Cognitive behavioral treatment of eating disorders

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Cognitive behavioral treatment of eating disorders
Specialty psychiatry

Cognitive behavioral therapy (CBT) is derived from both the cognitive and behavioral schools of psychology and focuses on the alteration of thoughts and actions with the goal of treating various disorders. [1] The cognitive behavioral treatment of eating disorders emphasizes on the minimization of negative thoughts about body image and the act of eating, and attempts to alter negative and harmful behaviors that are involved in and perpetuate eating disorders. [2] It also encourages the ability to tolerate negative thoughts and feelings as well as the ability to think about food and body perception in a multi-dimensional way. [3] The emphasis is not only placed on altering cognition, but also on tangible practices like making goals and being rewarded for meeting those goals. CBT is a "time-limited and focused approach" which means that it is important for the patients of this type of therapy to have particular issues that they want to address when they begin treatment. [4] CBT has also proven to be one of the most effective treatments for eating disorders. [5] [2]

Contents

CBT-Enhanced

A common form of CBT that is used to treat eating disorders is called CBT-Enhanced (CBT-E) and was developed by Christopher G. Fairburn throughout the 1970s and 1980s. Originally intended for bulimia nervosa specifically, it was eventually extended to all eating disorders. [6] Within Fairburn's enhanced CBT is CBT-Ef, designed to deal particularly with eating habits, and CBT-Eb for other issues that do not directly involve eating. [2] A study which compared two different types of cognitive-behavioral treatments for the patients with eating disorders was conducted. Out of the two targeted treatment approaches, one solely focused on eating disorder features and the other one which was a more complex form of treatment also addressed mood intolerance, clinical perfectionism, low self-esteem and interpersonal difficulties. This study was done involving 154 patients with DSM-IV eating disorders. This involved 20 weeks of treatment and 60 weeks period of closed follow up and the outcomes were measured by independent assessors who had no ideas about the treatment conditions. As a result, the patients with control conditions exhibited little change in symptom severity whereas the ones in two treatment conditions exhibited substantial and equivalent change which was even maintained during the follow-up weeks. The eating disorder diagnoses did not affect the treatment. Patients with marked mood intolerance, clinical perfectionism, low self esteem or interpersonal difficulties appeared to respond better to the more complex form of treatment and the remaining patients showed a reverse pattern. As a conclusion, these two were considered to be the most suitable forms of treatment for the patients with eating disorders. The first one is viewed as the most default version of treatment and the second one is reserved for patients with marked additional psychopathology of the type targeted by the treatment. [7] [5]

There have been numerous researches done to compare the effectiveness of Cognitive-behavioral therapy over the Interpersonal psychotherapy. [5] These researches conclude that Cognitive-behavioral therapy is more effective in treating eating disorders as compared to Interpersonal psychotherapy. One study also showed that Interpersonal psychotherapy may be as effective as Cognitive-behavioral therapy, however the interpersonal psychotherapy may be slower to reach its effects. CBT is notably more fast and rapid in generating improvement symptoms in patients with Bulimia nervosa, Anorexia nervosa and Binge eating disorder as compared to interpersonal psychotherapy. Therefore, CBT should be considered for treating eating disorders over interpersonal psychotherapy. The results of the study are evident that cognitive-behavioral therapy is significantly faster than IPT in ameliorating the primary symptoms of bulimia nervosa.

Per this study, Cognitive-behavioral therapy is more effective than interpersonal psychotherapy in modifying the disturbed attitudes to shape and weight, extreme attempts to diet, and self-induced vomiting. Cognitive-behavioral therapy is also more effective than behavior therapy in modifying the disturbed attitudes to shape and weight and extreme dieting, but it was equivalent in other respects. The findings suggest that cognitive behavior therapy, when applied to patients with bulimia nervosa, operates through mechanisms specific to this treatment and is more effective than both interpersonal psychotherapy and a simplified behavioral version of cognitive behavior therapy. [8]

