Mentor
Registered: Oct 18, 2007
Posts: 356
| Posted Yesterday at 12:42 PM | Reply with quote?#1? |
| A paper?was published?a few days ago?that, in my opinion, is very significant. It reports on a clinical trial of a model for treating anorexia nervosa in adolescents, enhanced cognitive behaviour therapy (CBT-E). Forty-six young women ages 13-17 with AN were treated with CBT-E. The treatment involved 40, 45-minute one-to-one sessions over 40 weeks, preceded by two 60-minute preparatory sessions and followed by one review?session 20 weeks after the end of treatment. Parental involvement consisted of a single one-hour session during the first two weeks and eight 15-minute sessions with the patient and parents together. The authors describe a portion of the treatment as follows: "The aim of the initial session with parents was to identify family factors liable to hinder the patient's attempts to change while the subsequent sessions were devoted to meal planning, the conduct of mealtimes and to the generation of solutions to problems that had emerged or were foreseeable. Additional sessions with the parents only took place if there were family crises, extreme difficulties at mealtimes or parental hostility towards the adolescent. Few such sessions were needed." The paper presented a fair amount of data. At the end of treatment, 28% of the kids had reached 95% of their expected weight.?Roughly one year later, an additional four patients had reached 95% of expected weight, resulting in a total of 44% of the treatment completers meeting that criterion. This is roughly equivalent to the results of FBT. (The authors note, by the way, that FBT is, at this time, the "leading empirically-supported intervention for adolescents with anorexia nervosa.") Unfortunately, about one-third of the study participants were classed as "non-responders" either because they required additional treatment due to concerns about their physical health or lack of progress, or because they ceased to attending treatment. Of course, a significant percentage of sufferers also seem not to respond well to FBT. In conclusion, the authors?write that "there is now a compelling case for comparing CBT-E and FBT in randomised controlled trials." Personally, I could not agree more. I hope this research comparing CBT-E and FBT proceeds as soon as possible. A detailed guide to CBT-E?has been written.? Cooper, Z. & Stewart, A. (2008) "CBT-E and the Younger Patient," in C. G. Fairburn (Ed.), Cognitive?Behavior Therapy and Eating Disorders. New York: Guilford Press The new paper is at http://www.sciencedirect.com/science/article/pii/S0005796712001441? ?? | |
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Moderator
Registered: July 31, 2007
Posts: 2,096
| Posted Yesterday at 02:15 PM | Reply with quote?#2? |
| Professor Fairburn appears to be conducting a vigorous campaign to get CBT-E evaluated for AN and to establish it as the evidence based treatment of choice. I don't have a problem with that in the sense that I agree that robust research must take place to find treatment approaches that work in a situation where the available evidence at the moment is poor. The UK NICE Guidelines are wishy washy and old, not because there is a lack of motivation to improve them, but because there is a lack of high quality evidence with which to do so. Fairburn is attempting to rectify that. In this paper http://www.ncbi.nlm.nih.gov/pubmed/23084515 he argues that CBT-E (which is empirically tested for patients with other eating disorders but not for AN) is an effective treatment for adults with AN and RCTs should be conducted to prove so. In the study above he has an effective but imperfect treatment with which to compare CBT-E, FBT. In neither case is there a control group and therefore the initial research is limited and has come in for quite a bit of criticism for this. However, one has to start somewhere and what Fairburn is arguing for is proper RCTs which will produce proper evidence. I hope that the funding bodies listen and that such trials can go ahead. It will add to the sum of knowledge about these horrible illnesses and will help those patients who respond well. What it won't do is to solve all, or even over half, of the problem. As Fairburn says "this treatment (FBT) has certain limitations, (so) alternative approaches are needed". Absolutely. No argument there. What we don't know yet though really is WHY FBT has these limitations, WHAT to look out for when judging whether the treatment is suitable for any individual, WHETHER those cases where families struggle with FBT would do any better with CBT-E, or whether the same challenges (co-morbidities, social circumstances, personality traits, bad luck....) that make FBT difficult would also hamper CBT-E. For that we need qualitative research as well as the RCTs and head to head comparisons. One problem with this is is that the same people; professionals, researchers and families; who have to push for research, take part in it, fight for funding as those who have to try, day by day, hour by hour, to fight these illnesses with their loved ones. Hard work, but worth it in both cases. | |
