Cognitive behaviour therapy for adolescents eating disorders

1. CBT-E with Younger Patients
13 – 18 years

2. Introduction
The treatment of adolescents with eating disorders
A 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

3. 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

4. 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.

5. CBT-E for adolescents with anorexia nervosa (N=46)
0
0.5
1
1.5
2
2.5
3
3.5
0 40 100
Weeks
EDE-Q
0
5
10
15
20
25
30
35
40
0 40 100
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%;

6. 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

7. 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

8. CBT-E with younger patients
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

9. CBT-E with younger patients
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

10. 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

11. Eating disorders in younger patients
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

12. Eating disorders in younger patients
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

13. Eating disorders in younger patients
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)

14. CBT-E with younger patients
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

15. 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

16. CBT-E with younger patients
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

17. Preparing younger patients
The Initial Appointment
Differences
• 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?”

18. Preparing younger patients
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

19. Preparing younger patients
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)

20. CBT-E with younger patients
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

21. 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

22. Parental involvement
Details of the parental involvement
One “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

23. Parental involvement
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

24. CBT-E with younger patients
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

25. Stage One
Starting Well
(sessions 1-7)
Stage Two
Taking Stock
(sessions 8-9)
Stage Three
Body Image
(Sessions 10-17)
Stage Three
Events, moods, and eatinng
(Sessions 10-17)
Stage Three
Dietary Restraint
(Sessions 10-17)
Stage Three
Setbacks and Mindset
(Session 15-17)
Stage Four
Ending Well
(Session 18-120)
CBT-E MAP

26. 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

27. Stage One
Differences
Engaging 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

28. 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

29. Stage Two
Key Points
• The same as Stage Two with adults
• Note the importance of highlighting progress

30. 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)

31. Stage Three
Body Image Module
Over-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)

32. 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

33. 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

34. Stage Four
Key points
• Same as with adult patients
• Most adolescent patients are keen to end treatment because of the
associated stigma (from peers)

35. CBT-E with younger patients
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
– Patients with a BMI >15.0 or equivalent BMI centile

36. Step One
Step Two
Step Three
Weight Regain is Achieved
in Three “Steps”
Underweight patients

37. Weight Regain is Achieved
in Three “Steps”
Step One
Patients see the need for weight regain and
decide to embark upon it
Step Two
Patients regain weight to a low-healthy level
Step Three
Patients 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
Underweight patients

38. Underweight patients

39. Weight Regain Step One
General Points
• CBT-E for adolescents is similar to CBT-E for adults
• Generally accomplished in fewer sessions (about 30)
Differences
Pros 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)

40. 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)

41. Weight Regain Step Two and Three
Differences
Identifying 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 )

43. Weight Regain Step Two and Three
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

44. Weight Regain Step Two and Three
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

45. Weight Regain Step Two and Three
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 meals
1. 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

46. Weight Regain Step Two and Three
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)

47. FBT vs CBT-E
for adolescents with anorexia nervosa
FBT CBT-E
Evidence of efficacy +++ +
Cost +++ +
Team Multidisciplinary Single therapist
Sessions 24 with two therapists
24 with a paediatrician
Hospitalization ( 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