Although a strictly cognitive-behavioural model for the aetiology of anorexia nervosa has not yet been recognized, a theory for faulty cognitions maintaining the illness has been put forward by Fairburn et al.(l29) The argument for examining the role of faulty cognitions in anorexia nervosa is inescapable. The original description of perceptual and conceptual disturbances in anorexia nervosa was put forward by Bruch in 1962. (6) It was appreciated that faulty attitudes to body size contributed in part to the patient's determination to reduce her food intake and lose weight.(56) These observations led to the first development of a cognitive-behavioural therapy for anorexia nervosa/1..30) Despite the appeal of a therapy based on a cognitive-behavioural approach, there have been virtually no controlled clinical trials of this therapy. The current evidence of its benefit relies therefore on clinical impressions and case reports. (126)
Cognitive-behavioural therapy has much in common with other methods of treatment including the refeeding programme which will be described under inpatient treatment. It relies on building a positive therapeutic alliance between therapist and patient.
The patient's weight and food intake is monitored at each session and she is told her weight at each session. She is encouraged to think of food as medication and to follow a meal plan. She is encouraged to keep a daily written record of all food and liquid consumed. The patient is educated in the disturbances of bodily and psychological function consequent on the state of starvation. The content of the therapy may be divided into two 'tracks'. The first track includes an examination of the behaviours adopted by the patient in order to reduce her weight or maintain it at a low level. The second track is more concerned with psychological themes such as self-esteem, perfectionism, interpersonal functioning, and family conflicts. By asking the patient to give her reasons for specific behaviours, the therapist discovers faulty beliefs and assumptions on her part. For example, the 'anorexic wish' is the patient's wish to recover from her disorder without gaining weight. She is gently persuaded that this is an impossible aim because her real psychological difficulties will remain inaccessible so long as her experiences are clouded by starvation and dieting. The patient also expresses a fear of 'losing control'. By 'losing control' she means that she will run the risk of overeating and become fat. It is explained to the patient that her rigid 'control' over eating deprives her completely of choice, and that far from being in control the reality is the converse. It is also useful for the therapist to analyse the pros and cons of maintaining the disorder of anorexia nervosa. She often feels more uncomfortable at confronting the hidden rewards of remaining thin, for example succeeding in losing weight when everyone else fails.
Having ascertained the particular meanings of attitudes and behaviours for the patient, she is helped to find more adaptive ways of achieving healthier goals, including more relaxed normal eating and weight gain.
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