TRANSDIAGNOSTIC CBT FOR
EATING DISORDERS
“CBT-E”
Christopher G Fairburn
www.psychiatry.ox.ac.uk/credo
WHY LEARN ABOUT CBT-E?
• Latest version of the leading evidence-based treatment for
eating disorders
• Theory-driven
• Suitable for a wide range of patients
– “transdiagnostic” in its scope
– designed for “complex patients”
• Highly acceptable to patients
• Detailed treatment guide
• Shown to be reasonably potent in an inclusive patient sample
GUIDE TO CBT-E
Fairburn CG. Cognitive Behavior Therapy and Eating
Disorders. Guilford Press, New York, 2008
Go to www.psychiatry.ox.ac.uk/credo
– obtain further information about CBT-E
– obtain the materials needed to practise CBT-E
– obtain copies of EDE-16.0D, EDE-Q6.0 and CIA 3.0
EATING DISORDERS
Anorexia nervosa
Bulimia nervosa
Eating disorder NOS
AN
ED-NOS
Comparable in severity to BN
Three subgroups:
• subthreshold cases of AN and BN
• “mixed states”
• binge eating disorder
BN
Leading treatment is
guided CB self-help
BED
No empirically supported treatment
AN
CBT leading empiricallysupported treatment:
ED-NOS
Just one treatment
study
BN
• but only 40% to 50% of
those who complete CBT-BN
make a full and lasting
recovery
TWO PROBLEMS
1. No evidence-based treatment for
–
–
AN
ED-NOS
2. CBT-BN not sufficiently potent
“ENHANCED” CBT (CBT-E)
CBT-E is designed to address both these problems. Hence .....
1. It is transdiagnostic in its scope
2. It is designed to be more potent than CBT-BN
THE “TRANSDIAGNOSTIC” VIEW
What is most striking about AN, BN and ED-NOS is:
– 1. How much they have in common, not what distinguishes
them ... they share the same distinctive psychopathology
– 2. The phenomenon of diagnostic migration
THE “TRANSDIAGNOSTIC” VIEW
CBT-E is designed to address these mechanisms .....
...... it is a treatment for eating disorder psychopathology,
not a treatment for a DSM-IV diagnosis
MAKING TREATMENT MORE POTENT ...
CBT-E is designed to be better than CBT-BN at ...
• Preparing patients for treatment
• Individualising treatment (“bespoke”)
• Engaging and retaining patients
• Achieving early change
• Addressing the over-evaluation of shape and weight and its expressions (e.g.,
body checking and avoidance, feeling fat, etc)
• (Towards the end of treatment) helping patients identify and manipulate their
eating disorder “mindset” to minimise the risk of relapse
• (In the “broad form” of CBT-E) addressing certain difficulties that obstruct
change in subsets of patients; namely, mood intolerance, clinical perfectionism,
core low self-esteem, or marked interpersonal difficulties
(Fairburn, 2008)
VARIOUS VERSIONS OF CBT-E
Two forms
• Focused: Core default version of the treatment
• Broad: Includes additional modules to address broader “external” maintaining
mechanisms: mood intolerance, clinical perfectionism, low self-esteem and
major interpersonal problems
Two intensities
• 20-session version for patients with a BMI >17.5
• 40-session version for patients with a BMI <17.5
Versions for different patient groups
• Adult outpatient version (Fairburn et al, 2008)
• Younger patients’ version (Cooper and Stewart, 2008)
• Intensive versions (inpatient, day patient and intensive outpatient versions), and
a group version (Dalle Grave, Bohn, Hawker and Fairburn, 2008)
PREPARING PATIENTS FOR CBT-E
• Provide a description of the treatment and address patients’ concerns.
A suitable handout available from www.psychiatry.ox.ac.uk/credo
• Advise patients that it is important to make the best possible use of
treatment
• Give detailed consideration as to when it would be best for CBT-E to
start. “False starts” should be avoided if at all possible
• Address potential barriers to change in advance:
• clinical depression
• significant substance abuse
• major distracting life problems and competing commitments
DEPRESSION
Clinical observations
1.
Antidepressant medication is remarkably effective in patients
with “primary depressive features”
–
–
–
–
–
–
–
–
decreased drive
thoughts about death and dying
heightened social withdrawal
personal neglect
marked hopelessness
suicidal thoughts and acts
tearfulness
pathological guilt
DEPRESSION
Clinical observations (cont)
2.
