File Name: cognitive behavior therapy and eating disorders fairburn .zip
Cognitive behavioral therapy CBT is the leading evidence-based treatment for bulimia nervosa. It ends with an outline of the treatment's main strategies and procedures. The eating disorders provide one of the strongest indications for cognitive behavioral therapy CBT. Two considerations support this claim. First, the core psychopathology of eating disorders, the overevaluation of shape and weight, is cognitive in nature.
Cognitive behavioral therapy CBT is the leading evidence-based treatment for bulimia nervosa. It ends with an outline of the treatment's main strategies and procedures. The eating disorders provide one of the strongest indications for cognitive behavioral therapy CBT. Two considerations support this claim.
First, the core psychopathology of eating disorders, the overevaluation of shape and weight, is cognitive in nature. This article starts with a description of the clinical features of eating disorders and then reviews the evidence supporting cognitive behavioral treatment. Eating disorders are characterized by a severe and persistent disturbance in eating behavior that causes psychosocial and, sometimes, physical impairment.
The overevaluation of shape and weight; that is, judging self-worth largely, or even exclusively, in terms of shape and weight.
This has been described in various ways and is often expressed as strong desire to be thin combined with an intense fear of weight gain and fatness. The active maintenance of an unduly low body weight. The unduly low weight is pursued in a variety of ways with strict dieting and excessive exercise being particularly prominent.
Recurrent binge eating. Extreme weight-control behavior, such as recurrent self-induced vomiting, regular laxative misuse, or marked dietary restriction.
In addition, the diagnostic criteria for anorexia nervosa should not be met. There are no positive criteria for the diagnosis of eating disorder NOS. Instead, this diagnosis is reserved for eating disorders of clinical severity that do not meet the diagnostic criteria of AN or BN. Eating disorder NOS is the most common eating disorder encountered in clinical settings constituting about half of adult outpatient eating-disordered samples, with patients with bulimia nervosa constituting about a third, and the rest being cases of anorexia nervosa.
The criteria for BED are recurrent episodes of binge eating in the absence of extreme weight-control behavior. Anorexia nervosa, bulimia nervosa, and most cases of eating disorder NOS share a core psychopathology: the overevaluation of the importance of shape and weight and their control. Whereas most people judge themselves on the basis of their perceived performance in a variety of domains of life such as the quality of their relationships, their work performance, their sporting prowess , for people with eating disorders self-worth is dependent largely, or even exclusively, on their shape and weight and their ability to control them.
This psychopathology is peculiar to the eating disorders and to body dysmorphic disorder. In anorexia nervosa, patients become underweight largely as a result of persistent and severe restriction of both the amount and the type of food that they eat. In addition to strict dietary rules, some patients engage in a driven form of exercising, which further contributes to their low body weight.
Patients with anorexia nervosa typically value the sense of control that they derive from undereating. These include depressed and labile mood, anxiety features, irritability, impaired concentration, loss of libido, heightened obsessionality and sometimes frank obsessional features, and social withdrawal. There are also a multitude of physical features, most of which are secondary to being underweight.
These include poor sleep, sensitivity to the cold, heightened fullness, and decreased energy. Patients with bulimia nervosa resemble those with anorexia nervosa both in terms of their eating habits and methods of weight control. The main feature distinguishing these 2 groups is that in patients with bulimia nervosa attempts to restrict food intake are regularly disrupted by episodes of objective binge eating.
These episodes are often followed by compensatory self-induced vomiting or laxative misuse, although there is also a subgroup of patients who do not purge nonpurging bulimia nervosa.
Features of depression and anxiety are prominent in these patients. Most have few physical complaints, although electrolyte disturbance may occur in those who vomit or take laxatives or diuretics frequently. The clinical features of patients with eating disorder NOS closely resemble those seen in anorexia nervosa and bulimia nervosa and are of comparable duration and severity.
Consistent with the current way of classifying eating disorders, the research on their treatment has focused on the particular disorders in isolation. Wilson and colleagues 8 have provided a narrative review of the studies of the treatment of the 2 specific eating disorders as well as eating disorder NOS, and an authoritative meta-analysis has been conducted by the UK National Institute for Health and Clinical Excellence NICE.
The conclusion from the NICE review, and 2 other recent systematic reviews, 9,10 is that cognitive behavioral therapy CBT-BN is the clear leading treatment for bulimia nervosa in adults. However, this is not to imply that CBT-BN is a panacea, as the original version of the treatment resulted in only fewer than half of the patients who completed treatment making a full and lasting recovery.
Interpersonal psychotherapy IPT is a potential evidence-based alternative to CBT-BN in patients with bulimia nervosa and it involves a similar amount of therapeutic contact, but there have been fewer studies of it.
There has been much less research on the treatment of anorexia nervosa. Most of the studies suffer from small sample sizes and some from high rates of attrition. As a result, there is little evidence to support any psychological treatment, at least in adults. In adolescents the research has focused mainly on family therapy, with the result that the status of CBT in younger patients is unclear. Preliminary findings have been reported from a 3-site study of the use of the enhanced form of CBT CBT-E to treat outpatients with anorexia nervosa.
