This chapter was revised by Círia Pereira, currently head of the Eating Disorders Consultation of Centro Hospitalar Lisboa Ocidental
Brief historic overview and description
Cognitive Behavioral Therapy (CBT) was firstly applied to eating disorders for treatment of Bulimia nervosa (BN) nearly 40 years ago (Fairburn, CG 1981).
Anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED) and most cases of eating disorder NOS share a distinctive “core psychopathology” that is cognitive in nature. It is characterized by an over-evaluation of body shape and weight and their control. For instance, patients with AN attempt to restrict their food intake in the same rigid and extreme way as patients with BN, and they too may vomit, misuse laxatives or diuretics, and over-exercise (Murphy R, et al 2010).
Based on this common “core psychopathology”, Fairburn, Cooper, and Shafran developed Enhanced Cognitive Behavior Therapy (CBT-E) as a re-conceptualization that extends the original CBT to all eating disorders. This transdiagnostic theory of CBT-E (Fig 1) identifies several other maladaptive cognitive processes associated with most patients like individual traits of perfectionism, low self-esteem, interpersonal difficulties and mood intolerance that can create further obstacles to treatment. Also suggeste a common pathological core, i.e. the majority of patients with eating disorders do not present a stable diagnose on the contrary, fluctuate between diagnoses within this group of disorders.
This revolutionary approach to EDs based on a more holistic understanding of these group of disorders have been proved to result in a more generalized application of CBT-E and a more successful treatment of this patients.
Figure 1: The “transdiagnostic” cognitive behavioral theory. From Cognitive Behavior Therapy and Eating Disorders by Christopher G. Fairburn. Copyright 2008 by The Guilford Press
CBT-E can be described as a subtype of CBT that shifts the therapy’s focus to the processes maintaining patients’ eating disorder psychopathology, rather than focusing on the cause of eating disorders.
Sessions are generally of fixed length, usually 30 minutes with the standard protocol including 20 treatment sessions over 20 weeks and can be divided in four relatively well-defined stages (Table 1).
Stage One is an intensive stage and appointments are twice-weekly. The magnitude of change in the first few weeks of treatment is a potent predictor of outcome. Therefore, it’s crucial to engage the patient in treatment and change, to jointly create a personalized plan with a realistic set of goals and provide relevant education. In this stage, two potent CBT-E procedures must be introduced “in-session weighing” and “regular eating”, which will continue to be done until the end of the therapy. Before starting stage 2 patients should be informed about weight, weighting and weight change, and should be learning to eat regular meals without eating between them.
Stage Two is a transitional stage and its purpose is to identify emerging difficulties and eventually review and change the plan defined in stage one if required. Appointments are weekly from this stage on and it is after this point that CBT-E becomes highly individualized.
Stage Three is the core of the treatment and the aim is to address the main processes maintaining the patient’s eating disorder. It usually comprises eight weekly appointments.
Stage Four is the final stage and has two fundamental objectives: to make sure the achieved changes are maintained (over the subsequent 20 weeks), and to minimize the risk of relapse in the long-term. The appointments are scheduled at 2-week intervals.
Stage in treatment
Week in treatment
Initial session, 1
20 weeks post-treatment
Table 1: The Temporal Pattern of Appointments in the 20-Session Version of CBT-E. Adapted from Cognitive Behavior Therapy and Eating Disorders by Christopher G. Fairburn 2008 by The Guilford Press
Main uses and Efficacy
Bulimia Nervosa (BN):
CBT-E is considered the treatment of choice being superior to other psychotherapies namely interpersonal psychotherapy or psychodynamic psychotherapy, with 30 to 50 percent of individuals reporting symptom abstinence following treatment and a higher percentage reporting symptom reduction (Fairburn CG et al 1993). It’s more effective in reducing binge eating and purging than other strategies and also more cost-effective (Stefini A et al 2017). CBT-E for bulimia nervosa has also been adapted into self-guided help formats, showing greater effectiveness than a waitlist control condition (Agras WS et al 2019).
