Reviewing Cognitive Treatment for Eating Disorders: From Standard CBT Efficacy to Worry, Rumination and Control Focused Interventions - EACBT 2015 Jerusalem

1. Reviewing Cognitive Treatment for
Eating Disorders: From Standard CBT
Efficacy to Worry, Rumination and
Control Focused Interventions
Giovanni Maria Ruggiero (1,2) Walter Sapuppo (2,1) Gabriele Caselli
(1,2) Marcantonio Spada (3) Sandra Sassaroli (1,2)
1 Studi Cognitivi, Cognitive Psychotherapy School and Research Center, Milano, Italy,
2 Psicoterapia Cognitiva e Ricerca, Cognitive Psychotherapy School and Research Center,
Milano, Italy,
3 Division of Psychology School of Applied Sciences London South Bank University, London,
UK

2. CBT standard for ED
• In the standard CBT model, ED share a common
psychopathology: the over evaluation of the
importance - and the control - of weight and
body shape
• This factor leads to dietary restraint and
restriction, manifested in various forms of
weight-control behaviour and body checking and,
obviously, preoccupation with thoughts about
shape, weight, and eating (Fairburn, 2008)

3. CBT standard for ED
• This theoretical background has led to a therapeutic
protocol which is considered the treatment of choice for BN
(National Institute for Health and Clinical Excellence, 2004;
Wilson, Grilo, & Vitousek, 2007; Shapiro et al., 2007).
• This protocol is known as cognitive behavioral treatment of
bulimia nervosa (CBT-BN) and was first described by
Christopher Fairburn (Fairburn 1981, 1985; Fairburn,
Cooper, & Cooper, 1986).
• This protocol proved to be efficacious with meta-analyses
comparing the efficacy of CBT-BN to control treatments
that found effect sizes in the medium range (Thompson-
Brenner, 2002; Hoffman et al., 2012).

4. Features of CBT standard for ED
• This protocol is generally divided in four stages and 20
sessions
– The first, intensive, phase provides two sessions a week with the
aim of educating the patient about treatment and the features
of their ED
– The second, transitional, phase aims to review the work,
identify obstacles and plan the third phase
– The third phase aims to address the mechanisms of
maintenance of the ED
– The fourth phase focuses on the planning of the future, focusing
on the maintenance of the achieved results and the reduction of
relapses (Murphy et al., 2010).
• The number of sessions doubles with patients who have a
Body Mass Index between 15 and 17.5

5. CBT standard for ED: limitations
• However, although the findings indicate that CBT-BN is an
effective treatment at its best only around half the patients
who start this protocol make a full and lasting recovery.
• Between 30% and 50% of patients cease binge eating and
purging, and a further proportion show some improvement
whilst others drop out of treatment or fail to respond
(Wilson & Fairburn, 2007).
• In addition, the model appears only to be suited for BN and
not for the other ED and is not able to explain the whole
psychopathological process underlying ED.
• In CBT-BN there is no room for biased beliefs regarding
clinical perfectionism and low self-esteem.

6. Non standard CBT cognition:
perfectionism and self-esteem
• Therefore, many scholars explored cognitive
antecedents of ED not directly related to food
and body aspects including perfectionism and
low self-esteem (Bastiani, Rao, Weltzin, & Kaye,
1995; Button, Sonuga-Barke, Davies, &
Thompson, 1996; Davis, 1997; Fairburn &
Harrison, 2003; Fairburn, Cooper, Doll, & Welch,
1999; Halmi et al., 2000; Hewitt, Flett, & Ediger,
1995; McLaren, Gauvin, and White, 2001;
Sassaroli & Ruggiero, 2005; Vitousek & Hollon,
1990;).

7. Enhanced CBT
• Consequently, Fairburn extended the CBT-BN model to all EDs
and called it cognitive behaviour therapy “enhanced” (CBT-E;
Murphy et al., 2010; Fairburn, 2008; Fairburn, Cooper, &
Shafran, 2003)
• The new version addresses 4 other psychopathological
processes:
– clinical perfectionism
– mood intolerance
– core low self-esteem
– interpersonal difficulties
• This treatment has improved outcomes up to a 65.5% rate of
remission at post-treatment and a 69.4 % rate of remission
over follow-up (20, 40 and 60 weeks post-treatment)
(Fairburn et al., 2015)

8. New directions: repetitive negative thinking
(RNT) and metacognitive processes
• Further steps ahead in widening our cognitive
understanding and treatment of ED may not only
lay in increasing the level of complexity of the
classic CBT model, but also in exploring new
directions.
• A possible alternative path for increasing the
clinical understanding of ED and enhance
therapeutic efficacy could be exploring the
possible role of metacognitive processes in
addition to those outlined in Fairburn’s CBT
model.

