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Psychiatr Clin North Am. 2010 Sep; 33(3): 611–627. PMCID: PMC2928448
doi: 10.1016/j.psc.2010.04.004 PMID: 20599136

Cognitive Behavioral Therapy for Eating Disorders

Rebecca Murphy, DClinPsych,∗ Suzanne Straebler, APRN - Psychiatry, MSN, Zafra Cooper, DPhil, DipPsych, and
Christopher G. Fairburn, DM, FMedSci, FRCPsych

Cognitive behavioral therapy (CBT) is the leading evidence-based treatment for bulimia nervosa. A
new “enhanced” version of the treatment appears to be more potent and has the added advantage of be‐
ing suitable for all eating disorders, including anorexia nervosa and eating disorder not otherwise speci‐
fied. This article reviews the evidence supporting CBT in the treatment of eating disorders and provides
an account of the “transdiagnostic” theory that underpins the enhanced form of the treatment. It ends
with an outline of the treatment's main strategies and procedures.

Keywords: Cognitive behavioral therapy, Eating disorders, Anorexia nervosa, Bulimia nervosa

The eating disorders provide one of the strongest indications for cognitive behavioral therapy (CBT).
Two considerations support this claim. First, the core psychopathology of eating disorders, the
overevaluation of shape and weight, is cognitive in nature. Second, it is widely accepted that CBT is the
treatment of choice for bulimia nervosa1 and there is evidence that it is as effective with cases of “eat‐
ing disorder not otherwise specified” (eating disorder NOS),2 the most common eating disorder diagno‐
sis. This article starts with a description of the clinical features of eating disorders and then reviews the
evidence supporting cognitive behavioral treatment. Next, the cognitive behavioral account of eating
disorders is presented and, last, the new “transdiagnostic” form of CBT is described.

Eating disorders and their clinical features

Classification and Diagnosis

Eating disorders are characterized by a severe and persistent disturbance in eating behavior that causes
psychosocial and, sometimes, physical impairment. The DSM-IV classification scheme for eating disor‐
ders recognizes 2 specific diagnoses, anorexia nervosa (AN) and bulimia nervosa (BN), and a residual
category termed eating disorder NOS.3

The diagnosis of anorexia nervosa is made in the presence of the following features:

1. The overevaluation of shape and weight; that is, judging self-worth largely, or even exclusively, in
terms of shape and weight. This has been described in various ways and is often expressed as strong
desire to be thin combined with an intense fear of weight gain and fatness.
2. The active maintenance of an unduly low body weight. This is commonly defined as maintaining a
body weight less than 85% of that expected or a body mass index (BMI; weight kg/height m2 or
weight lb/[height in]2 × 703) of 17.5 or less.
3. Amenorrhea, in postpubertal females not taking an oral contraceptive.

The unduly low weight is pursued in a variety of ways with strict dieting and excessive exercise being
particularly prominent. A subgroup also engages in episodes of binge eating and/or “purging” through
self-induced vomiting or laxative misuse.

For a diagnosis of bulimia nervosa 3 features need to be present:

1. Overevaluation of shape and weight, as in anorexia nervosa.

2. Recurrent binge eating. A “binge” is an episode of eating during which an objectively large amount
of food is eaten for the circumstances and there is an accompanying sense of loss of control.
3. Extreme weight-control behavior, such as recurrent self-induced vomiting, regular laxative misuse,
or marked dietary restriction.

In addition, the diagnostic criteria for anorexia nervosa should not be met. This “trumping rule” ensures
that patients do not receive both diagnoses at one time.

There are no positive criteria for the diagnosis of eating disorder NOS. Instead, this diagnosis is re‐
served for eating disorders of clinical severity that do not meet the diagnostic criteria of AN or BN.
Eating disorder NOS is the most common eating disorder encountered in clinical settings constituting
about half of adult outpatient eating-disordered samples, with patients with bulimia nervosa constitut‐
ing about a third, and the rest being cases of anorexia nervosa.4 In inpatient settings the great majority
of cases are either underweight forms of eating disorder NOS or anorexia nervosa.5
In addition, DSM-IV recognizes “binge eating disorder” (BED) as a provisional diagnosis in need of
further study. The criteria for BED are recurrent episodes of binge eating in the absence of extreme
weight-control behavior. It is proposed that BED be recognized as a specific eating disorder in DSM-
V.6

Clinical Features

Anorexia nervosa, bulimia nervosa, and most cases of eating disorder NOS share a core psychopatholo‐
gy: the overevaluation of the importance of shape and weight and their control. Whereas most people
judge themselves on the basis of their perceived performance in a variety of domains of life (such as the
quality of their relationships, their work performance, their sporting prowess), for people with eating
disorders self-worth is dependent largely, or even exclusively, on their shape and weight and their abili‐
ty to control them. This psychopathology is peculiar to the eating disorders (and to body dysmorphic
disorder).

In anorexia nervosa, patients become underweight largely as a result of persistent and severe restriction
of both the amount and the type of food that they eat. In addition to strict dietary rules, some patients
engage in a driven form of exercising, which further contributes to their low body weight. Patients with
anorexia nervosa typically value the sense of control that they derive from undereating. Some practice
self-induced vomiting, laxative and/or diuretic misuse, especially (but not exclusively) those who expe‐
rience episodes of loss of control over eating. The amount of food eaten during these “binges” is often
not objectively large; hence, they are described as “subjective binges.” Many other psychopathological
features tend to be present, some as a result of the semistarvation. These include depressed and labile
mood, anxiety features, irritability, impaired concentration, loss of libido, heightened obsessionality
and sometimes frank obsessional features, and social withdrawal. There are also a multitude of physical
features, most of which are secondary to being underweight. These include poor sleep, sensitivity to the
cold, heightened fullness, and decreased energy.

