CBT for binge-eating disorder

1. Introduction

Version followed: Fairburn's enhanced CBT (CBT-E), focused form, 20-session outpatient version for patients not underweight (Fairburn 2008; Murphy, Straebler, Cooper & Fairburn 2010), delivered in the three formats NICE NG69 (2017) recommends for adults with binge-eating disorder (BED): (a) CBT guided self-help using Fairburn's Overcoming Binge Eating (2nd ed., 2013); (b) group CBT-ED; (c) individual CBT-ED of 16 to 20 sessions. Where the INTERBED and Hilbert & Tuschen-Caffier modular CBT for BED adds techniques, they are labelled as that version.

CBT for BED is not a separate therapy invented for BED. It is the CBT for bulimia nervosa adapted to binge eating without compensatory behaviour, and since 2008 it is usually delivered as transdiagnostic CBT-E, which targets the processes maintaining the eating problem rather than the diagnosis [source: Murphy et al. 2010]. The core change model: binge eating is kept going by an interlocking set of maintaining processes. These are rigid dieting and dietary rules (breaking a rule tends to be followed by giving up control and bingeing) [uncertain: mechanism wording from general CBT-E knowledge, Fairburn 2003 and 2008], events and moods that trigger eating, and, in many but not all people with BED, over-evaluation of shape and weight. Change comes from first disrupting binge eating directly (real-time monitoring, regular eating, urge-management) and then dismantling whichever maintaining processes the formulation shows are active. People with BED typically have fewer active maintaining processes than people with bulimia nervosa, so treatment targets only those present [source: Murphy et al. 2010]. Weight loss is not a goal; psychological treatment has limited effect on weight [source: NICE NG69 1.4.1, 1.4.7].

2. Framework

Stepped formats (NICE NG69, adults; same treatments for children and young people)

[source: NICE NG69 1.4.2 to 1.4.8]

The Overcoming Binge Eating (2nd ed.) programme used for GSH

Nine modules: Getting Ready; Starting Well; Regular Eating; Alternatives to Binge Eating; Problem Solving; Taking Stock; Dieting; Body Image; Ending Well. Appendices include a note for therapists, a note for relatives and friends, and one for readers who are also overweight. It suits anyone with a binge-eating problem who is not substantially underweight [source: CREDO book page]. Number and length of guide sessions are not given on the publisher-side pages; use the NICE dose [uncertain: the book's "Note for Therapists"].

Individual CBT-E (20 sessions over 20 weeks)

[source: Murphy et al. 2010; Fairburn 2008 chapter titles: Starting Well, Achieving Early Change, Taking Stock, Shape Concern…, Dietary Restraint…, Events, Moods and Eating, Ending Well]

Variants: a 16-week weekly version (50-minute sessions; weeks 1 to 4 introduction, 5 to 6 transition, 7 to 14 main body, 15 to 16 final stage) was used in a BED trial "adapted from Fairburn and Mitchell" [source: NCT03604172 protocol]. The INTERBED version runs 20 sessions: initial phase (sessions 1 to 3: motivation, psychoeducation, food monitoring, goal setting, individual maintenance model), intensive phase (4 to 17: eating behaviour, body image and stress modules), self-management phase (18 to 20: relapse prevention) [source: INTERBED trial table 3; whether the comparison arm was individual or group is not clear from the table: uncertain]. A group adaptation of CBT-E exists (Straebler-Sproch, Group Cognitive Behavior Therapy for Eating Disorders, Routledge) but is not drawn on [uncertain].

Session length: individual sessions of about 50 minutes are standard in the trial protocols [source: NCT03604172]; the 50-minute figure for CBT-E itself is not confirmed in the sources [uncertain].

Typical individual session flow: in-session weighing (once weekly), joint review of monitoring records, agenda setting, main work on the problems found in the records and the current module, homework, summary [source: Murphy et al. 2010 for weighing and record review feeding the session; agenda and summary steps are standard CBT structure: synthesis].

3. Guiding principles

[source: Murphy et al. 2010 unless marked]

• Treat the maintaining processes, not the label. Ask "what keeps the bingeing going now?" and target only that.
• Formulation is personal, provisional and joint. Draw it in session 1 with the patient, starting from what they want to change; revise it at Stage Two.
• Early change is the priority. Change in the first weeks predicts outcome, so the twice-weekly start and regular eating by session 3 matter; protect them.
• Real-time over recall. Records are made at the time of eating, not reconstructed later; they drive each session.
• The patient makes the change. The therapist educates, sets up experiments and problem-solves; the patient is helped to choose change rather than having it imposed.
• Focused form by default. Add broad-form modules (perfectionism, core low self-esteem, interpersonal problems) only when these clearly maintain the eating problem.
• Deal with barriers before starting. Postpone if depression, substance misuse, crises or competing commitments would block engagement.
• No dieting during treatment; weight loss is not the target. Say so at the outset; stopping binges may bring long-term weight loss but therapy does not aim for it [source: NICE NG69 1.4.7].
• Weigh weekly, together, and only then. Weight is data, shared and plotted; checking at other times is discouraged.
• Firm but adjustable. Eating plans and rules are firm enough to give structure, flexible enough to fit life.
• Educate through reading. Assign book chapters rather than lecture; discuss them in session.
• Present first, past later. History is reviewed late in treatment, and only to help the patient step back from the eating-disorder mindset.
• Others are involved only when that helps or when they are making change harder.
• Setbacks are lapses, not relapses. Expect them and plan the response.
• In GSH, the guide supports adherence, not therapy. Sessions are spent helping the person follow the programme [source: NICE NG69 1.4.3]; guides in one trial "confined themselves to offering guidance in the use of the book" [source: Palmer et al. 2002].
• Homework every session. Skills are practised between sessions [source: NCT03604172].

