cbt-e for adolescents with eating disorders

CBT-E with Younger Patients

13 – 18 years

Introduction

The treatment of adolescents with eating disordersA particular form of family therapy, termed family-based treatment (FBT), is the leading empirically- supported intervention for adolescents with anorexia nervosa (NICE, 2004)

FBT limitations• It is not acceptable to some families and patients• It is labour intensive and therefore costly• Fewer than half the patients make a full treatment response (Lock, 2011;

Lock et al., 2010)• It is not effective for bulimia nervosa and other eating disorders

Alternative treatment approaches need to be found

Introduction (cont.)

CBT-E might be a potential candidate as an alternative to FBT • It is the leading empirically supported treatment for bulimia nervosa (NICE,

2004), a disorder with psychopathology that overlaps with that of anorexia nervosa

• The treatment has been adapted to make it suitable for any form of eating disorder, including anorexia nervosa

• CBT-E produces sustained change in patients with bulimia nervosa and OEDs• It is associated with a good outcome in two cohorts of adults with anorexia

nervosa

CBT-E with younger patients

Reading• Little written on the use of CBT-E with younger patients

Research findings• Dalle Grave R, Calugi S, Doll HA, Fairburn CG. Enhanced cognitive behaviour therapy for

adolescents with anorexia nervosa: An alternative to family therapy? Behaviour Research and Therapy 2013, 51: R9-R12.

• Calugi S, Dalle Grave R, Sartirana M, Fairburn CG. Time to restore body weight in adults and adolescents with anorexia nervosa. Submitted

Some key points about this use of CBT-E• Cooper Z, Stewart AD. CBT-E and the younger patient. In Fairburn CG, Cognitive Behavior

Therapy and Eating Disorders. New York: Guilford Press, 2008, pp 221–230.

CBT-E for adolescents with anorexia nervosa (N=46)

0 40 1000

0.5

1

1.5

2

2.5

3

3.5

Weeks

EDE-Q

0 40 1000

5

10

15

20

25

30

35

40

Weeks

BMI centile

Dalle Grave R et al Behaviour Research and Therapy 2013, 51: R9-R12.

Age, years 15.5 (1.3)

Duration of eating disorder, years, 0.86 (0-5)

Body mass index centile 2.86 (3.3)

BMI centile of <1.0. 23 (50%)

Completers: n=29, 63%;

CBT-E for adolescents and adults with anorexia nervosa

Significantly more adolescents reached the goal BMI than adults (65.3% vs. 36.5%; P=0.003).

The time required by the adolescents to restore body weight was about 15 weeks less than that for the adults (mean 14.8 weeks vs. 28.3 weeks, log-rank=21.5, P<0.001).

Calugi S, Dalle Grave R, Sartirana M, Fairburn CG, submitted

CBT-E anorexia nervosa studies

Findings with younger patients• Two-thirds completed treatment

• Among them, substantial increase in weight and reduction in ED psychopathology

• Effect well maintained

• Similar positive results from Perth and Minneapolis

• CBT-E for anorexia nervosa can be substantially shorter for adolescents than for adults (30 vs 40 sessions)

CBT-E is a potential alternative to family-based therapy


Topics 1. Eating disorders in younger patients

2. An overview of CBT-E for the younger patient

3. Preparing younger patients

4. Parental involvement

5. Stages One to Four

6. Underweight patients

Eating disorders in younger patients

Features Shared with Older Patients • Essentially the same ED psychopathology

– over-evaluation of shape and weight

– strict dieting

– self-induced vomiting

– laxative misuse

– binge eating

– overexercising

• These features can be addressed by CBT-E


Distinctive Features• Most adolescent patients are highly concerned about issues of control

and autonomy- This is not a problem as CBT-E is designed to enhance patients’ sense of control

and autonomy. CBT-E is collaborative with the therapist and patient working together to overcome the eating problem

• Many adolescent patients are highly ambivalent about treatment- This is not a problem as CBT-E is designed to be engaging and to address

ambivalence

• Some patients have over-evaluation of control over eating per se– This is not a problem as this form of over-evaluation can be addressed using an

adaptation of the “body image” module of CBT-E


Distinctive Features (cont.)• In the great majority of cases the patient’s parents need to be involved in

treatment – This requires modifying CBT-E, but only to a limited extent

• The youngest patients require a treatment that matches their cognitive development

– This is easily managed in CBT-E as it is not a complex treatment to receive


Distinctive Features (cont.)• The patient’s physical health is of particular concern in younger patients