Patients with bulimia nervosa resemble those with anorexia nervosa both in terms of their eating habits
and methods of weight control. The main feature distinguishing these 2 groups is that in patients with
bulimia nervosa attempts to restrict food intake are regularly disrupted by episodes of (objective) binge
eating. These episodes are often followed by compensatory self-induced vomiting or laxative misuse,
although there is also a subgroup of patients who do not purge (nonpurging bulimia nervosa). As a re‐
sult of the combination of undereating and overeating the weight of most patients with bulimia nervosa
tends to be unremarkable and is within the healthy range, BMI = 20–25. Features of depression and
anxiety are prominent in these patients. Certain of these patients engage in self-harm and/or substance
and alcohol misuse and may attract the diagnosis of borderline personality disorder. Most have few
physical complaints, although electrolyte disturbance may occur in those who vomit or take laxatives or
diuretics frequently.

The clinical features of patients with eating disorder NOS closely resemble those seen in anorexia ner‐
vosa and bulimia nervosa and are of comparable duration and severity.7 Within this diagnostic grouping
3 subgroups may be distinguished, although there are no sharp boundaries among them. The first group
consists of cases that closely resemble anorexia nervosa or bulimia nervosa but just fail to meet the
threshold set by the diagnostic criteria (eg, binge eating may not be frequent enough to meet criteria for
BN or weight may be just above the threshold in AN); the second and largest subgroup comprises cases
in which the features of AN and BN occur in different combinations from that seen in the prototypic
disorders—these states may be best viewed as “mixed” in character—and the third subgroup comprises
those with binge-eating disorder. Most patients with binge-eating disorder are overweight (BMI = 25–
30) or meet criteria for obesity (BMI ≥ 30).

The empirical status of cognitive behavioral therapy for eating disorders

Consistent with the current way of classifying eating disorders, the research on their treatment has fo‐
cused on the particular disorders in isolation. Wilson and colleagues8 have provided a narrative review
of the studies of the treatment of the 2 specific eating disorders as well as eating disorder NOS, and an
authoritative meta-analysis has been conducted by the UK National Institute for Health and Clinical
Excellence (NICE).1 This systematic review is particularly rigorous and, as with all NICE reviews, it
forms the basis for evidence-based guidelines for clinical management.

The conclusion from the NICE review, and 2 other recent systematic reviews,9,10 is that cognitive be‐
havioral therapy (CBT-BN) is the clear leading treatment for bulimia nervosa in adults. However, this is
not to imply that CBT-BN is a panacea, as the original version of the treatment resulted in only fewer
than half of the patients who completed treatment making a full and lasting recovery.8 The new “en‐
hanced” version of the treatment (CBT-E) appears to be more effective.2

Interpersonal psychotherapy (IPT) is a potential evidence-based alternative to CBT-BN in patients with

bulimia nervosa and it involves a similar amount of therapeutic contact, but there have been fewer stud‐
ies of it.11,12 IPT takes 8 to 12 months longer than CBT-BN to achieve a comparable effect. Antidepres‐
sant medication (eg, fluoxetine at a dose of 60 mg daily) has also been found to have a beneficial effect
on binge eating in bulimia nervosa but not as great as that obtained with CBT-BN and the long-term
effects remain largely untested.13 Combining CBT-BN with antidepressant medication does not appear
to offer any clear advantage over CBT-BN alone.13 The treatment of adolescents with bulimia nervosa
has received relatively little research attention to date.

There has been much less research on the treatment of anorexia nervosa. Most of the studies suffer from
small sample sizes and some from high rates of attrition. As a result, there is little evidence to support
any psychological treatment, at least in adults. In adolescents the research has focused mainly on family
therapy, with the result that the status of CBT in younger patients is unclear.

Preliminary findings have been reported from a 3-site study of the use of the enhanced form of CBT
(CBT-E) to treat outpatients with anorexia nervosa.14 This is the largest study of the treatment of
anorexia nervosa to date. In brief, it appears that the treatment can be used to treat about 60% of outpa‐
tients with the disorder (BMI 15.0 to 17.5) and that in these patients about 60% have a good outcome.
Interestingly and importantly the relapse rate appears low.
There is a growing body of research on the treatment of binge-eating disorder. This research has been
the subject of a recent narrative review15 and several systematic reviews.1,16,17 The strongest support is
for a form of CBT similar to that used to treat BN (CBT-BED). This treatment has been found to have a
sustained and marked effect on binge eating, but it has little effect on body weight, which is typically
raised in these patients. Arguably the leading first-line treatment is a form of guided cognitive behav‐
ioral self-help as it is relatively simple to administer and reasonably effective.18

Until recently, there had been almost no research on the treatment of forms of eating disorder NOS oth‐
er than binge-eating disorder despite their severity and prevalence.7 However, recently the first random‐
ized controlled trial of the enhanced form of CBT found that CBT-E was as effective for patients with
eating disorder NOS (who were not significantly underweight; BMI >17.5) as it was for patients with
bulimia nervosa with two-thirds of those who completed treatment having a good outcome.2

In summary, CBT is the treatment of choice for bulimia nervosa and for binge-eating disorder with the
best results being obtained with the new “enhanced” form of the treatment. Recent research provides
support for the use of this treatment with patients with eating disorder NOS and those with anorexia
nervosa.

The remainder of this article provides a description of this transdiagnostic form of CBT.

The cognitive behavioral account of eating disorders

Although the DSM-IV classification of eating disorders encourages the view that they are distinct con‐
ditions, each requiring their own form of treatment, there are reasons to question this view. Indeed, it
has recently been pointed out that what is most striking about the eating disorders is not what distin‐
guishes them but how much they have in common.19 As noted earlier, they share many clinical features,
including the characteristic core psychopathology of eating disorders: the overevaluation of the impor‐
tance of shape and weight. In addition, longitudinal studies indicate that most patients migrate among
diagnoses over time.20 This temporal movement among diagnostic categories, together with the shared
psychopathology, has led to the proposal that there may be limited utility in distinguishing among the
disorders19 and furthermore that common “transdiagnostic” mechanisms may be involved in their main‐
tenance.

