TRANSDIAGNOSTIC CBT FOR EATING DISORDERS “CBT-E”

1. TRANSDIAGNOSTIC CBT FOR EATING DISORDERS“CBT-E” Christopher G Fairburn www.psychiatry.ox.ac.uk/credo

2. 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

3. 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

4. EATING DISORDERS Anorexia nervosa Bulimia nervosa Eating disorder NOS

5. AN ED-NOS BN • Comparable in severity to BN • Three subgroups: • subthreshold cases of AN and BN • “mixed states” • binge eating disorder

6. 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

7. TWO PROBLEMS 1. No evidence-based treatment for • AN • ED-NOS 2. CBT-BN not sufficiently potent

8. 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)

9. 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

10. 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

11. 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)

12. 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)

13. 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

14. 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

15. 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

16. 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

17. 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)

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. BINGE EATING DISORDER Dissatisfaction with shape and weight and their control Intermittent dieting Events and associated mood change Binge eating

25. 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

26. 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”

27. 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

28. 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

29. 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”

30. 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)

31. 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

32. 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

33. 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

34. 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

35. 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”

36. 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

39. 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”

40. 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

41. 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

42. 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”

43. 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

44. 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

45. 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)

46. 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

47. 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)

48. 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)

49. “Feelings of fatness” Actual weight Time Available as a pdf from www.psychiatry.ox.ac.uk/credo

50. 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