Problem 2
Part 1 Learning Goals
- What kinds of treatments are there for different types of eating disorders?
o Which treatment works best for which disorder?
o How effective are these treatments?
- Pharmacological, psychotherapy, family therapy?
- What factors contribute to the effectiveness of the treatments?
WILSON – COGNITIVE BEHAVIORAL THERAPY FOR EATING DISORDERS
BULIMIA NERVOSA
Treatment Model
- Fairburn CBT model of BN:
- abnormal overvaluation of the importance of shape and weight leads to
dysfunctional dieting and unhealthy weight-control behaviors predisposes the
person to binge eat
- purging is a means to compensate for the calorie intake or reduce/cope with feelings
of negative effect
- CBT drives from this model, it is theory-driven and manual based
- CBT targets:
o replacing dysfunctional dieting with regular and healthy pattern of eating
o stopping purging and other forms of weight control
o decreasing overvaluation of body shape and weight
- CBT-E: enhanced CBT
o reformulation of CBT to all EDs, not just BD
o focus on common processes that maintain different forms of EDs
o treatment planning is personalized (instead of matching diff. diagnoses it
matches the person)
o addresses patient motivation
o focused CBT-Ef: addresses overvaluation of weight and shape, explicit
treatment for “mood intolerance” as a specific trigger of binging and purging
o broad CBT-Eb: focus on additional mechanisms that maintain and complicate
ED e.g. perfectionism, low self-esteem, interpersonal difficulties
- It’s been argued that manuals result in an inflexible and uniform approach!
- reducing dietary restraint is a partial mediator of change in the treatment of BN and
is included in CBT e.g. inclusion of forbidden and trigger foods
Treatment efficacy
- NICE guidelines for manual-based CBT for BN have a grade of A (reflecting strong
empirical support provided by well-conducted RCTs)
Comparative treatment research
- CBT-E was superior to psychoanalytic psychotherapy and IPT (interpersonal)
o remissions rates are higher than the first-generation CBT manual
o impressive maintenance improvement
,Generalizability of treatment effects
- convincing evidence from RCTs, that CBT-E can generalize to routine clinical practice
Predictors and moderators
- early response to CBT could be a predictor of outcome at post-treatment
o a pro of CBT-E: psychologist evaluates the effects of treatment early in the
course, if there’s absence of improvement barriers must be identified and
changed
- patients with a longer history of ED are less likely to benefit from any treatment
- higher levels of overvaluation may predict worse outcomes
Guided self-help (gsh)
- combines a self-help manual with limited brief therapy sessions
- effective first-level treatment, rapid education in binging, effective compared to
control conditions, cost-effective
- promising for BN
BINGE EATING DISORDER
- CBT-E is directly applicable to BED as a transdiagnostic treatment
Therapeutic Efficacy
- NICE guidelines assigned a grade A indicating strong empirical support from RCTs
- manual-based CBT produces remission rates in BED between 50%-70% that are well
maintained at follow-up (reduction in general psychopathology)
- however, it doesn’t produce clinically significant improvement in body weight
Comparative treatment
- CBT is more effective than behavioral weight loss treatment (BWL) and
pharmacotherapy (longer-term effectiveness over fluoxetine or placebo pill)
- combining CBT with medication produces superior outcomes to pharmacotherapy
only
Guided self help
- CBTgsh is effective and produces promising remission rates from binging in follow-up
Predictors and moderators
- rapid response to CBT is a predictor of outcome in BED (as it is in BN)
o rapid responders are more likely to achieve binging remission, greater
reductions in binging frequency, ED psychopathology and weight loss
- rapid response in CBTgsh also predicts outcome
o can be used a first-line treatment, and if it isn’t work IPL can be used since it
has equal efficacy for rapid and nonrapid responders
- overvaluation and self-esteem are predictors and moderators of treatment outcome
ANOREXIA NERVOSA
- AN is the most difficult ED to treat and study
, - different treatments, including CBT, have received a grade C from NICE (reflecting
expert opinion in absence of empirical data)
- studies encourage development and application of CBT-E for AN
o completers show improvement in weight and psychopathology, results are
mostly maintained in the long-term
- No evidence that CBT-E is superior to TAU
EFFECTIVENESS AND SCALABILITY OF CBT
Efficacy:
- CBT has long-term results of 1 year or more
- a second alternative with long-term results is IPT
Cost-effectiveness:
- CBTgsh is a cost effective
- shorter sessions, shorter trainings, but still not less effective than IPT
Clinical range/reach:
- CBT is the only evidence-based treatment for all EDs, same training for all EDs
- applicable to adults and adolescents
- applicable and effective across different settings
Brevity:
- being brief is cost-effective and offers a realistic alternative to routine clinical care
settings
- CBTgsh is as effective as lengthier manual based BCT
Task sharing:
- limited access to mental health treatment providers
- task-shifting/sharing: training less qualified people to take on tasks, more availability
and affordability
- has been effective in some RCTs
- nonspecialized facilitators, clinically inexperienced graduate students even peers etc.
