Cognitive Behavioral Therapy for Eating Disorders

Why CBT Is Usually Suggested as Part of Treatment

CBT session
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Cognitive behavioral therapy (CBT) is a psychotherapeutic approach that involves a variety of techniques. These approaches help an individual to understand the interaction between his or her thoughts, feelings, and behaviors and develop strategies to change unhelpful thoughts and behaviors in order to improve mood and functioning.

CBT itself is not a single distinct therapeutic technique and there are many different forms of CBT that share a common theory about the factors maintaining psychological distress.

Acceptance and Commitment Therapy (ACT) and Dialectical Behavior Therapy (DBT) are examples of specific types of CBT treatments.

CBT is typically time-limited and goal-oriented and involves homework outside of sessions. CBT emphasizes collaboration between therapist and client and active participation by the client. CBT is very effective for a number of psychiatric problems including depression, generalized anxiety disorder, phobias, and OCD.

History

CBT was developed by psychiatrist Aaron Beck and psychologist Albert Ellis in the late 1950s and 1960s, who emphasized the role of thoughts in influencing feelings and behaviors.

CBT for eating disorders was developed in the late 1970s by G. Terence Wilson, Christopher Fairburn, and Stuart Agras. These researchers identified dietary restriction and shape and weight concerns as central to the maintenance of bulimia nervosa, developed a 20-session treatment protocol, and began conducting clinical trials.

In the 1990s, CBT was applied to binge eating disorder as well. In 2008, Fairburn published an updated treatment manual for Enhanced Cognitive Behavioral Therapy (CBT-E) designed to treat all eating disorders. CBT-E comprises two formats: a focused treatment similar to the original manual, and a broad treatment which contains extra modules to address mood intolerance, perfectionism, low-self-esteem, and interpersonal difficulties that contribute to the maintenance of eating disorders.

CBT has been successfully applied in self-help and guided self-help formats for the treatment of bulimia nervosa and binge eating disorder. It can also be provided in group formats and higher levels of care, such as residential or inpatient settings.

More recent adaptations include the use of technology to widen the range of people who have access to effective treatments such as CBT. Research has begun on the delivery of CBT treatment by different technologies, including email, chat, mobile app, and internet-based self-help.

Effectiveness

CBT is widely considered to be the most effective therapy for the treatment of bulimia nervosa and should, therefore, be the preferred psychotherapeutic treatment. The UK’s National Institute for Health and Care Excellence (NICE) guidelines recommend CBT as the first-line treatment for adults with bulimia nervosa and binge eating disorder and one of three potential treatments to consider for adults with anorexia nervosa.

One study compared five months of CBT (20 sessions) for women with bulimia nervosa with two years of weekly psychoanalytic psychotherapy. Seventy patients were randomly assigned to one of these two groups. After five months of therapy (the end of the CBT treatment), 42 percent of patients in the CBT group and 6 percent of the patients in the psychoanalytic therapy group had stopped binge-eating and purging.

At the end of two years (completion of the psychoanalytic therapy), 44 percent of the CBT group and 15 percent of the psychoanalytic group were symptom-free.

Another study compared CBT-E with interpersonal therapy (IPT), an alternative leading treatment for adults with an eating disorder. In the study, 130 adult patients with an eating disorder were randomly assigned to receive either CBT-E or IPT. Both treatments involved 20 sessions over 20 weeks, followed by a 60-week follow-up period. At post-treatment, 66 percent of the CBT-E participants met criteria for remission, compared with only 33 percent of the IPT participants.

Over the follow-up period, the CBT-E remission rate remained higher (69 percent versus 49 percent).

Cognitive Model of Eating Disorders

The cognitive model of eating disorders posits that the core problem in all eating disorders is overconcern with shape and weight. The specific way this overconcern manifests can vary. It can drive any of the following:

Further, these components can interact to create the symptoms of an eating disorder. Strict dieting—including skipping meals, eating small amounts of food, and avoiding forbidden foods—can lead to low weight and/or binge eating. Low weight can lead to malnutrition and also can lead to binge eating. Bingeing can lead to intense guilt and shame and a renewed attempt to diet. It can also lead to efforts to undo the purging through compensatory behaviors. Patients typically get caught in a cycle.

Components of CBT

CBT is a structured treatment. In its most common form, it consists of 20 sessions. Goals are set. Sessions are spent weighing the patient, reviewing homework, reviewing the case formulation, teaching skills, and problem-solving.

