Eating Disorders: A CBT Approach Beverly Swann, MFT [email protected] 925-705-7036 Jennifer...

Eating Disorders:A CBT Approach

Beverly Swann, MFT

[email protected]

www.beverlyswann.com

925-705-7036

Jennifer Lombardi, MFT, Content Contributor

Let’s Get Started

Logistics Learning Objectives

Introductions / Expectations Syllabus / Flow of Class

Disclaimer

Ask questions Bring in material from your clients, taking

appropriate measures to protect identity Ask me to slow down or repeat material if

needed Network with each other during breaks

Please Do:

Cell phones ringing Take calls during class Text during class Side conversations Arrive late Discuss any client information presented in

class with anyone outside of class

Please Don’t:

Learning Objectives

Learn the DSM criteria for eating disorders (ED) Understand common themes in ED related to body

image and weight beliefs. Know the health problems that can occur from ED Develop knowledge of the biopsychosocial theories

about ED Apply assessment tools and a Cognitive Behavioral

Theory (CBT) case formulation to determine level of care needed and appropriate treatment interventions

Develop skills in applying CBT strategies to treat ED *Learn a lot of resources to learn more!

Introductions / Expectations

Your name

Experience/knowledge Eating Disorders

and/orCognitive Behavioral Theory

Expectations for the class

Why CBT?

ED is complex disorder, commonly w/co-occurring disorders

Have to address behavior as well as emotion Malnourished clients have difficulty using

insight to make long-term change Provides structure and stability for anxious

clients

Eating Disorder – DSM IV-TR

Anorexia Nervosa• Underweight (at or

below 85% ideal)• Disrupted menses• Fear of gaining

weight/being fat• Sometimes

purging behavior• Body/self-image is

distorted• Restricting Type,

Binge/Purge Type, Atypical

Bulimia Nervosa

• Normal or overweight

• Binge eating with compensatory behaviors

• Fear of gaining weight/being fat

• Body/self-image is distorted

• Purging Type and Non-Purging Type

EDNOS• Anorexia criteria

met but still having menses or weight is still in normal range

• Atypical eating disorders

• Binge eating disorder/compulsive eating

• Food aversion• Orthorexia• Diabulimia• Night eating

Compensatory Behaviors

60% Self-induced vomiting 25% Laxatives 5% Compulsive Exercise 5% Diet pills 5% Diuretics ? Restricting food

DSM-V – ED Proposed Additions (May 2013?)

Avoidant/Restrictive Food Intake Disorder (food aversion)

Binge Eating Disorder Feeding and Eating Conditions Not

Elsewhere Classified (more defined than NOS)

www.dsm5.org

DSM V: Binge Eating Disorder

Binge eating - Average of 2 times per week for 6 Binge eating - Average of 2 times per week for 6 monthsmonths

No compensatory behaviorsNo compensatory behaviors Associated with at least 3 of the following:Associated with at least 3 of the following:

Eating more rapidly than normal Eating until uncomfortable full Eating large amounts of food when not hungry Eating alone out of embarrassment of how much one eats Feeling disgust, depressed, guilty after overeating

More About Binge Eating Disorder

2-5% of the American population suffers from binge eating disorder

Men constitute 40% of those with BED Onset usually occurs during late adolescence

or in early adulthood

Medical Issues and Complications* - Anorexia Nervosa

*www.nationaleatingdisorders.org/nedaDir/files/documents/handouts/HlthCons.pdf

Cardiac issues (bradycardia, tachycardia, orthostasis) Problems w/kidney and liver function Low glucose and/or sodium Reduction of bone density (osteopenial/osteoporosis) Muscle loss and weakness Severe dehydration, which can result in kidney failure; fainting,

fatigue, and overall weakness. Lanugo – growth of extra body hair on arms, chest, and back Hair and Nail thinning Amenorrhea Edema Sleep disruption Dental/enamel loss Tinitis

Medical Issues and Complications - Bulimia Nervosa

Cardiac issues (bradycardia, tachycardia, orthostasis)

Esophageal ruptures/tearing (blood in vomit, cancer) Electrolyte imbalances Elevated CO2 Edema Sleep disruption Dental/enamel loss Low glucose Low sodium Swollen parotid glands Blood in stool

Medical Issues and Complications – EDNOS/BED

High blood pressure

High cholesterol levels

Heart disease as a result of elevated triglyceride levels

Type II diabetes mellitus

Gallbladder disease

Obesity

Joint/Muscle pain

Cancers

Gastrointestinal problems

Sleep apnea

Genetics loads the gun,

and

environment pulls the trigger.

