CBT-E for adolescents: Latest clinical evidence

Enhanced CBT in Adolescents:
Latest Clinical Evidence
Riccardo Dalle Grave, MD
Department of Eating and Weight Disorders
Villa Garda Hospital- Grada (VR). Italy

Background
• Anorexia nervosa (AN) has a profound impact on physical health and psychosocial
functioning
• It is important to treat it early and effectively as otherwise it can have long-lasting
effects.
• A particular form of family therapy, termed Moudsley therapy o family-based treatment
(FBT, Lock, Le Grange, Agras, & Dare, 2001) is the leading empirically-supported
intervention for adolescents with the disorder (NICE, 2017).
Introduction

Introduction (cont.)
FBT limitations
• It is not acceptable to some families and patients
• Fewer than half the patients make a full treatment response (Lock, 2011; Lock et al., 2010)
“FBT needs to be modified to make it more acceptable and effective, or alternative treatment
approaches need to be found.” (Lock, 2011)
CBT-E is the most valid alternative to FBT
• CBT-E works across the eating disorders
• Younger patients have essentially the same ED psychopathology as older patients

CBT-E and the younger patient
Topics
1. Eating disorders in younger patients
2. An overview of CBT-E for the younger patients
3. Effectiveness of CBT-E for the younger patients
4. Influence on the health policy

Features Shared with Older Patients
• Essentially the same ED psychopathology (over-evaluation of shape and weight; strict
dieting; self-induced vomiting; laxative misuse; binge eating; overexercising; etc)
• These features can be addressed by CBT-E
credo
Eating disorders in younger patients

Diagnosis N %
Anorexia Nervosa 81 60.0
Bulimia Nervosa 12 8.9
Binge-Eating Disorder 7 5.2
Avoidant restrictive food intake disorder 7 5.2
Other Specified Eating Disorders
Atypical Anorexia Nervosa 16 11.9
Bulimia nervosa (of low frequency and/or limited duration) 0 0
Binge-Eating Disorder (of low frequency and/or limited duration) 0 0
Purging Disorder 0 0
Night Eating Syndrome 0 0
Unspecified Eating Disorders 12 8.9
The distribution of eating disorder diagnosis among consecutive adolescent patients with eating
disorders attending an Italian (Verona) outpatient CBT-E clinical service from 2016 to 2018

Distinctive Features
• Most adolescent patients are highly concerned about issues of control and autonomy
• This is not a problem as CBT-E is designed to enhance patients’ sense of control and autonomy. CBT-E is
collaborative with the therapist and patient working together to overcome the eating problem
• Many adolescent patients are highly ambivalent about treatment
• This is not a problem as CBT-E is designed to be engaging and to address ambivalence
• Some patients have over-evaluation of control over eating per se
• This is not a problem as this form of over-evaluation can be addressed using an adaptation of the “body
image” module of CBT-E
credo

Distinctive Features (cont.)
• In the great majority of cases the patient’s parents need to be involved in treatment
• This requires modifying CBT-E, but only to a limited extent
• The youngest patients require a treatment that matches their cognitive development
• This is easily managed in CBT-E as it is not a complex treatment to receive
• The patient’s physical health is of particular concern in younger patients
• This necessitates careful assessment and monitoring, and a lower threshold for providing patients with a more
intensive intervention (e.g., hospitalisation)
credo

Design and implementation of the treatment
• In collaboration with the CREDO, the Department of
Eating and Weight Disorders of Villa Garda Hospital,
Italy, has adapted CBT-E for adolescents of at least 13
years of age
An overview of CBT-E for the younger patients
Strict dieting; non-
compensatory weight-control
behavior
Binge eating
Compensatory
vomiting/laxative
misuse
Significantly
low weight
Events and
associated mood
change
Over-evaluation of shape and
weight and their control

Lectures
• Dalle Grave, R., Calugi, S. Cognitive Behavioral Therapy for Adolescents with Eating
Disorder. New York: Guilford Press, in press.
• Dalle Grave, R., & Cooper, Z. (2016). Enhanced cognitive behavior treatment adapted for
younger patients. In T. Wade (Ed.), Encyclopedia of Feeding and Eating Disorders (pp. 1-
8). Singapore: Springer Singapore.
• Dalle Grave, R. (2019). Cognitive-behavioral therapy in adolescent eating disorders. In J.
Hebebrand & B. Herpertz-Dahlmann (Eds.), Eating Disorders and Obesity in Children and
Adolescents (pp. 111-116). Philadelphia: Elsevier.

