5.1 Introduction
In this module, you will learn how CBT-based interventions can be used to help clients with eating disorders overcome their difficulties. You will learn what eating disorders are and how people suffering from these conditions tend to think, feel and behave. The module will then address the ways in which CBT can reduce eating disorder symptoms. You will discover why CBT-E, a treatment programme designed specifically for people with eating disorders, can improve outcomes in this client group.
Fact
Approximately 1.25 million people in the UK have an eating disorder.
Source: www.beatingeatingdisorders.org.uk
5.2 What Are Eating Disorders?
Someone with an eating disorder experiences significant and ongoing distress that has its roots in an unhealthy attitude towards food, body shape and appearance. Someone with an eating disorder will exhibit both psychological and physical symptoms. Eating disorders are associated primarily with young women in the popular imagination and females between 13 and 17 years of age make up the majority of sufferers. Approximately 11% of those with eating disorders are male.
However, eating disorders can affect individuals of both sexes and across all age groups. If a patient does not receive timely intervention in their teens, their symptoms may continue well into adulthood. An eating disorder may begin as an apparently innocent diet, but it goes far beyond a desire to lose weight. Eating disorders are a constellation of symptoms that reflect an individual's image of themselves as a person, not simply as a body.
Activity: What Do You Know About Eating Disorders?
Estimated time: 5-10 minutes
Eating disorders are high-profile mental illnesses that often attract a lot of media attention.
What ideas about eating disorders do magazines, TV shows and films tend to promote?
5.3 The Different Types of Eating Disorders
The most common eating disorders are as follows:
Anorexia nervosa
This is perhaps the best-known of
all the eating disorders. Someone with anorexia usually aims to maintain a
very low body weight. They do this by undereating for a long period of time,
exercising far beyond what most people would consider reasonable and
healthy, or both. Although they might be underweight, they normally 'see'
themselves as fat. Anorexic people develop physical health problems as a
direct consequence of starvation. These include hair loss, dry skin,
dizziness, kidney problems, low immunity and abnormally low
blood pressure. Emotional and psychological effects include depression,
tiredness and difficulty concentrating. Mood swings are also common.
Fact
Around 20% of those suffering from anorexia die prematurely as a result of their illness.
Source: www.beatingeatingdisorders.org.uk
Bulimia nervosa
Bulimic individuals experience periods where they consume a lot of food - more than most people would eat in a comparable amount of time - and then attempt to compensate for this consumption via one or more purging methods. They may force themselves to vomit, abuse laxatives, fast, exercise to excess, or combine these methods.
The act of consuming a large amount of food is known as binge eating. This is different from greed, because binge eating is accompanied by a feeling of being out of control. After a binge, a bulimic person will usually feel guilty and panic at the prospect of putting on weight. They will use compensatory tactics, but then find themselves binge eating again. Bulimic patients place great emphasis on shape and weight, tend to suffer mood swings and are often highly self-critical. Most are ashamed of their behaviours, which can result in high levels of anxiety and depression.
Bulimic individuals are not usually underweight, but the condition can still result in serious long- term physical problems. Regular purging can lead to tooth damage, bad breath and tears to the throat lining and oesophagus. In rare cases, such tears can result in life-threatening infection and blood loss. Other potential complications include dry skin and hair, fits, muscle spasms and gastric problems such as constipation.
It is not yet clear what causes eating disorders. Psychologists believe that some people are vulnerable to media that glorifies thinness and this may inspire them to strive for an artificially low weight. This may be further compounded if someone is pressured to maintain a low weight as part of their job - dancers, models and actors are at elevated risk of eating disorders. Perfectionist personality traits, a history of sexual abuse, a family history of eating disorders or addictions and past teasing or criticism regarding shape and weight are further risk factors.
