Cognitive Behavior Therapy

f o r t h e E a t i n g D i s o rd e r s
William Stewart Agras, MD

KEYWORDS
 Cognitive behavioral therapy  Anorexia nervosa  Bulimia nervosa
 Binge eating disorder  CBT  CBT-E

KEY POINTS
 Cognitive behavior therapy (CBT) is an evidence-based treatment for bulimia nervosa and
binge-eating disorder.
 The briefer guided self-help form of CBT is effective in the treatment of binge-eating dis-
order and may be used as a first step in the treatment of bulimia nervosa.
 CBT-E (broad form) is likely more effective in patients with eating disorder with more severe
comorbidity.
 The role of CBT is uncertain in the treatment of both adult and adolescent anorexia nervosa.

OVERVIEW

Cognitive-behavioral therapy (CBT) is an evidence-based treatment for bulimia nerv-

osa (BN) and binge-eating disorder (BED), and may be useful in the treatment of
anorexia nervosa (AN).1,2 Most treatment guidelines consider CBT to be the first-
line treatment for BN and BED.3 Clinical observations led to a greater understanding
of the influences maintaining BN and to an enhanced version of CBT (CBT-E).1,4 At
the same time, a transdiagnostic view of eating disorders was developed, noting
that the core psychopathology was similar in all the eating disorders, with the adapt-
ed CBT-E regarded as a treatment for all eating disorders.5 Four additional processes
were theorized to maintain eating disorders in CBT-E. The first is extreme perfec-
tionism.6 The second involves faulty coping with intense mood states, including
depression, anxiety, and anger.6 The third is low core self-esteem, and the fourth
interpersonal difficulties. For patients who are not progressing well, an evaluation
of the potential role of each of these processes in maintaining the illness is of prime
importance.
The effectiveness of CBT for the treatment of eating disorders has been confirmed in
a number of clinical trials.7–14 Overall, CBT has been found as, or more effective, than

Disclosure Statement: The author have no conflict of interest in writing this article.
Department of Psychiatry and Behavioral Sciences, Stanford University, 401 Quarry Road,
#1322, Stanford, CA 94305, USA
E-mail address: [email protected]

Psychiatr Clin N Am - (2019) -–-

https://doi.org/10.1016/j.psc.2019.01.001 psych.theclinics.com
0193-953X/19/ª 2019 Elsevier Inc. All rights reserved.
2 Agras

other treatment approaches, such as medication and other psychotherapies for eating
disorders, except for AN.15,16

COGNITIVE BEHAVIOR THERAPY MODEL

BN develops in the context of weight loss consequent on dieting driven by concerns

about body shape and weight. Dieting that produces a caloric deficit eventually leads
to binge eating, and in patients with BN to compensatory behaviors such as self-
induced vomiting, diuretic and laxative abuse, and excessive exercise. Binge eating
is associated with a sense of loss of control over eating and is characterized by exces-
sive caloric intake. Repeated failures to avoid binge eating and purging result in
a negative mood and low self-esteem. This, in turn, reinforces weight and shape con-
cerns continuing the inexorable cycle of dieting, binge eating, and purging.

COGNITIVE BEHAVIOR THERAPY

As shown in Fig. 1, there are several areas that could form a focus for intervention.
However, in the first third of treatment with CBT, the primary aim is to reduce dietary
restriction. The first step is to create an agreed formulation of the factors maintaining
the disorder with the patient (Box 1). This is achieved using the CBT model (see Fig. 1)
as a basis for education and discussion. Weekly weighing with the therapist is insti-
tuted from the first session and continues throughout treatment. Even though patients
often want to weigh more often they are discouraged from doing so, pointing out that
daily weight fluctuations that have no physiologic meaning only add to worry about
body weight and shape.
Self-monitoring of dietary intake, binge eating, and purging and the circumstances
in which they occur provide data for both the therapist and patient. An example of
self-monitoring from a patient with BN is shown in Table 1. As can be seen, the pa-
tient eats very little between 9 AM and 12:15 PM, leaving her hungry and anxious as she
looks forward to lunch with her boyfriend. She then sets herself up for a binge by
allowing herself to loosen control over her eating when she decided that she was
going to purge. The binge was then followed by vomiting and taking 2 diuretics.
Shortly afterward, she ate a piece of chocolate and purged again “wanting an empty

