Handbook of Eating Disorders - part 7 pdf

COGNITIVE ANALYTIC THERAPY 281 OTHEROTHER MEME AIM AIM BELIEF BELIEF EMOTION EMOTION CONSEQUENCE CONSEQUENCE ? Figure 17.1 Reciprocal role relationship and procedural diagram over-control nurtures a child that may be controlling of others and over-controlled in them- selves. In therapy, these reciprocal role patterns are plotted in a sequential diagram, or map, providing an overview of the patient’s self states and interpersonal relationships, much as Kelly attempted to do with his repertory grids. Drawing from objectsrelations theorists, an affect arises from reciprocal role patterns. For example, abusive/abused is associated with terror and rage, while the controlling/crushed pattern is associated with rebellious anger. Thus alink is made into cognitive theory. Emotion is interrelated with motivation and cognition, which are represented by aim and belief respectively in the procedural diagram. The term procedure, rather than pattern, is used in CAT to illustrate that problematic relationships and behaviours are a closed system which are part of a sequential loop and thus lead to the same outcome, or consequence (see Figure 17.1). The consequence may be a behavioural response, or a further procedural sequence. Difficulties arise when the consequences arenegative, or maintainthe individual in the same stuck pattern of maladaptive relationships. Frequently, false assumptions, problems with emotional processing or coping, and maladaptive reciprocal role patterns serve to trap the individual in a vicious negative cycle, create a forced choice dilemma, or prohibit more adaptive choices of response. It is the restriction and lack of flexibility inherent in these features that make them maladaptive. We all have reciprocal role patterns and cognitive procedures arising from our early life experience that serve as templates for relationships with ourselves and others, and it is the maladaptive roles and procedures that are focused upon in therapy. For example, a common reciprocal role relationship pattern encountered in patients with eating disorders is controlling/crushed (see Figure 17.2). This pattern may arise from an early experience where emotions and needs are felt by the infant to be controlled by the early caretaker. Thus the infant experiences his or her feelings and needs as crushed and disallowed. This early experience gives rise to the belief that feelings and needs are bad and must be controlled. Later in life this experience is replicated both in relationships with others and in relation to oneself. Anorexia nervosa (AN) can be conceptualised as one of the consequences of this type of early experience. That is, anorexia provides a behavioural expression for the need to control the self and others arising from this relationship pat- tern. The controlling/crushed reciprocal role relationship pattern has obvious parallels with 282 CLAIRE TANNER AND FRANCES CONNAN CONTROLLINGCONTROLLING CRUSHEDCRUSHED BELIEF: needs and feelings are BELIEF: needs and feelings are bad and must be controlled bad and must be controlled EMOTION: rebellious angerEMOTION: rebellious anger AIM: to manage feelings and needs AIM: to manage feelings and needs CONSEQUENCE: control anger CONSEQUENCE: control anger Anger managed as a symptom Anger managed as a symptom Figure 17.2 The controlling/crushed reciprocal role relationship and procedural diagram. [The experience that feelings and needs are crushed and disallowed by controlling others gives rise to rebellious anger and the belief that feelings and needs are bad and must be controlled. The aim is therefore to manage feelings and needs, including the anger arising from this experience of relationships. Anger may either be controlled, thus maintaining the vicious circle of the controlling/crushed reciprocal role pattern, or the anger is managed as a symptom, such as food restriction or vomiting.] Fairburn’s cognitive theory for anorexia nervosa (Fairburn et al., 1999) in placing the need for control as a central theme. However, CAT extends the cognitive theory into the domain of interpersonal relationships and in doing so offers an understanding of how this need has arisen and how it can be modified. THE AIMS, STRUCTURE AND PROCESS OF CAT The aim of CAT, as perhaps any therapy, is to enhance self-efficacy and self-reflection and to generate change. The duration of CAT is fixed at the outset to 16–24 sessions, depending on the underlying level of disturbance in personality structure. The three main processes that promote change in CAT are reformulation of the problematic interpersonal and behavioural patterns, recognition of these patterns and then through recognition in the here and now and in life outside therapy, revision of the patterns. These three