Binge eating disorder (BED)
A person with BED regularly consumes large quantities of food in a short space of time. This results in feelings of physical discomfort accompanied by guilt, shame, depression, or sadness. Unlike anorexia and bulimia, BED tends to manifest for the first time in a person's late teens or early twenties. Men are more likely to suffer BED than bulimia or anorexia.
A person with BED will eat very quickly, usually alone. Their binges will typically be planned in advance and they may make a special shopping trip to buy their 'binge foods'. Often, an individual will feel as though they have no control over their behaviour. Although they might not want to binge, the compulsion will be so strong that they feel unable to resist.
Binge eating is considered a shameful activity, so usually it is conducted only in private. Some people may become obsessed with food and stockpile large quantities. Binge eating often results in weight gain, but not in all cases. Everyone's metabolism is different. There are no weight criteria a person must meet in order to be diagnosed with BED.
Other specified feeding or eating disorder (OSFED)
If someone does not quite fit into the standard categories for any of the three disorders listed above, they will usually be given a diagnosis of OSFED.
For instance
Someone who exhibits behaviours and thoughts associated with anorexia, but is of a normal weight, would be given this label. It is common for someone to 'switch' between eating disorders.
For example
Patients originally diagnosed with anorexia may start to binge if and when their body's survival mechanism kicks in and compels them to eat food high in calories.People with bulimia sometimes manage to overcome their compulsions to purge their binges - but they might find it hard to stop bingeing in the first place and therefore be diagnosed with BED instead. Another example could be a person who does not eat huge amounts of food, but still purges in an attempt to compensate for the calories they have consumed.
Activity: Perfectionism and Eating Disorders
Estimated time: 5 minutes
There is a link between perfectionism and eating disorders. Why do you think this is?
5.4 How Negative Thought Patterns Contribute to the Maintenance of Eating Disorders
Perfectionist thinking
Eating disorders are commonly fuelled by the belief that in order to be acceptable, it is important to be 'perfect'. People with eating disorders are often self-critical when it comes to their personalities, academic achievements, social success and virtually all other aspects of their lives. This results in a great deal of pressure, which manifests as a powerful drive to be 'better'. When they perceive themselves as 'too fat' or 'too ugly', this causes a lot of psychological suffering. Over time, the fact that they have an eating disorder might trigger further self-hatred if they label themselves as 'broken' or 'crazy'.
Perfectionists prefer to remain in control of a situation and to feel as though they have control of their lives in general. Someone who believes that they should be perfect and live a perfect life, is liable to experience significant stress and disappointment when something inevitably goes wrong. This psychological pain may be manifested by self-destructive behaviour. The regimented routines and rituals associated with eating disorders (cutting up food into tiny pieces, sticking to a strict list of permitted foods, planning binges and so on) might serve the purpose of helping an individual feel as though they can at least control some aspects of their life.
All or nothing thinking
Someone who engages in all or nothing thinking falls into the trap of believing that if something goes wrong then everything is ruined. This drives eating disordered behaviour.
For example
Suppose that someone with BED is trying to avoid bingeing. However, they slip up and eat an extra biscuit. They might think, “What the hell - I'm never going to get better, I've already ruined everything today, I'll just go on a binge”. Anorexic people tend to have rigid ideas when it comes to personal goals and routines. For instance, doing one hour of vigorous exercise rather than two could trigger feelings of self-hatred and inadequacy.
Negative self-schemas
Most people with eating disorders have poor self-esteem and do not believe themselves to be valuable human beings. Whilst some people with eating disorders have no history of trauma or abuse, many report being sexually abused or suffering serious mistreatment as children or teenagers. This may contribute to feelings of being 'wrong' or 'dirty'. Some psychologists believe that behaviours associated with eating disorders may represent a desire to punish the self, or to express pain caused by past events.
