Question 1

How can clinicians be better equipped to support clients with disordered eating?

Tracey Wade · Accepted Answer

Clinicians can benefit from understanding effective principles for the treatment of eating disorders before deciding on specific forms of treatment to use such as: Early intervention is essential Coordination of services is fundamental to all service models Services must be evidence-based Involvement of significant others in service provision is highly desirable A personalized treatment approach is required for all patients Education and/or psychoeducation is included in all interventions Multidisciplinary care is required and a skilled workforce is necessary. More information is available at the following link: https://doi.org/10.1186/s40337-020-00341-0

Question 2

What is CBT-T and how is it different from CBT-E?

Tracey Wade · Accepted Answer

Ten‐session Cognitive Behavioral Therapy (CBT-T) for non-underweight patients is a manualized outpatient treatment for people with non-underweight eating disorders. This brief intensive form distills the active ingredients of CBT-E into 10 sessions. Those ingredients include nutritional change, collaborative in-session weighing, exposure based on inhibitory learning principles, cognitive restructuring, behavioral experiments, addressing emotional triggers, body image work and relapse prevention. Elements of longer CBT-E with limited evidence, such as motivational work and individualized case formulation, have been omitted. CBT-T has been shown to reduce both the behavioral and cognitive symptoms of eating disorders, as well as secondary outcomes such as depression and anxiety. While no direct comparisons have been made between the two, results suggest no differences in outcomes. That is, more is not necessarily better. More information is available at the following link: https://doi.org/10.4324/9780367192280

Question 3

Can you advise on CBT-T training for an eating disorder practitioner?

Tracey Wade · Accepted Answer

Glenn Waller conducts regular training workshops in the UK and will also be conducting these in New Zealand in 2023. I (Tracey Wade) conduct regular training workshops in Australia. The CBT-T manual is an excellent resource, as is the website below that includes a range of video role-plays that illustrate the techniques to be used. Getting regular supervision, including peer supervision, is essential to ensure that CBT-T is used as it was intended. More information is available at the following link: https://cbt-t.sites.sheffield.ac.uk/home

Question 4

What psychometric tests are used to evaluate patients with eating disorders?

Tracey Wade · Accepted Answer

The Eating Disorder Examination (EDE) is the oldest and most widely used eating disorder interview accompanied by a self-report version (EDE-Q). It has four subscales (shape concern, weight concern, eating concern and dietary restraint) that combine to form a 22-item measure of global psychopathology. A seven-item version of the EDE-Q exists (EDE-Q7). It is the only form of the EDE-Q to have a robustly supported factor structure, including the full version, taking into account sex, self-identified gender and overweight status. The Body Image Acceptance and Action Questionnaire (BI-AAQ) has shown robust factor structure across different populations. BI-AAQ focuses on developing psychological flexibility around body image disturbance, which permits the development of constructive therapeutic goals. In addition, consider a quality of life measure, such as the 22-item Clinical Impairment Assessment. This self-report measure surveys the last 28 days with items covering impairment caused by eating across mood and self-perception, cognitive functioning, interpersonal functioning and work performance. More information is available at the following links: https://www.cbte.co/site/download/ede-17-0d/?wpdmdl=615&masterkey=5c644ef9b6149 https://doi.org/10.1017/9781108235433.027 https://www.cbte.co/site/download/clinical-impairment-questionnaire-cia-3-0/?wpdmdl=622&masterkey=5c64514135cc5

Question 5

What is a practical screening tool for eating disorders in 12-year-olds and up?

Tracey Wade · Accepted Answer

Consider the ED-15 for this age group – the youth version and the parent version. These are validated in children aged eight to 18 years. It comprises 10 items surveying eating disorder cognitions over the past week (for example, “felt distressed about my weight”), rated on a seven-point Likert scale from “not at all” (zero) to “all the time” (six). The remaining five items survey eating disorder behaviors, with participants reporting the number of times and days within the previous week they have engaged in objective binge eating, vomiting, laxative use, dietary restriction and driven exercise. More information is available at the following links: https://cbt-t.sites.sheffield.ac.uk/

Question 6

Can you get a mild eating disorder? For example, skipping meals and only eating small portions?

Tracey Wade · Accepted Answer

Yes, indeed. There is nothing mild about this form of eating and it is a precursor to the development of a diagnosable eating disorder. In young people, this represents starvation which impacts the brain and body adversely in terms of ongoing development. Research has shown that brain activity is affected by even modest dieting and a young person’s developing brain is particularly vulnerable. A starved brain shrinks and alters how we think, process information and manage our emotions. Someone with a starved brain will struggle to make decisions, solve problems and regulate their emotions. To recover fully, the brain needs to be nourished to achieve these changes. Since a starved brain won’t function optimally, the priority in treatment for an eating disorder is adequate nutrition.

