Binge Eating Disorder:

6. CBT Manual
James E Mitchell, M.D.
Cognitive-Behavioral Therapy
for BED
- Group Treatment Manual

- Self-help Manual

jmitchell@nrifargo.com
www.nrifargo.com
 CBT Is Well Established
Treatment for BED
Most patients improve substantially

Improvements generally maintained at 1

year

CBT more effective than other therapies:

Exception: IPT
Possible Exception: DBT
Possible Exception: Supervised Self-help
 Cognitive Therapy:
Philosophical Inspiration
“If thou art pained by any external thing, it is
not this thing which disturbs thee, but thine
own judgment about it. And it is within thy
power to wipe out this judgment now.”
Marcus Aurelius
The Meditations (“To Myself”)
CBT FOR Binge Eating Disorder:
Goals of Treatment
• Normalization of eating
• Weight loss ?
• Enhanced self-acceptance
• Improved body image disparagement
• Remediation of depressive symptoms?
 Modifications of CBT for BN when
Treating for BED
• Psychoeducation about obesity and binge
eating
• Differences in level of restraint
• Stimulus control techniques
• Acceptance of larger than average weight
and size
 For Whom Does This Seem to Work
Best?

Patients who binge eat at least twice per week

Motivated to change (binge eating is ego

dystonic)

Those without severe Axis II problems, severe

depression
 CBT Treatment Structure

15 sessions over 18 weeks

Semi-structured, problem oriented
Treatment as active process
Responsibility for change lies with patient
Sequence
- Review homework
- Group discussion
- Assign homework
 CBT Treatment Structure
- If possible, hold all female or all male
groups.
- If impossible to do one sex group, include
at least 2 of each sex
- Manual can also be used for individual
therapy with some wording changes
- Maximum number 8-10
- Start out with at least four members, since
you can anticipate at least one drop-out
 CBT FOR Binge Eating Disorder:
Therapist Role

• - Maintain focus on eating problems

• - Avoid derailment by group
members (“That’s certainly an
important problem. However, it is
beyond the scope of this group.
Perhaps you need additional therapy
with another therapist for that now,
or after this treatment”
 CBT FOR Binge Eating Disorder:
Therapist Role

• Focus on patients who are being

adherent and making progress
• Do not focus on non-adherent,
problematic patients, other than to
reinforce positive movement
• Therapist needs at times to exert
control
 Weekly Weighings
Goal: weigh self weekly on same morning
- May be an increase in concern about weight and/or
the urge to weigh self more than once per week
- May need to purchase or hide bathroom scale

Rationale:
- Track effect of treatment on weight
- Tolerate uncertainty of weight
 Food Logs
Quality of monitoring is related to therapist’s
attention:
1. Check timing and accuracy
2. Explore difficulties and seek solutions
3. Praise accurate monitoring
4. Have patient guide therapist through logs, or pair
off patients
5. Discuss excessive eating in detail
SESSION 1. Program Overview and What Is Binge-Eating Disorder?
SESSION 2. Cues and Consequences, Part I
SESSION 3. Cues and Consequences, Part II
SESSION 4. Thoughts, Feelings, and Behaviors
SESSION 5. Restructuring Your Thoughts
SESSION 6. Cues and Chains
SESSION 7. Impulsivity, Self-Control, and Mood Enhancement
SESSION 8. Body Image, Part I
SESSION 9. Body Image, Part II
SESSION 10. Self-Esteem
SESSION 11. Stress Management and Problem Solving
SESSION 12. Assertiveness
SESSION 13. Weight Management
SESSION 14. Relapse Prevention, Part I: Exposure to High-Risk Foods
and Situations
SESSION 15. Relapse Prevention, Part II: Review of Progress and
Long-Term Planning
SESSION 1. Program Overview and What Is
Binge-Eating Disorder?
 Psychoeducation for BED
• Patients generally don’t lose weight with CBT, but
eliminating binge eating may stabilize weight and
lessen the risk of further gain
• Multiple causes of obesity: strong genetic and
biological factors; behavioral factors also
important
• Weight loss through dieting is frequently regained
• Weight losses of 5-10% are medically significant
 REASONS FOR AND AGAINST CHANGING
UNHEALTHY EATING HABITS WORKSHEET
.