Negative body image
Virtually all individuals diagnosed with an eating disorder believe their bodies to be unattractive. It is not uncommon for patients to become obsessed with their bodies, passing hours every day evaluating their 'flaws'. Their self-worth is tied up with how closely they fit an ideal prescribed by themselves, society, other people in their life, or all of the above. Weight gain evokes a great deal of fear, because it is seen as a reflection on their worth as a human being. The other vital component of an eating disorder is a distinctive set of behavioural factors.
Specifically, these behaviours are problematic and are targeted during treatment:-
Dietary restraint
It is not uncommon for anorexic people to become vegetarian or vegan. They may also eliminate key food groups or ingredients such as complex carbohydrates or refined sugar. Whilst some people do choose to adjust their diets for health reasons, it is taken to extremes by those with eating disorders and is often fuelled by a desire to lose weight rather than ideology or sound logical reasoning.
Body avoidance
People who feel strongly that their bodies are abhorrent will often make a deliberate effort to avoid seeing themselves in the mirror, or even to be naked. Some people with eating disorders are reluctant to take showers or bathe. This behaviour reinforces the notion that their body is something to be avoided at all costs, which in turn promotes negative self-evaluation and unhealthy diet and exercise behaviours.
Body checking
Repeated, compulsive weighing and measuring are common behaviours seen in people with eating disorders. Although the patient will recognise on some level that their body is unlikely to have changed in the past few hours, they may still feel that unless they remain vigilant, their body will suddenly start changing beyond all recognition. Patients often hone in on one or more parts of the body that they dislike.
For instance
An anorexic person may state that they are 'too fat' in general, but single out their waist as a particular target. As a result, they might measure it several times each day.
Self-harm
Some people with eating disorders engage in self-harming behaviours. These include cutting, burning, skin picking and punching.
They can take on an addictive quality and it can be hard to stop a self-harming habit. Some patients self-harm as punishment for their eating disordered behaviours, which furthers their negative self- evaluation.
For example
A bulimic individual may cut themselves after a binge.
5.5 How CBT Practitioners Treat Eating Disorders (CBT-E)
Enhanced CBT, abbreviated to CBT-E, is a form of conventional CBT that has been developed with particular strategies to help address eating disorders. CBT-E addresses core psychopathology that includes distorted thinking about oneself, eating behaviours, body shape, size and weight etc. It is based on the principle that if our thinking isnegative, it drives us to behave in abnormal ways and this in turn makes feel low. In general, CBT-E is a solution-focused, talking therapy on the here and now. It's usually very time-specific and is clearly structured with a beginning, middle and an end.
The practitioner sets out goals and objectives with the client and assigns homework to do between sessions to reinforce learning. Clients are encouraged to maintain journals of their eating patterns, their thoughts as they eat and their feelings at different times. Clients must fill in their journals as soon as they eat to represent the truth as much as possible. Clients then bring their records to the next session and the therapist works with them to review them and set new goals.
CBT-E therapy is based on the following ideas:
All eating disorders are cognitive disorders at the core whereby distorted thinking leads to abnormal behaviours resulting in negative feelings.
The core issues to be challenged by CBT-E are:
1. Over-evaluation of body shape or weight
2. Distorted thinking about self-image and self-perception
3. Over-control and dieting
CBT-E was created in the 1970s and 1980s by psychiatrist Christopher Fairburn, who noticed that many of the bulimic patients he saw in his clinics were afflicted with similar thoughts, feelings and behaviours. CBT-E can be used with virtually any eating disorder patient, regardless of their diagnostic label or the severity of their symptoms. The standard CBT-E structure consists of 20 individual sessions delivered over the course of 20 weeks. CBT-E is a one to one treatment.
Although originally devised with adults in mind, it can also be a viable treatment option for young patients if family therapy (which is usually preferred) is not suitable in their particular case. There are various versions of CBT-E depending on the client's age, type of eating disorder and history. The overall aim is to bring all parameters of the eating behaviour within normal ranges.