Craig Johnson, PhD

Etiology

Five Reasons Why An Eating Disorder Develops

Genetics Loads The Gun: Biology Personality Traits/Temperament

And Environment Pulls The Trigger: Trauma/loss Family Dynamics Culture

The brain’s signal for hunger is turned down Anterior Insula Posterior Insula

Taste is experienced differently for patients with anorexia

Patients with ED do not experience normal “reward” for eating food – anorexia or binge

Diminished self-awareness of internal body states (dissociation)

Family history of anxiety and/or depression

Initiating Risk Factors

Neurotransmitters:Development And Maintenance Of Eating Disorders

DopamineDopamine Correlated with harm avoidanceCorrelated with harm avoidance Insensitivity to normal rewards Insensitivity to normal rewards (Frank, et al 2005)(Frank, et al 2005)

SerotoninSerotonin High level associated with anorexiaHigh level associated with anorexia Low levels associated with bulimia/ binge eating Low levels associated with bulimia/ binge eating

disorderdisorder Affect instabilityAffect instability ImpulsivityImpulsivity Self harming behaviorSelf harming behavior Interpersonal insecurities Interpersonal insecurities (Steiger et al, 2006)(Steiger et al, 2006)

Video – Erasing ED

Notice:

• Environmental factors

• Emotional factors

• Behaviors

• Temperament

• Medical complications

• Thoughts/beliefs

Cognitive Behavioral Therapy

““There’s nothing good or bad, There’s nothing good or bad,

but thinking makes it so.”but thinking makes it so.”

- Shakespeare’s HamletShakespeare’s Hamlet


Core ConceptsCore Concepts1.1. Thoughts cause our feelings and behaviorsThoughts cause our feelings and behaviors

Not external factors (people, places, etc.)Not external factors (people, places, etc.)

2.2. Time-LimitedTime-Limited Average of 16 to 20 sessionsAverage of 16 to 20 sessions

3.3. Therapeutic alliance important… but not the Therapeutic alliance important… but not the answeranswer Change occurs because client learns how to Change occurs because client learns how to

think differently and, as a result, act differentlythink differently and, as a result, act differently


Core Concepts ContinuedCore Concepts Continued

4. Goal-oriented4. Goal-oriented Collaborative – therapist listens, teaches Collaborative – therapist listens, teaches

and helps client implement learningand helps client implement learning

5. Stoicism 5. Stoicism Emphasis is on being calmEmphasis is on being calm

6. Socratic method6. Socratic method Ask questions & encourage client to do Ask questions & encourage client to do

the samethe same


Core Concepts ContinuedCore Concepts Continued7. Teach clients how

Using specific techniques, structure and Using specific techniques, structure and foster patient’s skillsfoster patient’s skills

8. Education-focused 8. Education-focused Concept of “unlearning”Concept of “unlearning”

9. Inductive method9. Inductive method Look at thoughts as “hypotheses” to be Look at thoughts as “hypotheses” to be

exploredexplored10. Homework!10. Homework!

Reading assignments and practice, Reading assignments and practice, practice, practice!practice, practice!


Stages of CBTStages of CBT1. Identify problems

Prioritize

2. Recognize thoughts, beliefs, feelings about the problem “Self talk” Interpretations Beliefs about self, relationships, situations, etc.

3. Identify faulty thinking Record physical, emotional and behavioral

reactions/responses

4. Challenge faulty thinking Validity testing… again and again

CBT: Important Factors for the Patient

Therapeutic allianceTherapeutic alliance HonestyHonesty Consistency/attendanceConsistency/attendance Expectations – progress variesExpectations – progress varies Won’t work without doing homeworkWon’t work without doing homework Express frustrationsExpress frustrations

CBT: Important Factors for the Therapist

Don’t forget about the alliance & Don’t forget about the alliance & empathyempathy

