Introduction

An eating disorder is a mental health condition caused by the control of food to process feelings and other situations.¹ Eating disorders are serious and can be fatal as they can disrupt behaviours, thoughts, and emotions.² Unhealthy eating patterns include eating too much or too little or even excessively worrying about your weight or body shape. Anyone can develop an eating disorder but teenagers between the ages of 13 and 17 are most at risk.³ Cognitive behavioural therapy (CBT) is a type of talking therapy that can help manage problems by focusing on changing how you think and behave. It is commonly used for anxiety and depression, but it can also be used for eating disorders. 

Understanding the different types of eating disorders²

Anorexia nervosa

This is a condition where people avoid food, eat very small quantities of food, or restrict themselves. They might be underweight and weigh themselves excessively,  which may experience body dysphoria. 

There are two types of anorexia nervosa:

Restrictive: people who severely limit the amount and type of food they consume.

Binge-purge: individuals with this type exhibit restrictive behaviour but also experience binge-eating and purging periods. They might eat large amounts of food but will vomit or use laxatives to remove what was consumed.

Anorexia nervosa can be fatal and has a high mortality rate compared to other mental disorders including:

• Extreme restricted eating
• Extreme thinness
• Wanting to be excessively thin and unwilling to maintain a normal weight
• Fear of gaining weight
• Body dysphoria
• Thinning of bones
• Mild anaemia
• Brittle hair and nails
• Dry and yellow skin
• Growth of fine hair around the body
• Severe constipation 
• Low blood pressure
• Slowed breathing and pulse
• Heart damage
• Brain damage
• Multiorgan failure
• Drop in internal body temperature
• Feeling tired all the time
• Infertility

Bulimia nervosa

This is a type of eating disorder where individuals have frequent episodes of eating large amounts of food and not being able to control these periods. This is followed by destructive behaviour such as:

• Forced vomiting
• Use of laxatives to purposefully empty the system
• Fasting
• Excessive exercise
• A combination of all the above

Symptoms of this condition include:

• Chronically inflamed or sore throat
• Swollen salivary glands in the neck and jaw
• Tooth enamel is worn away, becoming more sensitive and decaying teeth
• Acid reflux and other gastrointestinal problems
• Severe dehydration 
• Electrolyte imbalance which leads to a stroke or heart attack

Binge eating disorder (BED)

This follows the same characteristics as bulimia nervosa but is not followed by excessive exercise, purging, or fasting, which can lead individuals to become obese. Symptoms include:

• Eating an abnormally large amount of food in a short period of time
• Eating when full
• Eating alone or secretly due to embarrassment 
• Feeling guilty after binge eating
• Dieting without weight loss

Avoidant restrictive food intake disorder (ARFID)⁴

People with this limit the amount or type of food eaten, but unlike anorexia nervosa, they do not have a distorted body image. Symptoms include:

• Dramatic food restriction 
• Lack of appetite or interest in food
• Dramatic weight loss
• Gastrointestinal issues with no known cause
• ‘Picky eating’ which gets worse

Core components of CBT for eating disorders

CBT is a common type of talk therapy or psychotherapy, where you talk to a therapist and work through negative thinking. It is useful to treat a wide range of issues as it can identify specific challenges. When dealing with eating disorders, there are a few key strategies which are used on patients. 

The first step is education and engagement.⁵ The therapist educates patients about body weight and how to change their perspective on numbers on the scale. Many patients have misconceptions about food, which causes their eating disorder. Some topics of discussion may include:

• The characteristics of eating disorders, along with their physical and psychosocial effects
• How to regulate body weight
• The harm of vomiting and laxatives for weight control
• The harm of extreme dieting

Next, is the implementation of behavioural strategies. This includes the establishment of regular eating and exposure therapy for feared foods. Creating a pattern of regular eating is a key component of eating disorders. It displaces episodes of binge eating, and having a structured day, and introduces meals that can be increased in size (for those who are underweight). The eating pattern should take priority over other activities in the day so that these can adjust to the patient’s commitment.

The next step is cognitive restructuring, the process of identifying and challenging negative thought patterns to develop healthier habits.⁶ There are 4 steps to this process:

Step 1: Record the situation, thoughts, and feelings. Here, you choose and analyse a situation which triggers a negative feeling. You keep doing this for as many thoughts as you have.

Step 2: Pick one automatic thought from the list from step 1. Here you focus on the feeling that you feel is most responsible for the negative emotion and transform this into a statement.

Step 3: Develop different points of view about the situation. Ask yourself a series of questions, which help you to discover new perspectives on the situation such as: what is the effect of believing this thought? Or is there an alternative explanation?

Step 4: Create an alternative response. To challenge yourself, create a statement which includes the answers you thought of in step 3.

There are various coping mechanisms involved in CBT for eating disorders. Some techniques include:⁷

• Journaling feelings throughout the day
• Growing your support system
• Creating a list of feelings and referring to these at mealtimes
• Note down meal times- urges and restrictions
• Notice the way you speak to yourself about food
• Identify needs and limitations in your work and personal life
• Reciting positive affirmations
• Do activities you enjoy, relaxing yourself

CBT is effective, which can challenge and overcome automatic beliefs, using practical strategies to change behaviour.⁸ As a result, negative feelings turn into positive ones, which in turn lead to positive thoughts and behaviours. 

Challenges and limitations

Although CBT can be effective, it does come with disadvantages listed as follows:⁹

• Benefits depend on the patient’s ability to commit and to take on feedback being given
• Attending CBT sessions and carrying out extra work between sessions may be overwhelming
• As CBT is structured, it might not be suitable for those with complex mental health needs
• Patients might experience periods where they are more anxious or emotionally uncomfortable
• It doesn’t focus on past trauma and only targets current problems faced by the individual
• This method only focuses on thoughts, feelings and behaviours and does not address the patient’s health or well-being

CBT and other treatment modalities

There are other types of therapy which can be used, and these include:

Interpersonal psychotherapy (IPT): this is used to treat eating disorders or bulimia.¹⁰ They explore areas like interpersonal deficits, role disputes, role transitions and grief.

Family-based treatment (FBT): the family is involved in every part of the recovery process, such as maintaining healthy eating patterns.¹¹

Dialectical behaviour therapy (DBT): managing emotions and building up interpersonal skills, emotional expression and encouraging mindfulness.¹²

Acceptance and commitment therapy (ACT): this focuses on changing actions rather than feelings, but more research is needed on the effectiveness of this.

Cognitive remediation therapy (CRT): this promotes mental flexibility and broader thinking. This is mainly used for anorexia nervosa.¹³

Psychodynamic psychotherapy: this helps the patient to understand the cause of the eating disorder and explores internal conflicts.¹⁴

There is not a single effective method, but many people see an improvement with therapy.

Summary

CBT is a vital and effective tool in addressing the cause of eating disorders. Its core components encompass psychoeducation, behavioural strategies, cognitive restructuring, and coping mechanisms to provide a holistic approach to transforming negative thought patterns and fostering positive behaviours. While recognising challenges and limitations, including patient commitment, it is essential to acknowledge the diverse landscape of treatment modalities. Alternative approaches such as interpersonal psychotherapy, family-based treatment, and others offer individualised avenues for healing.¹⁵ The journey to overcome eating disorders is complex, and the effectiveness of therapeutic methods depends on the patient. As we continue to explore evolving therapies in mental health, collaborative and compassionate commitment ensures a comprehensive strategy for the recovery of individuals facing the challenges of eating disorders.