4. Intervention inventory

Order follows the individual CBT-E course; GSH, group and INTERBED-specific items are flagged. All example language is illustrative unless quoted and cited.

4.1 Evaluation interview and preparation for treatment

• Purpose: establish the eating problem, its maintaining processes and whether outpatient CBT is the right step; engage the patient. Use before any format, including GSH.
• Steps: (1) Hold the evaluation over two or more appointments, conducted to put the patient at ease [source: Murphy et al. 2010]. (2) Assess eating pattern, objective binges (unusually large amount with loss of control), dieting and dietary rules, shape and weight concern, body checking and avoidance, mood and events around binges, physical health, comorbidity and suicide risk. Standard instruments in this tradition are the Eating Disorder Examination interview, the EDE-Q self-report and the Clinical Impairment Assessment (reproduced as appendices in Fairburn 2008; do not copy items, obtain them from the authors' licensed sources). (3) Screen for barriers: physical concerns, severe depression, significant substance misuse, major life crises, competing commitments; deal with them or postpone [source: Murphy et al. 2010]. (4) Explain the treatment: its stages, twice-weekly start, weekly weighing, records, homework, and that it does not aim at weight loss and dieting should stop [source: NICE NG69 1.4.7]. (5) Agree format (GSH, group, individual) per the NICE sequence.
• Example language (illustrative): "This treatment is about stopping binge eating. It isn't a weight-loss programme, and I'll ask you to put dieting on hold while we work, because dieting is one of the things that drives binges."
• Watch for: BMI-related medical risk, suicidality, severe depression (treat first or alongside), hopes that therapy will deliver weight loss (address explicitly or engagement collapses later). Working: patient agrees to a start date and to monitoring and weighing.

4.2 Collaborative formulation

• Purpose: a shared diagram of what maintains the binge eating; it decides what is targeted and in what order.
• Steps: (1) In session 1, start from something the patient wants to change, usually binge eating [source: Murphy et al. 2010]. (2) Work backwards with the patient's own examples: what came before recent binges (strict dieting or rule-breaking, long gaps, events, moods), and what followed (distress, renewed dieting). (3) Add shape and weight over-evaluation only if it is present; in BED it often is less central [source: Murphy et al. 2010]. (4) Draw it by hand in the patient's words; call it provisional. (5) Give a copy; revisit and revise at Stage Two, and draw an extended formulation for shape concern in Stage Three. For individual CBT-ED NICE specifies the formulation should cover how dietary and emotional factors contribute [source: NICE NG69 1.4.7].
• Example language (illustrative): "Let's map last Tuesday's binge. What had you eaten that day? What was going on beforehand? And afterwards, what did you decide about eating the next day?"
• Watch for: therapist-authored jargon; overloading the diagram. Working: patient can explain the vicious circle and says "so if I stop dieting, binges should ease".

4.3 Real-time self-monitoring

• Purpose: the main data source for every session; makes binges, triggers and gaps visible; begins change by itself.
• Steps: (1) Introduce in session 1. (2) Record, at the time, everything eaten and drunk, time, place, whether it felt like a binge (mark it), and in a comments column thoughts, feelings and events [source: Murphy et al. 2010: eating, behaviour, thoughts, feelings and events; exact column layout not specified in the sources]. (3) Review the records together at the start of every session; the patient leads. (4) Pick the problems the records show and make them the main agenda. (5) Stop monitoring in Stage Four [source: Murphy et al. 2010]. In GSH the book's Starting Well module covers this; the guide reviews records with the patient [synthesis: guide's record review not confirmed in the GSH sources]. Group CBT-ED and INTERBED also begin with food self-monitoring [source: NICE NG69 1.4.5; INTERBED table].
• Example language (illustrative): "Write it down as soon as you can after eating, ideally within minutes. It's the binges you most want to skip recording that we most need to see."
• Watch for: retrospective filling-in, omitting binges, calorie counting in records (discourage), perfectionistic over-detail (a sign the broad form may be needed) [source: Murphy et al. 2010 on perfectionism]. Working: records are complete, brought every session, and the patient starts noticing patterns unprompted.