Such patients may have other characteristics of note
–
–
–
3.
premorbid depression
a late-onset eating disorder
intensification of depressive features in the absence of change in the
eating disorder
Higher than usual antidepressant doses are often required
–
–
fluoxetine (40mg to 100mg)
few side effects
DEPRESSION
Clinical observations (cont)
4.
Resolution of the depressive features facilitates subsequent
treatment
Resolution of the depressive features may, or may not, result
in a change in the eating disorder
5.
–
–
6.
in AN, dietary restraint may intensify
in BN, urge to binge may decrease
Follow-up suggests that some patients are prone to recurrent
depressive episodes
–
these may trigger recurrences of the eating disorder
OVERVIEW OF CBT-E
Stage One
• “Start well” (establish the foundations of treatment;
achieve early change)
Stage Two
• Review progress; identify emerging barriers to change;
design Stage Three
Stage Three
• Address the main maintaining mechanisms
Stage Four
• “End well” (maintain the changes obtained; minimise
the risk of relapse)
STAGE ONE - STARTING WELL
1.
2.
3.
4.
5.
6.
7.
8.
9.
Engage the patient in treatment and change
Assess the nature and severity of the psychopathology present
Jointly create a personalised formulation
Explain what treatment will involve
Establish real-time self-monitoring
Initiate in-session collaborative weighing
Provide psychoeducation
Establish a pattern of regular eating
See significant others
THE FORMULATION
Personalised visual representation of the processes that appear to
be maintaining the eating disorder
Rationale
•
•
•
•
•
Begins to distance patients from their problem (decentering)
Starts the process of helping patients step back from their eating
disorder and try to understand it
Can be highly engaging
Conveys the notion that eating disorders are a self-maintaining
system
Informs treatment
BULIMIA
NERVOSA
Over-evaluation of shape and
weight and their control
c
d
a
Strict dieting; non-compensatory
weight-control behavior
b
Events and
associated mood
change
e
Binge eating
f
Compensatory
vomiting/laxative misuse
Available as a pdf from www.psychiatry.ox.ac.uk/credo
ANOREXIA
NERVOSA
Over-evaluation of shape and
weight and their control
Strict dieting; non-compensatory
weight-control behaviour
Low weight with
secondary effects
•
•
•
•
preoccupation with eating
social withdrawal
heightened obsessionality
heightened fullness
Available as a pdf from www.psychiatry.ox.ac.uk/credo
COMPOSITE
TEMPLATE
FORMULATION
Over-evaluation of shape and
weight and their control
Strict dieting; noncompensatory weight-control
behaviour
Events and
associated mood
change
Binge eating
Significantly
low weight
Compensatory
vomiting/laxative
misuse
Available as a pdf from www.psychiatry.ox.ac.uk/credo
EXAMPLE OF
ED-NOS
Feel really bad about my weight
and the way I look
Diet; exercise a lot
Feel unhappy
Occasional
binges
Low weight?
