EATING DISORDERS 79

Rationale for treatment

In persuading patients to accept treatment, a clear rationale should be provided which gives an account of the development of the disorder, and a logical basis for intervention which naturally follows on from this. A detailed descriptive model of the development of anorexia nervosa may be obtained from Garner and Bemis (1982) or Slade (1982).

These describe how an external stressor such as examinations or an internal stressor such as puberty interact with a vulnerable personality type. Dieting is perceived as a solution to these difficulties, and weight loss is initially reinforced both externally by other people and the cultural value system, and internally by a sense of achievement. Social withdrawal becomes increasingly prominent in order to avoid situations involving eating, and this increases the opportunity for preoccupation with eating and body size to develop. An experimental study of the effects of starvation on normal volunteers conducted during the Second World War by Keys et al. (1950) provides evidence of numerous effects of food deprivation such as preoccupation and concern with eating which closely resemble many of the characteristics of anorexic patients. Garner and Bemis (1982) describe how dieting continues to be reinforced by both successful weight loss and fear of weight gain. They emphasise that losing weight rather than being thin becomes the critical factor, maintained by the development of a value system which views thinness as of fundamental importance.

Developmental models of bulimia again place great emphasis on the cultural value system which holds thinness to be a desirable goal. Several authors have suggested that binge eating is caused by food restriction (e.g. Polivy and Herman 1984; Wardle and Beinart 1981; Wardle 1987a). This link is based on parallels between the counter-regulation displayed by dieters who receive a preload of food, and eating binges in patients who attempt to restrict their food severely at other times. Symptoms such as cravings, eating binges, and fears of losing control may then be viewed as a response to the breakdown of strict cognitive control. The eating binges experienced by many of the volunteers in the Keys et al. (1950) semistarvation study provide further evidence for this viewpoint.

In the following excerpt, the relationship between dieting and binge eating has been described to Carol, and the therapist is helping her to understand its relevance in her particular case.

T: How do you feel after a day where you haven’t eaten anything except yoghurt and cottage cheese? P: I feel really good.

T: I expect it seems that you have achieved something—is that right? P: Yes, definitely.

T: What happens if you are near to some of your favourite fattening foods?

P: I don’t feel tempted, unless something’s gone wrong or I’m bored or something. T: And then?

P: Then I just seem to lose control—I can’t stop myself from eating it, and once I start, I think I might as well carry on… T: So once you’ve broken the rules, you think it’s too late and you might as well give up?

P: I suppose that’s what happens.

T: Can you see how that might be connected with what we were saying about dieting leading to cravings for food? P: You mean I get cravings because I’m trying not to eat any of the things I really like?

T: That’s right—the more you tell yourself they’re not allowed, the more you start to think about them and want to eat them. P: But that makes it impossible—I can’t just stop worrying and thinking about it.

T: That’s why it’s important for us to work together on the dieting, not just the binge eating.

Providing information and education

A crucial component of cognitive-behavioural approaches is the emphasis on providing information and education about a number of areas related to current concerns. Topics might usefully include nutrition, weight regulation, and the input-output factors affecting energy balance; cues for hunger and satiety; the type and amount of food eaten by normal eaters, and reasons for eating including social and emotional ones; set-point theory of weight, and experimental studies of starvation and counterregulation; the link between dieting and bingeing; and cultural values and pressures to achieve a lower-than-average weight, combined with data suggesting a steady increase in actual population weights.

An excellent summary of this type of information is provided in a chapter by Garner et al. (1985), and it provides ideal material for handing out to patients to read outside the sessions. Provision of reading material may range from academic literature on issues such as the effects of starvation and restrained eating (e.g. Wardle 1987a) through to the personal accounts of illness which have begun to appear in the literature (e.g. MacLeod 1981; Roche 1984), and which may serve to help people realise that they are not alone in their misery. The choice of reading material will depend partly on the patient’s level of education and intellectual ability. Setting homework tasks to find out about other people’s behaviour may also be useful in getting patients to question their assumptions, such as ‘normal people only eat when they’re hungry’, or ‘normal people only maintain a normal weight by eating “healthy” foods’.

80 COGNITIVE THERAPY IN CLINICAL PRACTICE

In order to explore the postulated link between food restriction and binge eating further in Carol’s case, it was agreed during the session that she would do several things. First, she would pay particular attention to the craving ratings in her food diary, to see whether these were related to hunger and to the types of food she was eating. Second, she decided to ask one of her flatmates about whether she attempted to restrict her intake of fattening foods, and how she felt in terms of anxiety, craving, and urge to binge if she did eat anything fattening. Third, she took a copy of the Garner et al. (1985) chapter home to read.