Interestingly and importantly the relapse rate appears low. There is a growing body of research on the treatment of binge-eating disorder. This research has been the subject of a recent narrative review 15 and several systematic reviews. This treatment has been found to have a sustained and marked effect on binge eating, but it has little effect on body weight, which is typically raised in these patients. Arguably the leading first-line treatment is a form of guided cognitive behavioral self-help as it is relatively simple to administer and reasonably effective.
Until recently, there had been almost no research on the treatment of forms of eating disorder NOS other than binge-eating disorder despite their severity and prevalence. Recent research provides support for the use of this treatment with patients with eating disorder NOS and those with anorexia nervosa. The remainder of this article provides a description of this transdiagnostic form of CBT.
Although the DSM-IV classification of eating disorders encourages the view that they are distinct conditions, each requiring their own form of treatment, there are reasons to question this view. Indeed, it has recently been pointed out that what is most striking about the eating disorders is not what distinguishes them but how much they have in common. In addition, longitudinal studies indicate that most patients migrate among diagnoses over time. The transdiagnostic cognitive behavioral account of the eating disorders 19 extends the original theory of bulimia nervosa 21 to all eating disorders.
According to this theory, the overevaluation of shape and weight and their control is central to the maintenance of all eating disorders. Most of the other clinical features can be understood as resulting directly from this psychopathology. It results in dietary restraint and restriction; preoccupation with thoughts about food and eating, weight and shape; the repeated checking of body shape and weight or its avoidance; and the engaging in extreme methods of weight control.
The one feature that is not a direct expression of the core psychopathology is binge eating. This occurs in all cases of bulimia nervosa, many cases of eating disorder NOS, and some cases of anorexia nervosa. The cognitive behavioral account proposes that such episodes are largely the result of attempts to adhere to multiple extreme, and highly specific, dietary rules. The repeated breaking of these rules is almost inevitable and patients tend to react negatively to such dietary slips, generally viewing them as evidence of their poor self-control.
They typically respond by temporarily abandoning their efforts to restrict their eating with binge eating being the result. This in turn maintains the core psychopathology by intensifying patients' concerns about their ability to control their eating, shape, and weight. It also encourages more dietary restraint, thereby increasing the risk of further binge eating.
Three further processes may also maintain binge eating. First, difficulties in the patient's life and associated mood changes make it difficult to maintain dietary restraint. Second, as binge eating temporarily alleviates negative mood states and distracts patients from their difficulties, it can become a way of coping with such problems.
Third, in patients who engage in compensatory purging, the mistaken belief in the effectiveness of vomiting and laxative misuse as a means of weight control results in a major deterrent against binge eating being removed.
In patients who are underweight, the physiological and psychological consequences may also contribute to the maintenance of the eating disorder. For example, delayed gastric emptying leads to feelings of fullness even after patients have eaten only modest amounts of food. In addition, the social withdrawal and loss of previous interests prevent patients from being exposed to experiences that might diminish the importance they place on shape and weight.
This illustrates the core processes that are hypothesized to maintain the full range of eating disorders. When applied to individual patients, its precise form will depend on the psychopathology present. In some patients, most of the processes are in operation for example, in cases of anorexia nervosa binge-purge subtype but in others only a few are active for example, in binge-eating disorder.
Thus, for each patient the formulation is driven by their individual psychopathology rather than their DSM diagnosis. As such, the formulation provides a guide to those processes that need to be addressed in treatment.
It is designed to treat eating disorder psychopathology rather than an eating disorder diagnosis, with its exact form in any particular case depending on an individualized formulation of the processes maintaining the disorder. CBT-E is designed to be delivered on an individual basis to adult patients with any eating disorder of clinical severity who are appropriate to treat on an outpatient basis. There are 2 forms of CBT-E. Preliminary evidence suggests that this more complex form of CBT-E should be reserved for patients in whom clinical perfectionism, core low self-esteem, or interpersonal difficulties are pronounced and maintaining the eating disorder.
There are also 2 intensities of CBT-E. With patients who are not significantly underweight BMI above This version is suitable for the great majority of adult outpatients. For patients who have a BMI below The additional sessions and treatment duration are designed to allow sufficient time for 3 additional clinical features to be addressed, namely, limited motivation to change, undereating, and being underweight.
In addition CBT-E has been adapted for younger patients 22 and for inpatient and day patient settings treatment. Further details of these adaptations of CBT-E, together with a comprehensive account of the treatment and its implementation, can be found in the main treatment guide. CBT-E is a form of cognitive behavioral therapy and in common with other empirically supported forms of CBT it focuses primarily on the maintaining processes, in this case those maintaining the eating disorder psychopathology.
