Skip to main content
Log in

Cognitive Behavioral Therapy for Anorexia Nervosa: An Update

  • Eating Disorders (C Grilo, Section Editor)
  • Published:
Current Psychiatry Reports Aims and scope Submit manuscript

Abstract

Cognitive behavioral therapy (CBT) for anorexia nervosa (AN), based on Beck’s cognitive theory, was developed in a “generic” form in the early eighties. In recent years, however, improved knowledge of the mechanisms involved in maintaining eating disorder psychopathology has led to the development of a “specific” form of CBT, termed CBT-E (E = enhanced), designed to treat all forms of eating disorders, including AN, from outpatient to inpatient settings. Although more studies are required to assess the relative effectiveness of CBT-E with respect to other available treatments, the data indicate that in outpatient settings it is both viable and promising for adults and adolescents with AN. Encouraging results are also emerging from inpatient CBT-E, particularly in adolescents, and clinical services offering CBT-E at different levels of care are now offered in several countries around the world. However, CBT-E requires dissemination in order to become widely available to patients.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Halmi KA, Agras WS, Crow S, Mitchell J, Wilson GT, Bryson SW, et al. Predictors of treatment acceptance and completion in anorexia nervosa: implications for future study designs. Arch Gen Psychiatry. 2005;62(7):776–81. doi:10.1001/archpsyc.62.7.776.

    Article  PubMed  Google Scholar 

  2. Carter JC, Blackmore E, Sutandar-Pinnock K, Woodside DB. Relapse in anorexia nervosa: a survival analysis. Psychol Med. 2004;34(4):671–9. doi:10.1017/s0033291703001168.

    Article  CAS  PubMed  Google Scholar 

  3. Walsh BT, Kaplan AS, Attia E, Olmsted M, Parides M, Carter JC, et al. Fluoxetine after weight restoration in anorexia nervosa: a randomized controlled trial. JAMA. 2006;295(22):2605–12. doi:10.1001/jama.295.22.2605.

    Article  CAS  PubMed  Google Scholar 

  4. Agras WS, Brandt HA, Bulik CM, Dolan-Sewell R, Fairburn CG, Halmi KA, et al. Report of the National Institutes of Health workshop on overcoming barriers to treatment research in anorexia nervosa. Int J Eat Disord. 2004;35(4):509–21. doi:10.1002/eat.10261.

    Article  PubMed  Google Scholar 

  5. Fairburn CG. Evidence-based treatment of anorexia nervosa. Int J Eat Disord. 2005;37 Suppl:S26-30; discussion S41-2. doi:10.1002/eat.20112.

  6. Bulik CM, Berkman ND, Brownley KA, Sedway JA, Lohr KN. Anorexia nervosa treatment: a systematic review of randomized controlled trials. Int J Eat Disord. 2007;40(4):310–20. doi:10.1002/eat.20367.

    Article  PubMed  Google Scholar 

  7. Lock J, Brandt H, Woodside B, Agras S, Halmi WK, Johnson C, et al. Challenges in conducting a multi-site randomized clinical trial comparing treatments for adolescent anorexia nervosa. Int J Eat Disord. 2012;45(2):202–13. doi:10.1002/eat.20923.

    Article  PubMed Central  PubMed  Google Scholar 

  8. Berg KC, Wonderlich SA. Emerging psychological treatments in the field of eating disorders. Curr Psychiatry Rep. 2013;15(11):407. doi:10.1007/s11920-013-0407-y.

    Article  PubMed  Google Scholar 

  9. Murray SB, Le Grange D. Family therapy for adolescent eating disorders: an update. Curr Psychiatry Rep. 2014;16(5):447. doi:10.1007/s11920-014-0447-y.

    Article  PubMed  Google Scholar 

  10. Watson HJ, Bulik CM. Update on the treatment of anorexia nervosa: review of clinical trials, practice guidelines and emerging interventions. Psychol Med. 2013;43(12):2477–500. doi:10.1017/s0033291712002620.

    Article  CAS  PubMed  Google Scholar 

  11. Garner D, Bemis K. A cognitive-behavioral approach to anorexia nervosa. Cogn Ther Res. 1982;6(2):123–50. doi:10.1007/BF01183887.

    Article  Google Scholar 

  12. Garner DM, Bemis KM. Cognitive therapy for anorexia nervosa. In: Garner DM, Garfinkel PE, editors. Handbook of psychotherapy for anorexia nervosa and bulimia. New York: Guilford Press; 1985. p. 107–46.