Binge eating disorder (BED):
BN and BED are both characterized by recurrent episodes of uncontrolled, excessive intake of food, therefore the treatment research for BED has focused on interventions that are equally effective in bulimia nervosa. However, the substantial portion of patients with BED who are overweight or obese may require additional intervention to achieve a healthier body weight.
As in bulimia nervosa, CBT is a highly effective treatment for BED with over 50 percent of individuals attaining abstinence from binge eating following treatment. CBT-E for BED is structured similarly to CBT-E for bulimia nervosa, without the focus on inappropriate compensatory behaviors (Agras, WS. et al 2019).
Anorexia nervosa (AN):
AN can be divided in two different phases: the acute phase in adolescence and the persistent phase usually evident in adults (Agras WS. et al 2019). Family-based therapies have shown to be effective in the acute phase or the adolescent form of AN with remission rates close to 40 % and improving rates up to 60%. Consequently, it’s recommended as a first-line treatment for adolescent AN. Regarding the adult phase, no particular psychotherapy has shown to be preferable, although several are used and recommended for clinical management of the disorder (Zipfel, S. et al 2014). CBT-E for AN is based on a similar model to the other eating disorders with concerns about weight, dieting leading to weight loss and maintenance of those losses. It may be useful to double the standard number of sessions to 40 sessions for better outcomes (Agras, WS. Et al 2019).
Comment from an expert and or quote from a famous psychotherapist (founder)
“Eating disorders and CBT are a perfect match because eating disorders are fundamentally cognitive disorders and CBT is of its very nature designed to produce cognitive change”.
Christopher G Fairburn, Professor of Psychiatry at the University of Oxford, in Cognitive behavior therapy and eating disorders
Comment from a trainee with some kind of experience (duration of the training, personnal thoughts)
“E-CBT evolved from an approach focused on the most severe and noticeable symptoms of Eating Disorders to a holistic clinical methodology exploring the most profound individual factors that determined the sprout of these diseases… it is still a truly updated concept of treatment…”
João Facucho-Oliveira, psychiatric trainee, Hospital de Cascais , Portugal
Books, manual, videos, published online courses or international association
Research opportunities in the field of CBT-E are vast and varying from determining whether CBT-E is culturally sensitive and efficacious for patients of different ethnic groups or to determine whether the success rates vary depending on gender. Additionally, investigating patterned presentations and personality traits might allow to develop more exquisite and patient-specific models of treatment. Indeed, initial evidence suggest that more “complex” patients who exhibit particular patterns of the maintaining processes, may have higher clinical benefits with CBT-E. These clinical presentations and the role of CBT-E on their clinical remission may benefit further investigation. Finally, it is still to clarify if integrated programs of treatment incorporating CBT-E, pharmacotherapy and occupational therapies are capable of promoting better clinical outcomes.
Agras WS. Cognitive Behavior Therapy for the Eating Disorders. Psychiatr Clin North Am. 2019;42(2):169-179.
Fairburn, CG. A cognitive behavioral approach to the treatment of bulimia. Psychological Medicine 1981, 11(4), 707–711
Fairburn, CG. Cognitive behavior therapy and eating disorders. New York: Guilford Press 2008.
Fairburn CG, Jones R, Peveler RC, Hope RA, O'Connor M. Psychotherapy and bulimia nervosa. Longer-term effects of interpersonal psychotherapy, behavior therapy, and cognitive behavior therapy. Arch Gen Psychiatry. 1993;50(6):419–428.
Murphy R, Straebler S, Cooper Z, Fairburn CG. Cognitive behavioral therapy for eating disorders. Psychiatr Clin North Am. 2010;33(3):611-627.
Stefini A, Salzer S, Reich G, et al. Cognitive-Behavioral and Psychodynamic Therapy in Female Adolescents With Bulimia Nervosa: A Randomized Controlled Trial. J Am Acad Child Adolesc Psychiatry. 2017;56(4):329-335.
Zipfel S, Wild B, Grob G, et al. Focal psychodynamic therapy, cognitive behavior therapy, and optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): Randomised controlled trial. Lancet. 2014;383(9912):127-137.