Goals
1. To engage patients in the treatment and involve them actively in the process of
change
2. To remove the eating disorder psychopathology, i.e. the dietary restraint and
restriction (and low weight if present), extreme weight control behaviours, and
preoccupation with shape, weight, and eating
3. To correct the mechanisms maintaining the eating disorder psychopathology
4. To ensure lasting change

General strategies
• It never adopts "prescriptive" or "coercive" procedures
• Patients are never asked to do things that they do not agree to do, as this may increase their
resistance to change
• The key strategy is to collaboratively create a personal formulation of the main processes
maintaining the patient’s individual psychopathology, as these will become the targets of
treatment
• Patients are educated about the processes 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 suspended, but this is a very rare occurrence

General strategies (cont.)
• The eating disorder psychopathology is addressed via a flexible set of sequential
cognitive and behavioural strategies and procedures, integrated with progressive patient
education
• To achieve cognitive change, patients are encouraged to observe, using real-time self-
monitoring, how the processes in their personal formulation operate in real life
• Patients are asked to make gradual behavioural changes and analyse their effects and
implications on their way of thinking.
• In the later stages of CBT-E, the treatment focuses on helping patients recognise the
early warning signs of eating disorder mind-set reactivation, and to decentre from it
quickly, thereby avoiding relapse

Structure
• Treatment duration
• 2 pre-treatment assessment
• 30–40 fifty-minute individual sessions in patients with a BMI between the 3rd and 25th
centile, and 20 sessions in those with a BMI > the 25th
• 3 post-treatment review sessions (after 4-12-20 weeks)

Structure
• Parent involvement
• One 50 minute sessions only with parents
• To identify and address any family-related factors that might hinder the patient’s attempts to
change
• Four to six (in patients who are not underweight) or eight to ten (in patients who are
underweight) 15–20 minutes jointly sessions with patient and parents
• To inform parents about what is happening and the patient’s progress and are also be used to
discuss, with the patient’s prior agreement, how they might help the patient make changes

STEP ONE: STARTING WELL AND DECIDING TO CHANGE
• Engaging the patient in treatment and change
• Establishing real-time self-monitoring
• Establishing collaborative in-session weighing
• Providing education
• Jointly creating the personal formulation
• Introducing a pattern of regular eating
• Thinking about addressing weight regain (in underweight patients)
• Involving parents
REVIEW SESSIONS*
• Conducting a joint review of progress
• Identifying emerging barriers to change
• Reviewing the formulation
• Deciding whether to use the broad form of
CBT-E
• Planning the rest of treatment
STEP TWO: ADDRESSING THE CHANGE
Focused CBT-E modules
• Underweight & Undereating (in underweight patients)
• Body Image
• Dietary Restraint
• Events and Mood Changes
• Setbacks & Mindsets
Broad CBT-E modules
• Clinical Perfectionism
• Core Low Self-Esteem
• Interpersonal Difficulties
• Mood Intolerance
STEP THREE: ENDING WELL
• Ensuring that progress is maintained
• Minimizing the risk of relapse
*One after Step One in non-underweight patients;
every 4 weeks in underweight patients
POST-REVIEW SESSIONS
After 4, 12 and 20 weeks
ASSESSMENT/PREPARATION CBT-E Map for younger patients

• 46 patients (13-17 years) with AN
• 40 sessions of CBT-E + 1 session with parents and 8 jointly session with patient and parents
• Non concomitant treatment
Anorexia Nervosa Verona Study
Dalle Grave R, Calugi, S, Doll HA, Fairburn CG, BRAT 2013
0
10
20
30
40
0 40 100
0
1
2
3
4
0 40 100
Weeks Weeks
EDE-Q
BMI
centile
Completers 63%

CBT-E per adolescenti e adulti con anoressia nervosa
Calugi S, Dalle Grave R, Sartirana M, Fairburn CG, J Eat Disord 2015
Significantly more adolescents reached the
goal BMI than adults (65.3% vs. 36.5%; P =
0.003).
The mean time required by the adolescents
to restore body weight was about 15 weeks
less than that for the adults (14.8 (SE = 1.7)
weeks vs. 28.3 (SE = 2.0) weeks, log-rank =
21.5, P < 0.001

