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Cognitive-behavioral therapy for anorexia nervosa
Many of the earlier clinical trials investigating CBT for AN were based on guidelines provided by
Garner et al. (1997). The essence of CBT for AN is the focus on changing weight-related behaviors
and beliefs about food and weight through challenging cognitive distortions (F.A. Carter et al. 2011;
J.C. Carter et al. 2009; Dalle Grave et al. 2013a; Garner et al. 1997; McIntosh et al. 2005; Pike et al.
2003). This includes challenging rationalizations that reinforce restrictive eating, either positively
(e.g., that restriction and weight loss behaviors are “healthy” or indicate control or mastery of one’s
behavior) or negatively (e.g., that eating a single serving of caloric foods will lead to catastrophic
weight gain or loss of control of eating). For the latter, reinforcement can include reductions in fears
of weight gain, but it may also include more complex meanings, such as, for example, avoidance of
psychosexual development and intimate interpersonal relationships. Treatment initially empha-
sizes building the therapeutic alliance and enhancing motivation for treatment, in part, through the
establishment of this personalized formulation and the recognition by the therapist of the ways in
which weight loss behaviors are reinforced. CBT includes a direct focus on eating disorder symp-
toms and an examination of core beliefs (i.e., schemas) and themes, such as self-control and perfec-
tionism. Typically, during the session, the clinician and the patient check the patient’s weight
together, and the patient’s self-monitoring records and homework from the prior session are re-
viewed. There is an initial focus on establishing a pattern of regular eating and then increasing the
size and variety of meals and snacks. Strategies to reduce purging behaviors are also addressed, if
relevant. An experimental model of change is incorporated throughout treatment to test out new
behaviors as a way to acquire new information to challenge beliefs around the value of weight loss.
The therapeutic relationship can also serve as a model of how the individual interacts with others,
which then permits dysfunctional core beliefs to be identified and cognitive distortions challenged,
with the goal of decreasing social avoidance and increasing interpersonal intimacy. Psychoeduca-
tion is embedded throughout treatment with a focus on the negative consequences of starvation on
physical health as well as psychosocial effects, such as increasing rigidity and social avoidance.