22. Anorexia nervosa: a cognitive-behavioural approach, Nursing Standard
(C) Copyright 1999 RCN Publishing Company Ltd.
Volume 13(19), 27-February 2 January 1999, pp 43-47
People with anorexia nervosa can be resistant to treatment because they do not
feel the therapist is on their side.This article focuses on the need to
establish a therapeutic relationship before interventions can begin. The author
also outlines important factors in the onset and maintenance of anorexia
Anorexia nervosa is a puzzling but dangerous illness during which a young person
- usually an adolescent female who is often attractive, intelligent and talented
- endeavours to starve herself. The illness was first recognised during the
1870s but did not become widely reported until the 1970s. By the mid 1980s
anorexia nervosa was a highly publicised disorder. While the disorder does
involve unusual eating patterns, a central focus is the intense pursuit of
thinness and a phobic dread of becoming fat (Gordon 1990). 
Four essential criteria must be present for a diagnosis of anorexia nervosa (APA
- The individual, usually female and either late adolescent or young adult,
maintains a body weight less than 85 per cent of the weight considered normal
for that person's age and height.
- The individual has an intense fear of gaining weight or becoming fat, and
weight loss does not diminish this fear.
- Individuals have a perceptual disturbance in the way their body shape and
weight are experienced.
- In post-menarcheal females, amenorrhoea prevails.
Palmer (1990)  suggested that there are two related types of the disorder:
- Restrictive - characterised by strict fasting and a rigid exercise regime.
- Binge-eating/purging - the person self-induces vomiting and/or misuses
laxatives and/or diuretics.
The associated physical and psychological manifestations of both types are shown
in Boxes 1 and 2.
Box 1. Physical signs of anorexia nervosa
- Abdominal pain
- Cardiac problems
- Cold intolerance
- Dental enamel erosion
- Impaired renal function
Box 2. Psychological signs of anorexia nervosa (Crisp 1980)
- Distorted attitude towards eating, food, body-shape and weight
- Obsessive/compulsive preoccupation with food
- Parasuicidal behaviour
- Reduced sexual libido
- Suicidal ideation
Anorexia nervosa is a complex disorder, and no single factor has been identified
as a cause. It is probably best understood as the result of the interaction
between various familial, sociocultural and biological factors.
Family dysfunction Kenny (1991)  and Palmer (1990)  emphasised the
interpersonal processes in the family that may provoke an episode of anorexia
nervosa. Kenny (1991)  suggested that an anorexic person:
- Comes from a family which discourages him or her from making outside contact.
- Is expected to succeed and achieve.
- Is oppressed by domineering parents.
As a result, people with anorexia have a profound sense of ineffectiveness and
an inability to influence the environment around them. Family dysfunctions have
been labelled more precisely by Palazzoli (1974)  as:
- A rejection of communicated messages.
- Poor conflict resolution.
- A covert alliance of family members.
Minuchin (1978)  also labelled these dysfunctions:
- Lack of conflict resolution.
When describing enmeshment, Fretwell (1991)  suggested that a coalition
develops between one parent and the anorexic child where the child subordinates
his or her own needs to protect the parent. For example, a child may assume
responsibility for organising household duties when she witnesses her father
continually undermining her mother's efforts.
Faulty core schema (self, other and world beliefs) may be an end product of such
Sociocultural factors In epidemiological terms, anorexia nervosa is more common
in females, develops during adolescence and is seen more often in affluent
social classes. This suggests underlying sociocultural factors (Garner and
Garfinkel 1980).  Szmukler (1985)  suggested that the increasing
prevalence of the disorder is a result of a cultural emphasis on thinness and
men's aesthetic preference for slim women. Gordon (1990)  suggested three
factors that make anorexia nervosa a phenomenon specific to changing western
- Changing female role.
- A preoccupation with appearance and body image.
- A culturally pervasive preoccupation with weight.
The new emphasis on female achievement and performance is an acute reversal from
traditional role definitions. This dissonance may further fuel the development
of problematic beliefs.
Biological factors Russell (1977)  suggested that a disorder of hypothalamic
function may play a role in the aetiology of anorexia nervosa. There is evidence
for a hypothalamic disorder in anorexia nervosa, although such disturbances are
usually secondary to malnutrition and weight loss (Palmer 1990). 
Before the onset of the illness, the person may experience a triggering event,
- Interpersonal conflict.
- The onset of secondary sexual development.
- Moving home.
- Starting a new school.
- Physical assault.
- Verbal assault.
