Eating disorders

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may also check their body size and weight. They may be particularly interested in food and cooking, and are usually preoccupied with weight and shape. They are often depressed or low in mood, and commonly are anxious about food and eating (for example, they may worry all day about what and how much they will have to eat at supper). They may also experience interpersonal difficulties. Self-esteem is typically low, with a desire for achieving perfection in all the things they do.

Bulimia nervosa

Bulimia nervosa patients are often ashamed and embarrassed about their eating related behaviour (e.g. purging) and keep it a secret from those around them. They may also attempt to restrict their eating, check aspects of their weight and shape (e.g. weigh themselves frequently), and/or avoid them (e.g. by wearing loose clothing). They may be low in mood (usually less so than in anorexia nervosa), generally anxious and worried, and preoccupied with weight and shape. Self-esteem (as in anorexia nervosa) is low and there may also be interpersonal difficulties. A subgroup engage in self-harm or reckless (so called impulsive) behaviour.

Eating disorder not otherwise specified

Although little researched, most EDNOS patients resemble those with either anorexia nervosa or bulimia nervosa except that one or more of the DSM-IV- TR criteria for the disorder are not fulfilled. Patients with binge eating disorder are often overweight and commonly older than bulimia nervosa patients. Their binges are also more like normal meals in composition (but of similar calorie content to patient binges).

Cognitive models

The importance of cognition in anorexia nervosa and bulimia nervosa is well documented (Cooper 1997). Clinical experience suggests that those with a diagnosis of EDNOS who resemble these patients may also share some of their key cognitions. Relatively little is known about cognitions in binge eating disorder.

There are general and specific cognitive models of eating disorders. Two of the general models are the cognitive transdiagnostic model (Fairburn et al. 2003), which provides the conceptual framework for this chapter, and the schema model of Waller et al. (2004). Specific cognitive models have been developed for anorexia nervosa (Fairburn et al. 1999) and bulimia nervosa (Fairburn et al. 1986; Cooper et al., in press) but not for EDNOS and binge eating disorder.

Experimental evidence supporting cognitive models of eating disorders is growing, though at this stage, with the exception of cognitive treatments for

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bulimia nervosa, there are few well-controlled outcome studies. The cognitive treatment developed by Fairburn and colleagues helps people with bulimia nervosa (Agras et al. 2000), and also appears to help many patients with binge eating disorder (e.g. Wilfley et al. 1993). However, while promising, outcomes indicate that approximately 50% of people may still be left with significant symptoms or an eating disorder diagnosis (Fairburn et al. 1995).

Key cognitions

Five key cognitive constructs form the framework for organizing the behavioural experiments in this chapter:

1Overevaluation of eating, weight, shape, and their control

2Mood intolerance

3Core low self-esteem

4Perfectionism

5Interpersonal problems

All five are identified in Fairburn et al.’s (2003) transdiagnostic model, which provides a framework that encapsulates many of the organizing principles of other models.

While the five constructs of the transdiagnostic model provide a useful organizing framework for the behavioural experiments featured in this chapter, disorder-specific models tend to provide greater detail about the specific nature of the cognitions involved. For example, Cooper et al.’s (in press) model of bulimia nervosa identifies different types of automatic thought (positive thoughts, lack of control thoughts, negative thoughts, and permissive thoughts), different types of underlying assumption, and negative self beliefs that are unconditional and absolute.

The specific cognitions tested in the behavioural experiments outlined here are typical of those identified in disorder-specific models.

Table 13.1 contains examples of cognitions from each of the transdiagnostic categories, as well as types of experiment that may be undertaken. The sample cognitions are drawn primarily from theoretical accounts that contain detailed information on specific cognitions, including the accounts of Garner and Bemis (1982), Fairburn et al. (1986), Wolff and Serpell (1998), Cooper et al. (in press), Waller et al. (2004), and from our clinical work.