Make myself sick
Available as a pdf from www.psychiatry.ox.ac.uk/credo
BINGE EATING
DISORDER
Dissatisfaction with shape and
weight and their control
Intermittent dieting
Events and
associated mood
change
Binge eating
THE FORMULATION
Procedure
•
•
•
•
•
Drawn out, using the patient’s terms and experiences, starting
with something that the patient wants to change
Transdiagnostic, but derived from a common template
Created jointly; handwritten
Provisional; modified as the therapist and patient get a better
understanding of the problem
Both the therapist and patient keep a copy; in each session, it is
on the table
SELF-MONITORING
Rationale
•
•
Helps patients distance themselves from the processes that are
maintaining their eating disorder, and thereby begin to recognise
and question them
Highlights key behaviour, feelings and thoughts, and the context
in which they occur
–
–
makes experiences that seems automatic and out of control more
amenable to change
must be in “real time”
SELF-MONITORING
Procedure
•
•
•
•
•
•
Discuss practicalities and likely difficulties
Stress that it must be “prospective”
Provide written instructions and a completed example
Form should be simple to complete
Reviewing the monitoring records is a crucial part of each session
Pay close attention to the process of monitoring in session #1 and
respond with perplexity if the patient has not monitored
COLLABORATIVE WEIGHING
Rationale
•
Patients with eating disorders are unusual in their frequency of
weighing
–
–
•
frequent weighing encourages concern about inconsequential
changes in weight, and thereby maintains dieting
avoidance of weighing is as problematic
Knowledge of weight is a necessary part of treatment
–
–
–
–
permits examination of the relationship between eating and weight
facilitates change in eating habits
necessary for addressing any associated weight problem
one aspect of the addressing of the over-evaluation of weight
COLLABORATIVE WEIGHING
Procedure
•
No weighing at home (but transfer to at-home weighing late in
treatment) but patient and therapist weighing the patient at the
beginning of each (weekly) session
–
–
–
joint plotting of a weight graph
repeated examination of trends over the preceding four readings
continual reinforcement of “One can’t interpret a single reading”
EDUCATION
Rationale
•
Reduces stigma, corrects myths, informs about important maintaining processes,
educates about health risks
Procedure
•
•
•
•
Guided reading
Overcoming Binge Eating” (Fairburn, 1995)
– all patients (even those who do not binge eat)
– chapters 1, 4 and 5
Provide additional information about “starvation” for those who are significantly
underweight (available as a pdf from www.psychiatry.ox.ac.uk/credo)
Reading set as graded homework with reviews at subsequent session(s)
REGULAR EATING
Key intervention for all patients (including underweight ones)
Rationale
•
•
•
•
•
Foundation upon which other changes in eating are built
Gives structure to the patient’s eating habits (and day)
Provides meals and snacks which can then be modified
Addresses one form of dieting
Displaces binge eating
Procedure
•
•
•
Help patients eat at regular intervals through the day .....
..... without eating in the gaps
..... what they eat does not matter at this stage
SIGNIFICANT OTHERS
Rationale
•
•
•
See “significant others” if this is likely to facilitate treatment and
the patient is willing
Usually the significant others are people who influence the patient’s
eating
Aim is to create the optimal environment for the patient to change
Procedure
•
Typically comprises up to three 30-minute sessions immediately
after a routine one; preparation is important
STAGE TWO
Whilst continuing with the strategies and procedures introduced in
Stage One ...
1. Review progress and compliance with treatment
2. Identify emerging barriers to change
3. Review the formulation
4. Decide whether to use the “broad” form of CBT-E
–
5.
clinical perfectionism, core low self-esteem, major interpersonal
problems
Design Stage Three
STAGE THREE
Whilst continuing with the strategies and procedures introduced in
Stage One, address the main maintaining mechanisms operating
in the individual patient’s case ...
1. Over-evaluation of shape and weight
2. Over-evaluation of control over eating
3. Dietary restraint
4. Dietary restriction
5. Being underweight
6. Event-related changes in eating
ADDRESSING THE OVER-EVALUATION OF
SHAPE OR WEIGHT
The “core psychopathology” of eating disorders is the over-evaluation of
shape and weight
• self-worth is judged largely or exclusively in terms of shape and weight
and the ability to control them
• other modes of self-evaluation are marginalised
• most other features appear to be secondary to the core psychopathology
• dieting
• repeated body checking and/or body avoidance
• pronounced “feeling fat”
ADDRESSING THE OVER-EVALUATION OF
SHAPE OR WEIGHT
Overview
1. Prepare the patient for change
i.
