Cognitive behavioural therapy as a treatment for anorexia nervosa

Cognitive behavioural therapy (CBT) is a psychological treatment that focuses on altering negative thought patterns and behaviours associated with anorexia nervosa (AN). It aims to help individuals develop healthier ways of thinking and behaving to achieve and maintain a healthy weight by addressing the cycle of shame, disgust, and weight control behaviours.

Phases of CBT for anorexia nervosa

CBT for AN is structured into three distinct phases, each targeting specific aspects of the disorder to support recovery.

Three phases of CBT for AN:

1. Behavioural phase - A collaborative plan is developed between therapist and patient to stabilise eating patterns and reduce anorexic symptoms. Coping strategies are introduced and practised to manage negative emotions effectively.
2. Cognitive phase - Focuses on teaching cognitive restructuring skills to challenge and change distorted thinking patterns. Issues related to relationships, body image, and self-worth are explored, alongside techniques for emotional regulation.
3. Maintenance and relapse prevention phase - Concentrates on identifying and reducing triggers for anorexic thoughts and behaviours, while equipping patients with strategies to prevent relapse and sustain long-term recovery.

Psychodynamic therapies for addressing anorexia nervosa

Psychodynamic therapies (PDTs) explore the unconscious roots of anorexia nervosa, often linking it to unresolved childhood conflicts or interpersonal issues. These therapies aim to uncover hidden thoughts and feelings to improve self-relationship and interactions with others.

Types of psychodynamic therapies for AN

• Focal psychodynamic therapy (FPT) - This approach helps patients understand unconscious conflicts from childhood that may contribute to AN. Therapists guide individuals to gain insight into these issues, fostering healing in their relationship with themselves and others.
• Interpersonal therapy (IT) - Focuses on low self-worth and anxiety stemming from problematic interpersonal relationships. Therapists assist patients in identifying negative relational patterns and developing strategies to improve these interactions for better mental health.

Research evidence on the effectiveness of psychological treatments

Several studies have investigated the outcomes of psychological treatments for AN, providing insights into their effectiveness and long-term impact.

Key studies on cognitive behavioural therapy

• Pike (2003) - Found that after one year, 22% of patients receiving CBT had either dropped out of treatment or relapsed, compared to 77% of patients receiving nutritional advice, suggesting CBT is effective.
• Carter et al. (2009) - Found that after one year, 35% of CBT patients who had regained a healthy weight had relapsed, compared to 66% of group therapy patients, suggesting CBT is an effective long-term maintenance treatment.

Key studies on psychodynamic therapies

• Egger et al. (2016) - Found that FPT had lower average costs than CBT, suggesting it as a cost-effective treatment option.
• McIntosh et al. (2005) - Found that IT was ineffective in reducing symptoms by the end of treatment compared to CBT or outpatient support, but at a 6.7-year follow-up had a similar recovery rate, suggesting some long-term effectiveness.

Strengths and limitations of psychological treatments

Psychological treatments for AN have both advantages and challenges, influencing their applicability and effectiveness in clinical settings.

Advantages of psychological treatments

• No side effects - Unlike pharmacological approaches, PDTs do not carry the risk of physical side effects, making them a safer option for many patients.
• Research support - Both CBT and PDTs are backed by empirical evidence, demonstrating their potential effectiveness in managing AN symptoms and supporting recovery.

Challenges of psychological treatments

• Requirement for trained professionals - Both CBT and PDTs necessitate skilled therapists, which can significantly increase the cost of treatment and limit accessibility.
• High drop-out rates in CBT - A notable issue with CBT is the frequent drop-out of participants, reducing sample sizes in studies. This makes it harder to generalise findings and accurately assess the treatment's true effectiveness.

Practical applications and issues in assessing treatments

Psychological treatments for AN have real-world implications and face specific challenges when their effectiveness is evaluated.

Practical implications of psychological treatments

• Increasing acceptance of PDTs - Clinicians are increasingly recognising the value of PDTs, which is promising given the complexity of treating AN. The availability of diverse treatment options can enhance patient outcomes by offering tailored approaches.

Methodological challenges in evaluation

• Variability in AN severity - Patients present with differing levels of AN severity, complicating the assessment of treatment effectiveness. This variability can obscure whether outcomes are due to the treatment itself or individual differences in condition severity.