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Eating disorders have a profound impact on the psychosocial functioning and physical health of adolescents. Early intervention and effective treatment is essential in order to avoid long-lasting negative effects. Family-based treatment (FBT), a specific form of family therapy, is the leading evidence-based treatment for adolescents with anorexia nervosa. There is also some more limited support for its use with young people with bulimia nervosa and its variants. However, FBT is not acceptable to some families and patients and does not benefit all patients, producing full remission in fewer than half the patients treated. These considerations suggest there is a need to design and evaluate further treatments.
“Enhanced cognitive behavior therapy” (CBT-E) (see “Enhanced Cognitive Behaviour Treatment: Transdiagnostic Theory and Treatment”), an evidence-based treatment for adults with eating disorders, is a potential candidate as an alternative to FBT since younger patients have essentially the same eating disorder psychopathology as older patients, and the treatment is transdiagnostic in its scope.
Distinctive Characteristics and Needs of Younger Patients
CBT-E has a number of features that make it well suited to meeting the needs of younger patients with eating disorders. CBT-E is a collaborative treatment in which the patient and therapist work together to overcome the eating problem and enhance patients’ sense of control more generally. This fits well with younger patients’ needs to develop autonomy and independence and their concerns about control. As CBT-E is designed to be engaging and to address and enhance motivation, it is suited to addressing the well-documented ambivalence about treatment often encountered in younger patients. The individualized approach of CBT-E is also easily adapted to the particular needs of younger patients at different developmental stages. For example, some younger patients have an overevaluation of control over eating per se rather than the overevaluation of weight and shape more commonly seen in older patients. This can be addressed in individualized CBT-E by using an adaptation of the standard procedures for addressing overevaluation but focusing instead on control of eating (see “Overevaluation of Shape and Weight and Its Assessment”). Finally, the youngest patients require a treatment that matches their cognitive development, but again this is easily managed in CBT-E. It is not a complex treatment for patients to understand or receive.
There are two distinctive characteristics of younger patients that do require modifications of standard CBT-E. First, physical health is of particular concern in younger patients, with some medical complication associated with eating disorders (e.g., osteopenia and osteoporosis) being particularly severe in adolescents. This necessitates careful assessment and monitoring of physical health and a lower threshold for providing patients with a more intensive intervention (e.g., hospitalization). Second, in the great majority of cases, parents need to be involved in treatment.
An Overview of CBT-E for the Younger Patient
CBT-E for adolescents is essentially the same treatment as for adults (see “Enhanced Cognitive Behaviour Treatment: Transdiagnostic Theory and Treatment”) with identical phases, steps, strategies, and procedures and the same reliance on a “sole” therapist. The treatment, as for the adult version, involves 20 sessions over 20 weeks for patients who are not underweight. For patients who are underweight, it is often shorter than for underweight adults as change often occurs more quickly, and, for example, 30 sessions may be sufficient.
CBT-E for Patients Who Are Not Underweight
Preparing Younger Patients for Treatment
Treatment begins with an initial interview with two main aims: to establish the nature of the eating problem and to begin to engage the patient by fostering a positive therapeutic relationship.
Although younger patients are often only partially aware that they have a problem when referred, an appropriate collaborative and engaging approach from the start may help to actively engage the majority in treatment. First parents are asked to consent to the CBT-E practitioner initially seeing the adolescent alone. This one-to-one approach facilitates the exploration of the young person’s perspective on the consultation and the nature of the problems and has the potential to lay the foundations for a sound therapeutic relationship. A key aspect of this interview is to dedicate adequate time to listening to patients’ views about their eating problems and treatment. This is especially important as their opinions on these issues will have rarely, if ever, been sought. Another important strategy for engaging younger patients involves emphasizing that in CBT-E the therapist will be operating entirely on their behalf rather than as an agent of their parents. One obstacle to engagement is that many younger patients ignore or treat as irrelevant the negative effects of their eating problems because they are focused entirely on the positive effects of controlling eating, shape, and weight. In such cases, a joint exploration of whether the control of eating, shape, and weight is a free choice, or whether it may have become a problem over which the young person no longer has control, may facilitate motivation to change.
The detailed assessment of the development and the current status of the eating problem in adolescents is similar to that for adults. The adult version of the Eating Disorder Examination Questionnaire (EDE-Q) is suitable for patients aged 16 or over, and a modified version is also available for use with younger patients.