Reasons for Stopping Reasons against Stopping

Stimulus Control Techniques
• Specific techniques
– Do nothing else while eating
– Confine eating to one place
– Limit available food while eating
– Leave food on plate
– Discard leftovers
– Slow eating (put fork down, pause)
– Leave table after eating
– Serve and eat one portion at a time
– Shopping (planned, not when hungry)
– Limit exposure to “danger” foods
 ALTERNATIVES TO BINGE-EATING WORKSHEET

1. Call a friend. Keep calling until you reach someone.

2. Take a bath or shower.
3. Take a walk.
4. Do a non-food-related activity outside the kitchen. Stay out of the kitchen.
5. Go to the library.
6. Do a relaxation exercise or meditation.
7. Distract yourself with a craft project, book, or TV program.
8. Read something inspirational.
9. Go to a movie, play, museum, etc.
10. Listen to music.
11. Clean or organize a room.
12. _______________________________________________________
13. _______________________________________________________
14. _______________________________________________________
SESSION 2. Cues and Consequences, Part I
SESSION 3. Cues and Consequences, Part II
STRATEGIES FOR CHANGE: FOCUSING
ON THE CUE
A major goal of treatment if to change your
unhealthy eating habits. One way to change
these habits is to take control of the cues by
breaking up the relationship between the cues
and your binge-eating responses. This is done
by (1) rearranging cues and (2) changing your
responses to cues.
 Rearranging Cues

1. AVOIDANCE - - The simplest method of

rearranging cues is to avoid the cue entirely.

2. RESTRICTED STIMULUS FIELD - - If you wish to

reduce the frequency of problem behavior, restrict
the cues that trigger the behavior (e.g., eat only at
the table apart from other cues, such as TV).

3. STRENGTHEN CUES FOR DESIRED BEHAVIOR - -

Expose yourself to existing cues that lead more
frequently to healthy behavior (e.g., binge-eating
while studying at home, but not in the library—
spend more time in the library).
 Changing Your Response to Cues

1. BUILD IN A PAUSE - - DELAY THE RESPONSE - -

Building in a pause allows time to pass and breaks up
the cue from the automatic behavioral response.

2. ALTERNATIVE BEHAVIORS - - Replace a problematic

behavior with a competing behavior that is adaptive.

3. EXPOSURE AND RESPONSE PREVENTION - - Structure

your environment so that binge-eating is unlikely or
impossible, following exposure to a cue
 POSSIBLE CONSEQUENCES

Categories Positive Consequences Negative Consequences

Social 1. Avoiding interpersonal conflict or 1. Social withdrawal

rejection 2. Lying and lack of trust in relationships
3. Problems from being overweight
Situational 1. Distraction from boring or 1. Occupational problems, procrastination
unpleasant tasks 2. Financial problems
2. Avoiding responsibility
Feelings 1. Relief from tension, stress, anger 1. Depression, guilt, shame, irritability,
2. Relief from boredom mood swings

Thoughts 1. Distraction from uncomfortable 1. Increase in negative self-esteem or

thoughts guilt-related thoughts
Physiologic 1. Reduction of hunger 1. Weight gain
Nutritional

The binge eating is maintained because the positive

consequences resulting from binge-eating behaviors are more
immediate than the negative consequences.
 SESSION 4. Thoughts, Feelings, and
Behaviors

CUES CONSEQUENCES
SESSION 5. Restructuring Your Thoughts
 Cognitive Restructuring
1. Articulate the circumstances and feelings
2. Identify the core thought
3. Critically examine the thought:
-- What evidence supports/opposes the thought?
-- What is the effect of believing the thought? Of
thinking differently?
4. Reach a reasoned conclusion which is
more accurate.
Thought Type of Thinking
“I’m no good” Overgeneralization
“I’m a failure”
“I never do anything right”
“I’m worthless”

“I can’t do it—I’ll never do it right” Catastrophizing

“I did it well, but I should have done it Minimization

better”

“If I don’t do well at one thing, it means Black-and-white thinking

I’ll never be successful”

“Everybody thinks I’m fat” Mind reading

“My boss just criticized me—she thinks I’m
incompetent”
 SESSION 6. Cues and Chains

finishing “I ate too feeling entering

“I might as
an ample much I’m anxious the kitchen
well eat
dinner going to more I
CUE gain already ate
weight” too much”

CONSEQUENCE
feeling
agitated
very
hungry, opening
binge eat, refrigerator
feelings of door, seeing
guilt cheesecake

skip lunch eating “I can’t control myself”

cheeseca
“I’m going feeling ke
skip to gain initially
breakfast five satisfied,
next day pounds” then more
anxious
SESSION 7. Impulsivity, Self-Control, and
Mood Enhancement
 Reward List

A. People: List two people with whom you would like to spend more time each
week but don’t get a chance
1.

2.
B. Places: List two places where you would like to spend more time, but don’t
get a chance to:
1.

2.
C. Things: List two things you do not own that you would like to have and can
afford (book, CD, new shoes, etc.):
1.

2.
D. Activities: List two activities you would like to do more often than you do
now:
1.

2.
.
SESSION 8. Body Image, Part I

SESSION 9. Body Image, Part II

 AFFIRMATIONS WORKSHEET
How you think about and talk to yourself can improve your body image
and your self-image.

List five positive statements about your body:

1.
2.
3.
4.

Now list five positive statements about yourself that do not relate to your
physical appearance (e.g., personality, sense of humor):
1.
2.
3.
4.

