COGNITIVE-BEHAVIOURAL THERAPY ASSOCIATED TO THE PSYCHOPHARMACOLOGICALTREATMENT IN A CASE OF BULIMIA NERVOSA WITH COMORBID DEPRESSIVE DISORDER

This paper presents the cognitive-behavioural intervention associated with psycho-pharmacological treatment in a patient suff ering from bulimia nervosawith co-morbid depressive disorder that require specifi c treatment in view of the coexistent clinical depression that maintains the eating disorder. Wedescribed the structure of the therapeutic process and the steps followed in the therapy to achieve the proposed objectives.

Acco rding to the ICD-10, bulimia nervosa is a syndrome characterized by repeated episodes of overeating and excessive concern on the control of body weight, leading to extreme measures to mitigate the effects of ‘fattening’ caused by food intake [1].

Nervous bulimia is characterized by a morbid concern about body weight and shape, with severe disruption of eating behaviour [2]. It is a disorder affecting the control of the eating urge characterized by impulsive consumption of large amounts of food in a short period time, during which a person would not be able consume such a quantity of food under the same conditions. It can be accompanied by a normal weight or a weight loss. Normal weight is maintained through dietary restrictions, use of diuretics, purgatives or catabolism stimulants, intense physical activity and self-inflicted vomiting.

Eating instinct disorders typically begin between 11 and 18 years of age, becoming diseases when interfering with physical and mental health, causing severe medical complications and disrupting the life of the affected person. Mental bulimia was initially considered a variant of mental anorexia, Russell (1979) introduced the term bulimia nervosa to describe a form of anorexia nervosa [3]. The eating instinct has an important role in conserving the individual. The nuclei involved in the control of appetite are located in the hypothalamus (the arcuate nucleus involved in regulating the appetite; the paraventricular nucleus is responsible with the coordination of the food intake with the autonomic nervous system and endocrine system; in the lateral nucleus, there is the centre of hunger, where the neuropeptide secretory neurons are situated, which stimulate appetite; the centre of satiety is located in the ventromedial nucleus; and the dorsomedial nucleus integrates the rhythm of eating with the rhythm of sleep).

Hypothalamic centres that control the feeding instinct are in relation to structures that control the sexual instinct, the vegetative nervous system and hormone secretions, with structures involved in the motivational system and which integrate the endogenous rhythms. Therefore, bulimia nervosa may be comorbid with depression that has the serotonergic dysfunction as neuropsychic substrate [4].

The treatment of bulimia nervosa consists in psychopharmacological treatment, administering tricyclic antidepressants or selective serotonin reuptake inhibitors (SSRIs), and psycho-therapeutic treatment consisting in cognitive-behavioural therapy, family therapy and interpersonal therapy [2].

Research in adults shows that the pharmacological treatment has less beneficial effects than the cognitive-behavioural therapy, and these effects tend to vanish in time, therefore medication is being used as an initial step in the management of bulimia. Moreover, recent research also suggests that pharmacological treatment is beneficial if patients have a favourable response within 2 weeks from the initiation of treatment. [5].

“Therapy should focus on the normalization of eating habits and of the attitudes towards food, and on attaining ideal body weight”. [6].

Fairburn (1981) published the first study on the positive results obtained in the treatment of bulimia nervosa through cognitive-behavioural psychotherapy, the eating disorder being considered until then incurable (Russel, 1979). It was subsequently revealed that cognitive-behavioural therapy is the most effective way of addressing eating habits disorders [7].

“According to the cognitive-behavioural theory of bulimia nervosa, the central element of the disorder is the fundamental psychopathology of these patients: their self-evaluation dysfunctional cognitive schema” [8].

“Cognitive therapy is based on the cognitive model which claims that people’s emotions and behaviours are influenced by the way they perceive events. It is not the situation itself that determines what people feel, but rather how they build a situation (Beck A.T. 1964). The way people feel is associated with how they interpret and think about a situation. The situation itself does not directly determine how they feel; Their emotional response is mediated by their perception of the situation”[9].

