How can eating disorders be treated? - Chapter 14

What is this chapter about?

Although the majority of eating disorders – anorexia nervosa (AN) and bulimia nervosa (BN) – begin in adolescence and persist during adulthood, surprisingly little research has been conducted on the effectiveness of interventions for adolescents with eating disorders. In particular older adolescents suffer from eating disorders. Bryant-Waugh and Lask (1995) state that 10% of the children they refer to are under the age of 14.

People suffering from AN show extreme weight loss, refuse to maintain healthy body weight, and have abnormal cognitions that lead to huge overestimations of the importance of body shape and body weight. These cognitions express themselves in a huge fear of gaining weight and a continuous preoccupation and dissatisfaction with their own shape and weight. Food intake is limited, laxatives are abused and excessive exercise are typical behaviours. Although amenorrhea (the absence of menstruation) is a diagnostic criterion of AN, the relevance to the diagnosis is questionable. Children with AN also often have difficulty staying hydrated.

BN is characterized by recurring periods in which a lot is eaten (loss of control), which is then "compensated" by activities that prevent gaining weight (such as vomiting yourself, using laxatives, or fasting). As in AN, there is a huge overestimation of (and preoccupation with) the importance of body shape and weight. People with BN often feel guilty and ashamed. Unlike AN, BN is sometimes difficult to diagnose, because the people who suffer from it are often at average body weight.

What scientific support for the effectiveness of CBT exists for adolescents with eating disorders?

There is some evidence that individual CBT treatments are effective for adolescents with BN, but there is no evidence yet for the effectiveness of CBT for adolescents with AN. In the latter case, CBT did not seem to be more effective than any other therapy (such as dietary therapy or parental counselling). Theoretically, CBT should be effective, as there are abnormal cognitions that lead to abnormal behaviors. Thus, more research is needed as to why it does not seem to be effective.

What does cognitive behaviour theory mean?

There are many cognitive behavioural models made of AN. In summary, predisposing factors – including individual vulnerabilities, general environmental influences and environmental influences related to diets, body weight and body shape – lead to the development of core beliefs and assumptions. These beliefs and assumptions, when activated by a so-called "critical incident", result in the development of thoughts and behaviors as we see them in people with eating disorders. See the figure in the book for an example of this process. This figure shows that in young people, these thoughts and behaviors are perpetuated by a number of factors, including behavioural factors, factors related to self-starvation, avoidance-related factors, family factors, social factors and emotional factors.

What is an analysis and formulation of eating disorders?

In any case, the initial analysis should map the following things: the current symptoms of the eating disorder, the history and course of the eating disorder, comorbid disorders and associated problems, physical health, information about their family, the individual’s development, their career, their social functioning, and positive characteristics. When developing the formulation, the therapist should not discuss too complicated matters, and present ideas/hypotheses (and not claim that these would be the "absolute truth").

Some additional considerations that the therapist should take into account are the physical (starving) condition and associated risks, the ability to maintain a curious attitude (without exerting pressure) and  boosting of the adolescent's involvement and motivation (as it is often the parents who want the child to get better; not the child him/herself). Thus, parents should sometimes be highly involved in the treatment.

What does the treatment of eating disorders consist of?

It is important to be transparent about the therapy, and to explain when and why confidentiality will be violated. The child/adolescents also needs to be told that some parts of the treatment cannot be changed, such as weighing. As a therapist, you need to stay interested in the person and want to understand his/her experience. At the beginning of treatment, the child should first be stimulated to regain a normal diet, and in the case of AN, to regain weight. The extent to which the family is involved depends on the diagnosis and severity of the disorder. In addition, it is important to set common goals as early as possible in the treatment. Explain to your client why you as a therapist can't help to achieve unhealthy goals, such as losing weight. Often, the person can often name targets they want to change that are not directly related to the disorder. Furthermore, it makes a lot of sense to schedule an "information meeting" at the beginning of the treatment in which psycho-education about eating disorders is provided. Finally, the client's motivation is very important. Motivation consists of two parts: the desire to change and confidence in that you can change. Motivational interviewing (MI) can be very useful in boosting the intrinsic motivation to change, by detecting and addressing ambivalence (contradictions). Since the level of motivation (the need and the confidence) can fluctuate very much, this is something that needs to be determined. It is advisable to let the client indicate on a scale of 0 to 10 how motivated she is at the beginning of each session. This allows the therapist to determine whether too little motivation is something he/she needs to deal with. Some motivation-related techniques are as follows:

1. The child creates a list of the pros and cons of changing the eating disorder. They will see that most of the benefits they cite ‘not changing the eating disorder’ are beneficial only on the short term.
2. Let the child write two letters to the eating disorder: one as a friend of the eating disorder, and one as an enemy. This provides insight into how the eating disorder hinders them in their lives and strengthens the bond with the therapist.
3. Ask the child about long-term plans: where do you want your life to be in one year (given school, friendships, relationships, family life, health, self-esteem, leisure and hobbies)? And what will it be like if you still have an eating disorder then?

Self-monitoring helps the child to identify thoughts, feelings and behaviors that cause stress and that sustain the behavior. This can be done by keeping a journal or a diary.

But, how can a therapist deal with compensatory behavior, such as vomiting and the use of laxatives? In this case, information should be given about the negative physical consequences and it should be explained that this is not an effective way to lose weight (this changes their motivation). Both behaviors lead to weight loss in the very short term, but the body recovers once it is sufficiently hydrated again. Excessive sporting, on the other hand, is more difficult to change. It is maintained by 5 factors: compulsion, behavioural rigidity, psychological dependence on sports for the mood, perfectionism, and of course the concerns about weight and body shape. The assumptions and beliefs associated with sports should be carefully addressed. Behavioural experiments are often very useful in testing predictions of assumptions and beliefs. Both planned and unplanned behavioural experiments can bring about more cognitive, behavioural and emotional change than just verbal cognitive techniques. Questionnaires can be used to test what the client thinks other people think is important (for example, to test the assumption "boys only find skinny girls handsome"). Another experiment is a discovery experiment: do something you never normally do, and see what happens. A hypothesis-testing experiment tests the validity of a specific belief. A therapist should think about the most appropriate behavioural experiment for each client.

Food, body weight and body shape determine to a large extent how the person thinks about themselves. Normally, things like sports, school, family and friends also play a big role, but in patients with an eating disorder this is completely out of balance. Together with the client, create a pie chart of the factors that contribute to self-esteem (see page 216 and 217). Then explain to the client that she does put all her money on one horse (all attention on one domain), which puts her under a lot of pressure and if something goes wrong within that domain, the person feels bad. Their goals are often unattainable, with a high likelihood failing. Then create a second pie chart that represents the ideals of the young person: what would be their best type of life? Then build bridges between these two diagrams.

People often say they feel "fat." However, "feeling fat" is not an emotion, so learn together to correctly identify the feelings in order to get to the heart of the feeling. Perfectionism is a huge factor in eating disorders. In this case, delve deeper into the advantages and disadvantages of perfectionism, address the sustained behaviors, tackle their beliefs and cognitive styles, and look at the history of this perfectionist behavior. In the context of relapse prevention, it is useful to identify what has been effective during treatment. Based on this, a plan can be made about how the client can deal with future risky situations.

Although the majority of eating disorders – anorexia nervosa (AN) and bulimia nervosa (BN) – begin in adolescence and persist during adulthood, surprisingly little research has been conducted on the effectiveness of interventions for adolescents with eating disorders. In particular older adolescents suffer from eating disorders. Bryant-Waugh and Lask (1995) state that 10% of the children they refer to are under the age of 14.