Cognitive-behavioral therapy (CBT) is the leading evidence-based treatment for eating disorders.﻿﻿ CBT is a psychotherapeutic approach that involves a variety of techniques. These approaches help an individual to understand the interaction between his or her thoughts, feelings, and behaviors and develop strategies to change unhelpful thoughts and behaviors in order to improve mood and functioning.

CBT itself is not a single distinct therapeutic technique and there are many different forms of CBT that share a common theory about the factors maintaining psychological distress. Acceptance and Commitment Therapy (ACT) and Dialectical Behavior Therapy (DBT) are examples of specific types of CBT treatments.﻿﻿

CBT is typically time-limited and goal-oriented and involves homework outside of sessions. CBT emphasizes collaboration between therapist and client and active participation by the client. CBT is very effective for a number of mental health concerns including depression, generalized anxiety disorder, phobias, and OCD.

History of CBT

CBT was developed in the late 1950s and 1960s by psychiatrist Aaron Beck, who emphasized the role of thoughts in influencing feelings and behaviors. CBT was initially developed to treat depression, although today it is an evidence-based treatment for many mental health conditions and symptoms, including disordered eating.

CBT for eating disorders was developed in the late 1970s by G. Terence Wilson, Christopher Fairburn, and Stuart Agras. These researchers identified dietary restriction and shape and weight concerns as central to the maintenance of bulimia nervosa, developed a 20-session treatment protocol, and began conducting clinical trials. In the 1990s, CBT was applied to binge eating disorder as well.﻿﻿

In 2008, Fairburn published an updated treatment manual for Enhanced Cognitive Behavioral Therapy (CBT-E) designed to treat all eating disorders. CBT-E comprises two formats: a focused treatment similar to the original manual, and a broad treatment with extra modules on mood intolerance, perfectionism, low self-esteem, and interpersonal difficulties that contribute to the maintenance of eating disorders.

CBT has been successfully applied in self-help and guided self-help formats for the treatment of bulimia nervosa and binge eating disorder. It can also be provided in group formats and higher levels of care, such as residential or inpatient settings.﻿﻿ More recent adaptations include the use of technology to widen the range of people who have access to effective treatments such as CBT.

Research has begun on the delivery of CBT treatment by different technologies, including email, chat, mobile app, and internet-based self-help. There is also support for a 10-session CBT for non-underweight eating disorder patients. This approach is brief and effective and allows more patients to get the help that they need.﻿﻿

CBT Effectiveness

CBT is widely considered to be the most effective therapy for the treatment of bulimia nervosa and should, therefore, usually be the initial treatment offered at the outpatient level.﻿﻿

The UK’s National Institute for Health and Care Excellence (NICE) guidelines recommend CBT as the first-line treatment for adults with bulimia nervosa and binge eating disorder and one of three potential treatments to consider for adults with anorexia nervosa.

One study compared five months of CBT (20 sessions) for women with bulimia nervosa with 2 years of weekly psychoanalytic psychotherapy.﻿﻿ Seventy patients were randomly assigned to one of these two groups.

After 5 months of therapy (the end of the CBT treatment), 42% of patients in the CBT group and 6% of the patients in the psychoanalytic therapy group had stopped binge-eating and purging. At the end of 2 years (completion of the psychoanalytic therapy), 44% of the CBT group and 15% of the psychoanalytic group were symptom-free.﻿﻿

Another study compared CBT-E with interpersonal therapy (IPT), an alternative leading treatment for adults with an eating disorder. In the study, 130 adult patients with an eating disorder were randomly assigned to receive either CBT-E or IPT.﻿﻿ Both treatments involved 20 sessions over 20 weeks, followed by a 60-week follow-up period.

At post-treatment, 66% of the CBT-E participants met criteria for remission, compared with only 33% of the IPT participants. Over the follow-up period, the CBT-E remission rate remained higher (69% versus 49%).

A 2018 systematic review concluded that CBT-E was an effective treatment for adults with bulimia nervosa, BED, and OSFED. It also noted that CBT-E for bulimia nervosa is highly cost-effective compared with psychoanalytic psychotherapy.﻿﻿

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Cognitive Model of Eating Disorders

The cognitive model of eating disorders posits that the core maintaining problem in all eating disorders is overconcern with shape and weight. The specific way this overconcern manifests can vary. It can drive any of the following:﻿﻿

Binge eating

Compensatory behaviors such as self-induced vomiting, laxatives, and excessive exercise

Low weight

Strict dieting

Further, these components can interact to create the symptoms of an eating disorder. Strict dieting—including skipping meals, eating small amounts of food, and avoiding forbidden foods—can lead to low weight and/or binge eating. Low weight can lead to malnutrition and also can lead to binge eating.

Bingeing can lead to intense guilt and shame and a renewed attempt to diet. It can also lead to efforts to undo the purging through compensatory behaviors. Patients typically get caught in a cycle.

Components of CBT Treatment

CBT is a structured treatment. In its most common form, it consists of 20 sessions. Goals are set. Sessions are spent weighing the patient, reviewing homework, reviewing the case formulation, teaching skills, and problem-solving.

CBT typically includes the following components:﻿﻿

Challenge of dietary rules. This involves identifying rules and challenging them behaviorally (such as eating after 8 p.m. or eating a sandwich for lunch).

Completion of food records immediately after eating and noting thoughts and feelings as well as behaviors.

Development of continuum thinking to replace all-or-nothing thinking.

Development of strategies to prevent binges and compensatory behaviors, such as the use of delays and alternatives and problem-solving strategies.

Exposure to fear foods. After regular eating is well-established and compensatory behaviors are under control, patients gradually reintroduce the foods they fear.

Meal planning. The patient should plan meals ahead of time and always know “what and when” his or her next meal will be.

Psychoeducation to understand what maintains the eating disorder and the psychological and medical consequences.

Regular weighing (usually once per week) in order to track progress and run experiments.

Relapse prevention to identify both strategies that have been helpful and how to deal with potential future stumbling blocks. Because the treatment is time-limited, the goal is for the patient to become his or her own therapist.

The use of behavioral experiments. For example, if a client believes that eating a cupcake will cause a five-pound weight gain, he or she would be encouraged to consume a cupcake and see if it does. These behavioral experiments are generally much more effective than cognitive restructuring alone.

Other components commonly included:﻿﻿

Cessation of body checking

Challenge of the eating disorder mindset

Development of new sources of self-esteem

Enhancement of interpersonal skills

Reduction of body avoidance

Good Candidates for CBT

Adults with bulimia nervosa, binge eating disorder, and other specified eating disorder (OSFED) are potentially good candidates for CBT. Older adolescents with bulimia and binge eating disorder may also benefit from CBT.﻿﻿

Patient Responsiveness to Treatment

Therapists conducting CBT aim to introduce behavioral change as early as possible. Research has shown that patients who are able to make early behavioral changes such as establishing more regular eating and reducing the frequency of purging behavior are more likely to be successfully treated at the end of treatment.﻿﻿

When CBT Doesn't Work

CBT is often recommended as a first-line treatment. If a trial of CBT is not successful, individuals can be referred for DBT (a specific type of CBT with greater intensity) or to a higher level of care such as partial hospitalization or residential treatment program.