4.4 Collaborative weekly weighing

• Purpose: gives accurate weight data, educates about normal fluctuation, and counters both frequent weighing and weight avoidance.
• Steps: (1) Weigh once a week in session, together. (2) Plot it on the patient's own graph. (3) Interpret trends over at least four readings, not single values. (4) Discourage weighing at other times [source: Murphy et al. 2010]. (5) Share the record with the person [source: NICE NG69 1.4.7]. (6) In Stage Four, move weekly weighing to home [source: Murphy et al. 2010].
• Example language (illustrative): "One number tells us little; weight goes up and down by a kilo or so day to day. We'll look at the trend over a month."
• Watch for: distress on the scale, refusal (explore fears; weight avoidance is also a target), home weighing several times a day. Working: patient tolerates the weigh-in and stops reacting to single readings.

4.5 Psychoeducation with guided reading

• Purpose: correct beliefs that keep binge eating going.
• Steps: (1) Cover the features of binge eating, body weight regulation (BMI, natural fluctuation), and the adverse effects of dieting, including the difference between strict dietary rules and flexible guidelines [source: Murphy et al. 2010; weight regulation and harms of dieting also in NCT03604172 protocol]. (2) Assign chapters from a CBT self-help book (e.g. Overcoming Binge Eating, Part I) and ask the patient to annotate what applies to them. (3) Discuss in the next session. (4) For overweight patients: psychological treatment has limited effect on weight; weight management is a separate question handled per obesity guidance, not during this treatment [source: NICE NG69 1.4.1].
• Example language (illustrative): "Mark anything in the chapter that sounds like you, and anything you disagree with. We'll go through it on Thursday."
• Watch for: reading as avoidance of behavioural change. Working: patient links reading to their own records.

4.6 Regular eating

• Purpose: the central early intervention for binge eating; removes the hunger and gaps that set up binges and displaces chaotic eating.
• Steps: (1) Introduce by about session 3 [source: Murphy et al. 2010]. (2) Plan three meals and two or three snacks a day, with rarely more than about 4 hours between them [source: Murphy et al. 2010; NICE NG69 1.4.7: regular meals and snacks to avoid hunger]. (3) The patient chooses what to eat; the priority is timing, not content; no calorie targets [synthesis on content-neutrality]. (4) Confine eating to these planned times; nothing in between. (5) Write the planned times on the record in advance; plan the day the night before when days vary. (6) Keep the plan firm but adjustable to circumstances [source: Murphy et al. 2010]. (7) No compensatory behaviour after eating. (8) Review adherence in records each session. Group CBT-ED calls this the daily food-intake plan [source: NICE NG69 1.4.5]; the book module is Regular Eating [source: CREDO].
• Example language (illustrative): "For now, what you eat matters less than when. Let's set times for breakfast, lunch, an afternoon snack, dinner and an evening snack, and see what happens to the urges in between."
• Watch for: skipping breakfast or the snacks (often due to fear of weight gain; return to education and weighing data), grazing between planned times, rigid meal content becoming a new diet. Working: gaps shrink, objective binges reduce within 2 to 4 weeks [synthesis on timescale].

4.7 Alternatives to binge eating and urge management

• Purpose: help the patient ride out urges between planned eating times.
• Steps: (1) From the records, identify high-risk times and situations. (2) Build a written list of activities incompatible with eating that the patient would actually do (e.g. a brisk walk, phoning a friend, a shower). (3) Add avoidance-of-cue steps (leaving the kitchen, not buying binge foods in quantity) [source: Murphy et al. 2010]. (4) Teach that urges rise, peak and subside and can be "surfed" rather than obeyed [source: Murphy et al. 2010]. (5) When an urge comes: note it on the record, start an alternative, wait, then reassess. (6) Review which alternatives worked; refine the list. Binges that persist are addressed later through the dietary-restraint and events-and-moods modules [source: Murphy et al. 2010]. The book module is Alternatives to Binge Eating [source: CREDO].
• Example language (illustrative): "The urge is like a wave. If you get out of the kitchen and do something else for twenty minutes, notice what happens to it."
• Watch for: alternatives that are too passive (sitting watching TV near food), using alternatives as distraction from all feeling (link to mood work). Working: logged urges outnumber binges and the gap grows.

4.8 Taking stock (Stage Two review)

• Purpose: decide how the rest of treatment is designed.
• Steps: (1) Over two sessions a week apart, review progress together using the records and weight graph [source: Murphy et al. 2010]. (2) Praise change specifically. (3) Identify barriers to change. (4) Revise the formulation. (5) Decide whether clinical perfectionism, core low self-esteem or interpersonal problems are maintaining the disorder; if so, use the broad form [source: Murphy et al. 2010]. (6) Choose and order Stage Three modules. In GSH this is the Taking Stock module [source: CREDO]; in GSH NICE sets a 4-week check: if not effective, step up to group CBT-ED [source: NICE NG69 1.4.4].
• Example language (illustrative): "Four weeks in, binges have dropped from five a week to two. Let's look at what's left and what is getting in the way."
• Watch for: little or no early change, which predicts poorer outcome and should be understood and acted on now [source: Murphy et al. 2010]. Working: both agree a written plan for the next 8 weeks.

