Cognitive behavioral therapy (CBT) is the leading evidence-based treatment for eating disorders.CBT is a psychotherapy method involving multiple techniques. These methods help an individual understand the interaction between his or her thoughts, feelings, and behaviors, and develop strategies to change unhelpful thoughts and behaviors to improve mood and function.
CBT itself is not a unique treatment technique, and there are many different forms of CBT, which have a common theory in maintaining the factors of psychological distress. Acceptance and Commitment Therapy (ACT) and Dialectical Behavior Therapy (DBT) are examples of specific types of CBT treatment.
CBT is usually time-bound and goal-oriented, and involves homework outside of the course. CBT emphasizes the cooperation between the therapist and the client and the active participation of the client. CBT is very effective for many mental health problems, including depression, generalized anxiety disorder, phobia and obsessive-compulsive disorder.
The history of CBT
CBT was developed in the late 1950s and 1960s by psychiatrist Aaron Beck, who emphasized the role of thought in influencing perception and behavior. CBT was originally developed to treat depression, although today it has become an evidence-based treatment for many mental health conditions and symptoms, including eating disorders.
CBT for eating disorders was developed by G. Terence Wilson, Christopher Fairburn, and Stuart Agras in the late 1970s. These researchers determined that dietary restrictions and body size and weight issues are at the core of maintaining bulimia nervosa, formulated 20 treatment plans, and began clinical trials. In the 1990s, CBT was also used for binge eating disorder.
In 2008, Fairburn released an updated Cognitive-Behavioral Therapy (CBT-E) treatment manual designed to treat all eating disorders. CBT-E includes two forms: an intensive treatment similar to the original manual, and an extensive treatment that includes additional modules for emotional intolerance, perfectionism, low self-esteem, and interpersonal difficulties that cause eating disorders.
CBT has been successfully applied to self-help and guided self-help forms for the treatment of bulimia nervosa and bulimia. It can also be provided in groups and higher levels of care, such as residential or hospital settings.Recent adjustments include the use of technology to expand the range of people who receive effective treatments (such as CBT).
Research has begun to provide CBT treatment through different technologies, including email, chat, mobile applications, and Internet-based self-help. It also supports 10 CBT for non-underweight patients with eating disorders. This method is short and effective, allowing more patients to get the help they need.
CBT is widely regarded as the most effective treatment for bulimia nervosa, so it should usually be the initial treatment offered in outpatient clinics.
The National Institute for Health and Care Excellence (NICE) guidelines recommend CBT as the first-line treatment for adult bulimia nervosa and bulimia, and it is also one of the three potential treatments that can be considered for adult anorexia nervosa.
A study compared CBT (20 sessions) for women with bulimia nervosa for 5 months with psychoanalytic psychotherapy once a week for 2 years.70 patients were randomly assigned to one of these two groups.
After 5 months of treatment (end of CBT treatment), 42% of the patients in the CBT group and 6% of the patients in the psychoanalytic treatment group stopped binge eating and elimination. At the end of 2 years (complete psychoanalytic treatment), 44% of the CBT group and 15% of the psychoanalytic group were asymptomatic.
Another study compared CBT-E with Interpersonal Relationship Therapy (IPT), which is an alternative primary treatment for adults with eating disorders. In this study, 130 adult patients with eating disorders were randomly assigned to receive CBT-E or IPT.Both treatments were treated with 20 treatments in 20 weeks, followed by a 60-week follow-up period.
After treatment, 66% of CBT-E participants met the remission criteria, while only 33% of IPT participants. During the follow-up period, the remission rate of CBT-E remained high (69% vs. 49%).
A 2018 systematic review concluded that CBT-E is an effective treatment for adults with bulimia nervosa, bed rest and OSFED. It also pointed out that CBT-E for bulimia nervosa is highly cost-effective compared to psychoanalytic psychotherapy.
Cognitive model of eating disorders
The cognitive model of eating disorders assumes that the core maintenance problem of all eating disorders is excessive attention to shape and weight. The specific manifestations of this excessive focus may vary. It can drive any of the following:
In addition, these ingredients can interact to produce symptoms of eating disorders. Strict dieting—including skipping meals, eating small amounts, and avoiding fasting—can lead to underweight and/or overeating. Low weight can lead to malnutrition and can also lead to overeating.
Overeating can lead to a strong sense of guilt and shame, and try dieting again. It can also lead to efforts to cancel the removal through compensatory actions. The patient usually gets stuck in a loop.
Components of CBT treatment
CBT is a structured treatment. In the most common form, it consists of 20 sessions. The goal has been set. The meeting is used for weighing patients, reviewing homework, reviewing case development, teaching skills and problem solving.
CBT usually includes the following components:
- Challenge the dietary rules. This includes determining rules and challenging them behaviorally (e.g. eating after 8pm or having a sandwich for lunch).
- Complete food records immediately after eating, and pay attention to thoughts, feelings, and behaviors.
- Develop continuum thinking to replace all or nothing thinking.
- Develop strategies to prevent binge eating and compensatory behaviors, such as using delays and alternatives, and problem-solving strategies.
- Exposure to fear food. After developing regular eating habits and controlling compensatory behaviors, patients will gradually reintroduce the foods they fear.
- Meal plan. The patient should plan meals in advance and always know “what and when” his or her next meal.
- Psychological education to understand what causes eating disorders and psychological and medical consequences.
- Weigh regularly (usually once a week) to track progress and run experiments.
- Prevent recurrence to determine useful strategies and how to deal with potential stumbling blocks in the future. Because treatment is time-limited, the goal is to make the patient his or her own therapist.
- Use of behavioral experiments. For example, if a customer believes that eating cupcakes will cause a weight gain of 5 pounds, he or she will be encouraged to eat cupcakes to see if it will increase. These behavioral experiments are usually more effective than cognitive reconstruction alone.
Other components usually include:
- Stop physical examination
- The challenge of an eating disorder mentality
- Develop new sources of self-esteem
- Improve interpersonal skills
- Reduce body avoidance
Good candidate for CBT
Adults with bulimia nervosa, binge eating disorder, and other specific eating disorders (OSFED) may be good candidates for CBT. Older adolescents with bulimia and bulimia may also benefit from CBT.
Patient’s response to treatment
The therapist performing CBT aims to introduce behavior changes as early as possible. Studies have shown that patients who can make behavior changes early, such as establishing a more regular diet and reducing the frequency of clearing behaviors, are more likely to receive successful treatment at the end of treatment.
When CBT does not work
CBT is usually recommended as a first-line treatment. If the CBT trial is unsuccessful, the individual can be referred for DBT (a specific type of CBT with higher intensity) or receive a higher level of care, such as a partial hospitalization or hospitalization program.