    Google Scholar 

  13. Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive therapy of depression. New York: Guilford Press; 1979.

    Google Scholar 

  14. Vitousek K, Hollon S. The investigation of schematic content and processing in eating disorders. Cogn Ther Res. 1990;14(2):191–214. doi:10.1007/BF01176209.

    Article  Google Scholar 

  15. Vitousek KB, Ewald LS. Self-representation in eating disorders: a cognitive perspective. In: Segal ZV, Blatt SJ, editors. The self in emotional distress: cognitive and psychodynamic perspectives. New York: Guilford; 1993. p. 221–66.

    Google Scholar 

  16. Vitousek K, Manke F. Personality variables and disorders in anorexia nervosa and bulimia nervosa. J Abnorm Psychol. 1994;103(1):137–47.

    Article  CAS  PubMed  Google Scholar 

  17. Vitousek K, Watson S, Wilson GT. Enhancing motivation for change in treatment-resistant eating disorders. Clin Psychol Rev. 1998;18(4):391–420.

    Article  CAS  PubMed  Google Scholar 

  18. Vitousek KM. The current status of cognitive-behavioral models of anorexia nervosa and bulimia nervosa. In: Salkovskis P, editor. Frontiers of cognitive therapy. New York: Guilford Press; 1996. p. 383–418.

    Google Scholar 

  19. McIntosh VV, Jordan J, Carter FA, Luty SE, McKenzie JM, Bulik CM, et al. Three psychotherapies for anorexia nervosa: a randomized, controlled trial. Am J Psychiatry. 2005;162(4):741–7. doi:10.1176/appi.ajp.162.4.741.

    Article  PubMed  Google Scholar 

  20. Carter FA, Jordan J, McIntosh VV, Luty SE, McKenzie JM, Frampton CM, et al. The long-term efficacy of three psychotherapies for anorexia nervosa: a randomized, controlled trial. Int J Eat Disord. 2011;44(7):647–54. doi:10.1002/eat.20879.

    Article  PubMed  Google Scholar 

  21. Pike KM, Walsh BT, Vitousek K, Wilson GT, Bauer J. Cognitive behavior therapy in the posthospitalization treatment of anorexia nervosa. Am J Psychiatry. 2003;160(11):2046–9. doi:10.1176/appi.ajp.160.11.2046.

    Article  PubMed  Google Scholar 

  22. Fairburn CG. A cognitive behavioural approach to the treatment of bulimia. Psychol Med. 1981;11(4):707–11.

    Article  CAS  PubMed  Google Scholar 

  23. Fairburn CG. Cognitive-behavioral treatment for bulimia. In: Garner DM, Garfinkel PE, editors. Handbook of psychotherapy for anorexia nervosa and bulimia. New York: Guilford Press; 1985. p. 160–92.

    Google Scholar 

  24. Fairburn CG, Marcus MD, Wilson GT. Cognitive-behavioral therapy for binge eating and bulimia nervosa: a comprehensive treatment manual. In: Fairburn CG, Wilson GT, editors. Binge eating: nature, assessment and treatment. New York: Guilford Press; 1993. p. 361–404.

    Google Scholar 

  25. Fairburn CG, Cooper Z, Shafran R. Cognitive behaviour therapy for eating disorders: a “transdiagnostic” theory and treatment. Behav Res Ther. 2003;41(5):509–28.

    Article  PubMed  Google Scholar 

  26. Milos G, Spindler A, Schnyder U, Fairburn CG. Instability of eating disorder diagnoses: prospective study. Br J Psychiatry. 2005;187:573–8. doi:10.1192/bjp.187.6.573.

    Article  PubMed Central  PubMed  Google Scholar 

  27. Bulik CM, Sullivan PF, Fear J, Pickering A. Predictors of the development of bulimia nervosa in women with anorexia nervosa. J Nerv Ment Dis. 1997;185(11):704–7.

    Article  CAS  PubMed  Google Scholar 

  28. Sullivan PF, Bulik CM, Fear JL, Pickering A. Outcome of anorexia nervosa: a case–control study. Am J Psychiatry. 1998;155(7):939–46.

