Cognitive Behavioral Therapy for Anorexia Nervosa: An Update
- 3.6k Downloads
Cognitive behavioral therapy (CBT) for anorexia nervosa (AN), based on Beck’s cognitive theory, was developed in a “generic” form in the early eighties. In recent years, however, improved knowledge of the mechanisms involved in maintaining eating disorder psychopathology has led to the development of a “specific” form of CBT, termed CBT-E (E = enhanced), designed to treat all forms of eating disorders, including AN, from outpatient to inpatient settings. Although more studies are required to assess the relative effectiveness of CBT-E with respect to other available treatments, the data indicate that in outpatient settings it is both viable and promising for adults and adolescents with AN. Encouraging results are also emerging from inpatient CBT-E, particularly in adolescents, and clinical services offering CBT-E at different levels of care are now offered in several countries around the world. However, CBT-E requires dissemination in order to become widely available to patients.
KeywordsCognitive behavior therapy Eating disorders Anorexia nervosa Bulimia nervosa Inpatient treatment Adolescence
The authors are very grateful to Christopher G. Fairburn for his suggestions and comments.
Compliance with Ethical Standards
Conflict of Interest
Riccardo Dalle Grave, Marwan El Ghoch, Massimilano Sartirana, and Simona Calugi declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This research did not rely on any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 5.Fairburn CG. Evidence-based treatment of anorexia nervosa. Int J Eat Disord. 2005;37 Suppl:S26-30; discussion S41-2. doi: 10.1002/eat.20112.
- 12.Garner DM, Bemis KM. Cognitive therapy for anorexia nervosa. In: Garner DM, Garfinkel PE, editors. Handbook of psychotherapy for anorexia nervosa and bulimia. New York: Guilford Press; 1985. p. 107–46.Google Scholar
- 13.Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive therapy of depression. New York: Guilford Press; 1979.Google Scholar
- 15.Vitousek KB, Ewald LS. Self-representation in eating disorders: a cognitive perspective. In: Segal ZV, Blatt SJ, editors. The self in emotional distress: cognitive and psychodynamic perspectives. New York: Guilford; 1993. p. 221–66.Google Scholar
- 18.Vitousek KM. The current status of cognitive-behavioral models of anorexia nervosa and bulimia nervosa. In: Salkovskis P, editor. Frontiers of cognitive therapy. New York: Guilford Press; 1996. p. 383–418.Google Scholar
- 23.Fairburn CG. Cognitive-behavioral treatment for bulimia. In: Garner DM, Garfinkel PE, editors. Handbook of psychotherapy for anorexia nervosa and bulimia. New York: Guilford Press; 1985. p. 160–92.Google Scholar
- 24.Fairburn CG, Marcus MD, Wilson GT. Cognitive-behavioral therapy for binge eating and bulimia nervosa: a comprehensive treatment manual. In: Fairburn CG, Wilson GT, editors. Binge eating: nature, assessment and treatment. New York: Guilford Press; 1993. p. 361–404.Google Scholar
- 30.••Dalle Grave R. Multistep cognitive behavioral therapy for eating disorders: theory, practice, and clinical cases. New York: Jason Aronson; 2013. This treatment manual outlines the theory and clinical application of multistep CBT-E for eating disorders.Google Scholar
- 31.Cooper Z, Stewart A. CBT-E and the younger patient. In: Fairburn CG, editor. Cognitive behavior therapy and eating disorders. New York: Guilford Press; 2008.Google Scholar
- 32.Grave Dalle R. Intensive cognitive behavior therapy for eating disorders. Hauppauge: Nova; 2012.Google Scholar
- 33.••Fairburn CG, Cooper Z, Doll HA, O’Connor ME, Palmer RL, Grave Dalle R. Enhanced cognitive behaviour therapy for adults with anorexia nervosa: a UK-Italy study. Behav Res Ther. 2013;51(1):R2–8. doi: 10.1016/j.brat.2012.09.010. This cohort study showed that CBT-E is a promising treatment for adults with anorexia nervosa.PubMedCentralCrossRefPubMedGoogle Scholar
- 34.••Dalle Grave R, Calugi S, Doll HA, Fairburn CG. Enhanced cognitive behaviour therapy for adolescents with anorexia nervosa: an alternative to family therapy? Behav Res Ther. 2013;51(1):R9–12. doi: 10.1016/j.brat.2012.09.008. This cohort study showed that CBT-E is a promising treatment for adolescents with anorexia nervosa.PubMedCentralCrossRefPubMedGoogle Scholar
