Post on 03-Jun-2018
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TRANSDIAGNOSTIC CBT FOREATING DISORDERS
CBT-E
Christopher G Fairburn
www.psychiatry.ox.ac.uk/credo
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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
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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
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Anorexia nervosa
Bulimia nervosa
Eating disorder NOS
EATING DISORDERS
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ED-NOS
AN
BNComparable in severity to BN
Three subgroups:
subthreshold cases of AN and BN
mixed statesbinge eating disorder
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ED-NOS
AN
BN
BED No empirically supported treatmen
CBT leading empirically-supported treatment:
but only 40% to 50% ofthose who complete CBT-Bmake a full and lastingrecovery
Just one treatmentstudy
Leading treatment isguided CB self-help
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1. No evidence-based treatment for
AN
ED-NOS
2. CBT-BN not sufficiently potent
TWO PROBLEMS
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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
ENHANCED CBT (CBT-E)
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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
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CBT-E is designed to address these mechanisms ........... it is a treatment for eating disorder psychopathology,
not a treatment for a DSM-IV diagnosis
THE TRANSDIAGNOSTIC VIEW
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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, 20
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VARIOUS VERSIONS OF CBT-E
Two forms
Focused: Core default version of the treatment
Broad: Includes additional modules to address broader external maintainingmechanisms: mood intolerance, clinical perfectionism, low self-esteem andmajor interpersonal problems
Two intensities
20-sessionversion for patients with a BMI >17.5 40-sessionversion for patients with a BMI
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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
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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
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DEPRESSION
Clinical observations (cont)
2. Such patients may have other characteristics of note
premorbid depression
a late-onset eating disorder
intensification of depressive features in the absence of change in the
eating disorder
3. Higher than usual antidepressant doses are often required
fluoxetine (40mg to 100mg)
few side effects
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DEPRESSION
Clinical observations (cont)
4. Resolution of the depressive features facilitates subsequent
treatment
5. Resolution of the depressive features may, or may not, result
in a change in the eating disorder
in AN, dietary restraint may intensify in BN, urge to binge may decrease
6. Follow-up suggests that some patients are prone to recurrent
depressive episodes
these may trigger recurrences of the eating disorder
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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)
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STAGE ONE - STARTING WELL
1. Engage the patient in treatment and change2. Assess the nature and severity of the psychopathology present
3. Jointly create a personalised formulation
4. Explain what treatment will involve
5. Establish real-time self-monitoring6. Initiate in-session collaborative weighing
7. Provide psychoeducation
8. Establish a pattern of regular eating
9. See significant others
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THE FORMULATION
Personalised visual representation of the processes that appear tobe maintaining the eating disorder
Rationale
Begins to distance patients from their problem (decentering)
Starts the process of helping patients step back from their eatingdisorder and try to understand it
Can be highly engaging
Conveys the notion that eating disorders are a self-maintaining
system
Informs treatment
BULIMIA
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Binge eating
Compensatory
vomiting/laxative misuse
Events andassociated moodchange
Over-evaluation of shape and
weight and their control
Strict dieting; non-compensatory
weight-control behavior
a
b
c
d
e
f
BULIMIANERVOSA
Available as a pdf from www.psychiatry.ox.ac.uk/cre
ANOREXI
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Strict dieting; non-compensatory
weight-control behaviour
Low weight with
secondary effects
Over-evaluation of shape and
weight and their control
preoccupation with eating
social withdrawal
heightened obsessionality
heightened fullness
ANOREXINERVOSA
Available as a pdf from www.psychiatry.ox.ac.uk/cre
COMPOSITE
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Strict dieting; non-
compensatory weight-control
behaviour
Binge eating
Compensatory
vomiting/laxative
misuse
Significantly
low weight
Events andassociated moodchange
Over-evaluation of shape and
weight and their control
COMPOSITETEMPLATEFORMULATIO
Available as a pdf from www.psychiatry.ox.ac.uk/cre
EXAMPLE O
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Diet; exercise a lot
Occasional
binges
Make myself sick
Low weight?Feel unhappy
Feel really bad about my weight
and the way I look
EXAMPLE OED-NOS
Available as a pdf from www.psychiatry.ox.ac.uk/cre
BINGE EATIN
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Binge eatingEvents andassociated moodchange
Dissatisfaction with shape and
weight and their control
Intermittent dieting
BINGE EATINDISORDER