4.9 Self-evaluation pie chart and extended formulation (over-evaluation of shape and weight)

• Purpose: show how much self-worth rests on shape, weight and eating control, and why that is a problem. Use in Stage Three when the formulation shows shape and weight over-evaluation.
• Steps: (1) Ask the patient to list the areas of life by which they judge themselves (work, relationships, parenting, sport, shape, weight, control of eating). (2) Have them draw a pie chart with slices sized by how much each matters to their self-judgement, guided by how upset they would be if things went badly in that area [uncertain: sizing method not stated in the sources]. (3) Discuss three problems the chart reveals: over-reliance on one domain, that control of shape and weight is elusive so self-esteem is repeatedly undermined, and the link to dieting and binge eating [source: Murphy et al. 2010]. (4) Draw an extended formulation linking over-evaluation to dieting, body checking, body avoidance, feeling fat and marginalised life areas [source: Murphy et al. 2010]. (5) Repeat the chart later to track change [synthesis].
• Example language (illustrative): "If this slice is two thirds of the pie, what does that mean for the rest of your life, and for how you feel on a bad body day?"
• Watch for: intellectual agreement without behavioural change. Working: the patient starts investing time elsewhere and the slice shrinks on re-drawing.

4.10 Developing marginalised domains of self-evaluation

• Purpose: enlarge the other slices so shape and weight matter relatively less.
• Steps: (1) Identify neglected activities and interests. (2) Choose one or two to restart or start. (3) Schedule them as homework, with problem solving for obstacles. (4) Review each session [source: Murphy et al. 2010].
• Example language (illustrative): "You mentioned you used to sing. What would be a first, small step back into that this week?"
• Watch for: choosing activities tied to weight (gym for weight loss). Working: the activities take place and are mentioned spontaneously.

4.11 Addressing body checking

• Purpose: reduce repeated checking of shape, which magnifies perceived flaws and maintains concern.
• Steps: (1) For one or two days (typically a weekday and a weekend day), have the patient record every instance of body checking in real time: mirror scrutiny, pinching, measuring, comparing with others, checking clothes fit [source: Murphy et al. 2010 on monitoring; examples synthesis]. (2) Review the results: frequency and effect. (3) Educate that checking gives biased information: scrutiny magnifies, and comparisons are skewed (e.g. comparing oneself with selected attractive people) [source: Murphy et al. 2010: checking yields biased information]. (4) Agree to stop unnecessary checks and reduce others. (5) Give detailed help with mirror use: use mirrors for ordinary purposes, avoid close scrutiny of disliked parts [source: Murphy et al. 2010: detailed help with mirror use; specifics synthesis].
• Example language (illustrative): "If you stared at your hands for ten minutes, you'd start to see flaws you never noticed. What happens when you check your stomach the same way?"
• Watch for: checking that is subtle (touching, clothes tightness) and missed in records. Working: fewer checks recorded and less distress after them.

4.12 Addressing body avoidance (body exposure)

• Purpose: reverse avoidance of seeing or feeling one's body, which keeps concerns untested. NICE lists body exposure training in group CBT-ED [source: NICE NG69 1.4.5]; CBT-E uses gradual habituation over many sessions [source: Murphy et al. 2010]; INTERBED uses a body-image diary, graded exposure to avoided body-related situations and body-pleasure exercises [source: INTERBED table].
• Steps: (1) Get informed consent: explain rationale, expected discomfort, that the patient controls pace and can stop. (2) List avoided situations (looking in a full-length mirror, wearing fitted clothes, swimming, being seen eating, photos, body contact). (3) Rank them by difficulty. (4) Start with a manageable item; do it repeatedly until discomfort eases. (5) Move up the hierarchy across many sessions. (6) Pair with work on negative body beliefs (4.17). (7) For mirror exposure, describe the whole body neutrally, top to bottom, rather than judging selected parts [synthesis: neutral-description method is common in body-exposure protocols but the manuals are not drawn on: uncertain].
• Contraindications and safety: defer or adapt in trauma involving the body or sexual abuse (risk of re-experiencing), current dissociation, active self-harm triggered by body exposure, or acute suicidality; never insist on undressing in session; in-session mirror exposure is done clothed in a private room with consent [synthesis].
• Example language (illustrative): "We'll go at your pace. The aim isn't to like what you see straight away; it's to learn you can look without the distress taking over."
• Watch for: safety behaviours (sucking in the stomach, quick glances), dissociation, shame flooding. Working: distress ratings drop across repetitions and avoided activities return.

4.13 Relabelling "feeling fat"

• Purpose: separate the feeling of being fat from actual body size; it is often a mislabelled emotion or body sensation.
• Steps: (1) Record times of intense "feeling fat" in the comments column. (2) Identify what was happening just before: moods such as boredom or sadness, sensations such as bloating, feeling hot or sweaty, clothes feeling tight [source: Murphy et al. 2010]. (3) Teach the patient to use the feeling as a cue to ask "what else am I feeling right now?" [source: Murphy et al. 2010, paraphrased]. (4) Address the underlying state directly (problem solving, mood modulation).
• Example language (illustrative): "Your body didn't change between 3 and 4 pm. Something else did. What was going on?"
• Watch for: the patient using the feeling as evidence to diet. Working: "feeling fat" episodes become less frequent and are linked to identifiable triggers.