The transdiagnostic cognitive behavioral account of the eating disorders19 extends the original theory
of bulimia nervosa21 to all eating disorders. According to this theory, the overevaluation of shape and
weight and their control is central to the maintenance of all eating disorders. Most of the other clinical
features can be understood as resulting directly from this psychopathology. It results in dietary restraint
and restriction; preoccupation with thoughts about food and eating, weight and shape; the repeated
checking of body shape and weight or its avoidance; and the engaging in extreme methods of weight
control. The one feature that is not a direct expression of the core psychopathology is binge eating. This
occurs in all cases of bulimia nervosa, many cases of eating disorder NOS, and some cases of anorexia
nervosa. The cognitive behavioral account proposes that such episodes are largely the result of attempts
to adhere to multiple extreme, and highly specific, dietary rules. The repeated breaking of these rules is
almost inevitable and patients tend to react negatively to such dietary slips, generally viewing them as
evidence of their poor self-control. They typically respond by temporarily abandoning their efforts to
restrict their eating with binge eating being the result. This in turn maintains the core psychopathology
by intensifying patients' concerns about their ability to control their eating, shape, and weight. It also
encourages more dietary restraint, thereby increasing the risk of further binge eating.

Three further processes may also maintain binge eating. First, difficulties in the patient's life and associ‐
ated mood changes make it difficult to maintain dietary restraint. Second, as binge eating temporarily
alleviates negative mood states and distracts patients from their difficulties, it can become a way of cop‐
ing with such problems. Third, in patients who engage in compensatory purging, the mistaken belief in
the effectiveness of vomiting and laxative misuse as a means of weight control results in a major deter‐
rent against binge eating being removed.

In patients who are underweight, the physiological and psychological consequences may also contribute
to the maintenance of the eating disorder. For example, delayed gastric emptying leads to feelings of
fullness even after patients have eaten only modest amounts of food. In addition, the social withdrawal
and loss of previous interests prevent patients from being exposed to experiences that might diminish
the importance they place on shape and weight.

The composite “transdiagnostic” formulation is shown in Fig. 1. This illustrates the core processes that
are hypothesized to maintain the full range of eating disorders. When applied to individual patients, its
precise form will depend on the psychopathology present. In some patients, most of the processes are in
operation (for example, in cases of anorexia nervosa binge-purge subtype) but in others only a few are
active (for example, in binge-eating disorder). Thus, for each patient the formulation is driven by their
individual psychopathology rather than their DSM diagnosis. As such, the formulation provides a guide
to those processes that need to be addressed in treatment.
 Fig. 1

The composite “transdiagnostic” cognitive behavioral formulation.

(Fairburn CG. Eating disorders: the transdiagnostic view and the cognitive behavioral theory. In: Fairburn CG.
Cognitive behavior therapy and eating disorders. New York: Guilford Press; 2008. p. 7–22).

Enhanced cognitive behavioral therapy

“Enhanced” cognitive behavioral therapy (CBT-E) is based on the transdiagnostic theory outlined earli‐
er and was derived from CBT-BN. It is designed to treat eating disorder psychopathology rather than an
eating disorder diagnosis, with its exact form in any particular case depending on an individualized for‐
mulation of the processes maintaining the disorder. CBT-E is designed to be delivered on an individual
basis to adult patients with any eating disorder of clinical severity who are appropriate to treat on an
outpatient basis. It is described as “enhanced” because it uses a variety of new strategies and proce‐
dures to improve outcome and because it includes modules to address certain obstacles to change that
are “external” to the core eating disorder, namely clinical perfectionism, low self-esteem, and interper‐
sonal difficulties.

There are 2 forms of CBT-E. The first is the “focused” form (CBT-Ef) that exclusively addresses eating
disorder psychopathology. Current evidence suggests that this form should be viewed as the “default”
version, as it is optimal for most patients with eating disorders.2 The second, a broad form of the treat‐
ment (CBT-Eb), addresses external obstacles to change, in addition to the core eating disorder psy‐
chopathology. Preliminary evidence suggests that this more complex form of CBT-E should be reserved
for patients in whom clinical perfectionism, core low self-esteem, or interpersonal difficulties are pro‐
nounced and maintaining the eating disorder.2
There are also 2 intensities of CBT-E. With patients who are not significantly underweight (BMI above
17.5), it consists of 20 sessions over 20 weeks. This version is suitable for the great majority of adult
outpatients. For patients who have a BMI below 17.5, a commonly used threshold for anorexia nervosa,
treatment involves 40 sessions over 40 weeks. The additional sessions and treatment duration are de‐
signed to allow sufficient time for 3 additional clinical features to be addressed, namely, limited motiva‐
tion to change, undereating, and being underweight.

In addition CBT-E has been adapted for younger patients22 and for inpatient and day patient settings
treatment.23,24 Limitations on space preclude a description of these other forms of CBT-E. Further de‐
tails of these adaptations of CBT-E, together with a comprehensive account of the treatment and its im‐
plementation, can be found in the main treatment guide.25

An overview of the core aspects of treatment

CBT-E is a form of cognitive behavioral therapy and in common with other empirically supported
forms of CBT it focuses primarily on the maintaining processes, in this case those maintaining the eat‐
ing disorder psychopathology. It uses specified strategies and a flexible series of sequenced therapeutic
procedures to achieve both cognitive and behavioral changes. The style of treatment is similar to other
forms of CBT, that of collaborative empiricism. Although CBT-E uses a variety of generic cognitive
and behavioral interventions (such as addressing cognitive biases), unlike some forms of CBT, it favors
the use of strategic changes in behavior to modify thinking rather than direct cognitive restructuring.
The eating disorder psychopathology may be likened to a house of cards with the strategy being to
identify and remove the key cards that are supporting the eating disorder, thereby bringing down the
entire house. Following, we summarize the core features of the focused and broad versions of CBT-E,
including adaptations that need to be made for patients who are underweight. The treatment has 4 de‐
fined stages.