Have a clear approach & communicateHave a clear approach & communicate Go to the core belief(s) about the Go to the core belief(s) about the

irrational thoughtsirrational thoughts Can’t just identify irrational thoughts – Can’t just identify irrational thoughts –

have to go the distance to help have to go the distance to help clientclient find new/replacement thoughtfind new/replacement thought

Talk about the roadmap – but Talk about the roadmap – but encourage/empower the client to driveencourage/empower the client to drive


HistoryHistory Behavioral therapy developed in the early 20Behavioral therapy developed in the early 20 thth century century

Jones’ work in “unlearning” fears with childrenJones’ work in “unlearning” fears with children Pavlov’s work in the 1950’sPavlov’s work in the 1950’s Wolpe’s work with systematic desensitization with Wolpe’s work with systematic desensitization with

animalsanimals B.F. Skinner’s “radical behavioralism” with psychiatric B.F. Skinner’s “radical behavioralism” with psychiatric

disorders disorders


HistoryHistory Cognitive therapy developed in the mid 20Cognitive therapy developed in the mid 20 thth century century

““Cognitive revolution” – a reaction to behavioralismCognitive revolution” – a reaction to behavioralism Added “mentalistic” thoughts and cognitionsAdded “mentalistic” thoughts and cognitions Present-focusedPresent-focused Albert Ellis’ Rational TherapyAlbert Ellis’ Rational Therapy

First form of cognitive behavioral therapyFirst form of cognitive behavioral therapy Aaron T. Beck Cognitive TherapyAaron T. Beck Cognitive Therapy

Discovered through free associationDiscovered through free association Recognized certain thoughts preceding certain emotionsRecognized certain thoughts preceding certain emotions


History ContinuedHistory Continued In 1980’s Merging of the Two Approaches In 1980’s Merging of the Two Approaches

OccurredOccurred Clark and Barlow for panic disorderClark and Barlow for panic disorder Arnold Lazarus’ multimodal therapyArnold Lazarus’ multimodal therapy

Included physical sensationsIncluded physical sensations Visual imageryVisual imagery Interpersonal relationshipsInterpersonal relationships Biological factorsBiological factors

Homework

Using Assessment Worksheet, analyze one or more clients you currently have or have treated in the past.

Assessment & Diagnosis

Initial Comprehensive History Includes:Initial Comprehensive History Includes: Eating disorder behaviors – current and pastEating disorder behaviors – current and past Substance abuse – current and pastSubstance abuse – current and past Treatment history – including medicationsTreatment history – including medications Medical complicationsMedical complications Social supportSocial support TemperamentTemperament CultureCulture History of trauma and lossHistory of trauma and loss Family history of mental health, medical issuesFamily history of mental health, medical issues History of abuse, self injury, suicidalityHistory of abuse, self injury, suicidality What patient views as causes - Often focuses on social as primary, What patient views as causes - Often focuses on social as primary,

intrapersonal distress secondary. Rarely recognize biological.intrapersonal distress secondary. Rarely recognize biological.

Assessment – Collaborating With Other Professionals

Importance of treatment team Primary Care Physician (PCP) Psychiatrist Other therapists Treatment centers Dietician

Release of Information forms!

Common Co-Occurring Disorders

Substance Abuse/Dependence

Depression

Anxiety

PTSD

Obsessive-Compulsive Disorder

Common Co-Occurring Disorders

Body Dysmorphic Disorder

Borderline Personality Disorder

Obsessive-Compulsive Personality Disorder

Other Addictions

Medical Illnesses

Co-Occurring Disorders

Anorexia Anxiety disorders – often pre-date the ED

Obsessive compulsive disorder Social phobia GAD

Major Depression Axis II?

Bulimia Affective Disorders

Major Depression Bipolar Disorder GAD

Substance Abuse Alcohol, marijuana


Binge Eating Disorder Affective Disorders

Major Depression Bipolar Disorder GAD

PTSD Axis II

Co-Ocurring Disorders – Personality Disorders

ED clients with Borderline Personality Disorder Prognosis not great Treatment resistant Suicide and self-harm concerns

ED clients with Obsessive-Compulsive PD features Perfectionism Food Rules In Anorexia, difficult to differentiate

from starvation effects


Example 1:

Janice is a 19 year old Olympic hopeful swimmer who has just completed 6 weeks of treatment for bulimia. She reports that her daily routine includes coffee at Starbucks and carrot sticks during breaks at practice, and appetizers when she goes out with her friends at night. She likes to go hot-tubbing after hitting the bars.

