© Springer International Publishing AG 2017
Sanjeev Sockalingam and Raed Hawa (eds.)Psychiatric Care in Severe Obesity10.1007/978-3-319-42536-8_1818. Cognitive Behavioural Therapy for Severe Obesity
(1)
Department of Psychology, Ryerson University, Toronto, ON, Canada
(2)
Department of Psychiatry, University of Toronto, Toronto, ON, Canada
(3)
Centre for Mental Health, University Health Network, Toronto, ON, Canada
Case Vignette
Mrs. Jones is a 48-year-old teacher who is married with two children. She was referred by her physician for bariatric surgery, and at the time of the initial assessment, her body mass index (BMI) was 48 kg/m2. She had a history of depression and occasionally had eating binges. She also had type 2 diabetes and reported significant joint pain. When asked about her expectations regarding the surgery, she hoped that she would lose 100 pounds by the end of the first year (BMI = 32 kg/m2) and that her diabetes would go into remission. Her surgery went smoothly, and she did not experience dumping syndrome or any other significant complications following the surgery. In fact, she reported that she was able to eat some “junk food” relatively soon after her surgery, as well as larger portion sizes than she had expected. She was disappointed that she was still able to continue some of her old unhealthy eating habits and reported that she wished in some ways that she did experience dumping syndrome to deter her from eating unhealthy foods and large portions.
Although she made some unhealthy food choices and occasionally ate large portions of food, her eating habits had actually improved significantly. In addition, she was working out with a personal trainer once to twice a week plus exercising on her own; her strength and cardiovascular fitness had improved significantly, and she was training for a 5 km race. She lost approximately 70 pounds in the first 8 months following surgery (BMI = 37 kg/m 2 ), her diabetes went into remission, and her joint pain had reduced significantly. Despite these improvements, she was beginning to give up hope that she would be able to lose 100 pounds in the first year (perhaps even ever) because she was informed prior to surgery that the most drastic weight loss occurs within the first 6–12 months following surgery. In speaking with other bariatric patients, she felt other people were making much greater progress than she was, and this left her feeling disappointed and discouraged. She began to have thoughts such as “I should have lost more weight by now”, “I am never going to reach my goal weight”, and “I am going to regain all of my weight and then some.” She found this last thought particularly distressing because it made her think, “Why bother continuing to work so hard then?” At her most recent weigh-in at the clinic, her weight loss had plateaued. She reported that she had not been exercising as much the past few weeks and had a few episodes of emotional overeating.
18.1 Introduction
In this chapter, we provide an overview of cognitive behavioural therapy (CBT), the rationale for integrating it into the management of severe obesity, and examples of CBT strategies that can be helpful in working with patients with severe obesity. We then review the empirical evidence supporting the effectiveness of CBT in patients with severe obesity (both surgical and non-surgical populations). Finally, we use a case example to illustrate the application of CBT techniques in clinical practice.
18.2 Overview of Cognitive Behavioural Therapy
Cognitive behavioural therapy (CBT) is a short-term, psychosocial intervention that is based on the premise that thoughts (cognitions), emotions, and behaviours are all interconnected [1]. The way an individual appraises a situation influences his/her emotional response and subsequent behaviour. Conversely, an individual’s behavioural response affects his/her cognitions and emotional responses, thus creating a potentially vicious feedback cycle. The cognitive behavioural model posits that “cognitive distortions ” (i.e., distorted thoughts) are at the root of psychopathology [1]. For example, having a thought such as “I am never going to lose weight”, might lead to feelings of pessimism, helplessness, sadness, and frustration, which in turn lead to withdrawing from social and recreational activities and engaging in emotional overeating or binge eating . This behaviour can then create a self-fulfilling prophecy, such that increased food consumption provides some objective evidence to support the thought, “I am never going to lose weight,” which subsequently amplifies negative emotions that further increase vulnerability to maladaptive eating behaviours.
Cognitive behavioural therapy is a skills-based intervention that focuses on the here-and-now. That is, it focuses on the factors that currently maintain problematic thoughts and behaviours to a much greater extent than the issues that originally lead to their development. Given that cognitions, emotions, and behaviours are all interconnected, CBT seeks to disrupt this feedback cycle by teaching clients coping skills to identify and alter maladaptive cognitions and behaviours that perpetuate the cycle of maladaptive eating patterns [1]. Cognitive behavioural therapy is a collaborative treatment approach in that the therapist and client work together to set treatment goals that are mutually agreed upon. The client is expected to actively participate in treatment sessions and practice the coping skills between sessions in order to maximally benefit from treatment and ultimately become his/her own therapist.
