The Best-studied Family Therapy for Persons With Anorexia Nervosa Is Known as the:

Psychiatr Clin North Am. 2010 Sep; 33(3): 611–627.

Cognitive Behavioral Therapy for Eating Disorders

Rebecca Murphy, DClinPsych,^∗ Suzanne Straebler, APRN - Psychiatry, MSN, Zafra Cooper, DPhil, DipPsych, and Christopher G. Fairburn, DM, FMedSci, FRCPsych

Cognitive behavioral therapy (CBT) is the leading evidence-based handling for bulimia nervosa. A new "enhanced" version of the handling appears to be more potent and has the added reward of being suitable for all eating disorders, including anorexia nervosa and eating disorder not otherwise specified. This commodity reviews the show supporting CBT in the treatment of eating disorders and provides an account of the "transdiagnostic" theory that underpins the enhanced class of the treatment. It ends with an outline of the treatment's main strategies and procedures.

Keywords: Cognitive behavioral therapy, Eating disorders, Anorexia nervosa, Bulimia nervosa

The eating disorders provide one of the strongest indications for cerebral behavioral therapy (CBT). Two considerations support this claim. Offset, the core psychopathology of eating disorders, the overevaluation of shape and weight, is cognitive in nature. Second, information technology is widely accepted that CBT is the treatment of choice for bulimia nervosa¹ and at that place is evidence that information technology is as constructive with cases of "eating disorder not otherwise specified" (eating disorder NOS),² the near mutual eating disorder diagnosis. This article starts with a description of the clinical features of eating disorders and so reviews the evidence supporting cognitive behavioral treatment. Next, the cognitive behavioral account of eating disorders is presented and, last, the new "transdiagnostic" form of CBT is described.

Eating disorders and their clinical features

Classification and Diagnosis

Eating disorders are characterized by a severe and persistent disturbance in eating beliefs that causes psychosocial and, sometimes, physical harm. The DSM-IV classification scheme for eating disorders recognizes ii specific diagnoses, anorexia nervosa (AN) and bulimia nervosa (BN), and a remainder category termed eating disorder NOS.³

The diagnosis of anorexia nervosa is made in the presence of the post-obit features:

one.

The overevaluation of shape and weight; that is, judging cocky-worth largely, or fifty-fifty exclusively, in terms of shape and weight. This has been described in diverse means and is ofttimes expressed as strong desire to be thin combined with an intense fearfulness of weight proceeds and fatness.
two.

The active maintenance of an unduly depression body weight. This is ordinarily defined equally maintaining a trunk weight less than 85% of that expected or a body mass index (BMI; weight kg/height chiliad² or weight lb/[peak in]² × 703) of 17.5 or less.
3.

Amenorrhea, in postpubertal females not taking an oral contraceptive.

The disproportionately depression weight is pursued in a variety of means with strict dieting and excessive practise being particularly prominent. A subgroup as well engages in episodes of rampage eating and/or "purging" through cocky-induced vomiting or laxative misuse.

For a diagnosis of bulimia nervosa 3 features need to be present:

i.

Overevaluation of shape and weight, as in anorexia nervosa.
2.

Recurrent binge eating. A "rampage" is an episode of eating during which an objectively large amount of food is eaten for the circumstances and at that place is an accompanying sense of loss of command.
3.

Farthermost weight-control beliefs, such every bit recurrent self-induced vomiting, regular laxative misuse, or marked dietary restriction.

In improver, the diagnostic criteria for anorexia nervosa should not be met. This "trumping dominion" ensures that patients do non receive both diagnoses at in one case.

At that place are no positive criteria for the diagnosis of eating disorder NOS. Instead, this diagnosis is reserved for eating disorders of clinical severity that practise not meet the diagnostic criteria of AN or BN. Eating disorder NOS is the virtually common eating disorder encountered in clinical settings constituting about half of adult outpatient eating-disordered samples, with patients with bulimia nervosa constituting virtually a third, and the rest beingness cases of anorexia nervosa.⁴ In inpatient settings the peachy majority of cases are either underweight forms of eating disorder NOS or anorexia nervosa.^five

In improver, DSM-Four recognizes "binge eating disorder" (BED) as a conditional diagnosis in need of further study. The criteria for BED are recurrent episodes of binge eating in the absence of extreme weight-control behavior. It is proposed that BED exist recognized as a specific eating disorder in DSM-V.^vi

Clinical Features

Anorexia nervosa, bulimia nervosa, and well-nigh cases of eating disorder NOS share a cadre psychopathology: the overevaluation of the importance of shape and weight and their command. Whereas well-nigh people approximate themselves on the basis of their perceived functioning in a variety of domains of life (such every bit the quality of their relationships, their work performance, their sporting prowess), for people with eating disorders self-worth is dependent largely, or even exclusively, on their shape and weight and their ability to control them. This psychopathology is peculiar to the eating disorders (and to torso dysmorphic disorder).