Example 2:

Mari comes to your office after being referred for domestic violence counseling. She weighs approximately 220 pounds and her complexion is very red, especially around the nose and cheek area.

Trauma or Loss

Several studies of both ED and PTSD patients have shown: Estimated 30 to 45 percent have some trauma

history Sexual Physical/neglect

Culture

42% of 1st-3rd graders girls want to be thinner 45% of boys and girls in 3rd-6th grades want to be

thinner 37% have already dieted

51% of 9-10 year olds feel better about themselves when dieting

9% of 9 year olds have vomited to lose weight 81% of 10 year olds are afraid of being fat 78% of 18 year old girls are unhappy with their

bodies The #1 wish for girls 11-17 years old is to lose weight

Body Wars, Margo Maine

Culture

Society Does Not Cause Eating Disorders

BUT… creates toxic environment

“Genetics loads the gun

and environment pulls the trigger.”

Craig Johnson, PhD

Cultural Considerations

Research shows that eating disorders are not limited to young, caucasian females. Studies have found rates of ED to be roughly the same in several other ethnic groups.

Factors to be aware of: Likelihood of seeking treatment – Asian and Hispanic

populations tend to utilize available treatment at a lower rate than caucasians; African American and Native American populations have a higher rate of utilization

Access to treatment Language barriers

Cultural Considerations

Acculturation

Socio-economic status – County clients

Gender considerations

Gay/lesbian populations

List of recommended readings:

www.nationaleatingdisorders.org/nedaDir/files/documents/handouts/IncorpDi.pdf

www.nationaleatingdisorders.org/nedaDir/files/documents/handouts/WomenCol.pdf

Temperament

Anxious Perfectionist Obsessional Harm or conflict avoidant Low Self-directedness Reward dependent Impulsivity (BN)

Temperament Associated with BED

Perfectionistic People pleasing Rigid, inflexible thinking Difficulties expressing needs and emotions Conflict or harm avoidant Impulsivity Reward dependence

Personality Traits/Temperament

Temperament & Character Inventory Harm Avoidance (AKA: “Peacemakers”) Low Self-Directedness Reward Dependence (AKA: Perfectionism) Novelty Seeking (AKA: Impulsivity)

The Psychology of Eating Disorders

How Patients Experience Eating DisordersHow Patients Experience Eating Disorders Security (something is constant, stable)Security (something is constant, stable) Avoidance (emotional numbing, isolating)Avoidance (emotional numbing, isolating) Mental Strength (finally feeling good at something)Mental Strength (finally feeling good at something) Self-Confidence (getting praise)Self-Confidence (getting praise) Identity (feeling of invincibility)Identity (feeling of invincibility) Elicit Care (from others, Elicit Care (from others, without having to askwithout having to ask)) Communication (communicating difficulties)Communication (communicating difficulties) Death (passive way to suicide)Death (passive way to suicide)

Nordbo, et al, 2006Nordbo, et al, 2006

Types of Assessment

Bio-psycho-socialBio-psycho-social

Medical evaluationMedical evaluation

Psychiatric evaluationPsychiatric evaluation

Nursing assessmentNursing assessment

Nutrition assessmentNutrition assessment

Assessment – Screening Tools

Eating Disorder Questionnaire (EDQ) Obligatory Exercise Scale Addiction Severity Index (ASI) Adult ADHD Self-Report Scale (ASR-v1.1) Alcohol Use Disorder Identification Test (AUDIT) Michigan Alcoholism Screening Test (MAST) Drug Abuse Screening Test (DAST) Beck Depression Inventory (BDI) Beck Scale for Suicide Ideation (BSS) Beck Anxiety Inventory (BAI) Brief Symptom Inventory (BSI) Mood Disorder Questionnaire URICA (readiness to change) FRIEL Co-dependency Inventory Multiscale Dissociation Inventory (MDI)

Assessment Tools

EDI III – based on females aged 13-53EDI III – based on females aged 13-53 HistoryHistory 91 items91 items 12 Primary Scales12 Primary Scales