Write your affirmations on index cards that you can keep with you to read
aloud and silently to yourself throughout the day.
 Reducing Body Image Disparagement
• Acknowledge stigmatization that exists
• Body image disparagement is painful and self-defeating,
tends to worsen binge eating
• Explore non weight-centered aspects of appearance and
overall self-concept
• Assign tasks to provide opportunities to challenge
dysfunctional thoughts (try on clothes, go dancing, go to
the beach)
• Exercise (if not excessive) can facilitate body awareness
and self-acceptance
SESSION 10. Self-Esteem
Self-Concept Inventory Domains

-Physical appearance

-How I relate to others

-Personality

-How others see me

-Performance at work/School

-Mental Functioning

-Family,Friends
SESSION 11. Stress Management and
Problem Solving
Types of stress Positive responses Negative
response responses
Thoughts I like a challenge. I am incompetent.
I can get it done. I must do this perfectly.
Relax, I’m doing what I I can’t handle this.
can.
Feelings Exhilaration Anxious
Excitement Angry
Frustrated
Sad
Behaviors` Assertive Withdrawal
Productive Avoiding situation
Task-oriented Procrastination
Physical States Increased pulse rate Knots in stomach
More strength Headache
Increased speech Trembling
 STRESS REDUCTION EXPERIMENT WORKSHEET
Identify a stressor in your life.
__________________________________________________
__________________________________________________
___________________________________
Choose one technique with which to cope or reduce this stressor.
__________________________________________________
__________________________________________________
___________________________________
Describe the results of your experiment.
__________________________________________________
__________________________________________________
___________________________________
 Systematic Problem Solving

1. Write down the problem as precisely as possible and as

soon as possible
2. Generate as many alternative solutions as possible
3. List the pros and cons of each solution as a means of
evaluating the effectiveness and feasibility of each solution
4. Choose a solution
5. Implement the solution
6. Evaluate the result
SESSION 12. Assertiveness
 HOW SELF-TALK CAN LEAD TO PASSIVE, AGGRESSIVE,
1. Passive
OR ASSERTIVE BEHAVIORS
Thoughts (self-statements) Feelings Behaviors Consequences
“My opinion isn’t important.” Anxiety Avoiding conversation Avoid making “stupid”
“I don’t want to sound stupid.” Fear Withdrawing remarks.
Feel increased anxiety and
frustration.
Urge to binge-eat.
2. Aggressive
“My opinion is the only right Frustrated Yelling Feel increased anger.
one.” Angry Standing too close to Feel alienated from others.
“These people are stupid.” others

3. Assertive
“My opinion is equally Calm Talking calmly Improved self-esteem
important.” Maintaining eye Fewer urges to binge-eat.
contact
SESSION 13. Weight Management
SESSION 14. Relapse Prevention, Part I:
High-Risk Foods and Situations
Exposure??????

SESSION 15. Relapse Prevention, Part II:

Review of Progress and Long-Term Planning
 HIGH RISK FOODS AND SITUATIONS

List of My High-Risk Foods

List your most troublesome foods. That is, list those foods that are high-risk for
triggering binge eating behaviors. Start the list with the least troublesome and end with the
most troublesome highest risk food.
1.__________________________________________________--(lowest risk)
2.___________________________________________________
3.___________________________________________________
4.___________________________________________________
5.___________________________________________________
6.___________________________________________________
7.___________________________________________________
8.___________________________________________________
9.___________________________________________________
10._________________________________________________--(highest risk)
 HIGH RISK FOODS AND SITUATIONS

List of My High Risk Situations

List the situations that are high-risk for triggering binge eating (lowest to highest risk).
Choose situations that you expect to encounter or be engaged in during the next month.
1._______________________________________________________--(lowest risk)
2._______________________________________________________
3._______________________________________________________
4._______________________________________________________
5._______________________________________________________
6._______________________________________________________
7._______________________________________________________
8._______________________________________________________
9._______________________________________________________
10.______________________________________________________--(highest risk)
LAPSE PLAN AND RELAPSE PLAN WORKSHEET

Lapse Plan: Write a step by step plan that you will carry out
if a lapse occurs. Focus on not only what you would do,
but also how you would change your thoughts.
1. _______________________________________________________________________________
_________________________________________________________________________________
2. _______________________________________________________________________________
_________________________________________________________________________________
3. _______________________________________________________________________________
_________________________________________________________________________________
4. _______________________________________________________________________________
_________________________________________________________________________________
5. _______________________________________________________________________________

Relapse Plan: Write a step by step plan that you will carry
out if relapse occurs. Again, focus on not only what you
would do, but also how you would change your thoughts.
1. ______________________________________________________________________________
________________________________________________________________________________
2. _______________________________________________________________________________
_________________________________________________________________________________
3. _______________________________________________________________________________
_________________________________________________________________________________
4. _______________________________________________________________________________
_________________________________________________________________________________
5. _______________________________________________________________________________
 HEALTHY LIFESTYLE PLAN
Hours per week Describe Activities
Work/School

Exercise/Physical activity

Time alone, meditation, relaxation

Hobbies and Educational pursuits

Social activities
Questions/Comments?