Cognitive Behavior Therapy in the Treatment of Eating Disorders

Related Articles Include : The Effects of Eating Disorders on Physical and Mental Health in Women

In the past decade, cognitive behavior therapy has become leading treatment for all varieties of eating disorders. Through its thought-centered approach, it has proven that eating disorders can be treated and although there are still some hurdles to overcome in the area, the future of cognitive therapy in the treatment of a range of eating disorders (as well as other psychological disorders) is promising. It is stunning to note that “cognitive behavior therapy is represented for almost all psychiatric conditions as well as numerous somatic conditions. In fact, it is difficult to find a major condition for which psychosocial interventions are implicated where cognitive behavior therapy has not been tested or, in many cases, has become the treatment paradigm of choice” (Anderson 2005). Generally speaking, the world should recognize the power of this treatment in dealing with eating disorders since it is being proven to work.

Throughout its history, cognitive behavioral therapy has gained credence after several statistical and clinical trials carried out by hundreds of research teams internationally. Instead of focusing on weekly sessions geared towards speaking alone, cognitive therapy is able to quickly treat eating disorders because it aims to focus on the negative thoughts associated with day to day activities and this therapy is reinforced through the use of daily activities by the client that are part of their lives outside of traditional therapy. This can include “homework” assignments that include reading and recording thoughts and ideas. Cognitive therapy is a proactive solution, but the patient must be willing to receive treatment in order for it to work best. The following report will detail many of the successes as well as some of the failures associated with this treatment and will discuss its application and rate of success in treating individual eating disorders in women such as bulimia nervosa, anorexia nervosa, and binge eating disorder. Although each case warrants its own description, it is fair to suggest that overall, cognitive behavior therapy offers patients new hope and will allow them to live normal lives. That said, there are still some issues, particularly with the longevity of success as well as aspects related to caring for issues that are the result of or part-cause of the disorder itself. Just as in the case of any disorder and treatment paradigm, there is no perfect solution and nothing will offer a 100 percent success rate simply because all patients are individual and have unique ways of responding to treatment. That said, the general consensus of this report and of the research of several scholar is that this is one of the most effective treatments available.

Interestingly, the success of cognitive behavior therapy is remarkable because of how basic the guiding principles behind it are. Instead of involving murky theoretical principles that have little use for the patient in an interactive way, cognitive behavioral therapy is straightforward and is designed to be integrated into the daily life of the patient. Cognitive behavioral therapy is by no means a complex idea within itself and for the most part, the theory is quite simple and although there are a variety of interpretations and ways of conducting the counseling itself, its basis is grounded and easy to understand. “In a nutshell, the cognitive model proposes that distorted or dysfunctional thinking (which influences the patient’s mood and behavior) is common to all psychological disturbances. Enduring improvement results from modification of the patient’s underlying dysfunctional beliefs” (Beck 1995). For example, according to this succinct definition, when applied to the area of eating disorders, a patient likely has an emotional or mental process that lead inexorably to their disordered actions such as binging or purging. According to the cognitive behavior therapy paradigm, with modification of these thought processes, the patient can be pulled out of the unwanted behavior simply by recognizing the triggers and then replacing the harmful thought with one that is revised and hopefully, more rational and healthy. In essence, this is what the whole of cognitive behavior therapy revolves around. Ideally, the patient and the counselor would look at the patterns of thought and throughout the course of treatment, no matter how long or short, these behaviors would be slowly dissolves and replaced by those that the counselor assists in placing. In other words, “The core of cognitive behavioral therapy lies in the enhancement of effective self-regulation of behavior” (Hutchinson-Phillips 2005). The key word is “self” in this paradigm of treatment as much of the emphasis is removed from the professional and put into the hands of the client.