3 ED specific3 ED specific 9 General psych (but highly relevant to ED)9 General psych (but highly relevant to ED)

6 Composites6 Composites ED RiskED Risk IneffectivenessIneffectiveness Interpersonal ProblemsInterpersonal Problems Affective ProblemsAffective Problems OvercontrolOvercontrol General Psych MaladjustmentGeneral Psych Maladjustment

Sample evaluationSample evaluation Context of What You Know About Patient and Family/Loved OnesContext of What You Know About Patient and Family/Loved Ones

Assessment Tools

Obligatory Exercise QuestionnaireObligatory Exercise Questionnaire ComparisonComparison ScalesScales

30 – 40 mild concern30 – 40 mild concern 40 – 50 moderate concern40 – 50 moderate concern 50 + serious concern50 + serious concern

Sample evaluationSample evaluation Context of What You Know About Patient and Context of What You Know About Patient and

Family/Loved OnesFamily/Loved Ones

Assessment Tools

Temperament and Character InventoryTemperament and Character Inventory 7 “Personality Dimensions”7 “Personality Dimensions”

4 Temperament4 Temperament Harm Avoidance, Novelty Seeking, Reward Harm Avoidance, Novelty Seeking, Reward

Dependence, PersistenceDependence, Persistence

3 Character3 Character Self-directedness, Cooperativeness, Self-Self-directedness, Cooperativeness, Self-

transcendencetranscendence

Assessment Tools

Common combinations:Common combinations: AnorexiaAnorexia

TemperamentTemperament High harm-avoidanceHigh harm-avoidance Low novelty-seekingLow novelty-seeking High reward-dependenceHigh reward-dependence High persistenceHigh persistence

CharacterCharacter Self-directedness variesSelf-directedness varies High cooperativeness High cooperativeness Low self-transcendenceLow self-transcendence

Assessment Tools

Common combinations:Common combinations: BulimiaBulimia

TemperamentTemperament Harm-avoidance variesHarm-avoidance varies High novelty-seekingHigh novelty-seeking High reward-dependenceHigh reward-dependence Low persistenceLow persistence

CharacterCharacter Low self-directednessLow self-directedness Cooperativeness varies Cooperativeness varies High self-transcendenceHigh self-transcendence

Treatment - Levels of Care

Outpatient – typically once a week therapy Intensive Outpatient (IOP) – 3-4 days/week,

half-day Partial Hospitalization (PHP) of Day

Treatment – 4-5 days/week, full-day Residential – 24/7 treatment,

client does not go home Inpatient – 24/7 medical

treatment to stabilize patient medically – usually short-term

Treatment Focus

Medical/Nutrition Stabilization for medically compromised clients

Weight restoration for underweight clients Neuronal plasticity – brain circuitry is modified

by experience – CBT! Resolve trauma Develop new habits Grieve loss of ED Discover “Who Am I Without ED?”


Notice:

• Co-occurring disorders

• Behavioral changes

• Thought changes

• Belief changes

• Possible CBT interventions


Stages of CBTStages of CBT1. Identify problems

Prioritize

2. Recognize thoughts, beliefs, feelings about the problem “Self talk” Interpretations Beliefs about self, relationships, situations, etc.

3. Identify faulty thinking Record physical, emotional and behavioral

reactions/responses

4. Challenge faulty thinking Validity testing… again and again


Things to Consider When Identifying Things to Consider When Identifying the Problem(s)the Problem(s) Gravity/severity of illness Length of symptoms/situation Rate of progress made during

treatment Level of stress-tolerance Support system

CBT – Cognitive Distortions

http://psychcentral.com/lib/2009/15-common-cognitive-distortions/

CBT InterventionsH = Hungry – am I physically hungry?

A = Angry (or other emotion) – am I emotionally

hungry?

L = Lonely – am I lonely?

T = Tired – do I need sleep rather than food?

