Intensive CBT-E

Riccardo Dalle Grave, MD

Villa Garda HospitalDepartment of Eating and Weight Disorders

The Villa Garda Clinical Service

Aims• To develop a novel way of providing treatment that overcomes some of the

difficulties encountered in more conventional services

Goals• Providing all patients with an evidence-based treatment (CBT-E), whatever their

ED diagnosis or age, and whether they are outpatients, day patients or inpatients.

• The default is to deliver CBT-E on an outpatient basis (a transdiagnostic evidence-based treatment), but some patients require more intensive treatment (i.e. intensive outpatient or hospitalisation) and these patients embark upon CBT-E while in hospital.

• Whenever possible, they continue with the CBT-E on discharge without any interruption

CBT-E Multistep

InpatientStep 3

Intensive outpatient

Outpatient

Step 2

Outpatient post-inpatient

Step 1 Step 3

Every level of care is based on the same theory, and uses similar strategies and strategies (more intensive in intensive outpatient and inpatient CBT-E)

Why a clinical service based on CBT-E?

Rational• It is a treatment to treat most patients with

– Patients with any ED diagnosis (“transdiagnostic”)

– Adults and adolescents

– Complex patients

– Outpatients, day patients and inpatients

• Liked by patients• Detailed treatment guide• Good evidence base

The treatment guides

Fairburn CG: Cognitive Behaviour Therapy and Eating Disorders.Guilford Press, New York, 2008

Dalle Grave, R. (2012). Intensive Cognitive Behavior Therapy for Eating Disorder. Hauppauge NY, Nova Publisher

Dalle Grave, R. (2013). Multistep Cognitive Behavioral Therapy for Eating Disorders: Theory, Practice, and Clinical Case. Lanham: Jason Aroson

CBT-E in intensive settings of care

Rational• A subgroup of patients does not respond to outpatient CBT-E• A subgroup of patients has an eating disorder of clinical severity not manageable

with outpatient CBT-E• Data on changing the nature of outpatient treatment (e.g., from CBT to IPT or

fluoxetine) are inconclusive. • The ineffectiveness of outpatient CBT-E in some patients might depend by the

insufficiently intensity of care rather than by the nature of the treatment

CBT-E in intensive settings of care

Rational (cont.)• CBT-E addresses the ED psychopathology – rather the DSM diagnosis

Ideal in an inpatient settings where patients have different DSM diagnosis

• CBT-E has a lasting effects – It address the maintaining mechanisms of the ED psychopathology

– It help patients addressing setbacks and preventing relapse

Ideal in an inpatient setting where the main problem is the relapse after discharge

The various forms of intensive CBT-E

• Inpatient CBT-E• Intensive outpatient CBT-E

– Both treatment have been developed at the Department of Eating and Weight Disorders of Villa Garda Hospital (Italy) under the supervision of Chris Fairburn

– These treatments can be adapted to meet the different health organization and resources of the countries where are implemented

Inpatient CBT-E

Research findings• Dalle Grave R, Calugi S, Conti M, Doll H, Fairburn CG. Inpatient cognitive behaviour therapy for

anorexia nervosa: A randomized controlled trial. Psychotherapy and Psychosomatics. 2013;82(6):390-8.

• Dalle Grave R, Calugi S, El Ghoch M, Conti M, Fairburn CG. Inpatient cognitive behavior therapy for adolescents with anorexia nervosa: immediate and longer-term effects. Frontiers in Psychiatry. 2014;5:14.

CharacteristicsAll Patients CBT-Ef CBT-Eb

Testp

(N=80) (N=42) (N=38) (value)

Age, years 23.4 (6.9) 23.1 (6.8) 23.7 (7.0) -.41 .681Gender, n (%) female 78 (97.5) 40 (95.2) 38 (100) 1.86 .173Duration of eating disorder, years, median (range)

5.0 (0-26.0) 4 (0-20.0) 5.0 (0-26.0) -.65 .517

Current other axis I disordera

- Major depressive episode, n (%) present

45 (56.3) 25 (59.5) 20 (52.6) .38 .535

- Any anxiety disorder, n (%) present

16 (20.0) 9 (21.4) 7 (18.4) .11 .737

Characteristics of the two samples at baseline.Data are shown as mean (SD) unless otherwise indicated.

