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What is the Effectiveness of Cognitive Behavior Therapy on Patients with Eating Disorders?

 

Alison Pedowitz

 

Vanderbilt University

 

May 4, 2010

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Abstract:

       Cognitive behavior therapy is a widespread treatment for various eating disorders. The goal of this literary review is to observe and evaluate the efficacy of cognitive behavior therapy on its own, and in relation to other forms of therapy. In the following review, four studies are analyzed for their objectives, methods of research, and conclusion. After surveying each study, we conclude that cognitive behavior therapy is effective in many cases and has an advantage over family therapy in particular. However, there have been cases with rapid relapses as well as other behavioral issues with this treatment.

 

Introduction:

       Despite its widespread relevancy and undeniable gravity, eating disorders have been severely neglected in the field of scientific research. As a result, the scientific community has been thus far unable to identify which form of therapy is most effective for patients. For those who suffer from eating disorders, there are quite a few options for treatment, including cognitive behavior therapy, interpersonal therapy, psychoanalytic therapy, and family therapy to name a few. The following literary review will serve to evaluate studies that have been done in order to test the efficacy of cognitive behavior therapy as the primary mode of treatment for eating disorders. We will analyze the results of both inpatient and outpatient programs and compare cognitive behavior therapy to various alternative therapies with the intention of concluding whether or not CBT is a viable form of therapy for eating disorder patients.

 

Literature Review:

       One particular research study on cognitive behavior therapy aimed to examine the effectiveness of an inpatient program used to treat thirty-two anorexia nervosa patients (Bowers, Ansher, 2008). The efficacy of the program was measured based upon changes in eating disorder psychopathy, depression, and general psychopathic tendencies. The core eating disorder psychopathy was calculated according to the Eating Attitudes Test as well as the Eating Disorders Inventory-2 test. Depression in therapy patients was measured by both the Hamilton Rating Scale and the Beck Depression Inventory. Finally, the general psychopathy of patients was ascertained through the Minnesota Multiphasic Personality Inventory-2 (Bowers, Ansher, 2008). Each patient underwent each of these evaluations before treatment, just before their discharge from the treatment facility, and one year after their discharge as a follow-up procedure. In comparison with the initial testing results, all thirty-two patients showed a marked positive change in all three aspects evaluated. Additionally, researchers found that the program had some sustained benefit in that some of the core eating disorder psychopathy as well as many of the depressive symptoms remained altered in the patients. In concluding this study, researchers felt that the cognitive behavior therapy in addition to weight restoration was very successful  during hospitalization and moderately successful with respect to longterm effects (Bowers, Ansher, 2008).

         In contrast to Ansher and Bower’s inpatient study, Mitchell and Ball constructed a randomized control study of anorexia nervosa patients in an outpatient cognitive behavioral therapy group (Ball, Mitchell, 2004). This treatment program was a 12-month, manual based cognitive behavioral program that was used in comparison to patients in a family therapy program. The CBT group consisted of twenty-five adolescents and young adults  who received around twenty-five sessions of treatment. After these sessions, each patient was evaluated on the basis of nutritional status, eating behaviors, mood, self-esteem, and family communication (Ball, Mitchell, 2004). Seventy-two percent of the patients who completed the therapy maintained a weight within 10% of the average body weight as well as regular menstrual cycles at their six-month follow-up. This 72% was considered a positive outcome for the treatment (Ball, Mitchell, 2004). The researchers did not find any significant differences between treatment groups and maintain that although their research was limited by a small sample size, the findings compliment earlier research in the field of eating disorder therapy (Ball, Mitchell, 2004).

         A third study observed adolescent patients with bulimia nervosa or EDNOS and compared cognitive behavioral therapy to family therapy in both efficiency and cost-effectiveness. Eighty-five adolescents from ages thirteen to twenty were chosen to participate in the study; forty-one were randomly assigned to family therapy while forty-four were assigned to CBT in the form of a guided self-care program assisted by a health professional. Each participant was assessed to confirm that they met the DSM-IV requirements for a diagnosis of either bulimia nervosa or EDNOS using the EATATE interview for assessing eating disorder histories in addition to the Eating Disorder Examination. Finally, the psychiatric comorbidity of each patient was evaluated through the Oxford, England, Risk Factor Interview (Schmidt, 2007).