Educate about self-evaluation
ii. Assess the patient’s scheme for self-evaluation and its expressions
iii. Expand the formulation
Family
Work
Shape, weight
and eating
Other
Friends
Sport
Music
Family
Work
Shape, weight
and eating
Other
ADDRESSING THE OVER-EVALUATION OF
SHAPE OR WEIGHT (cont)
Expand the formulation
Over-evaluation of shape and weight and their control
Dietary
restraint
Shape and weight
checking and/or
avoidance
Preoccupation
with thoughts
about shape
and weight
Mislabelling
adverse states
as “feeling
fat”
Marginalisation
of other areas
of life
ADDRESSING THE OVER-EVALUATION OF
SHAPE OR WEIGHT
2. Address the over-evaluation using two strategies:
Develop new domains
for self-evaluation
Reduce the importance
of shape and weight
ADDRESSING THE OVER-EVALUATION OF
SHAPE OR WEIGHT
Develop new domains for self-evaluation
– encourage patients to identify and engage in (neglected) interests
and activities, especially those of a social nature
ADDRESSING THE OVER-EVALUATION OF
SHAPE OR WEIGHT
Overview
1. Prepare for change
2. Address the over-evaluation using two strategies:
•
Develop marginalised self-evaluative domains
•
Addressing the expressions of the over-evaluation
•
body checking and avoidance
•
“feeling fat”
ADDRESSING THE OVER-EVALUATION OF
SHAPE OR WEIGHT (cont)
Shape checking
• Identify the various forms of shape checking
• often patients are not aware of them
• self-monitoring for 24 hours on two days
ADDRESSING THE OVER-EVALUATION OF
SHAPE OR WEIGHT (cont)
Shape checking
• Identify the various forms of shape checking
• Categorise them
– those best stopped (e.g., measuring dimensions)
– those best reduced in frequency and/or modified
• Progressively address
• Takes many successive sessions (one item on session agenda)
• Always address mirror use
ADDRESSING THE OVER-EVALUATION OF
SHAPE OR WEIGHT (cont)
Reflections on mirrors
• How do we know what we look like?
• Should we believe what we see in the mirror?
– things aren’t what they seem
– what we “see” in mirrors depends to a large extent upon how we
look
– scrutiny is prone to result in magnification (c.f., spider phobias)
– scrutiny creates and maintains dissatisfaction
• “If you look for fatness you will find it”
– contrast with incidental reflections (e.g., in shop windows)
ADDRESSING THE OVER-EVALUATION OF
SHAPE OR WEIGHT (cont)
Mirror use
• Always assess patients’ mirror use
• Educate about mirrors
– consider when it is appropriate to look in a mirror
• Encourage patients to think first before using a mirror
– what are they trying to find out?
– can they find this out?
– is there a risk that they will get “bad” information?
• Discuss how to avoid magnification
ADDRESSING THE OVER-EVALUATION OF
SHAPE OR WEIGHT (cont)
Comparisons with others
• Frequent
• Conclusions drawn are highly salient
• Biased
– subjects of the comparison (slim)
– method of appraisal (cursory)
Strategy
• Identify the phenomenon
• Educate
• Reduce frequency, experiment with bias (subjects & methods)
ADDRESSING THE OVER-EVALUATION OF
SHAPE OR WEIGHT (cont)
Body avoidance
• Avoidance is as problematic as repeated checking and scrutiny
• Identify the various forms of avoidance (NB: may co-occur with
checking)
• Educate
• Progressively encourage “exposure” (using behavioural experiments)
• Include the evaluation of other people’s bodies
• Takes many successive sessions (one item on agenda)
“Feelings of fatness”
Actual weight
Time
Available as a pdf from www.psychiatry.ox.ac.uk/credo
ADDRESSING THE OVER-EVALUATION OF
SHAPE OR WEIGHT (cont)
“Feeling fat”
•
•
•
Phenomenon little studied or written about
Fluctuates in intensity
Either:
–
–
an expression of an acute increase in body dissatisfaction
the result of mislabelling certain physical or emotional states
Strategy
• Identify in real time the triggers of (intense) feelings of fatness
• Examine the nature of the triggers
• Help patients ...
•
•
ask “What else am I feeling just now?” whenever they feel fat
address the triggers directly
ADDRESSING DIETARY RESTRAINT
Strict dieting
“Restraint”
“Restriction”
(attempted under-eating)
(actual under-eating)
ADDRESSING DIETARY RESTRAINT
•
Remind patients that (for them) dietary restraint is a problem,
not a solution
–
•
e.g., highlight any difficulty/inability eating with others (CIA)
Identify the main forms of restraint
–
delayed eating
• already addressed
– avoidance of specific foods
ADDRESSING DIETARY RESTRAINT
Food avoidance
•
•
•
Identify avoided foods
Categorise them
Systematically introduce (as behavioural experiments)
IDENTIFY AND CHALLENGE DIETARY RULES
Identify other dietary rules and rituals:
• Not eating more than 600 kcals daily
• Not eating before 6.00 pm
• Not eating in front of others
• Eating less than others present
• Not eating food of unknown composition
ADDRESSING RESIDUAL BINGES
•
•
Introduction of a pattern of regular eating displaces most binge
eating
Identify mechanisms responsible for each remaining binge
Binge Analysis
Breaking a dietary rule
• ………………………
Being disinhibited (e.g., alcohol)
• ………………………
Under-eating
Binge eating
• ………………………
Adverse event or mood
• ………………………
Lessons to learn:
• ……………………...
