Enhanced cognitive behaviour therapy (CBT-E) remains a cornerstone of evidence-based treatment for eating disorders (EDs). While effective for many individuals, its conceptual and procedural scope may not fully capture the clinical realities of some autistic, neurodivergent, multidiagnostic, and treatment-experienced populations. Drawing on recent research and clinical experience, we describe how ED behaviours in these groups are often shaped by sensory and interoceptive processes, neurobiological threat responses, chronic invalidation, trauma histories, and difficulties with emotional and interpersonal regulation that may operate alongside, or independently of, weight and shape concerns. When such mechanisms are under-specified, behaviour is more likely to be misinterpreted as resistance or non-compliance, and lived experience may lack uptake within dominant treatment frameworks. The challenge for the field is not to replace CBT-E, but to recognise the limits of any single model and to develop integrative treatment architectures that incorporate neurobiological, biosocial, and contextual determinants of behaviour. Using Multidiagnostic Eating Disorders-Dialectical Behavior Therapy (MED-DBT) an adaptation of DBT designed for individuals with eating disorders and co-occurring high-risk and regulatory difficulties, as an illustrative example, we outline a dialectical approach that supports epistemic humility, reduces misinterpretation, and promotes more inclusive and effective care for individuals least well served by existing models.
Federici et al. (Tue,) studied this question.