In anorexia nervosa, patients go underweight largely as a result of persistent and severe restriction of both the amount and the blazon of food that they consume. In addition to strict dietary rules, some patients appoint in a driven form of exercising, which further contributes to their depression torso weight. Patients with anorexia nervosa typically value the sense of command that they derive from undereating. Some practice self-induced vomiting, laxative and/or diuretic misuse, especially (just not exclusively) those who experience episodes of loss of command over eating. The corporeality of food eaten during these "binges" is often not objectively large; hence, they are described as "subjective binges." Many other psychopathological features tend to be present, some as a outcome of the semistarvation. These include depressed and labile mood, feet features, irritability, impaired concentration, loss of libido, heightened obsessionality and sometimes frank obsessional features, and social withdrawal. At that place are too a multitude of concrete features, about of which are secondary to beingness underweight. These include poor sleep, sensitivity to the cold, heightened fullness, and decreased energy.

Patients with bulimia nervosa resemble those with anorexia nervosa both in terms of their eating habits and methods of weight control. The chief feature distinguishing these ii groups is that in patients with bulimia nervosa attempts to restrict nutrient intake are regularly disrupted by episodes of (objective) binge eating. These episodes are often followed by compensatory self-induced vomiting or laxative misuse, although there is besides a subgroup of patients who practice non purge (nonpurging bulimia nervosa). Equally a result of the combination of undereating and overeating the weight of most patients with bulimia nervosa tends to exist unremarkable and is within the healthy range, BMI = 20–25. Features of depression and anxiety are prominent in these patients. Certain of these patients engage in cocky-harm and/or substance and booze misuse and may attract the diagnosis of borderline personality disorder. Most have few physical complaints, although electrolyte disturbance may occur in those who vomit or take laxatives or diuretics frequently.

The clinical features of patients with eating disorder NOS closely resemble those seen in anorexia nervosa and bulimia nervosa and are of comparable duration and severity.^vii Within this diagnostic grouping three subgroups may be distinguished, although at that place are no sharp boundaries among them. The first grouping consists of cases that closely resemble anorexia nervosa or bulimia nervosa only just neglect to run across the threshold set by the diagnostic criteria (eg, rampage eating may not be frequent enough to meet criteria for BN or weight may be just above the threshold in AN); the 2nd and largest subgroup comprises cases in which the features of AN and BN occur in different combinations from that seen in the prototypic disorders—these states may exist best viewed as "mixed" in character—and the third subgroup comprises those with rampage-eating disorder. Most patients with binge-eating disorder are overweight (BMI = 25–thirty) or meet criteria for obesity (BMI ≥ 30).

The empirical status of cerebral behavioral therapy for eating disorders

Consistent with the current way of classifying eating disorders, the inquiry on their treatment has focused on the particular disorders in isolation. Wilson and colleagues^viii have provided a narrative review of the studies of the treatment of the 2 specific eating disorders as well as eating disorder NOS, and an authoritative meta-analysis has been conducted past the UK National Establish for Wellness and Clinical Excellence (Squeamish).ⁱ This systematic review is peculiarly rigorous and, equally with all Squeamish reviews, it forms the basis for evidence-based guidelines for clinical management.

The conclusion from the NICE review, and 2 other contempo systematic reviews,^9,10 is that cognitive behavioral therapy (CBT-BN) is the clear leading handling for bulimia nervosa in adults. Withal, this is non to imply that CBT-BN is a panacea, as the original version of the treatment resulted in merely fewer than half of the patients who completed treatment making a full and lasting recovery.^eight The new "enhanced" version of the handling (CBT-Eastward) appears to be more than effective.²

Interpersonal psychotherapy (IPT) is a potential bear witness-based alternative to CBT-BN in patients with bulimia nervosa and information technology involves a similar amount of therapeutic contact, but at that place have been fewer studies of it.^11,12 IPT takes viii to 12 months longer than CBT-BN to attain a comparable consequence. Antidepressant medication (eg, fluoxetine at a dose of lx mg daily) has too been found to have a benign effect on binge eating in bulimia nervosa merely not as neat as that obtained with CBT-BN and the long-term effects remain largely untested.¹³ Combining CBT-BN with antidepressant medication does not appear to offer whatever clear reward over CBT-BN solitary.^xiii The handling of adolescents with bulimia nervosa has received relatively petty research attention to date.

At that place has been much less research on the treatment of anorexia nervosa. Most of the studies endure from small sample sizes and some from loftier rates of attrition. As a issue, there is picayune evidence to support whatever psychological handling, at least in adults. In adolescents the inquiry has focused mainly on family therapy, with the event that the status of CBT in younger patients is unclear.

Preliminary findings have been reported from a 3-site written report of the employ of the enhanced form of CBT (CBT-E) to treat outpatients with anorexia nervosa.¹⁴ This is the largest study of the handling of anorexia nervosa to appointment. In brief, it appears that the handling can be used to treat about 60% of outpatients with the disorder (BMI fifteen.0 to 17.v) and that in these patients about lx% take a expert outcome. Interestingly and chiefly the relapse rate appears low.