Bulimia nervosa

CBT is the best treatment for bulimia nervosa, as indicated by a number of studies [5] including one from the UK National Institute for Health and Clinical Excellence. [9] Enhanced CBT is delivered on an individual basis and usually in an outpatient situation and is meant to help with the psychopathology of the eating disorder rather than the diagnosis itself. [9] Research demonstrates that antidepressants may be an effective alternative to CBT for treatment of eating disorders; however, CBT continues to prove more effective than antidepressants specifically for the treatment of bulimia nervosa. [10] A small study on patients with bulimia combined CBT with text-messaging a therapist about the frequency of binge-purge behaviours and the strength of the patient's desires to binge and purge. The number of binge eating and purging episodes decreased significantly from base-line to post-treatment and followup. [11]

Anorexia nervosa

Less research has been conducted on the effectiveness of CBT for those with anorexia nervosa, but a recent study demonstrated that CBT was effective for 60% of the subjects tested – 60% of those for whom CBT was effective were improved upon receiving the treatment. [12] In addition, the US National Guideline Clearinghouse reported that CBT can alleviate symptoms of depression and compulsivity that are associated with anorexia nervosa. [4] With 40% of adults and 60% of adolescents attaining and retaining a normal body weight, CBT treatment has proved to be more workable and favorable treatment for the individuals with Anorexia Nervosa. Patients reach and maintain minimum remaining psychopathological symptoms, in cases of over half the adults and about 80% of adolescents patients. Adolescents can more effectively and rapidly regain weight in comparisons with the adults. Therefore, they have better chances to get efficiently treated from these short-term treatment programs. Consequently, the adolescents with eating disorders are recommended to take CBT-E as one of the evidence-based psychological interventions, by the NHS England "The Access and Waiting Time Standard for Children and Young People with an Eating Disorder". [13]

Binge-eating disorder

The same type of CBT used for bulimia nervosa has demonstrated that it can be helpful in the treatment of binge-eating disorder. However, one of the problems with administering CBT to those with this disorder is that it does not traditionally encourage weight loss. This can be problematic for the portion of the population of binge-eaters, who are overweight or obese. [9] As a result of issues like these CBT has not yet been established as the most effective treatment for binge-eating disorder. A commonly used alternative is behavioral weight loss because it prioritizes physical health by maintaining a healthy weight. [14]

The CBT representation model includes altering eating routines, which includes retaining and maintaining eating timetable along with weekly recording the weighing sessions. During tempting and triggering circumstances, the CBT patients are encouraged to look for substitutes and include reasonable behaviors instead of binge eating. They master some exercises which help them understand the relationship of their moods to their cravings for food. This also assists them in seeing weight in a healthy way. CBT also aims at relapse prevention besides strengthening patient's relationships with their family and peers. The treatment duration depends on the relapse rates as well as the patient's response to the treatment.

Many studies on binge eating target the adult population considering that binge eating disorders begin in early or late adulthood. While specific evidences of an adolescent with BED are not available, nevertheless, there are some studies that talk in favor of the efficacy of CBT for binge eating disorders providing significant evidences in the cases of adult population. However, early interventions may be beneficial for the adolescents in terms of targeting exclusively the issues with self-esteem as well as the overvaluation of shape and weight of the body.

Some studies conclude that to bring down the binge eating practices, aiming at weight loss may be advantageous. Weight maintenance, healthy eating as well as exercising to primarily lose weight, may eventually decrease the binge eating behaviors. It is important to not to see a treatment for a psychopathological disorders as a weight-loss program, even though weight loss and decrease in binge eating episodes may happen simultaneously. [15]

Other eating disorders

Eating disorders not otherwise specified (NOS) have been given less attention than anorexia nervosa and bulimia nervosa which are given their own categories in the DSM-IV-TR. That said, a recent study has shown that CBT is just as effective for treating eating disorders NOS as it is for bulimia nervosa.