18.3 Rationale for Integrating CBT into the Management of Severe Obesity
Obesity itself is not a mental disorder; however, individuals with severe obesity have elevated rates of psychopathology, including mood disorders, anxiety disorders, and binge eating disorder (BED) [2–5]. In addition to clinically significant eating disorders, a high percentage of individuals with obesity also endorse maladaptive eating behaviours such as emotional overeating, grazing, and loss of control eating [6, 7]. A proposed mechanism that accounts for this relationship is the tendency for people to eat as a means of coping with emotional difficulties [8–10]. Thus, in order to maintain weight loss, it is important that patients learn coping skills to better manage emotional difficulties. Major clinical guidelines recommend CBT as the gold standard psychosocial treatment for many of the psychological disorders which are prevalent among individuals with severe obesity, including depression [11] and binge eating disorder [12], and as described later in this chapter, empirical research supports the efficacy of CBT for weight management.
18.4 Cognitive Behavioural Therapy for Severe Obesity
A number of excellent resources exist for learning about CBT [1], and applying CBT in the treatment of binge eating [13], and weight management [14–16]. Clinical guidelines for the management of obesity [17] recommend that the following components be included in interventions: goal setting, self-monitoring , physical activity, stimulus control, problem-solving, assertiveness, cognitive restructuring (i.e. modification of distorted thoughts), relapse prevention, and strategies for dealing with weight regain.
18.4.1 Introduction to CBT and Goal Setting
Cognitive behavioural therapy should begin with an introduction to CBT and presentation of a cognitive behavioural model that explains some of the factors that have been implicated in overeating and weight gain [18]. The model should be tailored to the individual client, and focus on the factors that currently maintain his/her maladaptive eating behaviours (e.g., cognitive distortions , negative emotions, high levels of dietary restraint). The CBT model is used to illustrate the feedback cycle that exists, whereby overeating is reinforced by temporary relief or pleasure, but then followed by negative emotions that subsequently increase vulnerability for further overeating. Collaborative goal setting should then be used to develop treatment goals focused on improving eating behaviours. For example, treatment goals might include reducing binge eating or emotional eating, and in order to do so, it would be important to eat healthy meals and snacks at regular time intervals (e.g., self-monitoring using food records, engaging in normalized or “mechanical” eating), schedule pleasurable activities as alternatives to eating (e.g., activity scheduling, self-care), plan for difficult eating situations (e.g., stimulus control, problem-solving, assertiveness training), and reduce susceptibility to overeating by identifying, challenging, and altering maladaptive thoughts (e.g., cognitive restructuring) [14, 18].
18.4.2 Self-Monitoring and Using Food Records to Normalize Eating
Clients begin self-monitoring their eating behaviours using food records early in treatment. Food records are daily journals which are used to monitor the time and location of each episode, the amount and type of food or liquid consumed, the type of eating episode (e.g., snack, meal, binge, graze), and the context of eating episode (e.g., thoughts, emotions, situation). The purpose of the food records is to increase awareness of eating behaviours, identify maladaptive patterns in eating behaviours (e.g., skipping meals which increases vulnerability to subsequent overeating, grazing at home after work in the evening rather than sitting down for a proper meal), change eating behaviours, and monitor progress over time. Some of the recommendations for normalized eating including consuming three meals and two to three snacks per day, consuming something every 3–4 hours, and not grazing in between eating episodes. In addition, to reduce vulnerability to mindless eating, clients are encouraged to eat in a designated eating area (e.g., dining room table) and without distractions (e.g., no television, computer, telephone).
In addition to monitoring their food consumption, clients also begin monitoring their weight. It is not uncommon for individuals with obesity to either avoid the scale altogether or to weigh themselves too frequently, both of which can be maladaptive. Clients are encouraged to weigh themselves once per week at the same day and time so that they have a mechanism in place to receive regular feedback on their eating behaviours. Given that fluctuations can occur for a variety of reasons from week to week, clients are encouraged to plot their weight on a graph and examine monthly trends.
18.4.3 Scheduling Pleasurable and Self-Care Activities
Eating can provide a temporary sense of pleasure and be used to regulate negative emotions , such as depression, anxiety, anger, and boredom [10, 19, 20]. In order to make long-term changes to eating behaviours, it is important to find other pleasurable activities that can be used to ride out urges to overeat, reduce vulnerability to overeating (e.g., by improving mood), and enrich the client’s life outside of food. Clients are encouraged to create a list of potentially pleasurable activities, and ideally the list should include a variety of activities that are incompatible with eating, require physical movement, are inexpensive, do not require other people, and can be engaged in at any hour. This is to ensure that the client has some ideas for activities that can be used to ride out a late night urge to overeat while alone.