processes roughly map onto the three stages of therapy: reformulation is the focus of the first four sessions; the middle sessions focus upon recognition and preparation for revision; and the final four sessions focus upon ending, which if managed successfully facilitates further revision and change. Reformulation is a process in which both patient and therapist collaborate in developing an understanding of current problems and their evolution from past experience. The therapist takes a thorough history of the patient’s early life and evolution of the current difficulties. The patient is asked to complete the Psychotherapy File, a tool developed by Ryle listing commonly occurring problematic procedures. The patient is invited to consider the current situation and, from this, to identify and list patterns of thinking, feeling and behaving that may be contributing to things going wrong and feeling stuck. As part of the reformulation process, two or three target problems will be identified as a focus for the therapy. It is helpful if behavioural, emotional and interpersonal problems are each represented in the list of target COGNITIVE ANALYTIC THERAPY 283 problems. Patients with eating disorders are usually ambivalent about change and often do not identify weight and eating behaviour as a problem. By devoting time to negotiate the problems on which to focus, and enhancement of motivation, this issue can be addressed and low weight will usually be accepted as an appropriate focus in AN. Alternatively, a formula- tion can be offered focusing on why the patient does not see the eating disorder as a difficulty. Once the target problems have been agreed upon, the procedures that maintain the prob- lem are described. This description not only includes the present, but also links the past to the present. Examples from the patient’s childhood situation are used to illustrate ex- periences that would understandably have led to the development of procedures that were effective coping strategies originally, but now leave the patient with difficulties in current relationships and circumstances. The original relationships underlying current reciprocal roles are also described, particularly those with the patient’s attachment figures. Relation- ship patterns that have an emphasis on over-control, conditionality, admiration, emotional deprivation and abandonment are commonly present in the background of patients with eating disorders. Common procedures focus on issues of avoidance, placation, perfection, splitting and sabotage. The aim of reformulation is to facilitate understanding, not to apportion blame. Parental roles can be understood by hypothesising about parental experiences. For example, prior to the birth of the child who goes on to develop AN, the frequency of serious birth complications and obstetric loss is elevated (Cnattingius et al., 1999; Shoebridge & Gowers, 2000). High parental concern, over-protection and over-control may be understandable in this context. Once the therapist has ascertained the procedures that the patient is enacting and the reciprocal role patterns that lead to these procedures, then a letter is constructed by the therapist as a hypothesis with which to understand the difficulties. The letter is written empathically and aims as much as possible to employ the words and metaphors used by the patient to express her difficulties, in order to ensure an emphasis upon collaboration and empathic understanding. The reformulation letter describes the target problems, the problem procedures, and the reciprocal role relationships in such a way as to make clear the understandable links between the patient’s past, and possible origin of their procedures, and the way in which the procedures are occurring in the patient’s life currently. Predictions are also made in the letter as to how the procedures and reciprocal roles will be re-enacted in the therapy. Goals for change are set out in the letter in terms of recognising and revising the procedures. Rather than challenging the patient to give up her disorder outright, an indication of how change might be achieved is offered. The letter is concluded with a succinct list of target problems and associated procedures. The patient is offered a draft copy of the reformulation letter at sessions 4–6, when it is read aloud to the patient. The patient takes away the copy and is encouraged to re-read and change or agree to the reformulation. A diagram of the reciprocal roles and procedures is also developed with the patient in the following sessions as a shorthand and more visually accessible version of the reformulation letter. This is used in subsequent sessions to name re- enactments of the procedures as they occur. If the patient disagrees with the reformulation, then further work is done on descriptions of problems and procedures so that the patient and therapist agree on the focus of therapy. Flexibility is important and is encouraged, while avoiding collusion with minimisation of the seriousness of the problems. Flexibility is also useful in the timing of reformulation. For those with very disturbed personality structure and unstable reciprocal role patterns, early reformulation in the form of the map facilitates the process of engagement. Firstly, it helps the patient to feel empathically understood and, secondly, it serves to contain both patient and therapist anxiety. 