If CBT-E is to be recommended, it is important that it is accurately portrayed. Table 1 lists the main points that we make when describing the treatment to younger patients. Once patients have had an opportunity to ask questions and air concerns, it is our practice to suggest that they think over what has been proposed and let us know by the next appointment whether they would like to proceed with the treatment.
In the second evaluation session, generally held 1 week after the first, the assessing clinician reviews with the young person the pros and cons of starting the treatment, reinforces interest in change, and addresses any questions about the treatment.
Parental Involvement
In adults, significant others (friends, partner, or parents) are only seen with the consent of the patient and if it is thought likely that it will be beneficial to treatment. While similar principles apply to the treatment of adolescent patients, parents are invariably involved given these patients’ age and circumstances. Despite this, the great majority of sessions involve the adolescent patient alone.
A joint interview with parents or other relevant family members and the patient takes place after the initial session with the patient alone. The aim of this interview is to inform family members about the nature of the eating problem and to describe CBT-E in outline, focusing in particular on the role of parents in the treatment. A second joint interview takes place after the patient is seen for the second time when the family is told about the young person’s decision concerning treatment.
Subsequently parental or family involvement in CBT-E usually comprises an interview of about 90 min with parents alone in the first week of treatment and about four to six (in patients who are not underweight) and eight to ten (in patients who are underweight) 15–20 min sessions with the patient and parents together immediately after an individual session. Additional sessions with parents may take place in rare circumstances (i.e., in the event of family crises, extreme difficulties at mealtimes, or parental hostility toward the young patient).
The main aim of the session with parents alone is to identify and address family factors liable to hinder patients’ attempts to change. Its content and rationale is carefully explained to the patient beforehand so as to avoid jeopardizing the trust that has already begun to be built between the clinician and the patient. The 15–20 min joint sessions with patients and parents together have two main aims: (i) to inform parents about what is happening in treatment and about the patient’s progress and (ii) to discuss, with the prior agreement of the patient, how they might help the patient make changes.
General Strategies
CBT-E for younger patients, as for adults, is primarily concerned with the processes that maintain eating disorder psychopathology. The key strategy is therefore to create a formulation of the main mechanisms maintaining the individual’s eating problem thereby highlighting the processes to be addressed in treatment. The eating disorder psychopathology is addressed by means of a flexible series of sequential cognitive behavioral procedures and strategies, integrated with progressive patient education. The treatment focuses on the use of strategic changes in behavior rather than direct cognitive restructuring to modify thinking. Real-time self-monitoring and the accomplishment of strategically planned homework are of fundamental importance in achieving change. In the first phase of treatment, patients are encouraged to observe themselves and their behavior in real time and to engage in an attempt to change by considering the effects of their behavior. In the later phases of the treatment, when the main maintenance processes have been disrupted to a great extent, patients are shown how to manipulate their dysfunctional mindset when it is triggered.
Stage One (Starting Well)
The sessions are twice a week for 4 weeks and include the following:
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Engaging the patient in treatment and change. Although younger patients voluntarily decide to start CBT-E, it is common that they are very ambivalent about treatment and change. For this reason getting patients “on board” with treatment should be a priority during the entire course of CBT-E.
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Jointly creating the formulation of the processes maintaining the eating disorder. The creation of the personal formulation is very similar to that described for adults, but it is important to use terms and concepts that are familiar to younger patients and make sense to them. For adolescents, diagrams are often more helpful than words in thinking and communicating about formulations. As with adults, the formulation should be simple and focused only on the main maintaining mechanisms. Other elements may be added later as the therapist and patient achieve a better understanding of the eating problem.
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Establishing real-time self-monitoring of eating and other relevant thoughts and behaviors. The monitoring record used with younger patients is the same to that used with adults. Some adolescents ask about using smartphones and other specific apps for recording, but at present this practice should be discouraged because apps are often designed simply as food diaries and cannot easily be used with the flexibility and aims of CBT-E-monitoring records.
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Providing education. Younger patients, as with adults, are educated about body weight regulation and fluctuations, the physical complications of self-induced vomiting and laxative misuse as a means of weight control (if applicable), and the adverse effects of dieting. With older adolescents (i.e., more than 16 years of age), it is recommended that they read the book “Overcoming Binge Eating” to obtain reliable information. As with adults their reading is discussed in subsequent treatment sessions. With younger adolescents it is preferable to dedicate more time for education and discussion during treatment sessions.
