464 CHAPTER 10
For bulimia, antidepressants—particularly SSRIs—may reduce some symptoms
of the eating disorder. Compared to placebos, SSRIs can help decrease bingeing,
vomiting, and weight and shape concerns, although other symptoms may still
persist—including a fear of normal eating (Bacaltchuk, Hay, & Mari, 2000; Mitchell
et al., 2001). Symptoms of comorbid depression may also be reduced by SSRIs. The
SSRI prozac (fl uoxetine) is the most widely studied medication for bulimia, and the
FDA has approved it to treat this disorder. Studies of Prozac’s effects on bulimia
typically last no longer than 16 weeks, however, so it isn’t clear how long the medi-
cation should be taken (de Zwaan, Roerig, & Mitchell, 2004). Moreover, as with
other disorders, the benefi cial effects of medication used to treat eating disorders
typically stop soon after the medication is discontinued.Targeting Psychological Factors:
Cognitive-Behavior Therapy
Among the treatments that directly target psychological factors, CBT is the most
extensively studied and is considered the treatment of choice (Pike, Devlin, & Loeb,
2004). CBT for eating disorders focuses primarily on changes in thoughts, feelings,
and behaviors that are related to eating, food, and the body, at least in the initial
stages. At the outset of treatment, the patient and therapist discuss who monitors
the patient’s weight and at what point inpatient treatment would be recommended
and pursued (Pike, Devlin, & Loeb, 2004).CBT for Anorexia
CBT for anorexia focuses on identifying and changing thoughts and behaviors that
impede normal eating and that maintain the symptoms of the disorder. Cognitive
restructuring can decrease the patient’s irrational thoughts (such as the belief that
starving means having self-control) and help the patient develop more realistic
thoughts (for example, that appropriate eating indicates the ability to care for
herself). The therapist also helps the patient to develop more adaptive coping
strategies (Bowers & Ansher, 2008; Garner, Vitousek, & Pike, 1997; Wilson &
Fairburn, 2007), such as expressing anger or disappointment directly to other
people rather than hiding or denying such “negative” feelings. Treatment may
also involve psychoeducation (about the disorder and its effects), training in self-
monitoring (to notice hunger cues and become aware of problematic behaviors),
and relaxation training (to decrease anxiety that arises with increased eating). Be-
cause low weight can affect cognitive functioning, irrational thoughts may not
change substantially until the patient’s weight increases (McIntosh et al., 2005).
CBT can be effective in reducing symptoms of anorexia and has been shown to
prevent relapses (Pike et al., 2003).
Because people with anorexia may not seek help voluntarily, motivation (or
resistance) to change is often more of an issue than it is in the treatment of other
disorders. Motivational enhancement therapy (see Chapter 9) may be employed to
increase patients’ willingness to change; with anorexia, this treatment might ad-
dress the patient’s goals that are unrelated to eating, food, and weight, and help her
see how her behaviors—and the eating disorder symptoms—interfere with attaining
those goals.CBT for Bulimia
When used as a treatment for bulimia, CBT focuses on the thoughts, feelings, and
behaviors that (1) prevent normal eating and (2) promote bingeing, purging,
and other behaviors that are intended to offset the calories ingested during a binge.
CBT also addresses thoughts, feelings, and behaviors that are related to body im-
age and appearance and that maintain the symptoms of bulimia. In addition to
focusing on symptoms of the disorder, CBT may address perfectionism, low self-
esteem, and mood issues (Wilson & Fairburn, 2007). CBT for bulimia uses many