Preparation for treatment and change

An evaluation interview assessing the nature and extent of the patient's psychiatric problems is conduct‐
ed before starting treatment.26 This interview usually takes place over 2 or more appointments. The as‐
sessment process is collaborative and designed to put the patient at ease and begin to engage the patient
in treatment and in change. Information from the assessment informs how best to proceed and, in par‐
ticular, whether CBT-E is appropriate. If CBT-E is deemed to be appropriate, the main aspects of the
therapy are described and patients are encouraged to make the most of the opportunity to overcome
their eating disorder.

It is important that from the outset of CBT-E the patient is in a position to make optimum use of treat‐
ment. For this reason any potential barriers to benefiting from CBT-E should be explored. Important
contraindications to beginning treatment immediately are physical features of concern, the presence of
severe clinical depression, significant substance abuse, major distracting life events or crises, and com‐
peting commitments. Such factors should be addressed first before embarking on treatment.
Stage one

It is crucial that treatment starts well. This is consistent with evidence that the magnitude of change
achieved early in treatment is a good predictor of treatment outcome.27,28 This initial intensive stage,
designed to achieve initial therapeutic momentum, involves approximately 8 sessions held twice weekly
over 4 weeks. The aims of this first stage are to engage the patient in treatment and change, to derive a
personalized formulation (case conceptualization) with the patient, to provide education about treat‐
ment and the disorder, and to introduce and implement 2 important procedures: collaborative “weekly
weighing” and “regular eating.” The changes made in this first stage of treatment form the foundation
on which other changes are built.

Engaging the Patient in Treatment and Change

Many patients with eating disorders are ambivalent about treatment and change. Getting patients “on
board” with treatment is a necessary first step. Engagement can be enhanced by conducting the assess‐
ment of the eating disorder in a way that helps the patient to become involved in, and hopeful about, the
possibility of change and encourages the patient to take “ownership” of treatment.

Jointly Creating the Formulation

This is usually done in the first treatment session and is a personalized visual representation of the pro‐
cesses that appear to be maintaining the eating problem. The therapist draws out the relevant sections of
Fig. 1 in collaboration with the patient, incorporating the patient's own experiences and words. It is
usually best to start with something the patient wishes to change (eg, binge eating). The formulation
helps patients to realize both that their behavior is comprehensible and that it is maintained by a series
of interacting self-perpetuating mechanisms that are open to change. It is explained that “the diagram”
provides a guide to what needs to be targeted in treatment if patients are to achieve a full and lasting
recovery. At this early stage in treatment the therapist should explain that it is provisional and may need
to be modified as treatment progresses and understanding of the patient's eating problem increases.

Establishing Real-time Self-monitoring

This is the ongoing “in-the-moment” recording of eating and other relevant behavior, thoughts, feel‐
ings, and events (Fig. 2 is an example of a monitoring record). Self-monitoring is introduced in the ini‐
tial session and continues to occupy an essential and central role throughout most of treatment. Thera‐
pists should clearly explain the reasons for self-monitoring. First, that it enables further understanding
of the eating problem and it identifies progress. Second, and more importantly, it helps patients to be
more aware of what is happening in the moment so that they can begin to make changes to behavior
that may have seemed automatic or beyond their control. Fundamental to establishing accurate record‐
ing is jointly reviewing the patient's records each session and discussing the process of recording and
any difficulties with this. The records also help inform the agenda for the session: it is best to save any
problems identified in the records for the main part of the session.

Fig. 2

An example monitoring record.

(Fairburn CG, Cooper Z, Shafran R, et al. Enhanced cognitive behavior therapy for eating disorders: the core protocol.
In: Fairburn CG. Cognitive behavior therapy and eating disorders. New York: Guilford Press; 2008. p. 47–193.)

Establishing Collaborative “Weekly Weighing”

The patient and therapist check the patient's weight once a week and plot it on an individualized weight
graph. Patients are strongly encouraged not to weigh themselves at other times. Weekly in-session
weighing has several purposes. First, it provides an opportunity for the therapist to educate patients
about body weight and help patients to interpret the numbers on the scale, which otherwise they are
prone to misinterpret. Second, it provides patients with accurate data about their weight at a time when
their eating habits are changing. Third, and most importantly, it addresses the maintaining processes of
excessive body weight checking or its avoidance.

Providing Education
From session 1 onward, an important element of treatment is education about weight and eating, as
many patients have misconceptions that maintain their eating disorder. Some of the main topics to cover
are as follows:

• The characteristic features of eating disorders including their associated physical and psychosocial
effects
• Body weight and its regulation: the body mass index and its interpretation; natural weight
fluctuations; and the effects of treatment on weight
• Ineffectiveness of vomiting, laxatives, and diuretics as a means of weight control
• Adverse effects of dieting: the types of dieting that promote binge eating; dietary rules versus
dietary guidelines.

To provide reliable information on these topics, patients are asked to read relevant sections from one of
the authoritative books on eating disorders29,30 and their reading is discussed in subsequent treatment
sessions.

Establishing “Regular Eating”

Establishing a pattern of regular eating is fundamental to successful treatment whatever the form of the
eating disorder. It addresses an important type of dieting (“delayed eating”); it displaces most episodes
of binge eating; it structures people's days and, for underweight patients, it introduces meals and snacks
that can be subsequently increased in size. Early in treatment (usually by the third session) patients are
asked to eat 3 planned meals each day plus 2 or 3 planned snacks so that there is rarely more than a 4-
hour interval between them. Patients are also asked to confine their eating to these meals and snacks.
They should choose what they eat with the only condition being that the meals and snacks are not fol‐
lowed by any compensatory behavior (eg, self-induced vomiting or laxative misuse). The new eating
pattern should take precedence over other activities but should not be so inflexible as to preclude the
possibility of adjusting timings to suit the patients' commitments each day.

