Enhanced Cognitive Behavior Therapy (CBT-E) for Adolescents with Eating Disorders

Adolescents (12-19) with eating disorders

For children/adolescents ages: 12 - 19

Enhanced Cognitive Behaviour Therapy (CBT-E) for Adolescents with Eating Disorders has a transdiagnostic scope of the treatment which allows it to be used to treat the full range of disorders that occur in adolescent patients including anorexia nervosa (AN) and bulimia nervosa (BN). It can be used as an alternative to Family-Based Treatment.

Riccardo Dalle Grave, MD

• Agency/Affiliation: Department of Eating and Weight Disorders, Villa Garda Hospital, Garda (VR), Italy
• Website: http://www.dallegrave.it/en/cbt-e-multistep/
• Email: r.dallegrave@villagarda.it
• Phone: +390456208611

The goals of Enhanced Cognitive Behaviour Therapy (CBT-E) for Adolescents with Eating Disorders are:

• Engage in the treatment and be actively involved in the process of change.
• Eliminate the eating disorder psychopathology (i.e., the dietary restraint and restriction, and low weight if present; extreme weight control behaviors; and preoccupation with shape, weight, and eating).
• Learn how to recognize and counteract the mechanisms maintaining the eating disorder psychopathology.
• Experience lasting change.

The essential components of Enhanced Cognitive Behavior Therapy (CBT-E) for Adolescents with Eating Disorders include:

• Step One – Starting well and deciding to change
  • The aims are to engage the patient in treatment and change, including addressing weight regain.
  • The appointments are twice weekly for 4 weeks and involve the following:
    • Jointly creating a formulation of the processes maintaining the eating disorder
    • Establishing real-time self-monitoring of eating and other relevant thoughts and behaviors
    • Educating about:
      • Body weight regulation and fluctuations
      • The adverse effects of dieting
      • The ineffectiveness and physical complications of self-induced vomiting and laxative misuse as a means of weight control, if applicable
    • Introducing and establishing weekly in-session weighing, and becoming proficient in interpreting and coping with weight fluctuations
    • Introducing and adhering to a pattern of regular eating, with planned meals and snacks
    • Thinking about addressing weight regain (if indicated)
    • Involving parents to facilitate treatment
• Step Two – Addressing the change
  • The aim is to address weight regain (if indicated) and the key mechanisms that are maintaining the patient’s eating disorder.
  • The appointments are twice a week until the rate of weight regain stabilizes, at which time they are held once a week. This Step involves the following CBT-E modules:
    • Underweight and Undereating:
      • Creating a daily positive energy balance of about 500 kcal to achieve a mean weekly weight regain of about 0.5 kg
    • Overvaluation of Shape and Weight:
      • Providing education on overvaluation and its consequences
      • Nurturing previously marginalized domains of self-evaluation
      • Reducing unhelpful body checking and avoidance
      • Re-labelling unhelpful thoughts or feelings such as “feeling fat”
      • Exploring the origins of the overvaluation
      • Learning to identify and control the eating disorder mindset
    • Dietary Restraint:
      • Changing inflexible dietary rules into flexible guidelines
      • Introducing previously avoided foods
    • Events and Mood-related Changes in Eating:
      • Developing proactive problem-solving skills to tackle such triggering events
      • Developing skills to accept and modulate intense moods
    • Setbacks and Mindsets:
      • Providing education about setbacks and mindsets
      • Identifying eating‐disorder mindset reactivation triggers
      • Spotting setbacks early on
      • Displacing the mindset
      • Exploring the origins of the overvaluation.
• Review sessions
  • These are held one week after Step One and then every four weeks, for the purposes of:
    • Identifying barriers to change, both general (e.g., school pressures) and features of the eating disorder itself (e.g., difficulties in weight regain, presence of dietary restraint)
    • Adjusting the initial formulation in light of progress and/or emerging issues
    • Deciding to continue with the focused form of CBT-E rather than the broad form
      • The broad form of CBT-E includes four additional modules (i.e., clinical perfectionism, low self-esteem, interpersonal difficulties, or mood intolerance), one of which may be added to the focused modules in Step Two. This form of treatment is indicated if clinical perfectionism, low self-esteem, interpersonal difficulties, or mood intolerance are marked, and appear to be maintaining the disorder and obstructing change.
• Step Three – Ending well
  • The aims are to ensure that progress made during treatment is maintained, and that the risk of relapse is minimized. There are three appointments, 2 weeks apart, covering the following:
    • Addressing concerns about ending treatment
    • Devising a short-term plan for continuing to implement changes made during treatment (e.g., reducing body checking, introducing further avoided foods, eating more flexibly, maintaining involvement in new activities) until the post-treatment review session
    • Phasing out treatment procedures, in particular self-monitoring and in-session weighing
    • Education about realistic expectations and identifying and addressing setbacks
    • Devising a long-term plan for maintaining body weight, and averting and coping with setbacks
• Posttreatment review session
  • Reviewing the long-term maintenance plan around 4, 12, and 20 weeks after treatment has finished