Available as a pdf from www.psychiatry.ox.ac.uk/credo
STAGE THREE
Completing Stage Three
1.
2.
Review the origins of the eating problem (“historical review”)
Help patients learn to control their eating disorder “mindset”
ORIGINS OF THE EATING PROBLEM
Historical review
Rationale
- Normalising
- Encourages further distancing and awareness of the eating disorder
“mindset”
- Facilitates discussion of the “function” of the eating disorder in the
past and at present
- Enhances understanding of the eating disorder
Time period
Events and circumstances (that might have sensitized
me to my shape, weight and eating)
Before onset of eating
problem (up to age 16)
Mother very anxious about eating throughout my
childhood
A bit overweight aged 9
Always have been on the tall side and a bit clumsy
(have felt too "big")
Friend developed anorexia; slightly jealous
The 12 months before onset
(when I was 16)
Moved to new city and house
New school
Unhappy; no friends
The 12 months after onset
(when I was 17)
Started to cut back on my eating
Felt good and in control
Fights with my mum
Lost weight rapidly for a while
Since then (17 to 26)
Started purging (18)
Binge eating (18/19)
Went to college (19)
Regained weight (19); out of control; awful
Eating problem just as it is now (20 to present)
Dropped out of college (23)
Psychotherapy and antidepressants (24)
Fairburn et al (2008)
MINDSETS
Introduce the notion of mindsets once patients have alternating
psychological states (near the end of treatment)
Educate (DVD analogy)
•
all-embracing cognitive-emotional systems
•
we all have them
•
may be dysfunctional
•
create their own reality (they “filter” experience)
•
self-perpetuating
MINDSETS
One can influence mindsets in two ways:
i. By addressing their content
•
using conventional CBT procedures
MINDSETS
ii. By influencing their “playing”
•
decreasing the chances it is triggered
•
•
by spotting it coming into place
•
•
real-time awareness of potential triggers; inoculation against them
early warning signs (“relapse signatures”)
by displacing it
•
behaving healthily (“doing the right thing”)
•
plus potent distraction
STAGE FOUR - ENDING WELL
1. Maintain the changes obtained
•
•
Identify what problems remain
Jointly devise a specific plan for maintaining progress
[Template plan available for editing from www.psychiatry.ox.ac.uk/credo]
STAGE FOUR - ENDING WELL
2. Minimise the risk of relapse (in the long-term)
•
•
•
Ensure that the patient has realistic expectations
–
Achilles heel (the DVD still exists)
–
danger of viewing a “lapse” as a “relapse”
Identify future “at risk” times
–
if weight gain; if dieting; if under stress
Devise a plan for dealing with setbacks
–
detect early
–
deal with them promptly
i.
ii.
address the eating problem; do the right thing
address the trigger
[Template plan available for editing from www.psychiatry.ox.ac.uk/credo]
CBT-E
Strategies for patients who are
underweight
CBT-E
1.
Start well. Engage the patient in treatment and the
prospect of change
•
carefully consider when best to start treatment
150
•
be engaging, positive, supportive, interested in
patient as a person
140
130
BMI 20.0
120
110
100
90
80
0
2
4
6
8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40
Weeks
(Fairburn, Cooper, Shafran, Bohn, Hawker, Murphy and Straebler, 2008)
CBT-E
1.
Start well. Engage the patient in treatment and the
prospect of change
2.
