Are we really delivering evidence-based treatments for eating disorders? How eating-disordered patients describe their experience of cognitive behavioral therapy

Abstract

Psychotherapists report routinely not practising evidence-based treatments. However, there is little research examining the content of therapy from the patient perspective. This study examined the self-reported treatment experiences of individuals who had been told that they had received cognitive-behavior therapy (CBT) for their eating disorder. One hundred and fifty-seven such sufferers (mean age = 25.69 years) were recruited from self-help organisations.
Participants completed an online survey assessing demographics, clinical characteristics, and therapy components. The use of evidence-based CBT techniques varied widely, with core elements for the eating disorders (e.g., weighing and food monitoring) used at well below the optimum level, while a number of unevidenced techniques were reported as being used commonly. research blog (7)Cluster analysis showed that participants received different patterns of intervention under the therapist label of ‘CBT’, with evidence-based CBT being the least common. Therapist age and patient diagnosis were related to the pattern of intervention delivered. It appears that clinicians are not subscribing to a transdiagnostic approach to the treatment of eating disorders. Patient recollections in this study support the conclusion that evidence-based practice is not routinely undertaken with this client group, even when the therapy offered is described as such.

Cowdrey, N.D., & Waller G. (December 2015) Are we really delivering evidence-based treatments for eating disorders? How eating-disordered patients describe their experience of cognitive behavioral therapyBehavior Research and Therapy, 75(72).

Modular cognitive-behavioral therapy for body dysmorphic disorder: A randomized controlled trial

New Study (1)Abstract:

There are few effective treatments for body dysmorphic disorder (BDD) and a pressing need to develop such treatments. We examined the feasibility, acceptability, and efficacy of a manualized modular cognitive-behavioral therapy for BDD (CBT-BDD). CBT-BDD utilizes core elements relevant to all BDD patients (e.g., exposure, response prevention, perceptual retraining) and optional modules to address specific symptoms (e.g., surgery seeking). Thirty-six adults with BDD were randomized to 22 sessions of immediate individual CBT-BDD over 24 weeks (n=17) or to a 12-week waitlist (n=19). The Yale-Brown Obsessive-Compulsive Scale Modified for BDD (BDD-YBOCS), Brown Assessment of Beliefs Scale, and Beck Depression Inventory-II were completed pretreatment, monthly, posttreatment, and at 3- and 6-month follow-up. The Sheehan Disability Scale and Client Satisfaction Inventory (CSI) were also administered. Response to treatment was defined as ?30% reduction in BDD-YBOCS total from baseline. By week 12, 50% of participants receiving immediate CBT-BDD achieved response versus 12% of waitlisted participants (p=0.026). By posttreatment, 81% of all participants (immediate CBT-BDD plus waitlisted patients subsequently treated with CBT-BDD) met responder criteria. While no significant group differences in BDD symptom reduction emerged by Week 12, by posttreatment CBT-BDD resulted in significant decreases in BDD-YBOCS total over time (d=2.1, p<0.0001), with gains maintained during follow-up. Depression, insight, and disability also significantly improved. Patient satisfaction was high, with a mean CSI score of 87.3% (SD=12.8%) at posttreatment. CBT-BDD appears to be a feasible, acceptable, and efficacious treatment that warrants more rigorous investigation.

Wilhelm S, Phillips K. A., Didie E., Buhlmann U., Greenberg J.L., Fama J.M., Keshaviah A., & Steketee G. (2013) Modular cognitive-behavioral therapy for body dysmorphic disorder: a randomized controlled trial. Behav Ther. 2014 May;45(3):314-27. doi: 10.1016/j.beth.2013.12.007. Epub 2013 Dec 29.

Focusing on Long-Term Weight Loss: The Art of the Possible

Judith Beck_Deborah Beck Busis_2014-2015.jpgDeborah Beck Busis, LCSW

Diet Program Coordinator

Beck Institute for Cognitive Behavior Therapy

A recent article in the American Journal of Public Health (Fildes et al., 2015) reiterates the disheartening statistics on weight loss. This study and many others have shown that most obese people who lose weight gain it back.  In our experience, a major reason for this outcome is that dieters make changes that they are unable to sustain. For example, they reduce their calories too much, eliminate favorite foods, decline social events that include food, or set exercise goals that are too strenuous or time-consuming. When they inevitably return to previous eating, social, and exercise habits, they regain weight, feel helpless, become hopeless and stop their weight loss efforts altogether.

