W7L1 - Cognitive behavioral therapy - enhanced

development of CBT-E

CBT was the leading treatment for EDs but it wasn;t effective for EDNOS or AN or had recovery stats

CBTE-E developed at Oxford uni. by Fiarburn, Cooper and Shafran

CBT-E is NOT traditional CBT but is based on CBT principles (thoughts, behaviors, emotions) focused on cog distortions like ED behavior

CBT-E is

transdiagnostic approach to ED treatment

leading evidenced based treatment for ED in adults - used in/outpatient inpatient treatment + effective for younger patients

CBT-E is transdiagnostic bc

• people can have ED that doesn’t fit one category or people can transition to another ED

specific ED psychopathology

over-evaluation of shape and weight

• different from body dissatisfaction or normative discontent that drives ED behavior

• expressed through restricting, binge, purge, exercise

• ED patients will weigh themselves a lot, stress about weight, checking and avoiding behaviors

think because they feel fat they are fat, has an effect on social functioning and intimate relationships

2 versions of CBT- E

1. focused (core treatment) = main

2. Broad (mood intolerance clinical perfectionism, low self-esteem and interpersonal difficulties) = added later on

two intensities

1. 20 sessions version (BMI > 17.5)

2. 40 session version (15.0 < BMI > 17.5)

CBT-E foundations of treatment vs CBT

transdiagnostic formulation (creating a personalized formula for patient by building a relationship and finding the target)

psychoeducation (treatment process, medical complications of ED, physical and psychological effects of EDs, dispel myths about food and weight)

self-monitoring, regular eating, in-session weighing, incorporating significant others

CBT

• collaborative empiricism, psychoeducation, self-monitoring, exposures, behavioral experiments, HW

CBT-E stage 1 (wk 1-4)

8 sessions twice a week,

objective: achieve early change. predictive outcome

educate about eating and weight control

establish an eating pattern —> 3 meals, 2-3 snacks + involve S.O.s

agenda

• in sessions weighing and updating weight graph

• review self-monitoring records and HW

CBT- E first session - starting well

working together and engage with patient in assessing the nature and severity of the problem

creating a personalized formulation unique to each patient and explain what treatment will involve

establish real life self-monitoring and explaining hw (requires self-monitoring of if they’re eating, their thoughts, behaviors etc)

summarize and schedule next appt

CBT - E what psychoeducation entails

telling the patient what treatment will entail, educate on starvation

educate on medical complications associated with ED and the physical and psychological effects of starvation

talk about myths about food and weight

CBT- E self-monitoring

patients record ALL eating behaviors in a log that corresponds to their thoughts, behaviors and situations in real time

help patients distance themselves from processes so they can recognize their behaviors and question

helps patient see what is actively going on

if patient does not complete their HW log, explain its significance and have them complete with you

CBT- E in-session weighing

patients with ED don’t know their actual weight regardless of the diagnosis

reinforces concern about changes in weight and maintains dieting

avoidance of weighing is as problematic

knowledge of weight is a necessary part of treatment and important for patient

• allows examination of relationship between food and weight

• facilitates change in eating habits

• necessary for addressing any associated weight problem

• aspect of addressing the over-evaluation of weight

CBT- E regular eating

key intervention for ALL patients

gives structure to patients eating habits and addresses one form of dieting - about eating 2-4 hrs

reduces frequency of binge eating

CBT- E - S.O

significant others are people who influence the patient’s eating

aim is to create the optimal environment for the patient to change

patients are more likely to succeed if they have support

CBT- E Stage 2 - review progress

2 appts over 2 weeks

review progress - barriers to change and revise formulation if necessary

design stage 3 by identifying and addressing problems

CBT- E Stage 3 - main body of treatment

8 weekly sessions

addressing overvaluation of shape/weight, dietary rules, event-related changes in eating

addressing clinical perfectionism, low self-esteem, interpersonal problems, and mood intolerance

*these are all mechanisms that maintain EDs*

CBT- E Overevaluation of shape and weight - self evaluation

develop new domains for self-evaluations

• patient fills out what’s important to them and it’s usually their weight and eating habits

• point out to them how they feel about the fact that weight is their main concern in their lives

helps build things they can control and focus on other values

CBT-E - overevaluation of shape/weight by body checking, avoidance, comparisons

mirror use, pinching, measuring maintains dissatisfaction

avoidance can be just as problematic and reinforces neg. emotions

compare themselves to others

strategies

• identify how often they do these behaviors

• educate

• use behavioral experiments to decrease behaviors

CBT- E Overevaluation of shape and weight - feeling fat

mislabeling certain physical or emotional states - full does NOT equal fat

expression of acute increase in body dissatisfaction

Strategies:

• help patients become more aware of their experience: what else are they feeling

• identify triggers and examine their nature

• address underlying emotion or problem-solve situation to not focus on restriction

CBT- E dietary restriction and restraint

identify forms of restraint (intention of not eating certain things) and restriction (restricting food intake caloric):

• delayed eating, avoidance of specific foods and skipping meals

dietary rules and rituals:

• not eating more than 600 kcals daily

• nit eating after or before a certain time

• not eating in front of others

strategies:

• regular eating and exposure to challenging foods —> what the pattern leads to

• education on consequences of restriction/restraint

CBT-E - events, moods and eating

eating less to gain sense of personal control and identity

eating less to influence others - demonstrates feelings of distress, defiance or anger

overeating as a treat

binge eating or purging to cope with neg. events/moods

• give them skills to problem solve

broad CBT-E - mood intolerance, clinical perfectionism in EDs

mood intolerance:

• patients who are sensitive to intense mood states and have difficulty regulating their mood

• use DBT and self-monitoring strategies to address

clinical perfectionism:

• over-evaluation of stiving to achieve; seen in ED behaviors and others are of life like work, sports, etc

• CBT-E strategy for addressing over evaluation may be applied, behavioral experiments —> exposing them to not be perfect

broad CBT-E - low self-esteem, and interpersonal problems

low self-esteem:

• highly self-critical, global neg. view of themselves

• CBT strategies to address this

interpersonal problems:

• difficulty in interpersonal relationships

• use IPT strategies to enhance interpersonal functioning and resolve interpersonal problems - for people that struggle w relationships to express emotions

CBT-E Stage 4 - further problem-solving and relapse prevention planning (ending well)

3 appts, 2 weeks apart

focused on maintaining progress and reducing risk of relapse