         Each patient going through family therapy was given thirteen sessions of the Maudsley model of family therapy designed to treat anorexia nervosa. The purpose of this treatment is to “engage family members” and “emphasize the role of the family in promoting restoration of normal eating while providing education about bulimia” (Schmidt, 2007). The cognitive behavioral therapy was manual-based with accompanying workbooks and homework assignments. Individuals were given ten weekly sessions as well as three monthly follow-up sessions of treatment consisting of an initial focus on “the function of bulimia in the individual’s life and motivation for change” (Schmidt, 2007). This is then followed by the “self-monitoring of thoughts, feelings, and behaviors” (Schmidt, 2007). The follow up sessions then focuses on relapse prevention.

         After treatment, the therapy would be considered successful if the patient was abstaining from bingeing and purging as assessed by an interview given at the end of the treatment and again after one year. After six months of treatment, bingeing-purging behaviors had dramatically decreased in the CBT patients while they remained more prevalent in patients going through family therapy. Interestingly, after 12 months there was no longer a difference in the bingeing tendencies of patients. Overall, the researchers deemed cognitive behavior therapy more effective because of its lower cost, faster reduction of bulimia symptoms, and higher acceptability rate in adolescents. Another advantage of CBT treatments is that family therapy is not always acceptable to adolescents. For the study 28% of eligible adolescents who chose not to enter the study because they do not want to involve their family. In addition, one quarter of the participants chose to include a “close” relation in their therapy over their parents.

         The final study observes the real-world effectiveness of cognitive behavior studies in an outpatient program. This particular program was a community-based intensive treatment referred to as “Normalization of Eating” (Lowe, 2010). The intervention points were to “promote and maintain a regular pattern of food intake that would reduce dieting and maintain or increase body weight; identify specific fear-based practices or beliefs that underlie avoidance of food and eating; design behavioral tasks to be implemented during supervised meals and at home via homework assignments to gradually expose patients to feared foods and behaviors; and teach cognitive therapy techniques so patients can learn how to challenge their own extreme or irrational thoughts about food, eating, and weight” (Lowe 2010). The patients chosen for this study were between the ages of fourteen and fifty-five with DSM-IV eating disorder diagnoses. The patient population was entirely female and almost every one had comorbidity with an affective or anxiety disorder. These patients worked with a nutritionist to set up daily meals based on caloric and nutritional needs, however most meals in the program were much larger than the meals patients ate at home. This re-sensitized the patients to eating and many compensated by further restricting their consumption at home. Patients also participated in groups to promote motivation in a supportive environment. Overall, the researchers learned the many issues with sustaining patient motivation and participation in a real world clinical setting in this particular study (Lowe, 2010).

        

Discussion:

       Given Ansher and Bower’s study on inpatient cognitive behavior therapy, I was initially skeptical of the cognitive behavioral therapy’s efficacy. Although the program was very successful during the patients’ hospitalization, the effects wore off somewhat between the initial discharge and the one year follow-up. An ideal eating disorder treatment would have patients still responding to the therapy years after they have been discharged. After all, what is the point of a program if the patients must return to treatment after a few years? It is promising to see that all thirty-two of the patients had a positive response to the treatment program, however small the subject pool may be. This shows clear potential for cognitive behavior therapy. Further investigation must be done into the logistics of the therapy in order to prevent such rapid relapse. If the retention of cognitive behavioral therapy were to last longer, then perhaps it will become the therapy of choice for all forms of eating disorders.

         Mitchell and Ball’s research had a 75% positive outcome from the outpatient cognitive behavior treatment. The statistic is lower than Ansher and Bower’s 100% initial success rate, however this particular study was an outpatient program which naturally is harder to maintain because the patients are not being constantly monitored. This study was only twenty-five patients, which deters certainty in any findings due to a small subject pool. Other flaws in this study include a short span of treatment. Twenty-five sessions of therapy is not enough to successfully and permanently alter the irrational behaviors of eating disorder patients. The therapy sessions should be maintained over a longer period of time in order to solidify ideas being transferred through the therapy.