The trigger may activate faulty schemata and cause the person to experience low
self-esteem, ineffectiveness and psychological distress. For whatever reason,
people arrive at the idea that losing weight will dissolve their suffering, give
back a sense of control, and increase their self-worth.
(Figure 1) shows how the disorder may escalate following its onset. It is not
entirely clear that cognitive distortions are conscious at this stage, nor
whether these distortions stimulate the dieting behaviour. They may emerge in
response to the distress created by the person's fear of weight gain. Figure 2
shows how the disorder self-perpetuates (Kleifield 1995). 
Figure 1. Anorexia nervosa: onset
Figure 2. Anorexia nervosa: maintenance (Kliefield 1995) 
Much of an anorexic person's behaviour involves trying to avoid a feared
stimulus, such as fatness or weight gain. Dieting, exercise, vomiting and using
laxatives or diuretics increase after negative reinforcement. Weight loss brings
positive reinforcement - the person feels gratified and relieved by the
achievement. The physiological and psychological effects of starvation give the
person false messages about body size, shape and satiety. These messages,
coupled with existing problematic thoughts such as 'I'm ugly', 'I'm fat', cause
more dieting. Weight loss becomes the yardstick of self-evaluation and the
person's self-esteem is determined by success in the pursuit of thinness (Garner
and Bemis 1982). 
THE THERAPEUTIC RELATIONSHIP
Cognitive behaviour therapy is an important psychological approach to the
treatment of anorexia nervosa (Halek 1997, Padesky and Greenberger 1995, Wiseman
et al 1998). [15,20,32] It is often difficult to gain compliance in this form of
therapy because the client may feel that the therapist is promoting all that he
or she is fighting against. Vitousek (1996)  and George (1997)  stated
that the development of a strong therapeutic alliance is an important element of
treatment. In such a relationship, the therapist is warm, positive, honest,
empathetic and courteous. Cognitive behaviour therapy also develops an immediate
collaborative relationship between client and therapist through a process of
collaborative empiricism (Safran and Segal 1996).  The therapist guides the
client towards those distorted perceptions that are inconsistent with reality.
This is achieved using Socratic questioning (Box 3), a four-stage process
(Padesky 1993)  in which the therapist asks the client questions that:
- He or she has the knowledge to answer.
- Draw the client to information relevant to the issues being discussed.
- Move concepts from the concrete to the abstract.
- Allow the client to apply new information and either re-evaluate previous
conclusions or construct a new one.
Box 3. Useful Socratic questions
- What was it about this situation that was so awful?
- What is the worst thing that could happen if this were true?
- If your best friend or someone you loved thought this, what would you tell
- What evidence would they point out to you which would suggest your thought is
not 100 per cent true?
Other important aspects of collaboration include:
- Involving the client in clinical decision making.
- Eliciting regular feedback from the client about his or her views on treatment
- Actively encouraging teamwork between client and therapist.
Safran and Segal (1996)  recommended empathy as a means to enhance the
quality of the therapeutic alliance. When a client contacts new feelings, the
therapist's perceived reaction is critical in determining whether the experience
will be therapeutic. An accepting and empathic response to the expression of
painful feelings may help the client to 'own' this experience. This can lead to
a positive change in the client's sense of self.
Being heard, understood, and acknowledged are all necessary factors in a
therapeutic relationship. Empathy assists in positive outcome (Rogers 1967),
 constructive change (Authier 1986)  and self-esteem enhancement
(Williams 1989).  Burns and Nohen-Hoeksema (1992)  attempted to identify
specific therapeutic skills that affect treatment outcome. They concluded that
the quality of the therapeutic relationship significantly affected the clinical
outcome in the treatment of depression using cognitive behaviour therapy. In
particular, they identified the therapist's warmth, genuine interest in the
client and use of reflection - factors also suggested by Egan (1990).  The
therapist can convey empathy to the client in other ways, for example:
- Using language similar to the client's, with a similar tone of voice (Gazda
- Sitting facing the client.
- Using appropriate levels of eye contact.
- Offering, with sensitivity, a mirror image of the client's body posture and
gestures (Mansfield 1973). 
These skills will help to develop a therapeutic relationship in which there is
collaboration between therapist and client. The therapist can use the assessment
framework suggested by Fairburn and Cooper (1989)  to assess the client's
needs (Box 4).
Box 4. Assessment framework (Fairburn and Cooper 1989)
- Exact nature of the problem as seen by the client
- Specific psychopathology including:
- Attitude to body shape and weight
- Eating habits
- Methods of weight control
- Dysfunctional beliefs
- General psychopathology/mental health assessment
- Social circumstances
- Physical health
The next step is to help the client gradually to restore weight and to
restructure his or her problematic thoughts. Fairburn and Cooper (1989) 
suggested a wide range of interventions (Box 5).