While thus far cognitive behavior therapy has been described as being an almost magically simple way of “curing” eating disorders, it is far from perfect. There are still a large number of issues to consider and after looking at all of the facts, we see that while it is an effective treatment, this is a relative classification. The success rates are high but that is only in comparison to other methods. There are still large numbers of cases of eating disorders that are unfazed by treatment, no matter what variety. While cognitive behavior therapy may work well in comparison, there are other issues that must be considered in addition to this treatment for it to be truly effective. Although cognitive behavioral treatment is the treatment of choice in bulimia nervosa, anorexia nervosa, and binge eating disorders, patients’ response is variable. As one scholar notes, “A minority of patients do not respond at all and some never engage in treatment. Many of these patients were more likely to have been diagnosed as having borderline personality disorder and were more likely to have abused psychoactive substances and engaged in episodes of self-harm” (Coker 1993). This signals that there are inherent problems when discussing the vast success of this treatment. For example, what about these issues such as other addictions, depression, and other disorders that interfere with the potential success of cognitive behavioral therapy? Many researchers who seem quick to tout the benefits of the treatment ignore the fact that medication is also a necessary component in many cases, especially in the case of eating disorders. Patients who suffer from an eating disorder are likely to have other personality problems as well as these must be treated along with the actual symptoms of the eating disorder itself. Through an approach that balances traditional pharmaceutical lines with the newer cognitive behavior therapy, the success rates might be higher and more people will benefit from this new form of treatment.

One of the most promising findings in the last ten years in the field of cognitive behavior therapy and eating disorders has been in the case of bulimia nervosa. Cognitive behavior therapy for bulimia nervosa has demonstrated the largest success rate by far. “The results of over 20 randomized trials indicate that CBT-BN produces in completers (typically between 80-85%) an abstinence from binge eating and purge eating between 40-50%. CBT-BN is more effective than delayed treatment and pharmacotherapy, and as effective as, or more effective than delayed treatment, all the other psychotherapies evaluated” (Grave 2005). While scholars have yet to hypothesis any widely agreed upon reason for the higher success rate for this branch of eating disorder in particular, one must admit that the statistics are quite astounding. One potential hypothesis is that the problems associated with this disease are a bit easier to treat because many of the side issues such as depression can be the result of the disorder itself—not simply a foregone symptom that one must figure was present before the onset of symptoms. Something generally acts as a trigger to cause the behavior and such behavior is not quite as sustained as that which is associated with anorexia nervosa.

There is an important distinction between the two eating disorders that must be made in order to realize this more fully. “The main feature that distinguishes bulimia nervosa from anorexia nervosa is that attempts to restrict food intake are punctuated by repeated binges (episodes of eating during which there is an aversive sense of loss of control and an unusually large amount of food is eaten)” (Fairburn 2003). In most cases, the binge eating is followed up with self-induced vomiting or abuse of laxatives, although there is a classification for those who do not purge. Oftentimes, depression accompanies this illness as the feelings of lost control grow more prominent. When a patient being treated for bulimia nervosa enters cognitive behavior therapy, one of the first elements the counselor must begin with is that actual trigger for the behavior. After there is progress made in this area the depression will be treated, almost by proxy since the patient’s depression can often stem from the feelings of helplessness and lack of control associated with bulimia nervosa. Bulimia typically starts in teenage years; teens seeing it as a way of getting the pleasure of eating while not gaining weight as a result.  This behavior that begins in the teenage years, often time, the teen realizes the danger and stop this behavior.  It is at this crucial point where an individual may chose to continue this harmful behavior eventually it becomes an addiction.  Over time this cycle will continue until it encompasses an individuals every thought.  At this point the previous pleasure that was derived from this behavior has now been replaced with an obsession.  The conflict that this eating disorder creates is that a bulimic wants to be thin and have the ability to overeat.  It is this conflict that is the most difficult for a bulimic to overcome.  They are unable to give up; their behavior has taken over rational thought.  Although the behaviors are out of their control the individual is actually uncontrolled.  They feel that they have control because they determine what food enters their body and the act of purging is a decision.  That by just thinking of vomiting they are often able to do so, reinforcing their thinking of complete control over their behaviors. This cycle begins with an episode of binge eating.  Purging; using laxatives, syrup of ipecac or diuretics; or excessive exercise or starving themselves compensates the individuals’ intake of food.  It is common for individuals to develop a tremendous fear of gaining weight if they stop purging; however, the majority of bulimics have average weights. They see gaining weight as a worse option then the binge/purge behavior they are currently in.  By stopping bingeing behavior they feel they will not be able to eat healthy for fear that they will not have enough food.  To maintain a thin body the only option they can see is dieting throughout their life.  They see this as self-depravation.  These emotions and fears are what fuel this cycle of bulimia. In the field of cognitive behavior therapy, this cycle can only be halted by helping the patient understand that he or she is merely caught in the cycle of thoughts, not actions and that these thoughts can be changed. While this certainly takes a great deal of effort on both the part of the patient and the counselor, results can be seen and cognitive behavior has been the standard in the past decade for treating this disorder simply because it restructures these old thought patterns that were likely begun when a person was much younger.