4.14 Exploring origins and the eating-disorder mindset

• Purpose: late in Stage Three, help the patient step back from the mindset that keeps over-evaluation in place.
• Steps: (1) Conduct a historical review of how the concern with shape, weight and eating developed. (2) Identify any critical past event and reappraise it from the present-day adult perspective [source: Murphy et al. 2010]. (3) Help the patient notice when the mindset is "switched on" and its triggers, and practise stepping out of it [source: Fairburn 2008 chapter title "…Feeling Fat and Mindsets"; procedural detail not in the sources: uncertain].
• Example language (illustrative): "Looking back at that 13-year-old who was teased, what would you say to her now that you couldn't then?"
• Watch for: turning into open-ended exploratory therapy. Working: the patient can name the mindset and describe a recent time they stepped out of it.

4.15 Dietary rules: identify, test and replace

• Purpose: break the dieting that triggers binges (many people with BED alternate between strict rules and bingeing).
• Steps: (1) List the patient's dietary rules (avoid certain foods, eat nothing before a set hour, keep below a limit). (2) For each, identify the belief behind it ("if I eat bread, I'll binge"). (3) Plan to break the rule deliberately, in a planned way, as a behavioural experiment to test the belief [source: Murphy et al. 2010]. (4) Debrief: what was predicted versus what happened. (5) Turn rigid rules into flexible guidelines [source: NCT03604172 protocol]. (6) Remind the patient not to diet during treatment [source: NICE NG69 1.4.7]. Book module: Dieting [source: CREDO].
• Example language (illustrative): "Your rule says one biscuit leads to the whole packet. Shall we test that this week, after lunch, at a time you pick?"
• Watch for: new rules replacing old ones; experiments done on high-risk days. Working: rule-breaking no longer leads to binges.

4.16 Food avoidance: systematic reintroduction

• Purpose: for people who binge, avoided foods are often the binge foods; reintroducing them under control weakens the cycle. A priority in binge-eating patients [source: Murphy et al. 2010].
• Steps: (1) Have the patient visit a supermarket and list foods they avoid. (2) Rank them into four or so groups by difficulty [synthesis: grouping method assumed from CBT-E practice, not in the sources: uncertain]. (3) Introduce foods from the easiest group, as part of a planned meal or snack, at a low-risk time. (4) Progress up the groups week by week. (5) Continue until eating them is not feared and does not trigger binges [source: Murphy et al. 2010: systematic reintroduction]. INTERBED adds cue exposure and pleasure-focused eating exercises [source: INTERBED table].
• Example language (illustrative): "Let's add one food from your easiest group to Tuesday's afternoon snack, on a day you're not alone or tired."
• Watch for: reintroduction drifting into a binge (step back a level, check timing and state). Working: the avoided list shrinks.

4.17 Cognitive restructuring for emotional triggers and body beliefs

• Purpose: address thoughts that make emotions lead to binges, and negative beliefs about the body. NICE specifies cognitive restructuring for emotional triggers in individual CBT-ED and changing negative body beliefs in group CBT-ED [source: NICE NG69 1.4.5, 1.4.7].
• Steps: (1) Identify a trigger episode from the records. (2) Write down the thought ("I've ruined today", "I'm disgusting"). (3) Examine evidence and alternative views. (4) Write a balanced alternative. (5) Plan a behaviour to act on it. Standard CBT method; exact procedures in the NICE-named protocols are not drawn on [uncertain].
• Example language (illustrative): "What was the thought just before you went to the cupboard? How true does it feel now, out of 100?"
• Watch for: arguing the patient out of thoughts. Working: the patient generates alternatives without prompting.

4.18 Behavioural experiments

• Purpose: test predictions underpinning dietary rules, body concern, core low self-esteem and emotional triggers [source: Murphy et al. 2010; NICE NG69 1.4.7].
• Steps: (1) State the prediction and rate belief. (2) Design a test (eat the feared food; wear a fitted top). (3) Anticipate obstacles. (4) Carry it out. (5) Compare outcome with prediction; re-rate belief. (6) Draw the lesson.
• Example language (illustrative): "What do you predict will happen, exactly? How will we know if you're right?"
• Watch for: safety behaviours that spoil the test. Working: belief ratings drop.

4.19 Proactive problem solving (events and eating)

• Purpose: reduce binges triggered by everyday events and difficulties.
• Steps: (1) Use the records to spot event-triggered binges. (2) Teach the patient to identify a problem as early as possible, then: specify it clearly; generate many possible solutions; weigh the likely effect and feasibility of each; choose one or a combination; act; and the next day review the whole problem-solving process, not just the outcome [source: Murphy et al. 2010 names proactive problem solving; step list is the standard problem-solving sequence, not confirmed against Fairburn's text: uncertain]. (3) Practise with written examples on the back of the record. Book module: Problem Solving [source: CREDO]. INTERBED's stress module adds interpersonal problem solving and social-skills training [source: INTERBED table].
• Example language (illustrative): "Sunday evenings are when binges happen. Let's treat that as a problem to solve before it arrives, not after."
• Watch for: reacting only after binges. Working: the patient problem-solves ahead and event-triggered binges drop.

