The Current Status of CBT-E

The leading evidence-based treatment for adults with an eating disorder is a specific form of cognitive behaviour therapy. This is a one-to-one treatment that focuses on the characteristic disturbances in eating habits and attitudes to shape and weight. It was developed by Professor Christopher Fairburn as a treatment for bulimia nervosa and in this form it has been the subject of numerous clinical trials. It was the first psychological treatment (for any mental disorder) to be strongly endorsed by UK’s independent and highly regarded National Institute for Health and Care Excellence (NICE).

In the early 2000s the treatment was modified to make it suitable for all forms of eating disorder (Fairburn, Cooper and Shafran, 2003). The resulting “transdiagnostic” treatment, termed enhanced cognitive behaviour therapy (CBT-E), has been tested across the full range of eating disorders in studies emanating from the UK, Australia, Denmark, Italy and the USA.

There is some variability in the response rates obtained in the different studies. This may be due to differences in the patient samples, however the quality of the treatment provided may well be another factor. It is striking that the best results were obtained from studies that ensured CBT-E was delivered well. These are the studies that took place in the UK (Oxford and Leicester), Denmark (Copenhagen) and Italy (Verona).

If one focuses on studies in which CBT-E was delivered well, the evidence suggests that with patients who are not significantly underweight (the great majority of adult cases) about two-thirds of those who start treatment make a full recovery. This recovery appears to be well-maintained. Many of the remainder have also improved but not to this extent. The response rate is somewhat lower in patients who are substantially underweight and fewer complete treatment.

As matters stand, the research findings may be summarised as follows:

  • CBT-E has been shown to be suitable for all forms of eating disorder encountered in adults (Fairburn et al, 2009; Fairburn et al, 2013). This is not true of any other treatment
  • CBT-E has also been shown to be effective in the treatment of younger patients (Dalle Grave et al, 2013). It is therefore a potential alternative to the leading evidence-based treatment for this age group, family-based therapy
  • CBT-E may be used in inpatient and day-patient settings
  • Focusing on the studies in which CBT-E was well-delivered, CBT-E has been shown to be more effective than two other widely used treatments
  • In a direct comparison with a leading alternative psychological treatment for adults, interpersonal psychotherapy or IPT, CBT-E was found to be more potent (Fairburn et al, 2015)
  • It has been found to be more effective than 100 sessions of psychoanalytic psychotherapy delivered over two years (Poulsen et al, 2014)
  • Therapists need to receive training in CBT-E in order to obtain optimal effects
Further Reading

Byrne, S., Wade, T., Hay, P., Touyz, S., Fairburn, C. G., Treasure, J., … Crosby, R. D. (2017). A randomised controlled trial of three psychological treatments for anorexia nervosa. Psychological Medicine, 1-11. doi:10.1017/s0033291717001349

Wade, S., Byrne, S., & Allen, K. (2017). Enhanced cognitive behavioral therapy for eating disorders adapted for a group setting. International Journal of Eating Disorders, 50(8), 863-872. doi:10.1002/eat.22723

Cooper, Z., Allen, E., Bailey-Straebler, S., Basden, S., Murphy, R., O’Connor, M. E., & Fairburn, C. G. (2016). Predictors and moderators of response to enhanced cognitive behaviour therapy and interpersonal psychotherapy for the treatment of eating disorders. Behaviour Research and Therapy, 84, 9-13. doi:10.1016/j.brat.2016.07.002

Andony, L. J., Tay, E., Allen, K. L., Wade, T. D., Hay, P., Touyz, S., … Byrne, S. M. (2015). Therapist adherence in the strong without anorexia nervosa (SWAN) study: A randomized controlled trial of three treatments for adults with anorexia nervosa. International Journal of Eating Disorders, 48(8), 1170-1175. doi:10.1002/eat.22455

Calugi, S., Dalle Grave, R., Sartirana, M., & Fairburn, C. G. (2015). Time to restore body weight in adults and adolescents receiving cognitive behaviour therapy for anorexia nervosa. Journal of Eating Disorders, 3, 21. doi:10.1186/s40337-015-0057-z