In addition to regularly engaging in pleasurable activities that do not centre on food, it is important that clients practice good self-care habits to reduce vulnerability to overeating, including exercising regularly, socializing regularly, practicing good sleep hygiene, limiting consumption of alcohol, and avoiding illicit psychoactive substances [14].
18.4.4 Planning for Difficult Eating Situations
As part of treatment, clients identify the places, people, and foods that make it challenging to eat healthy, and learn problem-solving skills to help anticipate and troubleshoot such challenges. For example, a client may identify that he/she will be at greater risk of overeating at an upcoming holiday party. Problem-solving worksheets can be used to brainstorm and evaluate some options for reducing the risk, such as consuming food before the party to reduce hunger, contributing some healthy foods to the party, socializing away from the food table, and enlisting some social support. If a client is concerned that others might put on pressure to overeat during the holidays, assertiveness skills can be used to politely but firmly refuse requests.
Stimulus control refers to a number of strategies designed to reduce temptation to overeating, such as restructuring the environment. For example, a client who has a “junk food ” cupboard at home and frequently engages in mindless eating in front of the TV at night could be encouraged to replace the contents of the cupboard with some healthier alternatives, and to meet up with a friend to share a treat at a café after dinner instead. In order to maintain long-term changes to eating habits, it is important to incorporate all foods into a flexible meal plan and not avoid “forbidden foods” altogether. Thus, it is important to develop a plan to enjoy treats in moderation when the temptation to overeat is relatively low.
18.4.5 Using Cognitive Restructuring to Reduce Vulnerability to Overeating
In addition to changing behaviour, CBT focuses on teaching clients skills to identify, evaluate, and challenge negative thoughts that intensify negative emotions and lead to maladaptive behaviours. As mentioned, the cognitive behavioural model assumes that “cognitive distortions ” or distorted thoughts are at the root of psychopathology [1]. Below are some examples of cognitive distortions:
“If I have one bad food, I’ve totally blown my diet”—All-or-nothing thinking
“I always blow my diets, nothing I try ever works”—Overgeneralizing
“I’ve totally blown my diet” (went off track for 1 day, despite eating healthy the rest of the week)—Mental filter, disqualifying the positive
“No matter what I try, I won’t be able to lose weight”—Fortune-teller error
“If I have one bad food, I will regain all my weight and nothing else will ever work for me”—Catastrophizing
“I feel fat, therefore I must have gained weight”—Emotional reasoning
“I should have lost more weight by now”—Should statement
Patients are taught to use cognitive restructuring worksheets such as “thought records ” (adapted from Burns [21] and Greenberger and Padesky [22]) to evaluate the evidence supporting and not supporting their negative thoughts, and to generate more neutral, adaptive, and balanced thoughts that acknowledge the evidence on both sides. The goal of cognitive restructuring is to replace negative thoughts with more benign interpretations in order to reduce the intensity of negative emotions and engage in more adaptive behaviours.
18.4.6 Relapse Prevention
Prior to terminating CBT, clients are taught relapse prevention skills including identifying the progress they have made, identifying triggers for maladaptive eating behaviours and early warning signs that maladaptive eating behaviours are returning, distinguishing between a lapse and a full relapse, reviewing the CBT strategies and handouts, and setting additional goals to continue working on following treatment. The goal of CBT is to teach clients to become their own therapists in order to maintain their progress following treatment, and clients are encouraged to regularly schedule self-therapy sessions following treatment in order to continue the work [1].
18.5 Empirical Evidence for Cognitive Behavioural Therapy in Obesity Management
18.5.1 Cognitive Behavioural Therapy for Individuals with Obesity
Randomized controlled trials (RCTs) examining the efficacy of CBT for individuals with severe obesity demonstrate that CBT is more effective in reducing weight as compared to a wait list control group (WLC) . For example, Marchesini and colleagues [23] found that 12 weekly sessions of CBT delivered to 92 patients resulted in an average weight loss of 9.4 kg; in contrast, patients in the WLC group (n = 76) did not exhibit a significant decrease in weight (M = 0.6 kg). The CBT group also exhibited significant and superior improvement in health-related quality of life. Stahre and Hällström [24] found comparable results after a 10-week group CBT programme. Specifically, using a completer analysis, they found that patients in the CBT group lost an average of 8.5 kg at post-treatment and 10.4 kg by 1.5-year follow-up. In contrast, patients in the WLC group gained an average of 2.3 kg by 1.5-year follow-up.