The treatment proceeds as follows:-
Phase 1: Normalising eating patterns
The first phase of CBT-E addresses abnormal eating patterns. When treating an eating disorder, the physical wellbeing of the patient is of paramount importance. This means that if they are underweight, a therapist's first priority must be to help them overcome a reluctance to eat normal portions required to maintain a healthy weight.
If the patient is engaging in frequent purging, the primary objective is to help them eat reasonable amounts of food at regular intervals, learning to sit with the feelings of discomfort that compel them to binge and purge. This is key in breaking the binge-purge cycle. During this stage of therapy,sessions are delivered twice weekly so that the unhealthy behaviours can be broken quickly. Most patients find that when they adopt a more balanced eating routine and a more nutritious diet, their mood improves.
Phase 2: Review and collaboration
Once the patient has made significant progress with their eating behaviours and their physical condition has improved, the next step is for the therapist and client to work together in understanding the thoughts and feelings responsible for the maintenance of the eating disorder. During Phases 2 and 3, the sessions are delivered on a weekly basis. Phase 2 is very brief, consisting of a couple of sessions in which the therapist changes the focus of the therapy, moving away from behaviours and onto the client's thoughts about their body, shape, weight and eating.
A CBT-E therapist will consider the predisposing factors, precipitating factors, protective factors, maintaining factors and presenting problems, when formulating the client's case.
Here are a few examples of each:
Predisposing factors: Perfectionist personality, a history of eating disorders in the family, atendency towards a large body size, low self-esteem, dieting behaviour, difficulty in talking about negative emotions, unusual perspicacity as a young child. Precipitating factors: Natural changes that occur during puberty, family dysfunction, appearance-based bullying, academic stress, abuse, trauma, exposure to an environment in which appearance is regarded as a key determinant of personal worth.
Maintaining factors: Over-evaluation of shape and weight, abnormally high levels of perfectionism, difficulty in expressing and tolerating difficult emotions, negative self-image, negative body-image, poor relationship skills.
Presenting problems: Abnormally low body weight, injuries caused by excessive exercise,depression, anxiety, injuries to the throat caused by purging, inability to perform at school or work, social withdrawal.
Phase 3: Challenging the processes that maintain the eating problem
This phase uses general CBT techniques such as thought journaling, challenging negative thinking styles and cognitive restructuring. However, it uses these techniques in a way that tackles common 'eating disorder cognitions'. The therapist will teach the client how to cope with the extreme feelings of distress that can emerge during eating disorder recovery. Eating disorder patients tend to share the same concerns and these can be treated using reliable interventions.
For instance
Patients usually judge themselves to be much larger than they really are and to feel upset when looking at themselves in a mirror. They then think that because they are unacceptably large, they need to embark on a diet. Unfortunately, restrictive behaviours tend to backfire, leading to further feelings of guilt and negative self-evaluation. To break this cycle, the patient needs to learn how to deal with their intense emotions in a healthier manner and to reframe how they think about diets (i.e. not as a viable solution to body distress, but as an idea that will only worsen the situation).
Mirror exposure is a technique used to help patients learn to accept their appearance and to practise seeing themselves in the mirror without automatically unleashing a barrage of negative judgments and insults. The objective is to challenge the patient's notion that they can rely on a mirror as a valid source of information about their appearance, despite the fact that they have been diagnosed with a mental illness that warps their perception. With the patient's consent, the therapist will then expose them to a mirror and ask them to explain the thoughts and feelings they are experiencing. The therapist and client work together to assess the validity of the client's feelings and to challenge underlying core beliefs.
The majority of people with eating disorders judge their value as a person with reference to their body shape and size. This belief needs to be identified and challenged, otherwise the client will carry on engaging in maladaptive and possibly extreme restriction and bingeing behaviours. Another common belief is that unless the patient remains 'in control' of their eating and exercise behaviours at all times, they are a bad or unworthy person.
