Eating Disorders

Description of the Strategy

Cognitive-behavioral therapy (CBT) for eating disorders is a short-term, semistructured approach in which the therapist and client work collaboratively to address problematic thoughts and behaviors. When treating an individual who has an eating disorder, the therapist first completes a thorough assessment of the client's symptoms and background. Treatment begins by introducing the cognitive model of eating disorders. According to the cognitive model, the core psychopathology in eating disorders is a dysfunctional self-evaluation that is overly negative and based almost entirely upon body shape, weight, and ability to control eating. Overvaluation of appearance and weight contribute to an intense fear of fat, which leads to extreme and rigid dieting.

The cognitive model identifies dieting as a primary cause of binge eating. For most people, extreme dieting attempts cannot be sustained indefinitely. When rigid control is interrupted in any way, often by breaking a dieting rule, the reaction is to temporarily abandon any eating rules, resulting in a complete loss of control over eating. The binge episode allows a brief escape from rigid control and sometimes an escape from negative feelings, which reinforces bingeing. However, shortly after the binge come feelings of guilt, depression, self-loathing, and intense anxiety about weight gain. Purging, most typically through self-induced vomiting, reduces anxiety about weight gain following a binge, which negatively reinforces the purge. Both bingeing and purging contribute to poor self-esteem, thereby strengthening the negative self-schema. The individual renews her commitment to rigid dietary rules as a means to overcome feelings of inadequacy, and the diet/binge/purge cycle continues.

After introducing the cognitive model, the therapist teaches self-monitoring, a cornerstone of the treatment. Self-monitoring of foods eaten, times, binge eating, purging, moods, and situations provides specific information on antecedents and consequences of bingeing and purging. Using the cognitive-behavioral model as a framework, the therapist incorporates interview and self-monitoring information for a particular client into an individual conceptualization of the problem.

The first stage of treatment includes both psychoeducation and application of behavioral techniques to establish more regular eating habits, decrease rigid dieting, and decrease bingeing and purging. Clients are asked to eat three meals plus two snacks at regular times each day. Weekly weighing provides feedback to the client on how changes in her eating behaviors affect her weight. Self-control strategies, similar to those used in behavioral treatment of obesity, provide the client with tools to refrain from both purging and bingeing. Self-monitoring records help identify cues for binge eating or food restriction. The therapist teaches stimulus control techniques to help the client avoid or change situations that typically trigger a binge. For example, an evening telephone conversation with a young woman's mother is upsetting and often triggers a binge. She learns to substitute an alternative response of calling her good friend after speaking with her mother, which helps her to avoid the binge. Alternatively, she may decide to call her mother in the mornings, when she has less time and opportunity to [Page 264]binge. Self-reward strategies may be used to increase eating for individuals who are overly restrictive or to establish regular eating patterns when eating is chaotic.

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