“Therapy is based on conceptualizing the patient’s problems in cognitive terms, it requires a solid therapeutic alliance, emphasizes collaboration and active participation, is goal-oriented and focuses on the problem, emphasizes the present, is educative, aims to teach the patient to be his/her own therapist and focuses on preventing relapse. It aims to be short-term, the meetings are structured, teaching the patient to identify, evaluate and respond to his/ her own thoughts and dysfunctional beliefs, it uses a variety of techniques to modify the patient’s way of thinking, his/her affective states and behaviour”[9].

Dysfunctional o r distorted thinking styles can cause or exacerbate dysfunctional emotions and behaviours. Cognitive interventions have the role of identifying and debating distorted automatic thoughts, maladaptive beliefs and dysfunctional schemas. Likewise, behavioural techniques may be used to test and discuss the cognitive distortions [10].

“The characteristics of the behavioural therapy: It is based on scientific principles derived from experimental research in the field of learning, principles based on observation and not on personal beliefs; It deals with the current problems and the factors that influence them in the present, without focusing on the historical perspective; The patient plays an active role in therapy, which takes place as much as possible in the patient’s natural environment; It emphasizes behavioural selfcontrol techniques; Interventions are designed so as to accommodate each patient, evolving from simple to complex, from easy to difficult situations and from less to more threatening circumstances; The therapeutic approach is relatively short, the therapeutic techniques combine in some strategy packages to increase the effectiveness of psychotherapy” [7].

The methods operating within the frame of the behavioural therapy are recommended in child and adolescent eating disorders and they are also effective in early feeding problems. They may be used effectively both in hospital and in outpatient clinics, both in rehabilitation centres and at home (applied by parents, co-therapists) or at school [11].

Cognitive-behaviou ral therapy is a time limited, short-term therapy that uses Socratic dialogue and is based on a relationship of reciprocity among cognitions, emotions and behaviours. It uses behavior therapies based on learning principles and cognitive therapies based on the cognitive interpretation of experiences in determining emotions and behaviours.

CASE PRESENTATION

M.R, 17-year-11-mo nth old, female gender; From the urban environment. She came to the specialized ambulatory, on October 31, 2016, requesting hospitalization, for a psycho pathological picture dominated by: recurrent episodes of excessive eating (eating a large amount of food in a short period of time, for example: 2- 3 rice plates with roasted meat and potatoes, 3 pieces of flat bread, 3 bowls of rice with milk and honey, 2 pieces of flat bread, ice cream and 4 Danone puddings in less than 2 hours), feelings of lack of control on the eating activity during the episode: “I lose control”, “I think it is the last dish I eat, as if there were no longer another day, I can not stop eating”; the episodes are followed by purgative compensatory behaviour (excessive use of laxatives and, more rarely, self-inflicted vomiting).

The compulsive episodes have a duration of about 1-2 weeks, followed by restrictive diet (days when she sometimes eats only a carrot or an apple) for about 5 days. The patient also manifests: sad mood with mild crying, fatigue, awakening insomnia (goes to sleep at 10:00 or 11:00 p.m. and wakes up at 1:00 or 2:00 a.m.), ideas of guilt related to her physical appearance and school failure, autolytic tendencies “I often think that death is an easier escape”, “I have almost nothing to lose”, “I contradict myself – a normal part is bored and the other part is suicidal”), fright towards the future (“terrible fear of the future”, “I have always felt anxiety about the future”), no longer enjoying activities previously enjoyed (reading, music, films), socially withdrawn with restricted sphere of activity, low concentration of attention, low self-esteem.

MACRO-LEVEL OF ANALYTIC DATA

• Anamnestic/biographic data:

– The patient comes from a family disorganized by the divorce of parents in April 2016, when she was given in her mother’s custody. Parents live separately from the patient’s 2 years of age. She is a smoker and occasionally drinks alcohol, two years before, she used to consume alcohol and psychoactive substances (ethnobotanic substances, marijuana). Intra-familialrelations are tense and conflictual, with physical and emotional abuses. She has a 26-year-old brother who has founded a family and lives in England, and his wife and child live in Romania.

– Poor economic conditions. Mother is a maternal assistant, she had in foster care a child with a severe mental retardation since the child was 3 years old until the age of 14 (but she gave up in September

– affirmative – because of the child’s behavior disorders). Since September she took in foster careanother 10-year-old boy – affirmative – with severe mental retardation and genetic syndrome. The patient is jealous on this child because he took the place of the boy he grew up with as a brother and she would want the first boy back.

