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Transcript of Cognitive Behavioral Therapy of Eating Disorders Daniel Stein, M.D. Pediatric Psychosomatic...
Cognitive Behavioral Therapy of Eating Disorders
Daniel Stein, M.D.
Pediatric Psychosomatic Department
The Edmond and Lily Safra Childrenโs Hospital
The Chaim Sheba Medical Center, Tel Hashomer
Affiliated with the Sackler Faculty of Medicine
Tel Aviv University, Tel Aviv
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 .) : , 1993New York Guilford Press.
Cooper Z, Fairburn CG, Hawker DM: Cognitive-behavioral Treatment of
Obesity: A Clinician Guide. New York: Guilford Press, 2003.
Cognitive Behavioral Therapy (CBT) โ Cognitive Behavioral Therapy (CBT) โ Basic PrinciplesBasic 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 individualโs 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
Core Beliefs (Schemas)Core Beliefs (Schemas)
Core beliefs โ 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
Characteristic Core Beliefs
Lack of self-esteem (eating disorders, narcissistic disturbances)
Beckโs cognitive triad in depression โ negative perception of
oneself (helplessness)
the world around (inefficiency)
the future (hopelessness)
Insecurity, vulnerability, nothing is certain (anxiety disorders)
Intermediate Beliefs in Anorexia Nervosa
General beliefs โ someone has to be in complete control
to feel worthy
Personal rules/personal expectations โ I have to make a relentless effort
all the time to be in control of my needs ,
desires
Conditional assumptions โ if I ever lose control, or if anyone ever interferes
with this control, I will not feel worthy anymore
Compensatory strategies โ over-responsibility, perfectionism,
obsessionality, self-criticism, dichotomous thinking
Characteristics of Characteristics of Automatic ThoughtsAutomatic Thoughts
Arise spontaneously
Unnoticed (preconscious), associated emotions more
often recognized
Specific thoughts โ specific affects:
I am a failure โ depression
I do not know what will happen tomorrow โ anxiety
Individual unaware of presence, but easy to elicit
Characteristics of Automatic Characteristics of Automatic Thoughts (ATs)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
Dysfunctional Automatic ThoughtsDysfunctional Automatic Thoughts
))Cognitive DistortionsCognitive Distortions((
All or nothing (dichotomous) thinking
Catastrophizing
Emotional reasoning
Mind reading
Overgeneralization
Personalization
Discounting positive/magnifying negative
โShouldsโ & โmustsโ
Eliciting Automatic ThoughtsEliciting 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
โwhat was going through your mind just thenโ
Imagine situation
Role-playing
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 clientsโ active role between sessions (homework
Emphasizes therapist/client collaboration
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.
Structure of Therapeutic Session
4. Todayโs 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
Principles of CBTPrinciples 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
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
ืคืชืจืื ืืขืืืช โ ืขืงืจืื ืืชืคืชืจืื ืืขืืืช โ ืขืงืจืื ืืช
ืืืืื ืืืขืื ืงืจืื ืืื ืืืคืฉืจ ืืืืจ ืฉืืื ืงืจืชื.. 1
. ืืืืงืช ืื ืืืจืืื ืืืคืฉืจืืืช ืืคืชืจืื ืืืขืื.2
. ืืืืงืช ืืืขืืืืช ืืืคืฉืจืืืืช ืืืืฆืืข ืฉื ืื ืคืชืจืื.3
. ืืืืจืช ืืคืชืจืื ืืืชืืื.4
. ืืืืจืช ืืฆืขืืื ืืืฆืืข ืืคืชืจืื ืฉื ืืืจ.5
. ืืฆืืข ืืคืชืจืื ืฉื ืืืจ.6
. ืืืขืจืื ืืช ืื ืชืืืื ืคืชืจืื ืืืขืื ืืืื ืืื ืืืชืื ืืชืืฆืืืช ืืืืืจืื 7 ืฉืืชืจืืฉื
ืืืฆืืช ืืคืชืจืื ืื ืืคืืขื (ืืืืื, ืืืืื ืืช ืืคืชืจืื ืืขืืืช). ืืขืงืืืช
โ ืืืืืืคืชืจืื ืืขืืืชืคืชืจืื ืืขืืืช
ืืืขืื ืืืืฆืืช โ ืงืืฉื ืืืืืจ ืืืืช-ืืกืคืจ ืืืืจ ืืฉืคืื.
