Cognitive Behavioural Therapy for Eating Disorders

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Table of Contents

Introduction
Presenting Problem
Case Formulation
Using the Formulation
Outcome
Discussion
References

Introduction

The patient is a 35-years old male named John, currently unemployed. Information about John’s family and marriage status is unknown, perhaps due to privacy concerns. John’s primary diagnosis is bulimia nervosa, and he had undergone psychological assessment at the Eating Disorders Clinic. Additional data referred by the previous counsellor revealed that John started developing first symptoms when he was in school: he experienced bullying from his peers due to his weight. He reported feeling isolated from others as he believed he was not good enough for them, thus he began using food and eating as a coping mechanism to deal with frustration. Fairburn and Harrison (2003) state that “while eating disorders are an important cause of physical and psychosocial morbidity in adolescent girls and young adult women, they are much less frequent in men” (p. 407). The fact that John has been experiencing bulimia nervosa since teenage years up to his mid-thirties makes this case rather valuable for understanding eating disorders. No further information on John’s case was provided – the treatment plan will be built only on the knowledge above.

Presenting Problem

John suffers from bulimia nervosa: he usually refrains from eating in the morning but then binge-eats great amounts of food in the evening. However, he is also afraid that he will gain weight, so he induces vomit after overeating. Patients with eating disorders usually have ideas about their body that have been shaped by their environment. Thus, first of all, to assess John’s current condition, several questions were asked to form an appropriate image of the problem, such as:

When and why did you first start thinking about your weight and appearance?
When and why did you first have the idea that you are overweight?
When and why did you start criticizing your body?
When and how did you first realize that appearance is important?
What do your loved ones say about the shape of your body and your weight?
Was there someone who did not criticize your appearance during your school years?
Was there a period in your past when you liked your appearance?
How do you evaluate other people?
When did you first decide that being thin meant being successful?
What do your concerns about appearance deprive you of, and what do they prevent you from doing?
What do you like about your appearance?

In addition to beliefs, patients with eating disorders have a certain emotionally coloured attitude towards their body. In order to understand the essence of affect, it was suggested to use the imaginative technique by Waller and Cordery (2008):

John was asked to close his eyes and imagine himself at the earliest age he can remember;
Then he would describe in detail what his body looked like then;
Next, he was asked to recall specific, most significant events that influenced his attitude towards his body;
Finally, he was asked how this event made him feel: insecure, confident, hurt, and other emotions.

This approach served to discover John’s rules of life related to the body and thinness, as the examination of patient history and events associated with weight changes often helps to detect underlying issues. Understanding John’s predispositions and how his disorder progressed throughout the years and concrete events established a more comprehensive context. Moreover, it helped John to begin realizing what specifically he is struggling with and set his goals.

John’s main goal for the treatment was to develop healthier eating habits: stop binge-eating and inducing vomit. Additionally, he expressed hope that the therapy would help him improve his self-esteem and correct body perception. This was established thorough his assessment with questions and imaginative technique, and through pointing out that his eating behaviour is damaging his health. By recalling events that led him to believe he is “unworthy of attention and love” and understanding the effect his eating habits have on his overall health, John was able to set his treatment goals.

During his previous assessment at the Eating Disorders Clinic, John was given the diagnosis – bulimia nervosa (DSM-5 307.51; ICD-11 F50. 2). DSM-5 provides the following main criteria for diagnosing bulimia nervosa:

Recurrent episodes of overeating, where the binge episode is characterized by two specific features. The first is that the patient consumes food in absolutely excessive conditions over a certain period of time (for example, within two or three hours). Excessive in this case means the amount of food healthy people with similar body type cannot consume in the same period of time without feeling sick/nauseous/overwhelmed. Another distinct feature is that the patient does not feel like they have control over how much or what they eat during the binge episode.
There was at least one episode of binge eating and inappropriate compensatory behaviour such as fasting/starving/dieting/inducing vomit every week for the past three months.
Patient’s weight and body shape influence directly and heavily their self-esteem.

