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Enhanced Cognitive-Behavioral Therapy (CBT-E) for Eating Disorders: Case Study of a Client With Anorexia Nervosa
Amy L. Karbasi Clinical Case Studies 2010 9: 225 DOI: 10.1177/1534650110372541 The online version of this article can be found at: http://ccs.sagepub.com/content/9/3/225

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Enhanced CognitiveBehavioral Therapy (CBT-E) for Eating Disorders: Case Study of a Client With Anorexia Nervosa
Amy L. Karbasi1

Clinical Case Studies 240 9(3) 225 The Author(s) 2010 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI: 10.1177/1534650110372541 http://ccs.sagepub.com

Abstract This case study involved the treatment of a young adult female, referred to as Marie, who presented for treatment seeking help with her eating disorder. Marie evinced symptoms of dietary restriction, amenorrhea, low weight, and low body mass index (BMI); she was subsequently diagnosed with anorexia nervosa. She was treated with 20 sessions of enhanced cognitivebehavioral therapy (CBT-E), a relatively new, transdiagnostic treatment for eating disorders. Maries progress throughout treatment is detailed in this case study report. Results supported the promising but limited body of research available on this treatment, which was highly effective for this client and, therefore, may be more generally useful for clients with anorexia nervosa. Keywords anorexia nervosa; case study; CBT-E; eating disorders

1 Theoretical and Research Basis

Eating disorders are commonly occurring illnesses that frequently cause substantial physical and psychosocial impairment in those who suffer from them (Fairburn, Cooper, Shafran, & Wilson, 2008). They are often difficult to treat and impose a significant burden on health services. In inpatient mental health settings, most cases are diagnosed as either underweight forms of eating disorder not otherwise specified (NOS) or anorexia nervosa (Dalle Grave & Calugi, 2007). Although there is a prominent need for effective treatments for eating disorders, few are available. The current leading treatments (e.g., cognitive-behavioral therapy for bulimia nervosa [CBT-BN], interpersonal psychotherapy, antidepressant medication) tend to be effective for only half of clients who complete them, take a lengthy amount of time to achieve an effect, and/or the effects are not sustained (Fairburn et al., 2008). There has been little research on effective treatments for anorexia nervosa, particularly with adult clients. Existing studies tend to focus on adolescents and target a highly specific form of Family-Based Treatment (FBT; Lock, le Grange,
1

Xavier University

Corresponding Author: Amy L. Karbasi, 324A Joseph Building, Xavier University, 3800 Victory Parkway, Cincinnati, OH 45207. E-mail: karbasia@xavier.edu

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Agras, & Dare, 2001), which is emerging as the empirically supported treatment of choice for adolescent anorexia nervosa and bulimia nervosa (le Grange & Lock, 2010; Loeb & le Grange, 2009). Because of the pervasiveness and challenges involved in treating these disorders, a new, empirically supported treatment that addresses shortcomings of existing treatments and targets adults is needed. Enhanced CBT (CBT-E), a transdiagnostic form of CBT, has been developed for the full range of clinical eating disorders (Fairburn, Cooper, & Shafran, 2003). The transdiagnostic perspective purports that eating disorders outlined in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revision; DSM-IV-TR; American Psychiatric Association [APA], 2000), including anorexia nervosa, bulimia nervosa, and eating-disorder NOS, are not distinct clinical states but rather have many features in common. Overevaluation of control over eating, shape, and weight is central to the maintenance of all clinical eating disorders. Most of these features are not present in other psychiatric disorders, and clients tend to migrate between these diagnoses over time (Fairburn & Harrison, 2003). This temporal movement, together with the fact that the disorders share the same distinctive psychopathology, suggest that common transdiagnostic mechanisms are involved in persistence of eating-disorder psychopathology (Fairburn et al., 2003). The implication is that those treatments that are effective in addressing these common core features should be effective with all types of eating disorders. Consistent with the transdiagnostic view, clients with anorexia nervosa share essentially the same core psychopathology as those with bulimia nervosa and eating-disorder NOS. Clients in all three groups tend to overvalue shape and weight (as well as control over shape and weight), restrict their food intake, vomit, misuse laxatives or diuretics, and overexercise (Fairburn et al., 2003). The major difference is that in anorexia nervosa, undereating predominates, resulting in extremely low body weight and features of starvation. Related to this is the pronounced social withdrawal seen in starvation that leads to self-absorption and isolates clients from external influences that might diminish their overconcern with eating, shape, and weight. Whereas the maintaining factors are similar in all three disorders, the specific maintaining processes operating in any individual client depend on the nature of the eating-disorder psychopathology present. Consequently, the transdiagnostic view highlights processes that need to be addressed in treatment, helping the clinician design a tailored treatment to fit each clients unique psychopathology (Fairburn et al., 2003). CBT-E is described as enhanced because it utilizes a variety of new strategies and procedures designed to improve treatment adherence and outcome. There are two forms of CBT-E. These are a focused form (CBT-Ef) that targets eating-disorder psychopathology exclusively, and a more complex, broad form (CBT-Eb) that addresses additional obstacles to change that are external to the core eating disorder: mood intolerance, clinical perfectionism, low self-esteem, and interpersonal difficulties (Fairburn et al., 2008). Core areas on which to focus treatment are determined by the needs and pathology of the individual client. The treatment is delivered on an individual outpatient basis and typically lasts for 20 weeks, although longer versions may be utilized for clients who are significantly underweight. Although treatment is tailored individually to each clients needs and highly personalized case formulation, typical aspects of treatment include: assessing the client with standardized questionnaires designed to measure his or her eatingdisorder features and their impact on his or her psychosocial functioning; jointly creating a case formulation of processes that maintain the clients eating disorder; educating the client about body mass index (BMI) and his or her particular eating disorder; obtaining the clients commitment to change and attend at least 20 sessions; weekly in-session weighing; real-time self-monitoring of eating behaviors; establishing a regular eating pattern; reducing the influence of evaluation of shape and weight on self-value; and maintenance and relapse prevention (Fairburn et al., 2008). Because CBT-E is a relatively new treatment, there have been few empirical studies to evaluate its effectiveness. Existent studies tend to support efficacy of the treatment. Fairburn et al.

