70 COGNITIVE THERAPY IN CLINICAL PRACTICE

Outcome

Objective data from the final CBT session are given in Table 5.1, Margaret was still alive and free of cancer at 4-year followup. She had not required any referrals for psychiatric help.

Conclusions

CBT is widely used to treat a variety of emotional disorders. It successfully exposes people’s misinterpretations of reality. But in this case, on first analysis, the reality is bad. The patient is confronted with a diagnosis of cancer and an uncertain future. Her past history of depression in response to stressful life events made her vulnerable to the current illness. However, further examination reveals that this vulnerability was compounded by rigid, unrealistic expectations of herself. A prominent and organising schema seemed to be a belief that in order to be liked she should not manifest any weakness in the face of stress. The Dysfunctional Attitudes Scale (DAS) demonstrated further vulnerability with respect to high scores on issues of control and perfectionism. Having cancer made this woman feel powerless. This rapidly generalised to all aspects of her life. Her most frequent cognitive distortions were selective abstraction, dichotomous thinking, and overgeneralisation.

Through CBT she regained control over those aspects of her life that she could control and took on as much responsibility as possible for her health status. However, though she had initially arrived at the clinic in crisis because she had cancer, the CBT sessions also afforded an opportunity for the patient to re-examine her coping strategies as applied to other situations and to correct her distorted interpretations of her subjective reality. One of the most significant sessions in reducing her hopelessness and alleviating her distress revolved around how she coped with her relationship with her mother. This session had engaged the patient in therapy; she went away from that session knowing that the techniques could be effective and seeing the benefit that changing her perceptions had on her emotional state.

This is a single case study and many aspects of the application of CBT to cancer patients described earlier in the chapter (e.g. lowered self-esteem in the face of mutilating surgery) were not included. However, it does offer some validation of the view that CBT can be a powerful tool in treating the physically ill in general and cancer patients in particular.

References

Alberti, R.E. and Emmons, M.L. (1975) Your Perfect Right: A Guide to Assertive Behaviour, San Luis Obispo, CA: Impact.

American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorders 3rd (R) edition, Washington, DC: American Psychiatric Press.

Beck, AT., Emery, G., and Greenberg, R.L. (1985) Anxiety Disorders and Phobias: A Cognitive Perspective, New York: Basic. Beck, A.T., Rush, A.J., Shaw, B.F., and Emery, G. (1979) Cognitive Therapy of Depression, Chichester: Wiley.

Blackburn, I.M., Bishop, S., Glen, I.M., Whalley, L.J., and Christie, J.E. (1981) ‘The efficacy of cognitive therapy in depression: a treatment trial using cognitive therapy and pharmacotherapy, each alone and in combination’, British Journal of Psychiatry 39:181–9.

Bloom, J.R. (1982) ‘Social support, accommodation to stress and adjustment to breast cancer’, Social Science and Medicine 16:1329–38. Bloom, J.R., Ross, R.D., and Burnell, G.M. (1978) ‘The effect of social support on patient adjustment after breast surgery’, Patient

Counselling and Health Education 1:50–9.

Bradley, L.A. (1985) ‘Effects of cognitive behavioural therapy on pain behaviour of rheumatoid arthritis patients: preliminary outcomes’,

Scandinavian Journal of Behaviour Therapy 14:51–64.

Burns, D. (1980) Feeling Good: The New Mood Therapy, New York: William Morrow.

Dean, C, Chetty, U., and Forrest, A. (1983) ‘Effects of immediate breast reconstruction on psychological morbidity after mastectomy’, Lancet 1:459–62.

Devlin, H.B., Plant, J.A., and Griffin, M. (1971) ‘Aftermath of surgery for anorectal cancer’, British Medical Journal 3:413–18. Gomez, J. (1987) Liaison Psychiatry: Mental Health Problems in the General Hospital, London: Croom Helm.

Gordon, W.A., Freidenbergs, I., Diller, L., et al. (1980) ‘Efficacy of psychological intervention with cancer patients’, Journal of Consulting and Clinical Psychology 48:743–59.

Greer, S. (1985) ‘Cancer: psychiatric aspects’, in K.Granville-Grossman (ed.) Recent Advances in Clinical Psychiatry: Number 5, London: Churchill Livingstone.

Greer, S., Marcus, T., and Pettingale, K.W. (1979) ‘Psychological response to breast cancer: effect on outcome’ , Lancet 2:785–7.

