Workshop held at Eating Disorders Alpbach 2013,

The 21st International Conference,

October 17-19, 2013

10/ 21/ 2013

1

How to deal with body image and drive for

exercise in the t reatment of pat ients with

anorexia nervosa, bulimia nervosa and binge

eat ing disorders?

How to deal with body image and drive for

exercise in the t reatment of pat ients with

anorexia nervosa, bulimia nervosa and binge

eat ing disorders?

Prof. dr. M ichel Probst

KU Leuven, Fac. Kinesiology & Rehabilitat ion Sciences

Univ. Psychiat ric Centrum, campus Kortenberg, Belgium

Where in Belgium?

• Flanders, Flemisch

language

• Leuven: 25 km from

Brussel

• Kortenberg: between

Brussel and Leuven

KU Leuven

2 PT-Rooms

3 sporthalls

1 fitnessroom

1 swimming hall

1 squash room

1 room for relaxation

Outdoor facilities

18 beds

Psychiat rist

Assistant psychiat rist

Psychotherapist (2FT)

Nurses (4FTE/ 1FTE)

Social Worker (½ FTE)

Fysiotherapist /

psychomotor therapist (1/ 2 FTE)

Occupat ional therapist (1/ 2 FTE)

The content

• An int roduct ion

• Assesment – body oriented therapy (theory) –

psychoeducat ion – goals for BOT – exercises

• Evaluat ion

Treatment philosophy

• An ameliorat ion of a dysfunct ional body image is necessary

for effect ive t reatment of ED [Bruch, 1973]

• Today, cognit ive behavioural therapies with or without body-

oriented therapy are included in most mult idimensional

approaches of eat ing disorders (Vitousek, 2002).

• We believe that psychotherapy combined with body-oriented

therapy are a more value for the t reatment

10/ 21/ 2013

2

Inpat ient

t reatment

Day t reatmentOutpat ient

t reatment

Individual

therapy

Group

therapyChildren

adolescents

Adults

SEED

AN EDNOSBN BED

Assessment – body oriented therapy

(theory) – psycho-educat ion – goals

for BOT – exercises

• 20 items, 6 point scale

• M aximum 100

• Factor st ructure• a. negat ive appreciat ion body scope

• b. lack of familiarity

• c. dissat isfact ion concerning the prevent ion

• d. rest factor

• Reliability: intern consistency, test -retest- split half

• Validity: construct & criterion validity

• Cutt -off scores

• Translated & validity assessment in different languages

• norms

BAT:

Body at t itude test

What is body oriented therapy:

definit ion

• a method of t reatment

• corporality and movement

• a body image assessment

• in a methodical way

• in consultat ion with the pat ients

• to realise clearly formulated goals

The importance to have a good theory !

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3

Global self

concept

Academic self

concept

English Science

Non-academic

self-concept

Social self-

concept

Physical self-

concept

Emot ional

self-concept

(Shavelson et al., 1976; M arsh, 1997; Fox, 1989; Fortes et al., 2004; Kowalski et al., 2003;

M orin et al., submitted)

Self- concept: multidimensional & hierarchical

structure

Self concept (theory of M arsh, Fox e.a.)

• Physical self concept / Impression

• Emot ional self concept / expression

• Social self concept / communicat ion

Edgar Degas

1834-1917

• Physiologic & motor dimensions

• Sensory dimensions

• Cognit ive dimensions

• Affect ive dimensions

• Behavioural dimensions

• Communicat ive dimensions

• Relat ional dimensions

• Symbolic dimensions

Psycho-educat ion

• The body

– The misconcept ion about the (funct ioning) body

– The misconcept ion about hunger (feelings of hungry)

• Exercises

– What const itutes exercises?

– The misconcept ions about exercises (feelings about exercise)

– To explain the energy balance

What happen when you eat?

The food sink into the

oesophagus, the stomach to

the intest ine.

But in some cases

• the food is going to

the head

• What happen when

eat ing rise to your heath?