. ืืืืื ืื ืืกืืืืช ืืืืื ืืฉ ืงืืฉื ืืืืืจ ืืืืช ืืกืคืจ. 1ืืืฉื:
ืื ืืืืขืช ืื ืืืืื ืื ืืืืจืื.
ืื ืืืืขืช ืื ืืขืฉืืช ืื ืืฉืืื ืืืชื ืขื ืืืฉืคืื.
ืื ืืืืขืช ืืื ืืืืจ ืขื ืืืจืื ืืืืชื.
ืืกืืื ืฉื ืืืจื. ืืืื ืืืฉืื ืฉืื ื ืฉืื ื-
:ืืืืงืช ืื ืืืจืืื ืืืคืฉืจืืืช ืืคืชืจืื ืืืขืื. 2
ืืชืขืืืืช.
ืืืืฉืช ืืืืื ืจืืืื ืฉืืกืชืืจื ืืช ืืืืฃ.
ืืืืจ ืขื ืืืืจื \ ืืืขืฆืช ืืื ืฉืชืืื ืืจืืฉ ืืช ืืืืืื ืืืืจืื.
. ืืฆืืข ืคืขืืื ืืืคื ืืช ืืืืืฆืช ืืืืงืจ ืืคื ื ืืืืืื ืืืืช- ืืกืคืจ
ืืืืงื ืื ืคืชืจืื:. 3
ืืชืขืืืืช - ืืื ืืคืฉืจืืช.
ืืืืจ ืขื ืืืืจื โ ืืื ื ืจืืฆื ืืืจืืืฉ ืืืฆืืช ืืืคื.
ืคืขืืืืช ืืืคื ืืช ืืืืืฆืช ืืืืงืจ โ ืืื ื ืืคืฉืจืืช ืืืืืงื.
. โ ืืืืฉืช ืืืืื ืจืืืืืืคืชืจืื ืฉื ืืืจ .4
. ืืืืจืช ืืฆืขืืื ืืืชืืืืื ืืืฆืืข ืืคืชืจืื:5
ืงื ืืช ืืืืื ืืชืืืืื.
ืืืืงืช ืืชืืืช ืืืืืื โ ืืื.
ืืืืงื ืืืฆื ืืืชืืืจืืช ืืืืจืืช ืืืืืงื ืืืืืืช.
ืืืืื ืืืืชโืืกืคืจ ืขื ืืืืื ืฉื ืืืจื.. 6
. ืืืืงืช ืื ืืชืืืื ืืืื ืืื 7
(ืื ืืคื ื ืื, ืื ืื ืืจืืฉืืช ืืืืืื ืืืงืฉืืช ืขื ืืืืืงื)
- ืืืจืื ืื ืืขืืจื ืื, ืื ืืืขืชื ืื ืื ืฉืืชืงืื ืืื ืฉืื ืืจืืืฉ
ืฉืื ื โ ืฆืจืื ืืืฉืื ืขื ืคืชืจืื ืืืจ.
- ืืืื ืืื ืืืืฉืืช ืืืืืื ืืืคื ืชืืื ืืจืง ืื ื ืื โ ืืืืงื ืืืืืฉืช
ืฉื ืืชืืืช ืืืืืื.
- ืื-ืื ืฉืืืชื ืืืืืจ ืืืืช-ืืกืคืจ ืฉืืืคืชืขืชื ืื ืืฉืืชื ืขื-ืื
ืืืชืจ ืืื โ ืืคืชืจืื ืืชืืื.
