Reviewing Cognitive Treatment for Eating Disorders: From Standard CBT Efficacy to Worry, Rumination and Control Focused Interventions

Giovanni Maria Ruggiero (1,2) Walter Sapuppo (2,1) Gabriele Caselli (1,2) Marcantonio Spada (3) Sandra Sassaroli (1,2)

1 Studi Cognitivi, Cognitive Psychotherapy School and Research Center, Milano, Italy, 2 Psicoterapia Cognitiva e Ricerca, Cognitive Psychotherapy School and Research Center, Milano,

Italy, 3 Division of Psychology School of Applied Sciences London South Bank University, London, UK

CBT standard for ED

• In the standard CBT model, ED share a common psychopathology: the over evaluation of the importance - and the control - of weight and body shape

• This factor leads to dietary restraint and restriction, manifested in various forms of weight-control behaviour and body checking and, obviously, preoccupation with thoughts about shape, weight, and eating (Fairburn, 2008)

CBT standard for ED• This theoretical background has led to a therapeutic protocol

which is considered the treatment of choice for BN (National Institute for Health and Clinical Excellence, 2004; Wilson, Grilo, & Vitousek, 2007; Shapiro et al., 2007).

• This protocol is known as cognitive behavioral treatment of bulimia nervosa (CBT-BN) and was first described by Christopher Fairburn (Fairburn 1981, 1985; Fairburn, Cooper, & Cooper, 1986).

• This protocol proved to be efficacious with meta-analyses comparing the efficacy of CBT-BN to control treatments that found effect sizes in the medium range (Thompson-Brenner, 2002; Hoffman et al., 2012).

Features of CBT standard for ED• This protocol is generally divided in four stages and 20 sessions

– The first, intensive, phase provides two sessions a week with the aim of educating the patient about treatment and the features of their ED

– The second, transitional, phase aims to review the work, identify obstacles and plan the third phase

– The third phase aims to address the mechanisms of maintenance of the ED

– The fourth phase focuses on the planning of the future, focusing on the maintenance of the achieved results and the reduction of relapses (Murphy et al., 2010).

• The number of sessions doubles with patients who have a Body Mass Index between 15 and 17.5

CBT standard for ED: limitations• However, although the findings indicate that CBT-BN is an

effective treatment at its best only around half the patients who start this protocol make a full and lasting recovery.

• Between 30% and 50% of patients cease binge eating and purging, and a further proportion show some improvement whilst others drop out of treatment or fail to respond (Wilson & Fairburn, 2007).

• In addition, the model appears only to be suited for BN and not for the other ED and is not able to explain the whole psychopathological process underlying ED.

• In CBT-BN there is no room for biased beliefs regarding clinical perfectionism and low self-esteem.

Non standard CBT cognition: perfectionism and self-esteem

• Therefore, many scholars explored cognitive antecedents of ED not directly related to food and body aspects including perfectionism and low self-esteem (Bastiani, Rao, Weltzin, & Kaye, 1995; Button, Sonuga-Barke, Davies, & Thompson, 1996; Davis, 1997; Fairburn & Harrison, 2003; Fairburn, Cooper, Doll, & Welch, 1999; Halmi et al., 2000; Hewitt, Flett, & Ediger, 1995; McLaren, Gauvin, and White, 2001; Sassaroli & Ruggiero, 2005; Vitousek & Hollon, 1990;).

Enhanced CBT• Consequently, Fairburn extended the CBT-BN model to all EDs and

called it cognitive behaviour therapy “enhanced” (CBT-E; Murphy et al., 2010; Fairburn, 2008; Fairburn, Cooper, & Shafran, 2003)

• The new version addresses 4 other psychopathological processes: – clinical perfectionism – mood intolerance– core low self-esteem– interpersonal difficulties

• This treatment has improved outcomes up to a 65.5% rate of remission at post-treatment and a 69.4 % rate of remission over follow-up (20, 40 and 60 weeks post-treatment) (Fairburn et al., 2015)

New directions: repetitive negative thinking (RNT) and metacognitive processes

• Further steps ahead in widening our cognitive understanding and treatment of ED may not only lay in increasing the level of complexity of the classic CBT model, but also in exploring new directions.

• A possible alternative path for increasing the clinical understanding of ED and enhance therapeutic efficacy could be exploring the possible role of metacognitive processes in addition to those outlined in Fairburn’s CBT model.