Educate about the psychobiological effects of under-eating
and being underweight, and create a personalised
formulation
•
personalised education (based on handout)
•
personalised formulation (derived from CBT-E’s
transdiagnostic template formulation)
150
140
130
BMI 20.0
120
110
100
90
80
0
2
4
6
8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40
Weeks
(Fairburn, Cooper, Shafran, Bohn, Hawker, Murphy and Straebler, 2008)
EDUCATION
•
•
1. Psychological effects of maintaining a very low weight
Cognitive effects
–
–
–
–
•
inward-looking
preoccupied with food and eating
difficulty concentrating
inflexible thinking
Effects on mood
–
–
–
low mood
lability of mood
irritability
EDUCATION
•
Heightened obsessionality
–
–
–
•
rigidity of behaviour (e.g., fixed routines)
obsessional behaviour (e.g., ritualistic eating)
indecisiveness and procrastination
Social effects
–
–
–
withdrawal
loss of interest in the outside world
loss of interest in sex
EDUCATION
•
2. Subjective physical effects of maintaining a very low weight
•
•
•
•
feeling cold
sleeping poorly
feeling full after eating little
impaired taste (need to use lots of condiments)
•
•
3. Medical information
•
Effects on bones, growth, fertility, etc
EDUCATION
• Implications
• 1. Many features that the patient is experiencing are non-specific effects
of starvation
• feeling cold, sleeping poorly, feeling full
• being obsessive and inflexible, difficulty concentrating
• being infertile, having weak bones
– some are likely to maintain the eating disorder
– features of starvation mask the patient’s true personality
– reversed by weight regain; weight gain therefore a necessary part of
treatment
EDUCATION
• 2. Other features are not due to starvation
• extreme concerns about shape and weight
• the need to feel in “control”
– some of these features are responsible for the initiation and
maintenance of the starvation
– treatment must also be directed at these features
ANOREXIA
NERVOSA
Over-evaluation of shape and
weight and their control
Strict dieting; non-compensatory
weight-control behaviour
Low weight with
secondary effects
•
•
•
•
preoccupation with eating
social withdrawal
heightened obsessionality
heightened fullness
Available as a pdf from www.psychiatry.ox.ac.uk/credo
CBT-E
1.
Start well. Engage the patient in treatment and the
prospect of change
2.
Educate about the psychobiological effects of under-eating
and being underweight, and create a personalised
formulation
3.
Establish a pattern of regular eating
4.
Discuss pros and cons of change
5.
Initiate and then maintain weight regain
150
140
130
BMI 20.0
120
110
100
90
80
0
2
4
6
8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40
Weeks
(Fairburn, Cooper, Shafran, Bohn, Hawker, Murphy and Straebler, 2008)
How I feel now
Reasons to stay as I am
It makes me feel in control
and special
I get attention from others
I will not get ‘fat’
I am good at it
It makes me feel strong
It shows I have will-power
It is familiar and feels safe
I have an excuse for things
I don’t have to have periods
I am not hassled by men
If I change:
- I won’t be able to stop
eating
- my weight will shoot up
- my stomach will stick
out
- my thighs will get fatter
If I change people will think
that:
- I am weak and greedy
- I have given in
- I am getting fat
Thinking five years ahead ...
Reasons to change
Reasons to stay as I am
Reasons to change
I will get rid of my starvation
symptoms:
- thinking about food and
eating all the time
- feeling so cold
- not sleeping properly
- feeling faint
I will feel healthier
I will be healthier
I will be able to think more
clearly
I will have more time
I will be able to think about
other things
I will be less obsessive, and
more flexible and spontaneous
My life will have a broader
focus
I will be happier and have more
fun
I will be able to go out with
others and get on with people
better
I will discover who I really am
It makes me feel in control and special
I will not get ‘fat’
It is familiar and feels safe
If I change:
- I won’t be able to stop eating
- my weight will shoot up
- my stomach will stick out
- my thighs will get fatter
If I change people will think that:
- I am weak and greedy
- I have given in
- I am getting fat
I want to be a success at work
I want a long term relationship
I want a family
I want to be a positive role model
for my children
I want to go on holiday and be
spontaneous
I want to be in good health
I don’t want to still have
starvation symptoms or any
other effects of the ED
I want to be in ‘true’ control of
my eating
I don’t want to waste my life
I want to achieve things
I don’t want to be chronically ill
170
160
BMI 25.0 (157lbs)
150
Healthy
weight
140
Weight
(lbs) 130
BMI 20.0 (126lbs)
120
110
100
0
2
4
6
8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40
Weeks
CBT-E
1.
Start well. Engage the patient in treatment and the
prospect of change
2.
Educate about the psychobiological effects of under-eating
and being underweight, and create a personalised
formulation
3.
Establish a pattern of regular eating
4.
Discuss pros and cons of change
5.