ืืขืฆืื ืคืืืขืืืืืจืื ืคืืืขื
ืืงืืจ ืืืืืชืืืจืื ืืืจืืง
, ืฉืืืื, ืืื ืืงืื ืืฆืขืืงืืขืฆืื ืืจืืืฅ
, ืืืื ืื ืื ืืืจืื ืืงืื
ืืฆืืขืืช / ื ืืฉื ืืจืืฉ ืืชืื ืงืืืืช
, , ืืื ืืื ืืื ืืชืจืืฆืฆืืช ืืืฉืืืช
, , , ืงืืฆืจ ืืชืขืฆืื ืื ืืคืืงืืช ืืืืืื ืจืขืืืืชื ืฉืืื
, ืฆืืคืืจื ืืื, ืืืกืก ืืคื ืื ืกืืืง ืืืขื
ืจืืืข
- ืฉืงื ืื ืฉื ืชืืืฉื
, ืฉืืชืคืืก ืืฉืื ืืืงืฉ ืืืจืืฃ ืฉืง, ืืืชื ืืืฉื ืืฉืืืื ืืชืืช ื ืื ืก
ืฉืืืื ืขื ืืืื ืขื ืืืื
, ืจืืขืฉืช ืืืืืงื ืืืืช ืืืืฅ ืจืฅ
, ืืืืฅ , ืืขืฆืื ืืืืจ ืืืืืช ืืืฆื , , ืกืืคืจ ืืืจืื ืืกืืจ ืืื ืืืื ืืืืจ
, ืืื 10ืขื , ืืงืืืช ืืฆืืืจ ืกืืืจืื ืืขืฉืืงืจื ืื ืืืืขืืืงืืช ,ื ืฉืืืืช
ืคื ืื ืฉืืืฃ
, ืืืจ ืืื ืืืืจ ืืชืงืฉืจ
ื ืจืืืื โ ืืืืืื ืืืืื ื ืจืืืื โ ืืืื ืืืืืื ืืืืื ืืืื
ืืืื ืืืืื- ืื ืืจืงืกืื ื ืจืืืื
Stage 2: Dysfunctional Thought Record
Stage 2: Dysfunctional Stage 2: Dysfunctional Thought RecordThought Record
ืืืืืืืืืช ืืืืฉืื ืชืืื ืื
ืืืชื ืืชืืืืืื ืืื ืื ื ืจืง
ืืืช ืฉืขืืจื ืืื ืชื ืื
ืืฉืืขืืจ ืืืืขื ืื
ืื ืืกืคืืงื ืืืขืชืืง ืืืืื
ืืืืืืืืืช ืืืืฉืื ืืชื ืื ืื
ืื ืืืืคืืช: ืืืขืช ืืืืช ืืืืื ืื ืื ื , ืจืง ืืื ืื ืืื ืืืืขืืช ืืืืจืืช ืืื ืืช
.... ืืชืืืืืชื ืื ืคืขื ืืฃ ืืขืฆื ืฉืื ืืฉืขืจืืช ... , ืืฃ ืืจืืชื ืชืืื ืืืชืืืืืงื ืืืื ืืช ืขื
, ..... ืคืจืื ืืืจื ืื ืืฉืืื ืืืืชื ืืืฉ ืื ืคืขื. ืืืื ืืืื ื ืื ืฉืื ื ืื ืืืืชื ืชืืื
?ืืืคื: ืืืืจื ืื ืืืจ ืื
ืืชืคืืกื ืืืืคืืช: ืืขืืืช ืื ืฉืืฉ ืืฉื ืื ืืื , ืฉืื ื ืืืจืืืฉ ืื ืื ืืืจ ืืื ืืชืืืืืงื ืฉื
. ืืืืื ืฉืื ื
) ืืืฉื ) ืืืืืืืืืช ืืืืฉืื ืืชื ืื ืื
ืขื ืืืคื: ืืืจื ื ืงืืืืช ืฉืืคืืืฉื ืืืืจืช ืืชืฉื , ืืืจืืืฉ ืืืฉืืขืืช ื ืืชื ืฉืื ืืืืื ืฉืื ื
? ืืืจืื ืืขืฉืืช ืื ืืืืืืืฆืื ืื
.ืืืืคืืช: ืืืคืฉื ืฉืื ื ืืจืืืฉื ืืืืช ืื ืืืืชืขืกืงืืช ืฉืื ืืจืืืฉื ืื ื ืืืืจืื ืืืื , ืฉืื ื ืื ืืชืืืื ืื ืืืืฆืื ื ืืืจืื ืขื ืฉืื
, ืืืืืื ืขื ืฉืื ืืืชืขืกืงืืช ืื ืืขืืืจ ืจืืฆืืคืขื ืืฃ ืืืจืื ืฉืืืืจืื ืืจืืืฉื ืื ื ืื ืื , . ืืืืฆืื ืืืช ืืืืชื ืชืืื ืืืื ืืื ืืืื ืื
, ืื ืืฉืืื ืืขืืฉืื ืืืื ืืื ืืืงืื ืื ืืืืืื . , ืื, ืืฉืื ืขืืฉืื ืจืืงื ืืช ืคืื ืืจืืืฉื ืื ื ืืืชื
, , ืืฆืืื ืืื ืืืืื ืฆืื ืืืืืื ืืืจืฉืืืืืืืืืื.