    Article  CAS  PubMed  Google Scholar 

  29. Cooper Z, Fairburn CG. The evolution of “enhanced” cognitive behavior therapy for eating disorders: learning from treatment nonresponse. Cogn Behav Pract. 2011;18(3):394–402. doi:10.1016/j.cbpra.2010.07.007.

    Article  PubMed Central  PubMed  Google Scholar 

  30. Dalle Grave R. Multistep cognitive behavioral therapy for eating disorders: theory, practice, and clinical cases. New York: Jason Aronson; 2013. This treatment manual outlines the theory and clinical application of multistep CBT-E for eating disorders.

    Google Scholar 

  31. Cooper Z, Stewart A. CBT-E and the younger patient. In: Fairburn CG, editor. Cognitive behavior therapy and eating disorders. New York: Guilford Press; 2008.

    Google Scholar 

  32. Grave Dalle R. Intensive cognitive behavior therapy for eating disorders. Hauppauge: Nova; 2012.

    Google Scholar 

  33. Fairburn CG, Cooper Z, Doll HA, O’Connor ME, Palmer RL, Grave Dalle R. Enhanced cognitive behaviour therapy for adults with anorexia nervosa: a UK-Italy study. Behav Res Ther. 2013;51(1):R2–8. doi:10.1016/j.brat.2012.09.010. This cohort study showed that CBT-E is a promising treatment for adults with anorexia nervosa.

    Article  PubMed Central  PubMed  Google Scholar 

  34. Dalle Grave R, Calugi S, Doll HA, Fairburn CG. Enhanced cognitive behaviour therapy for adolescents with anorexia nervosa: an alternative to family therapy? Behav Res Ther. 2013;51(1):R9–12. doi:10.1016/j.brat.2012.09.008. This cohort study showed that CBT-E is a promising treatment for adolescents with anorexia nervosa.

    Article  PubMed Central  PubMed  Google Scholar 

  35. Calugi S, Dalle Grave R, Sartirana M, Fairburn CG. Time to restore body weight in adults and adolescents receiving cognitive behaviour therapy for anorexia nervosa. Int J Eat Disord. 2015;3:21. doi:10.1186/s40337-015-0057-z. This study showed that with CBT-E significantly more adolescents reached a normal body mass index range than adults, and the mean time to restore body weight was about 15 weeks less in adolescents than in adults.

    Article  Google Scholar 

  36. Zipfel S, Wild B, Gross G, Friederich HC, Teufel M, Schellberg D, et al. Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): randomised controlled trial. Lancet. 2014;383(9912):127–37. doi:10.1016/s0140-6736(13)61746-8. A randomized controlled trial in adults with anorexia nervosa that compared a hybrid form of CBT-E with focal psychodynamic therapy, and optimized treatment as usual, with the option of hospitalization. No significant differences emerged between the three interventions with regard to the primary outcome variable, gain in BMI. A proportion of this weight gain is likely to have been the result of hospitalization as this amounted to 25 days on average.

    Article  PubMed  Google Scholar 

  37. Byrne SM, Fursland A, Allen KL, Watson H. The effectiveness of enhanced cognitive behavioural therapy for eating disorders: an open trial. Behav Res Ther. 2011;49(4):219–26. doi:10.1016/j.brat.2011.01.006.

    Article  PubMed  Google Scholar 

  38. Watson HJ, Allen K, Fursland A, Byrne SM, Nathan PR. Does enhanced cognitive behaviour therapy for eating disorders improve quality of life? Eur Eat Disord Rev. 2012;20(5):393–9. doi:10.1002/erv.2186.

    Article  PubMed  Google Scholar 

  39. Dalle Grave R, Calugi S, Conti M, Doll H, Fairburn CG. Inpatient cognitive behaviour therapy for anorexia nervosa: a randomized controlled trial. Psychother Psychosom. 2013;82(6):390–8. doi:10.1159/000350058. This randomized controlled trial compared the effects of the focused and broad form of inpatient CBT-E in patients with anorexia nervosa. No significant differences emerged between the two programs in terms of changes seen either at the end of treatment or at follow-up.

    Article  PubMed Central  PubMed  Google Scholar 

  40. 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. Front Psychiatry. 2014;5:14. doi:10.3389/fpsyt.2014.00014. This cohort study showed that inpatient CBT-E is a promising treatment for adolescents with anorexia nervosa. Notably, the improvement in weight, eating disorder features, and general psychopathology at the end of hospitalization was well maintained at 12-month follow-up.

