TRANSDIAGNOSTIC CBT FOR

EATING DISORDERS
CBT-E
Christopher G Fairburn

www.psychiatry.ox.ac.uk/credo
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
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
EATING DISORDERS
Anorexia nervosa
Bulimia nervosa
Eating disorder NOS
 AN

ED-NOS
BN
Comparable in severity to BN
Three subgroups:
subthreshold cases of AN and BN
mixed states
binge eating disorder
 Leading treatment is
guided CB self-help
No empirically supported treatment
BED
AN

CBT leading empirically-

supported treatment:

ED-NOS BN but only 40% to 50% of

those who complete CBT-BN
Just one treatment make a full and lasting
study recovery
TWO PROBLEMS
1. No evidence-based treatment for
AN
ED-NOS
2. CBT-BN not sufficiently potent
ENHANCED CBT (CBT-E)
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
THE TRANSDIAGNOSTIC VIEW
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
CBT-E is designed to address these mechanisms .....
...... it is a treatment for eating disorder psychopathology,
not a treatment for a DSM-IV diagnosis
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, 2008)
VARIOUS VERSIONS OF CBT-E
Two forms
Focused: Core default version of the treatment
Broad: Includes additional modules to address broader external maintaining
mechanisms: mood intolerance, clinical perfectionism, low self-esteem and
major interpersonal problems
Two intensities
20-session version for patients with a BMI >17.5
40-session version for patients with a BMI <17.5
Versions for different patient groups
Adult outpatient version (Fairburn et al, 2008)
Younger patients version (Cooper and Stewart, 2008)
Intensive versions (inpatient, day patient and intensive outpatient versions), and
a group version (Dalle Grave, Bohn, Hawker and Fairburn, 2008)
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
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
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
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
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)
STAGE ONE - STARTING WELL
1. Engage the patient in treatment and change
2. 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-monitoring
6. Initiate in-session collaborative weighing
7. Provide psychoeducation
8. Establish a pattern of regular eating
9. See significant others
THE FORMULATION
Personalised visual representation of the processes that appear to
be maintaining the eating disorder
Rationale
Begins to distance patients from their problem (decentering)
Starts the process of helping patients step back from their eating
disorder and try to understand it
Can be highly engaging
Conveys the notion that eating disorders are a self-maintaining
system
Informs treatment
 BULIMIA
NERVOSA
Over-evaluation of shape and
weight and their control

a
c
Strict dieting; non-compensatory
d weight-control behavior

b
Events and
associated mood e Binge eating
change
f
Compensatory
vomiting/laxative misuse

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

 ANOREXIA
NERVOSA
Over-evaluation of shape and
weight and their control

Strict dieting; non-compensatory

weight-control behaviour
preoccupation with eating
social withdrawal
heightened obsessionality
heightened fullness
Low weight with
secondary effects

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

 COMPOSITE
TEMPLATE
FORMULATION
Over-evaluation of shape and
weight and their control

Strict dieting; non-

compensatory weight-control
behaviour

Events and
associated mood Binge eating Significantly
change low weight

Compensatory
vomiting/laxative
misuse

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

 EXAMPLE OF
ED-NOS
Feel really bad about my weight
and the way I look

Diet; exercise a lot

Occasional Low weight?

Feel unhappy
binges

Make myself sick

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

 BINGE EATING
DISORDER
Dissatisfaction with shape and
weight and their control

Intermittent dieting

Events and
associated mood Binge eating
change
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
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
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
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
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
EDUCATION
Rationale
Reduces stigma, corrects myths, informs about important maintaining processes,
educates 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)
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
SIGNIFICANT OTHERS
Rationale
See significant others if this is likely to facilitate treatment and
the 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
STAGE TWO
Whilst continuing with the strategies and procedures introduced in
Stage 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
STAGE THREE
Whilst continuing with the strategies and procedures introduced in
Stage 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
ADDRESSING THE OVER-EVALUATION OF
SHAPE OR WEIGHT

The core psychopathology of eating disorders is the over-evaluation of

shape and weight
self-worth is judged largely or exclusively in terms of shape and weight
and the ability to control them
other modes of self-evaluation are marginalised
most other features appear to be secondary to the core psychopathology
dieting
repeated body checking and/or body avoidance
pronounced feeling fat
ADDRESSING THE OVER-EVALUATION OF
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
ADDRESSING THE OVER-EVALUATION OF
SHAPE OR WEIGHT (cont)

Expand the formulation

Over-evaluation of shape and weight and their control

Dietary Shape and weight Preoccupation Mislabelling Marginalisation

restraint checking and/or with thoughts adverse states of other areas
avoidance about shape as feeling of life
and weight fat
ADDRESSING THE OVER-EVALUATION OF
SHAPE OR WEIGHT