There is a growing body of research on the treatment of rampage-eating disorder. This research has been the subject field of a contempo narrative review¹⁵ and several systematic reviews.^1,sixteen,17 The strongest support is for a form of CBT similar to that used to treat BN (CBT-BED). This handling has been found to have a sustained and marked effect on rampage eating, but it has little effect on trunk weight, which is typically raised in these patients. Arguably the leading first-line handling is a form of guided cognitive behavioral self-aid equally information technology is relatively simple to administer and reasonably effective.¹⁸

Until recently, there had been almost no research on the handling of forms of eating disorder NOS other than binge-eating disorder despite their severity and prevalence.⁷ However, recently the first randomized controlled trial of the enhanced form of CBT found that CBT-East was as effective for patients with eating disorder NOS (who were not significantly underweight; BMI >17.five) as it was for patients with bulimia nervosa with ii-thirds of those who completed treatment having a good outcome.ⁱⁱ

In summary, CBT is the handling of selection for bulimia nervosa and for binge-eating disorder with the best results being obtained with the new "enhanced" form of the treatment. Contempo inquiry provides support for the apply of this treatment with patients with eating disorder NOS and those with anorexia nervosa.

The residue of this article provides a description of this transdiagnostic form of CBT.

The cognitive behavioral account of eating disorders

Although the DSM-Four nomenclature of eating disorders encourages the view that they are distinct conditions, each requiring their own form of treatment, there are reasons to question this view. Indeed, it has recently been pointed out that what is most striking about the eating disorders is not what distinguishes them but how much they have in mutual.¹⁹ As noted earlier, they share many clinical features, including the characteristic core psychopathology of eating disorders: the overevaluation of the importance of shape and weight. In add-on, longitudinal studies indicate that near patients drift among diagnoses over time.²⁰ This temporal movement amid diagnostic categories, together with the shared psychopathology, has led to the proposal that there may be limited utility in distinguishing among the disorders^nineteen and furthermore that mutual "transdiagnostic" mechanisms may exist involved in their maintenance.

The transdiagnostic cognitive behavioral account of the eating disorders^xix extends the original theory of bulimia nervosa²¹ to all eating disorders. According to this theory, the overevaluation of shape and weight and their control is central to the maintenance of all eating disorders. Well-nigh of the other clinical features tin exist understood as resulting directly from this psychopathology. It results in dietary restraint and restriction; preoccupation with thoughts about food and eating, weight and shape; the repeated checking of body shape and weight or its avoidance; and the engaging in extreme methods of weight control. The 1 feature that is not a direct expression of the core psychopathology is binge eating. This occurs in all cases of bulimia nervosa, many cases of eating disorder NOS, and some cases of anorexia nervosa. The cognitive behavioral account proposes that such episodes are largely the result of attempts to attach to multiple extreme, and highly specific, dietary rules. The repeated breaking of these rules is well-nigh inevitable and patients tend to react negatively to such dietary slips, generally viewing them as bear witness of their poor self-control. They typically respond by temporarily abandoning their efforts to restrict their eating with binge eating being the result. This in turn maintains the core psychopathology by intensifying patients' concerns about their power to control their eating, shape, and weight. It also encourages more dietary restraint, thereby increasing the risk of further binge eating.

3 further processes may also maintain binge eating. Beginning, difficulties in the patient'southward life and associated mood changes make it difficult to maintain dietary restraint. Second, as rampage eating temporarily alleviates negative mood states and distracts patients from their difficulties, information technology tin go a way of coping with such bug. 3rd, in patients who engage in compensatory purging, the mistaken conventionalities in the effectiveness of vomiting and laxative misuse every bit a ways of weight control results in a major deterrent against binge eating being removed.

In patients who are underweight, the physiological and psychological consequences may also contribute to the maintenance of the eating disorder. For example, delayed gastric elimination leads to feelings of fullness fifty-fifty later on patients have eaten only small-scale amounts of food. In add-on, the social withdrawal and loss of previous interests prevent patients from being exposed to experiences that might diminish the importance they place on shape and weight.

The composite "transdiagnostic" formulation is shown in Fig. 1. This illustrates the core processes that are hypothesized to maintain the full range of eating disorders. When applied to individual patients, its precise course volition depend on the psychopathology present. In some patients, nearly of the processes are in functioning (for example, in cases of anorexia nervosa binge-purge subtype) but in others only a few are agile (for instance, in binge-eating disorder). Thus, for each patient the formulation is driven by their individual psychopathology rather than their DSM diagnosis. Every bit such, the formulation provides a guide to those processes that need to be addressed in treatment.

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The composite "transdiagnostic" cognitive behavioral formulation.

(Fairburn CG. Eating disorders: the transdiagnostic view and the cognitive behavioral theory. In: Fairburn CG. Cognitive behavior therapy and eating disorders. New York: Guilford Press; 2008. p. 7–22).