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(2009), in a two-site randomized controlled trial, compared the two forms of CBT-E (CBT-Ef and CBT-Eb) to a control condition over the course of 20 weeks of treatment and a 60-week follow-up period. Participants in the treatment conditions were 154 individuals who were diagnosed with an eating disorder. The control condition participants were on an 8-week waiting list period preceding treatment. Results demonstrated that clients in the control condition exhibited little change in symptom severity, whereas those in the two treatment conditions exhibited substantial and equivalent change, which was well-maintained during follow-up (Fairburn et al., 2009). At 60-week follow-up assessment, 51.3% of the participants in the treatment conditions had a level of eating-disorder features less than 1 standard deviation above the community mean. Treatment outcome did not depend on eating-disorder diagnosis, and clients with mood intolerance, clinical perfectionism, low self-esteem, or interpersonal difficulties responded better to CBT-Eb (the more complex treatment) than CBT-Ef. The researchers concluded that these two treatments appear to be suitable for the majority of outpatients with an eating disorder, with the more complex treatment being especially beneficial for clients with additional impaired psychological functioning. In a study investigating body-image interventions in individuals with binge-eating disorder (BED), Hilbert and Tuschen-Caffier (2003) randomly assigned 28 clients with BED to CBT-E or CBT with a cognitive restructuring component focused on body image (CBT-C). At posttreatment and 4-month follow-up, CBT-E and CBT-C were both effective in improving body-image disturbance and producing substantial and stable improvements in eating-disorder pathology. In a multidimensional meta-analysis of psychotherapy for bulimia nervosa, Thompson-Brenner, Glass, and Westen (2003) found that CBT-E produced response rates in the upper range of those reported in previous trials of other treatments, providing further support for the efficacy of CBT-E. Although CBT-E has been demonstrated to be highly effective with clients with eating disorders, few clients seem to receive it in practice, and there have been few studies evaluating treatments for anorexia nervosa (Fairburn & Harrison, 2003). In addition, no identified case studies describe the process and results of implementing CBT-E with a client with an eating disorder. The following case study describes the utilization of CBT-E in the treatment of an individual with anorexia nervosa. When the client presented for treatment, her symptoms and additional pathology (e.g., clinical perfectionism) made her an excellent candidate for this treatment. It was hypothesized that CBT-E would help the client reach her goals of normalizing her eating behaviors and patterns, attaining significantly better psychosocial functioning, and gaining weight. Information detailing the treatment of this client may be useful to clinicians who are unfamiliar with this treatment and may aid in facilitating its dissemination as a more widely used, efficacious treatment for clients with anorexia.

2 Case Presentation
Marie was a 19-year-old, White woman attending college to work toward a bachelors degree. She resided on her college campus and frequently visited her immediate family who lived near the campus. At the time of treatment, she was not involved in a romantic relationship and had few close friendships. She spent the majority of her time studying, exercising, working part-time, participating on the track team at her university, and visiting family. She self-referred to treatment seeking help with her irregular eating behaviors and the resulting negative impact on her psychological functioning.

3 Presenting Complaints
Maries eating-disorder symptomatology began when she entered her first year of college, 2 years before presenting for the treatment described in this case report. Upon entering college, she felt

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homesick and isolated and began to restrict her food intake. In addition, she began to exercise and study excessively. She developed amenorrhea approximately 6 months after onset of these behaviors, and this was still present at the time of treatment. Marie expressed having symptoms of anxiety and features of perfectionism, especially related to academic and other performancebased activities (e.g., running competitively). She noted frequent worrying, difficulty relaxing, and persistent negative thinking. In addition, she stated that she felt depressed, which included experiencing frequent crying spells, loss of interest in previously enjoyable activities, difficulty sleeping, and low energy. She stated that she had lost many of her friendships and did not feel like her normal self since developing these symptoms. Upon referral, her body weight was significantly below normal for her age and height (significantly underweight is defined as a BMI 17.5; at 110 pounds and a height of 5 ft 6.5 in., Maries presenting BMI was 17.5), and she reported a fear of weight gain. She stated that she obsessed and ruminated about food constantly and experienced extreme guilt and anxiety when she ate unhealthy foods (e.g., ice cream, french fries), even in small amounts. She tended to snack on healthy foods (e.g., fruit, pretzels) throughout the day and rarely ate full meals. Marie did not binge or purge, nor did she have a distorted body image (e.g., she did not view herself as overweight). Marie noted that her symptoms often improved when she went home for extended breaks from school, such as during the holiday season and during the summer months, during which she had more time and closer contact with her family. She presented for treatment when friends and family began to tell her that she looked too skinny, she noticed that her eating behaviors were not normal, and she was becoming more emotionally distressed.

