Cognitive Behavior

Therapy for Adolescents

with Eating Disorders

Riccardo Dalle Grave

Simona Calugi
Foreword by Christopher G. Fairburn

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 About the Authors

Riccardo Dalle Grave, MD, is Director of the Department of Eating and

Weight Disorders at Villa Garda Hospital in Verona, Italy. In collaboration
with Christopher G. Fairburn, Dr. Dalle Grave has developed an inpatient
treatment program for eating disorders at Villa Garda based entirely on
enhanced cognitive behavior therapy (CBT-E), including an adapted
program for adolescents. His current research includes assessing the
effectiveness of CBT-E in treatment of significantly underweight adults and
adolescents with eating disorders in both outpatient and inpatient settings.
Dr. Dalle Grave is editor of the CBT-E website (cbte.co) and Director of the
Advanced Training Course on the Treatment and Prevention of Eating
Disorders and Obesity sponsored by the Italian Eating and Weight Disorder
Association (AIDAP). He also provides CBT-E supervision for clinical
services in Europe, the United States, Australia, and the Middle East. Dr.
Dalle Grave is a Fellow of the Academy of Eating Disorders and serves on
the editorial boards of several journals in the field.

Simona Calugi, PhD, is Clinical Research Director of the Department of

Eating and Weight Disorders at Villa Garda Hospital. In collaboration with
Riccardo Dalle Grave and Christopher G. Fairburn, Dr. Calugi is involved in
assessing the effectiveness of CBT-E in treatment of significantly
underweight adults and adolescents with eating disorders in both outpatient
and inpatient settings. Dr. Calugi has extensive clinical experience in
delivering outpatient CBT-E to adolescent and adult patients with eating
disorders. She is a member of the online CBT-E training group (cbte.co) and
is on the teaching faculty of the Advanced Training Course on the
Treatment and Prevention of Eating Disorders and Obesity sponsored by the
AIDAP. She also serves on the faculties of several CBT-based psychotherapy
schools in Italy and is president of the AIDAP.
 Foreword

is is an important book. It fills two major gaps. For clinicians, it provides a
detailed guide to the treatment of any form of eating disorder seen in
adolescents. For researchers, it specifies for the first time how this
empirically supported treatment, “enhanced cognitive behavior therapy”
(CBT-E), should be implemented with young patients. Let me expand on
these two points.

A BOOK FOR CLINICIANS BY CLINICIANS

Too oen, treatment manuals are written by treatment “gurus” or

researchers who engage in little or no ongoing face-to-face clinical work.
is shows in a lack of attention to the dilemmas posed by “real-world”
clinical practice and a paucity of meaningful clinical illustrations. is book
is entirely different, as it has been written by two experienced practitioners,
both of whom are active clinically. e result is a truly useful guide to the
implementation of CBT-E with adolescents who have an eating disorder.
Some readers are aware that I have previously written a guide to the use
of CBT-E (Fairburn, 2008). Is there a need for a second one? e answer is
definitely “Yes,” as the original version of CBT-E has had to be adapted in
both style and content to make it suitable both for young patients and for
the clinical presentations most commonly encountered in this age group. It
is of note that the two authors of this book, Riccardo Dalle Grave and
Simona Calugi, pioneered these adaptations. ey have also pioneered
something else. ey have extended the use of CBT-E from being solely an
outpatient treatment to being an approach that can be used in a range of
clinical settings, including inpatient and day patient settings. is is
important, as it has the potential to minimize the disruption to treatment
that arises when a patient moves from one setting to another. e
description of how CBT-E is used in different settings is therefore a major
additional strength of this book.

A BOOK FOR RESEARCHERS, TOO

Testing a psychological treatment is difficult. One of the biggest challenges is

implementing the treatment correctly, a problem barely faced when
evaluating a pharmacological treatment. To achieve this, there has to be a
detailed specification of the treatment, like the one provided in this book.
Now that there is one, valid comparisons can be made between CBT-E and
other treatment approaches, most notably the family-based treatments for
anorexia nervosa in adolescents. Arguably, the most pressing clinical
questions in the eating-disorder field are how these two very different
treatment approaches compare in their effectiveness and whether particular
types of patients respond better to one or the other. anks to Dalle Grave
and Calugi, it is now possible to address these questions.

THE BOOK IN CONTEXT

Finally, where does this book, which focuses on adolescence, sit in relation
to the Fairburn (2008) CBT-E guide, and is that volume rendered
superfluous by the detailed online training program in CBT-E? (See cbte.co
for details.) e answer is simple. is book replaces the guide as a written
description of how to implement CBT-E with younger patients and, as for
the online training program, it extends and complements it through its
detailed attention to the specific needs of adolescents. What is also
abundantly clear is that the book will be a valuable resource for years to
come.

CHRISTOPHER G. FAIRBURN, DM, FMedSci,

FRCPsych
Wellcome Principal Research Fellow and
Professor of Psychiatry, University of Oxford
Director, Centre for Research on Eating
Disorders at Oxford (CREDO)
 Preface

Enhanced cognitive behavior therapy (CBT-E) is a specific form of cognitive

behavior therapy (CBT) developed at the Centre for Research on Eating
Disorders at Oxford (CREDO) in the United Kingdom. CBT-E has been
defined as enhanced because it uses a variety of innovative strategies and
procedures to enhance the effectiveness of the original CBT for bulimia
nervosa, and to address the cognitive processes that maintain the
psychopathology of eating disorders that operate in the patient. It is based
on a transdiagnostic perspective, meaning that the target of treatment is
eating disorders as a whole, rather than any particular diagnostic category
(i.e., anorexia nervosa, bulimia nervosa, binge-eating disorder, and other
eating disorders). e treatment was initially designed for adult patients
with eating disorders of clinical severity manageable on an outpatient basis
and with a body mass index (BMI) of between 15.0 and 40.0, and has been
evaluated in numerous clinical trials. Today it is considered the most
effective intervention for treating all clinical forms of eating disorders in
adults, and as such has been recommended for this purpose by the National
Institute for Health and Care Excellence (NICE; 2017).
e idea of adapting CBT-E for the treatment of adolescents was raised
10 years ago at the Department of Eating and Weight Disorders of Villa
Garda Hospital, Verona, Italy, during a periodic supervision visit by
Professor Christopher G. Fairburn, the undisputed “father” of CBT for
eating disorders. e observation that young patients with eating disorders
display the same specific psychopathology as adults led us to hypothesize
that adolescents could also benefit from a treatment, such as CBT-E,
designed to specifically address the psychopathology of eating disorders.
CBT-E has many additional features that, in our opinion, make it suitable for
meeting the needs of younger patients.
First and foremost, CBT-E is a psychological treatment that includes
numerous strategies for engaging the patient—a feature of vital importance
in the management of adolescents, who are usually very ambivalent toward
the prospect of starting treatment. Furthermore, CBT-E adopts a
collaborative approach aimed at improving the patient’s general sense of
control—a relational modality that is well suited to younger patients, in
whom the pursuit of control, autonomy, and independence are themes of
great relevance. CBT-E is also simple to understand and to receive, and
provides a flexible and individualized approach that is easily adaptable to the
specific needs of young patients at different stages of physical and cognitive
development in their lives. Finally, being based on a transdiagnostic
approach, CBT-E is able to address all the diagnostic categories of eating
disorders and is therefore suitable for a large proportion of adolescent
patients, who are oen plagued by an overvaluation of eating control per se,
rather than the overvaluation of shape and weight.
at being said, adolescents are at a delicate stage in their physiological
and psychological development, and we decided to create a form of CBT-E
adapted specifically for them that would take into account the distinctive
features of eating disorders in adolescents. is ultimately resulted in the
new treatment described in this book, which is the outcome of much
research and clinical experience, and is firmly grounded on the available
scientific evidence. e treatment is derived from CBT-E, but introduces
important changes that make it suitable for treating most adolescents with
eating disorders.
 It is well known that most adolescents are in an ego-syntonic phase of
the eating disorder, oen being completely unaware of having a problem,
and in many cases they are very difficult to engage in treatment. ese
characteristics have led to the development of treatments that view the
illness as separate from the patient (i.e., do not identify the patient with the
illness itself—“externalization”) in order to enable parents or clinicians to
take firm action against the eating disorder and not against the patient. e
aim of these treatments, based on “external” control, is to help young
patients to regain weight and to stop practicing extreme weight-control
behaviors, regardless of how willing they are to do so. A typical example of
this approach is family-based treatment (FBT), also called Maudsley family
therapy—a particular form of empirically supported family therapy for
adolescents with anorexia nervosa of recent onset. FBT considers
adolescents with eating disorders as being unable to control their behavior,
because they are controlled by the eating disorder and, like children, they
need constant supervision by their parents who are, therefore, prompted to
take control over their eating.
Unlike treatments based on external control, CBT-E never separates the
eating disorder from the adolescent patient. Instead, its proponents maintain
that young people can be helped to regain control by playing an active role
in their own treatment. For this reason, CBT-E never adopts “prescriptive”
or “coercive” procedures—in other words, it never asks the adolescent
patients to change things that they do not see as a problem, because, in our
clinical experience, this approach oen increases their resistance to change.
With this in mind, CBT-E for adolescents has introduced specific
procedures to engage adolescents in the decision to start treatment, and Step
One was designed primarily to help them think about change and, if
underweight, to decide whether or not to address weight restoration.
Attention to the adolescent’s motivation continues throughout the entire
course of treatment. One of the tools used to stimulate patients’ engagement
in change is, in fact, a key strategy used by CBT-E. is involves
collaboratively drawing up with the patients an individualized formulation
of the processes maintaining their psychopathology, which will become the
targets of the treatment. Young patients are educated about the processes
reported in their personal formulation, and are actively involved in making
the decision to address them. In other words, they are treated as young, self-
determining individuals rather than as children with no say in the matter. If
they do not reach the conclusion that they have a problem to address, the
treatment does not begin or is interrupted, although in our experience, this
rarely happens.
at is not to say that parents are not considered important treatment
facilitators. Even the version of CBT-E for adults involves significant others
(i.e., friends, partners, or parents) to a certain extent if the patient agrees
that they will be useful in supporting the implementation of treatment
(Fairburn, 2008). e same principles are applied in CBT-E for adolescents,
except that, given the age and circumstances of these patients, parents are
always kept informed and recruited to help the patient to apply specific
treatment procedures. However, the decision about how and to what extent
parents are involved is always taken in agreement with the patient and
explained to the parents in special joint patient–parents sessions.
Another key innovation in this version of CBT-E is the inclusion of the
Eating Problem Checklist (EPCL)—a new self-report questionnaire that
allows patients to monitor changes in their eating-disorder psychopathology
at weekly intervals (Dalle Grave et al., 2019). e EPCL was developed to
enable monitoring of the very rapid changes in eating-disorder
psychopathology (“sudden gains”) observed in some adolescents undergoing
treatment; these seem to be associated with better therapeutic alliance and
improved outcome (Tang, DeRubeis, Beberman, & Pham, 2005), and may
therefore inform treatment, which involves in-session reviews every 4
weeks. e focus of this review is to assess and analyze progress with a view
to boosting motivation and engagement, identifying any emerging obstacles
to change, and setting out a plan for the next 4 weeks.
Like the adult version, CBT-E for adolescents can be tailored to the
individual. It can be administered in a “focused” form that addresses the
eating-disorder psychopathology or in a “broad” form that also addresses
one of the external maintenance processes (clinical perfectionism, core low
self-esteem, marked interpersonal difficulties, and/or mood intolerance) in
the subgroup of patients who exhibit them (Fairburn, Cooper, & Shafran,
2003).
Furthermore, the treatment has been designed to be delivered at four
levels of care (outpatient, intensive outpatient, inpatient, and postinpatient
outpatient; Dalle Grave, 2013). e most distinctive feature of this approach
—a unique example in the field of psychological treatment of eating
disorders for adolescents—is that the same theory and the same strategies
and procedures are applied at every level of care. e only difference
between the various levels is the intensity of the treatment, which is lower in
the outpatient setting and greater in the inpatient setting. With this
approach, adolescent patients who do not respond to outpatient CBT-E can
be helped to overcome their eating disorder with intensive outpatient CBT-
E, where assisted meals are used as an adjunct to individual CBT-E sessions,
or with inpatient CBT-E, if they have physical and/or psychological
conditions that indicate the need for hospitalization. Finally, aer inpatient
CBT-E, patients complete their treatment pathway with postinpatient
outpatient CBT-E.
is approach was first developed at Villa Garda Hospital, Verona, Italy,
but similar services are also being set up in other European countries. A
cross-level clinical service based on CBT-E has two main advantages. First,
patients are treated with a single, well-delivered, evidence-based treatment,
rather than the unscientific eclectic approach common elsewhere. Second, it
minimizes the problems associated with transitions from outpatient to
intensive treatment, as it avoids subjecting patients to the confusing and
counterproductive changes in therapeutic approach that commonly
accompany such transitions. It goes without saying, however, that a different
form of treatment must be offered to any patients who do not respond to
CBT-E.
 Like CBT-E for adults, the adolescent version is the subject of ongoing
scientific and clinical research with a view to ensuring continuous
improvement and the effectiveness of procedures. It has been evaluated by
our research group in several cohort studies of patients ages 12–19 years
(Calugi & Dalle Grave, 2019; Calugi, Dalle Grave, Sartirana, & Fairburn,
2015; Dalle Grave, Calugi, Doll, & Fairburn, 2013; Dalle Grave, Calugi, El
Ghoch, Conti, & Fairburn, 2014; Dalle Grave, Calugi, Sartirana, & Fairburn,
2015; Dalle Grave, Sartirana, & Calugi, 2019). ree studies included
adolescents with severe anorexia nervosa treated with outpatient and
inpatient CBT-E, and one adolescent outpatient with bulimia nervosa or
other not-underweight eating disorders. e results of these studies indicate
that about two-thirds of young patients achieve lasting remission of their
eating disorder thanks to CBT-E. Interestingly, in a study that compared
treatment outcomes in adolescent and adult outpatients with anorexia
nervosa, it was observed that a significantly higher percentage of adolescents
reached normal weight as compared to adults (65.3% vs. 36.5%,
respectively), and that the time required by adolescents to normalize weight
was about 15 weeks lower (on average 14.8 weeks vs. 28.3 weeks for adults;
Calugi et al., 2015).
e promising results obtained from the studies described above have
influenced international health policy (National Collaborating Centre for
Mental Health, 2015), and the 2017 National Institute for Health and Care
Excellence (NICE) guidelines for eating disorders recommend CBT for
adolescents as an alternative to FBT for anorexia nervosa and bulimia
nervosa and guided self-help for binge-eating disorder (National Institute
for Health and Care Excellence, 2017). It was this international recognition
for CBT-E that encouraged us to write this book, which is designed to
provide clinicians with a complete description—accompanied by numerous
clinical examples and helpful vignettes—of how to implement CBT-E in
adolescent patients. All of the case material vignettes in this volume are
fictional/composite.
 It is important to read the chapters of the book consecutively, as each
chapter assumes that the reader is familiar with the information provided in
the previous chapters. We recommend integrating the information
contained in this book with the online CBT-E training, which illustrates the
treatment in great detail and is available to eligible therapists at no cost
(www.cbte.co/for-professionals/training-in-cbt-e). Learning CBT-E for
adolescents is not difficult, but the treatment must be taken seriously and
seen as a “work in progress” that necessitates constant practice. In our
experience, it requires 2–3 years of implementing the treatment to become
fully competent. When learning CBT-E, it is advisable to scrupulously follow
the protocol and not deviate from it in any way. In the beginning, it is
advisable to shadow an expert in the treatment of several cases to ensure
familiarity with the strategies and procedures involved. Where a trained
therapist is not yet part of the team, it is recommended that groups of
colleagues take the course together so that each can benefit from the others’
experience.
It is our hope that this book will assist clinicians to implement CBT-E
well, and that it will help raise awareness of this effective treatment for
adolescents with eating disorders.
 Acknowledgments

First and foremost, we would like to thank our esteemed mentor Professor
Christopher G. Fairburn, who supported and helped us in the complex and
labor-intensive task of adapting the transdiagnostic theory and CBT-E for
adolescents and intensive care levels of care. Heartfelt thanks also go to our
colleague Massimiliano Sartirana, who assisted with some of the fictional
vignettes, and to all of our colleagues at the Department of Eating and
Weight Disorders at Villa Garda Hospital, who, in addition to their valuable
suggestions, have helped enormously in the implementation and evaluation
of the effectiveness of the treatment. Additional thanks are also due to Anna
Forster for her editing services and professionalism.
 Contents

Cover

Title Page

Copyright Page

About the Authors

Foreword

Preface

Acknowledgments

Introduction and Overview

CHAPTER 1. Eating Disorders in Adolescence and Cognitive
Behavioral Theory

CHAPTER 2. CBT-E for Adolescents with Eating Disorders: An

Overview

CHAPTER 3. Assessment, Preparation, and Medical Management

 The Core Protocol
CHAPTER 4. The Three Steps of CBT-E for Adolescents: An Overview

CHAPTER 5. Session 0

CHAPTER 6. Parents-Only Session

CHAPTER 7. Session 1

CHAPTER 8. Session 2

CHAPTER 9. Deciding to Change

CHAPTER 10. Review Sessions

CHAPTER 11. Underweight and Undereating Module

CHAPTER 12. Body Image Module

CHAPTER 13. Dietary Restraint Module

CHAPTER 14. Events, Moods, and Eating Module

CHAPTER 15. Setbacks and Mindsets Module

CHAPTER 16. Ending Well

Adaptations for More Complex and Severe Cases

CHAPTER 17. The Broad CBT-E Modules

CHAPTER 18. Intensive Outpatient CBT-E

CHAPTER 19. Inpatient CBT-E

CHAPTER 20. Comorbidity and CBT-E for Adolescents

 Appendices
APPENDIX A. Terms Used to Describe Eating-Disorder Psychopathology

APPENDIX B. The Effects of Caloric Restriction and Weight Loss: The Minnesota
Starvation Experiment

APPENDIX C. The Starvation Symptom Inventory

APPENDIX D. The Eating Problem Checklist

References

Index

About Guilford Press

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select materials at www.guilford.com/dalle-grave-forms for personal use
or use with patients (see copyright page for details).
Introducti
on and
Overview
 CHAPTER 1

Eating Disorders in Adolescence

and Cognitive Behavioral Theory

Eating disorders are among the most common and serious health problems
that afflict teenagers. ey have a profound impact on the psychosocial and
physical health of adolescents, and are associated with an increased risk of
premature death. It is therefore crucial that they are treated early and
effectively to avoid long-lasting harm.
e current standard for classifying eating disorders suggests that there
are several distinctive eating disorders, each requiring a specific treatment.
However, there are various lines of research that point to a different way of
conceptualizing these conditions. Indeed, numerous studies suggest that
what we think of as the main “eating disorders” are, in fact, different
phenotypical manifestations of a single core psychopathology, and that they
can all be treated with minimal adaptations to one treatment—namely,
enhanced cognitive behavior therapy (CBT-E).
is chapter begins by discussing the way in which eating disorders are
currently classified. It then describes the main psychopathological, physical,
and social features of these eating disorders in adolescents, and ends by
bringing these features together to illustrate an alternative conceptualization
of “eating disorder”—a transdiagnostic theory.

THE CURRENT CLASSIFICATION OF EATING

DISORDERS

Eating disorders are currently characterized by a disturbance in eating habits

or weight-control behaviors, not secondary to any general medical disorder
or any other psychiatric condition that results in a clinically significant
impairment of physical health or psychosocial functioning. e fih edition
of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) groups
eating disorders and feeding disorders1 into a single category (American
Psychiatric Association, 2013), but provides specific diagnostic criteria for
anorexia nervosa, bulimia nervosa, and binge-eating disorder (outlined in
Table 1.1). It also includes two residual categories of eating disorders of
clinical severity that do not meet the diagnostic criteria for the three main
eating disorders—these have been termed “other specified eating disorders”
and “unspecified eating disorders.”
TABLE 1.1. Diagnostic Criteria for Eating Disorders
Anorexia nervosa
In essence, two main features must be present to make a diagnosis of anorexia nervosa:
1. Active restriction of energy intake relative to requirements, leading to a significant low
body weight in the context of age, sex, developmental trajectory, and physical health.
The threshold for considering someone significantly underweight in adults is debated and
varies, but usually a body mass indexa below 17.0, 18.0, or 18.5. For children and
adolescents, the recommendation is to determine a BMI-for-age percentile. The Centers
for Disease Control and Prevention (CDC) classify underweight status according to a
BMI for age below the 5th percentile,b but children and adolescents with a BMI above this
threshold may also be considered significantly underweight if they fail to maintain their
expected growth trajectory.
2. Overvaluation of shape, weight, and their control—that is, judging self-worth largely, or
even exclusively in terms of shape, weight, and the ability to control them.

Bulimia nervosa
In essence, three main features need to be present to make a diagnosis of bulimia nervosa:
1. Recurrent binge eating. A “binge” is an episode of eating during which an objectively
large amount of food is eaten, taking into account the circumstances, and there is a
sense of loss of control at the time.
2. One or more extreme methods of weight control (recurrent self-induced vomiting or
laxative or diuretic misuse, excessive exercising, sustained dietary restriction).
3. Overvaluation of shape, weight, and their control, as in anorexia nervosa.
The binge eating and inappropriate compensatory behaviors are required to occur, on
average, at least once a week for 3 months.

Binge-eating disorder
There is one primary feature, which is recurrent binge eating. This occurs in the absence of
the extreme weight-control behavior seen in bulimia nervosa. There is marked distress
regarding binge eating and, usually, accompanying shame and self-criticism. The binge
eating is required to occur, on average, at least once a week for 3 months.

Other specified eating disorders

Eating disorders of clinical severity that do not fulfill the full diagnostic criteria for any of the
three specified eating disorders. The diagnosis is used in situations in which the clinician
chooses to communicate the specific reason that the presentation does not meet the criteria
for any specific eating disorder.

Unspecified eating disorders

Eating disorders of clinical severity that do not meet the diagnostic criteria for anorexia
nervosa, bulimia nervosa, or binge-eating disorder. The diagnosis is used in situations in
which the clinician chooses not to specify the reason that criteria for a specific disorder are
not met, including presentations in which there is insufficient information to make a more
specific diagnosis.
a
Body mass index (BMI) is the most common way of representing weight adjusted for
height, and it is calculated by dividing the weight (in kilograms) by height squared (in
meters)—that is, weight/height2.
b
The BMI-for-age percentile growth charts are the most commonly used indicator to
measure the size and growth patterns of children and teens (up to 19 years of age). The
weight status categories defined by the CDC are as follows: underweight (less than the 5th
percentile), normal or healthy weight (5th percentile to less than the 85th percentile),
overweight (85th to less than the 95th percentile), obesity (equal to or greater than the 95th
percentile). However, for patients with eating disorders, it is advisable to consider a BMI-for-
age percentile corresponding to about a BMI of 19.0 in adults as the minimal threshold of
healthy weight, as below this BMI most people experience some adverse physical and
psychosocial effects of being underweight.

e “other specified eating disorders” are divided into five (more or less)
distinct subgroups (American Psychiatric Association, 2013):

1. Atypical anorexia nervosa. is is a subthreshold form of anorexia

nervosa in which the individual’s weight is above the specified
threshold for anorexia nervosa, despite significant weight loss.
2. Bulimia nervosa (of low frequency and/or limited duration). is is a
subthreshold form of bulimia nervosa in which the binge-eating and
extreme weight-control behaviors occur less frequently than once a
week and/or over a period of fewer than 3 months.
3. Binge-eating disorder (of low frequency and/or limited duration). is
is a subthreshold form of binge-eating disorder in which the binge
eating occurs, on average, less frequently than once a week and/or
over a period of fewer than 3 months.
4. Purging disorder. is presents with recurrent purging (i.e., self-
induced vomiting or the misuse of laxatives or diuretics) in the
absence of binge eating. However, since many people with purging
disorder also have “subjective binges” (i.e., the amount of eating is
not unusually large given the circumstances), they may be better
viewed as having a form of subthreshold bulimia nervosa.
5. Night eating syndrome. is is a disorder characterized by recurrent
episodes of eating in the evening or during the night. ere is an
awareness of the behavior, and it results in significant distress or
impairment.
 Few data are available on the distribution of eating disorders in
adolescence, but it seems that anorexia nervosa is the most common,
followed by the other specified or unspecified eating disorders, while
bulimia nervosa and binge-eating disorder are relatively less frequent. Table
1.2 illustrates the distribution of the eating-disorder diagnoses among
adolescents seeking treatment for outpatient CBT-E in our clinic in Verona,
Italy.

TABLE 1.2. The Distribution of DSM-5 Eating-Disorder Diagnoses

among 128 Consecutive Adolescent Patients Attending an Italian
Outpatient CBT-E Clinic from 2016 to 2018
Diagnosis No. %
Anorexia nervosa 81 63.3
Bulimia nervosa 12 9.4
Binge-eating disorder 7 5.5
Other specified eating disorders
Atypical anorexia nervosa 16 12.5
Bulimia nervosa (of low frequency and/or limited 0 0
duration)
Binge-eating disorder (of low frequency and/or limited 0 0
duration)
Purging disorder 0 0
Night eating syndrome 0 0
Unspecified eating disorders 12 9.3

DOES THE DSM-5 CLASSIFICATION REFLECT

CLINICAL REALITY?

e DSM-5 diagnoses described above have two main shortcomings that

undermine the validity of such distinctions (Fairburn, Cooper, et al., 2003).
First, the different forms of eating disorders actually have more clinical
similarities than differences. In other words, anorexia nervosa, bulimia
nervosa, and most of the other eating disorders have many highly distinctive
clinical features in common. ese include the overvaluation of shape and
weight, a characteristic and persistent form of dieting, and a tendency to
engage in extreme weight-control behaviors. From this perspective, the
specific divisions between the “eating disorders” seem to be somewhat
arbitrary.
Second, it is common to observe migration from one eating disorder
diagnosis to another. Contrary to what the DSM classification would
suggest, it seems evident that such migration does not reflect recovery from
one disorder and the onset of another but rather the evolution of a single
disorder. It is also notable that this migration occurs within the group of
eating disorders as a whole, lending support to the distinctiveness of this
wider category. In other words, the clinical reality indicates that eating
disorders might be better viewed from a transdiagnostic perspective—that
is, as a single category. Indeed, in addition to the general features observed
in other mental disorders, the psychopathology characteristic of eating
disorders consists of specific features seen only in this category (Fairburn,
2008).

SPECIFIC PSYCHOPATHOLOGICAL FEATURES

Core Psychopathology
Eating disorders can be considered cognitive disorders because, in most
cases, their shared specific core psychopathology is cognitive in nature.
Specifically, this is the overvaluation of shape, weight, and their control
(Fairburn, 2008; Fairburn, Cooper, et al., 2003). Unlike the majority of
people, who evaluate themselves on the basis of their perceived performance
in a variety of domains of life (e.g., their performance at school or work, the
quality of their relationships with peers or significant others, and their skill
at a certain sport or hobby), people with eating disorders judge their self-
worth largely, or even exclusively, in terms of their shape and weight, and
their ability to control them. is psychopathology can be termed “specific”
because it is a common feature of most people with eating disorders,
whereas it is uncommon in the general population; it is the same in females,
males, adolescents, and adults with eating disorders.
It is important to distinguish between the overvaluation of shape and
weight and “body shape dissatisfaction,” a term used to define a dislike of
one’s physical appearance. Body shape dissatisfaction is common in the
general population, but in most cases it does not reach clinical severity, and
it is sometimes referred to as “normative discontent.” Overvaluation of shape
and weight, on the other hand, is viewed as the “core” psychopathology of
eating disorders because their other main features stem either directly or
indirectly from it (see Appendix A for a glossary of terms used in the
description of the psychopathology specific to eating disorders).
Overvaluation of shape and weight is expressed in a variety of ways. A
common expression of this specific core psychopathology is a preoccupation
or concern with weight that leads people with eating disorders to check their
weight frequently (“weight checking”), or, in contrast, to actively avoid
knowing how much they weigh (“weight avoidance”). Another typical and
similar behavioral expression of this psychopathology is shape checking or
avoidance. Many people with eating disorders repeatedly check and
scrutinize their bodies, focusing on the parts that they dislike (“shape
checking”), whereas others actively avoid catching sight of themselves
(“body avoidance”), assuming that they look fat and disgusting. Another
form of shape checking commonly adopted by people with eating disorders
is to repeatedly compare their shape with that of others. Most are terrified of
weight gain and being fat, which they tend to equate with feeling fat, a
common experience in such individuals, whatever their actual weight.
In a large subgroup of adolescent patients in the early stages of their
disorder, but also in some adults who are underweight, this core
psychopathology takes the form of overvaluation of control over eating per
se (Dalle Grave, Calugi, & Marchesini, 2008b; Fairburn, Shafran, & Cooper,
1999). is psychopathology may coexist with an overvaluation of shape,
weight, and their control, but when it is present in isolation, patients do not
usually report body checking, body avoidance, or feeling fat. In other words,
it is not concern about their perceived physical appearance that drives their
eating disorder. Instead, such patients tend to be more preoccupied with
how, when, where, and what they eat for their own sake. ey therefore tend
to adopt extreme and inflexible dietary rules (i.e., control over eating) and
engage in various forms of dietary checking (e.g., calorie counting) and
avoidance (e.g., refusing to eat certain food groups). Many of these patients
report that they strongly value the sense of self-control that they get from
engaging in these behaviors. However, in some patients, strict dieting may
also be driven by other reasons (e.g., asceticism, competitiveness, a desire to
attract attention from others) that are different from the overvaluation of
shape, weight, and their control that is seen as specific to the eating
disorders.

Eating Habits and Weight-Control Behaviors

As the core psychopathology of eating disorders, overvaluation of shape,
weight, and their control has a major impact on eating habits, influencing
when, how much, and what an individual eats, and leads people with eating
disorders to adopt extreme and distinctive weight-control behaviors
(Fairburn, 2008). ese expressions of eating disorders are described as
follows:
Dietary restraint is the term we use for the particular form of dieting
seen in eating disorders; it is distinct from ordinary dieting, which tends to
follow general guidelines for eating. In contrast, people with eating disorders
adopt specific, excessively strict, and persistent dietary rules designed to
limit their food intake. ese extreme and inflexible dietary rules typically
include when, how much, and what to eat, and most patients have a large
number of foods that they attempt not to eat at all (“food avoidance”). Some
patients eat the same things every day, and feel compelled to know the
precise nutritional composition of the food that they are eating. It is
common for these patients to weigh food and set a maximum daily caloric
intake. e persistent attempts of such individuals to limit food intake is one
of the most idiosyncratic behaviors of people with eating disorders, and
dietary restraint is a prominent feature of most eating-disorder diagnoses,
except for binge-eating disorder, in which it is not common. is extreme
form of limiting food intake results in profound impairment, causing
constant preoccupation with food and eating that interferes with
concentration. In many cases, patients end up eating alone so that they feel
able to choose what they eat, and can concentrate on eating without being
distracted by others. is “mindset” makes eating out with others very
stressful, and this is generally avoided, or planned days in advance, given the
pressure to eat in front of others and to eat more than usual. In adolescents,
eating at home with parents becomes difficult for the same reason.
Dietary restriction, true undereating in a physiological sense, is another
behavioral feature that occurs when the attempts of patients to limit the
amount eaten are met with some success, as is common in adolescents in the
initial stages of their eating disorder. In these cases, patients lose weight and
may become significantly underweight, developing some specific physical
and psychosocial symptoms secondary to malnutrition (i.e.,
undernutrition). e effects of undereating and being underweight are
important for three main reasons (Fairburn, 2008): (1) some are life-
threatening (e.g., cardiovascular complications) or difficult to reverse (e.g.,
the loss of bone mineral density), (2) some serve to reinforce, or maintain,
the core eating-disorder psychopathology (e.g., social withdrawal) and
increase undereating (e.g., preoccupation with food and eating, heightened
fullness, and the reduction of energy expenditure associated with weight
loss), and (3) some result in profound impairment (e.g., reduced
concentration, poor sleep, irritability, mood swings, heightened
obsessionality, and indecisiveness). Some adolescent patients report loss of
appetite as the cause of their undereating, but this is rarely true. Indeed, with
the exception of the cases characterized by marked clinical depression,
“anorexia” (i.e., loss of appetite) is seldom the main cause of food limitation,
which instead is a goal to be actively pursued.
 Objective binge eating is another characteristic eating habit that occurs
across eating disorder diagnoses, not only in bulimia nervosa and binge-
eating disorder, although it is less common in adolescents compared to
adults and occurs less frequently in patients with anorexia nervosa. In its
diagnosis of bulimia nervosa and binge-eating disorder, DSM-5 sets a binge-
eating frequency threshold of one episode a week, although it may occur
several times a day. An objective episode of binge eating is characterized by
the intake of a large amount of food over a discrete period of time, and is
associated with a contemporaneous sense of loss of control. ere is a wide
range in the amount eaten per episode, but this is typically between 1,000
and 2,000 kilocalories (Fairburn, 2008). Afflicted individuals feel that they
cannot stop eating or control what and how much they are eating. In most
patients, with the exclusion of those with binge-eating disorder, the episodes
of binge eating occur in the context of severe dietary restraint with or
without accompanying dietary restriction. Another characteristic of binge-
eating disorder is that these patients also have a tendency to overeat (i.e.,
taking in a large amount of food without an accompanying sense of lack of
control) even when not bingeing, as opposed to the strict dieting seen in
patients with other eating-disorder diagnoses. Unlike dietary restraint and
dietary restriction, binge eating is considered aversive and distressing by
most patients, and is oen the reason that they seek help. However, some
patients report that binge eating helps them to modulate their mood.
Subjective binge eating is also characterized by a sense of lack of control,
although the amount eaten during these episodes is not, in fact, unusually
large, even though the individual perceives the amount eaten to be “too
much” or excessive. is type of binge eating, which may or may not be
followed by purging, is common in adolescent patients, and can be just as
distressing and impairing as objective binge-eating episodes. Most of the
binges reported by patients with anorexia nervosa also tend to be of this
type.
Purging (i.e., self-induced vomiting and/or the misuse of laxatives or
diuretics) follows the majority of binge-eating episodes in all eating
disorders, with the exception of binge-eating disorder. Purging may be
“compensatory” or ”noncompensatory.” Compensatory purging is used to
minimize the effects on weight of episodes of binge eating (objective and/or
subjective); it follows them, and only occurs when they occur. In contrast,
noncompensatory purging is used, like dieting, as a “routine” form of weight
control, and is not closely linked to episodes of “excessive” eating. It may be
expressed as the repeated spitting out of food. Like binge eating, purging
may function as a means of mood modulation.
Excessive exercising also occurs across the eating disorders, and is
particularly common among underweight adolescent patients. Exercise may
be defined as “excessive” when its duration, frequency, or intensity exceeds
that required for physical health, it increases the risk of physical injury (e.g.,
cardiovascular complications, fractures), and is associated with a subjective
sense of being driven or compelled to exercise. ree main forms of such
exercising have been identified (Dalle Grave, 2009): (1) excessive exercising
during routine daily activities (e.g., walking most of the day or standing
rather than sitting while studying or watching television), (2) excessive
forms of sports activities (e.g., training above and beyond a planned
schedule or going to the gym several times a day)—a form of exercising that
can be present in both competitive and recreational individual sports, and
(3) abnormal or unusual forms of excessive exercising (e.g., doing extreme
numbers of push-ups or sit-ups in unusual places, such as public restrooms).
Excessive exercising oen takes priority over other activities (e.g., school),
and is associated with feelings of guilt and anxiety. e motives behind
excessive exercising vary; in most instances it is used as a form of weight
control or a means of altering body shape, but in some cases it is used to
modulate mood.

Body Weight
Many adolescent patients with anorexia nervosa or another similar eating
disorder have a significantly low body weight as a consequence of persistent
undereating; this is frequently associated with hypogonadotropic
hypogonadism and arrested or delayed growth (Misra, 2008). In contrast,
most patients with binge-eating disorder present as either overweight or
with coexisting obesity due to their general tendency to overeat. However, a
large group of adolescent patients (i.e., those with bulimia nervosa or other
similar eating disorders) have a body mass index (BMI)-for-age percentile in
the healthy range. is is oen due to the fact that undereating and binge-
eating behaviors act to cancel each other out. Figure 1.1 shows the BMI-for-
age percentile of adolescents with eating disorders seeking CBT-E treatment.

FIGURE 1.1. e BMI-for-age percentile distribution of adolescent patients with anorexia nervosa,
bulimia nervosa, binge-eating disorder, and other eating disorders attending an Italian outpatient
CBT-E clinical service from 2016 to 2018.
 GENERAL PSYCHOPATHOLOGICAL FEATURES

e general psychiatric features of eating disorders are similar across all

diagnostic categories of eating disorders (Fairburn, 2008). For example,
many patients meet the diagnostic criteria for mood or anxiety disorders
(Keski-Rahkonen & Mustelin, 2016). at being said, depressive features are
generally observed more frequently in individuals with binge-eating
disorder, while anxiety and obsessional features are more common in
underweight patients and those who practice dietary restriction—in many
cases, a tendency toward anxiety and/or obsessing is accentuated by the state
of malnutrition. Another subgroup of patients engages in self-harming
behaviors (e.g., cutting) and an overlapping group reports substance misuse
(Keski-Rahkonen & Mustelin, 2016). ese features are more common
among patients who binge-eat and in those who are hospitalized.
It is common for patients with an eating disorder to receive a diagnosis
of personality disorder (e.g., borderline personality disorder in those who
engage in self-harm or substance misuse; Shah & Zanarini, 2018). However,
in reality, it is difficult to assess the personality of an adolescent patient
because this will be influenced by both the specific psychopathology of the
eating disorder and the repercussions of malnutrition (Garner, 1977).
Nevertheless, two personality traits—namely, perfectionism and low self-
esteem—are common in adolescent patients with eating disorders, and both
seem to be present before the eating-disorder onset (Fairburn, 2008).

PSYCHOSOCIAL CONSEQUENCES

If not treated early, eating disorders in adolescence lead to serious and

distinctive psychosocial problems (Cooper & Stewart, 2008). ey interfere
with adjustment to pubertal development and mastery of the developmental
tasks necessary to becoming a healthy, functioning adult. For example, it is
common to observe psychological regression and complete dependence on
parents. In severe cases, interpersonal relationships are gravely
compromised, and patients become socially isolated and indifferent toward
most of their previous interests at a time when families and peers are needed
to support development. If the disorder persists into adulthood, the person’s
sense of identity can be permanently damaged.

PHYSICAL CONSEQUENCES

Physical problems are common in patients with eating disorders, and are the
consequence of three main mechanisms, which oen work together
(Katzman, 2005): (1) undereating, (2) being underweight, and (3) purging
(i.e., self-induced vomiting and/or laxative and diuretic misuse). Table 1.3
shows the most common physical manifestations observed in eating
disorders (see Mehler & Andersen, 2017, for a detailed description).
TABLE 1.3. Main Physical Manifestations of Eating Disorders
Physical signs
Emaciation.
Growth arrest and failure of breast development (if prepubertal onset).
Bradycardia; orthostatic hypotension; cardiac arrhythmias (especially in underweight
patients and those with electrolyte abnormalities).
Hypothermia; cold hands and feet.
Edema (in the ankles, pretibial, and periorbital regions).
Dry skin; lanugo (downy hair) on the back, forearms, and side of the face; yellow–orange
discoloration of the skin of the palms and soles (in those with hypercarotenemia).
Telogen effluvium (i.e., very intense hair loss without the appearance of glabrous patches).
Erosion of inner surface of front teeth (in those who vomit frequently).
Swelling of parotid and submandibular glands (especially in those with binge eating).
Brittle nails.
Weak proximal muscles (elicited as difficulty rising from a squatting position).

Physical symptoms
Heightened sensitivity to cold.
Constipation and fullness after eating.
Dizziness and syncope.
Amenorrhea (in females not taking an oral contraceptive), low sexual appetite, infertility.
Poor sleep with early-morning wakening.

Physical complications
Gastrointestinal
Gastroesophageal reflux; esophagitis; hematemesis (in those who induce vomiting).
Gastroparesis.
Dilatation and gastric rupture (rarely, in those with binge eating).
Decreased colon motility (secondary to chronic laxative misuse).
Alteration of liver function test values.
High levels of serum amylase (especially in those with self-induced vomiting).
Endocrine/metabolic
Low levels of estradiol (in females) and testosterone (in males).
Low T3, T4 in low normal range; normal concentrations of thyroid-stimulating hormone
(low T3 syndrome).
Mild increase in plasma cortisol with elevated levels of free urinary cortisol in the urine.
Raised growth hormone concentration with low levels of IGF-1.
Amenorrhea; delayed puberty.
Osteopenia and osteoporosis (with heightened fracture risk).
Severe hypoglycemia (rare).
Low leptin (but possibly higher than would be expected for body weight).
Hypercholesterolemia.
Hypoglycemia.
Raised serum carotene.
Low levels of vitamin D.
Hydroelectrolytic
Dehydration.
Metabolic alkalosis and hypokalemia (in those with self-induced vomiting).
Metabolic acidosis (in those with laxative misuse).
 Hypokalemia (in those with purging).
Hypophosphatemia (especially during refeeding).
Hyponatremia (especially in those with excessive water intake).
Hematological
Moderate normocytic normochromic anemia.
Mild leukopenia with relative lymphocytosis.
Thrombocytopenia.
Cardiovascular
ECG abnormalities (especially in those with electrolyte disturbance): conduction defects,
especially prolongation of the Q-T interval, and U wave of major concern.
Renal
Kidney stones.
Reproductive
Infertility.
Insufficient weight gain during pregnancy and low weight of the newborn.
Neurological
Enlarged cerebral ventricles and external cerebrospinal fluid spaces (pseudoatrophy).
Peripheral neuropathy.

e physical issues that accompany eating disorders tend to be more

severe in adolescents than in adults. Indeed, because their organs are not yet
fully developed, adolescents are particularly vulnerable to the effects of
malnutrition and weight loss. In particular, three physical complications
require special attention (Katzman, 2005):

1. Osteopenia and osteoporosis. e onset of eating disorders oen

coincides with the period of bone development, when patients have not yet
reached peak bone mass (which usually occurs between 17 and 22 years).
e available data suggest that the loss of a significant amount of bone mass
is already identifiable aer 6 months of weight loss, and is almost always
present if the BMI is lower than 15.0. Moreover, if weight is not readily
recovered, the deposition of bone mass is compromised, and a permanent
condition of osteoporosis develops, which increases the risk of fractures in
adulthood (Misra, 2008).

2. Arrest or delay in growth. is complication, characterized by an

altered maturation of the sexual organs, develops when the onset of anorexia
nervosa occurs before pubertal development.

3. Structural and functional changes to the brain. Adolescents with

anorexia nervosa can develop structural and functional brain abnormalities.
is is one of the most common and early physical consequences of the
disorder, as highlighted by studies using magnetic resonance imaging,
positron emission tomography, single photon emission tomography, and
nuclear magnetic resonance spectroscopy. While in adults the structural and
functional brain alterations appear to be completely reversible via weight
normalization and long-term weight maintenance, data on adolescents
indicate a slight reduction of gray matter even aer the short-term
normalization of body weight, although no long-term data are available
(Seitz, Herpertz-Dahlmann, & Konrad, 2016).

As described above, these physical issues can be very serious and

potentially permanent if not arrested early on—if weight recovery is delayed
or incomplete, the physical damage can be irreversible. For this reason,
accurate assessment and monitoring of the physical status of the adolescent
is recommended in all cases, and a lower active-intervention threshold
should be adopted. Indeed, if weight restoration is not achieved with
outpatient treatment within a reasonable period of time, short-term
hospitalization in a specialized unit for the treatment of eating disorders
should be considered. Fortunately, adolescent patients tend to have a better
response to treatment than adults, and almost all physical complications are
completely reversible with timely normalization of eating and weight.

THE EVOLUTION OF EATING-DISORDER

PSYCHOPATHOLOGY

As previously seen, the eating-disorder categories seem arbitrary when the

eating-disorder psychopathology is considered cross-sectionally. However, it
seems even more arbitrary when the evolution of eating-disorder
psychopathology is observed longitudinally (Fairburn, 2008). In typical
cases, anorexia nervosa has its onset in adolescence, with some form of
dietary restriction that gradually becomes more extreme and rigid. In
addition to dietary restriction, some people pursue weight loss by exercising
excessively or self-inducing vomiting. ese behaviors result in a state of
being underweight, accompanied by the onset of symptoms characteristic of
malnutrition. In anorexia nervosa, the occurrence of binge eating
(sometimes subjective) is common, and in about half of the cases there is a
migration to bulimia nervosa or other subthreshold or mixed eating
disorders (Bulik, Sullivan, Fear, & Pickering, 1997). In some adolescents,
anorexia nervosa is short-lived and goes into remission with little or no
treatment, but in many cases it persists, and will therefore require prolonged
and complex specialized intervention (Keel & Brown, 2010).
Bulimia nervosa also has a typical onset in late adolescence or early
adulthood. It, too, usually starts with the adoption of extreme and inflexible
dietary rules motivated by excessive concerns about weight and body shape,
and about a quarter of the cases even meet the diagnostic criteria for
anorexia nervosa for a time (Sullivan, Bulik, Carter, Gendall, & Joyce, 1996).
However, in bulimia nervosa, this dieting is periodically interrupted by
binge eating, and the combination of dietary restraint, binge eating, and
purging rarely produces a persistent caloric deficit, which explains why such
individuals typically do not become underweight. Regarding the migration
to other eating disorders, though a large number of bulimia nervosa cases
have been diagnosed with anorexia nervosa at some point in their life, the
definitive transition to this disorder is very rare. In contrast, migration to
binge-eating disorder, or to other subthreshold or mixed eating disorders,
seems more common. Bulimia nervosa is highly self-perpetuating, and
about a quarter of the cases have a persistent disorder of clinical severity
(Steinhausen & Weber, 2009).
Binge-eating disorder, on the other hand, is not very common in
adolescents, and has a rather different course from the other eating
disorders. Although some cases are seen in adolescence, most patients are
middle-aged (Barry, Grilo, & Masheb, 2002), with a third or more being
male. Unlike other eating disorders, binge eating tends to be intermittent
rather than persistent. In fact, the majority of patients report prolonged
periods with no loss of control over eating. Nevertheless, these patients
display a general tendency to overeat, and many become overweight or
develop obesity as a result. Only a small subgroup of patients with binge-
eating disorder report a history of anorexia nervosa or bulimia nervosa.
Although little is known about the course of the other eating disorders,
in most cases, their onset occurs in adolescence or early adulthood, and
between a quarter and a third have a history of anorexia nervosa or bulimia
nervosa, respectively, with a similar duration of said disorder. In fact,
longitudinal studies on adult samples have revealed that, while a subset of
patients with eating disorders maintain a constant set of symptoms, most
migrate between the various eating-disorder diagnostic categories, though
rarely to other mental disorders.
Migration between the various diagnostic categories of eating disorders
does not happen by chance. In most cases, it reflects the fact that eating
disorders tend to start with the adoption of dietary restriction, which,
sooner or later, is interrupted by binge eating. When this happens, migration
from the diagnosis of anorexia nervosa to another form of eating disorder
oen occurs. Others meet the diagnostic criteria of bulimia nervosa or other
eating disorders from the onset, and then migrate between the two. is
being the case, should we consider these migrations as the recovery from
one psychiatric disorder to the onset of another, as the DSM-5 classification
would suggest, or is there is a simpler explanation—that they are in fact
different expressions of the same eating disorder?

THE TRANSDIAGNOSTIC PERSPECTIVE

As seen, the DSM-5 classification would have us view anorexia nervosa,

bulimia nervosa, and other eating disorders as several distinct categories,
but the fact that they share the majority of their clinical features and a
similar evolution as regards eating-disorder psychopathology challenges this
view. Indeed, studies on the course of eating disorders indicate that
migration between the respective diagnoses is frequent, while migration
toward other mental disorders is rare, indicating that eating disorders might
best be considered as a single diagnostic category (Fairburn, Cooper, et al.,
2003).
is calls into question the idea that the various DSM-5 eating-disorder
categories each require a distinct form of treatment. Indeed, the observation
that eating disorders tend to persist and evolve, but not migrate to other
mental disorders, suggests that common transdiagnostic processes play a
vital role in maintaining their underlying psychopathology (Fairburn,
Cooper, et al., 2003). It follows, therefore, that treatments designed to
address these maintenance processes should be effective for all diagnostic
categories of eating disorders—a hypothesis that is supported by the data
collected in recent years on the similar effects of CBT-E on various “eating
disorders,” both in adolescence and in adulthood. In fact, the cognitive
behavioral theory used successfully to treat various forms of eating disorder
is based on just such a transdiagnostic perspective, which is illustrated in
Figure 1.2.

FIGURE 1.2. Schematic representation of how eating disorders are classified according to DSM-5
and the transdiagnostic perspective. AN, anorexia nervosa; BN, bulimia nervosa; ODEs, other eating
disorders; ED, eating disorder.
 TRANSDIAGNOSTIC COGNITIVE BEHAVIORAL
THEORY

Several specific psychological theories have been proposed to explain the

onset and maintenance of eating disorders. Among these, cognitive
behavioral theory has most influenced CBT-E, an empirically supported
treatment for eating disorders (Fairburn & Harrison, 2003). Initially
developed in the early 1980s by Fairburn (1981) to elucidate and treat
bulimia nervosa, cognitive behavioral theory was mainly focused on the
processes that maintain bulimia nervosa, rather than those behind its initial
onset.
From its origins, the original theory for bulimia nervosa has been
improved and expanded by Fairburn, Cooper, et al. (2003). In particular, it
was extended to apply to all eating disorders of clinical severity, and
therefore became defined as “transdiagnostic”—furthermore, in addition to
the core eating-disorder maintenance processes described below, which
constitute great obstacles to change, it later encompassed four additional
maintenance processes that, in a subgroup of patients, interact with the
above. Figure 1.3 illustrates the core processes involved in the maintenance
of eating disorders according to transdiagnostic cognitive behavioral theory.
is theory accounts for the range of processes that maintain any eating
disorder, regardless of its exact diagnosis or presentation.
FIGURE 1.3. e core processes involved in the maintenance of eating disorders according to
transdiagnostic cognitive behavioral theory. From Cognitive Behavior erapy and Eating Disorders by
Christopher G. Fairburn. Copyright © 2008 e Guilford Press. Reprinted by permission.

Core Maintenance Processes

Transdiagnostic cognitive behavioral theory postulates that the
overvaluation of eating, shape, weight, and their control is of central
importance in the persistence of eating disorders. As explained above, the
other clinical features seen in these disorders seem to derive directly from
this “core” psychopathology. ese include extreme weight-control
behaviors (e.g., dietary restraint, dietary restriction, self-induced vomiting,
laxative and diuretic misuse, and excessive exercising), various forms of
body weight and shape checking and avoidance, and preoccupation with
eating, weight, and shape (Fairburn, 2008).
Undereating and other extreme weight-control behaviors create a
persistent calorie deficit, resulting in the significantly low body weight
typical of most cases of adolescents with eating disorders, at least in the
initial stages. ey also lead to the development of certain secondary
physiological and psychological consequences called “starvation symptoms,”
which themselves perpetuate undereating (Dalle Grave, Pasqualoni, &
Marchesini, 2011). For example, such individuals may interpret the sense of
fullness aer eating even modest amounts of food (as a result of delayed
gastric emptying) as having eaten too much, which will prompt them to
intensify dietary restriction. Moreover, the social withdrawal that oen
occurs secondary to an eating disorder oen has the effect of encouraging
self-absorption while simultaneously isolating patients from external
influences that might otherwise challenge their overvaluation of eating,
shape, weight, and their control. In a similar fashion, the preoccupation with
food that is a direct consequence of caloric restriction may predispose an
individual to adopt extreme and inflexible dietary rules (Dalle Grave, Di
Pauli, Sartirana, Calugi, & Shafran, 2007; Shafran, Fairburn, Nelson, &
Robinson, 2003).
One prominent feature of the eating-disorder category that is not a
direct expression of the core psychopathology is binge eating. However, this
occurs in many patients with eating disorders, whatever their DSM-5
diagnosis, and transdiagnostic cognitive behavioral theory proposes that
binge eating is, in fact, mainly maintained by attempts to adhere to extreme
and inflexible dietary rules (Fairburn, 2008). Indeed, regardless of their
diagnosis, people with an eating disorder tend to react badly and excessively
(oen dichotomously) when they break their self-imposed rules, which is an
almost inevitable consequence of having them in the first place. To such a
mindset, even a small dietary transgression is interpreted as evidence of poor
self-control and personal weakness, which prompts patients to “give in” to
the urge to eat. In this state of mind, any attempt to curb food intake is
abandoned, and binge eating (whether subjective or objective) is likely to
ensue. In turn, this binge-eating behavior acts to reinforce the core
psychopathology of the eating disorder by intensifying a patient’s concerns
about her or his ability to control his or her eating, shape, and weight. It also
encourages further dietary restraint, thereby increasing the risk of further
binge eating.
Two additional processes also contribute to and maintain binge eating.
First, adverse day-to-day events and associated mood changes increase the
likelihood that patients will break their dietary rules. In part, this is because
it is difficult to maintain dietary restraint under such circumstances, but it is
also important to bear in mind that binge eating can become a coping
mechanism because it temporarily changes the mood states associated with
such difficulties and distracts patients from thinking about their problems.
Second, when binge eating is followed by compensatory purging, this also
has the effect of maintaining binge eating—largely due to the common
misapprehension that purging is a way of preventing energy intake from
food. is removes a major deterrent to binge eating (i.e., fear of weight
gain), and patients need to be made aware that vomiting only eliminates
some of the food ingested, and laxatives have little effect, if any. In fact, when
recurrent episodes of objective binge eating occur, patients tend to regain
weight and, in many cases, lose their underweight status. is qualifies them
for the diagnostic classification of bulimia nervosa or subthreshold bulimia
nervosa, even though they continue to persist in severe dietary restraint
outside the episodes of binge eating. For those patients who continue to
meet the DSM-5 diagnostic criteria for anorexia nervosa, binge eating may
be mainly subjective in nature, or completely absent. Indeed, some patients
display only a limited number of the above processes (e.g., in binge-eating
disorder), while others exhibit many more (e.g., anorexia nervosa with binge
eating and purging). Transdiagnostic cognitive behavioral theory serves to
highlight the processes that are operating in a given individual, and
therefore provides a “road map” for treatment.

Additional Maintenance Processes

In addition to the core eating-disorder maintenance processes,
transdiagnostic cognitive behavioral theory posits that one or more of four
additional (“external”) processes may be operating in certain patients
(Fairburn, Cooper, et al., 2003): extreme perfectionism (“clinical
perfectionism”), unconditional and pervasive low self-esteem (“core low
self-esteem”), marked interpersonal issues (“interpersonal difficulties”), and
difficulties in tolerating changes in mood (“mood intolerance”). ese
additional maintenance mechanisms (described in detail in Chapter 17)
interact with the core processes, and when this occurs they constitute
further obstacles to change. Hence, it is important for these reinforcing
factors to be tackled during treatment (Fairburn, 2008; Fairburn, Cooper, et
al., 2003).

Evidence Supporting the Transdiagnostic Theory

e transdiagnostic cognitive view of the maintenance of eating disorders is
supported by the findings of numerous descriptive, comparative,
experimental, and treatment studies conducted in patients with eating
disorders (Cooper & Dalle Grave, 2017). However, despite the large amount
of direct support for cognitive behavioral theory, there is ongoing
controversy about the relationship between dietary restraint and binge
eating. For example, one study found a correlation between eating fewer
meals per day and more frequent binge-eating episodes, but binge eating did
not seem to be associated with eating small or low-calorie meals (Elran-
Barak et al., 2015). Moreover, another study found decreased binge eating in
patients with bulimia nervosa who were trying to lose weight (Lowe, Witt, &
Grossman, 2013). While this relationship is oen observed to be operating
in clinical situations, its investigation in a research context has been
complicated by issues of how dietary restraint is measured, and by cross-
sectional assessment of the association between dietary restraint and binge
eating. Indeed, it is common to see patients reporting transitory periods of
dieting without binge-eating episodes—during which they may also lose
weight—that are then interrupted by the onset or recurrence of binge eating.
All that being said, the following has been demonstrated in patients with
bulimia nervosa:

A relationship between the overvaluation of weight and shape, and

changes in dietary restraint and binge eating over time (Fairburn, Stice,
et al., 2003).
 A relationship between self-reported dietary restriction and binge
eating (Zunker et al., 2011).
An association between increased weight concern and both increased
dietary restraint and frequency of vomiting (Spangler, Baldwin, &
Agras, 2004).
A reduction in episodes of binge eating mediated by a reduction in
dietary restraint during treatment (Wilson, Fairburn, Agras, Walsh, &
Kraemer, 2002).

e following has been shown in patients with anorexia nervosa:

An association between greater weight increase and greater reduction

in the overvaluation of shape and weight during CBT-E (Dalle Grave et
al., 2014).
An association between a reduction in body weight and shape checking
and a reduction in concerns about weight and shape during CBT-E
(Calugi, El Ghoch, & Dalle Grave, 2017).
An association between a fear of weight gain with dietary restraint and
excessive exercising (Linardon et al., 2018).
A link between the overvaluation of shape and general
psychopathological features (i.e., symptoms of depression and anxiety;
Linardon et al., 2018).
An association between a reduction in preoccupation with shape and
weight and an improvement in eating concern, general
psychopathology, and work and social functioning (Calugi, El Ghoch,
Conti, & Dalle Grave, 2018).
An association between a lessening of fear of gaining weight and a
reduction in dietary restraint (Calugi, El Ghoch, et al., 2018).
An association between baseline concern about shape and weight, fear
of weight gain, and feeling fat with the achievement of normal weight
at 6 and 12 months aer inpatient CBT-E (Calugi, El Ghoch, et al.,
2018).
 An association between baseline preoccupation with shape and weight
and feeling fat, and improvement in BMI-for-age percentile over time
in adolescent patients (Calugi & Dalle Grave, 2019).
A close relationship between improvements in both starvation
symptoms and eating disorder and general psychopathology scores,
and the important role of refeeding in ameliorating both (Calugi,
Chignola, El Ghoch, & Dalle Grave, 2018).

In transdiagnostic samples (including patients with bulimia nervosa,

anorexia nervosa, and other eating disorders), the findings indicate:

A reciprocal relationship between the overvaluation of weight and

shape and moderate-to-extreme dietary restraint and exercising (Tabri
et al., 2015).
An association between an improvement in overvaluation of weight
and shape and the amount of exercising before treatment (Dalle Grave,
Calugi, & Marchesini, 2008a).
A tendency to interpret starvation symptoms (e.g., hunger, early
fullness, and weakness) in terms of shape, weight, and their control
(Dalle Grave et al., 2007; Shafran et al., 2003).

Other evidence supporting the transdiagnostic model comes from cross-

sectional studies using structural equation modeling (i.e., a diverse set of
mathematical models, computer algorithms, and statistical methods that fit
networks of constructs to data) in treatment-seeking patients (Dakanalis et
al., 2015; Lampard, Byrne, McLean, & Fursland, 2011; Lampard, Tasca,
Balfour, & Bissada, 2013) and community samples (Dakanalis et al., 2015;
Hoiles, Egan, & Kane, 2012).
Finally, indirect support for the theory is provided by the numerous
randomized control trials and cohort studies showing that the efficacy of
CBT-E, in adults and adolescents with all forms of eating disorders, is
greater than or equal to that of all the other psychological and
pharmacological treatments with which it has been compared (National
Institute for Health and Care Excellence, 2017).

1
Feeding disorders (i.e., pica, rumination, and avoidant/restrictive food intake disorder), which are
usually first diagnosed in infancy, childhood, or adolescence, are not described in this book since
these states present quite differently from the main eating disorders (i.e., there is an absence of the
core overvaluation of shape, weight, and their control, and no binge-eating episodes or compensatory
behaviors).
 CHAPTER 2

CBT-E for Adolescents with

Eating Disorders
An Overview

Eating disorders and CBT are a perfect match, as eating

disorders are fundamentally “cognitive disorders” and CBT is
by its very nature designed to produce cognitive change.
—FAIRBURN, COOPER, AND SHAFRAN (2008, p. 23)

Based on the transdiagnostic theory, outlined in Chapter 1, CBT-E is a

personalized psychological treatment for transdiagnostic eating-disorder
psychopathology rather than a particular DSM-5 eating-disorder diagnosis.
It is a specific form of CBT that focuses on the processes maintaining an
individual’s psychopathology. It was originally developed by Fairburn (1981)
as a treatment for adults with bulimia nervosa, and in this form it has been
the subject of numerous clinical trials. It was the first psychological
treatment for any mental disorder to be strongly endorsed by the United
Kingdom’s independent and highly regarded National Institute for Clinical
Excellence (now named the National Institute for Health and Care
Excellence). In the early 2000s, the treatment was modified by Fairburn,
Cooper, et al. (2003) to make it suitable for all forms of eating disorders in
adult outpatients with a BMI of between 15.0 and 40.0. Since then, the
treatment has also been adapted for intensive levels of care (i.e., day hospital
and inpatient; Dalle Grave, 2012; Dalle Grave, Calugi, Conti, Doll, &
Fairburn, 2013), and for adolescents of at least 12 years of age (Dalle Grave,
2019; Dalle Grave, Calugi, Doll, et al., 2013; Dalle Grave & Cooper, 2016). In
fact, CBT-E has been tested across the full spectrum of eating disorders in
studies emanating from the United Kingdom, Australia, Denmark, Italy, and
the United States, and it is now the only treatment recommended by NICE
guidelines for all forms of eating disorders in both adults and adolescents
(National Institute for Health and Care Excellence, 2017).
is chapter provides an overview of CBT-E for adolescents. Following a
description of the rationale for using this treatment in that population, the
goals, main strategies, procedures, structure, forms, and versions of CBT-E
for adolescents are discussed, together with some thoughts about the
respective roles of patients, parents, and therapists. e chapter ends by
summarizing the scientific findings supporting its effectiveness.

THE RATIONALE BEHIND CBT-E FOR

ADOLESCENTS

CBT-E has a number of features that make it well suited to younger patients
with eating disorders:

It is both comprehensible and easy to receive, and it adopts a flexible

and individualized approach that can be easily adapted to the needs of
an adolescent patient, in that it can be applied at different stages of
physical and cognitive development.
It is a collaborative treatment in which the patient and therapist work
together to overcome the eating disorder and enhance the patient’s
general sense of control. is fits well with younger patients’ need to
develop autonomy and independence, and their concerns about
control.
 It is designed to be engaging and to address and enhance motivation,
and it is well suited to addressing the well-documented ambivalence
toward treatment oen encountered in younger patients.
It takes a transdiagnostic approach that can be adapted to the
particular needs of younger patients. For example, some younger
patients have an overvaluation of control over eating per se rather than
the overvaluation of weight and shape more commonly seen in older
patients (Fairburn, Shafran, et al., 1999). is can be addressed as part
of individualized CBT-E using an adaptation of the standard
procedures for addressing overvaluation that focuses on eating control.

All that being said, there are two distinctive characteristics of younger
patients that do require modifications to standard CBT-E. First, some
medical complications associated with eating disorders (e.g., osteopenia and
osteoporosis) are particularly severe in this age range, and periodical
medical assessments and a lower threshold for hospital admission are
therefore integral parts of CBT-E for adolescents. Second, in the great
majority of cases, parents need to be involved in treatment, given the age
and circumstances of these patients.

TREATMENT GOALS

Bearing all this in mind, CBT-E for adolescents has four general goals:

1. To engage patients in the treatment and involve them actively in the

process of change.
2. To abolish the eating-disorder psychopathology—that is, dietary
restraint and restriction (and low weight if present), extreme weight-
control behaviors, and preoccupation with shape, weight, and eating.
3. To correct the mechanisms maintaining the eating-disorder
psychopathology.
4. To ensure lasting change.
 GENERAL TREATMENT STRATEGY

CBT-E for adolescents is a time-limited, personalized psychological

treatment designed to treat all diagnostic categories of eating disorders
(transdiagnostic approach) by addressing the behavioral and cognitive
processes maintaining the patient’s individual psychopathology (Fairburn,
2008). It is equally well suited for males and females, and patients do not
require any particular cognitive skills in order to benefit—in other words, a
lower level of education or lack of psychological understanding are no
barriers to CBT-E.
Furthermore, CBT-E for adolescents has been designed as a complete
treatment, not to be combined with other forms of therapy. It is a specific
form of CBT, and like other forms of empirically supported CBT, it is a time-
limited treatment that deals with the processes that maintain an individual’s
psychopathology. Unlike other treatments for adolescents with eating
disorders (e.g., family-based treatment) that postulate that the problems or
symptoms belong to the entire family, separate the illness from the patient
(externalization), and promote parents’ “taking control” of their child’s
eating (Dalle Grave, Eckhardt, Calugi, & Le Grange, 2019; Lock & Le
Grange, 2013), CBT-E maintains that the problem belongs to the individual.
As such, it treats the illness as part of the patient and encourages the patient,
rather than the parents, to take control.
In order to promote a feeling of self-control, CBT-E treatment
procedures are designed to involve patients actively in all phases of
treatment, from the decision to start treatment and the choice of problems
to be addressed to the procedures used to address them. Patients are told
that overcoming the eating disorder will be difficult, but worth it, and
treatment should therefore be considered a priority. Another essential
feature of CBT-E is that the therapist ensures that the patients understand
what is happening at all times, and encourages them to become active
participants in the process of achieving change. In short, CBT-E is a
collaborative means of overcoming eating disorders (collaborative
empiricism). Hence, CBT-E for adolescents never adopts “prescriptive” or
“coercive” procedures—in other words, patients are never asked to do things
that they do not agree to, as this may increase their resistance to change
(Dalle Grave, 2019).
e key strategy of CBT-E is to collaboratively create a personal
formulation (or set of hypotheses) of the main processes maintaining the
patient’s individual psychopathological features, as these will become the
targets of treatment (see Figure 1.3 in Chapter 1). e formulation aids in
the design of a tailor-made treatment to address the evolving individual
psychopathology of each patient (see Chapter 5 for a detailed description),
and it can be modified midcourse to address any emerging processes. To
promote self-empowerment, patients are educated about the processes at
play in their personal formulation and actively involved in the decision to
address them. If they do not reach the conclusion that they have a problem
to address, the treatment cannot start or must be postponed for a time, but
this is a rare occurrence.
Once patients are engaged in the process of change, their personal
eating-disorder psychopathology is addressed via a flexible set of sequential
cognitive and behavioral strategies and procedures, integrated with
progressive patient education. Two guiding principles underpin CBT-E: (1)
simpler procedures are preferred over more complex ones, and (2) it is
better to do a few things well rather than many things badly (the principle of
parsimony; Fairburn, 2008). However, the bottom line with CBT-E is
whether a strategy or procedure is effective or not.
In common with other forms of CBT, monitoring and success in
completing strategically planned homework tasks are of paramount
importance. Since in some cases these can create anxiety, the therapist needs
to be not only empathetic but also aware of when and how to keep the
patient firmly on track. While CBT-E for adolescents uses a variety of
generic cognitive behavior strategies and procedures (e.g., cognitive biases,
such as dichotomous thinking and selective attention, are addressed in the
usual way), it differs from certain forms of CBT in that conventional thought
recording is not used throughout, though it may be helpful for patients to
record their thoughts and feelings about particular topics at certain points
(e.g., when addressing feeling fat and/or body checking), in one column of
the standard monitoring record. Furthermore, the treatment does not
provide patients with recordings of their treatment sessions, as in our
experience, doing so tends to trigger persistent and unhelpful ruminative
thinking about shape, weight, and eating control. In addition, CBT-E does
not make much use of formal cognitive restructuring or other certain widely
used CBT concepts—namely, automatic thoughts, assumptions, core beliefs,
and schemas (Fairburn, 2008). In this particular patient population, and
especially in adolescents, we do not find these methods or concepts are
necessary to produce the required changes.
Instead, CBT-E for adolescents relies on exploratory questioning to help
patients clarify their thinking. Although a “Socratic” questioning style can
be helpful at times, it is not seen as essential (Fairburn, 2008), and our
experience dictates that in adolescent patients, the same end can very oen
be achieved using simpler and more efficient means. CBT-E for adolescents
also makes limited use of formal behavioral experiments as (once again
referring to this particular patient population) these tend to be hard to
interpret. In any case, the outcomes of greatest relevance to the core eating-
disorder psychopathology (i.e., changes in the overvaluation of shape and
weight) do not lend themselves to short-term experimentation, and so
different strategies are preferred.
In addition, CBT-E for adolescents considers it essential that patients
learn to decenter from their eating disorder (Fairburn, 2008). Patients are
stimulated to make gradual behavioral changes and analyze the effects and
implications of these on their way of thinking. is approach, easily
implemented with younger patients, enables them to gradually reduce their
preoccupation with eating, shape, weight, and their control. In the later
stages of the treatment, when the main maintenance processes have been
disrupted and the patients report experiencing periods free from shape,
weight, and eating concerns, the treatment focuses on helping them
recognize the early warning signs of eating-disorder mindset reactivation,
and to decenter from it quickly, thereby averting relapse.

THE EFFECTIVENESS OF CBT-E FOR

ADOLESCENTS

CBT-E for adolescents has been evaluated in five different cohort studies on
patients ages 13–19 years—four on patients with anorexia nervosa and one
on not-underweight adolescents with other eating disorders. e first study
evaluated the effect of outpatient CBT-E in 46 adolescents with anorexia
nervosa. Two-thirds of the patients who completed the 40 treatment
sessions displayed a significant increase in BMI-for-age percentile, from 3.36
(SD = 3.73) to 30.3 (SD = 16.7), and this was associated with a marked
improvement in eating-disorder psychopathology and general psychiatric
features (Dalle Grave, Calugi, Doll, et al., 2013). Despite minimal
subsequent treatment, there was little change in these positive outcomes
over the 60-week posttreatment follow-up period.
Two studies have assessed the effect of inpatient CBT-E in adolescents
with anorexia nervosa. In one (Calugi & Dalle Grave, 2019), 90.3% of the 62
adolescent patients completed the treatment. Among completers, 96.4%
reached an end-of-treatment BMI-for-age percentile corresponding to a
BMI ≥ 18.5 at 18 years, which fell slightly to 78.7% and 80.4% at 6- and 12-
month follow-ups, respectively. In a similar study on 27 patients with severe
anorexia (Dalle Grave et al., 2014), all but one completed the treatment. In
this case, the mean BMI-for-age percentile increased from 2.7 (SD = 4.3) at
admission to 34.2 (SD = 15.7) at discharge, and patients showed a marked
reduction in eating-disorder and general psychopathology scores. ese
outcomes were maintained at 12-month follow-up, when the mean BMI-for-
age percentile was 29.9 (SD = 20.1), and 81.5% of patients retained a normal
weight.
 Another study evaluated the effects of outpatient CBT-E on 68 not-
underweight adolescents with an eating disorder (Dalle Grave et al., 2015).
ree-quarters completed the full 20 sessions. At intent-to-treat analysis,
68% of patients had minimal residual eating-disorder psychopathology by
the end of treatment, and 50% of those with binge-eating or purging
episodes at baseline reported no longer having them.
A more recent study set out to assess the outcomes and determine the
predictors of change in a cohort of 49 adolescent patients with marked
anorexia nervosa treated with outpatient CBT-E in a real-world setting
(Dalle Grave et al., 2019). irty-five patients (71.4%) completed the
treatment, displaying a large increase in weight, together with a marked
decrease in eating-disorder and general psychopathology, and clinical
impairment scores. ese changes were maintained at 6-month follow-up,
suggesting that CBT-E is a promising treatment for adolescents with
anorexia nervosa when it is delivered in a real-world setting, even though no
baseline predictors of dropout and treatment outcome were found.
Significantly, in a study to compare the effects of CBT-E in 46
adolescents and 49 adults with anorexia nervosa (Calugi et al., 2015), more
adolescents than adults reached normal weight (65.3% vs. 36.5%,
respectively). Moreover, the mean time required by adolescents to restore
body weight was about 15 weeks less than that required by adults, suggesting
that a shorter CBT-E may be effective in adolescent patients.
As a whole, these findings indicate that CBT-E is particularly well
received by adolescents with anorexia nervosa across the severity spectrum,
as well as other eating disorders. ey suggest that it is efficacious in terms
of not only helping the majority of patients to restore body weight but also
improving their underlying psychopathology in a variety of settings,
including the real world. Longer-term follow-up data on these outcomes has
yet to become available, but these results provide clear scientific indication
of why NICE recommends CBT-E as a viable treatment for adolescents
(National Institute for Health and Care Excellence, 2017).
 TREATMENT STRUCTURE

CBT-E for underweight adolescent patients (i.e., those with a BMI-for-age

percentile corresponding to a BMI of 15.0–19.0 in adults) is delivered by a
single therapist in 30–40 fiy-minute sessions, but its exact duration,
generally 30–40 weeks, depends upon the amount of weight that needs to be
regained. e treatment involves two assessment/preparation sessions, and
in underweight patients—the most common group of treatment-seeking
adolescent patients with an eating disorder—is delivered in three main
“steps” to achieve weight restoration (see Figure 2.1).1 Every 4 weeks there is
a review session, and there are further review sessions 4, 12, and 24 weeks
aer the end of treatment. CBT-E for not-underweight adolescents has a
similar structure, but is delivered over the course of 20 weeks. In both cases
the initial stage, Step One, is intensive, with appointments being scheduled
twice weekly, followed by a review session. In Step Two the sessions are held
weekly, and in Step ree at 2-week intervals.
FIGURE 2.1. e CBT-E map for adolescents with eating disorders.
 FORMS OF CBT-E

Like CBT-E for adults, there are two forms of delivering CBT-E for
adolescents (Fairburn, 2008): (1) a “focused” form, which targets the eating-
disorder psychopathology exclusively, and (2) a “broad” form, which also
addresses one or more of the adjunctive mechanisms maintaining the eating
disorder, if applicable. e focused form is indicated for most patients, and
should be viewed as the default version. e broad form, on the other hand,
should be reserved only for patients in whom the “external” mechanisms
maintaining the core eating-disorder psychopathology are thought to be
playing an incisive role (see Chapters 1 and 18). e decision to use the
broad form is made in a review session held aer 4 weeks in not-
underweight patients, or in one of the review sessions in Step Two in
underweight patients.

CBT-E CLINICAL SERVICE

In the real world, the treatment options offered to patients with eating
disorders largely depend on the judgment and training of the examining
clinicians, and the local availability of treatments. Although evidence-based
psychological treatments such as CBT-E are available, they are not always
offered, or are applied in a manner that dris away from the protocol. In
some clinical services, there is an excessive emphasis on inpatient care, and
it is common for patients to receive completely different treatments, in terms
of both theory and content, when they switch from a less intensive form of
care (e.g., outpatient) to a more intensive treatment (e.g., inpatient) and vice
versa. is creates discontinuity in the care pathway, and understandably
disorientates patients about the procedures and strategies that they need to
use to overcome their eating disorders.
CBT-E for adolescents, being designed to treat all the diagnostic
categories across the spectrum of care settings, offers the concrete possibility
of implementing a treatment that overcomes some of the difficulties
encountered in more fragmented conventional services. e most distinctive
and unique feature of this approach, termed “multistep CBT-E” (Dalle
Grave, 2013), is that the same theory and procedures are applied in each
care setting (see Figure 2.2). e only difference between the various levels
of care is the intensiveness of treatment, with less unwell patients being
treated using outpatient CBT-E procedures, and more severely affected
sufferers being channeled directly to inpatient CBT-E. With this approach,
nonresponders to outpatient treatment and those whose physical conditions
do not warrant hospitalization but who would benefit from more support
can be offered a more intensive form of outpatient treatment within the
CBT-E framework. us, patients can be moved seamlessly from outpatient
care to inpatient care, and then on to the final phase of outpatient treatment
with no change in the nature of the treatment itself.

FIGURE 2.2. e four levels of care of multistep CBT-E for adolescents with eating disorders. Each
level of care is based on the same theory and uses similar strategies and procedures (more intensive in
intensive outpatient and inpatient CBT-E).

is approach was first developed in Garda, Verona, Italy, but similar
services are also being set up in other European countries. A clinical service
based on CBT-E has two main advantages (Dalle Grave, El Ghoch, Sartirana,
& Calugi, 2016). First, patients are treated using a single, well-delivered,
evidence-based treatment rather than the evidence-free eclectic approach
common elsewhere. Second, it minimizes the problems associated with
transitions from outpatient to intensive treatment, as it avoids subjecting
patients to the confusing and counterproductive changes in therapeutic
approach that commonly accompany such transitions. It goes without
saying, however, that a different form of treatment must be recommended to
any patients who do not respond to CBT-E.

CBT-E SETTINGS

CBT-E for adolescents can be delivered in four settings: (1) outpatient, (2)
intensive outpatient, (3) inpatient, and (4) postinpatient outpatient. e
rationale behind extending CBT-E to intensive treatment settings stems
from the consideration that in some patients the ineffectiveness of
outpatient CBT-E might be due to an insufficiency of care intensiveness
rather than the nature of the treatment itself.

Outpatient CBT-E
e outpatient version of CBT-E, which will be extensively described in the
following chapters, is indicated for most adolescent patients with eating
disorders. As evaluated in research trials, CBT-E for adolescents is a time-
limited treatment (i.e., 30–40 weeks in underweight patients and 20 weeks in
not-underweight patients). Although imposing time limitations on CBT-E
might be seen to affect its individual nature, there are considerable
advantages to a fixed time frame that outweigh such disadvantages
(Fairburn, 2008). In particular, a set time limit helps both the patient and
the therapist to focus on working hard to help the patient change, and
enables the so-called therapeutic momentum to be established. It also
increases the likelihood of the treatment having a formal ending, thereby
averting the uncertainty of more open-ended treatments. Last, but by no
means least, it ensures that future-oriented topics that are fundamental to a
patient’s long-term recovery will be dealt with in the final sessions.
 In some cases, the treatment needs to be shortened—for example, in
patients with binge-eating disorder, if the binge eating rapidly ceases and
there is little other psychopathology to address. More oen, however, there
is a case for extending treatment. Examples include when the treatment has
been disrupted (e.g., by a bout of clinical depression or an interpersonal
crisis), or when patients who benefit but are still significantly impaired
experience a setback not long aer the treatment has ended. Under these
circumstances, the treatment should be continued for some additional
months, with a detailed review of progress being held every 4 weeks to
ensure that continuing is justified.
In fact, it is our practice to end the treatment on time even for patients
presenting some residual features of their eating-disorder psychopathology
(e.g., occasional binge eating and vomiting, residual concerns about shape
and weight). Indeed, patients using CBT-E generally continue to improve
even aer the end of treatment provided that the main maintenance
mechanisms have been disrupted (Fairburn, Cooper, et al., 2003). Hence,
treatment can and should be wound up under these circumstances in order
to prevent the assumption that any continuing improvement is due to the
ongoing therapy as opposed to the patient’s own progress.

Intensive Outpatient CBT-E

Patients may be offered treatment in this setting if they need greater input
than outpatient CBT-E can provide, but do not have a sufficiently severe
condition as to warrant hospitalization. is form of treatment relies on the
same procedures and strategies as outpatient CBT-E, but also includes
several features developed specifically for this more intensive approach
(Dalle Grave, 2012; Dalle Grave, Bohn, Hawker, & Fairburn, 2008).
Intensive treatment lasts for a maximum of 12 weeks, but may be shorter
if patients make good progress in the areas that they struggled to tackle in
outpatient CBT-E (e.g., lack of progress in weight regain, reducing binge
eating, regular meals). e treatment can be flexibly adapted to both the
clinical needs of the patient and the logistical characteristics of the clinical
service that delivers it. However, in our view, the optimal treatment should
include the following procedures: (1) supervised daily meals on weekdays,
(2) individual CBT-E sessions twice weekly, (3) sessions with a CBT-E-
trained dietitian to plan and review weekend meals, and (4) regular reviews
with a CBT-E-trained physician. e clinical CBT-E team responsible for
such patients should meet weekly to monitor each patient’s progress. Toward
the end of intensive treatment, patients who have responded well are
gradually encouraged to eat meals outside of the unit, thereby allowing the
treatment to evolve into conventional outpatient CBT-E. (is form of
treatment is described in greater detail in Chapter 18.)

Inpatient CBT-E
Inpatient CBT-E is indicated for patients who have not responded well to
the less intensive versions, but should be considered a primary option for
those who require close medical supervision. It is designed to ensure a
unified, rather than eclectic, approach to a patient’s treatment. e inpatient
program maintains all of the main strategies and procedures of CBT-E,
which are delivered in both individual sessions and in a group format, but
three main features distinguish it from the outpatient version (Dalle Grave,
2012; Dalle Grave, Bohn, et al., 2008): (1) rather than a single therapist, the
treatment is delivered by a multidisciplinary team, comprising physicians,
psychologists, dietitians, and nurses, all fully trained in CBT-E, (2)
assistance with eating is provided in the first weeks of treatment to help
patients get over their difficulties in real time, and (3) adolescent patients are
expected to continue their studies during their stay in the hospital.
Inpatient CBT-E also includes additional elements designed to reduce
the high rate of relapse that typically follows discharge from the hospital. For
instance, the inpatient unit is open, and patients are free to come and go.
is ensures that they continue to be exposed to the types of environmental
stimuli that tend to provoke their eating-disorder psychopathology, but have
full access to staff support. Indeed, during the weeks immediately preceding
discharge, a concerted effort is made to identify any likely environmental
setback triggers and address them during the individual CBT-E sessions.
Furthermore, toward the end of treatment, parents receive help in creating a
positive, stress-free home environment in readiness for the patient’s return.
(See Chapter 19 for more details on inpatient CBT-E.)

Postinpatient Outpatient CBT-E

Perhaps the most important relapse-prevention measure adopted in
inpatient CBT-E is that it is always followed by a “stepped-down” CBT-E-
based treatment in an outpatient setting. is means that in this oen
difficult transitional phase, the patient’s treatment continues in much the
same way, and that the therapist is on hand to provide monitoring and
support. In our unit, we aim to ensure that postinpatient treatment is
delivered by the therapist who treated the patient during inpatient CBT-E.
is strategy promotes the continuity of both the therapeutic alliance and
the treatment content, which then becomes focused on relapse prevention
and the residual problems that remain at discharge.
Postinpatient outpatient treatment lasts 20 weeks and includes 20
individual CBT-E sessions—twice weekly in the first month (to provide a
high intensity in the first phase of transition from the hospital to the home
environment), once weekly in the second and third months, and every 2
weeks in the fourth and fih months. e goals of postinpatient CBT-E are
to help patients maintain the changes achieved during their hospitalization,
to deal with the difficulties that occur once they return home, and to prevent
relapse by identifying and addressing the residual maintenance and control
mechanisms.

THE PATIENT’S ROLE

Patients are told that overcoming an eating disorder is difficult but
worthwhile, and that treatment will need to be made a priority in their lives.
e motto that we share with the patients is “It’s hard but it’s worth it”
(Fairburn, 2008). erapists need to ensure that patients, especially the
underweight ones, understand what is happening at all times, and that they
are active participants in the sessions. In our clinical experience, if they feel
that they are being controlled, coerced, or misled, they will resist change,
and the treatment will have little, or no, probability of success.
Nevertheless, patients are told that it is vital that appointments start and
end on time. As such, we emphasize that the therapist will make sure that
she or he is ready to start the session on time and request that patients do
the same by arriving 10–15 minutes early. is will give them an
opportunity to focus and think things over before the session. We also
inform patients that they will have to work as part of a team with the
therapist to address the eating disorder. Together they will agree on specific
homework tasks to do between sessions. ese 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. Finally, patients are warned against interrupting the treatment in
order to avoid disrupting the therapeutic momentum necessary to overcome
the eating disorder.

THE PARENTS’ ROLE

In CBT-E for adults, significant others (friends, partners, or parents) are

seen in a minority of cases, and only with the consent of the patient if it is
considered probable that their involvement will be useful (Fairburn, 2008).
When this happens, their role is simply to support the implementation of an
individual’s treatment. e same principles apply to the treatment of
adolescent patients, except for the fact that parents are always involved given
the age and circumstances of these patients.
 Involving parents in CBT-E for adolescent patients is recommended for
several reasons (Dalle Grave, 2019). First, parents have the responsibility
and the right to make important decisions regarding the treatment of their
teenage children, and treatment cannot commence without their informed
consent. Second, some data indicate that how parents react to the symptoms
of the adolescent with an eating disorder may positively or negatively
influence the treatment outcome (van Furth et al., 1996). ird, adolescent
patients usually live at home with their parents, who can therefore be of
direct assistance in helping them to address the process of weight restoration
and other aspects of the eating-disorder psychopathology, or, in contrast, to
unknowingly hinder or prevent the change.
Parental involvement requires adaptation of standard CBT-E, but only to
a limited extent. Indeed, in the vast majority of sessions, the adolescent
patient is seen alone. Parental involvement is usually limited to two short
joint sessions with the patient during the assessment/preparation phase, and
periodically (four to six times in not-underweight patients, eight to 12 in
those underweight) at the end of a patient’s individual session. ese joint
sessions typically last about 15 minutes. Parents are also seen alone for about
50 minutes in the first week of treatment, and additional joint sessions can
be scheduled under rare circumstances (e.g., in the case of family crises,
extreme difficulties during meals, or parental hostility toward the patient).
In brief, the assessing clinician, aer obtaining consent to see the
teenager alone, invites the parents to join the session at the end of the first
assessment/preparation session—in the presence of their child, the clinician
should provide them with general information concerning their child’s
eating disorder, the nature of CBT-E, and the parents’ role in the treatment
(see “Involving Parents” in Chapter 3, for details). ey are also encouraged
to discuss with the teenager the pros and cons of starting treatment when
she or he gets home, emphasizing, however, that the final decision will be
entirely up to the adolescent. At the end of the second
assessment/preparation session, the assessing clinician should call in the
parents and, again in the presence of the adolescent, communicate the
decision of the latter on whether or not to start treatment. If the patient does
indeed decide to start CBT-E, the parents’ role should be gone over once
again.
When the parents are seen alone in the first week of the treatment (see
Chapter 6), this session should have the main aims of assessing the family
environment and educating the parents about their adolescent child’s eating
disorder and the processes maintaining it (with reference to the personal
formulation). It should also be seen as an occasion on which to instill hope,
address any self-blame, stress the importance of creating an optimal family
environment, and identify and address potential parental barriers to change.
When the treatment is underway, the main goals of the joint parent and
patient sessions are to keep parents informed about what is happening in the
treatment and up-to-date on the patient’s progress, as well as to discuss how
they might help. e frequency and number of these sessions are flexible,
and should be decided on the basis of the patient’s needs. In general,
however, a date is set for the first joint parent–patient session aer the
introduction of the regular eating procedure; this session should be
dedicated to explaining how parents may help the patient to implement it.
Other joint sessions may be set up when the underweight patient has made
the decision to address weight restoration to discuss the parents’ role before,
during, and aer meals. Finally, it may be helpful to involve parents in order
to help the patient implement some procedures of the Body Image; Dietary
Restraint; Events, Moods, and Eating; and broad CBT-E modules. Details
and examples of parental involvement are described in each module of the
treatment. However, as a general guideline, the therapist should first explain
the rationale and practical aspects of the procedure (e.g., regular eating) to
the patients and then, if they agree to implement them, the parents may be
involved provided that both the therapist and the patient think that they
may be in a position to facilitate its application.