CBT Interventions

Case Formulation – Vicious Flower Recording

Food/Mood Log How Treatment is Going

Identifying Barriers to Change Identifying “Rules”

Eating rules Exercise rules

Address impact of events on eating

CBT Case Formulation

Belief-Driven

http://www.psychologytools.org/download-therapy-worksheets.html/

CBT Case Formulation

Vicious Flower

http://www.psychologytools.org/download-therapy-worksheets.html/

CBT - REBT

Ellis’ Rational Emotive Behavior Therapy Ellis’ Rational Emotive Behavior Therapy (REBT)(REBT)

ABCABC A = Adversity or activating eventA = Adversity or activating event B = Belief(s) about the eventB = Belief(s) about the event C = Consequences (dysfunctional emotional and C = Consequences (dysfunctional emotional and

behavioral)behavioral)

Focus on evaluating BFocus on evaluating B Look for assumptions and thoughts that are Look for assumptions and thoughts that are

illogical, rigid, unrealistic &/or self-destructiveillogical, rigid, unrealistic &/or self-destructive

CBT - REBT

REBT assumes that humans have innate rational and REBT assumes that humans have innate rational and irrational tendenciesirrational tendencies Irrational tendencies:Irrational tendencies:

Self-blameSelf-blame CriticismCriticism AngerAnger Depression and anxietyDepression and anxiety AvoidanceAvoidance AddictionAddiction ProcrastinationProcrastination

How might these show up in an eating disorder client?How might these show up in an eating disorder client?

CBT - REBT

Primary goal: Primary goal: You Have A ChoiceYou Have A Choice To engage in helpful thoughts or self-

destructive thoughts Helpful emoting is good – unhelpful is

problematic Ingrain them over time with practice

Major Insights Irrational beliefs are “root” of issues People tend to hold on to irrational beliefs,

so focus on identifying, questioning and change

Insight alone rarely uproots emotional/psychological issues

REBT – 3 Core/Common Self-Destructive Beliefs

1. “I absolutely must, under all conditions, perform well and win the approval of others. If I fail… I am a bad, incompetent person, who will probably always fail and deserves to suffer.” Contributes to anxiety, panic, feelings of despair, hopelessness,

depression and low self-worth

2. “Other people… MUST, under practically all conditions and at all times, treat me nicely, considerately and fairly. Otherwise, it is terrible and they are rotten, bad, unworthy people who will always treat me badly and do not deserve a good life...” Contributes to anger, rage, vindictiveness

3. “The conditions under which I live absolutely MUST, at all times, be favorable, safe, hassle-free and… enjoyable. If they are not… it’s awful and horrible and I can’t bear it. I can’t ever enjoy myself… my life is impossible and hardly worth living.” Contributes to frustration, intolerance, self-pity, procrastination,

avoidance and feeling paralyzed.

REBT – Long-Term Goals

Humans are fallible – move toward Humans are fallible – move toward unconditional self-acceptanceunconditional self-acceptance

Accepting what they can and cannot Accepting what they can and cannot change about the worldchange about the world

Assessing skillsAssessing skills Insight is not enough – move toward Insight is not enough – move toward

challenging and changing irrational/self-challenging and changing irrational/self-destructive beliefsdestructive beliefs

REBT Core Beliefs

Each of the 3 core beliefs have the following in common:Each of the 3 core beliefs have the following in common: Awfulizing Frustration intolerance People depreciation or de-valuing Over-generalizing Catastrophizing

Each of the 3 core beliefs are dogmatic, rigid and over-use:Each of the 3 core beliefs are dogmatic, rigid and over-use: Shoulds Musts Oughts

Often lead to the patient being self-critical - they become aware of these beliefs on some level and become frustrated that they cannot change this quality/dynamic within themselves

REBT Interventions

1. Acknowledging the problem

2. Accepting emotional responsibility

3. Assessing, questioning and ultimately changing

4. Uses various methods, depending on problem Cognitive Emotive Behavioral

REBT and Eating Disorders

Useful with Temperament and CharacterUseful with Temperament and Character Irrational tendencies:Irrational tendencies:

Self-blame – High Persistence (perfectionism)Self-blame – High Persistence (perfectionism) Criticism – Low Cooperativeness (blaming)Criticism – Low Cooperativeness (blaming) Anger – High Novelty-seeking Anger – High Novelty-seeking Depression and anxiety – High Reward-Depression and anxiety – High Reward-

dependencedependence Avoidance – High Harm AvoidanceAvoidance – High Harm Avoidance Addiction – High Persistence (social Addiction – High Persistence (social

attachment)attachment) Procrastination – High Harm Avoidance (fear)Procrastination – High Harm Avoidance (fear)