4 History
Marie described her life prior to entering college as happy and carefree. She was close to her family, had several close friendships, and was actively involved in sports and volunteer activities. While she occasionally went on dates, she was not involved in any significant long-term relationships. Her grades in school were good; however, she was not overly concerned or anxious about academics. In addition, she maintained a healthy body weight and had no eating-disorder features or mental health problems. Marie had an insignificant medical history. She reported no history of physical, sexual, or emotional abuse. She began to experience symptoms of an eating disorder, anxiety, and depression during her first year of college. Approximately 1 year later (1.5 years before beginning the treatment described in this study), she sought therapy. However, she attended only a few sessions because she found them to be unhelpful and felt even more depressed after her sessions. Marie had never taken psychopharmacological medication.

5 Assessment
Upon presenting for treatment, Marie participated in a semistructured interview during which the therapist assessed the history, frequency, severity, and type of her presenting eating-disorder symptoms, as well as her current functioning across multiple domains (e.g., family, academic, social, etc.). Results of the clinical interview and criteria outlined in the DSM-IV-TR (APA, 2000) suggested that she was suffering from anorexia nervosa and that the symptoms associated with her eating disorder were significantly negatively influencing her psychosocial functioning in a variety of life domains. In addition to the clinical interview, Marie completed the Eating Disorders Examination Questionnaire (EDE-Q; Fairburn & Beglin, 1994), a self-report version of the EDE (Fairburn & Cooper, 1993), which is a well-established investigator-based interview. The EDE-Q is used to

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assess eating disorders and their associated features and pathology. It is comprised of four subscales: dietary restraint (DR), eating concern (EC), weight concern (WC), and shape concern (SC), as well as a global score (GS). The 28 items on the measure are rated on a 7-point scale (0 to 6), with higher scores reflecting greater severity or frequency. The questions specifically refer to the clients functioning over the course of the past 28 days. Research suggests that the EDE-Q has adequate reliability and validity (Fairburn & Beglin, 1994; Luce & Crowther, 1999; Mond, Rodgers, Hay, Owen, & Beumont, 2004; Wolk, Loeb, & Walsh, 2005). Maries results on the EDE-Q at pretreatment were the following: 4.8 on DR, 5.0 on EC, 4.2 on WC, 4.1 on SC, and 4.5 on GS. Based on normative data, Maries responses on each subscale were well above the average scores of a sample of 243 young adult women without eating disorders in the general population (see Fairburn & Beglin, 1994). After completing the EDE-Q, Marie completed the Clinical Impairment Assessment Questionnaire (CIA; Bohn & Fairburn, 2008). The CIA is a 16-item self-report measure that assesses the severity of psychosocial impairment related to eating-disorder features over the course of the past 28 days. The purpose of the CIA is to provide a simple, single index of the severity of psychosocial impairment (a global impairment score), and it is designed to be completed by clients before and after a period of treatment. It is recommended that the client complete the CIA immediately after completing a measure of current eating-disorder features that covers the same 28-day time frame (e.g., the EDE-Q). This ensures that clients have their eating-disorder features at the forefront of their minds when completing the CIA. The 16 items on the CIA assess impairment in the following life domains that are typically affected by eating-disorder psychopathology: mood and self-perception, cognitive functioning, interpersonal functioning, and work performance. Responses are rated on a 4-point scale (0 to 3). The total score ranges from 0 to 48, with a higher score indicating a higher level of secondary psychosocial impairment to an eating disorder. A score of 16 is used as the cutoff score for predicting eating-disorder status. Research indicates that this instrument demonstrates adequate reliability and validity (Bohn et al., 2008). When completing this measure at pretreatment, Marie obtained a score of 45, which was well above the mean score of 32.5 obtained in a sample of 123 individuals who had been diagnosed with an eating disorder. Assessment also included Maries daily self-monitoring of her eating behaviors as well as thoughts, feelings, emotions, and events related to her eating patterns. Each week, the therapist provided Marie with a packet of 7 self-monitoring forms to complete daily. These forms were evaluated throughout treatment to determine changes and progress in Maries eating patterns and associated behaviors, cognitions, and emotions over time. Finally, Maries BMI and weight were monitored over time. Each week, the therapist plotted Maries weight and BMI on a graph, with Maries target BMI (determined by her height) being between 19.0 and 19.9 (consistent with guidelines in CBT-E). Trends in BMI and weight were evaluated every 4 weeks. At pretreatment, Maries weight was 110 pounds with a BMI of 17.5.

6 Case Conceptualization
During the initial sessions of CBT-E, the common interplay of thoughts, emotions, behaviors, and physiology in the context of anxiety and anorexia were conveyed to Marie. Specifically, the therapist explained that individuals with anorexia typically have negative thoughts about their shape and weight. Negative thoughts lead to feelings of anxiety, which in turn leads to dietary restriction to reduce anxiety. Marie was asked whether this pattern seemed to be typical of her experience, to which she responded in the affirmative. The therapist and client then discussed the interplay of environment, thoughts, emotions, and behaviors in Maries life, in order to tailor the conceptualization specifically to her experience. Origins and maintaining factors of Maries