• Sixty-eight adolescent patients with an eating disorder and BMI centile corresponding to an adult BMI > 18.5
• 40 sessions of CBT-E + 1 session with parents and 4 jointly session with patient and parents
• Non concomitant treatment
Not Underweight Verona Study
Dalle Grave R, Calugi S, Sartirana M, Fairburn CG, BRAT 2015
0
20
40
60
80
100
ITT Completers
Response
rate (%) Completers 75%

CBT-E for adolescents in a real-world setting
Dalle Grave, Sartirana, Calugi, IJED 2019
0
10
20
30
40
Baseline End of treat 20-week fu
BMI centile
0
1
2
3
Global score EDE-Q
0
10
20
30
Global score CIA
B R I E F R E P O R T
Enhanced cognitive behavioral therapy for adolescents
with anorexia nervosa: Outcomes and predictors of change
in a real-world setting
Riccardo Dalle Grave MD | Massimiliano Sartirana PsyD | Simona Calugi PhD
Department of Eating and Weight Disorders,
Villa Garda Hospital, Garda, Italy
Correspondence
Simona Calugi, Department of Eating and
Weight Disorders, Villa Garda Hospital, Via
Monte Baldo, 89 I-37016 Garda (VR), Italy.
Email: si.calugi@gmail.com
Abstract
Objective: The study aimed to establish the outcomes and predictors of change in a
cohort of adolescents with anorexia nervosa treated via enhanced cognitive behav-
ioral therapy (CBT-E) in a real-world clinical setting.
Method: Forty-nine adolescent patients with anorexia nervosa were recruited from
consecutive referrals to a clinical eating disorder service offering outpatient CBT-E.
Body Mass Index centiles and Eating Disorder Examination Questionnaire, Brief
Symptom Inventory, and Clinical Impairment Assessment scores were recorded at
admission, at the end of treatment, and at 20-week follow-up.
Results: Thirty-five patients (71.4%) who finished the program showed both consid-
erable weight gain and reduced scores for clinical impairment and eating disorder and
general psychopathology. Changes remained stable at 20 weeks. No baseline predic-
tors of drop-out or treatment outcomes were detected.
Conclusions: Based on these results, CBT-E seems suitable for adolescent patients
with anorexia nervosa seeking treatment in a real-world clinical setting.
K E Y W O R D S
adolescents, cognitive behavioral therapy, outpatient treatment, predictor, treatment
outcomes
1 | INTRODUCTION
The National Institute of Clinical Excellence has recently recommended
cognitive behavioral therapy (CBT) for eating disorders for children and
young people when anorexia-nervosa-focused family therapy is unac-
ceptable, contraindicated, or ineffective (National Institute for Health
and Care and Clinical Excellence, 2017). Indeed, the enhanced version
of CBT (CBT-E) adapted for adolescents with anorexia nervosa has
demonstrated promising results in cohort studies of patients aged
between 13 and 19 years when delivered in clinical research settings
(Calugi, Dalle Grave, Sartirana, & Fairburn, 2015; Dalle Grave, Calugi,
Doll, & Fairburn, 2013). In such a setting, 36.9% of adolescent patients
failed to complete the CBT-E, but 65.3% of completers achieved resto-
ration of normal body weight (Calugi et al., 2015).
To date, no study has assessed the effect of CBT-E for adoles-
cents with anorexia nervosa in a real-world clinical setting. Therefore,
the aim of the present study was to provide benchmark data on the
outcomes and predictors of outcome at the end of treatment (EOT)
and at 20-week follow-up in a large sample of consecutively treated
adolescent patients with anorexia nervosa given outpatient CBT-E in
a real-world eating-disorder clinic.
2 | METHOD
2.1 | Design
Consecutive adolescent patients with anorexia nervosa were rec-
ruited, from September 2015 to December 2018, from an outpatient
Received: 16 April 2019 Revised: 14 May 2019 Accepted: 14 May 2019
DOI: 10.1002/eat.23122
Int J Eat Disord. 2019;1–5. wileyonlinelibrary.com/journal/eat © 2019 Wiley Periodicals, Inc. 1
• 49 adolescent patients with anorexia nervosa consecutively treated in a real world clinical
setting.
• Completers (71.4%) showed both considerable weight gain and reduced scores for clinical
impairment and eating disorder and general psychopathology. Changes remained stable at 20
weeks.
• No baseline predictors of drop-out or treatment outcomes were detected.

