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This article is an adaptation of a talk Dr. Mollick gave for a joint meeting of the Morris County Psychological Association and the Essex-Union County Association of Psychologists.
The article is based primarily on Christopher Fairburn’s transdiagnostic theory of eating disorders.
CBT for Eating Disorders
By Lynn Mollick
The core problem in all eating disorders is overconcern with shape and weight. When we correct patients’ overconcern with shape and weight, we’ve cured their eating disorder.
The specific ways that overconcern with shape and weight manifests itself varies from patient to patient. Some patients limit themselves to very few calories a day and become extremely thin; others repeatedly try to diet but remain normal weight or overweight. Some patients purge several times a day while others binge but never purge. Whether a patient’s DSM diagnosis is anorexia, bulimia, binge eating disorder, or eating disorder NOS, overconcern about shape and weight is their core problem.
Overconcern about shape and weight cannot be changed directly. CBT addresses the various behaviors, thoughts, and feelings that are components of the core overconcern with shape and weight. CBT also addresses general personality characteristics that maintain EDs. The four most important components of EDs are:
1. Strict dieting,
2. Low weight,
3. Bingeing, and
4. Compensatory behaviors.
These four components create an interacting system of behaviors, emotions, beliefs, personality traits, and physiological processes. This system is responsible for the most important symptoms of EDs.
How the four components of EDs interact
Strict dieting includes skipping meals, fasting, eating small amounts of food, and avoiding “bad” or forbidden foods. Strict dieting has two potential consequences: low weight and bingeing.
Low weight causes numerous physical and psychological problems that are sometimes severe or life threatening. Strict dieting always makes patients very hungry, and hunger eventually causes them to binge.
Bingeing elicits the core overconcern with shape and weight.
Compensatory behaviors are attempts to undo the effects of bingeing. Compensatory behaviors include vomiting (purging), laxative and diuretic abuse, and excessive exercise. But compensatory behaviors actually maintain bingeing because ED patients believe they can binge and later undo the effects of the binge with purging, exercise, laxatives, and diuretics. Bingeing also leads to continued dieting, and dieting causes hunger, low weight, further bingeing, and more dieting.
This is the system that ensnares the ED patient. Each component of the system is a cause of, and is caused by the other three components. In order to disrupt this pathological system, treatment should focus on six main goals.
Goal #1: Begin by replacing strict dieting with normal eating.
Goal #2: Overcome resistance to normal eating.
Goal #3: Control bingeing and purging.
Goal #4: Change negative body image
Goal #5: Develop new sources of self-esteem.
Goal #6: Address the eating disorder mindset.
Goal #1: Begin by Replacing Strict Dieting With Normal Eating.
Patients should follow six guidelines:
1. Eat 3 meals plus 2 snacks every day. (Anorexic patients should eat three meals plus three snacks.) The meals may be very small, but patients should eat at no other times. The goal is to establish a regular eating pattern. Once a pattern of 3 meals + 2 or 3 snacks is established, gradually increase the amounts eaten.
2. Patients should decide what to eat. As long as what’s chosen resembles a real meal or snack, any reasonable choice is a good choice. (A diet soda is not a snack.)
3. Each day, patients should make a detailed plan of what, when, and where they will eat. Without a precise plan, it’s easy for patients to “forget” to follow the 3 meal + 2 or 3 snack guideline, or be unable to decide what to eat, or not have appropriate food on hand.
4. Immediately after they eat, patients should record when and what they have eaten. If patients do not keep good food records, they will forget and/or distort what they have eaten by the time of their therapy appointment.
Patients should never record the number of calories or the precise amounts they eat. This is not “normal” eating. They should record “a glass of juice,” not “6 oz. of juice.”
5. Patients should weigh themselves only once a week. It doesn’t matter who does the weekly weighing, but it should always occur at the same time and place. Weekly weighing enables both the therapist and the patient to track progress. Anorexics must gain weight. Other ED patients must learn that normal eating does not cause weight gain. This is a crucial concept that patients only accept after they change their eating behavior and see that they do not gain weight.