Fig. 1. Cognitive-behavioral model of factors influencing the development of eating

disorders.
 CBT for Eating Disorders 3

Box 1
Elements of cognitive-behavioral therapy

Phase 1
 Patient/Therapist agree on factors influencing the eating disorder
 Weekly weighing with therapist
 Self-monitoring
 Eating by the clock
Phase 2
 Review of progress
 Adjust focus of treatment if needed
Phase 3
 Introduction of feared foods
 Address weight and shape concerns
 Address triggers of binge eating; for example, interpersonal conflicts
Phase 4
 Review of progress in reducing factors influencing the eating disorder
 Consider future triggers for relapse
 Discuss strategies in reducing risk
Those interested in online training in enhanced cognitive behavior therapy should contact
[email protected].

stomach.” An evening binge occurred at home followed by episodes of vomiting. She

ends the day with 2 diuretics.
Self-monitoring provides the data allowing recognition of the restricted eating pat-
terns as a basis for instituting a regular pattern of eating by the clock consisting of
3 meals and 2 snacks each day adjusted to the patient’s lifestyle. In the case illustrated
in Table 1, the first aim would be to increase food intake at breakfast and follow this with
a snack at approximately 10:30 AM, lunch at 12:30 PM, a snack at 3:30 PM, and dinner at
6:30 PM. Another snack may be needed before bedtime. Regular eating reduces the in-
tervals between eating episodes, thus reducing hunger, loss of control, binge eating,
and therefore purging. Studies have shown that increased regularity of eating is associ-
ated with symptom reduction and with abstinence from, or reduction of binge eating/
purging17–19; hence, the frequency of purging should begin to decrease as regular eating
is established. Education about the futility of using laxatives and diuretics because they
result in dehydration and not fat loss is useful at this point. Depending on the situation,
these forms of purging can be slowly phased out or in some cases simply stopped.
Studies have shown that if purging is reduced by 60% at session 4 of treatment, the
chance of a favorable outcome is greater than for those who fail to reach this crite-
rion.20–22 This measure provides an opportunity for patient and therapist to review
progress early in treatment, to discuss reasons why progress is slow, and to adjust
the therapeutic focus. At this point, triggers of binge eating should be explored
through the data collected in self-monitoring and solutions to these issues addressed
through formal problem solving.
As eating becomes more regular, the focus of treatment shifts to the content of food
with the aim of increasing the variety of foods consumed and slowly introducing
4 Agras

Table 1
Example of a self-monitoring form filled out for 1 day by a patient with bulimia nervosa

Time Food Intake Location Binge Purge Situation

3
9.00 AM /4 red apple 2D Woke up feeling bloated
12.15–1.15 PM Chinese chicken salad HoChow B V 2D Before lunch hungry and
1 small plate. restaurant anxious. Overwhelmed
Chicken with water with boy when food came; after
chestnuts ½ cup friend first bites I decided
5 honey walnut I was going to purge,
shrimp ate more than
4 Szechuan shrimp I wanted
Chow mein 1/3 cup
Chicken & vegetable
sauce 1 cup
Steamed rice 1 cup
2 diet cokes, 1 cup
tea, water
1:30 PM 1 piece of At work V Felt ashamed of binge
chocolate, water and wanted an empty
stomach
4:15 PM 24 oz diet coke At work Started to feel hungry
5:40 PM 4 Szechuan shrimp In car B Leftovers from lunch
7:00 PM 1/3 cup chicken and In kitchen B Wanting powdered sugar
water chestnuts covered donuts,
1 cheese enchilada frantic feeling, mad
2 cups leftover with myself
Chinese food
2 large chocolate
chip cookies
7:45 PM 1 peanut cluster, Lucky’s V
6 Oreo cookies in car
8:10 PM 1 pint B&J ice cream, Bedroom V
chocolate
fudge brownie
10:30 PM 2D

Abbreviation: B, binge; D, diuretic; V, vomiting.

avoided foods beginning with foods that cause the least anxiety. The aim here is to
decrease dietary restraint by widening the range of food choices.
When regular eating is established with a continuing reduction of binge eating and
purging, the focus shifts to the overvaluation of shape and weight. The consequences
of overvaluation are discussed and elaborated with the patient and attention given to
reducing the amount of body checking. Avoidance of activities based on body dissat-
isfaction also should be explored and homework developed to overcome such avoid-
ance. The final sessions focus on maintenance of the progress made, how to deal with
lapses, and taking a realistic view of the future. The usual length of treatment is 18 to
20 sessions.