Repetitive negative thinking (RNT)

• Worry, rumination an other types of repetitive negative thinking (RNT) are a definite transdiagnostic process found across diverse problems including affective disorders, anxiety disorders, insomnia or psychosis (Harvey & Colleagues, 2004)

• RNT are maintained and fueled by metacognitive processes related either to their (illusory) utility or uncontrolability and danger (Mathews and Wells, 1994; Wells, 2004)

Worry and metacognitive Beliefs and Processes in anxiety

• For example, in generalized anxiety disorder (GAD) the disorder is maintained by metacognitions regarding both the utility and the uncontrollability and danger of worrisome thinking (Behar, DiMarco, Hekler, Mohlman, & Staples, 2009; Wells, 2004).

• Pathological metacognitions (i.e., “worry is useful” and “worry is uncontrollable and dangerous”) are thought to lead to the maintenance of excessive levels of worry by causing futile attempts to stop worrying and thereby exaggerating the problem.

• This, in turn, leads to higher levels of anxiety and GAD

Worry as a transdiagnotic process: not only anxiety

• The key feature of worry is the predominance of repetitive negative thoughts that entail that those who worry pathologically think excessively about possible negative events they are afraid of (Borkovec, 1993; Vasey & Borkovec, 1992).

• Although worry is generally believed to be strictly linked to anxiety, it has been argued that it is present across diverse disorders (Ehring & Watkins, 2008) including ED (Ruggiero et al., 2005).

Worry in ED• Worry is a key metacognitive process. What about worry and

metacognition in ED?– Wadden, Brown, Foster, and Linowitz (1991) investigated different kinds

of worry in nonclinical adolescents and found that girls showed higher worry levels about weight and food than boys.

– Kerkhof et al. (2000) administered the Penn State Worry Questionnaire to ED patients and controls and found higher scores in the clinical sample.

– Scattolon and Nicky (1995) found that food consumption in a nonclinical sample of chronic dieters was triggered by social-evaluative/school-related worry.

– Sassaroli and Ruggiero (2005) also found that in a stress situation worry is related to the Eating Disorders Inventory’s subscales in nonclinical subjects.

Rumination in ED• Rumination indicates a variant of RNT present in depression and in

other mood disorders (Nolen-Hoeksema, 2000). • Rumination is related to past negative events, while worry is a

preoccupation with future negative events. • Rumination may contribute to the etiology of ED:

– The onset of bulimia is associated with rumination in response to life events (Troop & Treasure, 1997).

– Hart and Chiovari (1998) have shown that dieters show significant more rumination about eating and food than non-dieters.

– Nolen-Hoeksema and colleagues (2007) have also shown that rumination predicts future increases in bulimic symptoms as well as onset of binge eating.

Metacognitive Beliefs and Processes in ED

• Summing up, research indicates that worry and rumination (collectively called: negative perseverative thinking, RNT) are significantly higher in ED subjects than in a control groups and is clearly associated with the ED symptomatology

• A question remains unanswered: what’s the clinical link between RNT and ED?

Control as a link between ED and metacognition

• A key metacognitive belief regards uncontrollability and danger of negative thinking

• Therefore, it may not be a coincidence that ED are often defined as a psychopathology of perceived lack control (Bruch, 1973; Button, 1985, 2005; Katzman & Lee, 1997).

• Is “control” the link between ED and metacognition?

Control as a link between ED and metacognition

• Sassaroli, Gallucci and Ruggiero (2008) have shown that uncontrollability beliefs concerning not only eating, food and body aspects but also mental states and thoughts may be present in ED.

• Other studies (Cooper et al., 2007; Woolrich et al., 2008) have found differences in metacognitive beliefs in patients with AN when compared to control groups: higher levels of beliefs about uncontrollability and danger; lower levels of cognitive confidence; higher levels of beliefs about need for control thoughts; and higher levels of reported cognitive self-consciousness.

Control as a link between ED and metacognition

• Patients with AN were found to be less successful at using thought re-appraisal and reported to use metacognitive strategies to make “themselves feel worse” (Woolrich et al., 2008).

• McDermott & Rushford (2011) also found that AN patients had higher scores on metacognitive dysfunction: higher thought monitoring, thought control and negative beliefs about worrying.

• Olstad et al. (2015) underlined how patients with ED have more dysfunctional metacognitive beliefs than control groups, especially on negative beliefs about uncontrollability and danger and need to control thoughts.

Control as a link between ED and metacognition

• Summing up, many studies suggest that metacognitive beliefs regarding worry uncontrollability, thought monitoring and control are present in patients with ED and may be involved in the psychopathological processes and symptoms.

Control as a link between ED and metacognition

• We may conceptualize ED in metacognitive terms: there is a cognitive trigger focused on low self-esteem thought and a perfectionistic worry about weight control grounded on metacognitive belief (e.g. “it is important to think about food, eating and weight in order to retrieve control and self-esteem”) that lead the patient to involve in dieting and purging as illusory control strategies