Return to "Enhanced" cognitive behaviour therapy (CBT-E)

The Standing of CBT-E

The Standing 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 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 Clinical Excellence (NICE).

In the early 2000s we modified the treatment to make it suitable for all forms of eating disorder (Fairburn, Cooper and Shafran, 2003). The resulting “transdiagnostic” treatment, termed enhanced CBT (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 rate obtained in the different studies. This may be due to differences in the patient samples but the quality of the treatment provided may well be another factor. It is striking that the best results have been obtained from studies that have ensured that CBT-E was delivered well. These are the studies from 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 that 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:
    1. It has been found to be more effective than the leading alternative psychological treatment for adults, interpersonal psychotherapy or IPT (unpublished results)
    2. It has been found to be more effective than 100 sessions of psychoanalytic psychotherapy delivered over two years (Poulsen et al, 2014)

One other conclusion appears warranted. This is that therapists need to receive training in CBT-E in order to obtain optimal effects.

Further Reading

Byrne, S. M., Fursland, A., Allen, K. L., & Watson, H. The effectiveness of enhanced cognitive behavioural therapy for eating disorders: An open trial. Behaviour Research and Therapy 2011; 49: 219-226.

Dalle Grave, R., Calugi, S., Doll, H. A., & Fairburn, C. G. Enhanced cognitive behaviour therapy for adolescents with anorexia nervosa: an alternative to family therapy? Behaviour Research and Therapy 2013; 51: R9-R12.

Dalle Grave R, Calugi S, Conti M, Doll HA, Fairburn CG. Inpatient cognitive behaviour therapy for anorexia nervosa: A randomized controlled trial. Psychotherapy and Psychosomatics 2013; 82: 390-398.

Dalle Grave R, Calugi S, El Ghoch M, Conti M, Fairburn CG. Inpatient cognitive behavior therapy for adolescents with anorexia nervosa: Immediate and longer-term effects. Frontiers in Psychiatry 2014; 5: 1-6.

Fairburn, C. G. Cognitive Behavior Therapy and Eating Disorders. New York: Guilford Press, 2008.

Fairburn, C. G., Cooper, Z., Doll, H. A., O'Connor, M. E., Bohn, K., Hawker, D. M., . . . Palmer, R. L. Transdiagnostic cognitive-behavioral therapy for patients with eating disorders: A two-site trial with 60-week follow-up. American Journal of Psychiatry 2009; 166: 311-319.

Fairburn, C. G., Cooper, Z., Doll, H. A., Palmer, R. L., & Dalle Grave, R. Enhanced cognitive behaviour therapy for adults with anorexia nervosa: a UK-Italy study. Behaviour Research and Therapy 2013; 51: R2-R8.

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

Poulsen S, Lunn S, Daniel SIF, Folke S, Mathiesen BB, Katznelson H, Fairburn CG. A randomized controlled trial of psychoanalytic psychotherapy versus cognitive behavior therapy for bulimia nervosa. American Journal of Psychiatry 2014; 171: 109-116.

Wonderlich SA, Peterson CB, Crosby RD, Smith TL, Klein MH, Mitchell JE, Crow SJ. A randomized controlled comparison of integrative cognitive-affective therapy and enhanced cognitive-behavioural therapy for bulimia nervosa. Psychological Medicine 2014; 44: 543-553.

Zipfel S, Wild B, Gross G, Friederich H-C, Teufel M, Schellberg D, Giel KE, de Zwaan M, Dinkel A, Herpertz S, Burgmer M, Lowe S, Tagay S, von Wietersheim J, Zeeck A, Schade-Bittinger C, Schauenberg H, Herzog W. Focal psychodynamic psychotherapy, cogntive behaviour therapy, and optimised treatment as usual in outpatients with anorexia nervosa: randomised controlled trial. Lancet 2014; 383: 127-137.