335 ChristopherFairburn.cbte.Juni2009

8/12/2019 335 ChristopherFairburn.cbte.Juni2009

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TRANSDIAGNOSTIC CBT FOREATING DISORDERS

CBT-E

Christopher G Fairburn

www.psychiatry.ox.ac.uk/credo


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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


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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


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Anorexia nervosa

Bulimia nervosa

Eating disorder NOS

EATING DISORDERS


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ED-NOS

AN

BNComparable in severity to BN

Three subgroups:

subthreshold cases of AN and BN

mixed statesbinge eating disorder


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ED-NOS

AN

BN

BED No empirically supported treatmen

CBT leading empirically-supported treatment:

but only 40% to 50% ofthose who complete CBT-Bmake a full and lastingrecovery

Just one treatmentstudy

Leading treatment isguided CB self-help


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1. No evidence-based treatment for

AN

ED-NOS

2. CBT-BN not sufficiently potent

TWO PROBLEMS


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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)


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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

THE TRANSDIAGNOSTIC VIEW


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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


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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, 20


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VARIOUS VERSIONS OF CBT-E

Two forms

Focused: Core default version of the treatment

Broad: Includes additional modules to address broader external maintainingmechanisms: mood intolerance, clinical perfectionism, low self-esteem andmajor interpersonal problems

Two intensities

20-sessionversion for patients with a BMI >17.5 40-sessionversion for patients with a BMI


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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


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DEPRESSION

Clinical observations

1. 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


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DEPRESSION

Clinical observations (cont)

2. 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

3. Higher than usual antidepressant doses are often required

fluoxetine (40mg to 100mg)

few side effects


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DEPRESSION

Clinical observations (cont)

4. Resolution of the depressive features facilitates subsequent

treatment

5. 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

6. Follow-up suggests that some patients are prone to recurrent

depressive episodes

these may trigger recurrences of the eating disorder


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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)


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STAGE ONE - STARTING WELL

1. Engage the patient in treatment and change2. Assess the nature and severity of the psychopathology present

3. Jointly create a personalised formulation

4. Explain what treatment will involve

5. Establish real-time self-monitoring6. Initiate in-session collaborative weighing

7. Provide psychoeducation

8. Establish a pattern of regular eating

9. See significant others


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THE FORMULATION

Personalised visual representation of the processes that appear tobe maintaining the eating disorder

Rationale

Begins to distance patients from their problem (decentering)

Starts the process of helping patients step back from their eatingdisorder and try to understand it

Can be highly engaging

Conveys the notion that eating disorders are a self-maintaining

system

Informs treatment

BULIMIA


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Binge eating

Compensatory

vomiting/laxative misuse

Events andassociated moodchange

Over-evaluation of shape and

weight and their control

Strict dieting; non-compensatory

weight-control behavior

a

b

c

d

e

f

BULIMIANERVOSA

Available as a pdf from www.psychiatry.ox.ac.uk/cre

ANOREXI


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weight-control behaviour

Low weight with

secondary effects



preoccupation with eating

social withdrawal

heightened obsessionality

heightened fullness

ANOREXINERVOSA


COMPOSITE


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Strict dieting; non-

compensatory weight-control

behaviour

Binge eating

Compensatory

vomiting/laxative

misuse

Significantly

low weight




COMPOSITETEMPLATEFORMULATIO


EXAMPLE O


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Diet; exercise a lot

Occasional

binges

Make myself sick

Low weight?Feel unhappy

Feel really bad about my weight

and the way I look

EXAMPLE OED-NOS


BINGE EATIN


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Binge eatingEvents andassociated moodchange

Dissatisfaction with shape and


Intermittent dieting

BINGE EATINDISORDER


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THE FORMULATION

Procedure Drawn out, using the patients 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


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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


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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


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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


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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 cant interpret a single reading


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EDUCATION

Rationale

Reduces stigma, corrects myths, informs about important maintaining processeseducates 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)


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REGULAR EATING

Key intervention for all patients (including underweight ones)

Rationale

Foundation upon which other changes in eating are built

Gives structure to the patients 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


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SIGNIFICANT OTHERS

Rationale See significant others if this is likely to facilitate treatment andthe patient is willing

Usually the significant others are people who influence the patients

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


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STAGE TWO

Whilst continuing with the strategies and procedures introduced inStage One ...

