Myra Cooper

A cognitive model of bulimia nervosa.

This paper describes a new cognitive model of bulimia nervosa. It provides a detailed account of the development of the disorder and explains, in detail and encompassing cognition, behaviour, emotion, and physiology, how binge eating is maintained. Relevant maintaining factors include positive beliefs about eating, negative beliefs about weight and shape, permissive thoughts, and thoughts of no control. Relevant developmental factors include negative early experiences, negative self-beliefs, schema compensation processes, and different types of underlying assumption. Recent empirical findings on which the new model is based, and which support the model, are described. Existing observations and findings are also presented, and their consistency with the new model is confirmed. Novel features of the model are highlighted, and phenomena unexplained by existing cognitive models of bulimia nervosa, including treatment failure and relatively poor outcome following treatment with cognitive therapy, are assessed in the light of the new model. The relationship to recent findings on the role of dieting in bulimia nervosa and to developments in the understanding or normal eating is considered. Implications for basic and treatment-related research are then discussed. Finally, the clinical implications of the new model, including the use of schema-focused techniques, are briefly discussed.

Thoughts about eating, weight and shape in anorexia nervosa and bulimia nervosa

Concurrent verbalisation and a self-report questionnaire were used to investigate self-statements in patients with anorexia nervosa, patients with bulimia nervosa, two groups of dieters and non-dieting controls. Thoughts were collected while subjects performed three behavioural tasks, looking at themselves in a full-length mirror, weighing themselves and eating a chocolate covered mint. Both groups of patients had more negative thoughts related to eating, weight and shape than those in the three control groups. In addition, patients with anorexia nervosa showed a greater concern with eating while patients with bulimia nervosa showed a greater concern with weight and appearance. Differences were found between the patients and non-dieting controls using both methods but the self-report questionnaire was less sensitive than concurrent verbalisation to differences between the patients and dieters. Implications of the findings for cognitive-behavioural treatments of the two disorders are discussed.

Spontaneously occurring images and early memories in people with body dysmorphic disorder

A semi‐structured interview assessing the presence and characteristics of spontaneous appearance‐related images was designed and administered. A total of 18 patients with body dysmorphic disorder (BDD) and 18 normal controls took part. The BDD patients were found to have spontaneously occurring appearance‐related images that were significantly more negative, recurrent, and viewed from an observer perspective than control participants. These images were more vivid and detailed and typically involved visual and organic (internal body) sensations. The study also found that BDD images were linked to early stressful memories, and that images were more likely than verbal thoughts to be linked to these memories. Implications for theory and clinical practice are discussed.

Possible risk factors in the development of eating disorders in overweight pre-adolescent girls

OBJECTIVES: To investigate concerns about weight, shape and eating, dietary restraint, self-esteem and symptoms of depression in overweight girls. To investigate the relationship between concerns and self-esteem and depressive symptoms in this group.METHOD: Eighteen overweight girls and 18 average-weight girls completed the child version of the Eating Disorders Examination, the Harter Self-Perception Profile and the Short Moods and Feelings Questionnaire.RESULTS: Overweight girls had more concerns about weight, shape and eating and attempted dietary restraint more often. They had more negative self-esteem related to their athletic competence, physical appearance and global self-worth and more symptoms of depression. There was an association between concerns and self-esteem based on physical appearance in the overweight group.CONCLUSION: Overweight girls show some of the psychological features associated with the development of eating disorders, including a link between concerns and self-esteem based on physical appearance. This may help to explain why childhood obesity increases the risk of a later eating disorder.

Cognitive Theory in Anorexia Nervosa and Bulimia Nervosa: A Review

This paper reviews cognitive theories of eating disorders as they are usually applied in treatment. More recent theoretical contributions and theory that is not widely applied are also reviewed. A set of hypotheses is derived from these theories and evidence for the validity of each hypothesis is discussed: this includes evidence from treatment studies, questionnaire studies and from experimental psychology. Following review of existing evidence, the paper summarizes the current status of cognitive theory in eating disorders. It then considers ways in which theory and research could be developed in order to improve and extend our understanding of cognitive content and processes in eating disorders. Limitations of existing models are highlighted and gaps in our knowledge, including knowledge of variables that typically have a central role in cognitive theory, are identified. Further strategies to test the validity of hypotheses derived from cognitive theory are suggested, together with strategies that might extend existing theory. It is concluded that much further research is needed, both to test the validity of existing theoretical contributions and to extend theory so that it will be more useful in clinical practice.