Cognitive behavioral therapy alone might not be enough in many cases. Although it is a promising field with excellent results (particularly with this disorder) traditional methods of treatment cannot be foregone in favor of the cognitive end or else danger of relapse may be heightened. The primary goal of treatment for bulimia is to reduce or eliminate binge eating and purging behavior.  Nutritional information and guidelines to follow are needed; psychological intervention and medication management strategies are often successful.  Helping the bulimic establish a pattern of regular, non-binge meals and a regular exercise plan that is not excessive is extremely important.  Individual counseling, cognitive-behavioral therapy is recommended, group therapy that uses a cognitive-behavioral approach, and family or marital therapy have been reported to be effective. Psychotropic medications, primarily antidepressants such as the selective serotonin reuptake inhibitors (SSRIs), have been found helpful for people with bulimia, particularly those with significant symptoms of depression or anxiety, or those who have not responded adequately to psychosocial treatment alone. These medications also may help prevent relapse (Greeson 1993). This is an issue that must be remembered throughout this report because it seems that there are usually other serious issues to contend with including, but not limited to, personality disorders, depression (not necessarily as a result of the guilt and helplessness associated with the eating disorder) and other mood disorders. While cognitive therapy can be an effective way to manage and rehabilitate thought patterns, in serious cases there are many other issues that must not be ignored.

Another related eating disorder, binge eating, has also been shown to be highly compatible with cognitive behavior therapy. Much like bulimia nervosa, many of the same symptoms are present, particularly in terms of the feelings of depression that come as a result of feeling out of control and helpless. There are, however, important distinctions to be made between bulimia nervosa and binge eating. As one definition states, “Binge eating disorder is characterized by recurrent episodes of binge eating in the absence of regular compensatory behavior such as vomiting or laxative abuse. “Related features include eating until uncomfortably full, eating when not physically hungry, eating alone, and feelings of depression and guilt. Binge eating disorder is also associated with increased psychopathology, including depression and personality disorders…. Eating disorder treatments such as cognitive behavior therapy improve binge eating with abstinence rates of about 50%” (De Zwaan 2001). Although 50% may not sound as successful as one may wish, this is still quite high, especially when one considers that the success rates through traditional therapies was only between 35-40%. It is also important to note that these are two similar eating disorders with very similar causes and effects and these similarities can tell researchers quite a bit about how different therapies work for particular aspects of a condition (such as in terms of anxiety, depression, etc). Even still, the numbers seem as though they should be higher and it is clear that there must be more to discover about eating disorders and cognitive behavior therapies.