THE THERAPIST’S PREREQUISITES AND ROLE

ree main prerequisites required for a therapist to practice CBT-E for
adolescents, as per the version for adults (Fairburn, 2008), are (1) to have a
thorough knowledge of eating-disorder psychopathology and related terms,
(2) to take a transdiagnostic view of the eating disorders, and (3) to use the
CBT-E formulation (i.e., the case conceptualization diagram). In fact, it
should be emphasized that patients also need to be educated on these topics,
so familiarity with them is essential. e ideal therapist should be trained in
CBT and have prior experience of working with patients with eating
disorders. at being said, prior experience of CBT does not automatically
qualify a therapist to implement CBT-E for adolescents (one would not
expect an orthopedic surgeon to perform a complicated new surgical
procedure optimally the first time). Learning and implementing CBT-E for
adolescents is not difficult for experienced professionals, but the treatment
must be taken seriously and should be considered as a “work in progress”
that requires continuous practice. Our firm advice is to not only study this
book but also to carry out online training in CBT-E, which is available free
of charge (see Table 2.1). orough CBT-E training is provided in several
countries (e.g., the advanced training course in the treatment and
prevention of eating disorders and obesity held in Italy has trained more
than 400 therapists in CBT-E). For therapists who are not native-English
speakers, we also recommend participating in introductory CBT-E
workshops in their languages if no full CBT-E training course is available.
Information on clinical CBT-E workshops can be obtained from the CBT-E
website (www.cbte.co).
TABLE 2.1. Online Training in CBT-E
Evidence-based psychological treatments like CBT-E are difficult to disseminate and
implement widely. One of the major barriers to their dissemination and implementation is the
scarcity of suitably trained therapists. The currently accepted method of training typically
involves attending a specialist workshop, reading relevant texts, and a subsequent period of
supervision from someone expert in the treatment. As this method is both labor-intensive
and costly, and vulnerable to the shortage of treatment experts, it limits the number of
therapists who can be trained, and therefore, the number of people who might potentially
receive effective treatment.

To address these obstacles, CREDO has developed a new form of training, termed “web-
centered training,” that is designed to be both scalable and effective. It is capable of training
large numbers of therapists simultaneously. The training centers on the use of a specially
designed training website that describes and illustrates CBT-E in great detail and
incorporates features to help trainees grasp key concepts and master the main procedures.
Web-centered training may be used on its own (independent training) or it can be
accompanied by support from a nonspecialist “guide” (guided training). Even with guidance,
web-centered training is highly scalable.

The web-centered training program has two main parts: the Course and the Library. Briefly,
the Course is linear in nature and takes 8–9 hours to complete. It is a detailed practical
description of how to implement the main focused form of CBT-E given by an expert on the
treatment. This description is delivered in the form of multiple brief video presentations
accompanied by handouts and interspersed with formative learning exercises, video
recordings of acted illustrations of the treatment, and tests of knowledge together with
feedback. While working through the Course, trainees are encouraged to read relevant
sections from the treatment manual and treat one or more patients.

The second part of the training website, The Library, contains all of the material explained in
the Course, including the handouts, learning exercises, and clinical illustrations in indexed
form. In addition, there is a large amount of supplementary material on how to use CBT-E
with specific subgroups of patients, including adolescents, those who are severely
underweight, and those with clinical perfectionism, core low self-esteem, or marked
interpersonal difficulties. Participants are granted access to the Course and core Library
material from the start of training. They only have access to the supplementary Library
material once they have completed the study.

Information about the training can be obtained at www.cbte.co.

It is useful to learn CBT-E alongside other colleagues in order to benefit

from their experience. In our experience, maximum competence in
practicing CBT-E for adolescents is achieved 2–3 years aer starting to
implement the treatment. In the beginning, it is advisable to “shadow” an
expert in her or his treatment of cases to become familiar with the
procedures and strategies, and when taking on patients it is necessary to
strictly adhere to the protocol and not deviate from it (even if you feel some
reservations). Indeed, even though prior experience in the treatment of
eating disorders is useful, it can be dangerous because there is a risk of
“therapeutic dri” if aspects of the protocol are le out or improvised
(Waller & Turner, 2016). e CBT-E protocol has been developed through
long years of scientific and clinical research, and is designed to be
implemented as a whole. is should outweigh the judgment of even the
most experienced psychotherapist, whose opinions may be unwittingly
shaped by bias. Studies have highlighted that age and long duration of
practice are associated with a scarce adherence to evidence-based practice,
potentially putting her or his patients’ recovery at risk. For this reason, each
therapist should make a conscious effort to maintain fidelity to the
treatment protocol, even aer many years of practice.
e best CBT-E therapist takes the job seriously and continues to do so
even aer many years of experience, uses the treatment manual, is proud to
implement the treatment well and to help others do the same, rarely deviates
from the protocol, treats each case as a new challenge, and considers every
training session an opportunity to get up-to-date on relevant developments.
ese characteristics, combined with in-depth knowledge of the eating-
disorder psychopathology and the ability to handle the strategies and
procedures of the program, make the therapy user-friendly and simple to
understand for the patient.
A therapist’s competence in delivering CBT-E is the critical issue, and of
far greater importance than her or his appearance or gender. erapists may
serve as a role model in terms of acceptance of shape and weight, but a
therapist’s appearance is only relevant if she or he is the same gender and of
a similar age to the patient, which is unlikely to be an issue when treating
adolescents. Regarding gender, female therapists may have certain
advantages, as the great majority of patients with eating disorders are female.
In particular, female therapists may be viewed by female patients as more
likely to understand the difficulties that they are experiencing. It is
important to note, however, that if the therapist has had an eating disorder
in the past, it would not be appropriate to disclose this to her or his patients.
at being said, a history of eating disorder might make the therapist more
sensitive to the difficulties that such patients may face, though a loss of
objectivity must be carefully guarded against.
Regarding manner, the CBT-E therapist should be active and
empathetic, but also firm when necessary, in particular when the patient
needs to address tasks that are difficult and may cause anxiety (Fairburn,
2008). In CBT-E, it is crucial that the therapist and the patient come to share
a common understanding of eating-disorder psychopathology, and agree on
the strategies and procedures used to address it. For this reason, it is
essential that the therapist work collaboratively with patients, avoiding being
paternalistic, critical, or authoritarian, and do her or his best to keep
patients engaged in the treatment and change. Moreover, as previously
stated, the therapist should actively seek to promote therapeutic momentum
by avoiding interruptions in the treatment schedule. Finally, it is important
to note that anyone offering therapy to patients with an eating disorder must
also be aware of any potential associated medical complications and/or have
ready access to other competent medical specialists.

GENERAL SUGGESTIONS FOR IMPLEMENTING

THE TREATMENT WELL

To implement CBT-E for adolescents well, therapists are encouraged to bear

in mind the following (Fairburn, 2008):

• CBT-E is a complete treatment. It is not designed to be disassembled

into segments to be used on their own. CBT-E is not simply a set of
techniques—the sum is more than its parts. erapists with a lot of
experience may be tempted to deviate from the treatment protocol, but this
is never a wise move.
 • CBT-E is not designed to be used in conjunction with other psychological
treatments. Doing this will only confuse the patient and undermine the
treatment.

• CBT-E is to be delivered by a single therapist. In other programs,

adolescents with eating disorders may see multiple therapists at a time (e.g.,
physicians, a dietitian, and a psychologist), but this encourages patients to
partition their problems. If they discuss specific topics with specific
therapists, there is the risk of nobody being fully apprised of the extent or
breadth of the patient’s eating disorder. In CBT-E, on the other hand, only
one therapist is responsible for the psychological treatment, and even in the
inpatient version, when the involvement of multiple therapists is inevitable,
all practitioners who have contact with the patient (e.g., physicians,
psychologists, dietitians, and nurses) are fully trained in CBT-E and meet
weekly to discuss the case. Not only does this noneclectic approach work
well, it is rewarding for the therapist. It also makes the treatment more
practicable (and easier to disseminate) than those involving multiple
therapists. As mentioned, however, it is important for a CBT-E therapist to
have ready access to other specialists, particularly a pediatrician/physician
who can advise her or him how best to manage her or his patients’ physical
issues. In fact, each patient should have a named physician responsible for
her or his physical health, and a specialist dietitian may also contribute by
discussing the nutritional issues and the dietary management of specific
cases (especially in patients who are severely under- or overweight, or
adhering to a vegetarian or vegan diet).

• Breaks in treatment are to be avoided. CBT-E places great value on

establishing and maintaining therapeutic momentum. is is made clear to
patients when deciding the best time for the treatment to start. We ask
patients not to be away for longer than 2 consecutive weeks during the
course of treatment, and not at all during the first 4 weeks. When patients
are away, we maintain therapeutic contact by arranging weekly video-call
sessions. In advance, patients are asked to hold a preplanned self-
administered session following the usual session structure not including the
in-session weighing. When a therapist is going to be absent, patients are
informed that another CBT-E therapist will take her or his place, aer being
updated on their progress and the content of the last session, so that their
treatment can continue virtually uninterrupted.

• Modifying procedures and treatment is rarely appropriate, even if a

patient’s progress is slow. Instead, we suggest persevering with CBT-E, trying
to understand and address the obstacles to change. In our clinical
experience, the more severe the eating disorder of the patient, the fewer the
items that should be tackled; the intervention should be focused mainly on
the most important processes maintaining the eating-disorder
psychopathology.

• Dependence on treatment or the therapist should be prevented. In most

cases, the style of CBT-E and the fact that it is time limited prevents this
from becoming a problem. Nonetheless, patients with little social support, in
particular, may have difficulty adjusting to the gradual reduction in session
frequency, and may even attempt to make contact between sessions. is
should prompt the therapist to raise the issue, and explain to the patient that
a certain degree of dependence on treatment is nothing to worry about, as it
will be temporary; as the treatment progresses she or he will gradually feel
more in control, and more able to function independently, without the
therapist’s support.

• A protocol for dealing with late or nonattendance should be in place. e

therapist should take steps to preempt late or nonattendance from the very
first session by asking patients to arrive 10–15 minutes early for their
appointment, and by seeking to engender a sense of collective responsibility
for the optimal use of shared time. Indeed, treatment interruption is
common in routine clinical practice. Although this is sometimes due to
external circumstances (e.g., moving to a different house or changing jobs),
more oen than not it is caused by the eating disorder itself and/or issues
with the treatment. In order to prevent treatment dropout, therefore, it is
important to look out for the early warning signs, which may indicate
problems with engagement. For example, the therapist may perceive
disinterest or scorn on the part of the patient, or there may be problems with
attendance and/or punctuality. In such cases, it would be best to raise the
subject with the patient directly, as doing so can oen shed light on issues
that can easily be overcome. If a patient has not arrived 15 minutes aer the
scheduled appointment, the therapist should call the patient and express
concern about her or his absence. is should also be taken as an
opportunity to reschedule missed appointments at the earliest opportunity.
e therapist should also investigate whether the patient has any practical
barriers to attending (e.g., a long, difficult, or expensive journey), with a
view to proposing a workable solution. In adolescent patients, it may be
skepticism on the part of the parents that is conditioning their attitudes to
treatment, and so this may need to be addressed in family sessions.

1
e adult version of CBT-E is divided into four “stages” (Fairburn, 2008) designed to address the
eating-disorder psychopathology of the patients, while the process of achieving weight gain is
illustrated in three “steps” in underweight patients. We decided to use “steps” rather than “stages” in
the adolescent version of CBT-E because most young treatment-seeking individuals with eating
disorder are underweight; hence, three steps are used to help them to (1) decide to address weight
regain, (2) regain a healthy weight, and (3) maintain weight and prevent relapse. In our clinical
experience, underweight young patients appreciate this approach, finding the three steps easy to
understand and implement. In particular, as they tend not to see being underweight as a problem,
they appreciate that in Step One the goal is not weight regain but instead to collaboratively evaluate
the implications of change. However, the 20-week version of CBT-E given to not-underweight patients
is better described as four stages designed to address the patients’ eating-disorder psychopathology—
in particular, the ego-dystonic binge-eating episodes. For readers familiar with the description of the
adult version of CBT-E in four stages, it may be useful to remember that Stage One corresponds to
Step One, Stage Two to the review sessions, Stage ree to Step Two, and Stage Four to Step ree of
the adolescent version of CBT-E.
 CHAPTER 3

Assessment, Preparation, and

Medical Management

Many adolescents with eating disorders referred for the initial interview are
very ambivalent toward treatment. eir ambivalence may have various
origins. Some, especially those who are underweight, do not consider their
eating disorder as a problem, and, in fact, oen value some aspects of the
psychopathology (especially dietary control and weight loss). Others may be
ashamed of other features (e.g., binge eating), or they may have had adverse
experiences with treatments in the past. e assessing clinician therefore
needs to be sensitive to the patient’s attitude to the referral, and discuss it
with the patient. e assessment process should be collaborative. First
impressions are important, and a positive first meeting can start to engage
even the most ambivalent adolescent patient, whereas a negative encounter
can have quite the opposite effect—indeed, one may never see the patient
again.
e two main aims of the first assessment/preparation session are to
begin to engage the patient, forging a positive therapeutic relationship, and
to establish the nature of the eating disorder. ree further goals are to
assess the patient’s physical state, decide what form the treatment should
take, and, in adolescents, to begin to engage the parents.

FIRST ASSESSMENT AND PREPARATION

SESSION

First and foremost, parents are asked for their consent to the CBT-E
practitioner initially seeing the adolescent alone. is one-to-one approach
is used to facilitate the exploration of the adolescent’s perspective on
consultation and the nature of her or his problems, and to lay the
foundations for a sound therapeutic relationship (Dalle Grave & Cooper,
2016). Subsequently, joint interviews with the parents or other relevant
family members are held at the end of the first and second assessment and
preparation sessions.

Assessing the Patient’s Attitude toward the Interview

Usually, we start the interview by asking adolescent patients whether they
have come freely to the consultation, or whether they felt pressured to attend
by their parents. e therapist is likely to find that very few adolescents
come to the consultation of their own free will, and will therefore be
underequipped with the determination to address their eating disorder. For
this reason, the assessing clinician should not fail to tell patients that she or
he understands their difficult emotional state, deriving from their being in a
place that they do not want to be, and should ask whether they agree on the
main purpose of the interview—namely, to exchange information about any
problems they may have. In most cases, this nonthreatening goal is accepted
by even very ambivalent patients, who are reassured by the news that they
will not be forced to start treatment right away.
Another way in which we seek to reassure ambivalent patients is by
never failing to stress that we will be operating entirely on their behalf,
rather than as agents of their parents. is can be emphasized by clearly
explaining what the treatment will entail directly to the adolescent patients,
assuring them that they themselves will be entirely responsible for decisions
concerning its progress.

Assessing the Nature and the Severity of the Eating

Disorder
Aer patients have agreed on the purpose of the interview, it is our practice
to ask about the onset and current status of their eating disorder. is is an
essential step because what is apparently an eating disorder may in fact be an
anxiety disorder (e.g., a social phobia causing difficulty eating in the
presence of others), an expression of an underlying mood disorder (e.g.,
severe weight loss brought on by clinical depression), or straightforward
overeating in an individual with obesity (Fairburn, 2008). However, it is not
our practice to take an exhaustive personal history—rather, we focus on our
two main goals and do our utmost to achieve them. Table 3.1 lists the topics
that we routinely cover.
TABLE 3.1. Topics to Be Addressed When Assessing the Nature and Severity of the
Eating Disorder
Eating problem onset
Age of onset and nature of the behavioral precursor of eating problem (e.g., dietary
restriction, excessive exercising, self-induced vomiting, binge-eating episodes) maintained
for at least 3 consecutive months.
Body weight at the onset of the behavioral precursor of eating disorders.
The reasons for diet or adopting other extreme weight-control behaviors.
The most frequent reasons reported by adolescent patients are losing weight, changing
the body shape, coping with dyspeptic symptoms, having no appetite.

12 months before the onset

Events (precipitating factors) that may have triggered control of diet, weight, and body
shape.

6–12 months after the onset

“How did you feel?”
Most patients report feeling well and that they had the feeling of being in control during
that period, which some describe as the best in their life (the “honeymoon” phase of the
eating disorder).

Since then
Any change in eating habits (e.g., the onset of binge-eating episodes), unhealthy weight-
control behaviors (e.g., self-induced vomiting and/or laxatives misuse and/or excessive
exercising), and in the weight that occurred.
In this period, the main maintenance mechanisms described in Chapter 2 become
operational, and the eating disorder tends to become more or less self-sustaining.

Current state of the eating problem

(over the past 4 weeks and 3 months)
Current body weight, height, and BMI-for-age percentile.
BMI-for-age percentile history (before and since the eating problem started, lowest BMI-
for-age percentile, highest BMI-for-age percentile).
Frequency of menstruation. In adolescents with secondary amenorrhea, age of menarche.
Body weight changes.
Eating habits in a typical day.
Dietary rules (e.g., skipping meals, reducing portions, avoiding specific foods, calorie
counting, avoiding social eating) and reactions to their being broken.
Unhealthy weight-control behavior (e.g., self-induced vomiting, laxative misuse, excessive
exercising): frequency and triggers.
Binge-eating episodes (objective and subjective): frequency and triggers.
Other eating habits (e.g., chewing and spitting, rumination, specific food rituals, picking or
grazing).
Fluid intake (e.g., water, alcohol, other), smoking, and improper use of psychoactive
substances and their link with eating habits.
Weight and shape checking and avoidance: frequency and triggers.
Degree of fear of gaining weight.
Degree of concern about shape, weight, and eating control.
Degree of feeling fat, full, and bloated.
 Effects of the eating problem on physical health, psychological well-being, functioning,
social relationships (with parents and friends), and academic achievement.
Dietary restraint (nature of attempt to restrict food intake): dietary rules, reaction to any
breaking of these rules, calorie counting, calorie limits, delay eating (i.e., postponing
eating for as long as possible).
Dietary restriction (i.e., actual undereating).
Other weight-control behaviors (e.g., self-induced vomiting, laxative misuse, diuretic
misuse, excessive exercising): frequency, relationship with perceived overeating.
Episodes of overeating (amount eaten and the context, presence of the sense of loss of
control at the time): frequency and triggers.
Other eating habits (picking, chewing and spitting, rumination, ritualistic eating).
Drinking habits (consumption of water, coffee, tea, carbonated drinks, alcoholic
beverages) and their connection with eating habits.
Smoking habits and their connection with eating habits.
Social eating: ability to eat with others (family members, friends, etc.), eating out.
Concerns about shape and weight.
Views on shape and weight.
Importance of shape and weight in self-evaluation.
Body checking (weighing, mirror use, comparison with others, and other forms of
checking).
Body avoidance (weighing avoidance, shape avoidance).
Feeling fat.
Impact of the eating problem on psychological and social functioning (family members,
friends, etc.), mood and concentration, school performance, other people (family
members, friends, etc.), activities, and interests.
Other effects.

Personal and family medical history

Current and previous medical and psychiatric comorbidity.
Current psychiatric treatment (psychological, pharmacological).
Family medical and psychiatric history.

From Cognitive Behavior erapy for Adolescents with Eating Disorders by Riccardo Dalle Grave and
Simona Calugi. Copyright © 2020 e Guilford Press. Permission to photocopy this material is
granted to purchasers of this book for personal use or use with patients (see copyright page for
details). Purchasers can download enlarged versions of this material (see the box at the end of the
table of contents).

e assessment can be improved by asking patients to complete either

the standard Eating Disorder Examination Questionnaire (EDE-Q 6.0;
Fairburn, Cooper, & O’Connor, 2008b), which is suitable for patients ages 16
and above, or the modified version for younger patients (Carter, Stewart, &
Fairburn, 2001), as well as the Clinical Impairment Assessment (CIA 3.0;
Bohn, Doll, Cooper, O’Connor, Palmer, et al., 2001). e EDE-Q provides a
measure of the eating-disorder features, and the CIA assesses the influence
of the eating-disorder psychopathology on psychosocial functioning. Both
focus on the 28 days preceding the assessment. e full Eating Disorder
Examination interview (EDE-17.0D; Fairburn, Cooper, & O’Connor, 2008a)
is too detailed and time-consuming to use during the initial evaluation
interview(s), but it can be administered at the beginning of treatment for a
thorough assessment of the clinical features of the eating disorder and/or for
research purposes. All of these measures can be obtained from the CBT-E
website (www.cbte.co).

Exploring the Nature and Outcome of Prior Treatments

Aer having confirmed the presence of an eating disorder of clinical
severity, the next step is to ask whether patients have received any prior
treatment—if not, outpatient CBT-E should be proposed in most cases.
However, in the event that they have had any unsuccessful treatment in the
past, the type of the treatment received and the reasons for the failure should
be investigated. If the patients were offered treatments that did not require
their active involvement (e.g., family-based treatment), outpatient CBT-E
should be proposed. CBT-E can also be offered to patients in whom it has
previously been unsuccessful due to a lack of engagement, provided that
they report a change in attitude and are now ready to play an active role in
the treatment and make it a priority. Finally, in the rare cases that the patient
reports having been actively engaged in outpatient CBT-E but saw no
improvement, inpatient CBT-E could be considered. Otherwise, inpatient
CBT-E should be the option of choice if the patient’s medical conditions are
unstable.

Exploring What Patients Think about Their Eating

Disorder
e next step is to explore with the patients what they think about their
eating disorder by asking a question like “Now, I’d like to ask you a difficult
question: Do you think that your control of eating is a choice or a problem?”
It is common for underweight adolescent patients to respond to this
question with “It’s a choice.” In this case, the assessing clinician should
endeavor to find out what the patient means by “a choice” by posing a series
of targeted questions (e.g., “Could you eat normally for the next few days—
in other words, relax your control over eating? Or would you find this
difficult?”) designed to help patients to reach the conclusion that a main
requisite necessary for making a choice is the freedom to choose from
several options. In most cases, patients report that they do not feel free to eat
because they are extremely concerned about their shape, weight, and eating,
and they have a morbid fear of gaining weight.
Having reached this conclusion, it may also be useful to discuss with
patients that it is not easy to understand when some behaviors have become
a problem, and that they should consider whether they perceive that their
eating behaviors have produced impairments in some important aspects of
their life, such as interpersonal relationships, psychological well-being,
school performance, and physical health. ese topics should also be
addressed with patients who answer directly that their eating is a problem.
In this case, questions like the following should be posed: “What is the
evidence that makes you think that it is a problem?” e most typical reason
reported by adolescent patients is the deterioration of interpersonal relations
with peers and parents. However, a minority report the concerns expressed
by parents, the presence of continuous concerns about eating, the presence
of binge-eating episodes, and difficulty concentrating on their studies. Less
oen, adolescent patients report concerns about their physical health.
Some patients answer that it is both a choice and a problem. In this case,
the assessing clinician should review the evidence in support of the control
of shape, weight, and eating first as a choice and then as a problem. With
these patients it is oen clinically useful to share the conclusion that dieting
to lose weight might have been a choice initially (it is a common behavior in
the general population), but then the preoccupation with shape, weight, and
eating control has gradually evolved into a problem that is not under their
total control, and is creating impairment in various aspects of their life.

Educating Patients about Their Eating Disorder

At this point in the interview, if it seems that patients have an eating
disorder of clinical severity, we usually ask them whether they would be
interested in receiving some information about “eating problems.” In case of
an affirmative response, as usually occurs, we find it very useful to educate
the adolescent by creating a visual representation of her or his eating
disorder, drawing a provisional formulation, or diagram, based on the
information gathered during the assessment (see Figure 3.1). is exercise,
and the accompanying explanation, should illustrate the core problem of the
eating disorder as a dysfunctional schema of self-evaluation based
predominantly or exclusively on shape, weight, eating, and their control. We
usually explain this abstract concept by drawing a self-evaluation pie chart
of someone with an eating disorder (stressing that it is only an example, and
not necessarily a description of the patient’s own self-evaluation schema),
characterized by a predominant slice representing shape and weight, and a
few other slices. is can be contrasted with a pie chart representing
someone without an eating disorder, which will include a greater number of
slices and a smaller slice representing shape and weight. Most adolescents
with eating disorders immediately understand the concept, and that the size
and number of slices describe the degree of importance attributed to each
domain in their self-evaluation. is pictorial representation also makes it
easy for patients to see how their own eating disorder is affecting their life,
even if this is not explicitly pointed out.
FIGURE 3.1. An example of a provisional personal formulation developed with an underweight
patient with an eating disorder during the assessment and preparation session.

When drawing up the patient’s provisional formulation, we explain that

most of the features of the eating disorder derive directly or indirectly from
the excessive importance given to shape, weight, eating, and their control
(the core psychopathology). For example, we educate underweight patients
that a strict diet, characterized by extreme and inflexible dietary rules, is
understandable if self-evaluation is predominantly based on shape and
weight.
In such cases, we also point out that persistent undereating produces a
condition of low weight, which in humans is associated with the onset of
characteristic symptoms, called “starvation symptoms.” en we add the
symptoms that the patients report appearing aer weight loss (gathered
during the assessment) in the provisional formulation. We also discuss with
them the possibility that some of these symptoms may initially have had a
“positive” function, improving an individual’s chance of survival in times of
food scarcity (e.g., reduced energy expenditure increases the length of time a
person can go without eating, and preoccupation with food focuses the
attention of the individual on the search for food), but that these can be
problematic when they manifest as part of an eating disorder. Indeed, when
there is an eating disorder, these symptoms are interpreted as the need to
increase control over eating and intensify the use of shape and weight as a
system of self-evaluation through several maintenance mechanisms. For
example, reduced energy expenditure intensifies dietary restriction in order
to maintain weight loss or prevent weight regain (see Figure 3.1). Dietary
restriction is also accentuated by the early sense of fullness and
preoccupation with food that are secondary to weight loss. Moreover, the
social withdrawal associated with these factors increases the use of shape
and weight as a predominant means of self-evaluation because it restricts the
development of other self-evaluation domains. Finally, we emphasize that
people who have an eating disorder oen consider a strict diet and low
weight not as a problem, but rather an achievement, as they are a direct
expression of the overvaluation of shape and weight. is vicious circle
explains why it is difficult for patients to see the eating disorder as a problem
that needs to be addressed.
In not-underweight patients, education is focused on the mechanisms
maintaining binge-eating episodes and, obviously, does not include the
description of being underweight and the associated starvation symptoms
(see “Creating the Formulation” in Chapter 5).
Using the provisional formulation as a teaching aid has several benefits.
It helps to interest and intrigue adolescent patients about the psychological
nature of the eating disorder. It also helps them to understand the principal
mechanisms operating in maintaining their eating disorder. Finally, it
facilitates the description of the nature and targets of CBT-E. In most cases,
adolescent patients recognize themselves in their formulation, and many
report that this way of explaining their eating disorder and the treatment
was very engaging.

Explaining the Nature of CBT-E

If CBT-E is to be recommended, the treatment should be accurately
portrayed. We usually start by explaining that in the treatment of
adolescents with an eating disorder there are two main approaches. e first,
which we do not adhere to, is based on the premise that adolescent patients
have no control over their illness—they do not recognize it, and they
therefore require an external source of control (i.e., parents, doctors, and/or
health personnel, etc.). e second, which we propose, is a psychological
treatment called CBT-E; this never adopts “prescriptive” or “coercive”
procedures, and for this reason it never requires patients to address things
that they do not think are a problem. Indeed, unlike the other treatments
based on external control, CBT-E helps patients to regain control by
understanding the main processes maintaining their eating disorder and
being actively involved in the decision to address them. en, if the patients
decide to work toward change, the treatment introduces individualized
procedures that are designed to make them feel in control during the
process.
Next, referring to the previously drawn provisional formulation (see
Figure 3.1), we usually draw an arrow from the pie chart with the eating
disorder to that without the eating disorder, emphasizing that the main goal
of the treatment is to reduce the overvaluation of shape and weight, and to
develop a self-evaluation schema that is more “balanced”—that is, including
several domains, especially of an interpersonal nature (one of the few
features usually viewed as problematic by adolescent patients with an eating
disorder). We explain that to achieve this goal it will be necessary to address
the main expressions of the eating disorder pie chart, as these tend to
maintain the overvaluation of shape and weight (indicating the arrows on
the provisional personal formulation). We emphasize that this, however, will
not be easy, because some of these expressions (e.g., dietary restriction and
low weight) are usually seen as achievements rather than problems. For this
reason, the first step in the treatment, which we call “Starting Well and
Deciding to Change” (Step One), does not have the aim of addressing weight
restoration, but rather it is mainly focused on improving patients’
understanding of the processes maintaining the eating disorder, and on
evaluating the implications of addressing the change, including weight
regain.
We also explain that if, at the end of Step One, the patients decide to
address weight restoration, the treatment will move on to Step Two;
otherwise it will be interrupted. Indeed, Step Two addresses weight
restoration in a highly personalized way, as well as the other processes
maintaining the eating disorder, such as the extreme and inflexible dietary
rules, and negative body image. Step ree is the final phase of treatment,
and its aims are learning to maintain weight, concluding the therapy and
reducing the risk of relapse. Moreover, about every 4 weeks, part of the
session will be devoted to reviewing the treatment progress and, in
particular, identifying any obstacles to change and planning the rest of the
treatment. Most adolescent patients appreciate the fact that in Step One the
focus is not on weight regain, that they are involved actively in the decision
to change, and that the treatment is not based on external control.
Aer having described the general strategies of CBT-E, we go on to
explain the treatment in detail, covering the main points reported in Table
3.2. With the minority of adolescent patients who are not underweight, the
description of the treatment is similar, with the exception that it, like CBT-E
for adults, lasts 20 weeks, is divided into four stages (see the note on page 26
in Chapter 2), and does not address weight restoration at any point.
TABLE 3.2. Main Points to Make When Describing CBT-E to Underweight Adolescent
Patients
Cognitive behavior therapy (CBT), is one of the most promising treatments for adolescents
with an eating problem. Our data indicate that about two-thirds of people who complete
treatment have an excellent response. There is no reason why you should not be in this
group so long as you throw yourself into treatment and give it priority.

The treatment is a one-to-one-talking type and never adopts “prescriptive” or “coercive”

strategies or procedures—in other words, you will never be asked to do things you do not
agree to do. Indeed, the general treatment strategy is first for you and your therapist to
understand what are the main mechanisms maintaining your eating problem and then to
decide to address them with specific procedures. Afterward, you should try to apply the
agreed-upon procedures with maximum effort. Finally, you should review with your therapist
the effect of the procedure on your eating problem. If you do not reach an agreement with
your therapist, the treatment will be interrupted, but this rarely happens.

The treatment will be tailored to your eating problem and your specific needs. You and your
therapist will need to become experts on your eating problem and what is keeping it going.

Treatment will involve about 30–40 sessions over approximately 30–40 weeks, the first 20
or so sessions being twice a week. Thereafter, they will be spread out.

Treatment will also include one session with your parents alone and some brief sessions
with you and your parents together immediately after an individual session. The aim of
these sessions is to help your parents to create a home environment that will facilitate your
attempt to change. However, the nature of their assistance will be previously agreed to
between you and your therapist.

It is important that there are as few breaks in treatment as possible. This is because we
want to establish what we call “momentum” so we can work from session to session to
break down your eating problem. Gaps in treatment are very disruptive if momentum is lost.
It is especially important that there are no breaks in the first 6 weeks and no longer than 2-
week breaks thereafter. We need to take this into account when deciding on the best time to
start your treatment.

Each appointment will last just under 1 hour, with the exception of Session 0, which will take
more than 1 hour. For everyone’s sake it is important that appointments start and end on
time. Your therapist will make sure that she or he is ready at the due time, and we request
that you do the same. In fact, it is also advisable that you arrive 15 minutes in advance so
you will have the time to prepare the topics that you wish to discuss.

The patient and therapist work together as a team to tackle the eating problem, agreeing at
the end of each session on specific homework to do between sessions. This homework is of
fundamental importance and you will have to give it the highest priority. It is what you do
between the sessions that will determine the limitations or benefits of treatment.

Treatment should be considered as a special opportunity to start a new and more fulfilling
life. As with any change there are some risks, but the benefits that can be obtained are
enormous. They include thinking more freely without being continually oppressed by
thoughts about food, weight, and body shape; developing a broader mental perspective;
becoming happier, less irritable, and rigid; and being able to have a family and achieve
better health conditions.

Treatment will be hard work, but it will be worth it. The more you put in, the more you will get
out of it.

From Cognitive Behavior erapy for Adolescents with Eating Disorders by Riccardo Dalle Grave and
Simona Calugi. Copyright © 2020 e Guilford Press. Permission to photocopy this material is
granted to purchasers of this book for personal use or use with patients (see copyright page for
details). Purchasers can download enlarged versions of this material (see the box at the end of the
table of contents).

Agreeing on Homework for the Second

Assessment/Preparation Session
Aer having described the treatment (if possible with the aid of an
information sheet), and giving patients the opportunity to ask questions and
express concerns, it is our practice to suggest that they think over what has
been proposed in the first session. We ask them to write down the pros and
cons of starting Step One of the treatment at home, and to bring a list of
written questions to ask at the next appointment, which will focus on
discussing these issues. In addition to providing useful information for the
therapist to review with the patients, this strategy has the added advantages
of focusing the patients on the choice to begin therapy, and getting them
used to the idea of completing “homework” tasks between sessions, which
will become a major part of the treatment itself.

Involving Parents
A joint interview with the parents or other relevant family members and the
patient is held at the end of the first assessment and preparation session. Its
aim is to provide the parents with general information about their
adolescent child’s eating disorder, the nature of CBT-E, and the role that
they should play in the treatment. We explain that the adolescent’s
dysfunctional behavior is the consequence of a characteristic mindset that
operates in people with eating disorders. is mindset is maintained by
means of several mechanisms that perpetuate it, and addressing them is the
primary goal of treatment. To explain this concept, we outline the cognitive
behavioral theory of how eating disorders are maintained to the parents. We
then inform them that many adolescent patients recover completely from
their eating disorder, and that there is no reason to think that this will not
happen to their daughter or son. However, we explain that it is difficult for
adolescents to see the eating disorder as a problem, because they oen view
control of eating, shape, and weight as a positive achievement that makes
them feel better about themselves. For this reason, we explain that the first 4
weeks of the treatment will be mainly dedicated to helping their child
understand the nature of her or his eating disorder, including the need to
regain weight (if applicable), and make the decision to change.
We also explain to parents that there are two main approaches to
treating eating disorders in adolescents, one based on external control (i.e.,
by parents, doctors, health personnel, etc.), as the patients are considered
not to be in control of their illness as they are not aware of it, while the other
is “CBT-E,” which instead adopts a collaborative approach and never obliges
patients to do something that they do not want to do and do not see as a
problem. We explain to parents that the CBT-E approach is first to educate
patients about their eating disorder and the mechanisms that maintain it,
and then to analyze the implications of tackling the eating disorder. If the
adolescent agrees, only then will the treatment progress to jointly designing
specific strategies and procedures that can be enacted to overcome it. For
this reason, CBT-E uses a one-to-one flexible and individualized approach,
but parents will have an important role to play by creating a positive home
environment that is likely to support the patient’s efforts to change and, in
some cases, by helping their daughter or son to apply specific treatment
procedures.
At the end of this joint assessment and preparation session, we usually
suggest that if the parents agree to the proposal, they help their child to
evaluate the pros and cons of starting the treatment, taking care to stress
that they approach this in an inquisitive rather than authoritarian manner.
We emphasize at this point that the decision to start the treatment will be
made exclusively by the adolescent, because the treatment will probably fail
if the child feels pressured by others into making this decision.

SECOND ASSESSMENT AND PREPARATION

SESSION

In the second assessment and preparation session, generally held 1 week

aer the first, we review with the patient alone the pro and cons of starting
Step One of CBT-E, seeking to reinforce interest in change, and addressing
any questions about the treatment. Every reason for change should be
reinforced. e cons of starting Step One should not be ignored, as the aim
is to help patients make an informed decision to start CBT-E aer
understanding the nature of their eating disorder and assessing in detail the
implications (positive and negative) of change. In ambivalent patients, we
suggest that they “take the plunge” and try Step One of the treatment on a
trial basis, repeating that the goal of this phase of the treatment is not weight
restoration. Additional sessions should be scheduled with patients who
manifest strong ambivalence toward change, particularly if they are reluctant
to be engaged in the treatment. However, this is a rare outcome, since most
decide to start Step One of CBT-E based on the above approach.

Involving Parents
A second joint interview with the patient and the parents or other relevant
family members is held aer the second assessment and preparation session.
If applicable, we tell the parents that the patient has decided to start
treatment, and briefly review the nature and structure of CBT-E, as well as
the parents’ role in the treatment. We also schedule an appointment for an
interview alone with the parents in the first week of the treatment. In the
event that involving other significant persons (e.g., grandparents, teachers,
coach) seems beneficial, we ask for the patient’s and parents’ permission to
do so, stressing that their role too will be as helpers, and that we will be
operating exclusively on behalf of the patient.

POSSIBLE NEXT STEPS

At the end of the second assessment/preparation session, the type of

treatment is generally decided jointly with the patient. However, there are
some patients for whom CBT-E is not appropriate. In particular, because of
their level of cognitive development, CBT-E may not be suitable for some
patients under the age of 12 years. Instead, these patients oen benefit from
a family-focused approach, so a suitable alternative treatment should be
suggested. Furthermore, if the patient does not have an eating disorder of
clinical severity, a “do nothing” or “wait and see” approach is indicated. If
the eating disorder is mild or remitting, it is appropriate simply to give
advice and encouragement to the patient and family, scheduling a number of
review meetings to ensure that progress is being maintained. Self-help
literature may also be recommended/provided to such patients.
With some patients it is not appropriate or possible to embark directly
on outpatient CBT-E. is may be for a number of reasons (discussed in
more detail below in “Contraindications to Starting CBT-E Immediately”),
including an exceedingly large amount of weight loss (e.g., BMI-for-age
percentile <3rd), physical risk (e.g., rapid weight loss, frequent vomiting, or
laxative misuse), severe coexisting psychiatric problems, or suicide risk.
With these patients, a preliminary intervention is required, which may take
the form of day patient, intensive outpatient, or inpatient CBT-E. is can
be followed by outpatient CBT-E if it does not result in resolution of the
eating disorder directly, which is, however, likely in very young patients with
an eating disorder of recent onset. If the patient has the features described
above but refuses to engage with individual treatment, admission to a
general pediatric unit until her or his medical conditions have stabilized
may be suggested.
In the great majority of cases, however, patients will be suitable for
immediate outpatient CBT-E. is is appropriate for patients whose weight
is within the healthy range or those who are only moderately underweight
(BMI-for-age percentile ≥ 3rd) and are willing to engage in one-to-one
treatment. e following vignette indicates a typical outcome of the
assessment and preparation interview.
VIGNETTE
e patient, a 16-year-old girl with a body weight of 120 pounds, decided to diet to lose weight. In
a few months she had lost about 22 pounds, and her menstrual cycle had stalled. Despite the
insistence of her parents and various attempts by a family doctor, a child psychiatrist, and a
psychologist, she refused to start treatment. At the beginning of the assessment/preparation
session, she claims she has been forced to come to the interview, but nonetheless agrees to
exchange information with the assessing clinician. Asked whether she considered her diet and
weight loss a problem or a choice, she replies without any hesitation that it is a choice. However,
aer some hesitation, she agrees that she does not feel relaxed about food, and that she is unable
to eat without anxiety or to relax her extreme and inflexible dietary rules. She also admits that
before weight loss she had a sunny disposition and many friends, but now feels sad and isolated.
She also agrees to attend another appointment, and to evaluate and write down in two columns
the pros and cons of starting CBT-E Step One as preparation. At the second
assessment/preparation session she agrees to start CBT-E, because she now realizes that she has a
problem, but especially because she appreciates not feeling forced, as she had in previous
treatments, to address her eating disorder and weight restoration. She also affirms that she likes
the fact that the therapist would be operating on her behalf, not for her parents, and that she
would be playing an active role in all steps of the treatment.

CONTRAINDICATIONS TO STARTING CBT-E

IMMEDIATELY

ere are some contraindications to starting outpatient CBT-E immediately.

e most common are the following (Fairburn, 2008):

• Unstable medical condition. In this case, it will not be possible to deliver

outpatient CBT-E safely (see “Medical Features of Concern” below).
 • Suicide risk. is risk can be encountered in patients with coexisting
clinical depression, but also in those who feel hopeless about the prospect of
recovery.

• Severe clinical depression. e presence of clinical depression, not

secondary to the eating disorder, interferes with psychological treatment
(see Chapter 20), and should therefore be identified and treated before
starting CBT-E. However, as there are concerns about the use of
antidepressant medication in younger patients, it is important that clinicians
adhere to up-to-date national guidelines in this regard. Aer remission from
the depression, CBT-E may be commenced.

• Persistent substance misuse. Patients will not be in a position to benefit

from the treatment if they are intoxicated either during or outside treatment
sessions. CBT-E may be started once they are in remission from substance
misuse.

• Inability to attend treatment assiduously. A key strategy of CBT-E is

establishing and maintaining therapeutic momentum. For this reason, it is
essential that sessions in the early stage of the treatment be held frequently
(i.e., twice a week) and regularly. If the patients and their parents cannot
guarantee their constant presence for some reason (e.g., a prebooked
vacation), we prefer to defer treatment to avoid the risk of a “false start.”

• Absence of the therapist. We prevent this obstacle to the establishment

and maintenance of therapeutic momentum by guaranteeing to substitute
the nominated therapist with another CBT-E-trained specialist in the case of
unforeseen absences.

MEDICAL MANAGEMENT

In most cases, adolescent patients deemed treatable with outpatient CBT-E

do not require further medical management aer an initial medical
evaluation. However, clinicians delivering CBT-E should be familiar with
the principal medical complications of eating disorders and refer patients for
medical consultation should the need arise. e following section is written
for nonmedical therapists, and it is focused on the types of patients typically
treated using outpatient CBT-E (see Mehler & Andersen, 2017, for more
information). It also serves to stress that no medical investigation is
necessary to make a correct diagnosis of an eating disorder. Indeed, the
diagnosis is made by assessing the behavior and attitudinal features of the
patients, rather than their physical health, which must, however, be taken
into consideration when deciding which treatment would be more fitting.

General Points to Consider

e health and safety of adolescent patients is of primary importance and
must never be neglected. In particular, therapists should bear in mind that:

Eating disorders can be associated with medical complications and

clinicians treating these disorders must be aware of them.
Nonmedical therapists delivering CBT-E should have access to a
pediatrician/physician expert in the management of the physical
complications of eating disorders. is is especially important when
dealing with patients who are underweight, particularly in the initial
stages of the treatment when the patients have not yet started the
process of weight regain.
e physical complications of eating disorders are secondary to
extreme weight-control behaviors (e.g., dietary restriction, self-induced
vomiting, laxative or diuretic misuse) and a body weight that is too low
or too high.
Most of the physical complications resolve with restoration of healthy
eating habits and an appropriate BMI-for-age percentile. Exceptions
are the dental erosion secondary to self-induced vomiting, and
 osteoporosis secondary to being persistently underweight if weight is
not rapidly restored.

Medical Features of Concern

e therapist delivering outpatient CBT-E should refer the patients to their
pediatrician/physician if one or more of the medical features described
below are discerned, even though no medical treatment will be required in
most cases.

Eating-Disorder Features
Severe dietary or liquid restriction (e.g., fasting or drinking too little).
Frequent self-induced vomiting (two or more episodes a day).
Frequent laxative or diuretic misuse (two or more episodes a day at low
doses, or less frequent consumption of high doses).
Frequent exercising while underweight.
Rapid weight loss (>2 pounds per week for several weeks in
succession).
Low weight (BMI-for-age percentile <3rd).

Physical Symptoms or Signs

Episodes of fainting.
Episodes of disorientation.
Episodes of confusion or memory loss.
Awareness of heart rate changes or chest pains.
Muscle spasms.
Shortness of breath.
Swelling of the ankles, arms, or face.
Extreme weakness and fatigue.
Difficulty climbing stairs or getting up from a chair without using arms
as support.
Biohumoral and Other Tests That May Be Recommended
e following is a list of physical investigations that can be recommended to
patients before starting CBT-E. (Note: Nonmedical therapists should leave
interpretation of the physical investigation to the patient’s attending
physician.)

Blood count with formula (to identify the possible presence of anemia,
leukopenia, and thrombocytopenia).
Alkaline phosphatase (ALP), alanine transaminase (ALT), and
aspartate transaminase (AST; all to assess liver function).
Estimated glomerular filtration rate (eGFR; to assess renal function).
Serum potassium, sodium, calcium, magnesium, and phosphorus (to
assess electrolyte levels).
Erythrocyte sedimentation rate (ESR), ferritin, and albumin (to assess
nutritional status).
yroid-stimulating hormone (TSH; to assess thyroid function).
Estradiol in women and testosterone in men (to assess reproductive
function).
Urinalysis (to assess hydration status).
Electrocardiogram (to highlight any alterations in heart rhythm).
Blood pressure (to detect hypotension).
Dual-energy X-ray absorptiometry (DEXA) in patients who have been
amenorrheic for more than 6 months or have a BMI <15.0 (to detect
any osteopenia or osteoporosis).

Note: Unlike in adults, an adolescent’s weight status should be assessed

using national BMI growth charts.

Pharmacological Treatments That Can Be

Recommended
In general, pharmacological treatments must be prescribed sparingly in
adolescents with eating disorders because, as mentioned above, in most
cases, the complications secondary to the state of malnutrition will resolve
with the normalization of eating habits and body weight. In some cases,
however, the following supplements may be recommended:

Potassium. Potassium salt supplements can be prescribed by the doctor

if there is a condition of hypokalemia in patients reporting purging
behaviors, such as self-induced vomiting or misuse of laxatives or
diuretics. In these cases, it is important to encourage the patients to
suspend purging, and to monitor the level of potassium in the blood at
intervals.
Vitamin D and calcium. Calcium and vitamin D supplements can be
prescribed to patients who have osteopenia or osteoporosis.
Iron, folate, and B-complex vitamins. ese can be prescribed to
manage anemia if present.
Vitamin B1 (thiamine), phosphates, and other mineral salts. ese may
be prescribed for underweight patients to prevent or manage the
development of refeeding syndrome.
Vitamins. A daily multivitamin can be recommended for patients who
have a long history of dietary restriction and being underweight
(National Institute for Health and Care Excellence, 2017).

WAITING LISTS

Clinical services should do their best to minimize waiting times, since doing
so would not only decrease the duration of the patients’ eating disorder, but
might also improve treatment response, especially in adolescents. For
example, in the United Kingdom, the Access and Waiting Time Standard for
Children and Young People with Eating Disorders states that NICE-
concordant treatment with a designated health care professional should start
within a maximum of 4 weeks from first contact for routine cases and within
1 week for urgent cases (National Collaborating Centre for Mental Health,
2015).
The Core
Protocol
 CHAPTER 4

The Three Steps of CBT-E for

Adolescents
An Overview

STEP ONE: STARTING WELL AND DECIDING TO

CHANGE

e degree of change achieved in the first few weeks of treatment is a strong

predictor of outcome (at least in bulimia nervosa; Agras, Crow, et al., 2000),
and for this reason it is fundamental that treatment starts well. e patient
and the therapist must both be ready to begin, and any potential
impediments to treatment need to be addressed in the preliminary session
(Session 0, discussed in detail in Chapter 5).

Goals
Step One has five main goals:

1. To engage the patient in the treatment and change.

2. To create an individualized personal formulation to guide the
treatment.
 3. To provide psychoeducation and reduce concerns about weight.
4. To establish a pattern of regular eating.
5. To decide to change.

Structure
e structure of Step One is relatively standard due to the fact that the
procedures are introduced in a precise, sequential fashion, albeit on a
personalized basis. Step One lasts 4 weeks and the patient is seen for two 50-
minute sessions a week, with the exception of Session 0, which can last up to
90 minutes. However, in patients who are underweight, it can be reduced in
length if, aer the first four sessions, they decide to change and address
weight restoration. During the first week of the treatment proper, parents are
asked to participate in an evaluation session lasting about 50 minutes, and
two or three joint sessions with the patient 15 minutes aer the introduction
of the regular eating procedure.

Content
Engaging the adolescent patient in the treatment and change is the top
priority, as CBT-E has little chance of success unless the patient is fully
engaged. erefore, the CBT-E therapist should become skilled at engaging
young patients in both the process of change and the treatment itself. is is
one of the most important challenges with underweight adolescent patients,
who tend to be especially ambivalent about change because they tend to
view undereating and low weight as an achievement rather than a problem.
Engagement is also a top priority for those who are not underweight, as a
large number of these patients will have already lost a considerable amount
of weight (many are given the diagnosis of atypical anorexia nervosa), and
they too will not see undereating as a problem. Others may have aspects of
their disorder that they would like to change (e.g., binge-eating episodes),
but there are generally other elements that they do not consider a problem
(e.g., dietary restraint to lose weight). e therapist should also bear in mind
that most adolescent patients come to treatment because of parental
pressure, and have a range of misgivings and varying degrees of reluctance
about engaging in treatment.
As we have seen in the previous chapter, CBT-E has been specially
designed to promote engagement, and it is usual at this stage for this to have
been achieved to some degree. Aer having engaged the patients, however,
the next issue is how to proceed. In Step One, it is crucial to identify the
clinical feature(s) that play(s) the most influential role in maintaining an
individual’s eating-disorder psychopathology. CBT-E theorists liken the
psychopathology of eating disorders to a “house of cards” (Fairburn, 2008)
that can be easily collapsed provided that the card holding up the structure
is identified and removed. In other words, the treatment does not need to
address every clinical feature the patient presents. Indeed, many clinical
features (e.g., concerns about food, eating, shape, and weight; compensatory
vomiting and laxative misuse; calorie-counting; and, in many cases,
excessive exercising) are at the second or third tier of the eating disorder
“house,” and it is probable that they will dissipate once the key clinical
features at the base of the structure have been removed. So, it is fundamental
for the therapist to identify the key clinical features that are maintaining the
eating disorder of patients, and to work together with them to eliminate
them.
In patients who are underweight, the main priority is to address their
dietary restriction (i.e., the undereating) and being underweight (Fairburn,
2008). ese two features need to be tackled promptly, as maintaining a
significantly low weight has important negative physical and psychosocial
consequences that in turn tend to maintain both undereating and the
overvaluation of shape and weight. As discussed above, these consequences
create vicious circles that obstruct change and lock a patient into the eating
disorder. For this reason, the main goal of Step One, besides engagement, is
to help patients see the need for weight regain. In line with the collaborative
nature of CBT-E, it is important that patients make this decision themselves
rather than having it imposed on them (Fairburn, 2008). e other goals in
such patients are helping them to increase their understanding of the eating
disorder, reduce their concerns about weight, and establish a pattern of
regular eating.
For patients who are not underweight, the main goals are to engage
them in the treatment, increase their understanding of their eating disorder,
reduce their concerns about weight, and establish a pattern of regular eating
(Fairburn, 2008). As they are not underweight, psychoeducation should not
include the effects of being underweight, unless they have had significant
weight loss and are undereating. Instead, it should be personalized to cover
the main expressions of their psychopathology, whether binge eating, self-
inducing vomiting, laxative misuse, or excessive exercising and so forth.
Parental involvement (discussed in detail in Chapter 6) should be
flexible and vary from case to case as appropriate. However, in most cases,
we tend to have joint sessions with parents aer the introduction of regular
eating (i.e., at the end of Session 2), and when patients have made a
definitive decision to tackle weight regain.
Table 4.1 shows the main procedures of Step One, and the appropriate
time frame for their implementation.
TABLE 4.1. Step One Procedures and When They Are Implemented
Week No. 1 2 3 4
Session No. 0 1 2 3 4 5 6 7
Assessment ( )
Creation of the formulation ( )
Self-monitoring
Collaborative weighing
Psychoeducation
Regular eating
Helping to think about the
changea
Involving parentsb

Only in patients who are underweight.

a

Session only with parents between Sessions 0 and 1.

b

Desirable Outcome
In the usual course of the events, patients become engaged in treatment and
change, and make the decision to actively address weight restoration (if they
are underweight). At the end of Step One, the therapist should be familiar
with the patient and her or his eating disorder and individual circumstances.
e patient should have reached an understanding of her or his eating
disorder and the processes maintaining it (as a result of the formulation and
real-time self-monitoring; see Table 4.1). Patients should also have become
less concerned about their weight (as a result of collaborative weighing) and
have better knowledge about the effects of undereating and being
underweight (starvation symptoms), and/or their individual eating-disorder
features (as a result of personalized education). Finally, they should have
adopted a stable and regular pattern of eating, and, if applicable, a reduction
of the frequency of binge eating and/or the early sense of fullness (as a result
of regular eating).
Negative outcomes are less frequent, but may include a patient deciding
not to address weight restoration. On rare occasions, patients may decide to
interrupt the treatment, that they dislike CBT-E, or refuse to engage in self-
monitoring and/or collaborative weighing. Others have difficulties in
complying with regular eating, or have a comorbidity or circumstance (e.g.,
severe clinical depression) that interferes with progress. In these cases, if it is
not possible to address the obstacles, the therapist should recommend
another type of treatment.

REVIEW SESSIONS: TAKING STOCK

“Taking Stock” is introduced in a review session aer the end of Step One in
all patients, and at flexible intervals (usually every 4 weeks) during Step Two
in patients who are underweight. ese sessions should be partially
dedicated to reviewing progress, identifying any emerging barriers to
change, modifying the formulation as needed, and planning the following 4
weeks. Besides these things to do, each review has two main purposes
(Fairburn, 2008):

1. To identify patients who are not doing well; this is important because
unless the cause of their poor response is identified and addressed,
they are unlikely to achieve a good outcome.
2. To adapt the treatment based on the evolving nature of the
psychopathology of the eating disorder and administer highly
individualized treatment.

STEP TWO: ADDRESSING THE

PSYCHOPATHOLOGY

is is the main body of CBT-E and has the aim of addressing both weight
restoration (in patients who are underweight) and at the same time the main
mechanisms that are maintaining the patient’s eating-disorder
psychopathology. Precisely how this is done varies considerably from patient
to patient.

Goals
Step Two has three main goals:

1. To address the remaining eating-disorder features (including low

weight in those who are underweight).
2. To address the mechanisms that are maintaining the individual’s
eating-disorder psychopathology.
3. To build skills for tackling setbacks.

Structure
In Step Two, the treatment becomes highly individualized, based on the
patient’s individual psychopathology (Fairburn, 2008). Patients who are
underweight are seen twice a week until the rate of weight regain is stable,
then once a week, while those who are not underweight are offered one
session a week. Every 4 weeks, underweight patients should have a review
session to assess progress and obstacles. In this stage, parental involvement
should be flexible and vary from case to case, as appropriate. We tend to
have joint sessions with parents every 4 weeks (i.e., aer about three sessions
for patients who are not underweight, and aer about six or seven sessions
for those who are). e structure of these joint sessions is similar to that
described in Step One (see Chapter 8), although their content is determined
by patient-specific problems.

Content
Step Two addresses the remaining eating-disorder features (i.e., dieting,
excessive exercising, vomiting, laxative misuse) by continuing to implement
the strategies and procedures introduced in Step One (i.e., weekly weighing,
regular eating, and other strategies for addressing purging and excessive
exercising, if needed), and introducing other strategies to deal with the
maintenance mechanisms at play (i.e., dieting and food avoidance, binge
analysis). In order to address the factors that are maintaining the individual’s
eating disorder, one or more of the following CBT-E modules should be
used (covered in detail in Chapters 11–15):

Underweight and Undereating (see Chapter 11).

Body Image (see Chapter 12).
Dietary Restraint (see Chapter 13).
Events, Moods, and Eating (see Chapter 14).
Setbacks and Mindsets (see Chapter 15).

e decision about which modules to use and the order in which to

employ them should take account of (1) their relative contribution to the
eating-disorder psychopathology, (2) the time it will take to address them,
and (3) the need for early progress. At this stage a decision about whether or
not to use the broad form of CBT-E is usually made. Toward the end of Step
Two the module dealing with “Setbacks and Mindsets” should be introduced
in preparation for further work on staying well in the future, which will be
the focus in the last stage of treatment.

STEP THREE: ENDING WELL

Step ree is the final stage in treatment, and is concerned with ending the
treatment well. Just as it is important that treatment starts well, it is
important that it ends properly. In routine clinical practice, it is not
uncommon for treatment simply to fizzle out. is is regrettable, as there are
important tasks to conduct in the final weeks of treatment and patients do
not benefit from them unless there is a formal ending.
 Goals
Step ree has two main goals:

1. To ensure that the changes made in treatment are maintained.

2. To minimize the risk of relapse.

In addition, patients’ concerns about ending treatment need to be

addressed, and certain treatment procedures need to be phased out.

Structure
Step ree consists of three appointments, held 2 weeks apart. e usual
session structure is retained throughout, but the sessions become
progressively more future oriented and less concerned with the present. In
the vast majority of cases, treatment can and should end on time, as
planned. ere are circumstances under which it is appropriate to offer more
treatment or to extend it, but in our experience, they are not common. As
long as patients have gotten to the point where the principal maintenance
mechanisms have been disrupted, and the “house of cards” is beginning to
collapse (i.e., the eating-disorder psychopathology is becoming less
persistent), they should continue to improve aer treatment has ended.
Under these circumstances, treatment can be wound up, and it is in the
patients’ interest that it does. Otherwise, patients (and therapists) tend to
ascribe continuing improvement to the ongoing therapy rather than the
progress that the patients have already made. In practice, this means that it
is acceptable to end treatment with patients still dieting to an extent,
perhaps binge eating and vomiting on occasion, and having residual
concerns about shape and weight.

Content
Step ree has four components:
 1. Addressing concerns about ending treatment.
2. Ensuring that progress is maintained.
3. Phasing out certain treatment procedures.
4. Minimizing the risk of relapse in the long term.

e strategies and procedures involved are described in detail in Chapter

16.

POSTTREATMENT REVIEW SESSIONS

Posttreatment review sessions 4, 12, and 20 weeks aer the end of treatment
are designed to reassess the patient’s state and need for further treatment,
review progress, revise the long-term maintenance plan, and, if necessary
(e.g., if the patient has not resumed regular periods), to weigh the pros and
cons of further weight gain.
 CHAPTER 5

Session 0

STRUCTURE AND CONTENT

e initial session in Step One (Session 0) is longer than the other sessions,
as it may last up to 90 minutes. e session has five main components:

1. Engaging the patient in treatment and change.

2. Assessing the problem.
3. Creating the formulation.
4. Informing the patient about CBT-E.
5. Introducing real-time self-monitoring.

ENGAGING THE PATIENT IN TREATMENT AND

CHANGE

As mentioned, a particular challenge when working with adolescent patients

is engaging them, as many, even if they have decided to begin Step One, may
have started treatment reluctantly and under parental pressure. Some
patients may have had previous negative experiences with directive and/or
coercive treatments. e initial session is especially important, as the patient
will evaluate the therapist just as much as the therapist will evaluate the
patient. e therapist should therefore pay attention to the patient’s manner
and select her or his words very carefully in order to build a constructive
therapeutic relationship and avoid putting the patient off.
It is standard CBT-E practice to avoid long preparatory motivational
work to engage patients in the treatment. Indeed, CBT-E is inherently
motivating and, perhaps most motivating of all, is the experience reported
by patients of being understood and achieving early change. As in CBT-E for
adults, we strive to achieve both of these goals from the outset. Reducing the
delay between the initial evaluation and the start of treatment is also
important, as it has been reported that a long waiting list has a significant
association with dropout rates (Byrne, Fursland, Allen, & Watson, 2011)
erapists can enhance adolescents’ involvement early on by adopting
an engaging interpersonal style (Fairburn, Cooper, Shafran, Bohn, Hawker,
et al., 2008):

Be empathetic and “engaging” in manner.

Ask the patient her or his given name, and give the patient your name.
Be professional but not intimidating or paternalistic.
Actively involve the patient.
Listen carefully to what the patient says.
Check that you have understood.
Invite questions.
Do not rush.
Be sensitive to ambivalence.
Stress that you will operate entirely on the patient’s behalf and not on
behalf of the parents.
Instill hope.

Clinical examples that describe a therapist adopting an engaging style

follow.
PATIENT: My parents are always criticizing me for my eating habits.
THERAPIST: (empathetic and engaging) I can imagine how you feel! I
understand that your parents can make you feel judged and in the
wrong. If you agree, however, in the coming weeks, together we will
try to get to the bottom of your eating problem and the things about
it that you view as positive, but also the problematic aspects that
certain behaviors have for you. en we can invite your parents to
discuss with us the best attitude they can have in certain situations.
PATIENT: I vomited every day last week, so I got rid of all the calories I
ate while bingeing.
THERAPIST: (professional but not intimidating) If you would be interested
and you don’t already know, I can give you some information on how
effective vomiting actually is in eliminating the calories you take in
. . . (actively involving the patient in the assessment process and in all
the treatment procedures) Would you agree to my explaining to you
the nature of the treatment? is is a treatment focused on the
present . . . the monitoring record is useful for . . . and so on.
PATIENT: I don’t know if I’ll be able to recover from my eating problem.
THERAPIST: (seeking to instill hope) I understand; any change can create
worry, but I don’t see any reason why you wouldn’t have a good
chance of succeeding. First though, I think we should try to improve
our understanding of your eating problem, and then together we will
see the specific changes that you need to make. We will start with
small changes that you will be able to make, and together we will
assess their effects. If they are positive, maybe you will change your
mind about the possibility of recovery.
PATIENT: Can you not tell my parents about me vomiting?
THERAPIST: (emphasizing that she or he is working on behalf of the patient
and not as an agent of the parents) ank you for trusting me and
telling me that you vomit aer lunch. I won’t tell your parents about
 this behavior if you don’t want me to. However, I believe that we
should carefully evaluate together not only the positive functions
that you perceive this behavior to have, but also what its negative
effects are, and whether or not it is serving to maintain your eating
problem. en, we can decide what to do together. If you conclude
that vomiting aer lunch is a problem, we can discuss which
strategies and procedures may help you tackle it. We can also
evaluate the pros and cons of enlisting your parents in helping you to
address this behavior.

ASSESSING THE PROBLEM

In our clinical practice, the therapist who actually delivers CBT-E proper is
not always the person who completed the preparation phase. For this
reason, in Session 0 we complete a second assessment to get information
directly from the patients about the nature of their problems. Inevitably, this
evaluation overlaps to some extent with that done in the pretreatment
interview, but it is our experience that the benefits in terms of involvement
derived from the new assessment far outweigh the possible disadvantages
associated with asking patients to repeat the details of their history. We
therefore recommend doing a second assessment even if the therapist is the
same person who led the assessment/preparation sessions. Indeed, the
second assessment should be “treatment focused” rather than diagnostic, so
it will differ somewhat from the one conducted previously (Fairburn,
Cooper, Shafran, Bohn, Hawker, et al., 2008). Hence, the second assessment
includes the following areas:

Present status of the eating disorder (over the last 28 days)—features

likely to be of relevance for the formulation.
Onset of the problem and prior treatment.
Personal history.
 Current circumstances.
Comorbidities.
Physical health.
Other matters of concern (to either party).

e primary focus should be on the present status of the patient’s eating

disorder, and what is maintaining it, focusing in particular and in detail on
the features that are likely to be of relevance to the formulation that have
been exhibited during the preceding 4 weeks (28 days). In adolescent
patients who are underweight, particular attention should be paid to the
clinical characteristics secondary to undereating and being underweight.
ese can be assessed by asking patients whether or not they have noted any
physical symptoms or psychological and interpersonal changes that only
occurred aer the weight loss. With the help of the therapist, many
adolescent patients who are underweight report that they actually feel cold
and experience an early feeling of fullness when they eat, and that before
their weight loss they had a sunny disposition, while now they have
recurring thoughts about food, frequent changes in mood, irritability, and a
lack of interest in being around other people.

CREATING THE FORMULATION

What Is a Formulation?
e personal formulation is a visual representation (i.e., a diagram) of the
processes that seem to be maintaining an individual patient’s eating disorder
(Fairburn, Cooper, Shafran, Bohn, Hawker, et al., 2008).

Purpose
e creation of a formulation has the following aims:
 It promotes patients’ engagement in the treatment, because it improves
their understanding of their eating disorder.
It helps patients to understand the self-perpetuating nature of the
eating disorder (i.e., being trapped in a series of interactive
maintenance processes)—information generally appreciated by the
patients because it explains their difficulties in enacting change.
It helps patients to distance themselves from the problem, to take a step
back, taking a “decentralized” stance, and to be interested and
intrigued by their eating disorder and the processes maintaining it.
It helps patient and therapist to identify the features and maintenance
mechanisms to address, and thereby identify the goals of the treatment
(the formulation acts as a “road map” for CBT-E).
It helps patients feel in control, because it promotes understanding of
what will be addressed by the treatment.

It is important to emphasize that the formulation does not include the

potential cause of the onset of the eating disorder. If the patients (and/or
their parents) are perplexed by the fact that the treatment does not seem to
address the “root” of the problem, we explain that this is not generally
necessary for recovery. However, we also add that later in treatment the
origins of the problem will be discussed to prevent relapse, when the
principal processes that are maintaining the eating disorder have been
interrupted.

How to Create a Formulation

e individualized formulation must be created from scratch, even though a
provisional one was drawn up during the assessment/preparation phase, to
explain the nature and the aims of CBT-E. e composite transdiagnostic
CBT-E formulation (see Figure 1.3 in Chapter 1) should be used by the
therapist as a template for construction of a personalized formulation that
matches an individual patient’s eating disorder. Figures 5.1 and 5.2 show
example formulations typical of anorexia nervosa restricting type, and
bulimia nervosa, respectively, but each patient is different. Nevertheless, the
more familiar the therapist becomes with the formulation template, the
easier it will be to create a personalized formulation based on the
psychopathological features and maintenance mechanisms of the individual
patient.

FIGURE 5.1. Representative formulation of (“restricting”) anorexia nervosa. From Cognitive

Behavior erapy and Eating Disorders by Christopher G. Fairburn. Copyright © 2008 e Guilford
Press.

FIGURE 5.2. Representative formulation of bulimia nervosa. From Cognitive Behavior erapy and
Eating Disorders by Christopher G. Fairburn. Copyright © 2008 e Guilford Press.
 e creation of the personal formulation, which we usually refer to as a
“diagram,” must be done well, and it is a skill that develops with practice.
e personal formulation should be drawn slowly, step-by-step, writing
legibly on a sheet of paper placed between the therapist and the patient. In
order to avoid giving the impression that this procedure is prescriptive, the
patient and therapist should sit together around the corner of the desk (if
the desk is rectangular), rather than across from each other. While the
therapist leads the exercise, she or he should be careful to keep the patient
actively involved.
e initial formulation should include only the eating-disorder features
and major maintenance processes that appear to have been operating in the
previous 28 days—take care not to include too many things, otherwise you
risk confusing the patient. Indeed, as mentioned, this formulation is to be
considered provisional, and will be confirmed and/or modified as the
treatment progresses and information about other possible maintenance
mechanisms is collected. It is better to start by including something that the
patient wants to change (e.g., episodes of binge eating, feeling cold, sleeping
badly, not having friends), and then gradually moving on to other things.
Note that the terms used by patients can be written down verbatim on the
formulation if they are appropriate.

Underweight Patients
In adolescents who are underweight, the therapist should follow the general
strategy described above, starting with some of the effects of being
underweight that the patient perceives as negative (e.g., feeling cold, social
withdrawal). en, the therapist should ask the patient about which
behavior(s) resulted in her or his low weight (e.g., dieting, excessive
exercising). e next step is to ask about the reason(s) for dieting and other
weight-control behaviors, and to jointly assess their relationship to the
patient’s overvaluation of shape and weight. Finally, the therapist should
highlight the likely contribution of symptoms secondary to being
underweight that emerged during the assessment as maintaining the
patient’s eating disorder. Usually, the most pertinent are as follows:

• Preoccupation with food and eating. is is a consequence of dietary

restriction, low weight, and associated malnutrition. Continuing to think
about food or developing interests that were absent before weight loss, such
as cooking for others, collecting recipes, and watching TV shows about
food, are the consequences of a prolonged period of food deprivation.

• Social withdrawal and loss of previous interests. ese secondary effects

of being underweight prevent patients from exposing themselves to
experiences that can help diminish the importance they attribute to the
control of shape, weight, and eating. Patients oen fail to recognize how
unusual their way of behaving and lifestyle are as a result of being
underweight.

• Indecisiveness. is effect makes it difficult for patients to decide

whether or not to try to enact change, and explains the common tendency to
procrastinate observed in underweight patients with eating disorders.

• Heightened need for routine and predictability. is effect also interferes
with change, which may be perceived as “destabilizing” or threatening.

• Persistent hunger. is effect is not always present, but, if it is, it

contributes to accentuating concerns about eating. Indeed, some patients
interpret hunger as proof of their “greed,” and this leads them to increase
their attention to control over eating. In other patients, however, hunger and
other symptoms associated with being underweight (e.g., weakness,
dizziness, feeling cold) are positively interpreted as evidence of success in
controlling eating.

• Heightened feelings of fullness. is makes it difficult to increase the

amount eaten, and may induce patients to interrupt their meal, thinking
they have eaten too much.
 • Difficulty concentrating. is effect can erode performance in other
domains of life (e.g., at school) and, by negatively affecting patients’ general
self-evaluation, it accentuates their tendency to use control over eating,
shape, and weight as a principal means of judging themselves.

Once the formulation has been created, the therapist should discuss its
implications for treatment. ese are especially important in underweight
patients. ere are five points to cover:

1. Some of the features that the patient is finding aversive or impairing are
a direct result of being significantly underweight—for example (Fairburn,
Cooper, Shafran, Bohn, Hawker, et al., 2008):
Preoccupation with food and eating.
Being inflexible, having to stick to routines, and/or an inability to be
spontaneous.
Having difficulty making decisions.
Not wanting to socialize.
Having difficulty concentrating.
Sleeping poorly.
Feeling full quickly.
Feeling very cold.
Feeling physically weak.

2. Oen patients assume that their present state reflects their personality.
Patients are oen convinced that their current condition (e.g., being socially
isolated, inflexible, and/or insecure) is just who they are. Hence, it is
important to emphasize that their true personality is in fact masked by the
effects of being underweight, and that they will only be able to find out who
they truly are when their weight recovers. e therapist could try to interest
the patients in this effect by describing how other patients have regained
their “true” personality once they have regained weight.
VIGNETTE
 e patient is a 14-year-old girl who plays on a volleyball team. During the assessment, she
reports having been dissatisfied with the shape of her stomach from the age of 11, as her belly at
that age “stuck out,” and she was repeatedly teased by her teammates. Aer an attack of acute
gastroenteritis she lost some weight, and, as she felt good and liked the shape of her stomach
more, she started to adopt a strict diet that caused a weight loss of about 30 pounds in 3 months,
eventually reaching a severely low weight. However, despite feeling more in control and failing to
see low weight as a problem, she reported some negative changes in her personality as a result of
the weight loss, as she became more apathetic, sad, irritable, and isolated, and she also had less
desire to train and spend time with the other girls on her team.

3. Some of the physical consequences of being so underweight are

dangerous and/or risky causing long-term damage to health—for example,
cardiovascular effects and effects on the bones. Adolescent patients are
seldom worried about the physical consequences of being underweight—
however, if they are, the therapist should identify those that are of most
relevance and concern to the individual.

4. Some of the effects of being underweight maintain the eating disorder.

As mentioned, the effects of being underweight intensify the overvaluation
of shape and weight and the need for control over eating. It is important to
review these effects with underweight patients. An example of how the
therapist may discuss with an adolescent patient how the effects of being
underweight act to maintain the eating disorder (see Figure 5.3 for the
patient’s formulation) follows:
FIGURE 5.3. Representative formulation of an underweight adolescent patient with an eating
disorder, highlighting how the effects of significantly low weight maintain the eating problem. 1,
significant low weight and strict dieting are not seen as a problem but as an achievement; 2, feeling
full in interpreted as having eaten too much and prompts intensification of dieting; 3, food concerns
make the dieting even more rigid; 4, social withdrawal prevents experiences that can help reduce the
importance attributed to shape, weight, and eating control.

THERAPIST: If you think about it, it’s a natural process to be constantly

preoccupied with food and eating if you aren’t getting enough to eat.
It’s a mechanism that helps us to survive by enabling us to primarily
focus our attention on the search for food. It’s like being deprived of
oxygen . . . If you were deprived of oxygen, where would your
attention be focused?
PATIENT: On trying to get air.
THERAPIST: Of course, all of your mental energy would be focused on the
search for air.
PATIENT: Yes, I understand, but I’m afraid to eat, as I want to lose weight
. . . I feel in control only when I control my eating, my stomach is
flat, and my weight is under 95 pounds.
THERAPIST: I understand, but does your preoccupation with food and
eating further influence your eating?
PATIENT: Hmm . . . Yes, usually when I have these concerns, I skip meals.
THERAPIST: So, you are telling me that worrying about food makes you
eat less. Would you agree to us putting an arrow in the formulation
that goes from preoccupation with “food concerns” to “strict
dieting”?
PATIENT: Yes, that seems right.
THERAPIST: You have also told me that in the last 4 weeks you have been
feeling full aer eating only a little bit of food. As I explained to you,
this is a symptom of malnutrition due to a reduction in gastric
emptying that occurs in people who are underweight.
PATIENT: Yes, I remember.
THERAPIST: Good. For you, what is the effect of feeling an early sense of
fullness?
PATIENT: When I feel full, I feel really bad, and immediately stop eating.
THERAPIST: And what do you think at such moments?
PATIENT: I think I ate too much.
THERAPIST: OK, so when you feel full, you stop eating. Do you agree to
us putting an arrow between “feeling full” and “strict dieting” in your
formulation?
PATIENT: Yes, I agree. If I feel full, I eat less and less.
THERAPIST: And what about your social life? You told me that before
losing weight you were a happy person with a lot of friends.
PATIENT: Yes, that’s true.
THERAPIST: And now?
PATIENT: I’m always at home alone.
THERAPIST: As I explained to you, one effect of being underweight is
losing interest in other people and social withdrawal. Do you not
think that this effect of being underweight might be maintaining the
 excessive importance that you ascribe to the control of eating, shape,
and weight in evaluating yourself?
PATIENT: I don’t know, maybe . . . Why?
THERAPIST: What do you think?
PATIENT: Umm . . . maybe because I no longer have any interests besides
food, eating, and weight?
THERAPIST: In a certain sense, yes. Indeed, social isolation does not allow
you to do some things that might help you to develop other areas of
self-evaluation.
PATIENT: Yes, that might be true.
THERAPIST: Shall we put an arrow from “social withdrawal” to “excessive
importance of shape, weight, and eating control in my self-
evaluation”?
PATIENT: Yes, let’s do that.
THERAPIST: Finally, I would like to discuss why, despite all of the negative
effects of being underweight, you seem to not see low weight as a
problem.
PATIENT: Because I like being skinny.
THERAPIST: Do you think that this might be related to the fact that you
tend to evaluate yourself on the control you have on your weight,
body shape, and nutrition?
PATIENT: I don’t know . . . Yes, I think so.
THERAPIST: Can we put an arrow that goes from ”significant low weight”
to “excessive importance of shape, weight, and eating control in my
self-evaluation”?
PATIENT: OK.

5. Almost all of the effects of being underweight will resolve if the patient
regains weight to a low but healthy level. At the end of this discussion, it is
our practice to provide underweight patients with a handout containing a
detailed description of the Minnesota Starvation Experiment (Dalle Grave et
al., 2011; Garner, 1977; Keys, Brozek, Henschel, Mickelsen, & Taylor, 1950),
including the most extensive and thoughtful description of the symptoms
associated with dietary restrictions and being underweight that we have (see
Appendix B). We invite patients to read the handout for homework and
check the symptoms they developed aer they lost weight, adding them to
their personal formulation (under “significant low weight”). We also use the
Starvation Symptom Inventory (SSI), a validated self-report questionnaire
that may provide important clinical information regarding starvation
symptoms and their changes during treatment in underweight patients with
an eating disorder (Calugi, Miniati, et al., 2017; see Appendix C).

Not-Underweight Patients with Binge Eating

In adolescents who are not underweight, following the general strategy
described above, the therapist should start with binge eating, asking the
patients about what happens aer they binge-eat, and illustrating the cycle
of binge eating and subsequent vomiting or other compensatory behaviors
(if any). e therapist should then move on to discussing the association
between binge eating and extreme and inflexible dietary rules and/or
adverse events and moods. e next step is to ask the patients about the
reasons behind their dietary rules, and to assess their relationship to the
overvaluation of shape and weight. Finally, the therapist should help the
patients to see that their binge eating acts to reinforce their concerns about
their control over eating, weight, and shape.
An illustrative Session 0 transcript that highlights how the personalized
formulation of a not-underweight patient with recurrent episodes of binge
eating and self-induced vomiting is constructed (see Figure 5.4) follows:
FIGURE 5.4. Representative formulation of a not-underweight patient with an eating disorder.

THERAPIST: First of all, I’d like to thank you for the information you have
shared with me. I imagine it must have been difficult for you and I
appreciate your effort. Now, if you agree, I would like us to analyze
what is maintaining your eating problem.
PATIENT: OK.
THERAPIST: (placing the formulation sheet on the table between them) Well
. . . tell me whether you agree or disagree with what I write and let
me know at any time if there is something that it is not clear.
PATIENT: OK.
THERAPIST: So . . . I understand that you are very down at the moment
because you feel you do not have control of your eating.
PATIENT: Yes, I feel very sad and guilty because I binge every day.
THERAPIST: OK. So . . . we could start with your episodes of binge eating.
PATIENT: OK.
THERAPIST: (writing “binges” on the sheet) It seems to me that these
episodes make you feel very bad. Why?
PATIENT: Umm . . . because I have no control over my eating, and I feel
really bad about my weight and how I look.
THERAPIST: Does this lack of control over eating increase your concerns
about your body shape and weight?
PATIENT: Yes, of course, very much so.
THERAPIST: (writing “feel really bad about my weight and how I look” at
the top of the sheet, and drawing an arrow to it from “binges”) And
how do you manage these concerns aer an episode of bingeing?
PATIENT: I make myself sick to get rid of all the calories I have eaten.
THERAPIST: (writing “making myself sick” and tracing an arrow to it from
“binges”) I understand. However, maybe you should know that when
you vomit you only eliminate some of the calories you have
introduced.
PATIENT: Are you sure? It seems to me that everything comes up.
THERAPIST: Yes, I am sure. is has been confirmed by some experiments
on volunteers who measured the calories ingested during an episode
of binge eating and then those present in the vomit they self-induced
immediately aer they had finished eating. Another thing that could
help you to understand that vomiting does not eliminate all the
calories you eat is that, despite the fact that you eat very little outside
of the episodes of binge eating, your body weight remains stable—
this means that you are absorbing a part of the food you eat during
the binge-eating episodes, even if you self-induce vomiting
aerward.
PATIENT: I agree that that seems logical.
THERAPIST: On the other hand, the belief that by self-inducing vomiting
you can eliminate all calories you take in makes it easier for you to
lose control of your eating and therefore binge. Do you agree?
PATIENT: Yes, I agree, and I understand why I am not losing weight.
THERAPIST: (pointing out the arrow from “making myself sick” to ”binges”)
Aer having vomited, do you still feel really bad about your weight
and how you look?
PATIENT: For a while, no. I only feel exhausted. But aer a couple of
hours, the preoccupation returns.
THERAPIST: And how do you manage this feeling?
PATIENT: I usually skip the next meal or otherwise try to restrict my diet.
THERAPIST: (writing “strict dieting” under “feel really bad about my weight
and how I look” and an arrow that joins these two characteristics of the
patient’s eating disorder) Would you say that this is correct?
PATIENT: (looking at the diagram) Yes, that’s right! It’s me!
THERAPIST: It seems to me, however, that the attempts you make to
restrict your diet are later interrupted by a new episode of binge
eating.
PATIENT: Yes, that’s true.
THERAPIST: (connecting “strict dieting” and “binges” with an arrow) is
typically occurs through two main mechanisms. e first occurs
when people adopt extreme and inflexible dietary rules. We describe
dietary rules as “extreme” when there are a lot of them and it
requires continuous attention to stick to them. is means that it is
very easy to break these rules when you get distracted or have
negative emotions. “Rigid” means that even the slightest deviation is
interpreted as a total loss of control. is type of “all-or-nothing”
thinking usually leads to people abandoning any attempt at eating
control and consequently binge-eat.
PATIENT: at is exactly what happens to me—in particular, when my
mood changes.
THERAPIST: (writing “events and associated mood changes” and then a
dotted arrow between it and ”binges”) OK. e second mechanism
operates when people fast or skip meals for a certain period of time.
In these cases, there is inevitably an increase in the biological
pressure to eat that becomes so strong that it stimulates binge eating.
 PATIENT: at sounds right.

Aer having created the formulation, the therapist should discuss its
implications. e main point to emphasize is that to overcome the eating
disorder, the patients will have to address not only the things that they
would like to change (e.g., binge-eating episodes) but also the processes that
are responsible for their maintenance (the vicious circles). us, a patient
such as the one described above, who has binge-eating episodes followed by
self-induced vomiting, will have to address the strict dieting and concerns
about body weight and shape. Indeed, if these maintenance processes are
not disrupted, the probability of relapse will be high, even if the binge-eating
episodes are interrupted. e therapist could say to the patient that the
diagram shows the main mechanisms that are maintaining her eating
disorder, and if they are changed, recovery from the eating disorder will be a
probable outcome, but it will be necessary to address all of these
mechanisms to prevent relapse. e therapist should then describe CBT-E
and its goals, referring to the personal formulation in order to promote
engagement. e therapist should suggest to the patient to focus mainly on
her eating habits, and then move on to the other features of the eating
disorder shown on the diagram—for example, concerns about weight and
shape.
As with patients who are underweight, the therapist should give patients
a copy of their formulation and ask them to reflect on it and make any
modifications they feel relevant before the next session. e diagram will be
in front of the patient and therapist at each session.

Patients with Other Eating-Disorder Presentations

Many adolescent patients receive the diagnosis of atypical anorexia nervosa
because they meet all the criteria for anorexia nervosa except that their
weight is still within or above the normal range, despite significant weight
loss. Others report recurrent purging behavior to influence weight or shape
(e.g., self-induced vomiting and misuse of laxatives, diuretics, enemas, or
other medications) in the absence of binge eating, a condition that has been
termed “purging disorder.” In these patients, the procedure for creating the
formulation is similar to that described above for patients who binge-eat. In
these cases, too, it is advisable to start with the features that the patients
want to change (e.g., self-induced vomiting aer eating in those who use
these behaviors, or feeling cold in those who have lost a large amount of
weight) and explore what is reinforcing them, as described above.

INFORMING THE PATIENT ABOUT CBT-E

It is our practice to explain the treatment in detail to patients. Various topics

need to be covered:

• Review of what the treatment will involve. We usually repeat most of the
information given to the patient during the assessment/preparation sessions.
We tell patients the name, nature, and style of the treatment, as well as the
number, frequency, and length of sessions. We also emphasize the
importance of punctuality, attendance, and completing the treatment.

• Focus of treatment. Patients are informed that the treatment will focus
on the processes maintaining their eating disorder.

• Importance of in-session weighing. We inform adolescent patients that a

key procedure of the treatment called “collaborative in-session weighing”
will begin in the next session. We explain that in-session weighing is a vital
procedure that markedly reduces concerns about weight and yields reliable
information about any changes in weight and how to interpret the changes.
Occasionally, patients may be reluctant to get weighed, but in the context of
an “engaging” initial session and full explanation of the rationale, we find
that refusal is generally not a problem.
 • e need to make treatment a priority. We emphasize that to overcome
the eating disorder it is essential to make the treatment a priority (i.e., asking
“Is there anything else as important?”) and to make the most of the
opportunity.

• CBT-E is about change. For this reason, completing between-session

“homework” tasks is essential.

• Instilling “ownership,” enthusiasm, and hope. We stress that treatment is

“owned” by the patients, not their parents or the therapist. We also explain
that it is fundamental that patients have a full understanding of what they
are doing and why throughout the treatment, and that if they do not
understand something, they should ask about it. ey should also be
reminded to inform the therapist if they disagree with anything. In addition,
we seek to maximize enthusiasm and hope. is involves conveying the fact
that the scientific evidence to date indicates that, with treatment, adolescents
can achieve a complete remission from the eating disorder. We also suggest
to patients that the more quickly they recover from their eating disorder, the
less likely they are to experience the adverse effects of the disorder, either
currently or in the future.

• Practicalities. We do our best to accommodate patients’ school

commitments, and to acknowledge the difficulties they face traveling. By
paying attention to these practical issues, therapists can demonstrate that
they are concerned about patients’ overall welfare, and not just the state of
the eating disorder. is not only helps to engage patients but also brings to
the therapist’s attention any issues that might otherwise cause patients to
drop out. We give patients the clinic’s phone number in case they need to
contact us, and, with the permission of the parents, we ask for their phone
number (a cell phone is ideal) and e-mail address, in case we need to contact
them.
 • Patients’ questions and concerns. We encourage patients to ask
questions during sessions and to report any concerns they have. erapists
should repeatedly check that patients are “on board.” Common examples of
questions at this stage, alongside possible responses, follow:

PATIENT: Do I really need treatment?

