Cognitive Behavioural Therapy - Enhanced (CBT-E) (CBT for eating disorders)

CBT-E is an outpatient CBT treatment designed to treat adults with eating disorders. It is a structured and time limited therapy that involves an initial assessment session, followed by 20 treatment sessions across 20 weeks. Treatment length is sometimes modified due to the individuals presentation and needs.

CBT-E uses cognitive and behaviour therapy techniques with the aim to assist individuals to develop healthy coping skills and reduce eating disorder behaviours. It involves:

• Developing an understanding of the development and maintenance of the eating disorder
• Developing a formulation
• Addressing the topics of mood, body image concerns, dietary restraint, and triggering events
• Maintaining changes
• Managing Setbacks
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The key features of CBT-E are:

• A detailed daily food diary kept in real time (not written up later)
• Weekly weigh-ins at the beginning of each session where the weight is plotted on a graph
• From early on working towards eating regular meals and snacks (and refraining from eating in-between meals and snacks)
• Using CBT strategies to reduce compensatory behaviours
• Using CBT strategies to reduce body checking
  

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How was CBT-E developed?

CBT-E was developed in the across the 1970s and 1980s by Christopher Fairburn and his colleagues at the Centre for Research on Eating Disorders Oxford. It adapts and expands CBT strategies to specifically target eating disorders and their maintaining cognition and behaviours. CBT-E was initially developed for Bulimia Nervosa (CBT-BN), and then adapted for all eating disorders.

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CBT-E is Transdiagnostic

In the medical model, different types of eating disorders (such as Bulimia Nervosa, Binge Eating disorder etc.) are viewed as distinct conditions with each requiring its own form of treatment.

In contrast, CBT-E holds a transdiagnostic view of eating disorders. This means, it views the processes that maintain:

• Otherwise Specified Feeding and Eating Disorder (OSFED)
• Anorexia Nervosa (AN)
• Bulimia Nervosa (BN)
• Binge Eating Disorder (BED)
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as largely the same. Consequently, the treatment is the same (with minor modifications) regardless of the diagnosis.

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Exhale Psychology Centre and the Transdiagnostic View

At Exhale Psychology Centre, we hold the trandiagnostic view of eating disorders, focusing on treating the presenting issues eg. Urges to restrict, purging etc, rather than focusing on the specific eating disorder diagnosis.

That said, we recognise that some eating disorders can be quite different in nature and require a different approach, such as with Avoidant/Restrictive Food Intake Disorder (ARFID).

Who does it help?

CBT-E is an extremely well researched therapy, and has shown to be particularly effective for treating adolescents (1). Individuals receiving CBT-E report significant improvements by session 18, and these improvements tend to be maintained. Around 45% of people make a full recovery with just 18 sessions of CBT-E (2). This is extremely significant given the insidious nature of eating disorders.

People who received CBT-E for bulimia have reported significant reductions in depression and anxiety symptoms, and report profound improvements in their quality of life (3).

CBT-E Limitations

Although CBT-E is viewed as the gold standard treatment for eating disorders, it does not work for everyone. Around 50% of people do not recover after receiving CBT-E, some show no improvements, and roughly 25% if people drop out early due to dissatisfaction (4).

CBT-E does not target serious comorbities that can maintain eating disorders, such as treatment-resistant depression, trauma, ADHD etc. At present, there is not adequate evidence to demonstrate that individuals with complex presentations benefit from CBT-E. Individuals with serious comorbidities tend to be excluded from research studies (due to the complex variables) and when they are included dropout rates are high and outcomes are poor (5).

Part of the foundation of CBT-E is the view that the majority of difficulties for individuals will resolve when they weight restore/ their eating disorder behaviours reduce/ their intake stabilises.

Unfortunately, this is not the case for individuals with multiple comorbidities in which the eating disorders appears to be a dysfunctional coping strategy (rather than the core psychopathology).

At Exhale Psychology Centre, while we utilise CBT-E strategies, our target population group is individuals who:

• Have already tried CBT-E but it was unsuccessful
• Have complex comorbities
  

What other options are available?

For those that have tried CBT-E or have complex comorbities, we offer;

• Specialist Supportive Clinical Management (SSCM)
• Focal Psychodynamic Therapy for Eating Disorders
• Dialectical Behaviour Therapy for Eating Disorders
• Schema Therapy

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1. Grave, R.D., Conti, M., Sartirana, M., Sermattei, S., & Calugi, S. (2021). Enhanced Cognitive Behaviour Therapy for Adolescents with eating Disorders: A Systematic Review of Current Status and Future Perspectives. Italian Journal of Eating Disorders and Obesity.

2. Fairburn, A (2015). A Transdiagnostic Comparison of Enhanced Cognitive Behaviour Therapy (CBT-E) and Interpersonal Psychotherapy in the Treatment of Eating Disorders. Behaviour Research and Therapy 70, 64-71.

3. Wonderlich, S.A., Peterson, C.B., Crosby R.D., Smith, T.L., Klein, M.H., Mitchell, J. E., & Crow, S. J. (2014). A Randomized Controlled Comparison of Integrative Cognitive-Affective Therapy (ICAT) and Enhanced Cognitive-Behavioural Therapy (CBT-E) for Bulimia Nervosa. Psychological Medicine, 44, 543-553.‍

4. Linardon, J., Hindle, A., & Brennan, L. (2018). Dropout from Cognitive-Behavioral Therapy for Eating Disorders: A Meta-Analysis of Randomized, Controlled Trials. International Journal of Eating Disorders, 51, 381-391.

5. Kessler, U., Kleppe, M.M., Rekkedal, G.A., Ro, O., & Danielsen, Y. (2022). Experiences When Implementing Enhanced Cognitive Behavioural Therapy as a Standard Treatment for Anorexia Nervosa in Outpatient at a Public Specialised Eating-Disorder Treatment Unit. Journal of Eating Disorders, 10:15.

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