There are numerous problems that are unique to binge eating disorder and make it different to treat, even with cognitive behavior therapy. One must also consider that there are many health related issues involved with this disorder and that it is, just like bulimia, a cycle that the patient will have difficulty escaping once the trigger has been set off. Low self-esteem is often an important factor to consider because the patient feels guilty about his or her actions and worse because their disease becomes apparent to those around them since the majority of people who suffer from Binge Eating Disorder are overweight because they do not purge following a binge.  Reasons for binge eating are very individualized.  During a binge a trace-like state takes over the individual.  During and also immediately after a binge a numb feeling is described.  No feelings are able to get through to the individual; they feel no emotions.  Unfortunately, this process is a very maladaptive coping skill that is extremely unhealthy for the individual.  Many people use binges as a way to hide from their emotions, to fill a void they feel inside, and to cope with daily stresses and problems in their lives. For the binge eater there is usually a vicious cycle that takes place.  This addictive cycle can be broken down into a series of steps.  Although a binge may seem to come out of nowhere or the causes of the binge may vary, the pattern is the same each time.  The reason why cognitive behavior therapy has been so much more successful than other treatments is because it recognizes the mental thought-cycle that is perpetuated and works on eliminating that emotional and thought response. The key for the cognitive behavior therapist is to isolate the trigger since it is the starting point for all that follows. In cases of binge eating, The trigger is usually an emotional feeling.  This feeling results from a given situation in life.  It can be a one-time experience or daily happening.  Common feelings that lead to binges are anger, loneliness, rejection, resentment, helplessness and depression.  The trigger than leads to the desire/decision stage.  The desire to eat and the follow through are the second phase of this process.  Many people make the decision to binge hours before they actually do it.  Some make an elaborate ritual out of shopping or preparing for the binge.  A binge can also be put into place just minutes after the decision is made but first there must be a decision and this makes the thought the process and the control of the initial trigger crucial to the success or failure of a cognitive behavior treatment regime. Even still there are other issues that must come into play in order for the illness to be completely treated and all of the symptoms and related problems for those suffering from it must be considered.

Despite the success rate with this eating disorder in particular, it is still not considered to be a “miracle cure” by any means. Just as is the case with other psychiatric illnesses, there are any number of factors that could help or impede progress and recovery. For instance, even though the treatment is very effective for bulimia nervosa, the patient must continue practicing the skills learned throughout his or her lifetime in order to remain healthy. This can be especially difficult, particularly since one of the features of cognitive behavior therapy is the counselor’s role as a “cheerleader” and instructor of sorts. After the course of treatment, patients could easily experience relapse and thus begin to get int the cycle of depression and old behaviors just as easily as they got out of them. Furthermore, treatment with medication should be considered in cases where the depression is possibly more than just a side effect of the illness. If a patient is still feeling depressed, there is obviously a much greater risk of relapse as well. Even though cognitive behavior therapy has been hugely successful in the treatment of this particular eating disorder, there are still patients who require help and want it, but do not gain any benefit from standard cognitive behavior treatment. In such cases, there are more integrative approaches that combine a number of side-branches of the treatment paradigm. Using other treatments and branches of cognitive therapy can be especially useful in the most difficult cases. One study suggests that the use of imagery gives access to direct “primitive” schemas in a way that verbal cognitive therapy treatments do not. “The failure of verbal forms of CBT in some cases may be a product of therapists attempting to access cognitive representations via an inappropriate channel. It is argued that imagery rescripting in such cases allows the affect associated with the schema to be evoked” (Ohanian 2002). This access makes it possible to help adults to restructure the meanings they attached as children to early negative experiences and to modify the conclusions they are likely to make about themselves and their worlds. This knowledge can also be applied to other eating disorders such as anorexia or binge eating since the concept is broad and integrative.