THERAPIST: You concluded with Dr. during the
assessment that you have an eating problem that is interfering with
your life. For example, it makes it difficult for you/does not allow you
to eat with your friends, join the coming school trip, or to take part
in your favorite sports activities [as applicable]. We also concluded
that several things/features (specifies the particular ones) tend to keep
it operating and/or make it worse. e treatment will help you to
identify and change these features. is should improve/remove
.
PATIENT: Can I overcome the eating problem on my own?
THERAPIST: We know that is difficult to overcome eating problems
without professional help because there are so many things/features
that keep it in place. With treatment, however, we will help you to
become an expert at understanding your eating problem and at
finding ways to overcome it.
PATIENT: I’m afraid of getting fat . . . I do not want to gain weight.
THERAPIST: If you did not have this fear, you probably would not be here.
During the treatment we will spend a lot of time trying to
understand your concerns about your eating, shape, and weight, and
helping you to make changes that will ensure that you control your
weight and eat in a healthy way . . . I also want to reassure you that in
this treatment you’ll never be forced to do anything that you do not
want to do.
PATIENT: Do you think I will get better?
 THERAPIST: On the basis of the results we have had with this treatment, I
can say that you have a very good chance of benefiting. I suggest you
make the treatment a priority, because the more effort you put into
it, the more chance you will have of recovering.

INTRODUCING REAL-TIME SELF-MONITORING

Real-time self-monitoring is a key procedure of CBT-E. It consists of

recording relevant behaviors, thoughts, emotions, and events “in the
moment” they are experienced on a specific monitoring record. It is
introduced in Session 0, aer giving the patients a CBT-E “orientation”; its
use is refined in Session 1, and should be used by the patients until the
beginning of Step ree.

Rationale
ere are three main reasons why the real-time self-monitoring procedure is
employed in CBT-E:

1. It distances patients from their immediate behavior and helps them

see that change is possible.
2. It highlights key behaviors, thoughts, and feelings, and the context in
which they occur; patients can see themselves enacting the
formulation in real time.
3. It opens up new avenues for change.

It is essential that the self-monitoring be carried out in “real time,” as this

minimizes problems with recall and enables patients to make changes there
and then. It is important to stress that the monitoring record is not a “food
diary,” which is not generally written in real time, and is mainly focused on
the food eaten by the patients, rather than on their behaviors, thoughts, and
feelings.
 Procedure
e self-monitoring procedure is implemented across CBT-E in four main
steps:

1. Real-time self-monitoring is introduced at the end of Session 0.

2. A detailed review of the patient’s self-monitoring record is conducted
at the end of Session 1, focusing mainly on the process of recording.
3. In the following sessions, the content of the patient’s monitoring
records is reviewed, although an eye is still kept on the quality of the
self-monitoring, which is reinforced if needed.
4. Self-monitoring is phased out toward the end of the treatment.

Toward the end of Session 0, the therapist introduces the topic of self-
monitoring (the first step in the procedure), describing:

e rationale (see the three points described in “Rationale” above).

How to record, reviewing a blank monitoring record.
Discussing the practicalities
How to do it given the circumstances.
When to start.
Likely problems.
Addressing any concerns.
Explaining that each session will open with a review of the latest
monitoring record.

Indeed, the last monitoring records are reviewed at the beginning of

each session, and the therapist then files them for reference (if needed). As
long as the therapist takes self-monitoring seriously and dedicates time to it,
adherence on the part of the patients is generally very good. We usually
introduce the procedure by saying something like (Fairburn, Cooper,
Shafran, Bohn, Hawker, et al., 2008):
 “Self-monitoring is central to treatment. It is as important as attending
our sessions. It is your tool for becoming an expert on your eating
problem and overcoming it. It has two main purposes.
“First, it will help you to identify precisely what is happening on a
moment-to-moment and day-to-day basis. We need to know exactly
what you are doing, thinking, and feeling at the very moment that you
are doing, thinking, and feeling things. We need to know the details, and
then we can work out how you can make changes and thereby break
down your eating problem. So, you need to start to notice and record
key things of importance. Self-monitoring is designed to help you do
this.
“Second, self-monitoring will help you achieve change. By becoming
aware of what you are doing, thinking, and feeling at the very time that
things are happening, you will learn that you have choices, and that some
things that you thought were automatic and outside your control
(perhaps you weren’t even aware of them) can be changed with attention,
effort, and practice. But you can only achieve this with accurate real-
time self-monitoring. Of course, simply recalling how things were some
hours ago will not work.
“I should forewarn you that self-monitoring will probably have a
short-term negative effect. It will initially make you more preoccupied
with your eating, but this will only last a week or so and is worth it. Your
self-monitoring will be an essential procedure in our work and in all our
sessions we will review your monitoring records together.”

e therapist should emphasize that the patients should use their

monitoring record to report not only eating but also the associated thoughts,
feelings, and behaviors. Moreover, the therapist should also emphasize that
recording in real time helps bring about change.
e monitoring record (see Figure 5.5) used as part of CBT-E is simple
to complete, but real-time recording is difficult and requires a lot of effort.
However, it is essential for the reasons described above.
Day Date

Time Food and drink consumed Place * V/L/E Context and comments

FIGURE 5.5. A blank monitoring record. V, vomiting; L, laxative misuse; E, exercise. “E” was added
because excessive exercising is very common in adolescent patients with eating disorders. Reproduced
with permission from Online Training Program in CBT-E, CREDO Oxford, 2017.
From Cognitive Behavior erapy for Adolescents with Eating Disorders by Riccardo Dalle Grave and
Simona Calugi. Copyright © 2020 e Guilford Press. Permission to photocopy this material is
granted to purchasers of this book for personal use or use with patients (see copyright page for
details). Purchasers can download enlarged versions of this material (see the box at the end of the
table of contents).

Exactly what is recorded will evolve during treatment, and some patients
will need to make use of additional columns (e.g., to record alcohol intake or
body checking). However, in the early phase of the treatment, the emphasis
is mainly on the patients’ eating habits. To facilitate the description of how
to use the monitoring record, we highlight the following aspects using an
example created for this purpose (see Figure 5.6):

e function of the various columns.

How to record foods and liquids using simple descriptions.
How to use asterisks (to indicate every single food intake accompanied
by the sensation of loss of control), brackets (to delineate the main
meals, not the snacks or other episodes of food intake), and the letters
“V/L/E” to indicate every episode of self-induced vomiting, laxative
misuse, and excessive exercising, respectively.
How to use the “Context and Comments” column. In the initial stages
of CBT-E, this column is usually used to record the events that have
influenced eating and the development of concerns about eating,
shape, and weight. In addition, each time patients weigh themselves,
they should report their weight in this column.
e level of detail required. Patients are asked to provide a simple and
nondetailed description of the quantity of food and liquid consumed.
ey should not weigh the food or report its calorie content.
e monitoring record need not be neat, and patients should not worry
about making spelling mistakes. It should be clarified that for us it is
more important that they record in real time and never forget to bring
the monitoring record to the session.
FIGURE 5.6. An example of a completed monitoring record. V, vomiting; L, laxative misuse; E,
exercise.

How to record in social situations (e.g., at school, at the home of friends

or relatives, at the restaurant) should also be discussed. In this case, we
suggest that patients use a notebook or smartphone to write down/voice
record what they ate, how they felt, and so on, and then later copy those
notes onto their monitoring record once they get home. For the record, we
have yet to encounter any situation where real-time recording is not
possible.
We advise all of the therapists who start practicing CBT-E to use the
procedure of real-time self-monitoring themselves for a week, so that they
understand the difficulties the patients may face. ey can then share any
strategies they devise for overcoming such difficulties with the patients.
Patients who binge-eat may be tempted to omit episodes from their
monitoring record due to the shame and embarrassment that these
behaviors cause them. is is something that therefore needs to be discussed
with such patients beforehand. e point to stress is that the treatment has
the best chance of success if the patient and the therapist are aware of the
problem in its entirety. Furthermore, we tell patients that we will never judge
them on their eating behavior. It is always advisable to ask patients whether
they have any questions or concerns about the prospect of starting real-time
self-monitoring. e most common questions and doubts raised by patients
and a brief discussion of the answers that the therapist can give follow:

• “May I use an app to monitor my eating?” is question oen occurs

when treating adolescents, since they are comfortable with the use of
smartphone apps for a variety of purposes. However, we discourage the use
of currently available apps, as our experience over many years indicates that
CBT-E monitoring records work well. ey are large enough to allow the
detailed recording of behaviors, thoughts, and feelings, and they are capable
of being used flexibly, whereas apps and notebooks tend to restrict the
quantity and quality of the information that can be recorded, and, as a
result, are oen used simply as a food diary. Furthermore, our clinical
experience suggests that adolescents are used to producing handwritten
work (e.g., for school) and so do not find completing monitoring records
such an alien task. at being said, we think that an app designed to mirror
or closely resemble the essential features of CBT-E monitoring records
might be an attractive option for a subgroup of adolescents.

• “Can I let my parents see my monitoring records?” We discourage

patients from letting parents see their monitoring records, as this might
influence what patients write down. We tell them that they should consider
the monitoring record as a private document that they will discuss only with
their therapist.

• “Do I have to use the monitoring record during meals?” Patients are
encouraged to use the monitoring records in real time during meals.
Recording in real time oen helps patients to take a decentered stance from
thoughts and feelings arising during meals, and/or to interrupt some forms
of automatic behavior (e.g., eating too slowly or too fast, hiding foods).

• “I think I’ll be too embarrassed or ashamed to write down certain

behaviors and feelings.” e therapist might respond as follows: “I will never
judge your behaviors and feelings, but instead I will try to help you find
effective strategies for tackling them. For this to happen, however, I need
you to be honest and open about your problems.”

• “It will make me even more preoccupied with eating than I am already.”
In such cases, and those in which the patients express concern that self-
monitoring will prompt them to restrict their eating even further, the
therapist could say that this may be true—writing down what you eat can
lead to an increase in preoccupation with eating—but these are constructive
concerns because they will help us to become more aware of the problematic
eating behaviors and the processes that are maintaining them. It is also
useful to emphasize that self-monitoring is a necessary step on the road to
their becoming an expert on their eating disorder. e patients should
understand that, aer a week or two, such concerns about eating usually
vanish.

To conclude this part of Session 0, we give the patients about 20 blank

monitoring records, together with written instructions explaining how to
complete them (see Table 5.1). With younger adolescents (i.e., under 15
years of age), we review the written instructions point-by-point and ask for
feedback to be sure they have understood what they have been asked to do.
We suggest that patients start recording the following morning.
TABLE 5.1. Instructions for Self-Monitoring
During treatment, it is important that you record everything that you eat or drink, and what is
going on at the time. We call this “self-monitoring.” Its purpose is twofold: first, it provides a
detailed picture of how you eat, thereby bringing to your attention and that of your therapist
the exact nature of your eating problem; and second, by making you more aware of what
you are doing at the very time that you are doing it, self-monitoring helps you change
behavior that may previously have seemed automatic and beyond your control. Accurate
“real-time” self-monitoring is central to treatment. It will help you change.
At first, writing down everything that you eat may be irritating and inconvenient, but soon it
will become second nature and of obvious value. We have yet to encounter anyone whose
lifestyle made it truly impossible to monitor. Regard it as a challenge.
Look at the sample monitoring record to see how to monitor. A new record (or records)
should be started each day.
The first column is for noting the time when you eat or drink anything, and the second is
for recording the nature of the food and drink consumed. Calories should not be recorded:
instead, you should write down a simple (nontechnical) description of what you ate or
drank. Each item should be written down as soon as possible after it was consumed.
Recalling what you ate or drank some hours afterward will not work since it will not help
you change your behavior at the time. Obviously, if you are to record in this way, you will
need to carry your monitoring sheets with you. It does not matter if your records become
messy or if the writing or spelling is not good. The important thing is that you record
everything you eat or drink, as soon as possible afterward.
Episodes of eating that you view as meals should be identified with brackets. Snacks and
other episodes of eating should not be bracketed.
The third column should specify where the food or drink was consumed. If this was in your
home, the room should be specified.
Asterisks should be placed in the fourth column adjacent to any episodes of eating or
drinking that you felt (at the time) were excessive. This is your judgment, regardless of
what anyone else might think. It is essential to record all the food that you eat during
“binges.”
The fifth column is for recording when you vomit (write “V”), take laxatives (write “L” and
the number taken), or you exercise (write “E”). If you exercise, you should also report in
the “Context and Comments” column the type, duration, and why you exercised.
The last column will be used in various ways during treatment. For the moment, it should
be used as a diary to record events and feelings that have influenced your eating—for
example, if an argument precipitated a binge or led you to not eat, you should note that
down. Try to write a brief comment every time you eat, recording your thoughts and
feelings about what you ate. You may want to record other important events or
circumstances in this column, even if they had no effect on your eating. The last column
should also be used to record your weight (and your thoughts about it) each time that you
weigh yourself.
Every treatment session will include a detailed review of your latest monitoring sheets. You
must therefore remember to bring them with you!
Note. Adapted from Cognitive Behavior Therapy and Eating Disorders by Christopher G.
Fairburn. Copyright © 2008 The Guilford Press. Adapted by permission.
From Cognitive Behavior erapy for Adolescents with Eating Disorders by Riccardo Dalle Grave and
Simona Calugi. Copyright © 2020 e Guilford Press. Permission to photocopy this material is
granted to purchasers of this book for personal use or use with patients (see copyright page for
details). Purchasers can download enlarged versions of this material (see the box at the end of the
table of contents).

Educating Patients about Their Eating Disorder

Rationale

e provision of personalized education has four main aims:

1. It corrects misunderstandings, some of which maintain eating

disorders. Most adolescent patients have been misinformed about dieting
and eating disorders, and they are poorly informed about some other topics,
like the effects of vomiting and laxative misuse on calorie absorption, and
this misinformation may contribute to the maintenance of the disorder (e.g.,
misusing laxatives or vomiting in the belief that they will eliminate all the
calories ingested).

2. It provides reliable information about eating disorders and the processes

that maintain them and thereby reinforces the formulation. Information about
the processes that are maintaining patients’ eating disorders help them to
better understand their formulation and the rationale for addressing specific
features of their eating disorder.

3. It reduces stigma. Education helps patients understand that eating

disorders are not self-inflicted, and that suffering from an eating disorder is
not a sign of weakness.

4. It helps the patients to not identify themselves with their eating

disorder. Patients oen consider some expressions of the psychopathology of
eating disorders (e.g., strict dieting) as a sign of self-determination,
discipline, and willpower, and some feel that being able to lose weight to the
point of emaciation makes them special. Education (e.g., on the effects of
malnutrition) can help them understand how much their way of thinking
and acting is stereotypical and common to all people who are malnourished,
instilling doubts about being special in being able to control their body
weight and eating.

Procedure: Guided Reading

We provide patients with the book Overcoming Binge Eating, Second Edition
(Fairburn, 2013) as support for the CBT-E sessions. We invite them to read
the relevant parts concerning information on their particular eating disorder
(e.g., the effects of being underweight, binge eating, self-induced vomiting)
and the description of the procedures introduced in the session to ensure
that they use them appropriately (e.g., the use of monitoring records in
Session 0). Part I of the manual is exclusively educational, and reading the
manual guided by the therapist serves as support for educational
intervention, and is considered an important part of CBT-E.
We ask patients to highlight the parts they find most relevant to their
problem, cross out those that are not, and put question marks next to the
parts that they do not understand and/or wish to discuss. Patients are
encouraged to bring the manual to each session so the therapist can review
the various sections they have read. In this way, guided reading allows
patients to be educated in an efficient, exhaustive, and personalized way.
is review may also provide information that proves useful for tailoring a
patient’s personal formulation and treatment.
It should be noted that Overcoming Binge Eating, Second Edition
(Fairburn, 2013) is relevant to all patients with eating disorders, whether or
not they binge-eat, because it discusses eating-disorder psychopathology in
general, and not just binge eating. If patients are doubtful about its value and
say that it is not relevant as they do not binge-eat, it should be explained that
Part I is about eating disorders in general, and that in any case, most people
with eating disorders are at high risk of binge eating, and the book will
explain why this is the case. We also inform patients that while they might
not be binge eating at present, most patients with anorexia nervosa already
experience subjective binges, and will begin to have true objective binge-
eating episodes in time, and, in fact, up to half will develop typical bulimia
nervosa. e same is likely to be true of not-underweight patients who do
not currently binge-eat.

Topics to Cover

Table 5.2 lists the main topics that should be covered during the treatment
when educating patients. Note that some of this information will only be
relevant to certain subsets of patients.

TABLE 5.2. Main Topics to Cover When Educating

Adolescent Patients about Eating Disorders
The patient’s eating disorder and its treatment
The patient’s eating-disorder diagnosis.
Its prevalence and main features.
Associated health risks.
Its course and prognosis without treatment.
The treatment options and their likely effects.

Clinical features of eating disorders

Being underweight.
Characteristic extreme concerns about shape and weight.
Characteristic form of dieting.
Binge eating.
Self-induced vomiting.
Laxative misuse.
Overexercising.

From Cognitive Behavior erapy for Adolescents with Eating Disorders

by Riccardo Dalle Grave and Simona Calugi. Copyright © 2020 e
Guilford Press. Permission to photocopy this material is granted to
purchasers of this book for personal use or use with patients (see
copyright page for details). Purchasers can download enlarged versions
of this material (see the box at the end of the table of contents).
 Confirming Homework Assignments
“Homework” is an integral part of CBT-E, and is fundamental for achieving
change. Teenagers are accustomed to the idea of homework, and therefore
find this request quite normal, even in the context of psychological
treatment. Generally speaking, the following homework should be agreed
upon at the end of Session 0:

Reviewing the formulation. We ask patients to dedicate 15–30 minutes

to reviewing their written formulation before the next session. ey
should consider what seems most relevant, what may need to be added,
and what should perhaps be dropped. In addition, we ask underweight
patients to read the patient handout on the effects of being
underweight (see Appendix B) and add any of these effects, not present
before weight loss, that have not yet been included in the formulation.
Starting self-monitoring and carefully reading the instructions for doing
so. We also ask patients to write down the homework that has been
agreed to on the back of the first monitoring record.

Summarizing the Session and Arranging the Next

Appointment
Finally, we end the session by summarizing its content, restating the
homework assignments, and scheduling the next appointment.
 CHAPTER 6

Parents-Only Session

Parents participate in a single 50-minute assessment session during the first

week of Step One. is is the only session held with the parents alone. Its
content and rationale should be carefully explained to patients beforehand
so as to avoid jeopardizing the trust that has already been built up between
the therapist and patient. e main aim of the session with the parents alone
is to identify and address any family factors liable to hinder or prevent the
patient’s attempts to change.

ASSESSMENT OF THE FAMILY ENVIRONMENT

is is carried out in association with education about eating disorders and
includes assessment of the following areas:

• e development and the current status of the patient’s eating disorder.

We ask parents about their perception of the eating disorder, its onset and
evolution, and the resulting impairment. In particular, we inquire whether
they have noticed any changes in the personality, interpersonal
relationships, and/or school performance of their daughter or son, and what
effects these have had on the family life. We also ask about the presence of
any coexisting psychiatric and/or general medical problems, and seek to
obtain a brief history of the psychiatric and medical history of both the
adolescent and family, including previous treatments for eating disorders.

• e parents’ knowledge about the causes of eating disorders. is can

help to understand their reaction to the behavioral expressions of the
patient’s eating disorder.

• e parents’ interpretation and reactions to the patient’s eating disorder

symptoms.

• e adolescent’s reaction to the parents’ behavior and attitudes. For

example, criticism may produce a change of mood, triggering a binge-eating
episode, or excessive focus may intensify the adolescent’s control of her or
his eating in order to keep the parents’ attention.

• e presence in the home environment of factors that encourage dieting

and concerns about shape and weight. is assessment includes information
about the number and type of mirrors and weighing scales, the types of
magazines read by family members, and the presence of family members
who are on a diet, have particularly extreme and inflexible dietary rules, or
attach particular importance to shape and weight as a means of judging
self/others.

EDUCATION ON EATING DISORDERS AND THE

PARENTS’ ROLE IN THE TREATMENT

We usually give parents general information about the following:

• e cognitive behavioral theory of how eating disorders are maintained.

We inform parents that the patient’s behavior is the consequence of a
characteristic mindset that operates in people with eating disorders, and that
this mindset is maintained by several mechanisms that need to be addressed
by treatment. To explain this, we present the cognitive behavioral theory of
the maintenance of eating disorders to parents, together with the
adolescent’s personal formulation. e main expressions of being
underweight are covered where appropriate, and in such cases, parents are
reassured that the patient’s true personality will return once eating and
weight are normalized.

• Instilling hope. We stress that many adolescent patients recover

completely from their eating disorder, and that there is no reason to think
that this will not happen to their daughter or son.

• CBT-E. Parents are informed about the nature, style, and practicalities
of the treatment (i.e., the number, duration, and frequency of the treatment
sessions). We emphasize that a major focus of Step One is to engage patients
in playing an active role in their treatment. In the case of patients who are
underweight, parents are informed that the main immediate treatment goal
is to help their daughter or son see the need for weight regain and agree to
embark on the process. We also describe the other components of this stage
of treatment—namely, that patients are helped and encouraged to
understand their eating disorder, reduce their concerns about weight, and
establish a pattern of regular eating without, at this stage, increasing the
amount of food they eat. We emphasize that addressing the other eating-
disorder features and continuing work on weight restoration will be the
focus of the next phase of treatment (Step Two), whereas the last step (Step
ree) will focus on concluding treatment and preventing relapse. We also
inform parents that some joint sessions will be held as the treatment
progresses to discuss how they will be able to help their child achieve her or
his goals.

• Role of parents in the treatment. We explain that joint sessions with the
patient will be held periodically at the end of the individual sessions to
discuss together how to create an optimal family environment to facilitate
the patient’s efforts to change. Furthermore, if patients give their consent,
parents will be asked to help them to implement some of the treatment
procedures (e.g., eating regular meals, or, in the case of patients whose
weight is low, taking steps to regain weight).

CREATING AN OPTIMAL FAMILY ENVIRONMENT

As a positive environment is fundamental to facilitating patients’ efforts to

change, we discuss ways of creating such an environment and avoiding the
potential triggers that may accentuate patients’ concern about shape, weight,
eating, and their control. We provide parents with some general tips and
advice that should help them achieve these aims.

• Avoid following a restrictive diet. We explain that is very difficult for a

person with an eating disorder to address dietary restraint and restriction if
a family member is attempting to diet to lose weight or adopts atypical
eating practices. If a family member is on a low-calorie diet and has
difficulty in stopping dieting, we suggest a referral to address this problem. If
the diet is medically indicated, we suggest that the family member consider
(if her or his doctor agrees) temporarily suspending her or his weight-loss
diet and replacing it with a weight-maintenance plan that involves following
healthy nutritional guidelines in a flexible way.

• Avoid keeping junk food in the house. e presence of large quantities of

food at home, especially high-calorie foods (e.g., cakes, chocolates, snacks,
chips) may be a trigger for binge-eating episodes in patients who binge. We
suggest keeping supplies of highly palatable, easily consumed food to a
minimum.

• Avoid comments about the patient’s eating during meals. We advise

parents to not make any comments about eating during meals (whether
positive or negative), as they oen trigger negative emotions that may
adversely affect the patient’s eating.

• Avoid conversations that emphasize thinness. We explain that the core

goal of treatment is to help patients reduce their overvaluation of shape,
weight, and their control. Conversations about being thin and weight
control may undermine a patient’s attempt to change.

• Create an environment that does not encourage concerns about shape

and weight. We educate parents that numerous mirrors in the home may
trigger unhelpful shape checking, and that books, magazines, or television
programs devoted to dieting, cooking, and fashion may also be unhelpful. If
appropriate, we suggest reducing the numbers of mirrors, getting rid of
books and magazines on these topics, and not watching such television
programs.

• Create a warm and serene home environment. We strongly suggest that

it is important for patients to spend time with their families or friends in a
calm, relaxed, and welcoming atmosphere. Taking the time to experience
positive family emotions is as important as addressing the eating disorder.
For this reason, we encourage parents to spend time with their daughter or
son in a pleasant and relaxed way, to share pleasurable activities, relive
happy memories, and generally to have fun together. We also explain that it
is most helpful to communicate with their daughter or son in a warm,
understanding, and calm fashion.

• Create a “new” home environment. We suggest that parents change

some simple family habits (e.g., adjusting the seating arrangements of family
members at the table and buying new dishes, cups, and cutlery) and that
they make a few small changes in the layout of the home in order to convey
the feeling of a “fresh start.” If the family does not eat together, we strongly
recommend that they begin to do so.
 • Be reliable and instill hope. We stress that parents should reliably be on
hand to support the patient, and that they maintain and communicate their
confidence that their daughter or son can change and recover from the
eating disorder.

ASSESSING AND ADDRESSING PARENTAL

BARRIERS TO CHANGE

Potential barriers to change should be always assessed and promptly

addressed. e most common barriers follow:

Logistical and Work Barriers

Patients may have difficulties accessing clinical services because of time
pressures—a particularly troublesome issue for single parents and those in
full-time employment. Such problems may make it less likely that the
treatment proceeds without interruption, and should be addressed promptly,
preferably before the start of CBT-E. Although it is not always possible to
overcome these barriers, we do our best to schedule the sessions at
convenient times based around the parents’ work commitments. It is also
advisable, if possible, to locate clinical services in a place that is easily
accessible, and one that can be safely reached by patients alone.

Cultural Barriers
Some parents may view eating disorders as deviations from a moral or
cultural norm rather than from a psychological perspective. ey may
therefore prefer to consult relatives or religious leaders instead of
psychological or psychiatric services. Cultural barriers to treatment and
compliance are not easy to address. However, it is important to understand
these barriers, and to develop cross-cultural communication skills to
address such views and correct any possible misperceptions that might
impede treatment. It is oen useful to take a little extra time to build a
rapport before discussing the eating disorder. It is also important to be
aware of any different perceptions that other health professionals might
have, and to be open and understanding, encouraging questions.

Disagreement about the Nature of the Treatment

Proposed
Some parents may ask for inpatient rather than outpatient treatment. In
these cases, we actively listen to their views, and then outline our reasons for
recommending outpatient CBT-E for their daughter or son. We tell parents
that outpatient CBT-E is one of the most promising treatments for
adolescents with eating disorders available, and that outpatient treatment
has several advantages over hospitalization (e.g., addressing the triggers of
eating-disorder behavior in the environment in which the adolescent lives,
maintaining relationships with peers, continuing schooling, less likelihood
of relapse). We reassure parents that the patient’s physical state will be
carefully monitored, and that a referral to more intensive treatment will be
made in the event of any immediate medical risk or a poor response to
outpatient treatment. Parents may also object to CBT-E not addressing the
causes of the eating disorder. In these cases, we explain that the causes of
eating disorders are not yet fully understood. We reassure parents that,
despite this, we have obtained very promising results with CBT-E by
focusing primarily on addressing the mechanisms maintaining the eating
disorder. We add that in the later phases of the treatment, its potential
causes will be discussed. In the event that parents think that they have
caused the patient’s eating disorder, we stress that the available data do not
support this view. We inform them that they will be able to help their
daughter or son recover by actively supporting her or him during treatment.
 Disagreement between the Parents about the Need for
Treatment
For example, one parent may be aware of the clinical severity of the
adolescent’s eating disorder and believe that treatment is necessary, while
the other underestimates the gravity of the problem and thinks that it can be
managed without specialist treatment. We actively listen to the views
expressed by both parents, and provide education about eating disorders
and their effect on physical and psychosocial development. We emphasize
that without treatment these disorders are likely to persist, and add that
treatment is short and includes several strategies and procedures to prevent
relapse.

Parents with Clinical Depression or Other Mental

Disorders
Parents with depression or any other form of psychiatric disorder may have
decreased energy, irregular sleep, trouble concentrating, and maintaining
attention, irritability, and moodiness—all of which can contribute to their
being less available and supportive. We encourage parents who need
treatment to seek help for their own benefit but, should they not be willing
to do this, to do so for their child. We emphasize that acknowledging that
they need help and seeking it are signs of strength, and that creating an
atmosphere that welcomes open discussion about such problems is helpful.
Although the support of parents can be an invaluable resource in helping the
patients benefit from it, as described above, the treatment actively engages
the patients in change. Hence, whether they follow this advice or not, as
compared with other treatments, CBT-E has the advantage that it can be
successful even without parental support.
 CHAPTER 7

Session 1

STRUCTURE AND CONTENT

As in the first session, and in fact throughout Step One, the top priority in
the second appointment is engagement, as this is to all intents and purposes
the key to successful treatment. Hence, Session 1 is mainly focused on
instilling hope, cultivating enthusiasm, and getting the therapeutic
momentum going. is will necessarily involve asking about and addressing
any concerns, misgivings, or underlying pessimism (Fairburn, 2008).
Regardless of the presentation of the eating disorder, Session 1 should also
involve:

Initiating collaborative weighing, and providing personalized

information about weight and weighing.
Reviewing in detail and reinforcing self-monitoring.
Introducing the Eating Problem Checklist (EPCL).
Assessing attitudes toward treatment.
Reviewing the formulation.
Continuing the education on the effects of being underweight (if
appropriate).
 Like all the sessions that follow, this appointment will last about 50
minutes, but how this time is divided between tasks will vary on a case-by-
case basis, as how much input is required to thoroughly go over the
monitoring records and make sure the procedure itself is being performed
to a suitably high standard will vary from patient to patient. at being said,
we suggest that the following approximate time frames (in parentheses) are
allocated to the various tasks:

1. Initiating in-session weighing (5 minutes).

2. Reviewing monitoring records (about 10–15 minutes).
3. Setting the agenda for the session (a few minutes).
4. Working through the items in the agenda (25 minutes).
5. Summarizing the session, agreeing on homework, and arranging the
next appointment (5 minutes).

MAINTAINING ENGAGEMENT

As mentioned, the priority for Step One is cultivating and maintaining

patients’ engagement in treatment. erapists should continue to adopt an
engaging style, instill enthusiasm, and address any of the patient’s concerns,
negative attitudes, and so forth. It is vital that the therapist also shows
interest in the patient as a person (Fairburn, Cooper, Shafran, Bohn,
Hawker, et al., 2008). Simple but direct questions such as those that follow
show that the therapist is truly concerned about the patient’s overall well-
being and not just her or his eating and weight. ey also tend to unearth
aspects of secondary impairment that might otherwise remain undetected.

“I’d like to know what life is like for you at the moment.”
“How are things going?”
“Are you happy?”
“Can you let your hair down and be spontaneous?”
 “Are you able to do what other people your age do?”
“Do you have many friends?”
“How is your life compared to theirs?”
“Is there anything you wish was different? Really? All things
considered?”

COLLABORATIVE WEIGHING

Rationale
Many patients hold misconceptions about body weight, in particular, on
what is a “healthy” weight, and the causes of changes in weight. Moreover,
most are very concerned about their weight—they are dissatisfied with how
much they weigh, and anxious about the effects that the treatment will have
on their weight. ese concerns are reflected in how they monitor their
weight, and it is not uncommon for such individuals to weigh themselves
several times a day. is excessive weighing causes them to worry
unnecessarily about day-to-day fluctuations in weight that would not be
detected ordinarily. At the other end of the spectrum, other individuals
refuse to weigh themselves at all, despite it being the focus of their concern.
is kind of avoidance can be as worrying as frequent weighing, as patients
have no objective data to lessen or confirm their fears about their body
weight. As both frequent weighing and active weight avoidance are barriers
to changing eating habits, collaborative weighing is usually introduced early
on, in Session 1. In-session collaborative weighing is a key procedure of
CBT-E that is designed to correct misconceptions and reduce concerns
about weight. e procedure consists of (1) weekly weighing and recording
and (2) personalized education about weight and weighing, and has five
main goals:

1. To correct misconceptions.
2. To address either frequent weighing or weight avoidance.
 3. To provide patients with reliable information about their weight.
4. To help patients interpret the number on the scale correctly.
5. To reduce weight concerns.

Initiating Weekly Weighing

Collaborative weighing is the first step in weekly weighing. e therapist
and patient check the patient’s weight together (with the latter wearing
indoor clothing and no shoes). We use a beam balance scale rather than
electronic scales, as they are robust, accurate, and give sufficient precision.
We recommend avoiding scales that provide a digital readout, as patients
tend to perceive these as more accurate, and this reinforces concerns about
trivial changes in weight. We use a scale with 1-pound intervals, but it is
important for the weight to be measured in units that the patient
understands.
Patients are asked to cease weighing themselves at home (if applicable),
and it is important that the therapist devote time to addressing their
concerns about this and the collaborative weighing procedure. Indeed, it is
not uncommon for young people to be reluctant to be weighed or agree only
on the condition that they are not told their weight, sometimes claiming that
it will be easier for them to regain if they do not know the number on the
scale. Other patients ask that weighing be postponed until the following
week, hoping that they will lose weight in the interim. It is essential to reach
an agreement on weekly weighing early on, without it becoming a focus for
negotiation over several sessions. Hence, in cases of reluctance to begin, it is
important to explain carefully why it is best that they are aware of their
current weight, and that this is an integral part of treatment. It is essential to
emphasize that regular weighing will help them to feel in control, and will
reduce their concerns about weight. To lend weight to the importance of
initiating the procedure of weekly weighing, it may be useful with a
metaphor like the following:
 “Trying to reduce concerns about weight without measuring it regularly
is like trying to manage a business without doing the accounts. You will
never have reliable information about what is going well and what might
be improved, which puts you at risk of making decisions based on
doubts and guesswork, rather than reliable data. I’m sure you can see
how this would be counterproductive and put the company at risk.”

e therapist should adopt a calm, matter-of-fact manner, and take care

to ensure that the weighing itself is as collaborative as possible. Specifically,
the number on the scale should be agreed upon and spoken out loud,
thereby preventing weight avoidance, and the therapist and patient should
update an individualized weight chart (a graph that the therapist will have
prepared in advance) together. In underweight female adolescent patients, to
illustrate the patient’s minimum threshold healthy weight, we plot a line at
the 25th BMI-for-age percentile (for males the minimum threshold healthy
weight is set at the 10th BMI-for-age percentile), which corresponds to a
BMI of between 19.0 and 20.0 in adults (United States; Kuczmarski et al.,
2002; www.cdc.gov/growthcharts/percentile_data_files.htm), and another at
the 85th BMI-for-age percentile, which corresponds to the threshold for
being overweight in adults (see Figure 7.1). If the adolescent patients are not
underweight, however, we prefer not to draw any line so as not to impede
their acceptance of their current weight (see Figure 7.2).
FIGURE 7.1. A weight graph for an underweight adolescent patient with an eating disorder.
FIGURE 7.2. A blank weight graph of a not-underweight adolescent patient with an eating disorder.
 e collaborative weighing procedure should be implemented
consistently, once a week throughout treatment, and at the beginning of
each session the therapist and patient should jointly interpret the weight
measured. Obviously, this cannot be done in Session 1, as at this stage there
is only one data point to look at. Instead, the time in this session should be
devoted to educating patients about weight and weighing (see below).

PROVIDING PERSONALIZED EDUCATION ABOUT

WEIGHT AND WEIGHING

Four main topics should be addressed: (1) information about weight, (2)
information about weight change, (3) the effect of treatment on weight, and
(4) information on weighing.

Information about Weight

Patients should be educated about body weight, their BMI, BMI-for-age
percentile, and minimal BMI threshold. e main points to stress are as
follows:

• Body weight is difficult to influence in the long term due to the fact
that it is under strong physiological control.

• BMI, calculated by weight (in kilograms) divided by height squared (in

meters; i.e., weight/height2), is a convenient means for representing body
weight in patients with eating disorders ages 18 and over. If the weight is in
pounds and the height is in inches, the ratio in this formulation must be
multiplied by 703. In general, it provides a good classification of an adult’s
weight status. According to CBT-E, a BMI of between 19.0 and 20.0 is
generally considered the minimal BMI threshold in adults that does not
contribute to the maintenance of an eating disorder and is not associated
with psychosocial and physical impairment (Fairburn, Cooper, Shafran,
Bohn, Hawker, et al., 2008).

• Instead, a younger adolescent’s weight status should be assessed using

the relevant national BMI-for-age percentile chart, which classifies young
people ages 2–20 years. A low, healthy BMI-for-age percentile threshold will
differ between countries, but for patients with eating disorders, as described
in Chapter 1, in the United States, this is approximately the 25th BMI-for-
age percentile (10th BMI-for-age percentile for males). Indeed, below this
threshold, most adolescents with an eating disorder experience at least some
of the adverse physical and psychosocial effects of being underweight. For
patients who have a BMI-for-age percentile below this threshold, it can be
helpful to point out that the average weight of people their age and gender is
significantly higher than this. Adolescents easily understand that having a
50th BMI-for-age percentile means that half of the individuals of the same
age have a greater BMI and half a lower BMI; while having a 5th BMI-for-
age percentile means that 95% of individuals of the same age have a higher
BMI.

Information about Weight Change

e main points that we inform adolescent patients about are as follows:

As body weight is in part determined by genes, it is significantly

difficult to modify in the long term.
e number on the scale fluctuates during the day due to modifications
in the body’s water content, which accounts for about 60% of total
body weight. e main cause of short-term weight oscillations are
changes in hydration status.
e fact that weight fluctuates naturally makes it almost impossible to
maintain a constant body weight. In general, it is advisable to accept a
 weight range of about 6 pounds (or 3 kilograms) in magnitude to allow
for natural weight fluctuations, without modifying energy supply.

Here we report an example transcript for the part of Session 1 in which

the therapist helps a patient understand and accept normal weight
fluctuations.

THERAPIST: Wanting to have an exact weight all the time is like wanting
to always have an exact heart rate. Is that possible, in your opinion?
PATIENT: No, it’s impossible.
THERAPIST: You are right. Our heart rate varies according to different
circumstances, such as physical activity, emotional state, and so on.
In the same way, our weight is influenced by variations in the water
content of our body. In fact, water accounts for about 60% of our
weight.
PATIENT: OK. I understand.

The Effect of Treatment on Weight

e vast majority of patients feel anxious about how the treatment will affect
their weight. Although patients who are not underweight do not generally
experience dramatic weight changes, there are some patients who will gain
weight and others who will lose it. It is not possible to predict exactly what
will happen to an individual patient, but patients should be told that one of
the main aims of CBT-E is to give them control over their eating, and this
will allow them as much control over their weight as possible.
However, with patients who are underweight it is important to be
absolutely clear about their current weight, and the BMI-for-age percentile
that they would need to reach to be free from the adverse secondary effects
of being underweight. It is sometimes argued that the goal should be
individualized considering their weight history, but that a 50th BMI-for-age
percentile is appropriate in most cases. is seems reasonable on theoretical
grounds, but in reality there is no direct evidence to support this argument.
Furthermore, there is a major problem with this goal—it is unrealistic.
Indeed, it is difficult enough to help patients achieve and maintain a BMI-
for-age percentile around the 25th, let alone a BMI higher than this.
Instead, our position is that the goal of treatment should be to free
patients from the eating-disorder psychopathology and its adverse effects. In
our experience, as already explained, this can be achieved in most cases
when female patients go above a BMI-for-age percentile corresponding to
an adult BMI of between 19.0 and 20.0 (i.e., the 25th BMI-for-age percentile
in the United States; Kuczmarski et al., 2002), and are successful in
addressing the core maintenance mechanisms (the “house of cards”
analogy). In fact, this BMI goal is fairly ambitious, given the disappointing
data on the outcomes of most treatments for anorexia nervosa.
Near the end of treatment, when the patient’s eating habits have
stabilized, a specific goal weight range can be decided upon, provided that it
does not require more than slight restraint, because dietary restraint serves
to maintain a preoccupation with food and eating, making binge eating
more likely, and is associated with restoration of hypthalamic–pituitary–
ovarian function to avoid morbidity many years aer the adolescent has
recovered from the eating disorder (Golden et al., 1997). At this point, we
advise patients who have to restrict their eating to maintain a body weight
close to 25th BMI-for-age percentile to consider letting their weight rise a
little above until they can maintain the weight without dietary restriction.
We use a similar strategy with patients who are not underweight but exhibit
high weight suppression (i.e., those who meet the DSM-5 criteria of atypical
anorexia nervosa).
Young adolescents who have not yet completed their physical
development and whose growth has been arrested as a consequence of
undereating and being underweight should be informed that their weight
restoration will also be associated with the resumption of growth.
 Information on Weighing
ere are two main pieces of information to provide the patients about
weighing: (1) how to interpret the “the number on the scale” and (2) the
negative effects of weighing avoidance and frequent weighing. Patients need
to learn how to interpret the number on the scale that they see when they
weigh themselves correctly. e main information to give patients is the
following:

• People tend to misinterpret fluctuations in weight as changes in body

fat, when in fact they are largely due to variations in their hydration status.

• Single-scale readings can be misleading, and not necessarily linked to

stable changes in weight. Instead, in order to correctly interpret weight
change, it is advisable for patients to look at the trend in weight over a
period of 4 weeks by looking at their individual weight chart rather than
concentrating on the latest single reading. Indeed, individual readings are
almost impossible to interpret because of the uncertainty that surrounds
them. For this reason, therapists should repeatedly remind patients that “It is
impossible to interpret a single reading.” To help patients identify what is
happening to their weight, the therapist should use a transparent ruler to
identify the emerging weight trend.

Although it is not possible to interpret a patient’s weight until the fourth

session, it is useful to do an exercise on weight interpretation during Session
1—see, for example, that reported in the following transcript (see also
Figure 7.3).
FIGURE 7.3. Representative interpretation of weight fluctuations.
THERAPIST: Do you mind if we do an exercise to interpret the weight
changes of a girl of your age, who we can call Sarah?
PATIENT: OK.
THERAPIST: Sarah weighed herself 4 weeks ago, and the number on the
scale was 120 pounds. Can you put a black circle on 120 pounds in
week 1 of this weight graph?
PATIENT: Like this?
THERAPIST: Good. OK now, the following week, Sarah weighed herself
again and got a reading of 122 pounds. Can you mark it in week 2?
PATIENT: OK.
THERAPIST: en, in week 3, the scale said 122 pounds, while it said 120
pounds in week 4. Can you mark these on the weight graph, please?
PATIENT: Yes, of course. It’s not difficult.
THERAPIST: OK. Look at Sarah’s weight from week 1 to week 2. Has it
changed?
PATIENT: Yes, it has. She’s put on 2 pounds.
THERAPIST: OK. Now, tell me what happened between week 2 and week
3.
PATIENT: Her weight remained stable.
THERAPIST: And between weeks 3 and 4?
PATIENT: She lost weight.
THERAPIST: OK. Now, can you please assess the weight trend from week 1
to week 4? You can draw a dotted line to facilitate your interpretation
using this ruler. What do you conclude?
PATIENT: Sarah’s weight remained stable.
THERAPIST: Yes, you are right. As you can see from the weight graph,
interpreting single readings gives misleading information. Indeed,
the only way to understand whether your weight is fluctuating but
 remaining stable, as in Sarah’s example, or is showing a tendency to
increase or decrease, is to evaluate the weight trend over the last 4
weeks, rather than focusing on single readings.
PATIENT: Yes, you are right. I agree.

It is important for the patients to accept regular weighing, as most

adolescents with eating disorders report frequent weighing or avoidance of
weighing as a consequence of their concerns about weight, and both of these
behaviors maintain and intensify concerns about weight. Frequent weighing
(e.g., every day or several times each day) results in preoccupation with
inconsequential fluctuations in the number on the scale, and these tend to
be misinterpreted, encouraging dieting. Avoidance of weighing, on the other
hand, does not enable any information on weight variations to be collected;
weight may increase or decrease unchecked, and fears and assumptions
about weight cannot be countered with hard facts. To help the patients
understand the negative effects of frequent weighing or avoidance of
weighing, the therapist could return to the example of heart rate as follows:

THERAPIST: Try to imagine what might happen to a woman who is

worried about her heart function and is afraid of having a heart
attack.
PATIENT: OK.
THERAPIST: at woman is so afraid that she might be about to have a
heart attack that she checks her heart rate several times a day. What
effect might this frequent pulse checking have?
PATIENT: I don’t know . . . maybe she would worry when her heart rate
went up.
THERAPIST: Yes, I agree with you. e woman’s concerns would probably
increase, as well as her fear of having a heart attack. is happens
because the frequent pulse checking can lead someone to interpret
 the natural variations in heart rate as something going wrong in the
heart. In other words, frequent measurement of heart rate could
accentuate and maintain a person’s worries about having a sick heart.
PATIENT: Yes, that’s true.
THERAPIST: In contrast, being afraid of knowing the truth and never
measuring heart rate would not allow the woman to understand
whether or not her heart is beating normally, and this, too, could
have dire consequences.
PATIENT: Yes, I agree. Sometimes checking your pulse is useful.
THERAPIST: e same can be said for weighing. If we do it too frequently,
we might interpret natural fluctuations as proof that we are losing or
gaining weight. In this case, the consequence is that our concerns
about weight and eating would be heightened. If, on the other hand,
we avoid weighing ourselves altogether, we have no access to reliable
information on whether or not our weight is actually changing,
which may increase our concerns about our weight.
PATIENT: Yes, I see.
THERAPIST: is is why we suggest weekly weighing, because over a
period of 4 weeks we will have reliable data on any weight trend that
is developing.
PATIENT: OK.

is type of interaction naturally leads into the final step of this part of
the session—namely, to explain collaborative weighing to the patients. It
should be emphasized that collaborative weighing is a central aspect of the
treatment, as both have the dual aims of keeping control over weight but at
the same time reducing concern about it. If applicable, patients should be
urged to cease weighing themselves at home. If they have a scale at home
and they have difficulties resisting the urge to jump on the scale, we suggest
that they use a “coping card” to record the reasons for not weighing. If they
do weigh themselves at home, they should record this on their monitoring
record, together with the events, thoughts, and emotions that led them to
check their weight. Please note that we prefer not to advise the patients and
their parents to hide the scales, because it is important that patients learn to
manage the urge to weigh themselves.
e collaborative weighing procedure includes the following three
components, which should be explained carefully to the patient:

1. Weighing and recording. Patients are weighed once a week at the

beginning of each session. en, the therapist and patient plot the
latest reading on her or his weight chart.
2. Interpretation. Each week the therapist and patient jointly interpret
the emerging trend by examining the last 4 weeks’ readings, using the
motto “It is impossible to interpret a single reading.”
3. Consistency. is procedure should be repeated week-by-week.
Regular, collaborative measurement and interpretation of weight
have the effect of reducing weight concerns and consequently
generating in patients a greater willingness to change their eating
habits.

REVIEWING AND REINFORCING SELF-

MONITORING

e second major goal of Session 1 is to establish and reinforce accurate

real-time self-monitoring, mainly focusing on the process (point 2 of the
procedure), rather than the content, which will be analyzed in detail in
subsequent sessions. To this end, the therapist should ask the patient to talk
through each day’s record, in great detail with the therapist, which may take
upward of 15 minutes. In assessing the quality of self-monitoring, the
therapist will want to ask patients (1) how they feel about self-monitoring,
(2) how they think it has been going, and (3) whether they had any
problems. It will be necessary to inquire (4) how long aer eating and/or
drinking they have recorded and (5) whether they neglected to record
anything. From a practical perspective, the therapist should check that
brackets and asterisks have been used correctly, and praise patients for their
efforts, even if the records have not been filled in correctly. For this we
suggest using a statement like the following:

“You’ve made a great start. If you continue doing this, we will learn a lot
about your eating problem and the mechanisms that are maintaining it.
Now we need to hone your recording skills so that we can get even more
out of self-monitoring. is week, why don’t we work on . . . ?”

It is not entirely unusual for adolescent patients to come to Session 1

without having recorded anything. We tend to react to such an event with
perplexity, taking pains to explore with patients why they have not
attempted self-monitoring. To prevent patients feeling that they are being
“admonished” for not doing their “homework,” our therapists oen shoulder
some of the blame for the problem by saying something like this:

“It seems that I didn’t explain the importance of self-monitoring clearly

enough.”
“I think we should have discussed the practicalities of doing this in more
detail. Let’s think about this together.”

e therapist should be ready to address any issues that emerge from

this discussion, making clear that self-monitoring is a vital part of CBT-E,
and that the treatment cannot succeed without patients recording what we
ask them to. Although there may be problems at a later date, we have found
that in all cases, this explanation is sufficient to get patients to start self-
monitoring. Subsequent issues should be dealt with as they arise, and the
therapist should always make time in the session to monitor the accuracy of
the records, whether they are being completed in real time, and how the
patients feel about the process. In addition, each session’s monitoring
records should be filed chronologically in a large ring binder, so that earlier
records can easily be reviewed if need be. For example, with patients who
have difficulty recognizing the progress they are making, it can be helpful to
go over past records to highlight the changes that have been made.

INTRODUCING THE EPCL

Aer collaborative weighing, weight education, and monitoring review, the

EPCL (see Appendix D) should be introduced. e therapist should explain
to the patients how to use the EPCL, a 16-item self-report measurement tool
designed to assess eating-disorder behaviors and psychopathology in
patients with eating disorders session-by-session, which should be
completed once a week aer the joint review of the monitoring records. e
therapist should explain to the patients that it is important that the EPCL is
completed truthfully and accurately, because their responses will enable the
therapist and patient to jointly assess the improvements achieved and the
obstacles encountered each week. Based on this assessment, the patient’s
personal formulation can be updated, and any problematic behaviors and/or
issues can be identified and addressed (see “Reviewing the EPCL” in
Chapter 9 for this procedure).

ASSESSING ATTITUDE TOWARD TREATMENT

Adolescent patients may have very different attitudes toward treatment.

Some may be positive from the beginning and remain so throughout,
whereas others may start with reluctance or ambivalence, and will therefore
be more difficult to win over. It is also possible for patients to lose their
initial enthusiasm or remain ambivalent or reluctant even in the later stages.
It is important to monitor changes in attitude, as these may influence
treatment outcome. In particular, enthusiastic patients are more likely to do
well, as they commit wholeheartedly to the treatment and assiduously
complete their homework assignments. In contrast, those who remain
dubious about the treatment tend to make considerably less effort, and are
therefore less able to enact change, and, in fact, are more likely to drop out.
Hence, how patients perceive the treatment should be foremost in the
therapist’s mind, and they should, from time to time, dedicate part of the
session to its formal assessment.
is should begin in Session 1, when the therapist should inquire
explicitly about the patient’s view on treatment, by asking:

“How do you feel about having started treatment?”

“Do you have any worries or concerns about treatment that you would
like to discuss?”

REVIEWING THE FORMULATION

Asking about patients’ attitudes toward treatment should lead the therapist
naturally into inquiring whether they have reflected on their formulation
(which they were asked to do for homework in Session 0), and whether they
think any modifications need to be made. For example, in patients who are
underweight, we ask them whether they added any effects of being
underweight to the formulation aer having read the patient handout
describing these effects. It is also useful to ask patients whether they
understand the significance of the arrows (indicating the maintenance
mechanisms)—in particular, it should be ascertained that they comprehend
how the effects of being underweight maintain dieting, the overvaluation of
shape and weight, and binge-eating episodes (if appropriate), and whether
they have any questions about these. Adolescents do not usually have any
difficulty understanding the meaning of the formulation (they also like
diagrams), and frequently redraw their formulation using colors and their
own words, which should be praised, as it indicates engagement.
 CONTINUING EDUCATION ON THE EFFECTS OF
BEING UNDERWEIGHT (IF APPROPRIATE)

Reviewing the personal formulation provides a good opportunity to

continue education on the effects of being underweight, if the patient is, in
fact, underweight. is is essential, as it will help them to make the decision
to address weight regain and Step Two of the treatment. As patients should
have read the handout in Appendix B on the effects of being underweight
for homework, this can be addressed as part of a discussion on the following
important topics:

e significance of their current BMI-for-age percentile. Specifically,

patients should be told their current BMI-for-age percentile and the
thresholds for a healthy weight. It should be explained that their BMI-
for-age percentile is well below the desirable level, and that they will
therefore be subject to a range of adverse physical, psychological, and
social effects.
e secondary effects of being underweight. It is important to reiterate
the main points summarized in the patient handout shown in
Appendix B.
e underweight features they are currently experiencing. is can be
done by going through the handout (see Appendix B).
e implications of the information on the effects of being underweight.
ere are three points to highlight:
1. Many of the adverse experiences reported by patients are simply
consequences of their low body weight. ese should be specified.
2. Some of the secondary effects contribute to the maintenance of
their eating disorder. is is one of the main points to be
emphasized when creating their formulation.
3. ese secondary effects will resolve with weight restoration.
 CONFIRMING THE HOMEWORK, SUMMARIZING
THE SESSION, AND ARRANGING THE NEXT
APPOINTMENT

At the end of Session 1, patients should be given the following two

homework assignments:

1. Taking specific steps to improve self-monitoring.

2. Refraining from self-weighing at home.

en, the therapist brings the session to a close by summarizing what

has been addressed, reiterating the homework assignments, and scheduling
the next appointment. An example transcript from this part of Session 1
follows:

THERAPIST: Would you agree to us going over what we have covered this
session?
PATIENT: OK.
THERAPIST: Well, we began with collaborative weighing, and then we
talked about your weight and calculated your BMI-for-age
percentile. We also discussed how weight is regulated physiologically,
how to interpret weight changes, and the negative effects of frequent
weighing and weight avoidance.
PATIENT: Yes, that was all very interesting information, even though I’m
still very worried about my weight.
THERAPIST: en we reviewed in detail your real-time self-monitoring,
and we concluded that you did a good job. Your records provided a
lot of useful information.
PATIENT: anks!
THERAPIST: You told me that the first day of recording was difficult, but
now you’re getting used to it. Is that right?
PATIENT: Yes, it is.
THERAPIST: Please continue self-monitoring this week, so we can review
how things have been going next session.
PATIENT: Sure.
THERAPIST: Aer discussing self-monitoring, we went over the effects of
being underweight.
PATIENT: Yes, it was very useful for me to find out that some changes in
my personality seem to be the consequences of being underweight.
THERAPIST: Good. What else have we done today? Oh yes, you told me
you were happy to have finally started the treatment.
PATIENT: Yes, it’s true; I’m starting to understand more about my eating
problem.
THERAPIST: Right. At the end of the session, we decided that you would
continue to monitor and try not to weigh yourself at home, as we
will check your weekly weight together in the next session.
PATIENT: Yes, that’s right.
THERAPIST: Well then, if you agree, I’ll see you on Monday at 4 o’clock.
 CHAPTER 8

Session 2

STRUCTURE AND CONTENT

Session 2 introduces regular eating, a key procedure of CBT-E, and is the

forum for the joint session with patient and parents. It is always advisable to
make sure that the patients are “on board,” involving them actively in the
treatment, and the aim of this first joint session is to establish this kind of
relationship by informing them about their child’s eating disorder and
setting out how they can help. e priorities of Session 2 are:

1. To establish and maintain self-monitoring in real time.

2. To introduce the regular eating procedure.
3. To see the parents in the joint session with the patient.

Session 2 should therefore be structured as follows (the approximate

duration of each item is shown in parentheses):

1. Reviewing the content of the monitoring records (10–15 minutes).

2. Collaboratively setting the agenda for the session (a few minutes).
3. Working through the agenda and agreeing on homework tasks (up to
30 minutes).
 4. Summarizing the session, confirming the homework assignments,
and arranging the next appointment (5 minutes).
5. Seeing the parents in the joint session (15 minutes).

REVIEWING THE CONTENT OF MONITORING

RECORDS

From Session 2 onward, the review is mainly focused on the content of self-
monitoring (point 3 of the procedure), although the therapist should always
take time to assess recording accuracy. Reviewing the contents of the
monitoring record, if done well (i.e., calmly and actively involving the
patients), is very useful for increasing patients’ understanding of the
processes maintaining their eating disorder, and helping to reinforce and
modify their personal formulation. However, to achieve this end, the
relationship between the various behaviors (i.e., the arrows on the
formulation) should not be suggested to patients, but rather explored with
questions that generate curiosity and interest in the patients about what may
have promoted a specific behavior.
As a rule, the therapist should inquire whether the days were typical or
atypical (and if so, in what way). In addition, patients should also be
questioned to determine whether or not features are manifested. In the
following sample Session 2 transcript, the therapist reviews the processes
that emerged in the monitoring record shown in Figure 8.1.
FIGURE 8.1. An example of a patient’s monitoring record (Session 2). e numbers in parentheses
are the processes investigated by the therapist and described in the text.

THERAPIST: (investigating Process 1, skipping breakfast) I see that you felt

full and you skipped breakfast. Can you explain to me what you
mean by “I’m full, I won’t eat”?
PATIENT: Er . . . that there was no room le in my stomach.
THERAPIST: Is there some reason why you felt full?
PATIENT: I ate a lot the night before!
THERAPIST: Ah . . . Can you explain to me what happened?
PATIENT: I lost eating control and I ate a lot.
THERAPIST: OK. I understand . . . now I would like to ask you a question:
“If you had not lost control and did not feel so full, would you have
had breakfast?”
PATIENT: Well . . . I generally try to skimp on breakfast, so if I have some
loss of control during the day I don’t end up eating too much overall.
THERAPIST: (looking at the monitoring records to see what the patient ate
for breakfast on the other days) What do you mean by “skimp”?
PATIENT: I only have a vitamin supplement.
THERAPIST: (starting to explore Process 2, the function of going to school by
bike) OK. en I see that you went to school by bike. Do you always
bike to school?
PATIENT: Yes, I do.
THERAPIST: Why?
PATIENT: For convenience. So, I don’t have to bother my parents about
giving me a li.
THERAPIST: How far is it from your home to the school?
PATIENT: It’s about 2 miles; it takes me 20 minutes.
THERAPIST: I understand. How would you feel if, for some reason—for
example, bad weather—you couldn’t use your bike?
PATIENT: Well . . . it has already happened. In that case, I paid more
attention to what I was eating during the day.
THERAPIST: Why?
PATIENT: If I don’t compensate for the calories I would have burned by
cycling, I will get fat.
THERAPIST: (investigating Process 3) I see that you put an asterisk here.
PATIENT: Yes, I did.
THERAPIST: So, did you not intend to eat?
PATIENT: No, I didn’t.
THERAPIST: OK. Since it was not your intention to eat, what caused you
to do so?
PATIENT: I can’t control myself. I have no willpower.
THERAPIST: Ah, I understand . . . en I see that you made yourself sick.
Was there a quantity of food that would have made you feel it was
acceptable not to throw up?
PATIENT: None, because I had to skip lunch.
THERAPIST: Ah, I understand. And if you were unable to vomit, would
you have eaten? [is question aims to assess the function of self-
induced vomiting as a strategy that promotes loss of control.]
PATIENT: No . . . absolutely not.
THERAPIST: Are there any situations in which you can’t make yourself
sick?
PATIENT: Yes, there are . . . when I eat with my parents, since they are
keeping an eye on me.
THERAPIST: (investigating Process 4) I saw you put asterisks next to the
banana and ice cream, but not next to the chocolate bar. In this case,
did you consider it acceptable to eat the chocolate bar?
PATIENT: Exactly.
THERAPIST: What triggered your eating a banana and ice cream?
PATIENT: Hmm . . . It was a bad day.
THERAPIST: In what sense was it a bad day?
PATIENT: I should not have eaten those cookies.
THERAPIST: Even though you vomited them up?
PATIENT: Yes, it didn’t matter. In any case, I should not have eaten them
and I felt guilty.
THERAPIST: (investigating Process 5) Ah, I understand . . . I see that at 5
o’clock you did some exercises and squats. When did you decide to
 do these exercises?
PATIENT: I do them every day.
THERAPIST: (looking at the other monitoring records) What is your reason
for doing these exercises?
PATIENT: I don’t want to lose muscle tone.
THERAPIST: Have there been any days when you couldn’t do these
exercises because of other commitments?
PATIENT: Yes, a few times.
THERAPIST: And how did you feel and react?
PATIENT: I did the exercises twice the following day.

Reviewing the content of monitoring records requires some skill, since,

as we have experienced, there is the risk of becoming prescriptive by
eliciting the relationship between the various maintenance processes and/or
inviting patients to make behavioral changes prematurely, without patients
understanding their usefulness. Some examples of prescriptive sentences
that are unhelpful in the review of the monitoring records and should
therefore be avoided follow:

“at binge-eating episode was due to the fact that you skipped a meal.”
“If you had eaten something more at lunch, you would have had a lower
risk of losing control over eating.”
“You should eat more so you don’t feel so cold.”
“You exercise too much, you should stop it.”
“I saw that you always eat vegetables at lunch . . . you should eat carbs,
such as pasta, so you don’t have a binge-eating episode in the
aernoon.”

In underweight patients without binge-eating episodes, the review of the

monitoring records content is slightly different from not-underweight
subjects, due to the absence of egodystonic behaviors (i.e., binge eating). e
therapist should instead focus on the symptoms that the patients perceive as
most problematic (e.g., social isolation), and help them conclude that these
symptoms are the consequence of low weight, and understand through
which mechanisms they are maintaining the eating disorder.

ADDRESSING WEIGHING BETWEEN SESSIONS

(IF APPLICABLE)

Reviewing the content of the monitoring records also provides an

opportunity to elucidate whether or not patients have weighed themselves
since the last weekly session, and to educate them about the effect of
frequent weighing in maintaining concerns about weight, dieting, and binge
eating. In this event, the therapist should update the patient’s personal
formulation, adding “frequent weighing” (see Figure 8.2).

FIGURE 8.2. Representative personal formulation of a patient with frequent weighing.

VIGNETTE
e therapist, during the monitoring record review, observes that the patient has weighed herself
at home in the morning. e upward fluctuation of her weight increased her concerns about it so
much that she skipped lunch, was very irritable with her parents, and backed out of an outing
with friends in the aernoon. e therapist, referring to the patient’s personal formulation,
emphasizes the relationship between weighing and interpreting changes in weight at home,
increasing weight concern, skipping lunch, and worsening social life. en the therapist
 reinforces the importance of resisting the impulse to weigh between sessions in order to reduce
concerns about weight and eating.

ESTABLISHING REGULAR EATING

All CBT-E therapists need to become skilled at implementing the regular

eating intervention. is is no mean feat, as it will involve being persuasive,
conveying the rationale behind the intervention well, praising all signs of
progress, and tackling any objections and obstacles. Some patients have no
problem establishing a regular eating pattern—comprising three planned
meals and two or three planned snacks per day—while others may find it
more difficult, and it may take 3 weeks or more of determined effort to
succeed. However, regular eating is the key to treatment progress, and it is
necessary for some degree of success in this intervention to be attained
before moving on to other aspects of the agenda. Hence, regular eating may
be a focus throughout Step One, and even in early sessions in Step Two. If a
patient who binge-eats is still having difficulty establishing a regular eating
pattern at the end of Step One, it may be useful to adopt the binge analysis
strategy (see Chapter 14) to reinforce and extend the regular eating
intervention.

Rationale
e regular eating intervention is key for all patients, including those who
are not underweight. It is the foundation upon which other changes are
built, and it is greatly valued by patients. It is concerned with the patients’
eating patterns—that is, when they eat rather than what or how much to eat.
e goal is to help patients eat at regular intervals throughout the day.
In patients who binge-eat, establishing regular eating rapidly reduces the
frequency of this behavior. is is generally accompanied by a marked
improvement in mood and is highly reinforcing for patients. Any “residual
binges” that remain can then become a focus of Step Two. How this
reduction in binge eating comes about is not entirely clear, although a
variety of mechanisms are likely to be involved. For instance, regular eating
provides structure and control, which may be useful in patients who have
unstructured or chaotic eating habits, like a tendency to “graze” rather than
eating defined meals or snacks. In patients with high levels of dietary
restraint, on the other hand, regular eating can help tackle infrequent or
delayed eating.
With patients who are underweight, it is best to start by helping them
establish a pattern of regular eating rather than asking them to eat more.
is is for a number of reasons. First, patients need to eat regular meals and
snacks before portion size can be increased. Second, regular eating is a
change that most of these patients do not find too hard to accomplish, so
long as they are not expected to increase the amount that they eat. Since
increasing what is eaten is not part of regular eating, this is not a problem.
Patients can simply redistribute their current food intake across the planned
meals and snacks. ird, it is inherently beneficial, and there are a number
of advantages of establishing this eating pattern (Fairburn, Cooper, Shafran,
Bohn, Hawker, et al., 2008):

1. It tackles the tendency to delay eating, a form of dieting that is

common among underweight patients.
2. It seems to lessen these patients’ propensity to feel full.
3. Aer a few weeks, it generally produces a reduction in the degree of
preoccupation with food and eating.

Regular eating is the first time that patients are asked to change the way
in which they eat. It is generally introduced in Session 2, but can be
postponed by one session in underweight patients if the therapist deems it
necessary. It is difficult to give patients a simple and standard rationale for
the intervention. Instead, we find that a pragmatic one works well—for
example, the therapist might say:
 “It is now time you start making changes to your eating habits. e first
one is not to eat more, but simply to eat at regular intervals throughout
the day. It has been found that a regular eating pattern really helps
people with eating problems. Doing this, and doing it well, is very
important, as it is the foundation upon which all other changes will be
built.”

Procedure
ere are two elements to the intervention: (1) eating at regular intervals
throughout the day and (2) not eating in between. At this stage, what the
patient eats does not matter.

Item 1: Eating at Regular Intervals throughout the Day

is involves adopting an eating pattern comprising three planned meals

each day, plus two or three planned snacks. For example:

Breakfast.
Midmorning snack.
Lunch.
Midaernoon snack.
Evening meal.
Evening snack (if appropriate).

Other suggestions to give to the patients are the following:

• is pattern of eating should be given priority. It should take precedence

over other activities, and be adhered to, whatever the patient’s circumstances
or appetite. However, it should be adjusted to suit the patient’s day-to-day
commitments. Usually it will differ on school/work days and days off, for
instance.
 • Patients should plan ahead. ey should always know when they are
going to have their next meal or snack, and what it will be. To emphasize
this, we sometimes say “If I were to call you out of the blue, you should be
able to tell me when and what you will be eating next,” although we also
make it clear that we will not be doing this. Each morning (or the evening
before) patients should write out an outline of their plan for the day at the
top of the day’s monitoring record. If the day is going to be unpredictable,
they should plan ahead as far as possible and identify a time when they can
take stock and plan the remainder of the day.

• ere should rarely be more than a 4-hour interval between the planned
meals and snacks, and patients should not skip any of them. If a meal or snack
is skipped, this should be pointed out, and the therapist should highlight the
consequences of doing so (e.g., increased risk of overeating or binge eating
later on, greater preoccupation with food and eating, perpetuation of the
tendency to feel full).

• Patients should choose what to eat in their meals and snacks. At this
point in treatment, patients should not be pressured to change what they eat,
as this has the tendency to lead to their being unable to stick to a pattern of
regular eating. If patients seek advice on what they should be eating, they
should be told that the onus is on planning regular eating and adhering to
the plan, without any form of compensatory behavior, such as vomiting,
spitting, or laxative misuse. Following meals or snacks with purging is
“against the rules.” Although the priority is their pattern of eating rather
than what they eat, some guidance can be given regarding adopting a varied
diet with the minimum number of avoided foods if called upon to do so.
Calorie counting, especially keeping a running total, is to be firmly
discouraged.

• Patients should rely on time and the behavior of others, rather than
feelings of hunger or fullness, to indicate when to eat. In Western societies, the
majority of people eat at set times or together with other people, regardless
of whether or not they are hungry. Furthermore, the way that they have been
eating will have almost inevitably disturbed patients with an eating
disorder’s perception of hunger. Once patients have been eating regularly
(without purging) for several months, their sense of hunger and fullness will
return to normal, but even then it is better that they not rely on these
sensations as indicators of when to eat.

• Certain forms of social eating need particularly careful planning. For

instance, if the choice of what to eat is likely to be limited (as in a dinner
party at a friend’s house), or vast (at a buffet), the patients should be advised
not to get overwhelmed. Instead, they should assess what food is available,
and take a little “time out” (e.g., by going into another room) dedicated to
planning what and how they are going to eat in order to stick to their regular
eating pattern. In addition, patients at risk of overeating should be cautioned
to put down their cutlery and plate as soon as they have finished their first
helping at a buffet.

• A regular eating pattern may need to be introduced in steps. Patients

whose eating habits are chaotic or highly restrictive may need a stepwise
introduction to regular eating, which may take several weeks to master. In
such patients, regular eating should first be introduced to the part of the day
when their eating causes the fewest problems, usually the mornings. Once
this has been mastered, another section of the day should be focused on, and
so on, until a regular eating pattern spanning the entire day has been
established.

• Evening snacks are important for those prone to evening binges. For
obvious reasons, it is essential that such patients include an evening snack in
their regular eating plan.

Item 2: Not Eating between Meals and Snacks

Two rather different strategies may be used to help patients resist eating
between the planned meals and snacks. is procedure is mainly used in
patients with binge-eating episodes, or those who tend to eat many small
meals throughout the day.

1. Countering the urge. is involves engaging in distracting activities

that make binge eating less likely. is needs to be done for 3–4 hours at
most, by which time the urge to eat is likely to have waned and, in any case,
the patients will be due to eat. We advise patients to create, in advance, a list
of possible incompatible activities to have on hand when faced with a strong
urge to eat. Suitable activities are:
Interpersonal activities (e.g., chatting or visiting with friends, being
with a friend).
Getting out of the situation (e.g., going outside for a walk).
Changing the atmosphere (e.g., playing music incompatible with
binge eating).

2. Riding out the urge (urge surfing). In this way, patients learn to
decenter from the urge and observe it dispassionately rather than try to
eliminate it. As with feelings of fullness, they will find that the urge generally
dissipates within a few hours.

While the first of these strategies can be used in the early stages of
treatment, the second tends to be more difficult for most patients, at least at
this stage. It is therefore generally best le until later on, when urges to eat
between meals and snacks are intermittent and less overwhelming.
Figure 8.3 shows the monitoring record of patients implementing the
regular eating procedure. As you can see, the patient planned ahead
(“Today’s plan”) when, what, and where to eat, using the first three columns
of the monitoring record. en, under the line, she used the same sheet to
monitor in real time.
FIGURE 8.3. An example of a monitoring record of a patient who is applying the regular eating
procedure.

Common Difficulties in Implementing Regular Eating

e most common difficulties reported by our patients in establishing the
regular eating procedure follow:

• “Knowing in advance what I’m going to eat increases my concern about

eating. I want to be more free and spontaneous.” In this event, the therapist
should ask the patients whether they truly feel free and spontaneous when
they don’t plan ahead. To this end, when reviewing the monitoring records,
it can be useful to analyze whether the regular eating of meals and snacks
has been conditioned by the patient’s concern, emphasizing that perhaps
being spontaneous this early on in therapy is an unrealistic and premature
goal. e therapist should reiterate that the procedure of regular eating is,
however, temporary and, in addition to reducing the frequency of binge-
eating episodes or feeling full, it will provide information on the relationship
between eating and weight, which can reduce concern about both. In fact,
the procedure was designed to enable patients to learn to eat without being
concerned about eating, and patients should be firmly encouraged to follow
it. It is also useful to reassure the patients that the ultimate goal of the
therapy is to help them become more spontaneous and eat freely, but this
will only be feasible when concerns about eating have been reduced.

• “Planning in advance does not work; when I don’t stick to my eating plan,
I binge.” is objection is a good example of “black-and-white” thinking. It is
common for patients to interpret even the smallest deviation from the eating
plan as a “failure,” and to consider the whole day ruined. is kind of
reaction should be countered by the therapist highlighting the phenomenon,
and providing education on the dangers of an “all-or-nothing” approach.
e patient should be advised that varying degrees of compliance with
regular eating are possible, and the therapist may decide to introduce a
rating system, whereby the patient rates each day’s compliance on a scale
from 0 to 5.

• “I have never eaten five times per day, and neither do my family or
friends.” If a patient does voice this objection, the therapist should have a
ready response. is should be something to the effect that adopting a
regular pattern of eating will provide a foundation for the other changes that
need to be made, and will help patients to overcome their eating disorder.
Once this has been achieved, they will be able to decide exactly how they
eat, but while treatment is underway it is in their best interests to stick to a
regular eating plan. ey should also be educated that, physiologically
speaking, eating regular meals and snacks is healthy. Of note, breakfast may
become an issue with some patients who fear being unable to stop eating if
they begin so early in the day. However, this idea can be tested by adopting
regular eating on a trial basis, at which point patients should see that their
fear was groundless and become more compliant.

• “I don’t want to eat so many meals and snacks; it’ll make me put on
weight.” ese patients should be reassured that this seldom happens, as they
do not have to change what or how much they eat. In patients who binge-
eat, the therapist should also take care to emphasize that regular eating
reduces binge-eating frequency, and, as a consequence, will significantly
decrease how many calories they are consuming overall, because even if they
vomit, they absorb a significant amount of energy through bingeing (see
below). Even if reassured in this fashion, patients will commonly opt for
low-calorie meals and snacks. At this stage, this should be allowed, as the
focus is on when patients eat, not what or how much.

• “I feel full even aer eating relatively little.” is is a common problem,
and may trigger the urge to vomit or take laxatives aer eating. Feeling full is
especially strong in underweight patients, as a consequence of the delay in
gastric emptying seen in chronic undereaters. However, it is important to
reassure patients that this feeling generally subsides within an hour, and that
once a pattern of regular eating is in place, the propensity to feel full
gradually declines. (See “Addressing Feeling Full” in Chapter 11 for an in-
depth discussion of feeling full.).

• “Distraction activities are a waste of time.” Patients may express their

belief that “putting off ” eating will only delay inevitable binge eating. As this
is not at all the case, the therapist should explain to the patients the benefits
of “urge surfing” (i.e., learning to resist the urge to eat between planned
meals and snacks). ey should be told that doing so is a great achievement,
which is not discounted by any further urges to eat later on in the day.
Instead of focusing on daily goals, they should work from hour to hour
between set meals and snacks in order to establish a stable pattern of eating.
 Aer having described in detail the procedure of regular eating and
addressed all of the patients’ concerns, it is advisable to give patients a short
handout on regular eating (see Table 8.1) and ask them to read the part of
the book Overcoming Binge Eating, Second Edition (Fairburn, 2013) that
describes the procedure in detail.

TABLE 8.1. Patient Handout on “Regular Eating”

Eating regularly is the foundation on which other changes are built. The benefits of regular
eating are:
Providing structure to eating habits and to the day.
Addressing one of the three forms of strict dieting (i.e., delayed eating; the other two are
eliminating foods and reducing portions).
Interrupting the cycle of binge eating and dietary restriction.
In people who are underweight it can help to improve gastric function and to reduce the
early sense of fullness.

To eat regularly, it is necessary to adopt two behaviors:

1. Eating at regular intervals throughout the day (not greater than 4 hours apart). You will
need to plan in advance three meals plus two or three snacks to be eaten at set times,
for example:
Breakfast (8:00).
Midmorning snack (10:30).
Lunch (1:00).
Afternoon snack (4:00).
Evening meal (7:00).
Evening snack (10:00)
2. Not eating in the gaps. Points to keep in mind:
Eat planned meals and snacks, but do not eat between them.
Do not skip the planned meals and snacks.
Do not go more than 4 hours without eating.
Always know when and what to eat at the next meal or snack.

Note: If an unforeseen circumstance prevents you from sticking to your planned meal and
snack times, you should be flexible and adapt your mealtime to the situation. Being able to
adapt to these unforeseen circumstances will make it possible to manage the various
situations in the future requiring a modification of the usual meal and snack time (e.g., work,
holidays, dinner invitations). It is important not to skip any meals or snacks, even in the
event of unforeseen circumstances.

From Cognitive Behavior erapy for Adolescents with Eating Disorders by Riccardo Dalle Grave and
Simona Calugi. Copyright © 2020 e Guilford Press. Permission to photocopy this material is
granted to purchasers of this book for personal use or use with patients (see copyright page for
details). Purchasers can download enlarged versions of this material (see the box at the end of the
table of contents).
 INVOLVING PARENTS

With adolescent patients, parental involvement may be extremely useful in

terms of establishing regular eating. Hence, aer the therapist has explained
the rationale and practical aspects of the regular eating procedure to the
patients, and the patients have agreed to apply the procedure, this is an
aspect that needs to be discussed. e parents are involved only if both the
therapist and the patient think parents can be of help to facilitate
implementation of regular eating. If so, the therapist calls the parents in at
the end the session and, in the presence of the patient, provides the same
information previously discussed on the rationale behind and importance of
the regular eating procedure. In short, the parents should be told that the
intervention is fundamental to successful treatment as it is the foundation
upon which other changes are built, and its positive effects should be
conveyed. Specifically, in adolescents who are underweight, it addresses
infrequent or delayed eating, a form of dieting that is common among such
patients. It also helps to reduce the common propensity to feel full
associated with dietary restriction, and oen lessens the degree of
preoccupation with food and eating aer a few weeks. For patients who
binge, on the other hand, it helps to reduce the frequency of such episodes.
e therapist explains that the procedure has two components: (1) eating
three planned meals each day, plus two or three planned snacks, and not
eating between these, and (2) that the focus at this stage of the treatment is
not to increase the amount of food the patient eats and regains weight (if
applicable) but to establish a pattern of regular eating. en, the rest of the
session should be dedicated to discussing the parents’ role in supporting the
patient’s regular eating efforts. Specifically, parents are given advice about
their behavior around mealtimes, as follows:

Leave the patient free to plan what to eat, but ensure that the kinds of
food and drink the patient plans to eat are available.
 Work with the patient to prepare joint meals following the written plan
devised by the patient.
Gently encourage the patient to sit at the table if she or he is hesitant to
eat at the planned time.
Try to eat most meals with the patient.
Avoid urging the patient to eat more than planned.
Create a positive atmosphere by avoiding discussions about food and
arguments during meals.
Be supportive and not coercive. In difficult situations during meals,
empathize and use supportive phrases (e.g., “We know that the process
toward recovery is hard, but we are here to help you. Try to stick to
your plan, without being influenced by what you think or feel”).
Help the patient to practice distracting activities aer eating to help her
or him to control the urge to resort to compensatory behaviors.

We usually schedule another joint session with the patient and the
parents aer 1 week to discuss any difficulties in applying the regular eating
procedure that emerged. If there are no such difficulties, a new joint session
is scheduled to discuss how the parents can help the patient to eat the meals
designed to achieve weight regain, if applicable. is should be done at the
beginning of Step Two, or at the end of Step One if the patient decides not to
embark on Step Two. In the event of serious difficulties during meals,
however, the therapist may decide to schedule additional joint sessions
during Step One.
VIGNETTE
e patient is 17 years old and, according to the DSM-5 diagnostic classification, suffering from
anorexia nervosa, binge–purge type. In her monitoring records, she reports that during meals her
parents oen remind her not to overeat in order to avoid the onset of negative emotions and the
use of compensatory vomiting. However, she tends to react angrily to these comments, and
invariably ends up eating more than what she had planned. In the joint session, the therapist
educates the parents by illustrating the maintenance mechanisms included in the patient’s
personal formulation—specifically, that it is extreme and inflexible dietary rules rather than poor
control over eating that lead to binge-eating episodes. e therapist also discusses with the
parents the effect of their comments about eating control during meals, and all conclude that they
 are an important trigger of the patient’s negative emotions and binge eating. Finally, the therapist,
parents, and the patient discuss how to create a warm, positive atmosphere at mealtimes. e
parents also agree to serve the food as single dishes, like in a restaurant, rather than filling the
table with food, to facilitate their daughter’s eating control, and to spend 1 hour doing activities
with the patient aer meals in order to help her distract herself from the urge to vomit.

CONFIRMING THE HOMEWORK, SUMMARIZING

THE SESSION, AND ARRANGING THE NEXT
APPOINTMENT

ere are generally three pieces of homework at the end of Session 2:

1. Continuing real-time recording.

2. Refraining from weighing at home.
3. Establishing regular eating.

We also ask patients to read the part of the book Overcoming Binge
Eating, Second Edition (Fairburn 2013) that describes in detail how to apply
the regular eating procedure. en the therapist should conclude the session
by summarizing the content, reiterating the homework, and arranging the
next appointment.
 CHAPTER 9

Deciding to Change

STRUCTURE AND CONTENT

Having completed the first three sessions of Step One as described, most
patients should:

Be reasonably engaged in treatment and the prospect of change.

Understand and accept the provisional formulation.
Be getting adept at real-time recording.
Be accepting of “weekly weighing” and all that this involves.
Have established the regular eating procedure.

All the sessions from here on in are structured as follows (the

approximate duration of each element is shown in parentheses):

1. In-session weighing (in one of the two weekly sessions, up to 5

minutes).
2. Reviewing the monitoring records (about 10 minutes).
3. Reviewing the EPCL (on the same day as in-session weighing, up to 5
minutes).
4. Collaboratively setting the agenda for the session (a few minutes).
 5. Working through the agenda and agreeing on homework tasks (up to
30 minutes).
6. Summarizing the session, confirming the homework assignments,
and arranging the next appointment (up to 5 minutes).

Adhering to this structure makes the sessions efficient, and enables

implementation of the two key procedures of CBT-E (i.e., in-session
weighing and reviewing the monitoring records) efficiently. e content of
the central part of the session will vary, as it is dictated by the patients’
individual psychopathology, the strategies and procedures introduced, and
the progress achieved by the patient.
e remaining sessions of Step One have two new goals:

1. Helping the patient decide to change and to address weight

restoration (if appropriate)—this is the topic at the top of the agenda
in every remaining session of Step One.
2. Addressing eating style and/or extreme weight-control behaviors (if
applicable).

ese new goals are integrated with psychoeducation and the procedures
introduced in the first three sessions of Step One (i.e., updating the personal
formulation, self-monitoring in real time, in-session weighing, and regular
eating).

REVIEWING THE EPCL

e EPCL (see Appendix D), as previously described, is a 16-item self-

report measure that we ask the patients to complete aer reviewing their
monitoring records. is questionnaire allows both the therapist and the
patient to collaboratively assess weekly progress in the main features of the
eating disorder, and, if necessary, to update their personalized formulation.
is is especially important given that rapid changes in psychopathology are
observed in some adolescents (the so-called sudden gains), and these seem
to be associated with improvements in both therapeutic alliance and
outcomes (Tang et al., 2005).
In order to fulfill their end of the “deal,” therapists should always try to
identify any problems in the patients’ engagement and their use of the
treatment procedures promptly, identifying and addressing the underlying
reasons at the earliest opportunity. e EPCL permits detection and
reinforcement of the positive changes achieved by patients, and at the same
time enables the therapist to draw the patient’s attention to the eating-
disorder features that need to be addressed and any emerging obstacles to
change. However, it is important to bear in mind that adolescent patients
oen have a negative view of their progress. Hence, the therapist should also
be sure to use the changes in the EPCL scores to help patients arrive at a
balanced assessment of what they have in fact achieved. In order to
stimulate patients to play an active role in the treatment and to apply the
procedures of the program, the EPCL includes a question about the “days of
change” achieved by the patient. is can be used as a measure of the days in
which the patients did their best to change using the treatment procedures—
efforts that should be praised by the therapist. Indeed, it is important for the
therapist never to forget to congratulate patients on their achievements, and
to attribute the changes they have achieved to them alone. It is also a good
idea for the therapist to discuss with patients what they think has helped
them make progress, so as to reinforce the therapeutic procedures already
adopted.
By entering EPCL data into the EPCL summary spreadsheet of weekly
changes (see Appendix D), both the therapist and patient can easily observe
the features of the eating disorder that have changed and those that have not.
It also makes it clear how, aer a few weeks, changes in certain behaviors
(e.g., in-session weighing once a week and regular eating) have produced
changes in certain attitudes (e.g., a reduction in weight and eating concerns).
Nonetheless, a formal joint review of treatment progress should be
performed at the end of Step One (and, if necessary, periodically during Step
Two) to reiterate achievements to date, identify emerging obstacles to
change, and plan the rest of the treatment.

HELPING PATIENTS DECIDE TO CHANGE

is procedure is mainly used in Step One with adolescent patients who are
underweight. It may also be necessary for patients who have lost a
significant amount of weight, even if their weight remains within the healthy
range (i.e., those who receive a DSM-5 diagnosis of atypical anorexia
nervosa). e goal in CBT-E is that patients make the decision to regain
weight rather than having this decision imposed upon them.
e question is how to achieve this. Treatment up to this point (around
Session 3 or 4) has been designed to prepare the ground for what will be a
detailed discussion of the pros and cons of change. e therapist should
directly address the topic and put it at the top of the session agenda for a
series of successive sessions (oen four or more). is is a delicate part of
Step One, in which it is necessary to show empathy for both the patients’
difficulties in considering their low weight as a problem and understanding
of their ambivalence to change. At the same time, it is essential that the
therapist express her or his belief in the patient’s ability to change. e
intention is that the patients become intrigued by the benefits of change, and
see treatment as an opportunity to make a “fresh start” in life. is process
requires the measured and careful application of the following five steps:

1. Focusing on the present by creating a current pros-and-cons-of-

change table (in one session).
2. Focusing on the future by creating a future pros-and-cons-of-change
table (in the next session).
3. Creating a third table detailing their conclusions.
4. Helping the patient identify and accept the implications of these
conclusions.
 5. “Taking the plunge.”

The Present
Adolescent patients should be asked to consider their reasons for and
against change. It should be made clear that change will involve overcoming
the eating disorder, and that if they are underweight, this will eventually
require that they regain weight. Indeed, one of the desirable outcomes of
CBT-E for underweight patients is that they achieve a weight above the
minimum threshold of the 25th BMI-for-age percentile, as this is generally
the weight required to be free from the adverse effects of being underweight.
It is best to start discussing the advantages and disadvantages of change
by asking patients to list all the reasons why they do not want to change or
are afraid to do so. ese reasons should then be entered in a current pros-
and-cons-of-change table. It is important to acknowledge that many
adolescent patients view being underweight as providing something positive
that they fear losing. Once the “cons” of change have been listed, the focus
should shi to the patients’ reasons for taking this opportunity to change,
which should also be listed in the table. Patients should be helped to identify
personally salient adverse effects specific to their age (e.g., school, friends,
vacations, sport activities). All aspects of life should be considered,
including relationships with others, physical and psychological well-being,
school performance, and the ability to engage in other valued activities. As
part of the process of considering the pros and cons of change, the therapist
should stress that it is normal to be of two minds about changing (if this
indeed appears to be the case).
A typical current pros-and-cons-of-change table is shown in Table 9.1.
Patients should take home a copy and be asked to reflect upon it before the
next session, when the table should be reviewed, focusing on any
modifications that the patients have made to it. At this stage, it is not
necessary to question the content of the table.
TABLE 9.1. Examples of a Patient’s Current Pros and Cons of Change
Reasons to stay as I am
I feel strong and special.
I like to be thin and think that compared to
others I am small.
Sometimes I feel so beautiful because I am
thin.
If I change:
Others will think I am getting fat.
I will not be so thin.
My legs, hips, arms, stomach, and face
will get big again.
I will not feel comfortable in all kinds of
clothes.
I will be in awe of the girls who are thinner
than me.
Others will think that I eat too much.
Reasons to change
I will not be able to fit in all of my clothes.
I would not be tired and would sleep better.
I would stop being cold.
I would be able to take up dancing again.
I would be less unhappy.
I would be able to go out to eat with my
friends.
I would be less obsessed with food.
My parents would be less sad and angry
with me.