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eating disorder were identified in the case conceptualization. Together, the therapist and client generated a case conceptualization of Maries presenting issues from a cognitive-behavioral perspective, which is an essential component of CBT-E. Maries eating disorder and additional presenting issues began when she entered her first year of college. Prior to this, she described that she enjoyed a relatively carefree life; that is, her concern for shape, weight, and academic and work-related perfectionism were nonexistent, and she maintained a healthy weight. Upon entering college and moving into a dormitory on campus, she experienced the loss of her close support system and sense of security in the form of no longer seeing and interacting with her family on a daily basis. For Marie, beginning college was a major life transition in a novel, stressful environment. She began to feel homesick and lonely and found it difficult to fit in to the college atmosphere, which led her to socially isolate herself. Marie felt consistently poorly about herself for the first time in her life. Prior to college, she functioned well and felt competent and confident; thus, her current state led her to feel driven to compensate for feeling poorly about herself. Because she was bored and lonely, she began to pass her time by studying and working out at the campus gym. These two solitary activities comprised the vast majority of her time because her social isolation prevented her from engaging in other activities. Subsequently, she began to experience positive results in the form of weight loss, a more athletic build, and excellent grades, which began to make her feel confident about herself again. Because she obtained positive reinforcement from the results of working out, she began to restrict what she ate and refrained from eating unhealthy foods to maintain and advance these results. This was further reinforcing to her because she noticed even more pronounced results. For example, she was able to run faster than she did in high school, which resulted in her being one of the top performers on the track team. These behaviors and accomplishments were reinforcing for her because they made her feel better about herself and more in control in a chaotic environment that was making her feel poorly. Therefore, these contingencies maintained and increased her engagement in these activities (working out and studying), and she began to engage in them excessively in order to continue experiencing positive results. If Marie did not work out or study enough or if she ate something unhealthy, she experienced anxiety, guilt, depression, and feelings of failure and loss of control, all of which were punishing for her. Therefore, she continued restricting her diet and working out and studying excessively to reduce negative feelings, and, as a result, these behaviors continued to be reinforcing. This cycle was explained to Marie as the mechanisms by which her perfectionism, achievement focus, and subsequent eating disorder had developed and continued to be maintained. Although her maladaptive behaviors were reinforcing, Maries friends and family began to worry about her and comment about her thin appearance. In addition, Maries obsession with food was consuming her thoughts, leading to negative emotions and contributing to her social isolation. All of these factors were punishing for Marie. At this point, she realized that she needed to make changes in her life and sought therapy. The overarching goal of therapy was to reconfigure her case conceptualization to change contingencies and maintaining factors in her environment, as well as restructure her irrational thoughts (e.g., I must get straight As or I am a failure), so that what was previously reinforcing for Marie (e.g., studying excessively) would become punishing. This would increase the likelihood that she would engage in healthier behaviors for which she would be positively reinforced.

7 Course of Treatment and Assessment of Progress

Using Cognitive Behavior Therapy and Eating Disorders (Fairburn, 2008) as a guide, the therapist implemented CBT-E for eating disorders in the context of perfectionism. More specifically, CBT-Eb was implemented, as it has been demonstrated to be the more effective form of CBT-E

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for clients who exhibit complex symptomatology (e.g., perfectionism), in addition to eatingdisorder symptoms (Fairburn et al., 2009). Treatment techniques described in the remainder of this study adhere to the principles of CBT-E. Treatment began with psychoeducation about CBT-E and its efficacy in the treatment of eating disorders, after which Marie stated that she was enthusiastic about engaging in this type of therapy. Then, the therapist elicited commitment from the client to attend at least 20 sessions of CBT-E once per week, ideally with no breaks between sessions. Foreseeable problems with this commitment (e.g., going home frequently) were subjected to trouble-shooting. Marie completed the EDE-Q and the CIA in the beginning of treatment to assess her eating-disorder features and establish a baseline level of functioning. The therapist then established a commitment to change from the client. The therapist provided Marie with a handout of the effects of being underweight (see Fairburn, 2008) and asked her to create a list of personal reasons to gain weight. These lists were utilized throughout treatment to maintain and, when necessary, revive Maries motivation to change and gain weight. Whereas gaining weight may not be a typical goal for a client with anorexia nervosa, the therapist explained that this was a necessary aspect of treatment in order for the client to achieve better physical and mental health. Though Marie was initially anxious about the prospect of gaining weight, she agreed that this was necessary, stated she was ready to change and, therefore, articulated gaining weight as one of her therapeutic goals. The process of commitment to change may take several sessions for many clients with anorexia, but this was not the case with Marie; she presented for therapy with high motivation and commitment to change. Next, the therapist conveyed the common interplay of environment, thoughts, emotions, behaviors, and physiology that tend to facilitate, perpetuate, and maintain anorexia nervosa. Then, a specific conceptualization of Maries symptoms was derived (see the previous section describing Maries case conceptualization). Once Marie committed to treatment and gained an understanding of the conceptualization of her problems, the therapist educated her about BMI and the appropriate BMI range for her height. The therapist explained that CBT-E requires weekly in-session weighing. The rationale for this was explained to Marie as a way to provide her with accurate weekly weight and BMI data in an environment in which her therapist could help her manage feelings of anxiety regarding gaining weight. In addition, she was required to eliminate weighing herself outside of sessions. Though Marie was somewhat anxious about the prospect of weekly weigh-ins, she agreed to participate in this aspect of therapy. Her weight and BMI were plotted weekly on a graph, and because weight naturally fluctuates from week to week, the graph was reviewed in detail with Marie every 4 weeks with an emphasis on the overall trend in weight gain or loss. Maries graph as she progressed through therapy can be seen in Figure 1. The goal was for her to obtain a BMI of at least around 20, defined by Fairburn (2008) as between 19.0 and 19.9. The therapist explained to Marie that this was the BMI range at which positive physical and mental health benefits begin to occur, as described by Fairburn. The therapist explained that while a BMI of 20.0 to 24.9 is the healthy target range, a BMI between 19.0 and 19.9 was a realistic target to reach within the context of her disorder for the time being. However, the therapist conveyed that Marie would experience more significant physical and mental health benefits as her BMI increased and remained within the healthy range of 20.0 to 24.9. The therapist prepared Marie for the necessity of gaining weight and what that might be like for her (e.g., her clothes may fit more tightly, she may feel anxious, etc.). The client was also educated about natural fluctuations in weight and the lengthy amount of time it may take to regain weight and begin menstruating as her body acclimated to the changes she was making. Next, the therapist delineated the need for Marie to work toward a normalized pattern of eating. This pattern was defined as eating three meals and three snacks per day, spaced no longer than 4 hours apart, and was linked to her personal goal of eating in a more normalized way.

