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Integrative Review of CBT 2
Abstract
Eating disorders are significant psychiatric illnesses that affect many children and
adolescents and can have profound effects on physical and psychosocial health. Various therapies
are available for treatment, including different psychotherapies and medications. This integrative
review aimed to evaluate the literature available that pertains to adolescents with eating disorders
who undergo cognitive behavioral therapy. The EBSCO and PubMed databases were used to find
relevant literature. The initial search resulted in 2,135 articles. Five were selected because they
adequately addressed the authors specific criteria. Ultimate findings demonstrated that cognitive
behavioral therapy is an acceptable therapy for adolescents suffering from eating disorders.
Limitations to this research include the authors lack of experience and the lack of research about
CBT and adolescent eating disorders. Future research should aim to compare tradition therapies
Eating disorders of any variety are significant disorders that can have long-term physical
and psychological effects. These disorders involve obsessions with food, body weight and/or
shape, and loss of control (Eating Disorders, 2016). One population that is most vulnerable to
succumbing to eating disorders is the adolescent population. The National Institute of Mental
Health (NIMH) reports that 2.7% of all adolescents in the US suffer from some form of an eating
disorder and that adolescent females are 2.5 times more likely to develop an eating disorder than
their male counterparts. Various therapies are available as treatment options, one of which is
dealing with emotional issues. The goal is to change a persons pattern of thinking or behavior to
change attitude and way of thinking. While CBT has been studied extensively in adults and in
adolescents with anxiety and depression issues, it has not been aggressively pursued in the
population of adolescents with eating disorders. The aim of this integrative review was to
compile and evaluate the literature pertaining to the authors PICO question: what are the effects
of CBT on adolescents with eating disorders? The author chose to research this topic after
This integrative review evaluated five journal articles. The author utilized the EBSCO
and PubMed databases to find journal articles relating to the PICO question. Specific terms were
limited to CBT, cognitive behavioral therapy, adolescents, eating disorder, and eating
disorders. The author did not limit the search to one specific eating disorder as there was not
enough literature for the effect of CBT on specific eating disorders in adolescents. The PubMed
Integrative Review of CBT 4
database resulted in 20 articles while the search in the EBSCO database resulted in 2,115 articles.
It was noted that the EBSCO database highlighted many results that did not pertain to the
Limits were furthered implemented to obtain quality research. Articles had to be peer-
reviewed and published between 2011 and 2016. The author of this integrative review also
limited the search to those articles only published in English. The author was able to select five
articles that met the criteria and were pertinent to the PICO question. All five articles chosen
The findings and results of this integrative review indicate that CBT is an effective,
reliable treatment for adolescents suffering from a spectrum of eating disorders. The research
articles are summarized in Table 1. The findings and results of the effects of CBT on adolescents
were organized as follows: Binge Eating Disorder (BED), Anorexia Nervosa (AN), and Bulimia
Nervosa (BN).
Two of the studies reviewed the effects of CBT on adolescent who suffered from BED
Grave et al. (2015) set out to examine the effects of CBT on adolescents with BED who
were not underweight. This study was a quasi-experimental cohort study of 68 adolescents.
Participants had to be between the ages of 13-19 years, have a BMI greater than or equal to 18.5,
and fulfill DSM-IV criteria for a binge eating disorder. Patients underwent 20 sessions of CBT
administered by three specially trained psychologists over 20 weeks. Participants were divided
into two separate groups: completers and non-completers. Completers finished the full 20
Integrative Review of CBT 5
sessions while non-completers did not. Data was assessed at two points in both groups: before
CBT was initiated and after the 20 sessions of CBT. Body weight and BMI were measured using
appropriate tools. A self-report questionnaire, EDE-Q, was used to examine the severity of eating
disorders.
Overall, participants experienced a decrease in the frequency of binge eating habits. 75%
of participants completed the full 20 sessions of CBT. 67.6% of participants had minimal eating
disorder psychopathology once the 20 session of CBT were completed. This study showed that
CBT is a valid treatment option for adolescents dealing with binge eating disorders.
DeBar et al. (2013) performed a randomized trial with the aim of developing and testing
CBT that was specific to adolescents with BED. Participants had to be between the ages of 12-18
years and have experience binge eating episodes once a week for the last 3 months. 26 patients
were recruited and randomized into two separate groups. The first group received cognitive
behavioral therapy while the second group was treatment as usual/delayed treatment (TAU-DT).