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Establishing collaborative in session weighing. The procedure is similar to that adopted with adults and involves the patient and therapist checking the patient’s weight once a week and plotting it on an individualized weight graph. With adolescents, unlike with adults, weight status should be assessed using BMI centile cards.
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Introducing a pattern of regular eating involving planned meals and snacks. The procedure is the same as with adults and includes three components: (i) patients should eat three planned meals each day plus two or three planned snacks, (ii) patients’ eating should be confined to these meals and snacks, and (iii) patients should choose what they eat in their planned meals and snacks. With adolescents, unlike adults, parents and/or family members are usually involved in supporting regular eating (e.g., preparing meals following a written plan devised by the patient, creating a positive atmosphere and avoiding discussions about food or arguments during meals, and being supportive rather than being coercive in difficult situations during meals).
Stage Two
Stage Two, as with adults, comprises one or two sessions a week apart with the following goals: (i) conducting a joint review of progress, (ii) identifying emerging barriers to change, (iii) reviewing the formulation, (iv) deciding whether to use the broad form of CBT-E, and (v) designing the rest of the treatment. Younger patients often view their progress in an unduly negative light. It is especially important therefore that therapists help patients arrive at a balanced appraisal of what has changed and what has not.
Stage Three
In Stage Three, as in the adult version, treatment becomes more individualized, being determined by the patient’s psychopathology. Patients are seen once a week for 8 weeks, and their eating disorder psychopathology is addressed using one or more of the following modules as required:
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Overevaluation module. As in adults, the overevaluation of shape and weight is addressed using two strategies: (i) increasing the importance of other areas of life such as encouraging younger patients to take up or resume the activities of their peers (e.g., participating in sport or other hobbies, going to parties, etc.) and (ii) reducing the importance of shape, weight, and their control by addressing shape checking, body avoidance, and feeling fat. Shape checking, in particular mirror checking, and comparisons with peers and with media images (e.g., in magazines and the Internet) are often frequent and extreme in adolescents and need to be actively addressed in several sessions.
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Dietary restraint module. Dietary restraint is addressed with the same strategies and procedures as it is in adults. Highlighting the impairment caused by dietary restraint in social relationship with peers (i.e., inability to go parties, eat out, etc.) may help younger patients to see extreme and rigid dietary rules as a problem. The youngest patients may also be helped by their parents to address some dietary rules. For example, they may be accompanied by a parent to a supermarket to make a list of avoided food or to eat foods of unknown composition when they are out (e.g., at a restaurant).
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Events, moods, and eating module. The procedures to address events, moods, and eating are similar to that used with adults and include proactive problem solving (used in almost all cases) and directly addressing mood intolerance in the subgroup of cases for whom it is indicated. Training in proactive problem solving is particularly important in young patients who have major deficits in social skills and interpersonal problem solving.
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Setbacks and mindset module. Younger patients tend to achieve periods free from concern about their shape, weight, and control faster than adults. When this occurs, patient should learn about mindsets and how to control them. The DVD analogy is very useful with adolescents, and it is always used to explain the abstract concept of mindset. Adolescents are encouraged to “eject the eating disorder DVD” as soon as possible and to practice this skill for use in the future in dealing with any setbacks.
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Broad CBT-E modules. The broad version of CBT-E may be used with younger patients. However, as with adults, the focused version is the default version, and it is advisable to use the broad version with parsimony. If clinical perfectionism, core low self-esteem, or interpersonal difficulties are maintaining the eating disorder and proving an obstacle to treatment, they should be addressed. In practice no more than two broad modules should be used, and they should be addressed in conjunction with tackling core eating disorder psychopathology.
Stage Four (Ending Well)
Ending treatment well is essential. The procedures involved in doing this are similar to those described for adults. Adolescent patients may be keener to end treatment than adults because of their sensitivity to the associated stigma from peers. The last phase in treatment consists of three sessions held every 2 weeks. There are two main tasks: (i) ensuring that progress is maintained after the end of therapy by devising a short-term maintenance plan to focus on particular residual problems and the strategies required to address them and (ii) minimizing the risk of relapse by devising a long-term maintenance plan to identify and deal with setbacks.