Patients should be helped to adhere to their regular eating plan and to resist eating between the planned
meals and snacks. Two rather different strategies may be used to achieve the latter goals. The first in‐
volves helping patients to identify activities that are incompatible with eating and likely to distract them
from the urge to binge eat (eg, taking a brisk walk) and strategies that make binge eating less likely (eg,
leaving the kitchen). The second is to help patients to recognize that the urge to binge eat is a temporary
phenomenon that can be “surfed.” Some “residual binges” are likely to persist, however, and these are
addressed later.

Involving Significant Others

The treatment is primarily an individual treatment for adults. Despite this, “significant others” are seen
if this is likely to facilitate treatment and the patient is willing for this to happen. There are 2 reasons
for seeing others: if they could help the patient in making changes or if others are making it difficult for
the patient to change, for example, by commenting adversely on eating or appearance.

Stage two

Stage two is a brief, but essential, transitional stage that generally comprises 2 appointments, a week
apart. While continuing with the procedures introduced in Stage one, the therapist and patient take
stock and conduct a joint review of progress, the goal being to identify problems still to be addressed
and any emerging barriers to change, to revise the formulation if necessary, and to design Stage three.
The review serves several purposes. If patients are making good progress they should be praised for
their efforts and helpful changes reinforced. If patients are not doing well, the explanation needs to be
understood and addressed. If clinical perfectionism, core low self-esteem or relationship difficulties ap‐
pear to be responsible, this would be an indication for implementing the broad version of the treatment.

Stage three

This is the main body of treatment. Its aim is to address the key processes that are maintaining the pa‐
tient's eating disorder. The mechanisms addressed, and the order in which these are tackled, depend
upon their role and relative importance in maintaining the patient's psychopathology. There are general‐
ly 8 weekly appointments.

Addressing the Overevaluation of Shape and Weight

Identifying the overevaluation and its consequences The first step involves explaining the concept of
self-evaluation and helping patients identify how they evaluate themselves. The relative importance of
the various domains that are relevant may be represented as a pie chart (Fig. 3 is an example of a pie
chart with extended formulation), which for most patients is dominated by a large slice representing
shape and weight and controlling eating.
 Fig. 3

The overevaluation of shape and weight and their control: an extended formulation.

(Fairburn CG, Cooper Z, Shafran R, et al. Enhanced cognitive behavior therapy for eating disorders: the core protocol.
In: Fairburn CG. Cognitive behavior therapy and eating disorders. New York: Guilford Press; 2008. p. 47–193.)

The patient and therapist then identify the problems inherent in this scheme for self-evaluation. Briefly
there are 3 related problems: first, self-evaluation is overly dependent on performance in one area of life
with the result that domains other than shape and weight are marginalized; second, the area of control‐
ling shape and weight is one in which success is elusive, thus undermining self-esteem; and third, the
overevaluation is responsible for the behavior that characterizes the eating disorder (dieting, binge eat‐
ing, and so forth).31

The final step in the consideration of self-evaluation is the creation of an “extended formulation” de‐
picting the main expressions of the overevaluation of shape and weight: dieting, body checking and
body avoidance, feeling fat, and marginalization of other areas of life. The therapist uses this extended
formulation to explain how these behaviors and experiences serve to maintain and magnify the patient's
concerns about shape and weight and thus they need to be addressed in treatment.

Enhancing the importance of other domains for self-evaluation An indirect, yet powerful, means of di‐
minishing the overevaluation of shape and weight is helping patients increase the number and signifi‐
cance of other domains for self-evaluation. Engaging in other aspects of their life that may have been
pushed aside by the eating disorder results in these other areas becoming more important in the pa‐
tient's self-evaluation. Briefly, this involves identifying activities or areas of life that the patient would
like to engage in and helping them do so.

A second, direct, strategy is to target the behavioral expressions of the overevaluation of shape and
weight. This is done at the same time as enhancing the other domains for self-evaluation and it involves
tackling body checking, body avoidance, and feeling fat.
Addressing body checking and avoidance Patients are often not aware that they are engaging in body
checking and that it is maintaining their body dissatisfaction. The first step is therefore to obtain de‐
tailed information about their checking behavior by asking patients to monitor it. Patients are then edu‐
cated about the adverse effects of repeated body checking as the way in which they check tends to pro‐
vide biased information that leads them to feel dissatisfied. For example, scrutinizing parts of one's
body magnifies apparent defects, and only comparing oneself to thin and attractive people leads one to
draw the conclusion that one is unattractive. Most patients need substantial and detailed help to curb
their repeated body checking and invariably attention needs to be devoted to their mirror use.

Patients who avoid seeing their bodies also need considerable help. They should be encouraged to pro‐
gressively get used to the sight and feel of their body. This may take many successive sessions.

Addressing “feeling fat” “Feeling fat” is an experience reported by many women but the intensity and
frequency of this feeling appears to be far greater among people with eating disorders. Feeling fat is a
target for treatment because it tends to be equated with being fat (irrespective of the patient's actual
shape and weight) and hence maintains body dissatisfaction. Although this topic has received little re‐
search attention, clinical observation suggests that feeling fat is a result of mislabeling certain emotions
and bodily experiences. Consequently, patients are helped to identify the triggers of their feeling fat ex‐
periences and the accompanying feelings. These typically are negative mood states (eg, feeling bored or
depressed) or physical sensations that heighten body awareness (eg, feeling full, bloated, or sweaty).
Patients are then helped to view “feeling fat” as a cue to ask themselves what else they are feeling at the
time and once recognized to address it directly.

Exploring the origins of overevaluation Toward the end of Stage three it is often helpful to explore the
origins of the patient's sensitivity to shape, weight, and eating. A historical review can help to make
sense of how the problem developed and evolved, highlight how it might have served a useful function
in its early stages, and the fact that it may no longer do so. If a specific event appears to have played a
critical role in the development of the eating problem, the patient should be helped to reappraise this
from the vantage point of the present. This review helps patients distance themselves further from the
eating disorder frame of mind or “mindset.”