The CBT treatment consisted of 8 core sessions that focused on different topics related to healthy
eating habits and binging, followed by 4 optional sessions. TAU-DT participants received CBT
Participants were assessed at baseline, 3 months after randomization, and 6 months after
randomization. All were assessed using EDE, Beck Depression Inventory, Screen for Child
Anxiety Related Emotional Disorders, and a self-report satisfaction questionnaire. DeBar et al.
(2013) found that the CBT participants had an abstinence from binging rate of 92.3% at the 3-
month check while the TAU-DT participants only had a 30% abstinence from binging rate. At the
12-month check, both groups had improved abstinence rates, with the CBT group at 100% and
the TAU-DT group at 50%. However, once CBT was initiated in the TAU-DT group, there was a
Integrative Review of CBT 6
75% abstinence rate at the 3 month check mark. This study demonstrates that CBT is an effective
Two studies looked into the effectiveness of CBT in adolescent with anorexia nervosa:
Grave et al. (2014) hoped to use a modified CBT method to improve outcomes and
reduce relapse in adolescents with AN. The study was quasi-experimental cohort study of
adolescents with AN. 27 patients were recruited who met the study criteria of being between the
ages of 13-17 years, meeting DSM-IV criteria for AN, and having previously failed outpatient
treatment for AN. Participants underwent 20 weeks of CBT, which was delivered by a trained
psychologist.
Various data points were assessed before and after treatment, at 6-month and 12-month
follow-ups. These points included weight, height, BMI, and EDE. General psychiatric features
were also assessed using the Brief Symptom Inventory method. Overall, there was an increase in
mean BMI and weight. Participants also demonstrated a decrease in eating disorder
psychopathology and generally psychopathology. This study demonstrated that CBT had positive
Cowdrey et al. (2016) aimed to investigate if CBT would be an effective treatment for an
adolescent suffering form AN. The study was an A-B experimental design of a single adolescent
female with AN. Eleven sessions of CBT were completed over the course of 75 days. EDE-Q,
RCADS, and SDQ were assessed before and eight months after treatment. Weekly weights were
While CBT was occurring, the patient experienced increases in weight and reported mood
improvements, improved concentration, and a regular menstrual cycle. At the 8-month follow up,
however, the researchers determined that progress was only partially maintained although they
did not discuss exact parameters of partial maintenance. They recognized that this patient only
received 11 sessions of CBT whereas most patients receive a minimum of about 20 sessions.
This study demonstrated that some patients may experience the positive effects of CBT while in
therapy, but CBT may not have lasting effects for some individuals.
One quantitative study compared the use of CBT to that of family-based therapy (FBT)
for the treatment of bulimia nervosa (Grange et al., 2015). Grange et al. (2015) considered FBT
to be the more effective method for treating BN than CBT. The authors hypothesized that FBT
would be superior to CBT for this [adolescent] age group (Grange et al., 2015).
The authors of the study conducted a three-armed, 2-site randomized clinical trial. The
three interventions studied were CBT, FBT, and supportive psychotherapy (SPT). Participants
were recruited with the criteria that they be between the ages of 13-18 years and met the criteria
for DSM-IV diagnosed bulimia nervosa. 130 patients were recruited and randomized into the
CBT group, the FBT group, or the SPT group at a ratio of 2:2:1. Individuals underwent 18
sessions of whichever therapy they were assigned over the course of six months. Participants
were assessed at baseline, end of treatment, 6 months after completed therapy, and 12 months
after completed therapy using the EDE method. Results were then analyzed by utilizing
Grange et al. (2015) found that FBT was a more effective treatment for adolescents with
BN initially compared to CBT. At end of treatment, the group who receive FBT had an
Integrative Review of CBT 8
abstinence rate of 39.4% while the CBT group had a rate of only 19.7%. At 6-months post-
treatment, the FBT group still had higher abstinence ratings than that of the CBT group (44.0%
compared to 25.4%, respectively). However, at the 12-month follow-up, the two treatments were
comparable in their effectiveness. This study demonstrated that FBT may be more beneficial to
adolescents with BN in the short-term; however, CBT may be just as effective for other
The research addressed the PICO question of author of this integrative review.
Overall, the research in this review indicated that CBT has a positive effect in the treatment of
eating disorders. Most patients in these studies experienced improvements in weight gain and
decreases in eating disorder behaviors, such as binging, purging, or restricting. Much of the data
obtained in the articles was of statistical significance. This provided hard evidence for the
support of CBT in treating eating disorders in adolescents. It should be noted, however, that the
length of time CBT is provided is important. Cowdrey et al. (2016) found that CBT was
beneficial to their patient with AN while treatment was active; however, once treatment stopped,
CBT has been a widely accepted therapy in the adult population for many issues ranging
from depression to eating disorders. However, it has not been studied as intensively in the
adolescent population, especially in those adolescents with eating disorders of any variety. It is
important to identify and implement treatment in a timely manner due to the potential
catastrophic effects of eating disorders. Future research should look into comparing CBT alone
and CBT with other therapies. Grange et al. (2015) found that FBT was more beneficial in the
short-term treatment of BN than CBT. Long-term, both therapies proved to have the desired
Integrative Review of CBT 9
effects of improving patient conditions; however, it may be beneficial to merge the two therapies.