Related Research Articles

<span class="mw-page-title-main">Cognitive behavioral therapy</span> Therapy to improve mental health

Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. Cognitive behavioral therapy is one of the most effective means of treatment for substance abuse and co-occurring mental health disorders. CBT focuses on challenging and changing cognitive distortions and their associated behaviors to improve emotional regulation and develop personal coping strategies that target solving current problems. Though it was originally designed to treat depression, its uses have been expanded to include many issues and the treatment of many mental health conditions, including anxiety, substance use disorders, marital problems, ADHD, and eating disorders. CBT includes a number of cognitive or behavioral psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies.

An eating disorder is a mental disorder defined by abnormal eating behaviors that negatively affect a person's physical or mental health. Types of eating disorders include binge eating disorder, where the patient eats a large amount in a short period of time; anorexia nervosa, where the person has an intense fear of gaining weight and restricts food or overexercises to manage this fear; bulimia nervosa, where individuals eat a large quantity (binging) then try to rid themselves of the food (purging); pica, where the patient eats non-food items; rumination syndrome, where the patient regurgitates undigested or minimally digested food; avoidant/restrictive food intake disorder (ARFID), where people have a reduced or selective food intake due to some psychological reasons; and a group of other specified feeding or eating disorders. Anxiety disorders, depression and substance abuse are common among people with eating disorders. These disorders do not include obesity. People often experience comorbidity between an eating disorder and OCD. It is estimated 20–60% of patients with an ED have a history of OCD.

<span class="mw-page-title-main">Bulimia nervosa</span> Type of eating disorder

Bulimia nervosa, also known as simply bulimia, is an eating disorder characterized by binge eating followed by purging or fasting, and excessive concern with body shape and weight. This activity aims to expel the body of calories eaten from the binging phase of the process. Binge eating refers to eating a large amount of food in a short amount of time. Purging refers to the attempts to get rid of the food consumed. This may be done by vomiting or taking laxatives.

Binge eating disorder (BED) is an eating disorder characterized by frequent and recurrent binge eating episodes with associated negative psychological and social problems, but without the compensatory behaviors common to bulimia nervosa, OSFED, or the binge-purge subtype of anorexia nervosa.

Binge eating is a pattern of disordered eating which consists of episodes of uncontrollable eating. It is a common symptom of eating disorders such as binge eating disorder and bulimia nervosa. During such binges, a person rapidly consumes an excessive quantity of food. A diagnosis of binge eating is associated with feelings of loss of control. Binge eating disorder is also linked with being overweight and obesity.

Cognitive restructuring (CR) is a psychotherapeutic process of learning to identify and dispute irrational or maladaptive thoughts known as cognitive distortions, such as all-or-nothing thinking (splitting), magical thinking, overgeneralization, magnification, and emotional reasoning, which are commonly associated with many mental health disorders. CR employs many strategies, such as Socratic questioning, thought recording, and guided imagery, and is used in many types of therapies, including cognitive behavioral therapy (CBT) and rational emotive behaviour therapy (REBT). A number of studies demonstrate considerable efficacy in using CR-based therapies.

Interpersonal psychotherapy (IPT) is a brief, attachment-focused psychotherapy that centers on resolving interpersonal problems and symptomatic recovery. It is an empirically supported treatment (EST) that follows a highly structured and time-limited approach and is intended to be completed within 12–16 weeks. IPT is based on the principle that relationships and life events impact mood and that the reverse is also true. It was developed by Gerald Klerman and Myrna Weissman for major depression in the 1970s and has since been adapted for other mental disorders. IPT is an empirically validated intervention for depressive disorders, and is more effective when used in combination with psychiatric medications. Along with cognitive behavioral therapy (CBT), IPT is recommended in treatment guidelines as a psychosocial treatment of choice for depression.

The Eating Attitudes Test, created by David Garner, is a widely used 26-item, standardized self-reported questionnaire of symptoms and concerns characteristic of eating disorders. The EAT is useful in assessing "eating disorder risk" in high school, college and other special risk samples such as athletes. EAT has been extremely effective in screening for anorexia nervosa in many populations.