• 62 adolescent patients with AN
• Among completers of residential CBT-E (90.3%)
• 96.4% reached an end-of treatment BMI centile
corresponding to a BMI ≥ 18.5 at 18 years, which fell to
78.7% and 80.4% at 6- and 12-month follow- ups,
respectively.
• Baseline “Preoccupation with shape/weight” and
“Feeling fat” predicted improvement in BMI centile over
time
Body image concern and treatment outcomes in adolescents
with anorexia nervosa
Calugi & Dalle Grave 2019
variable (all p’s > .05). No change in BIC components from T0 to T1
affected any BMI centile trajectory over time.
Linear regression analysis indicated that all three T0 BIC component
scores were correlated to T1 Eating Concern scores (“Preoccupation
a slower improvement in BMI centile over time. This indicates that
BIC components are clinically relevant variables that should be
assessed by clinicians at baseline. That being said, our data suggest no
relationship between the change of BIC components that occurs dur-
ing treatment and the change in BMI centile over time. If interpreted
in light of its theoretical reference model, this finding confirms that
CBT-E, as stated in the original treatment manual, works as a whole;
in other words, the improvement in body weight seems to be
mediated by its overall application rather than its single components:
“CBT-E is not merely a collection of techniques: the sum is more than its
parts” (Fairburn, 2008, p. 30).
Higher baseline scores for the three BIC components considered
predicted lower rates of Eating Concern, Dietary Restraint and general
psychopathology scores at discharge. This indicates that body-image
concern may play a central role in the psychopathological outcome's
treatment for AN in adolescent patients.
A major strength of this study is that we recruited a sizable sam-
ple of adolescent patients with AN, treating them with a manualized,
evidence-based treatment in a real-world setting. Furthermore, to our
knowledge, this is the first longitudinal data study to enable analysis
of specific body-image concern components and their role in treat-
ment outcomes in adolescent patients with AN. However, although
we have follow-up data on BMI centile, we did not assess psychopa-
thology at these time-points. Moreover, we used single items to
assess different components of body-image concern, a strategy that
has, however, commonly been used by other studies evaluating
body-image concern in patients with eating disorder (Linardon, 2017;
Linardon & Mitchell, 2017; Mitchison et al., 2017; Mitchison, Mond,
Slewa-Younan, & Hay, 2013; Mond et al., 2013).
Nonetheless, our data does shed light on mechanisms maintaining
AN in adolescent patients, and suggests that intensive CBT-E is able
EDE dietary restraint 4.3 (1.2) 1.0 (1.1) 18.06 <.001
EDE eating concern 3.4 (1.2) 1.4 (0.13) 12.27 <.001
Weight concern 3.7 (1.8) 2.2 (1.4) 6.47 <.001
Shape concern 4.2 (1.6) 3.1 (1.5) 5.12 <.001
Global score 3.9 (1.2) 1.9 (1.2) 13.27 <.001
Brief symptom inventory 2.0 (0.7) 0.9 (0.7) 11.04 <.001
Note. Data are presented as mean (SD). Intention-to-treat and completers
analyses are shown.
FIGURE 1 Estimated means of body mass index (BMI) centile.
Estimates were obtained using mixed-effects modeling
B R I E F R E P O R T
Body image concern and treatment outcomes in adolescents
with anorexia nervosa
Simona Calugi PhD | Riccardo Dalle Grave MD
Department of Eating and Weight Disorders,
Villa Garda Hospital, Garda (VR), Italy
Correspondence
Simona Calugi, PhD, Department of Eating and
Weight Disorders, Villa Garda Hospital, Via
Monte Baldo, 89, I-37016 Garda (VR), Italy.
Email: si.calugi@gmail.com
Abstract
Objective: To ascertain the role of baseline measures of body-image concern (BIC) in changes in
body mass index (BMI) centile and psychopathological outcomes associated with intensive
enhanced cognitive behavioral therapy (CBT-E) in adolescents with anorexia nervosa (AN).
Method: The BMI centile of 62 adolescent patients with AN was recorded at four time-points
over 12 months, and Eating Disorder Examination interview (EDE) and Brief Symptom Inventory
(BSI) scores, were recorded at admission and discharge from CBT-E. Changes in three BIC com-
ponents, namely “Preoccupation with shape/weight”, “Fear of weight gain” and “Feeling fat”,
were assessed at admission and discharge.
Results: CBT-E was associated with a significant improvement in outcome variables and BIC
components. Among completers, 96.4% reached an end-of treatment BMI centile 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. Baseline “Preoccupation with shape/weight” and “Feeling fat” predicted
improvement in BMI centile over time, and all three baseline BIC components independently
predicted end-of-treatment EDE Eating Concern subscale score. Baseline “Feeling fat” also pre-
dicted end-of-treatment EDE Dietary Restraint subscale and BSI scores.
Discussion: These findings highlight the importance of assessing and addressing body image
when managing adolescent patients with AN.
KEYWORDS
adolescent, body image, cognitive behavioral therapy, eating disorder psychopathology, fear
of weight gain, feeling fat, inpatient treatment, preoccupation with shape or weight
1 | INTRODUCTION
Body-image concern (BIC) is a core construct of cognitive behavioral
therapy (CBT) (Fairburn, Cooper, & Shafran, 2003), one of the two lead-
ing recommended treatments for eating disorders in this population
(National Institute for Health and Care and Clinical Excellence, 2017).
As such, CBT-E—an enhanced form of CBT that has also been adapted
for adolescents (Dalle Grave, Calugi, Doll, & Fairburn, 2013; Dalle
Grave & Cooper, 2016)—features a specific module to target BIC.
We recently demonstrated that three BIC components, namely
“Preoccupation with shape/weight”, “Fear of weight gain”, and “Feel-
ing fat” can, in fact, predict CBT outcomes in adults (Calugi, El Ghoch,
Conti, & Dalle Grave, 2018). According to the transdiagnostic theory
of CBT (Fairburn et al., 2003), these components are the main cogni-
tive expressions of “Overvaluation of shape, weight and their control”,
considered the psychopathological feature at the heart of most of the
eating disorders.
Based on our earlier findings in adult patients with AN (Calugi
et al., 2018), we hypothesized that CBT-E for adolescents would be
associated with a significant improvement in BIC, as well as other psy-
chological and physical outcome measures, at 1 year, and that some
or all baseline BIC components would predict changes in measures of
the psychopathological underpinnings of AN.
2 | METHOD
2.1 | Participants and treatment
Our participants were selected among consecutive voluntary referrals
to our inpatient CBT-E programme for patients. Sixty-two of these
Received: 6 December 2018 Revised and accepted: 14 January 2019
DOI: 10.1002/eat.23031
Int J Eat Disord. 2019;1–4. wileyonlinelibrary.com/journal/eat © 2019 Wiley Periodicals, Inc. 1

