Kyle was a 22-year old, Caucasian, gay male undergraduate student in his junior year

Introduction and Background CASE CONCEPTUALIZATION Kyle was a 22-year old, Caucasian, gay male undergraduate student in his junior year at a large southeastern university. Kyle first presented for intake at a university-based anxiety health clinic in September of 2010 for treatment of Obsessive Compulsive Disorder (OCD) but was referred to the university psychology clinic after it was determined that his current obsessions and compulsions were solely related to issues regarding eating and body image. Kyle was born and raised in Jacksonville, Florida. At age 12, Kyle reported he was diagnosed with OCD and depression by a local psychiatrist and placed on 60mg Paxil. He reported the medication improved his symptoms until they finally remitted during his freshman year in high school. During that same year, Kyle came out to his parents, who subsequently had difficulty with accepting his being gay. While he said he was aware that his parents loved him, they often avoided talking about his sexual orientation, which he felt indicated a lack of support. Since then, he reported that their relationship had been less emotionally close. Presenting Problems Kyle s main complaints at intake were his obsessive food issues and mood fluctuations. During the intake interview, Kyle reported that he had lost 80 pounds (highest weight: 230, lowest: 150, current: 155) over 8 months during his sophomore year in college through extreme dieting. Despite the substantial weight loss, his lowest and current weight remained within the normal range (current BMI=21.6). Kyle attributed his motivation for this weight loss to pressures for gay men to look a certain way and a belief that no one would find him attractive at his previous weight. Kyle also reported intrusive thoughts related to eating and body image, including an intense fear of becoming fat again, and needing to be thin in order to feel good about himself. Further, he reported losing control while eating normal amounts of food (<1000

kcal) about once a week. Further, he frequently avoided eating in front of others for fear of judgment. Kyle also endorsed several rituals around eating, including counting calories, fasting, and excessive exercise approximately 3-4 days per week. Kyle expressed that he had been experiencing considerable mood fluctuations over the last month and was observably dysphoric during intake. He also reported anhedonia, including losing interest in: sex, his major at school, and socializing. Kyle acknowledged experiencing psychomotor agitation nearly every day, which was observable during intake. He reported a diminished ability to think and concentrate on schoolwork including reading and studying. Finally, he endorsed passive thoughts of death ( [just] being tired of all of this ) that occurred infrequently, while he denied any plans, preparations, or intent to harm himself. Kyle mentioned that he had previously experienced similar symptoms prior to being put on Paxil at age 12. Assessment Kyle s intake assessment was conducted in several steps. First, he completed questionnaires assessing symptoms and a screening interview. Next he completed relevant modules from the structured clinical interview for DSM-IV Disorders (First et al., 1995). During intake, Kyle s score on the Drive for Thinness subscale (score = 14) of the Eating Disorders Inventory (EDI), which measure attitudes and behaviors typical of anorexia nervosa (AN), fell within the clinical range. His scores on the Bulimia (score = 5), and Body Dissatisfaction subscales (score = 11) were within the normal range. These were consistent with his current restrictive eating patterns and lack of binge or purge episodes at intake. He scored within the moderate range on the Beck Depression Inventory (BDI = 23, 28) and in the mild range on the Beck Suicide Scale (BSS: 1-2). Due to his scores on the BSS and his self-reported passive thoughts of suicide, he was determined to be at low risk according to the Joiner et al. (1999)

framework. A coping card was created and suicide risk was monitored and remained low throughout treatment. Kyle also completed the Minnesota Multiphasic Personality Inventory (MMPI-2). He responded similarly to individuals who report feeling depressed, tend to ruminate a great deal, and feel their home situation is lacking support. These results were consistent with Kyle s mood problems and his relationship with his parents since coming out. During the SCID, Kyle met all criteria for AN, excluding the weight criterion, despite his substantial weight loss. Thus, Kyle was diagnosed with an eating disorder not otherwise Specified (EDNOS). Although Kyle denied depressed mood, his moderate BDI scores (23, 28), elevated MMPI-2 scale 2 score (70), and observably dysphoric affect all indicated depressed mood. This, in conjunction with his responses during the SCID, indicated that he met criteria for Major Depressive Disorder, recurrent, with full interepisode recovery. Kyle was also assessed for substance use disorders, but did not meet for any dependence or abuse diagnoses. Alcohol use was monitored, given that Kyle noted drinking sometimes led to loss of control eating, consistent with alcohol s role as a disinhibitor (Polivy & Herman, 1985). Case Conceptualization & Treatment Planning A treatment plan was developed based on empirically supported treatments for Kyle s configuration of symptoms. Given his diagnoses, there were two potential options for which symptoms to target first. The first treatment plan was to treat the eating disorder first, with the hypothesis that Kyle s depressive symptoms were a consequence of his eating disorder, consistent with studies on the affective consequences of semi-starvation (Franklin et al., 1948). Further, dysregulated eating can also be seen as a maintaining factor for affective instability. An alternative plan would be to treat the depression first, given that impairment due to depression could lead to significant interference in the treatment of the eating disorder (Bodell, Brown, &