4.20 Mood modulation (mood intolerance)

• Purpose: for patients who binge to change intense moods. Originally a broad-form module, now part of the focused form [source: Murphy et al. 2010].
• Steps: (1) From records, identify mood-triggered binges and the mood. (2) Explain that binge eating works short-term to change mood but maintains the problem. (3) Identify the early signs of the mood building. (4) Build a menu of functional ways to modulate it (talking to someone, physical activity, a calming routine) and practise accepting the mood without acting on it [source: Murphy et al. 2010: functional mood modulation; menu items synthesis]. (5) Review use. INTERBED includes emotion regulation and stress management [source: INTERBED table].
• Example language (illustrative): "The binge does take the edge off for twenty minutes. What else has ever taken the edge off, even slightly?"
• Watch for: self-harm or substance use replacing bingeing; assess and act per standard risk practice. Working: mood episodes occur without binges.

4.21 Binge-cue identification and stimulus control (group CBT-ED; INTERBED)

• Purpose: find the specific cues that precede binges and change exposure and response to them [source: NICE NG69 1.4.5: identifying binge-eating cues; INTERBED table: stimulus and response control].
• Steps: (1) From records, list external cues (being home alone, passing a shop, food in sight) and internal ones (tiredness, boredom, a row). (2) For each, choose a stimulus-control step (shop with a list after eating, keep binge foods out of easy reach, eat only at a table) or a response-control step (delay, leave the room, use an alternative). (3) Rehearse in session; review next week [steps: synthesis].
• Example language (illustrative): "Which of these cues could you remove altogether, and which do you need a plan for?"
• Watch for: stimulus control turning into food restriction (keep planned meals and snacks intact). Working: fewer binges at the identified cue points.

4.22 Hunger and fullness awareness, cue exposure and pleasurable eating (INTERBED eating module)

• Purpose: in the INTERBED version, normalise eating by retraining awareness of hunger and fullness, reducing reactivity to food cues, and restoring enjoyment of eating [source: INTERBED table]. Not part of Fairburn's CBT-E as described in the sources.
• Steps: (1) Add hunger and fullness ratings before and after planned meals to the record. (2) Practise eating a planned meal slowly, noticing taste and satiety. (3) Cue exposure: in session or at home, with consent, sit with a binge-trigger food in view, rate urge, and resist eating outside the plan until the urge falls. (4) Debrief [steps: synthesis; INTERBED protocol detail: uncertain].
• Example language (illustrative): "Before lunch, rate your hunger 0 to 10; after, rate fullness. We're re-learning signals that dieting and bingeing have scrambled."
• Watch for: fullness ratings used as a rule to stop eating early; cue exposure triggering a binge (do early exercises in session, end only when urge has fallen). Working: urges fall within sessions and across sessions.

4.23 Building regular physical activity (INTERBED)

• Purpose: establish enjoyable regular activity as part of normalising eating and coping, not as weight control [source: INTERBED table].
• Steps: (1) Identify activities the patient enjoys. (2) Plan gradual, regular sessions. (3) Review for enjoyment and mood effect. No exercise targets; watch for compensatory or compulsive exercise [synthesis].
• Example language (illustrative): "Pick something you'd do even if it burned no calories at all."
• Working: activity happens for its own sake.

4.24 Goal setting and self-reinforcement (group CBT-ED; INTERBED)

• Purpose: turn the analysis of problems into concrete weekly goals and reward progress [source: NICE NG69 1.4.5: analysing problems and goals; INTERBED table: goal setting and self-reinforcement across modules].
• Steps: (1) Agree one to three specific weekly goals (e.g. eat the planned afternoon snack every day). (2) Make them observable and recorded. (3) Plan a non-food reward for meeting them. (4) Review and reset weekly [steps: synthesis].
• Example language (illustrative): "What would count as success this week, in a way we could check on your record?"

4.25 Involving significant others

• Purpose: enlist help or remove obstacles.
• Steps: (1) Ask whether anyone's involvement would help, or whether someone is making change harder, e.g. by commenting on eating or appearance [source: Murphy et al. 2010]. (2) If so, and with consent, hold one or more joint sessions: explain the treatment, the regular-eating plan and why comments are unhelpful; agree specific helpful actions. The book includes a note for relatives and friends [source: CREDO].
• Example language (illustrative): "It would help most if you didn't comment on what or how much she eats, even kindly."

4.26 Broad-form module: clinical perfectionism

• Purpose: when perfectionism maintains the eating problem or interferes with treatment (over-detailed records, resistance to relaxing restraint) [source: Murphy et al. 2010].
• Steps: Parallel the shape-concern work: self-evaluation pie chart for performance; extended formulation; reduce performance checking, avoidance and procrastination; behavioural experiments with deliberately "good enough" standards [source: Murphy et al. 2010; experiment detail synthesis].
• Example language (illustrative): "What would happen if this week's record were deliberately just adequate?"