– Catholic religion.

– She attended the kindergarten, in primary and secondary school had very good school records.

Relationships with colleagues were good up to the 6th grade when “I started to dress myself strangely, I thought I was a punk”, “my colleagues made fun of me because I was fat”, “I was more isolated”. In the 8^th grade, she met a group of pupils from the School of Arts and began acting in theatrical performances with them. She was admitted to the “Grigore Moisil” High

School in Timisoara among the first candidates, at the intensive mathematics section, but failed to graduate it. In July, a teacher at the School of Arts chose “a colleague who did not have talent, just looked good” in order to play the leading a role in a theatrical play that the patient should have interpreted. After this incident, she was concerned that “if I went to the best high school, I also have to be very slim and beautiful”.

She tried to keep “slimming diets”. She went to school until October, when she stopped attending school because of her adherence to adolescent groups with behaviour problems, of drug consumption, and eating disorder. In March 2014, the maternal grandmother died, (attachment person) of whom the patient says “I loved her a lot, she was like a kind of mother”. She is not currently attending school.

• Anamnestic-clinical data:

History of the present illness

The patient entered the psychiatric circuit in November 2014 , being admitted to the NPCA Clinic in Timişoara with the diagnostics: anorexia nervosa and depressive disorder, and she had anxiolytic, mood stabilising medication and individual psychotherapy treatment with remission of symptoms of eating disorders and the persistence of depressive symptomatology.

In November 2015, she is admitted to hospital again for recurrent depressive disorder, the current episode is moderate, and was discharged with anxiolytic and mood stabilising treatment, without ever coming to the clinic for consultation.

Affirmative: evolution was good until July 2016, when the patient, feeling stressed, went to her father abroad, where she was physically and emotionally abused. Affirmative, she experienced marked anxiety states and negative emotional feelings with the appearance of bulimic episodes. During this period, a psychiatrist was consulted and they recommended antidepressant medication with Fevarin.

She is currently present in the specialised ambulatory, requesting hospitalization, following the accentuation of the symptomatology that debuted in Jordan.

Personal physiological antecedents: G – 2, P – 2, pregnancy with physiological evolution, affirmative, Caesarean birth, GA – 9 months, BW – 3200 gr, APGAR – 9, Physiological jaundice, performed vaccines, psycho motor development of age stages, affirmative, normal.

Personal pathological antecedents: Anorexia nervosa, depressive disorder– 2014

Family medical history:

Mother – depression and chronic alcoholism (affirmative: since the patient’s 5 years of age.)

Father – alcoholism.

Somatic examination: Good general condition, pale skin and mucosae, normally represented adiposev- connective tissue, balanced cardio-pulmonary and digestive.

BMI-24 Kg/mp (W=63Kg, H=1.61cm).

Clinical and para-clinical examinations: within normal limits.

STANDARDISED TOOLS

1. The Beck Depression Inventory (BDI), score 43, severe depression

2. Assessment of eating disorders, Christopher G.

Fairburn, bulimia with compensatory behaviours

Mental Level: IQ = 110 Raven.

Psychic exam: Patient in dark, sloppy, she widebodied clothing with poor body hygiene (she did not have a bath for 2 weeks), spatio-temporal, auto and allopsychic and situational orientation, clear current field of consciousness, visual contact is maintained intermittently for the duration of the interview, the psychic contact is done with slight difficulty, abstract thinking, coherent ideo-verbal flow, ideas of guilt and futility, ruminations on the physical aspect and on the theme of school failure, ideas of loss of control, ideas of unacceptability and futility, mild hypomnesia, difficulty in concentrating attention, no disturbances in the sphere of hallucinatory perception or the illusion type perception. Sad mood, easy crying, low capacity of emotional self-adjustment, irascibility, affective ambivalence towards her mother, low selfesteem, intra-psychic tension, anticipatory anxiety, inclination to social withdrawal, narrowing of the sphere of interests and activities, anhedonia, altered eating appetite (episodes of hyperphagia – large amounts of food in short periods of time lasting about 1-2 weeks, followed by a maximum of 5 day period of restrictive diet). Immediately after the episode of eating large amounts of food, the patient uses laxatives and sometimes self-inflicted vomiting. Modified nictemeral (circadian) rhythm, awakening insomnia, the insight is present.