John presents all three groups of symptoms, and his unhealthy eating behaviour has been occurring since his school days, which qualifies him for the diagnosis of bulimia nervosa. His problems began when he started being bullied for his weight, and as he felt more isolated from his peers, his self-confidence suffered greatly. Overeating became his sole coping mechanism; however, as John still struggled with his body image and feared that he would gain even more weight due to his habits, he started to induce vomit after eating. This process provided him a sense of relief: he could still indulge in food and feel better while simultaneously not having to worry about weighing more. This coping mechanism persists up to the beginning of the treatment. John stated that he have not received any therapy prior to this one, nor has he been prescribed any medication.

Before starting the treatment, John was asked to rate how much does individual’s body shape and weight influence how others see them, on a scale from 1 to 10. John’s assessment was 7: he believed that these particular physical features are very important to one’s public image, and that people are less accepting towards those who are overweight, even if slightly. When provided with Eating Attitudes Test (EAT 26) questionnaire, John scored a total of 22 which strongly indicates the presence of an eating disorder. Both these assessments point towards John having serious issues with his eating behaviour and body image.

Case Formulation

People whose weight and body shape do not meet the socially accepted standard are often perceived as lazy and weak. In addition, they themselves often tend to experience an intense sense of shame in connection with ideal body. Being able to recognize these negative feelings and counter them with self-compassion might reduce the severity of stress, and avoid developing an eating disorder. Still, in general, dissatisfaction with one’s own body is somewhat normal; it has been called “normative body dissatisfaction” (Fairburn, 2008). When this normative dissatisfaction reaches certain levels, an eating disorder might be triggered.

It is rather arguable that the socio-cultural environment itself, which provokes bodily anxiety, causes the development of eating disorders. However, it is precisely the environment that makes the reassessment of weight and body shape, the key psychopathology of eating disorders, possible (Fairburn, 2008). It creates the prerequisites for the use of restrictive eating styles which can trigger the development of eating disorders. According to Fairburn and Harrison (2003), “the cause of eating disorders is complex and badly understood; there is a genetic predisposition, and certain specific environmental risk factors have been implicated” (p. 407). Thus, such disorders occur in individuals predisposed to them if they are exposed to a number of adverse factors.

For example, sensitive temperament is an important aspect predisposing to the development of eating disorders. People with this type of temperament tend to take criticism more sharply than the rest. Thus, the comments of other people about the appearance often become exactly the critical event that triggers the development of eating disorders. This is precisely John’s case – he started to doubt his body image and lose self-esteem majorly because of excessive bullying and subsequent isolation.

Moreover, the internal factor that did not allow breaking out of the vicious circle of bulimia was intertwining food with the emotional coping mechanism. The lack of social connections and other ways to deal with emotions made overeating the pattern John used in all circumstances. Therefore, John’s negative ideas about his body and the reactions of others to him triggered a wave of anxiety that he could only deal with by binge eating. This was followed by a short emotional relief and fear of getting overweight which entailed the desire to correct the situation by cleansing.

The mechanism behind the process of eating disorders’ development has been researched for a long time. According to Fairburn’s transdiagnostic model of eating disorders, common to all eating disorders is a core psychopathology that is inherently cognitive: an over-evaluation of body shape, weight, and dietary control (Fairburn, 2008). There is a correlation between over-evaluation of body shape, weight, and control over them with other behavioural, cognitive, and affective manifestations of eating disorders (Figure 1).

Over-eveluation of shape and weight and their control — Figure 1

For example, the over-evaluation can be associated with attempts at dietary restrictions and constant checking of weight and body image. Murphy et al. (2020) and Waller et al. (2020) claim that presence of COVID-19 might further exacerbate the need to watch one’s body weight due to anxiety and fear. Nutley et al. (2021) support that idea, stating that the stress associated with lockdowns, isolation, and disease spread are triggering eating disorders symptoms in countries most affected by pandemic such as China and U.S. Over-evaluation’s impact on cognitive aspects is expressed with concern on the topic of weight and body shape. For instance, John is constantly worried that he will gain more weight due to his overeating. It is unclear yet if these underlying beliefs are the cause behind John’s current unemployment and caused poor school performance – this information is yet to be acquired.