Dalle Grave, R., Calugi, S., Sartirana, M., & Fairburn, C. G. (2015). Transdiagnostic cognitive behaviour therapy for adolescents with an eating disorder who are not underweight. Behaviour Research and Therapy, 73, 79-82. doi:10.1016/j.brat.2015.07.014

Fairburn, C. G., Bailey-Straebler, S., Basden, S., Doll, H. A., Jones, R., Murphy, R., … Cooper, Z. (2015). A transdiagnostic comparison of enhanced cognitive behaviour therapy (CBT-E) and interpersonal psychotherapy in the treatment of eating disorders. Behaviour Research and Therapy, 70, 64-71. doi:10.1016/j.brat.2015.04.010

Knott, S., Woodward, D., Hoefkens, A., & Limbert, C. (2015). Cognitive Behaviour Therapy for Bulimia Nervosa and Eating Disorders Not Otherwise Specified: Translation from Randomized Controlled Trial to a Clinical Setting. Behavioural and Cognitive Psychotherapy, 43(6), 641-654. doi:10.1017/s1352465814000393

Dalle Grave, R., Calugi, S., El Ghoch, M., Conti, M., & Fairburn, C. G. (2014). Inpatient cognitive behavior therapy for adolescents with anorexia nervosa: immediate and longer-term effects. Frontiers in Psychiatry, 5, 14. doi:10.3389/fpsyt.2014.00014

Poulsen, S., Lunn, S., Daniel, S. I., Folke, S., Mathiesen, B. B., Katznelson, H., & Fairburn, C. G. (2014). A randomized controlled trial of psychoanalytic psychotherapy or cognitive-behavioral therapy for bulimia nervosa. American Journal of Psychiatry, 171(1), 109-116. doi:10.1176/appi.ajp.2013.12121511

Wonderlich, S. A., Peterson, C. B., Crosby, R. D., Smith, T. L., Klein, M. H., Mitchell, J. E., & Crow, S. J. (2014). A randomized controlled comparison of integrative cognitive-affective therapy (ICAT) and enhanced cognitive-behavioral therapy (CBT-E) for bulimia nervosa. Psychological Medicine, 44(3), 543-553. doi:10.1017/s0033291713001098

Zipfel, S., Wild, B., Gross, G., Friederich, H. C., Teufel, M., Schellberg, D., … Herzog, W. (2014). Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): randomised controlled trial. Lancet, 383(9912), 127-137. doi:10.1016/s0140-6736(13)61746-8

Dalle Grave, R., Calugi, S., Conti, M., Doll, H., & Fairburn, C. G. (2013). Inpatient cognitive behaviour therapy for anorexia nervosa: a randomized controlled trial. Psychotherapy and Psychosomatics, 82(6), 390-398. doi:10.1159/000350058

Dalle Grave, R., Calugi, S., Doll, H. A., & Fairburn, C. G. (2013). Enhanced cognitive behaviour therapy for adolescents with anorexia nervosa: an alternative to family therapy? Behaviour Research and Therapy, 51(1), R9-r12. doi:10.1016/j.brat.2012.09.008

Fairburn, C. G., Cooper, Z., Doll, H. A., O’Connor, M. E., Palmer, R. L., & Dalle Grave, R. (2013). Enhanced cognitive behaviour therapy for adults with anorexia nervosa: a UK-Italy study. Behaviour Research and Therapy, 51(1), R2-8. doi:10.1016/j.brat.2012.09.010

Byrne, S. M., Fursland, A., Allen, K. L., & Watson, H. (2011). The effectiveness of enhanced cognitive behavioural therapy for eating disorders: an open trial. Behaviour Research and Therapy, 49(4), 219-226. doi:10.1016/j.brat.2011.01.006

Fairburn, C. G., Cooper, Z., Doll, H. A., O’Connor, M. E., Bohn, K., Hawker, D. M., . . . Palmer, R. L. (2009). Transdiagnostic cognitive-behavioral therapy for patients with eating disorders: a two-site trial with 60-week follow-up. American Journal of Psychiatry, 166(3), 311-319. doi:10.1176/appi.ajp.2008.08040608

Fairburn, C. G., Cooper, Z., & Shafran, R. (2003) Cognitive behaviour therapy for eating disorders: A “transdiagnostic” theory and treatment. Behaviour Research and Therapy, 41, 509-528.