Weight restoration

If patients are severely emaciated, the most urgent aim of treatment is to restore weight to a safer level. The focus of weight restoration should be on the need to return to a normal, healthy weight, and setting a target range within which weight will be maintained is more realistic than aiming for an exact poundage. One criterion for determining a healthy weight is that it is sufficient to permit the return of menses; for a further discussion of this issue, see Treasure (1987). Ovarian ultrasound monitoring has been employed recently to investigate endocrine functioning in anorexic patients, and this is likely to prove a useful index (Treasure et al. 1987). This can usually be identified from the menstrual history. However, in patients who developed an eating disorder whilst they were still growing, there is likely to be a certain amount of trial and error involved in finding the optimal weight for return of menses.

The immediate task of weight restoration is to set short-term, achievable goals of weight gain, and to specify how these might be achieved. A weight increase of one to two pounds a week is probably an acceptable out-patient target. If patients are reluctant to make exact plans as to how they will achieve weight gain, it may be helpful to use a graduated approach whereby they initially attempt to put on weight in an unstructured way, and are given feedback from regular monitoring at treatment sessions. If no gain occurs in the initial weeks of this approach, the therapist may then take increasing control by agreeing a specific eating plan with the patient, and stressing once more the dangers of continued starvation and the rationale for weight gain.

T:I know that you’re going to find it frightening to put on any weight. But as we discussed, what we’re aiming to do is to put it on gradually and to set an upper limit as well as a lower one for when you get to a normal weight.

P: I don’t think I could bear to be more than eight stone.

T: I think that’s something we can worry about when we get to it—you’re a long way off eight stone now, aren’t you. P: I know—but I couldn’t stand going back to being fat again.

T:I can understand that. But right now I’m much more worried about you losing any more weight, because you’re not feeling very strong or healthy now, are you?

P: I’m worried about that too. But I don’t want to come into hospital.

T: I’m going to try and help you to avoid coming into hospital—but you’re the one who’s going to have to do the hard work. P: I’ll try. I suppose I’ve got to put on some weight.

T: Do you think we should agree on how much you’re going to try to put on? P: Yes, OK.

T: What do you think would be a reasonable aim? P: I don’t really know.

T: Well, how about if we aimed for one to two pounds a week? P: It sounds a lot. But I suppose I’d better try.

T: I think we’d better agree about what to do if you should lose any more weight, as well. P: Will I have to come into hospital then?

T:First of all you’d have to see the doctor, to see how it affected you, and she might decide you had to come into hospital. I think you should probably see her straight away if you lost even another pound.

With bulimic patients it may also be necessary to encourage some weight gain if past history suggests that the patient’s natural weight was on the heavy side. This is a controversial issue, but Garner (1985) found that bulimic patients tend to have high premorbid weights, and suggested that a weight which is ‘normal’ by average standards could be too low for an individual patient.

Discussion of social and cultural attitudes to weight may enable the patient to adopt a more positive acceptance of her own body shape, and this kind of ‘consciousness raising’ can be an important background to treatment. Numerous popular books can be recommended which discuss this issue (e.g. Hutchinson 1985).

EATING DISORDERS 81

Eating behaviour

The first step in planning to help a patient to gain weight is to examine in detail the current eating pattern, on the basis of all the information collected from the interviews, food diaries, and so on. The aim now is to see what problems are likely to arise in modifying these eating patterns to reduce restraint and develop a normal meal pattern.

The basic principle of inducing weight gain is simply to start with the current food intake, and increase it sufficiently to produce an energy imbalance. An energy surplus of approximately 3,500 calories is needed to gain 1 pound. Thus a plan might be worked out with the patient as to how she might include an extra 500 to 1,000 calories a day on top of whatever she is already eating to produce a gain of 1 to 2 pounds per week. Weight restoration should focus on a gradual increase in both the amounts of food eaten and the types of food, to include a full range, particularly of fats and carbohydrates which are likely to be avoided.

It is helpful to examine particular difficulties with foods and eating situations by identifying these for the individual patient and working through them. During restricting times, patients usually have great difficulty in including reasonable amounts of sweet, high fat, or carbohydrate foods in their planned eating. It is usually these same avoided foods which trigger binges during times of breaking away from cognitive constraints. The factors implicated in triggering binge eating are likely to be composed of behavioural, emotional, and cognitive components. On the basis of the records obtained during the first two weeks, graded hierarchies of difficult foods and situations were constructed with Carol during the third session. She was asked to generate a list of foods which ranged from mildly to extremely difficult, and these were rated out of 100 per cent. ‘Difficult foods’ was defined as foods which she tried to avoid eating, but could relate to the tendency to binge once she started to eat them. The range of situations included both social pressures and emotional

Table 6.3 Examples of graded hierarchies

states where eating became a particular problem for her. Ten representative items were chosen from each list, and these can be seen in Table 6.3.