         The third study I found most compelling, particularly because it compared family therapy with cognitive behavior therapy. After six months of treatment, the cognitive behavioral therapy patients experienced a marked decrease in binge-purge behaviors that did not exist in the patients going through family therapy. This difference disappeared at the one year mark, but this does not discount the importance of such a contrast. The of group forty-four CBT patients recovered quicker than the group of forty-one participants in family therapy. Additionally, certain individuals refused family therapy because of poor relationships with their parents. In truth, CBT is more practical in many cases because adolescents don’t want or cannot have their parents involved in the process of recovery. Out of all the studies presented, this was the most convincing of cognitive behavioral therapy’s efficacy.

         Finally, Lowe’s study on the effects of the “Normalization of Eating” was less aimed at observing whether or not CBT was effective and more concerned with what issues one could expect while running such treatment. These problems include maintaining participation and motivation among patients, not re-sensitizing patients to feared foods and eating habits, and avoiding ambivalence. This article was the most forthcoming about issues with CBT programs and treating eating disorders in general.

 

Conclusion:

         Given these various studies on the efficacy of cognitive behavior therapy, I would not say for certain it is the best possible option for treating an eating disorder. Over all, the therapy has promising statistics for positive outcomes among patients but certain studies found that relapses were common. Given Schmidt’s comparison of the two therapies, I would recommend CBT over family therapy based on the records of more rapid recovery among bulimia patients. Perhaps a combination of CBT and family therapy could be viable, but only if the patient has a positive relationship with their parents. It was also pointed out that schema-focused cognitive behavior therapy is to be chosen mostly in the cases where comorbid dissociation, personality disorder, very low self-esteem or traumatic history diminishes the applicability of traditional cognitive behavioral therapy (Tolgyes, Unoka, 2009). This only serves to emphasize the point that it is possible that there is no one best form of therapy for eating disorders. In truth, each individual will find a type of therapy more effective based of their personality, comorbidity, environment, and experiences. Many individuals may find CBT to be the best form for them, and I believe it has great potential to improve the lives of many who suffer from eating disorders.

 

Work Cited:

 Bowers, W., & Ansher, L. (2008). The effectiveness of cognitive behavioral therapy on changing eating disorder symptoms and psychopathology of 32 anorexia nervosa patients at hospital discharge and one year follow-up. PubMed. Retrieved May 20, 2010, from http://www.ncbi.nlm.nih.gov/pubmed/18568579

 Ball, J., & Mitchell, P. (2004). A randomized controlled study of cognitive behavior therapy and behavioral family therapy for anorexia nervosa patients. Pub Med. Retrieved May 20, 2010, from http://www.ncbi.nlm.nih.gov/pubmed/16864523

 Schmidt, U., Lee, S., Johnson-Sabine, E., Jenkins, M., Frost, S., Dodge, L., et al. (2007). A randomized controlled trial of family therapy and cognitive behavior therapy guided self-care for adolescents with bulimia nervosa and related disorders. PubMed. Retrieved May 20, 2010, from http://www.ncbi.nlm.nih.gov/pubmed/17403972

 Tolgyes, T., & Unoka, Z. (2009). Cognitive behavior therapy in eating disorders. PubMed. Retrieved May 20, 2010, from http://www.ncbi.nlm.nih.gov/pubmed/20057003

 Brambilla, F., Grave, R. D., Calugi, S., Marchesini, G., Baroni, S., & Marazziti, D. (2009). Effects of cognitive-behavioral therapy on Eating Disorders: Neurotransmitter secretory response to treatment. PubMed. Retrieved May 20, 2010, from http://www.ncbi.nlm.nih.gov/pubmed/19962832

 Lowe, M., Bunnell, D., Neeren, A., Chernyak, Y., & Greberman, L. (2010). Evaluating the real-world effectiveness of cognitive-behavior therapy efficacy research on eating disorders: A case study from a community-based clinical setting. PubMed. Retrieved May 20, 2010, from http://www.ncbi.nlm.nih.gov/pubmed/20063375

 

 

 

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