Avoidant/restrictive food intake disorder (ARFID) is a feeding or eating disorder in which people avoid eating certain foods, or restrict their diets to the point it ultimately results in nutritional deficiencies. This can be due to the sensory characteristics of food, such as its appearance, smell, texture, or taste; due to fear of negative consequences such as choking or vomiting; having little interest in eating or food, or a combination of these factors. People with ARFID may also be afraid of trying new foods, a fear known as food neophobia.

Maudsley family therapy also known as family-based treatment or Maudsley approach, is a family therapy for the treatment of anorexia nervosa devised by Christopher Dare and colleagues at the Maudsley Hospital in London. A comparison of family to individual therapy was conducted with eighty anorexia patients. The study showed family therapy to be the more effective approach in patients under 18 and within 3 years of the onset of their illness. Subsequent research confirmed the efficacy of family-based treatment for teens with anorexia nervosa. Family-based treatment has been adapted for bulimia nervosa and showed promising results in a randomized controlled trial comparing it to supportive individual therapy.

<span class="mw-page-title-main">Anorexia nervosa</span> Type of eating disorder

Anorexia nervosa (AN), often referred to simply as anorexia, is an eating disorder characterized by low weight, food restriction, body image disturbance, fear of gaining weight, and an overpowering desire to be thin.

<span class="mw-page-title-main">Eating disorders and memory</span> Memory impairments linked to eating disorders

Many memory impairments exist as a result from or cause of eating disorders. Eating disorders (EDs) are characterized by abnormal and disturbed eating patterns that affect the lives of the individuals who worry about their weight to the extreme. These abnormal eating patterns involve either inadequate or excessive food intake, affecting the individual's physical and mental health.

Cognitive emotional behavioral therapy (CEBT) is an extended version of cognitive behavioral therapy (CBT) aimed at helping individuals to evaluate the basis of their emotional distress and thus reduce the need for associated dysfunctional coping behaviors. This psychotherapeutic intervention draws on a range of models and techniques including dialectical behavior therapy (DBT), mindfulness meditation, acceptance and commitment therapy (ACT), and experiential exercises.

Other specified feeding or eating disorder (OSFED) is a subclinical DSM-5 category that, along with unspecified feeding or eating disorder (UFED), replaces the category formerly called eating disorder not otherwise specified (EDNOS) in the DSM-IV-TR. It captures feeding disorders and eating disorders of clinical severity that do not meet diagnostic criteria for anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), avoidant/restrictive food intake disorder (ARFID), pica, or rumination disorder. OSFED includes five examples:

Christopher James Alfred Granville Fairburn is a British psychiatrist and researcher. He is Emeritus Professor of Psychiatry at the University of Oxford. He is known for his research on the development, evaluation and dissemination of psychological treatments, especially for eating disorders.

Chew and spit is a compensatory behavior associated with several eating disorders that involves chewing food and spitting it out before swallowing, often as an attempt to avoid ingesting unwanted or unnecessary calories. CS can be used as a way to taste food viewed as “forbidden” or unhealthy. Individuals who partake in CS typically have an increased desire for thinness, increased loss of control (LOC) and body dissatisfaction. CS can replace vomiting and/or binging behaviors, or serve as an additional behavior to many eating disorders.

Paul E. Garfinkel is a Canadian psychiatrist, researcher and an academic leader. He is a professor at the University of Toronto and a staff psychiatrist at Centre for Addiction and Mental Health (CAMH).

Body image disturbance (BID) is a common symptom in patients with eating disorders and is characterized by an altered perception of one's own body.

Atypical anorexia nervosa is an eating disorder in which individuals meet all the qualifications for anorexia nervosa, including a body image disturbance and a history of restrictive eating and weight loss, except that they are not currently underweight. Atypical anorexia qualifies as a mental health disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), under the category Other Specified Feeding and Eating Disorders (OSFED). The characteristics of people with atypical anorexia generally do not differ significantly from anorexia nervosa patients except for their current weight.

Body checking is a compulsive behaviour related but not exclusive to various forms of body dysmorphic disorders. It involves frequently collecting various information about one’s own body in terms of size, shape, appearance or weight. Frequent expressions of this form of behaviour entails for example mirror checking, trying to feel one’s own bones, pinching the abdomen, frequent body weight measurement and comparing your own body to that of others. Studies have shown that an increased rate of body checking correlates with an overall increased dissatisfaction with the own body.