 

To reverse this trend, we ensure that every change we suggest is reasonable and maintainable. This means that dieters usually do not lose weight as quickly as they have in the past or lose as much weight as they would like. But they are much more likely to keep off the weight (plus about five pounds or so) that they do lose. Our philosophy is that successful weight loss entails figuring out the art of the possible.

 

One of our dieters, for example, had a very busy schedule and disliked cooking. Through a variety of standard cognitive therapy techniques, we helped her prioritize exercise and healthy eating and then did problem solving. She committed to exercise 30 minutes three to four times a week, which meant reducing (but not eliminating) the time she spent watching television and reading for pleasure. She also chose not to cook dinner at home, so we created a list of healthy take out and frozen options and planned when she could make the time to pick up her food.  Could we have persuaded her to commit to several hours of shopping and cooking every Sunday to prepare healthy meals for the week? Probably. But as she disliked cooking, it seemed likely that at some point she would stop prioritizing and scheduling cooking and be left unprepared with no healthy food for the week.

 

Another dieter really loved pizza but believed, like many people, that he had to stop eating it altogether to lose weight.  Dieters frequently try to eliminate certain foods or entire food groups, but they almost always revert at some point to eating their favorite foods again (which is fine, as long as it is in moderation). Once they begin eating the “forbidden” food again, though, they overdo it, because they haven’t learned to plan when and how much they’re going to eat nor how to stick to this plan. They interpret their abstinence violation as a sign that they are off track and then have difficulty regaining control over their eating overall.

 

We taught this dieter a combination of cognitive and behavioral skills so he could stay in control around pizza. First we made a plan. He would go to a pizza shop several times and order two large slices to take out. We identified likely thoughts that would interfere with this plan and created strong responses that he read before he went. He practiced this plan several times, bringing the pizza home so he wouldn’t have immediate access to more. Once he gained confidence in his ability to eat a reasonable amount of pizza in a controlled environment, he practiced eating pizza in more difficult circumstances–when he went out to dinner and to a party. Each time we predicted the thoughts he might have that could lead him off track and developed coping cards for him to read. He was able to gain the skills and confidence to control himself around pizza, which significantly increased the probability of his keeping weight off long-term.

 

It just doesn’t work for most dieters long term to make changes they can sustain only in the short term. We believe that reversing the dismal statistics on weight loss starts first with a focus on the art of the possible and is predicated on two words: reasonable and maintainable.

 

Weighing patients within cognitive-behavioral therapy for eating disorders: How, when and why

New Study (1)Abstract
While weight, beliefs about weight and weight changes are key issues in the pathology and treatment of eating disorders, there is substantial variation in whether and how psychological therapists weigh their patients. This review considers the reasons for that variability, highlighting the differences that exist in clinical protocols between therapies, as well as levels of reluctance on the part of some therapists and patients. It is noted that there have been substantial changes over time in the recommendations made within therapies, including cognitive-behavioral therapy (CBT). The review then makes the case for all CBT therapists needing to weigh their patients in session and for the patient to be aware of their weight, in order to give the best chance of cognitive, emotional and behavioral progress. Specific guidance is given as to how to weigh, stressing the importance of preparation of the patient and presentation, timing and execution of the task. Consideration is given to reasons that clinicians commonly report for not weighing patients routinely, and counter-arguments and solutions are presented. Finally, there is consideration of procedures to follow with some special groups of patients.

 

Weighing patients within cognitive-behavioural therapy for eating disorders: How, when and why:Behaviour Research and Therapy, Volume 70, Issue null, Pages 1-10 Glenn Waller, Victoria A. Mountford

 

CBT is shown to be Effective for Body Dysmorphic Disorder

There are few effective treatments for body dysmorphic disorder (BDD) and a pressing need to develop such treatments. We examined the feasibility, acceptability, and efficacy of a manualized modular cognitive-behavioral therapy for BDD (CBT-BDD). CBT-BDD utilizes core elements relevant to all BDD patients (e.g., exposure, response prevention, perceptual retraining) and optional modules to address specific symptoms (e.g., surgery seeking).

