” body parts than at their “most beautiful” body part, an effect not observed in normal controls (Jansen, Nederkoon, & Mulkens, 2005). Key et al. (2002) reported a pilot study of “mirror confrontation” within an inpatient treatment of AN in which weight-restored patients received standard body image treatment with or without repeated use of the mirror exposure exercise. The mirror exposure group showed significant improvement at the 6-month follow-up compared with the standard treatment group, which did not exhibit statistically significant changes on any body image measures. Hilbert and colleagues (2002) evaluated the effects of repeated and prolonged body image exposure among women with binge eating disorder (BED). Although the BED group experienced decreased appearance self-esteem that was directly related to negative mood during the two exposure sessions, overall levels in Session 2 of negative mood and frequencies of negative cognitions were lower and appearance self-esteem was higher than in Session 1. Similarly, mirror exposure and training in the “neutral describing” technique (i.e., describing one's body as precisely and as neutrally as possible) produced increased body satisfaction and decreased anxiety in a controlled pilot trial with obese adolescents (Jansen et al., 2008). CBT for body image disturbance developed by Cash (1997) has also incorporated imaginal and in-vivo mirror exposure. In this desensitization exposure protocol, patients move through a hierarchy of “distressing body areas” while using relaxation skills to “dissolve any feelings of tension, distress, or discomfort” (p. 76). Self-monitoring of body image experiences and avoidant and compulsive behaviors is also included. One controlled trial (Butters & Cash, 1987) and several comparative studies (Cash and Lavallee, 1997 and Grant and Cash, 1995) indicate the effectiveness of this program among individuals with body image disturbance (and without clinical eating disorders). A recent study (Vocks, Wächter, Wucherer, & Kosfelder, 2008) examined the impact of a similar cognitive-behavioral body image therapy on responses to the in vivo situation of looking in a mirror for a prolonged time among women with eating disorders. After a 10-session group therapy that incorporated psychoeducation about body image, cognitive restructuring of dysfunctional thoughts, and body exposure (using mirror and video feedback), participants with eating disorders reported fewer negative body-related cognitions and emotions than at the start of treatment, whereas no change was observed in a non-eating-disordered control group. Wilson, 1999b and Wilson, 2004) has described a mindfulness-based adaptation of mirror exposure. Following Linehan's (1993) mindfulness training, patients are instructed to observe their entire body in a full-length mirror by taking a holistic view as opposed to selectively focusing on body parts that elicit distress, to describe it, to be nonjudgmental, and to stay in the present. The goal of this intervention is to help the patient shift from an automatic (and dysfunctional) mindset to a more controlled one in which she does not dwell on the past, worry about the future, or try to avoid any unpleasant aspect of the experience ( Segal, Williams, & Teasdale, 2002). The emphasis is on self-acceptance and tolerating negative feelings as they are experienced in the moment. Patients with BN tend to automatically judge their bodies in negative terms. Selective attention on real and perceived imperfections is hypothesized to maintain their dysfunctional concerns about shape and weight. This lack of self-acceptance generates frustration and negative affect, trapping them in a continuing cycle of distress. Mindful mirror exposure treatment is hypothesized to promote the emotional processing of distressing thoughts and feelings about body shape and weight. Behaviorally, mirror exposure prevents negative reinforcement or avoidance (Wilson, 1999a and Wilson, 1999b). In conjunction with mirror exposure, patients are instructed to engage in the behavioral homework assignments designed to reduce extreme avoidance (e.g., wearing baggy clothing or not allowing others to see their bodies) or excessive checking of body shape and weight. The behavioral assignments also serve as experiments for individuals to test their beliefs about avoidance and checking and to examine the function of these behaviors in regard to their reinforcement of negative thoughts and feelings. There is preliminary support for this approach, combining mirror exposure with behavioral interventions for checking and avoidance. Delinsky and Wilson (2006) evaluated the effectiveness of this therapy (in a 3-session format) compared with a nondirective therapy for 45 women with extreme weight and shape concerns who were randomly assigned to treatment condition. Mirror exposure resulted in significant improvements at termination and follow-up in body checking and avoidance, weight and shape concerns, body dissatisfaction, dieting, depression, and self-esteem. As hypothesized, mirror exposure was significantly better than nondirective therapy on many of the outcome measures. The present paper describes a patient with BN who was treated with supplemental body image exposure sessions in addition to standard CBT (Fairburn, Marcus, & Wilson, 1993). Treatment was provided by the first author under the supervision of the second author. Client Characteristics “Sara” was a 20-year-old single Caucasian female enrolled in her junior year of college at a large university. She reported that she had engaged in binge eating and purging for several years but did not seek treatment until the present time, when she agreed to come to the university eating disorders clinic at the urging of her boyfriend. Her body mass index (BMI) was 22.6, placing her in the normal weight range. She reported that she was engaging in intense daily exercise and eating two meals per day, while also trying to avoid carbohydrates and snacks. She was not involved in any other mental health treatment, nor was she on any psychotropic medication.