It uses specified strategies and a flexible series of sequenced therapeutic procedures to achieve both cognitive and behavioral changes. The style of treatment is similar to other forms of CBT, that of collaborative empiricism. Although CBT-E uses a variety of generic cognitive and behavioral interventions such as addressing cognitive biases , unlike some forms of CBT, it favors the use of strategic changes in behavior to modify thinking rather than direct cognitive restructuring.
The eating disorder psychopathology may be likened to a house of cards with the strategy being to identify and remove the key cards that are supporting the eating disorder, thereby bringing down the entire house. Following, we summarize the core features of the focused and broad versions of CBT-E, including adaptations that need to be made for patients who are underweight.
The treatment has 4 defined stages. An evaluation interview assessing the nature and extent of the patient's psychiatric problems is conducted before starting treatment. The assessment process is collaborative and designed to put the patient at ease and begin to engage the patient in treatment and in change. Information from the assessment informs how best to proceed and, in particular, whether CBT-E is appropriate. If CBT-E is deemed to be appropriate, the main aspects of the therapy are described and patients are encouraged to make the most of the opportunity to overcome their eating disorder.
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Garda Vr Italy. Two main features must be present to make a diagnosis of anorexia nervosa. Three main features need to be present to make a diagnosis of bulimia nervosa. There is one primary feature, which is recurrent binge eating. This occurs in the absence Many people with eating disorders do not meet the diagnostic criteria of anorexia nervosa
Cognitive-behavioral models describe the relationship between cognitions, emotions and behaviors in the onset and maintenance of psychological disorders. They are based on the assumption that distorted cognitive interpretations or appraisals of events negatively influence emotional, behavioral and physiological responses. This theoretical framework underpins the development and implementation of cognitive-behavioral therapies, which are currently the leading treatment approach for many disorders including adults with eating disorders. Earlier cognitive-behavioral models of eating disorders that were used to guide treatments focused on the specific and distinct diagnoses of anorexia nervosa and bulimia nervosa, while atypical and subclinical diagnoses were largely overlooked.
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.
Лифт спускался на пятьдесят ярдов вниз и затем двигался вбок по укрепленному туннелю еще сто девять ярдов в подземное помещение основного комплекса агентства. Лифт, соединяющий шифровалку с основным зданием, получал питание из главного комплекса, и оно действовало, несмотря на отключение питания шифровалки. Стратмору, разумеется, это было хорошо известно, но даже когда Сьюзан порывалась уйти через главный выход, он не обмолвился об этом ни единым словом. Он не мог пока ее отпустить - время еще не пришло. И размышлял о том, что должен ей сказать, чтобы убедить остаться. Сьюзан кинулась мимо Стратмора к задней стене и принялась отчаянно нажимать на клавиши.
Бринкерхофф уже пожалел, что не дал ей спокойно уйти домой. Телефонный разговор со Стратмором взбесил. После истории с Попрыгунчиком всякий раз, когда Мидж казалось, что происходит что-то подозрительное, она сразу же превращалась из кокетки в дьявола, и, пока не выясняла все досконально, ничто не могло ее остановить.
- Сегодня я не в духе. Меня огорчают твои разговоры о нашем агентстве как каком-то соглядатае, оснащенном современной техникой. Эта организация создавалась с единственной целью - обеспечивать безопасность страны. При этом дерево иногда приходится потрясти, чтобы собрать подгнившие плоды. И я уверена, что большинство наших граждан готовы поступиться некоторыми правами, но знать, что негодяи не разгуливают на свободе.
К ней снова вернулись страхи, связанные с новой попыткой найти ключ Хейла в Третьем узле. Коммандер был абсолютно убежден в том, что у Хейла не хватит духу на них напасть, но Сьюзан не была так уж уверена в. Хейл теряет самообладание, и у него всего два выхода: выбраться из шифровалки или сесть за решетку. Внутренний голос подсказывал ей, что лучше всего было бы дождаться звонка Дэвида и использовать его ключ, но она понимала, что он может его и не найти. Сьюзан задумалась о том, почему он задерживается так долго, но ей пришлось забыть о тревоге за него и двигаться вслед за шефом. Стратмор бесшумно спускался по ступенькам. Незачем настораживать Хейла, давать ему знать, что они идут.
Голый ландшафт испанской нижней Эстремадуры бежал за окном, слившись в неразличимый фон, затем замедлил свой бег. - Мистер Беккер! - послышался голос. - Мы на месте. Беккер встал и потянулся. Открыв полку над головой, он вспомнил, что багажа у него. Времени на сборы ему не дали, да какая разница: ему же обещали, что путешествие будет недолгим - туда и обратно.
Назад, или я сломаю… Рукоятка револьвера, разрезая воздух, с силой опустилась ему на затылок. Сьюзан высвободилась из рук обмякшего Хейла, не понимая, что произошло.
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Options for improving upon the efficacy and efficiency of CBT are discussed, primarily by incorporating an expanded range of principles and clinical strategies from CBT in general.Reply