Cognitive behavior therapy has also been applied in cases of anorexia nervosa and although the success rates are not as high as those associated with bulimia nervosa, there is promise in the future. There are several differences between the two eating disorders which makes treatment quite different, even if they are still disorders in the same area of classification. In the case of anorexia nervosa, the loss of weight is “primarily the result of a severe and selective restriction of food intake, with foods viewed as fattening being excluded. In some patients, the restriction over food intake is also motivated by other psychological processes, including asceticism, competitive behavior, and a wish to punish themselves” (Fairburn 2003). Unlike bulimia nervosa, this disease is one that takes rather constant vigilance and is associated with obsessive compulsive behavior. There are also many complex reasons and side issues associated with this particular illness which make it a different story treatment-wise than bulimia nervosa. Although these issues will be explored as we move along, it is still significant to note that cognitive behavior therapy is offering better success rates than many of the more traditional treatment paradigms for anorexia nervosa. As one study indicates, cognitive behavior therapy served patients much better after extended treatment when compared with the more standard approach of nutritional counseling. The study observed that, “After hospitalization, 33 patients with DSM-IV anorexia nervosa were randomly assigned to one year of outpatient cognitive behavior therapy or nutritional counseling. The group receiving nutritional counseling relapsed significantly earlier and at a higher rate than the group receiving cognitive behavior therapy (53% versus 22%). The overall treatment failure rate was significantly lower for cognitive behavior therapy (22%) than for nutritional counseling (73%)” (Pike 2003). While this might simply be proving that nutritional counseling was never the best option for post-hospitalization treatment, it would seem that at least cognitive behavioral therapy has shown itself to be an improvement on traditional treatment methods. It should be explored further, however, especially in the case of anorexia nervosa because there are any number of other issues that must be treated simultaneously in order for the model to be completely effective.

While the above study and related statements may have made it seem as though cognitive behavior therapy is one of the best solutions, especially for patients who are just leaving an extended hospital stay, there are some facts to be considered. One must recognize that although cognitive behavior therapy is quite promising, this is only in relative terms. We are looking at data that relates it to other traditional therapies and thus the success rate may seem higher than it is in “real life” simply because it is based on comparison. It is oddly difficult to find data that discusses cognitive behavior therapy as a stand-alone treatment (i.e. not being compared to other treatment methods) but what does exist does not bode particularly well for the treatment and shows that there are significant strides that must be made before it can be “officially” the best treatment available. While we all know it is the quickest treatment (since the average course of treatment is roughly 20 weeks) there are certainly flaws. For instance, in one study of anorexia patients who were assigned to one of three treatments: cognitive behavior therapy, interpersonal therapy, or a control treatment approach that combined clinical management and supportive psychotherapy. All patients were treated with 20 sessions over at least 20 weeks and were assessed after the 10^th week of therapy and after the final session, “9% of the women had a very good outcome and 21% more had improved considerably; 70% made only small gains or no gains” (Rich 2005). Of these patients, those receiving interpersonal treatment had the highest failure rate and those with cognitive therapy were the most successful. The fact that only 9% of the patients with anorexia had a good result is quite frightening and shows that must be flaws inherent to the treatment itself. With such a wide margin of successes to failures, it hardly seems to fair to think that patients and their desire (or lack thereof) are the cause, thus we must consider what might be missing from the current form of cognitive behavior therapy treatments for anorexia patients in particular.

As with the other eating disorders discussed in this study, cognitive therapy alone might not be enough to achieve total success (which means no relapse). In addition to cognitive therapy, the counselor must remember that there are usually a host of other issues involved in anorexia cases and it is generally not a condition independent of certain variables such as long-running low self-esteem and other aspects. Treatment of anorexia calls for a specific program that involves three main phases: First and most importantly the individual needs to gain the weight lost to severe dieting and purging.  Psychological counseling to work with internal issues such as distortion of body image, low self-esteem, and interpersonal conflicts; and the long-term goal of remission and rehabilitation, or full recovery.  For an anorexic this treatment may need to be provided in an inpatient hospital setting, where feeding plans address medical and nutritional needs. In some cases, intravenous feeding is recommended to counteract malnutrition and help with weight gain.  Psychotherapy has been proven to be significant in treating anorexics, although even still, cognitive-behavioral therapy is thought to be the most successful.