Cognitive behavioural therapy has also been shown to be superior to usual care (UC) . For example, Munsch, Biedert, and Keller [25] randomized 122 patients to one of two groups: (1) 16 sessions of CBT or (2) usual care consisting of regular contact with their general practitioner and non-specific psychoeducation about weight loss techniques. The CBT group demonstrated weight loss of 4.7 % of their pre-treatment weight, whereas the UC group lost an average of 0.5 % of their pre-treatment weight, and these results were maintained at 1-year follow-up. Eating pathology (as measured by the Three Factor Eating Questionnaire) was significantly improved in the CBT group across the 1-year follow-up period, and positive effects on body image were also reported.
In regard to maintenance of weight loss following treatment, CBT has been shown in some studies to be superior to other established treatments, such as behavioural weight loss therapy (BWL) . Sbrocco, Nedegaard, Stone, and Lewis [26] compared group CBT (n = 12) with group BWL (n = 12) on weight loss outcomes at post-treatment, and 3-, 6-, and 12-month follow-up. Patients in the BWL group lost significantly more weight (M = 5.6 kg) than those in the CBT group (M = 2.5 kg) at post-treatment. At 3-month follow-up, there was no significant difference between groups; however, CBT was found to be superior to BLW at both 6-month follow-up (M = 7.0 kg vs. M = 4.5 kg, respectively) and 12-month follow-up (M = 10.1 kg vs. M = 4.3 kg). More specifically, those in the BWL group demonstrated weight regain in the follow-up period, whereas those who received CBT continued to lose weight post-treatment. Of note, cognitive therapy alone (i.e. without a behavioural intervention component) appears to be less effective for weight loss than behavioural therapy; however, evidence for durable improvements in psychological correlates of obesity, such as depression , following cognitive therapy are notable even in the absence of significant weight loss [27, 28].
Another line of research has demonstrated that CBT combined with diet and/or physical activity treatment components is superior to CBT alone [29] and diet and physical activity alone [30, 31]. For example, Werrij and colleagues [31] randomized 204 patients to either ten weekly sessions of group CBT plus a dietetic intervention (CDT) or group dietetic intervention plus physical exercise (EDT). Patients were examined on psychological and physiological variables at baseline, post-treatment, and 1-year follow-up. Interestingly, based on an intent-to-treat analysis, at post-treatment both interventions resulted in equivalent, significant improvements in maladaptive cognitions, eating concerns, shape concerns, weight concerns, dietary restraint, eating pathology, depression, and self-esteem. There also was a statistically significant reduction in weight in both groups (4.1 % for CDT vs. 4.3 % for EDT), with no difference between interventions. Most psychological benefits were maintained at 1-year follow-up in both groups, with the exception of dietary restraint and depression . In addition, the CDT intervention was found to be superior in sustaining changes in weight concerns, eating concerns, and weight loss (4.0 % vs. 3.2 %, respectively) as compared to EDT , indicating that the addition of cognitive behavioural strategies to nutritional approaches for weight loss produced superior outcomes.
Taken together, these studies demonstrate that CBT is more effective in facilitating weight loss as compared to WLC (e.g., [23, 24]) and usual care (e.g., [25]) and that adding a dietetic and/or exercise component can enhance weight loss outcomes (e.g., [29, 31]). Further, while BWL may demonstrate superior effects on weight loss in the short term, CBT yields superior results in the longer term [26]. Despite these positive findings, it is important to note that a relatively small proportion of patients achieve clinically significant levels of weight loss (i.e. 5–10% of initial weight) in many studies conducted to date. In addition to weight loss, CBT has also been shown to improve health-related quality of life [23], eating pathology (e.g., [25, 31]), and aspects of general pathology [31] in individuals with severe obesity.
The prevalence of BED in individuals with obesity seeking weight loss treatment is approximately 30 % [32–34]. Individuals with obesity and BED exhibit elevated psychopathology in the form of anxiety, depression, low self-esteem, and poorer quality of life as compared to those without BED [35, 36]. Currently, CBT is the most thoroughly researched and well-supported psychological treatment for this patient population.
Several systematic reviews have reported significantly greater reductions in binge eating frequency following CBT as compared to WLC , BWL , and pharmacotherapy [37–39]. For example, Agras and colleagues [40] reported binge eating remission rates of 55 % following CBT as compared to 9 % in a WLC group. Further, Munsch and colleagues [41] found that CBT was superior to BWL with respect to binge eating abstinence rates (80 % vs. 36 %, respectively) at post-treatment. Additional studies have found similar results at both short-term [42] and longer term follow-up [43, 44].
Related posts:
The Role of Social Support in Weight Loss Management for Morbidly Obese Individuals
Sleep and Severe Obesity
Motivational Interviewing for Severe Obesity
Overview of Medical and Surgical Treatment of Severe Obesity
Young Adulthood and Obesity Management: Developmental Issues and Transition of Care
Addictive Disorders in Severe Obesity and After Bariatric Surgery
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