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20.7/130 19.9/125 BMI/Weight (lbs) 19.1/120 18.3/115 17.5/110 16.7/105 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 FP* Session Number

Figure 1. Weight and BMI assessment

Note: BMI = body mass index. *FP = 6-month follow-up.

To begin, the goal was simply for Marie to eat in a patterned way at specified times; the content of what she ate was irrelevant. At the beginning stages of treatment, Marie planned ahead at what times she would eat meals and snacks each day. As a more normalized pattern of eating became naturally established, she no longer needed to plan when to eat, and the focus shifted to the content of what she ate. Marie was encouraged to ignore sensations of fullness and hunger (which were likely distorted as a result of her eating disorder), refrain from eating outside of planned times, and adhere to the pattern under all circumstances. This was initially difficult for Marie, as one of her tendencies was to snack lightly throughout the day. If she felt the urge to snack, she was taught to engage in distracting, incompatible activities to snacking (e.g., taking a shower, grooming her fingernails, typing on a computer, etc.). Over time, the goal was for Marie to adopt an automatic, normalized pattern of eating. To help Marie adopt a regular pattern of eating, she was introduced to real-time self-monitoring in the form of daily food records, on which she tracked all of her food intake over the course of each day. In addition, she tracked emotions, thoughts, behaviors, and significant events associated with what she ate. She noted on the records whether she considered what she ate to be a meal or a snack, whether she felt anxious or guilty about what she ate, whether she thought what she ate was excessive, and how much she exercised. The importance of completing her food record in the moment, or very shortly after eating, was emphasized to facilitate accuracy in recording. The rationale for keeping these food records was presented to her as a way to help become aware of what was occurring in the moment, record accurate amounts of what she ate, provide information on where changes needed to be made, intervene with problems she had adhering to the pattern, and monitor her progress over time. Marie began to keep these records at the beginning of treatment and continued to do so through the final session. To reinforce completion of the records, the therapist praised Maries efforts and reviewed the records at the beginning of each therapy session in order to monitor progress, identify patterns, and problem-solve any difficulties she had. She was compliant in keeping the food records. Once Marie achieved a regular pattern of eating approximately midway through treatment, the focus shifted to changing the content of what she ate to help her gain and maintain a healthy

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weight. Marie tended to fear eating unhealthy foods, which she believed would result in weight gain. In addition, there was little variety in her diet, as she typically ate the same foods daily. A list of foods Marie typically avoided or feared was generated, and these foods were then placed into four categories. Category 1 foods were those least feared, and Category 4 foods were those most feared. Categories 2 and 3 included foods that she mildly feared. Via graduated exposure, these foods were slowly introduced into her diet in small portions, beginning with Category 1 and progressing to Category 4; they were recorded on her food records. One of her most feared foods was fried chicken, which she confronted successfully by the end of treatment. The objective was to demonstrate to Marie that she could vary her diet and enjoy these foods in moderation without getting fat. As she was gradually exposed to avoided foods over time, anxiety diminished after learning that the feared consequence (getting fat) did not occur. This added variety and spontaneity to her diet and led her to feel less anxious about eating out with friends, which she began to do more often. Introducing avoided foods was one method used to help Marie regain weight. The therapist further taught Marie that to regain weight, she needed to eat more often, eat larger portions, change her food choices, eat with others in social environments, and decrease her activity level. Although Marie quit the track team approximately one third of the way through therapy, she continued to engage in frequent, intense exercise (most often in the form of running), which impeded her from gaining weight. The therapist helped her to find a balance in which she could continue to exercise in a way that was not excessive or hindering her from gaining weight. If, after monitoring her weight/BMI graph for a few weeks, Marie was not gaining weight but was eating well, exercise was targeted as the problem and reduced. For example, during weeks 12 through 14, she lost a total of 4 pounds (see Figure 1) in spite of improved eating patterns on her food-monitoring records. Upon analysis of her exercise behaviors over the course of those three weeks, it was determined that she was exercising more than she had in previous weeks due to friends and relatives frequently requesting that she go for long runs with them, which were social opportunities that Marie found difficult to resist. Once exercise was targeted as the problem behavior to be reduced, Marie decreased her exercising and replaced it with engaging in social activities that were not exercise related. At this point, her weight once again began to increase. This was also helpful for weight maintenance, as Marie learned how to balance her eating and exercise so that she could successfully gain and maintain weight. In addition, Marie obtained positive reinforcement for gaining weight. Her therapist, friends, and family commented positively about her healthier appearance and more positive demeanor. As a result, she began to view gaining weight with enthusiasm and as a success rather than a failure. Once these patterns were established and Marie was regularly gaining weight, therapy continued to focus on weight gain while also shifting to a focus on overevaluation of shape and weight. Marie placed a great deal of her self-value on her shape and weight. To help her reduce the importance she placed on these characteristics, the client and therapist constructed a pie chart representing important areas of Maries life that affected the way she valued and judged herself. The largest areas of the pie were attributed to exercising and controlling and restricting her eating. The problems and consequences inherent in placing these behaviors so highly in valuing herself were discussed. Specifically, by doing so, she placed much less importance on other areas of her life. By putting all of her eggs in one basket, if she failed to restrict her diet or engage in exercise, she had little else in her life to contribute to self-value. The aim was to revise Maries views of herself to expand other pieces of the pie (e.g., family, friends, social activities, volunteer work), thus developing additional domains for self-evaluation and reducing the importance attached to shape and weight. The pie chart continued to be monitored and revised throughout therapy. By the end of treatment, the exercise and food restriction pieces decreased in size, while each of the other pieces increased.