Enhanced cognitive behavioral therapy

"Enhanced" cognitive behavioral therapy (CBT-Due east) is based on the transdiagnostic theory outlined before and was derived from CBT-BN. Information technology is designed to care for eating disorder psychopathology rather than an eating disorder diagnosis, with its exact form in any particular case depending on an individualized formulation of the processes maintaining the disorder. CBT-Eastward is designed to exist delivered on an individual ground to adult patients with any eating disorder of clinical severity who are appropriate to treat on an outpatient footing. It is described as "enhanced" because information technology uses a variety of new strategies and procedures to amend consequence and because it includes modules to address certain obstacles to change that are "external" to the core eating disorder, namely clinical perfectionism, low cocky-esteem, and interpersonal difficulties.

There are ii forms of CBT-Due east. The start is the "focused" course (CBT-Ef) that exclusively addresses eating disorder psychopathology. Current bear witness suggests that this course should be viewed as the "default" version, every bit it is optimal for nigh patients with eating disorders.ⁱⁱ The second, a broad form of the handling (CBT-Eb), addresses external obstacles to modify, in addition to the cadre eating disorder psychopathology. Preliminary evidence suggests that this more than complex form of CBT-Due east should be reserved for patients in whom clinical perfectionism, core low self-esteem, or interpersonal difficulties are pronounced and maintaining the eating disorder.^two

At that place are too 2 intensities of CBT-E. With patients who are non significantly underweight (BMI in a higher place 17.five), information technology consists of twenty sessions over 20 weeks. This version is suitable for the cracking majority of developed outpatients. For patients who have a BMI below 17.5, a commonly used threshold for anorexia nervosa, handling involves 40 sessions over 40 weeks. The boosted sessions and treatment duration are designed to allow sufficient time for 3 boosted clinical features to be addressed, namely, limited motivation to change, undereating, and being underweight.

In improver CBT-East has been adapted for younger patients²² and for inpatient and day patient settings handling.^23,24 Limitations on space forbid a description of these other forms of CBT-E. Further details of these adaptations of CBT-E, together with a comprehensive account of the handling and its implementation, can exist found in the main treatment guide.²⁵

An overview of the core aspects of treatment

CBT-E is a form of cerebral behavioral therapy and in mutual with other empirically supported forms of CBT information technology focuses primarily on the maintaining processes, in this example those maintaining the eating disorder psychopathology. It uses specified strategies and a flexible serial of sequenced therapeutic procedures to attain both cognitive and behavioral changes. The style of handling is similar to other forms of CBT, that of collaborative empiricism. Although CBT-E uses a multifariousness of generic cognitive and behavioral interventions (such every bit addressing cognitive biases), unlike some forms of CBT, it favors the use of strategic changes in behavior to modify thinking rather than direct cerebral restructuring. The eating disorder psychopathology may exist likened to a house of cards with the strategy being to identify and remove the central cards that are supporting the eating disorder, thereby bringing downwards the entire house. Following, we summarize the core features of the focused and broad versions of CBT-Eastward, including adaptations that demand to be fabricated for patients who are underweight. The handling has iv defined stages.

Preparation for treatment and change

An evaluation interview assessing the nature and extent of the patient's psychiatric problems is conducted before starting treatment.²⁶ This interview unremarkably takes place over 2 or more appointments. The assessment process is collaborative and designed to put the patient at ease and begin to appoint the patient in handling and in change. Information from the assessment informs how best to proceed and, in particular, whether CBT-East is advisable. If CBT-E is deemed to be advisable, the main aspects of the therapy are described and patients are encouraged to make the nigh of the opportunity to overcome their eating disorder.

It is important that from the outset of CBT-E the patient is in a position to make optimum use of treatment. For this reason any potential barriers to benefiting from CBT-E should be explored. Important contraindications to kickoff handling immediately are physical features of concern, the presence of severe clinical depression, meaning substance abuse, major distracting life events or crises, and competing commitments. Such factors should be addressed first earlier embarking on handling.

Stage ane

It is crucial that treatment starts well. This is consistent with evidence that the magnitude of change achieved early in treatment is a good predictor of treatment event.^27,28 This initial intensive stage, designed to achieve initial therapeutic momentum, involves approximately viii sessions held twice weekly over 4 weeks. The aims of this first stage are to engage the patient in treatment and change, to derive a personalized formulation (case conceptualization) with the patient, to provide education about handling and the disorder, and to introduce and implement 2 important procedures: collaborative "weekly weighing" and "regular eating." The changes made in this get-go stage of handling form the foundation on which other changes are congenital.

Engaging the Patient in Treatment and Modify

Many patients with eating disorders are ambivalent about handling and change. Getting patients "on board" with handling is a necessary beginning step. Engagement can be enhanced by conducting the assessment of the eating disorder in a way that helps the patient to become involved in, and hopeful about, the possibility of modify and encourages the patient to take "ownership" of treatment.