Child/Adolescent Services

Enhanced Cognitive Behavior Therapy (CBT-E) for Adolescents with Eating Disorders directly provides services to children and addresses the following:

• Eating disorder psychopathology such as over-evaluation of shape, weight and eating control, strict dieting, binge eating, self-induced vomiting, laxative misuse, diuretic misuse, excessive exercising, food checking, body checking, body avoidance, feeling fat, low weight and starvation syndrome; and/or co-existing psychopathology (in a subgroup of patients) such as clinical perfectionism, core low self-esteem, marked interpersonal difficulties, and/or mood intolerance

Recommended Intensity

Not underweight patients have 20 sessions of 50 minutes (twice a week in the first four weeks, then once a week; in the last 6 weeks there are three appointments, 2 weeks apart) with Posttreatment review at 4-, 12-, and 20-week follow-up. Underweight patients (BMI < 18.5) have 40 sessions (duration depends by the amount of weight that has to be regained). The appointments are twice a week until the rate of weight regain stabilizes, at which time they are held once a week. in the last 6 weeks there are three appointments, 2 weeks apart) with posttreatment review at 4-, 12-, and 20-week follow-up. Events and circumstances may influence the duration of treatment (e.g., life crisis, development of clinical depression).

Recommended Duration

Non-underweight patients: 20 weeks; Underweight patients: 40 weeks

Delivery Settings

This program is typically conducted in a(n):

• Group or Residential Care
• Outpatient Clinic

Homework

This program does include a homework component.

In common with other forms of CBT, monitoring and success in completing strategically planned homework tasks are of paramount importance. Therapist and patient agree on specific homework tasks to do between sessions. These are of fundamental importance and must be given absolute priority, as it is what patients do between the sessions that will determine the benefits or limitations of the treatment. Examples include real-time self-monitoring, regular eating, evaluating the pros and cons of weight regain, etc.

Languages

Enhanced Cognitive Behavior Therapy (CBT-E) for Adolescents with Eating Disorders has materials available in the following languages other than English:

• Italian

For information on which materials are available in this language, please check on the program's website or contact the program representative (contact information is listed in this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

Typical psychotherapy office

Prerequisite/Minimum Provider Qualifications

The minimum qualification to deliver the training depend on the rules to deliver psychological treatments, which varies from one country to another.

Manual Information

There is a manual that describes how to deliver this program.

Program Manual(s)

Dalle Grave, R., & Calugi, S. (2020). Cognitive behavior therapy for adolescents with eating disorders. Guilford Press. https://www.guilford.com/books/Cognitive-Behavior-Therapy-for-Adolescents-with-Eating-Disorders/Grave-Calugi/9781462542734

Dalle Grave , R., & el Khazen, C. (2022). Cognitive Behaviour Therapy for Eating disorders in young people: Parents’ guide. Routledge. https://www.routledge.com/Cognitive-Behaviour-Therapy-for-Eating-Disorders-in-Young-People-A-Parents/Grave-Khazen/p/book/9780367775049

Training Information

There is training available for this program.