The Future
When discussing the future, the therapist needs to focus primarily on the
more immediate future (6 months to a year), and emphasize those adverse
effects that are likely to motivate the young person (e.g., missing school for a
protracted period, not being able to sit for important exams, go on a trip
abroad, or go to college). Of course, although young patients tend to give
more importance to the immediate future, longer-term adverse effects of the
disorder should not be entirely omitted from the discussion. Here are some
questions that the therapist might ask adolescent patients:

“Imagine having a time machine and the possibility to travel to a not-

too-distant future—for example, 6 months or 1 year ahead. What do
you imagine that your life will be like? Do you have any plans for the
future? What are they?”
“How would you like to spend the summer? With whom? Would you
like to take a trip?”
“What about school? What about your relationships with your
classmates and teachers? Would you like to go on a school trip? Do
 you feel that you will be able to go? What about your exams at the
end of high school? What about going to college?”
“Would you like to have interests outside of school? If so, what are they?”
“What sort of relationships would you like to have with other people?
What about friends and social life? What about relationships with
your family? What about romantic relationships?”
“What sort of person would you like to be? How would you like to feel
about yourself? What sort of values would you like to have? What
would you like to be important to you?”
“Do you think that staying in a persistent state of malnutrition might
interfere with these things?”

Patients should be asked whether they have considered how the eating
disorder would affect their plans and aspirations. Usually, adolescent
patients have not thought about this. e therapist should therefore explain
what is likely to happen to their eating disorder if they decide not to change,
pointing out that much is known about the course of patients who are
underweight—briefly, in patients with an established eating disorder, the
problems are very likely to persist. While the disorder may remain
unchanged, a much more likely outcome is the development of binge eating
accompanied by uncontrolled weight gain. Indeed, up to 90% of such
patients start binge eating, and up to a half develop typical bulimia nervosa.
In other words, they lose control over their eating—an outcome that
represents these patients’ worst fears. Once this information has been
presented, patients should be reminded of their plans and aspirations, and
asked to consider how they would be affected by continuing to have an
eating disorder.
A future pros-and-cons-of-change table should be constructed; a typical
one is shown in Table 9.2. is table usually differs from the first. Once
more, patients should take home a copy of the table and modify it as needed
before the next session.
TABLE 9.2. Examples of a Patient’s Future Pros and Cons of Change (from the
Perspective of 1 Year’s Time)
Reasons to stay as I am
I feel strong and special.
I like to be thin and think that compared to
others I am small.
Sometimes I feel so beautiful because I am
thin.
If I change:
Others will think I am getting fat.
I will not be so thin.
My legs, hips, arms, stomach, and face
will get big again.
I will not feel comfortable in all kinds of
clothes.
I will be in awe of the girls who are thinner
than me.
Others will think that I eat too much.
I will not be able to fit in all of my clothes.
Reasons to change
I want to be free.
I want to finish the school year.
I want to go out with my friends and to
parties.
I want to eat without anxiety and fear.
I don’t want to be tired and cold or have dry
skin.
I want to be physically fit.
I want to take up dancing again.
I want my parents to be happy and not sad
for me.
I want to be a sunny person like I was
before the eating disorder.

Drawing Conclusions
e following step involves a detailed point-by-point discussion of the
content of the current and future pros-and-cons-of-change tables. During
this discussion the therapist should ensure that patients are focusing on the
likely impact of not capitalizing on the current opportunity to change their
short-term aspirations. While doing this, it is best to reinforce and, if
appropriate, expand upon their stated reasons for change. ese should
never be neglected since the benefits of no longer being underweight and
overcoming the eating disorder cannot be overstated. A patient’s individual
reasons not to change should also be explored in some detail. A transcript in
which the therapist discusses one of the “cons” of change reported by a
patient, as an example to illustrate how the discussion might best be
conducted, follows. In this case, the patient expresses a fear of being teased
about her shape and weight, as this had happened to her in the past, before
she lost weight.
THERAPIST: You wrote in the table that you are afraid of regaining weight
because you will be teased about your body, as you experienced in
the past.
PATIENT: Yes, that’s right!
THERAPIST: Can you explain?
PATIENT: I feel bad just thinking about it.
THERAPIST: I understand. I know it’s difficult for you, but I really would
like to understand better.
PATIENT: Well . . . at middle school a small group of boys made fun of
me, calling me “barrel.” (Starts to well up with tears.)
THERAPIST: (passing the tissues) Oh dear. at must have been terrible.
PATIENT: Yes, it was.
THERAPIST: Were these guys your classmates?
PATIENT: Two of them were in my class, the others weren’t.
THERAPIST: Did they tease anybody else?
PATIENT: Yes, they did . . . about how they dressed or because of their bad
grades.
THERAPIST: What did your classmates and teachers think about these
kids?
PATIENT: Not much. e teachers constantly scolded them, and the other
kids tended to avoid them. However, when they teased me, no one
ever said anything. In fact, some of them laughed.
THERAPIST: Did this teasing happen oen?
PATIENT: Yes. Every time I saw them they were always laughing at me.
THERAPIST: Have you ever talked to anyone about this?
PATIENT: Yes, I spoke with my mother. She advised me to avoid them and
stay with other people. But that wasn’t possible . . . they were at
school with me.
THERAPIST: Of course. Now, do you still have contact with them?
PATIENT: No.
THERAPIST: What are things like now with your classmates?
PATIENT: A little better with some, less with others, because they are so
superficial.
THERAPIST: In your opinion, is there any reason to think that your
classmates will tease you if your weight changes?
PATIENT: Some. I heard some girls talk about how they have to pay
attention to their eating, and once I heard them describe a girl as
“big.”
THERAPIST: By any chance, have any classmates made comments about
your current weight?
PATIENT: (Lowers her eyes and does not respond.)
THERAPIST: I’m sorry. Is that a painful question?
PATIENT: No, it’s because . . . some have asked me why I don’t eat.
THERAPIST: How did you feel about this comment?
PATIENT: Very uncomfortable.
THERAPIST: I understand. Why do you think they asked about your
eating?
PATIENT: I think that they asked me why I don’t eat because they think I
don’t eat enough. (Keeps looking down.)
THERAPIST: I see. In your opinion, what would they think if you were to
regain weight?
PATIENT: I think they would probably be pleased . . . but they are thin.
(Annoyed.)
THERAPIST: OK. What would the fact that they would look positively
upon it mean for you?
PATIENT: (Doesn’t respond.)
THERAPIST: I’m sorry. I know that it is hard for you to talk to me about
this. I appreciate the effort and I hope you don’t think I’m being too
intrusive. I think it is important that we address this topic. May we
proceed?
PATIENT: OK.
THERAPIST: Is it possible that your classmates are worried about your
diet?
PATIENT: Yes, it is possible.
THERAPIST: What does this mean to you?
PATIENT: Umm . . . I’m not sure!
THERAPIST: Is it possible that they are interested in you as a person,
regardless of your weight?
PATIENT: Maybe.
THERAPIST: Would you like to get closer to them?
PATIENT: I don’t know whether I can trust them.
THERAPIST: I understand . . . especially aer what happened to you in the
past. However, don’t you agree that we can find out how trustworthy
someone is only by getting to know her or him?
PATIENT: (Nods.)
THERAPIST: I really appreciate your effort in telling me about this episode.
Now, I would like us to summarize what you have told me and then
reflect on it. I think that what happened to you is really terrible. We
know that this type of teasing is one of the most negative experiences
that can happen to a person of your age, because it can damage your
self-esteem. Bearing this in mind, I would like us to discuss how you
feel about yourself at present, and how you envision your future.
PATIENT: OK.
THERAPIST: It seems that your current weight allows you to avoid any
criticism about your body. It is understandable to want this. But I
would also like you to reflect on the negative effects of keeping your
weight so low in the long term, only to reduce the risk of being
laughed at. Are there some potential negative effects that you can
think of?
PATIENT: Perhaps . . . maybe the effects of being underweight that we
discussed?
THERAPIST: Yes . . . and how does it make you feel about yourself?
PATIENT: Umm . . . I don’t know . . . I feel OK at the moment because
nobody tells me that I am fat.
THERAPIST: at is true . . . but don’t you think that avoiding a normal
weight and continuing to ascribe excessive importance to your
weight, in your opinion of yourself, has, in part, been influenced by
the effect of the criticism you’ve received in the past?
PATIENT: Well . . . yes, you’re right.
THERAPIST: I see. But don’t you think that you will always have to live
with the negative effects of being underweight, which, as we have
seen, prevent you from being free and spontaneous, as well as
stopping you in building relationships and engaging in activities that
could help you develop a different, more balanced way of evaluating
yourself? Is maintaining a low weight not a way of continuing to give
power to the unkind words of your classmates? Deciding to change
could give you the chance to finally silence those guys instead.
PATIENT: (Remains silent for a few seconds.) But I’m terrified of how I will
end up, because the only thing I can do well is control my eating and
weight.
THERAPIST: I understand what you are saying, and it is logical for you to
feel that way, because your eating problem does not allow you to do
anything else. Addressing the change doesn’t only mean regaining
 weight, but also developing a more balanced way of evaluating
yourself, a way that is not predominantly dependent on your shape
and weight, and the fear of your appearance being judged by others.

Note that, as always in CBT-E, careful attention should be paid to

patients’ use of words. Also note that throughout these discussions, the
therapist should adopt a genuinely inquisitive questioning approach, rather
than the more challenging style of questioning that Socrates would have
approved of. is style should also be adopted to inquire about the other
disadvantages of change reported by patients, with the aim of helping them
to develop alternatives to their concerns and to think about change as a
positive opportunity. A list of some of the most common reasons for not
changing, together with suggested responses that should be given in the
“so” style described above, follows:

• “It makes me feel in control.” e therapist should explore whether the

patients are truly “in control” or whether that is, in actual fact, a fallacy. To
this end it may be useful to ask the patients whether they would be able to
choose not to restrict their eating for a few days. e therapist should help
the patients to understand that if they would be unable to do so, this
indicates that their need to restrict their eating is out of control,
emphasizing that the goal of the treatment is for them to gain true control
over their eating.

• “It gives me an excuse not to deal with other aspects of life.” e therapist
should explore what the patients mean by “an excuse.” Generally, this
involves something to do with avoiding the need to meet their own, or their
parent(s)’, expectations. If this is the case, the patients should be helped to
evaluate whether they really need to be sick, and experience all of the
negative consequences of their eating disorder, just to avoid the fear of
failure, and whether it would not be more constructive to moderate their
expectations and obtain the benefits of change. It may also be useful to say
that, as therapists, we are constantly amazed by how able and competent our
patients become once they have recovered from their eating disorder.

• “It makes me feel special.” e therapist should explore what the patient
means by being “special.” is oen refers to receiving attention from others
(e.g., parents, friends). If this is the case, the patients should be helped to
understand that this positive effect is generally temporary, and tends to
wane over time, especially if they do not recover from the eating disorder.
During this discussion, the therapist should maintain a warm demeanor,
reassuring the patients by emphasizing that the treatment will help them
find less damaging ways of getting attention from others, as well as regaining
weight (if necessary). e patients should also be helped to assess whether it
is truly “special” to have an eating disorder, by analyzing the level of their
impairment.

• “I don’t know who I would be if I didn’t have an eating problem.” In

patients who are underweight, the therapist should remind them once again
that the effects of being underweight masks their personality; all people who
are underweight are very similar, being preoccupied with thoughts about
food and eating, inflexible and indecisive, socially withdrawn, and so on. In
other words, they have lost their specialness, and only if they regain weight
will their true personality shine through.

• “It makes me feel safe.” What a patient means by “safe” needs to be

explored. Usually this simply means not risking change (i.e., sticking to the
familiar).

• “If I change, people will think that I am weak and that I have given in.”
Here a patient is projecting her or his own view onto others. e reality is, of
course, quite different. In this case, the therapist should help patients to
understand that rather than viewing them as “weak,” people will think that
they are showing great strength by tackling their eating disorder. It is also
worth pointing out that for the patient, not eating is easy, whereas eating is
difficult, and therefore a worthy challenge.

• “If I start to eat more, people will think I’m greedy.” Again, the patient is
projecting her or his own view onto others. What the patient means by
“greedy” should be explored. Greed refers to an excessive appetite for food,
and patients should be helped to understand that this is quite different from
ceasing to undereat, especially in someone who is significantly underweight.
ey should understand that people will view the fact that the patient is
eating as evidence of willpower and determination, not greed.

• “If I change, I won’t be able to stop eating.” is is a cue to discuss the
fact that as matters stand, patients are more at risk of binge eating, and that
with treatment this risk will progressively decline. Here, it is also useful to
reiterate that treatment will give the patient true control over eating.

• “If I change, my weight will shoot up.” is concern is addressed as

above, as weight cannot “shoot up” if patients are effectively in control of
their eating. In reality, weight regain is very difficult—a point that is
expanded upon once the patients have decided to regain weight, but can be
made now if applicable. It may also be useful to explain at this point that
weight regain is associated with an increase in basal metabolic rate and daily
energy expenditure. is means that patients can eat a lot more than they
think without gaining weight. In contrast, when patients are underweight,
their energy expenditure is very low, and it is always necessary to eat very
little to avoid weight regain.

• “I feel good at this weight. I have no problems.” e therapist should ask

underweight patients whether they are really sure they feel good. It may be
useful to ask patients whether they would advise their friends or relatives to
get to their weight. If, as oen happens, the patients say no, the therapist
should ask why not. Patients should also be asked how they intend to
eliminate the effects of being underweight while remaining underweight,
and, given that they are experiencing these effects, can they really say that
they feel good, with no problems?

• “Staying as I am will ensure that I don’t get fat.” is is true, but patients
should be helped with kindness to understand that they are, in reality,
emaciated, or at risk of becoming so (as applicable). Is keeping oneself
emaciated a good way of avoiding becoming “fat”? e goal of treatment is
for patients to develop true control over eating, and thereby their shape and
weight as well, at least to the extent that it is possible to control them.
erefore, it is most unlikely that the patient would become “fat” in the
normal sense of the word, and the data on the outcomes of underweight
CBT-E patients support this. On the other hand, continuing to restrict
eating and remaining underweight increase the risk of binge eating and
consequent uncontrolled weight gain. Note that patients’ use of the term
“fat” should always be questioned. Underweight patients are not at risk of
obesity or being fat. is can be highlighted using the patient’s weight graph
as a reference.

• “e 25th BMI-for-age percentile threshold is too high for me.” e

therapist should say to patients that if they did not consider this threshold
too high, they would probably not be following a treatment for an eating
disorder. In reality, a 25th BMI-for-age percentile is the minimum threshold
for a healthy weight. It corresponds to weight that in most cases can be
maintained without a diet that is too restrictive, is not associated with the
symptoms of being underweight, and permits a healthy social life—three
necessary conditions for overcoming an eating disorder. However, the
patients should be reassured that through the treatment, which includes
numerous dedicated strategies and procedures, they should gradually come
to accept this threshold.

• “If I change, my thighs will get fatter.” e underweight patient’s thigh

muscles will currently be wasted. With weight regain, patients’ bodies will
change from being emaciated to being “bony,” then “skinny,” and eventually
“slim” or “thin”—the notion of becoming “fatter” (in the usual meaning of
the word) simply does not apply. What also needs emphasizing is that
patients may see parts of their body as larger than they really are. As
explained in Chapter 12, this appears to be due to the way that patients look
at themselves and is addressed later on in treatment.

• “If I change, people will think that I am getting fat.” is is another
projection of the patient’s own view. On the contrary, others will be relieved
to see her or him trying to regain weight and becoming less emaciated.

• “If I change, people will think that I am less attractive.” Again, this is a
projection of the patient’s own worldview and another untested assumption.
It is most unlikely that anyone would have viewed her or his emaciation as
attractive—rather, most people view a healthy body shape as attractive. In
this context, it can be useful to ask patients whether they would be
comfortable being seen naked (or wearing a bathing suit). Most
underweight patients realize deep down that their bodies do not look good.
Once more it is worth pointing out that one goal of treatment is to help the
patient regain sufficient weight to become “thin.” As matters stand, the
patient is a long way away from thinness. It can also be helpful to explore the
meaning of “attractiveness” by asking patients to consider the variety of
features that contribute to this attribute. ese are likely to include other
aspects of appearance (complexion, hair, etc.) and nonphysical attributes,
such as being entertaining, cheerful, interesting, sociable, chatty, relaxed,
caring, and so on. e goal is for it to become clear to patients that, in terms
of attractiveness, body shape is just one aspect, and that they have much to
gain from getting better.

• “First I want to solve my psychological problems and then I will regain

the weight.” Referring to their personal formulation, the therapist should
help patients to understand that it is impossible to solve psychological
problems while remaining underweight, because undereating and low body
weight impair psychological functioning and intensify the need to control
eating. However, it should also be stressed that the treatment will address
not only weight regain but also the psychological processes that maintain
the eating disorder.

is exploration and examination of patients’ reasons not to change

should not be hurried, and may take several sessions. Between these
sessions, patients should be encouraged to think more about what has been
discussed and raise any further concerns or questions they may have. ey
may be defensive about certain aspects of the eating disorder that they
particularly value. It is important that therapists have a good understanding
of these concerns so that patients feel understood, valued, and respected.
Eventually, aer all the patient’s concerns have been fully discussed, a
conclusions table should be drawn up (see Table 9.3).

TABLE 9.3. Pros and Cons of Change: An Example of a Patient’s

Conclusions
I want to get better and regain weight because . . .
1. I will be healthier. I will not be tired and will sleep better. I will stop being
cold. My periods will come back.
2. I will be happier and a sunny person, like I was before the weight loss.
3. I will be less obsessed with food.
4. I will be able to take up dancing again.
5. I will be able to go out to eat with my friends.
6. I will finish the school year.
7. My parents will be less sad and angry with me.
8. I will become slim and healthy. I will not become fat.
9. I will eat without anxiety and fear, and I will be able to have true control of
my eating. This will protect me from overeating and gaining weight without
control.

Taking the Plunge

Next, the full implications of this extended and highly personalized
discussion need to be brought into focus. In practice, this happens naturally,
and patients gradually begin to admit that being underweight has some
negative consequences. ey may also begin to consider the possibility of
regaining weight. At a certain point, although not on the first occasion this
happens, the therapist should acknowledge and confirm the patient’s views
by stating something along these lines:

“It sounds to me as if you are making a decision to take this opportunity

to tackle your eating problem and make a ‘fresh start.’ at’s great!”

Confirmatory statements such as this are important, as people who are

underweight are indecisive and therefore need help making decisions—
otherwise they are prone to procrastinating almost indefinitely.
It is important to note that patients’ motivation to change waxes and
wanes, and will therefore be an ongoing issue in treatment. e therapist
always needs to keep this in mind, and motivation may need to be addressed
several times. Taking into account these patients’ indecisiveness, the
therapist should take the next step on their behalf by saying, for example:

“I suggest that it is time to take the plunge and make a fresh start. e
sooner we start, the sooner you will experience the benefits of change;
putting it off just prolongs the agony, and increases the risk of you
having long-standing problems. It’s like standing at the edge of a
swimming pool and delaying diving in because the water looks cold and
uninviting. It’s better to just get on with it. Shall we begin?”

Most patients will agree, oen with some relief. e occasional patient will
want to discuss some outstanding matters or think about it longer—
obviously, this should be respected, but at some point, the therapist might
have to say:

“We have gone over everything. ere is nothing more to say. It really is
time to make the decision to get on with it. Shall we just do that?”
Almost always this is successful. If necessary, change may be presented as an
experiment, and patients can be told that if they do not like its effects, they
can return to their old way of living aer treatment ends. is is not difficult
—indeed, it is all too easy. erapists might add that they have not come
across any patient who has actually chosen to do this. Rather, patients tend
to say that they wished they had changed sooner because their life is so
much better than it was.
Occasionally, however, at the end of this process patients decide not to
address weight restoration. In these cases, the therapist should consider
ceasing CBT-E and referring them to a different form of treatment.

ADDRESSING EATING STYLES

Unless there are obvious problems, there is no need to address the way in
which a patient eats. However, eating style does need to be addressed in
adolescents who display a tendency to overeat, as it may in fact be
contributing to this issue. Some points that are worth mentioning follow:

• Formalized eating. It is best for meals to have a clear beginning and

end, and meals at home should be eaten only when seated at a set place.

• Eating directly from packages or pans. is should be avoided—instead,

meals should be prepared and taken to their set dining place, and any
remaining food should be cleared away before patients start eating. e
availability of easy access and/or tempting food should be limited at this
point, until control over eating has been regained.

• Combining eating with other activities. It is easy to eat too much while
doing activities such as messaging, surfing the Internet, using social media,
reading, or watching television. Instead, mealtimes should be dedicated to
enjoying food, which will generally increase satiety and reduce the risk or
the perception of overeating.
 • “Grazing” or “picking” at food. Some patients have a habit of nibbling
on food between meals or snacks, or when they are preparing a meal, which
may destabilize their attempts to stick to a pattern of regular eating. is
may be countered by chewing gum at times of high risk. Other patients,
especially the underweight, may pick at their food (or that of others) rather
than eating a full meal. By doing so they can convince themselves that they
have eaten very little, and this should be addressed if it is deemed a problem,
as patients need to learn to eat normally, and to acknowledge when they are
eating meals and snacks.

• Abnormal eating speeds. is may need to be addressed if problematic,

but note that the “wolfing down” that is typical of binge eating should not be
considered an issue, as the goal is for patients to stop binge eating entirely
rather than change how they do this. at being said, rapid eating when not
bingeing may result in overeating, and patients who display this behavior
should be encouraged to moderate their eating speed, as slowing down
generally helps them control how much they eat. Strategies for slowing
eating include taking sips of water or putting cutlery down between bites,
engaging in conversation, and mimicking the eating speed of others at the
table. Likewise, it is important to address the inordinately slow and
ritualized eating seen in some adolescent patients who are underweight if it
is obstructing progress. Otherwise it can be ignored, as it tends to reverse as
patients regain weight. If it does need to be tackled, it can be useful to
involve parents, who may be able to help patients to eat their meals at a
reasonable speed (provided the patient agrees).
VIGNETTE
e patient usually takes an hour and a half to consume a meal composed of meat, vegetables,
and one piece of fruit. e therapist inquires how she would feel about the idea of completing her
meal in around 40 minutes. e patient reacts anxiously, and expresses concern that she would
still be hungry if she ate at that speed, and would be more likely to have an episode of binge eating
later on. Aer giving the patient the opportunity to reflect on the fact that an hour and a half to
consume a meal is an excessively long time, and that this behavior increased the amount of time
she spent thinking about food and eating (and likely her anxiety as a result), the therapist points
 out that, biologically speaking, 40 minutes is plenty of time for the stomach to send satiety signals
to the brain. In agreement with the patient, the therapist plans the following strategy: to reduce
each meal’s duration by roughly 10 minutes until the patient is able to complete a meal in 40
minutes. is allows the patient to observe that limiting the duration of the meal has no effect on
her hunger and, in fact, reduces her preoccupation with food and eating.

ADDRESSING EXTREME WEIGHT-CONTROL

BEHAVIORS

Addressing Purging
As explained in Chapter 1, purging, by self-induced vomiting and/or the
misuse of laxatives, may be a “compensatory” or “noncompensatory” means
of controlling weight (Fairburn, Cooper, Shafran, Bohn, Hawker, et al.,
2008). Which purging behavior a patient is engaging in will likely determine
how it is addressed. It may not be an issue if the patient exclusively practices
compensatory purging, as this is used as a means of “balancing out” specific
episodes of perceived or actual overeating, and will therefore decline as the
patient gains control over eating. Noncompensatory purging, on the other
hand, is used as a routine weight-loss strategy, as if it were a valid alternative
to dieting, and is not so closely linked to the amount of food eaten. As a
general rule, this kind of purging needs to be addressed during the
treatment.
Some patients use self-induced vomiting as a dysfunctional mechanism
for coping with upsetting events and associated mood changes. Regardless
of the type of purging behavior practiced or the function it serves, all
patients need to be educated about its effects. Table 9.4 outlines the main
points that should be covered, and Overcoming Binge Eating, Second Edition
(Fairburn, 2013) contains detailed information that patients should be asked
to read.
TABLE 9.4. Main Topics to Cover When Educating Patients about Purging
Self-induced vomiting
It is used as a compensatory behavior after an objective or subjective episode of
overeating.
It is dangerous to health (e.g., hypokalemia and other electrolyte disturbances, cardiac
arrhythmias, enlargement of the salivary glands, erosion of dental enamel on the inner
surface of the front teeth).
It requires secrecy and subterfuge and produces feelings of guilt.
It is only partially effective in eliminating the calories introduced with food because in the
vomit there are only about half of the calories taken in during a binge-eating episode.
It maintains the binge-eating episodes because a deterrent against binge eating is
undermined.

Laxative misuse
It is used as a compensatory behavior after an objective or subjective episode of
overeating and/or a routine form of weight control.
It is dangerous to health (e.g., dehydration and electrolyte disturbance).
It requires secrecy and subterfuge and produces feelings of guilt.
It is an ineffective means of eliminating the calories ingested because laxatives eliminate
only water and electrolytes.
It only produces a temporary loss of weight due to the loss of fluids (diarrhea and urine),
which are quickly replaced as soon as one drinks and eats.
If used as a compensation behavior, it maintains binge-eating episodes because, like self-
induced vomiting, it undermines a deterrent against binge eating.
It is expensive.

From Cognitive Behavior erapy for Adolescents with Eating Disorders by Riccardo Dalle Grave and
Simona Calugi. Copyright © 2020 e Guilford Press. Permission to photocopy this material is
granted to purchasers of this book for personal use or use with patients (see copyright page for
details). Purchasers can download enlarged versions of this material (see the box at the end of the
table of contents).

When going over what the patient has read, the points in Table 9.4 need
to be covered, and it is especially important to emphasize that purging is not
an effective means of controlling weight, as it only eliminates part of what
has been eaten. It may be useful to suggest that patients who binge-eat
calculate the calorie content of a typical binge, even aer purging. is
generally helps them to see that in reality, vomiting does not compensate for
binge eating. It is also useful to discuss with the patients how, in actual fact,
purging reinforces the eating disorder. Although self-induced vomiting may
at first be viewed as an easy method of weight control, aer a while, binge-
eating episodes tend to increase in frequency because patients lose control
over eating, erroneously counting on being able to eliminate any unplanned
food eaten by purging.
Laxatives maintain the eating disorder through the same mechanisms
described for self-induced vomiting. Some patients think that they will gain
weight if they do not regularly move their bowels, but the prolonged misuse
of laxatives can lead to chronic constipation, which tends to increase
concerns about eating and the perceived flatness of the stomach. e misuse
of laxatives tends to hinge on an individual’s hydration status, which oen is
dysfunctionally labeled—dehydration may be experienced as feeling “light,”
“dry,” or “empty” and hydration as feeling “bloated,” “full,” or “fat.” Such
dysfunctional interpretations keep the patients locked in the eating-disorder
mindset. However, it is important to note that the abrupt cessation of
laxatives can produce transitory edema and weight gain (a few pounds),
which, in turn, can increase concerns about weight. If not handled correctly,
patients may, in response, tighten their dietary restriction or start to reuse
laxatives and diuretics.
Patients who engage in purging behavior that requires attention, such as
noncompensatory purging (including spitting, with or without rumination),
should be helped to evaluate the pros and cons of ceasing this behavior
through the creation of a dedicated table (see Table 9.5).
TABLE 9.5. Examples of a Patient’s Pros and Cons and Conclusions of Addressing
Self-Induced Vomiting
Pros Cons
I’d feel better and I’d have no more I’m afraid of gaining weight without control.
stomachaches. I’d have to control what I eat.
I’d be less tired. I’d have to find another way to manage my
I wouldn’t ruin my teeth anymore. negative emotions.
I would no longer have swollen facial I’d have to learn a different way to handle
glands. anxiety after eating.
I would have more chance to recover from
my eating problem.
I would be able to manage my weight
without making myself sick.
I would have more control of my diet and
reduce the risk of bingeing.
I would eat at a normal speed, enjoying the
taste of food, and not going to the bathroom
immediately after eating.
Conclusions
I want to stop making myself sick to have a better chance of recovering from my eating
problem, have better health, reduce the risk of bingeing, and being able to enjoy eating.

As with all CBT-E procedures, it is crucial that the decision to suspend

purging behaviors should be made by the patient, not imposed by the
therapist. Bear in mind, however, that sometimes this is a difficult decision
for patients, as they tend to consider purging as a positive means of
controlling their body weight and shape and/or managing upsetting events
and associated mood swings. Hence, when doing this exercise, patients
should be helped to evaluate the importance of stopping these behaviors to
free themselves from their negative effects and recover from their eating
disorder. Patients should also be helped to assess whether self-induced
vomiting and/or the misuse of laxatives and diuretics offers them something
positive that they are afraid of losing, but also reflect on the short- and long-
term effects of these behaviors on physical health, psychological
functioning, interpersonal relationships, and school performance. At the
end of this discussion, patients should reach a conclusion and write it under
the “Pros” and “Cons” columns in the table (see Table 9.5). Obviously, in
patients who are underweight, the pros and cons of stopping these behaviors
should be weighed alongside those associated with addressing weight
restoration.
e best strategy to adopt for ceasing laxative misuse will depend upon
how they are used by patients. If they take them intermittently, we suggest
going “cold turkey.” If, however, they are a frequent recourse, withdrawal
should be more gradual, and managed according to a defined schedule (e.g.,
by halving the dose each week). When laxatives are stopped, or while they
are being phased out, rebound fluid retention may cause patients to
experience a week or so of weight gain. Patients must be forewarned of this
possibility, and helped to cope with any edema and associated increase in
weight. To avoid potential relapse at this delicate time, patients should be
told in advance that these physiological changes will only be temporary, and
encouraged to throw away their supplies. In order to help patients resist
purging, they can employ some of the strategies (e.g., distractive activities,
urge surfing) to resist the urge to eat between meals and snacks (see
“Establishing Regular Eating” in Chapter 8).
If purging serves several functions (which will generally become evident
in Step Two), this indicates that it will need specific targeting (alongside the
mechanisms underlying it). However, additional functions may make
patients more resistant to change. Examples of additional functions are as
follows:

• It modulates mood. As mentioned briefly above, vomiting may have a

tension-relieving effect on patients, which helps them cope with strong
emotions. It may be that such patients are suffering from what is termed
“mood intolerance,” which can be handled using the strategies described in
Chapter 17.

• It stops them feeling full. If a patient vomits in order to avoid feeling

full, this can be tackled by the strategies discussed in Chapter 11.
 • It “empties” the stomach and makes the abdomen appear flatter. In the
misguided attempt to “empty” their stomach (which, as discussed above,
does not actually occur), some patients resort to vomiting. Others will take
laxatives to empty their gut so that their abdomen is concave when lying
down. However, in order to achieve this, they will generally need to induce a
copious amount of diarrhea. It is important for these patients to understand
that not only is this potentially harmful but their laxative misuse has little or
no effect on the amount of calories they absorb. Temporary gut emptying
has no permanent effect on body shape.

• It is a form of self-punishment. Some patients, generally those with low

self-esteem, induce vomiting as a means of punishing themselves. It may be
that they are suffering from clinical depression, so it is vital that they are
carefully assessed. Any self-esteem issues (see Chapter 17) or clinical
depression (see Chapter 20) will need to be directly addressed in addition to
the eating disorder.

Addressing Excessive Exercising

Exercising is defined as excessive1 when its duration, frequency, or intensity
exceeds what is required for physical health and increases the risk of
physical injury. It is a form of exercise that is associated with a subjective
sense of being driven or compelled to exercise, it has priority over other
activities (e.g., school), and it is associated with feelings of guilt and anxiety
when postponed (Dalle Grave, 2009).
Excessive exercising precedes dieting in a subgroup of patients with
eating disorders, and is not infrequent in adolescent patients with eating
disorders. It is most commonly seen in those who are underweight (Dalle
Grave, Calugi, & Marchesini, 2008a). Excessive exercising interacts with
eating-disorder psychopathology in maintaining the eating disorder, and
may result in “wear-and-tear” injuries. In underweight patients, it interferes
with weight gain, and in anorexia nervosa it is a predictor of poor treatment
outcome (Dalle Grave, Calugi, & Marchesini, 2008a).
Excessive exercising takes various forms, including (Fairburn, Cooper,
Shafran, Bohn, Hawker, et al., 2008):

Excessive daily activity (e.g., standing rather than sitting and/or walking
excessive amounts).
Exercising in a normal manner but to an extreme extent (e.g., going to
the gym three times every day).
Exercising in an abnormal manner (e.g., doing extreme numbers of
push-ups or sit-ups).

Excessive and driven exercising may also be classified according to its

function:

1. To control shape and weight. is is the most common function of

exercise adopted by adolescent patients with eating disorders, and, like
purging, may be compensatory or noncompensatory (Fairburn, Cooper,
Shafran, Bohn, Hawker, et al., 2008). If exercising is used to compensate for
specific episodes of real or perceived overeating, there is generally no need
to address this type of exercising, as it will wane as patients acquire eating
control. Compensatory exercising may also be preemptive, with patients
seeking to “burn-off ” calories before they are ingested (so-called debting),
and some feel that they can eat only if they have exercised beforehand.
Other compensatory exercisers may adjust their levels of physical activity in
line with what they have already eaten. When exercising becomes routine, as
opposed to reactionary, it is deemed noncompensatory, and may need to be
tackled separately as it has become divorced from eating behavior.

2. To modulate mood. Like purging, excessive exercising may be used to

neutralize or reduce awareness of adverse emotional states. If the therapist
concludes that patients displaying such behavior are suffering from mood
intolerance, the strategies described in Chapter 17 should be considered.
 e first step in deciding how to address excessive exercising is to assess
whether or not the exercise that the patient is engaging in is, in fact,
excessive. ere are usually readily observable indications that it may be so,
such as the patient always standing up in the waiting room, being reluctant
to sit down at the therapist’s request, and sitting upright in the chair without
leaning on the backrest. It is more difficult for patients to admit that they
have a problem in this regard, as excessive exercising is a habit, and, in any
case, they feel exercise is healthy. In order to overcome this obstacle to
change, the therapist should ask the patients to monitor their exercising
habits, recording all episodes with a letter “E” in the “V/L/E” column on
their monitoring record, and then reporting the type of exercise, its
duration, and the reasons for doing it in the “Context and Comments”
column. e clues indicating the presence of excessive exercising, to be
shared with patients, are the following:

Doing exercise that interferes with important activities (e.g., school).

Exercising in inappropriate moments or environments.
Feeling obliged to exercise, even if this may hurt.
Feeling guilty if exercise is not done for any reason.

Having ascertained that the patient’s exercising seems excessive, the

second step in the procedure is to educate her or him about the negative
aspects of this form of exercising and the benefits of adopting a healthy way
of exercising. e main points to stress are listed in Table 9.6.
 TABLE 9.6. Main Topics to Cover When Educating Patients
about Excessive Exercising
It may be used as a compensatory behavior after loss of
control over eating and/or as a routine form of weight control.
It is dangerous to health if you are underweight and/or have
osteoporosis or electrolyte disturbances.
It requires secrecy and subterfuge and produces feelings of
guilt.
It is relatively ineffective as a means of controlling weight.
It takes up a lot of time and impairs interpersonal relationships.
It takes precedence over other activities.

From Cognitive Behavior erapy for Adolescents with Eating Disorders

by Riccardo Dalle Grave and Simona Calugi. Copyright © 2020 e
Guilford Press. Permission to photocopy this material is granted to
purchasers of this book for personal use or use with patients (see
copyright page for details). Purchasers can download enlarged versions
of this material (see the box at the end of the table of contents).

In particular, it is important to point out (using the patient’s personal

formulation) that excessive exercising plays a central role in the
maintenance of eating-disorder psychopathology through several possible
mechanisms:

By contributing (in association with dietary restriction) to weight loss

and serving to maintain a low body weight.
By increasing the risk of binge-eating episodes. Although patients with
eating disorders who exercise excessively tend to report fewer objective
binge-eating episodes than those who do not, some patients who view
exercise as an effective means of weight control tend to relax their rigid
control over food intake and end up bingeing. is mechanism may be
established in both compensatory and noncompensatory exercising.
By intensifying the overvaluation of shape, weight, and their control.
e more intensive and frequent the exercise as a means of controlling
shape and weight, the more the individual is locked into her or his
concerns about shape and weight.
 By promoting social isolation. Individuals with eating disorders
typically exercise alone, and inevitably reduce the time spent with
others. In turn, the resulting marginalization of social life increases
their overvaluation of shape, weight, and their control.
By modulating mood in a dysfunctional way. Exercising that has the
role of modulating adverse mood states may seem beneficial in the
short term, but will become dysfunctional in the long term because it
obstructs the application of more functional ways of addressing day-to-
day difficulties associated with negative emotions.

e third step in addressing excessive exercising is actively involving the

patients in deciding to interrupt their excessive exercising. As standard in
CBT-E, the goal is that patients decide to do this rather than the decision
being imposed upon them. As patients usually tend to not see their
exercising as a problem, but rather as a positive way of controlling shape and
weight or modulating mood, this is oen a difficult task. It is crucial that the
therapist validate the experience of patients by acknowledging the perceived
positive effects of exercising and (if present) their ambivalence to change. It
is evident that in underweight patients, the decision to stop excessive
exercising should be taken in association with that of addressing weight
restoration. To help them make this decision, patients should be helped to
create a pros-and-cons-of-change table (see Table 9.7).
TABLE 9.7. Examples of a Patient’s Pros and Cons and Conclusions of Addressing
Excessive Exercising
Reasons to keep excessive exercising Reasons to change
It makes me burn calories and stops me I would have more time to develop new
from putting on weight. interests, make friends, and study.
It makes me feel in control. I would be free from the obsession of
It shows my willpower. control.
It makes me calm when I am anxious. I would be happier.
I would be healthier.
I would be able to exercise just for fun.
I would be less concerned about shape and
weight.
I would be better able to overcome my
eating problem.
Conclusions
I want to stop excessive exercising because I would have more time to develop new
interests, make friends, and study. I want to feel free to play sports just for fun and have a
better chance of recovering from my eating problem.

It is advisable to begin by asking patients to list the cons, and consider

whether exercising provides them with benefits that they would be afraid to
lose. en, patients should be asked to evaluate in detail the advantages of
changing, urging them to reflect on the short- and long-term effects of
excessive exercising on health, psychological function, relationships, and
school or work performance. e therapist should also emphasize that
change is a necessary step to liberating themselves from the adverse effects
of this type of exercising and overcoming the eating disorder. With patients
who report the fear of losing control over weight if they interrupt their
exercising, the therapist should reassure them that the adoption of a healthy
lifestyle is the best way to maintain long-term weight control. Finally, the
patients should be helped to come to the conclusion that they want to
attempt to change (see Table 9.7).
e fourth step, if the patient has decided to address their excessive
exercising, is to agree with them on which procedure to use. At this stage,
patients should always be informed that in the first few days of tackling their
behavior, their levels of anxiety and concern about shape and weight might
increase but will then gradually decrease, and this will be associated with
gaining the benefits of leading a healthy lifestyle. e main procedures to
suggest to such patients are the following:

• Self-monitoring exercise in real time. Patients are instructed to record

the events, thoughts, and emotions that precede the start of exercising in
real time in the “Context and Comments” column of their monitoring
record. If they do this before they start exercising, they will become aware of
what they are doing, thinking, and feeling at the precise time that the urge to
exercise is upon them, which will make it easier for them to resist doing it.

• Encouraging healthy exercising. Patients should be encouraged to

substitute excessive exercising with healthy social exercising. Our clinical
experience indicates that helping patients, even those who are underweight,
to be in “good shape,” both physically and psychologically, is an effective
strategy for addressing excessive exercising. We suggest that patients
exercise in less extreme ways, and do so with friends. Social exercising is a
useful means of escaping from isolation (a factor implicated in the
maintenance of eating-disorder psychopathology), it can be used to practice
body exposure, and it may help to dispel the urge to exercise and to accept
weight gain and changes in shape. Clinicians should be active in helping
patients plan a healthy exercise regime, and encouraging them to create
opportunities for social exercising (e.g., group tennis lessons, yoga classes).
It is also essential that patients break any link between eating and exercising,
and interrupt any form of compensatory exercising (e.g., to compensate for
excessive calorie intake or to burn calories in advance of eating).

• Addressing the urge to exercise. As with addressing the urge to binge

(see Chapter 8), this will involve the patients engaging in activities that make
the exercising less likely, or riding out the urge (urge surfing).

• Limiting exercising. If the procedures in the previous point are not

successful in helping a patient deal with the urge to exercise, the therapist
may consider, with the consent of the patient, involving parents or a trusted
person to help the patient to at least limit her or his exercising by means of
the same procedures described. However, if this fails, the therapist should
reflect upon whether it would be wise to intensify the treatment (e.g., by
switching to intensive outpatient CBT-E or inpatient CBT-E).

• Discontinuing competitive sports. e intense exercise regime practiced

by individuals involved in high-level competitive sports may be a potent
maintenance mechanism for eating-disorder psychopathology, and can be
dangerous for health. e therapist should encourage these patients,
potentially with input from their coach, to temporarily suspend both
practice and competitions. Patients who practice competitive sports can be
helped to accept this recommendation by emphasizing the fact that rest, and
achieving a healthy weight, is necessary to improve sports performance.

• Addressing events and associated mood changes that trigger exercising.

Specific strategies for helping such patients are described in Chapter 14.

Addressing Other Extreme Weight-Control Behaviors

A minority of people with eating disorders use other means of controlling
weight, such as drugs that suppress appetite or thyroid hormones to increase
energy expenditure. ese behaviors are extremely rare in adolescents with
eating disorders. However, it should be noted that, in addition to not being
effective in determining prolonged weight loss (appetite suppressants act for
only a short period of time and thyroid hormones mainly decrease muscle
mass), they can lead to serious physical complications. Another extreme
weight-control behavior that may be practiced by some adolescents with
eating disorders and type 1 diabetes is to reduce or omit their dose of insulin
aer a bingeing episode. In this way, they dramatically increase blood sugar
levels. As blood sugar thereby exceeds the renal elimination threshold of
glucose, it is excreted in the urine, but this practice should be firmly
discouraged as, in addition to being fairly ineffective, it can be very harmful.
Finally, some adolescents with eating disorders, especially those with binge-
eating episodes, use substances such as amphetamines to control weight,
thereby running the risk of develop a substance use disorder.
ese behaviors may be compensatory or noncompensatory, but in both
cases they contribute to maintaining the eating disorder through
mechanisms similar to those described in the previous paragraphs.

1
We prefer not using the terms “compulsive” or “driven” to refer to this kind of exercising, because
these may suggest to patients that they cannot control the exercise they do. For the same reason we do
not use the term “compulsive dieting.” We find it more useful to use the terms “excessive” exercising
and “inflexible” or “strict” dieting because this helps patients to see these behaviors as problematic and
decide to adopt healthy exercising and flexible dietary guidelines.
 CHAPTER 10

Review Sessions

STRUCTURE AND CONTENT

e progress of CBT-E is reviewed collaboratively with patients once a week;

this includes measurement and collaborative interpretation of their weight
and a review of the EPCL. In addition to this weekly evaluation, at the end
of Step One a part of the session is dedicated to taking stock of progress and
planning the rest of the treatment. In underweight patients, this review is
repeated every 4 weeks during Step Two. ese reviews have the following
aims (Fairburn, 2008):

To conduct a joint review of progress.

To identify emerging barriers to change.
To review the formulation.
To decide whether to use the broad form of CBT-E.
To plan the rest of the treatment.

At the same time, the procedures introduced in Step One continue to be

implemented. In patients who are not underweight, the frequency of
sessions goes from twice to once a week, while for those who are
underweight, sessions continue to be held twice a week until the weight
regain is stable.

CONDUCTING A JOINT REVIEW OF PROGRESS

Research on CBT for bulimia nervosa has shown that the magnitude of the
improvements achieved within the first 4 weeks of treatment—in particular,
the reduction in the frequency of binge-eating episodes and unhealthy
weight-control behaviors—predicts the outcome (Agras, Crow, et al., 2000;
Fairburn, Agras, Walsh, Wilson, & Stice, 2004). For this reason, patients are
encouraged to “start well” and try to achieve maximum behavioral change
during Step One.
e findings also suggest that, if progress has been limited, it is crucial to
act quickly to find the causes and implement potential solutions. Hence, it is
appropriate at this point in the treatment to conduct a detailed formal
review, actively involving patients, of the progress that has been achieved. It
may also be useful at this point to ask patients to complete the EDE-Q and
CIA to compare their responses with those given at the beginning of
treatment. is will provide an objective assessment of the nature and extent
of the change made. Indeed, as already mentioned, adolescent patients oen
tend to underestimate their progress; for this reason, they should be helped
to acquire a balanced view of all their improvements.
In cases in which the treatment is progressing well, aer 4 weeks not-
underweight patients generally report a reduction in the frequency of binge-
eating episodes and concerns about eating control (as a result of the regular
eating procedure) and weight (as a result of the in-session weighing
procedure), whereas concerns about body shape usually do not change
because they have not yet been specifically addressed. In those who are
underweight, it is considered an improvement if they agree to make the
change and initiate weight regain aer Step One, or if their weight increases
by about 1 pound per week in Step Two.
 e aim of the review is to identify which problems remain and which
need to be addressed, while highlighting and emphasizing the changes that
have occurred. It is also a good idea to discuss with patients what, in their
opinion, has helped them to achieve these results, to reinforce the
therapeutic procedures already used. In addition, the therapist should
always praise patients and attribute the change to them.

IDENTIFYING BARRIERS TO CHANGE

e second aim of the review is to identify any existing barriers to change.

is involves evaluating the patients’ attitudes toward treatment and the use
of the CBT-E procedures. is evaluation should be conducted openly,
introducing the topic to the patients and asking whether they are happy with
the treatment, and whether they consider the treatment suitable for them
(Fairburn, Cooper, Shafran, Bohn, Hawker, et al., 2008). en the therapist
should ask the patients to review how they have been able to make use of the
various elements of the treatment by making the changes that have been
agreed upon. e therapist can use a table or a list of the treatment elements
to assist the patients in this review (see Table 10.1).
TABLE 10.1. Review of How Treatment Is Going after Step One
How treatment is going
Going reasonably
Treatment elements Not going well well Going well
Attending sessions
Being on time
Recording
Not weighing at home
Reading Overcoming Binge
Eating
Eating regular meals and
snacks
Not eating between meals and
snacks
Making treatment a priority
Weight regaina
Other elements

Note. Adapted from Cognitive Behavior Therapy and Eating Disorders by Christopher G.
Fairburn. Copyright © 2008 The Guilford Press.
Only in patients who are underweight during the review held every 4 weeks in Step Two.
a

From Cognitive Behavior erapy for Adolescents with Eating Disorders by Riccardo Dalle Grave and
Simona Calugi. Copyright © 2020 e Guilford Press. Permission to photocopy this material is
granted to purchasers of this book for personal use or use with patients (see copyright page for
details). Purchasers can download enlarged versions of this material (see the box at the end of the
table of contents).

If there are any problems with engagement or issues with the use of
specific procedures, their origins need to be explored. It may be that these
are due to the eating disorder itself; in some patients, the mechanisms
maintaining their eating disorder may be too powerful, preventing them
from making changes even though they are trying their hardest. For
instance, many patients find the urge to binge-eat too difficult to overcome,
despite having successfully implemented the regular eating procedure. is
is likely at least partially due to their dietary restraint, which will be formally
addressed at a later stage, but mood and external events may also be exerting
a negative influence. In other cases, fears of weight gain may induce some
patients to continue to weigh themselves at home. In underweight patients,
it is not uncommon to see a continued reluctance to make the decision to
regain weight, or difficulties eating what they had planned to due to meal-
related anxiety.
Reviewing such barriers to change is best done with reference to the
patient’s formulation. e most common are the following (Fairburn,
Cooper, Shafran, Bohn, Hawker, et al., 2008; see Table 10.2):

Fear of changing. is is oen linked to reasons similar to those

described in Chapter 8 (the section on helping patients decide to
change and address weight restoration), specifically, fear of no longer
being “special,” not having an excuse for avoiding other aspects of life,
not knowing who they would be without the eating disorder, and/or
losing control over eating and continuing to gain weight. Chapter 9
discusses how to address such fears.
Resistance to change in general. is may be attributable to the
psychological effects of being underweight or the influence of clinical
perfectionism (if the latter, see Chapter 17).
Competing commitments (e.g., academic pressures). e therapist
should help the patients to evaluate the pros and cons of giving the
treatment priority.
Poor planning. Patients should be helped to become more organized.
Clinical depression. Patients with coexisting clinical depression tend to
make limited changes due to their reduced drive and optimism. See
Chapter 20 for how to assess and treat such patients.
Substance use disorder. e presence of persistent substance misuse
undermines patients’ ability to make the most of treatment. In such
cases, patients should be referred to a specialist in treatment for
substance use disorder. However, intermittent substance misuse can be
addressed in the context of CBT-E using the Mood Intolerance module
of broad CBT-E (see Chapter 17).
Interpersonal difficulties. In this case, the therapist should considering
implementing the Interpersonal Difficulties module of broad CBT-E.
See Chapter 17 for a description and treatment strategies.
Core low self-esteem. Patients with core low self-esteem do not believe
that they are capable of addressing their eating disorder, or that they do
not deserve the therapist’s efforts. Consider applying the Core Low
Self-Esteem module of broad CBT-E. See Chapter 17 for a description
and treatment strategies.
Clinical perfectionism. Patients with clinical perfectionism tend to
apply their high standards to their dieting, weight, and appearance,
making change difficult. ey oen apply their elevated standards to
treatment itself, which tends to complicate matters and slow progress.
Consider the use of the Clinical Perfectionism module of broad CBT-E.
See Chapter 17 for a description and treatment strategies.
TABLE 10.2. Obstacles to Change and Strategies Used to Address Them
Fear of changing (e.g., fear of no longer being “special,” fear of losing an excuse for not
addressing other things in life, fear of not knowing who one is without the eating problem,
and fear of losing control over eating and/or continuing to gain weight) can be addressed
using the strategies described in Chapter 8 to evaluate the pros and cons to address
weight regain.
Resistance to change in general (e.g., fear of the consequences of change or a general
resistance to any form of change). If the former, then the fear needs to be explored and
addressed. If the latter, the resistance may be attributable to the psychological effects of
being underweight or the influence of clinical perfectionism.
Competing commitments (e.g., pressure of school) can be addressed by stressing the
importance of giving treatment priority.
External events and interpersonal difficulties. Consider implementing the Interpersonal
Difficulties module of broad CBT-E (see Chapter 17).
Poor planning. Helping the patient become more organized.
Clinical depression. Treating the depression if necessary (see Chapter 20).
Core low self-esteem. Patients with severe low self-esteem tend not to believe that they
are capable of making changes nor do they think that they deserve the therapist’s efforts.
(These features may also be seen in those with a clinical depression.) Consider
implementing the Core Low Self-Esteem module of broad CBT-E (see Chapter 17).
Clinical perfectionism. Patients with clinical perfectionism apply their extremely demanding
standards to all aspects of life that they value. If they have an eating disorder, they apply
their high standards to their dieting, weight, and appearance. This makes change
especially difficult. They also apply their standards to the treatment itself, which tends to
complicate matters and slow progress. The broad version of CBT-E can be used to
address clinical perfectionism (see Chapter 17).
Substance misuse. Persistent substance misuse undermines a patient’s ability to make
the most of treatment. If it is proving a barrier to change, it needs to be addressed in its
own right and CBT-E suspended or postponed. However, intermittent substance misuse
can often be addressed in the context of CBT-E.
Dislike of CBT. In our experience, this is unusual. Occasionally, patients who have
received extensive prior exposure to other forms of therapy (e.g., psychodynamic
psychotherapy) have difficulty adjusting to the different rationale and mode of treatment,
but this is uncommon. Under these circumstances we ask patients to try to suspend their
skepticism and simply accept that this is an empirically supported treatment that has a
good chance of helping them if they commit themselves to it.
Poor implementation of the treatment by the therapist. It is advisable to have weekly peer
supervision meetings in the form of a “closed” group (i.e., restricted to CBT-E therapists),
to listen to the recordings of one another’s treatment sessions, and seek out training and
ongoing peer supervision.

REVIEWING THE FORMULATION

e review of progress and barriers is the ideal occasion to conduct a formal
and detailed review of the patient’s personal formulation. For this purpose,
the therapist should go over the monitoring records and the EPCL weekly
changes summary spreadsheet (see Appendix D) with the patient,
conducting a joint assessment of whether new maintenance processes have
emerged and therefore need to be added to the formulation, or whether
others have been overcome, and should therefore be deleted. If many
changes need to be made to the formulation, it may be useful to redraw it on
a new sheet of paper.

DECIDING WHETHER TO USE THE BROAD

VERSION OF CBT-E

e decision to implement the broad version of CBT-E is an important one,

because it will influence both the form and the content of the treatment.
Indications for making this decision are described in detail in Chapter 17. It
must be said, however, that the focused form of CBT-E is easier to
implement, and is the one that has shown success in outcome studies
involving adolescents with eating disorders.

PLANNING STEP TWO

Step Two addresses the key maintenance processes of the patient’s eating
disorder while continuing to implement the strategies and procedures
introduced in Step One. ere are seven key maintenance processes in
eating disorders. ese will vary from individual to individual (Fairburn,
Cooper, Shafran, Bohn, Hawker, et al., 2008) and therefore, all should be
considered:

1. Overvaluation of shape, weight, and their control. is “core”

psychopathology (see Chapter 1) is common in adolescents with an eating
disorder. If present, this will have been identified during the initial
assessment, and the patient’s formulation will be centered around it. In all
probability, it will have been a barrier to change throughout Step One.

2. Overvaluation of control over eating. Some adolescent patients,

especially those with an eating disorder of recent onset, will display
overvaluation of control over eating per se. In other words, for them, eating
control is an end in itself, rather than a means of controlling shape and
weight, although note that it is possible for these two features to coexist.
Patients who are focused on the control of eating per se tend to be
particularly detail oriented, displaying excessive interest in calorie counting,
food choices, and mealtimes. In such patients, body checking, body
avoidance, and feeling fat are uncommon. Note that this type of presentation
has also been reported in patients of non-Western origin.

3. Being underweight. ere is no single BMI-for-age percentile

threshold that satisfactorily defines being underweight in all cases, but the
thresholds specified earlier (see Chapter 3) make clinical sense and work
well in practice. With BMI-for-age percentile lower than the 25th, most
adolescents experience some of the adverse physical and psychosocial effects
of being underweight, and few young people can maintain a BMI-for-age
percentile at this level without actively restricting what they eat.

4. Dietary restriction. In essence, this means undereating in

physiological terms. Patients in whom this maintenance process is in effect
will inevitably have lost weight, or be persistently underweight. Either of
these conditions will necessitate dietary restriction being tackled directly.

5. Dietary restraint. Patients who make determined attempts to restrict

eating (dietary restraint) may or may not end up undereating (dietary
restriction). However, the majority of eating disorder cases are accompanied
by a particularly strict form of dietary restraint involving many extreme
dietary rules. In most cases, dietary restraint is maintained by the
overvaluation of shape, weight, and their control and/or the overvaluation of
eating control per se. Nevertheless, it usually needs to be handled as a
separate issue.

6. Other extreme weight-control behaviors. If purging (i.e., self-induced

vomiting, laxative or diuretic misuse) and/or excessive exercising are still
present at the end of Step One or during the course of Step Two, they should
be made a priority because they autonomously maintain the eating-disorder
psychopathology and may cause serious physical impairment. An inability
of the patients to discontinue these behaviors may indicate the need for
more intensive treatment, such as intensive outpatient or inpatient CBT-E.

7. Changes in eating triggered by moods or events. In some adolescent

patients, moods or events seem to play little to no role in maintaining their
eating disorder, but it is more common to see patients whose eating is
affected by these factors to a greater or lesser extent. In reactive cases—those
that are particularly sensitive to circumstances or mood—certain features,
such as binge eating, vomiting, and exercising, may be serving to help the
patients cope with adverse thoughts and feelings. CBT-E has a module
dedicated to resolving these issues (see Chapter 14).

e relative contributions of all these maintenance processes need to be

assessed when planning Step Two. At this point, it is also important for the
therapist to decide the order in which they will be tackled. is decision is a
crucial one, and the following guidelines should be taken into account:

• If the patient is underweight, this is the top priority, as being

underweight is physically harmful, especially in adolescents, and the
psychosocial consequences of starvation serve to powerfully maintain the
eating disorder. Aer patients have regained some weight and/or if they
report intense concerns about their shape and weight, it would be advisable
to address their overvaluation of shape, weight, and their control. In some
not-underweight patients with marked weight suppression (i.e., those with
atypical anorexia nervosa), dietary restriction and weight regain should be
the priority.

• In patients who are not underweight, it is advisable to start by

addressing the overvaluation of shape, weight, and their control, as this will
be the most powerful maintenance mechanism, and will require
considerable time to overcome. en it will be necessary to decide in which
order to tackle dietary restraint or mood issues. Generally speaking, a week
or two aer the patient has begun to tackle her or his overvaluation
mechanisms, dietary restraint may be dealt with together. However, if a
patient’s eating disorder is very reactive, if she or he experiences frequent
episodes of binge eating triggered by events or moods, for example, it is best
to address these first. Otherwise, it is best to start tackling events and moods
a week or two aer starting to deal with dietary restraint (if applicable).

us, bearing in mind the above guidelines, it is the patient’s

formulation that will determine the plan for Step Two. However, this will
not be set in stone, and may need to be adapted to any changes in
circumstances and/or expression of the eating disorder. As the treatment
progresses, it is important to maintain the therapeutic momentum generated
during Step One.
 CHAPTER 11

Underweight and Undereating

Module

e Underweight and Undereating module should be the first to implement

when treating adolescent patients who are underweight. However, as
described in Step One, it is essential that patients make the autonomous
decision to address weight restoration before beginning this module, the
goal of which is to help them regain weight until they reach a low healthy
weight. is will involve the following procedures:

1. Educating the patient about weight restoration.

2. Learning key strategies for regaining weight.
3. Involving parents.
4. Maintaining motivation.

EDUCATING THE PATIENT ABOUT WEIGHT

RESTORATION

Most adolescent patients have a number of concerns about weight regain,

many of which are ill founded and/or picked up from friends or social
networks. It is important that patients understand what is involved in
regaining weight so that they know what to expect, which may help them
feel in control during the process. e main points to cover with patients are
described below.

Calculating the Minimum Low Healthy Weight

Between sessions, the therapist should calculate the patient’s weight in
pounds (and in whatever weight unit the patient uses). A low healthy weight
target should be assessed on a case-by-case basis. In discussion with the
patients, the therapist should consider a weight range that fulfills the
following conditions:

1. It does not contribute to the maintenance of the eating disorder.

2. It can be maintained without the adoption of extreme weight-control
behaviors.
3. It is not associated with the effects of being underweight.
4. It is consistent with physical health and development.
5. It permits a social life.

In patients ages 16 and over, a BMI of between 19.0 and 20.0 is generally
reasonable. In patients under 16 years of age, the therapist should identify
the comparable BMI-for-age percentile. is differs between countries (e.g.,
in the United States, this is approximately the 25th BMI-for-age percentile in
females and 10th in males; Kuczmarski et al., 2002).

Weight Restoration
is involves patients establishing a daily energy surplus sufficient to regain
weight at a reasonable rate (i.e., at about 1 pound/0.5 kilogram a week). e
sooner the patients begin weight regain, the faster they will reach their goal
BMI range, at which time they will be able to practice maintaining their new
weight. It is remarkably difficult to gain weight if you have an eating
disorder and are underweight. is comes as a surprise to most patients,
who are oen afraid that their weight will shoot up beyond their control.
is does not happen.
Most patients are also surprised by the amount of energy surplus that is
involved in weight restoration. To regain weight at an average rate of 1
pound per week (roughly 0.5 kilogram per week), which is the optimal rate
for outpatient treatment of adolescents, patients need to consume on
average an extra 500 kilocalories of energy each day (i.e., an extra 3,500
kilocalories per week) over and above what is needed to maintain a stable
weight. If patients increase their level of physical activity, they will need to
consume proportionately more energy.
e rate of weight regain may be higher than 1 pound (0.5 kilogram) per
week in the first week or two. is will be due to rehydration (i.e., water
retention), as people who are undereating are oen dehydrated. e initial
jump in weight can frighten patients and lead them to cut back on their
energy intake. To avoid this unhelpful reaction, patients should be
forewarned.

Weight Maintenance
is will involve patients learning to maintain a stable weight with a range of
approximately 6 pounds (3 kilograms) above the minimum low healthy
weight. Ideally, at least 6–8 weeks should be devoted to reaching this goal.
e weight maintenance phase is appreciated by patients, as many of them
are afraid to continue gaining weight once they have started. Once again, if
patients increase their level of exercising, their energy needs will need to be
increased proportionately.

The Psychology of Weight Regain and Weight

Maintenance
When patients start the process of weight regain, the therapist should be
aware of and emphasize the following points (Fairburn, Cooper, Shafran,
Bohn, Hawker, et al., 2008):

Weight restoration is a long and demanding journey. Patients need to

dedicate the same level of commitment they used to control shape,
weight, and eating to the process of weight restoration.
Regaining weight is challenging, but it is worth it. With the
normalization of weight, patients will feel free from the eating-disorder
mindset and be ready to start a new life.
Weight regain is associated with several short-term benefits (e.g., the
remission of some starvation symptoms; Calugi, Chignola, et al., 2018),
but the full benefits will only be appreciated once weight is fully
restored and maintained for some years. Although partial weight
restoration is also a huge effort, it will not allow patients to experience
the full benefits of weight normalization.

KEY STRATEGIES FOR REGAINING WEIGHT

Many adolescent patients with eating disorders have the belief that if they
eat certain foods or certain amounts of food, they will lose control and gain
weight unpredictably. ey may seek to mitigate the anxiety generated by
this belief by dietary restriction or adopting other extreme weight-control
behaviors, which in turn maintain their eating disorder. To address these
problems, the treatment uses the following strategies:

Actively involving patients in interpreting weight regain.

Actively involving patients in planning meals and snacks to regain
weight.
Real-time self-monitoring of eating.
Using cognitive behavioral strategies to address difficulties during
meals (if applicable).
 Managing the time aer meals.

Actively Involving Patients in Interpreting Weight Regain

When patients decide to start Step Two and address weight restoration, the
therapist should draw a diagonal line on the weight graph from their latest
weight up to the target minimum threshold weight (i.e., the 25th BMI-for-
age percentile). is line should have a slope corresponding to an average
rate of weight gain of 1 pound (0.5 kilogram) per week. A representative
weight graph is shown in Figure 11.1. In the same session, these weights
should be discussed, and it should be explained that the slope of the
diagonal line represents the expected rate of weight regain. e therapist
should reiterate (as emphasized in Step One) the importance of interpreting
changes in weight, not relying on weekly readings but instead using the
weight over the last 4 weeks to determine whether or not the rate of weight
regain is in line with the goal of about 1 pound (0.5 kilogram) a week.
FIGURE 11.1. An example of a weight graph for an underweight adolescent patient with an eating
disorder on which the weight regain trajectory is drawn in.

Actively Involving Patients in Planning Meals and

Snacks
Patients should also be actively involved in planning the eating changes
needed to regain weight, which will necessarily involve consuming more
energy in the form of food and drink. In patients who are already eating
most food groups, and whose weight has been stable across the last 4 weeks,
it may be helpful to suggest changing the type of food choice to energy-rich
foods and drinks. “Diet” food and drinks should be avoided (Fairburn,
Cooper, Shafran, Bohn, Hawker, et al., 2008). is method has the
advantage of not requiring patients to consume large volumes of food and
drink, thereby minimizing their feeling of fullness. To help adolescent
patients, we provide them with an example of a list of foods (or food
combinations) that contain 500 kilocalories of energy. Patients can then
choose to supplement their usual diet with items from the list to create an
energy surplus of 500 kilocalories each and every day. During sessions
patients should be actively involved in interpreting emerging weight trends
over a 4-week period, and planning the changes required to maintain the
agreed-upon rate of weight regain. To this end, the therapist should also
inform patients that since weight regain is associated with an increase in
energy expenditure, it will be necessary to keep increasing energy intake in
order to reach the goal weight range.
In adolescent patients who follow extreme dietary rules that exclude
several food groups, or who have lost weight in the last 4 weeks, we provide
nutritional education and advice based on national food and nutrition
guidelines, with suggestions for meals and snacks using food exchange lists.
e goal is to devise a flexible plan involving the consumption of foods that
are acceptable to the patient and will produce the necessary initial daily
energy surplus of 500 kilocalories. In our clinic, we make use of a set of daily
representative “menus” labeled A, B, C, D, and so on, each containing three
meals (i.e., breakfast, lunch, and dinner) and two snacks, and all the food
groups, as a guide. Portions correspond to a medium portion usually
consumed by people without an eating disorder. Each menu has a mean
daily calorie content calculated on the basis of a weekly mean: Menu A has
about 1,500 kilocalories per day, Menu B 2,000 kilocalories per day, Menu C
2,500 kilocalories per day, and Menu D 3,000 kilocalories per day. Usually,
we advise patients to follow these weight-regain guidelines:

Start with Menu A, which includes all the food groups.

en, if the weight increases by less than 1 pound (0.5 kilogram) per
week, go to the next menu (Menu B, then Menu C, and so on).
If the weight increases by more than 2 pounds (1 kilogram) per week,
patients may choose to follow an intermediate menu (e.g., Menu B/C,
which provides about 2,250 kilocalories).

e calories are not reported in the various menus, and their calorie
content is a weekly mean, not fixed each day. e therapist should tell
patients that they are free to choose the type of food to eat, but encourage
them to include all food groups suggested in the relevant menu. It is
particularly important that patients pay close attention to portion sizes.
Implementing these strategies provides patients with an eating structure,
and gives them the opportunity to address some dietary rules (e.g., the
avoidance of some food groups). However, therapists should always be
aware that there is a danger that patients may transform this guidance into a
dietary rule and should take steps to guard against this.
Once the threshold weight is reached, the treatment should be focused
on addressing the residual dietary rules (see Chapter 13) and helping
patients to maintain their weight within a 6-pound (3-kilograms) range by
adopting healthy food guidelines in a flexible way. Patients are encouraged
to plan and write in advance (e.g., the day before) when, what, and where to
eat at the top of their monitoring record (using the first three columns), and
to draw a line at the end of the daily plan (see one patient’s “Today’s Plan” in
Figure 11.2).
FIGURE 11.2. An example of a monitoring record of a patient addressing weight regain.
 If patients need an intake of over 2,500 kilocalories per day to achieve
weight regain, they should be given the option of doing so using ordinary
food alone, or with the addition of high-energy drinks that contain about
250 kilocalories per carton or bottle. So, if two 250- kilocalorie drinks are
being consumed each day, then the patients’ weight should increase by about
1 pound (0.5 kilogram) per week, if they do not cut back on their intake to
compensate for the introduction of the energy drinks, of course. Used
judiciously, these drinks have some benefits. First, they provide the energy
surplus needed without requiring overeating. Second, they can be
eliminated once patients reach the target BMI range, obviating the need to
cut back on eating at that point. ird, they are relatively simple to use.
However, in our clinical experience, most adolescents prefer to increase the
energy content of their eating plan with natural foods.
Vegetarian or vegan patients should be asked about their reasons for
following such diets, as vegetarianism and veganism are sometimes a feature
of eating-disorder psychopathology, and may have started as a means of
controlling eating aer the onset of an eating disorder. If this is the case,
these dietary rules should be addressed using standard CBT-E procedures.
Patients who follow such diets for ethical reasons should be asked to
evaluate the pros and cons of suspending their vegetarianism or veganism
for a number of months to give themselves a better chance of overcoming
their eating disorder. In our experience, many patients are willing to do so. If
patients are not prepared to accept this temporary suspension, the therapist
might need to ask the advice of a dietitian to devise a healthy and flexible
vegetarian or vegan diet for the patients.

Self-Monitoring Eating in Real Time

e therapist should remind patients of the importance of keeping their
monitoring record on the table while eating, and filling it in in real time
following the procedure learned in Step One (see Figure 11.2, under the line
in the “Today’s Plan” column).
 Using Cognitive Behavioral Strategies to Address
Difficulties during Meals
e active involvement of the patients in interpreting weight regain (see
above) and planning meals and snacks to regain weight helps to reduce their
anxiety and concerns about eating and food. Indeed, this procedure helps
patients to experience weight regain as a predictable and controlled process,
countering the belief that eating certain types or amounts of food will
produce uncontrolled weight gain. Eating a broad range of foods also helps
patients to understand that “a calorie is a calorie” and that there are no foods
that cannot be part of a healthy diet.
However, we also teach patients the simple cognitive behavioral
strategies to use in the event of mealtime difficulties during the process of
weight regain in the following manner:

“Eat everything you planned to eat. is will help you regain weight at
an appropriate rate. It will also help you feel in control.”
“Do not ignore what was agreed upon in session. At times you will be
tempted to do so, but this would be a mistake. For a while you will
have to actively ‘ride out’ these urges.”
“Do not let feelings of hunger and fullness influence what you eat. ey
are distorted by your eating disorder, and are not a good guide for
deciding what and when to eat.”
“Do not be influenced by the presence of recurrent thoughts about food
and eating. ey are secondary effects of the eating disorder, and are
not a good guide to what or when to eat.”
“Be sure to eat ‘normally.’ e tendency to eat in an unusual fashion, by,
for example, eating very slowly, cutting up food into small pieces,
eating small morsels of things, and so on, is a secondary effect of the
eating disorder. Try to eat in the same way as others do. is will
help you regain weight at an appropriate rate.”
 “If you are having difficulties eating, record them (in real time) on your
monitoring record. is will give us the chance to come up with
solutions to the problems you are encountering.”

Finally, we advise patients that, in this phase of treatment, it is best to

consume meals together with a parent or other adult family member (e.g.,
grandparent). We meet with parents (and other adult family members if
parents cannot be present at every meal) to inform them of what has been
decided, and to discuss with them how they can support the patient’s weight
restoration. We suggest that patients eat their meals at home (rather than at
school) during the early stages of weight regain, if possible. Midmorning
and midaernoon snacks can, however, continue to be consumed at school.
If the patient is not able to eat at home and has to eat any meals at
school, we ask parents to discuss how this will be achieved with the school
staff. In some cases, with the permission of the patient and parents, we
contact the school directly to discuss how they can help. e school may be
asked either to assist with meals or to help with the readjustment to school if
the patient has had a period of absence due to her or his eating disorder.
Teachers may be asked to reduce the coursework load and to temporarily
lower their expectations for the patient while she or he is recovering from
the eating disorder.

Managing the Time after Eating

Patients are encouraged to engage in distracting activities (e.g., reading,
watching TV, studying, listening to music, or using the Internet) to cope
with the urge to engage in compensatory behaviors (e.g., vomiting or
excessive exercising) aer eating. Ways of managing behavior, such as
avoiding bathrooms (for those who vomit) or staying in the living room (for
those who tend to exercise excessively) for at least 1 hour aer eating are
discussed.
 OTHER STRATEGIES THAT CAN HELP TO
ADDRESS WEIGHT REGAIN

Wardrobe Changes
e clothing of patients who are regaining weight (and shape), and
becoming less emaciated, may well become too small. is can be a major
barrier to continuing weight regain. It is therefore best if patients either
choose to wear loose-fitting clothes during the weight gain process or, at
regular intervals, buy new “less small” clothes. Certain points are worth
noting:

It is best if patients plan ahead for shape changes and buy new clothes
before the old ones become tight.
Patients oen need help accepting that they need larger (“less small”)
clothes, as one of their measures of success when losing weight may
have been successive reduction in their clothing size. During weight
regain, they will have to move in the opposite direction, which many
find difficult. However, there are two positive aspects to this increase in
clothing size: (1) they will find that they have a greater range of clothes
to choose from and (2) they will discover that they look better in them.
It can be helpful to point out that in order to fit into their current
clothes, patients would need to stay ill. Indeed, they should never have
fitted into their current clothes in the first place.
Some patients have rather drab and dated clothes. If they can be helped
to buy clothes more like those of their peers, this can be helpful
developmentally.
Parents can help by financing (if possible) the purchase of new clothes.
Shopping expeditions with a friend who does not have an eating
disorder can be helpful when buying new clothes, and may enhance
shape acceptance.
 Some patients want to keep their old clothes. is should be
discouraged. ey should “burn their bridges” by giving the old clothes
away. A parallel can be drawn with someone wanting to keep clothes
from a period in their life during which they were severely ill (e.g.,
suffering from cancer). Do they want to have a constant reminder of
this period in their life, or is it truly time for a fresh start?

Addressing Feeling Full

Feeling full is a problem frequently experienced during refeeding and weight
regain. To prevent it from becoming a barrier to change, the first step is to
ask patients to complete, in real time, the “Context and Comments” column
of their monitoring record at the precise moment at which they experience
the feeling of fullness, in order to understand its nature. e second step is
to analyze with patients the potential processes implicated in the
development of such sensations. ese can sometimes operate
simultaneously (Fairburn, Cooper, Shafran, Bohn, Hawker, et al., 2008):

inking that one has eaten too much.

Feeling full (e.g., feeling there is too much food in the stomach).
Perceiving excessive protrusion of the abdomen.
Clothing feeling abnormally tight.
Feeling fat.

e third step in addressing feeling full is explaining to patients that this

tends to maintain the eating disorder because it is oen interpreted as
evidence of having eaten too much, and in some cases can be labeled
inappropriately as “feeling fat.” ese interpretations accentuate concerns
about shape, weight, and eating control, and may trigger an increase in
dietary restriction or other extreme weight-control behaviors.
Finally, aer having identified the nature of the feelings of fullness, the
therapist should suggest the following procedures to the patients, when
relevant:

• inking that one has eaten too much is a cognitive phenomenon

shaped by a patient’s view of how much food is an appropriate amount.
Patients oen have a warped notion of their daily energy requirements, and
frequently think that they will get fat if they eat more than 1,200–1,500
kilocalories per day. Education on this topic is therefore a must, and patients
with particularly inflexible eating standards can be identified by their excess
use of asterisks on their monitoring records.

• Feeling full is a physical experience that everybody has every day. It is

not indicative of having eaten too much or put on weight. If the patient is, or
has recently been, underweight, delayed gastric emptying will make them
especially susceptible to feeling full. Eating should not be guided by fullness
or hunger, as one or both of these sensations are likely to be disrupted in
people with eating disorders. Indeed, it is oen only aer several months of
regular and healthy eating that these sensations start to return to normal.

• Perceiving excessive protrusion of the abdomen is a common

phenomenon, especially in underweight patients. How much the abdomen
“sticks out” can be affected by the stage in the menstrual cycle, or eating a
bulky high-fiber diet, as well as wearing certain types of clothing and
consuming large quantities of carbonated drinks. It may be exaggerated by
self-scrutiny, especially in the early stages of weight regain, when fat is
preferentially deposited in the abdominal area (El Ghoch, Calugi,
Lamburghini, & Dalle Grave, 2014).

• Clothing feeling abnormally tight will be inevitable as the patients start

to regain weight. Addressing this aspect of feeling full involves education
about the natural changes in shape that may follow eating, and the fact that
it passes and is not indicative of having overeaten or being “fat.” Other topics
to be discussed are the effect of paying particular attention to sensations that
would normally go unnoticed, and the potential value of avoiding wearing
tight clothes when making changes to eating that could be perceived as
eating more. Obviously, however, patients’ clothes may actually be too small
and need to be replaced (see “Wardrobe Changes” above).

• Feeling fat. is experience and how to address it are discussed in

Chapter 12. is topic is best le until then, although some of the
educational issues may be raised at this point, especially the fact that feeling
fat should not be equated with being fat.
VIGNETTE
e patient is a 17-year-old girl who is having some difficulties during Step Two. She starts the
weight restoration procedure, but aer the first 2 weeks she reports feeling too full and being
unable to stick to her eating plan. e therapist educates the patient on feeling full and on the
potential experiences promoting this feeling—the patient states that her stomach is sticking out.
From a review of her monitoring records it can be seen that the patient has recorded feeling full
only aer lunch and dinner. When the therapist investigates, it emerges that the patient eats no
bread during these meals, and instead eats large amounts of vegetables and fruits. According to
the patient, she prefers fruits and vegetables to bread, and tries to substitute an equivalent amount
of these for her carb allowance.
e therapist congratulates the patient for trying to adhere to the total amount of food, but
points out that this behavior could have some counterproductive effects. e patient is invited to
evaluate the advantages and disadvantages of continuing to do this. e patient lists all the pros
and cons of substituting carbs with fruits and vegetables, and discusses this list with the therapist.
In the end, she concludes that there are several disadvantages to this choice—in addition to
making her feel full and leading her to deviate from her eating plan, it also means that she is not
addressing her food avoidance, and is unable to assess the role of carbs in weight regain. Based on
this analysis, the patient decides to include bread in her meal plan for lunch and dinner the
following week.

Addressing Feeling Bloated

e feeling of being bloated is also common in people without eating
disorders, especially in women in the premenstrual phase, due to an increase
in retention of body liquids. In people with eating disorders, feeling bloated
is frequently reported when the restoration of hydration occurs, aer a long
period of dehydration. In some patients, the feeling of being bloated serves
to maintain the eating disorder because it is oen interpreted as evidence of
having eaten too much and being “fat”; it therefore increases concerns about
eating, shape, and weight, and promotes an increase in dietary restraint
and/or the misuse of laxatives or diuretics.
During the early phases of refeeding and weight regain, and aer
interrupting laxative or diuretic misuse and self-induced vomiting, the
feeling of being bloated is particularly accentuated, and some patients may
experience refeeding edema, particularly in the legs. If patients do show
signs of edema, they should be reassured that it is usually a transitory
phenomenon lasting 1–2 weeks, and then referred to their general
practitioner to have her or him assess and manage the condition.
In the event that feeling bloated is not associated with signs of water
retention (edema), it is likely that patients are experiencing it because they
are not used to living with a normally hydrated body, and the therapist
should inform them that, within a few days, their body will get used to this
new, healthier physical state. Finally, with patients complaining of
premenstrual water retention, the therapist should suggest that they tolerate
this state for a few days and consider the increase in weight as temporary
and due to water retention, not fat.

Maintaining Motivation
Assessing motivation levels should be a point on the agenda throughout the
entire course of treatment, and any fluctuations in motivation need to be
explored on a weekly basis. It is important that patients are helped to see the
link between their behavior and their motivation to change. In order to help
identify factors that facilitate change, patients should be asked whether they
have noticed any changes in their motivation over the course of a week. If so,
it is important to explore what has influenced these changes and identify any
barriers to change. Conversely, once patients are making sustained progress,
they can be asked whether any of the secondary effects of being underweight
are lessening in severity.
 If patients report a decrease in motivation, it is important that the
therapist review with them the reasons for wanting to address weight
restoration. For some patients it may be useful to write these reasons on a
sheet of paper to keep on the table while they are eating. e therapist
should remind patients of the harm that their eating disorder causes to their
life, analyzing with them their short- and medium-term goals, and helping
them to identify what they find more difficult than their peers. When
patients show a reduction in their motivation to change, the therapist should
exhibit understanding of their ambivalence and try to instill hope in the
possibility of overcoming the eating disorder. However, it should be pointed
out to patients that they have at least five opportunities to choose to get
better (or not) each day, before each of their planned meals and snacks, and
it is these choices that will determine their progress.

INVOLVING PARENTS

Once the patient and therapist have devised a specific plan to create a
positive energy balance, a joint session with the patient and parents is
arranged. e aims of this session are to inform the parents that the patient
has decided to address the process of weight regain, and to educate them
about the weekly weight regain goal (i.e., an average rate of 1 pound/0.5
kilogram per week) and the procedures required to reach this goal (i.e.,
creating a positive energy balance of about 500 kilocalories a day). en the
therapist should review with the parents the difficulties the patient has
encountered when applying the regular eating procedure during meals, and
discuss the parents’ role in supporting their daughter’s or son’s weight regain
efforts. In addition to reiterating the general advice given for helping the
patient eat regularly (see above), the therapist should emphasize the
importance of working with the patient to choose and prepare family meals,
following the written plan devised to create a positive energy balance of
about 500 kilocalories a day. In case of any mealtime difficulties, parents are
encouraged to be calm and supportive, and to make helpful suggestions as
follows, encouraging them to apply one or more of the strategies that have
previously been discussed with them (see “Using Cognitive Behavioral
Strategies to Address Difficulties during Meals” above):

“We know that it is difficult but try to eat everything you planned to.
is will help you regain weight at an appropriate rate. It will also
help you to feel in control.”
“Don’t let feelings of hunger and fullness influence what you eat. ey
are distorted by your eating disorder and are not a good guide to
what and when to eat.”
“Don’t be influenced by the presence of recurrent thoughts about food
and eating. ey are secondary effects of the eating disorder and are
not a good guide to what or when to eat.”
“Try to eat in a normal manner. e tendency to eat slowly/cut up food
into small pieces/eating small morsels of things (as applicable) is a
secondary effect of your eating disorder. Try to eat in the same way
as others do. is will help you regain weight at an appropriate rate.”
“Record your difficulties (in real time) and the procedure you should use
to address them on your monitoring record. is will help you come
up with solutions to the problems you are encountering.”

Another joint session is usually held 1 week aer the weight regain plan has
been introduced. is joint session is dedicated to reviewing family meals
and devising solutions for any problems that may have emerged during the
week. Further family sessions are scheduled every 4 weeks to review both
progress and any obstacles encountered.
VIGNETTE
e patient is a 14-year-old girl who, at the end of Step One, decides to address weight
restoration. When she was losing weight she stopped eating with her family (her parents and an
older brother), as she was afraid of receiving negative comments about her eating and being
obliged to eat more. e patient reports that, in the past, her brother had oen insisted that she
 eat something from his plate, and her father used to criticize her when she ate only vegetables,
making her feel like a loser. e patient is now worried that the situation will not have changed. In
a joint meeting with the parents and the brother, the therapist explains to the patient and family
members about the importance of eating family meals together in order to address dietary
restriction and weight regain, and asks the parents and brother to avoid any kind of negative
comments about the patient’s eating and not force her to eat. However, the patient is still very
concerned, and continues to fear that someone may force her to eat. For this reason, all agree to
address the family meals gradually; the patient will first eat with her mother alone, then with both
parents, and finally also with her brother.

COMMON DIFFICULTIES WITH WEIGHT

RESTORATION

Helping adolescent patients regain weight requires sustained effort for

several months, and it is common for patients to want to give up before they
reach their goal weight range. To prevent this, the therapist will need to
work hard to help patients complete the process. It may be that the changes
they are making are too small. is is a common occurrence, and it must be
made absolutely clear to patients that they must not deviate from the eating
plan. Eating less than a daily average energy surplus of 500 kilocalories is
just not enough, and any reasons for doing so need to be investigated. As
mentioned, patients tend to overestimate the energy content of foods, and
this may be a reason for them eating too little. Patients may feel that making
small changes is “safer,” meaning that there is less risk of them overdoing it
and putting on too much weight, especially if they are eating foods they are
unused to eating, or those whose calorie content is difficult to assess. In
reality, of course, if they do not eat enough, this is “unsafe,” as they are
risking being unable to overcome their eating disorder. e therapist should
stress that the fear of “overeating” is unjustified. eir eating plan has been
specifically designed to provide a controlled rate of weight regain.
Furthermore, it should be pointed out that it normally takes just as much
effort to make large changes as it does to make smaller ones.
 If patients’ efforts start to trail off, the therapist should be sure to
acknowledge how difficult the process of weight restoration is, and
encourage them to move forward. e “mountain climbing” analogy (see
below) can be useful for explaining to patients how the process of weight
regain is difficult but worth the effort:

“Weight restoration is like going to the mountains and having to reach

the top of a peak. e destination is supposed to be beautiful, at least
that is what you have been told, but you have yet to see it for yourself.
e cable car you have taken has only brought you halfway up, and in
the past you have always decided to go back down on foot from that
point. It seems much easier to walk downhill, but now you are being
asked to climb (i.e., stop dieting) and try to reach the top. You know it
will take time and effort to reach the summit (the goal of a BMI
corresponding to at least the 25th percentile), but if you stop, you risk
slipping back, perhaps even rolling down the slope, or never reaching
the amazing destination (you will only feel the benefits of weight
restoration when you reach a BMI corresponding to at least the 25th
percentile).”

It is important that the therapist remains empathetic, encouraging, and

supportive, acknowledging the difficulties the patient is facing, while
remaining unambiguous about the work that needs to be done. A strong and
trusting therapeutic alliance is necessary to stay “friendly but firm” and
maintain the gentle but constant pressure required.
ere are many reasons why the patient may be struggling. ese are
some of the most common:

• A rigid and oppositional stance. Underweight patients (especially

teenagers), oen display a certain degree of stubbornness and inflexibility.
However, it may be that this stance reflects a premorbid character trait that
is being exacerbated by being underweight. An oppositional stance is best
approached indirectly, by identifying any unrelated difficulties that they may
be experiencing and instead focusing on overcoming these.