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THE FORMULATION
Procedure Drawn out, using the patients 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
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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
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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
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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
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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 cant interpret a single reading
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EDUCATION
Rationale
Reduces stigma, corrects myths, informs about important maintaining processeseducates 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)
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REGULAR EATING
Key intervention for all patients (including underweight ones)
Rationale
Foundation upon which other changes in eating are built
Gives structure to the patients 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
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SIGNIFICANT OTHERS
Rationale See significant others if this is likely to facilitate treatment andthe patient is willing
Usually the significant others are people who influence the patients
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
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STAGE TWO
Whilst continuing with the strategies and procedures introduced inStage 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
clinical perfectionism, core low self-esteem, major interpersonal
problems
5. Design Stage Three
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STAGE THREE
Whilst continuing with the strategies and procedures introduced inStage One, address the main maintaining mechanisms operating
in the individual patients 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
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The core psychopathology of eating disorders is the over-evaluation oshape and weight
self-worth is judged largely or exclusively in terms of shape and weighand the ability to control them
other modes of self-evaluation are marginalised most other features appear to be secondary to the core psychopatholog
dieting
repeated body checking and/or body avoidance
pronounced feeling fat
ADDRESSING THE OVER-EVALUATION OF
SHAPE OR WEIGHT
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ADDRESSING THE OVER-EVALUATION OF
SHAPE OR WEIGHT
Overview
1. Prepare the patient for change
i. Educate about self-evaluation
ii. Assess the patients scheme for self-evaluation and its expressions
iii. Expand the formulation
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Family
Work
Shape, weight
and eating
Other
Friends
Sport
Music
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Family
Work
Shape, weight
and eating
Other
ADDRESSING THE OVER-EVALUATION OF
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Expand the formulation
SHAPE OR WEIGHT (cont)
Over-evaluation of shape and weight and their control
Dietaryrestraint
Shape and weightchecking and/oravoidance
Preoccupationwith thoughtsabout shapeand weight
Marginalisationof other areasof life
Mislabellingadverse statesas feelingfat
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ADDRESSING THE OVER EVALUATION OF
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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
ADDRESSING THE OVER EVALUATION OF
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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
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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
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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
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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 arent what they seem
what we see in mirrors depends to a large extent upon how welook
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)
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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
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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)
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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 peoples bodies
Takes many successive sessions (one item on agenda)
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Feelings of fatness
Actual weight
Time
Available as a pdf from www.psychiatry.ox.ac.uk/cre
ADDRESSING THE OVER-EVALUATION OF
SHAPE OR WEIGHT ( t)
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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 statesStrategy
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
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Strict dieting
Restraint(attempted under-eating)
Restriction(actual under-eating)
ADDRESSING DIETARY RESTRAINT
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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
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ADDRESSING DIETARY RESTRAINT
Food avoidance
Identify avoided foods
Categorise them
Systematically introduce (as behavioural experiments)
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ADDRESSING RESIDUAL BINGES
Introduction of a pattern of regular eating displaces most binge
eating
Identify mechanisms responsible for each remaining binge
Binge Analysis
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Binge eating
Breaking a dietary rule
Being disinhibited (e.g., alcohol)
Under-eating
Adverse event or mood
Lessons to learn:
...