Dalle Grave et al. Psychotherapy and Psychosomatics. 2013;82(6):390-8.

Mean body mass index (BMI) and eating disorder psychopathology (global EDE-Q) over 20 weeks of treatment and 12-month of follow-up in completers

12

13

14

15

16

17

18

19

20

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

CBT-Ef

CBT-Eb

BMI EDE global

Completers: CBT-Ef, n=37, 88.1%; CBT-Eb, n=35, 92.1% (p = .550)

Dalle Grave et al. Psychotherapy and Psychosomatics. 2013;82(6):390-8.

Inpatient CBT-E for adolescents with anorexia nervosa (n = 26/27)

Dalle Grave et al. Frontiers in Psychiatry. 2014;5:14.

Characteristics

Age, years 16.0 (1.1)

Duration of eating disorder, years, 2.0 (0-7)

Body mass index centile 2.7 (4.3)

BMI centile of <1.0. 16 (59.6%)

Inpatient CBT-E

Differences with outpatient CBT-E• Multiple therapists• Assisted eating• Some CBT-E elements are delivered in group

Inpatient CBT-E

Indications• Poor response to well-delivered outpatient-based treatment• Presence of features that make outpatient eating disorder treatment

inappropriate (inpatient CBT-E)– Very low weight

– Rapid weight loss

– Marked medical complications (e.g., pronounced edema, severe electrolyte disturbance, hypoglycaemia)

– Significant suicide risk

– Severe interpersonal problems

Inpatient CBT-E

Contraindications• Daily substance abuse (intermittent drug abuse of alcohol, cocaine or ecstasy

is not considered a contraindication)• Acute psychotic disorders

Traditional inpatient ED treatments

Use of multiple therapists• Generally, intensive treatments are not theory-driven and are administered

by a “multidisciplinary eclectic team” – The psychologist may adhere to a psychoanalytic or systemic theory

– The dietitian may adopt some behavioural procedures and strategies

– The physicians may follow a biomedical prescriptive model

Each team member follows his/her theory and therapeutic practice, pursuing therapeutic goals related to his/her professional role

• Problems– Contradictory information

– Team conflicts

– Difficult to produce substantial improvements in treatment

– Difficult to replicate and disseminate the treatment to other units

Inpatient CBT-E

Use of multiple therapists• All the therapists are fully trained in cognitive behaviour theory and therapy

for eating disorders (non-eclectic approach)• All the therapists share the same treatment philosophy and the same

language• The personal formulation integrates each staff member's contribution to

treatment • The treatment fidelity is monitored

– Weekly review meeting with patient (round table)

– Weekly team meeting

– Peer supervision

– Sessions recording

Inpatient CBT-E

Use of multiple therapists (cont.)• CBT Psychologist

– Address the over-evaluation of control over eating, shape and weight, and implement the "broad" CBT-E modules.

• CBT Nurse – Has the usual tasks of a nurse in a hospital unit and oversees the weighing of the patient

• CBT Dietitian– Addresses the modification of eating habits and weight, and assisted eating

• CBT Physician/Psychiatrist– Treats the medical complication of the patients and is responsible for the medications

prescription

Inpatient CBT-E

Preparation• 3 to 8 sessions (some aspects are similar to the Step One of CBT-E for

underweight patients)– Assess the indications for the treatment

– Engage the patient

– Educate about the psychobiological effects of being underweight and consider the implications

– Create a personalized formulation with the inclusion of malnutrition symptoms

– Discuss the pros and cons of change (regaining weight) and to start the impatient CBT-E

– Assess the patient availability to play an active role in the treatment

– Information about the treatment

Inpatient CBT-E

Preparation (cont)Information for patients• The unit

• The cognitive behavioural theory

• The treatment

• Attitudes and commitment required – Treatment as an opportunity to make a “fresh start” and to

build a “new life”

– Treatment as a priority

– Starting well

– Active role in the treatment

– Responsibility towards other patients

• Patients receive a pamphlet describing the treatment

www.villagrada.it

Inpatient CBT-EGeneral Organization

Inpatient CBT-E map

Stage One(weeks 1-4)

Starting wellEngaging and educating patients

Self-monitoring, collaborative weekly weighing, and building the personal formulationAssisted meals

Stage Two(weeks 5-6)