Keel, in press). Given Kyle s own priorities and that his depressive episode began after his eating disorder, we chose to treat the eating disorder first. Consistent with theorized models of eating disorder development in gay men (Siever, 1994), the primary maintenance factor for Kyle s eating disorder was his desire to look thin and muscular to attract men, which led him to engage in fasting, rigid rules about eating, and excessive exercise. While these behaviors led to weight loss they also led to occasional loss of control eating and subsequent guilt about eating. This reinforced further restriction, which maintained the cycle of disordered eating. Additional triggers for Kyle s restrictive and loss of control eating included alcohol use and mood fluctuation. Further, Kyle was incredibly perfectionistic and valued overachieving, which also contributed to and maintained his restrictive eating pattern in order to look like the perfect gay man. While there are currently no empirically supported treatments for adults with AN or related EDNOS, cognitive behavioral therapy (CBT) has been shown to be superior to nutritionbased interventions in improving eating attitudes and behaviors (Serfaty et al., 1999; Pike et al., 2003). However, treatment manuals are targeted primarily at women and largely ignore specific issues and pressures that may affect gay men. A more recent transdiagnostic CBT manual by Fairburn et al. (2008) was developed to address some of these limitations by creating a flexible framework and a personalized model of the patients eating disorder. However, given that other studies have found no differences between CBT and nonspecific supportive clinical management (McIntosh et al., 2005), both treatment options were described to Kyle. Ultimately, Kyle felt that CBT would be most helpful. Several measures were administered throughout treatment to track Kyle's maintaining factors and assess progress. Food intake was measured through daily logs. The Brief Mizes

Anorectic Cognitions Scale (BMAC; Osman, Chiros, Guitierrez, Kopper, & Barrios, 2001) was administered weekly to track anorectic cognitions hypothesized to maintain Kyle s disorder. The Eating Disorder Examination Questionnaire (EDE-Q; Fairburn & Beglin, 1994), was chosen to measure monthly outcome, and assesses cognitive and behavioral symptoms in four categories: dietary restraint, weight, shape, and eating concerns. The BDI assessed Kyle s depressive symptoms and negative automatic thoughts were tracked on daily monitoring forms. Course of Treatment & Assessment of Progress After two sessions of CBT for eating disorders, it was clear that Kyle s depressed mood and difficulty concentrating due to depressive, self-defeating thoughts were too impairing to effectively treat the eating disorder first, supporting the alternative treatment plan. We agreed that once his mood remained stable and his BDI scores were within the minimal range, we would move on to treating his eating disorder. Kyle s depressed mood, which was maintained by selfdefeating cognitions and beliefs (e.g. I am a failure ), was targeted with CBT for Depression (Beck, 1979) beginning on 11/2/10. Sessions consisted of psychoeducation regarding the cognitive model, and identifying and restructuring negative automatic thoughts. After a few sessions, Kyle was able to identify common patterns of his cognitive distortions (e.g., black & white thinking, catastrophizing). Sessions then focused on evaluating his negative automatic thoughts through techniques including evaluating evidence for and against the thoughts. These helped Kyle consider plausible alternatives to his thoughts, which Kyle reported improved his mood, as corroborated by decreases in his BDI scores from moderate (29) on 11/2/11 to minimal (8) on 12/7/11 and no longer meeting diagnostic criteria. We reassessed the direction of treatment and began treating his eating disorder on 1/13/11. Phase I began with psychoeducation about eating disorder maintenance including

