Reprinted from Eating Disorders Review
March/April 2004 Volume 15, Number 2
©2004 Gürze Books
Three British researchers have recently developed a new cognitive model for bulimia nervosa (BN) that highlights the development and maintenance of the disorder, and also explores some reasons why binge eating is so persistent (Br J Clin Psychol 2004;43:1).
Dr. Myra J. Cooper, of Warneford Hospital, Oxford, UK, and two colleagues developed their model based on recent developments in cognitive theory, particularly Beck’s general schema and schema-based avoidance and compensatory behaviors. They also followed the idea that conflicting and interacting beliefs and unhelpful coping strategies are involved in maintaining some disorders.
The researchers initially conducted detailed semi-structured interviews with 12 female patients with DSM-III-R diagnoses of BN, assessing each patient’s most recent episodes of binge eating. They recorded the patient’s thoughts and feelings before, during, and after bingeing, and questioned the women about compensatory behaviors and dieting. Dr. Cooper and colleagues continued the interviews using Burn’s downward arrow technique (Burns, 1980) to identify underlying assumptions and core beliefs as well as any schema-driven processes and early experiences that might have contributed to the development of BN.
Negative experiences and development of BN
Negative or traumatic experiences in early childhood, such as neglect or indifference by parents, and, in extreme cases, sexual, physical, or emotional abuse, may lead to dysfunctional beliefs, especially negative self-beliefs, according to the authors. Experiences in adolescence may also give rise to negative self-beliefs. A person may then try to compensate for these negative self-beliefs. Dieting is the most common compensatory method. The person may believe that dieting will ensure that they will be accepted by others (‘If I lose weight, others will like me more’) and that they will be more acceptable to themselves (‘If I lose weight, it means I’m successful’). Usually, however, there are negative counterpoints to these positive assumptions (‘if I gain weight, then I have failed.’)
Maintaining bulimic behaviors
According to the authors, four specific types of cognitions are active in the vicious circles that maintain episodes of binge eating: (1) positive beliefs about eating, (2) negative beliefs about weight and shape, (3) thoughts of having no control, and (4) permissive thoughts.
An episode of binge eating may be preceded by the activation of negative beliefs about the self as an ‘acceptable’ person. Events that trigger binge eating may be related to eating, weight and shape—for example, this could be a remark about the person’s weight or how much they are eating, or catching sight of oneself in a mirror—or may be unrelated to weight or appearance. Some examples of this are an argument with a partner or making a mistake at work. The trigger then activates a negative self-belief (‘I’m unlovable’ or ‘I’m a failure’). People with eating disorders learn to manage negative self-directed emotions such as these by eating, for eating and the associated preoccupation with food gives them a distraction from the negative emotions. It also produces changes in cognition and through direct physiologic pathways and changes in interoception (including emotional states and sensations of hunger and satiety, according to the researchers.
Eating is commonly linked to a generally lowering of arousal and a general decrease of arousal and in the intensity of emotional states. At first these are interpreted positively and eating is thus linked to positive beliefs. However, eating behavior cannot help the patient restructure negative self-beliefs; thus, for those with BN, eating, especially overeating, is also linked with negative beliefs about the potential consequences. Thus, the person with BN is placed into a state of conflict in which both positive and negative beliefs about eating coexist.
The authors believe their model can be helpful for explaining changing and alternating patterns of behavior in which the individual binges and then uses other behaviors, including purging, to compensate for it. The dissonance between these two conflicting sets of beliefs is resolved by permissive thoughts and/or by thoughts of having no control. Once permissive thoughts and thoughts of no control are activated, eating takes place. After eating, negative self-appraisals ad associated negative emotions activate negative beliefs about eating once more, completing the vicious circle.
Triggering binge eating
There is much evidence that binge eating in BN is preceded by considerable emotional and cognitive distress. Anxiety is the most commonly reported emotion that precedes binge eating. Higher-than-average levels of depression have also been reported in these patients. There is also some suggestion that negative cognitions, especially thoughts or feelings of loneliness may also precede or trigger bingeing. Bodily sensations, particularly feeling hungry or feeling full, may also trigger the binge cycle. Feeling full may make a patient feel she lacks control over eating.
The new model has a number of implications for treatment using cognitive therapy; mainly, according to the authors, it suggests that both maintenance and developmental processes will need to be addressed in each case. Each of the different types of cognitions that maintain episodes of binge eating will need to be tackled, perhaps with verbal restructuring and graded behavioral experiments. For beliefs involved in the development of BN, a useful approach might be standardized techniques, including both verbal restructuring and behavioral experiments (in which the individual tests his own underlying assumptions to see if they stand up to realistic challenges). Schema-focused techniques might also be helpful.