The goals of manual-based cognitive-behavioral therapy (CBT) and nutritional counseling for eating disorders are similar, namely, eliminating dysfunctional patterns of eating. Modifying these behaviors requires specific therapeutic expertise in the principles and procedures of behavior change that is not typically part of the training of nutritionists and dieticians or mental health professionals without specific expertise. We discuss ways in which principles of behavior change can be applied to eating disorders by non-CBT experts. Specific nutritional rehabilitation programs have the potential to augment CBT in addressing the array of appetitive abnormalities present in eating disorder patients. The dysfunctional appetitive, hedonic, and metabolic characteristics of patients with bulimia nervosa (BN) and binge eating disorder are reviewed. These abnormalities constitute potential target areas that might be more fully addressed by nutritional interventions designed to restore normal appetitive function.
Cognitive-behavioral therapy (CBT) is the most intensively investigated and best empirically supported treatment for bulimia nervosa (BN) (American Psychiatric Association, 2000). CBT is quick-acting; produces a clinically significant degree of improvement across all four of the specific features of BN, namely, binge eating, purging, dietary restraint and abnormal attitudes about body shape and weight; reduces associated psychopathology (e.g., depressed mood); and is associated with good maintenance of change at 1-year follow-up Agras et al., 2000 and Fairburn et al., 1995. CBT is significantly more effective than either pharmacological or alternative psychological treatments with which it has been compared Wilfley & Cohen, 1997 and Wilson & Fairburn, 1998. As such, it is the first-line treatment of choice for BN (Walsh et al., 1997).
CBT is based on a cognitive model of what maintains BN (Fairburn, 1997). Social pressures on women to be thin results in overvaluation of body weight and shape. This leads them to restrict their food intake in rigid and unrealistic ways, a process that leaves them physiologically and psychologically susceptible to periodic loss of control over eating, namely binge eating. Purging and other extreme forms of weight control are the person's attempt to compensate for the effects of binge eating. Purging helps maintain binge eating by reducing the individual's anxiety about potential weight gain and disrupting learned satiety that regulates food intake. In turn, binge eating and purging cause distress and lower self-esteem, thereby reciprocally fostering the conditions that will inevitably lead to more dietary restraint and binge eating. Treatment is directed at reducing dietary restraint in favor of more normal eating patterns, developing cognitive and behavioral skills for coping with high risk situations that trigger binge eating and purging, and modifying dysfunctional thoughts and feelings about the personal significance of body weight and shape (Fairburn, Marcus, & Wilson, 1993).
Manual-based CBT has also been shown to be effective in treating BED, although, unlike the case of BN, it is not superior to alternative treatments such as interpersonal psychotherapy (IPT) or traditional behavioral weight loss control programs Marcus et al., 1995 and Wilfley, 1999.