As may be seen in Table 13.1, the first category, Overevaluation of eating, weight, shape, and their control has been divided into four subcategories. The second, Mood intolerance, may include use of food and eating to cope with distressing feelings and thoughts. Core low self-esteem frequently includes beliefs

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Target cognitions If I allow myself to eat something I like the taste of, I’ll be unable to stop myself bingeing. I’ll have to make myself sick, which will confirm my belief that I’m a greedy, disgusting person.

Alternative perspective It is possible to eat a little of what you like, enjoy the taste, and find that you are quite satisfied and have no desire for more.

Prediction Sheila regularly had supper with Freda, who always provided a pudding which Sheila always refused. She was sure that:

1If she agreed to have some pudding, Freda would be so surprised and pleased she would push her to have more, which Sheila would be unable to resist.

2Once started she would have to finish the bowl. Then she would have to make herself sick. She and Freda would be disgusted.

Operationalize prediction When Sheila was next invited to supper, she would test the prediction by eating some pudding.

Experiment Sheila arranged to have supper with Freda and asked her to prepare some of her special rhubarb crumble. She agreed to meet with the therapist the following day for debriefing.

Results Although very nervous about trying the pudding, Sheila was able to enjoy the taste and felt a sense of relief that she was acting the same as the others at the table, by eating dessert. Freda did not comment on her eating the pudding and did not offer her more. Sheila enjoyed the meal and was satisfied that she had had enough.

Reflection Sheila was amazed to realise that Freda had been unaware of her struggle and was not interested in evaluating her via her eating habits. She was surprised to find she could stop eating and that she felt satisfied and in control. She commented that this was partly because she felt that she could take the risk in the first place as she was in a safe place with others who were not expecting her to struggle. It would be much more difficult at home with no-one else around. The experiment did highlight her unease at doing something she liked, and this was a further area to work on.

Further experiments Ideas for further experiments included trying the same experiment in different environments (e.g. a restaurant where she had to choose her food off a menu, a self-service buffet, and eating at home).

Tips Issues around losing control and negative evaluation are frequently apparent in both food and non-food situations (e.g. ‘If I have too much fun, I’ll lose control’). It is important to make these links, and for the patient to understand the general principle which may then be applied in similar experiments across the board.

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Experiment 13.2: testing thoughts about eating, weight, and shape as a means to acceptance by others

Problem Cynthia successfully eliminated her bulimic behaviour in therapy, but still believed that other people would not accept her unless she was thin. When she put on weight during her first term, a friend of her father’s commented on her weight gain. When she subsequently lost weight after strict dieting, her friends at university told her she looked ‘lovely’.

Target cognitions I’m not worthy of being liked unless I am thin.

Alternative perspective I am worthy of being liked for who I am, not for how I look.

Prediction Cynthia predicted that if her friends were asked what they liked about her, they would focus on her appearance, and the fact that she was slim and athletic looking. She went rowing three times a week in all weathers to preserve this appearance (belief rating: 80%).

Experiment During the week, Cynthia asked half a dozen of her friends to write down what they saw as her positive qualities (this was easier than asking them to tell her to her face). She was somewhat embarrassed about doing this, but relieved to find that nobody objected or thought the request odd. Several of her closest friends knew that she was in therapy, and understood the importance of the exercise for her.

Results All Cynthia’s friends listed personal qualities, and none of them mentioned her physical attributes. One or two of them mentioned that they thought she was rather hard on herself. Among the qualities listed were that she was fun loving, had a sense of humour, and was caring, loyal, and intelligent.

Reflection Cynthia’s conclusion was that she was worthy, and that her friends accepted her for whom she was (belief rating: 90–100%). She described feeling ‘released’ from focusing on weight and shape. As her finals approached, she stopped rowing, and did not feel any anxiety about doing so. She also mentioned feeling more comfortable about eating with others.

