Introduction
 

Eating disorders are fairly common although they seldom come for treatment. DSM IV estimates the prevalence of anorexia nervosa alone at between 0.5-1.0%. King (1991) reports prevalence rates as high as 3.9% for females and 0.5% for males. However only those that suffer from severe symptoms that gives rise to social and/or occupational problems come or are brought for treatment. As such our experience with treating these patients are fairly poor compared with other psychiatric disorders. Much have been written about treating these patients but so far no one mode of treatment have stood out as the best form of treatment. Studies of psychotherapeutic treatment of anorexia suffer from major methodological weaknesses-in particular, small sample sizes and nonrepresentative (tertiary referral) samples-limiting conclusions about the comparative benefits of differing therapeutic modalities. There are a limited number of trials of psychotherapies other than CBT. These include individual and group IPT, supportive expressive psychotherapy, and cognitive analytic psychotherapy. At the end of treatment the effectiveness of these treatments appears comparable with CBT, and in one study nonbehavioural treatments were shown to be more effective on long term follow-up. In this paper I would like to share our experince with using CBT to treat a whole range of eating disorders. Although CBT has not been claimed to be the best technique for treating these patients, techniques of CBT are improving, and more recent studies are showing greater impact.

Definition

Eating disorders considered in this article are anorexia nervosa, bulimia nervosa and bulimia. For a complete definition please refer to DSM IV. For simplicity, I have summarized the various criterias of the three conditions in the table below:-

NB. These are criterias used in CBT for treatment., many are secondary to overvalued ideas concerning weight and shape.
ANOREXIA NERVOSA BULIMIA NERVOSA BULIMIA
weight >25% below mean
 
 

ANOREXIA NERVOSA	BULIMIA NERVOSA	BULIMIA
weight >25% below mean     ego-syntonic  determined effort to maintain low body weight  dysmorphophobia         Intense fear of fatness and over concern with weight  amenorrhoea  impaired social functioning  obsessional features  “starvation syndrome”	normal weight but often with history of anrexia  ego-dystonic  recurrent binges with feeling of no control  compensatory behaviours-starving, vomiting, purging, diuretics, exercise  > fear of fatness and over concern with weight  > irregularity of periods  >impaired social functioning  >obsessional features  dysphoria	>20% above mean  ego-dystonic  repeated attemps to lose weight     dislike of body           preoccupation with food and weight, loathing of fatness  medical complication  social difficulties       dysphoria

 

Factors in Conceptualization
 

In formulating the problem, in all cases we have to consider all of the following aspects:-

1. Behavioural

 Assess whether the problems are learnt responses from stress management, replication of behaviour patterns of others or simply bad habits. Sometimes the behaviour is being reinforced by someone or some situation and there is the presence of secondary gain. There have also been cases of limited coping repertoire in some patients.

2. Cognitive

 The usual technique is to assess the negative automatic thoughts in the usual manner. Also look at facilitating beliefs, early maladaptive schematas and core beliefs as well as the thinking errors being used. The patient’s motivation and stage of preparedness needs to be assessed. Psychological craving is an important aspect of the assessment as well.

3. Affective

 Stress and boredom can be a precipitating or perpertuating factor of eating disorders and so is the mood. Negative emotions have been the cause of binge eatings or starvations.

4. Biological

 Physiological craving and withdrawal are important to assess as well. Physiological sensations and starvation factors contribute to the problem.

5. Systemic

 The reinforcements from the family and other social and cultural factors can precipitate or perpertuate the problem and needs to be included in the formulation.

Our Experience

Our limited experience with these disorders have given us some insight into managing them more easily and we would like to share the experience with all our colleagues. We have seen 5 cases of Bulimia (B), 3 cases of Bulimia Nervosa (BN) and one case of Anorexia Nervosa (AN) over the last two years.

BULIMIA

All the patients were females and their ages range from 30-40 years old. All of them presented with depression and were referred to us for depression and not for treatment of B which were missed at the OPD. The following core beliefs/dysfunctional assumptions were collected from some of them;

If I can’t have food, I won’t be able to bear the boredom
There is nothing left in life for me except food
I don’t have the power to stop
Even if I stop, I’ll only start again
I’m entitled to this

BULIMIA NERVOSA

There were three patients with 2 females and a male. Their ages range from 30-35 and they presented with depression and anxiety to the OPD. Some of their dysfunctional assumptions were;

If I eat something, it will all be converted to fat
If I eat tonight, I can’t bear to look in the mirror tomorrow, I’ll have to stay indoors and loose those weight
When I see someone who is overweight, I worry I’m going to be like her
If I’m not in control, I’ll loose all control
If I gain 1 kilo., I’ll go on to gain more weight
If I gained 3 kilos , that means I’m hopeless
I’m fat, nobody wants me
If people talk about my weight, I’ll die of shame
If I eat too much, that means I’m out of control

ANOREXIA NERVOSA

There was only one 22 year old female patient. Her dysfunctional assumptions were;

I am special if I am thin
Gaining any weight would make me overweight
I am contented the way I am
I am responsible for my weight

The dysfunctional assumptions were elicited after several sessions with each patient using the techniques of Socratic questioning, upward arrow and sentence completion tasks.

ANALYSIS OF DYSFUNCTIONAL ASSUMPTIONS (DAs)

After looking at the themes of the various DAs identified in the patients the following themes were isolated;

Bulimia                             I deserve this
                                           I need food to be happy
                                           Food is the only thing left

Bulimia Nervosa            I need to be in control
                                           If people talk about my weight, I won’t take it
                                           I worry about overweight.