- 35.•Calugi S, Dalle Grave R, Sartirana M, Fairburn CG. Time to restore body weight in adults and adolescents receiving cognitive behaviour therapy for anorexia nervosa. Int J Eat Disord. 2015;3:21. doi: 10.1186/s40337-015-0057-z. This study showed that with CBT-E significantly more adolescents reached a normal body mass index range than adults, and the mean time to restore body weight was about 15 weeks less in adolescents than in adults.CrossRefGoogle Scholar
- 36.••Zipfel S, Wild B, Gross G, Friederich HC, Teufel M, Schellberg D, et al. Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): randomised controlled trial. Lancet. 2014;383(9912):127–37. doi: 10.1016/s0140-6736(13)61746-8. A randomized controlled trial in adults with anorexia nervosa that compared a hybrid form of CBT-E with focal psychodynamic therapy, and optimized treatment as usual, with the option of hospitalization. No significant differences emerged between the three interventions with regard to the primary outcome variable, gain in BMI. A proportion of this weight gain is likely to have been the result of hospitalization as this amounted to 25 days on average.CrossRefPubMedGoogle Scholar
- 39.••Dalle Grave R, Calugi S, Conti M, Doll H, Fairburn CG. Inpatient cognitive behaviour therapy for anorexia nervosa: a randomized controlled trial. Psychother Psychosom. 2013;82(6):390–8. doi: 10.1159/000350058. This randomized controlled trial compared the effects of the focused and broad form of inpatient CBT-E in patients with anorexia nervosa. No significant differences emerged between the two programs in terms of changes seen either at the end of treatment or at follow-up.PubMedCentralCrossRefPubMedGoogle Scholar
- 40.•Dalle Grave R, Calugi S, El Ghoch M, Conti M, Fairburn CG. Inpatient cognitive behavior therapy for adolescents with anorexia nervosa: immediate and longer-term effects. Front Psychiatry. 2014;5:14. doi: 10.3389/fpsyt.2014.00014. This cohort study showed that inpatient CBT-E is a promising treatment for adolescents with anorexia nervosa. Notably, the improvement in weight, eating disorder features, and general psychopathology at the end of hospitalization was well maintained at 12-month follow-up.PubMedCentralCrossRefPubMedGoogle Scholar
- 41.•Turner H, Marshall E, Stopa L, Waller G. Cognitive-behavioural therapy for outpatients with eating disorders: effectiveness for a transdiagnostic group in a routine clinical setting. Behav Res Ther. 2015;68:70–5. doi: 10.1016/j.brat.2015.03.001. This study assessed the effect of CBT-E in a transdiagnostic group of outpatients with eating disorders treated in a real world clinical service.CrossRefPubMedGoogle Scholar
- 43.National Institute for Clinical Excellence. Eating disorders: core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. London: National Institute for Clinical Excellence; 2004.Google Scholar
- 44.Keys A, Brozek J, Henschel A, Mickelsen O, Taylor HL. The biology of human starvation. Minneapolis: University of Minnesota Press; 1950.Google Scholar
- 47.Fairburn CG. Cognitive behavior therapy and eating disorders. New York: Guilford Press; 2008.Google Scholar
- 48.Dalle Grave R, Bohn K, Hawker D, Fairburn CG. Inpatient, day patient and two forms of outpatient CBT-E. In: Fairburn CG, editor. Cognitive behavior therapy and eating disorders. New York: Guilford Press; 2008. p. 231–44.Google Scholar
- 51.National Collaborating Centre for Mental Health. The access and waiting time standard for children and young people with an eating disorder. Commissioning Guide. Version 1.0. July 2015. http://www.england.nhs.uk/wp-content/uploads/2015/07/cyp-eating-disorders-access-waiting-time-standard-comm-guid.pdf
- 52.•Fairburn CG, Patel V. The global dissemination of psychological treatments: a road map for research and practice. Am J Psychiatry. 2014;171(5):495–8. doi: 10.1176/appi.ajp.2013.13111546. This article suggests innovative ways to improve the dissemination of evidence-based psychological treatments.CrossRefPubMedGoogle Scholar