Thirty-six adults with BDD were randomized to 22 sessions of immediate individual CBT-BDD over 24 weeks (n = 17) or to a 12-week waitlist (n = 19). The Yale-Brown Obsessive-Compulsive Scale Modified for BDD (BDD-YBOCS), Brown Assessment of Beliefs Scale, and Beck Depression Inventory–II were completed pretreatment, monthly, posttreatment, and at 3- and 6-month follow-up. The Sheehan Disability Scale and Client Satisfaction Inventory (CSI) were also administered. Response to treatment was defined as ? 30% reduction in BDD-YBOCS total from baseline. By week 12, 50% of participants receiving immediate CBT-BDD achieved response versus 12% of waitlisted participants (p = 0.026). By posttreatment, 81% of all participants (immediate CBT-BDD plus waitlisted patients subsequently treated with CBT-BDD) met responder criteria. While no significant group differences in BDD symptom reduction emerged by Week 12, by posttreatment CBT-BDD resulted in significant decreases in BDD-YBOCS total over time (d = 2.1, p < 0.0001), with gains maintained during follow-up. Depression, insight, and disability also significantly improved. Patient satisfaction was high, with a mean CSI score of 87.3% (SD = 12.8%) at posttreatment. CBT-BDD appears to be a feasible, acceptable, and efficacious treatment that warrants more rigorous investigation.

Wilhelm, S., Phillips, K. A., Didie, E., Buhlmann, U., Greenberg, J. L., Fama, J. M., Keshaviah, A., … Steketee, G. (2014). Modular Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Randomized Controlled Trial. Behavior Therapy, 45, 3, 314-327.

Internet-based CBT Skills for Parents or Partners of Individuals with Anorexia Nervosa

Anorexia nervosa (AN) poses a major burden on families. Carers (e.g. parents or partners) of people with AN are often highly distressed and may inadvertently respond in ways that can contribute to the maintenance of the disorder, e.g. through high levels of over-involvement and criticism [also known as expressed emotion (EE)]. This study aimed to evaluate the efficacy of a novel web-based systemic cognitive-behavioral (CBT) intervention for carers of people with AN, designed to reduce carer distress and teach skills in how to offer effective support. Carers of people with AN (n=64) were randomly allocated to either the web-intervention, overcoming anorexia online, with limited clinician supportive guidance (by email or phone), or to ad-hoc usual support from the UK patient and carer organization Beat. Carer outcomes were assessed at post-treatment (4 months) and follow-up (6 months). Compared with the control intervention, web-based treatment significantly reduced carers’ anxiety and depression (primary outcome) at post-treatment, with a similar trend in carers’ EE. Other secondary outcomes did not favor the online intervention. Gains were maintained at follow-up. This is the first ever study to use an online CBT program to successfully reduce carer distress and improve carers’ ability to support the person with AN.

Grover, M., Naumann, U., Mohammad-Dar, L., Glennon, D., Ringwood, S., Eisler, I., Williams, C., … Schmidt, U. (December 01, 2011). A randomized controlled trial of an Internet-based cognitive-behavioural skills package for carers of people with anorexia nervosa. Psychological Medicine, 41(12), 2581-2591.

 

CBT is Effective for Body Dysmorphic Disorder

There are few effective treatments for body dysmorphic disorder (BDD) and a pressing need to develop such treatments. We examined the feasibility, acceptability, and efficacy of a manualized modular cognitive-behavioral therapy for BDD (CBT-BDD). CBT-BDD utilizes core elements relevant to all BDD patients (e.g., exposure, response prevention, perceptual retraining) and optional modules to address specific symptoms (e.g., surgery seeking). Thirty-six adults with BDD were randomized to 22 sessions of immediate individual CBT-BDD over 24 weeks (n=17) or to a 12-week waitlist (n=19). The Yale-Brown Obsessive-Compulsive Scale Modified for BDD (BDD-YBOCS), Brown Assessment of Beliefs Scale, and Beck Depression Inventory-II were completed pretreatment, monthly, posttreatment, and at 3- and 6-month follow-up. The Sheehan Disability Scale and Client Satisfaction Inventory (CSI) were also administered. Response to treatment was defined as ?30% reduction in BDD-YBOCS total from baseline. By week 12, 50% of participants receiving immediate CBT-BDD achieved response versus 12% of waitlisted participants (p=0.026). By posttreatment, 81% of all participants (immediate CBT-BDD plus waitlisted patients subsequently treated with CBT-BDD) met responder criteria. While no significant group differences in BDD symptom reduction emerged by Week 12, by posttreatment CBT-BDD resulted in significant decreases in BDD-YBOCS total over time (d=2.1, p

Wilhelm, S., Phillips, K. A., Didie, E., Buhlmann, U., Greenberg, J. L., Fama, J. M., & … Steketee, G. (2013). Modular cognitive-behavioral therapy for body dysmorphic disorder: A randomized controlled trial. Behavior Therapy, doi:10.1016/j.beth.2013.12.007