The motivational basis of the activity associated with the control of food intake is gradually reborn, the semantic dominant becomes what was previously the goal and even the means to achieve it. The emerging rigid patterns of eating behaviour are filled with independent target content and become obsessive rituals. Maladaptive behaviour such as vomiting after eating, aimed at maintaining a low weight or its reduction, formed in response to a perceived threat, also complicates the course of disorder (Cooper et al., 2009). Eating habits and rituals, according to transdiagnostic model, help to change negative mood and reduce anxiety associated with food and weight gain (Fairburn, 2008). Essentially, they perform a function similar to the role of compulsions observed in the structure of obsessive-compulsive disorder (Cooper et al., 2009). Body testing is another type of behavioural ritual that usually appears in the structure of an eating disorder. Body checking rituals include examining body parts in a mirror, repeatedly weighing and measuring specific body parts (Cooper et al., 2009). Conceptually, this behaviour seems to be related to the desire to make sure that a frightening result (an increase in weight, body size) does not occur.

In addition, under the influence of over-evaluation of these physical features, patients tend to interpret many negative affective states or uncomfortable sensations as a feeling of fullness – the so-called “fat feeling” (Fairburn, 2008). Subsequently, fixation on the topic of weight and body shape leads to the fact that other areas of life – hobbies, personal qualities, and social connections – are marginalized and cease to be important. Fairburn (2008) suggests using a “self-esteem pie” for visual representation of this aspect of therapy. In Figure 2, one can see a typical “self-esteem pie” of patients with eating disorders, with weight and body shape taking the major part of one’s life – slightly less than three quarters of a pie. Other spheres of life – family, work, “other” – lack attention from the patient and take just slightly more than a quarter of person’s lifetime. John was encouraged to create his own “self-assessment pie” and review it regularly, observing how he evaluates himself, and what changes occur throughout his treatment.

Before the treatment it was impossible to extract additional information from John’s medical history about other factors in the development of the disease – family relationships, romantic relationships, other traumatic events. In addition, there is no data on John’s current lifestyle in order to form an understanding of what areas of life can be relied upon during the therapy. According to self-assessment pie, John tried to explain all the difficulties in life by problems with the body image. However, the description did not include examples of specific triggers and the mechanism for their reflection through an eating disorder perspective.

Using the Formulation

Cognitive behavioural therapy would be the best course of treatment for John’s individual case. According to the National Institute for Health and Care Excellence (2017), cognitive behavioural therapy is one of the best treatment options for bulimia nervosa and binge eating disorder. For anorexia nervosa, the efficacy is up to 75% for baseline BMI greater than 17.5 (Fairburn, 2008). For bulimia nervosa, 57% of cases go into remission and 79% experience a reduction in symptoms (Fairburn, 2008). Fairburn (2008) noted the absence of symptoms of bulimia nervosa in 48% of patients 6 years after the end of therapy. Linardon et al. (2017) add that cognitive behavioural therapy outperformed all other psychological interventions. The original Cognitive Behavioural Therapy for Bulimia Nervosa (CBT-BN) protocol was widely used in the 1990s but in the early 2000s, it was modified and a transdiagnostic model was created (Fairburn et.al., 2003). Using this specific approach, an individual treatment plan was designed for John.

As was formulated before, John was suffering from problems with self-esteem and unhealthy eating behaviour. He expressed hope that therapy would assist him in building his confidence in independence from his body shape and provide better eating habits, and stress coping mechanisms not associated with food. Wilson et al. (2007) emphasize that “CBT treatment consists of cognitive and behavioural procedures designed to enhance motivation for change, replace dysfunctional dieting, decrease undue concern with body shape and weight, and prevent relapse” (p. 204). This became the starting point for creating an individualized plan: John’s binge-eating needed to be addressed, along with his tendency to induce vomit after it. The first aim of the therapy was to reveal the supporting cycles and rituals for John’s eating behaviour.

At the beginning of therapy, patients often have many fears and concerns associated with it, and John was not an exception. Tatham et al. (2012) state that “the best chance of making CBT for the EDs effective is to do it properly from the beginning, where ‘properly’ is defined by both technique and clinician’s stance” (p. 225). Thus, it made sense to directly ask questions that were most likely to concern him after assessing his condition.

