1. From Oxford to Perth: Enhanced CBT in a new statewide Eating Disorders Service at CCI AACBT 12/9/06 Anthea Fursland Ph.D.

2. Overview of Presentation l Introduction - CCI Eating Disorders Programme l Background - Eating Disorders l Evidence-based treatment l CBT l CBT-E Overview l CBT-E: Main features l CBT-E: Specific interventions l Summary and Discussion

3. Introduction CCI Eating Disorders Programme l Part of CCI - clinical services, training & applied clinical research; staffed by clinical psychologists l New (2005). The first public eating disorders service for adults in WA l Treating people 16 and over l Out-patient l Referrals - GPs and Psychiatrists l Clinic - Northbridge (central Perth) l Fairburn’s model of CBT-E

4. Background - Eating Disorders Eating Disorders are serious mental illnesses l onset in teens (AN: 14-16; BN 16-20) l traditionally difficult to treat l better prognosis if treated early (first 6 months) l if untreated, can become chronic conditions with significant morbidity l AN: highest mortality rate of any psychiatric disorder l poor treatment outcomes; high dropout rates

5. Evidence-based Treatment l Anorexia Nervosa (little research): éNICE could not recommend one single treatment for AN based on solid research éNICE suggested family therapy (with focus on ED) might be helpful for adolescents l Bulimia Nervosa (extensive research): éNICE recommended CBT for BN, based on solid research éNICE also suggested IPT as possible alternative, and anti-depressants (but no other medications) l EDNOS: no research

6. Cognitive Behaviour Therapy n Focus on factors that maintain the disorder (rather than the triggers) n Emphasis on both behavioural and cognitive change n Therapeutic relationship based on collaborative empiricism n Time-limited treatment

7. CBT-E: Overview l Based on Fairburn’s original CBT model for BN l Extensive research showing his (original) CBT is the most effective treatment for BN, but: lOriginal CBT - still only 30-50% success rate lNo evidence-based treatment protocols for AN or EDNOS

8. CBT-E: Overview….. l Fairburn has improved (enhanced) his original treatment protocol: étransdiagnostic (applicable to AN & EDNOS; extended treatment for low-weight) émore successful outcome (70+%) éfewer drop-outs

9. CBT-E: Treatment interventions (1) Traditional CBT (with a twist!): l Assessment l Engagement l Psycho-education l Establishment of regular eating l In-session weighing l Homework: self-monitoring

10. CBT-E: Treatment interventions (2) Additional/enhanced interventions: l Construction of a formulation l Achieving meta-cognitive change l Additional maintaining mechanisms

11. CBT-E Interventions l Construction of a formulation éexclusive focus on the ED and maintaining mechanisms (vicious cycle) éforms the basis of treatment écreated jointly, drawn out; patient takes a copy; it’s on the table every session émodified as treatment progresses

12. BULIMIA NERVOSA Binge eating Compensatory vomiting/laxative misuse/driven exercise Events and associated mood change Over-evaluation of control over eating, shape or weight Strict dieting; dietary rules

13. ANOREXIA NERVOSA Over-evaluation of control over eating, shape or weight Strict dieting; dietary rules Features of under-eating and a low weight e.g., being inward-looking and preoccupied, social withdrawal, heightened fullness

14. MIXED Strict dieting; dietary rules Binge eating Compensatory vomiting/laxative misuse/driven exercise Features of under-eating + low weight Events and associated mood change Over-evaluation of control over eating, shape or weight

16. Metacognitive awareness n Being aware of one’s thought processes n Taking a “helicopter view” n Taking a step back and looking at oneself n Asking: “What’s going on?” and “What do I need to do?”

17. CBT-E: Interventions Achieving meta-cognitive change Addressing over-evaluation of control over weight/shape by: –Traditional cognitive restructuring –Behavioural experiments –Eating disorder “mindset”/DVD –Body checking/avoidance

18. CBT-E: Interventions (5) Additional maintaining mechanisms that are addressed where applicable: –Core low self-esteem –Clinical perfectionism –Mood intolerance –Interpersonal difficulties

19. Summary l New state-wide Eating Disorders Programme at CCI l Overview of Enhanced CBT l Focus on some crucial therapeutic interventions l Discussion Further training on CBT-E: Nov. 2 & 3 2006 Registration: www.cci.health.wa.gov.au