• Feeling full. e patient may be unable to maintain an increased level of

eating due to feelings of fullness. “Fullness,” and how to address it, are
discussed in detail earlier in this chapter (see “Addressing Feeling Full”). As
discussed above, the propensity to feel full is heightened in patients who are
underweight due to delayed gastric emptying. is delay is reversed by the
restoration of healthy eating habits. It is our experience that regular eating is
especially helpful in this regard.

• Concern about becoming “fat.” Patients may want to stop regaining

weight for this reason, and their labeling of themselves in this way needs to
be challenged, as it has no grounding in reality. Even in the worst-case
scenario they will be changing from emaciated to slim. Nonetheless, the
difficulty that they may be having in accepting their new shape should be
acknowledged. If patients feel that parts of their body are getting
unacceptably “fat,” the therapist should endeavor to help them understand,
reinterpret, and override this feeling. is will likely involve addressing
patients’ overvaluation of shape and weight at the same time (see Chapter
12), which should enable them to more easily accept weight regain.

• Concern about a change in body shape. Some patients check their

stomach during meals, and feeling a change in their stomach volume makes
them think that their stomach will get bigger. Others check in the mirror
before and aer meals to see whether their belly is protruding or whether
their thighs have undergone any changes. ese behaviors may prompt
patients to stop regaining weight, so when frequent and hindering weight
restoration, they should be addressed using the strategies to manage shape
checking (see Chapter 12). Patients should be informed that in the early
phase of weight restoration, the abdomen may appear to protrude due to
natural changes in the body when reversing emaciation because the
abdominal muscles will be too weak to hold the stomach in. As the back
muscles are also weakened, the fact that the body is so narrow will also
makes the belly appear to stick out disproportionately. is situation is
temporary, but must be discussed with any patients who express this
concern. Patients should be helped to see that it does not mean that they are
overeating or getting “fat.” In addition to controlling self-scrutiny, these
concerns may also be mitigated by practical steps to reduce this
phenomenon, like the consumption of energy-rich, rather than high-fiber,
foods, not drinking carbonated drinks, and avoiding wearing very figure-
hugging clothes.

• Concerns about clothes becoming tight. is may cause patients to want
to stop regaining weight, and should be preempted (see “Wardrobe
Changes” above).

• e patient states that “Eating all this high-calorie food is unhealthy.”

Should patients express this idea, they should be helped to see that it is their
low weight, rather than energy-rich food, that is the danger, and that the
normal rules of healthy eating do not apply in their emaciated state. General
dietary guidelines are not designed for people with an eating disorder, and it
is only by eating energy-rich foods that they will recover. Of course, once
they have reached their goal weight range, they will be free to limit their
consumption of such foods if they wish, provided that they avoid high levels
of dietary restraint and eat enough to maintain their weight.

• Comments from others. Although others are likely to be pleased that

patients are making positive changes and looking healthier, any comments
that they make are likely to be misinterpreted by patients, which may
adversely affect their attempts to regain weight. ey may feel that
comments about their improved appearance actually mean that they look
“fat,” while those about eating may be interpreted as an indication that they
are “greedy” and overeating. is is due to their eating-disorder mindset,
and patients need to be helped to see that they are in fact misconstruing
encouraging remarks as criticism. is needs to be discussed during the
session and the patients encouraged to try to experience such comments as
positive.

• e patients’ misconception that they have regained enough weight.

Oen patients who are still underweight will lose motivation when they
start approaching their target weight range. At this point it is important to
praise them for the efforts they have made so far, but to remind them that
this is only half the battle. If they stop now, they will not be able to enjoy all
the benefits of weight restoration (see “Common Difficulties with Weight
Restoration” above). Although, having put on some weight, they will be less
unhealthy than when they started the “climb”—maintaining a 15th BMI-for-
age percentile, for example, will not enable patients to overcome their
eating-disorder mindset permanently, leaving them at significant risk of
relapse. Moreover, should they lose any weight due to illness, and so on, they
will be thrust straight back into the “danger zone” inadvertently.

• Forgetting the reasons for regaining weight. In some patients, the eating-
disorder mindset reasserts itself as soon as they have le the therapist’s
office. is may cause them an inability to recall why they are pursuing
weight restoration mere minutes aer the end of the session. Patients should
therefore be encouraged to keep a list of their reasons for change close to
hand, and to read through it regularly, in particular, when they sit down to
eat and get up in the morning, as well as in “emergency” situations.
VIGNETTE
e patient is addressing weight regain in Step Two. She has been able to increase her weight
progressively, apparently without much difficulty, from the 5th to the 20th BMI-for-age
percentile. However, a review of her monitoring records from the last week reveals that she has
started skipping her midmorning and midaernoon snacks and restricting her main meals. In the
ensuing discussion with the therapist, the patient reports that she is pleased with her body,
accepts the 20th BMI-for-age percentile, and has good relationships. Hence, she is unable to see
any reason for reaching the 25th BMI-for-age percentile threshold. She also says that most of her
friends are skinny, and that now she is like them. e therapist congratulates the patient on being
able to regain weight, but asks her to evaluate the implications of her remaining underweight. e
goal of the therapist is to help the patient to reach the conclusion that staying at a low weight
maintains the eating disorder because it requires the adoption of extreme weight-control
 behaviors and is associated with malnutrition symptoms, such as concerns about eating control,
irritability, and mood changes, and does not allow a good social life because it is difficult to attend
social occasions involving food without anxiety. e patient partially agrees with these
considerations, but is not fully convinced. At the next session, she reports that she was invited to
eat at a restaurant with some friends during the week, and she ate only vegetables. However, her
friends were surprised and worried about her eating behavior, and repeatedly encouraged her to
eat like them. e therapist uses this experience to go over again with the patient the pros and
cons of reaching a low normal weight, and aer two sessions the patient reaches the conclusion to
try to reach a 25th BMI-for-age percentile threshold because she is tired of the negative influence
that her eating disorder is having on her interpersonal life.

MOVING FROM WEIGHT RESTORATION TO

WEIGHT MAINTENANCE

We generally start to discuss and address the topic of weight maintenance

when patients reach the 25th BMI-for-age percentile threshold—however,
the minimum threshold for the healthy weight maintenance range should be
assessed on a case-by-case basis. To this end we explain to patients that
together we have to identify a weight range that meets the following three
criteria:

1. It can be maintained without the adoption of dietary restriction or

other extreme weight-control behaviors.
2. It is not associated with starvation symptoms.
3. It allows a social life.

In comparison to weight restoration, maintenance is relatively simple.

With patients who gain weight at the appropriate rate, it is simply a matter of
slightly reducing the amount of food they are eating. is must be done with
caution, however, as there is a risk that they could lose weight. If, on the
other hand, they are using energy drinks, we suggest removing the first
drink when they are close to the identified minimum healthy weight
threshold and the second when they reach it.
 ere is a lot of trial and error involved when helping patients to achieve
a reasonably stable weight. e goal is for patients to maintain a weight
within a range of about 6 pounds (3 kilograms; see Figure 11.3), and to do
so they need to learn how to balance their activity levels and energy intake.
As mentioned, most patients are surprised at how much they can eat
without gaining weight. It is important to note that at this stage, the patient
and therapist will have very different concerns. While the therapist is
focused on helping the patients to maintain a healthy weight, the patients
are likely afraid that their weight will continue to rise. ey may therefore be
tempted to take preventive action, potentially resulting in their losing
weight. It is therefore important for the therapist to openly discuss with
patients that this is a risk, and to reiterate the dangers associated with weight
loss.
FIGURE 11.3. A representative weight graph of an underweight adolescent patient with an eating
disorder who has completed both the weight regain and the weight maintenance phases.

It is also vital during the weight maintenance phase that the therapist
continues to address the residual eating-disorder features. Hence, at this
stage it may be useful to ask the patients to complete the EDE-Q and CIA.
is will enable assessment of the current state of affairs regarding the eating
disorder and secondary impairment, respectively. Furthermore, the therapist
should help patients accept and take pleasure in their new appearance and
adjust to new, emerging aspects of their personality, which may be very
different from what they thought it was.
 CHAPTER 12

Body Image Module

e overvaluation of shape and weight and their control—that is, the

judging of self-worth largely, or even exclusively, in terms of shape and
weight and the ability to control them—is the distinctive “core”
psychopathology of most eating disorders. Indeed, as described in Chapter
2, most other expressions of eating disorders appear to derive directly or
indirectly from this psychopathology, and for this reason it occupies a
central place in most patients’ formulation and is one of the most important
targets of treatment; unless it is successfully addressed, patients are at
considerable risk of relapse (Fairburn, Cooper, Shafran, Bohn, Hawker, et
al., 2008). Overvaluation of shape and weight should be differentiated from
body dissatisfaction, as the former is more closely associated with self-
esteem than the latter, and better distinguishes individuals with eating
disorders from those without. Note, however, that in some younger patients,
the core psychopathology is the overvaluation of control over eating per se,
rather than a desire to control eating with the aim of influencing shape and
weight. e strategies and procedures for addressing the overvaluation of
control over eating are described in Chapter 13, but follow principles similar
to those described here.
 Addressing this psychopathology takes time; change is gradual, although
more rapid than in adults. erefore, in patients who are not underweight, it
is best to start this work early in Step Two. Once this has begun, it should
remain a permanent item on the session agenda. In underweight patients,
however, the Body Image module is usually implemented when they regain
a certain amount of weight and manifest concerns about shape and weight
hindering weight restoration.
e strategies for addressing concerns about body image are as follows:

1. Identifying the overvaluation and its consequences.

2. Creating the extended personal formulation.
3. Enhancing the importance of other domains of self-evaluation.
4. Addressing shape checking and avoidance. Weight checking and
avoidance were addressed in Step One.
5. Addressing “feeling fat.”

Generally, these elements are introduced in this order, but at which point in
the treatment each is introduced will need to be decided case by case. In
some patients, they are introduced early on in Step Two, as some expressions
of body image (e.g., shape checking) may be enhancing body dissatisfaction,
thereby hindering weight regain. In other patients, the Body Image module
will be introduced when patients are getting close to their low healthy
weight threshold and their body shape has changed accordingly. In patients
who are not underweight, on the other hand, the Body Image module is
introduced early on, as its procedures take time to implement and have an
effect.

IDENTIFYING OVERVALUATION AND ITS

CONSEQUENCES

In our clinical experience, adolescent patients welcome discussion of self-

evaluation. With the use of age-appropriate words and a pie chart (to
illustrate their individual self-evaluation system), most adolescents are able
to understand this complex and abstract topic.
e therapist should start the discussion by explaining that most people
tend to evaluate themselves on the basis of the success they achieve in areas
of life that they consider important. In adolescents, common self-evaluation
domains are relationships with family members and friends, and
achievements at school, in sports, and in other activities. e therapist
should explain, for example, that if people give a lot of importance to the
school domain, they feel good when they get a high grade, but feel bad when
they get a low grade. en, if they assign importance to their relationships
with others, they feel good when they are appreciated, sought out, and
involved in activities by peers, but feel sad or frustrated when they receive
criticism or perceive disinterest by others.
e therapist should also explain that people have many domains by
which they judge themselves, but not all the domains are ascribed the same
importance. Patients should also be helped to discriminate between
domains that they regard as important because they are generally thought to
be so (e.g., grades) but do not in fact influence how they judge themselves,
and the things that really impact their self-worth. To this end, the therapist
should explain that if a young person feels bad for a long time when an
aspect of her or his life is not going well, it is likely that this is an important
self-evaluation domain. For instance, if people evaluate themselves on the
basis of the grades they get at school, it is probable that, when they get a
grade that does not meet their expectations, they tend to have a strong and
lasting negative emotional reaction and, if the failure persists, may develop a
negative self-image.
e therapist, aer having checked that patients have clearly understood
this concept, encourages them to come up with a written list of the things
that could affect them in this way (i.e., their important self-evaluation
domains). At this stage, patients may even omit shape, weight, and their
control from the list, and it will be the therapist’s job to bring this up. A
dialogue to illustrate how this may be approached follows:
 THERAPIST: Well, I see you’ve included school, family, and friends, and a
romantic relationship on the list. Do you think that anything might
be missing?
PATIENT: No, they are all there . . . I can’t think of other important areas
in my life.
THERAPIST: Let’s try to think about it together, analyzing the reason
you’re here and the work we’re doing together. Why did you decide
to start the treatment?
PATIENT: Umm . . . because I want to get rid of all my fears . . . I want to
be free to live life as I wish and not be conditioned by a fear of weight
gain, the shape of my body, or what I can or can’t eat.
THERAPIST: I see. Why are you so scared of your weight or the shape of
your body changing? Let’s have a look at your formulation to better
understand it. Do you remember? We talked about it together.
PATIENT: Yes, I remember. I’m afraid because for me my weight and the
shape of my body are so very important . . . they have become more
important than all the other things in my life.
THERAPIST: at’s right! So, don’t you think that we should add this to the
list you wrote?
PATIENT: Yes, you are right. I have to add my weight and body shape. I
don’t know why I did not think of it before. Actually, I took it for
granted; they are the most important things in my life.
THERAPIST: OK, then let’s add that to the list.

e next stage of the process is to collaboratively generate a pie chart

illustrating the relative importance that patients give to their individual self-
evaluation domains. To this end, the therapist should refer to the list and
inquire which they consider more and less important. ey should be asked
how badly they would feel (in terms of intensity and duration) if things were
to go badly in each domain. is enables the various items to be ranked, but
bear in mind that it is important to establish how patients really judge
themselves, rather than an indication of how they think they should do so.
Once the items have been ranked, the therapist and patient can draw a
provisional pie chart to illustrate their self-evaluation scheme. e size of
each slice of the “pie” will represent the relative importance that patients
give to each domain. In Figure 12.1, an example of a pie chart produced by
an adolescent patient with an eating disorder is shown on the le, while one
produced by an adolescent without an eating disorder is shown on the right.
Before wrapping up, the therapist should ask patients what they think about
the pie chart they have made. Most adolescents readily identify with it, as it
provides them with a clear understanding of what is going on. In fact, they
also oen state that they give too much importance to shape, weight, and
eating control without any prompting.

FIGURE 12.1. An example of a pie chart of an adolescent patient with an eating disorder (on the
le) and one without an eating disorder (on the right).

en, it is time to assign the homework. Patients should be asked to have

a look at their pie chart each day, and to think about whether or not it
accurately represents how they actually think and behave day to day. It may
be helpful to suggest that they produce a new pie chart every evening (on
the back of the day’s monitoring record). Some adolescents are creative in
doing this homework (e.g., they may use different colors for the various
slices of the pie). e first pie chart should be discussed further at the next
session, and a new one drawn so that the size of the slices represent their
importance as perceived by the patients aer their week of reflection. It is
common at this stage for patients to increase the size of the slice
representing the importance they give to shape, weight, and eating.
e next step is for patients to consider the implications of how they
judge themselves, using their pie chart as a reference. ey should be
encouraged to think about whether this type of self-evaluation scheme may
be problematic. In the ensuing discussion, patients should be helped to
identify the unwanted effects of evaluating themselves in such a manner.
ese are usually as follows:

• Having a pie chart with a dominant slice is “risky.” e therapist, while

actively involving the patient in the discussion, should emphasize that a self-
evaluation system of this type works well, as long as things are going well.
However, when something begins to slip, it inevitably produces a negative
self-evaluation. Using the pie chart as a reference, the therapist reflects with
the patient that when something goes wrong in the control of shape and
weight, as this is the principal domain, this will inevitably lead to the whole
system of self-evaluation collapsing. e end result is for patients to judge
themselves negatively overall, as the other domains are too small to make up
for perceived failure in this one. In other words, “It’s like putting all your
eggs in one basket.”

• Judging oneself on the basis of appearance and weight, and one’s ability to
control them, is inherently problematic. e therapist might say:
 “In your case, the problem is not only one of having most of your eggs in
one basket, it also lies in the nature of the basket itself. Success in this
area of life may be difficult to achieve, and it is problematic for several
reasons.
“Your shape, weight, and eating are not fully under your control. We
only have a limited ability to control our eating (and hence our shape
and weight), as it is under strong physiological control. You can
manipulate it in the short term but to do so on a long-term basis
requires considerable and sustained effort, and you pay a price as a
result. Similarly, your overall body shape or physique is only partially
under your influence. It is mainly something you just have to accept.
“ere will always be other people who seem more attractive (i.e.,
successful in your eyes) than you. Both the way people with eating
disorders judge themselves and the way they compare themselves with
others make them see themselves as unattractive. We discuss these topics
later on, but for the moment it is important that you understand that as a
result of these two processes you are likely to repeatedly feel that you are
failing.”

• Judging oneself in this way leads a person to do things that harm her or
him. e therapist should list appropriate examples, such as undereating,
excessive exercising, binge eating, self-induced vomiting, and so on. Such
behavior thereby maintains the eating problem and interferes with day-to-
day life. e therapist may highlight the main sources of impairment
detected on the CIA questionnaire completed at the end of Step One.

• Excessive focus on one dominant slice of the pie makes it difficult to have
a well-rounded, happy life and is self-perpetuating. Being concerned almost
exclusively with shape, weight, and eating control marginalizes other areas
of life, reducing the interests of the individual to her or his body alone. e
therapist should therefore emphasize how, in this way, the commitment that
could be dedicated to other important areas of life (e.g., relationships,
school, hobbies) and those that contribute to developing a functional, stable,
and well-rounded self-evaluation system, is inevitably limited.

During the course of the treatment, the therapist should ask patients to
periodically redraw their pie chart to assess their progress in terms of self-
evaluation.

CREATING THE EXTENDED PERSONAL

FORMULATION

Aer the above discussion, it is only natural to progress to the creation of an

extended formulation—that is, a personal formulation that illustrates the
consequences of the patient’s individual type of overvaluation, in addition to
the behaviors already included in the provisional formulation. e therapist
starts this process by asking patients what they do or experience as a result
of the importance they place on shape, weight, and eating control. e goal
is to create a diagram that will permit identification of the key mechanisms
maintaining their overvaluation of shape, weight, and/or eating control to
address as part of the treatment. e following is a session transcript in
which the therapist begins to create the extended personal formulation with
the patient:

THERAPIST: Now that we have created your pie chart and evaluated its
implications, let’s try to understand together what its expressions are,
and how these reinforce your eating problem. In your opinion, how
does this self-evaluation system affect your daily life? Is there
anything that makes you see that shape, weight, and their control are
extremely important to you?
PATIENT: Certainly! e fact that controlling my body has become more
important to me than my school grades, and even if I don’t
concentrate and pay less attention in class, it is not that important to
 me now. Also, I don’t accept invitations from friends to eat out or go
to a party anymore, for fear of eating certain foods or, in any case,
more than usual.
THERAPIST: I see! is is an expression of the pie chart that we can call
“marginalization of other areas of life.” (Draws an arrow under
“excessive importance of shape, weight, and their control in my self-
evaluation” and writes “marginalization of other areas of life.”)
PATIENT: OK.
THERAPIST: Now we also have to consider that this marginalization, in
turn, tends to maintain the overvaluation. (Draws an arrow from
“marginalization of other areas of life” to “excessive importance of
shape, weight, and their control in my self-evaluation.”)
PATIENT: at is what we said when we discussed the pie chart. e less
importance I give to the other areas of my life, the more attention I
pay to controlling my shape and weight.
THERAPIST: Very good. is explains why it will be important for you to
increase the number and relative importance of the other areas of
your life. However, now let’s try to think of other expressions of
overvaluation. Are there, in your opinion, any behaviors you do,
excluding dieting, that express the importance you give to the
control of your shape and weight?
PATIENT: Umm . . . I look at myself in the mirror all the time and I oen
look at the thighs of my classmates, which are so thin. Could these
be some expressions?
THERAPIST: Yes, that’s right. is behavior, which we call shape checking,
is a typical expression of the importance that you give to the shape of
your body. We can write “shape checking” under “overvaluation of
shape, weight, and their control.” If you don’t mind, I would also like
to give you a brief outline of how shape checking maintains the
 overvaluation. We can discuss this topic in more detail later on if you
would like.
PATIENT: OK. I am interested.
THERAPIST: Good. In general, when people think that controlling their
shape is unduly important, they tend to do some distinctive forms of
shape checking. Typically, they focus their attention on the parts of
their body that they don’t like, and by doing so, they tend to amplify
their perceived defects and concerns about body shape. Moreover, by
comparing their body shape with that of others, as you also oen do,
in particular, if it is done rapidly and superficially, tends to confirm
the belief that some body parts are “wrong” and need to be changed.
Many people who place a lot of importance on body shape tend to
compare themselves only with skinny people or those with skinny
thighs, which leads them to conclude that they are “fat” and their
thighs are enormous. e result is an increase in concerns about
body shape.

e therapist continues this discussion, trying to identify all of the

expressions of the overvaluation of shape, weight, and their control, and
explains the various maintenance mechanisms involved. At the same time,
the therapist draws the patient’s extended personal formulation on a sheet of
paper (see Figure 12.2).

FIGURE 12.2. An example of a personalized extended formulation of an underweight adolescent

patient with an eating disorder.
 Two-Prong Strategy for Addressing Overvaluation
e therapist should explain to patients that two complementary strategies
will be adopted (see Figure 12.3) to address their dysfunctional self-
assessment system (Fairburn, Cooper, Shafran, Bohn, Hawker, et al., 2008):

1. Increasing the importance of other domains of life (i.e., increasing

the size and number of other slices in the patients’ pie chart).
2. Reducing the importance of shape, weight, and their control (i.e.,
decreasing the size of the “shape and weight” slice) by directly
tackling the principal expressions of their overvaluation (i.e., shape
checking, shape avoidance, and feeling fat). Frequent weighing or
avoiding weighing should already have been addressed in Step One
of the treatment, while undereating and being underweight and
dietary restraint are addressed in other specific modules (see
Chapters 11 and 13, respectively).

FIGURE 12.3. Two-prong strategy to address the overvaluation of shape, weight, and their control.

Commonly, adolescent patients immediately acquiesce to these goals.

With adolescent patients who are not underweight or only slightly
underweight, we immediately start working on enhancing the importance of
other domains of self-evaluation. However, with patients who are severely
underweight we prefer to introduce this procedure aer a period of weight
regain, because many of the effects of being underweight prevent them from
engaging in other domains, especially those that are interpersonal in nature.
In this case, we usually start by working on body checking, as decreasing
body dissatisfaction may remove some obstacles to weight restoration. Later,
when the negative effects of being underweight are reduced, we introduce
enhancing other self-evaluation domains, and tackle body avoidance and
feeling fat.

ENHANCING THE IMPORTANCE OF OTHER

DOMAINS OF LIFE

e goal is that patients begin to engage in other aspects of life (e.g., school,
social life, hobbies), and that these things become more important “slices” in
the patients’ self-evaluation scheme. ere are five steps to helping patients
engage in, and begin to value, other aspects of life (at each step the therapist
should play an active, proactive, and encouraging role, to emphasize its
importance, and to stimulate patients to change; Fairburn, Cooper, Shafran,
Bohn, Hawker, et al., 2008):

1. Explain the rationale for doing this. e first step is, as usual, to
explain to the patients why the procedure is important, clearly stating and
clarifying that to increase the number and importance of other domains of
life will help them no longer be solely focused on their shape and weight,
and will give them the opportunity of having other life experiences that may
indirectly help reduce the importance they attribute to shape, weight, and
their control.

2. Identify new activities in which the patient might become involved. e

therapist should encourage patients to reflect on old interests and activities
they did before the onset of the eating disorder and/or things that they
might like to try. In this phase, it is important to examine all the possibilities
to give patients a wide choice. Many adolescent patients are tentative, ruling
out even quite promising possibilities, and many have difficulty thinking of
activities because, even before the onset of the eating disorder, they were
engaged in relatively few. Sometimes good ideas can come from considering
what their friends do outside of school.

3. Agree on one or two activities that the patient will try out. It may be
useful to involve friends or peers in this, as patients will be more likely to
stick with an activity if they are doing it in company. is will also give them
a chance to work on their interpersonal skills.

4. Ensure that the patient sticks to the plan. Once a promising activity
(or two) has been identified, the therapist should seek to ensure that they
actually start to engage in it. is can be achieved by encouraging hesitant
patients to get started and asking them to record their progress in the last
column of their monitoring record.

5. Review progress week by week. is should be a permanent item on

the session agenda. e therapist should be encouraging, and the patients
should be prompted to use a proactive problem-solving procedure to
overcome any difficulties they might experience (see “Problem Solving:
Steps One–Four” in Chapter 14). Note that there is no point in beating a
dead horse; patients should abandon an activity aer three “unsuccessful”
attempts, and be encouraged to identify and adopt another one in its place.
Additional activities may also be added later on, while others may be
dropped. Toward the end of treatment, it is worth asking patients to redraw
their pie chart, as doing so provides an opportunity to review their progress
in this regard. Typically, the “slice” representing shape and weight has
shrunk in size, and new slices have been added. Naturally, the therapist
should praise the patients for any changes that they have made.

In helping the patients to develop other domains, the therapist should be

encouraging, but maintain the pressure to change. It is also important to be
specific with regard to homework and restate the rationale at intervals (e.g.,
“success breeds success”). It is also common for this procedure to be
associated with other benefits, such as paving the way to new opportunities,
resulting in the development of new relationships, improving self-esteem,
and helping patients to “catch up’ socially and developmentally.
VIGNETTE
e patient, discussing with the therapist the implications of her pie chart (drawn on the back of
her monitoring record), states that she is very upset about how her eating disorder has
marginalized other areas of her life. She also reports that now, having only a few residual binge-
eating and purging episodes, she has a lot of free time that she does not know how to occupy. She
also reports that when she is at a loose end she has noticed that her concerns about shape, weight,
and eating control increase. She says that before the onset of her eating disorder she was very
popular, had lots of friends, a boyfriend, and played volleyball, but now she spends most of her
time alone. Discussing this helps her to understand that having a pie chart with a dominant slice
means that her life is very narrowly focused, and that this is self-perpetuating. However, the
patient is reluctant to identify and engage in any activities, because she believes that there is really
nothing worth doing. She has fallen out of touch with her friends and her boyfriend, and no
longer enjoys playing volleyball. She admits that she is afraid of not being accepted by her old
friends because she had previously ruined all of her relationships. However, with some reluctance
she accepts the importance of addressing her marginalization, and agrees to call an old friend to
see whether she would like to meet up, and to enroll in a dance class. In the subsequent sessions,
the patient reports that she is pleased to be in contact with an old friend again, and that she has
developed new and interesting friendships in her dance class.

ADDRESSING SHAPE CHECKING

It is common for adolescents to check their body to some extent, but many
young people with eating disorders repeatedly do so, oen in a way that is
unusual. Such checking can become so “second nature” that they may not
actually be fully aware that they are doing it (e.g., they automatically
compare themselves with other people they see while walking down the
street). Since shape checking tends to be particularly influential in
maintaining dissatisfaction with shape and in encouraging dieting in
adolescents, it is best to address this aspect of body image first. e
procedure has six main steps.
 1. Explaining the rationale. e therapist should remind patients of (a)
the two reasons for addressing overvaluation and (b) the content of their
extended formulation. Moreover, if applicable, it is worth informing patients
that they have already addressed one form of body checking—namely,
weight checking—in Step One during in-session weighing. Almost
invariably, patients will have found in-session weighing helpful, as it will
have assuaged their concerns about weight (i.e., the number on the scale).
Patients should also be informed that shape checking needs to be addressed
directly because it maintains body dissatisfaction, and consequently
encourages dietary restraint and the adoption of other extreme weight-
control behaviors. ey should be told that, as with weight checking, they
may experience a short-lived increase in concerns about shape, but similar
benefits will result from addressing shape checking.

2. Identifying the various forms of shape checking. Next, the therapist

needs to assess the patients’ shape checking. Since recording shape checking
can be distressing, and patients are oen unaware that they are engaging in
this behavior, it is best to ask them to do it in real time in detail only for two
24-hour periods (using an adaptation of the usual monitoring record; see
Figure 12.4): one being a school day (if the patient attends school) and the
other being a day off from school.
FIGURE 12.4. An example of a monitoring record of an adolescent patient with an eating disorder
who is monitoring shape checking.

e therapist should also help patients to identify the various form of

shape checking, discussing the types of behavior that should be recorded.
Common examples include:
Scrutinizing particular body parts in the mirror (or reflective
surfaces)—a form of shape checking that is very common in
 adolescents.
Measuring their bodies using a tape measure.
Pinching or touching body parts, assessing the tightness of
particular items of clothing (e.g., pants or skirt waistbands) and
accessories (e.g., watches or rings).
Looking down at their thighs or stomach, for example, when sitting.
Comparing themselves with others.
For young male patients, it is build and muscularity rather than weight that
tend to be of concern.

3. Reviewing the adapted monitoring records. Next, the therapist

evaluates with the patients the reasons for and consequences of shape
checking, by asking the following questions (Fairburn, Cooper, Shafran,
Bohn, Hawker, et al., 2008):
“What are you trying to find out when you check your body? Do
you think you can find it out this way?” Usually, patient replies are
something like the following:
“To find out what my shape is like.” In this case, the therapist
should emphasize that checking the shape of the body tends to
magnify imperfections, and that some aspects of body shape are
normal (e.g., having a slightly protruding abdomen).
“To see if my shape is changing” (or “To see if I am getting fat”).
In this case, the therapist should make patients reflect on the fact
that checking body shape does not provide reliable data, but only
inaccurate impressions. For example, in the mirror you can oen
see differences between how you look in the morning and the
aernoon because we are not blessed with a photographic
memory of our body.
“Why are you checking yourself so frequently? Do you think you
might be checking yourself too oen?” Usually the patient’s answer
is “To check that my shape hasn’t changed.” In this case, the
therapist should ask whether the patient thinks that her or his body
shape can change so quickly as to justify such frequent checks and,
if necessary, explains that the shape of the body cannot change
within a few hours in the absence of significant changes in weight. If
the change in the shape of the belly is a concern, the patient should
always keep in mind that the fluctuations in abdomen shape are
normal, and assess whether or not this corresponds to a change in
weight.
“Do you ever look at the parts of your body you like?” In most
cases, the patient answers “No.”
“Do you feel better aer checking your body?” e majority of
patients respond “No.” In this case, the therapist should help the
patients reflect on why shape checking does not make them feel
better, in order to highlight how this behavior maintains and
accentuates concerns about body shape. Some patients may respond
“Yes. It reassures me because it reminds me that I am thin.” In this
case, the therapist should emphasize that the result of this, however,
is actually to maintain and accentuate concerns about body shape.
“Do you think your shape checking has any adverse effects?”
Usually, patients have not reflected on this aspect, and are not aware
that shape checking has numerous negative consequences. In these
cases, the therapist should remind patients that shape checking is
unhelpful for the following reasons:
It maintains concern about the shape of the body because the
parts of the body that one does not like are continuously
scrutinized.
It makes even the most attractive people find “flaws,” as what we
see depends largely on how we view ourselves.
It amplifies apparent defects because we tend to focus on what we
do not like, rather than looking at the bigger picture. As a
consequence, we have no reference points for size or scale.
 While most adolescent patients rapidly understand the contribution of
body checking in maintaining their eating disorder and are prepared to
address it, a subgroup is ambivalent, as they value this behavior. Common
objections expressed by such patients and examples of therapists’ responses
follow:
PATIENT: Body checking does not have an important role in maintaining
my eating problem.
THERAPIST: Try to stop body checking for a couple of weeks and assess
the effect on your concerns about weight and body shape. Once you
have done this experiment, let’s talk about this again.
PATIENT: Body checking helps me to control my weight.
THERAPIST: It is true, healthy body checking, like checking weight once a
week, may help to maintain control over weight. On the other hand,
other types of body checking—for example, weighing yourself
several times a day, spending a lot of time looking at parts of your
body you do not like, or measuring yourself with a tape measure—
provide an inaccurate estimate of your size and increase concerns
about shape and weight.
PATIENT: I feel good when I feel my bones stick out; it is a sign that I am
thin.
THERAPIST: How long does this state of well-being last? Why do you need
to touch your bones so frequently? Perhaps you feel reassured at not
having lost control over your shape and weight? However, it seems
that this state of well-being does not last long because aer a while
you still need to touch your bones again. Are you sure that this is an
accurate method for estimating the shape and weight of your body?
How much should your bones protrude? Do you think that checking
your bones may increase your concerns about shape and weight?
PATIENT: I compare myself with fat people and I tell myself that I must
continue to diet to avoid becoming like them.
 THERAPIST: Are people who you compare yourself with really fat?
Individuals with eating problems oen judge people who are in a
normal weight range as “fat.” Maybe the people who you label as “fat”
are happier than you. For example, they may feel good about
themselves because they are fulfilled in their work and have
satisfactory relationships with others. When you compare yourself
with others, try to focus your attention on characteristics other than
their body—for example, their hair or their style, and so on.
PATIENT: You say that addressing body checking will reduce my concerns
about shape and weight, but being preoccupied with my body helps
me to control my weight.
THERAPIST: at may be true, but your excessive concern prevents you
from thinking about other important things in life, such as friends,
school, and hobbies. Are you sure that you need to think about shape
and weight all day in order to control them? Most people rarely
think about their shape and weight but maintain their weight within
a healthy range and are free to do other fulfilling activities.

4. Categorizing the various forms of shape checking. e therapist and

patient should allocate the identified forms of shape checking to one of two
groups:
ose best stopped altogether.
Unusual, non-normative, forms of behavior (e.g., pinching parts
of the body to assess “fatness”; repeatedly touching the abdomen,
thighs, and arms; feeling bones; checking the tightness of rings
and watchbands; and looking down when sitting to assess the
extent to which one’s abdomen bulges out over the waistband of
one’s pants or skirt or the degree to which one’s thighs spread).
ose that are usually secretive, as they would be embarrassing if
someone else found out (e.g., using a tape measure to check thigh
circumference; checking whether there is a gap between the thighs
 when standing with the knees placed together; and, when lying
down, placing a ruler across the hip bones to check that the
surface of the abdomen does not touch it).
ose best modified. ese are more normative forms of behavior,
whose frequency or extent may be an issue (e.g., mirror use,
comparison checking).

5. Helping patients stop non-normative forms of shape checking. Patients

are told that they need to become aware that they are shape checking in real
time, as this helps to stop this behavior. Oen patients succeed in stopping
non-normative forms of shape checking without too much difficulty. In our
experience, it is best that they go “cold turkey” rather than trying to phase
these behaviors out. Such behavior tends to undermine self-respect and,
aer a few weeks, stopping it is experienced as a relief. As with reducing the
frequency of weight checking in Step One, modifying habitual shape-
checking behavior results in a short-lived increase in preoccupation with
thoughts about shape. However, this is subsequently followed by a marked
reduction in these thoughts and the associated concerns, although note that
some patients may need to engage in alternative forms of behaviors for a
while.

6. Helping patients modify normative forms of shape checking. Again,

patients need to become aware of the behavior in real time, and then learn
to question themselves before checking (i.e., “think first”) with the goal that
they gain control over their behavior and become better at interpreting what
they see. Patients are encouraged to ask themselves the same questions that
the therapist asked the patients when reviewing their adapted monitoring
records (see point 3 above).

e procedure of addressing shape checking has the goal of reducing the

frequency of such behaviors and enabling the patients to reinterpret what
they see. e best example is mirror use (see “Addressing Mirror Use”
below). Oen the procedure needs to be blended with education about body
shape and its assessment, referring the patients to the relevant part of the
manual Overcoming Binge Eating, Second Edition (Fairburn, 2013). Usually,
the procedure takes many weeks, and it is a recurring item on the session
agenda. However, if done well, it can have a profound impact on the
patients’ quality of life.
VIGNETTE
e patient is a 17-year-old girl in the final phase of weight restoration who, despite having
addressed some shape checking, continues to report extreme concerns about the shape of her
body that are preventing her from achieving a healthy body weight. A review of her monitoring
records reveals that she oen has difficulty eating her evening meal or aernoon snack. e
patient states that during the aernoon she has more concerns about her body shape, even if she
does not understand the reason, and that this has caused her to deviate from the meal plan. e
therapist suggests that she use the monitoring record to reassess her shape checking, explaining
that some shape checking might still be acting to increase her body dissatisfaction, even if she is
not aware that this is happening. e patient agrees to accurately monitor shape checking again,
focusing in particular on what happens during the aernoon. At the next session, the patient
arrives, saying that she was amazed by what she found, as self-monitoring had revealed that she
was shape checking without being aware of it. Indeed, aer reviewing her monitoring records, it
becomes evident that the patient looks at her thighs reflected in the oven, which is at just the right
height, every time she walks through the kitchen, and that this mostly happens in the aernoon,
when she is not at school. e patient can now see that this behavior is frequent, and understands
that it is greatly contributing to her increase in concern about the shape of her thighs, ultimately
causing her to restrict her diet. e patient agrees to address this form of residual shape checking
by taking notice of the behavior in real time. In a few weeks, this reduces the patient’s concerns
about the shape of her thighs, and helps her to reach a healthy body weight.

Addressing Mirror Use

People tend to believe what they see in the mirror, so mirror use is a form of
shape checking that has the potential to provide misleading information
about appearance. Although patients may think that what they see should be
believed, information obtained from mirror use is complex and prone to
misinterpretation by those with shape concerns. us, problematic mirror
use, especially scrutiny, is likely to play a major role in maintaining many
adolescent patients’ body dissatisfaction. Addressing mirror use is therefore
of great importance, and the procedure for doing so includes three steps:
 1. Assessment. As always, the first step is to find out exactly what
patients are doing. e therapist should assess:
Frequency of mirror use. is can be done by looking at the shape-
checking records, and asking about their mirror use at home and at
school. Patients are also encouraged to monitor their mirror use
starting now.
Manner of mirror use. is can be assessed by asking the following
questions:
“How long do you spend looking in the mirror on each occasion?”
“What exactly are you checking? Which part are you looking at
and which are you ignoring or avoiding?”
“What exactly are you trying to find out?”

2. Education. Patients need to be educated about mirrors and how to

interpret what they “see.” To this end, there are four main pieces of
information that the patients should know:
Information obtained from mirrors is complex. Patients are invited to
consider the size of their image when they look at themselves in a
full-length mirror. Is it to scale? To get the answer to this question
we suggest that patients ask a friend to mark the top and bottom of
their reflection on the mirror when their whole body is reflected,
and to measure how far they have to stand back to be able to see
themselves entirely. Although they had not probably realized this,
they will now see that their mirror image is half their actual size.
Patients may be persuaded that they need to be careful about how
they interpret what they see when they look in a mirror by the fact
that they have not noticed this before.
What you see is influenced by how you look in the mirror. For
example, scrutiny magnifies the perceived defects (“If you look for
bulges, you will find them”).
Many patients use mirrors in ways that are liable to magnify their
apparent size. For example, they scrutinize their body for a long
 time without taking in reference points for scale.
Drawing a contrast with incidental reflections. Ask patients whether
they have ever accidentally caught sight of themselves in a store
window, for example, and not immediately recognized themselves.
Many will acknowledge that on these occasions their negative
opinion only “kicked in” when they realized it was their own
reflection that they were looking at, and their first glance showed
them as they truly are.

3. Modifying the behavior. e therapist should ask patients the

following questions:
“When it is appropriate to use the mirror?” Appropriate use may
include to check hair and clothing, to apply or remove make-up,
and/or shave.
“What forms of mirror use are inappropriate or unhelpful?”
Examples of inappropriate mirror use include focusing on body
parts that one dislikes, and scrutinizing them for long periods of
time.
“How can we avoid magnifying our apparent defects?” To avoid
magnification we should avoid focusing on body parts that we
dislike, and instead look at the whole body, including more neutral
areas (e.g., hands, feet, knees, hair). In addition, we should take in
the background environment, as this helps give us a sense of scale.

On this basis, the therapist should help patients modify their mirror use
using two main strategies:

1. Questioning themselves before looking in the mirror and doing real-

time recording.
2. Changing the way they look at themselves in the mirror.
 Addressing mirror use will usually take several sessions. e goal is for
patients to adjust their behavior and become more skilled in interpreting
what they see. It is not necessary to recommend avoiding mirrors entirely,
but rather to restrict mirror use to the purposes listed above, at least for the
meantime. It is also instructive to ask patients how much time they spend
choosing what to wear before they go out, and whether they have any
difficulty deciding on an outfit. Many admit that, in fact, they spend a long
time in front of a mirror, being unable to decide among several outfits. ey
may also express that this makes them feel gradually more despondent and
dissatisfied with their shape. With every outfit their self-esteem drops, and
they may even give up on the idea of going out altogether because of this. It
can be helpful to suggest to patients who report this behavior to commit to
an outfit before they try it on, and not to get dressed in front of a mirror.

Addressing Comparison Making

A particular form of shape checking that actively maintains concerns about
shape is repeated comparison making. Usually, there are two forms of
comparison making: (1) comparison with other people and (2) comparison
with media images. is behavior is common in adolescents, and is seen
particularly in patients who are of average or low weight. e nature of these
comparisons typically results in patients concluding that their body is
unattractive relative to that of others. e comparison is oen biased in one,
or both, of the following ways:

Subjective bias. e comparison is with someone who is attractive

(selective attention). When making these comparisons, patients tend to
choose biased reference groups composed of thin, good-looking people
of the same gender and age. ey fail to notice others who are less thin
and good-looking. us, there is an inherent unfavorable bias both in
the way that shape is assessed, and in the objects of comparison.
 Assessment bias. e way the other person’s body is evaluated is
cursory. In marked contrast to their prolonged negative appraisal of
their own bodies, patients’ assessment of other people is oen based on
uncritical snap judgments.

Addressing comparison making involves two steps:

1. Addressing subject bias. Patients should be helped to appreciate the

subject bias inherent in their comparison making and draw logical
conclusions. To this end, the therapist should ask patients to conduct an
experiment (Fairburn, Cooper, Shafran, Bohn, Hawker, et al., 2008). ey
should walk along a street and compare themselves with every third person
their age and gender, and then reflect on what they discover. It is likely to
emerge that people are far more varied in appearance than the patients had
previously noticed, and that some people with body shapes that they
consider “unattractive” actually look pretty good. It is also important to
encourage patients to reflect on the notion of “attractiveness,” which is not
only related to thinness, and to broaden their comparison making to include
aspects of people other than their shape (e.g., their hair, shoes, sense of
humor).

2. Addressing assessment bias. In order to help patients to appreciate the

assessment bias inherent to their comparison making and draw logical
conclusions, the therapist should ask patients to engage in another
experiment. is involves going into a shared changing room (e.g., at a
swimming pool, in a store), quickly assessing those present, and identifying
someone who they think looks “good”; they should then furtively scrutinize
that person’s body, focusing on what they dislike about their own body, and
then reflect on what they find (Fairburn, Cooper, Shafran, Bohn, Hawker, et
al., 2008). It is likely to emerge that bodies that appear attractive at first
glance have “flaws” and imperfections if they are studied more carefully (in
the way that the patients study their own body); what they “see” is
influenced by the way that they assess their own body.

Addressing Comparison with Media Images

It is common for adolescents with an eating disorder to compare themselves
with people portrayed in the media. For this reason, the therapist should
always ask the patients to monitor this form of comparison making, which
might include images from magazines and/or the Internet. In order to
inoculate patients against the uncritical acceptance of media images, they
should be educated (with examples) on the manipulation of images
(airbrushing) and encouraged to do some research on the subject.

ADDRESSING SHAPE AVOIDANCE

Some adolescents with eating disorders avoid looking at their bodies, and
dislike other people looking at them. Oen these adolescents have engaged
in repeated body checking in the past but have switched over to body
avoidance because body checking became too distressing. Shape avoidance
may take the form of avoiding looking in the mirror, not wearing tight
clothes, covering the stomach (e.g., with loose clothing or a cushion when
seated), and not looking at photographs of themselves. is kind of
expression is problematic, as it allows concerns and fears about shape and
appearance to persist in the absence of an awareness of what one actually
looks like. erefore, addressing shape avoidance is of great importance, and
includes three steps:

1. Explaining the rationale. As with shape checking, the therapist should

remind patients of (a) the two reasons for addressing overvaluation and (b)
their extended formulation. Moreover, if applicable, it is worth informing
patients that they have already addressed one form of body avoidance—
namely, avoidance of knowledge of body weight—in Step One during in-
session weighing. Almost invariably, patients will have found in-session
weighing helpful, as it will have assuaged their concerns about weight. ey
should be told that similar benefits will result from addressing shape
avoidance, but that this may also likely result in a short-lived increase in
concerns about shape.
Patients should also be informed that shape avoidance needs to be
addressed directly because it causes profound impairment. It maintains
dissatisfaction with shape by leaving assumptions unchallenged, and
consequently encourages dietary restraint and the adoption of other extreme
weight-control behaviors. Moreover, it may prevent patients from
socializing, being physically intimate with their partner, swimming, using
public changing rooms, or buying new clothes.

2. Identifying the various forms of body avoidance. e assessment of

body avoidance is relatively straightforward, as generally it is something
patients are aware of. Usually it exists on a spectrum ranging from minor
sensitivity to seeing one’s body or others seeing it to total shape avoidance.

3. Addressing shape avoidance. e strategy involves progressive

“exposure” in its technical and literal sense. e therapist should help
patients to recognize their shape avoidance and then plan specific body
exposure “experiments,” beginning with situations that will create the least
discomfort. Patients need to get used to the sight and feel of their own
bodies. ey need to get used to others seeing their body, too. Patients need
to stop dressing and undressing in the dark, and wearing shapeless, baggy
clothes. ey also need to get used to using mirrors (bearing in mind the
information in “Addressing Mirror Use” above) and participating in
activities that involve body exposure, such as swimming or going to the
beach. Some aspects of body avoidance and how to gradually address shape
avoidance are as follows:
 Avoiding others seeing the body (e.g., patients avoid wearing tight or
revealing clothes).
Start by wearing less baggy, shapeless clothes.
Work toward being able to wear more form-fitting clothes,
including bathing suits.
Avoiding being touched.
Start by getting hugged by a friend.
Work toward being able to be touched by friends and a romantic
partner.
And in extreme situations:
Avoiding the sight of the body (e.g., patients can only get dressed and
undressed in the dark).
Start by putting candles in the bedroom.
Work toward having the light on and the curtains open.
Avoiding touching the body (e.g., patients wash without touching
themselves).
Wash in a self-aware way, using bare hands and starting with
neutral body parts (e.g., feet, forearms, or hands). Apply body
lotion to the same areas.
Work toward being able to wash the whole body with the hands
and being able to apply body lotion all over.

A typical objection of patients to the suggestion that they should not

hide their bodies by wearing baggy clothes is saying that it is merely their
chosen style of dress. In this case, the therapist should ask something like
this:

“Did you also avoid wearing better-fitting clothes before the onset of your
eating disorder? If not, why did you change your style?”
e therapist may also ask the patient if she or he would be able to wear
tighter clothes than usual to go to a party. e goal is to help the patients
understand that wearing loose clothing, as well as other forms of body
avoidance, is not a free choice, but is instead dictated by their eating
disorder.
Body avoidance may take a considerable number of sessions to address if
it is particularly severe. Patients need help establishing normative levels and
forms of body checking, and the therapist must take care to ensure that
patients do not merely exchange body avoidance for repeated body
checking, which is always a risk.
VIGNETTE
e patient has reached a normal weight and is addressing body avoidance. With the help of the
therapist, she identifies several avoidance situations, including going to bars or dancing, where
other people can see her body. e few times she has been to such places she has worn loose-
fitting clothing that covers her from head to toe. e patient states that it is too difficult for her to
address this kind of avoidance, because she gets extremely anxious even thinking about it.
However, she is also sad because she likes to socialize with her peers at the bar, and she loves to
dance. When analyzing the patient’s fears, it emerges that she was teased about her body shape
(wide hips) in the past, and she is afraid that this will happen again. e patient, however, also
reports that the young bullies who teased her also harassed other girls, and that she does not see
them anymore because she has changed schools. e therapist, using the patient’s extended
formulation, explains that body avoidance maintains her concerns about body shape, not
allowing her to see whether what she fears will materialize, and preventing her from having a
fulfilling social life. e patient agrees on the importance of addressing body avoidance, and
between subsequent sessions she starts to go to bars and dancing wearing progressively better-
fitting clothes. To her surprise, she notes that no one criticizes her body shape, and this helps her
to continue wearing form-fitting clothes and spend enjoyable time with her friends.

ADDRESSING “FEELING FAT”

“Feeling fat” is an experience reported by many adolescents, but the

intensity and frequency of this feeling appears to be far greater among those
with an eating disorder. ere has been very little research on feeling fat in
adolescents; indeed, remarkably little has been written about it. Feeling fat
may not be a major problem for underweight adolescent patients during the
first stages of weight restoration, as other experiences, such as feeling full
and feeling bloated, are usually dominant. However, some patients do equate
these feelings with feeling fat, and this may become more significant when
they are near to achieving their target weight range. “Feeling fat” tends to be
equated with “being fat” by both underweight and not-underweight
patients. Patients who are not initially underweight, on the other hand, may
feel fat from the beginning of treatment. It is worth noting that people with
obesity may have this experience, too, although many are simply dissatisfied
with their shape. It is an expression of excessive concern about shape and
weight, but it also maintains it, reinforcing shape dissatisfaction and
prompting dieting, and so needs to be addressed.
Patients should be helped to understand that feeling fat fluctuates from
day to day and throughout the day, while body shape barely changes within
such a short time frame. erefore, something else is likely to be responsible
for the fluctuations in feelings of fatness. In fact, feeling fat appears to result
from a mislabeling of certain other experiences:

Body awareness (in those who are dissatisfied with their appearance).
Adverse physical states.
Adverse emotional states.

In general, addressing feeling fat is best le until inroads have been
made into body checking and body avoidance, because these behaviors may
be a trigger for feeling fat. However, this is not always the right strategy—
with patients in whom feeling fat is particularly prominent or distressing,
the therapist should reverse the order and address it first. e strategy is to
help patients identify the experiences that trigger feeling fat and to address
them directly. Over time, this results in patients no longer equating feeling
fat with being fat, and it ceases to be a maintenance mechanism. e
strategy includes three steps:

1. Identifying “peak” times for feeling fat.

 2. Identifying their triggers.
3. Addressing the triggers directly.

e therapist should put the topic on the agenda in the first week and
discuss it in outline form, asking patients to identify the “peak times” they
feel fat in real time using the “Context and Comments” column of the
monitoring record. e following week, the therapist should put the topic on
the agenda and discuss any “peaks” identified, and what might be triggering
them, encouraging patients to conclude that it would be best to explore the
trigger in detail in real time. As homework, patients should undertake to ask
themselves, immediately aer each peak, the following two questions:

“Has anything happened in the last hour that might have triggered my
feeling fat?”
“What else am I feeling just now (in addition to feeling fat)?”

e therapist should again put the topic on the agenda and review the
patients’ records, labeling the apparent trigger for each “peak” as one of
those listed below. e therapist should then consider with the patients how
best to address these triggers directly and immediately; here are some
examples of how to do so:

Heightened body awareness triggers (e.g., comments on appearance,

body checking, physical contact, being sweaty, body shaking, tight
clothing). ese require reappraisal with or without behavior change
(e.g., looser clothes) and a continued focus on addressing body image.
Adverse physical states triggers (e.g., feeling bloated, premenstrual, full,
hungover, or sleepy). Require reappraisal with or without behavior
change (e.g., having a nap).
Adverse emotional states triggers (e.g., feeling depressed, lonely, bored,
unloved). Require reappraisal and application of the problem-solving
procedure (see “Problem Solving: Steps One–Four” in Chapter 14).
 Once addressing feeling fat has begun, it needs to be a recurring item on
the session agenda. Using the above procedures, it may take 4–8 weeks. Over
this time, the frequency and intensity of feeling fat generally gradually
wanes, and patients become able to stop equating it with being fat. Once this
happens, feeling fat loses its potency to maintain the patients’ shape
concerns.
VIGNETTE
e patient has been implementing the Body Image module for several sessions, and has
markedly reduced her episodes of shape checking. Despite this, she still reports intense feelings of
being “fat,” which she copes with by reducing the portions of food she eats. e therapist first
educates the patient about feeling fat, and then asks her to monitor when she has particularly
intense feelings of fatness. In the next session, it emerges that the patient feels fat around 1:30
P.M., aer coming back from school and having stood for half an hour on the bus because there
were no free seats. e therapist encourages the patient to try to identify any potentially masked
feelings and sensations associated with these episodes. In the next session, the patient reports that
her feeling fat is triggered either by feeling tired or sleepy (adverse physical states). Finally, the
therapist encourages the patient when she feels fat to ask herself the question “What am I really
feeling right now and why?” and address the triggers using the problem-solving procedure.

INVOLVING PARENTS

If the patient and therapist decide to involve the parents, they should be
informed about the overvaluation of shape and weight and their control, and
how it is maintained (with the aid of the patient’s extended formulation), as
well as the main strategies used to address it. Here are some examples of
ways parents may help:

Helping and supporting the patient to remove unhelpful mirrors from

the home.
Removing any triggers of shape and weight concerns in the home (e.g.,
diet magazines).
Refraining from making comments about the body weight and shape
of the patient or others.
 Helping the patient overcome practical obstacles to expanding
marginalized domains of self-evaluation (e.g., taking the patient to join
a choir).
Helping the patient (in a manner agreed upon with both the therapist
and the patient) to become aware of shape checking and reminding her
or him how to stop it.
Helping the patient to throw away fashion magazines that glorify
thinness.
Avoiding giving the patient repeated reassurance about body shape and
weight.
Refraining from taking the initiative to buy new clothes for the patient
until the patient and therapist have agreed upon a plan to do so.
Not interfering in or commenting on the patient’s choice of clothes.
Helping the patient tackle an agreed-upon “exposure” task (e.g., going
with her or him to the beach).
Helping the patient to store clothes that are too small in an inaccessible
place, or better still, help her or him to give the clothes away.
Encouraging the patient to use her or his monitoring record in real
time to understand the triggers of feeling fat.

VIGNETTE
e patient, a 15-year-old girl who has just reached her 25th BMI-for-age percentile threshold in
Step Two of CBT-E, reports experiencing a marked increase in concerns about her shape and
weight over the preceding week. A collaborative review of her monitoring records shows the
presence of frequent shape-checking comparisons with her 10-year-old sister, triggering a
recurrence of caloric restriction. e patient affirms that these shape-checking comparisons
began when her mother gave her younger sister the clothes that the patient was no longer able to
wear because they had become too tight. In the joint session, the therapist explains to her parents
that when she sees her “emaciated-state” clothes worn by her younger sister, this reactivates her
eating-disorder mindset and reasserts her concerns about shape and weight, which she attempts
to manage by restricting her diet. e mother reports that it would be a waste to throw away all of
those clothes, but understanding the difficulties her daughter has in seeing them worn by her
sister, agrees with the therapist and her daughter that the clothes should be donated to charity.
 CHAPTER 13

Dietary Restraint Module

Most adolescent patients with eating disorders, with the exception of those
with binge-eating disorder, diet to an extreme extent. Rather than adopting
general guidelines about how they should eat, they set themselves multiple,
demanding, and highly specific dietary rules to limit what they eat. is
“strict dieting” has three main characteristics: (1) it is persistent, (2) it has
extreme goals (i.e., it is characterized by the adoption of several dietary rules
requiring continuous vigilance and a constant commitment, and (3) it is
inflexible (i.e., characterized by the adoption of rules that must always be
followed to the letter).
Such a rigid attitude to dieting may stem from a desire to lose weight or
to prevent weight gain and “getting fat,” in which case it is driven by the
overvaluation of shape and weight, or by a need to maintain strict control
over eating, in which case the culprit is the overvaluation of eating control
per se. e dietary rules that are adopted tend to vary from patient to
patient, but usually involve when it is acceptable to eat, how much can be
eaten, and, above all, what they will allow themselves to eat. As a result of
these rules, the way in which patients eat becomes stereotyped and
inflexible.
 It is important to distinguish two aspects of strict dieting, since patients
may or not be successful in their attempts to restrict eating (Fairburn,
Cooper, Shafran, Bohn, Hawker, et al., 2008); these are:

1. Dietary restraint (i.e., attempting to restrict what one eats).

2. Dietary restriction (i.e., undereating in the physiological sense).

Both of these need to be addressed in treatment because they impair and

maintain eating-disorder psychopathology. To tackle dietary restraint, CBT-
E uses a twofold strategy. e first step is to discover the reasons for dieting,
paying particular attention to concerns about shape and weight. In most
cases, this is begun early in Step Two, at the same time that weight regain
begins, in patients who are underweight. In patients who are not
underweight, it can be started one or two sessions aer the Body Image
module (see Chapter 12) has begun.
e second step is to address dietary restraint directly using the Dietary
Restraint module. e focus of this module is to address dietary restraint
and dietary rules, alongside the overvaluation of control over eating. Dietary
restriction is discussed in the Underweight and Undereating module (see
Chapter 11).

HELPING PATIENTS VIEW THEIR DIETING AS A

PROBLEM

ere is one major obstacle to addressing patients’ dieting: they do not view
it as a problem. is is for several reasons (Fairburn, Cooper, Shafran, Bohn,
Hawker, et al., 2008):

It creates a strong (but misplaced) sense of control.

It can be used to control body weight and shape.
It is socially reinforced.
It is used as a measure of willpower.
 It is used as a compensatory behavior in those who have binge-eating
episodes.
It is viewed as a necessity in order to manage excess body weight in
those who are overweight.

erefore, the first step is to help patients view their dieting as a problem,
and to do this we discuss the following points:

Dietary restraint is a problem if it is strict and inflexible—that is, if

patients’ dieting involves highly specific rules that must be followed in
order for them to believe that they are in control of their eating. It is
this type of dieting that makes binge eating more likely.
Dietary restraint is also a problem if it is “extreme,” in either of the two
following ways:
1. ere are many dietary rules.
2. ese rules are demanding in nature.

We try to help patients understand that these characteristics have major

adverse effects (Fairburn, Cooper, Shafran, Bohn, Hawker, et al., 2008):

ey cause concern about eating that impairs concentration in many

activities of everyday life, such as studying, watching television, reading
a book, and spending time with friends.
ey cause anticipatory anxiety every time one eats due to the fear of
not being able to follow the extreme and inflexible dietary rules.
ey cause guilt when the dietary rules are broken.
ey impair interpersonal relationships because it makes it difficult to
eat with others.

en, making reference to the patients’ personal formulation, we inform

them that dieting in this way maintains the eating disorder through two
main mechanisms (Fairburn, Cooper, Shafran, Bohn, Hawker, et al., 2008):
 1. It may result in dietary restriction and weight loss or may maintain the
low weight. If dietary restraint is successful in producing persistent
undereating, being underweight is an inevitable outcome, and the eating-
disorder psychopathology is consequently maintained via the mechanisms
described in Chapter 11.

2. It is a major contributory factor to binge eating (objective or

subjective). e adoption of extreme and inflexible dietary rules, as opposed
to flexible dietary guidelines, together with a tendency to react in a negative
and extreme manner to the almost inevitable occasions on which these rules
are broken, oen leads to a temporary abandonment of control over eating
(e.g., an episode of objective or subjective binge eating); this may in turn be
further promoted by the biological pressures exerted by calorie restriction.

IDENTIFYING DIETARY RULES

e identification of dietary rules may be difficult, as many adolescent

patients tend to deny that they have them, or view their eating habits as
unproblematic. A clue to recognizing their dietary rules comes from
analyzing the asterisks in their monitoring records, and the patients’
description of having deviated from the eating plan. e triggers of binge-
eating episodes can be particularly revealing. We usually ask patients to
monitor, in real time, for the presence of dietary rules, but if they have
difficulties in identifying them, we ask them whether they have difficulty in
eating in certain situations (e.g., at a restaurant, someone’s home) and, if so,
why.
In general, extreme and inflexible dietary rules concern (1) the type and
amount of food to eat, (2) the food to avoid, and (3) the time when eating is
permitted/not permitted. ere may also be other rules, such as eating an
exact number of calories, not eating more than anyone else present, not
eating until one has earned it, and so on.
 ADDRESSING DIETARY RULES

Dietary rules are addressed via the following five steps (Fairburn, Cooper,
Shafran, Bohn, Hawker, et al., 2008):

1. Identifying a specific rule and what is motivating it. e identification

of a specific rule can be facilitated by asking patients what concerns they
would have if they should break it. In general, the dietary rule is motivated
by the goal of losing weight or avoiding weight gain, but in patients with
binge-eating episodes, it may motivated by fear that breaking the rule will
result in an episode of binge eating.

2. Exploring with the patient the likely consequences of breaking the rule.
In general, breaking most dietary rules does not result in weight gain (which
depends on the amount of food ingested) or a binge-eating episode (which
depends on a cognitive reaction to breaking the rule). e positive
consequences of adopting flexible eating guidelines should be highlighted
(see above).

3. Purposefully breaking the rule. Patients should be asked to decide

what they will eat, when, where, and with whom, and helped to learn how
best to manage the subsequent period following the rule breaking (see
“Problem Solving: Steps One–Four” in Chapter 14).

4. Examining the implications of the managed rule breaking. is should

be done by taking into consideration the concerns and beliefs that the
patient had before breaking the rule, what really happened, and reiterating
the potential advantages of adopting a more flexible approach to eating.

5. Planning further episodes of breaking the same rule. e therapist

should help patients to continue until breaking the rule has no particular
significance for them.

Addressing Food Avoidance

We usually start by addressing food avoidance (i.e., the attempt to exclude a
range of foods from a person’s diet), as it is simple and easy to detect. Most
patients have the belief that if they eat certain foods, they will gain weight or
have an episode of binge eating. ese beliefs can be challenged by asking
patients to introduce the avoided food in a planned meal or snack on a day
when they are feeling in control and capable of resisting binge eating.
Patients are also instructed to plan in advance when and how much they will
eat, and what they will do aer eating (e.g., using distractive behaviors). By
doing this experiment several times, patients become aware of the fact that a
binge-eating episode is not the inevitable consequence of breaking a dietary
rule, and that introducing food they have previously avoided does not
automatically lead to weight gain. If weight gain happens, patients begin to
see this dietary rule as a problem rather than a useful way of controlling
eating and body weight.
e procedure used to address food avoidance involves four steps
(Fairburn, Cooper, Shafran, Bohn, Hawker, et al., 2008):

1. Educating the patient about food avoidance. e therapist should

discuss with patients the following key points concerning food avoidance:
ere is no food that is inherently fattening. It all depends upon
how much of it one eats.
Avoiding eating foods of uncertain composition is likely to impair
social life, as it almost invariably precludes eating out with peers.
Knowledge of exactly what one is eating (e.g., usually in terms of
calorie or fat content) is not needed for successful weight control.

2. Identifying all the types of food being avoided. is can be ascertained
by asking patients to take a trip to the local supermarket and come up with a
list of all the foods they would be reluctant to eat; this may be because they
think they are fattening, or because they are afraid of them triggering a
binge-eating episode.
 3. Rating these food items on the basis of the difficulty they would have in
eating them. Patients should score each avoided food on a scale of 1–4, and
then divide them into corresponding groups (see Figure 13.1).

Group 1 Group 2
Cream Soft cheese
Cakes Fried chicken
French fries Snacks
Parmesan cheese Ice cream
Mortadella Cookies
Bacon Pastries and croissants
Oil Chocolate salami
Sugar Pork
Pie Pasta
Group 3 Group 4
Chocolate Fruit
Chips White bread
Pizza Red meat
Crackers Ham
Grapes Corn flakes
Bananas Potatoes
Avocado Whole milk
Sushi
Hard candies

FIGURE 13.1. An avoided food list of an adolescent patient with an eating disorder.

4. Encouraging patients to introduce these foods into their diet. Over the
following weeks, patients should start to face their fears in order to challenge
their own beliefs. It is best for them to start with foods from the least
problematic group, moving gradually up the scale. As always, they should
note their attempts on their monitoring records. Figure 13.2 shows a
monitoring record that illustrates a patient tackling food avoidance (see
“NEW” in the “Food and Drink Consumed” column).
FIGURE 13.2. A monitoring record showing the introduction of avoided foods.
 Sometimes the list of avoided foods is very long, so that the inclusion of
each individual food would require too many sessions. e best strategy in
these cases is to select within the same category of foods those that are
representative, since success with one representative food usually has the
effect of reducing concern about the whole food category. e amount of
food consumed does not necessarily have to be large enough to represent a
whole portion, although the ultimate goal is for patients to be able to eat
normal amounts of these foods without difficulty. Sometimes this result
must be achieved gradually, however, and the systematic introduction of
avoided foods should continue until patients are no longer anxious about
eating them. An illustrative dialogue with a patient who is reluctant to
introduce avoided foods follows:

PATIENT: Eating certain foods goes against a healthy diet.

THERAPIST: Of course, what you say may be true if you eat these foods
every day. However, the goal of the work we are doing is not to have
an unhealthy diet, but to make sure that you can freely choose what
to eat without being influenced by fears and concerns.
PATIENT: But how will I know the amount of food I should be eating?
THERAPIST: At this point, the goal is that you try to address your
concerns about food you avoid. So, if it scares you to eat even a
mouthful, it’s OK for you to take just a small bite. Later, we will work
on eating normal portions.
PATIENT: But there are some foods I just don’t like!
THERAPIST: I understand . . . but I would ask you whether the problem is
that you don’t like that particular food, or if, in reality, you avoid that
food for the fear that it could have consequences on your body or
your self-evaluation. If you really do not like it, you can decide not to
introduce it; otherwise it is important that you try to address it to
prevent concerns about that food from persisting. Sometimes it’s
 worth experimenting and trying to eat a food that you don’t like
(everybody does this sometimes) and analyze how you feel.
PATIENT: ere are foods here that aren’t even essential, like juices, for
example. Why should I have them?
THERAPIST: You are right, there are foods that we do not need to
consume, they are not indispensable in a diet, but remember that our
goal is for you to be free to choose what you eat without worrying
about the consequences. So, if introducing that type of food makes
you worried, even if you will only eat it infrequently, on special
occasions say, in the future, it is important that you face it now to
prevent your worries from dictating your future food choices.
VIGNETTE
e patient is a 17-year-old female who is implementing the Dietary Restraint module in Step
Two. Upon agreement with the therapist, she plans to introduce pasta—one of the foods she has
been avoiding in order to control her weight—to her diet. In the next session, she reports that she
had pasta for lunch and was pleasantly surprised that her weight did not increase. However, from
the monitoring record review it emerges that she walked for an hour beforehand with the aim of
preventing potential weight gain arising as a consequence of her including pasta in her diet. e
therapist discusses with the patient whether this exercising might have undermined the aim of the
experiment (i.e., reducing her concerns about eating pasta). e patient agrees that this is the
case, and plans to include pasta in a meal without burning off calories in advance. In the next
session, the patient reports that she was able to eat pasta, and with surprise noted that her weight
has remained stable. is helped her to reduce her concern over eating and the degree of dietary
restraint.

Addressing Other Dietary Rules

ere are other specific dietary rules that should be addressed. e
procedure to use is similar for each and focuses on the belief that maintains
the rule, breaks the rule, and then evaluates the implications of having done
so. e therapist should always emphasize the positive aspects of breaking
dietary rules. e following sections describe some specific rules to be
addressed (Fairburn, Cooper, Shafran, Bohn, Hawker, et al., 2008).
 Rules Concerning When to Eat (or, Rather, When Not to Eat)

ese dietary rules have already been addressed in Step One with the
introduction of regular eating. If patients are still having difficulty in
regularizing the frequency of their meals and snacks, it is important that the
therapist remind patients that there is no right or wrong time to eat, that
there are no differences in calorie absorption if the food is eaten at different
times of the day, and that delaying eating as much as possible makes binge-
eating episodes more likely. It should be reiterated that eating regularly, at
maximum intervals of 4 hours, has many advantages: (1) it provides
structure to eating habits (and the day), (2) it addresses one of the three
forms of dieting (skipping meals; the other two are eliminating food and
reducing food portions), (3) it interrupts the cycle between dietary restraint
and binge eating, (4) it reduces the sense of early fullness that underweight
people oen have, and (5) it reduces concerns about eating. e therapist
should encourage the patients to adopt behaviors that facilitate regular
eating (see Chapter 8).

Rules Concerning How Much to Eat

e therapist should explain to patients that the “right” amount of food to

eat overall is that conducive to maintaining a stable healthy weight. is
applies not only to daily intake but also meals and portion sizes. (For
accepted nutritional guidelines and other useful information, see
www.health.gov.)

Rules Concerning Not Eating in Front of Others

ese rules impair social functioning and damage relationships. In general,

they hinge on the dysfunctional assumption that others will notice how
much one is eating and may think that one is greedy or has no control. e
therapist should therefore help patients to understand the error of reasoning
behind this rule—namely, that it is a mistake to think that other people have
the same way of reasoning that they have with regard to eating control.
Generally, people do not pay attention to what other people eat and, in any
case, do not make these types of judgments about other people’s eating
behavior.

Rules Concerning Not Eating More Than Anyone Else Present

is is a dietary rule that highlights an error of reasoning called

“generalization.” In this case, the patients draw general conclusions about
how much others eat from a single instant, not taking into account what
others have eaten before, or what they will eat, or their energy expenditure,
weight, sex, and age. To help patients understand the worthlessness of this
rule, a parallel can be made with breathing—that is, asking patients whether
they have ever thought of trying to breathe less than others.

Rules Concerning Not Eating Unless One Is Hungry

e therapist should discuss with patients that there is nothing special about
resisting eating or eating only when one is very hungry. Extreme hunger is a
condition that changes the way we think and act, oen in a negative sense,
and can lead to uncontrolled eating behaviors, such as binge eating.

Rules Concerning Not Eating Unless One Has Done Some

Exercise

e therapist should educate patients that the human body burns energy
even when at rest. Indeed, the energy that a human being uses is determined
by (1) basal metabolism—the energy used to make the vital organs of our
body work (e.g., the heart, lungs, nervous system, kidneys, liver, intestines,
sexual organs, and skin)—which constitutes about 60–75% of our daily
energy expenditure, (2) diet-induced thermogenesis—the amount of heat
produced when we ingest food—which constitutes about 10% of our daily
energy expenditure, and (3) physical exercise, which accounts for 15–30% of
our energy expenditure—a quantity that does not justify not eating if one
has not done some exercise.

Rules Concerning Avoiding Eating Out

Avoiding eating in restaurants, pizzerias, and snack bars compromises a

patient’s social life and diminishes the pleasure of living. is rule has to do
with being afraid of both eating foods of unknown calorie composition and
eating in front of others. In this case, in addition to following the indications
for these two specific rules (see above), it is advisable to ask patients to make
a list of the social eating situations they avoid, and to start facing them step-
by-step, starting from those that create less anxiety.

Addressing Patients’ Reactions to Dietary Rule Breaking

A dysfunctional reaction to dietary rule breaking should identify and
address with standard cognitive behavior procedures the underlying
cognitive mechanisms. Here are most common examples, derived from
dichotomous reasoning:

Breaking a dietary rule is interpreted as evidence of having lost control

(“I’ve ruined my diet”) and lack of willpower (“I’ve failed”). e
therapist should help patients to conclude that real control is adopting
flexible dietary guidelines rather than extreme and inflexible dietary
rules.
Breaking a dietary rule has led to the abandonment of control over
eating (“I’ve lost control; I might as well give up any attempt to control
eating”).

It is important that patients who have these reactions be helped to detect

this kind of “all-or-nothing” thinking in real time, to question what it
means, and to respond accordingly. With practice they should get better at
not resorting to self-criticism and/or binge eating.

ADDRESSING FOOD CHECKING

Dysfunctional checking of control over eating (e.g., counting calories

repeatedly before and aer eating, weighing food to eat repeatedly, checking
food labels, and making comparisons with what other people eat) is
common in adolescent patients with eating disorders, particularly in those
who are underweight and in those who tend to overvalue eating control per
se (see “Addressing the Overvaluation of Control over Eating” below). ese
types of behaviors need to be addressed because they contribute to
maintaining excessive eating concern and disrupt social life by making it
impossible to eat outside of the home. e steps to address dysfunctional
checking of control over eating are the following:

1. Real-time self-monitoring. Since some of these behaviors are

automatic, and oen patients are not aware of doing them, the therapist
should suggest that for two 24-hour periods they use the “Context and
Comments” column on their monitoring record to record every behavior
they use to check control over eating in real time.

2. Assessing which checking to stop and which to modify in frequency

and/or nature. Examples of the former will include calorie counting,
checking food labels, and making comparisons with what other people eat,
and the latter may include behaviors such as dysfunctional portioning of
food (see point 4 below).

3. Stopping food-checking behaviors. e therapist should ask patients to

become aware that they are checking their control over eating in the precise
moment that they are doing it, using real-time self-monitoring. e goal is
to stop food checking, and they should be able to interpret why they are
exhibiting this dysfunctional behavior. e therapist can make a parallel
with body checking, pointing out that stopping checking control over eating
may create an initial increase in anxiety and concerns about eating, but these
will gradually fade. If patients are afraid to interrupt checking their control
over eating due to a fear of gaining weight, the therapist should stress that it
is not necessary to count calories to maintain a stable weight.

4. Modifying food-checking behaviors. e dysfunctional practice of

portioning food by measuring or weighing it meticulously and repeatedly
should be discouraged because it intensifies a patient’s concern about
minimal and insignificant variations in the quantity of food. In order to
adopt a healthy control of the amount of food to eat, patients should instead
be encouraged to portion out food by eye; they should make reference to the
amounts that are usually served in restaurants, or the quantity that they
would serve to a friend who is not on a diet if they invited the friend to
dinner.

ADDRESSING TRANSITORY UNDEREATING

is is a form of transitory dietary restriction that can be detected from a

review of the patients’ monitoring records. It is characterized by small meals
and snacks and/or long gaps between them, and increases the risk of binge
eating. If it is mainly expressed as long gaps between meals (intermittent
fasting), patients should be helped to distribute their eating more evenly
across the day. However, if it is characterized by very small meals and
snacks, patients should be educated about the risks associated with eating in
this way, and helped to maintain a stable and healthy energy intake.

INVOLVING PARENTS
In general, we recommend that parents support the patient in doing what
has been agreed upon with the therapist, and do not attempt to impose rule
breaking on the patient. Here are some examples of ways in which parents
might help:

Accompanying the patient to the supermarket to identify avoided

foods.
Ensuring that the avoided food the patient plans to eat is available.
Avoiding comments on the quality of the food chosen by the patient
(e.g., “Don’t you worry that this food will make you fat?” or “I think
you would be better off choosing another food, because this has too
much salt/fat/carbs”).
Helping the patient manage reactions to rule breaking by encouraging
the use of distracting activities.
Accompanying the patient to eat at a restaurant or snack bar.
Encouraging the patient to use monitoring records in case of
difficulties.
Not encouraging the patient to introduce more foods or larger
amounts than she or he is willing to eat.

In this phase of treatment, parents should encourage patients to invite their

friends out for meals, and to accept invitations to social occasions.

ADDRESSING THE OVERVALUATION OF

CONTROL OVER EATING

A subgroup of adolescent patients presents an overvaluation of eating

control, but not of shape and weight control. ese patients have a
particularly high level of dietary restriction and restraint, and tend to be
particularly concerned about the precise details of eating. is is because
they judge themselves predominantly or even exclusively on what they are
eating. Such patients tend to repeatedly count calories and rigorously
monitor nutrients that they “should” be eating or avoiding (carbohydrates,
fats, and/or proteins). Some may even try to control their energy
expenditure to this end. To address such excessive monitoring of dietary
intake, the therapist should follow the procedures listed here (see also
Chapter 12):

• Identifying the overvaluation and understanding its consequences. is is

approached using essentially the same strategy as that used to address the
overvaluation of shape and weight, but the content needs to be adapted so
that it targets the overvaluation of control over eating per se. e extended
formulation of these patients will not include the typical expressions of the
overvaluation of shape and weight (i.e., preoccupation with shape and
weight, body checking, body avoidance, or feeling fat), but rather those
caused by the overvaluation of eating control (i.e., preoccupation with food
and eating and food checking; see Figure 13.3).

FIGURE 13.3. An example of an extended formulation of an adolescent patient with overvaluation

of control over eating.

• Enhancing the importance of other domains for self-evaluation. is

involves the same strategies and procedures described in Chapter 12.

• Reducing the importance attached to eating control. e best way to do

this is to address the expressions of the overvaluation. Specifically, food
checking needs to be tackled using the strategies describe above (see
“Addressing Food Checking”), because it maintains a preoccupation with
calories, food, and eating. Patients should avoid reading recipes and
cookbooks, and be discouraged from looking at websites dedicated to food
and eating.

• Learning to manipulate the eating-disorder mindset (see Chapter 15).

• Exploring the origins of the overvaluation (see Chapter 15).

 CHAPTER 14

Events, Moods, and Eating

Module

e eating behavior of people with eating disorders is oen influenced by

events and moods. However, this association becomes more evident with the
progress of the treatment—in particular, when the major maintenance
mechanisms of the eating-disorder psychopathology (e.g., undereating and
being underweight) have been eliminated. e typical dietary changes
associated with events and moods are eating in an uncontrolled way (binge
eating), or eating less or fasting, but sometimes there is also an
intensification in exercising, or the frequency of laxative misuse. e main
mechanisms responsible for the association among events, moods, and
eating are as follows (Fairburn, Cooper, Shafran, Bohn, Hawker, et al., 2008):

Binge-eating episodes can be used both to distract from negative

events and from problems that cause anxiety, and to mitigate intense
and intolerable emotional states. e same effect on the modulation of
mood can also be achieved via self-induced vomiting and/or exercise.
Eating less can help people feel in control when events are perceived to
be out of control.
 Overeating can be a way to achieve gratification; this is oen the case
in people who are overweight or have obesity.
Eating less can be a way to influence the behavior of others—for
example, as a manifestation of feelings, such as anguish or anger. is
behavior is typical of underweight adolescent patients, who, for
example, may stop eating in response to an argument with their
parents.

ASSESSING WHETHER EVENTS AND MOODS

ARE A PROBLEM

In Step Two, it is advisable to assess whether events and moods seem to be

contributing to the maintenance of patients’ eating-disorder
psychopathology. If so, they are a problem that needs to be addressed
directly and effectively. is mechanism is recognizable when there are
repeated deviations from regular eating or planned meals and snacks that
can be traced back to external events or changes in mood. ese may
manifest as recurrent binge-eating episodes, skipping meals and/or snacks,
and/or repeated episodes of self-induced vomiting or excessive exercising.

ADDRESSING EVENTS INFLUENCING EATING

When patients report a change of eating, the therapist should:

1. Analyze collaboratively with the patients their monitoring record to

find the event associated with the change in over- or undereating.
2. Identify the processes involved in changing eating.
3. Apply the following proactive problem-solving procedure to address
it.

is procedure involves four main steps.

 Problem Solving: Step One
• e therapist identifies the tendency to binge-eat, diet, vomit, or
exercise in response to events and mood.

• e therapist explains that such reactions are not inevitable, and helps
the patient to understand and agree that this tendency needs to be
addressed.

Problem Solving: Step Two

• e therapist recommends using proactive problem solving as a means
of countering the identified tendency.

• e patient is provided with an explanation of the principles of

proactive problem solving (with reference to Overcoming Binge Eating,
Second Edition; Fairburn, 2013).

e problem-solving procedure itself involves seven steps (Fairburn,

Cooper, Shafran, Bohn, Hawker, et al., 2008), as follows:

1. Identifying the problem as early on as possible. Every time an event

leads or has the potential to lead to a change in eating, patients should try to
identify the underlying problem.

2. Accurately specifying the problem. is requires detailed

reconstruction of the triggering event and subsequent feelings, thoughts,
and behavior. Common triggers include pressure at school, an argument, or
having nothing to do all day.

3. Considering a range of possible solutions. Patients should try to think

of as many potential solutions to the problem as possible (brainstorming), no
matter how nonsensical or impractical they may seem. Even implausible
solutions should be included on the list, as this may lead to the identification
of a previously unconsidered solution.
 4. inking through the implications of each solution. Patients should
examine the pros and cons of each of the potential solutions identified.

5. Choosing the best solution(s). is should be easy if the previous step
has been completed carefully.

6. Putting the best solution(s) into practice. e most important step in

the entire process of problem solving is “acting”—that is, applying the
chosen solution(s). Patients should be instructed not to be too inflexible in
adhering to what they have planned; if they notice that the chosen solution
is not sufficiently effective, they should try another of the solutions
identified in points 3 and 4 above.

7. Assessing the process of problem solving. e patients should be given

an opportunity to assess the success of the problem solving. is will involve
them in thinking about how they applied the procedure, rather than on
whether the problem was successfully overcome. In other words, the focus
should be on developing their problem-solving skills.

In general, a recent problem is taken as an example and worked through

using the proactive problem-solving procedure during the session. If a
recent issue is not apparent, an earlier one should be sought by looking
through patients’ monitoring records. If nothing comes to mind, the
therapist should ask patients about a recent day-to-day difficulty they have
had (e.g., a disagreement with a friend or parent), to be used as an example.
e discussion should be collaborative, with the patients being encouraged
to take the lead whenever possible. If time allows, another recent example
should be identified and approached in the same way.

Problem Solving: Step Three

• A proactive approach to problem solving is important. Patients should
be able to see problems coming so that they are forearmed. To this end, each
time they have a meal or snack they should look ahead to the remainder of
the day and try to “predict” when a problem might arise.

• When a problem is identified, patients should (see Figure 14.1):

Write the word “problem” in the “Context and Comments” column of
their monitoring record.
Turn over the page and practice problem solving there and then (in
writing).
Act on the solution identified.
e following day, patients should review their problem-solving
attempt in terms of their compliance, and write point 7 (above) of the
procedure on the back of their monitoring record.
Problem
Step 1: My boyfriend is sick.
Step 2: Joseph called me this morning to tell me that he cannot get out because he has a
headache and fever. I’m disappointed because this Sunday afternoon I feel a bit sad and I
wanted to talk to him. I am afraid because I’m tired and I do not have plans for the
afternoon. I do not know what to do and I’m afraid of losing control. Plus, my aunt has just
brought home a cake made by her. In the kitchen there is such a nice smell that I dare not
even get close. I feel it is a risk.
Steps 3 and 4: Things I could do and pros and cons.
a. Phone a friend to go out. + Would make me feel better.
– She might not be able to come.
b. Message with my friends. + Would help me to relax.
– I can’t message all afternoon.
c. Surf the impulse to binge + It’s about time for me to handle the impulse
without going out. without bingeing.
– I am afraid of succumbing to the impulse to
binge.
d. Go for a walk in the park. + Would make me feel better and distract me
from the smell of cake.
– I would be thinking about burning calories.
e. Think about my parents’ + Nothing.
reaction if they found out. – When I feel bad, I don’t care what my parents
think.
Step 5: Options a, b, and c are the best.
Step 6: Do the three things.
Step 7: Review.
I dealt with the problem immediately and that was the best thing. I phoned a friend, but
she was not free. However, we set a date for next week. Messaging with friends helped
me to relax and lifted my mood. It was also very helpful to think that I was able to handle
the impulse of binge eating. Other times, on afternoons like this, I would certainly binge.

FIGURE 14.1. Example of problem solving by an adolescent patient with an eating disorder.

Problem Solving: Step Four

• Session aer session, patients’ use of the procedure should be reviewed
and refined. e emphasis should be on helping them acquire the ability to
address or forestall events that would otherwise trigger changes in eating.
 • If a patient comes to the session having failed to attempt problem
solving, the therapist must endeavor to discover why this is the case.
Adolescent patients commonly report that it is not that they did not try, it is
just that they failed to identify any problems that needed solving. In this
event, the therapist should point out to patients that all of us encounter
problems more or less on a daily basis, and seek to identify examples on
their monitoring records for the preceding week. e patients should then
be encouraged to acknowledge that these were, in fact, problems, albeit
minor, and therefore opportunities to practice problem solving. ey should
be helped to view any small difficulties as chances to practice problem
solving in preparation for any greater difficulties that may arise.

We usually introduce the proactive problem-solving procedure in Step

Two, except in patients whose binge eating is triggered almost exclusively by
events and moods (and not the result of extreme dietary restraint). is is
oen the case, and once these patients have established regular eating it may
be best to implement this module as early as Step One to prevent their
efforts from being sabotaged by their dysfunctional reactions to events and
moods.

BINGE ANALYSIS

Binge eating is common among patients with eating disorders, and it

generally responds well and rapidly to the regular eating intervention
implemented as part of Step One. With some patients it ceases altogether,
but with others binge eating persists into Step Two, albeit at a reduced
frequency. CBT-E uses a specially designed procedure called “binge-eating
analysis” to help patients identify the causes of each “residual binge”
immediately aer it occurs. e procedure involves real-time self-
monitoring and providing guidance to patients on how to do this. One
important advantage of binge analysis is that it counters the tendency of
many patients to be excessively self-critical following any remaining binges.1

Patients are instructed to ask themselves the following three questions

immediately aer every episode of binge eating:

“Was the binge triggered by breaking a dietary rule?”

“Might I have been undereating over the last 24 hours?”
“Was the binge triggered by something that happened or how I was
feeling?”

If events and mood are repeatedly disrupting adherence to the pattern of

regular eating, two procedures can be used:

1. Proactive problem solving to address triggering events (used in every

case).
2. Addressing mood intolerance (used in a subgroup of cases) with the
procedures described in the broad CBT-E modules (see “Mood
Intolerance Module” in Chapter 17).

Note: e same strategy can be used to analyze other deviations from

regular eating (e.g., a period of undereating, skipping meals or snacks, or
episodes of noncompensatory vomiting or exercising).