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In addition to focusing on overevaluation of shape and weight, the therapist helped Marie learn to engage in new and well-liked activities in order to increase her social support and decrease her social isolation, which was a trigger for her eating disorder. Marie generated a list of enjoyable activities in which she engaged in the past as well as new activities that she would like to try. Each week, she engaged in at least one to two activities, most often involving other people (solitary activities were discouraged). Because Marie tended to return to her parents home on the weekends and during school breaks, she was encouraged to stay on campus more often to develop a support network at school and feel less lonely. She recorded these activities on monitoring forms, and they were discussed in session each week. The intention was for engagement in social activities to become positively reinforcing, increasing the likelihood that Marie would continue these activities. By the end of treatment, Marie went home less often and spent significantly more time developing relationships and engaging in activities with others. Finally, near the end of treatment, Maries perfectionism was addressed. Perfectionism was not conceptualized as part of her personality style, but rather an adjustment reaction to a major life change, as she did not possess this trait before entering college. Therefore, working toward changing her patterns of perfectionistic thinking may not have been as time intensive as with a client who has a perfectionistic personality style. The therapist explored in detail the origins of Maries perfectionism and explained that this was a maintaining factor of her eating disorder. As an example of Maries perfectionistic thinking, she espoused the belief that she was a failure if she did not earn straight As or missed a day of work. The therapist engaged Marie in cognitive restructuring, focusing on her irrational beliefs and teaching her to challenge and change them. This consisted of identifying the maladaptive thought, assessing evidence for the thought, identifying evidence against the thought, and devising a more rational conclusion on the basis of the evidence (this was also done with regard to other features of her eating disorder, such as overevaluating shape and weight). Marie compiled a list of challenges to some of her common irrational thoughts and reviewed the list when she found herself thinking irrationally. The therapist also helped Marie generate a list of her positive self-qualities to redirect her from overvaluing body shape, weight, and achievement and learn to value other important aspects herself. In addition, the therapist and client worked toward restructuring Maries life goals to be more rational, as the goals she set for herself tended to be unrealistic. For example, one of Maries life goals was to do well in her career, a subgoal of which was to never miss a day of work. This subgoal was restructured as not missing work unless she is ill, an emergency occurs, or she takes vacation time. In addition, she learned to believe that if she does miss work, she is not lazy or a failure, which were her previous beliefs. Marie was also taught to engage in activities that were based less on performance (e.g., spend less time studying and running races) and more on enjoyment (e.g., spend more time with friends). Over time, Marie began to place less value on performance and achievement. At the end of treatment, Marie was educated about how to maintain the changes she had made and prevent relapse. Future situations that may be stressful for her and potentially trigger eatingdisorder symptoms and perfectionism were identified (e.g., returning to school in the fall, studying excessively, and isolating herself). Because she anticipated the possibility of relapsing once the new semester began (when she would once again face academic-related stress), she remained in therapy for a few weeks into the new semester, progressed well, and then felt she was ready to terminate. She was reminded that she had learned the tools she needed to maintain the changes she had made. Marie identified the specific components of CBT-E that were most helpful to her as keeping the self-monitoring food records, weighing herself weekly in session, keeping and reviewing lists of reasons to gain weight to increase her motivation, and cognitive restructuring. She was encouraged to continue with these activities until she felt she had her symptoms under control for a sustained period of time. The therapist provided her with recommendations for

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continued improvement, essentially reminding her of the skills she had learned and encouraging her to continue utilizing them to prevent relapse. She was advised to keep food in her house regularly, eat with others when possible, refer to the lists she had made throughout treatment, go home less, be mindful of the triggers to her eating disorder, reduce exercise or eat more when she exercises, and see a physician if her menstrual cycle did not return within the next several weeks. At the end of treatment, she once again completed the EDE-Q and the CIA to assess her progress.

Assessment of Progress
As indicated, several tools were used to assess Maries progress throughout therapy. One tool was the daily food record, which was reviewed at the beginning of each therapy session and assessed over time. A review of her food records indicated that, over time, Marie improved by eating varied, whole meals (rather than snacks) in a regularly patterned way. At the beginning of therapy, her monitoring records indicated that she tended to snack throughout the day at irregular times, eating foods that were often low in calories. In addition, she was inclined to eat the same foods (e.g., pretzels and raisins in the middle of the day, salad later in the day, one spoonful of ice cream in the evening, etc.). In the middle and ending stages of therapy, Maries records demonstrated that she ate a greater variety of foods that were higher in calories, and she deviated from the pattern (three meals and three snacks per day) much more rarely than she did in the beginning of treatment. In addition, as therapy progressed, she viewed what she ate as excessive less often and felt anxious and guilty less often about what she ate, compared to the beginning of therapy. Review of her records also indicated that she spent less time per week exercising (and at a lower intensity) than in the beginning of treatment. Additional results based on Maries self-report indicated that by the end of treatment, she focused less on obtaining perfect grades, she experienced emotions (e.g., mild anger) that she had not felt or expressed since the onset of her eating disorder, and she began dating. She reported that she developed closer, more meaningful relationships with friends, felt less anxious about leaving her family, began to enjoy eating again, and felt more like her old self. She stated that she was happy to have regained the weight and that she felt physically and mentally better once gaining it, despite initially feeling anxious about doing so. Marie reported that she felt less guilty, anxious, and worried overall, and she noticed a significant decrease in her obsessive thoughts about food. She stated that she felt she had reached her goals and had gained the tools necessary to continue to improve. Essentially, therapy changed the maintaining conditions of her eating disorder, and because healthier activities became reinforcing for her, she continued to engage in those activities. At the end of treatment, her amenorrhea was still present, and the therapist explained to her that it would likely take more time for her body to return to normal after a long period of dietary restriction. Finally, Marie expressed that she enjoyed the treatment and found it to be extremely helpful to her. Weekly weigh-ins and measurement of BMI were also utilized as assessment tools (see Figure 1). At week 1, Marie weighed 110 pounds at a height of 5 ft 6.5 in., resulting in a BMI of 17.5, which is within the range of significantly underweight. As expected, her weight fluctuated over time, especially over the course of the first few weeks of therapy when her body was acclimating to the changes she was making. It was hypothesized that the reasoning for her weight loss in the beginning of treatment was due to loss of muscle mass as a result of significantly reducing her running. Over time, the trend indicated that her weight and BMI steadily increased. By the end of treatment (session 20), her weight had increased to 122 pounds, for a total weight gain of 12 pounds and a BMI of 19.4, which was within the target range of 19.0 to 19.9. Marie was encouraged to gain at least a few more pounds after terminating therapy to achieve a higher BMI