Tips In this case, Cynthia accepted the results of her survey of her friends’ views. Had she discounted the results as the product of politeness or kindness, as some more mistrustful patients do, it would have been important for her to seek more evidence of the genuineness of her friends’ responsiveness to the personal attributes they had identified in her. In conducting a survey like this, it is also important to know something about the friends being surveyed. Some people with eating disorders associate principally with other sufferers, who may share similar attitudes about the importance of thinness. In such cases, a survey of this kind

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could be less helpful, and should be approached carefully, for instance, by considering that weight or shape might be one of the attributes mentioned, and thinking with the patient about whether this could reinforce their existing beliefs.

Experiment 13.3: testing thoughts about eating, weight, and shape as a means to self-acceptance

Problem Wendy was recovering from anorexia nervosa. She was trying to eat a wider range of foods.

Target cognitions If I eat a jacket potato with cheese it means I’m bad—useless, no good, out of control.

Alternative perspective It means I am trying to eat a healthier diet, to look after myself, to get better.

Experiment Wendy undertook a discovery-oriented survey experiment to see if she could gain any evidence to support the alternative perspective. She asked two close friends who knew about her difficulties with eating whether they thought that eating cheese with a potato at lunchtime was ‘healthy’ and might represent progress. She then tried eating cheese with her potato, and used the data collected from the survey and in-session thought challenging to confirm and support her alternative belief.

Results Wendy’s friends both thought eating cheese with the potato was a sign of progress—a view reinforced by challenging her prediction in session with her therapist. Although anxious about eating cheese, she managed to eat a small amount on a prearranged day.

Reflection Wendy was reassured by the experiment. She reflected that paying attention to the data she had collected in and out of session, and the interpretations she was making, had helped to convince her that it was her thinking that was ‘wrong’, rather than eating cheese.

Follow-on experiments Wendy might continue to build up evidence that eating a wider range of foods is healthy, and expand her food choices.

Experiment 13.4: testing positive and negative thoughts about body image

Problem Helen had bulimia nervosa. She was living at home and studying for her final high-school exams. She was in her target weight range for age and height, but felt she was fat, and spent a lot of time in front of the mirror each day looking at her stomach from every angle.

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Target cognitions If my stomach is flatter, I’ll feel better and less depressed. Checking my stomach helps.

Alternative perspective Body image changes in different situations. Checking my body frequently will focus attention on it and leave me feeling more anxious about it.

Prediction If she limited the time she spent checking her stomach, she would become more anxious about her body image and feel worse about herself.

Experiment Over the next week, Helen continued to check her body six times a day, as usual, for three days, and then spent two days without checking. In the latter condition, she limited the time in front of the mirror to what she needed to brush her hair, apply make-up, etc. She monitored her level of concern about her body and her mood each morning, afternoon, and evening.

As Helen was anxious about not checking her body, she built in other activities to do instead of checking (e.g. ringing a friend, going out for a walk, listening to music). She also decided to approach the experiment in steps. Initially, she stopped checking for just part of the day, and then built up to a whole day, and then two days.

Results On days when she checked herself frequently, she was more anxious about her body and her mood was lower. Her general levels of satisfaction about her body depended on what she was doing. For instance, when she was out enjoying herself with her friends, she felt better. When she did not check herself and substituted other activities, her satisfaction with her body was higher.

Reflection Helen was truly surprised at the results, and at how much time was freed up to do other things.

Mood intolerance

Experiment 13.5: testing thoughts about loss of control of feelings

Problem Nicky had fallen into the habit of cutting herself or bingeing whenever she felt ‘emotional’. She had managed to stabilize her eating for the most part, but found that she slipped back into bingeing and vomiting when things ‘felt too much’.

Terry had recently sexually harassed Nicky. She felt unable to do anything about her feelings of violation and anger, and binged and vomited instead.

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Target cognitions If I see Terry, he will sexually harass me, and I will feel powerless to stop him. I will feel like a fool, which will be unbearable, and I will have to binge to feel better.