Addressing Dietary Rules

Patients are helped to recognize that their multiple extreme and rigid dietary rules impair their quality
of life and are a central feature of the eating disorder. A major goal of treatment is therefore to reduce,
if not eliminate altogether, dieting. The first step in doing so is to identify the patient's various dietary
rules together with the beliefs that underlie them. The patient is then helped to break these rules to test
the beliefs in question and to learn that the feared consequences that maintain the dietary rule (typically
weight gain or binge eating) are not an inevitable result. With patients who binge eat, it is important to
pay particular attention to “food avoidance” (the avoidance of specific foods) as this is a major contrib‐
utory factor. These patients need to systematically re-introduce the avoided food into their diet.
Addressing Event-related Changes in Eating

Among many patients with eating disorders, eating habits change in response to outside events and
changes in their mood. The change may involve eating less, stopping eating altogether, overeating, or
binge eating. If these changes are prominent, patients need help to deal directly with the triggers. Gen‐
erally this may be achieved by training them in “proactive” problem solving coupled with the use of
functional means of modulating mood.

Addressing Clinical Perfectionism, Low Self-esteem, and Interpersonal Problems

As noted earlier, there are 2 main forms of CBT-E. The components of the focused version are de‐
scribed previously. The “broad” version also includes these strategies and procedures but, in addition,
addresses one or more “external” (to the core eating disorder) processes that may be maintaining the
eating disorder. It is designed for patients in whom clinical perfectionism, core low self-esteem, or
marked interpersonal problems are pronounced and appear to be contributing to the eating disorder. If
the therapist decides, in the review of progress (Stage two), to use one or more of these modules, they
should become a major component of all subsequent sessions. In the original version of the broad form
of CBT-E a fourth module, “mood intolerance,” was included but this has since been integrated in to
the standard, focused, form of the treatment as part of addressing events and moods. A description of
the main elements of the 3 modules follows. A more detailed account is available in the main treatment
guide.32

Addressing clinical perfectionism The psychopathology of clinical perfectionism is similar to that of an

eating disorder.33 Its core is the overevaluation of striving to achieve and achievement itself. People
with clinical perfectionism judge themselves largely, or exclusively, in terms of working hard toward,
and meeting, personally demanding standards in areas of life that they value. If they have a coexisting
eating disorder such extreme standards are applied to their eating, weight, and shape. This intensifies
key aspects of the eating disorder including dietary restraint, exercise, and shape checking. It is usually
evident from the patient's behavior and it can interfere with important aspects of treatment, leading to,
for example, overly detailed recording and a strong resistance to relaxing dietary restraint.

The strategy for addressing clinical perfectionism mirrors that used to address the overevaluation of
shape and weight and the two can be addressed more or less at the same time. The first step is to add
perfectionism to the patient's formulation and to consider the consequences of this for the patient and
his or her life, including the self-evaluation pie-chart. Patients are then encouraged to take steps to en‐
hance the importance of other, nonperformance related, domains for self-evaluation.

It is helpful to consider collaboratively patients' goals in areas of life that they value, which are usually
multiple, rigid, and extreme, and whether these goals are in fact counterproductive and impairing their
actual performance. Performance checking is addressed similarly to shape checking, beginning by first
asking patients to record times when they are checking their performance. Then the therapist helps
them appreciate that the data they obtain is likely to be skewed as a result of using biased assessment
processes, such as selective attention to failure. Avoidance and procrastination also need to be ad‐
dressed, as they interfere with patients being able to assess their true ability with the result that their
fears of failure are maintained.

Addressing core low self-esteem People with core low self-esteem (CLSE) have a longstanding and
pervasive negative view of themselves. It is largely independent of the person's actual performance in
life (ie, it is unconditional) and is not secondary to the presence of the eating disorder. The presence of
CLSE results in the individual striving especially hard to control eating, weight, and shape to retain
some sense of self-worth. It is generally a barrier to engaging in treatment as patients do not feel they
deserve treatment nor do they believe that they can benefit from it.

If it is to be directly addressed in treatment, it is added to the patient's formulation in Stage two and
tackled alongside, although slightly later than, the steps addressing the overevaluation of shape and
weight. This involves educating patients about the role of CLSE in maintaining the eating disorder and
contributing to other difficulties in their life. Patients are helped to identify and modify the main cogni‐
tive maintaining processes, including discounting positive qualities and the overgeneralization of appar‐
ent failures. Previous views of the self are reappraised, using both cognitive restructuring and behav‐
ioral experiments, to help patients to reach a more balanced view of their self-worth.

Addressing interpersonal problems Interpersonal problems are common among patients with eating
disorders, although they generally improve as the eating disorder resolves. Such problems may include
conflict with others and difficulties developing close relationships. If these problems, and the resulting
effects on mood, directly influence the patient's eating, they may be addressed through the use of proac‐
tive problem solving and functional mood modulation and acceptance (as described earlier). However,
in some cases interpersonal problems powerfully maintain the eating disorder through a variety of di‐
rect and indirect processes or they interfere with treatment itself. Under these circumstances, they need
to become a focus of treatment in their own right.

The strategy used in CBT-E is to use a different psychological treatment to achieve interpersonal
change, namely Interpersonal Psychotherapy (IPT). This is an evidence-based treatment that helps pa‐
tients identify and address current interpersonal problems. In style and content IPT is very different
from CBT-E. For this reason it is not “integrated” with CBT-E as such: rather, each session has a CBT-
E component and an IPT one. More detailed information about IPT and its use with patients with eating
disorders is available in a recent book chapter.34

Stage four

Stage four, the final stage in treatment, is concerned with ending treatment well. The focus is on main‐
taining the progress that has already been made and reducing the risk of relapse. Typically there are 3
appointments about 2 weeks apart. During this stage, as part of their preparation for the ending of treat‐
ment, patients discontinue self-monitoring and begin weekly weighing at home.
To maximize the chances that progress is maintained, the therapist and patient jointly devise a personal‐
ized plan for the following few months until a posttreatment review appointment (usually about 20
weeks later). Typically this includes further work on body checking, food avoidance, and perhaps fur‐
ther practice at problem solving. In addition, patients are encouraged to continue their efforts to develop
new interests and activities.

