Cognitive Behavioural Therapy is the recommended choice of treatment for people suffering eating disorders (NICE 2004). However, there is growing and mountain concerns that there is lack of clinical trail to prove the efficacy of CBT in treating eating disorders. Therefore, what this review aims to achieve is to examine and explore what studies and literature has been made available in this field and to systematically analyse these research or findings.
In additions, it aims to make strong recommendations for way forward. This paper will aim to critically examine some researcher articles, reviewing and questioning each stage of the research from begging to end. The rationale of choice is eating disorders have the highest mortality rate among all mental health illness in United Kingdom (NICE 2004). As a trainee CBT therapist it will be a great achievement to help scale this tread to its lowest. What do l know about anorexia nervosa
Patients with an eating disorder of any type have a significantly increased risk for death, but anorexia nervosa appears to be particularly deadly and linked to the highest mortality and suicide rates, similarly elevated mortality rates were found for those with bulimia nervosa and eating disorder not otherwise specified (EDNOS). However, the rate was even higher for those with anorexia nervosa, with a weighted annual rate of 5 deaths per 1000 person-years.
Of those who died, 1 in 5 did so by committing suicide. In addition, an older age at first presentation for those with anorexia, especially between the ages of 20 and 29 years, was found to be a significant predictor of mortality. Results showed that the highest mortality rates were found for those with anorexia (weighted mortality, 5. 1; SMR, 5. 86). Of the 12,808 total patients with anorexia, 639 died (mean follow-up period, 12. 82 years). Among these, 1. 3 deaths per 1000 person-years were from suicide.
This literature review aims to also look at the research conducted by others and what is being done to help improve and reduce the rate of mortality in eating disorders. The leading scheme for classifying and diagnosing eating disorders, the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Health Disorders Forth Edition (DSM-IV), recognizes two eating disorders, anorexia nervosa and bulimia nervosa, together with a residual diagnostic category termed eating disorder not otherwise specified (EDNOS).
Fairburn 2008 describes easting disorders as cognitive disorder. Fairburn mentions the psychopathology of eating disorders Is the over-evaluation of shape and weight and their control, where as majority of people evaluate themselves on the basis of their perceived performance in a variety of domains in life, people with eating disorders judge their self-worth largely in terms of their shape and weight and their ability to control them (Fairburn 2008).
The writer will look into the effective of CBT in relation to the treatment of anorexia, at times basing its emphasis on eating disorder as a whole. CBT and Psychotherapy An article Gowers 2006, titled Evidence Based Research in CBT with Adolescent Eating Disorders, states that CBT is becoming the treatment of choice for a number of adolescent mental health problems. The research further states CBT may be effective at the symptomatice level, this is in improving self-esteem.
Gowers and Bryant-waugh, 2004 suggest that there is insufficient evidence to recommend CBT over other therapies. In this same article Gowers mentioned that the impact of psychotherapeutic interventions in anorexia nervosa failed to satisfy the NICE systematic reviewers of its robustness in their findings. CBT and Behavioural Family Therapy Julian Ball and Phillip Mitchell from the Prince of Wales Hospital, Sydney Australia compared CBT with Behavioural Family Therapy for anorexia nervosa patient.
In their study they compare CBT with BFT and both therapy demonstrated significant improvement over time on measure of eating attitudes and behaviours, self-esteem, depression and state anxiety. In contrast to this, Helen Davies and Kate Tchanturia from the Institute of Psychiatry Kings College, University of London, describe the efficacy of CBT as part of the treatment programme in acute anorexia nervosa to stimulate mental activities and improve thinking skills and information-processing systems when other therapies, for example CBT ,may be too complex and intense for the patient to engage in. t further suggest that CRT may be an effective tool in improving flexibility of thinking in AN, as previous neuropsychological finding have proved that rigidity is one of the maintaining factors in AN (Davies and Tchanturia, 2005). Its striking that Beck .. Mentioned that CBT models are made to fit round the client and not the client to fit round the model, yet there are suggestions and comments made that other therapy are more flexible than CBT.
Davies and Tchanturia commented on their introduction page of their article that there is no established first-choice treatment for anorexia nervosa, which is in agreement with Westbrook, Kennerley and Kirk, 2011. They emphasis that CBT treatment for anorexia nervosa has some limited support for efficacy and but maintained strong emphasis on the treatment of CBT for Bulimia as having clear evidence of efficacy (Westbrook et al). It becomes striking again that despite the lack of evidence and research in CBT for the treatment of anorexia, Fairburn 2008, mentions that CBT and eating disorders is a perfect match.