Hibbard, M.R., Gordon, Egelko, and Langer, K. (1987) ‘Issues in the diagnosis and cognitive therapy of depression in brain-damaged individuals’, in A. Freeman and V.Greenwood (eds) Cognitive Therapy: Applications in Psychiatric and Medical Settings, New York: Human Sciences Press Inc.

Holland, J.C., Hughes, A., Silberfarb, P., et al, (1983) ‘Patients with depression in pancreatic and gastric cancer’ (abstract), Proceedings of the American Society of Clinical Oncology 2:127.

Holland, J.C., Rowland, J., Lebovits, A., and Rusalem, R. (1979) ‘Reactions to cancer treatment: assessment of emotional response to adjuvant radiotherapy as a guide to planned intervention’, Psychiatric Clinics of North America 2:347– 57.

CANCER PATIENTS 71

Hughson, A., Cooper, A.F., McCardle, C.F., Russell, A.R., and Smith, D.C. (1980) ‘Psychiatric morbidity in disease-free survivors following radiotherapy and adjuvant chemotherapy for breast cancer: a two year follow-up study’, British Journal of Surgery 67:370.

Larcombe, N.A. and Wilson, P.H. (1984) ‘An evaluation of cognitive therapy for depression in patients with multiple sclerosis’, British Journal of Psychiatry 45: 366–71.

Levine, P.M., Silberfarb, P.M., and Lipowski, Z.J. (1978) ‘Mental disorders in cancer patients’, Cancer 42:1385–91.

McIntosh, J. (1974) ‘Processes of communication, information seeking and control associated with cancer’, Social Science and Medicine 8: 167–87.

Maguire, P., Hopwood, P., Tarrier, N., and Howell, T. (1985) ‘Treatment of depression in cancer patients’, Acta Psychiatrica Scandanavica (Suppl) 320:81– 4.

Massie, M.J. and Holland, J.C. (1984) ‘Psychiatry and oncology’, in L.Grinspoon (ed.) Psychiatry Update: Volume III, Washington, DC: American Psychiatric Press.

Morris, T. (1979) ‘Psychological adjustment to mastectomy’. Cancer Treatments Review 6:41–61.

Pearce.S. and Richardson, P.H. (1987) ‘Chronic pain: treatment’, in S.Lindsay and G.Powell (eds) A Handbook of Clinical Adult Psychology, Aldershot: Gower.

Rush, A.J., Beck, A.T., Kovacs, M., and Hollon, S.D. (1977) ‘Comparative efficacy of cognitive therapy and imipramine in the treatment of depressed outpatients’, Cognitive Therapy and Research 1:17–37.

Schmale, A.H., Morrow, G.R., Davis, A., et al. (1982) ‘Pre-treatment behavioural profiles associated with subsequent psychological adjustment in radiation therapy patients: a prospective study’, International Journal of Psychiatry in Medicine 12:187–95.

Schonfield, J. (1972) ‘Psychological factors related to delayed return to an earlier life-style in successfully treated cancer patients’,

Psychosomatic Medicine 45: 163–9.

Schwarz, S.P. and Blanchard, E.B. (1986) ‘Behavioural treatment of irritable bowel syndrome; a 1 year follow-up study’, Biofeedback Self Regulation 11:189–98.

Scott, J. (1988) ‘Cognitive therapy with depressed inpatients’, in P.Trower and W.Dryden (eds) Developments in Cognitive Psychotherapy, London: Sage Publications. In press.

Silberfarb, P., Maurer, L.H., and Crouthamel, C.S. (1980) ‘Psychological aspects of neoplastic disease: I: Functional status of breast cancer patients during different treatment regimes’, American Journal of Psychiatry 137:450–5.

Sobel, H.J. and Worden, J.W. (1980) Helping Cancer Patients Cope: A Problem Solving Intervention Programme for Health Care Professionals, New York: Guilford Press.

Stern, M.J., Plionis, E., and Kaslow, L. (1984) ‘Group process expectations and outcome with post-myocardial infarction patients’, General Hospital Psychiatry 6:101–8.

Tan, S.Y. and Bruni, J. (1986) ‘Cognitive behaviour therapy with adults with epilepsy: a controlled outcome study’, Epilepsia 27:225–33. Valliant, P.M. and Leith, B. (1986) ‘Impact of relaxation training and cognitive therapy on coronary patients post-surgery’, Psychological

Reports 59:1271–8.

Weisman, A.D. and Worden, J.W. (1977) Coping and Vulnerability in Cancer Patients: A Research Report, Boston, MA: Massachusetts General Hospital.