Jointly Creating the Formulation

This is ordinarily washed in the offset handling session and is a personalized visual representation of the processes that appear to be maintaining the eating trouble. The therapist draws out the relevant sections of Fig. 1 in collaboration with the patient, incorporating the patient's own experiences and words. It is usually best to start with something the patient wishes to change (eg, binge eating). The formulation helps patients to realize both that their behavior is comprehensible and that information technology is maintained past a series of interacting cocky-perpetuating mechanisms that are open up to change. Information technology is explained that "the diagram" provides a guide to what needs to exist targeted in treatment if patients are to achieve a full and lasting recovery. At this early stage in treatment the therapist should explain that it is conditional and may need to be modified every bit handling progresses and agreement of the patient'due south eating problem increases.

Establishing Existent-time Self-monitoring

This is the ongoing "in-the-moment" recording of eating and other relevant behavior, thoughts, feelings, and events (Fig. two is an example of a monitoring tape). Self-monitoring is introduced in the initial session and continues to occupy an essential and key function throughout well-nigh of treatment. Therapists should clearly explain the reasons for cocky-monitoring. Get-go, that it enables further understanding of the eating problem and it identifies progress. 2nd, and more importantly, it helps patients to be more aware of what is happening in the moment and so that they can begin to brand changes to behavior that may accept seemed automatic or beyond their control. Primal to establishing accurate recording is jointly reviewing the patient'due south records each session and discussing the process of recording and whatever difficulties with this. The records likewise help inform the agenda for the session: it is best to save any bug identified in the records for the main role of the session.

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An example monitoring tape.

(Fairburn CG, Cooper Z, Shafran R, et al. Enhanced cognitive behavior therapy for eating disorders: the core protocol. In: Fairburn CG. Cerebral behavior therapy and eating disorders. New York: Guilford Press; 2008. p. 47–193.)

Establishing Collaborative "Weekly Weighing"

The patient and therapist check the patient'south weight once a week and plot it on an individualized weight graph. Patients are strongly encouraged non to weigh themselves at other times. Weekly in-session weighing has several purposes. Showtime, information technology provides an opportunity for the therapist to educate patients about body weight and help patients to interpret the numbers on the scale, which otherwise they are prone to misinterpret. 2d, it provides patients with accurate data about their weight at a fourth dimension when their eating habits are irresolute. 3rd, and most importantly, information technology addresses the maintaining processes of excessive body weight checking or its avoidance.

Providing Education

From session 1 onward, an of import element of treatment is education well-nigh weight and eating, as many patients take misconceptions that maintain their eating disorder. Some of the main topics to comprehend are as follows:

• The characteristic features of eating disorders including their associated physical and psychosocial effects
• Torso weight and its regulation: the trunk mass index and its estimation; natural weight fluctuations; and the effects of treatment on weight
• Ineffectiveness of vomiting, laxatives, and diuretics as a means of weight command
• Adverse furnishings of dieting: the types of dieting that promote binge eating; dietary rules versus dietary guidelines.

To provide reliable information on these topics, patients are asked to read relevant sections from one of the authoritative books on eating disorders^29,thirty and their reading is discussed in subsequent treatment sessions.

Establishing "Regular Eating"

Establishing a pattern of regular eating is fundamental to successful treatment whatever the class of the eating disorder. It addresses an important type of dieting ("delayed eating"); it displaces virtually episodes of binge eating; it structures people'due south days and, for underweight patients, it introduces meals and snacks that tin can be subsequently increased in size. Early in treatment (normally by the tertiary session) patients are asked to consume 3 planned meals each day plus 2 or iii planned snacks so that in that location is rarely more than than a 4-60 minutes interval between them. Patients are as well asked to confine their eating to these meals and snacks. They should cull what they eat with the but condition being that the meals and snacks are not followed past whatever compensatory beliefs (eg, self-induced vomiting or laxative misuse). The new eating pattern should take precedence over other activities just should not be then inflexible equally to preclude the possibility of adjusting timings to suit the patients' commitments each day.

Patients should exist helped to attach to their regular eating programme and to resist eating betwixt the planned meals and snacks. Two rather different strategies may exist used to achieve the latter goals. The first involves helping patients to identify activities that are incompatible with eating and likely to distract them from the urge to binge eat (eg, taking a brisk walk) and strategies that make rampage eating less likely (eg, leaving the kitchen). The 2nd is to assist patients to recognize that the urge to rampage eat is a temporary phenomenon that can be "surfed." Some "residual binges" are likely to persist, however, and these are addressed later.

Involving Pregnant Others

The treatment is primarily an private treatment for adults. Despite this, "significant others" are seen if this is probable to facilitate treatment and the patient is willing for this to happen. There are two reasons for seeing others: if they could help the patient in making changes or if others are making it difficult for the patient to change, for instance, past commenting adversely on eating or appearance.