There are 2 elements to minimizing the risk of relapse. First, patients need to have realistic expectations
regarding the future. Expecting never to experience any eating difficulties again makes patients vulnera‐
ble to relapse because it encourages a negative reaction to even minor setbacks. Instead, patients should
view their eating problem as an Achilles heel. The goal is that patients identify setbacks as early as pos‐
sible, view them as a “lapse” rather than a “relapse,” and actively address them using strategies that
they learned during treatment.

Underweight patients

The strategies and procedures described so far are also relevant to patients who are underweight (most‐
ly cases of anorexia nervosa but some cases of eating disorder NOS). However, CBT-E has to be modi‐
fied to address certain characteristics of these patients.

The first priority is to address motivation, as often these patients do not view undereating or being un‐
derweight as a problem. This may be done in several ways and relies on a good therapeutic alliance.
The patient is provided with a personalized education about the psychological and physical effects of
being underweight. This helps them to understand that some of the things that they find difficult (eg,
being obsessive and indecisive, being unable to be spontaneous, being socially avoidant, lacking sexual
appetite) are a direct consequence of being a low weight rather than being a reflection of their true per‐
sonality. The patient is helped to think through the advantages and disadvantages of change, including a
consideration of how things are likely to be in the future if they choose not to change and how this
would fit with their aspirations. The therapist shows intense interest in the patient as a person, beyond
the eating disorder, and helps them to reflect on the state of all aspects of their life, including their rela‐
tionships, their physical and psychological well-being, their work, and their personal values. The pa‐
tient is encouraged to experiment with making changes to learn more about the pros and cons of their
current behavior. The goal is for patients themselves to decide to regain weight rather than this decision
being imposed by the therapist. If this is successful, it greatly assists subsequent weight regain.

Second, the undereating and the consequent state of starvation must be addressed. It is important to
help patients to realize that undereating, and being underweight maintain the eating disorder and this is
illustrated in a personalized formulation. Once the patient has agreed to regain weight it is explained
that weight regain should be gradual and steady and that they should aim to maintain an average energy
surplus of 500 calories each day to regain an average of 0.5 kg (1.1 lb) per week. The therapist helps the
patient to devise and implement a daily plan of eating (which may be supplemented by energy-rich
drinks) that meets this target.
Treatment needs to be extended from the typical 20 weeks to about 40 weeks to allow sufficient time
for patients to decide to change, to reach a healthy weight, and then practice maintaining it. It can be
helpful to involve others in the weight-gain process to facilitate the patient's own efforts. This is espe‐
cially so with young patients who are living at home with their parents.

Final comments

Hopefully it will be clear from this brief account of CBT for eating disorders that major advances have
been made and are continuing to be made. Perhaps most prominent among these is the adoption of a
transdiagnostic approach to treatment whereby treatment is no longer for a specific eating disorder (eg,
bulimia nervosa) but is directed at eating disorder psychopathology and the processes that maintains it.
As a result, an empirically supported treatment approach has evolved that is suitable for all forms of
eating disorder and one that is highly individualized.

Many challenges remain. First and foremost, treatment outcome needs to be further improved, especial‐
ly in the case of patients who are substantially underweight. Second, understanding more about the way
in which treatment works, and the active ingredients of treatment, could inform the design of a more
potent version. Doubtless some elements could be discarded whereas others may need to be
enhanced.35 We need treatments that are effective and efficient. Last, we need to facilitate the dissemi‐
nation of evidence-based practice. Many patients receive suboptimal treatment. There are several possi‐
ble reasons for this but prominent among them is the fact that few therapists have received the neces‐
sary training.

Footnotes

C.G.F. is supported by a Principal Research Fellowship from the Wellcome Trust (046386). R.M., S.S., and Z.C. are
supported by a program grant from the Wellcome Trust (046386).

References

1. National Institute for Clinical Excellence (NICE) NICE; London: 2004. Eating disorders—core interventions in the treatment
and management of anorexia nervosa, bulimia nervosa and related eating disorders.http://www.nice.org.uk Available at: Accessed
October 2009. NICE Clinical Guidance No. 9. [PubMed] [Google Scholar]

2. Fairburn C.G., Cooper Z., Doll H.A. Transdiagnostic cognitive behavioral therapy for patients with eating disorders: a two-site
trial with 60-week follow-up. Am J Psychiatry. 2009;166:311–319. [PMC free article] [PubMed] [Google Scholar]

3. American Psychiatric Association . 4th edition. American Psychiatric Association; Washington, DC: 1994. Diagnostic and
statistical manual of mental disorders. [Google Scholar]

4. Fairburn C.G., Bohn K. Eating disorder NOS (EDNOS): an example of the troublesome “not otherwise specified” (NOS)
category in DSM-IV. Behav Res Ther. 2005;43:691–701. [PMC free article] [PubMed] [Google Scholar]
5. Dalle Grave R., Calugi S. Eating disorder not otherwise specified on an inpatient unit. Eur Eat Disord Rev. 2007;15:340–349.
[PubMed] [Google Scholar]

6. Miller G., Holden C. Proposed revisions to psychiatry's canon unveiled. Science. 2010;327(5967):770–771. [PubMed] [Google
Scholar]

7. Fairburn C.G., Cooper Z., Bohn K. The severity and status of eating disorder NOS: implications for DSM-V. Behav Res Ther.
2007;45(8):1705–1715. [PMC free article] [PubMed] [Google Scholar]

8. Wilson G.T., Grilo C.M., Vitousek K.M. Psychological treatment of eating disorders. Am Psychol. 2007;62(3):199–216.
[PubMed] [Google Scholar]

9. Shapiro J.R., Berkamn N.D., Brownley K.A. Bulimia nervosa treatment: a systematic review of randomized controlled trials.
Int J Eat Disord. 2007;40(4):321–336. [PubMed] [Google Scholar]

