Cognitive Behavioral Therapy of Eating Disorders

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Cognitive Behavioral Therapy of Eating Disorders
Daniel Stein, M.D. Pediatric Psychosomatic
Department The Edmond and Lily Safra Childrens
Hospital The Chaim Sheba Medical Center, Tel
Hashomer Affiliated with the Sackler Faculty of
Medicine Tel Aviv University, Tel Aviv
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References Fairburn Cg, Marcus MD, Wilson GT
Cognitive-behavioral therapy for binge eating and
bulimia nervosa A comprehensive treatment
manual. In Fairburn CG, Wilson TG (Eds), Binge
eating Nature, assessment and treatment (pp
361-404). New York Guilford Press, 1993. Cooper
Z, Fairburn CG, Hawker DM Cognitive-behavioral
Treatment of Obesity A Clinician Guide. New
York Guilford Press, 2003.
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Cognitive Behavioral Therapy (CBT) Basic
Principles      Cognitive behavioral therapy
(CBT) is defined in terms of the cognitive model
rather than the specific set of techniques
employed   The CBT model emphasizes the
importance of the individuals perception of the
world - primacy of meaning of event       
Psychopathological disorders are conceptualized
in terms of persistent disordered thinking,
derived from embedded dysfunctional
beliefs       Improvement results from
evaluation and modification of dysfunctional
thinking      Evidence-based treatment
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Core Beliefs (Schemas)   Core beliefs
early-onset, deep-seated (unconscious)
persisting beliefs
concerning oneself, significant others, the
world
around   Characteristics in psychopathology-
rigid, global, (always, never) ("???")
considered absolute truth , self-critical,
negative irrational dysfunctional
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Characteristic Core Beliefs Lack of self-esteem
(eating disorders, narcissistic disturbances)
Becks cognitive triad in depression negative
perception of
oneself (helplessness)

the world around (inefficiency)

the future (hopelessness) Insecurity,
vulnerability, nothing is certain (anxiety
disorders)
 
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Intermediate Beliefs in Anorexia Nervosa General
beliefs someone has to be in complete control

to feel worthy Personal
rules/personal expectations I have to make a
relentless effort
all the time
to be in control of my needs,

desires Conditional assumptions if I ever lose
control, or if anyone ever interferes
with this
control, I will not feel worthy anymore

Compensatory strategies over-responsibility,
perfectionism,
obsessionality, self-criticism,
dichotomous thinking
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Characteristics of Automatic Thoughts
Arise spontaneously Unnoticed (preconscious),
associated emotions more often recognized
Specific thoughts ? specific affects
I am a failure ?
depression
I do not know what will happen tomorrow ?
anxiety Individual unaware of presence, but
easy to elicit
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Characteristics of Automatic Thoughts (ATs)
Often brief fleeting, in telegraphic form
(I am stupid, worthless) Verbal and/or
imagery Accepted as true, no reflection/evaluation
Universal evaluated according to validity
functionality In psychopathology - rigid,
absolute truth, dysfunctional
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Dysfunctional Automatic Thoughts (Cognitive
Distortions)
All or nothing (dichotomous) thinking Catastrophiz
ing Emotional reasoning Mind reading Overgeneraliz
ation Personalization Discounting
positive/magnifying negative Shoulds musts
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Eliciting Automatic Thoughts   What thoughts,
images, feelings went through your mind when the
specific event occurred (when
thinking about the event)    Ask question when
noting a shift in affect during session
IF NEEDED    Have the client describe a
problematic situation. When noting affective
shift ask what was going through your
mind just then    Imagine situation   
Role-playing
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Principles of CBT       Focus on present (here
now), problem-oriented       Structured (each
session, whole treatment process, homework,
supervision)       ) Time-limited (improvement
continues also after termination of
treatment         Psychoeducational (familiarizes
client with the CBT model, emphasizes relapse
prevention)        ) Importance of clients
active role between sessions (homework       
Emphasizes therapist/client collaboration
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Structure of Therapeutic Session    1. Setting
agenda     2. Bridge from last session    3.
Reviewing homework assignment from last session
(e.g., activity chart in depression,
monitoring of eating in eating disorders,
identification of dysfunctional
automatic thoughts)   Important to provide
rationale for homework, ensure that client
sees it as meaningful, understands, agrees, and
is able to perform it (experience of
success) starting rehearsing assignment
in session insistence on completion of
assignment.
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Structure of Therapeutic Session     4.
Todays agenda items      5. Homework
assignment for next session      6.
Summary of session      7. Feedback from
client therapist   At the start
therapist sets most targets as treatment
advances client becomes actively
responsible for most of therapeutic work
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Principles of CBT Principles similar
regardless of specific psychopathology
Three stages 1. Psychoeducation on cognitive
model Introduction of behavioral
techniques to replace maladaptive
with adaptive behavior
Cognitive technique to modify dysfunctional
cognitions .2   3. Maintenance of change, relapse
prevention
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Principles of Stage 1 in bulimia nervosa, binge
eating, obesity Structured monitoring of
eating-behaviors (diary) Introducing weekly
weighing Prescription of regular eating as
opposed to dieting Cessation of vomiting,
laxatives The use of alternative behaviors to
avoid bingeing/purging Stimulus control of eating
related behaviors Informing significant others
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Stage 2 Dysfunctional Thought Record
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Stage 2 Dysfunctional Thought Record
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Third stage of CBT consolidation and relapse
prevention Set realistic goals   Differentiate
between lapse and relapse   Have a prepared
written plan   Reinstitute past efficient
techniques if Worsening of problem
Sensing a risk of relapse
Significant imminent stress
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Third stage of CBT in bulimia nervosa binge
eating disorder - consolidation and relapse
prevention   Restart daily monitoring Restart
planned daily eating schedule Plan every day
ahead Plan alternative activities social
contacts at times of risk Restart a once weekly
weighing Confide in trustful others
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Clinical Recommendations CBT Treatment of
choice in bulimia nervosa, binge eating disorder,
and obesity CBT Superior or a
least as effective as any other psychotherapy CBT
Superior to SSRIs or TCAs in bulimia nervosa
binge eating disorder
(combination of CBT and mediations probably
superior to each modality alone)
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Clinical Recommendations Addition of SSRIs
indicated 1. Comorbid disorders (depression,
OCD, anxiety, impulse control) 2. Severe bulimic
symptomatology, partial response to CBT 3.
Patients not complying with CBT 4. Centers that
do not have access to CBT 5. When cost is a
consideration
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Advantages of CBT in bulimia nervosa binge
eating disorder 50-70 complete abstinence from
bingeing 35-55 no evidence of purging At 1 6
years after treatment 48 no bingeing/purging At
6 years after treatment 37 have an eating
disorder
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Limitations of CBT in bulimia nervosa and binge
eating disorder 20-35 - no improvement 35
- dropout Cluster B personality disorders
(particularly borderline personality
disorder relative contraindication) Little
change in core features of ED perfectionism
ineffectiveness Limited efficacy in anorexia
nervosa lack of motivation
need
of weight restoration Obesity findings not
clear but promising