*7.3.2 Cognitive behavioral therapy*

Cognitive behavioral therapy is the leading empirically supported treatment for BN and BED, but also there is evidence of its effectiveness in AN [83]. Enhanced CBT (CBT-E) is based on the transdiagnostic theory and is designed to treat eating psychopathology rather than being a DSM eating disorders diagnosis [6]. The word "enhanced" refers to new strategies and procedures to improve treatment outcomes and test the model in different groups (e.g., in patients, day-patients, adults, adolescents, etc.). CBT-E can also be conducted in a multistep approach (outpatient, intensive outpatient, and inpatient) by a multidisciplinary team according to the patient's needs. This intervention focuses on understanding the eating disorder mindset and its function. It is assumed that a change in the ED mindset will lead to symptom reduction. A standard CBT-E is a four-stage model. The first stage of treatment is aimed at creating a therapeutic alliance with assessment and case formulation. Regulation of eating behavior is the primary goal of this stage, through behavioral change. Patients are required to use self-monitoring sheets regarding their eating, and every session starts with a review of these records and in session weighing. The second stage (traditional CBT does not have this stage) is an overview and determination stage for possible barriers to change. Preoccupation with food and body is the main theme of the third stage. In addition, interpersonal problems, body checking behaviors, emotion regulation, ED mindset, and other individual factors related to the symptoms are central areas to work on. The last stage is focused on symptom prevention and possible future problems. Many cognitive and behavioral techniques including cognitive restructuring, exposure, and problem-solving training are used during this therapy.

Research indicates promising results regarding the efficacy of CBT-based interventions [95], especially on symptom prevention [91]. Thus, it is concluded that CBT-E is a cost-effective alternative to family-based treatments of anorexia [96].

#### *7.3.3 Other psychotherapy approaches*

Benefits of family-based interventions for adolescents are evident, and these approaches and CBT also work for adult cases to some degree although not for all. For these reasons the effect of different psychotherapies has gained attention. Research points to the effectiveness of psychodynamic therapy [97], third wave therapies (schema therapy, acceptance-commitment therapy, mindfulness-based interventions) [98], dialectical behavioral therapy [99], and EMDR [100], but no specific approach has shown clear superiority. Adding motivational techniques are also helpful [101], as deficits in treatment motivation are common among patients with AN. These findings suggest that a combination of nutritional therapy and anorexia nervosa-specific psychotherapy is an effective way to treat AN.