REBT and Eating Disorders

REBT and Eating DisordersREBT and Eating Disorders Using the ABCUsing the ABC

A = Adversity or activating event – Body Changed A = Adversity or activating event – Body Changed During PubertyDuring Puberty

B = Belief(s) about the event – B = Belief(s) about the event – I can’t trust my bodyI can’t trust my body My body will gain weight foreverMy body will gain weight forever I can’t trust myself with certain foodsI can’t trust myself with certain foods

C = Consequences (dysfunctional emotional and C = Consequences (dysfunctional emotional and behavioral) – I must always be on a diet to control my behavioral) – I must always be on a diet to control my body weight (or eventually I need my eating disorder)body weight (or eventually I need my eating disorder)

Focus on evaluating BFocus on evaluating B Look for assumptions and thoughts that are Look for assumptions and thoughts that are

illogical, rigid, unrealistic &/or self-destructiveillogical, rigid, unrealistic &/or self-destructive

Linehan’s Dialectical Behavioral Therapy (DBT)

Originally designed for treating Borderline Originally designed for treating Borderline Personality DisorderPersonality Disorder

Combines CBT techniques with Mindfulness Combines CBT techniques with Mindfulness and Distress Toleranceand Distress Tolerance Uses cognitive challenges around distorted Uses cognitive challenges around distorted

thoughts/beliefsthoughts/beliefs Mindfulness training as self-soothing skillsMindfulness training as self-soothing skills Research indicates effectiveness with mood Research indicates effectiveness with mood

disorders, self-injury, sexual abuse survivors and disorders, self-injury, sexual abuse survivors and substance abusesubstance abuse

Therapist is an “ally”

DBT Basics

Four Basic Modules in DBT TreatmentFour Basic Modules in DBT Treatment Mindfulness - Mindfulness - “What” and “How”“What” and “How” Distress ToleranceDistress Tolerance Emotion RegulationEmotion Regulation Interpersonal EffectivenessInterpersonal Effectiveness

3 Primary Techniques/Tools3 Primary Techniques/Tools Diary CardsDiary Cards Chain AnalysisChain Analysis MilieuMilieu

DBT – Basic Modules

1.1. Mindfulness – to challenge impulsivityMindfulness – to challenge impulsivity ““What” – describe an event w/o taking emotions What” – describe an event w/o taking emotions

and thoughts literallyand thoughts literally ““How” – how patient attends and participates in How” – how patient attends and participates in

the event; focus on taking a non-judgmental the event; focus on taking a non-judgmental stance – event is neither “good” nor “bad”stance – event is neither “good” nor “bad”

2.2. Interpersonal EffectivenessInterpersonal Effectiveness Asking for what one needsAsking for what one needs Saying “no”Saying “no” Coping with interpersonal conflictCoping with interpersonal conflict

DBT Basic Modules

3.3. Emotion Regulation SkillsEmotion Regulation Skills Identifying and labeling emotionsIdentifying and labeling emotions Identifying obstacles to changing emotionsIdentifying obstacles to changing emotions Reduce vulnerability to the “emotional mind”Reduce vulnerability to the “emotional mind” Increasing positive events, mindfulnessIncreasing positive events, mindfulness Taking “opposite action” (doing something nice when you are Taking “opposite action” (doing something nice when you are

angry)angry)

4.4. Distress Tolerance SkillsDistress Tolerance Skills Accepting one’s environmentAccepting one’s environment Not placing “demands” on it to be differentNot placing “demands” on it to be different Experience emotions without trying to stop or change themExperience emotions without trying to stop or change them Observe thoughts/actions without trying to stop/or control themObserve thoughts/actions without trying to stop/or control them Key component: acceptance of reality is Key component: acceptance of reality is NOTNOT equivalent to equivalent to

approval of realityapproval of reality

DBT Primary Techniques/Tools

Diary CardsDiary Cards Start with Myths Sheets (handout – G)Start with Myths Sheets (handout – G) Move to Diary of day, event, emotion’s Move to Diary of day, event, emotion’s functionfunction

Chain AnalysisChain Analysis Look at environmental and personal antecedents Look at environmental and personal antecedents

to eventto event Consequences of eventConsequences of event At what point(s) could different choice(s) have At what point(s) could different choice(s) have

been madebeen made MilieuMilieu

Provides rich learning opportunity to practice Provides rich learning opportunity to practice skills on regular basisskills on regular basis

