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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

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transdiagnostic cbt for eating disorders cbt e
TRANSDIAGNOSTIC CBT FOR EATING DISORDERS“CBT-E”

Christopher G Fairburn

www.psychiatry.ox.ac.uk/credo

why learn about cbt e
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
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

slide4

EATING DISORDERS

Anorexia nervosa

Bulimia nervosa

Eating disorder NOS

slide5

AN

ED-NOS

BN

  • Comparable in severity to BN
  • Three subgroups:
    • subthreshold cases of AN and BN
    • “mixed states”
    • binge eating disorder
slide6

Leading treatment is guided CB self-help

No empirically supported treatment

BED

AN

  • CBT leading empirically-supported treatment:
  • but only 40% to 50% of those who complete CBT-BN make a full and lasting recovery

BN

ED-NOS

Just one treatment study

slide7

TWO PROBLEMS

1. No evidence-based treatment for

  • AN
  • ED-NOS

2. CBT-BN not sufficiently potent

slide8
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)

slide9

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
slide10
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

making treatment more potent
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
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
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
DEPRESSION

Clinical observations

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

depression15
DEPRESSION

Clinical observations (cont)

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

Higher than usual antidepressant doses are often required

fluoxetine (40mg to 100mg)

few side effects

depression16
DEPRESSION

Clinical observations (cont)

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

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
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
STAGE ONE - STARTING WELL
  • 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
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
slide20

BULIMIA NERVOSA

Over-evaluation of shape and weight and their control

a

c

Strict dieting; non-compensatory weight-control behavior

d

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

slide21

ANOREXIA NERVOSA

Over-evaluation of shape and weight and their control

Strict dieting; non-compensatory weight-control behaviour

  • preoccupation with eating
  • social withdrawal
  • heightened obsessionality
  • heightened fullness
  • Low weight with secondary effects

Available as a pdf from www.psychiatry.ox.ac.uk/credo

slide22

COMPOSITE TEMPLATE FORMULATION

Over-evaluation of shape and weight and their control

Strict dieting; non-compensatory weight-control behaviour

Events and associated mood change

Significantly low weight

Binge eating

Compensatory vomiting/laxative misuse

Available as a pdf from www.psychiatry.ox.ac.uk/credo

slide23

EXAMPLE OF ED-NOS

Feel really bad about my weight and the way I look

Diet; exercise a lot

Low weight?

Occasional binges

Feel unhappy

Make myself sick

Available as a pdf from www.psychiatry.ox.ac.uk/credo

slide24

BINGE EATING DISORDER

Dissatisfaction with shape and weight and their control

Intermittent dieting

Events and associated mood change

Binge eating

the formulation25
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
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 monitoring27
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
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 weighing29
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
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
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
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
STAGE TWO

Whilst continuing with the strategies and procedures introduced in Stage One ...

  • Review progress and compliance with treatment
  • Identify emerging barriers to change
  • Review the formulation
  • Decide whether to use the “broad” form of CBT-E
    • clinical perfectionism, core low self-esteem, major interpersonal problems
  • Design Stage Three
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 ...

  • Over-evaluation of shape and weight
  • Over-evaluation of control over eating
  • Dietary restraint
  • Dietary restriction
  • Being underweight
  • Event-related changes in eating
addressing the over evaluation of shape or weight
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 weight36
ADDRESSING THE OVER-EVALUATION OF SHAPE OR WEIGHT
  • Overview
  • Prepare the patient for change
    • Educate about self-evaluation
    • Assess the patient’s scheme for self-evaluation and its expressions
    • Expand the formulation
addressing the over evaluation of shape or weight cont
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

Marginalisation of other areas of life

Mislabelling adverse states as “feeling fat”

addressing the over evaluation of shape or weight40
ADDRESSING THE OVER-EVALUATION OF SHAPE OR WEIGHT
  • 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 weight41
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 weight42
ADDRESSING THE OVER-EVALUATION OF SHAPE OR WEIGHT
  • Overview
  • Prepare for change
  • 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 cont43
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 cont44
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 cont45
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 cont46
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 cont47
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 cont48
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)
slide49

“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 cont50
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
ADDRESSING DIETARY RESTRAINT

Strict dieting

“Restriction”

(actual under-eating)

“Restraint”

(attempted under-eating)

addressing dietary restraint52
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 restraint53
ADDRESSING DIETARY RESTRAINT

Food avoidance

Identify avoided foods

Categorise them

Systematically introduce (as behavioural experiments)

slide54

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
ADDRESSING RESIDUAL BINGES
  • Introduction of a pattern of regular eating displaces most binge eating
  • Identify mechanisms responsible for each remaining binge
slide56

Binge Analysis

  • Breaking a dietary rule
    • ………………………
  • Being disinhibited (e.g., alcohol)
    • ………………………
  • Under-eating
    • ………………………
  • Adverse event or mood
    • ………………………
  • Lessons to learn:
    • ……………………...