The Eating Disorder Belief Questionnaire: Preliminary development

This paper describes the development of a self-report questionnaire designed to assess assumptions and beliefs associated with eating disorders. Factor analyses suggested to replicable four-factor structure consisting of the following dimensions: negative self-beliefs; weight and shape as a means to acceptance by others; weight and shape as a means to self-acceptance; and control over eating. The subscales possess good psychometric properties and significant correlations were found between the subscales and other measures of the specific and general psychopathology of eating disorders. The questionnaire also distinguished two groups of patients with eating disorders from normal controls. The usefulness of the measure and implications of the findings for cognitive theories of eating disorders are briefly discussed.

Core beliefs and underlying assumptions in bulimia nervosa and depression.

In a pilot study, core beliefs and underlying assumptions were investigated in patients with bulimia nervosa, patients with depression and female controls, using a new self-report measure. The patients with bulimia nervosa did not differ from the patients with depression in negative self beliefs but they did differ in assumptions concerned with weight, shape and eating. Both groups of patients also differed from the female controls, with the exception of one comparison including the depressed patients. The findings support recent developments in cognitive theories of eating disorders. Treatment implications are briefly discussed.

Content, Origins, and Consequences of Dysfunctional Beliefs in Anorexia Nervosa and Bulimia Nervosa

A semi-structured interview was used to investigate negative self beliefs in female patients with eating disorders and women without an eating disorder history. Information about possible developmental influences on these beliefs was also collected. Beliefs linking eating behavior with weight and shape and beliefs about the self were identified, but only by the patients. Self-beliefs were invariably negative and unconditional. Beliefs about eating, weight and shape were usually in the form of conditional assumptions. Most patients identified specific origins for their negative self-beliefs: usually trauma or abuse in childhood. All patients believed that dieting was a way of counteracting the negative implications associated with their self-beliefs. Bingeing seemed to provide an initial distraction in some cases from negative automatic thoughts, images, negative self-beliefs and negative emotional states. However, after bingeing, these intensified. Implications for cognitive theories of eating disorders and for clinical practice are discussed.

Demographic and clinical correlates of selective information processing in patients with bulimia nervosa.

Demographic and clinical correlates of interference with color-naming words related to eating, weight, and shape were investigated in 75 patients with bulimia nervosa. Interference with color-naming was related to two measures, overall level of psychiatric symptoms and frequency of purging. Multiple regression analysis showed that frequency of purging, and not level of general psychiatric symptoms, was the best predictor of interference. Thus, as would be predicted by cognitive theories, interference appears to be most closely related to features specific to bulimia nervosa rather than to measures of general psychopathology.

Emotional processing in women with anorexia nervosa and in healthy volunteers.

Emotional processing was investigated in patients with anorexia nervosa (AN) and in healthy volunteers (HVs) using self report questionnaires and information processing tasks. Compared to the HVs, patients with AN had lower levels of self reported emotional awareness and expression. They also responded more slowly to, correctly identified fewer emotions and misclassified more emotions in a facial recognition task, and responded more slowly to, and recalled fewer, self-referent emotion words. There were no key differences between the two groups on non-emotional control tasks, suggesting that their deficits are specific to emotional information and not a general feature of the illness. Analysis indicated that some, but not all, of the differences found remained when depressive symptoms were taken into account. Exploratory analysis of sub-groups (medicated vs. unmedicated patients) indicated that those who were on medication may perform very differently from those who were not on medication, including when level of depression is controlled, although it is important to emphasise that these findings are preliminary. The implications of a deficit in emotional processing in those with AN, including discussion of the specific differences found between medicated and unmedicated, are discussed in relation to previous findings in the area. A number of implications for future research, theory and therapy with those with AN are discussed.