284 CLAIRE TANNER AND FRANCES CONNAN Constructing reformulations in CAT is a complex set of skills and thus regular supervision is offered to therapists. Once reformulation has been constructed, then supervision is used to enable therapists to recognise when re-enactments are occurring in therapy. The following 12–20 sessions of CAT are used to enable patients to recognise when they are enacting their procedures. This is accomplished by homework, such as diary keeping, monitoring of mood states, written work such as letter writing etc. Observing the enactment of procedures during a session in the here and now is a particularly effective way of enabling patients to understand the way their procedures operate. By focusing on the procedures, conflict is contained, an understanding of resistance is offered, and thus avoided, and pa- tients are offered the opportunity to reflect upon themselves and understand their motives, behaviours and emotional reactions. The therapist encourages patients to use the map to be able to reflect on the way that both their mind and that of significant others work. Thus the development of a theory of mind and self-reflective function is facilitated by use of the map, which serves as an external example of a theory of mind. The process of reformulation and recognition helps the patient to feel empathically un- derstood and offers a new experience of relating, in which feelings and needs can be acknowledged and expressed. For patients with eating disorders, the model of CAT can provide meaning for their anorexia or bulimia that was previously beyond their grasp. The offering of an understanding that can be internalised by the patient is one of the key fac- tors for change in CAT. It is through this experience that a therapeutic alliance can be fostered. The structure, focus and tools of CAT help to make this possible with even the most difficult-to-engage patients. A therapeutic alliance is crucial to the process of revision and change (Safran, 1993). Once established, patient and therapist are able to collaborate in developing strategies for revision of maladaptive relationship patterns and procedures. CAT is eclectic in this respect and draws upon a range of therapeutic techniques depend- ing upon the symptom profile of the patient. Thus, guided by clinical assessment and the evidence base, CBT techniques, such as goal modification and cognitive restructuring; in- tention implementation; expressive therapies and psychodynamic techniques may each be employed as appropriate. Expression of emotions that have perhaps been prohibited is en- couraged and tolerated. New behaviours are attempted as experiments, with the support of the therapist. As CAT is a brief, time-limited therapy, endings are paid particular attention. Endings are often frightening, distressing and can be experienced as rejecting or abandoning. Discussion of the ending begins at least four sessions before the end. Many patients feel subjectively worse towards the end of treatment because they are struggling with painful emotions that have previously been avoided with procedures and symptoms. Many will also have great difficulty expressing their ambivalence and distress and this becomes a focus for the final sessions. The aim is for the patient to be able to acknowledge both the good and bad aspects of the therapy and the therapist, and to accept the experience as having been ‘good enough’. For these reasons, endings are a particular challenge for patients with perfectionistic, placating, depriving or abandoning relationship patterns, all of which are common in those with eating disorders. Goodbye letters are exchanged between the therapist and the patient during the penultimate or final session. These letters review changes made, predict potential difficulties and further work to be done, and acknowledge the relationship between the therapist and the patient. Follow-up is offered at regular intervals to monitor change and the revision of procedures. In addition, these sessions, and the letters and maps the patient has received, serve to maintain the attachment after weekly sessions have ended and provide further opportunity