2. Address the over-evaluation using two strategies:

Develop new domains Reduce the importance

for self-evaluation of shape and weight
ADDRESSING THE OVER-EVALUATION OF
SHAPE OR WEIGHT

Develop new domains for self-evaluation

encourage patients to identify and engage in (neglected) interests
and activities, especially those of a social nature
ADDRESSING THE OVER-EVALUATION OF
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
ADDRESSING THE OVER-EVALUATION OF
SHAPE OR WEIGHT (cont)
Shape checking
Identify the various forms of shape checking
often patients are not aware of them
self-monitoring for 24 hours on two days
ADDRESSING THE OVER-EVALUATION OF
SHAPE OR WEIGHT (cont)
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
ADDRESSING THE OVER-EVALUATION OF
SHAPE OR WEIGHT (cont)
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 we
look
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)
ADDRESSING THE OVER-EVALUATION OF
SHAPE OR WEIGHT (cont)
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
ADDRESSING THE OVER-EVALUATION OF
SHAPE OR WEIGHT (cont)
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)
ADDRESSING THE OVER-EVALUATION OF
SHAPE OR WEIGHT (cont)
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)
Feelings of fatness

Actual weight

Time

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

ADDRESSING THE OVER-EVALUATION OF
SHAPE OR WEIGHT (cont)

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 states
Strategy
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
ADDRESSING DIETARY RESTRAINT

Strict dieting

Restraint Restriction
(attempted under-eating) (actual under-eating)
ADDRESSING DIETARY RESTRAINT
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
ADDRESSING DIETARY RESTRAINT
Food avoidance
Identify avoided foods
Categorise them
Systematically introduce (as behavioural experiments)
IDENTIFY AND CHALLENGE DIETARY RULES

Identify other dietary rules and rituals:

Not eating more than 600 kcals daily
Not eating before 6.00 pm
Not eating in front of others
Eating less than others present
Not eating food of unknown composition
ADDRESSING RESIDUAL BINGES
Introduction of a pattern of regular eating displaces most binge
eating
Identify mechanisms responsible for each remaining binge
 Binge Analysis
Breaking a dietary rule

Being disinhibited (e.g., alcohol)

Binge eating
Under-eating

Adverse event or mood

Lessons to learn:
...

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

STAGE THREE
Completing Stage Three
1. Review the origins of the eating problem (historical review)
2. Help patients learn to control their eating disorder mindset
ORIGINS OF THE EATING PROBLEM
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
 Events and circumstances (that might have sensitized
Time period
me to my shape, weight and eating)

Before onset of eating Mother very anxious about eating throughout my

problem (up to age 16) 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 Moved to new city and house

(when I was 16) New school
Unhappy; no friends

The 12 months after onset Started to cut back on my eating

(when I was 17) Felt 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)
MINDSETS
Introduce the notion of mindsets once patients have alternating
psychological 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
One can influence mindsets in two ways:
i. By addressing their content
using conventional CBT procedures
MINDSETS
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
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 from www.psychiatry.ox.ac.uk/credo]

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 from www.psychiatry.ox.ac.uk/credo]

 CBT-E
Strategies for patients who are
underweight
CBT-E

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 in
patient as a person

BMI 20.0

Weeks

(Fairburn, Cooper, Shafran, Bohn, Hawker, Murphy and Straebler, 2008)

CBT-E

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

prospect of change
2. Educate about the psychobiological effects of under-eating
and being underweight, and create a personalised
formulation
personalised education (based on handout)
BMI 20.0
personalised formulation (derived from CBT-Es
transdiagnostic template formulation)

Weeks

(Fairburn, Cooper, Shafran, Bohn, Hawker, Murphy and Straebler, 2008)

EDUCATION
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
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
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
Implications
1. Many features that the patient is experiencing are non-specific effects
of 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
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
 ANOREXIA
NERVOSA
Over-evaluation of shape and
weight and their control

Strict dieting; non-compensatory

weight-control behaviour
preoccupation with eating
social withdrawal
heightened obsessionality
heightened fullness
Low weight with
secondary effects

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

CBT-E

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

prospect of change
2. Educate about the psychobiological effects of under-eating
and being underweight, and create a personalised
formulation
3. Establish a pattern of regular eating
BMI 20.0
4. Discuss pros and cons of change
5. Initiate and then maintain weight regain

Weeks

(Fairburn, Cooper, Shafran, Bohn, Hawker, Murphy and Straebler, 2008)

 How I feel now Thinking five years ahead ...
Reasons to stay as I am Reasons to change Reasons to stay as I am Reasons to change