John was told that during therapy, many patients may feel that once they start eating, they will not be able to stop. John confirmed that he has this fear, and some others, related to his reduced ability to cope with stress without overeating. Juarascio et al. (2017) explain that “some patients may continue to experience binge eating due to difficulty complying with the prescribed behavioural components and a lack of focus on strategies for coping with intense stress” (p. 1). However, after discussing his concerns and offering solutions for potential situations that troubled him the most, John admitted that he was now less anxious and more ready to start treatment. Therefore, an open discussion of possible concerns is key in reducing anxiety and increasing trust. Fairburn (2008) emphasizes the importance of the therapist’s empathic, not paternalistic behaviour. Addressing John’s fear in a supportive manner helped him formulate his goals more clearly. Ultimately, the main aim for his CBT was introduced: learn healthy coping mechanisms and regulate his eating behaviour, along with building a new foundation for his self-esteem.

The key hypotheses of how and why John had developed bulimia nervosa was school bullying due to his weight and subsequent isolation. Thus, his treatment first focused on dismantling his beliefs about the importance of slenderness of the body. Within the transdiagnostic model of Fairburn (2008), over-evaluation of weight and body shape is a key psychopathology of eating disorders. Various studies confirm that symptoms such as body checks and avoidance are behavioural expressions of this psychopathology, consistent with the CBT model. Accordingly, to improve the results of therapy, as well as to prevent the risk of relapse, it is extremely important to work with body dissatisfaction in patients with eating disorders.

While working on that aspect with John, it was revealed that both his parents were consistently lean no matter their diets, while he tended to lose and gain weight quickly. Despite the fact that his parents never shamed his for appearance, John was often upset at his body as it seemed “faulty” to him due to the fact that he did not inherit his parents’ metabolism. He admitted that he began comparing himself to them even more as he progressed into adulthood and started to become slightly overweight due to his binge-eating. During John’s childhood, his parents rarely ever paid attention to his eating habits when he became a teenager, as they got busy with his grandfather growing severely ill and bedridden. The combination of all the frustration John felt comparing himself to his parents, stress from constant bullying, and worry about his grandfather resulted in him acquiring unhealthy coping mechanisms. This information helped make the treatment more focused – it became more clear how John first started to develop self-esteem issues and why bullying affected him this much later.

An important component of therapy, which was present throughout the whole course of treatment, was the keeping of a self-observation diary. John was advised to write not only all his meals in it but to evaluate how each of them affected his mood, and what emotions did he experience. Patients with bulimia nervosa and compulsive overeating often report that keeping such a diary helps to streamline the process of eating and reduce the number of episodes of overeating (Waller and Cordery, 2008). Mulkens and Waller (2021) supply that “the ability to use the weekly information provides feedback that the clinician and patient can use collaboratively” (p. 578). The entries in the diary were regularly discussed with John, and he noted that with it, it became easier for him to eat more consistently in the morning.

In addition, psychoeducation about nutrition became a significant part of the treatment, as it helped John understand better the effects of his eating behaviour on his health. Schmidt et al. (2016) supply that “quality of life in eating disorders is as low as that in symptomatic coronary heart disease or major depression and worsens with illness duration” (p. 314). Patients with eating disorders often have false beliefs about the effectiveness of “cleansing” methods such as inducing vomiting (Waller and Cordery, 2008). John firmly believed that if he overeats and then resorts to inducing vomit, then he completely got rid of food and compensated for his overeating. In the process of psychoeducation, it was important to explain to John that this is a false assumption and that a large amount of food eaten remains in the stomach in case of vomiting. John needed to understand that this method is completely ineffective as a compensation for the amount of calories eaten.

John’s therapy blueprint revolved around his self-esteem issues and eating behaviour. It was aimed at identifying his most problematic areas and what he wanted to improve. John was asked to elaborate on his beliefs and assumptions related to body shape and weight, on how he perceives himself and others, and what constitutes his self-esteem. The blueprint required John to constantly review and re-evaluate his eating behaviour throughout the therapy, and what affects it the most. By the time of writing this report, John has already started learning new coping skills, and was asked to provide feedback on which mechanisms did or did not work for him.