Stage two

Stage two is a cursory, only essential, transitional stage that generally comprises 2 appointments, a calendar week apart. While standing with the procedures introduced in Phase one, the therapist and patient accept stock and conduct a articulation review of progress, the goal beingness to identify problems still to be addressed and any emerging barriers to change, to revise the formulation if necessary, and to pattern Stage 3. The review serves several purposes. If patients are making practiced progress they should be praised for their efforts and helpful changes reinforced. If patients are not doing well, the explanation needs to be understood and addressed. If clinical perfectionism, core low self-esteem or relationship difficulties appear to exist responsible, this would be an indication for implementing the wide version of the treatment.

Stage iii

This is the principal trunk of handling. Its aim is to address the key processes that are maintaining the patient's eating disorder. The mechanisms addressed, and the club in which these are tackled, depend upon their role and relative importance in maintaining the patient's psychopathology. There are generally 8 weekly appointments.

Addressing the Overevaluation of Shape and Weight

Identifying the overevaluation and its consequences

The offset stride involves explaining the concept of self-evaluation and helping patients identify how they evaluate themselves. The relative importance of the diverse domains that are relevant may exist represented as a pie nautical chart (Fig. 3 is an case of a pie chart with extended formulation), which for most patients is dominated past a large slice representing shape and weight and controlling eating.

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The overevaluation of shape and weight and their control: an extended conception.

The patient and therapist then place the problems inherent in this scheme for cocky-evaluation. Briefly in that location are iii related problems: showtime, self-evaluation is overly dependent on performance in one area of life with the upshot that domains other than shape and weight are marginalized; second, the surface area of controlling shape and weight is one in which success is elusive, thus undermining cocky-esteem; and third, the overevaluation is responsible for the behavior that characterizes the eating disorder (dieting, binge eating, and then along).³¹

The final stride in the consideration of self-evaluation is the creation of an "extended formulation" depicting the main expressions of the overevaluation of shape and weight: dieting, trunk checking and body abstention, feeling fat, and marginalization of other areas of life. The therapist uses this extended formulation to explain how these behaviors and experiences serve to maintain and magnify the patient's concerns virtually shape and weight and thus they need to be addressed in treatment.

Enhancing the importance of other domains for self-evaluation

An indirect, still powerful, means of diminishing the overevaluation of shape and weight is helping patients increase the number and significance of other domains for self-evaluation. Engaging in other aspects of their life that may have been pushed aside past the eating disorder results in these other areas condign more than important in the patient's cocky-evaluation. Briefly, this involves identifying activities or areas of life that the patient would like to engage in and helping them do so.

A 2nd, direct, strategy is to target the behavioral expressions of the overevaluation of shape and weight. This is done at the aforementioned time every bit enhancing the other domains for cocky-evaluation and it involves tackling body checking, trunk avoidance, and feeling fatty.

Addressing body checking and avoidance

Patients are frequently non aware that they are engaging in torso checking and that it is maintaining their trunk dissatisfaction. The first step is therefore to obtain detailed data well-nigh their checking beliefs by request patients to monitor it. Patients are then educated about the adverse furnishings of repeated torso checking as the manner in which they check tends to provide biased data that leads them to feel dissatisfied. For instance, scrutinizing parts of one'due south body magnifies apparent defects, and only comparing oneself to thin and bonny people leads one to describe the decision that i is unattractive. Most patients need substantial and detailed help to curb their repeated torso checking and invariably attention needs to exist devoted to their mirror use.

Patients who avoid seeing their bodies also need considerable aid. They should be encouraged to progressively get used to the sight and feel of their body. This may take many successive sessions.

Addressing "feeling fat"

"Feeling fatty" is an feel reported past many women only the intensity and frequency of this feeling appears to be far greater among people with eating disorders. Feeling fat is a target for treatment because it tends to be equated with being fat (irrespective of the patient'due south bodily shape and weight) and hence maintains body dissatisfaction. Although this topic has received little research attention, clinical observation suggests that feeling fat is a outcome of mislabeling certain emotions and bodily experiences. Consequently, patients are helped to identify the triggers of their feeling fat experiences and the accompanying feelings. These typically are negative mood states (eg, feeling bored or depressed) or concrete sensations that enhance torso awareness (eg, feeling full, swollen, or sweaty). Patients are then helped to view "feeling fatty" equally a cue to enquire themselves what else they are feeling at the time and in one case recognized to accost it directly.

Exploring the origins of overevaluation

Toward the end of Stage iii it is often helpful to explore the origins of the patient's sensitivity to shape, weight, and eating. A historical review can help to make sense of how the problem developed and evolved, highlight how it might have served a useful function in its early on stages, and the fact that it may no longer practice so. If a specific event appears to have played a critical part in the development of the eating trouble, the patient should be helped to reappraise this from the vantage point of the present. This review helps patients distance themselves farther from the eating disorder frame of mind or "mindset."

