Cognitive Behavioural Therapy for Bulimia Nervosa
CBT has an impressive empirical track record during the past decade for the treatment of Bulimia Nervosa and is now by and large considered the treatment of choice for this eating disorder.

The first stage of treatment outlines the cognitive view of Bulimia Nervosa, as seen below

and behavioural techniques are used to help patients gain control over their eating, such as an emphasis on REGULAR EATING.

The emphasis on the second stage of treatment is on the examination and modification of problematic thoughts and attitudes, using COGNITIVE RESTRUCTURING TECHNIQUES. Patients are taught to identify, evaluate and change dysfunctional thinking patterns, so that therapeutic change in mood and behaviour can occur.

Eating disorder patients typically present with a number of problematic thoughts and attitudes about their eating and body weight.

Typical Negative Automatic Thoughts of a bulimic may include the following:

• 'I must not eat anything tomorrow because I must make up for the binge I had today'.
• 'People are staring at me because I'm so fat and ugly'.
• 'I can't eat anything at the party tonight because I won't be able to get rid of it afterwards without people noticing'.
• 'That's it, I've blown my diet'.

Therapy involves learning ways to challenge these Automatic Thoughts, by identifying THINKING ERRORS, and looking for RATIONAL RESPONSES.

Identifying THINKING ERRORS is one example of learning to rationalise distorted thinking.

Thinking Errors

A. All or Nothing Thinking: This is where things are seen only as black or white and there are no shades of grey. One mistake leads to total failure.
B. Overgeneralisation: here, one unfortunate event leads to the assumption that this will happen every time, but remember, there is no justification for seeing one instance as proving the rule.
C. Mental Filter: This is where you pick out and dwell exclusively on the negative and worrying details.
D. Disqualifying the Positive: Here, positive experiences do not count for some reason. Successes are a 'fluke'. No pleasure is taken from positive events.
E. Jumping to Conclusions: You assume the worst when there is no reason to e.g. expecting failure before having tried.
F. Catastrophising: Here you exaggerate your own imperfections e.g. 'I made a mistake, how awful, I can never show myself here again'. Common misfortunes become disasters. Do you think about other people's mistakes in the same way?
G. Emotional Reasoning: This means taking your feelings as facts, e.g. because you feel so afraid there must really be some danger.
H. 'Should' Statements: Thinking you should be able to stay calm all the time or you should never get angry. Rigid statements like this are overdemanding and unreasonable and cause unnecessary pressure.
I. Labelling and Mislabelling: You label yourself as a 'useless person' on the basis of one mistake. It makes as much sense as labelling yourself as a joiner because you put up a shelf.
J. Personalisation: Attribute things going wrong to oneself. 'My parents fight because I'm an awful daughter'.

The following outlines useful questions for patients to ask themselves when challenging their irrational thinking.

Looking For Rational Answers

1. What is the evidence?
a. What evidence do I have to support my thoughts?
b. What evidence do I have against them?

2. What alternative views are there?
a. How would someone else view this situation?
b. How would I have viewed it before I got depressed?
c. What evidence do I have to back these alternatives?

3. What is the effect of thinking the way I do?
a. Does it help me, or hinder me from getting what I want? How?
b. What would be the effect of looking at things less negatively?

4. What thinking error am I making?
a. Am I thinking in all-or-nothing terms?
b. Am I condemning myself as a total person on the basis of a single event?
c. Am I concentrating on my weaknesses and forgetting my strengths?
d. Am I blaming myself for something which is not my fault?
e. Am I taking something personally which has little or nothing to do with me?
f. Am I expecting myself to be perfect?
g. Am I using double standards - how would I view someone else in my situation?
h. Am I paying attention only to the black side of things?
i. Am I overestimating the chances of disaster?
j. Am I exaggerating the importance of events?
k. Am I fretting about the way things ought to be instead of accepting and dealing with them as they come?
l. Am I assuming I can do nothing to change my situation?
m. Am I predicting the future instead of experimenting with it?

5. What action can I take?
a. What can I do to change my situation?
b. Am I overlooking solutions to problems on the assumption they won't work?
c. What can I do to test out the validity of my rational answers?

Thought records are the main tool to implement these cognitive therapy strategies. They are designed to help patients gain a broader perspective on a situation, so that their emotional reactions are more balanced responses to the total circumstances of their lives. It is not simply a matter of substituting a negative thought with a positive one, but rather weighing up the evidence and examining a belief or thought from all angles.

Two examples of Thought Records are given below:

 

Situation	Feelings	Automatic Thoughts	Thinking Errors	Rational Response
In refectory at lunch.	Self-conscious. Panicky	People are staring at me because I am fat and ugly.	Jumping to conclusions.	What evidence do I have to support my thought.People are getting on with lunch and chatting.I am accepting feelings as facts.

 

Please record something positive that has happened today:

 

Situation	Feelings	Automatic Thoughts	Thinking Errors	Rational Response
Sitting at home after a binge.	Disgust.Anger.Guilt.	I must not eat anything tomorrow to make up for the binge.	Black and white dichotomous thinking.	I am much more likely to binge if I do not eat.Today has not been the best, but tomorrow can be different.

 

Please record something positive that has happened today:

 

To Summarise These Points

Cognitive Behavioural Therapy involves a specific protocol, the core of the disorder being fear of weight gain and concerns re weight and shape issues.

The aim of therapy is to decrease the fear of weight gain and weight control measures, working on cognitive biases, Automatic Thoughts and Core Beliefs relating to worthlessness etc.

Cognitive Behavioural Therapy for Anorexia Nervosa

Although there is less evidence to support the use of CBT in the treatment of Anorexia Nervosa, it is still widely considered a valuable treatment option.

The use of cognitive behavioural strategies are similar to those used in treating Bulimia Nervosa, the main differences in Anorexia Nervosa being the patient's motivation (i.e. more resistant) and the fact that dangerously low weight means treatment focuses more on weight gain. Hence pace, style and strategies vary. Compared to Bulimia Nervosa there is a greater awareness of medical risks and hospitalisation. Treatment involves more emphasis on starvation syndrome side effects and overall the therapist is more directive.

As expected, treatment would also be considerably longer.

 

 

Published: 09/10/2020 10:19