1. Review progress and compliance with treatment

2. Identify emerging barriers to change

3. Review the formulation

4. Decide whether to use the broad form of CBT-E

clinical perfectionism, core low self-esteem, major interpersonal

problems

5. Design Stage Three


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STAGE THREE

Whilst continuing with the strategies and procedures introduced inStage One, address the main maintaining mechanisms operating

in the individual patients case ...

1. Over-evaluation of shape and weight

2. Over-evaluation of control over eating

3. Dietary restraint

4. Dietary restriction

5. Being underweight

6. Event-related changes in eating


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The core psychopathology of eating disorders is the over-evaluation oshape and weight

self-worth is judged largely or exclusively in terms of shape and weighand the ability to control them

other modes of self-evaluation are marginalised most other features appear to be secondary to the core psychopatholog

dieting

repeated body checking and/or body avoidance

pronounced feeling fat

ADDRESSING THE OVER-EVALUATION OF

SHAPE OR WEIGHT


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SHAPE OR WEIGHT

Overview

1. Prepare the patient for change

i. Educate about self-evaluation

ii. Assess the patients scheme for self-evaluation and its expressions

iii. Expand the formulation


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Family

Work

Shape, weight

and eating

Other

Friends

Sport

Music


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Family

Work

Shape, weight

and eating

Other



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Expand the formulation

SHAPE OR WEIGHT (cont)

Over-evaluation of shape and weight and their control

Dietaryrestraint

Shape and weightchecking and/oravoidance

Preoccupationwith thoughtsabout shapeand weight

Marginalisationof other areasof life

Mislabellingadverse statesas feelingfat


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ADDRESSING THE OVER EVALUATION OF


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Develop new domains for self-evaluation

encourage patients to identify and engage in (neglected) interests

and activities, especially those of a social nature


SHAPE OR WEIGHT



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SHAPE OR WEIGHT

Overview

1. Prepare for change

2. 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


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Shape checking

Identify the various forms of shape checking

often patients are not aware of them

self-monitoring for 24 hours on two days


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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


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Reflections on mirrors

How do we know what we look like?

Should we believe what we see in the mirror?

things arent what they seem

what we see in mirrors depends to a large extent upon how welook

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)


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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



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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)


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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 peoples bodies

Takes many successive sessions (one item on agenda)


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Feelings of fatness

Actual weight

Time



SHAPE OR WEIGHT ( t)


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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 statesStrategy

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


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Strict dieting

Restraint(attempted under-eating)

Restriction(actual under-eating)

ADDRESSING DIETARY RESTRAINT


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Remind patients that (for them) dietary restraint is a problem,

not a solution

e.g., highlight any difficulty/inability eating with others (CIA)

Identify the main forms of restraint

delayed eating

already addressed

avoidance of specific foods


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Food avoidance

Identify avoided foods

Categorise them

Systematically introduce (as behavioural experiments)


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ADDRESSING RESIDUAL BINGES

Introduction of a pattern of regular eating displaces most binge

eating

Identify mechanisms responsible for each remaining binge

Binge Analysis


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Binge eating

Breaking a dietary rule

Being disinhibited (e.g., alcohol)

Under-eating

Adverse event or mood

Lessons to learn:

...


STAGE THREE


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STAGE THREE

Completing Stage Three1. Review the origins of the eating problem (historical review)

2. Help patients learn to control their eating disorder mindset


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Historical review

Rationale

- Normalising

- Encourages further distancing and awareness of the eating disorder

mindset- Facilitates discussion of the function of the eating disorder in the

past and at present

- Enhances understanding of the eating disorder

ORIGINS OF THE EATING PROBLEM


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Time periodEvents and circumstances (that might have sensitized

me to my shape, weight and eating)

Before onset of eating

problem (up to age 16)

Mother very anxious about eating throughout my

childhood

A bit overweight aged 9

Always have been on the tall side and a bit clumsy

(have felt too "big")

Friend developed anorexia; slightly jealous

The 12 months before onset

(when I was 16)

Moved to new city and house

New school

Unhappy; no friends

The 12 months after onset(when I was 17)