Box 5. Interventions in the treatment of anorexia nervosa (Fairburn and Cooper
- Provide a cognitive-behavioural model of anorexia nervosa and a rationale
- Educate and inform about:
Dangers of weight reduction
Normal weight regulation
- Normalise eating habits by
Gradual introduction of avoided foods
- Identify dysfunctional thoughts
- Cognitive restructuring techniques
- Self-esteem enhancement
- Relapse prevention
Bibliotherapy Offering the client written information about the illness helps to
develop the collaborative relationship by demystifying the illness. It shows
that the therapist is prepared to share his or her knowledge openly and
honestly. Reading can help to correct the client's faulty notions about weight
control, dieting and purgative use. The client is offered information on:
- The condition.
- Body weight and its regulation.
- The physical consequences of binge eating, self-induced vomiting, purgative
- The relative ineffectiveness of vomiting and purgative use as a means of
- The adverse effects of dieting.
Freeman (1992)  suggested that this sort of education enhances clients'
autonomy and self-empowerment.
Cognitive restructuring Dysfunctional thoughts become a stimulus for further
dietary restriction. Central to the cognitive therapy approach is the restructuring
of thought patterns that maintain the condition. Once the therapist highlights
the relationship between these thoughts and consequent behaviour, the client may
understand why these thoughts deserve to be challenged. Box 6 Figure 3 shows
examples of thinking errors reported in anorexia nervosa.
Figure 3. Box 6. Thinking errors reported in anorexia nervosa
Greenberger and Padesky (1995)  provided useful guidance on identifying
negative automatic thoughts, dysfunctional assumptions and core beliefs. They
suggested teaching the client the skills to develop alternative ways of
thinking. The client tries to replace thinking errors with more balanced,
adaptive thoughts which move behaviour towards equilibrium.
Thought record A three-column thought record (Table 1) can help the client to
develop skills for eliciting negative automatic thoughts. This can progress to a
more detailed seven-column thought record (Greenberger and Padesky 1995) 
which gathers evidence for and against the automatic thought, and ultimately
replaces it with a more balanced thought. Common themes are often identified
from the completion of several thought records. These themes can suggest core
beliefs (schema) which may be amenable to sensitive and gentle challenge. Schema
change processes include:
Table 1. Three-column thought record
- The continuum method - charting progress on an adaptive continuum, thus
developing acceptance of the alternative more adaptive belief, for example, 'I
- Positive data log - clients keep a diary of all their observations which are
consistent with their new beliefs.
- Historical tests (Padesky 1994)  - life experiences are used to examine
the evidence for and against core schema (beliefs).
For example, a therapist may encourage a client to keep a record of evidence
that a core belief (I am useless) is not true, and evidence that supports the
new alternative belief (I am useful).
Assertive skills In anorexia nervosa, self-esteem is inextricably linked with
weight loss. The person's self-evaluation is based on his or her ability to
maintain a certain weight. When he or she loses this control, self-esteem is
severely affected and he or she needs to develop self-esteem in other ways.
Assertive skills training is a useful strategy for people with anorexia.
Temple and Robson (1991)  showed how an assertive skills programme improved
self-esteem in a group of people with anorexia. An eight-week training course
covered issues such as 'making requests', 'giving and receiving compliments',
and 'expressing feelings'. This taught participants how to negotiate their needs
This article has described the important factors, from a cognitive-behavioural
perspective, in the onset and maintenance of anorexia nervosa. Essential
components for assessment and intervention have been identified. Developing a
therapeutic relationship through collaboration, guided discovery and the
purposeful use of empathy is suggested as being fundamental to assessment and
treatment. Education, cognitive restructuring and the enhancement of self-esteem
are identified as significant interventions within a cognitive-behavioural
- Cognitive restructuring - replacing unhelpful ways of thinking with more
- Cognitive behaviour therapy - a psychological approach which combines
cognitive and behavioural techniques to help alleviate unhelpful beliefs,
underlying assumptions and maladaptive behaviours which cause psychological
- Collaborative empiricism - therapist and client work together as a team,
systematically testing the validity of unhelpful thoughts and beliefs
- Core schema (beliefs) - absolute statements about self, others, or the world.
That is, 'I'm a bad person', 'Other people are dangerous', or 'The world is an
- Faulty schema - unhelpful, invalid beliefs
- Socratic questioning - described in text
- Thought records - described in text
- Enmeshment - over-involved relationship