4.27 Broad-form module: core low self-esteem

• Purpose: when global, longstanding negative self-view blocks change.
• Steps: Cognitive restructuring and behavioural experiments targeting discounting of positives and overgeneralising from failures; e.g. a daily log of positive qualities and evidence [source: Murphy et al. 2010; log is synthesis].
• Example language (illustrative): "You've told me three things you did well this week and dismissed each one. Let's write them down before you can."

4.28 Broad-form module: interpersonal problems

• Purpose: when interpersonal difficulties maintain binge eating.
• Steps: Run IPT alongside CBT-E: each session has a CBT-E part and an IPT part, using IPT's problem areas and methods [source: Murphy et al. 2010]. Requires IPT training [synthesis].

4.29 Ending well: maintenance plan and relapse prevention

• Purpose: keep gains and handle setbacks after treatment.
• Steps: (1) In Stage Four (three sessions about two weeks apart) stop self-monitoring and move weekly weighing to home [source: Murphy et al. 2010]. (2) Write a personalised plan for the months until a review about 20 weeks later: remaining work (body checking, food avoidance), continued problem solving, developing interests [source: Murphy et al. 2010]. (3) Set realistic expectations [source: NCT03604172]. (4) Prepare for setbacks: identify likely triggers (dieting, stressful events, weight gain worries), early warning signs, and the steps to take; teach to treat a slip as a "lapse" not a "relapse" [source: Murphy et al. 2010]. (5) Group CBT-ED covers relapse prevention and coping with current and future risks and triggers [source: NICE NG69 1.4.5]; INTERBED's final phase has patients act as their own therapist [source: INTERBED table]. Book module: Ending Well [source: CREDO].
• Example language (illustrative): "A binge after treatment doesn't mean you're back at square one. It means: restart regular eating at the next planned time and look at what set it off."
• Watch for: plans to start dieting after therapy ends (a major relapse risk; discuss). Working: the patient can describe the plan and their lapse response in their own words.

4.30 Guided self-help support sessions

• Purpose: first-line format: help the person follow a CBT self-help programme [source: NICE NG69 1.4.2 to 1.4.3].
• Steps: (1) Provide the book (e.g. Overcoming Binge Eating, 2nd ed.) and explain how to use it. (2) Offer brief supportive sessions, e.g. 4 to 9 sessions of 20 minutes over 16 weeks, weekly at first [source: NICE NG69 1.4.3]. (3) In each, review which module the person is on, how the exercises went (monitoring records, regular-eating times, alternatives list), praise effort, help solve obstacles to using the programme, and agree the next step and the date to move to the next module [synthesis, consistent with NICE's adherence focus]. (4) Do not provide other therapy: one trial's nurse-guides "confined themselves to offering guidance in the use of the book" [source: Palmer et al. 2002]. (5) At about 4 weeks, check whether it is working; if not, or GSH is unacceptable or contraindicated, offer group CBT-ED [source: NICE NG69 1.4.4]. Guides in trials have included masters-level clinicians and nurse therapists [source: IAEDP summary of Striegel-Moore et al. 2010; Palmer et al. 2002].
• Example language (illustrative): "Where have you got to in the book? Show me your records from this week, and let's see what made the evening snack hard."
• Watch for: reading without doing the exercises; stalling at Regular Eating. Working: steady progress through modules and falling binge frequency by week 4.

4.31 Running the group format

• Purpose: deliver CBT-ED to groups (NICE: typically 16 weekly 90-minute sessions over 4 months) [source: NICE NG69 1.4.5].
• Steps: (1) Structure the course in the NICE sequence: psychoeducation, self-monitoring and goals; daily food-intake plan and cue identification; body exposure and body beliefs; relapse prevention. (2) Each session: brief individual check-in on records and goals, a teaching segment, a skills exercise in pairs or the full group, homework setting. (3) Keep personal weighing and record review private where possible, e.g. brief individual check-ins before the session [synthesis: group-running detail not in the primary sources]. (4) Handle body exposure exercises individually or as home assignments rather than publicly [synthesis].

5. Handling problems

The sources give little explicit troubleshooting. Items tagged [source] come from them; the rest is [synthesis] grounded in the CBT-E principles above.