Started to cut back on my eatingFelt good and in control

Fights with my mum

Lost weight rapidly for a while

Since then (17 to 26) Started purging (18)

Binge eating (18/19)

Went to college (19)

Regained weight (19); out of control; awful

Eating problem just as it is now (20 to present)

Dropped out of college (23)Psychotherapy and antidepressants (24)

Fairburn et al (2008


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Introduce the notion of mindsets once patients have alternatingpsychological states (near the end of treatment)

Educate (DVD analogy)

all-embracing cognitive-emotional systems

we all have them

may be dysfunctional

create their own reality (they filter experience)

self-perpetuating

MINDSETS


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MINDSETS

One can influence mindsets in two ways:

i. By addressing their content

using conventional CBT procedures


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ii. By influencing their playing

decreasing the chances it is triggered

real-time awareness of potential triggers; inoculation against them

by spotting it coming into place

early warning signs (relapse signatures)

by displacing it

behaving healthily (doing the right thing)

plus potent distraction

MINDSETS


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STAGE FOUR - ENDING WELL

1. Maintain the changes obtained

Identify what problems remain

Jointly devise a specific plan for maintaining progress

[Template plan available for editing fromwww.psychiatry.ox.ac.uk/credo]

STAGE FOUR - ENDING WELL


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STAGE FOUR ENDING WELL

2. Minimise the risk of relapse (in the long-term) Ensure that the patient has realistic expectations

Achilles heel (the DVD still exists)

danger of viewing a lapse as a relapse

Identify future at risk times

if weight gain; if dieting; if under stress

Devise a plan for dealing with setbacks detect early

deal with them promptly

i. address the eating problem; do the right thing

ii. address the trigger

[Template plan available for editing fromwww.psychiatry.ox.ac.uk/credo]


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CBT-E

Strategies for patients who areunderweight

CBT-E


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0 2 4 6 8 10 12 14 16 1 8 20 22 2 4 26 2 8 30 3 2 34 3 6 38 4 0

BMI 20.0

Weeks

1. Start well. Engage the patient in treatment and the

prospect of change carefully consider when best to start treatment

be engaging, positive, supportive, interested inpatient as a person

(Fairburn, Cooper, Shafran, Bohn, Hawker, Murphy and Straebler, 200

CBT-E


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BMI 20.0

Weeks


prospect of change2. Educate about the psychobiological effects of under-eating

and being underweight, and create a personalisedformulation

personalised education (based on handout)

personalised formulation (derived from CBT-Estransdiagnostic template formulation)


EDUCATION


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1. Psychological effects of maintaining a very low weight

Cognitive effects inward-looking

preoccupied with food and eating

difficulty concentrating

inflexible thinking

Effects on mood

low mood

lability of mood

irritability


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EDUCATION

Heightened obsessionality

rigidity of behaviour (e.g., fixed routines)

obsessional behaviour (e.g., ritualistic eating)

indecisiveness and procrastination

Social effects

withdrawal

loss of interest in the outside world

loss of interest in sex


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EDUCATION

2. Subjective physical effects of maintaining a very low weight

feeling cold

sleeping poorly

feeling full after eating little

impaired taste (need to use lots of condiments)

3. Medical information

Effects on bones, growth, fertility, etc

EDUCATION


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Implications

1. Many features that the patient is experiencing are non-specific effectsof starvation

feeling cold, sleeping poorly, feeling full

being obsessive and inflexible, difficulty concentrating

being infertile, having weak bones

some are likely to maintain the eating disorder

features of starvation mask the patients true personality

reversed by weight regain; weight gain therefore a necessary part of

treatment

EDUCATION


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2. Other features are not due to starvation

extreme concerns about shape and weight the need to feel in control

some of these features are responsible for the initiation and

maintenance of the starvation

treatment must also be directed at these features


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CBT-E


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BMI 20.0

Weeks





4. Discuss pros and cons of change

5. Initiate and then maintain weight regain


Reasons to stay as I am Reasons to change Reasons to stay as I am Reasons to change

How I feel now Thinking five years ahead ...