1
Some patients like some aspects of binge eating, and are therefore reluctant to stop. ese patients
can be difficult to help. It is best to explore in detail what they gain from binge eating (e.g., immediate
enjoyment of eating, relaxation of restraint) and then to consider the disadvantages (e.g., potential
weight gain, expense, secrecy and deceit, self-criticism, perpetuation of the eating disorder in the long
term). ey should be asked to evaluate the short- and long-term pros and cons of continuing this
behavior (the procedure used with underweight patients; see “Helping Patients Decide to Change” in
Chapter 9). Once such patients fully appreciate the long-term costs of continuing to binge-eat, they
are usually more willing to give it up.
 CHAPTER 15

Setbacks and Mindsets Module

Overvaluation of shape, weight, and/or eating control is the expression of a

particular “mindset,” or frame of mind, which has multiple ramifications
(Fairburn, Cooper, Shafran, Bohn, Hawker, et al., 2008). In particular,
patients with this mindset:

Exhibit characteristic forms of behavior, such as dietary restraint, self-

induced vomiting, laxative misuse, and excessive exercising.
Tend to have a dysfunctional way of filtering external and internal
stimuli (e.g., only looking at thin people for reference or viewing tight
clothes as evidence of being fat).
Oen mislabel physical and emotional experiences as “feeling fat.”

e eating-disorder mindset is usually reinforced by these factors via the

mechanisms described in the cognitive behavior formulation (see Figure 1.3
in Chapter 1 and Figure 12.2 in Chapter 12), thereby ensuring that the
patient becomes “locked in” to this frame of mind.
Guided by the personal formulation, the strategies and procedures of
Steps One and Two usually produce a marked reduction and oen remission
in the principal eating-disorder features (e.g., low weight, dietary restriction
and restraint, binge-eating episodes, self-induced vomiting, excessive
exercising) and other direct expressions of eating-disorder psychopathology
(e.g., body checking and body avoidance, feeling fat). As a result of these
interventions, the mechanisms responsible for keeping the eating-disorder
mindset locked in place will gradually erode, progressively leaving times for
healthier mindsets, appropriate for the circumstances, to be installed.
Patients who are making good progress oen show signs of this or even
report it spontaneously during the last third of treatment—for example, they
may suddenly realize that they experienced no concern about eating or their
appearance on a particular day. Such reports are evidence that the eating-
disorder mindset is being displaced, and this should be emphasized to the
patients. However, they should also be told that at the beginning these
periods are brief because the eating-disorder mindset may oen be activated
by several different triggers, and once this happens, their eating-disorder
features may rapidly return. It is at this point in the treatment that patients
should also be informed that setbacks are inevitable, but if they are
addressed immediately, relapse will be avoided. e first step, therefore, is to
educate patients on setbacks and mindsets.

EDUCATING THE PATIENT ABOUT SETBACKS

AND MINDSETS

Patients should be educated that setbacks involve a return of one or more

aspects of the eating disorder (e.g., binge eating, laxative misuse, excessive
exercising, body checking, or undereating). Some of these aspects may not
be noticed if they are ego-syntonic (e.g., undereating), but as the return of
the eating-disorder feature is preceded by activation of the eating-disorder
mindset, it is important they be promptly identified and dealt with.
e first step in recruiting patients’ assistance in this matter is to explain
to them what we mean by “mindset” (Teasdale, 1999)—that is, the eating-
disorder “way of thinking” (excessive concerns about eating, shape, and
weight). To do this, the therapist asks them to equate comparing their mind
to a box of DVDs that contains, for example, the “friend” DVD, the
“daughter/son” DVD, the “student” DVD, the “athlete” DVD, the “artist”
DVD, the “musician” DVD, and so on. Each DVD corresponds to a
characteristic mindset that is activated on specific occasions. For instance, at
school the “student” DVD is activated, while spending the aernoon with
friends the “friend” DVD starts playing, and while in the company of
parents the “daughter/son” DVD is on. When one has an eating disorder,
however, she or he also has the “eating-disorder” DVD. Unlike the others,
this mindset tends to get “stuck” so that its DVD keeps playing, whatever the
situation, once it has fully developed, blocking the machine, so to speak. In
this state of mind, the other DVDs that are appropriate to the circumstances
at hand cannot be played. us, at school, instead of activating the “student”
DVD, the “eating-disorder” DVD remains active; by producing continuous
concerns about weight, body shape, and eating control, this makes it
impossible to concentrate fully on the lesson or other activities. is
explanation of the eating-disorder mindset is easily understood by
adolescent patients, and in most cases, they report that it fits with their
experience.
Continuing with this analogy, the therapist explains that in the later
stages of treatment, once the principal maintenance mechanisms of the
eating disorder have been eroded, patients will likely start to notice that
there are times when the “eating-disorder” DVD is not playing, and the
other DVDs start playing again in line with the circumstances. As a result,
patients experience being in alternating states of being “in” or “out” of their
eating disorder. However, the “out” periods are brief because (early on) it is
easy for the eating-disorder mindset to be reactivated, and once that
happens, eating-disorder features rapidly return (binge eating, dieting,
vomiting, laxative misuse, exercising, and/or body checking; see Figure
15.1). Although with CBT-E treatment the propensity for the “eating-
disorder” DVD to reactivate decreases over time, in the initial stages of
recovery it is very likely. e therapist therefore advises patients that this is
the right time to learn how to control the “eating-disorder” DVD (i.e., the
eating-disorder mindset).

FIGURE 15.1. Sequence of events. Reproduced with permission from Online Training Program in
CBT-E, CREDO Oxford, 2017.

VIGNETTE
e patient is a 16-year-old girl who, as part of Step ree, is maintaining a normal weight. Aer
a period free from binge-eating episodes, she comes to the session disheartened about the
possibility of overcoming her eating disorder, because she had a binge followed by self-induced
vomiting just the day before. From a collaborative review of her monitoring records it emerges
that she had started to experience concerns about eating some days before the binge-eating
episode, aer having heard her coach say that athletes must pay attention to their diet, and in
particular, limit the amount of carbs they eat to improve their performance. e patient, who was
not satisfied with her athletic performance over the last week, started to cut carbs from her diet,
not eating the planned pasta and rice for lunch or bread for dinner the day aer having heard the
coach’s comment. In the “Context and Comments” column of her monitoring record, alongside
these meals she wrote, “However, I ate well if, by eating fewer carbs I can improve my fitness and
athletic performance” and “What does it matter if I do not eat pasta today?” On the following day,
the patient started to do some shape checking, which she had previously overcome. She spent
some time scrutinizing the shape of her legs and stomach, and this was accompanied by an
intensification of her concerns about her body shape. e day before the session, the patient, aer
having eaten a cracker offered to her by her sister during lunch, started to become worried about
having ruined her diet, and aer having lunch she had a binge, eating a tub of ice cream meant for
six people, followed by an episode of self-induced vomiting. Aer reviewing the relevant
monitoring records with the patient to help her to reconstruct this sequence of events, the
therapist takes the opportunity to educate her on setbacks, the eating-disorder mindset, and how
to control it in the future.

STRATEGY FOR CONTROLLING THE EATING-

DISORDER MINDSET

Having educated the patients on mindsets, the therapist should explain the
strategy used as part of CBT-E for controlling the eating-disorder mindset.
Specifically, patients should learn to (Fairburn, Cooper, Shafran, Bohn,
Hawker, et al., 2008):

Identify stimuli that are likely to reactivate the eating-disorder mindset

(“DVD”).
Recognize the first signs that their eating-disorder mindset is
reasserting itself (i.e., recognize the first “track” on their “eating-
disorder DVD”).
Displace the mindset (i.e., “press the eject button”).

Note: It is not advisable to introduce this strategy in the early phases of

the treatment because at that point the patients’ eating-disorder mindset is
firmly locked in place, and they have no other state to contrast it with.

Identifying Eating-Disorder Mindset Reactivation

Triggers
e most common stimuli likely to trigger the eating-disorder mindset are
the following:

1. Adverse shape- or weight-related events (e.g., weight changes, clothes

feeling tighter, mirror checking, feeling fat, receiving critical
comments from others).
2. Adverse eating-related events (e.g., eating an avoided food, eating “too
much,” binge eating, feeling full).
3. Adverse events in general (e.g., failure to perform well in a sport
competition or at school, being rejected or scolded).
4. Low mood (e.g., secondary to adverse circumstances or an expression
of clinical depression).

e therapist should encourage the patients to monitor the types of

stimuli that are most likely to trigger their “eating-disorder DVD” in real
time. In most cases, such in-the-moment awareness is sufficient to inoculate
the patients against the influence of these stimuli.

Spotting Setbacks Early On

e therapist should, however, inform patients that there will inevitably be
some circumstances when the “eating-disorder DVD” will reactivate. In this
event, it is fundamental to immediately identify the early changes in eating
behaviors (e.g., dietary restriction, excessive exercising, body checking),
known as the relapse signature, and to recognize that such changes are early
warning signs of the return of their eating-disorder mindset. If the eating-
disorder mindset is not rapidly “ejected” within a day or two, the main
maintenance mechanisms will start to lock the eating-disorder mindset back
in place, where it will become extremely difficult to displace. In contrast, it is
quite easy to displace the eating-disorder mindset as soon as the “DVD”
activation is noticed.

Displacing the Mindset

In principle, the patients need to:

“Do the right thing” (generally, the opposite of the behavior driven by
the eating-disorder mindset).
Engage in distracting interpersonal activities.

“Doing the right thing” refers to following what has been learned in
treatment about overcoming the eating disorder. Generally speaking, the
patients should do the exact opposite of what the eating-disorder mindset is
dictating. It is also helpful for them to do something fun or interesting in an
attempt to override these urges. Activities that involve other people (e.g.,
going out with a friend) are usually best for this purpose, but, unfortunately,
these are usually the most difficult for patients with eating disorders.
Nevertheless, it is important that the patients understand that these
challenges are essential steps on the way to permanently displacing the
eating-disorder mindset. In fact, any setbacks can be beneficial, as they
provide concrete opportunities to practice identifying the reactivation of the
eating-disorder mindset and dealing with it using the appropriate strategies.
eir efforts can then be assessed together with the therapist, and any
obstacles can be worked on until patients are confident that they will be able
to deal effectively with any setbacks that occur in the future.

The Usual Course of Events

With practice, patients become increasingly adept at displacing their
mindset. Practice is important, and a success at ejecting the “eating-disorder
DVD” creates a sense of mastery over setbacks. Although, as a general rule,
vulnerability to setbacks progressively declines over time, patients need to
retain this skill for possible use in the future.

EXPLORING THE ORIGINS OF THE

OVERVALUATION

Toward the end of treatment, it is helpful to explore the origins of patients’

sensitivity to shape, weight, and eating. is can help make sense of how the
eating disorder developed and evolved. In addition, it can highlight how this
might have served a useful function in its early stages and why it no longer
does so. To help patients review their past experiences (a historical review, in
CBT-E terminology), they should be asked to consider four distinct periods
in their life:

1. Before the eating disorder (i.e., up to a point 12 months before its

onset).
2. e 12 months immediately prior to its onset.
 3. e first months aer its onset.
4. Since then.

For each time period, patients should consider whether any events or
circumstances might have sensitized them to their shape, weight, or eating,
or reinforced existing concerns. ese events and circumstances may then
be tabulated in a life chart (see Figure 15.2).

Time period Events and situations

Prior to the onset of the eating Slightly overweight by age 7.
problem (until 13 years).
The 12 months immediately
prior to onset.
The 6 months after the onset.
Since then.
Mom dieting.
Negative comments and criticism about my body shape
from parents and friends.
My best friend was slim and attractive.
The guy I like said that I’m fat.
Changing school and classmates.
Loneliness and sadness.
My friend started a diet.
Stuck to my diet perfectly.
Sense of full control.
Positive comments from friends.
More attention from the boys.
Rapid weight loss.
Quarrels with mom.
Sleep disturbance, irritability, social isolation, poor
concentration, and depression (at 14).
Psychotherapy and antidepressants (at 14).
Stopped going to school (at 14½).
Hospitalization in a pediatric unit for low weight (at 15).

FIGURE 15.2. An example of a life chart of an adolescent patient with an eating disorder.

Using this table, hypotheses about why the eating disorder developed
and evolved in the way that it did can be constructed. Typically, events in the
first period are of a type that might increase the salience of shape, weight,
and eating, whereas those in the second (the 12 months leading to the onset)
tend to be disruptive triggers, although generally nonspecific in nature.
Oen the patients will have been unhappy, and may have had difficulty
adjusting to a change in circumstances (e.g., moving from one city to
another, changing schools, parental separation, or death of a relative). e
third period, if characterized by dieting, is oen described in positive terms,
and frequently there is reference to having felt “in control.” e fourth
period is generally the one during which the eating disorder became self-
perpetuating and the processes outlined in the formulation began to
operate. It is at this point that the eating disorder became more or less
autonomous.
Occasionally, specific events are identified that appear to have played a
critical role in sensitizing patients. Commonly, these involve patients having
been made to feel humiliated about their appearance. In these instances, the
therapist should help the patients reappraise the critical event from the
vantage point of the present.
is historical review needs to be done sensitively under the guidance of
the therapist. It is best if it takes place in session as a major item on the
session agenda, and is followed up with a detailed review at the next session.
Between the two sessions, patients should be asked to think about what has
been discussed.
Obviously, it would be naïve to assume that the factors and processes
identified in the historical review operated in the way specified, or could
constitute anything like a full explanation of the eating disorder.
Nevertheless, reviewing the past in this way seems to benefit patients,
particularly in the later stages of treatment, when they can see that they are
beginning to overcome their eating disorder. It serves to distance them still
farther from the problem, and tends to enhance their understanding of the
processes they are currently undergoing. It therefore has a valuable “healing”
function.
 CHAPTER 16

Ending Well

e end of the treatment is as important

as the beginning.

CBT-E, unlike other psychological treatments, which oen simply fizzle out,
places a great deal of importance on the final phase of therapy. ere are
four components to Step ree:

1. Addressing concerns about ending treatment.

2. Ensuring that progress is maintained.
3. Phasing out certain treatment procedures.
4. Minimizing the risk of relapse in the long term.

ADDRESSING CONCERNS ABOUT ENDING

TREATMENT

Most adolescent patients are keen to end treatment because of the stigma
(usually from peers) associated with being in therapy. Also, they will have
known from the outset that treatment will end aer a set number of weeks.
Despite this, a subgroup of adolescent patients and their parents believe that
they will be an exception, and that their treatment will continue. Some
adolescents fear that they may be unable to cope on their own. is fear may
be especially acute if the therapist has become a role model and provided the
kind of guidance and support they have not previously received.
e first step in managing such fears is to ask patients how they feel
about the treatment coming to an end. en their individual concerns can
be managed effectively. For instance, if patients feel sad and worried about
their treatment ending, these feelings can be dealt with. As part of this
discussion, we tell patients that, while it is true that the treatment will soon
be ending, this does not mean that their progress in overcoming the eating
disorder has ended (Fairburn, Cooper, Shafran, Bohn, Hawker, et al., 2008).
Indeed, patients normally show continued improvements once the sessions
have been wound up, especially regarding their concerns about shape and
weight. ey should also be informed that only aer a break from treatment,
when they have had time to practice all of the things they have learned
without professional support, will it be possible to gauge just how much
progress they have made. It should be stressed, however, that in order to
fully recover, they will need to continue to work hard over the following
months, maintaining the changes that they have made and striving for
further progress.
To help patients understand why the treatment needs to end, we oen
draw parallels with learning a foreign language. In the beginning, one needs
to rely on a teacher and has to do a lot of homework. en, aer a while, if
one has studied hard, it becomes increasingly important to put the skills
acquired into practice, talking to foreign people who speak that language
and, if possible, going abroad to fully verify what has been learned. We also
make it clear to patients that they will not be abandoned; there will be
postreview sessions 4, 12, and 20 weeks aer the last session, and that these
will have the aim of taking stock of the situation and discussing any
problems that they may have encountered.1
It is important to note that bringing the treatment to a close can also be
difficult for therapists, as they may feel regret about not being able to see the
adolescent grow and progress. However, the end of treatment also provides
an opportunity for the therapist to explain that such a good relationship is
ending simply because it is time for the patient to be more independent and
not because something went wrong. We tell adolescents that our work with
them has been gratifying, and that we enjoyed it, but we feel confident that
they will be able to continue to make progress on their own. e aim is to
express confidence in the adolescents and emphasize that we believe that
they now have the skills to address problems independently.

ENSURING THAT PROGRESS IS MAINTAINED

e procedure involves three steps:

1. Assessing what progress has been made. is may be done informally
by asking patients what has changed and what has not, but it is best to
conduct this review using a more systematic approach, as follows:
Use the EDE-Q to measure eating disorder features and the CIA to
measure secondary psychosocial impairment, and compare them
with baseline ratings.
Refer to early monitoring records.
Redo the pie chart.
is review needs to be done collaboratively, focusing on the positive.
e therapist should emphasize what the patients have achieved and praise
them for their efforts; patients should be aware that they are responsible for
the changes they have made.

2. Identifying features that still need to be addressed. Subsequently,

usually in the following session, the therapist and patient should jointly
assess which eating disorder features still remain to be tackled in the interval
before the next posttreatment review. A review of the patient’s formulation
will highlight which residual features of the maintenance mechanisms
should be addressed.
 3. Creating a personalized written “short-term maintenance plan.” Once
the features that still need to be addressed have been identified, a
personalized plan for the prereview period should be drawn up. is will
have two components:
Continuing to “do the right thing.” In other words, patients should
continue to behave in line with the ways identified during treatment
(e.g., eating at regular intervals, controlling body checking);
otherwise they will not obtain the full benefits.
Working on a limited number of residual features (up to four).
Examples of features typically targeted during the prereview period
include the following:
Dietary restraint (continuing to introduce avoided foods, working
on social eating).
Concerns about shape and weight (persisting in trying new
activities and persevering with ones that have been taken up,
tackling residual forms of body checking, further body exposure,
and continuing to reinterpret feeling fat).
Events, moods, and eating (continuing proactive problem solving).
Additional modules (any further work required on clinical
perfectionism, core low self-esteem, interpersonal difficulties, or
mood intolerance).
Setbacks (identifying problems early, practicing “ejecting the
eating-disorder DVD”).

e template shown in Table 16.1 can be used as a guide for drawing up

the short-term maintenance plan on a case-by-case basis. Patients are given
a copy of their personalized plan at the end of treatment and are advised to
keep it on hand for regular reference.
TABLE 16.1. Short-Term Maintenance Plan Template (Edit to Suit the Individual
Patient)
Problems to focus on How to address
Overconcern about Keep an eye out for unhelpful body shape checking (frequent
shape and weight mirror use, inappropriate clothing checks, pinching/touching,
comparing self with others), consider whether information is
helpful and accurate, and reduce/stop as discussed.
Be sure not to avoid seeing body shape. If this is happening,
try to be more aware of your body (e.g., by wearing different
clothes, having a massage).
Use mirrors carefully.
Keep an eye out for “feeling fat”; identify the triggers and
relabel.
Avoid weighing outside the set weekly time; do not interpret
single readings.
Avoid judging yourself solely on the basis of shape and weight.
Maintain and develop other life interests (e.g.,
).

Dietary restraint and Try to eat a flexible and varied diet.

restriction Practice eating socially (e.g., with others, in restaurants).
Take care not to avoid certain foods.
Try and eat “enough” and avoid undereating.
Eat regularly (at least every 4 hours).
Avoid strict (rigid and extreme) dietary rules (e.g., concerning
amount to eat [calories], when to eat, eating less than others,
compensating for food already eaten, “debting” by eating less
to compensate for a later meal).
Feeling full is a normal and short-lived sensation. If troubled by
recurrent feelings of fullness, identify triggers (e.g., not being
used to eating a normal amount, being underweight, not eating
regularly, wearing too-tight clothing, eating an “avoided” food)
and address.

Binge eating Conduct a “binge analysis,” if needed, to identify triggers

(undereating, being underweight, going for too long without
eating, breaking a dietary rule, alcohol relaxing dietary control,
responding to a problem in life) and address.
Practice problem solving the triggers.

Other weight-control Avoid vomiting/taking laxatives/overexercising, as they keep

behaviors the eating problem going (and are relatively ineffective).
Other:

Weight regain and Weekly weighing on a set day is crucial.

maintenance Maintain weight within goal weight range (i.e., from
to ).
If weight falls below this weight range, → alarm bells! Review
pros and cons of weight regain by taking a long-term
 perspective. Remember, you need to eat 500 extra calories
every day to regain on average 1 pound (0.5 kilogram) a week.

Weight loss Trying to lose weight is risky if you have had an eating
problem.
The goal of weight loss is appropriate only if you are medically
overweight.
Remember not to try to lose weight over the next 20 weeks.
Avoid rigid and extreme dietary rules.
If medically overweight, can use “binge-proof” dieting after 20
weeks for a limited time (i.e., modest weight loss goals, flexible
guidelines for eating).
Have a realistic goal weight range that is possible to attain
without strict dieting.
Remember, it is unrealistic and unhealthy to lose more than 1
pound (0.5 kilogram) a week.

Slip-ups and lapses Minor slip-ups are to be expected.

Spot slip-ups early on and react positively by (1) trying to
understand the trigger and (2) trying to get back on track as
soon as possible (see “Long-Term Maintenance Plan” in Table
16.2).
If struggling to get back on track, contact
.
Becoming underweight is particularly serious. If BMI is below
the 25th percentile ( pounds/ kilograms) for two
readings in a row, contact .

Other

Note. Adapted from Cognitive Behavior Therapy and Eating Disorders by Christopher G.
Fairburn. Copyright © 2008 The Guilford Press. Adapted by permission.

From Cognitive Behavior erapy for Adolescents with Eating Disorders by Riccardo Dalle Grave and
Simona Calugi. Copyright © 2020 e Guilford Press. Permission to photocopy this material is
granted to purchasers of this book for personal use or use with patients (see copyright page for
details). Purchasers can download enlarged versions of this material (see the box at the end of the
table of contents).

PHASING OUT CERTAIN TREATMENT

PROCEDURES

ree sessions before the end of the treatment, the therapist should ask the
patients to stop self-monitoring. Indeed, it is neither realistic nor
appropriate to ask the patients to continue monitoring themselves
indefinitely, and it is more useful that the interruption occur while the
patients are still being supervised, so as to evaluate the effects of suspending
it. Many teenagers are happy to stop self-monitoring, while others, albeit a
minority, report some concerns regarding the possibility of no longer feeling
in control if they are no longer tasked with observing and analyzing what
they are doing. e therapist should point out that, at this stage in the
treatment, they have already acquired the skills needed to be more aware of
their own behaviors, thoughts, and emotions, and, therefore, self-
monitoring, which was indispensable in the first two steps of the program, is
no longer useful. e therapist should, however, encourage the patients to
remain vigilant with respect to the way they are eating, and all other aspects
of the eating disorder that have been addressed during treatment (e.g.,
dietary rules, body checking, and body avoidance).
Another procedure to be interrupted during this session is in-session
weighing. e therapist should suggest that the patients weigh themselves at
home in the same way that they had previously been doing collaboratively
(i.e., on a set day, once a week, with the number entered onto a weight
graph; and weight interpreted in the context of the last 4 weeks). In the first
few weeks of Step ree, however, weighing should be done both in session
and at home, so as to calibrate the two scales. ereaer, patients should
begin to weigh themselves only at home. e therapist should review the
patients’ weight graph with them while the sessions are ongoing and deal
with any difficulties, but in-session weighing should cease at this time.

MINIMIZING THE RISK OF RELAPSE IN THE LONG

TERM

e other major focus of Step ree is on minimizing the risk of relapse in

the future. is builds upon and extends what had been learned about
dealing with setbacks in the latter half of Step ree. Specifically, patients are
reminded that relapse is not uncommon following treatment for an eating
disorder, and that the period of greatest risk is the weeks and months
following the end of treatment. It is also important to stress the importance
of addressing setbacks quickly and effectively, thereby nipping potential
relapses in the bud.
e therapist should ensure that patients understand the following three
main points:

1. e importance of having realistic expectations. e therapist, without

being negative, should suggest the patients view their eating disorder as an
Achilles’ heel: the “eating-disorder DVD” may start playing in certain
circumstances. However, as patients will have learned in Step Two, this is
something that they can influence.

2. ere are “at-risk” situations. Situations that put the patients at risk of
a relapse include:
Engaging in (strict) dieting (e.g., restarting dieting, breaking a
major remaining dietary rule, an episode of binge eating).
Experiencing a change in shape and weight (e.g., an increase in
weight, an apparent increase in “fatness,” critical comments from
others, shape and weight change following pregnancy, or loss of
weight due to illness).
Experiencing stressful circumstances or events (e.g., negative events
in general, especially those that threaten self-esteem).
Developing clinical depression.

3. It is crucial not to see lapses (setbacks) as relapses. Patients should be

told that how they react to any setbacks will determine what happens next.
Setbacks should therefore be viewed as mere “lapses” rather than a full-scale
“relapse,” as this kind of “black-and-white thinking” will likely result in a
self-fulfilling prophecy. Hence, instead of adopting a hopeless passive stance,
patients should be encouraged to adopt a “can-do” attitude to the problem,
dealing with it as they have learned to do.
 Discussing the Strategy for Addressing Setbacks
Patients need to develop a personalized plan for dealing with any setbacks
that occur. Essentially, this should have two components:

1. Spotting the setbacks promptly (avoiding wishful thinking) and

“ejecting the eating-disorder DVD” as soon as possible by “doing the
right thing” and engaging in activities, preferably interpersonal, that
will displace the mindset.
2. Addressing the trigger. Patients need to take “time out” to consider
what might have been the cause of the setback and then address it
using the problem-solving procedure learned during treatment.

The Long-Term Maintenance Plan

It is essential for patients to be prepared to face the future. To this end, the
last thing to accomplish is to collaboratively develop a written, personalized,
long-term maintenance plan. is will contain personalized advice on
minimizing the risk of relapse (e.g., reminders on how to deal with triggers
and setbacks). e template shown in Table 16.2 may be modified for this
purpose.
TABLE 16.2. Long-Term Maintenance Plan Template (Edit to Suit the Individual
Patient)
How to minimize the risk of setbacks
Stick to a pattern of regular eating.
Avoid dieting, especially rigid and extreme diets, and those that exclude lots of foods.
Maintain weight within your goal weight range.
Beware of engaging in unhelpful body checking or body avoidance.
Maintain and develop other life interests.
Use problem solving to tackle life problems.

Circumstances that might increase the risk of a setback

Life changes and difficulties, changes to usual routine (e.g., vacations, Thanksgiving).
Weight loss or weight gain.
Pregnancy and after pregnancy.
Low mood and/or the onset of clinical depression.
Wedding day (being the focus of attention, pressure to look good).

“Early warning signs” of a lapse

Be on the lookout for your “eating-disorder DVD” starting up. The following early warning
signs form part of the first “track” of the DVD:
Changes in eating, especially eating less, skipping meals or snacks, delaying eating, and
eating “diet” foods.
Restarting reading diet or fashion magazines and/or visiting related websites.
Restarting or increasing body checking or body avoidance.
Restarting or increasing making body shape comparisons.
Weighing outside of set times.
Increasing exercising.
Having the urge to vomit or use laxatives.
Having the urge to binge-eat.
Increasing preoccupation with food and eating.
Increasing dissatisfaction with shape and weight, and a strong desire to change shape or
weight.
Weight dropping below pounds ( kilograms).
If you spot any of these early warning signs, react quickly and positively by taking a “time
out” to think about what is happening and plan a course of action.

Dealing with triggers and setbacks

Identify trigger.
Deal with external triggers (life) by problem solving (see Overcoming Binge Eating,
Second Edition [Fairburn, 2013]).
Beware of labeling a setback as a “relapse” (when one is back to square one).
Nip setbacks in the bud by following guidelines from treatment (see Overcoming Binge
Eating)—for example, restart self-monitoring, adopt pattern of regular eating, plan eating
 ahead and review eating pattern, weigh yourself each week and interpret carefully, avoid
following rigid and extreme dietary rules, question “feeling fat,” analyze binges, use
distraction activities and problem solving, and reduce problematic body checking or body
avoidance.
If pregnant/after pregnancy, ask nurse/midwife to give you information on what is usual
regarding weight and eating, and the typical time taken to lose the weight gained in
pregnancy.
As a general guideline, do the opposite of what the eating-disorder mindset (or “DVD”)
makes you want to do (i.e., “Do the right thing”). Get involved in other aspects of your life,
such as socializing (thereby putting in other healthier DVDs).
Other:
Other:
If the above has not worked within 4 weeks, consider seeking help.
If your BMI drops below the 25th percentile ( pounds/ kilograms) for 2
consecutive weeks, seek help.

Note. Adapted from Cognitive Behavior Therapy and Eating Disorders by Christopher G.
Fairburn. Copyright © 2008 The Guilford Press. Adapted by permission.

From Cognitive Behavior erapy for Adolescents with Eating Disorders by Riccardo Dalle Grave and
Simona Calugi. Copyright © 2020 e Guilford Press. Permission to photocopy this material is
granted to purchasers of this book for personal use or use with patients (see copyright page for
details). Purchasers can download enlarged versions of this material (see the box at the end of the
table of contents).

POSTTREATMENT REVIEW SESSIONS

Review sessions are planned 4, 12, and 20 weeks aer the end of the
treatment. We find that these intervals of time are about the right length for
adolescent patients with eating disorders. On the one hand, they are short
enough to give patients something to work toward, while on the other hand,
they are long enough to ensure that they have enough time to put their
interim maintenance plan into practice and deal with the setbacks that will
almost inevitably arise. e time intervals are also long enough so that
patients do not get confused about whether or not the treatment has ended.
e review has seven purposes:
 1. To provide patients with an opportunity to check in and report their
progress. It gives them a target to work toward.

2. To reassess the eating disorder. is should be done in the usual way
using the EDE-Q and CIA.

3. To review the patient’s implementation of the short-term plan. e

therapist should review each aspect of the patient’s short-term plan and
whether it is still relevant.

4. To review how setbacks have been handled. is is important. e goal

is to refine problem-solving skills.

5. To decide whether there is a need for additional treatment. e

therapist should look out for signs that a patient’s progress is being
significantly affected by residual eating-disorder features. If this is the case,
“top-up” treatment may be necessary. A few sessions should be enough to
get patients back on track aer a setback, and help them prepare to face any
future setbacks. As setbacks oen arise secondary to the onset (or
recurrence) of clinical depression, this will need to be dealt with promptly.
en, once patients have been stabilized, they can be encouraged to address
the setback by themselves.

6. To discuss the need for ongoing weekly weighing. Whether patients

need to continue weekly weighing will depend on their attitude toward their
weight. If it remains an influential issue, they should be encouraged to
continue the procedure, but, if not, they can weigh themselves once every
month or so.

7. To create or review the long-term maintenance plan. Some new “early

warning signs” or triggers may have emerged, and it is important to check
whether there is the need to modify the long-term maintenance plan.

With the great majority of patients, the review appointments are positive
occasions, and the 20-week session will be the last time that the patient and
therapist need to meet.

1
Although CBT-E for adults provides only one postreview session, 20 weeks aer the end of the
treatment, with adolescents it is advisable to hold more frequent review meetings because some
expressions of the eating disorder (e.g., dietary restriction), due to their ego-syntonic nature, oen
risk being undervalued, and more frequent contact helps the patients to get back on track more
rapidly.
Adaptatio
ns for
More
Complex
and
Severe
Cases
 CHAPTER 17

The Broad CBT-E Modules

In the broad form of CBT-E, the strategy

is to address additional maintenance
mechanisms.

OVERVIEW OF THE BROAD FORM OF CBT-E

In the late 1990s, a systematic study of patients who had had a poor
response to CBT for bulimia nervosa, the forerunner of CBT-E, identified
patients with characteristic additional forms of psychopathology, separate
from the eating-disorder psychopathology, that had interfered with
treatment response. e “broad” form of CBT-E was designed to help these
people (25–30% of patients); this comprises additional modules that are
designed to address such “external” mechanisms that contribute to
maintaining the eating-disorder psychopathology and thereby obstruct
change (Fairburn, Cooper, et al., 2003).

When to Use the Broad Form of CBT-E

Clinically, the decision about whether or not to use the broad form of the
treatment is a major one, as it governs the form and content of treatment
from Step Two onward. Also, it might have an impact on the patient’s
outcome (either for better or for worse).
e broad form of CBT-E consists of four additional treatment modules,
each designed to address a commonly encountered “external” mechanism:

1. Clinical Perfectionism.
2. Core Low Self-Esteem.
3. Interpersonal Difficulties.
4. Mood Intolerance.

e decision whether to use broad CBT-E is made in the review session

(aer the first 4 weeks in patients who are not underweight, or in one of the
review sessions carried out during Step Two in those who are underweight).
We recommend that the decision be based on the following two guidelines:

1. e default form of CBT-E should be the focused version. is is the

treatment that has proved its worth in trials involving both
underweight and not-underweight adolescents, and it is easier to
implement.
2. e broad form of CBT-E should only be used if, in the review
sessions following Step One, it is concluded that one or more of the
external psychopathological features (i.e., clinical perfectionism, core
low self-esteem, marked interpersonal problems, or mood
intolerance) (a) are pronounced, (b) appear to be maintaining the
eating disorder, and (c) seem likely to interfere with the response to
treatment.

All three of the conditions in point 2 must be met. If in doubt, the focused
form of CBT-E should be used. If one or more external mechanisms seem to
be operating, we suggest selecting the one that appears to be contributing
the most to maintaining the eating-disorder psychopathology. In fact, it is
rare for us to implement more than one external module in adolescents. In
adolescent patients who are underweight, we usually introduce only one of
the adjunctive modules, and only if there is clear evidence that an external
maintenance mechanism is interfering with weight restoration. Indeed, in
many adolescents, the normalization of body weight and the gradual
removal of the eating-disorder psychopathology produce an improvement in
self-esteem and interpersonal difficulties, and in some cases, perfectionist
attitudes and mood intolerance are also mitigated.

How to Implement the Broad Form of CBT-E

Like focused CBT-E, broad CBT-E can be delivered as a part of the
treatment. Implementing broad CBT-E starts with presenting the idea to
patients. We do this by making reference to the patient’s formulation and
adapting the formulation to include the selected additional maintenance
mechanism. en, for the remainder of the treatment, broad CBT-E has two
aims (Fairburn, Cooper, Shafran, Bohn, & Hawker, 2008):

1. Addressing the “internal” processes that are maintaining the eating-

disorder psychopathology (using focused CBT-E strategies and
procedures).
2. Addressing the identified “external” processes that are maintaining
the eating-disorder psychopathology (using one or more additional
modules).

Since the two aims are allocated an equal amount of time within each
session, this results in less time being available to address the eating-
disorder psychopathology if session length and overall number remain
unchanged. Hence, in adolescents, we prefer to increase the length of CBT-E
by about 10 sessions (e.g., to 30 sessions in patients who are not
underweight or up to 40–50 sessions in those who are underweight) to allow
more time for the external mechanisms to be tackled.
 Toward the end of the treatment, when the focus shis to dealing with
setbacks, maintaining change, and relapse prevention, the two treatment
targets (internal and external processes) continue to be addressed in relation
to these topics. e patient’s maintenance plans should incorporate elements
from both the internal and external processes, and posttreatment review
sessions should focus on progress in both areas.

CLINICAL PERFECTIONISM MODULE

Both clinical experience and scientific evidence indicate that traits of

perfectionism are common among people with eating disorders, and are
oen evident before the onset of the eating disorder itself (Fairburn, Cooper,
Doll, & Welch, 1999; Fairburn, Cooper, et al., 2003). Although it has not yet
been established whether it influences treatment outcome, so-called clinical
perfectionism (Shafran, Cooper, & Fairburn, 2002) does seem to interfere
negatively with treatment response, and should therefore be addressed by
the treatment.

Description of Clinical Perfectionism

Clinical perfectionism is a state in which the patients’ perfectionist attitudes
and behaviors are so extreme that their life becomes impaired. e core
feature of clinical perfectionism is the overvaluation of achieving (and
striving to achieve) personally demanding standards despite adverse
consequences. As with the overvaluation of shape and weight, this is a
dysfunctional system of self-evaluation. People with clinical perfectionism
judge themselves largely, or even exclusively, in terms of working hard
toward and meeting personally demanding standards in areas of life that are
important to them.

Implications for CBT-E

e psychopathology of clinical perfectionism intensifies aspects of the
eating disorder and makes it harder to treat (see Figure 17.1).

FIGURE 17.1. Representative formulation of an underweight adolescent patient with an eating

disorder and clinical perfectionism.

When people with clinical perfectionism also have an eating disorder,

they apply their extreme standards to their eating, weight, shape, and their
control (Fairburn, Cooper, et al., 2003). is results in dieting especially
intensely and adopting similarly rigorous standards for exercising. In these
circumstances, patients’ behavior may be especially difficult to change
because it is also maintained by their pursuit of perfectionist standards of
achievement with regard to control of their eating, weight, and shape.

Treatment Strategy
If a patient’s perfectionism meets the criteria for using broad CBT-E (see
above), the Clinical Perfectionism module is added to the formulation in the
first review session, or in one of the early review sessions in patients who are
underweight.
Clinical perfectionism is addressed using the same strategy that is used
to address body image (i.e., the overvaluation of shape and weight). e two
psychopathologies are discussed more or less in tandem, with discussion of
body image being a few weeks “ahead.” is is because the Clinical
Perfectionism module builds on the understanding acquired by patients
when addressing body image.

Identifying the Overvaluation of Achieving and Its

Consequences
e overvaluation of achieving and achievement is a form of
psychopathology equivalent to the core psychopathology of eating disorders,
as it is also a dysfunctional system of self-evaluation. Like the overvaluation
of shape and weight, it has various consequences or expressions that need to
be addressed for two reasons:

1. ey are in themselves impairing.

2. ey maintain the overvaluation of achieving and achievement.

e main consequences or expressions of the overvaluation of achieving and

achievement, not all invariably present, are (Shafran et al., 2002):

Marginalization of other areas of life.

Striving to meet demanding and inflexible standards and resetting
standards if goals are met.
Performance avoidance or performance checking.

e preparatory phase mirrors the procedures used to identify the

overvaluation of shape and weight, which will have been applied a few
sessions earlier. ere are six steps.

1. Referring to the patient’s pie chart.

2. Discussing the role of clinical perfectionism in the patient’s system of

self-evaluation. e therapist should illustrate to the patients that there is a
dominant “slice” representing the overvaluation of achieving and
achievement (see Figure 17.2).
FIGURE 17.2. An example of a pie chart of a patient with the overvaluation of achieving and
achievement.

3. Discussing the implications of judging oneself primarily in terms of

achieving and achievement. When discussing the pie chart, the therapist
helps patients to reach the conclusion that, just as with the overvaluation of
shape and weight, having a dominant slice is “risky,” self-perpetuating, and
tends to limit one’s life.

4. Identifying the consequences of the overvaluation. is includes:

Identifying the following expressions:
Marginalization of other areas of life.
Striving to meet demanding and inflexible standards, and
resetting standards if goals are met.
Performance avoidance or performance checking.
Considering whether they cause impairment (e.g., fear of failure,
avoidance of tests of performance, impaired performance).
Creating an extended formulation to demonstrate the self-
maintaining nature of clinical perfectionism (see Figure 17.3).
FIGURE 17.3. Representative extended formulation of an adult patient with an eating disorder
featuring overvaluation of achieving and achievement. Reproduced with permission from Online
Training Program in CBT-E, CREDO Oxford, 2017.

It is also important to consider the role of this form of overvaluation in

maintaining a patient’s eating disorder, making reference to the revised
formulation created in the early review sessions.

5. Considering the implications. Help the patients arrive at the

conclusion that there are two reasons to address the overvaluation of
achieving and achievement:
It drives clinical perfectionism, which in turn maintains the eating-
disorder psychopathology.
It has direct expressions that themselves cause impairment (e.g.,
fear of failure, avoidance of tests of performance, impaired
performance).

6. Proposing a two-pronged treatment strategy (as with body image):

To increase the importance of other areas (domains) of life (i.e.,
address the marginalization).
To reduce the importance of achieving and achievement (i.e., by
addressing performance checking and performance avoidance, and
by addressing perfectionist standards and striving).
 Enhancing the Importance of Other Domains of Life
e overvaluation of achieving and achievement results in the
marginalization of other aspects of life. is marginalization occurs with the
overvaluation of shape and weight, but is more pronounced in patients with
clinical perfectionism. e strategy for addressing such marginalization is
described in Chapter 12, and will serve the dual function of helping to
reduce the importance of both shape and weight and achieving and
achievement. ere are two points to note when helping patients with
clinical perfectionism:

1. Patients should be encouraged to choose activities with the following

characteristics:
Performance in them is not easily quantified (to avoid the risk that
their clinical perfectionism will be applied to them).
ey may have been dismissed in the past as a waste of time (e.g.,
reading novels/newspaper, listening to music, staying in touch with
friends), but now time should be set aside for them.
2. Spontaneity should be encouraged, as patients with clinical
perfectionism find this difficult.
Flexibility can be increased using the dice procedure (i.e., plan three
or more options and then let the roll of a die dictate which option is
selected).

Addressing Perfectionist Standards and Striving

People with clinical perfectionism tend to set themselves demanding and
inflexible standards (goals) against which they judge their performance in a
variety of areas of life. ese standards are inflexible and tend to be viewed
in an all-or-nothing manner. is results in patients:

Striving to meet (multiple) demanding goals.

 Resetting standards if they are met.
Neglecting or dismissing achievements.
Being dismissive of activities that are not productive, as they are
considered as a waste of time.

Despite striving, such patients’ performance is oen impaired because they

work excessively and so are likely to be less effective due to fatigue. ey also
tend to be indecisive, as getting things right is so important to them. As they
are oen unable to meet all their goals, they may have frequent experiences
of failure.

Goals

e goals of treatment are to modify the patient’s standards to make them:

Less demanding. To achieve this goal, the therapist should discuss with
patients how they could become “more effective.” Education about
work/study habits is particularly useful, as patients oen believe that
the harder they work or study, the better they will do. is is oen not
the case. Indeed, their performance may improve if they work less.
erapists need to counter patients’ view that working less hard is
tantamount to lowering their standards.
Flexible rather than rigid. To achieve this goal, patients are encouraged
to change inflexible standards into flexible guidelines. Switching to
guidelines reduces the risk of “failure” and so makes avoidance,
indecision, and procrastination less likely.

Procedure

e procedure for addressing standards and striving has five steps:

1. Helping patients specify their standards (goals) in the various

domains of life by which they judge themselves. (Note: e therapist must be
prepared to feel overwhelmed by the amount of information that patients
provide.)

2. Taking patients’ own standards as an example, discussing the

negative effect on self-esteem of repeatedly dismissing achievements and
resetting standards.

3. Discussing the feasibility of meeting multiple demanding standards

(goals) in many areas of life. In our clinical experience, seeing their
standards written down helps patients realize that what they are trying to
achieve is impossible. erapists should convey to patients that trying to be
“perfect” in many areas of life is unrealistic, exhausting, and demoralizing.

4. Helping patients think about their long-term aspirations and goals.

erapists should discuss patients’ long-term life goals, and whether they are
feasible given their perfectionism. e discussion should also address the
possibility that they may lead happier and more fruitful lives by accepting a
level of performance that is “good enough.” It should also be emphasized
that it is important to keep the big (i.e., longer-term) picture in mind.

5. Helping patients adapt their standards so that they are less extreme
and more flexible. e therapist should discuss patients’ goals, helping them
to assess whether they are truly appropriate (all things considered) or
whether they need to be adjusted. Patients should also be encouraged to
experiment with new ways of behaving by aiming to do things “well
enough,” introducing flexibility and spending less time on tasks.

Addressing Performance Checking

While encouraging the importance of other domains of self-evaluation, the
therapist should directly target the patient’s overvaluation of achieving and
achievement. It is oen best to begin with its expression in the form of
performance checking, since this tends to be particularly powerful in
maintaining the overvaluation.
 Performance checking is defined as the repeated assessment of
performance, generally focused on perceived shortcomings. It takes many
forms:

Assessing (checking personal performance). Examples include:

General: rereading homework repeatedly, being preoccupied with
how well one said something, repeatedly checking e-mails.
Eating disorder: frequent weighing, repeatedly checking appearance,
checking calories eaten.
Comparison making (comparing personal performance with that of
others). Examples include:
General: comparing hours studied with classmates, comparing
performance in a specific task (e.g., a race, test results) with that of
others, comparing how oen friends call the person with how oen
she or he calls others.
Eating disorder: comparing one’s shape or food intake with that of
others.
Reassurance checking (asking others about one’s performance).
Examples include:
General: repeatedly asking a teacher/coach for feedback.
Eating disorder: repeatedly asking for feedback on appearance or
eating.

As performance checking tends to focus on deficits in performance, it

leads to patients discontinuing or ignoring what they have achieved. As a
result, it creates undue dissatisfaction with performance. Furthermore, by
scrutinizing their performance, patients do not see the overall picture. is
reduces productivity by undermining morale, as a result of being distracted
by thoughts about performance. is all serves to maintain the
overvaluation of achieving and achievement.

Procedure
e procedure for addressing performance checking has four steps:

1. Discussing how performance checking maintains clinical perfectionism

(in general) and providing education about its three forms. Performance
checking highlights failures, thereby encouraging further striving. It is worth
discussing this vicious circle to see whether patients identify with it.

2. Identifying the patient’s particular types of performance checking in all

affected areas of life. is may not be straightforward, as the patients may not
be aware of many of them. Hence, there are two methods of doing this:
Ask the patients directly.
Ask the patients to record any performance checking over two 24-
hour periods in an adapted monitoring record (see Figure 17.4);
one should be a school day (if applicable), while the other should be
a day off from school.
Day Date

Time Food and drink * V/L/E Performance Place Context,

consumed checking (what thoughts, and
done, time taken) feelings

FIGURE 17.4. Blank monitoring record adapted to record performance checking. Reproduced with
permission from Online Training Program in CBT-E, CREDO Oxford, 2017.
From Cognitive Behavior erapy for Adolescents with Eating Disorders by Riccardo Dalle Grave and
Simona Calugi. Copyright © 2020 e Guilford Press. Permission to photocopy this material is
granted to purchasers of this book for personal use or use with patients (see copyright page for
details). Purchasers can download enlarged versions of this material (see the box at the end of the
table of contents).

3. Identifying and discussing the adverse effects of performance checking.

e main point here is that performance checking is generally driven by a
fear of failure and a focus on failures rather than accomplishments.
erapists should discuss the adverse effects of the patient’s particular forms
of checking. ey should also highlight the two forms of bias that are usually
present in the patient’s comparison making:
Selective comparison with top performers.
Critical evaluation of self with a superficial evaluation of others.
 4. Helping patients moderate their performance checking. e main
strategies for moderating performance checking are the following:
Engaging in fewer forms of checking.
Checking less oen.
Changing the form of checking (including achievements, making
less biased comparisons, etc.).
Reinterpreting the findings to take into account achievements, as
well as the broader context (i.e., what else has been happening, and
the “big picture”),

Patients should be encouraged to ask themselves the following questions

before performance checking:

“What am I trying to discover? Can I find it out this way?”

“Is this helping me to achieve more/be more productive?”
“Will doing this make me feel better about myself?”
“Does it make sense to do this so oen?”

Patients should be helped to be more “scientific” when choosing who to

compare themselves with. Moreover, they should be encouraged to become
aware of things they actually are achieving (“look for success, however
small”) and to judge their performance in the context of their overall life.
Note that to do this, patients need to be recording in real time.

Addressing Performance Avoidance

Avoidance can take two main forms. First, patients may avoid assessing their
own performance. is results in their having little or no information about
their true progress or ability. Instead, they “fear the worst.” With respect to
eating-disorder psychopathology, the various forms of body avoidance are
good examples of expressions of this type of thinking. Second, patients may
avoid external tests of performance, such as school tests, sports
competitions, social events, singing in front of others, and so on.
Avoidance may also take the form of procrastination, with tasks being
put off because it is feared that they will not be performed to the highest
standards. is form of avoidance tends to be accompanied by rumination,
self-criticism, and distress. It involves putting off tasks for one or more of the
following reasons:

Fear of not doing them well enough.

inking it will take too long to complete the task well.
Inability to stop the task halfway through.
Concern about feeling overwhelmed.

As with patients who manifest body checking and body avoidance, those
with clinical perfectionism tend to switch between periods of intense
striving and periods of avoidance. Avoidance has several adverse effects:

Patients not obtaining information about their actual performance and,

instead, assuming the worst.
Patients not achieving things or performing suboptimally due to lack
of time.
Patients no longer gaining experience from practicing tasks and
learning from mistakes, and thereby not improving their performance.

Last but by no means least, avoidance maintains the overvaluation of

achieving and achievement.

Procedure

e procedure for addressing avoidance has five steps:

1. Discussing how avoidance (and procrastination) maintains clinical

perfectionism (in general). If applicable, it is useful to draw a parallel
 with body avoidance.
2. Identifying the patient’s forms of avoidance in all affected areas of life.
is is relatively straightforward because patients are usually aware of
their avoidance.
3. Identifying and discussing the adverse effects of the various forms of
avoidance, and how avoidance maintains the patient’s clinical
perfectionism.
4. Exploring the patient’s reasons for avoidance. In most cases it is
motivated by fear of failure.
5. Addressing the avoidance. Both forms of avoidance need to be
addressed by devising behavioral experiments to test patients’ beliefs
and introduce new ways of behaving (e.g., taking a school test despite
not feeling “fully” prepared, or asking someone out on a date).
Patients should also be helped to introduce normative ongoing
performance checking, and to consider the immediate and longer-
term pros and cons of completing external tests of performance.

Involving Parents
If parents are to be involved, they should be educated about the main
features and maintenance mechanisms of clinical perfectionism, and about
the overvaluation of achieving and achievement, using the patient’s
formulation. en, it should be discussed how they can help the patient to
address some of the maintenance mechanisms and implement specific
procedures from the module. Here are some examples:

Helping the patient reduce academic or sport pressures by de-

emphasizing the importance of performance and tests.
Helping the patient identify and perform activities “just for fun”; these
should not be measurable with regard to performance.
Avoiding making negative comments (also negative nonverbal
expressions) about the patient’s or others’ performance.
 Helping the patient notice performance checking, and helping her or
him to stop doing it.
Stopping giving repeated reassurances about the patient’s performance.
Taking the patient (if agreed upon) to address a challenging situation,
such as playing a sport she or he does not excel at, just for fun.
Helping the patient to accept failure and learn that it is possible to
enjoy a good life without being perfect.
Encouraging the patient to use the monitoring records to understand
the triggers of performance checking and performance avoidance.

Exploring the Origins of the Overvaluation

It is oen helpful to ask patients to consider the sources of their concerns
about performance. is can help them make sense of how their
perfectionism developed and evolved. Crucially, it can also highlight how it
might have served a useful function in the past (perhaps at school), before
becoming extreme and impairing.
Since it is oen difficult to date the onset of clinical perfectionism, it is
best to look for events or circumstances that might have sensitized the
patients to performance, rather than to try to examine their exact
contribution in the development of the problem (as is done with concerns
about shape, weight, and eating; see Chapter 15). e therapist may ask
patients to think about events and circumstances that might have sensitized
them to their performance. ese are some examples:

Parental high standards.

Parental pressure to succeed.
Early “successes” and “failures,” and the reaction of significant others.
Influence of the patient’s education.
Peer pressure.

Dealing with Setbacks

e core psychopathology of clinical perfectionism, like that of eating
disorders, can be viewed as a mindset. Just as the procedures for tackling the
overvaluation of shape and weight erode the eating-disorder mindset, the
procedures directed at clinical perfectionism erode that mindset. is
process allows more appropriate mindsets to become established. At first,
this happens only intermittently.
Just as it is important that patients learn how to regulate their eating-
disorder mindset, they should learn to manipulate their clinical-
perfectionism mindset. erapists should employ strategies and procedures
similar to those used for the eating-disorder mindset so that patients learn
to do the following three things:

1. Identifying triggers of setbacks. Typical triggers for adolescents are:

Beginning college.
Increased pressure to study (e.g., for important exams).
Taking part in a competitive sport.
Comparing pictures/achievements on social media.
2. Recognizing the first signs that the perfectionism mindset has returned.
Common signs are:
Striving harder (e.g., studying longer hours).
Increasing performance checking and/or increasing comparison
making.
Avoiding and/or procrastinating.
3. Displacing the mindset. Patients are encouraged to use the same
strategy described with regard to displacing the eating-disorder
mindset.

Ending Well
e strategies and procedures used to maintain progress and minimize the
risk of relapse are the same as those used with respect to the eating-disorder
psychopathology (see Chapter 15). e therapist should identify the
problems that remain and devise a specific perfectionism-oriented
maintenance plan for the patients to implement over the following months.
e same applies to relapse prevention in the longer term, with particular
attention being paid to identifying both a patient’s likely relapse signature,
and what action she or he should take if she or he experiences a setback.
VIGNETTE
e patient is a 16-year-old competitive artistic gymnast who has suffered from bulimia nervosa
since the age of 14. Her binge-eating episodes followed by self-induced vomiting started aer a
period of strict dietary restriction to lose weight, with the aim of improving her athletic
performance. However, with the eating disorder her training performance is getting progressively
poorer.
e patient has an extreme form of perfectionism, which is expressed in her gymnastic
training. She makes herself do 2 hours of extra training every day, over and above the training
schedule set by her coach, in a bid to improve her athletic performance. She also mentally checks
her performance several times, looking for mistakes during the execution of an exercise, and has
implemented a rule forcing her to repeat the routine from the beginning if she makes a visible
mistake. is perfectionism is also expressed in her dieting and body checking, and is hindering
the treatment. Indeed, although she is extremely scrupulous in self-monitoring, she is reluctant to
change her eating habits and to eat regularly for fear of gaining weight. Moreover, her
overvaluation of gymnastic achievement and her worries about her athletic performance
worsening as a result of reducing the duration and frequency of training preclude her
commitment to addressing excessive exercising.
In the review session aer 4 weeks of treatment, she agrees that she is being affected by
clinical perfectionism, and that this is being expressed in two main domains: the achievement of
extreme standards in gymnastics, and the control of weight, shape, and eating. Shared processes
are identified in these two domains (e.g., repeated performance checking and body checking,
striving in training and following dietary rules, resetting goals if her standards are met). She also
agrees that this system of self-evaluation is counterproductive because it impairs her athletic
performance (i.e., overtraining exceeding her recovery capacity and potentially leading to injury,
halting progress, and causing her strength and fitness to diminish), her control over eating and
weight (i.e., the adoption of extreme and inflexible dietary rules favoring the development of
binge eating), and other important areas of life (i.e., the pursuit of demanding standards in
gymnastics and eating control, compromising her interpersonal relationships).
In Step Two, albeit with difficulty, she gradually addresses all the maintenance mechanisms in
her personal formulation by implementing the Body Image, Dietary Restraint, and Clinical
Perfectionism modules. At the same time, the therapist helps her to develop new, performance-
free domains of self-evaluation (e.g., listening to music, spending time with friends). At the end of
the treatment, the clinical perfectionism is still evident, but a greater flexibility in terms of diet
has produced a remission from binge eating and the interruption of dysfunctional body checking.
e introduction of performance-free activities has helped her to accept her body weight and
 shape, and stopping overtraining and performance checking has improved her athletic
performance.

Note: If the clinical perfectionism persists, the therapist should consider

a full-scale psychological treatment directed at it once CBT-E has been
completed (Egan, Wade, Shafran, & Antony, 2004).

CORE LOW SELF-ESTEEM MODULE

Most adolescent patients with eating disorders are highly self-critical due to
their perceived failure to meet their goals of controlling shape, weight, and
eating—a form of negative self-evaluation that may be termed “secondary
self-criticism.” Secondary self-criticism does not generally need to be
addressed in treatment because it oen does not obstruct change.
Furthermore, self-esteem commonly improves as the eating disorder is
successfully treated, even if it has not been explicitly targeted. However,
there is a subgroup of patients who have extreme, or “core,” low self-esteem,
which maintains the eating disorder and obstructs change (Fairburn,
Cooper, et al., 2003). In this case, the possibility of treatment with CBT-E
success is scarce, unless core low self-esteem is also addressed (Fairburn,
Peveler, Jones, Hope, & Doll, 1993). It is for these patients that the Core Low
Self-Esteem module has been designed.

Description of Core Low Self-Esteem

Core low self-esteem is defined as an unconditional and pervasive negative
view of self-worth that is long-standing, largely independent of current
circumstances and performance, and not explained by the presence of a
clinical depression (Fairburn, Cooper, Shafran, Bohn, Hawker, et al., 2008).
Patients with core low self-esteem believe that they have little or no value as
people and describe themselves as “worthless,” “useless,” “stupid,” a “failure,”
and so on.
 Implications for CBT-E
If a patient with an eating disorder also has core low self-esteem, achieving
change in the eating disorder is particularly difficult due to two main
processes (Fairburn, Cooper, Shafran, Bohn, Hawker, et al., 2008):

1. e unconditional and pervasive nature of patients’ negative view of

themselves results in their seeing little or no prospect of recovery.
2. e intensity of patients’ low self-esteem leads them to strive
especially hard to control their eating, shape, and weight in order to
reduce their sense of worthlessness.

Identifying the Presence of Core Low Self-Esteem

It is important to distinguish the two forms of negative self-evaluation:
secondary self-criticism and low self-esteem.
Secondary self-criticism:

Is conditional on current performance in valued areas of life.

Fluctuates (i.e., the patient is not persistently self-critical).

Patients with secondary self-criticism:

Do not view specific “failures” as equating with being a failure as a

person.
Do not view themselves in globally negative terms.

By contrast, core low self-esteem is characterized by:

An unwavering unconditionally negative view of self.

A global negative view, not related to specific aspects of performance.
Negative overall judgment of self-worth, and an inability to distance
from a self-critical stance (i.e., a person’s identity).
 Negative comparisons with others.

Other features of core low self-esteem are the presence of pronounced

negative cognitive processing biases, such as a negative vision of the future
and the belief that it is impossible to change, both of which tend to
undermine the treatment. Like clinical perfectionism, core low self-esteem is
also a risk factor for the development of anorexia nervosa or bulimia
nervosa (Fairburn, Cooper, et al., 1999; Fairburn, Welch, Doll, Davies, &
O’Connor, 1997). Furthermore, it is always long lasting, and its onset is
difficult to determine. It is particularly problematic to identify core low self-
esteem in the presence of clinical depression, because the two conditions
share many clinical characteristics. Our suggestion is that if there is
coexisting clinical depression, it should be addressed first, and self-esteem
reassessed aerward.

Treatment Strategy
Self-esteem should be an additional target of treatment if it is concluded that
the patient has core low self-esteem, and provided that the three criteria for
the broad version of CBT-E are met. In CBT-E, core low self-esteem is
addressed in two ways (Fairburn, Cooper, Shafran, Bohn, Hawker, et al.,
2008):

1. It may be tackled directly using cognitive behavioral procedures (as

described in this module).
2. Alternatively, it is possible to tackle core low self-esteem indirectly by
enhancing patients’ interpersonal functioning (using the
Interpersonal Difficulties module).

Which of these two methods will be used should be decided either in the
review session aer Step One or in one of the subsequent review sessions for
those who are low weight. If a patient has obvious cognitive biases, it is best
for core low self-esteem to be addressed directly, but the indirect method
may be more suitable if it seems feasible to create a self-sustaining network
of positive interpersonal relationships. In either case, the formulation should
be amended to reflect the additional module to be implemented.
If the indirect method is selected, explain that in the therapist’s opinion,
the best way of improving patients’ self-esteem would be to enhance the
quality of their relationships (see “Interpersonal Difficulties Module”
below). On the other hand, if the direct method is chosen, core low self-
esteem should be included (in outline format) in the personal formulation
(see Figure 17.5). On rare occasions (usually only in longer versions of the
treatment), both strategies may be used concomitantly, as they can be
complementary. However, if the patient is receiving the 20-week version, it is
not usually realistic to consider both options.

FIGURE 17.5. e transdiagnostic formulation with the inclusion of core low self-esteem.
Reproduced with permission from Online Training Program in CBT-E, CREDO Oxford, 2017.

Core low self-esteem should be addressed using standard cognitive

behavioral strategies and procedures (Fennell, 2009). As with the other
additional modules, it should be addressed alongside eating-disorder
psychopathology, allocating half of the agenda time to each. Change in self-
esteem is usually facilitated by change in other areas, such as the
amelioration of eating-disorder psychopathology or improved interpersonal
functioning.

Personalized Education
Before core low self-esteem can be addressed, the therapist should inform
patients of what it is, and how it is contributing to the maintenance of their
eating disorder. It is crucial to emphasize that low self-esteem and the eating
disorder reinforce each other via a powerful vicious circle. Specific points to
cover as part of this personalized education are the following:

Negative Beliefs

People with core low self-esteem have negative beliefs about themselves that
they view as facts (e.g., “I am a failure/worthless/unlovable/useless”). ese
beliefs oen appear to stem from past negative experiences. ey affect
patients in many ways (in their relationships and how they see the world)
and can be compared to “prejudices” against themselves.

Cognitive Bias

is affects the way in which people with core low self-esteem see the world,
their future, and their past. It results in information being filtered in such a
way that only negative information is perceived, thereby confirming their
negative self-opinion. e most common expressions of this type of
cognitive bias are:

Discounting positive qualities or information.

Selective attention to information consistent with a negative self-view.
 Double standards (harsh standards for self vs. more lenient standards
for others).
Overgeneralization (from any instance of not succeeding to being a
failure).
Dichotomous appraisal of self-worth (e.g., “If I am not strong, I must
be weak”).

A good way of helping people with core low self-esteem understand how
their cognitive bias operates is to employ the following “sunglasses analogy”
(Fairburn, Cooper, Shafran, Bohn, Hawker, et al., 2008):

“Imagine that overnight someone puts sunglasses on you without your

knowing. You wake up in the morning and it seems very dark outside.
is is your reality; it is how you see and judge the world. You conclude
that since the weather is so gloomy, you will need to wear warm clothes.
“You then go to the bathroom and look in the mirror; you see that
you have been wearing sunglasses and you take them off. Now
everything looks quite different. Outside it is light. You realize that you
were seeing things incorrectly. ere will be no need for those warm
clothes.
“is is what having low self-esteem is like. You see the world from
an unduly negative perspective. e glass is half-empty rather than half-
full. But your pessimistic way of looking at things is biased: it is as if you
were wearing dark sunglasses and were not aware of it. Life is not how
you see it.”

Problematic Rules or Expectations

People with core low self-esteem set problematic rules and expectations for
themselves (sometimes termed “rules for living”). ese rules make it
possible for them to operate more or less effectively (based on the
assumption that the negative beliefs about themselves are true), but in
reality, these rules or expectations place heavy demands on them and are
impossible to live up to. Typical examples are the following:

“I am not good enough” (“I need to be the absolute best at my school in

order to be worthwhile”).
“I am unlovable” (“Unless I do everything people expect of me, I will
be rejected”).
“I am inferior” (“Nothing I do is worthwhile unless it is recognized as
such by others”).

Experiences of Repeated Failure and Generalization

Problematic rules, when combined with cognitive bias, result in people with
core low self-esteem experiencing what they see as repeated “failures.” ey
generalize from these perceived failures and see themselves as failures, which
confirms their negative self-evaluation.
Core low self-esteem, when it co-occurs with an eating disorder, leads
people to strive particularly hard to control their eating, shape, and weight
to reduce their sense of worthlessness. Rule breaking and any resulting
episodes of loss of control over eating are viewed as failures, which feeds
into the patient’s global negative self-image. A number of vicious circles
serve to maintain both core low self-esteem and eating disorders. It is
important that both are addressed in treatment. Figure 17.6 shows the
personal formulation of a patient with anorexia nervosa and core low self-
esteem, explaining how the expressions of the latter maintain the eating-
disorder psychopathology.
FIGURE 17.6. Representative personal formulation showing how the expressions of core low self-
esteem maintain the eating disorder in a patient with bulimia nervosa. 1, the control of shape, weight,
and eating is used to reduce feelings of worthlessness; 2, breaking any rule is experienced as a failure
and confirms negative self-belief; 3, the person is never satisfied by the weight achieved as a result of
problematic rules and cognitive biases. Reproduced with permission from Online Training Program
in CBT-E, CREDO Oxford, 2017.

Addressing Cognitive Bias

e main cognitive processes that create negative self-evaluation are
addressed using conventional cognitive behavioral procedures.

Discounting Positive Qualities

is should be addressed promptly, once Step Two has begun. e focus is
on helping patients identify and validate their positive qualities (no matter
how trivial), as they tend to notice only their negative qualities. e ultimate
aim is to help patients achieve a more balanced self-opinion. e procedure
for addressing discounting positive qualities has two steps:
 1. Asking patients to make a list of their positive attributes, noting their
skills and strengths. Patients may find this difficult, so it is therefore
best to start the list in session. It is useful to ask about:
eir achievements (no matter how small).
eir skills or talents.
Challenges they have faced.
What other people like or value in them.
Which qualities and actions that they value in others do they
possess.
Which of their attributes do they value in others.
Which bad qualities they do not possess.
How a person who cares about them might describe them.
2. Helping patients to use the above list to raise their awareness of their
good points on a day-to-day basis. For example, the therapist should
ask patients to:
Review the list created in the previous step and recall specific times
when they exhibited qualities that appear on the list.
Look out for these qualities on a daily basis in everyday life and
record them.
Regularly ask themselves what has gone reasonably well that week
and why. At first the therapist should lead this questioning in
session, but ultimately the patients should do this independently. A
written record of this procedure should be kept on the back of each
day’s monitoring record.

Selective Attention

In patients with core low self-esteem, there is a vicious circle between

negative self-evaluation and selective attention to perceived failures. ey
look for means to judge themselves harshly, which they will inevitably find.
e procedure to address this kind of selective attention has three steps:
 1. Educating patients about selective attention. In general, people pay
particular attention to stimuli that are salient to them. For example, if
one buys a new car, one starts to notice many more cars like it. is is
not because there are more of them around, but rather because one is
more aware of that type of car. e same happens in patients with low
self-esteem. ey look for failure and find it. As a result, their
negative self-evaluation is confirmed. Just as “If you look for bulges,
you will find them” and “If you look for failure, you will find it.”
2. Discussing patients’ tendency to look for failure, and how this confirms
their negative self-evaluation. e therapist may ask patients to give
examples (e.g., only remembering times when they received criticism
at school, not remembering positive feedback).
3. Helping patients become more aware of situations in which they engage
in selective attention. e goal here is that patients learn to broaden
their focus of attention at such times instead of concentrating only on
their “failures.”

Double Standards

Typically, patients with core low self-esteem have one set of (harsh)
standards for judging themselves, and another (more lenient) set for others.
Addressing double standards involves three main steps:

1. Helping patients recognize that they have harsh standards for

themselves and more lenient standards for others by pointing out real-
life examples. For example, ask patients what their reaction would be
if someone they cared about approached them with a problem.
Would they treat that person differently from the way in which they
treat themselves?
2. Reviewing in detail any justification for such double standards,
discussing the negative impact of constant harsh internal self-criticism.
 3. Encouraging patients to be kind, sympathetic, and encouraging to
themselves, just as they would be to another person.

Overgeneralization

Patients with core low self-esteem tend to view any instance of not
succeeding as a failure, and then generalize from such failures to being “a
failure” in general. is is addressed using three steps, in much the same way
as double standards:

1. Fostering patients’ awareness of their tendency to overgeneralize from a

specific failure to being a failure by helping them notice when it occurs.
2. Questioning the basis of the patients’ thinking. Ask them whether they
would generalize to their being a wonderful person on the basis of
doing one thing well.
3. Encouraging patients to look at the bigger picture and to refrain from
making global judgments without taking all the evidence into account.

Dichotomous Appraisals of Self-Worth

People with core low self-esteem oen assess themselves in all-or-nothing

terms. ey use terms such as “always/never,” “everyone/no one,” and
“everything/nothing” when describing themselves (e.g., “If I am not always
strong, I must be weak”). Such examples of black-and-white thinking should
be addressed using the following three steps:

1. Helping patients recognize their tendency to appraise themselves in

black-and-white terms.
2. Reviewing in detail any justification for such dichotomous
assessments of themselves.
3. Encouraging patients to evaluate themselves in a more flexible and
nuanced way.
 Addressing Problematic Rules

Problematic rules are almost ubiquitous among patients with core low self-
esteem. ese include views such as “I need to be really good at
to be worth anything.” Beliefs of this kind may be addressed
using the following four steps:

1. Helping patients recognize and identify their rules.

2. Helping patients consider the impact of their rules on their lives (e.g.,
relationships, school, leisure time).
3. Helping patients question their current rules. Ask patients (a) where
the rules came from and (b) what the advantages and disadvantages
of acting in accordance with them are.
4. Encouraging patients to find alternative rules that are more realistic
and helpful and to put them into practice. e therapist should remind
patients that the new rules open the door to their accepting
themselves and achieving their life goals.

Involving Parents
As in clinical perfectionism, parents may become involved in helping
patients to address core low self-esteem. In this case, parents are first
educated about the main features and maintenance mechanisms of core low
self-esteem and how it interacts to maintain the eating disorder, illustrating
the patient’s formulation. Subsequently, how they can be of assistance to
patients in addressing the external maintenance mechanisms is discussed.
Here are some examples:

Praising their daughter or son not only for a job well done but also for
her or his efforts.
Using warmth and humor to help the patient both learn about her- or
himself and appreciate what makes her or him unique.
 Trying to provide a positive role model by nurturing their own self-
esteem. If parents are excessively hard on themselves, pessimistic, or
unrealistic about their abilities and limitations, their children may be,
too.
Helping the patient identify and modify negative beliefs, cognitive
biases, and problematic rules and expectations.
Helping the patient to set more achievable standards and be more
realistic in her or his self-evaluation.
Helping the patient view situations in a more objective way.
Trying to be spontaneous and affectionate. For example, expressing
affection and pride when they see their daughter or son making efforts
to change.
Giving frequent and honest praise (without overdoing it).
Creating a safe, loving home environment, while watching carefully for
signs of abuse by others, problems at school, trouble with peers, and
other factors that could affect the patient’s self-esteem.
Encouraging the patient to share problems that she or he cannot solve
unaided.
Encouraging the patient to get involved in constructive experiences.
Activities that encourage interpersonal cooperation rather than
competition are especially helpful in bolstering self-esteem (e.g.,
volunteering and contributing to the local community, or mentoring
programs in which an older child teaches a younger one to read can do
wonders for both parties).

Exploring the Origins of the Core Low Self-Esteem

It is helpful to conduct a thorough historical review for patients with core
low self-esteem, similar to that performed in cases of clinical perfectionism.
is is best done collaboratively in session, as some patients find the process
distressing and may become preoccupied with particular adverse
experiences. While it is oen difficult to date the onset of core low self-
esteem, the procedure for doing so has the following two steps:

1. Asking patients to think about events or circumstances that might have

contributed to their developing low self-esteem. ese typically include:
Adverse experiences, such as abuse, bullying, teasing, family
instability, lack of friendships, and other negative life events during
childhood.
Family members with a history of low self-esteem.
A family environment characterized by frequent criticism, extreme
discipline, excessive parental control, rejection, unpredictability,
and/or lack of affection or warmth.
2. Helping patients reevaluate past events and experiences. To do this,
therapists need to help patients examine and question their old
appraisals of past experiences and develop new ones.

Arriving at a Balanced View of Self-Worth

e strategies and procedures described above are designed to modify
patients’ negative views of their worth or value as people. At the same time
that patients’ overconcern with shape and weight should be lessening, they
should be developing new domains for self-evaluation and their
interpersonal functioning should be improving. e final step in addressing
core low self-esteem involves helping patients formulate and accept a more
balanced (i.e., less negative) view of themselves. Patients should be helped to
draw conclusions from what they are learning by considering the
implications for their negative self-belief. Useful questions to ask are:

“What do the changes that you are making tell you about yourself? Are
they consistent with your prior views and beliefs?”
“Are the (positive) things you are observing consistent with your prior
beliefs?”
 “What do you make of all of this? What view of yourself accounts for
everything you are finding out about yourself?”

e goal here is to get patients to arrive at a more realistic appraisal of their

qualities. For example, the judgment “I am weak” may be questioned by
reviewing times when they have been strong, especially at times when it
would be acceptable or understandable not to be strong (also appreciating
that no one is strong all the time). While such a reappraisal might lead
patients to identify areas where they would still like to make changes, the
therapist should help patients realize that this does not warrant the
conclusion that they are “weak.”
e notion of acceptance is central to this type of reappraisal. It is
imperative that the patients understand the need to strike a balance between
acceptance and change. ey need to accept that there are aspects of life,
such as past experiences, height, or constitution, that cannot be changed, but
that accepting that this is so is a sign of strength (Wilson, 2004). Other
things, like excessively high standards, can be changed, albeit sometimes
with difficulty. By accepting the fact that some things are “out of their
control,” patients should be in a better position to judge themselves more
fairly, and to act accordingly. ey should be better able to take a balanced
view of their achievements and any undeserved criticism they receive,
making them more able to engage in new activities, make new friends, and
ask for help (previously viewed as a sign of weakness).
VIGNETTE
e patient is a 15-year-old female suffering from restrictive anorexia nervosa. Even though she
agreed to address weight restoration in Step Two, she has made very limited progress. In the
review session held 4 weeks aer the start of Step Two, it emerges that she believes she is
worthless and a failure as a patient. In the sessions, she rarely looks the therapist in the eye, and is
extremely critical of herself. She expresses the idea that it will be impossible for her to overcome
her eating disorder. She agrees that she has a negative view of herself, and that this is negatively
influencing the treatment. e therapist suggests addressing low self-esteem as part of her
treatment, and she agrees.
e following sessions include a specific focus on self-esteem, in addition to the usual
procedures for addressing weight restoration and the eating-disorder psychopathology. e
 therapist provides education about the potential cognitive biases that seem to be maintaining the
patient’s negative self-image, and encourages her to monitor them in real time. is helps the
patient to recognize that the most prominent cognitive biases were discounting positive qualities
(“I have no positive qualities”), selective attention to minor mistakes (labeled as “failures”), and
overgeneralization (“I am a failure”). e therapist assists her in identifying and correcting these
cognitive biases in real time, and encourages her to focus on and accept her positive experiences.
is work gradually helps the patient to question her negative assumptions about herself and start
to believe that it will be possible to overcome her eating disorder. She therefore becomes more
active in addressing weight restoration, and by the end of the treatment has reached the 30th
BMI-for-age percentile. She recognizes that her view of being worthless and a failure was
erroneous, and begins, albeit with difficulty, to address life by accepting her new body shape and
herself as a person.

INTERPERSONAL DIFFICULTIES MODULE

Interpersonal difficulties are common among adolescent patients with eating

disorders. In general, these improve as the eating disorder improves, and do
not therefore interfere with treatment. Given this, they do not oen need to
be the focus of the intervention. Moreover, proactive problem solving may
help patients address interpersonal difficulties.
However, there is a subgroup of patients whose interpersonal difficulties
need to be addressed. is is because interpersonal difficulties contribute
significantly to maintaining the patient’s eating disorder and/or interfere
with the implementation of treatment (Fairburn, Cooper, et al., 2003). For
such patients, the Interpersonal Difficulties module should be employed. As
noted above, this module may also be used to address core low self-esteem
in some patients.

The Role of Interpersonal Difficulties in Maintaining

Eating Disorders
Everyday eating is strongly influenced by external circumstances, which can
also activate eating-disorder psychopathology, resulting in dieting being
intensified or abandoned, binge eating, vomiting, laxative taking, or
excessive exercising. Proactive problem solving can be used to address
isolated interpersonal events. However, for some patients, interpersonal
difficulties are so severe that they interfere with treatment. Two examples
are:

1. Interpersonal turbulence. When life difficulties hijack treatment

sessions or interfere with the patients’ compliance with homework.
2. Interpersonal vacuum. When an absence of relationships prevents
patients from exploiting some aspects of treatment (such as
developing new self-evaluation domains).

Deciding to Use the Interpersonal Difficulties Module

is decision is made at the review session aer Step One or in subsequent
review sessions during Step Two. e module is implemented when one of
the following three conditions apply:

1. Interpersonal difficulties are contributing significantly to maintaining

the patient’s eating disorder.
2. Interpersonal difficulties are interfering with the implementation of
treatment.
3. It has been decided that core low self-esteem should be addressed by
tackling interpersonal difficulties.

e analysis of the interpersonal history of a patient can help clarify whether

interpersonal difficulties meet one of the three conditions necessary to
include the module in the treatment (see Table 17.1).
TABLE 17.1. Interpersonal History Table
Eating, shape, Interpersonal
Age and weight relationships Events/circumstances Emotions

From Cognitive Behavior erapy for Adolescents with Eating Disorders by Riccardo Dalle Grave and
Simona Calugi. Copyright © 2020 e Guilford Press. Permission to photocopy this material is
granted to purchasers of this book for personal use or use with patients (see copyright page for
details). Purchasers can download enlarged versions of this material (see the box at the end of the
table of contents).

Furthermore, through this procedure it is possible to identify the most

impactful interpersonal problems and whether there are other associated
problematic interpersonal issues. In our clinical experience, the marked
interpersonal difficulties observed in adolescents with eating disorders can
be divided into three main categories:

1. Social isolation and interpersonal functioning deficit.

2. Interpersonal conflicts.
3. Role transitions.

If the conclusion is reached that interpersonal difficulties are a problem to

address, the therapist should suggest that it may be helpful to address a
patient’s interpersonal problems at the same time as addressing the eating
disorder. In this case, the therapist should add “life” to the personal
formulation (see Figure 17.7).

FIGURE 17.7. e transdiagnostic formulation with the inclusion of marked interpersonal

difficulties (“LIFE”). Reproduced with permission from Online Training Program in CBT-E, CREDO
Oxford, 2017.
 Goals

e module has three goals:

1. Resolving current interpersonal difficulties (e.g., conflicts, role

transitions, or difficulties in forming and maintaining relationships).
2. Enhancing interpersonal functioning (e.g., quality of relationships,
appropriate assertiveness).
3. Addressing developmental delay (e.g., to “catch up” interpersonally).

Treatment Strategy
In the adult version of CBT-E, the above goals are achieved by dedicating
half of the agenda time of the session to interpersonal psychotherapy (IPT)
and half to CBT-E (Fairburn, Cooper, et al., 2003). IPT is an empirically
supported, psychological treatment originally devised as a short-term
treatment for clinical depression (Klerman, Weissman, Rounsaville, &
Chevron, 1984), but its efficacy in bulimia nervosa has also been
demonstrated (Agras, Walsh, Fairburn, Wilson, & Kraemer, 2000).
at being said, we decided to use CBT strategies and procedures to
achieve the same ends as IPT in the treatment of adolescents with eating
disorders. is decision was motivated by the following reasons:

IPT has never been tested in adolescents with eating disorders.

Very few CBT clinicians are expert in delivering IPT.
CBT has integrated an increasing number of interpersonal processes
and interpersonal patterns without compromising the underlying
theory (Beck, Freeman, & Associates, 1990; Linehan, 1993).
Patients tend to apply reasoning errors, assumptions, and
dysfunctional behaviors similar to those that maintain the
psychopathology of the eating disorder.
Delivering such conceptually and procedurally different treatments as
CBT-E and IPT might confuse the adolescent patient and dilute the
 effect of the individual interventions (Wilson, 2004).

Addressing Social Isolation and Interpersonal

Functioning Deficit
Providing Personalized Education

e most frequent interpersonal problem in adolescents with eating

disorders is a lack of satisfying relationships. People with this problem lack
social skills or have dysfunctional and pervasive ways of reacting to
relationships. In these situations, the search for thinness can become a
dysfunctional means of trying to please others and develop more intimate
and satisfying relationships.
If it emerges that patients have a deficit in interpersonal functioning that
is hindering treatment, the therapist should educate them about the three
main mechanisms through which it maintains the eating disorder:

1. It intensifies the overvaluation of shape and weight because it hinders

the formation of other self-evaluation domains (other slices of the pie
chart cannot be developed).
2. It can worsen self-esteem and, consequently, encourages the use of
shape, weight, and eating control to improve self-evaluation. is
process is common in adolescents because self-esteem, particularly in
females, is positively influenced by the number and quality of
interpersonal relationships, and thinner and prettier girls are
generally more popular among their peers (Striegel-Moore,
Silberstein, & Rodin, 1993).
3. It may damage the implementation of the treatment (e.g., prevent
establishing regular eating).

In turn, the consequences of eating disorders (e.g., low weight, dietary

restriction and restraint, secondary depression) worsen interpersonal
functioning and promote social isolation through two main mechanisms:
(1) avoidance of relationships to reduce the risk of breaking extreme and
inflexible dietary rules and (2) loss of interest in interpersonal relationships
as a result of starvation symptoms. us, a vicious circle is created that
maintains and intensifies the interpersonal difficulties and the
psychopathology of the eating disorder.

Analyzing Repetitive Dysfunctional Behaviors

It is quite common for adolescents who have deficits in interpersonal

functioning to continue to apply repetitive and similar dysfunctional
behaviors in every relationship they encounter. Since these interpersonal
behaviors tend to repeat themselves, it can be helpful to review them and
analyze them together with patients.
VIGNETTE
Whenever the patient, a 16-year-old girl with anorexia nervosa and a problem with excessive
dependence on relationships, starts a new relationship with a friend, the belief that she is not
interesting enough is activated, and she adopts various dysfunctional behaviors in a bid to hold
on to the friendship (e.g., doing everything to satisfy the friend’s demands, flooding her with gis,
calling her several times a day). Although these behaviors are, in the beginning, generally
appreciated by people, in the long run they become unbearable. e end result is that she has
been repeatedly abandoned by friends and, when this occurs, she criticizes herself for not having
been smart enough or done enough for the friend and, at the same time, accentuates her dietary
restriction to manage the feeling of not being in control.

Using Assertive Communication

People with eating disorders and interpersonal functioning deficits oen

adopt passive or aggressive attitudes and behaviors because they fear being
criticized, or, on the contrary, not being heard, but the result is a progressive
deterioration of their interpersonal relationships. Helping patients to
suspend these behaviors and adopt an assertive communication style may
initially have the effect of increasing concerns about the feared outcome, but
gradually this effect disappears as interpersonal functioning improves.
 Assertiveness training was developed in the 1980s and 1990s as a way of
improving personal development. Initially, it was reserved for women as a
means of freeing themselves from their traditional submissive role, but over
the years a growing number of men have discovered its benefits, and it has
been seen that it can be useful for improving interpersonal relations in
general. Many of the ideas that led to the development of assertiveness
training were proposed by Smith (1975) in the book When I Say No, I Feel
Guilty, and are based on the key principle that everyone has a fundamental
right to be the final judge of themselves, and asserting that prevents
manipulation by other people.
A full description of assertiveness training is beyond the scope of this
book, but we recommend observing the dysfunctional interpersonal
patterns of patients in session, as this will provide an indication of how they
behave outside of therapy. e patient, for example, can be encouraged to
examine thoughts that interfere with assertiveness and then put this into
practice in a session. e therapist and patient may then plan situations
outside of the session in which to apply the newly acquired skills. Below are
some of the most frequently recommended suggestions for adolescent
patients:

Take the necessary risk to get to know someone better.

Make yourself see how you really behave with your friend.
Share something about yourself that you usually hide from others.
Listen to your friend and respect her or his point of view.
Ask for advice (remind the patient that an assertive friend can say no
and still be a friend).
Tell the friend that you like being around her or him.
Use the proactive problem-solving procedure (see Chapter 14) to
address obstacles to forming a friendship.

We educate adolescent patients that relationships have more chance of being

consolidated when each member openly expresses her or his feelings (e.g.,
“If I know you will be honest with me, that you will say no to me if you don’t
like an idea, I’ll feel more comfortable being myself and I will know I can
fully trust you”). Patients should be told that expressing their feelings of
affection is a highly assertive act (with verbal and nonverbal behavior; e.g.,
giving the person a handshake, a hug, or a kiss, or saying words that express
affection) and can help build a sincere friendship. We also recommend that
patients read and implement the relevant sections from the self-help book
on assertiveness Your Perfect Right (Alberti & Emmons, 1970).

Addressing Interpersonal Avoidance

Interpersonal avoidance is a strategy oen implemented by those with a

passive stance that serves to help them avoid having to deal with others and
thereby proving their own inadequacy. e procedures for addressing
avoidance are similar to those used for body exposure, clinical
perfectionism, and core low self-esteem, and include:

Identifying interpersonal avoidance. is is not a difficult task, because

patients are usually aware of the behaviors they avoid in interpersonal
relationships.
Dealing with avoidance. Patients should be informed that in the
beginning there will be an increase in anxiety and worries, but then,
with increasing frequency of exposure, concerns will gradually
diminish.

Developing New Interests and Relationships

is strategy, which relies on the same procedures as those used in the Body
Image module to enhance the importance of other domains of life, can help
patients fill the empty spaces in their life, reduce their sense of loneliness,
expose themselves to feared situations, and create new self-evaluation
domains. However, if social isolation has lasted for a long time, it is difficult
for patients to find opportunities to develop new friendships and
interpersonal relationships. In these cases, it may be useful to help them find
social support. Examples are participating in a self-help group, and enrolling
in training courses or activities that require doing things together (e.g.,
dancing, drawing, painting, group excursions).

Addressing Interpersonal Conflicts

Providing Personalized Education

Interpersonal conflicts occur when a person and at least one significant

other have nonreciprocal expectations about the roles they should have in
the relationship (Klerman et al., 1984). Disputes of this nature can be
present with any important figure in the life of an adolescent with an eating
disorder, including parents, siblings, and friends. In a subgroup of people
with eating disorders, interpersonal conflicts can be an important trigger
and maintenance factor of the disorder. For example, an adolescent girl
constantly treated like a child may use eating control to assert her
independence and autonomy toward her mother who, nevertheless, reacts
by treating her daughter even more like a child. In another case, the
emotions triggered by conflict with the father can be modulated by a
teenager through binge-eating episodes. If an interpersonal conflict seems to
be hindering treatment, patients should be informed about the mechanisms
by which it seems to maintain the eating disorder, and the need to address it
should be discussed.

Dealing with Interpersonal Conflicts

ree CBT-E procedures can be used to help patients to address conflictual

situations: (1) using the proactive problem-solving procedure (see Chapter
14), (2) adopting an assertive communication style (see above), and (3)
addressing cognitive biases. Cognitive biases are addressed using standard
CBT procedures. Here are some examples:

• Negative predictions. If patients make negative predictions about future

relationships based on past experience (e.g., “It has always gone wrong
before, so it will continue to go wrong in the future”), this type of cognitive
bias can be addressed using the following procedures:
Educating patients on the nature of cognitive bias.
Discussing the risks of using past experience to predict the future,
rather than addressing new situations and trying to handle them
better.
Helping patients to expose themselves to new situations.

• Selective attention. Paying selective attention to the information that is

consistent with a negative view of relationships (e.g., “We quarreled; our
relationship does not work”) is a cognitive bias can be addressed in three
steps. e aim is to help patients broaden their focus, rather than paying
selective attention only to failures, by:
Educating patients about the nature of the cognitive bias (e.g., by
explaining the phenomenon of getting pregnant—that is, a pregnant
woman who has difficulty in getting pregnant tends to notice all the
women with children and concludes that she is the only woman
unable to have one).
Discussing the tendency to look selectively at negative relational
experiences and how this can confirm a negative view of
relationships.
Helping patients become aware of situations in which they expresses
selective attention.