• Chaos10 000 sit ups!

If one seconde/sit up: 3hrs

If two seconde/sit up: 6hrs

10/ 21/ 2013

4

• Chaos

• Anxiety,

• Anger,

• Hopelessness,

• Violence,

• Danger,

• Fear, unrest , agitat ion,

• Enemies,

• Fight & fight ,

• Power, control

• History,

• Prisoners,

• Pain,

• Sorrow, dist ress,

• Discriminat ion,

• Escaping,

• Wait ing,

• No perspect ives, no plans, no future

• Sun, warmth

• Rest , sleep

• Relaxat ion,

• Love,

• Peace,

• Dreams,

• Space,

• Freedom,

• Happiness,

• Sat isfact ion,

• Carefree,

• Structure,

• Future,

• Enjoy life

Armist ice

ParadiseWar

War is over.

You are more relaxed.

You have to be on the alert against

unforeseen situat ions.

There is freedom.

You need t ime to become familiar with the

new situat ion.

You can start making plans for the future.

You can rebuild a new life for yourself.

Relat ion r = 0,60

R²= 40%

10/ 21/ 2013

5

Body experience

Neutral lens

“ How do I really look?”

Intern lens

“ How do I see myself?”

Extern

Lens

“ How others

see me?”

Ideal

Lens

“ How would

I like

to look?”

The theory of lenses (Probst , 2007)“ Noli me tangere” (Don’t touch me)

Professional touch

Accidental touch

Funct ional touch (to give a hand)

Task-focused touch (basketball)

Support ive touch

Aggressive touch

Expressive touch (a hug)

...

A sum !

• 5 x 4 = 20

• 48 + 8 = 56

• 32 -11 = 21

• 12 x 3 = 39

• 55 : 5 = 11

• 45 + 21 = 66

• 76 – 9 = 68

• 7 x 8 = 56

• 64 : 8 = 8

• 15 x 4 = 60

• 5 x 4 = 20

• 48 + 8 = 56

• 32 -11 = 21

• 12 x 3 = 39

• 55 : 5 = 11

• 45 + 21 = 66

• 76 – 9 = 68

• 7 x 8 = 56

• 64 : 8 = 8

• 15 x 4 = 60

2 mistakes

8 Correct answers

H2O H2O

N=?

N = 10

Negat ive energy Posit ive energy

Chemistry

What are the goals for a body

oriented therapy?

Goals for body oriented therapy in ED Goals for body oriented therapy in ED

• (Re-)building a realist ic self-image

– Get tuned in to the body

– Awareness of the changes

– Acceptance of the changes

• Curbing hyperact ivity, tensions and impulses

• Communicat ion: Developing social skills

10/ 21/ 2013

6

“concretely formulated research goals…”

Specific – M easurable – Acceptable –Realist ic - Time

“SM ART”

Condit ions for

good goals !

- At home.- Seven floors: to take the stairs.- with the goal to decrease the shortness of breath

- Next week: If I don’t feel pain, I will take 3 times a week the elevator and climb stairs from the sixth floor to the seventh floor,- I succeed if I am not shortness of breath. At that moment I will take the elevator to the fifth floor.

- This change in behavior will influence in a positive way my health.

- It has been proven that more exercise and climbing stairs leads to better physical health and less breathlessness,

- Within 6 months, I want to do all floors without breathing problems.

Stepwise approach

One of my experience

A stepwise approach

Pat ients have to convince

themselves!

• Postural awareness

• Breathing exercises

• Relaxat ion

• Sensory & body awareness

• M assage

• Physical act ivit y, yoga, tai chi

• Dance & expression

• M irror exercises

• Guided imagery exercises

• Videoconfrontat ion

10/ 21/ 2013

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The exercise on itself

The exercise and the message behind the

exercise

Relaxat ion exercises

• Relaxat ion of Bernstein & Berkovec, based on

the progressive relaxat ion

• Autogenuous t raining

• Tai chi

• M assage

• Yoga

• M indfulness

• An Italian study 19 studies in which 1,231 people part icipated clearly shows that :

• Simple relaxat ion can do "miracles" for people who are anxious or tense. Two simple examples :

– Let your hands frequent ly hanging totally relaxed beside your chair or seat during a few seconds .