for expression and resolution of ambivalent feelings associated with ending. COGNITIVE ANALYTIC THERAPY 285 Many patients are able to achieve considerable change during the follow-up period. For those that continue to experience significant illness at the end of follow-up, further therapy may be offered. In this context, the patient is helped to view the completed therapy not as a failure on the part of either therapist or patient, but as important and helpful preparation for further work. EVIDENCE AND RATIONALE FOR THE APPLICATION OF CAT TO THE TREATMENT OF EATING DISORDERS There is little empirical evidence to support the use of CAT in the treatment of eating disorders. There are only two treatment studies reported in the literature. The first was a pilot study in which 30 outpatients with AN, many of whom had poor prognostic features, were randomly allocated to either CAT or educational behaviour therapy (EBT). Those in the CAT group reported significantly greater subjective improvement at 1 year follow-up than the EBT group.The CAT group also showed consistently better outcome oneach ofthe subscales of a standard eating disorders outcome scale (the Morgan and Russell scale), although these differences were not statistically significant in this small sample (Treasure et al., 1995). In a larger scale study comparing CAT with family therapy, psychodynamic psychotherapy and supportive therapy, the specific therapies performed better than supportive therapy, and there were no significant differences between CAT, family therapy and psychodynamic therapy (Dare et al., 2001). If there is no clear efficacy advantage for CAT over other specific therapies, why chose CAT? A theoretical rationale for CAT in the treament of AN has been given by Treasure and Ward (1997). Target problems maintain the focus on weight, which can be important for work with placating patients, but also allows focus on other issues which may underly the problem with eating. The open and collaborative style of CAT helps to diffuse the power struggles that are commonly encountered with patients enacting a controlling reciprocal role, and faciliates engagement of ambivalent patients. Patients with AN frequently ex- perience significant interpersonal (Schmidt et al., 1997) and emotional difficulties (Troop et al., 1995) and the dual emphasis upon maladaptive relationship patterns and emotional processing is therefore valuable. Patients with AN perform poorly on theory of mind tasks (Tchanturia et al., 2001), and the disorder has been conceptualized as an empathy disorder (Gillberg et al., 1994). The use of the CAT map to facilitate development of theory of mind may therefore be particularly relevant to this group of patients. CAT provides an excellent set of tools for engaging and working with difficult patients and for managing therapist frus- tration and collusion. The integrationist style of CAT allows for the use of other techniques, such as motivational enhancement (Ward et al., 1996) to address ambivalence, and CBT techniques to facilitate behaviour change. The time-limited nature of the therapy and the focus upon a well-managed ending is helpful when separation and individuation are issues, as they frequently are in AN. Because the treatment of severe AN often requires prolonged therapeutic input, the brevity of therapy may also be seen as a disadvantage. However, follow-up sessions can be used to extend the therapeutic relationship and, if appropriate, further therapy can be considered after a period of reflection during follow-up. There may also be a cost-effectiveness advantage to CAT: it can be delivered in half the number of sessions of a standard 40-week psychodynamic therapy, but may be as effective. CAT train- ing is also relatively short and is equally applicable to all members of the multidisciplinary team, helping to facilitate a shared model of understanding within the team. Finally, the 286 CLAIRE TANNER AND FRANCES CONNAN flexibility of CAT means that it can be generalized to a variety of settings, including inpatient treatment and family work. Much of the rationale for CAT in the treatment of AN is also applicable to BN. Borderline personality features and comorbid psychiatric symptoms such as substance misuse and self-harm are prevalent among patients with BN, and the CAT model may have particular advantages for this patient group. Firstly, the broad focus of CAT allows for comorbid problems to be addressed alongside the eating disorder. More narrowly focused treatments may require that patients with complex presentations are sent to different centres for different aspects of their care. This fragmentation may reinforce the internal splits and the sense of self as too overwhelming, and renact experiences of rejection and abandonment. Secondly, the