Taking stockReviewing the progress and planning Stage Three

Adjunctive modules

Clin perfectionismCore low self-esteem

Interpersonal problems

Body imageSelf-evaluationBody checking

Body avoidanceFeeling fat

Stage Three(weeks 7-17)

Dietary restraint

Dietary restrictionDietary restraint

Events, mood and eating

Problem solvingMood intolerance

Stage Four(weeks 18-20)

Ending wellIdentifying the residual problems and the procedures to use after discharge

Developing strategies and procedures to prevent the relapse Organizing the post-inpatient treatment

Building the post-inpatient plan

Da Dalle Grave, 2013

Inpatient CBT-E

Core procedures1. Creating a personalized formulation

2. Establishing self-monitoring

3. Monitoring and interpreting the weight

4. Monitoring the course of the treatment

5. Assisted eating

6. Non-assisted eating

7. The weekly review meeting

8. Individual CBT-E sessions

9. Group treatment sessions

10. Exercise sessions

Inpatient CBT-E

Core procedures1. Creating a personalized formulation

2. Establishing self-monitoring

3. Monitoring and interpreting the weight

4. Monitoring the course of the treatment

5. Assisted eating

6. Non-assisted eating

7. The weekly review meeting

8. Individual CBT-E sessions

9. Group treatment sessions

10. Exercise sessions

Core procedures

Assisted eating• Over the first six weeks or until patients reach a BMI > 18.5 • Three meals and a snack each day (breakfast, lunch, mid-afternoon snack

and dinner) • Assistance of the CBT dietitian (or CBT nurse)

Core procedures

Assisted eating (cont)The patient’s role• “Active role” in applying the cognitive behaviour strategies during the meals

– Your role is nor just eating, but also applying the cognitive behaviour strategies to to handle your eating disorder mindset

– If you eat passively, when you will consume the meals by yourself, you will not be able to handle your eating disorder mindset

Core procedures

Assisted eating (cont)CBT-E strategies to address the meals• Eating all the planned food

– “The eating plan will help you to feel in control during the weight restoration you may predict the rate of weight regain”.

• Eating without being influenced by internal signals of hunger, and fullness– “Try to eat without being influenced by internal signals of hunger, feeling full, because they

are altered by your underweight state”.

• Eating without being influenced by preoccupations on eating and food– “Say to yourself that these are the expression of the eating problem mind-set that you

want to change”.

Core procedures

Assisted eating (cont)CBT-E strategies to address the meals (cont)• Distancing the behaviour from thoughts and preoccupation on eating and food

– “Do not follow the thoughts of your eating problem mindset - make the opposite”.

• Avoiding the use of rituals at the table

– "Try to adopt the mindset of an athlete before high jumping. He concentrates on the technique to use and not on the fear of failing or on how high the bar may be”.

• Using the self-monitoring record in real time

– “If you have difficulties during the meals write the strategies you should apply in your monitor record”

Core procedures

Assisted eating (cont)The dietitian/nurse’s role• Support and encouragement • Cognitive behavior strategies

– de-centering from internal states and problematic thoughts– distancing the behavior from thoughts– dissuading from practicing any atypical methods of food intake and rituals to

control eating

Core procedures

Assisted eating (cont.)Managing the moments following the meals• After the assisted eating you are encouraged to remain in the sitting room and for an

hour to apply alternative activities (e.g., read, watch TV, study, listen to music, use the internet, etc..) for managing the impulse to adopt compensatory behaviours (i.e., exercising, self-induced vomiting)

• In this hour you are encouraged to avoid the use of the bathroom

Core procedures

Non-assisted eating• When the period of assisted eating over

– Patients start gradually eating outside the unit – The treatment addresses dietary restraint as outpatient CBT-E

• At discharge patients should be able to maintain their weight in a normal range following flexible dietary guidelines

Core procedures

The weekly review meeting (round table)• Once a week between patient and all his or her therapists at a round table

– To discuss the various elements of the treatment and their relationship to one another are discussed

• This permits all the team members to have a complete picture of the patient’s eating disorder and to avoid the delivery of contradictory messages

• Patients interpret their BMI graphic and suggest, using the intensive CBT-E weight regain CBT-E guideline, the diet changes for weight regain (1 kg per week) or maintenance

