Effectiveness of CBT for Anorexia Nervosa Treatment

Anorexia Nervosa is a common eating disorder, and many people in the United States are affected by it. Anorexia nervosa is an obsessive desire to lose weight by refusing to eat. It typically begins to manifest during early adolescence, but also seen in young children and adults. It is still unclear the causes of the disorder, but there are factors that may contribute to it, these factors may include, severe trauma or emotional stress, pressured by others to become the ideal weight for competitive sports, abnormalities in brain chemistry, negative social media attention on lean bodies, and a family history of anorexia nervosa. AN can be difficult to treat because the disorder has physical, psychological and biological factors that contributes to it. Treatment is usually designed individually, depending on the contributing factors of the patient. An important key in recovery is the patient being able to admit they need help, and is willing to corporate in the treatment therapy. Increasing awareness about the disorder and its potential danger, has led patients to seek help.

The Diagnostic Statistical Manual V, a manual for psychologists outlining the characteristics of mental disorders, provides the guidelines for recognizing anorexia nervosa. The signs and symptoms are refusal of maintaining a healthy body weight relative to their height and frame, distortion of body image, denial of weight loss, amenorrhea, lanugo, yellow skin, low blood pressure, low body temperature, and imbalanced blood glucose level (Winkler, 2017). In addition, 50% of anorexics show bulimic symptoms, such as vomiting and laxative abuse, which has its own problems, including erosion of teeth by gastric acids, parotid gland enlargement and electrolyte imbalances (Winkler, 2017). Also, in patients with severe anorexia nervosa, bones become extremely brittle and break easily due to the loss of calcium (Nakamura, 2018).

All of these activities contribute to deteriorated physical and mental health, and unless intervention occurs can lead to death. Anorexia nervosa has the highest mortality rate of any psychiatric disease, at a rate of around 5.9%, which may actually be higher (Huas, 2011). Death also occurs due to other present medical conditions, such as complications with the heart, brain or gastrointestinal system. Clearly this is a dangerous disorder, with severe consequences for the individual.

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Scientists from the National Institute of Mental Health (NIMH) have also found that patients suffer from other psychiatric illnesses. Anxiety disorders generally precede the onset of the eating disorder, yet persist throughout adolescence an adulthood. Young anorexic hold fears similar to those with social phobias and these fears are experienced not only in connection with eating but also in other social situations. Depression is the major disorder associated with anorexic patients and helps to keep the patient in a perpetual cycle of self-abuse. Recently evidence has been found that supports the theory that depression stems from maladaptive thinking patterns regarding body image and eating rather than depression being the drive for the eating disorder (Darcy, 2016). These problems place them at high risk for suicidal behavior. Another commonly associated psychological illness is obsessive-compulsive disorder, an illness characterized by repetitive thoughts and behaviors.

 There are multiples approaches in the treatment of anorexia nervosa, and one approach most commonly used and finds to be effective is the cognitive behavioral therapy approach. The cognitive factors of CBT are aimed to reduce over evaluation of weight and shape, poor body image, self worth, self-injurious thoughts, perfectionism, and low self-esteem. The behavioral factors of CBT are aimed to reduce food restrictions and restraints, binge eating, purging, self-harm, body check or body avoidance. CBT aims to enhance and motivate patients for change, replace negative thoughts and behaviors and establish a regulated routine. Patients’ outcomes are to replace unhealthy eating habits with a scheduled, well balanced diet, reduce concerns about one’s body image and weight to prevent relapse. The final stage of CBT is maintenance and relapse prevention, the goal to reduce triggers and continue with the progress that has been made. Aside from eliminating symptoms, the main goal of CBT is to restore normality, wellness to the patient prior to anorexia nervosa (Lockwood, 2012).

 Cognitive behavioral therapy reduces symptoms of anorexia nervosa in 30-50% of patients, and the remaining cases showed improvements, or dropped out of treatment. As a result, CBT also reduced major psychiatric symptoms that accompanied anorexia nervosa, as well as improvement overall self-esteem and social functioning (eatingdisorder.org).  

 To measure effectiveness of cognitive behavioral therapy, weight and height of patients were recorded to obtain their BMI measurements at baseline. Data are to be collected to gain information about the patient and their history. Followed by a self-report questionnaire of eating behaviors called the Eating Disorders Examination Questionnaire, consisting of questions regarding the eating attitudes, which are restraint, eating concerns, shape concerns, and weight concerns. After, there are additional self-report questionnaires called the Brief Symptom Inventory, which asks about symptoms that reflect the patient’s psychological patterns. Scores from both tests indicated that the higher the score, the greater the level of eating pathology (Lockwood, 2012).

 Results from this study indicated that among the 34 women within the 10 sessions for anorexic patients treated with CBT, had a mean weight gain of 2.12 kg. Assuming a consistent rate in weight gain, patients gained a normal, compatible, functional weight over the 40 CBT sessions. The impact of weight gain also depended on the patient’s comorbidity of other psychological factors mentioned above, such as depression, anxiety, OCD along with scores of the questionnaires (Lockwood, 2012).

 Another approach of CBT that included intensive family exposure in the treatment showed improvements in both physical and psychological in patients. The study found that family involvement improved patient outcome by providing additional support to the patient. Family involvement also educated family members on how to care and support and learns skills on how to change maladaptive behaviors outside of treatment settings (Sepúlveda, 2017).