Binge eating

Available as a pdf from www.psychiatry.ox.ac.uk/credo

stage three57
STAGE THREE

Completing Stage Three

Review the origins of the eating problem (“historical review”)

Help patients learn to control their eating disorder “mindset”

origins of the eating problem
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

mindsets
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
mindsets61
MINDSETS
  • One can influence mindsets in two ways:
  • i. By addressing their content
    • using conventional CBT procedures
mindsets62
MINDSETS
  • 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
stage four ending well
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 well64
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

address the eating problem; do the right thing

address the trigger

[Template plan available for editing fromwww.psychiatry.ox.ac.uk/credo]

cbt e
CBT-E

Strategies for patients who are underweight

cbt e66
CBT-E
  • Start well. Engage the patient in treatment and the prospect of change
    • carefully consider when best to start treatment
    • be engaging, positive, supportive, interested in patient as a person

BMI 20.0

Weeks

(Fairburn, Cooper, Shafran, Bohn, Hawker, Murphy and Straebler, 2008)

cbt e67
CBT-E
  • Start well. Engage the patient in treatment and the prospect of change
  • 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)

BMI 20.0

Weeks

(Fairburn, Cooper, Shafran, Bohn, Hawker, Murphy and Straebler, 2008)

education68
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

education69
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

education70
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

education71
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

education72
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

slide73

ANOREXIA NERVOSA

Over-evaluation of shape and weight and their control

Strict dieting; non-compensatory weight-control behaviour

  • preoccupation with eating
  • social withdrawal
  • heightened obsessionality
  • heightened fullness
  • Low weight with secondary effects

Available as a pdf from www.psychiatry.ox.ac.uk/credo

cbt e74
CBT-E
  • Start well. Engage the patient in treatment and the prospect of change
  • Educate about the psychobiological effects of under-eating and being underweight, and create a personalised formulation
  • Establish a pattern of regular eating
  • Discuss pros and cons of change
  • Initiate and then maintain weight regain

BMI 20.0

Weeks

(Fairburn, Cooper, Shafran, Bohn, Hawker, Murphy and Straebler, 2008)

slide75

How I feel now

Thinking five years ahead ...

slide76

BMI 25.0 (157lbs)

Healthy weight

Weight (lbs)

BMI 20.0 (126lbs)

Weeks

cbt e77
CBT-E
  • Start well. Engage the patient in treatment and the prospect of change
  • Educate about the psychobiological effects of under-eating and being underweight, and create a personalised formulation
  • Establish a pattern of regular eating
  • Discuss pros and cons of change
  • 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 500kcals per day
    • offer the option of high-energy drinks

BMI 20.0

Weeks

(Fairburn, Cooper, Shafran, Bohn, Hawker, Murphy and Straebler, 2008)

cbt e78
CBT-E
  • Start well. Engage the patient in treatment and the prospect of change
  • Educate about the psychobiological effects of under-eating and being underweight, and create a personalised formulation
  • Establish a pattern of regular eating
  • Discuss pros and cons of change
  • Initiate and then maintain weight regain
  • Address other psychopathology at the same time
  • Practise weight maintenance and end well
    • ensure that progress is maintained
    • minimise the risk of relapse

BMI 20.0

Weeks

(Fairburn, Cooper, Shafran, Bohn, Hawker, Murphy and Straebler, 2008)

slide79

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
extended theory fairburn et al 2003
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
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
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 cont84
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 cont85
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
addressing mood intolerance cont
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 cont88
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)
addressing mood intolerance cont89
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)

ADDRESSING MOOD INTOLERANCE (cont)
clinical perfectionism
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
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)

slide92

Over-evaluation of shape and weight and their control

Over-evaluation of achieving and achievement

Pursuit of personally demanding standards in valued areas of life

Strict dieting; non-compensatory weight-control behaviour

Events and associated mood change

Significantly low weight

Binge eating

e.g., work, sport, friendships, etc

Compensatory vomiting/laxative misuse

Available as a pdf from www.psychiatry.ox.ac.uk/credo

clinical perfectionism cont93
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

slide94

Over-evaluation of achieving and achievement

Rigorous pursuit of personally demanding standards and/or avoidance of tests of performance

Preoccupation with thoughts about performance

Marginalization of other areas of life

Performance-checking with selective attention to deficiencies in performance

Re-setting standards if goals are met

Available as a pdf from www.psychiatry.ox.ac.uk/credo

core low self esteem
“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
“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 cont97
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

ADDRESSING CORE LOW SELF-ESTEEM
interpersonal difficulties
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
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