from oxford to perth: enhanced cbt in a new statewide eating disorders service at cci aacbt 12/9/06...

From Oxford to Perth:Enhanced CBT

in a new statewide Eating Disorders Service

at CCI

AACBT

12/9/06

Anthea Fursland Ph.D.

Centre for

Clinical

Interventions

•Psychotherapy•Research•Training

Overview of Presentation

Introduction - CCI Eating Disorders Programme

Background - Eating Disorders

Evidence-based treatment

CBT

CBT-E Overview

CBT-E: Main features

CBT-E: Specific interventions

Summary and Discussion

IntroductionCCI Eating Disorders Programme

Part of CCI - clinical services, training & applied clinical

research; staffed by clinical psychologists

New (2005). The first public eating disorders service for

adults in WA

Treating people 16 and over

Out-patient

Referrals - GPs and Psychiatrists

Clinic - Northbridge (central Perth)

Fairburn’s model of CBT-E

Background - Eating Disorders

Eating Disorders are serious mental illnesses

onset in teens (AN: 14-16; BN 16-20)

traditionally difficult to treat

better prognosis if treated early (first 6 months)

if untreated, can become chronic conditions with

significant morbidity

AN: highest mortality rate of any psychiatric disorder

poor treatment outcomes; high dropout rates

Evidence-based Treatment

Anorexia Nervosa (little research):

NICE could not recommend one single treatment for

AN based on solid research

NICE suggested family therapy (with focus on ED)

might be helpful for adolescents

Bulimia Nervosa (extensive research):

NICE recommended CBT for BN, based on solid

research

NICE also suggested IPT as possible alternative, and

anti-depressants (but no other medications)

EDNOS: no research

Cognitive Behaviour Therapy

Focus on factors that maintain the disorder (rather than the triggers)

Emphasis on both behavioural and cognitive change

Therapeutic relationship based on collaborative empiricism

Time-limited treatment

CBT-E: Overview

Based on Fairburn’s original CBT model for BN

Extensive research showing his (original) CBT is the most effective treatment for BN, but:

Original CBT - still only 30-50% success rate

No evidence-based treatment protocols for AN or EDNOS

CBT-E: Overview…..

Fairburn has improved (enhanced) his original treatment protocol:

transdiagnostic (applicable to AN & EDNOS; extended treatment for low-weight)

more successful outcome (70+%)

fewer drop-outs

CBT-E: Treatment interventions (1)

Traditional CBT (with a twist!):

Assessment

Engagement

Psycho-education

Establishment of regular eating

In-session weighing

Homework: self-monitoring

CBT-E: Treatment interventions (2)

Additional/enhanced interventions:

Construction of a formulation

Achieving meta-cognitive change

Additional maintaining mechanisms

CBT-E Interventions

Construction of a formulation

exclusive focus on the ED and maintaining mechanisms (vicious cycle)

forms the basis of treatment

created jointly, drawn out; patient takes a copy; it’s on the table every session

modified as treatment progresses

BULIMIA NERVOSA

Binge eating

Compensatory vomiting/laxative

misuse/driven exercise

Events and associated mood change

Over-evaluation of control over eating, shape or weight

Strict dieting; dietary rules

ANOREXIA NERVOSA

Over-evaluation of control over eating, shape or weight

Strict dieting; dietary rules

Features of under-eating and a low weight e.g., being inward-looking and preoccupied, social withdrawal, heightened fullness

MIXED

Strict dieting; dietary rules

Binge eating

Compensatory vomiting/laxative

misuse/driven exercise

Features of under-eating + low weight

Events and associated mood change

Over-evaluation of control over eating, shape or weight

Metacognitive awareness

Being aware of one’s thought processes

Taking a “helicopter view”

Taking a step back and looking at oneself

Asking: “What’s going on?” and “What do I need to do?”

CBT-E: Interventions

• Achieving meta-cognitive change

• Addressing over-evaluation of control over weight/shape by:

–Traditional cognitive restructuring

–Behavioural experiments

–Eating disorder “mindset”/DVD

–Body checking/avoidance

CBT-E: Interventions (5)

Additional maintaining mechanisms that are addressed where applicable:

– Core low self-esteem

– Clinical perfectionism

– Mood intolerance

– Interpersonal difficulties

Summary

New state-wide Eating Disorders Programme at CCI

Overview of Enhanced CBT

Focus on some crucial therapeutic interventions

Discussion

Further training on CBT-E: Nov. 2 & 3 2006

Registration: www.cci.health.wa.gov.au