6. Introduce forbidden foods, but only after patients are comfortable following the 3 meals + 2 or 3 snacks plan. Avoiding “forbidden foods” reinforces overconcern with shape and weight, and contributes to craving and bingeing. Introducing forbidden food into the ED patient’s diet counteracts strict dieting and the fear of becoming fat. When introducing forbidden foods:
a) Let patients choose what forbidden food to eat, but instruct them to eat only small amounts.
b) Plan when and where to eat the food, making certain that the situation is not stressful. If the situation is stressful, patients are likely to binge.
c) Make it clear that the forbidden food will not be a part of the patient’s regular diet.
Goal #2: Overcome Resistance to Normal Eating.
ED patients will resist giving up strict dieting. Here are four techniques that help patients accept the goal of learning to eat normally:
1. Describe the 3 meals plus 2 or 3 snacks plan as a way to gain control of eating. At the beginning of treatment, ED patients readily acknowledge that they have lost control of their eating and their lives.
2. Educate patients about the relationship among bingeing, purging, and calorie restriction. (Illustrated in chart above.) This provides a rationale for CB treatment. Explaining the deleterious health effects of calorie restriction, extreme weight loss, vomiting, and diuretic/laxative abuse provides further motivation for change.
3. Make changes slowly and encourage an empirical approach to change. Ask ED patients to do behavioral experiments. Suggest they try the 3 meals + 2 or 3 snacks plan for one week to see if they gain any weight. When they don’t, suggest continuing the experiment for a second week.
4. Use motivational interviewing techniques. Compliance is always intermittent and motivation must be continually renewed. Rather than instructing patients to change, empathize with their fears. Ask them to discuss the pros and cons of continuing their current eating habits versus trying something new.
Goal #3: Control Bingeing and Purging.
Once relatively normal eating resumes, bingeing ends or diminishes greatly. When bingeing ends, the need for compensatory behaviors also ends. Residual bingeing or purging rarely occurs more than twice a week.
Residual bingeing and purging are controlled by negative moods or interpersonal difficulties, not hunger. Initially, ED patients are not aware of these mood and interpersonal precipitants. Patients come to understand the variables that control their residual binges and purges by repeatedly doing a thorough assessment of the specific events, cognitions, and emotions that precede and follow residual binges or purges. Have patients keep records and follow up with detailed questions at their sessions:
1. To learn about controlling antecedents, ask about the setting in which the binge or purge occurred, the events that precipitated the decision to binge or purge, the actions that the patient took between the decision and the binge or purge, and the thoughts and feelings the patient experienced at each point in the chain of events preceding the binge or purge.
2. To learn about the consequences and reinforcement of the binge or purge, ask about what the patient did afterwards. How did the patient feel as a result? What did the binge or purge accomplish? Once you have a narrative of the events leading up to and following a binge or purge, use traditional CB techniques to find more adaptive ways to cope with negative moods and interpersonal difficulties. For negative moods suggest:
a) Activities that alter the mood without doing harm -- listening to music, talking to friends, taking a warm bath or a cold shower.
b) Learning to accept negative moods with mindfulness skills or by saying “this bad mood will pass” or “I can tolerate this.”
c) General psychotherapy. Communication training, family therapy, or couple therapy may improve interpersonal difficulties. Interpersonal Therapy (Klerman, et al., Interpersonal Psychotherapy of Depression, 1984) has received empirical support for the treatment of eating disorders.
Goal #4: Change Negative Body Image.
Negative body image has many cognitive and behavioral manifestations: “feeling fat”; comparing oneself to others; compulsive checking of weight or shape (e.g. mirror checking); and avoidance of information about weight and shape (e.g. mirror avoidance). Many of these are subtle and easy to overlook, but each reinforces overconcern with weight and shape, and each should be a target of therapeutic intervention.