Diagnosis according to the DSM 5 diagnostic criteria

Bulimia nervosa. Recurrent major depressive disorder – present episode is severe without psychotic symptoms. Problems connected with education in the family. Problems with school education and school instruction.

The DSM 5 diagnostic criteria for bulimia nervosa: recurrent episodes of compulsive eating consisting in the ingestion, in a relatively short period of time, approximatively 2 hours, of an amount of food that surpasses by far the amount that the majority of persons would eat in the same period of time and in the same circumstances; the sensation of lack of control over the food ingested during the episode; the feeling that she cannot stop herself from eating, that she loses control, that she cannot control the neither the foods that she ingested, nor their amount; recurrent compensatory behaviours in order to prevent the increase in weight gain: abuse of laxatives and provoked vomiting; on the average the compulsive and compensatory behaviours appear at least once a week for three months. The patient has a low self esteem influenced by her bodyweight and appearance. The disturbance does not appear exclusively during an episode of anorexia nervosa.

Level of severity: on average 8-13 inadequate compensatory behaviour episodes a week. (severe) [12]

The DSM 5 diagnostic criteria for major depressive disorder: – current episode is severe without psychotic symptoms: the presence of more depressive episodes, with at least 2 consecutive months when the criteria for major depressive episode were not satisfied, depressive disposition the largest part of the day, diminished interest and pleasure for activities the largest part of the day, weariness, lack of energy, feelings of uselessness and guilt, decrease of the capacity to concentrate de attention, recurrent thoughts of death and those connected with school failure, suicidal ideation, significant deterioration in the social and schooling field. The symptoms determine a clinically significant deterioration in the social and schooling field as well as in other areas of functioning. The episodes are not due to the physiological effects of a substance or of a medical affection and the depressive episode is not explained by a schizophrenic disorder, schizophrenia, schizophreniform disorder, delusional disorder or by other disorders in the spectrum of schizophrenia, or other psychotic disorders and there was no maniacal or hypo-maniacal episode [12].

Problems due to family education – quality of parentchild relationship influence the medical evolution, prognostic or treatment. The dysfunctional parent-child relationship associates with functioning disturbance in the behavioural, cognitive or affective area [12].

Problem due to school education and instruction – school abandonment impacted on the diagnosis and the treatment [12].

Differential diagnosis – Bulimia nervosa:

anorexia nervosa, type with compulsive eating, compulsive eating disorder, Kleine-Levin syndrome, depressive disorder with atypical elements, Borderline personality disorder.

Differential diagnosis – Major depressive disorder: all the somatic organic disorders, depressive or bipolar disorder induced by substances or medicaments, bipolar disorder, personality disorders, adaptation disorder with depressive disposition, anxious disorders, hyperkinetic disorder.

“The comorbidity of psychic disorders is frequent in individuals with bulimia nervosa, most of them having at least one more psychic disorder. The comorbidity is not limited to a particular subgroup, but rather it includes a large range of mental disorders” [12].

Micro-level data Predisposing factors: the dysfunctional family; genetic vulnerability; lack of adequate supervision; lack of parents’ involvement in bringing up and educating the patient; the parents’ alcohol consumption; absence of daily activities; depression comorbidity.

Precipitating factors: visit to the father.

Perpetuating/maintaining factors: family environment; lack of the social support network; dysfunctional schemas: “I am useless”, “Nobody likes me because I am fat”, “I will be accepted only if I am thin”; maladaptive beliefs: “If I am fat, I cannot do anything in life”; distorted automated thoughts: “I am a loser”, “Everything goes wrong for me”, “I have nothing to lose”, “I am a cow”.

CONCEPTUALIZATION

The central element is represented by the overestimation of the silhouette, of bodyweight and of their control.

The compulsive eating is the result of the tendency to restrict the food intake. The patient adheres to strict eating habits and reacts negatively when the rules cannot be observed and are violated, even a small deviation from the strict rules is considered a proof of the lack of control (“I feel that I am losing control”).