Training Contact

Training Type/Location:

The online training program in CBT-E is now available to any eligible therapist who wants to receive training at no cost. Access to the training is funded by Health Education England in partnership with Oxford Health NHS Foundation Trust.

https://www.cbte.co/for-professionals/training-in-cbt-e/

It is also recommended that they receive expert clinical supervision that may be available via videoconferencing (or face-to-face, if local) by a member of the CBT-E Training Group. For further information please contact: credoenquiries@psych.ox.ac.uk

Number of days/hours:

Varies dependent on personal pace through the training

Fidelity Measures Required

Self-report checklist and audio recording. Contact Dr. Rebecca Murphy, The Centre for Research on Eating Disorders at Oxford (CREDO), Department of Psychiatry University of Oxford, atwww.psych.ox.ac.uk/research/credo for more information

Child Welfare Outcome: Child/Family Well-Being

“What is included in the Relevant Published, Peer-Reviewed Research section?”

• Le Grange, D., Eckhardt, S., Dalle Grave, R., Crosby, R. D., Peterson, C. B., Keery, H., Leser, J., & Martell, C. (2020). Enhanced Cognitive-Behavior Therapy and family-based treatment for adolescents with an eating disorder: A non-randomized effectiveness trial. Psychological Medicine, 52(13), 2520–2530. https://doi.org/10.1017/S0033291720004407

  Type of Study: Pretest–posttest study with a nonequivalent control group (Quasi-experimental)

  Sample:

  Age — 12–18 years (Mean=14.6 years)

  Participants: 97

  Race/Ethnicity — 89% Caucasian, 4% Multiracial/Other, 3% Asian, 3% Not Reported, and 1% African American

  Gender — 83% Female

  Status — Participants were adolescents with a DSM-5 eating disorder diagnosis and their parents.

  Location/Institution: The Center for the Treatment of Eating Disorders (CTED) at Children’s Minnesota, MN, a pediatric specialty clinic in the USA.

  Summary:

  The purpose of the study was to compare the relative effectiveness of Family-Based Treatment (FBT) and Enhanced Cognitive-Behavior Therapy (CBT-E) [now called Enhanced Cognitive Behavior Therapy (CBT-E) for Adolescents with Eating Disorders]. Participants were assigned to FBT and CBT-E treatments by choice. Measures utilized include the Eating Disorder Examination (EDE) or the Eating Disorder Examination Questionnaire (EDE-Q), the Clinical Impairment Assessment (CIA), the Beck Anxiety Inventory (BAI), the Child Depression Inventory (CDI-2), the Rosenberg Self-Esteem Scale (RSE), the Child Behavior Checklist (CBCL), the Brief Symptom Inventory (BSI), the McMaster Family Assessment Device (FAD) and the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-Kid). Results indicate that slope of weight gain at the end of treatment was significantly higher for FBT than for CBT-E, but not at follow-up. There were no differences in the EDE Global Score or most secondary outcome measures at any time point. Several baseline variables emerged as potential treatment effect moderators at the end of treatment. Choosing between FBT and CBT-E resulted in older and less-well participants opting for CBT-E. Limitations include that an a priori power calculation to guide recruitment efforts was not conducted, participants were not randomly allocated to either FBT or CBT-E, compliance with postbaseline assessments was less than optimal, and diversity was limited.

  Length of controlled postintervention follow-up: 6 months and 1 year.

• Rahmani, S., Kashani, H. F., Kohani, M., Barazandeh, A., & Babaei, F. S. (2025). The effectiveness of Enhanced Cognitive Behavioral Therapy (CBT-E) on body image and self-criticism in overweight adolescents without a formal diagnosis of eating disorders. International Journal of Education and Cognitive Sciences, 6(4), 1–9.

  Type of Study: Randomized controlled trial

  Sample:

  Age — 13–17 years

  Participants: 60

  Race/Ethnicity — Not specified

  Gender — Not specified

  Status — Participants were overweight adolescents without a formal diagnosis of eating disorders.