Overcoming such thoughts can be a lengthy undertaking, because they are often acquired at an early age from parents, friends and other influential people. CBT-E also helps people with eating disorders improve their self-esteem and establish an identity that does not revolve around their mental illness. They are often obsessed with food, shape and weight, to the point at which they experience an identity crisis when the behaviours are removed. Recovering from an eating disorder has even been likened to grieving, despite the fact that they can be fatal. Exercises that encourage patients to schedule positive activities and improve their social lives often yield good results.
Phase 4: Maintenance and relapse prevention
Those with eating disorders are at risk of relapse, so the end of Phase 3 and the entirety of Phase 4 is dedicated to equipping the client with the skills they need to handle problems in the future without lapsing into destructive behaviours. Towards the end of the therapy, the patient's body weight should have stabilised, so work can begin on helping them adapt to their new body shape. This can be an emotionally draining process, especially if the patient has been required to gain a significant amount of weight for the sake of their health.
Each client will have their own ED triggers. This phase of therapy involves identifying situations, feelings and relationships that have previously resulted in the client engaging in ED behaviours.
For example
The client may have established that when they feel pressured at work, they binge on food in a bid to make themselves feel better. This will not necessarily be a conscious decision - after a while, these responses become automatic. In this case, the therapist will help them devise new strategies for handling these feelings of pressure. The best solution will depend on the client's personality, preferences and resources.
To continue with the above example, the client might need to learn how to challenge negative feelings about pressure (e.g. “If I feel pressured at work, it's because I'm not good enough to get all my tasks done”), to talk to their supervisor about their feelings (which might entail working on beliefs about standing up for their needs), to learn relaxation exercises that help them control their anxiety, or a combination of the above.
5.6 How Effective is CBT-E?
CBT-E is considered a highly effective treatment.If a client adheres to the treatment protocol, they can expect significant improvement. It was the first specialised form of ED treatment to be recommended by the National Institute for Clinical Excellence (NICE). Researchers in the UK, Denmark, Australia, Germany, the USA and Italy have investigated the efficacy of CBT-E. Research carried out in the UK, Denmark and Italy have shown the most promising results.
This may be because the teams that ran CBT-E trials in these countries took special measures to make sure that the programme was delivered properly by therapists with an appropriate level of training. It seems likely that CBT-E outcomes, much like any form of therapy, are influenced by the quality of the intervention.
The Centre for Research on Eating Disorders at Oxford (CREDO) website currently summarises the outcome studies as follows:-
“If one focuses on studies in which CBT-E was delivered well, the evidence suggests that with patients who are not significantly underweight (the great majority of adult cases) about two-thirds of those who start treatment make a full recovery that appears to be well-maintained. Many of the remainder have also improved, but not to this extent. The response rate is somewhat lower in patients who are substantially underweight and fewer complete treatment”.
Module Summary
Eating disorders are serious and long-term mental illnesses. The most common eating disorders seen in clinical practice are anorexia, bulimia and binge eating disorder. People who exhibit traits associated with two or more of these conditions, or who fall short of the full diagnostic criteria, but nevertheless suffer significant distress, are given the diagnosis of Other Specified Feeding and Eating Disorder (OSFED).
In the 1970s and 1980s, a form of CBT aimed at treating bulimic patients was developed by doctor Chris Fairburn. CBT-E is a specialist form of structured treatment aimed at adults with eating disorders, but it can also work well for younger patients who are not suitable for family therapy. CBT-E is delivered in four phases over a period of approximately five months.
*The first phase focuses on stabilising the patient's eating patterns, which usually has the effect of improving mood and motivation.
*The second phase consists of a brief review, during which the client and therapist establish the client's goals.
*In the third phase, the client is taught how to challenge the cognitive and behavioural factors that keep their ED going, such as an inappropriate emphasis on shape and weight.
*The final phase focuses on maintenance and relapse prevention. This entails identifying ED triggersand devising more constructive ways of responding to them that do not involve ED behaviours.
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