Cognitive behaviour therapy for eating disorders: a “transdiagnostic” theory and treatment

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Abstract

This paper is concerned with the psychopathological processes that account for the persistence of severe eating disorders. Two separate but interrelated lines of argument are developed. One is that the leading evidence-based theory of the maintenance of eating disorders, the cognitive behavioural theory of bulimia nervosa, should be extended in its focus to embrace four additional maintaining mechanisms. Specifically, we propose that in certain patients one or more of four additional maintaining processes interact with the core eating disorder maintaining mechanisms and that when this occurs it is an obstacle to change. The additional maintaining processes concern the influence of clinical perfectionism, core low self-esteem, mood intolerance and interpersonal difficulties. The second line of argument is that in the case of eating disorders shared, but distinctive, clinical features tend to be maintained by similar psychopathological processes. Accordingly, we suggest that common mechanisms are involved in the persistence of bulimia nervosa, anorexia nervosa and the atypical eating disorders. Together, these two lines of argument lead us to propose a new transdiagnostic theory of the maintenance of the full range of eating disorders, a theory which embraces a broader range of maintaining mechanisms than the current theory concerning bulimia nervosa. In the final sections of the paper we describe a transdiagnostic treatment derived from the new theory, and we consider in principle the broader relevance of transdiagnostic theories of maintenance.

Introduction

This paper is concerned with the psychopathological processes that account for the persistence of the full range of severe eating disorders. For clarity, we take as our starting point bulimia nervosa and its cognitive behavioural theory and treatment (CBT-BN) since both have been well-specified and extensively studied. The treatment was first described by Fairburn in 1981 (Fairburn, 1981). Several years later further procedural details were described (Fairburn, 1985) together with a more complete exposition of the theory upon which it was based (Fairburn, Cooper, & Cooper, 1986). A full treatment manual was published in 1993 (Fairburn, Marcus, & Wilson, 1993b) and this has been widely used in subsequent treatment trials (e.g., Agras, Crow, Halmi, Mitchell, Wilson and Kraemer, 2000a, Agras, Walsh, Fairburn, Wilson and Kraemer, 2000b, Fairburn, Jones, Peveler, Hope and O’Connor, 1993a). As a result of further experience across different treatment centres, a supplement to the manual was published in 1997 in which aspects of its implementation were discussed (Wilson, Fairburn, & Agras, 1997). The theory was elaborated in the same year (Fairburn, 1997a).

Section snippets

The cognitive behavioural theory

The theory that underpins CBT-BN is primarily concerned with the processes which maintain bulimia nervosa, although it is also of relevance to the development of the disorder. According to the theory, central to the maintenance of bulimia nervosa is a dysfunctional system for evaluating self-worth. Whereas most people evaluate themselves on the basis of their perceived performance in a variety of domains of life (e.g., the quality of their relationships, work, parenting, sporting ability, etc),

A new cognitive behavioural theory of the maintenance of bulimia nervosa

The new theory represents an extension of the original theory illustrated in Fig. 1. Specifically, it is proposed that in certain patients one or more of four additional maintaining processes interact with the core eating disorder maintaining mechanisms shown in Fig. 1 and that when this occurs it is an obstacle to change. The first of these additional maintaining mechanisms concerns the influence of severe perfectionism (“clinical perfectionism”); the second concerns the impact of

A transdiagnostic perspective

We now turn to our second line of argument, that concerning transdiagnostic maintaining mechanisms, starting with anorexia nervosa.

The transdiagnostic treatment

In this paper we have proposed that a network of inter-related maintaining mechanisms accounts for the persistence of anorexia nervosa, bulimia nervosa and the atypical eating disorders. This network is illustrated in schematic form in Fig. 4. More specifically, we have suggested that in the great majority of cases there is a central cognitive disturbance characterised by the over-evaluation eating, shape and weight and their control, and that in subgroups of these patients one or more of four

Broader implications

It has not escaped our attention that this transdiagnostic approach to theory and treatment has implications beyond the field of eating disorders6. We therefore close this paper by addressing the circumstances under which such a strategy is likely to be of value.

In principle,

Acknowledgements

All three authors are supported by the Wellcome Trust: CGF is supported by a Principal Research Fellowship (046386); ZC is supported by a programme grant (046386); and RS is supported by a Research Career Development award (063209). Without the Wellcome Trust’s sustained support this work would not have been possible. The ongoing transdiagnostic trial is being conducted in collaboration with Dr Robert Palmer of the University of Leicester. This trial is funded by the programme grant from the

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    This paper is based upon a keynote address given by CGF at the Annual Meeting of the British Association for Behavioural and Cognitive Psychotherapies held in Glasgow in July 2001. The three authors contributed equally to this paper

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