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It makes me feel in controland specialI get attention from otherswill not get fatI am good at itIt makes me feel strongIt shows I have will-powerIt is familiar and feels safeI have an excuse for thingsdont have to have periodsI am not hassled by menIf I change:- wont be able to stopeating- my weight will shoot up- my stomach will stickout- my thighs will get fatterIf I change people will thinkthat:

- I am weak and greedy- I have given in- I am getting fat

I will get rid of my starvationsymptoms:- thinking about food andeating all the time- feeling so cold- not sleeping properly- feeling faintI will feel healthierI will be healthierI will be able to think moreclearlyI will have more timeI will be able to think aboutother thingsI will be less obsessive andmore flexible and spontaneousMy life will have a broaderfocusI will be happier and have morefunI will be able to go out withothers and get on with peoplebetterI will discover who I really am

It makes me feel in control and specialwill not get fatIt is familiar and feels safeIf I change:- wont be able to stop eating- my weight will shoot up- my stomach will stick out- my thighs will get fatterIf I change people will think that:- I am weak and greedy- I have given in

- I am getting fat

I want to be a success at workI want a long term relationshiI want a familyI want to be a positive role modfor my childrenI want to go on holiday and bspontaneousI want to be in good healthdont want to still havestarvation symptoms or anyother effects of the EDwant to be in true control ofmy eatingdont want to waste my life I want to achieve thingsdont want to be chronically

170


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0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40

BMI 20.0 (126lbs)

BMI 25.0 (157lbs)

Healthy

weight

Weeks

Weight

(lbs)

CBT-E


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Weeks







take the plunge

educate about the physiology of weight regain

let patients try it their way

help patients maintain an energy excess of 500kcalsper day

offer the option of high-energy drinks


CBT-E


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6. Address other psychopathology at the same time

7. Practise weight maintenance and end well

ensure that progress is maintained

minimise the risk of relapse



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weight-control behaviour

Low weight with

secondary effects



body checking and avoidance

feeli ng fat

marginali sation of other areas of li fe

dietary restraint and restr iction

dietary rules

over-exercising


80/100

CBT-E

Broad version

EXTENDED THEORY (Fairburn et al, 2003)


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Certain external maintaining mechanisms operate in

subgroups of patients and these are barriers to change

Four sets of mechanisms appear to be especially important

mood intolerance

clinical perfectionism

core low self-esteem interpersonal difficulties

Predicted that the successful addressing of thesemechanisms should improve outcome

The broad form of CBT-E is based on this theory


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MOOD INTOLERANCE

There is a subgroup of patients with mood intolerance

exceptionally sensitive to intense mood states

usually adverse mood states (e.g., anger, anxiety)

unable to accept and deal appropriately with these states


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MOOD INTOLERANCE (cont)

Respond dysfunctional mood modulatory behaviourwhich

reduces awareness of the mood state and neutralises it, but at a

personal cost

self-injury (e.g., cutting or burning their skin)

taking psychoactive substances (e.g., alcohol or tranquillisers) binge eating, vomiting or exercising intensely (which may also become

habitual means of mood modulation)


84/100


Not clear whether these patients actually experience unusually

intense mood states or are unduly sensitive to them

Cognitive processes contribute (e.g., I cant stand feeling like

this) and can amplify the initial mood state


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Treatment

Existing CBT treatment procedures are often not sufficientfor these patients needs

Treatment strategies and procedures have been developed

that are relevant to mood intolerance: elements of dialectical behaviour therapy (Linehan, 1993)

enhancement of metacognitive awareness

ADDRESSING MOOD INTOLERANCE


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1. Analyse in detail a recent example in session

recreate the exact sequence triggering events

any mood change

associated cognitions

behavioural response

immediate effect later appraisal

2. Start to monitor in detail the relevant phenomena

ask the patient to monitor closely the relevant behaviour and its

antecedents and consequences


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ADDRESSING MOOD INTOLERANCE (cont)

Adverse event

Deterioration in mood

Dysfunctional behaviour

Immediate improvement in mood

Later negative appraisal

Pressure at work

Tension

Binge eating and/or cutting

Release of tension

Binge eating like this is hopeless.I have no will-power



88/100

3. Prospectively analyse future examples ask the patient to analyse in real time the occurrence (or incipient

occurrence) of future episodes of mood intolerance

requires very careful in the moment recording of circumstances,

thoughts and feelings

patients find this frustrating

rationale:

slows down and distances the patient from the phenomenon

highlights points in the sequence when alternative courses of action are

possible



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4. Address using the procedures that seem most pertinent range of options available

important that patients intervene early

one success breeds further successes

real-time monitoring has an impact in its own right choose those procedures that seem most applicable

do not forget the value of simple interventions (e.g., putting barriers in

the way of engaging in DMMB)

do not overload patients (principle of parsimony)