 

CBT is Effective for Bulimia Nervosa

According to a new study published in the American Journal of Psychiatry, cognitive behavior therapy (CBT) is a more effective and efficient treatment for binging and purging associated with bulimia nervosa than psychoanalytic psychotherapy. In the current study, 70 patients with bulimia nervosa were randomized to receive either 2 years of weekly psychoanalytic psychotherapy (n=34) or 20 sessions of CBT during a 5-month period (n=36). The Eating Disorder Examination Interview was administered to measure participant progress, before treatment at baseline, after 5 months, and after 2 years. While both treatments resulted in improvement, there was a significant difference in outcome between the two groups. After 5 months of treatment, 42% of patients in the CBT group had stopped binging and purging compared to 6% of patients in the psychoanalytic psychotherapy group. At 2 years, 44% in the CBT group and 15% in the psychoanalytic psychotherapy group had stopped binging and purging. Despite the considerable difference in treatment duration, CBT was more effective and generally faster in relieving binging and purging.

Poulsen, S, Lunn, S. Daniel S.I., Folke, S. Mathiesen, B.B., Katznelson, H. Fairburn, C.G. (2013). A Randomized Controlled Trial of Psychoanalytic Psychotherapy or Cognitive-Behavioral Therapy for Bulimia Nervosa. American Journal of Psychiatry, doi:10.1176/appi.ajp.2013.12121511

CBT Is as Effective in the Treatment of Purging and Non-Purging Eating Disorders

NewStudy-Graphic-72x72_edited-3A new study published in Behaviour and Research Therapy examined the efficacy of cognitive behavior therapy (CBT) for women with a variety of purging behaviors. The study compared 3 groups: those who engaged in self-induced vomiting, those who engaged in multiple purging methods (i.e., laxatives and diuretics), and those who engaged in restrained eating and/or excessive exercise as a means of weight control. First, participants in each group self-reported on their shape and weight concerns, subjective feelings about bulimic episodes, and eating disorder symptoms. Those individuals who engaged in self-induced vomiting or purging methods reported a longer duration of their disorder, more objective bulimic episodes, more severe shape and weight concerns, higher scores for eating disorder symptoms, and high depressive scores than those who did not engage in purging behaviors. A portion of the sample (75%) then completed 20 weeks of CBT. At post-treatment, all three groups showed significant reductions in objective and subjective bulimic episodes, weight and shape concerns, anxiety and depressive symptoms, vomiting, laxative and diuretic use, excessive exercising, and restrained eating. Researchers concluded that despite the greater clinical severity associated with the presence of purging behaviors in eating disorders, these variable do not impact the efficacy of inpatient CBT.

Reference

Dalle Grave, R., Calugi, S. & Marchesini, G. (2009). Self-induced vomiting in eating disorders: Associated features and treatment outcome. Behaviour Research and Therapy, 47, 680-684.

Anorexia Nervosa Relapse Prevention Benefited by CBT

NewStudy-Graphic-72x72_edited-3 A recent clinical study in the International Journal of Eating Disorders found preliminary evidence supporting the notion that Cognitive Behavioral Therapy (CBT) is beneficial to preventing relapse and improving outcomes in patients with weight-restored Anorexia Nervosa (AN). The aim of the present study was to compare the relapse prevention effectiveness of CBT versus maintenance treatment as usual (MTAU) for weight-restored AN.

Participants were patients suffering from AN who were part of the inpatient or day hospital program at the Toronto General Hospital Eating Disorders Program. After participants reached a body mass index (BMI) of at least 19.5 for 2-3 weeks, they were able to begin participation in the present study. About half of the participants chose to enter into the CBT treatment condition and the rest received MTAU. Participants in the CBT group focused on addressing thoughts and behaviors about eating and weight that increase the risk of relapse, and then changing those thoughts and behaviors to healthier strategies and skills. In addition cognitive strategies were taught for a broader range of issues, such as self-esteem, interpersonal problems, and developmental issues.

Results showed that participants in the CBT group had a significantly longer time to relapse than those in the MTAU group, with 65% of the CBT group and 34% of the MTAU not having relapsed after 1 year. The authors concluded that “the current findings provide preliminary evidence that CBT may be helpful in improving outcome and preventing relapse in weight-restored AN.”

Study authors: J. C. Carter, T. L. McFarlane, C. Bewell, M. P. Olmsted, D. B. Woodside, A. S. Kaplan, R. D. Crosby