Ethnic, racial and cultural considerations:
- CBT and CBTgsh are effective on different cultures, races and ethnicities, not many
differences in treatment outcomes
Scalability
- CBT has the capacity to scale up treatment so, provide greater access to treatment
for large numbers of people who don’t have access
- the use task-sharing, self-help strategies, and technological innovations
- internet-based CBT treatments and e-therapy have shown positive outcomes
DISSEMINATION AND IMPLEMENTATION OF CBT
- research-practice gap
- patients are not receiving evidence-based treatments in usual clinical care or these
are delivered in suboptimal fashion
- attitudinal factor among clinicals in which they ignore empirically supported evidence
in favor of their subjective judgement and personal experience
- solution is better education and training
- establishing institutional standards of accountability
- train-the-trainer model or web-centered training
Part 1 Learning Goals
- What kinds of treatments are there for different types of eating disorders?
o Which treatment works best for which disorder?
o How effective are these treatments?
- Pharmacological, psychotherapy, family therapy?
- What factors contribute to the effectiveness of the treatments?
WILSON – COGNITIVE BEHAVIORAL THERAPY FOR EATING DISORDERS
BULIMIA NERVOSA
Treatment Model
- Fairburn CBT model of BN:
- abnormal overvaluation of the importance of shape and weight leads to
dysfunctional dieting and unhealthy weight-control behaviors predisposes the
person to binge eat
- purging is a means to compensate for the calorie intake or reduce/cope with feelings
of negative effect
- CBT drives from this model, it is theory-driven and manual based
- CBT targets:
o replacing dysfunctional dieting with regular and healthy pattern of eating
o stopping purging and other forms of weight control
o decreasing overvaluation of body shape and weight
- CBT-E: enhanced CBT
o reformulation of CBT to all EDs, not just BD
o focus on common processes that maintain different forms of EDs
o treatment planning is personalized (instead of matching diff. diagnoses it
matches the person)
o addresses patient motivation
o focused CBT-Ef: addresses overvaluation of weight and shape, explicit
treatment for “mood intolerance” as a specific trigger of binging and purging
o broad CBT-Eb: focus on additional mechanisms that maintain and complicate
ED e.g. perfectionism, low self-esteem, interpersonal difficulties
- It’s been argued that manuals result in an inflexible and uniform approach!
