Zafra Cooper

Cognitive behaviour therapy for eating disorders: a “transdiagnostic” theory and treatment

This paper is concerned with the psychopathological processes that account for the persistence of severe eating disorders. Two separate but interrelated lines of argument are developed. One is that the leading evidence-based theory of the maintenance of eating disorders, the cognitive behavioural theory of bulimia nervosa, should be extended in its focus to embrace four additional maintaining mechanisms. Specifically, we propose that in certain patients one or more of four additional maintaining processes interact with the core eating disorder maintaining mechanisms and that when this occurs it is an obstacle to change. The additional maintaining processes concern the influence of clinical perfectionism, core low self-esteem, mood intolerance and interpersonal difficulties. The second line of argument is that in the case of eating disorders shared, but distinctive, clinical features tend to be maintained by similar psychopathological processes. Accordingly, we suggest that common mechanisms are involved in the persistence of bulimia nervosa, anorexia nervosa and the atypical eating disorders. Together, these two lines of argument lead us to propose a new transdiagnostic theory of the maintenance of the full range of eating disorders, a theory which embraces a broader range of maintaining mechanisms than the current theory concerning bulimia nervosa. In the final sections of the paper we describe a transdiagnostic treatment derived from the new theory, and we consider in principle the broader relevance of transdiagnostic theories of maintenance.

Clinical perfectionism: A cognitive-behavioural analysis.

This paper reviews the characteristics of clinical perfectionism and proposes a new definition of the phenomenon. It is suggested that the defining feature of clinically significant perfectionism is the overdependence of self-evaluation on the determined pursuit (and achievement) of self-imposed personally demanding standards of performance in at least one salient domain, despite the occurrence of adverse consequences. It is suggested that such clinical perfectionism is maintained by the biased evaluation of the pursuit and achievement of personally demanding standards. Specifically, it is suggested that people with perfectionism react to failure to meet their standards with self-criticism. If they do meet their standards, the standards are re-evaluated as being insufficiently demanding. Anorexia nervosa and bulimia nervosa are considered to have a particular relationship to perfectionism, with both disorders often being direct expressions of perfectionism. Under these circumstances self-evaluation is dependent on the pursuit and attainment of personally demanding standards in the domain of control over eating, shape and weight. The implications of this analysis for research and practice are considered.

Transdiagnostic Cognitive-Behavioral Therapy for Patients With Eating Disorders: A Two-Site Trial With 60-Week Follow-Up

OBJECTIVE The aim of this study was to compare two cognitive-behavioral treatments for outpatients with eating disorders, one focusing solely on eating disorder features and the other a more complex treatment that also addresses mood intolerance, clinical perfectionism, low self-esteem, or interpersonal difficulties. METHOD A total of 154 patients who had a DSM-IV eating disorder but were not markedly underweight (body mass index over 17.5), were enrolled in a two-site randomized controlled trial involving 20 weeks of treatment and a 60-week closed period of follow-up. The control condition was an 8-week waiting list period preceding treatment. Outcomes were measured by independent assessors who were blind to treatment condition. RESULTS Patients in the waiting list control condition exhibited little change in symptom severity, whereas those in the two treatment conditions exhibited substantial and equivalent change, which was well maintained during follow-up. At the 60-week follow-up assessment, 51.3% of the sample had a level of eating disorder features less than one standard deviation above the community mean. Treatment outcome did not depend on eating disorder diagnosis. Patients with marked mood intolerance, clinical perfectionism, low self-esteem, or interpersonal difficulties appeared to respond better to the more complex treatment, with the reverse pattern evident among the remaining patients. CONCLUSIONS These two transdiagnostic treatments appear to be suitable for the majority of outpatients with an eating disorder. The simpler treatment may best be viewed as the default version, with the more complex treatment reserved for patients with marked additional psychopathology of the type targeted by the treatment.

Cognitive Behaviour Therapy for Eating Disorders

The eating disorders provide one of the strongest indications for cognitive behaviour therapy (CBT). This bold claim arises from two sources: first, the fact that eating disorders are essentially cognitive disorders and second, the demonstrated effectiveness of CBT in the treatment of bulimia nervosa, which has led to the widespread acceptance that CBT is the treatment of choice. In this paper the cognitive behavioural approach to the understanding and treatment of eating disorders will be described. A brief summary of the evidence for this account and of the data supporting the efficacy and effectiveness of this form of treatment will be provided. Challenges for the future development and dissemination of the treatment will be identified.