• No early change by week 4. Poor early progress predicts poor outcome and should be understood and tackled at the Stage Two review [source: Murphy et al. 2010]. Check: are records complete and real-time? Is regular eating actually in place, including snacks? Is undeclared dieting continuing? Is a barrier present (depression, crisis, substance misuse) that should be treated first [source: Murphy et al. 2010]? In GSH, step up to group CBT-ED if not effective after 4 weeks [source: NICE NG69 1.4.4].
• Not monitoring, or partial records. Revisit the rationale; ask what makes recording hard (shame, time, practicality); simplify the format, allow phone notes; review every record line in session so effort is visibly used; treat missing binges in records as information, not failure [synthesis].
• Over-detailed or perfect records. Suggests clinical perfectionism; set "good enough" recording as an experiment; consider the broad form [source: Murphy et al. 2010 for the link; experiment synthesis].
• Won't drop dieting because weight loss is the real goal. Restate that therapy does not aim at weight loss, dieting tends to trigger binges, and stopping binges may lead to long-term weight loss [source: NICE NG69 1.4.7]. Do a pros-and-cons review of continuing to diet now versus postponing a decision on weight until binges have stopped [synthesis; pros-and-cons method is described for motivation in underweight patients, source: Murphy et al. 2010]. Use the weekly weight graph to show regular eating does not cause the feared gain [synthesis].
• Weight gain fears or actual gain during regular eating. Interpret trends over four weeks, not single readings; review the weight-regulation reading; check for compensatory restriction later in the day [synthesis].
• Refuses weighing. Explore the feared outcome, treat avoidance as a target, offer to weigh with the number shown only to the therapist for the first week or two as a graded step [synthesis].
• Overwhelmed by many modules. Remember BED usually has fewer active maintaining processes; target only what the formulation shows [source: Murphy et al. 2010]. Cut homework to one key task.
• Emotional overwhelm, self-harm or suicidal thoughts. Assess risk with standard practice (current ideation, plans, intent, history, protective factors), collaborate on a safety plan, and include lethal-means counselling (safe storage or removal of means). Pause eating-focused homework if needed; treat severe depression first or alongside [source: Murphy et al. 2010 on depression as a barrier; risk procedure synthesis].
• Binges replaced by other impulsive behaviour (alcohol, self-harm). Assess and address directly; mood modulation module (4.20) [synthesis].
• Body exposure too distressing or dissociation. Lower the step, shorten exposure, use grounding, reconsider timing if trauma is involved; never pressure [synthesis].
• Rupture (feeling judged about eating or weight). Name it, invite the patient's view, acknowledge your part, link back to shared goals; check your own weight-related assumptions [synthesis].
• Family or partner undermining. Joint session per 4.25 [source: Murphy et al. 2010].
• Group-specific: comparing weights or bodies, one member dominating, members bonding over dieting. Set ground rules at session 1 (no numbers, no diet talk), keep weighing private, redirect dieting talk back to the model [synthesis].
• GSH-specific: reading without doing. Agree a single exercise and review only that next session; a guide who starts delivering therapy has stepped out of role [source: Palmer et al. 2002 on role; rest synthesis].
• Binges stopped but body concern remains. Continue body checking, avoidance and marginalised-domain work into the Stage Four plan [source: Murphy et al. 2010].
• Lapse after treatment. Use the plan: return to regular eating at the next planned time, restart monitoring briefly, problem-solve the trigger; book a review if binges recur over several weeks [source: Murphy et al. 2010 for lapse framing; rest synthesis].

Sources

Sources:

• NICE NG69 Eating disorders: recognition and treatment (guideline PDF)
• NICE NG69 Recommendations page (loaded only partially)
• Murphy, Straebler, Cooper & Fairburn (2010) Cognitive behavioral therapy for eating disorders, Europe PMC full text
• CREDO Oxford: Overcoming Binge Eating, Second Edition
• Guilford Press: Cognitive Behavior Therapy and Eating Disorders, contents
• ClinicalTrials.gov NCT03604172 protocol (CBT for BED, 16 weeks)
• Palmer et al. (2002) Self-help for bulimic disorders, British Journal of Psychiatry
• INTERBED trial, Trials 13:220, Table 3
• IAEDP Eating Disorders Review: Self-Help for Recurrent Binge Eating (summary of Striegel-Moore et al. 2010)

Books and papers cited (not drawn on; main manuals):

• Fairburn, C. G. (2008). Cognitive Behavior Therapy and Eating Disorders. New York: Guilford Press.
• Fairburn, C. G. (2013). Overcoming Binge Eating (2nd ed.). New York: Guilford Press.
• Fairburn, C. G., Cooper, Z., & Shafran, R. (2003). Cognitive behaviour therapy for eating disorders: a "transdiagnostic" theory and treatment. Behaviour Research and Therapy, 41, 509–528.
• Hilbert, A., & Tuschen-Caffier, B. (2010). Essanfälle und Adipositas: Ein Manual zur kognitiv-behavioralen Therapie der Binge-Eating-Störung. Göttingen: Hogrefe.
• Striegel-Moore, R. H., Wilson, G. T., DeBar, L., et al. (2010). Cognitive behavioral guided self-help for the treatment of recurrent binge eating. Journal of Consulting and Clinical Psychology, 78, 312–321.
• Straebler-Sproch, S. (n.d.). Group Cognitive Behavior Therapy for Eating Disorders. Routledge.

Further reading (not drawn on): Europe PMC full texts of Striegel-Moore et al. 2010 and a related GSH paper; Guilford sample chapter 4 of Fairburn 2008; CREDO CBT-E pages. Details that depend on these are marked [uncertain].