These items were used as part of a graded exposure programme; Carol practised eating the items during the sessions, either in her imagination or in vivo, until she felt comfortable with each and ready to move to a higher item. Modelling of comfortable eating was provided by the therapist where appropriate. There was a broad aim of progressing at the rate of one item from each list each week of treatment.

Techniques such as relaxation and distraction may be used in conjunction with exposure to aid patients where appropriate. Techniques for dealing with cognitions about restriction and binge eating will be dealt with in a later section.

Binge eating

There are two important principles involved in dealing with binge eating. The first is to decrease the pattern of dietary restraint, as described above, and the cognitions which mediate this (to be described below). The second employs the technique of exposure and response prevention, namely exposure to the factors which serve as cues to binge, and prevention of binge eating in response to these.

Practice sessions of exposure and response prevention should take place both in and out of the treatment sessions, to maximise effectiveness. A typical practice session might involve asking the patient to bring a reasonable quantity of feared food along with her. She would be asked to rate her degree of anxiety, craving, and urge to binge before, during, and after eating some of this food, and to list her thoughts during this procedure. After a portion of the food had been consumed, she would be asked to stop eating for a short period, perhaps ten minutes, whilst the food remained within sight and easy reach. She would then be asked to taste the food again, to see whether she still wanted to eat some more of it. She would be instructed to carry on and

82 COGNITIVE THERAPY IN CLINICAL PRACTICE

eat another portion if she did still want more, but still to leave some uneaten. This procedure would be repeated until any desire to binge or eat more was minimal. This seldom requires more than two or three tasting sessions. The interval between stopping eating and tasting again can be gradually extended to increase control.

This experimentation should be generalised to the home situation as soon as patients feel able to carry this out. Practice should be at least daily, building up to the more difficult items. Patients are also encouraged to keep a supply of feared foods around the home, to maximise their understanding that they can learn to control eating binges. Later in this process, attention can be directed towards sensations of hunger and satiety, to help patients develop appropriate perceptions of these.

Vomiting and laxative abuse

In patients who vomit to compensate for overeating, the desire to do so is likely to decrease once binge eating becomes less of a problem. If this does not prove to be the case, or if vomiting occurs independently of bingeing, then direct steps need to be taken. The most useful strategy involves delaying the interval between eating and vomiting, perhaps by only ten minutes in the first instance, and employing relaxation or distraction strategies. The length of the delay can then be increased until the time of vomiting is so far removed from food intake that the food is mostly digested, and vomiting becomes ineffective.

It is important to focus also on the natural satiety process which will be destroyed if artificial stomach emptying takes place by means of vomiting. It should be explained to the patient that if she induces vomiting, she is likely to feel hungry again in the near future, and this will feed into her fears of loss of control and desires to eat voraciously (Wardle 1987b). She can thus be helped to experience the more gradual reduction in sensations of stomach fullness which come about through the digestion process, since sensations of fullness appear to be a specific trigger for anxiety.

Laxative abuse is dealt with in a similar fashion to vomiting, by encouraging gradual decreases in the amount taken and increasing the delay between eating and ingesting it, and by emphasising the pointlessness of tampering with natural satiety mechanisms. The relative inefficacy of laxatives as a means of reducing energy intake can be mentioned (Bo-Linn et al. 1983). Finally, the hazards to physical health which might ensue as a result of each of these methods should also be stressed.

Identifying dysfunctional thoughts

At an early stage in the treatment, work may begin on eliciting cognitions which may represent central themes or schemata underlying the patient’s

Table 6.4 Examples of dysfunctional thoughts in anorexic and bulimic patients

belief system. The first stage of identifying such cognitions involves heightening people’s awareness of the thoughts which pass through their minds relating to sensitive areas of concern. These can then be further examined to see whether they appear to play a crucial role in maintaining the disorder (Beck 1976).

Garner and Bemis (1982) drew up a list of systematic distortions typifying patients with eating disorders, based on Beck’s (1976) classification of types of thinking errors. These included errors of ‘overgeneralisation’, or extracting a rule on the basis of one example and applying it to all situations; ‘magnification’, or overestimating the significance of undesirable events; and ‘dichotomous’ reasoning, or thinking in extreme or absolute terms. Examples of the types of dysfunctional thoughts commonly encountered with anorexic or bulimic patients are given in Table 6.4.

Cognitive-behavioural approaches typically ask patients to keep records of their dysfunctional thoughts, and these are used as a basis for monitoring and challenging the thoughts. Examination of these thoughts is an integral part of treatment, both as an intervention strategy in its own right and as a major aspect of any behavioural task. Patients should be given a clear explanation of the need to identify habitual dysfunctional thoughts and the triggers associated with them, which might be situational, such as mealtimes or trying on clothes, or emotional, such as mood changes. They may then be asked to keep records of every time they start thinking about food and body size. Concurrent recording at the time of getting the thought is obviously preferable, but is not always practicable. If this presents difficulties, sampling procedure can be used, where