Williams, J.M.G. (1984) The Psychological Treatment of Depression: A Guide to the Theory and Practice of Cognitive Therapy,

Beckenham: Croom Helm, and New York: Free Press.

Worden, J.W. (1987) ‘Cognitive therapy with cancer patients’, in A.Freeman and V.Greenwood (eds) Cognitive Therapy: Applications in Psychiatric and Medical Settings,

Chapter six

Eating disorders

Shelley Channon and Jane Wardle

Introduction

Anorexia nervosa and bulimia nervosa are closely related disorders characterised by intense concern about body shape and the use of strategies to avoid weight gain. Anorexia nervosa is specifically marked by severe emaciation, and bulimia nervosa is marked by frequent episodes of binge eating (American Psychiatric Association 1980; Russell 1979, 1981). Although current diagnostic systems differentiate the two disorders, the distinction between them is clouded by several features, including (1) the similarities between them, (2) the frequency of binge eating in anorexic patients, (3) the fact that many patients move between the two diagnoses and (4) the difficulty in defining normal weight for an individual (Fairburn and Garner 1986).

The diagnostic difficulties suggest that anorexia nervosa and bulimia nervosa might best be understood as manifestations of the same core disorder of body image, with the symptom profile modified by the level of weight loss and the predominant methods of weight control (Fairburn and Garner 1986). This assumption underlies much of the recent therapeutic work on eating disorders, in that procedures for modifying concerns about body shape, fear of weight gain, restrictive eating patterns, and fear of loss of control over eating are common to both disorders, with techniques for managing binge eating or weight restoration being included where necessary.

The incidence of eating disorders, particularly normal-weight bulimia nervosa, is said to be rising (Crisp et al. 1976; Willi and Grossman 1986), no doubt in part because of the prevailing western cultural preference for a thin appearance in women (Garner et al. 1980). Once established, eating disorders run a serious and chronic course. Toner et al. (1986) followed up fiftyfive anorexic patients treated previously at the Clarke Institute in Toronto. They found that about one-third were asymptomatic and just under one-third were unchanged, with no difference between restrictive and bulimic subgroups. Five patients (two bulimic and three restrictive) had died. Psychometric assessment revealed continuing disturbances in attitudes to eating and weight, and in addition there was a high incidence of anxiety and depression. These results confirm other findings that eating disorders are resistant to change (Hsu 1980; Schwartz and Thompson 1981; Abraham et al. 1983; Swift et al. 1987).

Treatment for anorexia nervosa has undergone several changes over the past few decades. Initially bed-rest, naso-gastric feeding, and a variety of different pharmacotherapies were the main prescriptions, directed principally at weight restoration. With the advent of behavioural treatment programmes (e.g. Bachrach et al. 1965), a regime based on reinforcing weight gain became popular, and more or less formal versions of this remain in use for very underweight patients (Agras 1987). Most weight-gain regimes are fairly successful in the short term but the relapse rate is high, and even if weight is stabilised, many patients continue to show disturbances in their attitudes to eating and weight (Morgan and Russell 1975). This has prompted the development of treatments directed at the specifie cognitive and behavioural disturbances which characterise these patients (Garner and Bemis 1982; Cooper and Fairburn 1984).

Bulimia nervosa has been identified much more recently (Russell 1979) and treatments have been predominantly in the cognitive-behavioural domain (Fairburn 1981; Garner 1986; Wardle 1987a).

There are still relatively few controlled studies evaluating the outcome of cognitive-behavioural treatment, especially for anorexia nervosa. Uncontrolled case series and cross-over designs comparing two treatments constitute the major evidence for the efficacy of these techniques (Fairburn 1981; Smith and Medlik 1983; Cooper and Fairburn 1984; Johnson et al. 1986; Wolchik et al. 1986; Wilson et al. 1986). The few controlled studies that have been reported find that cognitive behaviour therapy is a promising treatment for bulimia nervosa (Lacey 1983; Kirkley et al. 1985; Fairburn et al. 1986).

The outcome for anorexia nervosa is less clear, and undoubtedly more work is needed to identify the critical ingredients of cognitive-behavioural treatment programmes, to improve the therapeutic impact, and to identify the patient characteristics which are associated with a successful outcome (Channon et al. 1989). However, despite their relatively short history, treatment procedures which are broadly cognitive-behaviourally based have proven popular and acceptable to patients and have opened new avenues for these difficult disorders.