The sense of loss of control makes the patient give up for a while the restrictive diet and, for a while, she yields to the impulse to eat resulting from food restriction and diet. This situation leads to a period of excessive, uncontrolled eating, an episode of binge eating, thus creating a vicious circle where the patient’s attempts to reduce food intake are interrupted by compulsive eating episodes. Compulsive eating maintains and amplifies the patient’s concern with weight and silhouette, enhancing the decrease in food consumption and increasing the risk of compulsive eating episodes.

These episodes of compulsive eating are triggered by negative emotional experiences and negative events. At the same time, compulsive eating episodes make the

CONCEPTUALIZATION

patient turn to compensatory behaviours (laxatives, vomiting), which also maintain compulsive nutrition.

The depressive symptomatology (at behavioural, c ognitive, affective, motivational and somatic levels) is the consequence of cognitive distortions and cognitive schemas that have developed according to the early experiences undergone by the patient in the first period of childhood, these early experiences led to the formation maladaptive beliefs. Activation of the schemas occurred when the patient was faced with both external and internal stressors (the stress during the visit to her father). The activation of schemas has led the patient to have a negative perception of her self-image, of her present and future living experiences, negative perceptions about others and the world in general.

These negative beliefs about oneself and about the others are maintained by distorted automatic negative thoughts that represent a dysfunctional thinking style and are based on a series of errors of thought.

The vulnerability that played the role of risk factor in developing the depression was maternal depression, parental alcoholism, and the parents’ separation.

THERAPEUTIC TARGETS

The patient’s targets according to their importance:

• “Not to be dependent on laxatives and not to eat in excess.”

• “To be able to continue my school studies.”

• “To be able to sleep” Targets established together with the tharapist:

• “to eliminate the compulsive eating episodes and laxative consumption”

• “to get involved in activities aiming at social and school integration”

TREATMENT PLAN

Medication: Antidepressant – selective inhibitors of serotonin uptake, SSRI (Sertraline) inhibitori selectivi ai recaptării serotoninei, SSRI (Sertralină), mood stabilising (Topiramate) and anxiolytic (Alprazolam).

1. Cognitive – behavioural therapy

The first stage of the cognitive-behavioural therapy lasted 3 weeks, with two sessions a week.

During this stage, the patient’s medical case history was assessed in order to establish the diagnosis, the severity of the symptomatology with the evaluation of the suicidal risk and the establishment of the most adequate treatment modality; at the same time, a contract between the patient and the therapist has been concluded concerning the suicidal risk. Another aspect was to involve the patient in the therapy, the therapeutic relationship being a priority.

For the assessment of the patient, besides medical history, the standardised tools mentioned above were used. The Socratic interview was used.

• Psycho-education concerning bulimia (the characteristics of bulimia, importance of regular meals, of the gap between meals, myths about eating, “the forbidden food”, lack of influence of laxatives on intestine absorption and elimination of excess kilogrammes, BMI (body mass index), implication of neurotransmitters, serotonin in satiety and appetite, dopamine in reward) and the optimised cognitive-behavioural therapy of bulimia, information that is necessary to increase adherence to the therapy.

• Conceptualization and establishment of therapeutic targets (the list of the patient’s target list and the list set up together with the therapist.)

• Measuring body weight and outlining the schedule of body weight evolution for the duration of the therapy in order to inform the patient on the weight and to find out the changes in weight during the therapy and to interpret weight correctly. The patient was taught that she should not focus her attention on each weighing, the latter being irrelevant due to variations in hydration level and to other biological processes; the changes are relevant only during the last 4 weeks.

Functional analysis: Lang model

• The patient drafted a list of forbidden foods, then she was advised that, if she avoids these foods, thinking that eating them she will put on weight, then she will have a compulsive eating episode. A small amount of the forbidden food will mean that the imposed rules have been broken, and she will feel that she has lost control, and this will bring a new episode of compulsive eating. There are no fattening foods by their nature, everything depends on the amount of the food that is eaten. The recommended amount of foods is what allows the preservation of am optimal bodyweight and contains the nutrients necessary to a balanced diet.

The second stage, of transition, unfolded over a period of 2 weeks (one session a week) and consisted in the assessment of the progress and of the evolution,the difficulties and obstacles faced during the previous six sessions and in the execution of the homework tasks. This stage prepares and helps in the planning of the third stage. The attitude of the patient towards the treatment as well as the efficiency of the techniques used in the therapy.