Initiate and then maintain weight regain
150
140
130
BMI 20.0
120
110
100
•
take the plunge
•
educate about the physiology of weight regain
•
let patients try it their way
•
help patients maintain an energy excess of 500kcals
per day
•
offer the option of high-energy drinks
90
80
0
2
4
6
8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40
Weeks
(Fairburn, Cooper, Shafran, Bohn, Hawker, Murphy and Straebler, 2008)
CBT-E
1.
Start well. Engage the patient in treatment and the
prospect of change
2.
Educate about the psychobiological effects of under-eating
and being underweight, and create a personalised
formulation
3.
Establish a pattern of regular eating
4.
Discuss pros and cons of change
5.
Initiate and then maintain weight regain
6.
Address other psychopathology at the same time
7.
Practise weight maintenance and end well
•
ensure that progress is maintained
•
minimise the risk of relapse
150
140
130
BMI 20.0
120
110
100
90
80
0
2
4
6
8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40
Weeks
(Fairburn, Cooper, Shafran, Bohn, Hawker, Murphy and Straebler, 2008)
Over-evaluation of shape and
weight and their control
• body checking and avoidance
• feeling fat
• marginalisation of other areas of life
Strict dieting; non-compensatory
weight-control behaviour
• dietary restraint and restriction
• dietary rules
• over-exercising
Low weight with
secondary effects
CBT-E
Broad version
EXTENDED THEORY (Fairburn et al, 2003)
•
•
Certain “external” maintaining mechanisms operate in
subgroups of patients and these are barriers to change
Four sets of mechanisms appear to be especially important
–
–
–
–
•
•
mood intolerance
clinical perfectionism
core low self-esteem
interpersonal difficulties
Predicted that the successful addressing of these
mechanisms should improve outcome
The “broad” form of CBT-E is based on this theory
MOOD INTOLERANCE
• There is a subgroup of patients with “mood intolerance”
– exceptionally sensitive to intense mood states
– usually adverse mood states (e.g., anger, anxiety)
– unable to accept and deal appropriately with these states
MOOD INTOLERANCE (cont)
• Respond “dysfunctional mood modulatory behaviour” which
reduces awareness of the mood state and neutralises it, but at a
personal cost
– self-injury (e.g., cutting or burning their skin)
– taking psychoactive substances (e.g., alcohol or tranquillisers)
– binge eating, vomiting or exercising intensely (which may also become
habitual means of mood modulation)
MOOD INTOLERANCE (cont)
• Not clear whether these patients actually experience unusually
intense mood states or are unduly sensitive to them
• Cognitive processes contribute (e.g., “I can’t stand feeling like
this”) and can amplify the initial mood state
MOOD INTOLERANCE (cont)
Treatment
• Existing CBT treatment procedures are often not sufficient
for these patients’ needs
• Treatment strategies and procedures have been developed
that are relevant to mood intolerance:
– elements of dialectical behaviour therapy (Linehan, 1993)
– enhancement of metacognitive awareness
ADDRESSING MOOD INTOLERANCE
1. Analyse in detail a recent example in session
• recreate the exact sequence
–
–
–
–
–
–
triggering events
any mood change
associated cognitions
behavioural response
immediate effect
later appraisal
2. Start to monitor in detail the relevant phenomena
• ask the patient to monitor closely the relevant behaviour and its
antecedents and consequences
ADDRESSING MOOD INTOLERANCE (cont)
Adverse event
Pressure at work
Deterioration in mood
Tension
Dysfunctional behaviour
Binge eating and/or cutting
Immediate improvement in mood
Release of tension
Later negative appraisal
“Binge eating like this is hopeless.
