psychotherapy - cbt for eating disorders

why does CBT-E take a transdiagnostic approach?

many ED features present across diagnoses, most patients migrate across diagnoses over time, over-evaluation of shape/weight is central maintenance factor

what symptoms external to core ED can be addressed with additional “enhanced” modules?

perfectionism, low self-esteem, major interpersonal problems

what is the level of intensity treatment specific to?

weight status because treatment for underweight clients includes gaining weight, which takes longer

how long is CBT-E for clients with a BMI over 17.5?

20 sessions over 20 weeks 

how long is CBT-E for clients with a BMI under 17.5?

40 sessions over 40 weeks

what does “starting well” include?

engage the patient in treatment and change, increase motivation/commitment to treatment, collaboratively create a case conceptualization, psychoeducation

what should be established during starting well?

self-monitoring, weekly weighing, regular eating

what is the philosophy of the “transdiagnostic” case conceptualization?

ED is vicious cycle maintained by interaction among thoughts, behaviors, and beliefs

what is the goal of the transdiagnostic case conceptualization?

to understand what factors and symptoms are relevant to the patient

what is the purpose of self-monitoring?

better understand processes maintaining the eating disorder, accurate record of patient’s food intake, highlights key behaviors, feelings, thoughts, and the contexts in which they occur

what is included in self-monitoring forms?

the time, food consumed, place, whether is was a meal, snack, binge, or purge, exercise, and circumstances

why is weekly weighing instituted?

to reduce the number of times some people weigh themselves and to expose those who don’t (due to avoidance of shape/weight) to weighing

why is weekly weight plotted out over time?

misinterpreting numbers or inconsequential weight fluctuations is likely to result in weight control behaviors no matter what the reading

procedure of weekly weighing

no weighing at home, open weighing the client at the beginning of each weekly session, joint plotting of weight graph, examination of trends over time

regular eating

prescribed pattern of regular eating, 3 meals and 2-3 planned snacks with no more than 3-4 hours between

what is regular eating based on?

schedule, not hunger, bc their hunger cues are thrown out of whack

what is the initial emphasis of regular eating?

when the client is eating, examine what the client is eating later

what should clients do when they feel urges to eat between meals/snacks?

problem solve, do something that can’t be done while eating, “surf the urge” (wait it out)

what should you do for a client who engages in vomiting?

educate on ineffectiveness (only rid self of 30-50% calories), review medical consequences of vomiting, use behavioral experiment to evaluate the urge to vomit

what should you do for a client who uses laxatives and diuretics?

educate on ineffectiveness at preventing calorie absorption, throw away supplies or plan a schedule of withdrawal (consult with physician)

what techniques can be used to address overevaluation of shape and weight?

develop new domains for self-evaluation, decrease the importance of shape and weight

how can a client develop new domains for self-evaluation?

identify and try interests and activities

how can a client decrease the importance of shape and weight?

address body checking and avoidance, “feeling fat”

how can you address shape checking?

identify forms of shape checking, self-monitor for 1-2 days, mirror use - think before you look

what questions should a client ask themselves before looking in the mirror?

what am I trying to find out? can I find this out? is there a risk that I will get unhelpful information?

how can you address body avoidance?

identify forms of avoidance and encourage exposure

how can you address body comparison to others?

reduce frequency (awareness), behavioral experiments (illustrate sample bias)

dietary restraint

attempted undereating, ie food rules

dietary restriction

actual undereating

how can dietary restraint be addressed?

systematic exposure of avoidance of certain foods or other rules and rituals

how can you address a food hierarchy?

gradual exposure to feared foods with systematic exposure from easiest to most difficult, can also incorporate other fears

what is the goal of exposure to address the food hierarchy?

decrease patient fear of loss of control, modify distorted assumptions

how can you address residual binge eating?

identify triggers for remaining binges using “binge analysis”, whether it’s breaking a dietary rule, being disinhibited, under-eating, and adverse event or mood

what did de Jong, Schoort, & Hoek (2018) find about CBT-E?

performed better than interpersonal psychotherapy, psychoanalytic therapy, and no treatment, and was equivalent to integrative cognitive affective therapy, broad and focused versions were equivalent

what did Tatham et al (2020) find about CBT-T?

change in eating disorder symptoms and clinical impairment was similar in CBT-E vs CBT-T

what is the difference between CBT-T and CBT-E?

CBT-T focuses on early parts of treatment protocol, include more exposure exercises, delivered by assistant psychologists