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Cognitive behavioral therapy (CBT) is one of the recommended therapeutic approaches for anorexia nervosa (AN). CBT for AN often needs to be designed for individual cases,1 and previously we have developed a behavioral therapy program combined with liquid nutrition for AN: Kyoto Prefectural University of Medicine Behavior Therapy (KPT).2 Here, we describe a newly designed video-assisted CBT for a patient with AN refractory to KPT.

The patient was a 16-year-old girl who had been diagnosed with restricting-type AN at age 14, based on DSM-IV criteria, and was refractory to KPT. To acquire credits for graduation, she attended school during the day and returned to hospital at night. The patient repeatedly stated that she could not communicate with her classmates easily because she was too fat. Psychological interventions were started to address this belief, in addition to KPT. However, she continued to maintain her belief. We focused on her maladaptive eating behavior related to AN, rather than on her distorted cognition. At meals, she took too much time to eat and tended to mash her food into paste using chopsticks and a spoon. The therapist suggested to her that this abnormal eating behavior might be strange to those around her, and that it tended to complicate her communication with others. The patient resisted the verbal advice regarding her maladaptive eating behavior.

We then tried a video-assisted visual tool to bring awareness of her abnormal eating behavior. We proposed following a structured CBT and the patient accepted this treatment. Once a week, we filmed her eating dinner at hospital, and on another day the patient and her therapist watched the video together and talked about her approach to eating. In the first three sessions, the patient responded, ‘My way of eating is normal.’ However, at the fourth session, she laughed at a scene in which she spilled mashed food onto herself from her mouth, and said to the therapist that she always crushed sandwiches into small parts. She then asked, ‘Do my friends find me strange in any way?’ and the therapist replied, ‘I think so’. In that session, the patient agreed to the challenge to eat food in normally sized pieces and to spend less time at meals. By the seventh session, she commented, ‘My way of eating might have caused a curious impression and alienated my classmates from me; since I have now changed my eating habits, I can start to talk to my classmates in a more friendly way.’ The patient gradually developed a more normal eating manner and her bodyweight increased. After 10 sessions over 6 months she had completed her inpatient treatment.

In the present case we kept records of abnormal eating behavior using a video-assisted visual tool. Being asked to watch a scene of herself eating a meal contributed to objective reorganization of the abnormality of the patient’s eating behavior and acceptance of her illness. Because patients with AN often show cognitive impairment and disturbed self-awareness in association with low bodyweight, a video-assisted approach might be more effective than the use of verbal psychotherapy only.

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