Patients with eating disorders evaluate their body solely in terms of “lean or fat.” However, they do not think about the functions that the body performs. John was advised to think about his body outside of its weight and shape: how it keeps him alive, regardless of how he treats it. He was asked to write out how his body – his scars, birthmarks, other significant features – tells the story of his life, about the joyful and sad moments that he experienced. Discussing the body in this way helped John gain a more balanced view of his body and a broader perspective.

John’s deep-rooted assumptions about the ideal figure being the most important part of his life and that he would be deserving of love and attention only if he is lean were the most difficult to overcome. His issues with not being as “perfect” as his parents that served as the first blow to his feeling of self-worth only intensified with years as he became a target for bullying. Moreover, the fact that he felt isolated from others solidified his belief that to be accepted, he needs to be lean. Deconstruction of these opinions began with consistent filling of “Personal Strengths and Their Use” worksheets which helped John recognize his good personal qualities that were not tied to his weight (Wood-Barcalow et al., 2021). Moreover, he was asked to perform a visualization exercise: John had to imagine his best possible self and describe his life in detail to see that his goals are not unattainable.

Outcome

At the time this report was written, John managed to improve his eating behaviour significantly: he began to eat more consistently and distribute his meals throughout the day, avoiding night overeating. He admits that he still feels the urge to eat more than one portion of food in the evening, especially if he had a stressful day or if his favourite show is airing. There were several relapses in his new eating regime but he still managed to control himself to some extent and, while definitely consuming excessive amounts of food, not eat as much as he used to. Only two of these relapses ended in him inducing vomit, and, as he stated, it did not feel cleansing to him as much anymore. John scored 19 on his latest EAT 26 assessment, noting that he does feel less tempted to resort to food as his coping mechanism.

The biggest concern up to date remains the issue with John’s self-worth. While his eating habits have improved considerably with the help of self-assessment diary and consistent diet, he still struggles a lot with his body image and beliefs related to it. Vitousek et al. (1998) explain that patients with bulimia nervosa, while more motivated to heal, are more prone to clinging to the idea of slenderness. Further treatment will need to focus more on deconstructing his unhealthy assumptions about the importance of being lean to be loved while simultaneously supporting his new eating behaviour. This might prove to be difficult to manage at once, and more relapses are to be expected. John will need to work on his cognitive distortions in order to detach himself from his image of “perfect body” and focus more on other aspects of life. Cognitive testing and restructuration might be useful for these goals as they allow to look more critically at one’s inner thoughts and assumptions.

Discussion

This case proved to be of immense importance in learning about cognitive behavioural therapy for eating disorders – specifically, the transdiagnostic model. The case highlighted that it is crucial to work with a key psychopathology: an over-evaluation of weight and body shape. A distorted, negative perception of one’s body is the first thing to address through the treatment. During cognitive behavioural therapy, patients’ perception of their body should change from a sharply negative attitude towards a more accepting one, which, in turn, helps them begin to take reasonable care of it.

The initial formulation was correct in assessing John’s main issues and specific behaviours; however, as the treatment progressed, more information about his underlying beliefs was revealed. This information was rather valuable for adjusting the treatment plan as it allowed to determine the earliest causes of John’s self-esteem problems and thus address them in a more targeted manner. Waller et al. (2019) note as one of the advantages of cognitive behavioural therapy its flexibility that serves to fit patient’s individual needs better. Understanding that school bullying was not the originating factor in John’s unhealthy behaviour but rather one of the consequences of a deeper, more personal issue shifted the focus of the therapy towards building self-compassion.

The main success of the therapy up to date revolved around John’s improved attitude towards eating. John came into therapy fully understanding that his eating behaviour is unhealthy, and it became his main motivation to change his habits. With the support and assurance from the therapist that potential relapses do not mean that John’s efforts are futile, John addressed his anxiety and overcame eat. Self-observation diary and psychoeducation about nutrition helped him build a more consistent eating schedule that he was actually able to stick to. John’s self-esteem and body image have not yet improved greatly but the treatment is not fully completed, and with the new information about what caused these issues revealed, the therapy plan can be adjusted.

References

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