9. Repetitive negative thinking (RNT)
• Worry, rumination an other types of repetitive
negative thinking (RNT) are a definite
transdiagnostic process found across diverse
problems including affective disorders, anxiety
disorders, insomnia or psychosis (Harvey &
Colleagues, 2004)
• RNT are maintained and fueled by metacognitive
processes related either to their (illusory) utility
or uncontrolability and danger (Mathews and
Wells, 1994; Wells, 2004)

10. Worry and metacognitive Beliefs and
Processes in anxiety
• For example, in generalized anxiety disorder (GAD) the
disorder is maintained by metacognitions regarding
both the utility and the uncontrollability and danger of
worrisome thinking (Behar, DiMarco, Hekler, Mohlman,
& Staples, 2009; Wells, 2004).
• Pathological metacognitions (i.e., “worry is useful” and
“worry is uncontrollable and dangerous”) are thought
to lead to the maintenance of excessive levels of worry
by causing futile attempts to stop worrying and
thereby exaggerating the problem.
• This, in turn, leads to higher levels of anxiety and GAD

11. Worry as a transdiagnotic process: not
only anxiety
• The key feature of worry is the predominance of
repetitive negative thoughts that entail that those
who worry pathologically think excessively about
possible negative events they are afraid of
(Borkovec, 1993; Vasey & Borkovec, 1992).
• Although worry is generally believed to be strictly
linked to anxiety, it has been argued that it is
present across diverse disorders (Ehring &
Watkins, 2008) including ED (Ruggiero et al.,
2005).

12. Worry in ED
• Worry is a key metacognitive process. What about worry
and metacognition in ED?
– Wadden, Brown, Foster, and Linowitz (1991) investigated
different kinds of worry in nonclinical adolescents and found
that girls showed higher worry levels about weight and food
than boys.
– Kerkhof et al. (2000) administered the Penn State Worry
Questionnaire to ED patients and controls and found higher
scores in the clinical sample.
– Scattolon and Nicky (1995) found that food consumption in a
nonclinical sample of chronic dieters was triggered by social-
evaluative/school-related worry.
– Sassaroli and Ruggiero (2005) also found that in a stress
situation worry is related to the Eating Disorders Inventory’s
subscales in nonclinical subjects.

13. Rumination in ED
• Rumination indicates a variant of RNT present in depression and in
other mood disorders (Nolen-Hoeksema, 2000).
• Rumination is related to past negative events, while worry is a
preoccupation with future negative events.
• Rumination may contribute to the etiology of ED:
– The onset of bulimia is associated with rumination in response to life
events (Troop & Treasure, 1997).
– Hart and Chiovari (1998) have shown that dieters show significant
more rumination about eating and food than non-dieters.
– Nolen-Hoeksema and colleagues (2007) have also shown that
rumination predicts future increases in bulimic symptoms as well as
onset of binge eating.

14. Metacognitive Beliefs and Processes in
ED
• Summing up, research indicates that worry
and rumination (collectively called: negative
perseverative thinking, RNT) are significantly
higher in ED subjects than in a control groups
and is clearly associated with the ED
symptomatology
• A question remains unanswered: what’s the
clinical link between RNT and ED?

15. Control as a link between ED and
metacognition
• A key metacognitive belief regards
uncontrollability and danger of negative
thinking
• Therefore, it may not be a coincidence that
ED are often defined as a psychopathology of
perceived lack control (Bruch, 1973; Button,
1985, 2005; Katzman & Lee, 1997).
• Is “control” the link between ED and
metacognition?

16. Control as a link between ED and
metacognition
• Sassaroli, Gallucci and Ruggiero (2008) have shown
that uncontrollability beliefs concerning not only
eating, food and body aspects but also mental states
and thoughts may be present in ED.
• Other studies (Cooper et al., 2007; Woolrich et al.,
2008) have found differences in metacognitive beliefs
in patients with AN when compared to control groups:
higher levels of beliefs about uncontrollability and
danger; lower levels of cognitive confidence; higher
levels of beliefs about need for control thoughts; and
higher levels of reported cognitive self-consciousness.

17. Control as a link between ED and
metacognition
• Patients with AN were found to be less successful at using
thought re-appraisal and reported to use metacognitive
strategies to make “themselves feel worse” (Woolrich et al.,
2008).
• McDermott & Rushford (2011) also found that AN patients
had higher scores on metacognitive dysfunction: higher
thought monitoring, thought control and negative beliefs
about worrying.
• Olstad et al. (2015) underlined how patients with ED have
more dysfunctional metacognitive beliefs than control
groups, especially on negative beliefs about
uncontrollability and danger and need to control thoughts.

18. Control as a link between ED and
metacognition
• Summing up, many studies suggest that
metacognitive beliefs regarding worry
uncontrollability, thought monitoring and
control are present in patients with ED and
may be involved in the psychopathological
processes and symptoms.

19. Control as a link between ED and
metacognition
• We may conceptualize ED in metacognitive
terms: there is a cognitive trigger focused on
low self-esteem thought and a perfectionistic
worry about weight control grounded on
metacognitive belief (e.g. “it is important to
think about food, eating and weight in order
to retrieve control and self-esteem”) that lead
the patient to involve in dieting and purging as
illusory control strategies