– The medical complication associated with EDs may be severe in adolescents

Osteopenia and osteoporosis

Growth arrest

Delayed puberty

• This necessitates careful assessment and monitoring, and a lower threshold for providing patients with a more intensive intervention (e.g., hospitalisation)

An overview of CBT-E for the younger patient

Main Points • It is essentially the same treatment as the adult form of CBT-E

- Same stages, strategies and procedures

- Same use of one single therapist

• There are some minor differences- Particular effort is made to engage patients from the very outset

- Treatment tends to be shorter as change often occurs more quickly (e.g., with underweight patients 30 sessions may be sufficient)

- Parents are involved in treatment in a circumscribed way

Preparing younger patients

The Initial AppointmentDifferences

• Start by asking the parents if you might first see the patient alone

• With the patient alone, ask him/her whether they are attending of their own choice or because of pressure from others

• Emphasise that your sole concern is their well-being, not that of others- You will not be operating on behalf of their parents or other people

• When assessing the eating disorder, ask patients (if applicable) if they are in true control of their eating

– “Could you eat more normally for the next few days – in other words, relax your controls over eating? Or would you find this difficult?”


The Initial Appointment (cont.)Differences

• Raise the topic of treatment and ask the patient (between this appointment and the next one) to list of the pros and cons of having treatment

• Give the patient the handout on CBT-E and ask the patient to list any questions he/she has about the treatment

• Then see the parents with the patient and – Describe treatment in outline

– Ask them to discuss with the patient the pros and cons of having treatment, but emphasise that the decision lies with the patient


The Second Appointment Differences • With the patient alone

– Review the pros and cons of starting treatment, and address any questions

– Interest the patient in the prospect of change

– If applicable, suggest that the patient “Takes the plunge”

• With the patient and parents together

– If applicable, tell the parents that the patient has decided to start treatment

– Explain their role in treatment (described later in this module)

Parental involvement

Main Points• The role of the parents is to support the one-to-one treatment

– i.e., their role is similar to that of significant others in the adult version of CBT-E


Details of the parental involvementOne “parents alone” session early in treatment• To educate the parents about the nature of the patient’s eating disorder and the

processes maintaining it (with reference to the patient’s formulation)• To address self-blame and instil hope• To explain that they may be able to help the patient benefit from CBT-E• To stress the importance of a happy home environment• To identify and address possible parental contributions to the maintenance of the

eating problem• To assess and address parental barriers to change


Details of the parental involvement (cont.)Up to eight 15-minute sessions with the patient and parents together (at the end of a patient-therapist session) • To inform the parents about what is happening in treatment and the patient’s

progress

• (If applicable) To discuss how they might be of help

Stage OneStarting Well(sessions 1-7)

Stage TwoTaking Stock(sessions 8-9)

Stage ThreeBody Image

(Sessions 10-17)

Stage ThreeEvents, moods, and eatinng

(Sessions 10-17)

Stage ThreeDietary Restraint

(Sessions 10-17)

Stage ThreeSetbacks and Mindset

(Session 15-17)

Stage FourEnding Well

(Session 18-120)

CBT-E MAP

Stage One

Key Points• Essentially the same as Stage One with adults but with

- One “parents alone “ session early in treatment

- Often one 15-minute end-of-session parental meeting at some point in Stage One

Stage One

DifferencesEngaging the patient• Encourage patients to take “ownership” of the treatment and be active in attempting

to change

Creating the formulation• Often highly engaging as younger patients like diagrams; generates of sense of

understanding and control; avoid technical terms

Establishing self-monitoring• Younger patients are able to comply with real-time self-monitoring; likely to ask

about apps etc; may also use as a personal diary

Stage One

Differences (cont.)Personalised education• Welcomed by younger patients

• Guided reading of “Overcoming Binge Eating” for older adolescents (>16 years)

• Younger patients require in-session education

Addressing weight concern• Same as CBT-E with adults

Establishing regular eating• Same as CBT-E with adults

Stage Two

Key Points• The same as Stage Two with adults

• Note the importance of highlighting progress

Stage Three

Key Points• Similar to Stage Three with adults • Note that some patients have over-evaluation of control over eating per

se, rather than over-evaluation of shape and weight– Addressed using the same strategy as that used to address the over-evaluation

of shape and weight– Also employ equivalent procedures (see the CBT-E treatment guide)

Stage Three

Body Image ModuleOver-evaluation of shape and weight• The creation of the pie chart is welcomed and valued by adolescents

Developing other domains• Important to encourage younger patients to take up the activities of their peers

(sports, hobbies, parties, etc)

Body checking• Shape checking is often extreme in adolescents

• Comparisons with media images usually needs to be addressed

Body avoidance• Affects clothes choice, sports (e.g., swimming), leisure (beach holidays, parties, etc)

and relationships (physical intimacy)

