Enhanced Cognitive Behavioural Therapy for Patients With Eating Disorders

A Systematic Review

Martie de Jong; Maartje Schoorl; Hans W. Hoek


Curr Opin Psychiatry. 2018;31(6):436-444. 

In This Article

Abstract and Introduction


Purpose of review: The aim of this study was to provide an update of the most recent (since January 2014) enhanced cognitive behavioural therapy (CBT-E) effectiveness studies (randomized controlled trials and open trials) on bulimia nervosa, binge eating disorder and transdiagnostic samples.

Recent findings: Out of 451 screened studies, seven effectiveness studies (five randomized and two open trials) were included in this review: of these, three had a bulimia nervosa sample and four a transdiagnostic sample (all conducted in an outpatient setting). Substantial differences in posttreatment remission rates were found (range: 22.2–67.6%) due, in part, to differences in samples and operationalization of clinical significant change.

Summary: There is robust evidence that CBT-E is an effective treatment for patients with an eating disorder. However, more studies on differential effects and working mechanisms are required to establish the specificity of CBT-E.


Eating disorders are severe mental disorders, which often begin in adolescence,[1] frequently have a chronic course[2] and can have considerable impact on quality of life.[3] Eating disorders make a substantial contribution to the global burden of disease, especially among young women.[4] Although anorexia nervosa is a relatively rare disorder in many non-western countries, bulimia nervosa and binge eating disorder (BED) are common disorders worldwide.[5] Previous reviews showed that, among young women in Europe, Asia, Africa and Latin America, bulimia nervosa is reported by 1–2% and BED by 1–4%.[6–10] Recent studies show that eating disorders (especially bulimia nervosa and BED) are also common among older persons; according to the DSM-5 criteria, the prevalence of all eating disorders combined is around 3.5% in older (aged >40 years) women and around 1–2% in older men.[11] Despite that increasing numbers of individuals with eating disorders are receiving treatment, European samples show that only about one-third are detected via healthcare.[6]

In terms of the DSM-IV, the most common eating disorder diagnosis in both clinical and community samples was 'Eating disorder not otherwise specified' (EDNOS). With the introduction of the DSM-5 and concurrent changes in the eating disorder section (including the introduction of BED as an official category, and lowering the threshold for anorexia nervosa and bulimia nervosa), the percentage of 'Other specified feeding or eating disorder' (OSFED; DSM-IV EDNOS) was significantly reduced, even though this diagnosis might still be the most common one in this population.[12–14]

According to a recent international comparison between nine evidence-based clinical guidelines for eating disorders, cognitive behavioural therapy (CBT) is widely used as the preferred treatment for bulimia nervosa and BED.[15] The major guidelines for the treatment of eating disorders[16–18] recommend CBT as the psychological treatment of first choice for bulimia nervosa and BED. CBT-E (enhanced) is a specific form of CBT and is designed to be suitable for the full range of eating disorder diagnoses.[19] It is based on the transdiagnostic theory of the maintenance of eating disorders, in which it is assumed that most of the mechanisms involved in the persistence of eating disorders are common to all eating disorders, rather than being specific to each diagnostic group separately. It asserts that central to all eating disorders is a dysfunctional evaluation of self-worth that is overly based on shape and weight.[20] CBT-E uses strategies and procedures to address this overevaluation of shape and weight by focusing on targeting these mechanisms (known as the 'focused' version of CBT-E). The treatment protocol can be extended with interventions that target additional maintaining mechanisms, that is core low self-esteem, clinical perfectionism and interpersonal problems (known as the 'broad' version of CBT-E). For the OSFED diagnoses, CBT-E has an advantage over other CBT protocols because of its transdiagnostic reach. CBT-E has been investigated in several samples in which CBT-E for bulimia nervosa, BED and EDNOS proved to be a successful treatment in the first studies after development of the CBT-E protocol.[21,22]

This review provides an update of the most recent (i.e. published since 2014) CBT-E effectiveness studies [randomized controlled trials (RCTs) and open trials] on bulimia nervosa, BED and transdiagnostic samples. Studies on the transdiagnostic samples include bulimia nervosa, BED, OSFED and, sometimes (i.e. in studies with lower BMI inclusion criteria), anorexia nervosa. However, excluded from the present review were studies with an anorexia nervosa sample alone, due to differences in treatment duration and other treatment variables (e.g. a focus on weight gain).

In this review, the characteristics of the included studies are described, possible explanations for the variability in outcome are proposed, recommendations are made for future research and the methodological quality of the RCTs is described. Due to the small number of included studies, no meta-analysis was performed.