Addressing Dietary Rules

Patients are helped to recognize that their multiple farthermost and rigid dietary rules impair their quality of life and are a primal feature of the eating disorder. A major goal of treatment is therefore to reduce, if not eliminate altogether, dieting. The offset step in doing and so is to place the patient's various dietary rules together with the beliefs that underlie them. The patient is then helped to suspension these rules to exam the beliefs in question and to learn that the feared consequences that maintain the dietary rule (typically weight gain or binge eating) are not an inevitable result. With patients who rampage swallow, information technology is important to pay detail attention to "food avoidance" (the avoidance of specific foods) as this is a major contributory cistron. These patients need to systematically re-introduce the avoided food into their nutrition.

Addressing Event-related Changes in Eating

Among many patients with eating disorders, eating habits alter in response to outside events and changes in their mood. The alter may involve eating less, stopping eating birthday, overeating, or binge eating. If these changes are prominent, patients demand help to deal straight with the triggers. By and large this may be accomplished by training them in "proactive" problem solving coupled with the use of functional ways of modulating mood.

Addressing Clinical Perfectionism, Depression Self-esteem, and Interpersonal Bug

As noted earlier, there are ii principal forms of CBT-E. The components of the focused version are described previously. The "broad" version besides includes these strategies and procedures but, in add-on, addresses one or more than "external" (to the core eating disorder) processes that may be maintaining the eating disorder. Information technology is designed for patients in whom clinical perfectionism, core depression self-esteem, or marked interpersonal problems are pronounced and appear to be contributing to the eating disorder. If the therapist decides, in the review of progress (Stage two), to use one or more of these modules, they should become a major component of all subsequent sessions. In the original version of the broad form of CBT-East a fourth module, "mood intolerance," was included but this has since been integrated in to the standard, focused, form of the treatment every bit office of addressing events and moods. A description of the principal elements of the iii modules follows. A more detailed account is bachelor in the main treatment guide.³²

Addressing clinical perfectionism

The psychopathology of clinical perfectionism is similar to that of an eating disorder.³³ Its cadre is the overevaluation of striving to attain and achievement itself. People with clinical perfectionism judge themselves largely, or exclusively, in terms of working hard toward, and meeting, personally demanding standards in areas of life that they value. If they have a coexisting eating disorder such farthermost standards are applied to their eating, weight, and shape. This intensifies central aspects of the eating disorder including dietary restraint, practice, and shape checking. It is commonly evident from the patient'south behavior and it can interfere with important aspects of treatment, leading to, for example, overly detailed recording and a strong resistance to relaxing dietary restraint.

The strategy for addressing clinical perfectionism mirrors that used to accost the overevaluation of shape and weight and the ii can be addressed more than or less at the same time. The first step is to add perfectionism to the patient's formulation and to consider the consequences of this for the patient and his or her life, including the self-evaluation pie-nautical chart. Patients are so encouraged to take steps to heighten the importance of other, nonperformance related, domains for cocky-evaluation.

It is helpful to consider collaboratively patients' goals in areas of life that they value, which are usually multiple, rigid, and extreme, and whether these goals are in fact counterproductive and impairing their actual operation. Performance checking is addressed similarly to shape checking, starting time by first asking patients to record times when they are checking their performance. Then the therapist helps them appreciate that the data they obtain is likely to be skewed equally a result of using biased assessment processes, such equally selective attention to failure. Abstention and procrastination also need to be addressed, as they interfere with patients existence able to appraise their true power with the result that their fears of failure are maintained.

Addressing core low cocky-esteem

People with core depression self-esteem (CLSE) have a longstanding and pervasive negative view of themselves. It is largely independent of the person's actual performance in life (ie, it is unconditional) and is not secondary to the presence of the eating disorder. The presence of CLSE results in the individual striving especially difficult to command eating, weight, and shape to retain some sense of self-worth. Information technology is generally a bulwark to engaging in treatment as patients practice not feel they deserve treatment nor exercise they believe that they can do good from it.

If it is to be directly addressed in treatment, information technology is added to the patient's formulation in Phase two and tackled alongside, although slightly later than, the steps addressing the overevaluation of shape and weight. This involves educating patients near the role of CLSE in maintaining the eating disorder and contributing to other difficulties in their life. Patients are helped to identify and modify the master cognitive maintaining processes, including discounting positive qualities and the overgeneralization of apparent failures. Previous views of the self are reappraised, using both cognitive restructuring and behavioral experiments, to help patients to reach a more balanced view of their cocky-worth.

Addressing interpersonal problems

Interpersonal problems are mutual amidst patients with eating disorders, although they generally improve every bit the eating disorder resolves. Such issues may include disharmonize with others and difficulties developing close relationships. If these problems, and the resulting effects on mood, directly influence the patient's eating, they may be addressed through the utilize of proactive trouble solving and functional mood modulation and acceptance (as described earlier). However, in some cases interpersonal problems powerfully maintain the eating disorder through a diverseness of directly and indirect processes or they interfere with treatment itself. Under these circumstances, they need to go a focus of treatment in their own correct.

