Abnormal Psychology

Eating Disorders 465

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of the same methods as for anorexia: psychoeducation, cognitive restructuring,

self-monitoring, and relaxation. In addition, treatment may employ a method used

to treat obsessive-compulsive disorder (OCD):exposure with response prevention

(discussed in Chapters 4 and 7). For bulimia, this method generally involves expos-

ing the patient to anxiety-provoking stimuli, such as foods she would typically eat

only during a binge. Patients are asked to consume a moderate amount of the binge

food during a therapy session (the exposure), and the response prevention involves

not purging or responding in another usual way to compensate for the calories

ingested. The benefi ts of CBT for bulimia are well documented (Agras, Crow, et al.,

2000; Fairburn et al., 1995; Ghaderi, 2006; Walsh et al., 1997).

Researchers have proposed three possible mechanisms to explain the benefi cial

effects of CBT as a treatment for bulimia (Wilson et al., 2002):

1. CBT leads to more normal eating.


2. CBT decreases patients’ dietary restrictions, which reduces the risk of bingeing
   (and subsequent purging) because of hunger or inadequate nutrition.


3. CBT increases patients’ ability to cope with potential triggers of bingeing and
   purging, which increases a sense of self-effi cacy, which in turn further decreases
   bingeing and purging (Wilson & Fairburn, 2007).

Using CBT Manuals to Treat Eating Disorders

CBT manuals have been adapted for both anorexia and bulimia, although clini-

cians often need to deviate from the manuals (see Chapter 5 for a more general

discussion about manual-based treatment). Such manuals provide a session-

by-session guide with specifi c goals and techniques. As shown in Table 10.5,

manual-based treatment may last 20 sessions or less, and generally consists of

three phases, each of which has a different focus and uses different techniques.

The fi rst phase focuses on the behaviors themselves; the second focuses on the

thoughts that underlie such behaviors; and the third focuses on how to prevent

relapse. Research has shown that relapse is more likely to occur after treatment

that uses behavioral techniques only and does not address the inappropriate

thoughts about weight and appearance that underlie the problematic behaviors

(Fairburn et al., 1993). Here’s a therapeutic interchange from the second phase

of treatment, addressing the underlying cognitive distortions that contribute to

disordered eating behavior:

Therapist (T): Did you notice any situations leading to binge episodes or urges to binge

in the past week that involve problem thoughts?

Patient (P) Well, I binged after skiing one day. I was upset, because I went skiing

and the people were nicer to my friend than they were to me and I was

sure that it was because she is thinner and prettier than I am.

T: I’m hearing some faulty reasoning here. Let’s work to uncover the un-

derlying problem thought.

Phase of

Treatment Focus of Phase Techniques Employed

Phase 1 Behavioral symptoms related to food and

appearance

Psychoeducation; self-monitoring; assignments to normalize

eating and decrease bingeing and purging, including

exposure with response prevention

Phase 2 Cognitive symptoms related to the eating

disorder

Cognitive restructuring of illogical thoughts pertaining to

food, weight, appearance, purging, and self; problem solving

Phase 3 Relapse prevention Problem solving about possible eating and appearance

concerns or other factors likely to lead to relapse

Sources: Fairburn, Marcus, & Wilson, 1993; Pike, Devlin, & Loeb, 2004.

Table 10.5 • Three Phases of CBT for Bulimia