• Overgeneralization. Concluding that they are unable to have good

relationships if something negative happens (e.g., “He did not invite me to
go out; this means that I am undatable”). To address this cognitive bias, the
following procedures may be used:
 Educating patients on the nature of cognitive bias.
Encouraging patients to become aware of the tendency to generalize,
and highlighting it when it occurs.
Asking patients whether they consider themselves persons with
excellent interpersonal skills when something positive occurs.
Encouraging patients to look at the big picture in life, and to refrain
from making global judgments about relationships.

• Personalization. “Taking the blame” for the end of or difficulties in a

relationship (e.g., “If things are going this way, it is only my fault”) can be
addressed by means of the following procedures:
Educating patients on the nature of cognitive bias.
Discussing their tendency to attribute every problem to themselves,
ignoring other relevant information about things that might have
negatively influenced the relationship.
Helping patients to assess each situation and take into consideration
the role of the other party.

• Unrealistic expectations. Having unrealistic expectations about how the

relationship should be (e.g., “Friends are those with whom I can share
everything”) is a cognitive bias that can be tackled as follows:
Educating patients on the nature of the bias.
Discussing how this distorted way of thinking about relationships
will inevitably lead, on the one hand, to being disappointed in others,
and, on the other hand, to underestimating some relationships that
only involve sharing some aspects of life.
Helping patients to become aware of this attitude, and suggesting that
they evaluate the friendship on the basis of some specific areas of life
(e.g., a passion for movies or a sport).

Addressing Role Transitions

 Providing a Personalized Education

Role transitions are common in young people with eating disorders because
of their age; they have to address some important changes, such as changing
body shape, starting a new school, having the first experiences with the
other sex, and so on. For example, in early adolescence, the development of
secondary sexual characteristics and losing the “safe” body of a child, which
brings greater attention from the other sex and the need to develop gradual
autonomy from parents, can cause young people to feel out of control and to
curb their eating, both as a means of feeling in control and in the attempt to
revert back to their prepubescent body shape (Crisp, 1995). Binge eating and
self-induced vomiting, on the other hand, can be used to modulate negative
emotions aer the breakup of a relationship.
In a subgroup of adolescents with eating disorders, the difficulties related
to role transition are one of the main triggers and maintenance factors of
eating disorders. Hence, if it appears that a role transition is hindering
treatment, patients should be informed about the mechanisms by which it
works to maintain the eating disorder and the need to address it should be
discussed.

Reviewing the Positive and Negative Aspects of the Old and

New Roles

It is common for patients with role transition issues to idealize their old role,
minimizing the negative aspects that were almost invariably present, and
focusing only on the negative aspects of the new role without considering
the opportunities that it could offer. Helping patients to analyze and write in
a table the pros and cons of the old and new roles may help them to assess
the positive and negative aspects of both roles in a more balanced way, and
therefore to reach a more functional conclusion.

Exploring Thoughts and Emotions Associated with Role

Change
Even when changes are desired and sought aer, the abandonment of an old
role can be experienced as a loss. To facilitate the transition into the difficult
new role (e.g., starting high school, which coincided with the onset of the
eating disorder) it may be useful to ask patients to write on the back of their
monitoring records the thoughts and emotions (e.g., the sense of loss,
emptiness, guilt, or anger) that they are experiencing during this transition.

Developing New Social Skills

Most transitions require the acquisition of new skills. To succeed in this

task, the patients should be encouraged to practice the suggestions offered
above to develop an assertive communication style. In applying these
abilities, it is important that patients try to combat concerns about
performance, and to realize when they are making negative predictions
associated with anxiety, or exhibiting excessive control or avoidance
behaviors. Sometimes patients encounter difficulties because they have
stereotyped assumptions about the new role, which are maintained by
selective attention. For example, a 16-year-old patient who had just started a
romantic relationship said, “All relationships end badly,” paying selective
attention only to the relationships of peers that had gone wrong, and not to
those that were going well.

Developing New Interests and Relationships

A role transition oen requires the need to develop relationships with new
people. In the transition phase, patients may feel alone or have difficulty
forming new bonds. In this case, it may be useful to suggest that they follow
the suggestions given in “Addressing Social Isolation and Interpersonal
Functioning Deficit” above, and in the meantime, have them evaluate the
various opportunities they may have to become involved with other people.
VIGNETTE
 e patient is a 15-year-old female whose eating disorder began at age 14, a few months aer she
started high school. She had been the best in the class in middle school, but the transition to high
school was very difficult because she suffered from greater competition among female students to
be the best in the class and most popular with the boys. She feels alone because she had lost touch
with all of her friends from middle school. She also feels out of control and, since she is
dissatisfied with the shape of her body, she has severely restricted her diet and vomits whenever
her parents oblige her to eat. ese behaviors have produced a progressive weight loss and a
corresponding deterioration in school performance.
In Step One, although she agrees to start the treatment, it becomes clear that interpersonal
circumstances are having a major influence on her eating. When she is stressed about school or
feels lonely, she will only eat dinner (abandoning regular eating), and vomits immediately
aerward. However, she agrees to address weight restoration, and in the review sessions also
concurs that interpersonal difficulties are a mechanism maintaining her eating disorder and a
major obstacle to treatment progress.
In Step Two, part of each session is dedicated to addressing role transition at school as a major
interpersonal problem. e therapist helps the patient to identify the hurdles that the transition
involves, but also the potential advantages. e treatment focus is on helping her to accept not
being at the top of the class, but also stimulating her to actively engage in developing new
friendships. At each session, she reflects on what has happened during the previous week and
what could be learned from it. She gradually makes progress, developing a close friendship with
two girls, relaxing her control over eating, and reaching a low normal body weight. At the end of
the treatment, she has some residual eating-disorder features (i.e., avoidance of some foods and
sporadic episodes of vomiting), but these have resolved completely by the last posttreatment
review.

Involving Parents
Parental involvement is indicated if the therapist and the adolescent patient
agree that parent(s) can help to facilitate the application of some of the
procedures used to address interpersonal difficulties. In general, the first
step is to educate parents on the role of marked interpersonal difficulties in
maintaining the patient’s eating disorder, making reference to her or his
personal formulation. e parents are then invited to participate in joint
sessions with the patient to agree on the type of help they can offer. Here are
some examples:

Role Disputes
When the role dispute involves one or both parents, it is oen helpful to
involve them in treatment. e therapist should explain to both the patient
and parents how interpersonal role disputes may contribute to maintaining
the eating disorder, and how the resolution of these disputes may assist in
overcoming the disorder. Later, the therapist may help to address the
expectations and communication difficulties that are at the core of the
dispute. If the adolescent is engaging in objectively inappropriate behavior,
the therapist should discuss this with both the adolescent and parent(s). e
therapist should also help to negotiate guidelines for more socially
acceptable behavior.

Interpersonal Role Transitions

Parents should be educated about normal developmental milestones for an

adolescent, the feelings such milestones may elicit in the parents, and ways
of coping with these feelings. In doing this, the therapist should be sensitive
and respectful of differences of opinion among families. e aim is to help
the parents see the adolescent’s point of view, and oen to help the
adolescent better understand the parents’ perspective, by encouraging
effective communication. Parents who have difficulty accepting that their
adolescent wants to spend more time with friends than family, wants later
curfews, or does not share personal information with them, should be
educated about “normal” behavior in adolescents, so that they know what
kind of behavior to accept. Asking parents about their own adolescent
experiences may help them empathize with their daughter or son.

Interpersonal Deficits

Parents may be involved when the patient’s interpersonal deficits affect

family relationships. In the joint sessions, the therapist should focus on
specific interaction processes and skills, and only then on larger patterns of
interactions between the adolescent and the family.
 MOOD INTOLERANCE MODULE

In a subgroup of adolescent patients with eating disorders, eating is

markedly influenced by events and moods (Meyer, Waller, & Waters, 1998).
ese patients suffer from a problem called “mood intolerance” (Fairburn,
Cooper, et al., 2003). Since this contributes to maintenance of the eating-
disorder psychopathology and hinders the treatment, it should be directly
addressed by means of an approach that overlaps with elements of
dialectical behavior therapy (Linehan, 1993).

Description of Mood Intolerance

Mood intolerance is a form of psychopathology that may coexist with an
eating disorder and, when it does, tends to maintain it. Mood intolerance
has two principal components (Fairburn, Cooper, et al., 2003; Linehan,
1993):

1. An extreme sensitivity to intense (mainly aversive) mood states

characterized by an inability to accept and deal appropriately with
them.
2. e use of dysfunctional mood-modulation behaviors to reduce
awareness of an intense mood state and neutralize it, which come at a
personal cost.

Dysfunctional mood-modulation behaviors take two main forms: (1) self-

harm (e.g., cutting or burning the skin) and (2) taking a psychoactive
substance (e.g., alcohol, other substances). In addition, patients with mood
intolerance who develop an eating disorder discover that certain eating-
disorder behaviors, such as binge eating, self-induced vomiting, and
excessive exercising, also help them cope with their mood (see Figure 17.8).
Under these circumstances, mood intolerance generally needs to be
addressed, as it is an additional mechanism maintaining the eating disorder.
FIGURE 17.8. How mood intolerance and dysfunctional mood-modulation behaviors interact with
expressions of an eating disorder.

Identifying Patients with Mood Intolerance

e presence of mood intolerance should be suspected if the patient has a
recurring association between mood changes and some behavioral
expressions of eating disorders, and when the procedure for proactive
problem solving (see Chapter 14) has not been sufficient to deal with this
issue. e decision to use the Mood Intolerance module is taken in Step
Two, aer the patient has correctly learned and tried the proactive problem-
solving procedure. It is generally advisable to address mood intolerance in
the following cases:

Presence of intense emotional states that stimulate certain behavioral

expressions of the eating disorder (e.g., binge-eating episode, self-
induced vomiting, excessive exercising).
Present or past use of other dysfunctional mood-modulation behaviors
(e.g., self-harm or taking a psychoactive substance).

Treatment Strategy
Mood intolerance is addressed, upon agreement with the patient, together
with the eating-disorder psychopathology in Step Two of CBT-E. However,
it should be noted that an improvement in mood is also seen in the context
of the focused version of CBT-E, as a result of the following changes:

Regular eating.
Reduction in dietary restriction.
Normalization of body weight.
Improvement in problem-solving skills.

Education on Mood Intolerance

e first step is to discuss with patients the role of mood intolerance in
maintaining their eating disorder, adding it to their personalized
formulation (see Figure 17.9) and the need to address it.

FIGURE 17.9. Example of a formulation of a not-underweight adolescent patient with an eating

disorder and mood intolerance.

e point to emphasize is that some mood-modulation behaviors are

dysfunctional because, while they may help to cope with mood change in
the short term, they prevent the acquisition of skills for tolerating moods in
the long run and create severe impairment. e therapist should warn the
patient that learning to tolerate mood in a more functional way will be
difficult but worthwhile.
 Analyzing a Recent Example of Mood Intolerance
e second step is analyzing with the patient a recent example of mood
intolerance with the aim of re-creating the sequence of seven events
(Fairburn, Cooper, Shafran, Bohn, Hawker, et al., 2008):

1. e occurrence of a triggering event (e.g., an argument on the phone

with the patient’s boyfriend or girlfriend).
2. Cognitive appraisal of the event (e.g., resentment: “It isn’t fair—he is
always blaming me”).
3. An aversive mood change (e.g., anger).
4. Cognitive appraisal of the mood change, followed by rapid (within
seconds), cognitive amplification of the mood (e.g., “I can’t stand
feeling angry like this,” leading to greater mood amplification over a
short period resulting in thoughts such as “I REALLY CAN’T
STAND FEELING LIKE THIS”).
5. e initiation of dysfunctional mood-modulation behavior (e.g., the
patient starts to binge or self-harm).
6. e immediate amelioration of the aversive mood (e.g., dissipation of
feelings of anger).
7. Later cognitive appraisal (e.g., “I am such a failure; I have absolutely
no control over my eating”).

e therapist should stress that this response is dysfunctional for several

reasons:

It does not enable day-to-day difficulties to be addressed.

It leads to unpredictable behavior and oen worsens interpersonal
problems.
It maintains the eating disorder.
It makes one feel bad about oneself.
 Discussing the Mechanisms Involved in Mood
Intolerance
e third step is discussing with the patient the processes involved in mood
intolerance, taking care to emphasize the following two points:

1. Each episode consists of a rapidly unfolding sequence of thoughts

and feelings, which leads to engaging in dysfunctional mood-
modulation behaviors.
2. If the chain of events can be slowed down, a number of different ways
of intervening will emerge.

Slowing Down, Observing, and Analyzing

e fourth step involves asking patients to capture the sequence of thoughts
and feelings the next time they experience an urge to engage in a
dysfunctional mood-modulation behavior, or immediately thereaer.
Patients should be forewarned that this will be difficult and will require in-
the-moment recording, and that, at first, capturing only part of the sequence
is fine. Each attempt to capture the sequence should be reviewed and
praised, and patients should be asked to continue to do this, starting written
real-time self-monitoring as early as possible in the sequence. e therapist
should emphasize that doing this might be frustrating, as it prevents escape
from the mood state, but it will bring about several benefits:

It heightens awareness of the sequence of events.

It promotes decentering.
It slows the sequence down, thereby creating interference with
cognitive amplification.
It highlights points where intervention may be possible.

Intervening in the Sequence of Events

e fih step is to ask the patient to intervene at the next opportunity, the
goal being to prevent further full-blown episodes. Patients are also
encouraged to use whatever procedure seems practicable and relevant, and
the therapist should stress the following points:

“Success breeds success.”

It is crucial to learn the importance of early intervention.
Real-time self-monitoring has an impact in its own right.

It is advisable to avoid overloading patients with procedures (the principle of

parsimony) and the value of intervention alone (i.e., putting barriers in the
way of engaging in dysfunctional mood-modulation behaviors) should not
be forgotten. Some indications for the various strategies and procedures are
shown in Figure 17.10.

FIGURE 17.10. Procedures to intervene in the sequence of events in mood intolerance. MMB,
mood-modulation behaviors. Reproduced with permission from Online Training Program in CBT-E,
CREDO Oxford, 2017.

By beginning to slow down, observe, and analyze the usual sequence of

events and, in doing so, interrupting it by preventing cognitive
amplification, patients will be in a better position to intervene at various
points in the sequence. e indications for the various strategies and
procedures are described below.

Preventing the Occurrence of Triggering Events

If the event is predictable, patients are advised to use and implement the
proactive problem-solving procedure (see Chapter 14). is should never be
dismissed as a technique. It is generally of great value, even with the most
chaotic of patients. It is used to prevent many of the types of problems that
would otherwise lead to an episode of mood intolerance.

Addressing the Cognitive Appraisal of Events

Cognitive restructuring, a generic CBT procedure, is used to target

unhelpful cognitive appraisal of events (especially dichotomous or negative
thinking), as it is designed to help patients assess events and their personal
significance in a more functional way. Cognitive restructuring should be
associated with behavioral “experiments” to test the new interpretation of
the events.

Addressing Aversive Moods and Their Cognitive Appraisal

(“Mood Acceptance”)

e therapist should educate patients on the following concepts:

It is normal to experience a variety of different mood states, some of

which may be intense and/or aversive.
ese moods rarely persist for long (unless one has a mood disorder,
such as a clinical depression).
It is not necessary to react to, or act on, one’s mood; “It can just be
accepted.” is involves resigning oneself to the mood without reacting
to it.
 It is possible to “mood surf ”—that is, to observe one’s mood go up and
down, wax and then wane.
Alternatively, if the moods are too aversive or intense, one can engage
in “functional” ways of modifying them.

Introducing Functional Mood Modulation

e therapist should explore with patients functional ways of modulating

their mood and encourage them to practice using them. e choice of
method should be influenced by the patient’s preferences, the nature of the
mood, and the circumstance at the time. e main options include the
following:

Mood-altering music or movies.

Talking to others (face-to-face or over the phone).
Exercising (e.g., brisk walking).
Taking a cold shower.

e therapist should help patients persist in practicing functional mood-

modulation behaviors. It is important to forewarn patients that it may take
some time for the new behavior to become a habit, but that instances when
an episode of dysfunctional mood modulation is avoided can have a major
positive effect. With practice, the new behavior will become increasingly
second nature and, if used early and implemented well, it will help to reduce
the intensity of the patients’ mood and displace their reliance on
dysfunctional mood-modulation behaviors.

Putting Barriers in the Way of Dysfunctional Mood Modulation

is is a simple procedure, but important. It involves keeping the items

needed for self-harm (e.g., cutting using razor blades or knives) or substance
misuse (e.g., alcohol) out of reach, especially at times of risk.
 Adopting a Healthy Lifestyle and Making Radical Life Changes

To reduce the onset of negative emotions and simultaneously create positive

ones, the therapist should also encourage the patient to adopt a healthy
lifestyle, which may involve (Linehan, 1993):

Treating physical diseases.

Adopting healthy eating guidelines in a flexible way.
Not using psychoactive substances.
Sleeping at least 8 hours a night.
Exercising regularly.
Engaging in rewarding activities that occupy the day.

Finally, it can be useful to suggest to patients (if applicable) the possibility of

their making long-term radical changes to their life (e.g., changing schools,
breaking up an unsatisfactory relationship) in order to make positive events
happen more oen.

Involving Parents
If the parents are involved, they should be informed about how events and
mood influence eating, and the procedures used to address them should be
discussed. Here are some examples of ways parents may help:

Creating an environment with a low level of negative emotions, in

particular during meals, to reduce the risk of triggering negative mood
changes (e.g., avoiding critical comments, and displaying warmth and
support).
Encouraging the patient to use proactive problem solving when facing
problematic events.
Encouraging the patient to use monitoring records and to practice
distracting activities when they observe a mood change.
 Preventing access to dangerous objects (e.g., razor blades, knives, or
substances used to modulate moods, if applicable).

VIGNETTE
e patient is a 16-year-old not-underweight girl who experiences three binge-eating episodes
followed by self-induced vomiting daily, and recurrent episodes of self-harm (i.e., horizontal cuts
with a razor on the forearms). Her self-injurious behavior started at age 13, immediately aer the
separation of her parents. Aer a few months, she also started having recurring binge-eating
episodes, which resulted in a weight increase of about 20 pounds (9 kilograms) in a few months
(from 120 to 140 pounds [54 to 64 kilograms]). She then started to adopt extreme and inflexible
dietary rules (i.e., skipping meals and avoiding all carbs) in order to lose the weight she had put
on. However, the dietary restraint was interrupted by daily binge-eating episodes.
e patient actively engaged in the treatment, and aer just 2 weeks of regular eating has
markedly reduced the frequency of binge-eating episodes from three times a day to three times a
week. In this period, she has also reported only three episodes of self-harm using a razor, all three
aer arguments with her mother. In Step Two, the binge-eating and self-harm analysis highlights
that these episodes are oen triggered by rapid changes in her mood.
Proactive problem solving has proved to be insufficient for her to manage her rapid mood
changes, and for this reason it is decided, in agreement with the patient, to address mood
intolerance. e parents are recruited to create a home environment where there is no easy access
to dangerous objects (e.g., razor or knives), and agree to stop criticizing the patient’s eating
behavior. e procedures to address mood intolerance, associated with parental assistance in
creating a safe environment, enable the patient to stop self-harming in only 2 weeks, and to
understand that she is able to tolerate mood changes by accepting and managing them in a more
functional way (e.g., listening to music, taking a walk). Furthermore, these procedures, associated
with those in the Dietary Restraint and Body Image modules, allow the patient to reduce both the
frequency of binge episodes to no more than one every 2 weeks, and the level of dietary restraint
and overvaluation of shape and weight. In the last posttreatment review session, aer 20 weeks,
the patient reports that she has not experienced any self-harm episodes aer the end of therapy,
and only a few sporadic binge-eating episodes associated with mood changes in the first 2
months, but none in the last 3 months.
 CHAPTER 18

Intensive Outpatient CBT-E

Intensive outpatient CBT-E is the second level, in terms of care

intensiveness, of CBT-E for adolescents. It was developed to provide an
alternative for patients who would benefit from a higher-impact approach
than outpatient CBT can provide, but whose condition is not sufficiently
severe as to warrant hospitalization (Dalle Grave, 2011; Dalle Grave, Bohn,
et al., 2008). Hence, this type of treatment adopts most of the procedures
and strategies of standard outpatient CBT-E, but also integrates several
developed specifically for this approach.

DISTINCTIVE FEATURES OF INTENSIVE

OUTPATIENT CBT-E

Intensive outpatient CBT-E has been designed to address the main barriers
to progress in standard outpatient CBT-E. For example, some patients in
stable medical condition, despite having decided to address the
psychopathology of their eating disorder, are unable to address undereating
and weight restoration or to reduce the frequency of some eating-disorder
behaviors (e.g., binge-eating episodes, self-induced vomiting, excessive
exercising). ese patients may be given access to a treatment tailored to
address these obstacles, without having to destabilize them further by
removing them from their supportive home environment (as is usual with
hospitalization). Once these obstacles have been overcome, the treatment
can continue with standard outpatient CBT-E. In this way, a more intensive
treatment is provided and continuity of care is ensured without the health
care costs, stigma, fear, and discomfort associated with inpatient treatment.

INDICATIONS AND CONTRAINDICATIONS

Deciding when patients need a more intensive level of care is oen a

therapeutic dilemma. Indeed, to prolong standard outpatient CBT-E without
any improvement may increase costs needlessly and, since the eating-
disorder psychopathology tends to evolve, a “hands-off ” approach may even
risk worsening the clinical severity of a patient’s eating disorder. However, to
intensify a treatment too early may interrupt a patient gradually developing
the motivation to change and benefiting from a less intensive and costly
treatment. Judging by our own clinical experience with outpatient CBT-E
for adolescents, however, patients who do not start to regain body weight
aer 4 weeks of Step Two are unlikely to do so without more intensive
assistance. We therefore suggest that 4 weeks of Step Two with no significant
weight regain is a reasonable indication for intensive outpatient CBT-E.
Obviously, however, intensive outpatient CBT-E should be implemented
earlier in patients who continue losing weight during outpatient CBT-E, or
later in those who, aer a period of weight regain, are not able to reach the
healthy weight threshold.
Intensive outpatient treatment may also be indicated for patients with
frequent binge-eating episodes and self-induced vomiting, even if they are
not underweight, when eating habits do not improve during standard
outpatient CBT-E aer 4 weeks of Step Two. Finally, in patients with a long-
standing eating disorder who have not responded to several outpatient
approaches, or in very underweight adolescent patients who cannot rely on
parental support during mealtimes, intensive outpatient treatment may be
considered as the first option.
Intensive outpatient CBT-E is not indicated for patients with daily
substance misuse, acute psychotic disorders, and/or severe medical
complications that cannot be managed safely in an outpatient setting.

PREPARING FOR INTENSIVE OUTPATIENT CBT-E

e preparatory phase has the main aim of helping patients who have not
improved with outpatient CBT-E to make the decision to intensify the
treatment. e therapist should have a straightforward discussion with the
patient regarding the reasons why standard outpatient CBT-E appears not to
be working. Generally, in our clinical experience, the most common barriers
to treatment are loss of motivation, clinical depression, significant substance
misuse, distracting major life events, competing commitments, fear of
change, rigidity, and difficulties in reducing the frequency of binge-eating
and purging episodes. If the therapist perceives that the barrier(s) cannot be
overcome in the context of standard outpatient CBT-E, she or he should
explain to patients why they would benefit from a more intensive, targeted
approach to their eating disorder, such as intensive outpatient CBT-E.
e next step is to describe intensive outpatient CBT-E in detail, and ask
patients to think about the pro and cons of intensifying their treatment. As
in outpatient CBT-E, patients should be informed about the aims, duration,
organization, procedures, and expected results of the more intensive form,
and that although the decision to intensify the treatment is voluntary, it
should be considered a priority (see Table 18.1).
TABLE 18.1. Information Sheet for Patients Being Admitted to Intensive Outpatient
CBT-E
To get the maximum benefit from intensive outpatient treatment, we suggest that you follow
these guidelines. They were created both to help you get the most benefit from treatment,
and to enable other patients attending the outpatient unit to have their privacy.

The decision to engage in intensive outpatient CBT-E is voluntary, and should be

considered as a special opportunity to overcome your eating problem. For this reason, we
recommend you put the maximum effort into treatment and see it as a priority.
The treatment is different from most intensive treatments for eating disorders because it
never adopts “coercive” or “prescriptive” procedures—in other words, you will never be
asked to do things that you do not agree to. The general treatment strategy is first, with
the help of your therapist, to understand what the main maintenance mechanisms of your
eating problem are, and to agree to address them with specific procedures. Then, you
should try to apply the agreed-upon procedures with the maximum effort. Finally, you
should review with your therapist the effect of the procedure on your eating problem. If you
do not reach an agreement with your therapist, the treatment will be interrupted, but this
rarely happens.
It is important to participate actively in all treatment procedures (i.e., assisted meals,
collaborative weighing, individual sessions with the dietitian and the psychologist, and
medical examination by the doctor) without interruptions, to obtain what we call
therapeutic momentum.
We would encourage you to arrive at each session 15 minutes in advance so that you
have time to prepare the topics to be discussed with the therapist.
The use of alcohol and psychotropic substances is not allowed in the outpatient unit
because they interfere with the treatment; they prevent you from being free to concentrate
on the things you need to do to address your eating problem.
You should only take the medications prescribed by the team doctors.
Although it is a difficult task, as being underweight causes biological concern for food, and
the eating problem is characterized by the overvaluation of shape, weight, and their
control, you should do your best not to speak with the other patients in the unit about food,
eating, shape, and weight. Talking about these topics damages both you and the other
patients because thoughts and concerns about these aspects will only increase if you do
so. Remember that in this program you have the responsibility to both improve your
behavior and not to negatively affect the behavior of other patients.
We also suggest that you avoid any discussion or reassurances about the food that is
served to you, both during and outside of the meals. This only increases the thoughts and
concerns about eating.
You should try to consider assisted eating as a therapy session, and do your best to apply,
with the help of a therapist, the psychological strategies that are designed to address
meals with less anxiety (e.g., using the monitoring record in real time; eating without being
influenced by signals of hunger and satiety, as these are altered by being underweight and
concerns about eating—that is, expressions of your eating problem).
After meals you should try not to go to the toilet for at least an hour to handle the urge to
use compensatory behaviors.
You will plan your meals once a week, according to the guidelines that will be explained to
you by the dietitian, so that you regain 1 pound (0.5 kilogram) per week.
 During the week you should try not to ask for changes to your meal plan.
As you have voluntarily decided to start intensive outpatient CBT-E, you will have to do
your best to stop all extreme weight-control behaviors that hinder change (e.g., excessive
exercising and/or self-induced vomiting).
In the event of any problems during the day, we recommend that you apply the proactive
problem-solving procedure and engage in distracting activities (e.g., reading a book,
listening to music, watching television, surfing the Internet).
We also ask you not to leave the outpatient unit without permission or go to the kitchen
outside of mealtimes or enter a therapist’s office without authorization. If you urgently need
to talk to a therapist, please ask the secretary.

From Cognitive Behavior erapy for Adolescents with Eating Disorders by Riccardo Dalle Grave and
Simona Calugi. Copyright © 2020 e Guilford Press. Permission to photocopy this material is
granted to purchasers of this book for personal use or use with patients (see copyright page for
details). Purchasers can download enlarged versions of this material (see the box at the end of the
table of contents).

THE INTENSIVE OUTPATIENT UNIT

Centers offering intensive outpatient CBT-E for adolescents should provide

a specialized unit for the purpose, bearing in mind the treatment procedures
outlined below. Care should be taken to create a psychologically welcoming,
rather than clinical, environment—a place where patients will feel at home.
In addition to the standard treatment rooms, the unit needs to be equipped
with a kitchen (with a teapot, microwave, a refrigerator with a large freezer, a
sink, and a dishwasher), a dining room where assisted eating can take place,
a recreation room, and facilities to enable patients to study.

THE INTENSIVE OUTPATIENT CBT-E TEAM

Intensive outpatient CBT-E needs to be managed by a multidisciplinary,

non-eclectic team fully trained in CBT-E (see Chapter 19 for more details)
that comprises physicians, psychologists, and dietitians. e dietitian
addresses patients’ low weight and undereating, preparing and assisting
patients during the meals consumed at the center, dispensing food to be
eaten outside of the unit, helping patients to plan their weekend meals, and
reviewing any problems encountered the previous weekend. e
psychologist addresses the other features of eating-disorder
psychopathology and implements the broad CBT-E modules, and the
physician assesses and treats any medical complications, prescribing
medications as necessary.

GENERAL ORGANIZATION

Intensive outpatient treatment is scheduled to last a maximum of 12 weeks,

but can usually be brought to a close beforehand, when patients successfully
address the key factors responsible for the lack of progress in outpatient
CBT-E (e.g., weight regain, binge eating, regular meals). In order to
maximize the opportunities for assisted eating, in our unit patients generally
attend every weekday from 12:45 A.M. to 7:45 P.M., and follow the procedures
outlined below (see Table 18.2):

ree supervised meals a day (lunch, midaernoon snack, and evening

meal—severely underweight patients should also be offered the
possibility of assisted breakfast and midmorning snack).
Provision of meals to be eaten outside of the unit (breakfasts,
midmorning snack, and weekend meals).
Two individual CBT-E sessions per week with a CBT-E-trained
psychologist.
Two individual sessions a week with a CBT-E-trained dietitian.
Regular checkups with a CBT-E-trained physician.
TABLE 18.2. An Example of How Intensive Outpatient CBT-E for Adolescents Is
Organized
Time Monday Tuesday Wednesday Thursday Friday
12:45–1:00 Body weight
measurement

1:00–2:00 Assisted Assisted Assisted Assisted Assisted

lunch lunch lunch lunch lunch

2:00–3:00 Free time for Free time for Free time for Free time for Free time for
studying or studying or studying or studying or studying or
doing other doing other doing other doing other doing other
activities activities activities activities activities

3:00–4:00 Individual CBT-E Medical CBT-E Individual

session with session with examinationa session with session with
dietitian psychologist psychologist dietitian
(weekend (weekend
revision and preparation)
meal
planning)

4:30–5:00 Assisted Assisted Assisted Assisted Assisted

snack snack snack snack snack

5:00–6:30 Free time for Free time for Free time for Free time for Free time for
studying or studying or studying or studying or studying or
doing other doing other doing other doing other doing other
activities activities activities activities activities

6:30–7:30 Assisted Assisted Assisted Assisted Assisted

evening meal evening meal evening meal evening meal evening meal
a
Weekly in severely underweight patients (BMI percentile < 5th) and/or those with medical
complications.

e team meets weekly with patients to monitor their progress and, toward
the end of treatment, gradually encourages responders to eat more meals
outside of the unit, thereby allowing the treatment to evolve into
conventional outpatient CBT-E.

CORE TREATMENT PROCEDURES

Many procedures and strategies of intensive outpatient CBT-E are the same
as those described for standard outpatient CBT-E, and therefore are not
described here. Instead, we concentrate on those that have been adapted or
developed specifically for this particular step.

Monitoring of Eating, Weight, and Progress

e patient’s monitoring record should distinguish between assisted and
nonassisted eating, and in the former, they need merely note the name of the
meal consumed (e.g., lunch, snack, evening meal), as its content is
established on the basis of the daily menu agreed upon by the patients with
the dietitian. Nonassisted eating should be recorded by the patient in real
time, as per standard outpatient CBT-E.
Collaborative weighing follows the same procedure as in standard
outpatient CBT-E, and it is done with the assistance of the dietitian. Patients
are shown how to plot their weight on the weight graph, and write the
interpretation of weight changes in the ”Context and Comments” column of
the monitoring record.

Individual Sessions with the CBT-E Psychologist

In intensive outpatient CBT-E, individual sessions are similar to those of
conventional outpatient CBT-E, but are conducted more oen (twice weekly
for the entire duration of the program). ese sessions focus mainly on
helping the patient to accept the rapid changes in eating, weight, and shape
that usually occur in intensive outpatient CBT-E, and to cope with the
alterations in mood associated with these changes. As treatment progresses,
the content of the sessions gradually evolves into addressing, in a
personalized way, the modules of the focused form of CBT-E and, in a
subgroup of patients, one or more modules from the broad form of CBT-E.
 Individual Sessions with the CBT-E Dietitian
Sessions with the dietitian should be scheduled for Mondays and Fridays.
e agenda of the Monday session is mainly dedicated to reviewing the
weekend entries on the monitoring record, collaborative weighing, and
helping patients to make any calorie content adjustments necessary to
maintain a steady weight gain of 1 pound (0.5 kilogram) per week. Patients
are encouraged to interpret their weight change as if they were therapists,
and to suggest modifications to their diet for the following week according
to the weight-regain guidelines discussed at the beginning of the treatment
(see “Actively Involving Patients in Planning Meals and Snacks” in Chapter
11). e dietitian uses the patient’s weight interpretation to educate her or
him on weight regulation, and to restructure any cognitive biases regarding
weight changes and the calorie content of the diet to follow.
e Friday session, on the other hand, should be devoted to reviewing
the progress and obstacles encountered during the preceding week, and to
plan the meals for the weekend ahead. Patients are instructed to use
proactive problem solving to address any difficulties encountered during the
previous weekend.

Medical Examination by the CBT-E Physician

e CBT-E physician examines patients with medical complications (e.g.,
severe weight loss, electrolyte abnormalities, refeeding syndrome,
gastrointestinal symptoms) once a week, although in some cases it may be
necessary for this to occur more oen until they achieve a stable medical
condition. Patients being treated with antidepressants are usually examined
every 2 weeks.

Assisted Eating
Intensive outpatient CBT-E has been principally designed for patients who
are not able to adjust their eating habits in standard outpatient CBT-E. To
address this problem, intensive outpatient CBT-E adopts the procedure of
assisted eating. Patients consume two meals plus one snack each day (lunch,
midaernoon snack, and evening meal) with the assistance of the CBT-E
dietitian, who, in the event of any difficulties, prompts the patients to adopt
cognitive behavioral procedures to address their obstacles toward eating (see
“Using Cognitive Behavioral Strategies to Address Difficulties during Meals”
in Chapter 11 for details). Patients are encouraged to use the monitoring
record in real time, and to eat without being influenced by any external (e.g.,
food availability) or internal (e.g., hunger, anxiety, and thoughts) cues. is
new form of eating is encouraged until patients can eat without being
influenced by anxiety or preoccupations about control over shape, weight,
and eating. Other therapeutic techniques adopted during the meal in this
phase are support, education, distraction, and, in patients who are not too
preoccupied, decentering from problematic thoughts and urges. During the
meals, the therapist also addresses some ritualistic modes of eating (e.g.,
cutting the food into small pieces) if a patient adopts this behavior to
increase control over eating. Patients are also asked to refrain from going to
the bathroom for 1 hour aer eating.
e food services given to patients will largely depend on the resources
available. Food provided in our CBT-E unit is either prefrozen or packaged
so that it does not require much preparation and can be handled without
any fuss (a fact that permits implementation of assisted eating in a normal
outpatient setting). To encourage investment, all foods are given to patients
by the CBT-E dietitian 10 minutes before meals, but are microwaved by the
patients themselves. At 7:00 P.M., the CBT dietitian gives patients their food
for the following breakfast, and on Friday evenings the prepackaged meals
for the weekend are dispensed. To expose patients to eating food of
uncertain calorie content and preparation, two meals a week are assisted
outside of the unit in restaurants, pizzerias, or other suitable eating
establishments.
 Regarding what the patients eat, this will depend on their minimum
BMI-for-age threshold. Underweight adolescent patients are trained in the
same CBT-E weight-regain guidelines described in the Underweight and
Undereating module (see “Actively Involving Patients in Planning Meals
and Snacks” in Chapter 11), which indicate how to modify the calorie
content of the diet to maintain a steady weight regain of about 1 pound (0.5
kilogram) per week (i.e., starting with “Menu A,” which provides a mean
energy intake of about 1,500 kilocalories per day; then, if the weight
increases by less than 1 pound [0.5 kilogram] per week, switching to the
next menu, which provides 500 kilocalories more than the previous one).
Although assisted eating is particularly helpful, and perhaps
indispensable, in aiding underweight patients to regain weight, it is also
useful in not-underweight patients with binge-eating and purging episodes
who have not managed to curb this behavior in conventional outpatient
CBT-E. In these cases, assisted eating is designed to show them that they can
eat a diet comprising three meals and two snacks, and a varied diet, without
gaining weight, and that they are able to digest these meals without binge
eating or purging. Interruption of the binge–purge cycle in the intensive
outpatient setting is used as evidence that some processes encouraging this
behavior in operation at home will need to be addressed later on during the
treatment if setbacks are to be preempted.

Unassisted Eating
In the first weeks of intensive outpatient CBT-E, patients are instructed to
adopt the same eating approach for weekends and breakfast as they do in the
CBT-E unit. On these occasions they should consume the frozen meal packs
given to them in advance by the CBT-E dietitian. Once they learn to manage
meals outside of the unit well, patients are encouraged to eat progressively
more meals outside of the unit, replacing frozen or prepackaged food with
normal meals, and the treatment gradually evolves into standard outpatient
CBT-E, in which all meals are unassisted.
 Involving Parents
e first joint session, attended by the patient, parents, and dietitian, is
usually scheduled on the Friday of the first week of treatment, and is focused
on how to address family meals over the weekend. Although, during the
early weeks, discussions on the preparation of meals are generally forestalled
by the use of prepackaged and frozen foods provided to the patient, parents
are educated on how to give assistance during meals, adopting the same
procedures described in the Underweight and Undereating module of
standard outpatient CBT-E (see Chapter 11). A second joint meeting should
be held to review any difficulties encountered with weekend meals, and any
obstacles should be addressed with the aid of the proactive problem-solving
procedure (see “Problem Solving: Steps One–Four” in Chapter 14),
encouraging the patient and parents to come up with solutions to improve
how family meals are handled.
In most cases, only a few additional family sessions are needed with the
dietitian because, if the patients are not able to consume meals properly
during the weekend, the transition to inpatient CBT-E should be considered.
Other family sessions occur when the patient starts eating normal meals at
home, in order to discuss the best way to prepare them. In general, parents
are invited, as in most families, to handle the shopping and food preparation
with the patient to arrange a flexible and healthy meal plan. When the young
patients have normalized their body weight and are addressing the residual
dietary restraint, social eating with nonfamily members is also gradually
resumed.

Maintaining Changes in Eating Outside of the Unit

Intensive outpatient CBT-E has introduced the following strategies to help
patients maintain the changes in eating outside of the outpatient unit:
 In the first weeks of treatment, patients are provided the same meal
packs they eat in the unit for breakfasts and at weekends. is prevents
them having to buy and cook the food, two situations that typically
trigger concerns over eating.
Patients who binge-eat are encouraged to remove foods that could
trigger binge-eating episodes from their environment, and to adopt a
regular eating pattern (see Chapter 8).
Sessions with the CBT-E dietitian focus on accurately preparing and
reviewing weekends and eating outside of the unit.
Patients are given more support than in conventional outpatient CBT-
E.
e involvement of parents is used to create a home environment that
is likely to support the patient’s efforts to change her or his eating
patterns.

ese strategies, and the intensive outpatient treatment itself, have been
devised to counter the high rate of relapse typically observed in patients
aer discharge from inpatient eating-disorder units. Indeed, relapse is likely
to be driven by patients’ removal from the protected, supportive
environment of the hospital where the eating and weight changes took place,
being “cast out,” so to speak, back into the environment that undoubtedly
fostered their eating-disorder psychopathology in the first place. Moreover,
it is commonplace for major disruption of treatment to occur upon
discharge, particularly in structures whose outpatient philosophy is not
coherent with the inpatient approach. It is evident, therefore, that these
problems are preempted by intensive outpatient CBT-E, where eating and
weight change occur while the patient is living at home, and individual
CBT-E sessions with the same therapist continue, even aer the treatment
intensiveness has been stepped down.
VIGNETTE
e patient is a 17-year-old girl who, despite her motivation to change, had not gained any weight
aer 4 weeks of Step Two, maintaining the same underweight that she had at the beginning of
outpatient CBT-E. In the review session performed 4 weeks aer the start of Step Two, two main
obstacles to change emerged. ese were connected both to the psychopathology of the patient’s
eating disorder (e.g., her intense fear of gaining weight; extreme inflexibility, probably
accentuated by the state of being underweight; excessive exercising; and early sensation of
fullness, which prevented her from increasing her caloric intake), and the lack of support she
received from her (divorced) parents during meals, as the mother was not at home all day for
work reasons, and the father lived in another town during the work week. Because these obstacles
seemed difficult to overcome in the context of standard outpatient CBT-E, the therapist suggested
to the patient that they jointly evaluate the pros and cons of starting intensive outpatient CBT-E,
explaining the reasons, the treatment’s aims (i.e., to address the obstacles to weight regain
described above), duration, organization, procedures, and expected results. e patient, aer
initial ambivalence, decided voluntarily, with the consent of both parents, to start intensive
outpatient CBT-E.
e first 4 weeks of the intensive treatment are mainly focused on addressing weight
restoration, undereating, and feelings of fullness via assisted eating. Individual CBT-E sessions are
dedicated to addressing her excessive exercising in the recreation room during intervals between
meals, and her body image concerns and mood changes associated with weight regain.
Furthermore, thanks to delivery of the frozen food to be consumed during the weekends, the
patient is helped to stick to her meal plan outside of the unit. Aer 4 weeks, the intensiveness of
treatment has gradually decreased, with a progressive reduction in both the number of meals
consumed in the unit and of the frequency of individual CBT-E sessions. In the last 2 weeks of
intensive outpatient CBT-E, the patient, who has achieved the 20th BMI-for-age percentile, is
eating her meals in the unit only on Mondays, and has one session per week with the CBT-E
psychologist and one with the CBT-E dietitian.
Aer 8 weeks of postintensive outpatient CBT-E, the patient has reached the 25th BMI-for-
age percentile threshold, and the last 6 weeks of treatment are focused on addressing her residual
dietary restraint, as well as weight maintenance, relapse prevention, and bringing therapy to a
close. At the final posttreatment review session (20 weeks aer the end of the therapy), the patient
has maintained the 25th BMI-for-age percentile and her eating-disorder psychopathology is in
total remission.
 CHAPTER 19

Inpatient CBT-E

e outpatient setting is ideal for the treatment of adolescent patients with

eating disorders. is is because outpatient treatment is less disruptive than
inpatient treatment, meaning that the changes made are more likely to last,
as patients make them while living in their normal environment. However,
as some patients respond poorly or not at all to outpatient treatments
(standard or intensive) and some cannot be managed safely on an outpatient
basis, a more intensive form of care—namely, inpatient treatment—may
become necessary. An adapted form of CBT-E for adolescents, developed at
the Department of Eating and Weight Disorders at Villa Garda Hospital,
Verona, Italy (Dalle Grave, 2012; Dalle Grave, Bohn, et al., 2008; Dalle Grave
et al., 2014), can be used to treat patients in an inpatient setting, as
summarized in this chapter.

RATIONALE FOR EXTENDING CBT-E TO

INPATIENT SETTINGS

e rationale behind extending CBT-E to inpatient treatment stems from

several considerations:
 Patients may present with an eating disorder of extreme clinical
severity that is not manageable in an outpatient setting.
A large subgroup of patients fails to improve with either conventional
or intensive outpatient CBT-E.
Available data indicate that patients not responding to outpatient CBT
for an eating disorder also tend not to respond to other types of
outpatient treatment (e.g., IPT or fluoxetine; Mitchell et al., 2002;
Wilson, 1996).
In some patients, the ineffectiveness of outpatient CBT-E may be due
to insufficient care intensiveness rather than of the nature of the
treatment itself.
CBT-E addresses the eating-disorder psychopathology rather than the
DSM-5 (American Psychiatric Association, 2013) diagnosis, and this is
an optimal approach in an inpatient setting where patients with
different DSM-5 eating-disorder diagnoses are treated.
CBT-E has a lasting effect (Fairburn et al., 2009, 2013), as it addresses
some key maintenance mechanisms of the eating-disorder
psychopathology and helps patients to develop specific personalized
skills for preventing relapse—two ideal characteristics for an inpatient
program, many of which are associated with a high risk of relapse aer
discharge.

DISTINCTIVE FEATURES OF INPATIENT CBT-E

Inpatient treatment for anorexia nervosa produces a faster weight gain than
outpatient treatment (Hartmann, Weber, Herpertz, & Zeeck, 2011) and is
oen successful in bringing about weight restoration. e problem is that
few patients are able to maintain this weight gain aer discharge, and about
30% of these patients require rehospitalization during the first year following
discharge (Herzog et al., 1999; Pike, 1998). In the current state of affairs,
nonresponders to outpatient treatment and severe cases are generally
hospitalized in specialized eating-disorder units. Unfortunately, however,
most eating-disorder units adopt an eclectic approach not driven by a single
unifying theory, which is oen associated with a high rate of relapse aer
discharge.
is failure to maintain the changes achieved in the hospital has led to
the development of posthospitalization treatments aimed at preventing
relapse. A small preliminary study suggested that fluoxetine might be useful
in this regard (Kaye et al., 2001), but this was not confirmed by a subsequent
controlled trial (Walsh et al., 2006). ere is also preliminary evidence that
CBT for anorexia nervosa may be beneficial, although this result still needs
to be replicated (Carter et al., 2009).
However, inpatient CBT-E for adolescents has adopted a different
strategy, modifying the inpatient version itself with a view to reducing
patients’ propensity to relapse on discharge. To this end, in our unit, the
traditional multidisciplinary eclectic approach to inpatient treatment has
been replaced with a specialized intensive CBT-E program derived from
outpatient CBT-E. is treatment has been specifically designed to produce
enduring change and, as described above, appears to have lasting effects
when delivered on an outpatient basis. Inpatient CBT-E includes other
additional elements designed to reduce the high rate of relapse that typically
follows discharge from the hospital, and these are described below.

GENERAL TREATMENT STRATEGIES

Inpatient CBT-E differs from most inpatient treatments for eating disorders,
like the outpatient version, because it never adopts “coercive” or
“prescriptive” procedures—in other words, patients are never asked to do
things that they do not agree to. All procedures have been designed to make
patients feel in control at all times, actively involving them at all stages of the
treatment, from the decision to be admitted to the choice of the problems to
address, and the procedures to use for overcoming them. Like outpatient
CBT-E, the treatment is transdiagnostic and addresses the main processes
maintaining a patient’s eating-disorder psychopathology (not the DSM-5
diagnosis) with a personalized and flexible approach. e therapist and
patient work together to overcome the eating disorder (collaborative
empiricism). Patients are encouraged to become active participants in the
process of care and to see treatment as a priority.
Since patients start to address change and weight restoration from the
first day of inpatient CBT-E, the treatment is similar to outpatient CBT-E
Step Two but more intensive, while the preparation before admission adopts
some procedures overlapping those of Step One. For patients who are
underweight, as in outpatient CBT-E, a review session is held every 4 weeks
to review the patient’s progress and obstacles to change, and to plan the 4
weeks that will follow. e key strategy is to create a personalized
formulation of the main maintenance mechanisms that will need to be
addressed by the treatment. Simpler procedures are preferred over the more
complex and the treatment adheres to the “principle of parsimony” (doing a
few things well rather than many things badly), addressing only the most
powerful maintenance mechanisms that are operating in the individual.
e treatment adopts a variety of generic cognitive behavioral
procedures; to achieve psychological (cognitive) change, patients are
encouraged to make gradual behavioral changes in the context of their
formulation and to analyze the effects and implications of these changes on
their way of thinking. In the most advanced stages of treatment, patients are
helped to recognize the first signs of activation of their eating-disorder
mindset and to decenter rapidly from it, thereby avoiding relapse. Finally, in
the last 2 weeks of inpatient CBT-E, a postdischarge plan is devised to
address the residual eating-disorder features, prevent relapse, and organize
the postinpatient outpatient CBT-E.

INDICATIONS AND CONTRAINDICATIONS FOR

INPATIENT CBT-E
Inpatient CBT-E is indicated for adolescents with eating disorders in whom
well-delivered outpatient treatments have failed, or as a first treatment
option in patients with a high level of medical risk. Typical cases feature a
very low BMI-for-age percentile (e.g., <3rd), rapid weight loss (>2 pounds
[1.0 kilogram] per week) over the course of several weeks, and/or marked
medical complications (e.g., pronounced edema, severe electrolyte
disturbances, electrocardiogram [ECG] alterations, or hypoglycemia). Other
indications include high frequency and intensity of binge eating and self-
induced vomiting or excessive exercising, severe interpersonal problems,
and/or a troubled home life.
Inpatient CBT-E is not recommended for patients with daily substance
misuse, acute psychosis, high suicide risk, and/or medical conditions
requiring urgent treatment. Nonetheless, once these acute states have been
resolved, these patients can readily be admitted to inpatient CBT-E.

PREPARATION FOR INPATIENT CBT-E

Admission to inpatient CBT-E is voluntary, and hinges on a patient’s

willingness to change and play an active role in the treatment, which, in
order to be successful, needs to become a priority in her or his life.
Moreover, since admitted patients are expected to address weight restoration
from the first day of hospitalization, it is necessary that they have made the
decision to address it before admission. For these reasons pretreatment
preparation for inpatient CBT-E is a fundamental stage. In keeping with the
individualized nature of the CBT-E program as a whole, the preparation
stage is adjusted in line with the reason for hospitalization. us,
nonresponding CBT-E outpatients (standard or intensive) are dealt with
differently from patients referred by general practitioners or other outpatient
eating-disorder specialists.
As patients in the former group have already been extensively assessed
during the course of their ongoing treatment, they do not need to be
reassessed for inpatient CBT-E. In these cases, the main aim of the
preparation step is to get patients to agree to treatment intensification. ey
should therefore be helped to see that outpatient CBT-E is not proving
sufficient, and a more intensive intervention may help them make the
necessary changes. Once agreement has been reached, patients should
receive a detailed explanation of inpatient CBT-E (and be provided with an
information pamphlet that explains the procedures and goals of the
treatment in detail) and evaluate collaboratively with the therapist both the
pros and cons of intensifying the treatment. is decision-making process
should involve a visit to the unit, which allows patients to observe the
environment directly and experience its (welcoming) atmosphere.
Patients not previously treated by outpatient CBT-E (i.e., those referred
by others) will require a thorough assessment as part of their preparation.
is is conducted in a similar fashion to that described in Chapter 3, and has
the following aims:

To determine whether or not the patient has an eating disorder of

clinical severity. e assessment also necessarily includes a thorough
physical examination, as many referred patients arrive at the
consultation in a medically precarious condition.
To assess whether inpatient CBT-E will be a suitable treatment option
(i.e., ruling out the abovementioned contraindications).
To educate patients about their eating disorder and the inpatient CBT-
E program.
To help patients to evaluate the pros and cons of starting inpatient
CBT-E.

Since the process of change, in particular weight regain, starts from the first
day of hospitalization, the preparation sessions should also include some
procedures of outpatient CBT-E Step One to help patients to make the
decision to address change and weight restoration (if indicated). In
particular, patients are educated about the effects of being underweight and,
with the construction of the provisional personal formulation, on how these
effects act to maintain the eating disorder. Finally, patients are helped to
evaluate the pros and cons of addressing weight restoration and the other
features of their eating disorder with inpatient CBT-E.
In most cases, at least four sessions are devoted to preparing patients for
inpatient CBT-E, but sometimes more are needed before ambivalent patients
are able to reach the decision to start treatment. If patients draw the
conclusion that inpatient CBT-E represents a good opportunity for them to
change, they are placed on a waiting list and generally admitted 4–6 weeks
later. One week before admission, which is usually planned for a Monday,
patients have another session to review the treatment procedures in detail
and to reevaluate and confirm their motivation to change.

THE INPATIENT UNIT

Inpatient CBT-E should be delivered in a specialized unit for the treatment

of eating disorders. Our unit at Villa Garda Hospital, for example, accepts 28
patients, and has been designed to create a homey atmosphere by being
furnished with comfortable, rather than institutional, furniture. Bedrooms
house two or three patients, and are equipped with a private bathroom,
dressers, and desks. Patients are encouraged, as if in a student residence, to
decorate their room with posters, personal items, and photos. Shared spaces
include a dining room, a recreation room—where there is also a kitchen for
cooking—a computer room with Internet access, and a living room with
digital TV, DVD player, and a selection of DVDs and books. During the day,
patients may also be given access to other areas of the unit, such as the gym,
the gardens, and rooms set aside for individual and group therapy.
It is particularly important that as well as being homey, the unit is open
—that is, patients are free to come and go during the day, provided that they
are judged to be in a stable medical condition. Similarly, patients are free to
receive visits from significant others whenever treatment sessions are not in
progress. In addition to limiting any stigma or discomfort a patient may feel
at being “institutionalized,” an open unit has the added advantage of not
shielding patients from exposure to a wide range of environmental triggers
associated with the maintenance of their eating disorder. is fundamental
strategy has the twofold aim of reducing the relapse rate aer discharge and
minimizing patients’ dependency on the unit—two problems oen observed
in conventional, closed units.

GENERAL ORGANIZATION

Inpatient CBT-E, as organized at Villa Garda Hospital, lasts 13 weeks and is

followed by 7 weeks of day hospital treatment. In the day hospital stage,
patients sleep at home or, if they live too far from the hospital, in an
apartment close to the unit. In some cases—for example, when a patient’s
weight at admission is very low—the team can suggest to patients that their
treatment be prolonged by a few weeks. Aer the day hospital phase,
patients are given postinpatient outpatient CBT-E to further support their
transition back to the real world.

THE CBT-E TEAM

Inpatient CBT-E is delivered by a “noneclectic” multidisciplinary team

comprising physicians (internists and psychiatrists), dietitians,
psychologists, and nurses. All team members are fully trained in CBT-E, and
therefore use the same concepts and terms, adopting mutually compatible
CBT-E procedures and strategies. e individual contribution of each staff
member is determined on a case-by-case basis according to the
prescriptions of each patient’s personal formulation. In general, the CBT-E
dietitian’s primary focus is helping patients to change their eating habits and
weight, while the CBT-E psychologist addresses patients’ overvaluation of
shape and weight, and any additional maintenance mechanisms. e
patients’ physical health is overseen by the CBT-E physician, and the CBT-E
nurse is charged with the usual tasks of supervising the administration of
medications, assisting patients in collaborative weighing, and helping them
to manage daily difficulties and major crises. If one of a patient’s therapists
must be absent for a period exceeding 1 week, a fully trained replacement
must be found to ensure continuity of appropriate care. Other professionals
—such as educators, who help young patients to address homework or
study, and physiotherapists, who run the exercise sessions—also operate in
the unit. Like the clinical staff, these therapists need to be trained in CBT-E.
In our unit, each therapist’s fidelity to the treatment protocol is
monitored through weekly team meetings, the weekly roundtable (with the
patient, see below), and periodic peer supervision.

ADMISSION

At admission, patients are welcomed by the nurse, who assigns them a room
and provides verbal and written information on how to approach the
treatment (see Table 19.1).
TABLE 19.1. Patient Handout on How to Address Inpatient CBT-E
Attitudes toward the treatment
The treatment should be considered as a special opportunity for you to overcome your
eating problem and to start a new and more satisfying life. As with every change there are
some risks, but the benefits you can get are huge, and include thinking more freely without
being continuously oppressed by thoughts about eating, shape, and weight; developing a
broader mental perspective; become happier; less irritable and rigid; being able to have a
family; and better health.

Inpatient CBT-E is different from most hospital treatments for eating disorders because it
never adopts “coercive” or “prescriptive” procedures—in other words, you will never be
asked to do things that you do not agree to. The general treatment strategy is first, with the
help of your therapist, to understand what the main maintenance mechanisms of your
eating problem are, and agree to address them with specific procedures. Then you should
try to apply the agreed-upon procedures with the maximum effort. Finally, you should review
with your therapist the effect of the procedure on your eating problem. If you do not reach
an agreement with your therapist, the treatment will be interrupted, but this rarely happens.

It is essential that you play an active role to address the change from the first day of your
admission. The treatment has little or no chance of success if you are not actively involved.
For this reason, some procedures, such as education on your eating problem and
assessment of the pros and cons of addressing change and weight regain, have been
addressed in the preparation sessions you attended before hospital admission. However,
even after good preparation it is common to be ambivalent toward the change. If this is your
case, we suggest that you “take the plunge” to test the impact of weight regain and reduce
the importance you give to shape and weight on your life, as an experiment. If you are
unsatisfied with the results achieved during treatment, you can always go back to the
control of eating and weight imposed by your eating problem.

Another winning attitude that we recommend you adopt is to shift your efforts from control of
eating to the treatment—in other words, we encourage you to consider the treatment as a
priority and to put the same effort that you dedicate to the control of eating, shape, and
weight in trying to change. The motto we recommend you adopt is “It is hard, but it will be
worth it.”

It is important that every appointment starts and ends on time. The therapist will also do her
or his best to always be on time, and the same is required of you. It is a good idea to arrive
a little early to each session (e.g., 15 minutes before). This will give you the opportunity to
get comfortable, relax, and prepare things to discuss in the session.

You and your therapist will work together as a team to address your eating problem.
Together you will agree on specific homework to do between the sessions. Doing the
homework well is of fundamental importance, as it is what you do outside the session that
will determine the effectiveness of the treatment.

From a practical point of view, it is essential to start the treatment well. Indeed, available
data indicate that the extent of the change obtained in the first 4 weeks is the most
important predictor of good treatment outcome. For this reason, you and your therapist have
to be ready to start building what we call therapeutic “momentum” because success breeds
success. Any impediments must be promptly addressed, as it will be difficult to make up lost
ground.
 Your responsibility toward other patients
In residential treatments, patients influence one another, and this can have positive or
negative effects. One of the main tasks of the team is to create a positive atmosphere in the
unit, where patients help one another to overcome their eating problems. It may occur,
however, that some patients, even involuntarily, have a negative influence on other patients.
Examples of behaviors that tend to negatively affect the other patients are the following:
Criticizing treatment and therapists.
Stating that no one can recover from their eating problem.
Not applying the treatment procedures.
Teaching other patients unhealthy weight-control behaviors.
Introducing drugs or alcohol into the unit.

Being admitted to the treatment implies taking the responsibility not to negatively influence,
with your behaviors and attitude, other patients’ adhesion to the treatment. Constructive
criticism of treatment is welcome, but it should be shared with your therapist, not aired in
front of other patients. A particularly destructive behavior that negatively influences other
patients is not being actively engaged in treatment and deliberately not applying its
procedures. If you or any one else is having any doubts, therefore, you should keep your
distance from the person concerned and inform your therapist about that person’s behavior
—they will explore with you or that person the reasons behind these doubts, and help find
constructive and useful solutions. In the rare event that these solutions prove impractical,
the patient involved will be asked to stop treatment.

From Cognitive Behavior erapy for Adolescents with Eating Disorders by Riccardo Dalle Grave and
Simona Calugi. Copyright © 2020 e Guilford Press. Permission to photocopy this material is
granted to purchasers of this book for personal use or use with patients (see copyright page for
details). Purchasers can download enlarged versions of this material (see the box at the end of the
table of contents).

Aerward, patients meet the dietitian, who explains how the treatment
is organized and outlines the procedures used to implement assisted eating.
On the same day, patients meet the doctor for a physical exam and
prescription of the necessary blood tests and clinical workup.

ASSESSMENT

A thorough and accurate assessment of the patient needs to be performed at

admission, and should include the following procedures:

Medical examination.
 Psychiatric examination.
Blood tests and clinical workup.
EDE-17.0D.
EDE-Q.
CIA.
Brief Symptom Inventory (BSI).

e assessment should enable detection of any medical and/or psychiatric

comorbidities that will need to be managed during the treatment, and to
assess the nature and severity of the eating-disorder psychopathology; this
will be reassessed at the end of treatment, and at 20 and 60 weeks of follow-
up aer discharge.
Note: Some patients with eating disorders admitted to inpatient CBT-E
have acute medical complications, and many of those without acute
complications are nevertheless medically compromised as a result of their
undereating and very low weight. All members of the inpatient unit must
therefore pay careful attention to their patients’ medical status and have
suitably experienced physicians available.

MODULES AND FORMS OF THE TREATMENT

Inpatient CBT-E for adolescents is designed to address each patient’s eating-

disorder psychopathology and maintenance mechanisms in an
individualized and flexible way, with the strategic use of specific modules.
Like outpatient CBT-E, the treatment can be delivered in either a focused or
broad form.
e modules of the focused form of the treatment are the following:

Underweight and Undereating (see Chapter 11).

Body Image (see Chapter 12).
Dietary Restraint (see Chapter 13).
Events, Moods, and Eating (see Chapter 14).
 Setbacks and Mindsets (see Chapter 15).
Preparation for returning home.

Any excessive exercising, purging, and binge eating are also tackled in the
focused form (see Chapter 9). e modules of the broad form of the
treatment are designed to address additional obstacles to change (see
Chapter 17):

Clinical Perfectionism.
Core Low Self-Esteem.
Interpersonal Difficulties.
Mood Intolerance.

Each module includes specific strategies and procedures to address the

psychopathological feature in question and the processes that maintain it.

CORE TREATMENT PROCEDURES

Inpatient CBT-E adopts the main procedures of outpatient CBT-E, some of

which are adapted to suit the inpatient setting, as well as other procedures
specifically designed for inpatient CBT-E.

Jointly Creating the Formulation

In the first 2 weeks, together with the CBT-E psychologist, patients build
their formulation of their own eating disorder. is personalized
formulation is used by patients and all team members to identify features to
address, and will be revised as necessary during the course of treatment. e
aim is to create a bespoke treatment that is perfectly suited to each patient’s
particular problem.

Real-Time Self-Monitoring
e monitoring record is the same as that used in outpatient CBT-E, and it
is reviewed by the patient, together with the CBT-E psychologist, in each
individual CBT-E session. However, unlike outpatient CBT-E, during the
assisted-eating phase patients are instructed to record only the name of the
meal (e.g., breakfast, lunch) and not the individual foods ingested (see
Figure 19.1).
Day Tuesday Date September 10

Time Food and drink consumed Place * V/L/E Context and comments
8:30 Breakfast Hospital 92 pounds. I’ve regained
dining 2 pounds in the last
room week. I’m in the range of
planned weight gain.
I will continue to follow
the same menu plan.
I’m a little scared, but I
am in control.

12:00 Lunch Hospital I started to eat slowly

dining and brood about food.
room Then I told myself to eat
without being influenced
by my thoughts and it
went better. I feel in
control.

3:45 Snack Hospital I’ve never had a snack

dining before. I tell myself that I
room need it to overcome my
eating problem.

4:15 E I walked for 10 minutes

in the park at the unit to
compensate for the
snack. I was encouraged
by the nurse to sit down.
Now I am OK.

6:00 1 cappuccino Hospital * I was hungry. Now I feel

hot drinks fat.
dispenser

7:00 Dinner Hospital I feel full after a few

dining mouthfuls. I tell myself
room it’s a transient feeling
and that it will pass. I
must remember to wear
clothes that do not hug
my belly.

FIGURE 19.1. A monitoring record of an inpatient having assisted eating.

Collaborative Weighing
Patients in the unit are weighed once a week. Collaborative weighing is
performed in private with the assistance of the nurse, and has the same goals
as in outpatient CBT-E. To prevent meticulous weight checking, a scale with
1-pound (0.5-kilogram) intervals is used. Patients are instructed to record
their weight on a personalized graph, and to interpret their change in weight
in the “Context and Comments” column of the monitoring record,
considering the previous 4 weeks. On the basis of their weight
interpretation, patients should also write in that same column any variation
in their meal plan necessary to maintain a weight regain rate of 2–3 pounds
(1.0–1.5 kilograms) per week (see below). e trend in and interpretation of
weight, together with the meal plan for the following week, are discussed
during the roundtable that takes place on the same morning.

Weekly Assessment of Eating-Disorder Behaviors and

Attitudes
Aer each weigh-in, patients fill in the EPCL, answering questions about
their frequency of binge eating, weight-control behaviors (e.g., dietary
restraint, self-induced vomiting, misuse of laxatives and diuretics, excessive
exercising), body checking and body avoidance, and concerns about shape,
weight, and eating control over the previous week. e EPCL data are then
entrusted to the nurse, who records the new entries in a database to be
discussed the same morning at the review meeting.

Assisted Eating
e predominant reason why patients are admitted to the inpatient CBT-E
unit is that they have previously been unable to address weight restoration
or interrupt binge eating and self-induced vomiting. is may be due to
various reasons, including the intensity of preoccupation with thoughts
about food and eating, the fear of losing control over eating and weight, the
presence of extreme rituals affecting eating, and ambivalence toward change.
Assisted eating has therefore been designed to help patients to overcome
these problems.
Assisted eating typically takes place over the first 6 weeks of inpatient
treatment, or until patients reach the 25th BMI-for-age percentile threshold.
In this stage of the treatment, patients consume three meals (breakfast,
lunch, and evening meal) in the dining room, together with the other
patients and with the assistance of a CBT-E dietitian or CBT-E nurse.

Role of the Dietitian or Nurse

e task of the CBT-E dietitian and CBT-E nurse is to provide support and
encouragement to patients during meals, and to help them by using
cognitive behavioral strategies and procedures to eat without being
overwhelmed by concerns about food.

Role of the Patient

As with any CBT-E procedure, it is essential that during assisted eating the
patients play an active role, trying to do their best to apply the agreed-upon
strategies. ese are intended to help patients to feel less anxious about
eating and to maintain control during the process of weight regain without
being influenced by the eating-disorder mindset. It is explained to the
patients that eating meals passively, without applying the suggested cognitive
behavioral strategies, is of little use, as when they eat meals without
assistance they will not be able to cope with their eating-disorder mindset.

Mealtime Strategies and Procedures

Adolescents with eating disorders generally have the belief that if they eat
certain foods or certain amounts of foods, they will lose control and gain
weight unpredictably. e anxiety generated by this belief is generally
reduced by patients adopting extreme and inflexible dietary rules and/or
other extreme weight-control behaviors. To address such difficulties,
inpatient CBT-E encourages patients to actively use the following three
procedures: (1) meal planning, (2) adopting cognitive behavioral strategies,
and (3) managing time aer meals. ese procedures are explained to
patients in detail by the dietitian before patients have their first meal in the
unit.

Meal Planning

Each week, during the roundtable, aer interpreting the weight changes,
patients decide, with the help of their therapists, whether there is a need to
change their meal plan, referring to the weight-regain guidelines (see below)
explained by the CBT-E dietitian on the day of admission. ese are similar
to those described for outpatient CBT-E, with the exception that in inpatient
CBT-E, the weekly weight-regain goal is higher (i.e., between 2 and 3
pounds [1.0 and 1.5 kilograms] per week). is more ambitious goal is
motivated by the need to help patients reach a healthy body weight (i.e., at
least the 25th BMI-for-age percentile) before the end of the hospital
treatment. Indeed, our data have shown that achieving a normal weight at
discharge represents the most powerful predictor of long-term outcome of
inpatient CBT-E (El Ghoch, Calugi, Chignola, Bazzani, & Dalle Grave,
2016).
In order to achieve this goal, inpatient CBT-E weight-regain guidelines
shared with the patients give the following indications:

e energy intake during the first week of treatment is set at about

1,500 kilocalories per day (but it may be set lower—at about 1,200
kilocalories per day—in patients with a very low BMI-for-age
percentile and at a high risk of developing refeeding syndrome), and
then it is increased to about 2,000 kilocalories per day in the second
week.
 Subsequently, the energy intake is collaboratively adjusted on the basis
of the patient’s rate of weight regain as follows:
No energy intake adjustment if the body weight increases between 2
and 3 pounds (1.0 and 1.5 kilograms) per week.
An increase of about 500 kilocalories per day if the body weight
increases by less than 2 pounds (1.0 kilogram) per week.
A reduction of about 250 kilocalories per week if the body weight
increases by more than 3 pounds (1.5 kilograms) per week.
If patients require an intake of over 2,500 kilocalories per day to
achieve adequate gain, they are given the option of doing so using
normal food alone or with the addition of high-energy drinks.
Once patients exceed the 25th BMI-for-age percentile threshold, their
energy intake is gradually adjusted so that they reach and maintain the
body weight within the goal BMI range without dietary restriction.
Since the treatment is voluntary, neither nasogastric tube feeding nor
parenteral nutrition are used to address undereating or low weight.
Instead, if patients are not able to eat planned meals, even with
assistance, they will be referred to another form of treatment.

Patients also receive the following information about the inpatient CBT-E
menus:

e menus are labeled with letters (A, B, C, D, etc.), and each contains
three meals (i.e., breakfast, lunch, and dinner) and one snack.
Every menu has a mean daily calorie content calculated on the basis of
a weekly mean.
Menu A has about 1,500 kilocalories per day, Menu B about 2,000
kilocalories per day, Menu C about 2,500 kilocalories per day, and
Menu D about 3,000 kilocalories per day.
Each menu contains all of the food groups, even those typically
avoided by people with an eating disorder.
 e portions correspond to a medium portion usually consumed by
people without an eating disorder.
Lunch and dinner are served by the nurse, while breakfast and the
snack are served as a buffet, with patients being encouraged to choose
the foods according to their meal plan.

One of the principal aims of inpatient CBT-E is to help patients to feel in

control during the process of weight regain. Indeed, the active involvement
of patients in interpreting their own weight changes and deciding the nature
of their own weekly meal plan helps them to reduce anxiety and concerns
about eating because it makes them feel in control during the weight regain
process by providing predictability on the menus’ effects on weight changes.
Patients are encouraged to become active participants in deciding their goal
BMI range (which should be above the 25th BMI-for-age percentile) and the
nature of their diet, which should adhere to the inpatient CBT-E weight-
regain guidelines (see above and Chapter 11), as explained to them by the
dietitian on the day of admission.
In patients admitted due to binge eating and purging that have proved
impossible to control on an outpatient basis, assisted eating is designed to
show patients that they are able to eat a normocaloric diet comprising three
meals and a snack per day without gaining the weight that they fear, and that
they can eat these meals without binge eating or purging. is will help
these patients to understand that some processes encouraging binge eating
and/or purging are at work in their home environment, and that these will
need to be addressed during a later stage of the treatment if relapse is to be
avoided.

Adopting Cognitive Behavioral Procedures

Patients are encouraged not to eat meals passively, but instead to apply
cognitive behavioral procedures in the event of difficulty, as follows:
 Eating all of the planned food. “e meal plan will help you to feel in
control during weight restoration; it makes it possible for you to
predict the rate of weight regain.”
Eating without being influenced by internal signals of hunger and
fullness. “Try to eat without being influenced by internal signals of
hunger or feeling full, because they are altered by your being
underweight.”
Eating without being influenced by preoccupations with eating and food.
“Say to yourself that these are the expressions of the eating-problem
mindset that you want to change.”
Distancing the behavior from thoughts and preoccupations about eating
and food (in those who are not extremely concerned about eating). “Do
not what your eating-problem mindset wants you to do—do the
opposite.”
Avoiding the use of rituals at the table. “Try to adopt the mindset of an
athlete before a high jump. She or he concentrates on the technique to
use and not the fear of failing or how high the bar may be.”
Using the monitoring record in real time. “If you experience any
difficulty during meals, write down the strategies you should apply on
your monitoring record.”

Unassisted Eating
When the period of assisted eating is over, patients are encouraged to eat
without assistance, and to start eating outside of the unit while continuing
their weekly weigh-ins and real-time self-monitoring. e goals of this
phase are to help the patients maintain the weight achieved without assisted
eating and to address residual dietary restraint. e procedures adopted are
therefore based on the levels of the patient’s residual dietary restraint and
include the following:
 1. Learning to consider dietary restraint as a problem to be addressed
and not a solution.
2. Following healthy eating guidelines in a flexible way.
3. Identifying and addressing any residual extreme and inflexible
dietary rules and/or food checking (e.g., weighing food overly
carefully or counting calories).
4. Identifying and addressing dysfunctional reactions with patients who
are breaking their own dietary rules.

In this phase, patients eating in the unit are free to choose their own
food, as in a self-service restaurant, and are given free access to the
bathroom. From week 14 forward, patients live outside of the hospital, either
at home or in a temporary accommodation, eating meals they have planned
in advance and recording them in much the same way as is in outpatient
CBT-E. Dietary restraint and dietary rules are approached in a day hospital
setting using the strategies and procedures described for outpatient CBT-E
(see Chapter 13).
Before patients are sent home full time, they are encouraged to spend
some weekends and several weekdays at home, thereby gradually building
up to consuming all meals outside of the hospital. Upon discharge, patients
should be able to maintain their weight within a normal range, following
flexible dietary guidelines, and not resort to extreme weight-control
behaviors. erefore, it may be necessary to occasionally slow down or
prolong this mealtime normalization to deal with any setbacks or
difficulties.

Individual CBT-E Sessions

ese sessions are held twice a week for the first 4 weeks, then once a week
in the following period. e initial focus is on engaging patients in the
treatment and then helping them to accept the rapid changes in weight and
shape, as well as to address events and emotions influencing eating and the
overvaluation of shape and weight. In some patients, one or more external
maintenance mechanisms are also tackled. Finally, with the active
participation of the patient, a postdischarge treatment plan is prepared in
order that they achieve a smooth transition from inpatient to outpatient
CBT-E.

Group Therapy Sessions

In addition to individual counseling, patients are scheduled to attend group
therapy sessions. is combination has the advantage of efficiency, and also
encourages self-disclosure, mutual support, and learning from patients who
are doing well, while helping patients address issues of secrecy and shame.
Two types of group sessions are scheduled: psychoeducational and CBT-E
focused. e psychoeducational groups are held three times a week, and aim
to stimulate discussion among patients about eating disorders and the CBT-
E strategies used to address them. e CBT-E groups are held twice a week
and focus on two main topics: (1) addressing events and associated mood-
influenced eating using proactive problem solving and (2) addressing
negative body image using CBT-E strategies and procedures.

Weekly Review Meeting (Roundtable)

Once a week, on the same morning as the collaborative weighing, the
patient and her or his therapists (i.e., physician, psychologist, dietitian, and
nurse) meet together to discuss the various elements of the treatment and
their relationship to one another. is fundamental review meeting starts by
analyzing the patient’s interpretation of her or his weight graph. en, the
patient is encouraged to suggest changes to be made to her or his meal plan
based on the weight-regain or weight-maintenance goal decided at
admission. e personal formulation and EPCL scores are also analyzed
collectively, and the maintenance mechanisms to be focused on in the
following week are also discussed. Finally, the roundtable is also dedicated to
discussion of the organizational aspects of the treatment (e.g., transition
from assisted to unassisted eating, transition to day hospital, weekends at
home) and, if needed, to the prescription of tests and/or medicines to assess
and/or manage complications and comorbidities associated with the eating
disorder.

Exercise Sessions
Twice a week, patients participate in group physical activity sessions led by a
CBT-E-trained physiotherapist. ese sessions are designed to help the
patients (1) maximize the restoration of muscle mass, (2) improve fitness,
(3) accept changes in shape, and (4) learn to exercise without thinking about
shape, weight, and calorie consumption.

Hospital Schooling
Patients should have the possibility, if the local health and education
authorities allow it, to continue their studies during their hospital stay. In
the Villa Garda inpatient CBT-E unit, for example, patients receive lessons
from accredited schoolteachers either directly or via the Internet, using new
technologies for information and communication. e patients/students are
periodically given accredited oral and written tests to assess their learning.
An electronic school register is also available for sharing lesson programs
and the hospitalized student’s learning pathway. Periodic meetings between
the nursing team and teachers are scheduled with the purpose of evaluating
and addressing the various obstacles that may emerge during rehabilitation
and schooling. We have found that providing school-age patients with these
opportunities helps prevent early school dropout, and facilitates their
reintegration into the traditional scholastic context—two issues that may
promote relapse aer discharge from inpatient treatments.
 ADDRESSING WANING MOTIVATION

Addressing the eating disorder and some of its features (e.g., being
underweight, dietary restriction, and dietary restraint) is rarely easy. It is
almost inevitable that patients will alternate between periods in which they
are determined to change and others in which they would like to abandon
the treatment before it is completed. Since following the treatment in a
discontinuous fashion is not advisable, motivation is a primary focus of the
agenda for the entire duration of inpatient CBT-E. To help patients stay
focused on the process of change, it is recommended that they periodically
review with the therapist the reasons why they decided to be hospitalized
and address their eating disorder. It may also be useful to ask patients to
write down these reasons and keep them in a readily accessible location
(e.g., in a diary or on a paper hanging on the wall near their bed); these
should be read at regular intervals, before meals, and/or every morning just
aer waking up. Patients are also advised to regularly evaluate and address
their reasons for wanting to get well, recommending that they bear in mind
both short- and long-term perspectives, analyzing in particular the degree of
impairment caused to their life by their eating disorder, and whether they
have difficulty doing what their peers do. Likewise, when patients are
successful in implementing the desired changes, they are encouraged to
consider whether any of the side effects of their eating disorder have
decreased in severity.
At regular intervals, the therapist should ask patients to think about
their future plans, and whether their eating disorder is compatible with
them. It is also important to encourage patients to link their motivation to
change with their behavior, reminding them that in inpatient CBT-E they
have the opportunity to choose whether or not to change their behavior four
times a day (i.e., before every planned meal or snack). In the event of
difficulty in coping with meals, patients are instructed to review their
reasons for change before every meal or snack. We also advise them to
record their concerns about eating in the “Context and Comments” column
of the monitoring record in real time, analyzing and responding to them
immediately (e.g., concern: “I’m eating too much”; response: “I’m not eating
in excessive quantities, given my weight. e way I am eating is helping me
regain weight at the right speed”), and then trying to behave accordingly.
e patients should also be specifically prompted to analyze fluctuations
in motivation and their causes with the therapist in the individual CBT-E
sessions. In this analysis, patients are encouraged to evaluate how their
motivation has changed over the course of the week and what may have
influenced this change. ese evaluations can help patients to identify the
factors facilitating change that need to be reinforced, and those that are
hindering the change that must be immediately addressed.

DAILY MANAGEMENT DIFFICULTIES

In CBT-E group sessions and in individual CBT-E sessions with the

psychologist, patients are trained to cope with “external” events by applying
proactive problem-solving techniques and functional means of modulating
mood (see Chapter 14). However, if the application of these strategies is not
at first sufficient to enable patients to overcome their difficulties without aid,
the CBT-E nurse should be trained and on hand to help them to address
these problematic moments.

MAINTAINING CHANGE AFTER DISCHARGE

Traditional inpatient treatments for eating disorders distance patients from

the environmental triggers that maintain their eating disorder. is
approach facilitates weight regain and eating normalization during the
hospitalization, but makes the patients vulnerable to relapse when they
return home and are reexposed to numerous environmental stimuli not
present in the unit. Another problem that facilitates relapse is a poorly
managed transition to postinpatient treatment, which is oen conceptually
very different from that which the patients receive during inpatient
treatment. However, inpatient CBT-E has been designed with the problem of
relapse aer discharge in mind, and is accordingly focused both on
modifying the mechanisms thought to perpetuate eating-disorder
psychopathology and developing personalized relapse-prevention skills.
Moreover, it includes some specific elements to maximize the chances that
the changes made in the unit will be maintained aer the patient is sent
home, which are explained in the following sections.

Open Unit
e inpatient CBT-E unit is “open”—patients are free to go outside (see
below). In this way, they continue to be exposed to the types of
environmental stimuli that tend to provoke their eating-disorder
psychopathology while remaining in a stable, nurturing environment set up
to deal precisely with their reactions to these stimuli. In the later stages of
the treatment, patients also have the opportunity to be exposed to typical
stimuli they will meet outside of the unit and in their home environment,
such as a consuming meals in restaurants or with parents, relatives, and
friends; going to buy clothes; and participating in activities with others.

Day Hospital Phase

Inpatient CBT-E is followed by a day hospital treatment phase near the end
of the stay, during which patients must face some of the difficulties that they
will encounter aer discharge while still having the support of their
therapeutic team. During the days spent in the day hospital, patients are
encouraged to note all of the eating-disorder psychopathology triggers that
they encounter at home. Some of these triggers may encourage body
checking (e.g., too many mirrors in the house), others may increase shape
dissatisfaction (e.g., clothes that are too tight, having previously been worn
while underweight), dieting (e.g., diet books; a member of the family who
diets, is very thin, or has an eating disorder; or “pro-ana” websites), or
negative emotions that foster binge eating or dietary restraint (e.g.,
interpersonal difficulties with family members). Once the triggers have been
identified, these are then addressed in turn during the individual CBT-E
sessions, wherein patients are provided with effective preventative and
counteractive coping strategies.

Parental Involvement
Parents participate in six joint sessions with the patient and the CBT-E
psychologist, and two sessions with the dietitian to plan how meals at home
will be organized. e aims of the sessions are (1) to educate parents on
eating disorders according to the transdiagnostic cognitive behavioral view,
(2) to create a positive stress-free environment that will positively influence
the patient’s eating behavior, (3) to improve communication between family
members, and (4) to develop functional strategies for managing crises.

Postinpatient CBT-E
Toward the end of treatment, in the day hospital phase, considerable effort is
put into arranging suitable postdischarge outpatient treatment, preferably
CBT-E-based, so as to ensure continuity of care. In order to ensure that
patients continue to improve, the logical suggestion is outpatient CBT-E.
is is supported by research that has highlighted a decrease in the rate of
relapse in patients given outpatient CBT aer discharge from the hospital
(Carter et al., 2009).
Indeed, our data indicate that relapse occurs mainly in the early months
aer discharge, and seems to be, at least in part, influenced by three main
factors: (1) the transition from an intensive to a less intensive therapy, (2) a
change in therapist, and oen the nature of the new treatment, and (3) the
exposure to multiple environmental stimuli (e.g., family environment,
school, peers, sports, or lack of friends and social support) that can activate
the eating-disorder mindset. To address these difficulties, we have designed
a postinpatient outpatient CBT-E that can be delivered by the same
psychologist who has attended the patient during the inpatient CBT-E, or
another therapist who has received CBT-E training.
Postinpatient CBT-E has the aims of addressing the residual eating-
disorder features using CBT-E strategies and procedures, and developing
specific skills to prevent relapse. e treatment in question has a duration of
20 weeks and includes 20 individual sessions, held twice a week in the first
month (to provide a higher intensity of care in the first phase of transition
from inpatient CBT-E to the home environment), once a week in the second
and third months, and, finally, once every 2 weeks in the fourth and fih
months. e advantages of postinpatient outpatient CBT-E are (1) it enables
patients to receive a time-limited treatment focused on addressing only the
residual eating-disorder features and preventing relapse, (2) patients can
continue treatment with the same therapist or one adopting the same model
of care, and (3) intensive support is provided in the initial months aer
discharge.
VIGNETTE
e patient is a severely underweight 17-year-old female. She reports the onset of the eating
disorder at 15 years of age (when she had a normal weight), when she decided to go on a diet to
lose weight and change the shape of her legs and belly. e course of her eating disorder has been
characterized by a progressive loss of weight, the appearance of secondary amenorrhea, and the
occurrence of recurrent episodes of subjective bingeing followed by self-induced vomiting and
self-harm (razor cuts to the arms and legs).
e patient has previously received two multidisciplinary eclectic outpatient treatments
combining individual psychodynamic therapy with fluoxetine and olanzapine, but there was no
improvement in her eating-disorder psychopathology. She has also been hospitalized in a
pediatric unit, where she was refed via a nasogastric tube. is intervention produced a weight
regain of about 10 pounds (4.5 kilograms), but no improvement in her eating-disorder
psychopathology.
In the first session of the preparation phase, the patient states that she has been obliged to
attend, and does not see her eating disorder as a problem. Moreover, she reports that she has been
traumatized by her previous inpatient experience and nasogastric feeding. However, despite her
reluctance, she agrees to exchange information with the assessing clinician. She appreciates the
nature of the inpatient CBT-E, which requires her active involvement in the decision to be
admitted and to address both weight restoration and concerns about eating, shape, and weight.
She agrees to attend some preparation sessions aimed at better understanding the nature of her
eating disorder, and weighing up the possibility of addressing it with inpatient CBT-E. Aer six
preparation sessions, the patient agrees to be put on the waiting list, and is admitted a month
later.
e patient immediately becomes engaged in treatment and develops a collaborative
relationship with her therapists. On the first day of treatment she interrupts the episodes of self-
induced vomiting and self-harm. At discharge she has reached the 35th BMI-for-age percentile
and shows a marked improvement in eating-disorder psychopathology, although she still retains
some residual dietary rules, particularly an excessive rigidity in planning meals and difficulty
accepting the shape of her legs and belly. During postinpatient outpatient CBT-E, the patient
experiences several subjective binge-eating episodes, triggered by arguments with her mother, but
thanks to her continued therapy she succeeds in addressing her residual dietary rules, and her
acceptance of her body shape improves. A further improvement in her eating-disorder
psychopathology is associated with an increase in socialization.
Twenty weeks aer completing postinpatient outpatient CBT-E, the patient has reached the
50th BMI-for-age percentile, complete remission of the eating-disorder psychopathology, and is
involved in a romantic relationship. To the question “What was the main reason that led you to
make the decision to actively address your eating problem?” the patient answers:
“e fact that I was being treated as a person and not as an illness, and was being actively
involved in all stages of treatment. is made me feel in control, and allowed me to face the
difficulties associated with weight regain with less anxiety and, gradually, to appreciate the feeling
of being free from the dictates of my eating problem.”
 CHAPTER 20

Comorbidity and CBT-E for

Adolescents

e term “comorbidity” was coined by Feinstein (1970, pp. 456–457), who

called it “the existence or occurrence of a distinct entity in the clinical
course of the patient who has the disease index under study.” e term is
frequently used and somewhat “fashionable” in psychiatry to indicate not
only those cases in which a patient receives a psychiatric diagnosis and a
medical one (e.g., major depression and type 2 diabetes, respectively) but
also those cases in which the patient receives two or more psychiatric
diagnoses (e.g., major depression and panic disorder; Maj, 2005).
However, comorbidity is a complex topic, both conceptually and
clinically. e definition of comorbidity from a conceptual point of view
refers to a situation in which “a distinct clinical entity develops during the
course of a disease” (e.g., when a patient with diabetes mellitus develops
Parkinson’s disease). In this case, there are two distinct clinical entities and a
lifetime concept is applied. e definition of comorbidity from a clinical
point of view refers, instead, to a situation in which “two or more distinct
clinical entities coexist.” In this case, the prevalence of comorbidity depends
on the definition of the disorders (i.e., the classification system and its
diagnostic rules). In the field of mental health, in which specific biomarkers
are thus far lacking, it is questionable whether psychiatric illnesses are
“distinct” clinical entities (Maj, 2005), or simply the result of the current
classification described in DSM-5 (American Psychiatric Association, 2013).
DSM-5 diagnostic criteria, based on the symptoms presented, encourage the
application of several psychiatric diagnoses in the same patient.
Problems related to the definition of comorbidity can have important
clinical consequences that affect the treatment. For example, the
characteristics of depression are common in patients with eating disorders,
but may be evidence of either a coexisting clinical depression (“true
comorbidity”) or the direct consequence of an eating disorder (“spurious
comorbidity”). In the first case, clinical depression must be treated directly,
whereas in the second case, the treatment of the eating disorder should lead
to a remission in the depressive features.