Available as a pdf from www.psychiatry.ox.ac.uk/cre
STAGE THREE
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STAGE THREE
Completing Stage Three1. Review the origins of the eating problem (historical review)
2. Help patients learn to control their eating disorder mindset
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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
ORIGINS OF THE EATING PROBLEM
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Time periodEvents 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 eatingFelt 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
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Introduce the notion of mindsets once patients have alternatingpsychological 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
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MINDSETS
One can influence mindsets in two ways:
i. By addressing their content
using conventional CBT procedures
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ii. By influencing their playing
decreasing the chances it is triggered
real-time awareness of potential triggers; inoculation against them
by spotting it coming into place
early warning signs (relapse signatures)
by displacing it
behaving healthily (doing the right thing)
plus potent distraction
MINDSETS
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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 fromwww.psychiatry.ox.ac.uk/credo]
STAGE FOUR - ENDING WELL
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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. address the eating problem; do the right thing
ii. address the trigger
[Template plan available for editing fromwww.psychiatry.ox.ac.uk/credo]
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CBT-E
Strategies for patients who areunderweight
CBT-E
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80
90
100
110
120
130
140
150
0 2 4 6 8 10 12 14 16 1 8 20 22 2 4 26 2 8 30 3 2 34 3 6 38 4 0
BMI 20.0
Weeks
1. Start well. Engage the patient in treatment and the
prospect of change carefully consider when best to start treatment
be engaging, positive, supportive, interested inpatient as a person
(Fairburn, Cooper, Shafran, Bohn, Hawker, Murphy and Straebler, 200
CBT-E
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80
90
100
110
120
130
140
150
0 2 4 6 8 10 12 14 16 1 8 20 22 2 4 26 2 8 30 3 2 34 3 6 38 4 0
BMI 20.0
Weeks
1. Start well. Engage the patient in treatment and the
prospect of change2. Educate about the psychobiological effects of under-eating
and being underweight, and create a personalisedformulation
personalised education (based on handout)
personalised formulation (derived from CBT-Estransdiagnostic template formulation)
(Fairburn, Cooper, Shafran, Bohn, Hawker, Murphy and Straebler, 200
EDUCATION
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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
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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
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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
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Implications
1. Many features that the patient is experiencing are non-specific effectsof 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 patients true personality
reversed by weight regain; weight gain therefore a necessary part of
treatment
EDUCATION
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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
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CBT-E
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80
90
100
110
120
130
140
150
0 2 4 6 8 10 12 14 16 1 8 20 22 2 4 26 2 8 30 3 2 34 3 6 38 4 0
BMI 20.0
Weeks
1. Start well. Engage the patient in treatment and the
prospect of change2. Educate about the psychobiological effects of under-eating
and being underweight, and create a personalisedformulation
3. Establish a pattern of regular eating
4. Discuss pros and cons of change
5. Initiate and then maintain weight regain
(Fairburn, Cooper, Shafran, Bohn, Hawker, Murphy and Straebler, 200
Reasons to stay as I am Reasons to change Reasons to stay as I am Reasons to change
How I feel now Thinking five years ahead ...
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It makes me feel in controland specialI get attention from otherswill not get fatI am good at itIt makes me feel strongIt shows I have will-powerIt is familiar and feels safeI have an excuse for thingsdont have to have periodsI am not hassled by menIf I change:- wont be able to stopeating- my weight will shoot up- my stomach will stickout- my thighs will get fatterIf I change people will thinkthat:
- I am weak and greedy- I have given in- I am getting fat
I will get rid of my starvationsymptoms:- thinking about food andeating all the time- feeling so cold- not sleeping properly- feeling faintI will feel healthierI will be healthierI will be able to think moreclearlyI will have more timeI will be able to think aboutother thingsI will be less obsessive andmore flexible and spontaneousMy life will have a broaderfocusI will be happier and have morefunI will be able to go out withothers and get on with peoplebetterI will discover who I really am
It makes me feel in control and specialwill not get fatIt is familiar and feels safeIf I change:- wont be able to stop eating- my weight will shoot up- my stomach will stick out- my thighs will get fatterIf 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 workI want a long term relationshiI want a familyI want to be a positive role modfor my childrenI want to go on holiday and bspontaneousI want to be in good healthdont want to still havestarvation symptoms or anyother effects of the EDwant to be in true control ofmy eatingdont want to waste my life I want to achieve thingsdont want to be chronically
170
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100
110
120
130
140
150