dietary restraint theory (Polivy & Herman, 1985), to illustrate how dietary restriction can lead to loss of control eating and obsessional thoughts about food and eating. We developed a comprehensive flowchart of the factors maintaining Kyle s eating disorder that guided our treatment focus. During this phase, Kyle was asked to keep track of all food and beverages that he consumed each day on a self-monitoring form, as well as his thoughts regarding eating, weight, or shape. Kyle also recorded whether or not he engaged in exercise, as well as tracking the intensity of his thoughts on a 1-10 scale regarding both eating and body image. Weekly weigh ins were also introduced to monitor any significant changes in weight throughout treatment, as well as to provide disconfirming evidence to the possibility that regularizing Kyle s eating would cause him to gain weight. After his weekly weigh-in, we discussed thoughts about his current weight, reviewed his self-monitoring sheet, and set new goals for the coming week. These goals first focused on regularizing his meal pattern by eating three meals and two snacks a day at regular times. We also determined that during this phase Kyle should refrain from exercising, as he did not feel he could exercise moderately. Kyle was motivated to engage with treatment and quickly adapted to the eating plan. When we identified days that Kyle engaged in dietary restriction we discussed and problem-solved triggers. During this period of time Kyle also reduced his drinking as we identified this as a factor contributing to his dysregulated eating. After establishing a regular meal pattern, we formulated a feared food hierarchy to help expand Kyle s food choices. Kyle was then given weekly homework assignments to gradually incorporate these foods into his meal plan. In session we reviewed the process of consuming the feared foods and problem-solved obstacles to reaching his goals, resulting in Kyle consuming one of the foods highest on his hierarchy (a fried chicken sandwich with cheese).

After 8 sessions, Kyle s scores on the dietary restraint subscale of the EDE-Q had decreased substantially from a score of 4.6 on the 6-point scale to 1.8, which was only slightly above the community norms of 1.0. Kyle s scores on the remaining cognitive subscales of the EDE-Q and the BMAC remained stable and within clinical ranges, which was expected given the behavioral focus of phase I. Thus, we agreed that Kyle was ready to transition to phase II. Phase II included identifying dysfunctional cognitions, addressing underlying beliefs, and associated symptoms of the eating disorder. To begin, common cognitive distortions were reviewed. Kyle then practiced identifying his negative automatic thoughts regarding his belief that he needed to be thin and muscular. Initially throughout phase II, Kyle s ruminative and overly perfectionistic thinking style became a substantial obstacle to traditional cognitive restructuring, which was consistent with research showing that individuals with a ruminative style of thinking have poorer prognosis using traditional cognitive restructuring techniques (Teasdale et al., 1995). Thus, we incorporated Dialectical Behavior Therapy mindfulness-based techniques (McKay, Wood, & Brantley, 2007). These focused on having Kyle observe, describe, and let his thoughts go rather than trying to fight against them. Mindfulness exercises were practiced in session and assigned for homework. As this phase of treatment progressed, more traditional cognitive restructuring exercises and homework assignments were employed. These sessions also addressed the social consequences of Kyle s eating disorder, including distorted ideas about dating and relationships and his avoidance of eating in front of others. We targeted the cognitions related to these fears and discussed ways to increase social support and expand Kyle s current network of friends, including attending campus LGBT activities to increase his sense of connectedness within the gay community.

Throughout the 20 sessions in phase II, Kyle s scores on the EDE-Q dietary restraint subscale continued to decrease and by September of 2011, stabilized below community norms. Further, his scores on the eating, shape, and weight concerns subscales also showed substantial reductions from January (2.2, 2.6, 2.6, respectively) to September (.8,.9, 1.0), when they reached the level of community norms. Kyle s scores on the BMAC also showed substantial decreases over time (38 to 24), with his final score below the community average. These scores, in conjunction with Kyle s self-reported improvement, led us to move into phase III. Phase III consisted of three sessions focused on reviewing progress and building a relapse prevention plan. We discussed the likelihood of symptom reoccurrence based on the course of EDNOS (Keel & Brown, 2010) and clarified the difference between a lapse and a relapse. We identified potential triggers of relapse and Kyle detailed a written plan of how to cope effectively, using the skills that he learned throughout treatment. Assessment of Final Progress & Future Directions Kyle was reassessed for an eating disorder diagnosis and was found to no longer meet any criteria; this in conjunction with his normal scores on the EDE-Q indicated that he was in full remission from EDNOS. Kyle s scores on the BDI remained in the mild range throughout the treatment of the eating disorder (10-15) and stabilized below the minimal range (under 10) beginning in July of 2011. Thus, his depression remained in full remission. While Kyle s eating and mood symptoms were no longer clinically significant, Kyle requested to remain in treatment to further work on some of the cognitive distortions that he had around people s perception of his sexual orientation. Since October, 2011 we have completed 8 sessions on cognitive restructuring for the coming out process and romantic relationships. Kyle has successfully been able to restructure his cognitive distortions on his own and we will be terminating in January.