APPLICATIONS TO CLINICAL SYNDROMES

Bulimia Nervosa
The existing clinical trials indicate that CBT is superior to wait-list controls, placebo
conditions, and other psychotherapies such as interpersonal psychotherapy (IPT)
 CBT for Eating Disorders 5

and psychodynamic psychotherapy (PDT). Two recent meta-analyses came to similar

conclusions.23,24 The first, a network analysis that allows comparisons of all treat-
ments to each other, found that CBT was likely the most effective treatment for BN.
The second meta-analysis came to a similar, but slightly stronger conclusion that
therapist-led CBT was more effective than wait-list conditions, interpersonal and other
psychotherapies to which it has been compared.
However, differences between CBT and IPT tend to disappear during follow-up. For
example, in a trial comparing CBT and IPT for BN, CBT was significantly superior to
IPT in the proportions of patients recovered and remitted at end of treatment8;
however, at follow-up, there was no significant difference between groups. It seems
that IPT, perhaps because the focus of treatment is not directly on the eating-
disordered behaviors of BN but rather on interpersonal behaviors, works more slowly.
In the second study, CBT-E was found superior to IPT at posttreatment for the
primary outcome, percent remitted (CBT 65.5%; IPT 33.3%) and at 12-month
follow-up (CBT-E 69.4%; IPT 49.0%).9 The finding that IPT has a slower effect on
eating-disordered symptoms than CBT was replicated in this study. It is reasonable
to conclude from these findings that IPT is a reliable second-line treatment for
BN and may be particularly useful in patients with marked interpersonal issues that
trigger binge eating.
An important question is whether CBT is as, or more effective than psychodynamic
psychotherapy given that many practicing psychotherapists use the latter treatment.
Two randomized controlled trials comparing CBT-E and psychodynamic psychother-
apy came to different conclusions on this question.25,26 In the first study,25 70 patients
with BN were randomized to 20 sessions of CBT-E or the focused form of psychoan-
alytic psychotherapy in weekly sessions over a period of 2 years. The results were
dramatically in favor of CBT-E both after 20 weeks (CBT-E 42% abstinent; psychoan-
alytic psychotherapy 6%) and at the 2-year assessment (CBT-E 44% abstinent; psy-
choanalytic psychotherapy 15%). It is important to note that this study was carried out
at a site that had developed the psychoanalytic psychotherapy and that therapists
from that site were trained in CBT-E. The second study randomized 81 women with
BN or partial BN to up to 60 sessions of either CBT or PDT over a 12-month period.
It should be noted that this is far more than the usual number of sessions for CBT,
and that the primary outcome was not meeting diagnostic criteria for BN (full or par-
tial), a less stringent definition of remission. For CBT, 33.3% and for PDT, 31.0% no
longer met criteria for BN with similar results at 12-month follow-up. However, the
effect sizes for reductions in binge eating and purging favored CBT. It is difficult to
compare the 2 studies because of differences in those entered to the study, different
lengths of treatment, and a different definition of outcome. However, even in the sec-
ond study, CBT was more effective in reducing binge eating and purging. Hence, the
evidence suggests that CBT is more cost-effective because fewer sessions are
needed and more effective in reducing binge eating/purging.

Guided self-help
A brief form of CBT has been found effective in reducing binge eating and purging in a
number of clinical trials.27,28 Treatment sessions are usually shorter than in full CBT, for
example, 30 minutes, and fewer in number, for example, 8 to 10, with less experienced
therapists. Books for the lay population, such as Fairburn’s Overcoming Binge
Eating,29 are often used, with the therapist supporting the patient in making the
needed behavior changes. Hence, the patient becomes responsible for behavior
change with the therapist acting as a coach. Guided self-help (GSH) has been shown
to be more effective than no treatment, and in some studies as effective as full CBT.11
6 Agras

However, the overall effect size of treatment is small, leading to the recommendation
that GSH may be best used as a first step in the treatment of BN with a step-up to full
CBT if necessary. The fact that GSH is based on the principles of CBT makes step-up
to full CBT relatively easy.

Is enhanced cognitive behavior therapy more effective than cognitive behavior

therapy?
This question is not easy to answer because there have been few studies that have
compared CBT-E with CBT. One relevant study compared the focused form of CBT
(a revised form of CBT) with the broad form of CBT-E for individuals with BN and
borderline personality disorder.30 This subgroup of individuals tends to have a worse
outcome with treatment than individuals without borderline personality disorder and
the associated behavioral and affective symptoms. Fifty women meeting criteria for
BN were randomly allocated to the 2 treatments. At the end of treatment and all
follow-up points there was no difference in outcome between the 2 treatments, with
42% of individuals achieving remission. However, a moderator analysis found that
participants with more severe affective and interpersonal psychopathology had better
outcomes with CBT-E. Hence, it seems likely that CBT-E with the extra modules is
more effective for individuals with severe comorbid psychopathology.