CBT typically includes the following components:

  • Psychoeducation to understand what maintains the eating disorder and the psychological and medical consequences.
  • Replacement of dieting with normal eating—typically three meals plus two to three snacks per day. The patient can decide what to eat as long as it resembles a meal or snack.
  • Meal planning. The patient should plan meals ahead of time and always know “what and when” his or her next meal will be.
  • Completion of food records immediately after eating and noting thoughts and feelings as well as behaviors.
  • Regular weighing (usually once per week) in order to track progress and run experiments.
  • Development of strategies to prevent binges and compensatory behaviors, such as the use of delays and alternatives and problem-solving strategies.
  • Challenge of dietary rules. This involves identifying rules and challenging them behaviorally (such as eating after 8 p.m. or eating a sandwich for lunch).
  • Development of continuum thinking to replace all-or-nothing thinking.
  • The use of behavioral experiments. For example, if a client believes that eating a cupcake will cause a five-pound weight gain, he or she would be encouraged to consume a cupcake and see if it does. These behavioral experiments are generally much more effective than cognitive restructuring alone.
  • Exposure to fear foods. After regular eating is well-established and compensatory behaviors are under control, patients gradually reintroduce the foods they fear.
  • Relapse prevention to identify both strategies that have been helpful and how to deal with potential future stumbling blocks. Because the treatment is time-limited, the goal is for the patient to become his or her own therapist.

Other components commonly included:

  • Cessation of body checking
  • Reduction of body avoidance
  • Development of new sources of self-esteem
  • Challenge of the eating disorder mindset
  • Enhancement of interpersonal skills

Good Candidates for CBT

Adults with bulimia nervosa, binge eating disorder, and other specified eating disorder (OSFED) are potentially good candidates for CBT. Older adolescents with bulimia and binge eating disorder may also benefit from CBT.

Response to Treatment

Therapists conducting CBT aim to introduce behavioral change as early as possible. Research has shown that patients who are able to make early behavioral changes such as establishing more regular eating and reducing the frequency of purging behavior are more likely to be successfully treated at the end of treatment.

When CBT Doesn't Work

CBT is often recommended as a first-line treatment. If a trial of CBT is not successful, individuals can be referred for DBT (a specific type of CBT with greater intensity) or to a higher level of care such as partial hospitalization or residential treatment program.

Sources:

Agras, W. Stewart, Ellen E. Fitzsimmons-Craft, and Denise E. Wilfley. 2017. “Evolution of Cognitive-Behavioral Therapy for Eating Disorders.” Behaviour Research and Therapy, Expanding the impact of cognitive behaviour therapy: A special edition in honor of G. Terence Wilson, 88 (January): 26–36. doi:10.1016/j.brat.2016.09.004.

“Eating Disorders: Recognition and Treatment | Guidance and Guidelines | NICE.” 2017. National Institute for Health and Care Excellence: UK. https://www.nice.org.uk/guidance/ng69.

Fairburn, C.G. (2008). Cognitive Behavior Therapy and Eating Disorders. New York, NY: Guilford Press.

Fairburn, Christopher G., Suzanne Bailey-Straebler, Shawnee Basden, Helen A. Doll, Rebecca Jones, Rebecca Murphy, Marianne E. O’Connor, and Zafra Cooper. 2015. “A Transdiagnostic Comparison of Enhanced Cognitive Behaviour Therapy (CBT-E) and Interpersonal Psychotherapy in the Treatment of Eating Disorders.” Behaviour Research and Therapy 70 (July): 64–71. doi:10.1016/j.brat.2015.04.010.

Poulsen, Stig, Susanne Lunn, Sarah I. F. Daniel, Sofie Folke, Birgit Bork Mathiesen, Hannah Katznelson, and Christopher G. Fairburn. 2014. “A Randomized Controlled Trial of Psychoanalytic Psychotherapy or Cognitive-Behavioral Therapy for Bulimia Nervosa.” American Journal of Psychiatry 171 (1): 109–16. doi:10.1176/appi.ajp.2013.12121511.

Turner, Rhonda and Swearer Napolitano, Susan M., "Cognitive Behavioral Therapy (CBT)" (2010). Educational Psychology Papers and Publications. 147p. 226-229. Copyright 2010, Springer

Waller, Glenn, Helen Cordery, Emma Corstorphine, Hendrik Hinrichsen, Rachel Lawson, Victoria Mountford, and Katie Russell. 2013. Cognitive Behavioral Therapy for Eating Disorders. Cambridge: Cambridge University Press.

Wilson, G.T., Grilo, C., & Vitousek, K.M. (2007). Psychological treatment of eating disorders. American Psychologist, 62(3). 199- 216.

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