Given the efficacy among adults of Cognitive Behavioral Therapy for bulimia nervosa (CBT-BN) and the success of adapting the CBT framework for adolescents with other disorders (e.g., depression), a modified form of this treatment has been developed for adolescents with BN. The cognitive-behavioral model of BN posits that dysfunctional thoughts and attitudes toward weight and shape are the main factors involved in the maintenance of BN.
CBT-BN, as applied to adolescents, includes elements common to CBT-BN for adults as well as modifications informed by development. The three primary stages of CBT-BN remain intact: Stage One focuses on presenting the model underlying the maintenance of bulimic symptoms with an emphasis on self-monitoring and normalizing eating patterns, including eliminating dietary restraint; Stage Two works on identifying and modifying cognitions that maintain the eating disordered behaviors and that may serve as triggers, and engages patients in behavioral experiments to challenge thought patterns; and Stage Three targets relapse prevention.
Adaptations for adolescents include: (1) paying increased attention to a collaborative therapeutic alliance in order to increase adolescent motivation; (2) using less "CBT jargon" and concentrating more on concrete examples to illustrating CBT skills; (3) considering adolescent developmental concerns (such as peer relationships, desire for autonomy, and identity development) within the context of BN; and (4) involving parents by educating them about CBT, helping them provide appropriate support and encouragement to their adolescent, and encouraging their creation of an eating environment that reduces triggers for bulimic behavior.
In addition to traditional CBT adaptations, two other CBT-related approaches have been developed. A CBT guided self-care approach targeting bulimic symptoms has been modified for adolescents. This approach uses a manual (presented at the 8th grade reading level) with accompanying workbooks for the adolescent and a "close other" (often a parent), as well as a clinician's guide. The therapist and adolescent meet weekly for 10 sessions with 3 follow-up sessions focusing on relapse prevention. In addition, the approach incorporates 2 optional sessions with the "close other" where the aim is to guide the supportive individual in how they can best help the adolescent. The therapist's role is to encourage and guide the adolescent through the workbooks. Treatment and homework focus on: (1) motivation to change and the function of bulimia in the adolescent's life; (2) education about the self-maintaining nature of bulimic symptoms; (3) self-monitoring of thoughts, feelings, and behaviors; and (4) problem-solving and behavioral experiments to test beliefs about weight and shape. Another promising self-help approach involves a web-based CBT-BN package for adolescents, which includes 8 interactive CBT sessions, peer support through message boards, and contact via email with a support clinician.
Given that the onset of BN is typically in adolescence and the gold standard for adults with BN is CBT-BN, it is surprising that few treatment studies have examined the efficacy of adaptations for CBT for adolescents. The limited results are promising, however, with some evidence that traditional CBT-BN modified for adolescents is associated with decreases in binge eating frequency and disordered eating attitudes. Regarding guided self-care, there is preliminary support for it being at least as effective as family therapy and possibly more acceptable, in particular for adolescents resistant to involve family in their treatment. Additionally, a study of the web-based CBT program found that this intervention was feasible and resulted in significant reductions in bulimic behaviors and attitudes. Some researchers have suggested that the web-based program may be a first, cost-effective step in treating adolescents with BN.
References & Recommended Readings
Fischer, S., Doyle, A.C., & le Grange, D. (2009). Cognitive-behavior therapy for eating disorders in childhood and adolescence. In D. McKay & E.A. Storch (Eds.), Cognitive-behavior therapy for children: Treating complex and refractory cases (pp. 259-291). New York, NY: Springer Publishing.
Lock, J. & Fitzpatrick, K.K. (2007). Evidence-based treatments for children and adolescents with eating disorders: Family therapy and family-facilitated cognitive-behavioral therapy. Journal of Contemporary Psychotherapy, 37, 145-155.
Pretorius, N., Arcelus, J., Beecham, J., Dawson, H., Doherty, F., Eisler, I.,et al. (2009). Cognitive-behavioural therapy for adolescents with bulimic symptomatology: The acceptability and effectiveness of internet-based delivery. Behaviour Research and Therapy, 47, 729-736.
Schapman-Williams, A.M., Lock, J., & Couturier, J. (2006). Cognitive-behavioral therapy for adolescents with binge eating syndromes: A case series.International Journal of Eating Disorders, 39, 252-255.
Schmidt, U. (2009). Cognitive behavioral approaches in adolescent anorexia and bulimia nervosa. Child and Adolescent Psychiatric Clinics of North America, 18, 147-158.
Schmidt, U., Lee, S., Beecham, J., Perkins, S., Treasure, J.T., Yi, I., et al. (2007). A randomized controlled trial of family therapy and cognitive behavior therapy guided self-care for adolescents with bulimia nervosa and related disorders. American Journal of Psychiatry, 164, 591-598.
Wilson, G.T. & Sysko, R. (2006). Cognitive-behavioural therapy for adolescents with bulimia nervosa. European Eating Disorders Review, 14, 8-16.