Well-Being Therapy in a Patient with Anorexia Nervosa
Authors: Elena Tomba, Lucia Tecuta
Journal: Psychotherapy and Psychosomatics (2016)

While cognitive-behavioral therapy (CBT) is considered a first-line intervention for eating disorders (ED) [1], the development of novel strategies to improve recovery rates is needed. The concept of recovery in CBT is based on the absence of illness or the reduction of negative behavioral outcomes, commonly considered the gold standards for mental health. Gains in positive functioning are frequently not considered, despite findings indicating impaired psychological well-being in various psychiatric illnesses, including EDs [2]. Such impairments may be associated with increased vulnerability to future adversity [3,4]. A higher dropout risk, a common occurrence in EDs, is associated with a lack of positive psychological characteristics, specifically a low ability to pursue life goals [5]. Following standard treatment, ED patients also frequently report persistence of psychological symptoms [6]. Therefore, effective treatment may benefit from promoting positive functioning in ED patients.Well-being therapy (WBT) is a specific short-term psychotherapy focused on the promotion of psychological well-being. So far it has been applied in sequential combination with CBT, but may be used as the only therapeutic strategy [3]. It emphasizes self-observation and monitoring of moments of well-being with the use of a structured diary, through which patients identify automatic thoughts and behaviors that interrupt well-being prematurely. WBT is based on the conceptualization of positive mental health proposed by Jahoda [7], translated into a psychometric questionnaire by Ryff [4]. Psychological well-being encompasses six inter-related dimensions of optimal functioning: a sense of autonomy, continued personal growth, mastery over one's environment, a sense of purpose in life, positive relations with others, and self-acceptance. While clinical interest for WBT is mounting [3], it has never been tested in ED before. The following case report illustrates a possible application of WBT in a patient with anorexia nervosa binge-eating/purging subtype.Patient M. is a 23-year-old woman with a diagnosis of anorexia nervosa with a body mass index (BMI) of 16.0 who reported bi-weekly binging-purging episodes and not using laxatives or diuretics. At the age of 13 she was overweight, and soon after her father separated from her mother she began experiencing disordered eating behaviors with chronic restrictive dieting. She was assessed and diagnosed with anorexia nervosa by a psychiatrist the following year. Between 17 and 21 years of age she underwent several cognitive-behavioral and nutritionally based treatment programs based on the guidelines of the American Psychological Association [8], which did not greatly improve her clinical status. The focus on distress during her CBT was a trigger for increased anxiety and self-doubt for the patient, which brought on more severe restriction and binging and purging. Indeed, her records showed only a short-term improvement in her BMI from 15.3 to 16.0 and in binging-purging episodes (reduced from 4 times weekly to bi-weekly), and showed persistent comorbid depressive symptoms, high irritability, and environmental reactivity as measured by the Clinical Interview for Depression (CID) [9]. She was unable to resume her studies or find work and her life generally had no direction. She described finding her disorder unbearable and wanting to get well. Given her nonresponsiveness to CBT she was referred to a different psychotherapist who applied WBT following two clinical hypotheses. Firstly, due to her high environmental reactivity, the patient through WBT could work on automatic thoughts using a well-being instead of a distress-centered approach. Secondly, due to both an intolerance to getting well and identification with her disorder (e.g. 'If I change the way I am, how am I going to spend my time? I will have nothing to live for'), WBT could encourage the recovery process of the patient, haltered by distressing feelings of loss of identity and purpose in life. She completed eight 45-min weekly individual sessions of WBT, according to the treatment manual [3]. The first two sessions aimed at identifying episodes of well-being in the patient's life. The third and fourth sessions focused on identifying and recording in a diary thoughts and behaviors that interrupted well-being prematurely. Through the use of the diary she realized that her positive experiences were blocked by negative thoughts, for example, 'If I eat like them I will lose my specialness', during dinner with friends. To prepare for cognitive restructuring, in the fifth session the patient was asked to complete the Psychological Well-Being Scales (PWB) [4], discussing with the therapist which dimensions, compared to normative data, were impaired and deserved more attention. In her case, environmental mastery, positive relations, and purpose in life were impaired while her score in personal growth was instead particularly high. In the last three sessions, behavioral homework was devised to both promote moments of well-being and support cognitive restructuring which focused on creating alternative beliefs to contrast the negative thoughts that interrupted her positive experiences. For example, she was requested to list positive personal characteristics she may be interested in developing and possible goals in life. Patient M. expressed her wish to be a socially conscious and caring person. For example, appropriate activities were assigned in accordance with her interests, such as volunteering at the local women's shelter and becoming a member of a local association that promotes women's mental health. These activities facilitated cognitive restructuring: 'I may not be special anymore because of my thinness and control, but I'm learning to develop new abilities and interests that make me unique and worthwhile'. After the eighth session, altered PWB scores were adjusted to healthy optimal levels (table 1). Motivation towards recovery was increased as she invested more time and energy in fulfilling activities, new interests, and friendships. She learned to tolerate positive experiences and effectively manage interfering negative thoughts. Her BMI improved to 17.2 and she reported occasional binging-purging episodes. Symptoms of depression, irritability, and environmental reactivity also improved. She remained stable after 6 months of follow-up. The promotion of balanced levels of psychological well-being through WBT may constitute a supportive strategy for patients with ED in their recovery process. Such patients often distortedly attribute life meaning to their disorder which constitutes a source of comfort and security [10]. Indeed, in our previous study PWB-purpose in life was significantly correlated with dietary restraint [2]. Moreover, WBT may be helpful as an alternative strategy in ED patients for whom CBT increases self-doubt and anxiety. Future studies investigating the suitability of WBT in a larger sample are warranted.