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6 5 4 3 2 1 0 Eating Restraint Eating Concern Shape Concern Weight Concern Total Pre-test Post-test Follow-up*

EDE-Q Score

EDE-Q Subscales

Figure 2. EDE data at pre-, post-, and follow-up assessments

Note: EDE = Eating Disorders Examination. *Six-month follow-up on all subscales = 0.

that would be within the healthy range (20.0 to 24.9) and would allow her some room if she happened to lose weight due to illness, relapse, or some other factor. Marie was also assessed with a more standardized measurement of eating-disorder psychopathology, the EDE-Q (Fairburn & Beglin, 1994), and a measure of psychosocial impairment related eating-disorder features, the CIA Questionnaire (Bohn & Fairburn, 2008). Each of these measures was completed at pre- and post-treatment (Session 20) and 6-month follow-up. As can be seen in Figure 2, Maries scores across the subscales of the EDE-Q significantly declined across time from pretreatment through follow-up. Each of her subscale scores at pretreatment was well above the average for the sample on which the EDE-Q was normed, and at posttreatment, each of her subscale scores was below the average, with the exception of EC, which was only very slightly above average. Figure 3 demonstrates that Maries scores on the CIA also declined significantly over time. At pretreatment, she was well above the cut-point for eatingdisorder status, and at posttreatment, her score had decreased by 30 points, which was below the cut-point. Overall, according to DSM-IV-TR (APA, 2000) criteria and these standardized measurements, Marie no longer met the diagnostic criteria for anorexia nervosa after only 3 months (20 sessions) of treatment in CBT-E.

8 Complicating Factors
The only apparent complicating factor in this case was Maries participation on the track team during the first several sessions of treatment. Long-distance running, which was a requirement of the team, was perpetuating her focus on performance and achievement and impeding her from gaining weight. However, toward the middle stage of therapy, after some discussion in therapy of the pros and cons of leaving the team and the possible negative and positive implications, Marie decided to leave the track team so that she could focus on improving her mental and

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Figure 3. CIA data at pre-, post-, and follow-up assessments

Note: CIA = Clinical Impairment Assessment Questionnaire. *Six-month follow-up score = 0.

physical health. Upon quitting the team, it became easier for her to gain weight and find other pleasurable social activities that involved neither performance nor achievement. She later stated that she felt fully satisfied with her decision.

9 Managed Care Considerations

Maries treatment in CBT-E was not in any way inhibited or limited by managed care. As a college student, she attended therapy sessions free of charge.

10 Follow-Up
Six months after terminating therapy and completing the EDE-Q and CIA at post-treatment, these two measures were mailed to Marie for her to complete and provide information on her current weight and psychological functioning. She earned scores of 0 on each of the two standardized measures at follow-up (See Figures 2 and 3), indicating that she was experiencing no eating disorder symptoms or associated psychosocial impairment whatsoever. This was a dramatic decrease over time, from preassessment through follow-up. Marie reported that her weight at 6-month follow-up was 126 pounds, an increase of 4 pounds from posttreatment and a total increase of 16 pounds from pretreatment. This resulted in a BMI of 20.0 (an increase from 19.4 at posttreatment and 17.5 at pretreatment), which was within the healthy target range of 20.0 to 24.9. She indicated that she was back to her old high school weight and felt significantly better. In addition, she noted that she was dating regularly and greatly enjoying her social life. Marie also indicated that she had had three consecutive regular menstrual cycles over the past 3 months. Marie noted on her follow-up measures that her responses of 0 on all of the questions were

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honest and that much in her life had completely changed. Clearly, Marie made significant improvements, overcame her eating-disorder behaviors and mind-set, and continued to improve and experience benefits several months after treatment was terminated.