Stage Three

Dietary Restraint Module• Marked dietary restraint results in secondary psychosocial impairment

– Often interferes with relationships with peers

• Under the guidance of the therapist, parents may be able to help patients address certain dietary rules

Events, Moods and Eating Module• Some patients are interpersonally inexperienced and need help to “catch

up”

• Proactive problem solving may need to be simplified for very young patients

Stage Three

Setbacks and Mindsets• Progress in response to treatment is often faster in adolescents than adults

with the result that setbacks and mindsets can be addressed earlier

• The DVD analogy works well with younger patients

Stage Four

Key points• Same as with adult patients

• Most adolescent patients are keen to end treatment because of the associated stigma (from peers)








– Patients with a BMI >15.0 or equivalent BMI centile

Step One

Step Two

Step Three

Weight Regain is Achieved in Three “Steps”

Underweight patients

Weight Regain is Achieved in Three “Steps” Step OnePatients see the need for weight regain and decide to embark upon itStep TwoPatients regain weight to a low-healthy levelStep ThreePatients become accomplished at weight maintenance

The addressing of the ED psychopathology is integrated with the three weight gain steps

Step One

Step Two

Step Three


Weight Regain Step One

General Points• CBT-E for adolescents is similar to CBT-E for adults

• Generally accomplished in fewer sessions (about 30)

DifferencesPros and cons of change• Help patients identify personally salient adverse effects (e.g., missing school and

school exams; not being able to go on vacation)

• Suggest a shorter time frame when thinking about the future (6 months)

Weight Regain Step Two and Three

General Points• Steps Two and Three are similar to CBT-E for adults

• Weight regain is generally accomplished in fewer sessions

• Most of the strategies and procedures are the same as those used with adults

• This applies both to the weight regain process and the addressing of the maintaining mechanisms (Body image; Dietary restraint; Events, moods and eating)


DifferencesIdentifying a goal weight range• Needs to be a weight range that:

i. Is not associated with psychosocial features of starvation (so that patients can discover their true psychological characteristics)

ii. Is healthy from a physical perspective and one that takes into account developmental needs

iii.Does not require dietary restriction

• In patients over 18 years, a BMI between 19.0 and 20.0 is a reasonable figure

• In patients below 18 years, therapists need to identify the comparable BMI centile (which differs from country to country – In Italy 25° centile )


Differences (cont)Establishing and maintaining weight regain• Very similar to CBT-E for adults, except that younger patients sometimes need

guidance regarding what foods to eat in their meals and snacks

• Be aware of the risk that this guidance is converted by the patient into a dietary rule


Differences (cont)Establishing and maintaining weight regain (cont)In the session

• Patients cease weighing themselves at home (if applicable) and instead are weighed each week at the beginning of the sessions

• Therapist and patients plot the latest reading onto a weight graph

• Every week the therapist and patient jointly interpret the emerging trend minimum of 4 weekly readings)

• Patients plan, with the help of the therapist, the eventual changes in the meal plan to maintain a weight regain of 0.5 kg per week


Differences (cont)Establishing and maintaining weight regain (cont)At home

• Regular eating (3+2+0)

• 500 kcal positive energy balance per day

• Self-monitoring in real time

• Cognitive behaviour strategies to address difficulties during the meals1. Eating all the planned food

2. Eating without being influenced by internal signals of hunger, and fullness

3. Eating without being influenced by preoccupations on eating and food

4. Distancing the behaviour from thoughts and preoccupation on eating and food

5. Avoiding the use of rituals at the table

6. Using the self-monitoring record in real time


Differences (cont)Involving parents in the weight regain process (Step Two)• Having educated the patient about the weight regain process (500 kcal per day, etc),

do the same with the parents

• Discuss how to behave during family meals

• Try to create a positive atmosphere

• If the patient is having difficultes, be supportive and encouge him/her to apply what has been learned in treatment (see earlier)

• Avoid being coercive

Involving parents in the weight maintenance process (Step Three)• Parents need to be informed when this starts

• They can help with the addressing of residual dietary rules (e.g., food avoidance)

FBT vs CBT-E for adolescents with anorexia nervosa

FBT CBT-EEvidence of efficacy +++ +

Cost +++ +

Team Multidisciplinary Single therapist

Sessions 24 with two therapists24 with a paediatricianHospitalization ( 15%)

30

Age (years) 12-18 13-18

BMI centile (mean) 7 3

Adolescent’s involvement Not actively involved Actively involved

Parents’ involvement Vitally important Useful but not essential

cbt-e for adolescents with eating disorders

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