map provides a particularly useful tool for understanding and recognising dissociative states and impulsive behaviours. CASE STUDY Susie Susie was a 23-year-old patient who was referred by her GP. Her BMI was 16.8 at the time of referral. The onset of her AN was two years previously, following the death of her father from cancer. As the father’s death was so rapid and unexpected, the family (Susie, her mother and her younger sister) did not mourn him, nor were they able to function as a family. Susie’s mother knew her daughter had a problem, but was unable to comment upon her daughter’s weight, or help her to eat. Susie was very unhappy, terrified of being anorexic and having therapy, but willing to try. This is the reformulation letter read to her at session 4: Dear Susie, As promised, here is my reformulation letter to you. In it I will be attempting to describe your present problems and their origins in your past. Some of the difficulties you are having now, you have had before and it would be helpful if we linked the past with the present. To start, however, I would like to describe your present problems. You have an eating disorder that started at the unexpected death of your father two years ago. Your eating disorder has helped you to feel in control and your life has been both physically and emotionally affected by this eating disorder. It is making you feel depressed and ashamed. Perhaps we can look at the other times in your life when you have needed to be in control when you felt depressed and ashamed. You described to me a pleasant childhood, and also that you were told that you were a very demanding baby who your mother found difficult to cope with. When you started school you felt all your demanding behaviour stopped and you needed to control yourself, but often felt bad. You felt that you were a good girl, but underneath you felt ashamed because you knew you really were bad. When you were seven years old you were in a very bad car accident and had to be hospitalised for some months. You remember desperately wanting your parents with you but they couldn’t be and again you felt bad and ashamed for wanting too much and not getting it. You struggled again to be a good girl, having to learn to walk again, and feeling that you must be in control of yourself, not causing a fuss, and not being demanding towards your parents. This you managed to do. As an adolescent you felt you couldn’t rebel as you caused your father particular distress because you were so bad at maths. He used to tutor you and shout at you because you were so bad at it. You again tried to control yourself emotionally and learn to do maths. But perhaps you were unable to express your fear, anger and shame at his treatment and at your inability to be good at maths. When your father died, perhaps such COGNITIVE ANALYTIC THERAPY 287 distressing emotions as fear, loss, anger and grief made you feel ashamed again, as they did not seem able to be expressed by your family. So again you went out of control, this time using control of your eating and body as a way of managing your distress. The conditional rules of your childhood, be in control, don’t be demanding and don’t be emotional, are applying to you now. You seem to need to control both your emotions and your needs and this is what the anorexia does. You want to be the good girl again and being in control is the best way to do this, as you perhaps discovered as a child. The problem is that it is the anorexia that is in control and stopping you from having a social life, a boyfriend and causing the shame and distress. So our task in therapy, Susie, is to find ways for you to express neediness and emotions and not to be in perfect control. Perhaps by changing the definition of being a good girl, we can change your behaviours so that you don’t feel ashamed of what you need and feel. Perhaps we can find ways that you can experience your relationships as something other than controlling and conditional both of yourself and of others. You can be demanding, emotional and, angry and still get love, attention and care. To do this, I suggest that we focus on the following procedures. I am fearful of making demands because I will upset others, so I try to please and be the good girl. I feel distressed, angry and ashamed so I try even harder to please and be the good girl. I either keep myself in perfect control but am depressed and ashamed, or I express myself and fear rejection for being too demanding. I am bad and greedy inside so I cannot allow myself to want too much. I must starve and be in control to punish myself for being too demanding. Susie accepted the letter and worked together with her therapist in developing a map (see Figure 17.3) and on recognising the above procedures. As she