Reccomended psychological treatments
NICE guideline May 2017 – NG69
Bulimia Nervosa Binge-Eating
Disorder
Anorexia Nervosa OSFED
Adults GSH
If it is ineffective
CBT-ED
GSH
CBT-ED
CBT-ED o “Mantra”
o SSCM
FPT
Treatments for the
ED it most closely
resembles
Young people FT-BN
CBT-ED
GSH
CBT-ED
FT-AN
CBT-ED o ANFT
Treatments for the
ED it most closely
resembles
AFP-AN = Adolescent- Focused Psychotherapy for Anorexia Nervosa; CBT-ED = Cognitive Behavior Therapy for
Eating Disorders; GSH = Guided Self-Help; FPT= Focal psychodynamic therapy: MANTRA = Maudsley Anorexia
Nervosa Treatment for Adults; OSFED = other specified feeding and eating disorders; SSCN = Specialist
Supportive Clinical Management

• CBT-E is a promising treatment for adolescents with eating disorder
• It is well accepted by adolescents, probably due to its collaborative approach, which
grants ambivalent young patients a feeling of being in control
• The transdiagnostic nature of CBT-E makes it suitable for treating all the main eating
disorders that afflict adolescent patients
• The promising results obtained in cohort studies suggests, as recommended by NICE,and
also in real-world settings suggest that CBT-E for adolescents is a promising treatment
for adolescents with eating disorders
• Future studies should compare CBT-E with FBT across the full range of eating disorder
presentations to provide useful information regarding treatment in adolescents and to
identify moderators and mediators of the twos
Conclusions

CBT-E for adolescents: Latest clinical evidence

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