• Revision of the state of the personal formulation

Rational• Maintaining fidelity to the treatment and ensuring cross-therapist consistency in its

implementation

• Encouraging patients to become a “therapist” of their eating problem

Inpatient CBT-E

Modules CBT-Ef• Underweight and dietary restriction

• Dietary restraint

• Excessive and compulsive exercising

• Purging

• Body image

• Events, moods and eating

• Setbacks and mindset

3 key strategies:1. Identification2. Education3. Procedures to address the

maintaining mechanism

CBT-Eb • Clinical perfectionism

• Core low self-esteem

• Interpersonal problems

Inpatient CBT-E

Program’s elements to reduce relapse• CBT-E modules to address the eating disorder psychopathology … plus• Open unit• Day treatment• Involvement of other significant• Ending well

Program’s elements to reduce relapse

Open unit• Inpatient CBT-E is provided in a specialized unit for the treatment of eating disorders

• The unit is ‘open’, and patients in a stable medical condition are free to go outside it

• Significant others are free to visit the patient at any time other than mealtimes and when treatment sessions are occurring

Program’s elements to reduce relapse

Open unit (cont)• The unit atmosphere is psychological rather than medical, and not

institutional – The staff does not wear medical scrubs and uniforms – Patients are free to decorate their room

Program’s elements to reduce relapse

Day treatment• During the day treatment stage patients are helped to identify triggers of

their eating disorder mindset that are not present on the unit. – These are then addressed in treatment

• Gradual decrease of the treatment intensity– The treatment evolves towards the outpatient treatment

Program’s elements to reduce relapse

Involvement of significant others• With the patient’s consent if they can facilitate the treatment• Three sessions after the individual CBT-E sessions• Goal

– Create a positive stress-free home environment for the patient's return

Program’s elements to reduce relapse

Ending well1. Identifying the residual problems and the procedures to use after

discharge

2. Developing strategies and procedures to prevent relapse

3. Organizing the post-inpatient treatment

4. Building the post-inpatient plan

Ending well

Identifying the residual problems• EDE• CIA• Monitor records• Personalized formulation of the residual problems

Identifying the procedures to use after discharge• Self-monitoring• Weekly weighing plus..• Procedures individualized on the basis of the patient’s problems

Ending well

Trigger Return of mindset

Return of the ED characteristics (a setbacks)

Prevent the triggers - Proactive problem

solving

Identify immediately the trigger- Weight and shape

triggers- Eating triggers- Events and moods

triggers

Decentring immediately

Make the right thing “Make the opposite”

Identify immediately the setbacks

It is a lapse (not a relapse)

Back immediately on the track

Developing strategies and procedures to prevent relapse

Ending well

Organizing the post-inpatient treatmentEducation on the period after discharge • At the end of the inpatient treatment there are some residual problems that

need to be addressed • The first period after discharge is the most risky for relapse

– Transition from an intensive to a low intensive treatment

– Change of the therapist and often the nature of the treatment

– Exposure to multiple environmental triggers (family environment, school or work, lack of friends and social support)

• It is fundamental to develop specific skills to prevent relapse

Ending well

Organizing the post-inpatient treatment (cont)Information about the post-inpatient CBT-E• Aims

– Addressing the residual problems

– Developing skills to prevent relapse

• Advantages

– Maintenance of the same treatment

– High initial intensity

– Time limited (20 sessions in 20 weeks )• Weeks 1 to 4: two sessions a week

• Weeks 5 to 12: one session a week

• Weeks 13 to 20: one session biweekly

Ending well

Organizing the post-inpatient treatment (cont)Nature of the post-inpatient CBT-E• Similar to the Stage Three of the standard CBT-E

– Self-monitoring

– Collaborative weekly weighing

– Regoular eating

– Modules (their use depend by the residual problems of the patient)

• Body image

• Diatary restraint

• Events, moods and eating

• Adjunctive modules (CBT-Eb)

• Setbacks and minsets

• Concluding the treatment (similar to the Stage Four of the standard CBT-E)

• Follow-up session after 20 weeks

Ending well

Building the post-inpatient plan• A written post-discharge maintenance plan is jointly built with the patients

–My life after discharge• School/work

• Residence

• Interpersonal relationships

• Interests to marginalize my eating problem

–My outpatient therapy– Problems which I have to focus on after discharge – How I will minimize the risk of relapse