– Keep at tent ion to your breathing. Is that short and fast ? Slow down your breathing and t ry to breath deeper. A deeper, slowed breathing has an immediate posit ive impact on the mental and physical st ress level .

• Persons that consciously control their hands and breathing, do simple but accurate st ress management .

• M anzoni GM , Pagnini F, et al. (2013). Relaxat ion t raining for anxiety: a ten-years systemat ic review with meta-analysis. BM C Psychiat ry. 08 Jun 2;8(1):41.

Breathing exercises

– especially those aimed at a lowering respirat ion

frequency, amplifying abdominal respirat ion, and

lengthening expirat ion - are often included in relaxat ion

t raining.

– The object ive is not just to regulate respirat ion, it also

facilitates learning how to sense one's own body.

Sensory awareness

training

• These exercises aim at discovering the body through the senses in a non-threatening manner.

• Being conscious of internal sensat ions has a direct effect on the abilit y to recognize feelings. It is also the step to perceiving a mutual relat ion between bodily sensat ions and feelings.

– Body boundary exploration concent rates on tact ile awareness of the difference between one's body and the outside world.

– "Body scanning" (" t rip around the body" ) is a tact ile exercise to explore the external manifestat ions of the body through touching and feeling of the body boundaries

– M indfullness exercises

Passive mobilisat ion

• Body awareness (blind fold or not)

• Touch

• Control

to dare touching

to allow touching

• Relaxat ion

10/ 21/ 2013

8

Exercise : M irror, mirror on the wall…

Is made of glass that has been coated on one side

with a thin layer of reflect ive silver or aluminium

plate.

Italy, 16th Century

Intervent ion• M ild, non judge, curious,

respect ful way

• To be more aware or familiar with the body

• The whole body & body parts (frontal and profile image)

• Psycho educat ion

• The mental image

• Relat ion with self esteem

• Confrontat ion with their own

• Responsibility

• Discussion

The idea: habituat ion t raining

Invitat ion

2 x / week: At 9 AM and 1PM

½ hour & ¼ hour discussion

“ M y belly is fat ”

“ M y stomach is fat ”

“ I feel me thick”

Negat ive thought : “ M y belly is too fat ”

Alternat ive thoughts:

• M y bell isn’t fat at all, perhaps I' am wrong

• With this low weight , my belly cannot be fat

• I have a small size in clothing so my belly

cannot be fat

• Others never make any remarks about my

belly

• Perhaps I am too crit ical regarding my looks

A full bloated feeling in the abodomen

A disturbance in the movement pattern of the

stomach (gastric motility).

[a reduced motor funct ion of the lower part of the

stomach & a reduced relaxing power (adapt ive

relaxat ion) of the upper port ion of the stomach.]

8

AM

8

PM

10/ 21/ 2013

9

AN-P

AN-R

BN

Cut off

M irror exercises: evolut ion

2,1

2,3

2,5

2,7

2,9

3,1

3,3

Time 1 Time 2 Time 3 Time 4

BIAQ

BCQ

BCCS

Subject ive experience of ED pat ients

with PT

• 82% of pat ients indicated that they were

sat isfied with the body image therapy.

• The mirror exercises prove very valuable and

influence in a posit ive way the problems

• Pat ients with eat ing disorders experience the

body image therapy as valuable

• They ment ioned that it should be part of a

t reatment for pat ients with eat ing disorders.

“ Searching for Utopia”

(Jan Fabre)

Thank you for your attention !

For more informat ion & art icles

ht tp:/ / www.kuleuven.be/ wieiswie/en/ person/ u

0003430

M ichel.probst@faber.kuleuven.be