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Mentor
Registered: Oct 30, 2011
Posts: 2,354
| Posted Yesterday at 02:19 PM | Reply with quote?#3? |
Christopher your article says this "Of course, a significant percentage of sufferers also seem not to respond well to FBT." Who is qualifying this with "Of Course" The study author? | |
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Mentor
Registered: May 08, 2012
Posts: 1,130
| Posted Yesterday at 02:26 PM | Reply with quote?#4? |
| I believe that studies of FBT shows that it is effective with about half of those who were assigned to the FBT condition in these studies. ?This is a very high success rate compared to other methods. FBT is not a guarantee, unfortunately, it is simply the best approach that we have to date. I betcha Christopher has an article at his fingertips that summarizes the findings of rigorous studies of FBT, and can provide a link!!! YP | |
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Moderator
Registered: July 31, 2007
Posts: 2,096
| Posted Yesterday at 03:21 PM | Reply with quote?#5? |
I'm sure you're right YP. Christopher has a wealth of data at his fingertips and it's very heartening that he shares it here .It's true that FBT doesn't have a 100% success rate and is not suitable for all adolescents. My personal concern (and it IS just personal borne out of our struggles with both FBT AND CBT) is that SOME of the people for whom FBT isn't suitable may also struggle with CBT-E. Comparing two promising treatments which work for a good proportion of people with each other MAY do nothing for the people who currently do worst. That is why, while I applaud this work, I am concerned that cash strapped funding bodies (be they state health services or private insurance companies) may decide ONLY to fund these well publicised, well known treatments that have the backing of very influential people in the field and that this would be like only funding comparisons between two antibiotics - good for those who respond to either, life saving for those who are allergic to one and do well on the other but no use at all to people who are antibiotic resistant. No reason at all not to be excited at this development and to get some real data out of trials and some proper guidelines on best practice, but I would put in a word for more qualitative research as well, like this study which I believe is still recruiting parents to interview. | |
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Mentor
Registered: June 15, 2009
Posts: 2,384
| Posted Yesterday at 03:56 PM | Reply with quote?#6? |
| Another HUGE problem is finding a local therapist who is proficient in doing the advanced CBT. Hugs! | |
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Moderator
Registered: Nov 20, 2010
Posts: 2,745
| Posted Yesterday at 04:12 PM | Reply with quote?#7? |
| Christopher Fairburn's book! Aaaargh!! | |
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Moderator
Registered: July 31, 2007
Posts: 2,096
Moderator
Registered: Nov 20, 2010
Posts: 2,745
| Posted Yesterday at 04:18 PM | Reply with quote?#9? |
| Wonder where that book ended up...? | |
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FEAST Advisor
Registered: May 24, 2011
Posts: 212
| Posted Yesterday at 04:33 PM | Reply with quote?#10? |
| I don't share the enthusiasm for this study, especially given that there wasn't a control group (as far as I can tell). This is also the case for another study of CBT-E in adults with AN, which was analyzed in absolutely fantastic detail?here. I'm not saying CBT doesn't work, just that these results are *very* preliminary and there are problems in other studies by Fairburn of how he analyzed the data (which have been brought up at international meetings) that inherently increase my wariness. I would like to see further studies, however. | |
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Mentor
Registered: April 29, 2008
Posts: 997
| Posted Yesterday at 04:36 PM | Reply with quote?#11? |
| I would guess that Fairburn is an academic who does not realise just how the so-called professionals in ed treatment teams are capable of 'making or breaking' FBT as an option,?because he really doesn't have a clue as to how it works. I'm maybe being cynical........ | |
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Registered: March 07, 2012
Posts: 199
| Posted Yesterday at 05:04 PM | Reply with quote?#12? |
| Very interesting idea Christopher but Rather than randomization between fbt and e-cbt, I guess I'd rather see studies combining e-cbt with fbt ( parents seen separately) or e-cbt after a trial of unsuccessful fbt,, or a crossover. That said, I still think we need many more subjects in randomized trials! | |
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Moderator
Registered: July 31, 2007
Posts: 2,096
| Posted Yesterday at 05:06 PM | Reply with quote?#13? |