The measurement of impairment due to eating disorder psychopathology.

Eating disorders have a profound and highly specific impact on psychosocial functioning. The aim of this research was to develop a measure of such secondary impairment. A 16-item, self-report instrument was developed, the Clinical Impairment Assessment (CIA), which was designed to measure such impairment overall and in three specific domains (personal, cognitive, social). The psychometric properties of the instrument were evaluated using data collected in the context of a transdiagnostic treatment trial. The findings consistently supported the utility of the instrument with the CIA being shown to have high levels of internal consistency, construct and discriminant validity, test–retest reliability, and sensitivity to change. The CIA should be of value to clinicians when assessing patients with eating disorders and their response to treatment. It should also help inform epidemiological research.

Attentional bias in eating disorders

Objective: To examine the relationship between eating disorders and attentional biases. Method: The first study comprised 23 female patients with clinical eating disorders, women with high levels ofanxiety (n = 19), and three female normal control groups comprising low (n = 31), moderate (n = 21), or high levels of shape concern (n = 23). The second study comprised 82 women with clinical eating disorders and 44 healthy controls. All participants completed measures of eating disorder psychopathology and completed a modified pictorial dot-probe task. Results: In the first study, biases were found for negative eating and neutral weight pictures, and for positive eating pictures in women with eating disorders; these biases were greater than those found in anxious and normal controls. The second study replicated these findings and biases were also found for negative and neutral shape stimuli. Conclusion: It is concluded that future research should establish whether such biases warrant specific therapeutic interventions.

Cognitive Behavioral Therapy for Eating Disorders

Cognitive behavioral therapy (CBT) is the leading evidence-based treatment for bulimia nervosa. A new “enhanced” version of the treatment appears to be more potent and has the added advantage of being suitable for all eating disorders, including anorexia nervosa and eating disorder not otherwise specified. This article reviews the evidence supporting CBT in the treatment of eating disorders and provides an account of the “transdiagnostic” theory that underpins the enhanced form of the treatment. It ends with an outline of the treatments main strategies and procedures.

Testing a new cognitive behavioural treatment for obesity: A randomized controlled trial with three-year follow-up

It is remarkably difficult for people with obesity to maintain a new lower weight following weight loss. The aim of the present study was to examine the immediate and longer-term effects of a new cognitive behavioural treatment that was explicitly designed to minimise this post-treatment weight regain. One hundred and fifty female participants with obesity were randomized to the new treatment, behaviour therapy (the leading alternative psychological treatment) or guided self-help (a minimal intervention). Both of the main treatments resulted in an average weight loss of about ten percent of initial weight whereas weight loss was more modest with guided self-help. The participants were subsequently followed-up for three years post-treatment. The great majority regained almost all the weight that they had lost with the new treatment being no better than the behavioural treatment in preventing weight regain. These findings lend further support to the notion that obesity is resistant to psychological methods of treatment, if anything other than a short-term perspective is taken. It is suggested that it is ethically questionable to claim that psychological treatments for obesity “work” in the absence of data on their longer-term effects.

Therapist competence, therapy quality, and therapist training

Large numbers of therapists worldwide wish to receive training in how to deliver psychological treatments. Current methods of training are poorly suited to this task as they are costly and require scarce expertise. New forms of training therefore need to be developed that are more cost-effective and scalable. Internet-based methods might fulfil these requirements whilst having the added advantage of being able to provide trainees with extensive exposure to the treatment as practised. New strategies and procedures for evaluating training outcome are also required. These need to be capable of assessing the therapist’s knowledge of the treatment and its use, as well as the therapist’s ability to apply this knowledge in clinical practice. Standardised role play-based techniques might be of value in this regard.

Understanding persistence in bulimia nervosa: A 5-year naturalistic study.

Bulimia nervosa shows a marked tendency to persist, suggesting that powerful maintaining mechanisms operate. Using data from a prospective, 5-year, study of the natural course of 102 people with bulimia nervosa, the authors sought to identify predictors of persistence and to test specific hypotheses derived from the cognitive-behavioral theory of the persistence of bulimia nervosa. The results of both sets of analyses were consistent with the theory, with the degree of overevaluation of shape and weight and a history of childhood obesity predicting a persistent course. There was also support for the central prediction of the cognitive-behavioral theory. These findings suggest that the mechanisms specified by the theory influence its longer term natural course.