Applications to adolescents
Relatively few studies are available for CBT applied to adolescents with BN. An
uncontrolled study of 68 adolescents with an eating disorder who were not under-
weight (approximately 30% BN) and treated with 20 sessions of CBT-E found that
half had stopped binge eating/purging at the end of treatment, suggesting that the
outcome for adolescents with BN is similar to that of adults. The adolescents’ par-
ents were involved at a baseline session and for 4 brief sessions during the course
of treatment. The first controlled study compared CBT guided self-help (CBTgsh)
with family therapy adapted for BN,31 finding that CBTgsh was superior to family
therapy at the end of treatment, but that at 6-month follow-up there were no differ-
ences between treatments, with approximately 55% of adolescents remitted in both
groups at that point. Another study compared CBT with family-based treatment
(FBT),32 entering 130 adolescent participants with BN to the study. FBT was superior
to CBT both at the end of treatment and at 6-month follow-up, but not at 12-month
follow-up when 49% of the FBT group was remitted compared with 32% of the CBT
group. Given these different outcomes, it would seem that both CBT and FBT are
reasonable treatments for adolescents with BN. However, CBTgsh is less costly to
provide and on those grounds may be the preferred treatment, although further
studies in adolescents are needed before firm conclusions as to relative efficacy
can be drawn.

Binge-Eating Disorder
BED is characterized by episodes of loss of control over eating accompanied by binge
eating with no compensatory behaviors. Binges are smaller than in BN probably
because no calories are lost by means of self-induced vomiting. Comorbid psychopa-
thology is as frequent and as severe as in BN. In the clinic setting, most patients with
BED are overweight or obese, although BED is not necessarily related to being
overweight. Because of the similarity between BN and BED, the therapeutic model
is identical and CBT can be applied without modification. However, because many
patients wish to lose weight, it is necessary to ensure that they do not engage in
restricted eating but rather gradually adopt a healthy diet that can be sustained
 CBT for Eating Disorders 7

over time. Recovery rates tend to be higher in BED than in BN, perhaps because the
placebo response is larger in BED.33
The difference in short-term outcomes favoring CBT over IPT in BN does not
replicate in BED, in which the 2 treatments appear similar both in short-term and
long-term outcome.12,13 A recent meta-analysis suggested that CBT was superior
to behavioral weight-loss treatment (BWL) in short-term follow-up in reducing
binge eating.34 In a study with a 2-year follow-up, 208 individuals were randomly
allocated to 1 of 3 groups: CBTgsh, BWL, and IPT.14 At the end of treatment there
was no difference among the 3 groups in reducing binge eating, although BWL was
more effective in reducing weight at this point. At the 2-year follow-up there was no
difference between groups in weight loss. However, both CBTgsh and IPT were
superior to BWL in reducing binge eating with no difference between these 2 treat-
ments. Hence, full CBT, CBTgsh, or IPT seem useful as first-line treatments for
BED.

Enhancing cognitive behavior therapy

CBT results in remission or significant improvement in symptoms in approximately
50% to 60% of patients with BN and BED. Hence, the question arises whether adding
medication or another psychotherapy might enhance the results of CBT. Several
controlled studies have examined the addition of medication to CBT.16 The most com-
mon medication has been an antidepressant such as imipramine, desipramine, or
fluoxetine.7 None of these additions was more effective than CBT alone in reducing
binge eating or purging, although one study reported a significant lowering of depres-
sion over that produced by CBT alone. Hence, there is no evidence that antidepres-
sants enhance the effectiveness of CBT in reducing binge eating or purging. Even
fewer studies have examined the utility of adding another psychotherapy to enhance
CBT. The addition of interpersonal psychotherapy for those not responding to CBT did
not enhance outcome in a study that added IPT to those who failed to respond well to
CBT.35 Hence, apart from CBT-E probably adding to the effectiveness of CBT in
patients with severe comorbidities, no other psychotherapy enhances reductions of
binge eating and purging.

Anorexia Nervosa
In considering treatments for AN, it is necessary to take into account 2 different
phases of the disorder: the acute phase in adolescence and the persistent phase usu-
ally evident in adults. Persistent AN is a chronic disorder characterized by low weight
and physiologic instability, accompanied by comorbid psychopathology, particularly
depression, obsessive-compulsive and other anxiety disorders, social disability, and
one of the highest rates of death for any psychiatric disorder. Deaths are due to either
medical complications of chronic starvation or to suicide. The clinical picture is often
further complicated by the patient’s refusal to cooperate with treatment. The relative
rarity of the disorder adds difficulty to the recruitment of adequate sample sizes for
controlled studies of treatment modalities, resulting in some uncertainty in considering
the relative efficacy of different treatment approaches. Hence, sample sizes are often
small and dropout rates are high, making it difficult to draw certain conclusions about
relative efficacy.36,37
The treatment of the adolescent form of the disorder is somewhat easier
because despite the resistance to treatment shown by many adolescents, the fam-
ily is a valuable resource to manage and stabilize the situation. Hence, treatment
dropout rates tend to be lower in adolescents than in adults. The most researched
treatment is FBT that results in some 40% of patients remitted and more than
8 Agras

60% improved and hence has become recommended as a first-line treatment for
adolescent AN.

