There is no established cognitive-behavioural treatment for anorexia nervosa. A general cognitive-behavioural approach has been specified (21) but there is nothing approaching a treatment manual. There are two ongoing studies of the use of cognitive-behaviour therapy following weight restoration in hospital but their findings are not yet available. Furthermore, their relevance to the routine care of patients with anorexia nervosa is uncertain given that most patients are managed exclusively on an outpatient basis.
As described above, the cognitive-behavioural account of the maintenance of bulimia nervosa can be readily extended to anorexia nervosa. As in bulimia nervosa, these patients' extreme dietary restriction may be understood as emanating from their concerns about shape and weight. In anorexia nervosa, however, the state of starvation also contributes to the maintenance of the disorder. A further maintaining factor is the egosyntonicity of the anorexic state. Unlike bulimia nervosa, there is little about having anorexia nervosa that is distressing; indeed, as Vitousek et ai.'(22> have noted, the patients tend to view it more as an accomplishment than an affliction.
It is possible to treat anorexia nervosa using an adaptation of the cognitive-behavioural treatment for bulimia nervosa. Three main modifications are required: the motivation of these patients needs to be enhanced, the state of starvation needs to be corrected, and the patient's family may need to be involved. Each of these modifications will be discussed in turn.
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