During Stage Four self-monitoring and in-session weighing are phased out in preparation for ending treatment. A follow-up session 20 weeks after the end of treatment is arranged to ensure that the patients continue to make progress.
Patients Who Are Underweight
For patients who are underweight, CBT-E has three main steps with sessions held twice a week until patients achieve a stable pattern of weight regain. Frequency is then reduced to weekly sessions. Stage-two-style reviews take place every 4 weeks until low normal weight is restored.
Step One, which lasts from 4 to 8 weeks, has as its main goal the engagement of patients in the process of treatment and change. Once engaged the therapist should help patients see the need to regain weight and encourage them to make a decision to do so. It is important that patients make the decision to regain weight themselves rather than have it imposed on them. In discussing the implications of weight regain, it is better to help younger patients focus on the immediate future (6 months to a year) rather than on the longer term (5 years or more), as the latter is more difficult, if not impossible, for adolescent patients to envisage. The other goals of Step One are similar to those of Stage One of the 20-week version of treatment: patients are helped to increase their understanding of their eating problem, to reduce their concerns about weight with the collaborative in session weighing, and to establish a pattern of regular eating.
In Step Two patients are encouraged and helped to regain weight while at the same time addressing their eating disorder psychopathology and the processes maintaining it using the modules of Stage Three described above. The major goal is to help patients achieve a low-healthy weight – one that will not perpetuate the eating disorder. In patients aged 18 or more, a BMI between 19.0 and 20.0 is generally reasonable. In patients under 18, therapists should identify the comparable BMI centile. Patients are told that the optimal rate of weight regain is approximately 0.5 kg per week and that to achieve this they will need to consume, on average, an extra 500 kcal of energy each day over and above what they are currently consuming, assuming their weight is stable. Patients are informed that they will be actively involved in the process of weight regain and in interpreting weekly weight change. Parents are provided with the same information, and possible ways in which they can help and encourage the patient during meals are discussed in a joint session.
In Step Three the focus is on helping patients to become accomplished at weight maintenance and at maintaining the other changes that they have made. This includes developing personalized strategies for minimizing the risk of relapse (see section “Stage Four (Ending Well)” above) and rapidly reversing setbacks if they occur.
Effectiveness of CBT-E for Younger Patients
CBT-E for younger patients has been evaluated in three cohort studies of patients aged between 13 and 19 years. Two studies included adolescents with severe anorexia nervosa and one was of adolescents who were not underweight with other eating disorders.
In the first study, 49 patients with marked anorexia nervosa were offered treatment and 46 accepted suggesting that this form of treatment was acceptable to the great majority of patients. The patients were substantially underweight with a mean BMI centile of 2.86 (SD 3.35, range 0.5–13.0, median 0.75) and 23 patients (50 %) having a BMI centile of <1. Two-thirds completed the full 40 sessions of treatment. In the patients who completed treatment, there was a substantial increase of BMI centile from 3.36 (SD = 3.73) to 30.3 (SD = 16.7) together with a marked decrease in eating disorder psychopathology with almost all patients (96.6 %) having only minimal residual eating disorder psychopathology at the end of treatment, defined as having a global EDE-Q score below 1SD above the community mean. General psychiatric features also improved substantially. At 60 week follow one-third of the total sample and 45 % of completers had gained sufficient weight to reach 95 % of the expected weight for their age and sex.
The second study assessed the effect of CBT-E in a group of 27 adolescent inpatients with severe anorexia nervosa. The patients were substantially underweight with a mean BMI centile of 2.7 (SD 4.3) and with 16 patients (60 %) having a BMI centile of <1. All but one patient completed treatment. There was a marked increase in weight. By the end of treatment, the mean BMI centile had increased to 34.2 (SD 15.7). At 6-month follow-up the mean BMI centile was 27.3 (SD 20.8) and at 12-month follow-up it was 29.9 (SD 20.1), and 81.5 % of patients had a BMI centile corresponding to a BMI ≥18.5. There was also a marked decrease in the level of eating disorder and general psychopathology from baseline to discharge that was maintained at both the 6- and 12-month follow-up.