- reducing dietary restraint is a partial mediator of change in the treatment of BN and
is included in CBT e.g. inclusion of forbidden and trigger foods
Treatment efficacy
- NICE guidelines for manual-based CBT for BN have a grade of A (reflecting strong
empirical support provided by well-conducted RCTs)
Comparative treatment research
- CBT-E was superior to psychoanalytic psychotherapy and IPT (interpersonal)
o remissions rates are higher than the first-generation CBT manual
o impressive maintenance improvement
,Generalizability of treatment effects
- convincing evidence from RCTs, that CBT-E can generalize to routine clinical practice
Predictors and moderators
- early response to CBT could be a predictor of outcome at post-treatment
o a pro of CBT-E: psychologist evaluates the effects of treatment early in the
course, if there’s absence of improvement barriers must be identified and
changed
- patients with a longer history of ED are less likely to benefit from any treatment
- higher levels of overvaluation may predict worse outcomes
Guided self-help (gsh)
- combines a self-help manual with limited brief therapy sessions
- effective first-level treatment, rapid education in binging, effective compared to
control conditions, cost-effective
- promising for BN
BINGE EATING DISORDER
- CBT-E is directly applicable to BED as a transdiagnostic treatment
Therapeutic Efficacy
- NICE guidelines assigned a grade A indicating strong empirical support from RCTs
- manual-based CBT produces remission rates in BED between 50%-70% that are well
maintained at follow-up (reduction in general psychopathology)
- however, it doesn’t produce clinically significant improvement in body weight
Comparative treatment
- CBT is more effective than behavioral weight loss treatment (BWL) and
pharmacotherapy (longer-term effectiveness over fluoxetine or placebo pill)
- combining CBT with medication produces superior outcomes to pharmacotherapy
only
Guided self help
- CBTgsh is effective and produces promising remission rates from binging in follow-up
Predictors and moderators
- rapid response to CBT is a predictor of outcome in BED (as it is in BN)
o rapid responders are more likely to achieve binging remission, greater
reductions in binging frequency, ED psychopathology and weight loss
- rapid response in CBTgsh also predicts outcome
o can be used a first-line treatment, and if it isn’t work IPL can be used since it
has equal efficacy for rapid and nonrapid responders
- overvaluation and self-esteem are predictors and moderators of treatment outcome
ANOREXIA NERVOSA
- AN is the most difficult ED to treat and study
, - different treatments, including CBT, have received a grade C from NICE (reflecting
expert opinion in absence of empirical data)
- studies encourage development and application of CBT-E for AN
o completers show improvement in weight and psychopathology, results are
mostly maintained in the long-term
- No evidence that CBT-E is superior to TAU
EFFECTIVENESS AND SCALABILITY OF CBT
Efficacy:
- CBT has long-term results of 1 year or more
- a second alternative with long-term results is IPT
Cost-effectiveness:
- CBTgsh is a cost effective
- shorter sessions, shorter trainings, but still not less effective than IPT
Clinical range/reach:
- CBT is the only evidence-based treatment for all EDs, same training for all EDs
- applicable to adults and adolescents
- applicable and effective across different settings
Brevity:
- being brief is cost-effective and offers a realistic alternative to routine clinical care
settings
- CBTgsh is as effective as lengthier manual based BCT
Task sharing:
- limited access to mental health treatment providers
- task-shifting/sharing: training less qualified people to take on tasks, more availability
and affordability
- has been effective in some RCTs
- nonspecialized facilitators, clinically inexperienced graduate students even peers etc.
Ethnic, racial and cultural considerations:
- CBT and CBTgsh are effective on different cultures, races and ethnicities, not many
differences in treatment outcomes
Scalability
- CBT has the capacity to scale up treatment so, provide greater access to treatment
for large numbers of people who don’t have access
- the use task-sharing, self-help strategies, and technological innovations
- internet-based CBT treatments and e-therapy have shown positive outcomes
DISSEMINATION AND IMPLEMENTATION OF CBT
- research-practice gap
- patients are not receiving evidence-based treatments in usual clinical care or these
are delivered in suboptimal fashion
- attitudinal factor among clinicals in which they ignore empirically supported evidence
in favor of their subjective judgement and personal experience
- solution is better education and training
- establishing institutional standards of accountability
- train-the-trainer model or web-centered training