| I would call it realistic Mel. Out there in the real world there are clinicians with far fewer resources and far less training than those in the major researchers and there are thousands of cases that don't meet the research criteria but still desperately need help. It's good that pure academic research goes on (and that researchers hold each other to account when the research has flaws) but it's also vital that day by day hour by hour families as supported in their struggle in the here and now. The evidence and research of both Faiburn and the professionals behind FBT has influenced and informed my daughter's care amd I'm grateful for that but I'm far more grateful for the day to day support of family, church amd friends, particularly you knowledgable friends here on the forum. | |
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Registered: Sept 16, 2008
Posts: 636
| Posted Yesterday at 08:36 PM | Reply with quote?#14? |
| My stepfather mentioned this study the other day because it popped up on some journal alert he subscribes to. From a purely anecdotal standpoint, we have family friends who used CBT-E after a bad experience with FBT.? At the time their daughter was sixteen and seventeen so the therapist did adapt a little because she was under eighteen and still living at home with parents who were more involved than in the original protocol.? The protocol of this study sounds similar to what they did and it worked well for their daughter.? That was the important thing at the time!? I will say that I'm not sure that FBT with a different (and much more competent) therapist wouldn't have worked for their daughter also.? They unfortunately had a therapist who wasn't particularly skilled and didn't really grasp the importance of medical stability to refeed at home.? After a medical disaster during FBT she did eventually receive the medical attention she needed and did improve.? When she reached the point where it might have been safe to restart FBT everyone was a bit wary to do that so CBT-E was the option they went with.? I do wonder if CBT-E may be a better option for older adolescents working towards independence and college.? It does seem to lend itself to a solid relapse prevention plan and that is incorporated into the program.? This worked well for them and their daughter.? She has absolutely thrived attending college on the other side of the country.? | |
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Mentor
Registered: Oct 30, 2011
Posts: 2,354
| Posted Today at 11:58 AM | Reply with quote?#15? |
| Strongmom's view point above gets my thumbsup. We did a modified FBT (because my D is so young) and essentially there is no manualized FBT for a 10 yr old. | |
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Mentor
Registered: May 08, 2012
Posts: 1,130
| Posted Today at 12:01 PM | Reply with quote?#16? |
| We are doing CBT and FBT simulataneously, with the same psychologist, but the CBT is not addressing much related to ED except fear foods. It isn't clear to me how "enhanced" CBT differs from regular CBT ... YP | |
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FEAST Advisor
Registered: May 24, 2011
Posts: 212
| Posted Today at 12:15 PM | Reply with quote?#17? |
| The "enhanced" bit focuses on ED-specific problems, like body image, etc. It uses a transdiagnostic approach, which means it effectively treats all EDs the same, regardless of diagnosis.? There's a more lengthy explanation in the Eating Disorders Review. I have problems with viewing the "overvaluation of weight/shape" as being central to EDs. It's a symptom that needs addressing, but the cause/effect hasn't been established to my liking. | |
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Mentor
Registered: Oct 30, 2011
Posts: 2,354
| Posted Today at 12:20 PM | Reply with quote?#18? |
| oooh I guess we did "enhanced" then. I feel kinda special. I totally agree that the dysmorphia was a symptom not cause/effect in my D's case. My Ds body dysmorphia presented that she truly saw herself as huge. Fun House mirror stuff. CBT had her draw her image as she thought she was on large scroll of life size paper on the floor. Then in different pen she had her lied down and trace her actual outline. Much different..... She did many of these "exercises" first twice weekly, then weekly and now.........monthly. She would tell me that what is so hard with the littles is one minute the flexibility in thinking is there.....then it is not. We kept doing non manualized FBT at the same time. | |
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Mentor
Registered: Oct 18, 2007
Posts: 356
| Posted Today at 01:59 PM | Reply with quote?#19? |