160
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40
BMI 20.0 (126lbs)
BMI 25.0 (157lbs)
Healthy
weight
Weeks
Weight
(lbs)
CBT-E
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80
90
100
110
120
130
140
150
0 2 4 6 8 10 12 14 16 1 8 20 22 2 4 26 2 8 30 3 2 34 3 6 38 4 0
BMI 20.0
Weeks
1. Start well. Engage the patient in treatment and the
prospect of change2. Educate about the psychobiological effects of under-eating
and being underweight, and create a personalisedformulation
3. Establish a pattern of regular eating
4. Discuss pros and cons of change
5. Initiate and then maintain weight regain
take the plunge
educate about the physiology of weight regain
let patients try it their way
help patients maintain an energy excess of 500kcalsper day
offer the option of high-energy drinks
(Fairburn, Cooper, Shafran, Bohn, Hawker, Murphy and Straebler, 200
CBT-E
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80
90
100
110
120
130
140
150
0 2 4 6 8 10 12 14 16 1 8 20 22 2 4 26 2 8 30 3 2 34 3 6 38 4 0
BMI 20.0
Weeks
1. Start well. Engage the patient in treatment and the
prospect of change2. Educate about the psychobiological effects of under-eating
and being underweight, and create a personalisedformulation
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
(Fairburn, Cooper, Shafran, Bohn, Hawker, Murphy and Straebler, 200
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Strict dieting; non-compensatory
weight-control behaviour
Low weight with
secondary effects
Over-evaluation of shape and
weight and their control
body checking and avoidance
feeli ng fat
marginali sation of other areas of li fe
dietary restraint and restr iction
dietary rules
over-exercising
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CBT-E
Broad version
EXTENDED THEORY (Fairburn et al, 2003)
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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 thesemechanisms should improve outcome
The broad form of CBT-E is based on this theory
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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
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MOOD INTOLERANCE (cont)
Respond dysfunctional mood modulatory behaviourwhich
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)
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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 cant stand feeling like
this) and can amplify the initial mood state
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MOOD INTOLERANCE (cont)
Treatment
Existing CBT treatment procedures are often not sufficientfor 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
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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
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ADDRESSING MOOD INTOLERANCE (cont)
Adverse event
Deterioration in mood
Dysfunctional behaviour
Immediate improvement in mood
Later negative appraisal
Pressure at work
Tension
Binge eating and/or cutting
Release of tension
Binge eating like this is hopeless.I have no will-power
ADDRESSING MOOD INTOLERANCE (cont)
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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)
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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
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Over-evaluation of striving to achieve, and achieving, personally demandistandards despite adverse consequences
Form of psychopathology equivalent to the core psychopathology ofeating disorders (i.e., it is also a dysfunctional system for self-evaluatio
(Shafran R, Cooper Z, Fairburn CG. Clinical perfectionism: A cognitive-behaviouralanalysis. Behaviour Research and Therapy 2002; 40: 773-791)
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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 oflife (e.g., performance at work, sport, music, etc)
Over-evaluation of shape and
weight and their controlOver-evaluation
of achieving and
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Strict dieting; non-
compensatory weight-control
behaviour
Binge eating
Compensatory
vomiting/laxative
misuse
Significantly
low weight
Events andassociated moodchange
g o c ev g d
achievement
Pursuit of persona
demanding
standards in value
areas of life
e.g., work, sport,
friendships, etc
Available as a pdf from www.psychiatry.ox.ac.uk/cre
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CLINICAL PERFECTIONISM (cont)Treatment
Cognitive behavioural analysis of clinical perfectionism has clearimplications for treatment
i.e., the CBT-E strategy (for addressing the over-evaluation ofeating, shape and weight) may also be applied to clinicalperfectionism
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Over-evaluation of achieving and achievement
Rigorous pursuit ofpersonally demandingstandards and/oravoidance of tests of
performance
Performance-checking withselectiveattention todeficiencies in
performance
Preoccupationwith thoughtsabout
performance
Re-setting standardsif goals are met
Marginalizationof other areas oflife
Available as a pdf from www.psychiatry.ox.ac.uk/cre
CORE LOW SELF-ESTEEM
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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)
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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
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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
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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
ADDRESSING CORE LOW SELF-ESTEEM
INTERPERSONAL DIFFICULTIES
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Well-recognised that many patients with eating disorders haveimpaired 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)
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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