Future research should also look into how CBT can be delivered remotely. Not everyone has
access to in-patient or outpatient care settings. It is imperative to reach those individuals who
may be isolated.
There are several limitations in this study that should be noted. Primarily, the author has
little experience performing research and writing integrative reviews. This could skew the results
to what the author hopes to find, instead of the true evidence available in the literature. Another
limitation is the breadth of literature available on this issue. Although the initial literature search
appeared to result in thousands of articles, many of them did not pertain to the PICO question at
all. Instead, they addressed issues in the adult population or in children with anxiety and
depressive disorders. There was a noted delimitation. The author of this integrative review only
In conclusion, this integrative review found solid evidence in support of using CBT in
adolescents with eating disorders. Many patients experienced positive results while undergoing
CBT and these results lasted during follow-up for some patients.. Although there this integrative
review provides support for the use of CBT, there is need for further research in the area to
continue determining CBTs effectiveness long term, how it may be used in conjunction with
Resources
https://www.nimh.nih.gov/health/topics/eating-disorders/index.shtml?
utm_source=rss&utm_medium=rss
National Alliance on Mental Illness (2016). Eating Disorders Among Children. Retrieved
from
https://www.nimh.nih.gov/health/statistics/prevalence/eating-disorders-
among-children.shtml
Grave, R., et al. (2015). Transdiagnostic Cognitive Behaviour Therapy for Adolescents
With an Eating Disorder Who are not Underweight. Behaviour Research Therapy
73, 79-82.
DeBar, L. et al. (2013). Cognitive Behavioral Treatment for Recurrent Binge Eating in
Adolescent Girls: A Pilot Study. Cognitive and Behavioral Practice 20, 147-161.
5 (14), 1-7.
Grange, D. et al. (2015). Randomized Clinical Trial of Family Based Treatment and
Design/Method/ - Quantitative
Philosophical - Randomized trial
Underpinnings - Half of participants randomized into CBT while other half was
randomized into the control group of TAU-DT
- CBT consisted of 8 core sessions focusing on different topics
that revolved around eating behavior and emotion, as well as 4
optional sessions
Sample/ - Ethical considerations: None mentioned; assumed due to the
Setting/Ethical fact that the study was conducted by non-profit HMO
Considerations - Sample eligibility: female between ages of 12-18 years;
currently living with parent; binge eating episode (as defined by
DSM-IV) of at least once a week for last 3 months
- Sample: 26 participants; mean age 15.2 years;
- Setting: primary care clinic
Major Variables - Cognitive Behavioral Therapy (CBT): short-term
Studied (and their psychotherapy that addresses a patients cognitive processes
definition), if of dealing with emotional issues; goal is to change a persons
appropriate pattern of thinking or behavior to change attitude and way of
thinking
- Treatment as usual/delay treatment (TAU-DT): treatment
protocol that is currently in place and practiced for this
population (TAU); receiving treatment at a later date in a study
than those in the experimental group (DT)
- Binge Eating Disorder (BED): eating episodes that involve
consuming more than the average person over a 2 hour period
while experiencing a loss of control
Measurement - 3 assessment points: baseline, 3 months after randomization,
Tool/Data 6 months after randomization
Collection Method - Modified version of Eating Disorder Examination (EDE)
- Screen for Child Anxiety Related Emotional Disorders
- Beck Depression Inventory
- Self-report Client Satisfaction Questionnaire
Data Analysis - Chi-square and t-test to compare baseline of CBT group and
TAU-DT group
Findings/Discussi - All CBT participants attended 6 of 8 core sessions; 77% of
on CBT participants attended all 8 core sessions
- Only 70% of TAU-DT participants attended 6 of 8 core
sessions
- CBT participants had 92.3% abstinence from binge eating at 3
month check and 100% abstinence at 6 month check
- TAU-DT participants had only 30% abstinence form binge
eating at 3 month check and 50% abstinence at 6 month check;
however, once CBT was initiated in this group, there was 75%
abstinence from binge eating at 3 month check. Suggests
treatment works in both groups
Integrative Review of CBT 14