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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 !
10/ 21/ 2013
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
7
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