Anorexia Nervosa         I am responsible/accountable for my weight
 

COGNITIVE PROCESSING IN OUR EATING DISORDER PATIENTS

Based on these findings it seems that there is a difference in the cognitive processing among the three eating disorders. Those with B and BN seem to have cognitive processing similar to those with substance abuse (deserving it and control issues) while those with AN seem to have cognitive processing similar to OCD (responsibility issues).
 

PERSONALITY PROFILE

Using cognitive processing as a criteria of assessing profile of personality traits among our patients, the following were found;

Bulimia

I’m fat, they’ll reject me                                      - AVOIDANT
I’m entitled to all this                                          - ANTISOCIAL

Bulimia Nervosa

I need food to be happy                                     - DEPENDENT
Only I control what I eat                                     - PASSIVE AGGRESIVE
I deserve all these                                               - NARCISSISTIC
I can go by my feeling                                        - HISTRIONIC

Anorexia Nervosa

I must keep at this weight perfectly, it’s best         - OBSESSIVE COMPULSIVE
Can’t trust them I know my weight                           - PARANOID
 

Looking at the actual personality profiles and DAs as described by Beck and Freeman (1990) we can see similarities of the DAs and the profiles of our patients. The table below shows some DAs of the personalities as described by Beck and Freeman (1990).
 
 
 
 

Personality Profile	Some Dysfunctional Assumptions/Core Beliefs as described by Beck & Freeman	Our patients’ diagnosis when they have similar DAs/CBs (Keywords in our patients are underlined)
AVOIDANT	It’s terrible to be rejected If they know the real me they’ll reject me Can’t tolerate unpleasant feelings	Bulimia
ANTISOCIAL	Entitled to break rules Others are patsies, wimps Others are exploitative	Bulimia
DEPENDENT	Need people to survive Need steady flow of support	Bulimia Nervosa
PASSIVE AGGRESIVE	Others interfere with my freedom Control by others is intolerable Have to do things my own way	Bulimia Nervosa
NARCISSISTIC	Since I’m special I deserve special rules I’m above the rules I’m better than others	Bulimia Nervosa
OBSESSIVE COMPULSIVE	I know what’s best; details are crucial, it must be perfect People should do better, try harder	Anorexia Nervosa
PARANOID	Motives are suspect Be on guard Don’t trust	Anorexia Nervosa
HISTRIONIC	People are there to serve or admire me They have no right to deny me my just deserts I can go by my feeling	Bulimia Nervosa

 
 
 

As such it seems that even the personality profiles of the different three groups appear to be different. All these means that the approach to these patients need to be different.

Core Beliefs in Eating Disorders

In a recent small study done in Oxford (Cooper et al, 1996), they found that there are more negative self beliefs in AN and BN compared to controls (AN=30%, BN=37%, C=3%). There were also more negative beliefs regarding weight, shape and eating in AN and BN compared with normal controls (AN=32%, BN=26%, C=2%). However both AN and BN had positive beliefs about others and this is comparable to the control group (AN=65%, BN=78%, C=75%). Their negative beliefs about the world are also comparable to normal controls (AN=65%, BN=50%, C=75%).

Technique

Having found the predominant DAs and CBs of the patients which technique should one attempt? There are many CBT techniques available and very frequently these are updated and improved because new findings provide new approaches to managing these patients. However the Fairburn approach (Fairburn, Cooper, 1993) is fairly popular and easy to do. The treatment is divided into three phases.

Phase 1

Is educating the patient and the teaching of self-monitoring for baseline information and the establishment of responsibility on the part of the patient. Behaviour intervention and problem solving is instituted at this phase.

Phase 2

Here the emphasis is purely cognitive. The usual processes of identification and modification of DAs, beliefs, values/CBs are carried out here.

Phase 3

This phase uses CBT to maintain the change that have been instituted and also deals with termination.

Conclusion

1.  It seems that B and BN are closer to substance dependence in their cognitive processing while AN is closer to OCD. As such if the CBT approach is to be used in treatment then the two groups of patients need to be approached differently. The B/BN patients would require us to work on their deserving for food and need for control while the AN requires the responsibility approach.

2.  B/BN/AN all have different personality profiles based on their DAs and CBs. This again means that we need to approach them differently and this could account for their presentation in (1) above.

3.  AN/BN have more negative beliefs about self and the world but not of others. This could be used to advantage in psychotherapy as their positive beliefs about others including the therapist helps in rapport development and therapy process.

4.  It is important to build positive beliefs as well as challenge and change negative beliefs in these patients.

I must admit that the patient sample that we have is extremely small to make significant conclusions but they seem to show some pattern. We hope to continue collecting data and see if any other pattern emerges. We also welcome suggestions or collaboration with anyone interested in this topic. PERSIKOL will help to coordinate research in this area.

References

Beck AT, Freeman A (1990) Cognitive  profiles. In Cognitive Therapy of Personality Disorders, 40-57,Guilford Press, New York.

Cooper M, Todd G, Cohen-Tovee E (1996) Core beliefs in eating disorders, International Cognitive Therapy Newsletter,10,1,2-3

Fairburn C, Cooper P (1993) Eating Disorders. In Cognitive Behaviour Therapy for Psychiatric Problems, K. Hawton, PM Salkovskis, J Kirk, DM Clark (Eds), 277-314, Oxford University Press

King MB (1991) The natural history of eating pathology in attenders to primary care. International Journal of Eating Disorders,10,379-387
 

Assoc. Professor Dr. Azhar M. Zain
Consultant Psychiatrist & Psychotherapist
Psychotherapy Clinic
USM Hospital
Kubang Kerian
16150 Kota Bharu