started to recognise Compliant, Defiant, Compliant, Defiant, Crushed Crushed Rebellious Rebellious Controlling, Conditional Controlling, Conditional Contemptuous Contemptuous Contemptible Contemptible Perfect, Admiring and Perfect, Admiring and Offering CareOffering Care Perfect Admired andPerfect Admired and Cared for Good Girl Cared for Good Girl AIM: to keep this intact BELIEF:I must maintain perfect control of my needs EMOTION: smug CONSEQUENCE: I starve Success Failure BELIEF: I am needy, demanding and bad EMOTION: ashamed and depressed AIM: to control myself and others AIM: to dismiss feelings BELIEF: I must not express anger EMOTION: anger EMOTION: fear of feelings and needs BELIEF: I must be perfectly in control of feelings and needs or I will be rejected AIM: to be perfectly in control and cared for Figure 17.3 Susie’s CAT map 288 CLAIRE TANNER AND FRANCES CONNAN how much she needed to be in control to be the good girl, she was able to start chal- lenging this and express herself emotionally to her family, her friends and her therapist. She found writing to be useful and wrote a letter to her father telling him how she felt about his death. She was able to express the distress of changing and not getting it right, both wanting to get better and fearful of getting better. The ending of therapy was very difficult as Susie was worried about not having the support of the therapist. She wrote a very moving goodbye letter where she was able to express her disappointment in her not gaining any weight during the therapy, how she would miss the therapist and her fears about the future. However, at her three-month follow-up, Susie had gained 4 kilos and felt she was well on the road to recovery. She had recruited her mother to help her to eat and this was working successfully. The use of CAT in the above therapy helped both the patient and the therapist to understand the nature of Susie’s anorexia, and to find ways for Susie to deal with her difficulties other than anorexia. The control issues were managed between the therapist and the patient by working with the re-enactment of the procedures rather than simply focusing on weight gain or loss. The reformulation letter helped to establish a good therapeutic alliance where control was the main issue rather than anorexia. REFERENCES Bandura, A. (1977) Self-efficacy: towards a unifying theory of behavioral change. Psychol. Rev., 84, 191–215. Bandura, A. (1986) Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice Hall. Cnattingius, S., Hultman, C.M., Dahl, M. & Sparen, P. (1999) Very preterm birth, birth trauma, and the risk of anorexia nervosa among girls. Arch. Gen. Psychiat., 56 (7), 634–638. Dare, C., Eisler, I., Russell, G., Treasure, J. & Dodge, L. (2001) Psychological therapies for adults with anorexia nervosa: randomised controlled trial of out-patient treatments. Br. J. Psychiat., 178, 216–221. Fairburn, C.G., Shafran, R. & Cooper, Z. (1999) A cognitive behavioural theory of anorexia nervosa. Behav. Res. Ther., 37 (1), 1–13. Gillberg, I.C., Rastam, M., & Gillberg, C. (1994) Anorexia nervosa outcome: six-year controlled longitudinal study of 51 cases including a population cohort. J. Am. Acad. Child Adolesc. Psychiat., 33 (5), 729–739. Kelly, G. (1963) Theory of Personality: The Psychology of Personal Constructs. New York: Norton. Lazarus, R. (1999) The cognition-emotion debate: a bit of history. In T. Dalgleish & M. Power (Eds) Handbook of Cognition and Emotion (pp. 3–19). Chichester: John Wiley & Sons. Mineka, S. & Thomas, C. (1999) Mechanisms of change in exposure therapy for anxiety disorders. In T. Dalgleish & M. Power (Eds) Handbook of Cognition and Emotion (pp. 747–764). Chichester: John Wiley & Sons. Ryle, A. (1990) Cognitive Analytical Therapy: Active Participation in Change. A New Integration in Brief Psychotherapy. Chichester: John Wiley & Sons. Safran, J. (1993) Breaches of the therapeutic alliance: an arena for negotiating authentic relatedness. Psychotherapy, 30 (1), 11–23. Schmidt, U., Tiller, J., Blanchard, M., Andrews, B. & Treasure, J. (1997) Is there a specific trauma precipitating anorexia nervosa? Psychol. Med., 27 (3), 523–530. Sheldon & Cashdan (1988) Object relations theory: An overview. In Object Relations Therapy: Using the Relationship. New York: W.W. Norton & Co. Shoebridge, P. & Gowers, S.G. (2000) Parental high concern and adolescent-onset anorexia nervosa. A case-control study to investigate direction of causality. Br. J. Psychiat., 176, 132–137. Tchanturia, K., Hape, F., Godley, J., Treasure, J., Bara-Carril, N. & Schmidt, U. (2001) Theory of mind in anorexia nervosa. Am. J. Psychiat. COGNITIVE ANALYTIC THERAPY 289 Treasure, J. & Ward, A. (1997) Cognitive analytical therapy in the treatment of anorexia nervosa. Clin. Psychol. Psychother., 4 (1), 62–71. 