References

  1. ↑ "Psychotherapies". National Institute of Mental Health.
  2. 1 2 3 Kaye, Walter; McCurdy, Danyale. "A review of "Fairburn, C., Cooper, Z., Doll, H, et al. (2009). Transdiagnostic cognitive behavioral therapy for pa tients with eating disorders: A two site trial with 60-week follow-up. American Journal of Psychiatry, 166, 311-319" (PDF). National Eating Disorders Association. Archived from the original (PDF) on 2011-09-07. Retrieved 2012-04-09.
  3. ↑ Wilson, G. Terence (1997). "Cognitive behavioral treatment of bulimia nervosa". The Clinical Psychologist. 50 (2): 10–12.
  4. 1 2 Grohol, Josh M. (2016-05-17). "Treatment for Anorexia". PsychCentral. Archived from the original on 2013-05-11. Retrieved 2012-04-09.
  5. 1 2 3 4 Agras, W. Stewart; Bohon, Cara (7 May 2021). "Cognitive Behavioral Therapy for the Eating Disorders". Annual Review of Clinical Psychology. 17 (1): 417–438. doi: 10.1146/annurev-clinpsy-081219-110907 . ISSN   1548-5943. PMID   33962536. S2CID   233998712.
  6. ↑ Fairburn, Christopher G. (2008). Cognitive behavior therapy and eating disorders. New York: Guilford Press. ISBN   978-1593857097.
  7. ↑ Fairburn, Christopher G. (1 March 2009). "Transdiagnostic Cognitive-Behavioral Therapy for Patients With Eating Disorders: A Two-Site Trial With 60-Week Follow-Up". The American Journal of Psychiatry. 166 (3): 311–319. doi:10.1176/appi.ajp.2008.08040608. PMC   3035831 . PMID   19074978.
  8. ↑ Agras, W. Stewart (May 2000). "A Multicenter Comparison of Cognitive-Behavioral Therapy and Interpersonal Psychotherapy". Archives of General Psychiatry. 57 (5): 459–66. doi:10.1001/archpsyc.57.5.459. PMID   10807486.
  9. 1 2 3 Murphy, Rebecca; Straebler, Suzanne; Cooper, Zafra; Fairburn, Christopher G. (2010). "Cognitive Behavioral Therapy for Eating Disorders". Psychiatric Clinics of North America. 33 (3): 611–627. doi:10.1016/j.psc.2010.04.004. PMC   2928448 . PMID   20599136.
  10. ↑ Wilson, G.T.; Fairburn, C.G. (2007). "Treatments for Eating Disorders". In Nathan P.E., Gorman J.M. (ed.). A Guide to Treatments That Work (3rd ed.). New York: Oxford University Press. pp. 581–583.
  11. ↑ Shapiro, Jennifer R. (2010). "Mobile therapy: Use of text-messaging in the treatment of bulimia nervosa". International Journal of Eating Disorders. 43 (6): 513–519. doi:10.1002/eat.20744. PMID   19718672. S2CID   225304.
  12. ↑ Fairburn, C.G. (2009). Transdiagnostic CBT for Eating Disorders "CBT-E", Presented at Association for Behavioral and Cognitive Therapy. New York.{{cite book}}: CS1 maint: location missing publisher (link)
  13. ↑ Grave, Riccardo Dalle (22 December 2015). "Cognitive Behavioral Therapy for Anorexia Nervosa: An Update". Current Psychiatry Reports. 18 (1): 2. doi:10.1007/s11920-015-0643-4. PMID   26689208. S2CID   21285390.
  14. ↑ DeAngelis, Tori. "Binge-eating disorder: What's the best treatment?". Monitor on Psychology. American Psychological Association.
  15. ↑ Gohl, Rebekah (2017). "Cognitive Behavioral Therapy for Binge Eating Disorder in Adolescence". Augustana digital commons.
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