DBT Interventions

1.1. Mindfulness – What & How = challenge Mindfulness – What & How = challenge impulsivity of behaviorsimpulsivity of behaviors

2.2. Interpersonal Effectiveness – Saying “no” Interpersonal Effectiveness – Saying “no” and coping with conflict = challenges harm and coping with conflict = challenges harm avoidance, reward dependenceavoidance, reward dependence

3.3. Emotion regulation – reducing vulnerability Emotion regulation – reducing vulnerability to emotional states = challenges harm to emotional states = challenges harm avoidance, high novelty seekingavoidance, high novelty seeking

4.4. Distress tolerance – accepting/not trying to Distress tolerance – accepting/not trying to change environment = challenges novelty change environment = challenges novelty seeking, harm avoidanceseeking, harm avoidance

CBT-E

Created by Christopher Fairburn, associatesCreated by Christopher Fairburn, associates An “enhanced” version of CBTAn “enhanced” version of CBT Emphasizes processes that Emphasizes processes that maintainmaintain ED ED

psychopathology – not initial developmentpsychopathology – not initial development Goal is to create a “formulation” or Goal is to create a “formulation” or

hypothesis of the processes that maintain hypothesis of the processes that maintain the “Eating Disorder Mindset” - These the “Eating Disorder Mindset” - These become the features targeted in treatmentbecome the features targeted in treatment

CBT-E Stages

Time-limited: 20 sessions (40 for acute AN)Time-limited: 20 sessions (40 for acute AN) Four StagesFour Stages Stage One – 2x/week for 4 weeksStage One – 2x/week for 4 weeks

1.1. Establish trustEstablish trust

2.2. Formulate hypothesis of processes that maintain Formulate hypothesis of processes that maintain EDED

3.3. Establish Two ThingsEstablish Two Things In-session WeighingIn-session Weighing Regular EatingRegular Eating

CBT-E Stages

Stage Two – 1x/week for 2 weeksStage Two – 1x/week for 2 weeks

1.1. Take stock in stability with behaviors, weightTake stock in stability with behaviors, weight

2.2. Plan stage 3 – tackling mechanisms that maintain EDPlan stage 3 – tackling mechanisms that maintain ED Stage Three (the Bulk of Treatment) – 1x/week for 8 weeksStage Three (the Bulk of Treatment) – 1x/week for 8 weeks

1.1. Addressing Shape Checking, “Feeling Fat” and MindsetsAddressing Shape Checking, “Feeling Fat” and Mindsets Use pie charts, monitoring records, life chart,Use pie charts, monitoring records, life chart,

2.2. Addressing Dietary RulesAddressing Dietary Rules Food avoidance listFood avoidance list

3.3. Events, Moods and EatingEvents, Moods and Eating Problem solving chart, slowing down/observing and Problem solving chart, slowing down/observing and

analyzing, pros and cons list for ED, reasons to change analyzing, pros and cons list for ED, reasons to change listlist

CBT-E Stages

Stage Four (Ending Well) – 1x/every 2 Stage Four (Ending Well) – 1x/every 2 weeks for one monthweeks for one month1.1. Empowering patient to “do the right Empowering patient to “do the right

thing” and reinforcing competencything” and reinforcing competency

2.2. Distinguishing “lapse” from “relapse”Distinguishing “lapse” from “relapse”

3.3. Learning the stages/warning signs for Learning the stages/warning signs for return of the ED mindsetreturn of the ED mindset


Notice:

• What improved in their lives?

• Life without ED?

• Hope

Local ED Treatment Centers

Casa Serena – IOP, Concord Cielo House – IOP, PHP, Belmont and San Jose Herrick/Alta Bates – Inpatient/Outpatient, Berkley La Ventana – IOP/PHP, San Francisco, San

Jose, and Marin (some dual diagnosis treatment) New Dawn – PHP, San Francisco (some dual

diagnosis treatment) Summit – IOP/PHP/Residential

Wrapping It All Up

Question / Answer / Review

Eating Disorders:A CBT Approach

Beverly Swann, MFT

[email protected]

www.beverlyswann.com

925-705-7036

Jennifer Lombardi, MFT, Content Contributor

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