British Team Promotes ‘Enhanced’ CBT

Realistic expectations and early identification of relapses may be more effective for all eating disorders.

Cognitive behavioral therapy, or CBT, is the leading evidence-based treatment for bulimia nervosa (BN). According to a team of British researchers, transdiagnostic CBT appears to be more potent and effective than traditional CBT for treating all eating disorders, including anorexia nervosa (AN) and eating disorders not otherwise specified (EDNOS).

Dr. Rebecca Murphy and colleagues with Christopher Fairburn’s group at Warneford Hospital, Oxford, UK, recently challenged the traditional DSM-IV approach that each eating disorder is a distinct condition requiring its own individual form of treatment (Psychiatr Clin North Am 2010; 33:611). According to the authors, what is most striking about eating disorders is not what distinguishes one from the other but how much they have in common, such as overvaluation of the importance of body shape and weight. In addition, they point out, longitudinal studies show that most patients travel among diagnoses over time. Thus, “transdiagnostic” mechanisms may be involved in the perpetuation of these disorders.

According to the authors, the transdiagnostic approach extends the original theory of BN to all eating disorders. Thus, over-evaluation of shape and weight and their control is central to the maintenance of all eating disorders. This then leads to dietary restraint and restriction, preoccupation with thoughts about food and eating, weight and shape, repeated checking of body weight and shape or its avoidance, and use of extreme methods to control weight. The single characteristic that is not a direct expression of the core psychopathology is binge eating. According to the authors, binge eating occurs in all cases of BN, many cases of EDNOS, and in some cases of AN. The traditional CBT approach proposes that binge eating episodes are largely due to attempts to adhere to multiple extreme, and highly specific, dietary rules. Breaking these rules is almost inevitable, and afterward patients respond negatively, viewing “slips” as evidence of their poor self-control. This creates a perpetual cycle.

How enhanced CBT differs

Enhanced CBT is designed to treat eating disorder psychopathology rather than a specific eating disorder diagnosis, and is delivered on an individual basis to adult patients with any eating disorder that can be treated on an outpatient basis. The authors described two forms of CBT-E: a “focused” form that exclusively addresses eating disorder psychopathology, and a broader form that addresses external obstacles to change. The second form of CBT-E is reserved for patients in whom clinical perfectionism, low self-esteem, or interpersonal difficulties are pronounced and are helping maintain the eating disorder. CBT-E also offers two intensities of treatment. The first is designed for patients with body mass indexes (BMI) above 17.5 kg/M²; for this group, 20 sessions are suggested over 20 weeks. For those with lower BMIs, a commonly used threshold for AN treatment, the authors recommend 40 sessions over 40 weeks. The additional sessions are designed to give therapists time to address problems such as limited motivation to change, under-eating, and underweight.

CBT-E uses a four-stage approach to treatment. In the first stage, an effort is made to engage patients in treatment and in change. Real-time self-monitoring and collaborative weekly weight checks by patient and therapist are made and graphed. Patients are strongly encouraged not to weigh themselves at other times. Information about weight and eating is provided, and the therapist helps the patient establish a pattern of regular eating, with 3 planned meals each day plus 2 or 3 snacks. Thus, there is rarely more than a 4-hour delay between meals and snacks. Significant others are also seen by the therapist, with the patient’s consent.

Stage 2 of treatment is a short but essential transitional stage that usually involves 2 appointments set a week apart. As stage 1 treatment continues, the therapist and patients take stock and conduct a joint review of progress, identifying any problems and barriers to change.

Stage 3 is the main body of treatment, and is aimed at addressing the key processes that are maintaining the patient’s eating disorder. Usually this involves 8 weekly appointments during which the patients identify areas of over-evaluation and its consequences. Patients are urged to find other areas of their life that may have been pushed aside by their eating disorder, and to address body-checking and food avoidance, and “feeling fat.” They learn to identify the effects of outside events and changes in mood. Proactive problem-solving is encouraged and patients learn how to deal with “triggers” and ways to use proactive problem-solving. Interpersonal problems, low self-esteem, and clinically significant perfectionism are all targeted in this stage.

Stage 4, the final stage of treatment, is concerned with ending treatment well by maintaining progress and reducing the risk of relapse. Using 3 appointments about 2 weeks apart, the therapist and patient jointly devise a personalized plan for the following months and set a follow-up review appointment about 20 weeks later. This includes further work on body-checking, food avoidance and problem-solving.

According to the authors, two important elements reduce the risk of relapse: realistic expectations about the future and identifying setbacks as early as possible. Setbacks are viewed as “lapses” rather than “relapses,” and patients are encouraged to actively approach their lapses using strategies learned during treatment.