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(2000) A multi-family group day treatment programme for adolescent eating disorder European Eating Disorders Review, 8, 4–18 Dodge, E., Hodes, M., Eisler, I & Dare, C (1995) Family therapy for bulimia nervosa in adolescents: An exploratory study Journal of Family Therapy, 17, 59 78 Eisler, I (1995) Family models of eating disorders In G.I Szmukler, C Dare & J Treasure (Eds), Handbook of Eating Disorders: ... cognitive-behaviour therapy (although less effective in the short term) which suggests that further study of the possible role of family therapy in bulimia nervosa are warranted FAMILY INTERVENTIONS 301 MULTIPLE-FAMILY THERAPY IN THE TREATMENT OF ADOLESCENT EATING DISORDERS The effectiveness of family interventions with adolescent eating- disordered patients and the need to develop more intensive forms of. .. understanding of the mechanisms which bring about change is limited When one takes a look at the history of family therapy for eating disorders much of the above is readily applicable The pioneering work of Selvini Palazzoli (1 974 ), Minuchin (Minuchin et al., 1 975 , 1 978 ) and others made very strong claims for the approach While the empirical evidence for the effectiveness of family therapy, particularly... nervosa: A randomised controlled trial of out-patient treatments British Journal of Psychiatry, 178 , 216–221 Dare, C (19 97) Chronic eating disorders in therapy: Clinical stories using family systems and psychoanalytic approaches Journal of Family Therapy, 19, 319–351 Dare, C & Eisler, I (19 97) Family therapy for anorexia nervosa In D.M Garner & P.E Garfinkel (Eds), Handbook of Psychotherapy for Anorexia Nervosa... theoretical accounts of some of the pioneer figures of the family therapy field, such as Salvador Minuchin (Minuchin et al., 1 975 ) and Mara Selvini Palazzoli (1 974 ) and has undoubtedly been one of the important factors in the major changes in the treatment of eating disorders that the field has witnessed in the past 10 to 15 years Paradoxically, alongside of the data for the effectiveness of family therapy,... contribute to attaining abstinence of bingeing In the treatment of obesity the long-term results of pharmacotherapy have been disappointing However, new developments suggest a more promising role for medication in the treatment of obesity This chapter will provide an update of the research (RCTs) and clinical implications in the field of pharmacotherapy of eating disorders Results of clinical trials and clinical... because of the differing nutritional status of the two patient groups In the starved state there may be reduced synaptic 5-HT, due to reduced availability of tryptophan, the essential amino-acid precursor of serotonin Cyproheptadine, a serotonin antagonist, prescribed as an anti-allergic medicine with weight gain as a side-effect, showed some positive results in double-blind RCTs (Vigerski & Loriaux, 1 977 ;... severe, the prescription of antidepressant medication should be considered It seems reasonable to choose a SSRI given the suggested role of serotonin in the pathophysiology of eating disorders Furthermore, the clinical picture often shows features of anxiety disorders, on which SSRIs often have a favourable effect The same arguments for prescribing a SSRI are valid in cases of anxiety disorders that interfere... of eating Handbook of Eating Disorders Edited by J Treasure, U Schmidt and E van Furth C 2003 John Wiley & Sons, Ltd 292 IVAN EISLER ET AL disorder was derived, are flawed Minuchin et al.’s (1 978 ) model of the ‘psychosomatic family’ which has probably been the most influential, hypothesized that there was a specific family context within which the eating disorder developed The authors argued that a particular... D & Dodge, E (19 97) Family and individual therapy in anorexia nervosa A 5-year follow-up Archives of General Psychiatry, 54, 1025–1030 Eisler, I., Dare, C., Hodes, M., Russell, G.F.M., Dodge, E & le Grange, D (2000) Family therapy for adolescent anorexia nervosa: The results of a controlled comparison of two family interventions Journal of Child Psychology and Psychiatry, 41, 72 7 73 6 Fairburn, C.G., . RATIONALE FOR THE APPLICATION OF CAT TO THE TREATMENT OF EATING DISORDERS There is little empirical evidence to support the use of CAT in the treatment of eating disorders. There are only two. and that of significant others work. Thus the development of a theory of mind and self-reflective function is facilitated by use of the map, which serves as an external example of a theory of mind. The. Thomas, C. (1999) Mechanisms of change in exposure therapy for anxiety disorders. In T. Dalgleish & M. Power (Eds) Handbook of Cognition and Emotion (pp. 74 7 76 4). Chichester: John Wiley