Description of the development of Villa Garda clinica service eneterely based on CBT-E

1. Villa Garda CBT-E Clinical Service
for Eating Disorders
Riccardo Dalle Grave, MD

2. Agenda
• Hystory of Villa Garda clinical service
• Problems we had in 2002
• Why we chose to introduce CBT-E?
• How this was done step-by-step?
• Adaptations you have had to make to CBT-E?
• Difficulties we addressed
• Future plans

3. Villa Garda
Eating Disorder Clinical Service
Hystory
1984 – 1994
• Psychodynamic Psychotherapy with medical/psychiatric management
1995– 2002
• Generic and broad CBT with medical/psychiatric management
2003 – 2008
• Transition to CBT-E
From 2008
• CBT-E with patients of all ED diagnosis and age (from 13 years), and in three levels of
care
– Outpatient treatment
– Intensive outpatient treatment
– Inpatient + Day-hospital treatment

4. Problems we had in 2002
Eclectic and not theory driven treatment
Psychologists
• delivered a generic and eclectic form of CBT (4 psychologist – 4 different
treatments!!)
Other team members (dietitians, nurses, physicians, and psychiatrists)
• maintained a predominantly medical-directive-based approach
Patients
• were not focused on addressing the core maintaining mechanism of their eating
problem
• received contrasting information and different treatment strategies and
procedures
• had a different nature of treatment when changed the intensity of care (e.g.,
from outpatient to inpatient and vice versa)

5. Why we chose to introduce CBT-E
2002 – 2008
Transition to CBT-E
Christopher Fairburn presented in Verona the new transdiagnostic cognitive
behavior theory and outpatient treatment for all eating disorders
Strictdieting;non-
compensatoryweight-control
behavior
Bingeeating
Compensatory
vomiting/laxative
misuse
Significantly
lowweight
Eventsand
associatedmood
change
Over-evaluationofshapeand
weightandtheircontrol

6. Why we chose to introduce CBT-E
Main reasons
1. The transdiagnostic nature of CBT-E is particularly suitable for the inpatient
treatment where patients with different DSM diagnoses are usually admitted
2. CBT-E is a flexible and high individualized treatment (liked both by patients and
therapists) addressing the psychopathology (not the DSM diagnosis) of the
patients
3. CBT-E involve actively the patients in the treatment and does not use a directive
approach that may increase their resistance to change
4. The personal formulation of CBT-E is a potent instrument to integrate the work of
a multidisciplinary team
5. The precise method of addressing the eating disorder psychopathology helps to
focus the treatment on the core maintaining mechanisms of severe ED patients
6. The ineffectiveness of outpatient CBT-E in some patients may depend on
insufficiently intensive care rather than the nature of the treatment itself

7. How this was done step-by-step
Main Steps
1. We discussed the idea of adapting the new CBT-E for inpatient treatment with
Christopher Fairburn
2. We designed a completely new inpatient treatment based on the CBT-E
theory and treatment
3. We implemented the new treatment in the unit
– Periodic supervisions with Christopher Fairburn
– Round table with therapists and patient
– Peer supervision
4. We designed and implemented a 3-year randomized control trial
– Promising result for a large number of inpatients

8. Mean BMI and eating disorder psychopathology (global EDE-Q)
over 20 weeks of Villa Garda inpatient treatment and 12-month of follow-up
12
13
14
15
16
17
18
19
20
Before
treatment
After
treatment
6-month
follow-up
12-month
follow-up
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Before
treatment
After
treatment
6-month
follow-up
12-month
follow-up
CBT-Ef
CBT-Eb
BMI EDE global
Completers: CBT-Ef, n=37, 88.1%; CBT-Eb, n=35, 92.1% (p = .550)
Dalle Grave R, Calugi S, Conti M, Doll HA, Fairburn CG. Inpatient cognitive behaviour therapy for anorexia
nervosa: A randomized controlled trial. Psychotherapy and Psychosomatics 2013; 82: 390-398.

9. Villa Garda inpatient cognitive behavior therapy for adolescents
with anorexia nervosa: immediate and longer-term effects
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.
83% of patients still had normal
weight 1 year after treatment

10. How this was done step-by-step
Further developments
1. We developed intensive outpatient CBT-E
– To offer to patients who were unresponsive to conventional
outpatient CBT-E a less expensive treatment than day-hospital or
inpatient treatments
2. We developed and adaptation of CBT-E for adolescents
Inpatient
Step 3
Intensive
outpatient
Outpatient
Step 2
Outpatient
post-inpatient
Step 1 Step 3

11. CBT-E for adolescents with anorexia nervosa (N=46)
0
0.5
1
1.5
2
2.5
3
3.5
0 40 100
Weeks
EDE-Q
0
5
10
15
20
25
30
35
40
0 40 100
Weeks
BMI
centile
Dalle Grave R et al Behaviour Research and Therapy 2013, 51: R9-R12.
Age, years 15.5 (1.3)
Duration of eating disorder, years, 0.86 (0-5)
Body mass index centile 2.86 (3.3)
BMI centile of <1.0. 23 (50%)
Completers: n=29, 63%;

12. CBT-E for adolescents and adults with anorexia nervosa
Significantly more adolescents
reached the goal BMI than adults
(65.3% vs. 36.5%; P=0.003).
The time required by the adolescents
to restore body weight was about 15
weeks less than that for the adults
(mean 14.8 weeks vs. 28.3 weeks,
log-rank=21.5, P<0.001).
Calugi S, Dalle Grave R, Sartirana M, Fairburn CG, Journal of Eating Disorders, 2015

13. Three-quarters of 68 patients completed the full 20 sessions. There was a marked
treatment response with two-thirds (67.6%, intent-to-treat) having minimal residual
eating disorder psychopathology by the end of treatment.

14. Difficulties we addressed
Organization
• We actively involved the organisation in this change
– Describing the problem of the eclectic treatment
– Describing the advantages (clinical and economics)
Collegues attitudes
• We actively involved the colleagues in this change
– Group discussion
– Extensive training
– External supervision with CGF
– Peer supervision
– Workshops
– Inpatient RCT
… Two psychologists decided to leave the unit

15. Difficulties we addressed
Treatment
• We gradually eliminated any residual procedures that were inconsistent with
the new CBT-E-based approach
– Medical-directive-based approach
– Broad and eclectic psychological procedures
– Medical unit atmosphere
• We developed new procedures specifically designed for the inpatient CBT-E
– Assisted eating
– CBT-E groups
• We developed new procedures specifically designed for the adolescent CBT-E
– Patients’ engagement
– Parents involvement

16. The Villa Garda Clinical Service
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

17. Villa Garda CBT-E Clinical Service
Advantages
1. Patients are treated with a single, well-delivered, evidence-based treatment,
rather than the evidence-free “eclectic” approach common elsewhere
2. It minimizes the problems associated with transitions from outpatient to
intensive treatment, as it avoids subjecting patients to the confusing and
counterproductive changes in therapeutic approach that commonly
accompany such transitions.
.

18. Villa Garda CBT-E Clinical Service
Future
1. Collect good outcome data
2. Disseminate CBT-E clinical services
3. Developing more potent procedures to address some features of eating
disorder psychopathology
.

19. 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

20. 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

21. Buona CBT-E da Villa Garda