) ืืืฉื ) ืืืืืืืืืช ืืืืฉืื ืืชื ืื ืื
ืฉืืช ืืืคื: , ืืจืืืฉืืื ืืื ืืืืื ืฉืื ื ืฉืืช? ืืืื ืื ืืืืื ืฉืื ื ืฉืืช ืืืืจ ืื
.ืืืืคืืช: ืชืืื ืืฉืืกืชืืืื ืื ืฉืื ื ืืจืืืฉื ืื ื. ืืืืืช ืืฉืื ื ืืืฉืืื ืื ืขืื ืื ืืื ื ืจืืืช ืฉืื ื
ืืืืืช ืื ื ืื
ืืงืจืื ืืืคื: ืืืืืืช ืืช ืื ืฉืืฉ ืืืืจืช ืืขืฆื ืืช. ืืืจืื ืฉื ืืืฉืืืช
(. ืืืืคืืช: ืื ) ืื ืืืืืจ ืื ืฆืืืงืช ืื ืื ืื , ืื ืขื ืืชืขืกืงืช ืฉืื ื ืงืืืืช ืืคืืืฉื ืฉืืืจืช
, . ืื ื ื ืืื ืื ืืืืืื ืืคืืืช ืื ื ืื ืืืื ืืืืจืื. , ืืืจืื ืขื ืืืืืช ืืืืื ืคืืืืช
) ืืืฉื ) ืืืืืืืืืช ืืืืฉืื ืืชื ืื ืื
ืืคืื ืืืคื: ืื ืฉืืฉืคืืข ืฉืื ืืืืจ ืืขืฆื ืื. ืฉืื, ืืืืืืช ืืืฉืจ ืืืชืจ ืฉืื
. ืืืืคืืช: ืืืงืฆืืขืืช ืืืืืืืื ืืคืืืช ืืื ืื ื , , ืื ื ืฉืืื ื ืืกืืืืช ืืืกืืืืืื ืืืงืื ืืฉ ืืื
, ืืชืืื ืืื ืื ืฉืืฉ ืืืฉืจืื ืืช ืืช ืืืืืื ืืืืื ืื , ืื ื, ืขืฆืื ืืช ืืืืืข ืืืืื ืื ืื ื ืฉืืื ื ืืกืื
. ืืืชื ืืขืฉืืช ืืืืื ืื
Third stage of CBT โ 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
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
Clinical Recommendations
CBT โ Treatment of choice in bulimia nervosa, binge eating disorder,
and obesity
CBT โ Superior or a least as effective as any other psychotherapy
CBT โ Superior to SSRIโs or TCAโs in bulimia nervosa & binge eating
disorder
(combination of CBT and mediations probably superior to each
modality alone)
Clinical Recommendations
Addition of SSRIโs 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
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 โ 48% no bingeing/purging
At 6 years after treatment โ 37% have an eating disorder
Limitations of CBT in bulimia nervosa and binge eating disorder
* 20-35% - no improvement
* โฅ35% - dropout
* Cluster B personality disorders (particularly borderline personality
disorder โ relative contraindication)
* Little change in core features of ED โ perfectionism ineffectiveness
* Limited efficacy in anorexia nervosa โ lack of motivation
need of weight restoration
* Obesity โ findings not clear but promising