Alternative perspective If I see Terry, when he starts to sexually harass me, I can tell him to stop, and this will leave me feeling better.

Prediction If I tell Terry to stop harassing me, he will deny it and I’ll look a fool. This will be unbearable, so is to be avoided at all costs (belief rating: 90–100%).

Experiment On the next occasion that Nicky met Terry, she would get up and move away as soon as he started harassing her. She would take the action immediately, with minimum fuss and no discussion.

Results Nicky was surprised to find that when she acted decisively, feelings of anger and frustration were minimal. Terry was completely taken aback and made no attempt to humiliate her. Her feelings afterwards were quite bearable. No further action was necessary.

Reflection Nicky was amazed to discover she could affect her feelings by such a small action. She felt relatively secure in the belief that she had not made a fool of herself (40%) and that Terry was at fault. She noted that even if he had made her feel foolish, she didn’t much care—at least she’d taken decisive action.

Follow-up experiments Nicky decided to try this with other acquaintances who were imposing their views on her. She quickly discovered that with straightforward feedback, they often backed off. No-one attempted to humiliate her, and her own feelings were quite tolerable.

Tips It is a good idea at first, in a situation like this, to choose people who are not so personally important, so that if the experiment does not go quite to plan, it will not feel so personally significant. Patients who think in an ‘all or nothing’ fashion may need reminding that actions can be taken discreetly, to avoid major confrontation. This means minimal feelings are evoked, and they avoid being overwhelmed.

Core low self-esteem

Experiment 13.6: testing core beliefs indicative of negative self-worth

Problem Karen had an 11-year history of bulimia and depression. In addition to bingeing and purging, she abused alcohol and self-harmed by cutting. She had also taken several overdoses. Despite having gained a first-class degree at university, she had an extremely poor opinion of herself.

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was the only way to be happy herself. Unfortunately, this proved to be an impossible task, so she ended up feeling a failure and retreating to her anorexia for solace.

Target cognitions If I don’t focus on making others happy, they will perceive me as a selfish, self-centred person and will have nothing to do with me. I will end up with no relationships at all.

Alternative perspective My friends and family may be relieved that I accept their feelings—positive and negative—at face value, without trying to turn them into something happy. They may appreciate not being controlled by my good intentions, and may even feel more able to approach me.

Prediction Each evening, mum expressed that she was feeling tired and sometimes fed up. Jo would always go into ‘rescue’ mode, telling mum why life was good, offering to do tasks to make her feel better, and trying to convince her that she really did not feel bad at all. She was sure that:

1If she didn’t do this, mum would feel hurt and rejected and be very upset.

2The next evening mum would withdraw from Jo, and would want nothing to do with her. Jo would then feel very upset herself.

Experiment She would go home as usual that evening, and ask her mother about her day. If her mother expressed any distress, she would listen to her, resisting any temptation to ‘make things better’. She would contain any of her own feeling of distress by e-mailing her therapist. She would repeat the experiment each evening as necessary.

Results Jo found the first night with her mother very difficult, as she herself felt very anxious. Her mother, however, did not show any additional stress or upset with Jo. Over the following few evenings, Jo’s anxiety reduced and there were no signs at all from her mother that she felt rejected by Jo.

Reflection Jo found the experiment nerve wracking. However, she had not gone into rescue mode. Surprisingly, her mother seemed less pressurized, and ended up feeling better. Jo noted that it got easier for her to ‘back off ’ as the experiment went on. There was no evidence at all for the belief that mum would reject her.

Further experiments Jo accepted that the next time to try out her new approach would be with a group of friends at the pub. She would try the ‘listening’ rather than the ‘sorting’ approach. This would then be extended to offering her opinions and stating her needs, rather than always waiting for the friends to take responsibility.