While we have seen that there are many benefits to cognitive behavior therapy, it is crucial to recognize that there are still several aspects that are important to keep in mind. Even though there appears to be a high success rate, the treatment is far from perfect. One of the most often cited problems with cognitive behavior therapy is that after the course of treatment the rate of relapse is rather high. As one researcher notes, “Existing research evidence suggest the benefits of cognitive behavior therapy last for up to a year following the end of a course of treatment. A new trial has found that more than half of a group of people who had undergone cognitive behavior therapy and were followed up for 2-14 years were still diagnosed with some form of mental illness and very few had mild or no symptoms” (Ennis 2005). This poses one of the greatest problems in the entire field of treatment options. If the typical course of treatment for cognitive behavior therapy is 20 weeks, how do ensure that patients are continuing to feel the benefits without their “cheerleader” and instructor there to guide them? Furthermore, what good is a treatment that is highly effective in the first year after treatment but whose message and benefits become obsolete within a relatively short time frame? The only that seems reasonable is that cognitive behavioral therapy should act as a “kick start” in the case of an eating disorder. During that course of the initial 20 weeks, the patient can identify and begin to control his or her thoughts in order to achieve temporary success. If the mental health professionals see that this is not a permanent solution, then there will be better long-term plans laid. Although cognitive behavior therapy will be the most important step, patients must be informed to keep coming back, albeit at a less frequent rate. They should also be given access to traditional treatment options to supplement and hopefully extend the benefits and learning that took place during the cognitive behavioral sessions. The results of several studies suggest “a need to focus treatment directly on factors such as hopelessness and depression in addition to standard eating disorder procedures to ensure clients are able to engage in therapy” (Steel 2000). Furthermore, the patients need to be able to hold on to what they’ve learned during their cognitive behavior sessions and traditional treatments such as medications and standard psychotherapy might be the best way to extend what they’ve learned.

While in the end there are no infallible treatment options for eating disorders, cognitive behavioral therapy offers patients a potential solution that will help them identify and change thought patterns. With enough follow-up care and determination, this could, in select cases, truly be the “miracle cure” for such a complex and often devastating illness.

Works Cited

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Coker, Sian. (1993). Patients with Bulimia Nervosa Who Fail to Engage in Cognitive Behavior Therapy. International Journal of Eating Disorders, 13(1), 35

De Zwaan, M. (2001). Binge eating disorder and obesity. International Journal of Obesity, 25(5), S51

Ennis, B. (2005). Effects of CBT eroded over time. Practice Nurse, 30(10), 6

Fairburn, Christopher G. (2003). Eating disorders. Lancet, 361(9355), 407

Grave. (2005). A multi-step cognitive behaviour therapy for eating disorders. European Eating Disorders Review, 13(6), 373

Greeson, Janet, PH.D.  It’s Not What You’re Eating, It’s What’s Eating You.  New York, NY:  Simon & Schuster Inc., 1999

Hutchinson-Phillips. (2005). Differing roles of imagniation and hypnosis in the self-regulation of eating behavior. Contemporary Hypnosis, 22(4), 171

Ohanian, Vartouhi. (2002). Imagery Rescripting Within Cognitive Behavior Therapy for Bulimia Nervosa: An Illustrative Case Report. International Journal of Eating Disorders, 31(3), 353

Pike, K.M. (2003). Cognitive behavior in the posthospitalization treatment of anorexia nervosa. American Journal of Psychiatry. 160(11).

Openshaw. (2004). Group cognitive-behavior therapy for bulimia nervosa: Statistical versus clinical significance of changes in symptoms across treatment. International Journal of Eating Disorders, 36(4), 363

Rich, B.R. (2005). Evaluating Three Psychotherapeutic Approaches for Anorexia Nervosa. Eating Disorders Review, 16(3), 4

Steel, Zachary. (2000). Why the High Rate of Dropout from Individualized Cognitive-Behavior Therapy for Bulimia Nervosa? International Journal of Eating Disorders, 28(2), 209

Article by Nicole Smith  ~   All Content Copyright 2007 Article Myriad. All Rights Reserved.

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