It makes me feel in I will get rid of my It makes me feel in control I want to be a success
control and special starvation symptoms: and special at work
I get attention from - thinking about I will not get fat I want a long term
others food and eating all the
It is familiar and feels safe relationship
I will not get fat time
If I change: I want a family
I am good at it - feeling so cold
- I wont be able to stop I want to be a positive
It makes me feel - not sleeping role model for my
eating
strong properly children
- my weight will shoot up
It shows I have will- - feeling faint I want to go on holiday
power - my stomach will stick
I will feel healthier and be spontaneous
out
It is familiar and feels I will be healthier I want to be in good
safe - my thighs will get
I will be able to think fatter health
I have an excuse for more clearly I dont want to still
things If I change people will think
I will have more time that: have starvation
I dont have to have I will be able to think symptoms or any other
periods - I am weak and greedy effects of the ED
about other things
I am not hassled by - I have given in I want to be in true
I will be less
men - I am getting fat control of my eating
obsessive, and more
If I change: flexible and I dont want to waste
- I wont be able to spontaneous my life
stop eating My life will have a I want to achieve things
- my weight will broader focus I dont want to be
shoot up I will be happier and chronically ill
- my stomach will have more fun
stick out I will be able to go out
- my thighs will get with others and get on
fatter with people better
I will discover who I
 BMI 25.0 (157lbs)

Healthy
weight
Weight
(lbs)
BMI 20.0 (126lbs)

Weeks
CBT-E

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

prospect of change
2. Educate about the psychobiological effects of under-eating
and being underweight, and create a personalised
formulation
3. Establish a pattern of regular eating
BMI 20.0
4. Discuss pros and cons of change
5. Initiate and then maintain weight regain
take the plunge
educate about the physiology of weight regain
let patients try it their way
Weeks
help patients maintain an energy excess of 500kcals
per day
offer the option of high-energy drinks

(Fairburn, Cooper, Shafran, Bohn, Hawker, Murphy and Straebler, 2008)

CBT-E

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

prospect of change
2. Educate about the psychobiological effects of under-eating
and being underweight, and create a personalised
formulation
3. Establish a pattern of regular eating
BMI 20.0
4. Discuss pros and cons of change
5. Initiate and then maintain weight regain
6. Address other psychopathology at the same time
7. Practise weight maintenance and end well
ensure that progress is maintained
Weeks
minimise the risk of relapse

(Fairburn, Cooper, Shafran, Bohn, Hawker, Murphy and Straebler, 2008)

 Over-evaluation of shape and
weight and their control
body checking and avoidance
feeling fat
marginalisation of other areas of life

Strict dieting; non-compensatory

weight-control behaviour
dietary restraint and restriction
dietary rules
over-exercising

Low weight with

secondary effects
 CBT-E
Broad version
EXTENDED THEORY (Fairburn et al, 2003)
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 these
mechanisms should improve outcome
The broad form of CBT-E is based on this theory
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
MOOD INTOLERANCE (cont)
Respond dysfunctional mood modulatory behaviour which
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)
MOOD INTOLERANCE (cont)
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
MOOD INTOLERANCE (cont)
Treatment
Existing CBT treatment procedures are often not sufficient
for 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
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
ADDRESSING MOOD INTOLERANCE (cont)
Adverse event Pressure at work

Deterioration in mood Tension

Dysfunctional behaviour Binge eating and/or cutting

Immediate improvement in mood Release of tension

Later negative appraisal Binge eating like this is hopeless.

I have no will-power
ADDRESSING MOOD INTOLERANCE (cont)
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
ADDRESSING MOOD INTOLERANCE (cont)
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
Over-evaluation of striving to achieve, and achieving, personally demanding
standards despite adverse consequences

Form of psychopathology equivalent to the core psychopathology of

eating disorders (i.e., it is also a dysfunctional system for self-evaluation)

(Shafran R, Cooper Z, Fairburn CG. Clinical perfectionism: A cognitive-behavioural

analysis. Behaviour Research and Therapy 2002; 40: 773-791)
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 of
life (e.g., performance at work, sport, music, etc)
 Over-evaluation of shape and Over-evaluation
weight and their control of achieving and
achievement

Strict dieting; non- Pursuit of personally

compensatory weight-control demanding
behaviour standards in valued
areas of life
Events and
associated mood Binge eating Significantly
change low weight e.g., work, sport,
friendships, etc
Compensatory
vomiting/laxative
misuse

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

CLINICAL PERFECTIONISM (cont)
Treatment
Cognitive behavioural analysis of clinical perfectionism has clear
implications for treatment
i.e., the CBT-E strategy (for addressing the over-evaluation of
eating, shape and weight) may also be applied to clinical
perfectionism
 Over-evaluation of achieving and achievement

Rigorous pursuit of Preoccupation Performance- Marginalization

personally demanding with thoughts checking with of other areas of
standards and/or about selective life
avoidance of tests of performance attention to
performance deficiencies in
performance
Re-setting standards
if goals are met
Available as a pdf from www.psychiatry.ox.ac.uk/credo
CORE LOW SELF-ESTEEM
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)
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
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
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
INTERPERSONAL DIFFICULTIES
Well-recognised that many patients with eating disorders have
impaired 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)
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