Cognitive behavior therapy–enhanced

The enhanced form of CBT is based on a similar model to the other eating disorders
with concerns about weight and shape driving dieting, leading to weight loss and
maintenance of those losses.1,4 However, approximately half the patients lose control
over their dietary restriction and begin to binge eat and to use compensatory behav-
iors such as self-induced vomiting, laxative misuse, and overexercise. In the first
phase of treatment, the focus is on helping the patient to understand the factors main-
taining the disorder. This is followed by a detailed examination of the motivation to
continue dieting and weight loss so that patients better understands their eating dis-
order. The evidence for and against changing their eating behavior is then examined
and if the patient is willing to continue treatment, the focus becomes weight gain
with gradual modification of the patient’s dietary intake using self-monitoring and
weekly weighing by the therapist before the treatment session. The reason for the
therapist to do the weighing is that the patient’s concerns about weight are often
provoked by weighing and can be dealt with either immediately or in the session.
Concerns about weight and shape are addressed in detail, as are perfectionism,
intense mood states, and interpersonal problems. Up to 40 treatment sessions are
recommended for AN. The treatment adapted for adolescents includes brief sessions
with the parents. In these sessions, factors within the family that may be maintaining
the disorder and barriers to treatment are explored. However, the main focus is on
dietary advice and the conduct of family meals.
Two meta-analyses considering treatment for persistent AN came to similar conclu-
sions, that in comparing treatment approaches, no one treatment was more effective
than another.36,37 Hence, CBT was no more effective than other psychotherapies with
which it was compared. In one multicenter controlled trial, 120 individuals meeting
criteria for AN were randomized to 3 treatments: CBT-E, Maudsley Anorexia Nervosa
Treatment (MANTRA), and specialist supportive clinical management (SSCM).38
MANTRA is accompanied by a workbook and is individually tailored to each patient.
The foci of treatment include the patient’s thinking and relational style, family members
responses to the illness, and beliefs about the usefulness of AN in the patient’s life. SSCM
consisted of clinical management together with supportive psychotherapy focused on
normalization of eating and weight restoration. Forty percent of patients did not complete
treatment, which did not differ among groups. Patients showed similar improvement in all
3 groups, with approximately 50% of the remaining patients achieving a healthy weight
(body mass index >18.5) that was largely maintained at the 1-year follow-up.

Applications to adolescents
There are relatively few studies applying CBT to adolescents with AN. A meta-analysis
that separated adolescent and adult studies found that for adolescents, FBT was more
effective than individual psychotherapy; however, there were too few comparisons
to ensure firm conclusions.39 At this point, there have been no controlled comparisons
of FBT and CBT-E. In one cohort study, 46 patients were treated with CBT-E.40
The treatment was similar to that for adults except that parents were seen during
the 40-session course of therapy. The dropout rate was 40%. At the end of treatment,
22% of patients were remitted with their weight at or above 95% of their expected
weight in the intent-to-treat cohort. During a 1-year follow-up, the proportion of
remitted patients increased to 28%.
 CBT for Eating Disorders 9

SUMMARY

Most patients with an eating disorder, whether adolescents or adults, can be treated
on an outpatient basis. CBT is an effective, evidence-based, first-line treatment for BN
and BED. The enhanced form of the treatment is probably more effective in treating
patients with severe comorbid psychopathology than the original form of the treat-
ment. The GSH form of CBT can be applied by less specialized therapists and hence
may be useful in situations in which there are no therapists able to administer CBT. In
addition, many experts recommend that CBTgsh be used as a first step in the treat-
ment of BN and particularly for BED, in which it has been shown to have short-term
and long-term effects comparable to other evidence-based treatments. The choice
of psychotherapy for the persistent form of AN is more difficult in that no specialized
psychotherapy, including CBT-E, has been shown to be more effective than special-
ized clinical management. There is only preliminary evidence of the effectiveness of
CBT-E in the treatment of the adolescent form of AN, and a specific form of FBT is
likely the most effective approach to adolescent AN.

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 CBT for Eating Disorders 11

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