10. Hay P.P.J., Bacaltchuk J., Stefano S. Psychological treatments for bulimia nervosa and binging. Cochrane Database Syst Rev.
2009;4 CD000562. [PMC free article] [PubMed] [Google Scholar]

11. Fairburn C.G., Jones R., Peveler R.C. Psychotherapy and bulimia nervosa: the longer-term effects of interpersonal
psychotherapy, behaviour therapy and cognitive behaviour therapy. Arch Gen Psychiatry. 1993;50:419–428. [PubMed] [Google
Scholar]

12. Agras W.S., Walsh B.T., Fairburn C.G. A multicenter comparison of cognitive behavioral therapy and interpersonal
psychotherapy for bulimia nervosa. Arch Gen Psychiatry. 2000;57:459–466. [PubMed] [Google Scholar]

13. Wilson G.T., Fairburn C.G. Treatments for eating disorders. In: Nathan P.E., Gorman J.M., editors. A guide to treatments that
work. 3rd edition. Oxford University Press; New York: 2007. pp. 581–583. [Google Scholar]

14. Fairburn CG. Transdiagnostic CBT for eating disorders “CBT-E”, presented at association for behavioral and cognitive
therapy. New York; 2009.

15. Mitchell J., Devlin M., de Zwaan M. Guilford; New York: 2008. Binge eating disorder. Clinical foundations and treatment. p.
65–9. [Google Scholar]

16. Brownley K.A., Berkman N.D., Sedway J.A. Binge eating disorder treatment: a systematic review of randomized controlled
trials. Int J Eat Disord. 2007;40:337–348. [PubMed] [Google Scholar]

17. Sysko R., Walsh T. A critical evaluation of the efficacy of self-help interventions for the treatment of bulimia nervosa and
binge-eating disorder. Int J Eat Disord. 2008;41:97–112. [PubMed] [Google Scholar]

18. Wilson G.T., Wilfley D.E., Agras W.S. Psychological treatments of binge eating disorder. Arch Gen Psychiatry.
2010;67(1):94–101. [PMC free article] [PubMed] [Google Scholar]

19. Fairburn C.G., Cooper Z., Shafran R. Cognitive behaviour therapy for eating disorders: a “transdiagnostic” theory and
treatment. Behav Res Ther. 2003;41:509–528. [PubMed] [Google Scholar]

20. Fairburn C.G., Harrison P.J. Eating disorders. Lancet. 2003;361:407–416. [PubMed] [Google Scholar]
21. Fairburn C.G., Cooper Z., Cooper P. The clinical features and maintenance of bulimia nervosa. In: Brownwell K.D., Foreyt
J.P., editors. Physiology, psychology and treatment of eating disorders. Basic Books; New York: 1986. pp. 389–404. [Google
Scholar]

22. Cooper Z., Stewart A. CBT-E and the younger patient. In: Fairburn C.G., editor. Cognitive behavior therapy and eating
disorders. Guilford Press; New York: 2008. pp. 221–230. [Google Scholar]

23. Dalle Grave R., Bohn K., Hawker D. Inpatient, day patient, and two forms of outpatient CBT-E. In: Fairburn C.G., editor.
Cognitive behavior therapy and eating disorders. Guilford Press; New York: 2008. pp. 231–244. [Google Scholar]

24. Dalle Grave R, Fairburn CG. Intensive CBT for eating disorders. New York: Guilford Press, in press.

25. Fairburn C.G. Guilford Press; New York: 2008. Cognitive behavior therapy and eating disorders. [Google Scholar]

26. Fairburn C.G., Cooper Z., Waller D. The patients: their assessment, preparation for treatment and medical management. In:
Fairburn C.G., editor. Cognitive behavior therapy and eating disorders. Guilford Press; New York: 2008. pp. 35–40. [Google
Scholar]

27. Fairburn C.G., Agras W.S., Walsh B.T. Prediction of outcome in bulimia nervosa by early change in treatment. Am J
Psychiatry. 2004;161:2322–2324. [PubMed] [Google Scholar]

28. Agras W.S., Crow S.J., Halmi K.A. Outcome predictors for the cognitive-behavioral treatment of bulimia nervosa: data from a
multisite study. Am J Psychiatry. 2000;157:1302–1308. [PubMed] [Google Scholar]

29. Fairburn C.G. Guilford Press; New York: 1995. Overcoming binge eating. [Google Scholar]

30. Schmidt U., Treasure J. Psychology Press; Hove (UK): 1993. Getting better bit(e) by bit(e). A survival guide for sufferers of
bulimia nervosa and binge eating disorders. [Google Scholar]

31. Fairburn C.G., Cooper Z., Shafran R. Enhanced cognitive behavior therapy for eating disorders: the core protocol. In:
Fairburn C.G., editor. Cognitive behavior therapy and eating disorders. Guilford Press; New York: 2008. pp. 47–193. [Google
Scholar]

32. Fairburn C.G., Cooper Z., Shafran R. Clinical perfectionism, core low self-esteem and interpersonal problems. In: Fairburn
C.G., editor. Cognitive behavior therapy and eating disorders. Guilford Press; New York: 2008. pp. 47–123. [Google Scholar]

33. Shafran R., Cooper Z., Fairburn C.G. Clinical perfectionism: a cognitive-behavioural analysis. Behav Res Ther. 2002;40:773–
791. [PubMed] [Google Scholar]

34. Murphy R., Straebler S., Cooper Z. Interpersonal psychotherapy (IPT) for eating disorders. In: Dancyger I.F., Fornari V.M.,
editors. Evidence based treatments for eating disorders. Nova Science Publishers; New York: 2009. pp. 257–274. [Google
Scholar]

35. Kazdin A.E., Nock M.K. Delineating mechanisms of change in child and adolescent therapy: methodological issues and
research recommendations. J Child Psychol Psychiatry. 2003;44:1116–1129. [PubMed] [Google Scholar]