Fairburn mentions eating disorders and CBT are a perfect match because eating disorders are fundamentally cognitive disorders and CBT is of its very nature designed to produce cognitive change. In contrast Davies et al suggest the use Cognitive Remediation Therapy (CRT) over CBT, mentioning CRT could be one of the possible interventions for the acute anorexia nervosa population, as it does not directly address thought, beliefs or emotions. It says CRT helps the patient to engage in stimulating and positive mental activities without the burden or complexity of confronting issues or emotions that relate to their eating disorder.
And by building and improving thinking skills and information-processing systems, these skills can be everyday living skills, as well as being utilized in future therapy, which does not address though, belief and emotion (Davies et al, 2005). Beck, 1976 mentions CBT is not a static form of therapy, rather an evolving and growing therapy. CTB is a form of therapy that works; this displaces suggestions and ideas Davies et al of their choice of CRT over CBT (Course Note, 2011). Result and Findings There were differences and similarity or in the findings of the article examined.
A call for further research, study and trails were common talk among all article writers. Emphasis were made on the limitations on CBT trails, there was only one comparison made between CBT and BFT. Furthermore, it was difficult making comparison as some research used focus groups and other based their study individuals. A study by Ball et al concludes that CBT is unhelpful in anorexia nervosa. And in order to improve its effectiveness, process issues such as motivation, therapeutic alliance and shared goals cannot be ignored.
It further states, a sensible method seems to increase the length of therapy, so that these issues can be properly addressed. Ball et al made a case that an alternative option is to use group CBT as part of a wider treatment package for individuals with anorexia nervosa. This confirms findings by Leung et al, who carried out a 10 session group CBT treatment for twenty anorexic women. Changes in eating psychopathology, there were no significant differences in eating symptomatology before and after group CBT, and no treads towards any such improvement after the 10 sessions.
It also conclude that group CBT in its current short form is insufficient to induce changes, due to its failure to address some process issues central to anorexia nervosa, such as lack of insight, poor motivation and ambivalence towards treatment. Different result was indicated by Carter et al, when they compared the treatment CBT and Treatment as Usual for anorexia nervosa. It mentioned at the time of discharge from the initial inpatient or day hospital treatment phase, patient in the CBT and MTAU conditions were quite similar.
However, the CBT group had significantly higher EDI Drive for thinness subscale scores (t (79)=1. 95, p =0. 05). This variable was entered as covariate in all subsequent analyses of differences between the two groups. This study used 46 participants in the CBT groups, eight were withdrawn from the study as treatment failures due to deterioration in their clinical state, ten dropped out of treatment prematurely before relapsing and two were withdrawn for missing too many treatment sessions or not complying with the medication regime.
Twenty six participants completed the entire 1 year CBT treatment protocol. Of the 42 participants in the MTAU condition, 12 dropped out of the study within the 12-month follow up period in that they were unwilling to continue to participate in the assessments. No significant difference in drop out rates was found between CBT bad MTAU groups (B= -0. 24, SE = 0. 43,df=1, p= 0. 57). When relapse was defined as a BMI? 17. 5 for 3 months, time of relapse was significantly longer in the CBT condition when compared with MTAU. At 1 year 24. 4% of the CBT group and 50. % of the MTAU had relapsed. In terms of remission rates, 65% of CBT and 34% of MTAU remained remitted at 1 year. In a Naturalistic study of treatment and response carried by Thompson-Brenner et al says that, although CBT showed the strongest association with the outcome in a subsample characterized by poor relation, personality functioning, dynamic therapy was associated with better global outcome in the overall sample. Clinicians reported that their patients were responding to treatment; however, these improvements required an application of time and effort.
The treatments described here were sampled before their conclusion, at an average of 8 months into treatment and the clinicians reported that almost 70% were showing significant improvement in treatment and 30% had recovered from eating disorders. The observed improvements were associated with the amount of time in treatment. The average length of treatment before achievement of recovery was more than 6 month, suggesting that at least 6 months of treatment is required for recovery among this population, and the majority seem to require additional treatment to achieve remission.
What this study does not make clear is the type of diagnosis of eating disorders that they had success with. This makes it difficult to understand or to compare it with other models of treatment or even to consider a combine treatment formula. Conclusion Most of the trails done where based on individuals and groups of patient either recovering from eating disorders or had adequate body mass index. These made it unclear in the areas of whether people suffering sever eating disorders are able to received treatment for CBT. I believe this area of eating disorders should be explored and tested further for clarity.
However, one can understand the reasons why research in this area is inadequate, in that a severally anorexia patient will find it difficult to engage in therapy, moreover their cognition may be impaired at this stage and therefore, meant need some form of emergency medical treatment before beginning therapy. Much has changed since the treatment of eating disorders began many years back. It has been extensively evaluated, made more effective and modified so that it is now inline for all forms of eating orders. There has been some progress indeed, but much needs to be done. Through this research three priorities where identified.