I have no will-power”
ADDRESSING MOOD INTOLERANCE (cont)
3. Prospectively analyse future examples
• ask the patient to analyse in real time the occurrence (or incipient
occurrence) of future episodes of mood intolerance
• requires very careful “in the moment” recording of circumstances,
thoughts and feelings
• patients find this frustrating
• rationale:
– slows down and distances the patient from the phenomenon
– highlights points in the sequence when alternative courses of action are
possible
ADDRESSING MOOD INTOLERANCE (cont)
4. Address using the procedures that seem most pertinent
•
•
•
•
•
•
range of options available
important that patients intervene early
one success breeds further successes
real-time monitoring has an impact in its own right
choose those procedures that seem most applicable
do not forget the value of simple interventions (e.g., putting barriers in
the way of engaging in DMMB)
• do not overload patients (principle of parsimony)
CLINICAL PERFECTIONISM
Over-evaluation of striving to achieve, and achieving, personally demanding
standards despite adverse consequences
• Form of psychopathology equivalent to the “core psychopathology” of
eating disorders (i.e., it is also a dysfunctional system for self-evaluation)
• (Shafran R, Cooper Z, Fairburn CG. Clinical perfectionism: A cognitive-behavioural
analysis. Behaviour Research and Therapy 2002; 40: 773-791)
CLINICAL PERFECTIONISM (cont)
• When clinical perfectionism and an eating disorder co-exist their
psychopathology overlaps
– perfectionist standards for controlling eating, shape and weight
– in addition to perfectionist standards for other valued domains of
life (e.g., performance at work, sport, music, etc)
Over-evaluation of shape and
weight and their control
Strict dieting; noncompensatory weight-control
behaviour
Events and
associated mood
change
Binge eating
Compensatory
vomiting/laxative
misuse
Significantly
low weight
Over-evaluation
of achieving and
achievement
Pursuit of personally
demanding
standards in valued
areas of life
e.g., work, sport,
friendships, etc
Available as a pdf from www.psychiatry.ox.ac.uk/credo
CLINICAL PERFECTIONISM (cont)
Treatment
• Cognitive behavioural analysis of clinical perfectionism has clear
implications for treatment
– i.e., the CBT-E strategy (for addressing the over-evaluation of
eating, shape and weight) may also be applied to clinical
perfectionism
Over-evaluation of achieving and achievement
Rigorous pursuit of
personally demanding
standards and/or
avoidance of tests of
performance
Preoccupation
with thoughts
about
performance
Performancechecking with
selective
attention to
deficiencies in
performance
Marginalization
of other areas of
life
Re-setting standards
if goals are met
Available as a pdf from www.psychiatry.ox.ac.uk/credo
“CORE” LOW SELF-ESTEEM
• Many patients with eating disorders are highly self-critical
– due to failure to meet their goals (e.g., perfect control over eating)
– generally lessens with successful treatment
• Subgroup that has a more global negative view of themselves - “core
low self-esteem"
– unconditional and pervasive negative view of themselves
– part of their permanent identity
– leads them to make negative judgements about themselves that are autonomous
and independent of performance
“CORE” LOW SELF-ESTEEM (cont)
• Generally longstanding
– antecedent risk factor for developing AN and BN (like perfectionism)
• Obstructs change (relatively consistent predictor of poor response to CBT-BN)
– creates hopelessness about the capacity to change
– encourages particularly determined pursuit of valued goals
• Self-perpetuating state
– pronounced negative processing biases coupled with over-generalisation
– results in patients being prone to see themselves as repeatedly failing, and
these failures being viewed as confirmation that they are failures as people
CORE LOW SELF-ESTEEM (cont)
Treatment
• Are many well-described CBT strategies and procedures available
(e.g., Fennell, 1998)
• Change is greatly facilitated by concurrent change in other areas
(i.e., change in the eating disorder; enhanced interpersonal
functioning)
ADDRESSING CORE LOW SELF-ESTEEM
Reading
• Fennell MJV (1998). Low self-esteem. In Treating Complex Cases: The
Cognitive Behavioural Therapy Approach (eds N Tarrier, A Wells, G Haddock).
Wiley, Chichester
• Fennell M (1999). Overcoming Low Self-esteem. Robinson, London
INTERPERSONAL DIFFICULTIES
• Well-recognised that many patients with eating disorders have
impaired interpersonal functioning
• Their significance has come to the fore with the well-replicated
finding that an exclusively interpersonal treatment (IPT) is a
relatively effective treatment for BN (Fairburn et al, 1993; Agras et
al, 2000)
INTERPERSONAL DIFFICULTIES (cont)
Treatment
•
•
CBT-E addresses interpersonal functioning (when relevant)
with there being three interpersonal goals:
• to resolve interpersonal problems
• to enhance general interpersonal functioning
• to address developmental issues
Achieved using an embedded interpersonal module that
employs IPT strategies and procedures