COMORBIDITY IN EATING DISORDERS

A narrative review has recently summarized the European studies to date

that have evaluated the prevalence of psychiatric comorbidity in eating
disorders (Keski-Rahkonen & Mustelin, 2016). Comorbidity has been
diagnosed in over 70% of people with eating disorders; the most common
coexisting disorders are anxiety disorders (>50%), mood disorders (>40%),
self-harm (>20%), and substance use disorder (>10%). e lifetime presence
of obsessions and compulsions seems to be frequent, and one study
performed in patients with anorexia nervosa has reported it in about 70% of
cases (Halmi et al., 2003). An aggregation of autism spectrum disorders in
probands with anorexia nervosa and their relatives has also been found
(Koch et al., 2015). Finally, there is some evidence of the existence of an
association between attention-deficit/hyperactivity disorder and eating
disorders (Sala et al., 2018).
 Nevertheless, it should be emphasized that data from the studies carried
out present a wide variability in the rate of psychiatric comorbidity in eating
disorders—for example, the prevalence of a lifetime history of an anxiety
disorder has been reported in as few as 25% to as many as 75% of cases
(Swinbourne & Touyz, 2007). is range inevitably casts significant doubts
on the reliability of these observations. Likewise, studies that assessed the
prevalence of personality disorders coexisting with eating disorders reported
an even greater variability, ranging from 27 to 93% (Vitousek & Manke,
1994).
at being said, anorexia nervosa has been frequently associated with
avoidant personality disorder (Cluster C, anxious/fearful), while bulimia
nervosa is more frequently associated with personality disorders from
Cluster B (dramatic/erratic/emotional). However, a recent meta-analysis,
which found a personality disorder prevalence of 53% in patients with any
type of eating disorder compared to 9% in healthy controls, did not find
statistically significant differences in the total prevalence of personality
disorders in anorexia nervosa (49%) and bulimia nervosa (54%) patients, or
in the various clusters of personality disorders, except for obsessive–
compulsive personality disorder, which was found to be more prevalent in
anorexia nervosa (23%) than in bulimia nervosa (12%; Martinussen et al.,
2017).

METHODOLOGICAL PROBLEMS

Studies that have evaluated comorbidity in eating disorders suffer from

serious methodological problems that reflect the embarrassingly wide
variability in the results of research that has attempted to assess this issue. In
summary, the main methodological flaws are the following:

Chronological onset. A distinction has not always been made whether

the “comorbid” disorder occurred before or aer the eating disorder.
 Small samples. e samples evaluated are, in most cases, small and with
a statistical power too low to permit reliable conclusions to be drawn.
Sample composition. e samples evaluated included the diagnostic
categories of eating disorders in different proportions.
Clinical samples. In most studies, clinical samples, in which the
prevalence of psychiatric comorbidity is likely to be greater than in
nonclinical samples, were evaluated.
Different tools. A large and heterogeneous number of diagnostic
interviews and self-administered tests were used to assess comorbidity.
Limited use of control groups. A control group based on gender and age
was rarely included in the studies.
Absence of evaluation of the secondary effects of the eating disorder. It
was almost never assessed whether the characteristics of comorbidity
were secondary to the disturbance in the diet.
Diagnosis performed by researchers or clinicians. e prevalence of
comorbidity may vary if the diagnosis is made by researchers using
standardized tools, or by clinicians who do not use them.

In personality disorders, moreover, numerous problems complicate the

interpretation of personality data in patients with eating disorders (Vitousek
& Manke, 1994). In particular, it is difficult to assess the true personality of
patients with eating disorders because it is influenced by specific
psychopathology and the consequences of malnutrition (Dalle Grave et al.,
2011). Furthermore, it is especially risky to make a diagnosis of coexisting
personality disorders in adolescents, because patients with eating disorders
who have an onset of their eating disorder at a young age have not
experienced a period free from the presence of an eating disorder (Fairburn,
2008).

COMORBIDITY OR COMPLEX CASES?

As in most cases, it is not clear whether concomitant diagnoses reflect the
presence of distinct clinical entities or refer to multiple manifestations of a
single clinical entity—the use of the term “comorbidity” to indicate the
concomitance of two or more psychiatric diagnoses is considered erroneous
by some (Maj, 2005). However, it is a fact that the finding of several
coexisting psychiatric diagnoses has become more and more frequent. is
is partly the consequence of the use of standardized diagnostic interviews,
which help to identify different clinical aspects that in the past had remained
unnoticed aer the main diagnosis, but is probably mainly the consequence
of the current DSM-5 classification system for at least four principal reasons
(Maj, 2005):

1. e use of the implicit rule that the same symptom should not appear
in more than one disorder (e.g., anxiety should not appear as a
symptom in the diagnostic criteria of major depression, although
people with depression oen have symptoms of anxiety).
2. e proliferation of new psychiatric diagnostic categories.
3. e limited use of hierarchical diagnostic categories.
4. Diagnosis based on operational criteria rather than on criteria based
on clinical descriptions.

e artificial division of complex clinical conditions into small pieces has

the negative effects of preventing a more holistic approach to treatment and
promoting an unjustified use of several drugs to treat single pieces of a
broader and more complex clinical picture (Maj, 2005). For this reason, in
mental disorders it seems more appropriate and clinically useful to talk
about “complex cases” rather than comorbidities.
However, the notion that there is only a subset of “complex cases” cannot
be applied to eating disorders (Fairburn, Cooper, & Waller, 2008). Indeed,
almost all patients suffering from eating disorders can be considered
complex cases. Most, as described above, meet the diagnostic criteria for one
or more DSM-5 psychiatric disorders, particularly for clinical depression,
anxiety disorders, and substance use disorders, and many fit the description
of some personality disorder. Finally, physical complications are common,
and some patients have coexisting and interacting medical pathologies.
Interpersonal difficulties are the norm, and the chronic course of the
disorder can have a strong negative impact on the development and
interpersonal functioning of a person. All this shows that in patients with
eating disorders, complexity is the rule rather than the exception.

THE PRAGMATIC CBT-E APPROACH TO

COMPLEX CASES

CBT-E for adolescents adopts a pragmatic approach for addressing

psychiatric and medical comorbidity associated with eating disorders.
Comorbidity is recognized and eventually addressed only when it is
significant and has clinical implications. To this end, CBT-E divides
comorbidities into three groups:

1. Disorders that likely do not interfere with CBT-E but probably respond
to it. ese disorders need to be recognized, monitored, and
reassessed during the treatment, but they are not given special
attention. Examples are:
Clinical depression secondary to the eating disorder.
Social anxiety attributable to the eating disorder.
Malnutrition.
Unstable diabetes.
2. Disorders that likely interfere with CBT-E but do not respond to it.
ese disorders need to be recognized and a decision made about
when to treat them (e.g., before or aer, but not simultaneously with
CBT-E). Examples are:
Posttraumatic stress disorder, including reported sexual abuse.
 Obsessive–compulsive disorder (the possibility of associating CBT-
E with a selective serotonin reuptake inhibitor [SSRI] may be
assessed, but not another psychological treatment).
Obesity.
3. Disorders that interfere with CBT-E. ese disorders need to be
recognized and treated before starting CBT-E. Examples are:
Continuous misuse of substances.
Acute psychosis.
Clinical depression not secondary to the eating disorder.

COEXISTING CLINICAL DEPRESSION

Understanding whether the coexistence of an eating disorder and clinical

depression is a comorbidity is especially complex, because there is a
substantial conceptual overlap between the two conditions (Fairburn,
Cooper, & Waller, 2008). In anorexia nervosa, many features used for the
diagnosis of clinical depression are known to be the consequences of being
underweight. Examples are:

Low mood.
Social withdrawal.
Heightened obsessionality and indecision.
Poor sleep.
Decreased energy and drive.
Loss of interest in sex.
Impaired concentration.
Irritability.

Likewise, in bulimia nervosa, many features used for the diagnosis of clinical
depression are known to be the consequence of the recurrent binge-eating
episodes. Examples are:
 Self-criticism.
Low mood.
Social withdrawal.
Shame.
Guilt.
Feelings of impotence.

Features that we view as suggestive of clinical depression not secondary but

coexisting with an eating disorder are the following:

A personal history of clinical depression before the onset of the eating

disorder.
Late onset of an eating disorder.
Recent intensification of depressive features in the absence of any
change in the eating-disorder psychopathology (e.g., low mood, social
withdrawal, and suicidal thoughts and plans).
Loss of interest, crying, recurrent thoughts on the uselessness of life,
and personal neglect.

e more of these features are present, the more confident we are that a
diagnosis of a clinical depression is warranted.
Patients with an eating disorder and clinical depression may think that it
is not possible to change, do not have the energy to address the treatment,
and their concentration is too poor to understand and retain the
information provided. In these cases, we recommend, aer having educated
the patient and obtained informed consent from the parents, a
pharmacological treatment (antidepressants) for 9–12 months. e decision
to use antidepressants and not a psychological treatment to treat the
coexisting clinical depression was made in light of two main observations
(Fairburn, Cooper, & Waller, 2008): (1) psychological treatment of clinical
depression requires a lot of time, and progress is limited by the presence of
the eating disorders, as the two psychopathologies negatively interact, and
(2) antidepressants, in particular SSRIs (e.g., fluoxetine and sertraline), work
well and rapidly.
e management of coexisting clinical depression in adolescence is
controversial. SSRI antidepressant medications are associated with few side
effects in adolescents, but they may trigger agitation and abnormal behavior
in certain individuals. Hence, the pros and cons of pharmacological
treatment should be carefully evaluated, especially considering the increased
risk of suicidal thoughts or behavior in children and adolescents treated
with antidepressants (Jureidini et al., 2004). Indeed, fluoxetine and
escitalopram are the only medications approved by the U.S. Food and Drug
Administration for use in treating depression in children from ages 8 and
12, respectively. Should the CBT-E physician decide to prescribe an
antidepressant medication, adolescent patients must be closely monitored,
especially in the first few weeks of treatment, for any worsening of
depression, emergence of suicidal thinking or behavior, or unusual
behavioral changes, such as sleeplessness, agitation, or withdrawal from
normal social situations.
If clinical depression does appear to be present, we explain to the patient
and parents that it is important to treat it first, as recovering from depression
will not only result in the patient feeling better but it will also mean that she
or he will be more capable of overcoming her or his eating disorder. We also
explain that our preferred mode of treatment is antidepressant medication
because it works well and rapidly, thereby allowing us to move quickly on to
the psychological treatment of the eating disorder. We add that
antidepressant drugs are not addictive, are easy to stop, and in the case of
fluoxetine, there is no discernible withdrawal syndrome—it is not a mood
enhancer, but it does treat clinical depression. ere are very few side effects
(e.g., nausea that usually lasts no more than 5 days, a fine tremor, difficulty
swallowing, and reduction or loss of sexual appetite and responsiveness)—a
small number of patients choose to discontinue the drug due to these.
However, there is also a greater sensitivity to the intoxicating effects of
alcohol, so patients are advised to avoid drinking. Finally, fluoxetine does
not increase appetite or weight. Indeed, at higher doses (60 milligrams) it
can reduce the propensity to binge-eat.
If the patient and/or parents refuse antidepressant drugs, we recommend
inpatient CBT-E because a study has shown that there are no differences in
the short- and long-term outcomes of patients with an eating disorder with
clinical depression in comparison to those without (Calugi, El Ghoch, Conti,
& Dalle Grave, 2014).
VIGNETTE
e patient is a 17-year-old female. At the time of the assessment and preparation session she
reports the onset of an eating disorder at 14 years of age. is was characterized by the adoption
of dietary restriction, which resulted in a progressive weight loss from 123 to 101 pounds (55.8 to
45.8 kilograms), and the onset of secondary amenorrhea. Aer about a year, the dietary
restriction phase was interrupted by the appearance of recurrent binge-eating episodes followed
by self-induced vomiting. ese behaviors were associated with weight gain, and her maximum
weight was 150 pounds (68 kilograms). e patient was given a nonspecific psychological
treatment for about 2 years without any improvement in her eating-disorder psychopathology.
Aer the suspension of this treatment, however, she reduced the frequency of binge-eating
episodes, mitigated her dietary restriction, and maintained a weight of around 121 pounds (54.8
kilograms).
Nonetheless, at the assessment she reports that 6 months ago her parents separated, and since
then she has been experiencing an intensification in concerns about shape, weight, and eating
control, and her body weight has dropped to 110 pounds (49.8 kilograms). During the interview,
she displays the presence of a very low mood, with frequent crying, which is accentuated when
the interviewer asks about her parents’ divorce and the effect of this on her life. She also reports
impaired concentration, loss of interest, and negative thoughts about herself characterized by
continuous doubts about being able to complete her studies, and about her ability to recover from
the eating disorder. e interviewer explains to the patient that these features are characteristic of
clinical depression coexisting with the eating disorder, and recommends, with the agreement of
both parents, that first the clinical depression be treated with 20 milligrams of fluoxetine per day.
e patient is reassessed aer 2 and 4 weeks, and reports a marked improvement in mood, as
well as improved capacity to concentrate. She also reports being motivated and ready to start
CBT-E, which she completes in about 20 weeks. Aer 9 months, the antidepressant is
discontinued and the patient is in complete remission from the eating disorder.

COEXISTING ANXIETY DISORDERS

Anxiety disorders are common in adolescents with eating disorders, but
they do not pose nearly as great a management problem as clinical
depression because they do not generally interfere with treatment. Some
features suggestive of an anxiety disorder are oen present in patients with
an eating disorder. For example, avoidance of socializing due to difficulty
eating in front of others is not uncommon, especially among underweight
patients. It is not indicative of a social phobia, however, as the fear is
attributable to the eating disorder. e same is true of ritualized eating and
hoarding, which is likely a nonspecific effect of being significantly
underweight rather than evidence of an obsessive–compulsive disorder.
Although coexisting anxiety disorder does not tend to interfere with
treatment, there are some exceptions:

Severe agoraphobia. is needs to be treated first, as it makes it

impossible for patients to attend sessions.
Obsessive–compulsive disorder in which the compulsions affect the
patients’ eating in such a way as to maintain the eating disorder (e.g.,
fear of food contamination causing food intake to be limited). Such
patients need to have either the anxiety disorder addressed first, or the
two disorders treated in tandem (by the same therapist). e latter
option is difficult and requires an especially skilled and experienced
therapist capable of adapting CBT-E to accommodate obsessive–
compulsive disorder and its treatment.

Other anxiety disorders are separate from the eating disorder and do not
interact with it, nor will they affect treatment. A typical example is
posttraumatic stress disorder, or obsessive–compulsive disorders with
compulsions not influencing a patient’s eating. In such cases, we discuss with
the patient and the parents which problem they would like to address first,
as we think it unwise to engage in two psychological treatments at once. In
most cases, secondary anxiety features will dissipate if the eating disorder is
successfully treated, and sometimes this is true of coexisting anxiety
disorders, such as generalized anxiety disorder.

COEXISTING SUBSTANCE MISUSE

Substance misuse is common among patients with eating disorders and

binge-eating episodes. It may involve excessive alcohol intake or the use of
recreational drugs (e.g., marijuana or ecstasy), while a small proportion of
adolescent patients take cocaine or amphetamines. In the latter case, they
may be used in part as a means of weight control.
If the substance misuse is intermittent, we generally address it in the
context of treating the eating disorder. In many of these patients, the
presence of mood intolerance should be assessed, as it may be serving to
maintain both the eating disorder and the substance misuse. In such
patients, substance misuse may be intermittent (e.g., nonsocial binge
drinking), as opposed to steady, and they may report a history of self-harm
or other forms of dysfunctional mood modulation. We usually treat these
cases with CBT-E incorporating the Mood Intolerance module (see Chapter
17). However, if patients are frequently intoxicated during the day, we
suggest they get specialist help for their substance misuse prior to beginning
CBT-E.
As cigarette smoking seldom interferes with CBT-E, it is rarely addressed
during treatment unless it is being used as a means of dietary restriction. In
this case, it is advisable to suggest healthier alternatives as opposed to
quitting, which would be too great a challenge for patients while they are
attempting to tackle their eating disorder. Cigarette smoking can be
addressed once patients have recovered from their eating disorder.

COEXISTING PERSONALITY DISORDERS

As previously discussed, it is difficult to assess the personality of patients
with eating disorders because many of the features of interest are directly
affected by the presence of the eating disorder. Due to this, and other
reasons, it is not our practice to do so. However, we do treat many patients
who receive a general diagnosis of personality disorder by adding one or two
modules from the broad form of CBT-E. Here are some examples:

e Mood Intolerance module with patients who engage in self-harm

or substance misuse (oen diagnosed with borderline personality
disorder).
e Clinical Perfectionism module with patients with clinical
perfectionism (who oen receive a diagnosis of obsessive–compulsive
personality disorder).
e Core Low Self-Esteem module with patients with core low self-
esteem (who may receive a diagnosis of avoidant or dependent
personality disorder).

OTHER COEXISTING MENTAL DISORDERS

Albeit with less frequency, patients with eating disorders may have another
mental disorder, including bipolar I or II, schizophrenia, conversion
disorder, hypochondriasis, or body dysmorphic disorder. If patients are
stabilized, CBT-E can proceed as usual, and these patients oen do well;
otherwise they should be treated for the coexisting psychiatric disorder
before starting the treatment for the eating disorder. Unfortunately, however,
some neuroleptics and mood-stabilizing drugs undermine control over
eating and result in weight gain—side effects that are unacceptable to
patients with eating disorders.

COEXISTING OBESITY
Obesity is the general medical condition most commonly observed among
patients with eating disorders. It coexists frequently with binge-eating
disorder, and in some cases of bulimia nervosa. When they coexist, obesity
and eating disorders negatively interact with each other through two main
mechanisms: (1) binge-eating episodes promoting weight gain and (2)
excess weight increasing concern about body weight and shape, and
encouraging the adoption of dieting and other extreme weight-control
behaviors that, in turn, increase the risk of episodes of binge eating.
However, CBT-E for adolescents is focused on the eating-disorder
psychopathology, not on weight loss. is is because the adoption of a strict
diet maintains the psychopathology of an eating disorder, increasing in turn
a preoccupation with food and eating and the risk of binge-eating episodes,
which tends to intensify the overvaluation of shape, weight, and their
control. Weight loss can be considered aer prolonged remission of the
eating disorder (e.g., at the posttreatment review), but it is important to find
an approach that will likely not lead to relapse of the eating disorder. In such
patients, so-called binge-proof dieting, characterized by flexible dietary
guidelines rather than strict rules, is a viable option.

COEXISTING TYPE 1 DIABETES

e prevalence, clinical features, and medical consequences of eating

disorders in people with type 1 diabetes mellitus have received increasing
attention since reports of this dangerous combination were first published in
the 1980s (Szmukler, 1984). Although, initially, the specificity of this
association was not clear, systematic research carried out over the last 20
years has shown that eating disorders are more frequent in people with type
1 diabetes than in the general population (Young et al., 2013). Current
evidence indicates that the coexistence of an eating disorder with type 1
diabetes is associated with poor glycemic control and, consequently, a higher
risk of medical complications (Pinhas-Hamiel, Hamiel, & Levy-Shraga,
2015).
Type 1 diabetes may interact negatively with eating disorders through
two main mechanisms (Fairburn, Cooper, & Waller, 2008): (1) the hunger
that can follow injecting insulin may make it difficult for patients to follow
the regular eating intervention, and (2) binge-eating episodes or the
manipulation of insulin to control weight (e.g., reducing the insulin dose to
eliminate glucose in urine) compromises glycemic control, and there is an
increased risk of diabetic coma in the short term and vascular complications
in the long term.
However, in most cases, type 1 diabetes does not preclude CBT-E, and
the treatment of an eating disorder can improve a patient’s ability to control
blood sugar. e only adjustments to be made to CBT-E are to include the
omission of insulin and its consequences in the personal formulation (see
Figure 20.1), and to report insulin units and daily blood sugar levels in the
“Context and Comments” column of the monitoring record.

FIGURE 20.1. Formulation of a patient with bulimia nervosa and type 1 diabetes.

Nevertheless, in the first phases of the treatment, a transient worsening

of glycemic control may occur as a result of weight regain and the
introduction of avoided food. When such interactions are possible, it is
essential that the therapist maintain close contact with the team that is
managing the general medical disorder.
In some cases, particularly in adolescent patients with anorexia nervosa
and type 1 diabetes, or in those who have repeated episodes of ketoacidosis
due to the omission of insulin, inpatient CBT-E may be indicated, as it has
been shown to determine weight normalization 1 year aer discharge in
81% of cases (Dalle Grave et al., 2014).
VIGNETTE
e patient is a 16-year-old female with anorexia nervosa and type 1 diabetes. From diabetes
onset at the age of 10 to the age of 14, the patient scrupulously followed the instructions received
for managing both her insulin and diet through the calculation of carbohydrate intake. At 14
years of age, however, when she started high school at a weight of 123 pounds (55.8 kilograms),
she began to restrict her diet in order to lose some weight and change the shape of her body, in
particular the shape of her legs and belly. In a few months, the patient had lost about 22 pounds
(10 kilograms), accompanied by the onset of secondary amenorrhea. Aer 6 months she began to
have recurrent episodes of binge eating, which she initially tried to compensate for, without
success, via self-induced vomiting and subsequently with the reduction in, and in some cases,
omission of insulin. ese behaviors produced a dramatic deterioration of her glycemic control
and led to an episode of ketoacidosis coma treated with an urgent hospitalization.
Aer discharge, the patient tried a specialized treatment for her eating disorder with
unsatisfactory results. For this reason, she was referred to us by her diabetologist to assess the
possibility of inpatient CBT-E. At the time of the assessment and preparation session, the patient
weighs 69 pounds (31.3 kilograms) and reports the adoption of extreme and inflexible dietary
rules (skipping meals, eliminating carbohydrates, not eating with others) and recurrent binge-
eating episodes (an average of two per week), which she compensates for by not taking insulin
and fasting for a whole day. She also reports extreme fear of getting fat, overvaluation of shape,
weight, and their control, frequent body checking, irritability, social isolation, and no longer
going to school. e latest lab tests show a glycated hemoglobin level of 12% (optimal value <7%).
Aer four preparation sessions, the patient agrees to make inpatient CBT-E a priority, and
play an active role in overcoming her eating disorder so that she can improve her glycemic control
and “have a life.” She actively engages in intensive CBT-E, which lasts 20 weeks (13 weeks of
hospitalization and 7 weeks of day hospital), and reaches a 30th BMI-for-age percentile. In
agreement with the diabetologist, it is collaboratively decided to suspend her carbohydrate
counting (a procedure that intensifies her concerns about food) and to introduce a broad variety
of foods to allow her to maintain a healthy low weight by adopting healthy nutritional guidelines
in a flexible way. e normalization of the patient’s body weight, together with the elimination of
dietary restriction and extreme and inflexible dietary rules, is associated with a remission in
binge-eating episodes and a marked improvement in her glycated hemoglobin (7.3% in the last
 week of hospitalization). However, concerns about shape and weight and their control and
secondary amenorrhea are still present at discharge.
Aer completing the inpatient program, the patient participates in 20 postinpatient outpatient
CBT-E sessions, in which she addresses residual problems concerning her negative body image,
and develops skills to identify and manage early signals of activation of the eating-disorder
mindset in order to prevent relapse. At the last posttreatment review session (40 weeks aer
discharge) the patient has a 35th BMI-for-age percentile, a regular menstrual cycle, a glycated
hemoglobin level of 6.2%, and only moderate concern about the shape of her legs. She has also
resumed attending school, is achieving good grades, and has reestablished relationships with the
friends she had interrupted in the acute phase of her eating disorder.

OTHER COEXISTING GENERAL MEDICAL

CONDITIONS

In a small subgroup of patients, other general medical conditions (e.g., celiac

disease, irritable bowel syndrome, food intolerance, and food allergy) may
coexist with the eating disorder. With such conditions, as for type 1 diabetes,
the interactions may be bidirectional, but are usually less marked and
harmful. In these cases, CBT-E may not need to be modified at all, although
liaison with the relevant physician is always important.
Appendice
s
 APPENDIX A

Terms Used to Describe Eating-

Disorder Psychopathology

Anorexia: lack or loss of appetite for food.

Body image disparagement: viewing one’s body as loathsome or repulsive.
Body mass index (BMI): an approximate measure of whether someone is over- or underweight,
calculated by dividing the person’s weight in pounds by the square of the person’s height in inches
and then multiply that number by 703.
BMI-for-age percentile: BMI levels among children and teens expressed relative to other children of
the same age and sex. It determines a child’s weight status based on an age- and sex-specific
percentile for BMI rather than the BMI categories used for adults. is is because children’s body
composition varies as they age and also depends on their gender.
Body-shape dissatisfaction: dislike of one’s own appearance.
Concerns about weight, shape, and eating: repeated and recurring thoughts associated with anxiety
and apprehension about weight, body shape, and eating control.
Core psychopathology: the characteristic overvaluation of shape, weight, and eating control seen in
most people with eating disorders.
Debiting: the creation of an energy deficit to accommodate subsequent eating.
Delay eating: postponing eating.
Dietary guidelines: general flexible dietary objective.
Dietary restraint: attempts to limit the amount of food eaten.
Dietary restriction: undereating in a physiological sense.
Dietary rules: highly specific dietary goals.
Eating-disorder mindset: an established set of attitudes held by people with eating disorders.
Excessive exercising: when the duration, frequency, or intensity of exercise exceeds what is required
for physical health and increases the risk of physical injury. It is a form of exercising that is
associated with a subjective sense of being driven or compelled to exercise; it has priority over
other activities (e.g., school), and is associated with feelings of guilt and anxiety when postponed.
Fear of weight gain or of becoming fat: fear of gaining weight or becoming fat, which is not reduced
by weight loss.
Feeling fat: inaccurate labeling of unpleasant physical states, unpleasant emotional states, and states
of heightened body awareness as “feeling fat.”
Food avoidance: the purposeful avoidance of certain foods.
Food checking: repeated and frequent checking of the portion of the food to be eaten (e.g., weighing,
counting the calories, checking food nutrition labels, making comparisons with the eating
behavior of others).
Grazing: the tendency to pick more or less continuously at food throughout the day.
Objective binge eating: episodes of eating characterized by both of the following: (1) eating a large
amount of food given the circumstances and (2) a sense of lack of control during such episodes.
Overvaluation of shape and weight and their control: judging self-worth largely, or even exclusively,
in terms of shape and weight and the ability to control them.
Purging: self-induced vomiting and/or laxative or diuretic misuse.
Compensatory purging: episodes of purging that occur in response to objective or subjective
binge eating.
Noncompensatory purging: episodes of purging that do not occur in response to objective or
subjective binge eating.
Shape avoidance: avoiding looking at or touching one’s own body or showing other parts of one’s
body.
Shape checking: repeated and frequent checking of one’s body shape (e.g., in the mirror, measuring
various parts of the body, making comparisons with the shape of other people’s bodies, and/or
making repeated requests of other people for reassurance about the shape of one’s own body).
Starvation symptoms: the physical and psychosocial symptoms that occur secondary to dietary
restriction and undereating.
Subjective binge eating: episodes of eating characterized by both of the following: (1) eating an
amount of food that is not large given the circumstances and (2) a sense of lack of control during
the episodes.
Weight avoidance: avoiding measuring one’s own body weight.
Weight checking: repeated and frequent measurement of one’s body weight.
 APPENDIX B

The Effects of Caloric Restriction and

Weight Loss
The Minnesota Starvation Experiment

e Minnesota Starvation Experiment is considered the key reference on the effects of dietary
restriction and weight loss in normal-weight individuals. e study was carried out at the University
of Minnesota between November 19, 1944, and December 20, 1945 (Keys et al., 1950). It was designed
to evaluate the physiological and psychological effects of severe and prolonged dietary restriction and
the effectiveness of nutritional rehabilitation strategies. e principal aim of the study was to guide the
assistance to famine victims in Europe and Asia during and aer World War II by using the data
derived from a laboratory simulation of severe famine.
More than 100 male volunteers signed up to participate in the study as an alternative to military
service. Of this initial sample, 36 men with the best physical health and psychological functioning,
and the highest motivation to participate, were selected (Keys et al., 1950). e participants were all
white males between 22 and 33 years of age. Of the 36 volunteer individuals, 25 were members of the
historic peace churches (Mennonites, Church of the Brethren, and Quakers).
e study was divided into three phases: a control period of 12 weeks, 24 weeks of semistarvation,
and 12 weeks of rehabilitation. During the control period the mean daily energy intake of the
participants was 3,492 calories, during the period of semistarvation this was decreased to a mean of
1,570 calories, and during the rehabilitation period it was increased to normal levels. In the
semistarvation period, participants were fed foods most likely consumed in European famine areas,
and lost approximately 25% of their body weight.
Complete data are available only for 32 participants because four participants dropped out of the
study during or at the end of the second phase of semistarvation. e individual reactions to
semistarvation and weight loss were varied, but in most cases, the participants experienced dramatic
effects and the development of a set of so-called starvation symptoms (see Table B.1).
 TABLE B.1. Effects of Semistarvation Reported by
Participants in the Minnesota Starvation Experiment
Behavioral effects
Eating rituals (eating very slowly, cutting food into small
pieces, mixing food in a bizarre way, ingesting very hot food).
Reading cookbooks and collecting recipes.
Increasing coffee and tea consumption.
Increasing the use of salt, spices, gums, hot soup, and water.
Nail-biting.
Increased smoking.
Binge-eating episodes.
Increasing exercise to avoid the reduction of the calorie
content of the diet.
Self-mutilation.

Psychological effects
Impairment of concentration capacity.
Poor insight and critical judgment.
Preoccupation with food and eating.
Depression.
Mood swings.
Irritation.
Hunger.
Anxiety.
Apathy.
Psychotic episodes.
Personality changes.
Social impairment.
Social withdrawal.
Loss of sexual appetite.

Physical effects
Abdominal pain.
Gastrointestinal discomfort.
Sleep disturbances, vertigo.
Headache.
Weakness.
Hypersensitivity to light and noises.
Edema.
Cold intolerance.
Paresthesia.
Reduction of basal metabolism.
Reduction of heart rate and respiratory frequency ±45.
Note. Derived from The Biology of Human Starvation by A. Keys, J. Brozek, A.
Henschel, O. Mickelsen, and H. Taylor (1950).

Knowledge of these starvation symptoms and how they interact with eating-disorder expressions
have important implications for both understanding and treating eating disorders (Dalle Grave et al.,
2011; Garner, 1977).

BEHAVIORAL EFFECTS
Toward the end of the semistarvation phase the participants were spending almost 2 hours eating a
meal similar to those that they had previously consumed in a few minutes. Many participants read
cookbooks and collected recipes. Some increased their coffee and tea consumption, drank large
amounts of water or soups to increase their satiety, and developed specific eating rituals (e.g., eating
very slowly, cutting the food in small pieces, mixing the food in a bizarre way, ingesting hot food). e
use of salt, spices, and gum increased, as did nail-biting and smoking. Many of these behaviors
persisted during the 12-week weight-restoration phase.
During semistarvation, all of the participants reported a significant increase in hunger. Some were
able to tolerate it, while others had binge-eating episodes followed by self-criticism. In the weight-
restoration phase, when participants had access to large amounts of food, some lost the control of
eating, taking in more or less than necessary. Aer 5 months of nutritional rehabilitation, most of the
participants had normalized their eating habits, but a subgroup continued to eat large amounts of
foods. Many participants reduced their habitual level of physical activity and complained of having
less energy. However, some individuals used intense exercise so that they were allowed a larger
amount of food or to avoid a reduction of the caloric content of the diet.

PSYCHOLOGICAL EFFECTS
Most of the participants showed marked cognitive and emotional changes. ey reported decreased
concentration capacity, insight, and critical judgment, even though no changes in intellectual ability
were observed. e impairment in concentration capacity was probably due to the presence of
recurrent thoughts about food and eating that were reported by most of the participants. Some
suffered from periods of depression, while others had frequent periods of mood swings. Some became
irritated and developed episodes of hunger explosion. Anxiety and apathy were common, and in a
subgroup of participants, the emotional disturbances became so severe that the researchers coined the
term “starvation neurosis” to describe them. e emotional changes were confirmed by the Minnesota
Multiphasic Personality Inventory (MMPI; Schiele, Baker, & Hathaway, 1943), which showed a
significant increase in depression, hysteria, and hypochondria. Two participants developed psychotic
symptoms, and one self-mutilated three fingers of his hand to modulate his mood. In general, the
emotional changes did not disappear immediately aer rehabilitation, but persisted for many weeks.
However, some participants did not show any psychological deterioration for the entire course of the
study.

SOCIAL EFFECTS
Semistarvation also had a large effect on social functioning. Participants become inward looking and
self-focused, which led to social isolation. In general, they also reported a loss of sexual desire,
another effect that could have contributed to social withdrawal.

PHYSICAL EFFECTS
e most frequent symptoms reported by participants during the dietary restriction phase were
abdominal pain, difficult and long digestion, sleep disturbances, vertigo, headache, strength
reduction, hypersensitivity to light and noises, edema, cold intolerance, sight and hearing alterations,
and paresthesia (“pins and needles”). Participants showed a marked reduction in their basal
metabolism (almost a 40% decrease), as well as in pulse rate and respiratory frequency. During the
weight-restoration phase, their basal metabolic rate increased proportionally with the increased
energy intake, and they regained their baseline body weight aer having lost 25% or more of their
initial body weight.

COMMENTS BY PARTICIPANTS IN THE

MINNESOTA STARVATION EXPERIMENT
In 2003–2004, 18 of the 36 participants were still alive, and were interviewed by researchers from the
Johns Hopkins School of Medicine, Baltimore, Maryland (Kalm & Semba, 2005). Participants were in
their 80s when interviewed, and each spoke passionately when discussing why they chose to be a
conscientious objector and to participate in the experiment. Although data from the study have been
reported in great scientific detail in e Biology of Human Starvation (Keys et al., 1950), interviewees
painted an even more vivid picture of their daily lives during the experiment. ey reported that, aer
initial enthusiasm, they suffered from great changes in their personalities during the period of
semistarvation. ey became increasingly irritable and impatient with one another, and began to feel
the physical effects of calorie restriction. ey also reported an increase in introversion and less
energy, in addition to dizziness, extreme tiredness, cold intolerance, muscle soreness, hair loss,
reduced coordination, ringing in their ears, and poor concentration. Food became an obsession for all
participants, and several men confirmed that their interest in women and dating disappeared soon
aer the study began. Despite the difficulties of semistarvation, they reported a strong determination
to continue the study, and suggested different reasons for their dedication (e.g., religious overtones,
discipline, and willpower; Kalm & Semba, 2005).
For some men, the rehabilitation period was considered the most difficult part of the experiment.
ey reported that symptoms of dizziness, apathy, and lethargy were the first to decrease, while
feelings of tiredness, loss of sex drive, and weakness were much slower to improve. ey said that they
had not returned to normal by the end of the 3-month recovery period. Many overate aer they le
Minnesota and developed obesity. ey estimated that the time to achieve a full recovery ranged from
2 months to 2 years. However, none of the participants believed they experienced any negative long-
term health effects as a cause of the experiment.

IMPLICATIONS FOR PEOPLE WITH AN EATING

DISORDER
e Minnesota Starvation Experiment shows that many symptoms that were thought to be specific to
anorexia nervosa are, in fact, consequences of calorie restriction and being underweight (Garner,
1977). ese symptoms are not limited to food and weight, but potentially extend to all areas of social
and psychological functioning. It is therefore essential to normalize body weight to restore normal
psychological function and personality (Garner, 1977).
However, the effects of being underweight in individuals with eating disorders is different from
those observed in subjects without these disorders. Indeed, in the absence of eating-disorder
psychopathology, starvation symptoms lead individuals to focus their attention primarily toward the
search for food, and when food becomes available they eat without being concerned about losing
control of their shape and weight. In contrast, in people with eating disorders, the presence of an
eating-disorder psychopathology (i.e., the overvaluation of shape, weight, and their control)
(Fairburn, Cooper, et al., 2003), interacting with starvation symptoms, tends to maintain the eating
disorder through several mechanisms (see Table B.2).

TABLE B.2. Proposed Mechanisms through which Starvation Symptoms Maintain

Eating-Disorder Psychopathology

1. Starvation symptoms increase the need to get control over eating, shape, weight, or
oneself in general.
2. Preoccupation with food and eating keeps the eating-disorder mindset permanently
“in place.”
3. Social withdrawal and loss of previous interests prevent the development of other
domains of self-evaluation.
4. Remaining underweight requires the adoption of a hypocaloric diet, which reinforces
the preoccupation with food and eating.
5. Indecisiveness makes it difficult for patients to decide whether to change
(procrastination).
6. Heightened need for routine and predictability interferes with change.
7. Heightened feeling of fullness makes it difficult to increase the amount of food eaten.

In particular, it has been suggested that in some people, symptoms of being underweight stimulate
further dietary restriction by undermining their sense of being in control over their eating, shape,
weight, or themselves in general (Fairburn, Shafran, et al., 1999), while other symptoms exaggerate
the tendency to use control over eating as an indicator of self-control in general (Shafran et al., 2003).
It has also been proposed that some individuals interpret the symptoms of being underweight as a
positive sign of being in control and as evidence that they are working hard to achieve their goal of
controlling eating, shape, and weight (Dalle Grave et al., 2007; Shafran et al., 2003).

From Cognitive Behavior erapy for Adolescents with Eating Disorders by Riccardo Dalle Grave and
Simona Calugi. Copyright © 2020 e Guilford Press. Permission to photocopy this material is
granted to purchasers of this book for personal use or use with patients (see copyright page for
details). Purchasers can download enlarged versions of this material (see the box at the end of the
table of contents).
 APPENDIX C

The Starvation Symptom Inventory

NATURE AND USE

e Starvation Symptom Inventory (SSI; Table C.1 on page 324) is a 15-item self-report measure that
evaluates the symptoms of starvation in underweight patients with eating disorders. It is focused on
the past 28 days. e SSI can be easily integrated in routine clinical practice to assess starvation
symptoms in underweight patients with eating disorders, and to assess their changes during the
process of weight restoration in those who attend specialized eating-disorder treatments. It can also be
used in studies designed to assess the effects of treatments for an eating disorder.
TABLE C.1. The Starvation Symptom Inventory (SSI)
Instructions: The following questions are about the past 4 weeks (28 days). Please read
each question carefully and respond to all questions. Thank you.

13– 16– 23–

How many times in the last 28 days 1–5 6–12 15 22 27 Every
have you: Never days days days days days day
1. Worried about food?

2. Collected recipes, menus, or

cookbooks?

3. Increased your consumption of

tea, coffee, or spices?

4. Felt depressed?

5. Felt anxious?

6. Felt irritable?

7. Had mood swings (between

excitement and depression)?

8. Stayed away from other people?

9. Experienced a loss of
concentration?

10. Felt apathetic?

11. Had disturbed sleep?

12. Felt weak?

 13. Experienced a lack of interest in
sex?

14. Felt cold?

15. Felt full early?

From Cognitive Behavior erapy for Adolescents with Eating Disorders by Riccardo Dalle Grave and Simona Calugi.Copyright ©
2020 e Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use with
patients (see copyright page for details). Purchasers can download enlarged versions of this material (see the box at the end of the
table of contents).

STATUS OF THE SSI

e design and validation of the SSI was published in the journal Nutrients.
e structure of the SSI mirrors that of the EDE-Q, and participants are asked to provide an
estimate of the number of days out of the preceding 28 (4 weeks) in which they have experienced the
symptoms on a 7-point Likert scale ranging from “never” (0) to “always” (6).
Principal component analysis identified a single-factor, 15-item scale that demonstrated good
internal consistency (Cronbach’s alpha = .91) and test–retest reliability (r = .90). e SSI global score
was significantly correlated with eating-disorder and general psychopathology scores, demonstrating
good convergent validity. SSI scores were significantly higher in the anorexia nervosa sample than in
healthy controls, and not-underweight eating-disorder and bipolar depressive-episode samples. ese
findings suggest that the SSI is a valid self-report questionnaire that may provide important clinical
information regarding symptoms of starvation in patients with anorexia nervosa.
A study of 90 female patients with anorexia nervosa treated with inpatient CBT-E showed that
baseline starvation symptoms were correlated with measures of eating-disorder and general
psychopathology. e treatment was associated with a significant increase in BMI, improvement in
eating-disorder and general psychopathology scores, and a significant reduction in starvation
symptoms. e change in SSI scores from baseline to 4 weeks predicted the improvement in eating
concern and general psychopathology at 6-month follow-up. Among patients who had restored their
body weight by the end of treatment, dietary restraint and eating concern EDE-Q subscales, global
EDE-Q, and SSI scores showed greater improvement in the first 4 weeks than in the remaining 16
weeks of treatment. ese findings underscore the close relationship between improvements in both
starvation symptoms and eating-disorder and general psychopathology, and indicate the important
role of refeeding in ameliorating both.

SSI SCORING
e questionnaire is scored by adding the scores from the 15 items. e resulting scores range from 0
to 90, where the highest score indicates increased frequency of starvation symptoms over the last 28
days. In patients with anorexia nervosa, the average score obtained is 55.1, while in healthy controls it
is 10.4.

REFERENCES
Calugi, S., Chignola, E., El Ghoch, M., & Dalle Grave, R. (2018). Starvation symptoms in patients with
anorexia nervosa: A longitudinal study. Eating Disorders, 26(6), 523–537.
Calugi, S., Miniati, M., Milanese, C., Sartirana, M., El Ghoch, M., & Dalle Grave, R. (2017). e
Starvation Symptom Inventory: Development and psychometric properties. Nutrients, 9(9), 967.

e SSI (and its items) is under copyright. However, it is freely available for noncommercial research
use only and no permission need be sought.
 APPENDIX D

The Eating Problem Checklist

NATURE AND USE

e Eating Problem Checklist (EPCL; Table D.1 on pages 327–328) is a 16-item self-report measure
designed to assess eating-disorder behaviors and psychopathology in patients with eating disorders
session by session. It is focused on the past 7 days. e 16 items cover the principal behaviors and
attitudes of eating-disorder psychopathology.
TABLE D.1. Eating Problem Checklist (EPCL) 3.1
Instructions: The following questions are about the past 7 days only. Read each question
carefully. Please answer all of the questions so that they are true for you. Thank you.

In the past 7 days, how often (indicate the number of times that this has No. of
occurred in the box on the right): episodes
. . . have you eaten a large amount of food with a sense of having lost control
(i.e., an objective binge-eating episode)?

. . . have you eaten a not large amount of food with a sense of having lost
control (i.e., a subjective binge-eating episode)?

. . . have you made yourself sick (vomited) as a means of controlling your

shape and weight?

. . . have you taken laxatives as a means of controlling your shape and

weight?

. . . have you taken diuretics (water pills) as a means of controlling your shape
and weight?

. . . have you exercised excessively as a means of controlling your weight,

shape, or amount of fat, or to burn extra calories?

. . . have you weighed yourself?

In the past 7 days, how often (check the 0 1 2 3 4

box that is true for you): never rarely sometimes often always
. . . have you avoided some foods as a
means of controlling your weight, shape,
and/or eating?
. . . have you reduced your food portions as
a means of controlling your weight, shape,
and/or eating?
. . . have you checked your food (e.g.,
calorie counting, weighing food, checking
the food’s nutritional content)?
. . . have you checked your shape (e.g.,
looking at parts of your body in the mirror,
measuring the circumference of parts of your
body, or compared your body shape with
that of other people)?
 . . . have you avoided your body (e.g.,
avoided weighing, avoided particular
clothes, avoided looking at your body)?
. . . have you felt fat?

. . . have you been worried about your

weight?

. . . have you been worried about your

shape?

. . . have you been worried about your eating

control?

How many “days of change” have you had?

Note. A “day of change” is when you did your best to change using the procedures you have learned during treatment.

From Cognitive Behavior erapy for Adolescents with Eating Disorders by Riccardo Dalle Grave and Simona Calugi. Copyright ©
2020 e Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use with
patients (see copyright page for details). Purchasers can download enlarged versions of this material (see the box at the end of the
table of contents).

e EPCL is quick and easy to complete, and can therefore be readily integrated into routine
clinical practice, enabling assessment of weekly changes. e tool allows the clinician and the patient
to assess, through a review of each single item score, any changes in specific eating-disorder
psychopathology expressions at weekly intervals. Moreover, through the assessment of the two
subscale scores (i.e., body image and eating concerns), the tool enables weekly changes in the core
psychopathology of eating disorders to be assessed. As an aid for clinicians and patients to identify
improvement and/or deterioration, the EPCL enables prompt focusing of the treatment on specific
expressions of an individual’s eating-disorder psychopathology. Moreover, sudden gains (i.e., large,
rapid, and stable changes in symptomatology between two consecutive treatment sessions) seem
associated with greater overall posttreatment symptom reduction and better outcomes. Associations
between sudden gains and short- and long-term improvements also appear to have a positive impact
on the therapeutic alliance (Graves et al., 2017).
In our clinical practice, we find it useful to review and discuss carefully with the patient the single-
item EPCL scores on a weekly basis (aer the CBT-E collaborative weighing procedure). is review,
if associated with the monitoring record review of the last 7 days, helps to highlight—when there is a
change of at least 1 point in one or more items of the EPCL—the changes that patients have made over
the week and identify the behavioral expressions of their eating-disorder psychopathology to be
addressed by the treatment. What is more, by recording weekly EPCL data on a summary spreadsheet
(Table D.2 on page 329), it is possible to observe whether modification of certain behaviors (e.g.,
adopting regular eating, reducing dietary restraint, weekly weighing, and/or interrupting
dysfunctional body checking) is associated with a reduction in concerns about eating, shape, and
weight over time—one of the primary goals and theoretical underpinnings of CBT-E.
TABLE D.2. Eating Problem Checklist (EPCL) Weekly Changes Summary
Spreadsheet
a
Number of events in the last 7 days.
b
Never = 0, rarely = 1, sometimes = 2, often = 3, always = 4.

From Cognitive Behavior erapy for Adolescents with Eating Disorders by Riccardo Dalle Grave and Simona Calugi. Copyright ©
2020 e Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use with
patients (see copyright page for details). Purchasers can download enlarged versions of this material (see the box at the end of the
table of contents).

STATUS OF THE EPCL

e design and validation of the EPCL has been published in the journal Eating Disorders. e EPCL
has demonstrated good internal consistency, test–retest reliability, and concurrent and criterion
validity. e principal component analysis of the session-by-session data identified two factors (eating
concern and body image concern) that accounted for 51.3% of the variance. Furthermore, session-by-
session analysis indicates that the EPCL is able to identify specific weekly changes and/or
deterioration in eating-disorder psychopathology.

EPCL SCORING
e total score is obtained by adding the items of section 2, while the scores of the two subscales are
obtained by adding together the scores for the following sets of items, all from the second section:
body image concern = the sum of items 4–8; eating concern = the sum of items 1–3 and 9.

REFERENCE
Dalle Grave, R., Sartirana, M., Milanese, C., El Ghoch, M., Brocco, C., Pellicone, C., & Calugi, S.
(2019). Validity and reliability of the Eating Problem Checklist. Eating Disorders, 1–16.

e EPCL (and its items) is under copyright. However, it is freely available for noncommercial
research use only and no permission need be sought.
 References

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American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th
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Barry, D. T., Grilo, C. M., & Masheb, R. M. (2002). Gender differences in patients with binge eating
disorder. International Journal of Eating Disorders, 31(1), 63–70.
Beck, A. T., Freeman, A., & Associates. (1990). Cognitive therapy of personality disorders. New York:
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Bohn, K., Doll, H. A., Cooper, Z., O’Connor, M., Palmer, R. L., & Fairburn, C. G. (2008). e
measurement of impairment due to eating disorder psychopathology. Behaviour Research and
erapy, 46(10), 1105–1110.
Bulik, C. M., Sullivan, P. F., Fear, J., & Pickering, A. (1997). Predictors of the development of bulimia
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 Index

e pagination of this electronic edition does not match the edition from which it was created. To
locate a specific passage, please use the search feature of your e-book reader or select a page number
link below.

Note. f or t following a page number indicates a figure or a table. Boldface numbers indicate a
vocabulary term from Appendix A.

Acceptance, 251–252, 267–268

Activities, 158–159, 176–178, 297
Addressing the Psychopathology step of treatment. See Step Two stage of CBT-E for adolescents
All-or-nothing thinking, 201–202, 234–236, 249
Anorexia nervosa
coexisting type 1 diabetes, 310
comorbidity and, 302
diagnostic criteria for, 5t, 6t
effectiveness of CBT-E for adolescents and, 25–26
formulation and, 67, 67f, 68f
inpatient CBT-E and, 282
overview, 4, 14–15, 315
transdiagnostic perspective and, 19–20
Anxiety and anxiety disorders, 19, 302, 307–308
Appraisals, 249, 267–268
Assertive communication, 257–258, 259
Assessment process. See also Assessment/preparation sessions
attitude towards treatment and, 104–105
binge analysis, 209
Events, Moods, and Eating Module and, 205–209, 208f
inpatient CBT-E and, 286, 288
maintaining progress and, 218–219, 220t–221t
medical management and, 52
mood intolerance and, 265–266, 265f
 origins of the overvaluation of eating, shape, weight, and their control, 214–216, 215f
overview, 38
parents-only session, 87–91
during Session 0, 65–66
shape avoidance and, 188
shape checking and, 184–185
Step One stage of CBT-E for adolescents and, 59t
Assessment/preparation sessions. See also Assessment process; CBT-E for adolescents; Session 0; Step
One stage of CBT-E for adolescents
contraindications to starting CBT-E, 50
first session of, 38–48, 40t–41t, 43f, 47t
formulation and, 66–67
medical management and, 51–53
overview, 26, 38
parents’ role in treatment and, 32–33, 87–91
second session of, 48–50, 65–66
Assisted eating, 277–278, 291–294. See also Eating habits
Atypical anorexia nervosa, 4, 6t, 75–76
Avoidance, 130–133, 239–240, 257–258. See also Body avoidance; Food avoidance; Shape avoidance;
Weight avoidance

Behavioral changes, 24, 40t–41t, 178–187, 180f–181f, 256–257, 318, 319t. See also Change
Binge eating
analyzing, 209
assessment and, 40t–41t
educating patients regarding, 44–45
establishing regular eating and, 113, 118
formulation and, 72–75, 73f
intensive outpatient CBT-E and, 272
maintenance plan and, 220t
mood intolerance and, 264
real-time monitoring and, 79–83, 80f, 81f, 84t
review sessions and, 144–145
transdiagnostic perspective and, 16–19, 17f
Binge-eating disorder, 4, 5t, 6t, 14–15
BMI-for-age percentile, 315
Body avoidance, 187–189, 315. See also Shape avoidance
Body image, 61, 132–133, 231–232. See also Body Image Module
Body image disparagement, 315
Body Image Module. See also Overvaluation of eating, shape, weight, and their control; Step Two stage
of CBT-E for adolescents
body avoidance and, 187–189
engaging in other aspects of life, 176–178
 extended personal formulation and, 173–176, 175f, 176f
feeling fat and, 189–191
inpatient CBT-E and, 288
overvaluation and its consequences, 170–173, 172f
overview, 169–170
parental involvement in, 191–192
shape checking and, 178–187, 180f–181f
Body mass index (BMI)
collaborative weighing and, 95
inpatient CBT-E and, 283
overview, 315
psychoeducation and, 98–103, 101f, 105–106
reasons given to avoid change and, 132
Body weight. See also Weight restoration; Weight-controlled behaviors
assessment and, 40t–41t
collaborative weighing and, 93–94, 94–95, 96f, 97f
intensive outpatient CBT-E and, 276
medical management and, 52
minimum low healthy weight and, 151–152
overview, 10, 11f
physical consequences, 11–14, 12t–13t
psychoeducation and, 98–103, 101f
reasons given to avoid changing, 130–133
Body–shape dissatisfaction, 7, 165, 315. See also Concerns about weight, shape, and eating
Broad form of CBT-E, 26, 28, 229–231, 289, 308–309. See also CBT-E for adolescents; Clinical
Perfectionism Module; Core Low Self-Esteem Module; Enhanced cognitive behavior therapy
(CBT-E); Interpersonal Difficulties Module; Mood Intolerance Module
Bulimia nervosa
coexisting type 1 diabetes, 309–310, 310f
comorbidity and, 302
diagnostic criteria for, 5t, 6t
overview, 4, 14–15

Caloric restriction, 105–106, 317–321, 319t, 321t. See also Dietary restriction
Case formulation. See Formulation
CBT-E (enhanced cognitive behavior therapy). See Enhanced cognitive behavior therapy (CBT-E)
CBT-E for adolescents. See also Assessment/preparation sessions; Broad form of CBT-E; Enhanced
cognitive behavior therapy (CBT-E); Inpatient CBT-E; Intensive outpatient CBT-E; Review
sessions; Step One stage of CBT-E for adolescents; Step Two stage of CBT-E for adolescents;
Step ree stage of CBT-E for adolescents
contraindications to starting, 50
effectiveness of, 25–26
first session of, 38–48, 40t–41t, 43f, 47t
 implementation of, 35–37
levels of care and, 28–29, 28f
overview, 21–24, 26, 27f, 28
psychoeducation regarding, 45–46, 47t, 75, 76–77, 88–89
rationale behind, 22
roles of patients, therapists, and parents in, 31–32, 32–33, 33–35, 34t
settings for, 28–31, 28f
suitability for, 49–50
therapist training and prerequisites, 33–35, 34t
waiting lists and, 53
Change. See also Behavioral changes; Pros and cons of change
barriers to, 145–148, 146t, 147t
CBT-E for adolescents and, 23–24
educating patients regarding CBT-E and, 76
helping patients decide to change, 124–134, 125t, 126t, 133t
maintaining following inpatient CBT-E, 297–300
parental barriers to, 90–91
pros and cons of, 124–126, 125t, 126t
reasons given to avoid, 130–133
Step One stage of CBT-E for adolescents and, 59t
viewing dieting as a problem, 194–195
Checking behaviors. See Food checking; Shape checking; Weight checking
Choice, 42, 115, 141
Classification systems, 3–6, 5t, 6t, 14–15, 303–304
Clinical Impairment Assessment (CIA 3.0), 39, 145, 224
Clinical perfectionism. See Perfectionism
Clinical Perfectionism Module, 231–242, 232f, 233f, 238f, 289, 309. See also Broad form of CBT-E;
Perfectionism
Clothing, 160–161, 165
Cognitive behavioral strategies, 156, 158
Cognitive behavioral therapy (CBT), 47t, 147t
Cognitive bias, 245–246, 247–250, 247f, 259–260
Collaboration, 38, 48, 49–50
Collaborative weighing. See also Weighing practices
education regarding weight and weighing and, 94–95, 98–103, 101f
inpatient CBT-E and, 289–290
overview, 93–95, 96f, 97f
Step One stage, 59t, 92
Communication skills, 257–258, 259
Comorbidity
anxiety disorders, 307–308
CBT-E and, 304
clinical depression, 305–307
 compared to complex cases, 303–304
medical concerns and, 312
methodological problems in studying, 302–303
obesity, 309
overview, 301–302, 309
personality disorders, 308–309
substance misuse and, 308
type 1 diabetes, 309–312, 310f
Comparison making, 186–187, 236. See also Shape checking
Compensatory purging, 9, 316. See also Purging behaviors
Compliance, 37, 103–104, 116–118
Concerns about weight, shape, and eating, 7, 165, 166, 315. See also Fear of weight gain or of
becoming fat; Preoccupation with eating, shape, weight, and their control
Conflict, interpersonal, 258–260
Control. See also Weight-controlled behaviors
collaborative weighing and, 94–95, 96f, 97f
educating patients regarding CBT-E and, 76–77
formulation and, 66
reasons given to avoid change and, 130–133
strategies for regaining weight and, 158
Coping mechanisms, 102–103, 136, 140
Core Low Self-Esteem Module. See also Broad form of CBT-E; Self-esteem
balanced view of self-worth and, 251–252
comorbidity and, 309
inpatient CBT-E and, 289
origins of core low self-esteem, 251
overview, 242–252, 245f, 247f
parental involvement in, 250–251
treatment strategy for, 244–250, 245f
Core psychopathology, 6–7, 315. See also Psychopathological features
Current pros-and-cons-of-change table, 124–125, 125t, 126t, 127–133, 133t. See also Change; Pros and
cons of change

Day hospital treatment, 298. See also Inpatient CBT-E

Debiting, 315
Delay eating, 315
Depression
CBT-E and, 304
comorbidity and, 301, 305–307
contraindications to starting CBT-E, 50
identifying barriers to change and, 147
parents with, 91
transdiagnostic perspective and, 19
Developmental factors, 10–11, 13, 40t–41t, 87
Diabetes, 304, 309–312, 310f
Diagnosis
comorbidity and, 301, 303–304
overview, 3–6, 5t, 6t
psychopathological features, 6–10, 11f
transdiagnostic perspective, 15–20, 16f, 17f
Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
comorbidity and, 301, 303–304
overview, 3–6, 5t, 6t
transdiagnostic perspective and, 15–20, 16f, 17f
Dichotomous reasoning, 201–202, 249
Dietary guidelines, 315
Dietary restraint. See also Dietary Restraint Module
caloric restriction, 105–106, 317–321, 319t, 321t
identifying and addressing dietary rules and, 195–202, 197f, 198f
identifying barriers to change and, 145–146
maintenance plan and, 220t
overview, 8, 315
planning Step Two stage of CBT-E for adolescents, 149
transdiagnostic perspective and, 18–19, 19–20
Dietary Restraint Module, 193–204, 197f, 198f, 204f. See also Step Two stage of CBT-E for adolescents
Dietary restriction. See also Caloric restriction; Dietary Restraint Module
assessment and, 40t–41t
food avoidance and, 196–200, 197f, 198f
formulation and, 66, 67f, 68f
identifying and addressing dietary rules and, 195–202, 197f, 198f
maintenance plan and, 220t
medical management and, 51
overview, 8, 316
planning Step Two stage of CBT-E for adolescents, 149
psychoeducation and, 44, 105–106
Dietary rules, 195–202, 197f, 198f, 316. See also Dietary restriction; Rules for living
Dietitians, 276, 291
Discounting the positive bias, 247–248
Distraction activities, 118, 158–159
Diuretic misuse, 51, 75–76
Double standards, 249
Drinking habits, 40t–41t, 51

Eating Disorder Examination Questionnaire (EDE-Q), 39, 145, 224

Eating disorders in general
assessment of, 39, 40t–41t
 classification of, 3–6, 5t, 6t
educating patients regarding, 42–45, 43f
evolution of, 14–15
Eating habits. See also Events, Moods, and Eating Module; Regular eating intervention
assessing the role of events and moods to eating-disorder psychopathology, 205–209, 208f
assessment and, 40t–41t
creating positive environments and, 89–90
inpatient CBT-E and, 291–294
intensive outpatient CBT-E and, 276, 277–278
medical management and, 51
overview, 8–10, 205
reasons given to avoid changing, 130–133
rules concerning, 200–201
Step One stage and, 59t, 113–119, 117f, 119t, 134–135
strategies for regaining weight and, 153–162, 154f, 157f
Eating Problem Checklist (EPCL)
complete, 327–329
inpatient CBT-E and, 290
introducing in session 1, 92, 104
overview, 325–326
review sessions and, 123–124, 144
Eating-disorder mindset, 61, 211–212, 212–214, 316. See also Setbacks and Mindsets Module
Education regarding eating disorders. See Psychoeducation
Ending Well step of treatment. See Step ree stage of CBT-E for adolescents
Engagement. See also Motivation
assessment/preparation sessions and, 38
CBT-E for adolescents and, 23–24, 37, 58, 63–65, 92–93, 122
formulation and, 66
identifying barriers to change and, 145–146
patient’s role in treatment and, 31–32
Enhanced cognitive behavior therapy (CBT-E). See also Broad form of CBT-E; CBT-E for adolescents;
Inpatient CBT-E; Intensive outpatient CBT-E
clinical perfectionism and, 231
complex cases and, 304
effectiveness of, 25–26
forms of, 26, 28
overview, 3, 21–23, 26, 27f
psychoeducation and, 45–46, 47t, 75, 76–77, 88–89
review sessions and, 148
transdiagnostic perspective and, 15–20, 16f, 17f
Environmental factors, 87–88, 89–90, 297. See also Home environment
Events, 149–150, 206–209, 208f, 213–214. See also Events, Moods, and Eating Module; Triggers
Events, Moods, and Eating Module, 205–209, 208f, 288. See also Eating habits; Events; Moods; Step
Two stage of CBT-E for adolescents
Exercise, healthy, 142–143, 295
Exercising excessively
addressing during the Step One stage of CBT-E for adolescents, 139–143, 140t, 142t
medical management and, 52
mood intolerance and, 264
overview, 9–10, 316
rules concerning eating and, 201
transdiagnostic perspective and, 19–20
Expectations, 246–250, 247f, 260. See also Perfectionism
Exploratory questioning, 24, 129–133
Extended personal formulation, 173–176, 175f, 176f, 233, 233f. See also Formulation

Family factors, 40t–41t, 87–88. See also Parents

Fat, feeling, 160–161, 175–176, 176f, 189–191, 316
Fear of change, 146–147, 147t. See also Change
Fear of weight gain or of becoming fat. See also Concerns about weight, shape, and eating; Weight
change
assessment and, 40t–41t
difficulties with weight restoration and, 165, 166
identifying barriers to change and, 145–146
overview, 316
transdiagnostic perspective and, 19–20
Food avoidance, 196–200, 197f, 198f, 316. See also Dietary restriction
Food checking, 202–203, 316
Formulation
Clinical Perfectionism Module and, 231–232, 232f, 233f
Core Low Self-Esteem Module and, 244–245, 245f
creating, 66–76, 67f, 68f, 70f, 73f
Dietary Restraint Module and, 203–204, 204f
extended personal formulation, 173–176, 175f, 176f
homework assignments regarding, 86
inpatient CBT-E and, 289
Interpersonal Difficulties Module and, 255, 255f
mood intolerance and, 265–266, 265f
not-underweight patients with binge eating, 72–75, 73f
overview, 66
purpose of, 66
review sessions and, 105, 148
Step One stage of CBT-E for adolescents and, 59t
underweight patients and, 68–72, 70f
viewing dieting as a problem, 194–195
Fullness, feelings of, 69, 118, 159–161, 164–165, 293
Future, 125–126, 126t
Future pros-and-cons of change table, 125–126, 126t, 127–133, 133t. See also Pros and cons of change

Goals of treatment. See Treatment goals

Grazing, 316

Handouts
e Effects of Caloric Restriction and Weight Loss, 72, 105–106, 317–321
monitoring record form, 79–83, 80f, 81f, 84t
Regular Eating, 119t
Home environment, 87–88, 89–90, 102–103, 278, 279–280. See also Environmental factors; Family
factors; Parents
Homework. See also Real-time monitoring
Body Image Module and, 171–173, 172f, 190–191
confirming during Session 0, 85–86
following session 1, 106–107
following session 2, 46, 121
reviewing and reinforcing monitoring and, 103–104
Hope, 76–77, 88, 90
Hospitalization. See Inpatient CBT-E
Hunger, 69, 201, 293

Inpatient CBT-E. See also CBT-E for adolescents; Enhanced cognitive behavior therapy (CBT-E);
Treatment levels
admission to, 286, 287t–288t
assessment and, 286, 288
CBT-E for adolescents and, 28–29, 28f, 30–31
daily management difficulties, 297
indications and contraindications for, 283
maintaining progress and, 297–300
modules and forms of, 288–289
motivation and, 296–297
organization of, 285
overview, 281, 282
preparing for, 284–285
rationale for, 281–282
schooling during, 295–296
specialized unit for, 285
treatment procedures, 289–296, 290f
treatment strategies and, 282–283
treatment team, 286
Intensive outpatient CBT-E. See also CBT-E for adolescents; Enhanced cognitive behavior therapy
(CBT-E)
organization of, 274–275, 275t
overview, 271
parental involvement in, 278
preparing for, 272, 273t–274t
specialized unit for, 274
treatment decisions regarding, 272
treatment procedures, 275–280
treatment team, 274
Intensive outpatient treatment level, 28–29, 28f, 30. See also Treatment levels
Interpersonal Difficulties Module, 252–263, 254t, 255f, 289. See also Broad form of CBT-E;
Interpersonal functioning
Interpersonal functioning, 148, 200–201, 256–258, 261–262, 320. See also Interpersonal Difficulties
Module
Interpersonal psychotherapy (IPT), 255–256
Isolation, social, 256–258, 261–262

Joint sessions with parents, 32–33, 162–163. See also Parents

Lapses. See Setbacks and Mindsets Module

Laxative misuse. See also Purging behaviors
addressing during Step One, 135–139, 136t, 137t
establishing regular eating and, 118
formulation and, 75–76
medical management and, 51
Levels of treatment, 28–31, 28f. See also Inpatient CBT-E; Intensive outpatient CBT-E; Outpatient
treatment level; Postinpatient outpatient treatment level
Life chart, 214–216, 215f
Long-term maintenance plan, 222, 223t–224t, 225. See also Maintenance plan
Loss of interest, 68–69

Maintenance plan, 219, 220t–221t, 221–222, 223t–224t, 225. See also Planning
Maintenance processes
assessment and, 65–66
CBT-E for adolescents and, 23–24
formulation and, 67, 70–72, 70f
identifying barriers to change and, 145–146
interpersonal difficulties and, 253
maintaining progress and, 218–219, 220t–221t
Step Two stage and, 60, 61, 150
transdiagnostic perspective and, 15, 16–18, 17f
Meals
 addressing eating styles and, 134–135
cognitive behavioral strategies and, 156, 158
food avoidance and, 196
inpatient CBT-E and, 291–294
intensive outpatient CBT-E and, 277–278
real-time monitoring and, 82
rules concerning, 200
strategies for regaining weight and, 153, 155–156, 157f
Medical concerns. See also Physical consequences
coexisting type 1 diabetes, 309–312, 310f
comorbidity and, 312
contraindications to starting CBT-E, 50
formulation and, 70
intensive outpatient CBT-E and, 272, 277
medical management and, 51–53
Mental disorders, 91, 132, 309. See also individual disorders
Menu planning, 153, 155–156, 157f, 277–278, 291–293. See also Meals; Planning; Snacks
Mindsets. See Eating-disorder mindset
Minnesota Starvation Experiment, 72, 317–321, 319t, 321t
Monitoring record form. See also Real-time monitoring
addressing frequent weighing practices, 112
assisted eating and, 294
Dietary Restraint Module and, 203
establishing regular eating and, 116, 117f
food avoidance and, 197, 198f
inpatient CBT-E and, 289, 290f
intensive outpatient CBT-E and, 276
overview, 79–83, 80f, 81f, 84t
performance checking and, 237, 238f
reviewing in session 2, 108–112, 109f
shape checking and, 179–183, 180f–181f
Mood intolerance. See also Mood Intolerance Module; Moods
identifying in patients, 264
inpatient CBT-E and, 297
intervening in the process of, 266–269, 268f
mechanisms involved in, 266
overview, 263–264, 264f
transdiagnostic perspective and, 18
treatment strategy for, 264–265
Mood Intolerance Module. See also Broad form of CBT-E; Moods
analyzing a recent example of mood intolerance, 265–266, 265f
comorbidity and, 309
inpatient CBT-E and, 289
 intervening in the sequence of events, 267–269, 268f
overview, 263–270, 264f, 265f, 268f
parental involvement in, 269–270
treatment strategy for, 264–265
Moods. See also Events, Moods, and Eating Module; Mood intolerance; Mood Intolerance Module;
Triggers
assessing the role of events and moods to eating-disorder psychopathology, 206–209, 208f
excessive exercising and, 140, 143
purging behaviors and, 136
Step Two stage and, 61, 149–150
Motivation. See also Engagement
engaging the patient during Session 0 and, 63–64
helping patients decide to change and, 124–134, 125t, 126t, 133t
inpatient CBT-E and, 296–297
strategies for regaining weight and, 162

Negative beliefs, 245, 259

Night eating syndrome, 4, 6t
Noncompensatory purging, 9, 135–139, 136t, 137t, 316. See also Purging behaviors
Not-underweight patients, 72–75, 73f, 150. See also Patients
Nurses, 291

Obesity, 304, 309

Objective binge eating, 8–9, 316
Obsessive–compulsive disorder (OCD), 304, 307–308
Online training. See Training
Other specified eating disorders, 4, 5t, 6t, 75–76
Outpatient treatment level, 28–30, 28f, 298–300. See also Postinpatient outpatient treatment level;
Treatment levels
Overcoming Binge Eating, Second Edition (Fairburn, 2013), 85, 118, 121, 136
Overgeneralization, 249, 259
Overvaluation of achieving and its consequences, 232–234, 233f, 240–241. See also Perfectionism
Overvaluation of control over eating, 149
Overvaluation of eating, shape, weight, and their control. See also Body Image Module
creating positive environments and, 89–90
Dietary Restraint Module and, 203–204, 204f
engaging in other aspects of life, 176–178
identifying overvaluation and its consequences, 170–173, 172f
interpersonal difficulties and, 256
maintenance plan and, 220t
mindset of, 210–211
origins of, 214–216, 215f
overview, 7, 316
 planning Step Two stage of CBT-E for adolescents, 148–149
transdiagnostic perspective and, 16–17, 17f, 19–20
two-prong strategy to address, 175–176, 175f, 176f

Parents. See also Joint sessions with parents

Body Image Module and, 191–192
change and, 90–91
Clinical Perfectionism Module and, 240
Core Low Self-Esteem Module and, 250–251
Dietary Restraint Module and, 203
educating regarding eating disorders, 88–89
excessive exercising and, 143
inpatient CBT-E and, 298
intensive outpatient CBT-E and, 278
Interpersonal Difficulties Module and, 262–263
Mood Intolerance Module and, 269–270
parents-only session, 87–91
real-time monitoring and, 82
role of in CBT-E for adolescents, 32–33, 48–49, 88–89
Step One stage of CBT-E for adolescents and, 38–39, 48–49, 58, 59t, 119–121
Underweight and Undereating Module and, 162–163
Patients. See also Not-underweight patients; Underweight patients
admission to inpatient CBT-E and, 286, 287t–288t
attitudes of, 39, 42, 87–88, 104–105
change and, 124–134, 125t, 126t, 133t
planning Step Two stage of CBT-E for adolescents, 150
questions and concerns of, 77
role of in CBT-E for adolescents, 31–32
Perfectionism. See also Clinical Perfectionism Module
addressing perfectionist standards and strivings, 234–236
identifying barriers to change and, 147t, 148
low self-esteem and, 246–247
overview, 10, 231
transdiagnostic perspective and, 18
Performance avoidance, 239–240
Performance checking, 236–237, 238f
Personality disorders, 10, 302, 308–309
Personalization, 260
Pharmacological treatments, 53, 304, 305–306
Physical consequences. See also Medical concerns
formulation and, 70
medical management and, 52
Minnesota Starvation Experiment, 319f, 320
 overview, 11–14, 12t–13t
Physicians, 277
Pie chart technique, 171–173, 172f, 176–178
Planning. See also Menu planning
engaging in other aspects of life, 177
establishing regular eating and, 114–115, 117
food avoidance and, 196
identifying and addressing dietary rules and, 196
identifying barriers to change and, 147
maintenance plan and, 219, 220t–221t, 221–222, 223t–224t
minimizing the risks of relapse and, 221–222, 223t–224t
strategies for regaining weight and, 153, 155–156, 157f
Postinpatient outpatient treatment level, 28–29, 28f, 31, 298–300. See also Inpatient CBT-E;
Outpatient treatment level; Treatment levels
Posttraumatic stress disorder (PTSD), 304
Posttreatment review sessions, 62, 224–225. See also Review sessions
Preoccupation with eating, shape, weight, and their control, 7, 19–20, 68–69, 83, 100, 102–103, 116–
117, 293. See also Overvaluation of eating, shape, weight, and their control
Preparation sessions. See Assessment/preparation sessions
Problem solving, 206–209, 208f, 259, 297
Progress review. See also Review sessions
conducting a joint review of progress, 144–145
ending treatment and, 218–219, 220t–221t
engaging in other aspects of life, 177
intensive outpatient CBT-E and, 276
overview, 218–219, 220t–221t
Pros and cons of change. See also Change; Current pros-and-cons-of-change table; Future pros-and-
cons of change table
drawing conclusions from, 127–133, 133t
excessive exercising and, 141–142, 142t
helping patients decide to change and, 124–126, 125t
overview, 126t
purging behaviors and, 137–139, 137t
Provisional formulation, 42–46, 43f, 47t. See also Formulation
Psychoeducation
assessment/preparation sessions and, 42–45, 43f
educating patients regarding weight restoration, 151–153
excessive exercising and, 140–141, 140t
explaining CBT-E and, 45–46, 47t, 75, 76–77
food avoidance and, 196
formulation and, 66
intensive outpatient CBT-E and, 272, 273t–274t
interpersonal difficulties and, 256, 258–260
 low self-esteem, 245–247, 248
mood intolerance and, 265
overview, 83, 85, 86t
parents-only session and, 88–89
performance checking and, 237
purging behaviors and, 136–137, 136t
role transitions and, 260–261
setbacks and mindsets, 211–212, 212f
shape checking and, 178–179, 185
Step One stage and, 59t, 92
weight and weighing, 95, 98–103, 101f
weight restoration, 72
Psychologists, 276
Psychological effects of starvation, 318, 319t
Psychopathological features, 6–10, 11f, 14–15, 22–23. See also Symptoms
Purging behaviors. See also Laxative misuse; Vomiting, self-induced
addressing during the Step One stage of CBT-E for adolescents, 135–139, 136t, 137t
formulation and, 75–76
overview, 9, 316
physical consequences, 11–14, 12t–13t
Purging disorder, 4, 6t, 75–76

Reactive cases, 149–150

Real-time monitoring. See also Homework; Monitoring record form; Self-monitoring; Weighing
practices
addressing frequent weighing practices and, 112
assisted eating and, 294
excessive exercising and, 142
following session 1, 106–107
food avoidance and, 197, 198f
food checking and, 202
inpatient CBT-E and, 289, 290f
introducing in session 0, 78–86, 80f, 81f, 84t, 86t
overview, 78–83, 80f, 81f, 84t
rationale behind, 78
reviewing and reinforcing, 103–104
Step One stage of CBT-E for adolescents and, 59t
strategies for regaining weight and, 156f, 159–160
Refeeding, 159–160. See also Weight restoration
Regaining weight. See Weight restoration
Regular eating intervention. See also Eating habits
addressing in session 2, 113–121, 117f, 119t
difficulties in implementing, 116–118, 119t
 eating styles and, 134–135
parental involvement in, 119–121
Relapse. See also Setbacks
Clinical Perfectionism Module and, 241–242
inpatient CBT-E and, 297–300
intensive outpatient CBT-E and, 279
minimizing the risks of, 221–222, 223t–224t
Resistance, 146, 147t
Review sessions. See also CBT-E for adolescents
broad form of CBT-E and, 229–230
Clinical Perfectionism Module and, 231–232
explaining CBT-E and, 46, 47t
identifying barriers to change, 145–148, 146t, 147t
inpatient CBT-E and, 295
joint review of progress, 144–145
overview, 26, 60
posttreatment review sessions, 62, 224–225
reviewing the formulation, 148
Step One stage, 144–150, 146t, 147t
Step Two stage, 148–150
structure and content of, 144
treatment decisions, 148
Role disputes, 262–263
Role transitions, 260–262, 263
Routines, 68–69, 114–115, 134–135
Rules for living, 246–247, 250. See also Dietary rules; Perfectionism

School commitments, 146, 147t, 176–178

Selective attention, 248–249, 259
Self-esteem. See also Core Low Self-Esteem Module
balanced view of self-worth and, 251–252
identifying barriers to change and, 147t, 148
Interpersonal Difficulties Module, 256
origins of core low self-esteem, 251
overview, 10, 242–244
transdiagnostic perspective and, 18
treatment strategy for, 244–250, 245f
Self-evaluation. See also Real-time monitoring
assessment/preparation sessions and, 42–45, 43f
cognitive bias and, 245–246, 247–250, 247f
low self-esteem and, 242–244
treatment strategy for, 244–250, 245f
Self-harm, 264, 302
Self-monitoring. See Real-time monitoring
Session 0. See also Assessment/preparation sessions; Step One stage of CBT-E for adolescents
ending, 86
engaging the patient and, 63–65
formulation and, 66–76, 67f, 68f, 70f, 73f
homework assignments, 85–86
psychoeducation and, 75, 76–77, 83, 85, 86t
real-time monitoring and, 78–86, 80f, 81f, 84t, 86t
structure and content of, 63
Session 1. See also Step One stage of CBT-E for adolescents
attitude towards treatment and, 104–105
collaborative weighing and, 93–95, 96f, 97f
ending, 106–107
engagement and, 93
introducing the Eating Problem Checklist (EPCL), 104
psychoeducation and, 98–103, 101f, 105–106
reviewing and reinforcing monitoring, 103–104
reviewing the formulation, 105
structure and content of, 92–93
Session 2. See also Step One stage of CBT-E for adolescents
addressing frequent weighing practices, 112, 112f
ending, 121
establishing regular eating, 113–121, 117f, 119t
parental involvement in, 119–121
reviewing monitoring record form, 108–112, 109f
structure and content of, 108
Setbacks. See also Relapse; Setbacks and Mindsets Module
Clinical Perfectionism Module and, 241
controlling the eating-disorder mindset and, 212–214
educating patients regarding, 211–212
maintenance plan and, 221t
minimizing the risks of relapse and, 221–222, 223t–224t
Step Two stage of CBT-E for adolescents and, 60, 61
Setbacks and Mindsets Module, 210–216, 212f, 215f, 288. See also Eating-disorder mindset; Setbacks;
Step Two stage of CBT-E for adolescents
Severity of the eating disorder, 39, 40t–41t
Shape avoidance, 7, 40t–41t, 175–176, 176f, 187–189. See also Body avoidance
Shape checking
addressing, 178–187, 180f–181f
assessment and, 40t–41t
overview, 7, 316
two-prong strategy to address overvaluation and, 175–176, 176f
Slip-ups. See Setbacks
Snacks
addressing eating styles and, 134–135
establishing regular eating and, 113–119, 119t, 177f
food avoidance and, 196
intensive outpatient CBT-E and, 277–278
rules concerning, 200
strategies for regaining weight and, 153, 155–156, 157f
Social activities, 176–178, 201. See also Activities
Social isolation, 256–258, 261–262
Social skills, 261. See also Interpersonal Difficulties Module; Interpersonal functioning
Socratic questioning, 24, 129–133
Starting Well and Deciding to Change step of treatment. See Step One stage of CBT-E for adolescents
Starvation Symptom Inventory (SSI), 72, 322–323, 324
Starvation symptoms. See also Symptoms
educating patients regarding, 44
formulation and, 72
Minnesota Starvation Experiment, 317–321, 319t, 321t
overview, 316
planning Step Two stage of CBT-E for adolescents, 150
transdiagnostic perspective and, 17, 20
Step One stage of CBT-E for adolescents. See also Assessment/preparation sessions; CBT-E for
adolescents; Session 0; Session 1; Session 2
addressing eating styles and, 134–135
addressing weight-control behaviors during, 135–143, 136t, 137t, 140t, 142t
CBT-E for adolescents and, 26, 27f
Eating Problem Checklist (EPCL) and, 104, 123–124
ending sessions, 86, 106–107, 121
explaining CBT-E and, 45–46, 47t
helping patients decide to change and, 124–134, 125t, 126t, 133t
overview, 57–60, 59t
parents-only session, 87–91
preparing for, 48–49
review sessions and, 144–150, 146t, 147t
structure and content of, 57–58, 63, 92–93, 108, 122–123, 144
Step Two stage of CBT-E for adolescents. See also Body Image Module; CBT-E for adolescents;
Dietary Restraint Module; Events, Moods, and Eating Module; Setbacks and Mindsets Module;
Underweight and Undereating Module
CBT-E for adolescents and, 26, 27f
explaining CBT-E and, 45–46, 47t
overview, 60–61
planning, 148–150
Step ree stage of CBT-E for adolescents. See also CBT-E for adolescents
CBT-E for adolescents and, 27f
 concerns about ending treatment, 217–218
explaining CBT-E and, 45–46, 47t
maintaining progress and, 218–219, 220t–221t
minimizing the risks of relapse and, 221–222, 223t–224t
overview, 61–62, 217
phasing out certain treatment procedures and, 219, 221
posttreatment review sessions, 62, 224–225
Strivings, 234–236
Subjective binge eating, 9, 316
Substance use/misuse
CBT-E and, 304
comorbidity and, 302, 308
contraindications to starting CBT-E, 50
identifying barriers to change and, 147, 147t
intensive outpatient CBT-E and, 272
mood intolerance and, 264
Suicide risk, 50
Symptoms. See also Psychopathological features; Starvation symptoms
educating patients regarding, 42–45, 43f
general psychopathological features, 10
medical management and, 51–53
physical consequences, 11–14, 12t–13t
psychopathological features, 6–10, 11f
psychosocial consequences, 10–11
transdiagnostic perspective and, 16–18, 17f

Taking Stock sessions. See Review sessions

Termination, 61, 217–218. See also Step ree stage of CBT-E for adolescents
erapists, 33–35, 34t, 50, 64–65, 147t
Training, 33–35, 34t
Transdiagnostic perspective
Core Low Self-Esteem Module and, 244–245, 245f
formulation and, 67
Interpersonal Difficulties Module and, 255, 255f
overview, 15, 16–18, 16f, 17f
Treatment goals
addressing perfectionist standards and strivings, 235
helping patients decide to change and, 124–134, 125t, 126t, 133t
overview, 22–23
Step One stage, 57
Step Two stage, 60
Step ree stage, 62
Treatment levels, 28–31, 28f. See also Inpatient CBT-E; Intensive outpatient CBT-E; Outpatient
treatment level; Postinpatient outpatient treatment level
Treatments, 15, 36, 41, 51–53, 98–99. See also Enhanced cognitive behavior therapy (CBT-E)
Triggers. See also Events; Moods
assessing the role of events and moods to eating-disorder psychopathology, 206–209, 208f
controlling the eating-disorder mindset and, 213
feeling fat and, 191
long-term maintenance plan and, 223t–224t
mood intolerance and, 267
planning Step Two stage of CBT-E for adolescents, 149–150

Unassisted eating, 278, 294. See also Eating habits

Undereating. See also Underweight and Undereating Module
assessment and, 40t–41t
Dietary Restraint Module and, 203
physical consequences, 11–14, 12t–13t
Step Two stage of CBT-E for adolescents and, 61
transdiagnostic perspective and, 17
Underweight and Undereating Module. See also Step Two stage of CBT-E for adolescents;
Undereating; Underweight patients
difficulties with weight restoration, 163–167
educating patients regarding weight restoration, 151–153
inpatient CBT-E and, 288
intensive outpatient CBT-E and, 277–278
joint sessions with parents and, 162–163
moving to weight maintenance and, 167, 168f
overview, 151
parental involvement in, 162–163
strategies for regaining weight, 153–162, 154f, 157f
Underweight patients. See also Patients; Underweight and Undereating Module
collaborative weighing and, 94–95, 96f, 97f
educating patients regarding the effects of being underweight, 105–106
establishing regular eating and, 113–114, 118
excessive exercising and, 141
formulation and, 68–72, 70f
intensive outpatient CBT-E and, 277–278
review sessions and, 144
Step One stage and, 58–59
Step Two stage and, 61, 149, 150
Unspecified eating disorders, 4, 5t, 6t
Urge surfing, 116, 118
Urges, 116, 118, 143
Vomiting, self-induced. See also Purging behaviors
addressing during Step One stage, 135–139, 136t, 137t
establishing regular eating and, 118
formulation and, 72–76, 73f
intensive outpatient CBT-E and, 272
medical management and, 51
mood intolerance and, 264

Wardrobe changes, 159, 160–161, 165

Weighing, collaborative. See Collaborative weighing
Weighing practices. See also Collaborative weighing
following session 1, 106–107
overview, 94–95, 100, 102–103
reasons given to avoid changing, 130–133
between sessions, 112, 112f
weight checking, 7, 40t–41t, 316
Weight, body. See Body weight
Weight avoidance
assessment and, 40t–41t
collaborative weighing and, 94–95, 96f, 97f
overview, 7, 316
weighing practices and, 100, 102–103
Weight change, 52, 98–103, 101f, 105–106, 221t. See also Fear of weight gain or of becoming fat
Weight checking, 316
Weight graphs, 153, 154f
Weight maintenance, 167, 168f, 220t
Weight restoration. See also Body weight
CBT-E for adolescents and, 26, 27f
difficulties with, 163–167
educating patients regarding, 151–153
formulation and, 72
maintenance and, 167, 168f, 220t
overview, 152
parental involvement and, 162–163
Step Two stage of CBT-E for adolescents and, 60
strategies for, 153–162, 154f, 157f
Weight-controlled behaviors
addressing during the Step One stage of CBT-E for adolescents, 135–143, 136t, 137t, 140t, 142t
assessment and, 40t–41t
caloric restriction, 105–106, 317–321, 319t, 321t
food checking and, 202–203
maintenance plan and, 220t
medical management and, 51
overview, 8–10
planning Step Two stage, 148–149
review sessions and, 144–145
transdiagnostic perspective and, 17
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