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Cognitive behavioral therapy for anorexia

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Cognitive behavioral therapy (CBT) is one of the leading evidence-based treatments for eating disorders, including anorexia nervosa (AN). (1) This form of psychotherapy involves a variety of therapeutic approaches which helps a person understand the relationship between their thoughts, feelings, and behaviors. Over time this helps a person to develop strategies to change unhelpful eating disorder thoughts and behaviors to aid in AN recovery. (2)

Keep reading to learn more about using cognitive behavioral therapy for anorexia nervosa treatment, and what you can expect during CBT.

Last updated on 
December 22, 2022
In this article

What is Cognitive Behavioral Therapy?

Cognitive behavioral therapy (CBT) is a form of talking therapy that focuses on the interactions between thoughts, feelings, and behaviors. During CBT, you’ll address the negative thoughts and emotions that trigger the disordered behaviors associated with your anorexia nervosa (AN), such as food restriction or other behaviors.

Once the underlying causes of your disordered thoughts and feelings have been identified, you can work with your psychotherapist to change them into something more constructive and positive. 

CBT will also help you to address restrictive eating behaviors - including your fear foods and other concerns about eating - to help you reestablish nutritionally sound eating patterns. Furthermore, as with most eating disorders including AN, there are issues with negative body image, CBT will challenge your perceptions and feelings about your weight, shape, and size, offering skills for coping with these thoughts.

While therapist-led CBT is the most effective form of this type of psychotherapy, guided self-help CBT is another effective option. In self-guided CBT, you’ll work through a manual at home and can also meet regularly with a psychotherapist to discuss your progress and set further goals.

There are many different forms of CBT that share a common theory about the factors that start and maintain your eating disorder. Examples of specific types of CBT treatment include Enhanced Cognitive Behavioral Therapy (CBT-E), dialectical behavioral therapy (DBT), and acceptance and commitment therapy (ACT). (3)

Enhanced Cognitive Behavioral Therapy (CBT-E)

Enhanced cognitive behavioral therapy (CBT-E) is a form of CBT that has proved to be one of the most effective treatments for eating disorders, including anorexia nervosa. (4) CBT-E is about developing strategies to challenge the unhelpful thoughts and behaviors that maintain an eating disorder, with the goal of improving physical symptoms and mood. For example, changing a behavior (such as excessive exercise to moderate exercise) to get a positive benefit (reduced fatigue and physical pain).

During CBT-E therapists work closely with patients to formulate a plan that is tailored specifically to their eating disorder and individual needs. Some areas that might be addressed during treatment include mood intolerance, perfectionism, low self-esteem, and interpersonal difficulties.

Dialectical Behavioral Therapy (DBT)

Dialectical behavioral therapy (DBT) has the same foundations as CBT, which focuses on the concepts of acceptance and change. (5) DBT asserts that two things that are seemingly opposing can exist at the same time, for example, a person can be doing their best in dealing with their eating disorder, while simultaneously needing to grow and change.

Through DBT, a person learns to regulate their emotional responses to better cope with distressing situations without resorting to disordered eating behaviors. There are four main areas of treatment in DBT: Mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness (improving relationships).

Acceptance and Commitment Therapy (ACT)

Acceptance and commitment therapy (ACT) is a form of CBT that focuses on mindfulness skills and “psychological flexibility”. (5) Psychological flexibility involves approaching the current moment as it is and acting in accordance with longer-term values and goals as opposed to short-term impulses, thoughts, and emotions.

During ACT, individuals are encouraged to accept and adapt to reality as it is, as well as develop acceptance of their prior disordered beliefs, so they can let them go. ACT can also help a person ultimately see the ineffectiveness of their rigid beliefs surrounding food and adopt more flexibility in their beliefs.

What to Expect During Cognitive Behavioral Therapy

CBT is a structured form of psychotherapy, which usually takes place over 20 sessions when done with an individual therapist. During each session homework is reviewed, coping and problem-solving skills are taught, and new goals are set. 

CBT for the treatment of eating disorders like AN usually includes the common components: (6)

  • Challenge your food rules. This involves identifying the rules your eating disorder imposes (such as only eating at a certain time or banning entire food groups) and challenging these behaviors.
  • Development of strategies to prevent other eating disorder behaviors such as purging These strategies include the use of delays or alternatives and problem-solving skills.
  • Completion of food records immediately after eating and noting down thoughts, feelings, and behaviors.
  • Meal planning, working out meals ahead of time, so you know “what and when” your next meal will be.
  • Exposure to fear foods once regular eating is well-established and compensatory behaviors are under control.
  • Psychoeducation and nutritional counseling, so you understand what maintains your anorexia nervosa, the psychological and medical consequences, and why proper nutrition is needed for the body to function.
  • Relapse prevention to identify strategies that help you cope with potential stumbling blocks to your recovery. The goal of relapse prevention is for you to feel confident enough to redirect and prevent negative thoughts and behaviors.
  • Behavioral experiments e.g. if you believe eating a specific food will cause a weight gain, you’re encouraged to eat the fear food. These experiments can be extremely effective.

Does CBT Work?

There is a wealth of evidence in the support of CBT as an effective treatment for adult patients with eating disorders. (6) Research has shown that those who are able to make early behavioral changes, like those achieved through CBT treatment, such as establishing more regular eating, are more likely to be healed from their eating disorder at the end of their treatment plan.

Disclaimer about "overeating": Within Health hesitatingly uses the word "overeating" because it is the term currently associated with this condition in society, however, we believe it inherently overlooks the various psychological aspects of this condition which are often interconnected with internalized diet culture, and a restrictive mindset about food. For the remainder of this piece, we will therefore be putting "overeating" in quotations to recognize that the diagnosis itself pathologizes behavior that is potentially hardwired and adaptive to a restrictive mindset.

Resources

  1. Agras, S. A. W., Fitzsimmons-Craft, E. E., & Wilfley, D. E. (2017, January 19). Evolution of cognitive-behavioral therapy for eating disorders. Behaviour Research and Therapy. Retrieved December 21, 2022, from https://www.sciencedirect.com/science/article/abs/pii/S0005796716301619?via%3Dihub 
  2. Lauren Muhlheim, P. D. (2020, July 20). Cognitive behavioral therapy for eating disorders. Verywell Mind. Retrieved December 21, 2022, from https://www.verywellmind.com/cognitive-behavioral-therapy-for-eating-disorders-4151114 
  3. Murphy, R. D., Straebler, S., Cooper, Z., & G.Fairburn, C. (2010, July 3). Cognitive behavioral therapy for eating disorders. Psychiatric Clinics of North America. Retrieved December 21, 2022, from https://www.sciencedirect.com/science/article/pii/S0193953X10000468?via%3Dihub 
  4. A description of CBT-e. CBT. (n.d.). Retrieved December 21, 2022, from https://www.cbte.co/what-is-cbte/a-description-of-cbt-e/ 
  5. Cognitive behavioral therapy (CBT) for eating disorders. Eating Disorder Hope. (2021, October 29). Retrieved December 21, 2022, from https://www.eatingdisorderhope.com/treatment-for-eating-disorders/types-of-treatments/cognitive-behavioral-therapy-cbt 
  6. Institute, aP. P. (n.d.). Enhanced cognitive behavioural therapy for patients with... : Current opinion in psychiatry. LWW. Retrieved December 21, 2022, from https://journals.lww.com/co-psychiatry/Fulltext/2018/11000/Enhanced_cognitive_behavioural_therapy_for.4.aspx

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