To achieve positive patient outcome, the first step is to build a strong patient and nurse relationship, although this can be difficult because anorexic refuses to believe they’re ill (DSM-V), and usually seek help when others are concerned. It is important to engage the patient in treatment and change, encouraging the patient to become involved, and encourage the patient to take ownership of the treatment plan. There are a lot of misconceptions the disease, and it is important to educate and answer questions patients may have. It is important to explain the characteristics of eating disorders, and the physical and psychological factors of it (Brown, 2014).

Education is an important factor for a positive outcome in patients with anorexia nervosa. When patients gain knowledge about the general information about the disorder, the symptoms become visible to the patient, making her more aware. Educate patients on the ineffectiveness of vomiting, laxative abuse, and use of diuretics of to control weight. Teach patients about healthy alternatives about diet and exercise.

Medication can also be useful for a patient, especially when other psychological illnesses may be present with the anorexia nervosa. Cyproheptadine, an appetite stimulant, may be prescribe to help aid the patient in her quest for weight gain (Mantovani, 2011). Evidence states that when antidepressants such as fluoxetine combined with CBT, has shown to be effective in patients. Since depression is highly prevalent in anorexic patients, medication such as fluoxetine may help boost the patient’s mood and in turn help increase feelings of self-value. Fluoxetine also helps improve weight maintenance after weight gain and control obsession. Medication, however helpful, can never be considered a substitute for therapy and primarily serves to complement individual therapy, not to replace it (Lock, 2012).

Even with treatment programs, an estimated five percent of patients suffering from anorexia will still die from their condition. Similarly, anorexia nervosa has an uncommonly high relapse rate and 20% do not improve their symptoms (Huas, 2011). It is believed however, that with continuing therapy, patients may fully recover and lead a stable and healthy life. Many may need to remain in therapy for several years, and some may have to restart therapy after a prolonged absence of therapy. This generally occurs when a stressful event triggers the patient’s response to focus her stress on her eating habits again rather than deal with the necessary problem at hand. Despite this seemingly grim outlook, it is believed that 70% of anorexic patients can recover and restore their lives (Brown, 2014).

Anorexia nervosa is a very complex yet delicate psychological disorder to assess, diagnosis, and successfully treat. Through a combination of therapies, the biological, psychological, cultural and familial influences on a patient can be reversed and allow the patient to live a fuller, healthier life. Although time and support are the key factors for a positive prognosis, anorexics must know that they are not alone in their struggle and that they do have the ability to overpower this seemingly unconquerable disease.

References:

• Darcy, A. M., Fitzpatrick, K. K., & Lock, J. (2016). Cognitive remediation therapy and cognitive behavioral therapy with an older adult with anorexia nervosa: A brief case report. Psychotherapy, 53(2), 232-240.
• Brown, A., Mountford, V., & Waller, G. (2014). Clinician and practice characteristics influencing delivery and outcomes of the early part of outpatient cognitive behavioural therapy for anorexia nervosa. The Cognitive Behaviour Therapist, 7.
• Lockwood, R., Serpell, L., & Waller, G. (2012). Moderators of weight gain in the early stages of outpatient cognitive behavioral therapy for adults with anorexia nervosa. International Journal of Eating Disorders, 45(1), 51–56.
• Deering, C. G. (1987). Developing a therapeutic alliance with the anorexia nervosa client. Journal of Psychosocial Nursing and Mental Health Services, 25(3), 10–17.
• Sepúlveda, M. I., Nadeau, J. M., Whelan, M. K., Oiler, C. M., Ramos, A., Riemann, B. C., & Storch, E. A. (2017). Intensive family exposure-based cognitive-behavioral treatment for adolescents with anorexia nervosa. Psicothema, 29(5), 433–439.
• Winkler, L. A., Frølich, J. S., Schulpen, M., & Støving, R. K. (2017). Body composition and menstrual status in adults with a history of anorexia nervosa-at what fat percentage is the menstrual cycle restored? International Journal of Eating Disorders, 50(4), 370–377.
• Nakamura, Y., Kamimura, M., Koiwai, H., & Kato, H. (2018). Adequate nutrition status important for bone mineral density improvement in a patient with anorexia nervosa. Therapeutics & Clinical Risk Management, 14, 945–948.
• Huas, C., Caille, A., Godart, N., Foulon, C., Pham-Scottez, A., Divac, S.,
• Falissard, B. (2011). Factors predictive of ten-year mortality in severe anorexia nervosa patients. Acta Psychiatrica Scandinavica, 123(1), 62–70.
• “Connecting Feelings, Thoughts and Deeds: Cognitive Behavior Therapy and Eating Disorders.” The Center for Eating Disorders, eatingdisorder.org/treatment-and-support/therapeutic-modalities/cognitive-behavioral-therapy/.
• Lock, J., Brandt, H., Woodside, B., Agras, S., Halmi, W. K., Johnson, C., Wilfley, D. (2012). Challenges in conducting a multi-site randomized clinical trial comparing treatments for adolescent anorexia nervosa. International Journal of Eating Disorders, 45(2), 202–213.
• Mantovani, G., Macciò, A., Massa, E., & Madeddu, C. (2001). Managing Cancer-Related Anorexia/Cachexia. Drugs, 61(4), 499–514. Retrieved from https://gold.worcester.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=4369355&site=ehost-live&scope=site