| The?paper I cited, above, was merely intended to be a pilot study. The purpose was to get an early indication whether CBT-E might offer benefits to some sufferers. If the results had come back showing that none of the patients had been helped, the whole idea of using CBT-E probably would have been dropped. Similarly, if 100% of the people in the experiment had recovered, the conclusion probably would have been that exploring CBT-E further in clincial trials should probably be the number one priority in worldwide eating disorder?research. I think any fair reading of the data is that the results were mixed but promising.?The authors acknowledged it as such. Consequently, they argue that it is reasonable to move to the next stage -- an experiment in which half the participants in a study are randomly assigned to FBT, and half to CBT-E.? The rates of recovery in the two groups?would be compared over time in order to try to measure the relative effectiveness of the two approaches and begin to identify, if possible, circumstances that might favor one over the other so that treatments can best be?tailored to individuals. I think it's hard to argue that such a study would not be useful. In addition to the potentially promising results of the Dalle Grave/ Fairburn pilot study,?the thought is that it would be?important to test CBT-E against FBT in a randomized clinical trial because, after all,?in many countries,?CBT is?the most?widely used treatment for AN today, even though FBT has more empirical data supporting it. Given the wide dissemination of CBT, an?experiment needs to be conducted, urgently, in order to try to determine whether CBT is actually effective or not in a good experiment conducted in the real world. If it is shown?to be ineffective, or?less effective than FBT, the word would need to go out to clinicians in the community right away, warning them?that their assumptions about the relative effectiveness of CBT and FBT need to be reconsidered. On the other hand, if CBT were to outperform FBT in an experiment, then FBT clincians would need to reassess. In the meantime, the authors?of this new paper?acknowledge that for now FBT remains the leading empircally--supported intervention for adolescents who suffer from AN. This conclusion, it seems to me, is clearly correct. A few years ago, the U.S. National Institute of Mental Health gave a grant to a leading reseacher to review all the relevant studies. She concluded that, at this time, the best available evidence supports FBT. Keel, In the U.S., most of the funding for research on eating disorders is determined by the National Institutes of Health. Researchers who wish to receive funding for specific experiments generally apply to the NIH for grants. The FBT v. AFT study published in 2010, for example, was funded by the NIH. The public has very little input into how the NIH chooses to distribute research funds.?Instead, grant applications are reviewed by panels?composed of other researchers, not the general public,?and are scored based on this peer review. Only the highest scoring grants receive money. In the U.S., in recent years, due to federal budget cutbacks,?only a small percentage of NIH grant applications?receive funding. The rest are rejected due to limited funds available, even though they may have merit.?There is intense competition for scarce NIH?research funding dollars.?Eating disorder researchers?need to?compete with researchers who study?other illnesses, from heart disease to?schizophrenia. Parents and families?are pretty well shut out of the process of allocating NIH?research funding, even though it?is?they who are deeply affected. In addition to NIH funding, some private charities allocate funds for eating disorder research.? Autism parents have banded together and raise millions of dollars to support scientific research to supplement government-based funding. No comparable organization exists to fund eating disorders research. The scientific?research on?anorexia nervosa?can accessed at?http://www.pubmed.gov. In the search bar, type in anorexia nervosa. This will give you summaries of thousands of research papers.?Try?sorting by "most recent."? This will?make it easy to follow the new papers as they are coming out. | |
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Registered: March 07, 2012
Posts: 199
| Posted Today at 02:43 PM | Reply with quote?#20? |
Christopher, I like where you are going with this!? I've been thinking about this for a while.?? Autism spectrum disorders are perhaps a little higher in prevalence than eating disorders,? type 1 diabetes is a little lower in prevalence than eating disorders.? Yet as?you point out, those two examples have amazingly strong, rich, and powerful advocacy groups.? I notice that there are a few eating disorders advocacy groups out there, and some support research directly.? Could they be combined for a stronger unified voice? Also, I want to point out this recent review which discusses the challenges of getting FBT applied in the clinic.? This article makes the case that FBT is "hard" and that is a barrier for its use in the clinic.?FBT is certainly hard for families to undertake, but from the therapists point of view, they play a?critical but basically supportive role in the beginning.?? Another challenge is "unity across the team professionals".? Again, many of us are well-aware of that phenomenon.?? In addition to to research for efficacy, we also need the?kind of research that?can help make?sure that clinicians USE what works, and research to find out how to help clinicians make sure they are?doing it right and not "drifting"?by keeping track of outcomes in their own practices... | |
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