The third stage played an important role in the therapy and dealt with the modalities by which the patient’s psychopathology is maintained. The duration was of 8 sessions, with the frequency of 1 session a week.

The last stage, the final one, consisted in 2 sessions scheduled at 2 weeks’ distance, focused on the future, to prevent relapses. The plan of relapse prevention consisted in the assessment of the risk situations and of the alarm signals, summarizing the sessions, techniques and exercises performed during the therapy, plans for the future.The cognitive-behavioural techniques used during the therapy were the following:

Behavioural intervention:

Planning a diet with regular meals (3 meals, 2 snacks as follows: breakfast, lunch, afternoon snack, dinner, evening snack, without nibbling between meals, the patient was to eat nothing besides the meals and snacks), followed by the rapid decrease in compensatory behaviours. The patient had to choose what she wanted to eat during the meals and snacks, on condition that they would not be followed by compensatory behaviours.

No more than 4 hours were to pass between meals and snacks and she was not to skip any of the scheduled meals and snacks; she had to take into account the times when her family had their meals and not her hunger or satiety sensation. The choice of the foods was not to be influenced by the hunger or satiety sensation. When she had to go on visits or in town with her friends, she had to plan what she was going to eat, to analyse the possibilities in the menu, which she might order, and then to plan how and how much she would eat.

In order not to eat between the planned meals and snacks, the patient performed various activities which should avert her attention from the hunger and satiety sensation. Likewise, the patient became involved in various activities in order to divert her attention at the moment when the thoughts which feed her compulsive and compensatory behaviours appear. Such activities are: talking to mother, calling a friend, imagining pleasant things, reading a couple of pages from a book, watching a film.

During the meals, the patient should not have gotten involved in other activities which might have led to excessive consumption of food, she had to put theportion of food on the plate before starting to eat and put away the container with the rest of the dish, so as not to be tempted to supplement her portion; the duration of the meal had to be of about 15 minutes, and the patient had to avoid eating quickly, being able to control this activity by talking with her mother during the meal.

• Planning the activities, the patient draws a pie chart with the daily activities and together with the therapist designs a personal care plan, with supporting and opposing solutions and then chooses the best solution. Likewise, a plan for enrolling in a form of education is established as well as a plan of the activities that are to be performed.

• Management of contiguities for a balanced diet and avoidance of “nibbling” between meals;

• Behavioural activation with the planning of daily activities and self-rewarding;

• Learning assertive skills in the relationship with the family. For example: “I understand that you are angry, but it would help if you tell me what you want me to do so as not to make you angrier.”

Interruption of negative thoughts (“stop” to the negative thoughts, a method that helps the interruption of the flow of negative ideas)

Cognitive interventions:

• Identification and cognitive restructuring of the dysfunctional schemas, of the distorted automated thoughts and of the maladaptive beliefs, with the explanation of the way how the schemas are formed and how they distort events. For example, “I am useless”, “Nobody likes me as I am fat”.

• Registering the negative automated thoughts (NAT): For example: “I am fat, desperate, disgusted, pathetic”, “In society, it is important how one looks like”; Assumption: “If I do not lose weight, I will not be able to do anything.” Basic schema: I am unacceptable.

• The road to change with the following obstacles: (obstacles: “one single thought: to start my clean life again, I take laxatives”, “social events”, “I want to lose weight a little, to have a nice body”, “I lose control”, “I cannot forbear”)

• Understanding the belief: “In life you cannot achieve anything if you are fat” – “If I am fat, I cannot achieve anything in my life”. Examples of “fat” persons who are successful.

• Proofs that sustain and that contradict the thought: “I am not obese, but I am fat.” Analysis: “The feeling of being fat” or “I am fat” with the analysis of stimuli (boredom after the meal, sensation of being full, despair) and of emotions (sadness, anxiety) which she feels at that moment. The perception of the patient that she “feels fat” is important in the therapy, because the perception tends to be equivalent to being fat, regardless of the patient’s real weight.

• ABC Diary

Example 1:

A Situation: “Afternoon. At home. I ate a lot.”

B Thoughts, convictions: “Before: don’t do this, eat less and eat something healthy! After: if you are a pig, you deserve to die, you will never be successful and you will not be happy!”

