Eating Disorders

Why CBT-E for Adolescents with Eating Disorders?

CBT-E is an alternative to FBT for adolescents with eating disorders.

Posted Jan 31, 2020

Eating disorders have a profound impact on the physical health and psychological and interpersonal development of adolescents. Early intervention and effective treatment are essential in order to avoid long-lasting psychological and medical complications including, in some cases, an early death. 

A specific form of family therapy, termed family-based treatment (FBT), 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 embraced by all families and patients because it requires parents to participate at sessions and that parents control the eating of their child. It’s also is labor-intensive, and fewer than half of patients exhibit a full recovery. These considerations indicate that alternative approaches are needed.

CBT-E (Enhanced Cognitive Behavior Therapy)

CBT-E was developed to address the psychopathology of eating disorders in adults, rather than a specific eating disorder diagnosis. It is a treatment for all forms of eating disorders including anorexia nervosa, bulimia nervosa, binge-eating disorder, and other similar states​. 

When working with people who are not significantly underweight, CBT-E generally involves an initial assessment appointment followed by 20 individual treatment sessions over 20 weeks, lasting 50-minutes each. 

With people who are underweight, treatment needs to be longer, often involving around 40 sessions over 40 weeks. In this version of CBT-E, weight regain is integrated with addressing eating disorder psychopathology. Before embarking on weight regain, patients and therapists spend the first weeks of this treatment carefully considering the reasons for and against this change. The goal in CBT-E is for patients themselves to decide to regain weight rather than having this decision imposed upon them. During the final step of weight regain, the patients are helped to successfully maintain their weight.

CBT-E can be delivered in two forms: (1) a “focused” form, which exclusively addresses the specific psychopathology of eating disorders, or (2) a “broad” form, which features specific modules to address one or more of the adjunctive mechanisms maintaining the eating disorder (i.e., clinical perfectionism, core low self-esteem, interpersonal difficulties, and mood intolerance).

CBT-E has been evaluated in numerous controlled and cohort clinical trials and is now recommended for all clinical forms of adult eating disorders. 

CBT-E adapted for adolescents

CBT-E has been adapted for adolescents taking into account two distinctive characteristics, namely physical health and parental involvement. Indeed, some medical complications associated with eating disorders are particularly severe in this age range, therefore periodical medical assessments and a lower threshold for hospital admission are integral parts of CBT-E for adolescents. In addition, parental involvement in the treatment is required in the great majority of cases. 

CBT-E has a number of features that make it well suited to adolescent patients with eating disorders. Firstly, it adopts a flexible and individualized approach, which is easily adaptable to the needs of adolescents’ cognitive development. Indeed, CBT-E isn’t a “one-size-fits-all” treatment. The therapist creates a specific version of CBT-E to match the exact eating problem of the person receiving treatment. Moreover, CBT-E is both comprehensible and easy to receive and promotes the pursuit of control and autonomy as it actively involves the patients in the decision to change. These are issues of major relevance to younger patients, who therefore respond favorably to a collaborative treatment such as CBT-E. Last but not least, CBT-E includes several strategies for actively engaging patients in the treatment, a feature that is vital for the management of adolescents who, by nature, are usually ambivalent about their treatment.

CBT-E for adolescents involves two preparatory/assessment sessions followed by three main steps: Step One – Starting Well and Deciding to Change; Step Two – Addressing the Change; Step Three – Ending Well. Treatment is delivered, as the adult version of CBT-E, by a single therapist in 20 sessions in not underweight patients, but in those patients who are underweight, treatment can be often concluded in 30 sessions, and it can be delivered in the “focused” or in the  “broad” form.

Parents are asked to participate alone in an interview lasting approximately 90 minutes during the first week of the treatment. Subsequently, the patient and parents are seen together in sessions four to six (in patients who are not underweight) or sessions eight to ten (in patients who are underweight). Further, 15 to 20 minutes sessions are held immediately after the patient’s individual session. These joint sessions should inform parents about what is happening and the patient’s progress; they should also be used to discuss, with the patient’s prior agreement, how they might help the patient make changes.

How effective is CBT-E for adolescents? 

To date, four different cohort studies on patients aged between 11 and 19 years assessed the effectiveness of CBT-E for adolescents. Three of the four studies investigated the effects on patients with anorexia nervosa, and one investigated the effects on non-underweight adolescents with other eating disorders. Findings from these studies showed that most adolescent patients with eating disorders agreed to address the treatment. In patients with anorexia nervosa who complete the treatment (60 to 65 percent) about 60 percent achieved a full response (i.e., normal weight and minimal eating disorder psychopathology), while about 70 percent of non-underweight patients displayed minimal residual eating disorder psychopathology, and half of those with prior episodes of binge-eating or purging reported no longer having them. 

The results of these studies led the National Institute for Health and Clinical Excellence (NICE) guidelines to recommend CBT-E for adolescents with eating disorders as an alternative to FBT when FBT is unacceptable, contraindicated, or ineffective.

Conclusions

In conclusion, 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 strong alternative to FBT.  

References

Dalle Grave, R. (2019). Cognitive-behavioral therapy in adolescent eating disorders. In J. Hebebrand & B. Herpertz-Dahlmann (Eds.), Eating disorders and obesity in children and adolescents (pp. 111-116). Philadelphia: Elsevier.

Dalle Grave, R., & Calugi, S. (2020). Cognitive behavior therapy for adolescents with eating disorders. New York: Guilford Press.

Dalle Grave, R., Sartirana, M., & Calugi, S. (2019). Enhanced cognitive behavioral therapy for adolescents with anorexia nervosa: Outcomes and predictors of change in a real-world setting. International Journal of Eating Disorders, 0(0). doi:10.1002/eat.23122

Lock, J., & Le Grange, D. (2019). Family-based treatment: Where are we and where should we be going to improve recovery in child and adolescent eating disorders. International Journal of Eating Disorders, 52(4), 481-487. doi:10.1002/eat.22980

National Institute for Health and Care and Clinical Excellence. (2017). Eating disorders: recognition and treatment | Guidance and guidelines | NICE. Retrieved from https://www.nice.org.uk/guidance/ng69