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Treatment as a behavioural experiment

If there is a strong illness identity, the whole of treatment can be conceptualized as an overarching behavioural experiment. This can be discussed explicitly and, if appropriate, form a framework for treatment.

Sensitive and realistic beliefs

Some of the beliefs of patients with eating disorders are very personal or sensitive; some may be realistic. Personal, sensitive, and realistic beliefs will need careful and tactful handling, especially as many will involve relationships with family or a partner. Examples include:‘My partner will be critical if I gain weight’, or ‘My illness keeps the family together’. Others may involve a valued career (e.g. in cooking, dance, or fashion). With these kinds of belief the aim is not to challenge or set up a behavioural experiment to test the belief, especially if the predicted negative consequence may well result. Instead, one may need to look at the costs and benefits of change, and the resources that the patient has to make any change, if this seems desirable. Lack of resources to do this (which is not uncommon in these patients) may necessitate specific skills training.

Medical issues

Eating disorders may be associated with significant medical problems, so it is advisable to seek a medical opinion before embarking on cognitive therapy with a patient.

Other related chapters

As noted in the chapter, people with eating disorders often have underlying low self-esteem and interpersonal problems. So, Chapters 19 and 20 are highly relevant. Social anxiety, depression, worry, and avoidance of affect are also frequently accompaniments of eating disorders. So, Chapters 7, 10, and 17, that address these issues, may also be useful.

Further reading

Cooper, M.J., Todd, G., and Wells, A. (2000). Bulimia nervosa: a client’s guide to cognitive therapy. Jessica Kingsley, London.

Fairburn, C.G. (1995). Overcoming binge eating. Guilford Press, New York.

Fairburn, C.G., Marcus, M.D., and Wilson, G.T. (1993). Cognitive behaviour therapy for binge eating and bulimia nervosa: a comprehensive treatment manual.

In: C.G. Fairburn and G.T. Wilson (ed.), Binge eating: nature, assessment and treatment.

Guilford Press, New York, pp. 361–404.

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Freeman, C. (2000). Overcoming anorexia nervosa. Robinson, London.

Garner, D.M., Vitousek, K.M., and Pike, K.M. (1997). Cognitive-behavioural therapy for anorexia nervosa. In: D.M. Garner and P.E. Garfinkel (ed.), Handbook of treatment for eating disorders (2nd edn). Guilford Press, New York, pp. 94–144.

Tales from the Front Line

The cool on the hill

After careful preparatory work by his therapist, Tony, who had PTSD as a consequence of a severe car accident, was revisiting the accident site. In line with recent cognitive theories, the purpose of the behavioural experiment was to revisit the site of the trauma, in order to update the trauma memory by drawing distinctions between what happened then, and what the reality is now.

The initial accident had happened on a dark winter evening at the bottom of a hill, when an accelerating white van had crashed into the back of Tony’s red Renault. The last thing Tony had seen were the headlights of another car coming through the back of his car, which ended up wrapped around the metal barrier dividing the two lanes.

The therapist and Tony took up their position at the bottom of the hill. First, the therapist asked Tony to close his eyes and visualize the accident. Then Tony was to open his eyes and see that his car was no longer on the barrier; that the barrier had been repaired; and that he was alive and in one piece.

Moments later, there was the sound of an accident. On the opposite lane, a white van had smashed into a red Renault. On the face of it, this might have been a disastrous confirmation of a belief that accidents like this happen regularly. Not missing a beat, the therapist took Tony over to see the accident (both drivers were unhurt) and carried on with the then versus now disconfirmation:

“What’s different between today and what happened to you?”

“Is your car still wrapped around the metal on the central reservation?” “Has the metal been replaced?”

“Are you now in one piece? What was the situation then?”

“Are you now just watching an accident, rather than being involved in one?” “What’s the difference between the accident that’s just happened, and the

one you were involved in? What does that tell you?”

When therapists are very clear about the purpose of behavioural experiments, even seemingly disastrous events can be turned to advantage.

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