11 Treatment Implications of the Case

Multiple implications can be derived from this case study. First, this case study provides further support for the utilization of CBT-E for clients with eating disorders (in this case, anorexia nervosa), corroborating the research that demonstrates the effectiveness of CBT-E (Fairburn et al., 2009; Hilbert & Tuschen-Caffier, 2003; Thompson-Brenner et al., 2003). It is important to build on the body of research on effective treatments for individuals with anorexia nervosa due to the typical severity of this disorder and the lack of available effective treatments. CBT-E was quite efficacious for this client; thus, there is reason to believe that similar results can be obtained in other individuals with anorexia. Therefore, it may be quite useful for clinicians treating these clients to learn and implement CBT-E. Anorexia can result in severe medical, social, and psychological complications (Fairburn et al., 2008), and there is little research on treatments for anorexia nervosa (Lock et al., 2001). As such, it is imperative for researchers to continue to investigate effective treatment interventions for this eating disorder. A second implication of this study is that efficacious outpatient interventions do exist for individuals with eating disorders. Because eating disorders can cause a great deal of stress for individuals who suffer from them, these individuals may seek inpatient hospitalization, which they may view as the only way to treat their problem. Though inpatient care may be necessary at some point throughout treatment, such as if the client is in medical danger, a first and more economical choice for treatment is likely to be outpatient psychotherapy. Patient hospitalizations have been known to be quite expensive and, therefore, may not be available to all individuals who need services. The economic advantages of outpatient psychotherapy over inpatient hospitalization exist for the individual seeking treatment, his or her family, insurance companies, and society as a whole. CBT-E is one such form of outpatient psychotherapy that has demonstrated significant improvement in individuals with eating disorders. In addition, the results of this study suggest that CBT-E can address the limitations of other treatments for eating disorders (e.g., interpersonal psychotherapy, antidepressant medication) by demonstrating effectiveness in a shorter period of time and sustaining improvements. A third implication of this study is that further research on the efficacy of CBT-E for individuals with eating disorders, particularly anorexia nervosa, is needed. The research on CBT-E is currently limited, as this is a relatively new treatment. However, the studies that have been conducted on CBT-E, including the current study, have demonstrated positive results and great promise. Most studies that have focused on CBT-E have targeted clients with bulimia nervosa, and the literature in general on treatments for anorexia nervosa is limited, as this form of eating disorder is particularly difficult to treat. However, the current study indicates that CBT-E can be effective in treating anorexia nervosa. Though this study demonstrates highly positive results, it does lack external validity, as it was only implemented with and based on the experiences of one client and, therefore, may not necessarily generalize to all clients with anorexia. Further research should include large-scale, randomized studies investigating the efficacy of CBT-E for eating disorders and comparing CBT-E to other forms of psychotherapy and control groups. In addition, Marie was a highly motivated, compliant client who developed an eating disorder as an adjustment reaction to a life change. CBT-E treatment may be more difficult, long-term, and intensive for clients who present with little motivation to change, resist the necessity of gaining weight, exhibit deeper personality tendencies related to eating-disorder

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development (e.g., perfectionism as an enduring personality trait), and who are not as compliant with the treatment. A possible limitation of the treatment methodology in this study is that it may be problematic to set the standard BMI at around 20, defined by Fairburn (2008) as between 19.0 and 19.9. Defining the target BMI in this way was not problematic for this particular client; however, this may be dangerous for many clients with anorexia, as they may justify a BMI of around 20 as a treatment success. In reality, a BMI in this range is still considered to be low weight. Therefore, achieving a BMI around 20 may reinforce maintenance of a low BMI in many clients. To address this limitation, it is imperative that clinicians fully educate clients about healthy BMI ranges. Specifically, the range of 19.0 to 19.9 only signifies probable improvements in physical and mental health and does not preclude clients from continuing to increase their weight and BMI. Clinicians should encourage their clients to reach this target BMI range but continue to strive for a healthier weight and BMI.

12 Recommendations to Clinicians and Students

This case study report, in conjunction with other research, generates several recommendations for clinicians and students. The first recommendation is for clinicians and students to give strong consideration to the utilization of CBT-E when presented with a client who is diagnosed with anorexia nervosa. Though prior research has demonstrated CBT-E to be effective with clients with eating disorders, most often bulimia nervosa (Thompson-Brenner et al., 2003), this case study suggests that CBT-E has promise as an intervention for clients with anorexia nervosa. Clinicians and students interested in conducting this treatment are encouraged to obtain Fairburns (2008) book. An additional recommendation for clinicians and students utilizing this treatment is to tailor CBT-E specifically to the clients needs. One of the most unique and useful aspects of this treatment is that it is designed to do just that. Fairburns (2008) book is not a step-by-step treatment manual; rather, it is a guide for treatment, and, therefore, the clinician utilizing it must become quite familiar with it to successfully adhere to the treatment and, at the same time, tailor it to the needs of the client. While it is recommended to be as adherent to the treatment as possible, it is also recommended, when helpful, to educate the client about additional CBT techniques, such as thought-stopping when thoughts about food become consuming and intrusive, or self-reward after engaging in effective behaviors. A final recommendation is to be attentive to the progress the client is making throughout therapy by continuously assessing the clients behaviors and progress. This can be done via the methods described in this study, such as utilizing self-monitoring of eating behaviors, which provides data on the clients normalized pattern of eating. Weekly weigh-ins can help assess progress with weight gain. In addition, administering standardized assessment measures (such as the EDE-Q and CIA) at various points throughout treatment and at follow-up aids in collecting objective data that are helpful to both the therapist and the client in assessing progress throughout therapy. These objective assessments can help reassure both therapist and client that treatment has been an effective undertaking and a valuable use of time and resources. Declaration of Conflicting Interests
The author declared that she had no conflicts of interests with respect to the authorship or the publication of this article.

Funding
The author received no financial support for the research and/or authorship of this article.

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Bio
Amy L. Karbasi, MA, is a third-year clinical psychology student and doctoral candidate at Xavier University in Cincinnati, Ohio. She is interested in empirically supported cognitive-behavioral treatments, including Dialectical Behavior Therapy (DBT), in which she has been trained.

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