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Cognitive Behaviour Therapy for Anorexia

CBT provides the steps for treating Anorexia

Cognitive Behaviour Therapy, or CBT, is a well-known form of therapy used for a wide range of psychological problems. Chris Fairburn, from the University of Oxford, has been in the forefront of developing CBT programs for eating disorders. His eating disorder treatment, which he called CBT-E (Enhanced), was first published in 2008, and there is now a significant body of evidence supporting the use of CBT-E with people suffering from Anorexia Nervosa as well as other eating disorders.


Overconcern with weight and shape

According to Fairburn, the central problem in all eating disorders is over-concern with shape and weight, and therefore his model of treatment is based on the tenet that once we correct this over-concern, we have resolved the eating disorder. In common with other CBT approaches, CBT-E addresses the processes of thoughts, behaviors and feelings that are maintaining the eating disorder, or keeping it going. Addressing the origins of the eating disorder is not generally necessary as the eating disorder may have existed for many years and the factors and processes that caused the eating disorder in the first place may be no longer relevant.

The formulation is a diagram that shows why Anorexia keeps going

Formulation for Anorexia Nervosa

A personalised diagram of the processes that appear to be maintaining an eating problem is called a formulation. This is the formulation developed by a young woman with Anorexia Nervosa. (To understand some of the elements of this formulation please refer to the article Effects of being under-weight).


We can see from this formulation how the elements of the disordered eating interact. Obviously the over-concern with weight and shape causes the strict dieting, which can involve skipping meals, fasting, eating small amounts of food and avoiding “bad” or forbidden foods. The strict dieting over time causes the low weight and it is largely the many effects of being under-weight that maintain the person’s eating problem. The preoccupation with eating, which occurs as a natural response to starvation, keeps thoughts about food and weight in the forefront of the sufferer’s mind, so that she or he is likely to continue to be vigilant about food restriction and managing weight. The social withdrawal, which is also a behavioral response to starvation, means that the person is not exposed to life events and circumstances that might reduce the importance she or he places on controlling eating and weight. People with Anorexia commonly fail to recognize how unusual their lifestyle and behaviors are.

Several other cognitive effects of being underweight contribute to a difficulty in making change, and thus often lead to procrastination and lack of change. These include indecisiveness, heightened obsessionality with strict adherence to dietary and eating rules and routines, and heightened need for predictability and intolerance of change. Increased feelings of fullness, which result from gastrointestinal changes in response to starvation, make it difficult to increase the amount eaten. 


Weight restoration is essential

During CBT-E sessions the psychologist and the person suffering from Anorexia Nervosa frequently review this formulation, and it helps the person understand how being underweight causes the eating disorder to persist, and therefore that weight restoration is essential. Many sufferers will initially believe that weight restoration is not the answer to their problems, so it is emphasised using the formulation that while treatment will address all facets of the eating problem, no one can overcome an eating problem like this without weight restoration. 

The first goal in treating Anorexia Nervosa is therefore replacing strict dieting with regular eating, with a guideline of eating three meals and three snacks daily. Change is made gradually and sessions help renew motivation. Once sufficient weight has been restored the core problem of over-valuation of weight, shape and controlling eating has to be resolved. Behaviours such as frequent weighing and body checking that reinforce over-concern about weight and shape are addressed, and new sources of self-esteem developed. The final phases of treatment involve re-establishing old and new interests, and recreational, occupation and social activities that the food-preoccupied person has been neglecting or completely disregarding, and the person is taught how to recognize and deal with potential triggers for eating disorder behaviors to recur.

If you or someone you know is suffering from Anorexia Nervosa it is very important that appropriate treatment is established. I understand that seeking treatment can be scary, and I encourage you to contact me so that we can discuss your situation and I can answer your questions.

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