Question 7

Could you speak on the intersection of eating disorders in clients with autism? I am finding it hard to treat them due to the rigidity of their thoughts and habits.

Tracey Wade · Accepted Answer

Most clinicians find this mix very difficult to work with and you may like to adopt some Cognitive Remediation Therapy (CRT) approaches. CRT has been used for Anorexia Nervosa to tackle problems with set-shifting and central coherence. You may find it beneficial to consult the Peace Pathway website - it has useful clinical resources and a book for people with eating disorders and autism. More information is available at the following links: https://www.peacepathway.org/clinicians/resources https://www.peacepathway.org/ https://www.katetchanturia.com/clinical-work-packages--protocols

Question 8

How would you recommend approaching treatment for a client who has an eating disorder but also feels they don't deserve to be better and is actively trying to self-harm?

Tracey Wade · Accepted Answer

I would ask the client to agree to try a time-limited therapy based on treating themselves as though they deserve respect, regardless of whether they believe this. The treatment will proceed on this basis and if they can work with this stance, the therapy and the client will not be pulling in different directions, thus increasing the chances of a better outcome. This agreement includes working to decrease eating disorder behaviors (starving self, binge eating, purging and self-harm). The outcome can be reviewed collaboratively to see if this approach works better and what may have changed while the client adopted this way of treating themselves. You can also explore that there is no point in treating an eating disorder if self-harm continues. Since these behaviors are often for the purpose of emotional regulation, the aim is to experiment with alternative coping strategies that treat the person as though they deserve respect.

Question 9

What should clinicians do from a treatment perspective when clients have obsessions and ritualized, compulsive rules around eating (very much like OCD) in addition to low self-worth and poor image?

Tracey Wade · Accepted Answer

I would start by treating the eating disorder and see how much progress can be made. If these issues become barriers to progress, you may wish to supplement therapy (as in CBT-E broad, using half-half sessions) with Metacognitive training for Obsessive Compulsive Disorder (MCT-OCD) which mainly focuses on OCD-relevant cognitive biases and metacognitions. Taking individual experiences into account, patients identify their cognitive biases and metacognitions in a playful way using humorous exercises and functional coping strategies. MCT-OCD also addresses dysfunctional beliefs (for example, "I always have to do everything perfectly") and coping strategies (such as thought suppression). Eight cognitive biases/metacognitions are addressed in total: perfectionism, intolerance of uncertainty, fusion beliefs, control of thoughts, overestimation of threat, inflated responsibility, biased cognitive networks and biased attention. Since OCD and depression often co-occur, depressive thinking patterns are also addressed. More information is available at the following link: https://clinical-neuropsychology.de/mct-ocd/

Question 10

What kind of education pathways did you take to develop your specialty in eating disorder treatment? Is it work-based or were there particular learning pathways you found useful? I have tried to find specific in-depth education to build upon my skills but have struggled to find clear direction on courses.

Tracey Wade · Accepted Answer

My pathway was postgraduate training in clinical psychology followed by a research PhD. Over the years, the most useful aspects for developing a specialty have been attending relevant workshops – such as with the Academy of Eating Disorders and the Australia and New Zealand Academy of Eating Disorders – and discussing issues with colleagues regularly.

Question 11

How can you work with distorted body image when the client clearly sees him/herself as “fat” in the mirror? Would medication help to bring down this altered, near-psychotic, state? Is there a neurological reason this happens in eating disorders?

Tracey Wade · Accepted Answer

Most of our clients see themselves as fat in the mirror and no medications are helpful in this case. It is best treated as a symptom of the eating disorder and exacerbated by starvation, whether underweight or not, which will be alleviated with adequate nutrition. One quick and powerful technique is asking the client to estimate how much space they would take up between their hips if they had their back to a wall and to place colored stickers or blue tack to show this. After this, get them to stand with their back to the wall between these markers and add new colored stickers to denote the actual width of the person. With this data, discuss the discrepancy and its meaning with the person. If the person does not have Anorexia Nervosa there are a range of body image activities available in CBT-T – see the videos in sessions seven to nine for mirror exposure in particular. More information is available at the following link: https://cbt-t.sites.sheffield.ac.uk/videos

Question 12

Have there been any new successful treatments and medications to help with bulimia since the 1990s?

Tracey Wade · Accepted Answer

There has been nothing extraordinarily more effective for treating Bulimia Nervosa since the development of CBT and interpersonal psychotherapy, with the possible addition of some antidepressant medication (fluoxetine or topiramate) to help with binge eating. The focus is on making therapies focused and shorter but just as effective (for example, CBT-T) and considering personalization of therapy (such as CBT-E broad) to manage comorbid issues that maintain disordered eating. Potential strategies include imagery rescripting, mindfulness, dialectical skills training groups, cognitive remediation training, media literacy skills training and CBT for perfectionism. More information is available at the following link: https://doi.org/10.1016/j.psc.2018.10.002

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