How Intensive CBT-E Can Help Adolescents With Anorexia

The role of illness duration as a predictor and moderator of treatment outcomes has been extensively studied in adult patients with eating disorders. Surprisingly, findings suggest this variable does not seem to influence clinical outcomes. In contrast, limited research has evaluated the impact of illness duration on treatment outcomes in adolescent patients. This lack of data may stem from more uniformity in illness duration among adolescents than adults. Alternatively, it could be attributed to a general preference for considering patients' age, which is more straightforward to assess and appears closely linked to the duration of illness.

Family-based treatment (FBT) has the highest level of evidence regarding efficacy in adolescents with eating disorders. The first randomized controlled trial of FBT, initially known as Maudsley family therapy or "the Maudsley approach," compared it with individual supportive therapy. The study found that FBT proved more effective for adolescent patients who had anorexia nervosa for less than three years. Subsequent investigations into FBT have predominantly concentrated on adolescents with an illness duration of less than three years. Nevertheless, research exploring predictors of FBT has produced conflicting results regarding the role of illness duration in adolescent patients with eating disorders, both in both randomized clinical trials and observational longitudinal studies.

Enhanced cognitive-behavioral therapy (CBT-E) is a specialized psychological transdiagnostic treatment for all forms of eating disorders, including anorexia nervosa, bulimia nervosa, binge eating disorder, and other similar states. CBT-E was developed as an outpatient treatment for adults but then adapted by my team for adolescents and intensive care settings.

The effectiveness of CBT-E for adolescents has been confirmed through longitudinal studies conducted in outpatient and intensive (day-hospital and residential) real-world settings. These results led the National Institute for Health and Care and Clinical Excellence to recommend CBT for adolescents with eating disorders when FBT is deemed unacceptable, contraindicated, or ineffective.

Intensive CBT-E

Intensive CBT-E never adopts coercive or prescriptive attitudes or procedures, and patients are never expected to do anything they do not agree to. The aim is to actively involve adolescent patients in decision-making throughout treatment, enhancing their sense of empowerment and control. Patients eligible for intensive CBT-E (i.e., those who do not respond to a well-delivered outpatient treatment) attend four preparatory sessions in which they are introduced to the nature and aims of the treatment. Since patients are expected to address weight restoration from the first day of residential treatment, it is vital that they have decided to commit to this goal before they are admitted.

The treatment is delivered in a specialized unit for eating disorders by a ''non-eclectic'' multidisciplinary team (physicians, psychologists, nurses, and dieticians) all trained in CBT-E. The treatment lasts 20 weeks (13 of residential treatment followed by seven weeks of day-hospital).

Intensive maintains all the main strategies and procedures of outpatient CBT-E, which are delivered in both individual sessions and in a group format, but with three main features that distinguish it from the outpatient-based version. First, the treatment is delivered by a non-eclectic multidisciplinary team comprising physicians, psychologists, dieticians, and nurses, all fully trained in CBT-E. Second, assistance with eating is provided in the first weeks of treatment to help patients overcome their difficulties in real time. Third, the adolescent patients continue their course of study during the treatment. Intensive CBT-E also includes additional elements designed to reduce the high rate of relapse that typically follows discharge from residential treatments. For instance, the unit is open, and patients are free to go outside. In this way, they continue to be exposed to the types of environmental stimuli that tend to provoke their eating disorder psychopathology, but with full access to staff support. Furthermore, during the weeks immediately preceding discharge, a concerted effort is made to identify likely environmental setback triggers, which are then addressed during the individual CBT-E sessions. Moreover, towards the end of treatment, parents are helped to create a positive, stress-free home environment in readiness for the patient’s return. Before discharge, patients collaborate on identifying setbacks, including joint sessions.

What is the outcome of intensive CBT-E in adolescents?

So far, no study has compared the outcomes of CBT-E in adolescent patients with illness durations of less than three years versus those with durations of three years or more.

Our recent study published in the International Journal of Eating Disorders has addressed this research gap, assessing the effectiveness of intensive CBT-E in adolescents with anorexia nervosa and duration of illness exceeding three years, as compared to those with a shorter duration of illness.

One hundred and fifty-nine consecutive patients who have failed outpatient treatment were enrolled (n=122 with a duration of illness <3 years and n=37 ≥ 3 years). The key findings can be summarized as follows.

1. Regarding the acceptability of intensive CBT-E, more than 80% of eligible patients agreed to commence treatment, and 81% completed it.
2. A substantial proportion of adolescents (23.3%) with anorexia nervosa, contrary to those usually included in the FBT studies, had a duration of illness ≥3 years.
3. The duration of illness was not associated with differences in the severity of psychopathological features.
4. No discernible differences were found between adolescents with a duration of illness <3 or ≥3 years across various outcome measures (dropout rates, improvements in body weight, and psychopathology). Furthermore, more than 70% of adolescents achieved good body mass index (BMI = kg/m2) outcomes, and approximately 60% maintained a full response at 20-week follow-up in both illness duration groups.

Clinical implications

The findings support the use of intensive CBT-E in adolescents with anorexia nervosa who have failed previous outpatient treatments, irrespective of whether the duration of illness is equal to or longer than three years. With over 80% of patients completing treatment and demonstrating substantial improvement, the study reveals sustained positive changes until the 20-week follow-up, with approximately 60% achieving a full response.

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In conclusion, this new study suggests that the outcome of intensive CBT-E is not influenced by the duration of illness in adolescents with anorexia nervosa, and there is a concrete possibility of recovery in those with a duration of ≥ 3 years who have failed previous outpatient treatment.