    Article  PubMed Central  PubMed  Google Scholar 

  41. Turner H, Marshall E, Stopa L, Waller G. Cognitive-behavioural therapy for outpatients with eating disorders: effectiveness for a transdiagnostic group in a routine clinical setting. Behav Res Ther. 2015;68:70–5. doi:10.1016/j.brat.2015.03.001. This study assessed the effect of CBT-E in a transdiagnostic group of outpatients with eating disorders treated in a real world clinical service.

    Article  PubMed  Google Scholar 

  42. Waller G, Cordery H, Corstorphine E, Hinrichsen H, Lawson R, Mountford V, et al. Cognitive behavioral therapy for eating disorders: a comprehensive treatment guide. Cambridge: Cambridge University Press; 2007.

    Book  Google Scholar 

  43. National Institute for Clinical Excellence. Eating disorders: core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. London: National Institute for Clinical Excellence; 2004.

    Google Scholar 

  44. Keys A, Brozek J, Henschel A, Mickelsen O, Taylor HL. The biology of human starvation. Minneapolis: University of Minnesota Press; 1950.

    Google Scholar 

  45. Dalle Grave R, Pasqualoni E, Marchesini G. Symptoms of starvation in eating disorder patients. In: Preedy VR, editor. Handbook of behavior, food and nutrition. New York: Springer Science + Business Media; 2011. p. 2259–69.

    Chapter  Google Scholar 

  46. Polito A, Fabbri A, Ferro-Luzzi A, Cuzzolaro M, Censi L, Ciarapica D, et al. Basal metabolic rate in anorexia nervosa: relation to body composition and leptin concentrations. Am J Clin Nutr. 2000;71(6):1495–502.

    CAS  PubMed  Google Scholar 

  47. Fairburn CG. Cognitive behavior therapy and eating disorders. New York: Guilford Press; 2008.

    Google Scholar 

  48. Dalle Grave R, Bohn K, Hawker D, Fairburn CG. Inpatient, day patient and two forms of outpatient CBT-E. In: Fairburn CG, editor. Cognitive behavior therapy and eating disorders. New York: Guilford Press; 2008. p. 231–44.

    Google Scholar 

  49. von Ranson KM, Wallace LM, Stevenson A. Psychotherapies provided for eating disorders by community clinicians: infrequent use of evidence-based treatment. Psychother Res. 2013;23(3):333–43. doi:10.1080/10503307.2012.735377.

    Article  Google Scholar 

  50. Waller G, Stringer H, Meyer C. What cognitive behavioral techniques do therapists report using when delivering cognitive behavioral therapy for the eating disorders? J Consult Clin Psychol. 2012;80(1):171–5. doi:10.1037/a0026559.

    Article  PubMed  Google Scholar 

  51. National Collaborating Centre for Mental Health. The access and waiting time standard for children and young people with an eating disorder. Commissioning Guide. Version 1.0. July 2015. http://www.england.nhs.uk/wp-content/uploads/2015/07/cyp-eating-disorders-access-waiting-time-standard-comm-guid.pdf

  52. Fairburn CG, Patel V. The global dissemination of psychological treatments: a road map for research and practice. Am J Psychiatry. 2014;171(5):495–8. doi:10.1176/appi.ajp.2013.13111546. This article suggests innovative ways to improve the dissemination of evidence-based psychological treatments.

    Article  PubMed  Google Scholar 

  53. Cooper Z, Doll H, Bailey-Straebler S, Kluczniok D, Murphy R, O’Connor ME, et al. The development of an online measure of therapist competence. Behav Res Ther. 2015;64:43–8. doi:10.1016/j.brat.2014.11.007.

    Article  PubMed Central  PubMed  Google Scholar 

Download references

Acknowledgments

The authors are very grateful to Christopher G. Fairburn for his suggestions and comments.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Riccardo Dalle Grave.

Ethics declarations

Conflict of Interest

Riccardo Dalle Grave, Marwan El Ghoch, Massimilano Sartirana, and Simona Calugi declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This research did not rely on any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Eating Disorders

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Dalle Grave, R., El Ghoch, M., Sartirana, M. et al. Cognitive Behavioral Therapy for Anorexia Nervosa: An Update. Curr Psychiatry Rep 18, 2 (2016). https://doi.org/10.1007/s11920-015-0643-4

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11920-015-0643-4

Keywords

Navigation