Lecture 12 - CBT for Eating Disorders Flashcards
CBT-Enhanced (CBT-E) for Eating Disorders: What is the transdiagnostic approach?
➢Transdiagnostic approach:
▫Many ED features present across diagnoses (e.g., weight/shape concerns, binge eating, purging, dietary restriction)
▫Most patients migrate across diagnoses over time
▫Over-evaluation of shape/weight is central maintenance factor
Philosophy: ED is vicious cycle maintained by interaction among thoughts, behaviours, and beliefs
Goal is to understand what factors and symptoms are relevant to the patient
See graph slide 5
CBT-Enhanced (CBT-E) for Eating Disorders: ➢Precise form of applied treatment depends on presentation
-Additional “enhanced” modules can be used to address symptoms external to core ED such as….?
-perfectionism
-low self-esteem
-major interpersonal problems
Level of intensity specific to weight statusBMI > 17.5, 20 sessions over 20 weeksBMI < 17.5, 40 sessions over 40 week
What is the “Starting Well” phase? What are the 3 things to establish?
“Starting Well”
➢Engage the patient in treatment and change, increase motivation/commitment to treatment
… especially motivating for people with binge eating
➢Collaboratively create a personalized formulation
➢Psychoeducation about treatment and eating disorder
➢3 things to establish:
▫Self-monitoring
▫Weekly weighing
▫Regular eating
“Starting Well” phase: What is the point of self-monitoring?
➢Better understand processes maintaining the eating disorder (for therapist & patient)
➢Accurate record of patient’s food intake
➢Highlights key behaviours, feelings, thoughts, and the contexts in which they occur
▫Specific examples to address in session
▫Therapeutic work between sessions
▫Increases patient self-awareness
➢Encourage self-monitoring in “real time” (not done right before session in the car as homework)
Example of self-monitoring:
time, food consumed, place, meal/snack/binge/purge, exercise, circumstances (context)
“Starting Well” phase: What is the point of weekly weighing? How is it done?
Explain to client that it is normal for weight to fluctuate throughout the day and week (just ate? went to toilet? bloated?)
➢Misinterpreting numbers or inconsequential weight fluctuations is likely to result in weight control behavioursno matter what the reading:
▫If weight is up or the same: diet harder
▫If weight is down: dieting reinforced, “better keep it up!”
Procedure:
▫No weighing at home (transfer to at-home weighing late in treatment)
▫Weigh patient jointly at the beginning of each weekly session
▫Joint plotting of weight graph
▫Examination of trends over time
“One can’t interpret a single reading”
“Starting Well” phase: What is considered regular eating? Is it only when hungry? Does what you eat matter?
➢Prescribed pattern of regular eating
➢3 meals and 2-3 planned snacks
➢No more than 3-4 hours between meals/snacks
➢Mechanical, based on schedule, not hunger!
➢Eating takes precedence over other activities
➢Initial emphasis on WHEN, later examine WHAT!
➢Urges to eat between meals/snacks?▫Problem solve, use incompatible behaviors, “surf the urge”
What are compensatory behaviours? How do we treat them?
➢Vomiting
▫Educate on ineffectiveness (only rid self of 30-50% calories)
▫Review consequences of vomiting
▫Delay (use behaviouralexperiment to evaluate urge)
➢Laxatives and diuretics
▫Ineffective at preventing calorie absorption
▫Throw away supplies or plan a schedule of withdrawal (consult with physician)
What is over-evaluation of shape and weight and how do we treat it?
➢Address the over-evaluation using two techniques:
▫Develop new domains for self-evaluation
*Identify and try interests & activities
▫Decrease the importance of shape and weight
*Body checking and avoidance, “feeling fat”
Shape Checking
▫Identify forms of shape checking; self monitor for 1-2 days (usually there is quite a bit –patients not always aware prior to monitoring)
▫Mirror use –Think before you look
*What am I trying to find out?
*Can I find this out?
*Is there a risk that I will get unhelpful information?
Body Avoidance
▫Identify forms of avoidance
▫Encourage exposure
Body Comparison to Others
▫Reduce frequency (awareness)
▫Behavioral experiments, e.g., compare to every 5th women you pass on the street (illustrate sample bias)
“Feeling Fat”
Feeling fat fluctuates much more than actual weight… means there is something underneath
▫Identify triggers (monitoring) & address
▫Psychoeducation
“What else am I feeling right now?… what is the real emotion behind feeling fat (which isn’t an emotion)?
What is the difference between dietary restraint vs. dietary restriction? How do we treat them?
➢Restraint: Attempted under-eating (e.g., food rules)
➢Restriction: Actual under-eating
Restraint
➢Avoidance of certain foods →Systematic exposure
➢Other common rules and rituals to address
▫Not eating after certain time
▫Eating less in front of others
▫Only eating food if nutrition known
Treatment:
Food Hierarchy
➢Gradual exposure to feared foods
➢Systematic exposure from easiest to most difficult
➢Can also incorporate other fears (e.g., eating after 7pm, eating in public)
➢Combination of in-session and home exposures
➢Goal = Decrease patient fear of loss of control, modify distorted assumptions
➢Plan ahead: Identify food, when, where, etc.
What about residual binge eating?
➢Regular eating should stop most binge eating(and subsequent compensatory behaviours)
▫Identify triggers for remaining binges using “binge analysis”
Ex: breaking a dietary rule, being disinhibited (ex: alcohol), under-eating, adverse event or mood…
CBT-E for Eating Disorders: what is the evidence? What results were found in the de Jong article?
➢de Jong, Schoort, & Hoek, 2018; Current Opinion in Psychiatry
▫Seven trials (5 RCTs; 2 open trials) since January 2014
▫Three with a BN sample; Four with a transdiagnosticsample
▫In RCTs:
*CBT-E performed better than IPT, psychoanalytic therapy, and no treatment
*CBT-E was equivalent to integrative cognitive affective therapy; Broad and focused versions were equivalent
▫Remission rates varied from 22.2-67.6% due to differences in sample and operationalization of clinically significant change
CBT-E for Eating Disorders: what is the evidence? What results were found in the Tatham article?
➢Tatham et al., 2020; International Journal of Eating Disorders
▫CBT-Ten session protocol (CBT-T)
▫Cohort comparison between patients treated with CBT-E versus CBT-T at same clinic
▫Differences in treatments: Focus on early parts of treatment protocol; include more exposure exercises; delivered by “assistant psychologists”
▫Change in eating disorder symptoms and clinical impairment was similar in CBT-E vs. CBT-T
▫Large decreases during treatment, with gains maintained at 6-month follow-up