  Location/Institution: Tehran, Iran

  Summary:

  The purpose of the study was to evaluate the effectiveness of Enhanced Cognitive Behavioral Therapy (CBT-E) [now called Enhanced Cognitive Behavior Therapy (CBT-E) for Adolescents with Eating Disorders] in reducing body image dissatisfaction and self-criticism among overweight adolescents without a formal diagnosis of eating disorders. Participants were randomly assigned to receive either 20 sessions of CBT-E or standard CBT. Measures utilized include the Body Shape Questionnaire-34 (BSQ-34) and the Forms of Self-Criticizing/Attacking and Self-Reassuring Scale (FSCRS). Results indicate that the CBT-E group showed significantly greater reductions in both body image dissatisfaction and self-criticism compared to the standard CBT group. Post-hoc analyses confirmed that improvements in the CBT-E group were maintained at the three-month follow-up. Effect sizes were large for CBT-E on both outcomes (body image and self-criticism), indicating clinically meaningful gains. Limitations include a small sample size, limited generalizability due to study demographics, length of follow-up, and exclusion of participants without any formal diagnosis of eating disorders.

  Length of controlled postintervention follow-up: 3 months.

• Note: The following study was not included in rating Enhanced Cognitive Behavior Therapy (CBT-E) for Adolescents with Eating Disorders on the Scientific Rating Scale.

  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. https://doi.org/10.1016/j.brat.2012.09.008

  Summary:

  The purpose of the study was to establish the immediate and longer-term outcomes following Enhanced Cognitive-Behavior Therapy (CBT-E) [now called Enhanced Cognitive Behavior Therapy (CBT-E) for Adolescents with Eating Disorders]. Participants received CBT-E. Measures utilized include the BMI centiles, Eating Disorder Examination Questionnaire (EDE-Q6.0), and the Symptom Checklist-90. Results indicate that there was a substantial increase in weight, together with a marked decrease in eating disorder psychopathology. Over the 60-week posttreatment follow-up period, there was little change despite minimal subsequent treatment. Limitations include a lack of a control group, limited generalizability due to gender and ethnicity, a lack of controlled postintervention follow-up, and a small sample size. Note: This article was not used in the rating process due to the lack of a control group.

• Note: The following study was not included in rating Enhanced Cognitive Behavior Therapy (CBT-E) for Adolescents with Eating Disorders on the Scientific Rating Scale.

  Dalle Grave, R., Sartirana, M., & Calugi, S. (2019). Enhanced Cognitive Behavioral Therapy for Adolescents with anorexia nervosa: Outcomes and predictors of change in a real‐world setting. International Journal of Eating Disorders, 52(9), 1042–1046. https://doi.org/10.1002/eat.23122

  Summary:

  The purpose of the study was to establish the outcomes and predictors of change in a cohort of adolescents with anorexia nervosa treated via Enhanced Cognitive-Behavior Therapy (CBT-E) [now called Enhanced Cognitive Behavior Therapy (CBT-E) for Adolescents with Eating Disorders] in a real-world clinical setting. Participants received CBT-E. Measures utilized include the BMI centiles, Eating Disorder Examination Questionnaire, the Brief Symptom Inventory, and the Clinical Impairment Assessment. Results indicate that patients (71.4%) who finished the program showed both considerable weight gain and reduced scores for clinical impairment, eating disorder, and general psychopathology. Changes remained stable at 20 weeks uncontrolled post-intervention. No baseline predictors of drop-out or treatment outcomes were detected. Limitations include a lack of controlled postintervention follow-up, a small sample size, limited generalizability due to gender and ethnicity, and a lack of a control group. Note: This article was not used in the rating process due to the lack of a control group.

• Dalle Grave, R., Eckhardt, S., Calugi, S., & Le Grange, D. (2019). A conceptual comparison of family-based treatment and enhanced cognitive behavior therapy in the treatment of adolescents with eating disorders. Journal of Eating Disorders, 7, Article 42. https://doi.org/10.1186/s40337-019-0275-x

• Dalle Grave, R., Sartirana, M., Sermattei, S., & Calugi, S. (2021). Treatment of eating disorders in adults versus adolescents: Similarities and differences. Clinical Therapeutics, 43(1), 70-84. https://doi.org/10.1016/j.clinthera.2020.10.015

• Dalle Grave, R. (2019). Cognitive-behavioral therapy in adolescent eating disorders. In J. Hebebrand & B. Herpertz-Dahlmann (Eds.), Eating disorders and obesity in children and adolescents (pp. 111-116). Elsevier.