Cognitive behavioural therapy for anorexia nervosa

Cognitive behavioural therapy (CBT) is a structured psychological treatment that targets the thoughts, feelings, and behaviours maintaining anorexia nervosa. It views restrictive eating as a form of phobia towards food and weight gain, while also recognising it as a way to cope with broader life challenges. This therapy combines behavioural techniques to gradually change eating habits with cognitive methods to challenge unhelpful beliefs. As a result, patients learn to reduce anxiety around food, identify distorted thoughts (such as overvaluing thinness), and build new problem-solving skills. CBT progresses through distinct phases, building from immediate symptom management to long-term relapse prevention, and often extends to address other life areas for holistic recovery.

Phases of cognitive behavioural therapy:

1. Behavioural phase - Here, the therapist and patient collaborate to create a plan for stabilising eating patterns and reducing symptoms like severe restriction. This involves techniques such as graduated exposure, where food intake is increased slowly to overcome fears. Emotions can become more intense during this stage, so coping strategies are developed to manage feelings like anxiety or distress, forming a key foundation for the rest of the therapy.
2. Cognitive phase - As treatment progresses, the focus shifts to cognitive restructuring. This means identifying and challenging thoughts that sustain the disorder, such as "I will only be happy if I lose this weight." Patients work on adopting healthier perspectives, like "My self-worth doesn't depend on my size or shape."
3. Maintenance and relapse prevention phase - In the final stage, therapy emphasises reducing triggers that could lead to setbacks and maintaining the gains achieved.

Broader goals and benefits of CBT

Beyond symptom reduction, CBT aims to support a full return to a healthy life. Once core issues like eating patterns are addressed, the therapy often broadens to explore other concerns and emotional wellbeing. This leads to the adoption of more realistic thinking patterns, which in turn encourage positive behaviours. As a result, patients gain tools for long-term emotional resilience.

Drug therapy for anorexia nervosa

Selective serotonin reuptake inhibitors

Selective serotonin reuptake inhibitors (SSRIs) are a class of antidepressants. They are commonly prescribed for anorexia nervosa because patients often experience co-occurring symptoms like depression and obsessive thinking.

Evaluation of SSRIs:

• Results - Research studies and clinical experience indicate that SSRIs can be beneficial for managing sadness and obsessional behaviours in some patients.
• Limitations - However, they do not effectively aid weight recovery in low-weight individuals, as malnutrition seems to block their usual mood-enhancing effects.

Antipsychotic medications

Antipsychotic drugs, originally developed for conditions like schizophrenia, target both dopamine and serotonin systems in the brain. These medications can increase appetite in patients with major psychiatric disorders. In anorexia nervosa, they are not primarily used for weight gain but to address symptoms like distorted body image and fear of weight gain.

Key example: Olanzapine

Olanzapine is a specific antipsychotic often prescribed for anorexia nervosa. It reduces anxiety and obsessional thoughts, which can make patients feel less "stuck" in inflexible behaviours. This leads to greater flexibility in thinking and actions, helping with overall symptom management.

Evaluation of olanzapine:

• Results - Clinical observations show that olanzapine significantly boosts appetite and can lead to weight gain in some cases, while also easing psychological symptoms like body image distortions.
• Limitations - Paradoxically, while effective for appetite in other psychiatric disorders (such as bipolar disorder), antipsychotics like olanzapine are less reliable for weight restoration in anorexia. They are mainly valuable for symptom relief rather than core recovery.