EATING DISORDERS 73

Cognitive behaviour therapy for eating disorders has developed from a systematic analysis of the characteristic emotional, cognitive, and behavioural disturbances. The treatment programmes draw widely upon basic techniques for anxiety reduction, self-management of behaviour, and modification of maladaptive cognitions. Compared to cognitive therapy for some disorders, depression for example, the behavioural components of eating disorders are given greater emphasis in treatment. This is because behavioural disturbances (e.g. starving or vomiting) are central features of the disorder which have to be controlled.

The aim of the present chapter is to describe the application of the main elements of a cognitive-behavioural treatment programme. Clinical examples are given to illustrate the practice and the problems of the procedures.

Case history

Carol’s history is very similar to that of many anorexics. She was referred through her general practitioner to a unit specialising in eating disorders. At the time of referral she was a 19-year-old hotel receptionist who had left home a year before to take up her present job. She had done a secretarial course after leaving school at 16 with five ‘O’ levels, and had worked for a market research firm for eighteen months. Until taking up hotel work she had lived at home in a small town sixty miles away with her mother, sister, and stepfather. Her decision to leave home had been partially prompted by her mother’s remarriage, which she had initially found difficult to accept. Since leaving she had maintained regular contact and now felt that she got on well with them all.

She now lived in a staff flat which she shared with three other hotel employees. They all worked shift hours, and days off were often during the week rather than at weekends. Carol liked her fellow workers, but had not got to know them very well as yet. She tended to work overtime hours when extra work was available, in order to save for driving lessons and buying a car. Otherwise she would read or knit, go shopping, visit her family or occasionally go to the pub with the others from the flat.

Her presenting problem was progressive weight loss over the previous fifteen months, with amenorrhoea for the past nine months. Her mother had become worried about her daughter’s deteriorating health, and had finally persuaded her to seek treatment. She had a history of treatment for anorexia nervosa which had resulted in one in-patient admission nearly three years previously. At this time she had presented with low weight and depressed mood, but no bulimic symptoms. She had apparently responded well to treatment, regained her weight, and maintained it until around the time of leaving home. There was no other psychiatric history in the family, although her younger sister did show a tendency to diet.

Carol finally agreed to seek help because she herself had become concerned that she was losing control over her eating. In the previous few months she had started to go on binges where she would eat large amounts of left-over food from the hotel kitchen. This now occurred several times a week, usually in the evenings if she was not working. At other times she restricted her food in an attempt to eat a ‘healthy’ diet, but felt continuously preoccupied with thoughts of food. In the first six months of dieting she had lost a stone (14 pounds) slowly from a premorbid level of nearly 9 stone (126 pounds). Since this time weight loss appeared to have escalated until she reached 6 stone 2 pounds (86 pounds), at which weight she looked emaciated. She also described low mood and physical exhaustion in carrying out her job.

The general issues raised by a case such as Carol’s will be discussed next, before returning to their specifie application to Carol.

Medical assessment

In any out-patient treatment for disorders of eating and weight, the issue of medical involvement should be considered since there are a number of physiological correlates of severe weight loss, obesity, or binge eating and vomiting or purging which may need to be closely monitored (see Table 6.1). The severity of the particular features of the illness will determine the need to collaborate with a sympathetic physician who will assess physical well-being at regular intervals. For a discussion of the physical complications of eating disorders, see Garfinkel and Garner (1982). Carol’s physical condition was assessed by a psychiatrist attached to the Eating Disorders Unit. Despite severe emaciation, she did not appear to have any serious complications which would require immediate hospitalisation. It was therefore decided that she would receive a trial of cognitive-behavioural treatment, and would be examined physically every four weeks.

Historically, attempts to treat anorexia nervosa were initially almost entirely hospital-based and aimed at rapid weight gain through a variety of operant and drug methods. However, follow-up studies found that weight restoration in hospital was not necessarily maintained after discharge (e.g. Morgan and Russell 1975), and Channon and de Silva (1985) showed that improvements in attitudes to eating and weight were only partially maintained at follow-up. The emphasis has therefore shifted towards finding more effective out-patient treatments. From a long-term perspective, out-patient treatment has a number of advantages over hospitalisation. First, patients are often very resistant to the idea of going into hospital, and may be more willing to accept out-patient treatment. Second, out-patient treatment provides the opportunity to learn to deal with factors in the environment which may maintain the presenting difficulties. Hospital can provide a temporary respite, but upon return to the community the same issues are likely to arise again. Finally, in out-patient treatment the responsibility remains