CLINICAL PERFECTIONISM


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Over-evaluation of striving to achieve, and achieving, personally demandistandards despite adverse consequences

Form of psychopathology equivalent to the core psychopathology ofeating disorders (i.e., it is also a dysfunctional system for self-evaluatio

(Shafran R, Cooper Z, Fairburn CG. Clinical perfectionism: A cognitive-behaviouralanalysis. Behaviour Research and Therapy 2002; 40: 773-791)


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CLINICAL PERFECTIONISM (cont) When clinical perfectionism and an eating disorder co-exist their

psychopathology overlaps

perfectionist standards for controlling eating, shape and weight

in addition to perfectionist standards for other valued domains oflife (e.g., performance at work, sport, music, etc)


weight and their controlOver-evaluation

of achieving and


92/100

Strict dieting; non-

compensatory weight-control

behaviour

Binge eating

Compensatory

vomiting/laxative

misuse

Significantly

low weight


g o c ev g d

achievement

Pursuit of persona

demanding

standards in value

areas of life

e.g., work, sport,

friendships, etc



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CLINICAL PERFECTIONISM (cont)Treatment

Cognitive behavioural analysis of clinical perfectionism has clearimplications for treatment

i.e., the CBT-E strategy (for addressing the over-evaluation ofeating, shape and weight) may also be applied to clinicalperfectionism


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Over-evaluation of achieving and achievement

Rigorous pursuit ofpersonally demandingstandards and/oravoidance of tests of

performance

Performance-checking withselectiveattention todeficiencies in

performance

Preoccupationwith thoughtsabout

performance

Re-setting standardsif goals are met

Marginalizationof other areas oflife


CORE LOW SELF-ESTEEM


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Many patients with eating disorders are highly self-critical

due to failure to meet their goals (e.g., perfect control over eating) generally lessens with successful treatment

Subgroup that has a more global negative view of themselves - core

low self-esteem"

unconditional and pervasive negative view of themselves

part of their permanent identity leads them to make negative judgements about themselves that are autonomous

and independent of performance

CORE LOW SELF-ESTEEM (cont)


96/100

Generally longstanding

antecedent risk factor for developing AN and BN (like perfectionism) Obstructs change (relatively consistent predictor of poor response to CBT-BN)

creates hopelessness about the capacity to change

encourages particularly determined pursuit of valued goals

Self-perpetuating state

pronounced negative processing biases coupled with over-generalisation results in patients being prone to see themselves as repeatedly failing, and

these failures being viewed as confirmation that they are failures as people


97/100

CORE LOW SELF-ESTEEM (cont)Treatment

Are many well-described CBT strategies and procedures available(e.g., Fennell, 1998)

Change is greatly facilitated by concurrent change in other areas

(i.e., change in the eating disorder; enhanced interpersonal

functioning)

ADDRESSING CORE LOW SELF ESTEEM


98/100

Reading Fennell MJV (1998). Low self-esteem. In Treating Complex Cases: The

Cognitive Behavioural Therapy Approach(eds N Tarrier, A Wells, G Haddock).Wiley, Chichester

Fennell M (1999). Overcoming Low Self-esteem. Robinson, London

ADDRESSING CORE LOW SELF-ESTEEM

INTERPERSONAL DIFFICULTIES


99/100

Well-recognised that many patients with eating disorders haveimpaired interpersonal functioning

Their significance has come to the fore with the well-replicated

finding that an exclusively interpersonal treatment (IPT) is a

relatively effective treatment for BN (Fairburn et al, 1993; Agras et

al, 2000)

INTERPERSONAL DIFFICULTIES (cont)


100/100

Treatment CBT-E addresses interpersonal functioning (when relevant)

with there being three interpersonal goals:

to resolve interpersonal problems

to enhance general interpersonal functioning to address developmental issues

Achieved using an embedded interpersonal module that

employs IPT strategies and procedures

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