1. Teach patients that “feeling fat” is not a feeling. “Feeling fat” is a belief or self-criticism. Ask patients when they experience this “feeling” intensely and have them observe the “feeling” during the week. Get lots of details about each individual experience: What were patients doing, thinking, and feeling when they “felt fat”? What was going on in the environment? Who was present? What led up to the “feeling“?
Patients are seldom aware of the psychology that creates “feeling fat.” Repeated inquiry is usually required before patients recognize that “feeling fat” typically occurs in one of two situations:
a) When patients suppress emotions such as feeling embarrassed or discouraged;
b) When patients misinterpret ordinary physical sensations: when they’re squeezing into clothes that are too small, or when they sit down and notice the rounding of their bellies.
As patients experience rather than suppress their emotions, they can recognize “feeling fat” as an emotion or a physical sensation. Correctly recognizing emotions and physical sensations enables ED patients to respond in more appropriate ways than dieting, bingeing, or purging.
2. Stop compulsive checking whenever it occurs. ED patients frequently check their shape and weight. They compulsively weigh themselves, glance sideways in mirrors to make sure their stomachs are flat, or surreptitiously pinch themselves to make sure they haven’t suddenly become fat. They also obsessively compute the number of calories they’ve consumed each day, and compare themselves to celebrities and/or every person they meet.
Checking reinforces overconcern with shape and weight, and maintains continued dieting, bingeing, and purging. Response prevention strategies disrupt checking compulsions and can weaken this overconcern with shape and weight. Here are some response prevention techniques:
a) Ask patients to give their scale to a trusted friend or family member. They should be getting weighed once a week at the same time and place (such as their therapist’s office), so they have no need for a scale.
b) Instruct patients to use mirrors appropriately – only to fix their hair or put on make-up before going out.
c) Ask patients to record each instance of compulsive checking. Self-monitoring reduces dysfunctional behaviors, including compulsive checking.
3. Overcome shape avoidance. Some patients avoid mirrors; others undress in the dark, wear baggy clothes, or avoid social situations where their bodies might be on display (e.g. the beach). Being able to look at and touch their bodies, letting others do the same, and making an objective appraisal of their appearance are important components of treatment success. Exposure -- normal observation of their bodies -- is the first step. Cognitive and acceptance interventions are additional techniques for weakening overconcern with shape and weight.
Goal #5: Develop New Sources of Self-Esteem.
ED patients evaluate themselves exclusively by their shape and weight. Ultimately, this is a futile enterprise. Low weight is difficult to maintain and a perfect shape is impossible for all but a few. Helping patients exercise moderately, eat a healthy diet, and accept their shape and weight alleviates low self-esteem and the unsatisfying focus on shape and weight.
Treatment should also help patients answer this question: “If I can’t change my basic shape, what can I change that will make me happier?” Becoming involved with new interests, learning new skills, and developing better relationships compete with and reduce overconcern with shape and weight.
Goal #6: Address the Eating Disorder Mindset.
ED cognitions, behaviors, and emotions are components of a pathological, self-reinforcing system. But healthy cognitions, behaviors, and emotions about shape and weight create an opposing system. As treatment progresses, patients’ healthy cognitions, behaviors, and emotions about shape and weight become stronger, but patients remain vulnerable to relapse into the ED mindset for a long time.
Teach patients to identify triggers for the ED mindset – negative events related to shape and weight (e.g. gaining weight, violating healthy eating rules), negative moods, or other upsetting events in their lives. Prepare patients to act immediately when these triggers occur. Remembering skills they learned in treatment and distracting themselves from ED thoughts prevent relapse into the ED cognitions, behaviors, and emotions that comprise the ED mindset.
Further reading: Christopher Fairburn’s Cognitive Behavior Therapy and Eating Disorders, 2008, Guilford Press.
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