C Consequences/reactions: “Disappointment, despair, fright, nervousness. I bustle, I glut, I steal money, I take laxatives.”

Example 2:

A Situation: Evening at home”

B Thoughts, convictions: Before: “I do not have to eat, I have to resist, I resist now and that’s it, I tried to oppose desperately, panicked, fearing

that I would fail.” During: “it would have been better that the food were tastier” After: “I could have resisted, the food was not so good anyway, the taste disappeared but the kilogrammes are still there.”

C Consequences/reactions: “Existentialist crisis: desperate, disgusted, disappointed, pathetic.”

In the course of the therapy, the patient’s insomnia ameliorated, with ulterior remission due to adherence to certain rules: establishment of fixed hours of going to bed and of waking up; during sleeping, the only reason for getting up had to be urinary incontinence and to prevent incontinence, the intake of liquids and hard-to-digest foods was reduced after 7 o’clock in the evening; before bedtime, renunciation to activities with a high degree of activation, as for example telephone, television, reading; patient should not propose herself to fall asleep and think that she does no longer think of anything; she had to count from 100 backwards, every seventh number; should not have bright sources of light in the room and should not listen to loud music at headphones.

The tasks assigned to the patient during the therapy period consisted in:

– Reading about bulimia and CBT in the materials provided by the therapist and on www.bulimie.ro website;

– Keeping a real time, self-monitoring diary to track behaviours, thoughts, emotions and situations, events that are relevant for the preservation of psychopathology (self-monitoring process being continuous during the whole therapy period;

– Implementing the daily schedule of 3 meals and 2 snacks, at regular times, without nibbling in between;

– Avoiding compensatory behaviours;

– Diverting attention between meals;

– Taking care of corporal hygiene and applying to a form of education according to the plan;

– Writing a letter from the future: what the future would look like in 5 years’ time, what she would write about herself after 5 years if at present she undergoes therapy and how she sees herself in 5 years’ time and what she would write to herself if she did not undergo therapy.

At the beginning of each session, the homework tasks were assessed and the patient and the therapist discussed the difficulties faced in performing the current tasks.

Observations: Taking into consideration the depression comorbidity, during the therapy, the work with the patient involved both cognitive-behavioural techniques specific to eating disorders and cognitivebehavioural techniques for depression. In the 3rd stage, the conceptualization for depression was done.

The therapy ended in an agreement between the therapist and the patient, at the moment when the proposed target were reached, with remission of the eating disorder, improved affective mood and attainment of a level of functioning corresponding to the patient’s age.

During the last two sessions, the discussions focused on the departure for the experience exchange abroad, enrolment to swimming and ballroom dance classes, taking job during the summer holiday in order to earn a supplementary income, completing the high school studies and the patient’s wish to attend the faculty of psychology or medicine, her wish to enter into a relationship.

The follow-up meetings meant to prevent the relapses and assess the evolution in time took place at 1 month after the completion of therapy, before the departure abroad, respectively at returning from abroad; at 4 months after the completion of therapy, at the end of the academic year and before being hired as cashier at a supermarket; the next follow-up meetings were to take place after about 6 month from the completion of therapy, at the beginning of the new academic year, after 1 year or whenever needed.

Forms of progress: The evolution was favourable with “the control” of compulsive episodes and the lack of compensatory behaviours, with periods of “sliding” before session no. 10 and session no. 14; the patient wears clothes that fit her waistline, her appearance is tidy, the corporal hygiene is preserved, well-groomed, she lost 6 kg in weight; enrolled in a private high school, completing the 9th grade with very good school records, at the end of March she went to an experience exchange abroad; she reads, listens to music, watches films, goes for walks; she is sociable, attends classes of swimming and ballroom dances.

Favourable prognostic factors: age, intellect and compliance to treatment.

Unfavourable prognostic factors: lack of social support networks, presence of co-morbidities, the dysfunctional family, anomalous educational environment, lack of adequate controlling on the parents’ part, the parents’ alcohol consumption, mother’s untreated depression.

Peculiarity of the case: The therapeutic relationship, adherence to treatment, personality traits and the intellect facilitated the modification of the “problematic” behaviours, cognitive restructuring of the dysfunctional thoughts, increase in self esteem and positive affective living thus developing resilience to the negative events and the their risk factors.