The strategy used in CBT-Eastward is to utilize a different psychological treatment to achieve interpersonal change, namely Interpersonal Psychotherapy (IPT). This is an evidence-based treatment that helps patients identify and address current interpersonal problems. In style and content IPT is very different from CBT-East. For this reason it is non "integrated" with CBT-E equally such: rather, each session has a CBT-E component and an IPT one. More detailed information about IPT and its use with patients with eating disorders is available in a recent book chapter.³⁴

Stage four

Phase four, the final stage in handling, is concerned with ending treatment well. The focus is on maintaining the progress that has already been made and reducing the adventure of relapse. Typically there are 3 appointments about 2 weeks apart. During this phase, as role of their training for the ending of treatment, patients discontinue cocky-monitoring and begin weekly weighing at domicile.

To maximize the chances that progress is maintained, the therapist and patient jointly devise a personalized plan for the following few months until a posttreatment review appointment (usually virtually xx weeks after). Typically this includes farther work on torso checking, nutrient abstention, and perhaps further practice at trouble solving. In addition, patients are encouraged to continue their efforts to develop new interests and activities.

At that place are two elements to minimizing the risk of relapse. First, patients need to accept realistic expectations regarding the future. Expecting never to experience whatsoever eating difficulties once again makes patients vulnerable to relapse considering information technology encourages a negative reaction to even small setbacks. Instead, patients should view their eating problem as an Achilles heel. The goal is that patients identify setbacks equally early on as possible, view them as a "lapse" rather than a "relapse," and actively address them using strategies that they learned during treatment.

Underweight patients

The strategies and procedures described so far are as well relevant to patients who are underweight (mostly cases of anorexia nervosa but some cases of eating disorder NOS). Even so, CBT-East has to exist modified to accost sure characteristics of these patients.

The commencement priority is to accost motivation, equally often these patients do non view undereating or beingness underweight as a trouble. This may be washed in several means and relies on a proficient therapeutic alliance. The patient is provided with a personalized education near the psychological and physical effects of being underweight. This helps them to empathize that some of the things that they find difficult (eg, being obsessive and indecisive, being unable to exist spontaneous, being socially avoidant, lacking sexual appetite) are a straight consequence of being a low weight rather than being a reflection of their true personality. The patient is helped to think through the advantages and disadvantages of change, including a consideration of how things are probable to be in the future if they choose non to modify and how this would fit with their aspirations. The therapist shows intense involvement in the patient as a person, beyond the eating disorder, and helps them to reverberate on the land of all aspects of their life, including their relationships, their physical and psychological well-being, their work, and their personal values. The patient is encouraged to experiment with making changes to learn more about the pros and cons of their current beliefs. The goal is for patients themselves to decide to regain weight rather than this decision being imposed by the therapist. If this is successful, information technology greatly assists subsequent weight regain.

Second, the undereating and the consequent state of starvation must exist addressed. It is important to assist patients to realize that undereating, and being underweight maintain the eating disorder and this is illustrated in a personalized formulation. Once the patient has agreed to regain weight information technology is explained that weight regain should be gradual and steady and that they should aim to maintain an average energy surplus of 500 calories each day to regain an boilerplate of 0.5 kg (i.one lb) per week. The therapist helps the patient to devise and implement a daily plan of eating (which may be supplemented past free energy-rich drinks) that meets this target.

Handling needs to be extended from the typical 20 weeks to virtually xl weeks to allow sufficient fourth dimension for patients to decide to alter, to reach a healthy weight, and so practice maintaining it. It can exist helpful to involve others in the weight-gain process to facilitate the patient's own efforts. This is especially so with immature patients who are living at abode with their parents.

Terminal comments

Hopefully it will be clear from this cursory account of CBT for eating disorders that major advances have been made and are continuing to be made. Maybe almost prominent amid these is the adoption of a transdiagnostic approach to treatment whereby treatment is no longer for a specific eating disorder (eg, bulimia nervosa) but is directed at eating disorder psychopathology and the processes that maintains information technology. Every bit a result, an empirically supported treatment approach has evolved that is suitable for all forms of eating disorder and i that is highly individualized.

Many challenges remain. First and foremost, treatment consequence needs to be further improved, especially in the case of patients who are substantially underweight. Second, understanding more about the way in which treatment works, and the active ingredients of treatment, could inform the pattern of a more potent version. Doubtless some elements could exist discarded whereas others may need to be enhanced.³⁵ We need treatments that are effective and efficient. Final, nosotros demand to facilitate the dissemination of show-based practise. Many patients receive suboptimal treatment. There are several possible reasons for this only prominent among them is the fact that few therapists have received the necessary training.

Footnotes

C.Chiliad.F. is supported past a Chief Enquiry Fellowship from the Wellcome Trust (046386). R.G., S.S., and Z.C. are supported by a program grant from the Wellcome Trust (046386).

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2928448/