The third study evaluated the effects of CBT-E on 68 non-underweight adolescents with an eating disorder. Three-quarters (51) completed the full 20 sessions. Intent-to-treat analysis showed a marked treatment response with just over two-thirds (68 %) having minimal residual eating disorder psychopathology by the end of treatment and 50 % of those who were binge eating or purging at the beginning of treatment having ceased to do so by the end of treatment. A limitation of this study is that there was no follow-up and so the longer-term effects of treatment could not be studied.
While these studies suggest that CBT-E appears to be a promising treatment for younger patients, it should be noted that, at present, there are no randomized controlled trials (RCTs) comparing CBT-E for adolescents with either wait list controls or other active treatments.
Future Directions
CBT-E is a promising treatment for adolescents with eating disorders. It has a number of advantages. It is acceptable to young people, and its collaborative nature is well suited to ambivalent young patients who may be particularly concerned about issues of control. The transdiagnostic scope of the treatment is an advantage as it is able to treat the full range of disorders that occur in adolescent patients. It therefore provides a potentially good alternative to FBT. As noted, the evidence to date supporting CBT-E for young people is from cohort studies. Further support is required for both the efficacy and comparative efficacy of CBT-E from RCTs. In particular, there is an urgent need to compare CBT-E with FBT, the other leading approach for adolescent eating disorders, across the full range of eating disorder presentations. Such a study would provide valuable information about how best to treat adolescent eating disorders as well as further understanding about the mechanisms of action of the two treatments. Perhaps most important from a clinical standpoint would be the identification of moderators of treatment response that might assist clinicians in matching young patients to CBT-E or FBT.
References and Further Reading
Calugi, S., Dalle Grave, R., Sartirana, M., & Fairburn, C. G. (2015). Time to restore body weight in adults and adolescents receiving cognitive behaviour therapy for anorexia nervosa. Journal of Eating Disorders, 3, 21.
Carter, J. C., Stewart, D. A., & Fairburn, C. G. (2001). Eating disorder examination questionnaire: Norms for adolescent girls. Behaviour Research and Therapy, 39, 625–632.
Cooper, Z., & Stewart, A. D. (2008). CBT-E and the younger patient. In C. G. Fairburn (Ed.), Cognitive behavior therapy and eating disorders (pp. 221–230). New York: Guilford Press.
Dalle Grave, R. (2013). Multistep cognitive behavioral therapy for eating disorders: Theory, practice, and clinical cases. New York: Jason Aronson.
Dalle Grave, R., Calugi, S., Doll, H. A., & Fairburn, C. G. (2013). Enhanced cognitive behaviour therapy for adolescents with anorexia nervosa: An alternative to family therapy? Behaviour Research and Therapy, 51, R9–R12.
Dalle Grave, R., Calugi, S., El Ghoch, M., Conti, M., & Fairburn, C. G. (2014). Inpatient cognitive behavior therapy for adolescents with anorexia nervosa: Immediate and longer-term effects. Frontiers in Psychiatry, 5, 14.
Dalle Grave, R., Calugi, S., Sartirana, M., & Fairburn, C. G. (2015). Transdiagnostic cognitive behaviour therapy for adolescents with an eating disorder who are not underweight. Behaviour Research and Therapy, 73, 79–82.
Dalle Grave, R., El Ghoch, M., Sartirana, M., & Calugi, S. (2016). Cognitive behavioral therapy for anorexia nervosa: An update. Current Psychiatry Reports, 18, 1–8.
Fairburn, C. G. (2008). Cognitive behavior therapy and eating disorders. New York: Guilford Press.
Fairburn, C. G. (2013). Overcoming binge eating: The proven program to learn why you binge and how you can stop (2nd ed.). New York: Guilford Press.
Lock, J., & Le Grange, D. (2013). Treatment manual for anorexia nervosa: A family-based approach (2nd ed.). New York: Guilford Press.
Lock, J., Le Grange, D., Agras, W. S., Moye, A., Bryson, S. W., & Jo, B. (2010). Randomized clinical trial comparing family-based treatment with adolescent-focused individual therapy for adolescents with anorexia nervosa. Archives of General Psychiatry, 67, 1025–1032.
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Dalle Grave, R., Cooper, Z. (2016). Enhanced Cognitive Behavior Treatment Adapted for Younger Patients. In: Wade, T. (eds) Encyclopedia of Feeding and Eating Disorders. Springer, Singapore. https://doi.org/10.1007/978-981-287-087-2_176-1
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DOI: https://doi.org/10.1007/978-981-287-087-2_176-1
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