As noted in my previous blog post and the comments that follow, full nutrition and weight restoration will often reduce or eliminate the body image disturbance that plagues so many people with Anorexia Nervosa (AN). This is one of the many reasons why it is essential for AN treatment to require full nutrition and prompt weight restoration.
On the other hand, some people with AN continue to experience intense body dissatisfaction after weight restoration. In these cases, Cognitive-Behavioral Therapy (CBT) can help improve body image and reduce suffering.
In order for CBT to be effective, the patient has to have some motivation to engage in the treatment and some desire to improve her body image. The patient also needs to have the insight to understand that her body itself is not the problem, so changing her body weight or shape is not the solution. Rather, the problem is that she has some negative thoughts, feelings, and behaviors related to her body that cause her to suffer. It is those negative thoughts, feelings, and behaviors that will be the targets for intervention. The insight, motivation, and judgment required for effective body image treatment is yet another reason why this intervention is most effective after full weight restoration.
Many of the CBT-informed interventions for body image are similar to those that are effective in treating anxiety and depression. Consider the following:
This involves identifying and challenging distorted automatic thoughts related to one’s body image. Examples of distorted automatic thoughts include: “My thighs are enormous,” “I’m the fattest person in this room,” or “Everyone is staring at me because I’m huge.”
The patient may need some help identifying distorted thoughts because they may seem normal or accurate to her. Once she is able to identify a distorted thought as such, the patient is asked to keep a log of the thoughts as they occur. With the help of the therapist, the patient then learns to identify patterns of distorted thoughts, challenge her own thinking, and generate more rational thoughts to replace the distorted ones.
For example, “Everyone is staring at me because I’m huge” contains distortions of over-generalization and mind-reading. Is EVERYONE really staring at you? No. In a room of 30 people, maybe 2 are looking at you. That isn’t everyone. Do you know for sure that they think you are huge? No, because they didn’t say anything of the sort. Why else might they be looking at you? Maybe they like your shirt.
Exposure and Response Prevention
This involves systematically desensitizing the patient, little by little, to her body image fears for the purpose of improving her quality of life. For example, if the patient loves the beach but can’t bring herself to go because she is ashamed of her body in a bathing suit (this is a frequent scenario in my South Florida-based practice!), the therapist may begin by helping her create a hierarchy or “ladder” of challenges increasing in difficulty. The patient would need to “master” each task before moving on to the next one.
1.) Go to the beach with your best friend at a time when very few people are there, wearing a shirt and shorts over your swimsuit.
2.) Go to the beach with your best friend at a time when very few people are there, wearing just shorts over your swimsuit.
3.) Go to the beach with your best friend at a time when very few people are there, wearing just a shirt over your swimsuit.
4.) Go to the beach with your best friend at a time when very few people are there, and spend 2 minutes wearing just your swimsuit.
5.) Go to the beach with your best friend at a time when very few people are there, and spend 10 minutes wearing just your swimsuit.
6.) Go to the beach with your best friend at a time when very few people are there, and spend an hour wearing just your swimsuit.
7.) Go to the beach with your best friend when many other people are there, and wear a cover-up.
8.) Go to the beach with your best friend and spend 2 minutes wearing just your swimsuit.
9.) Go to the beach with your best friend when many other people are there, and spend 10 minutes wearing just your swimsuit.
10.) Go to the beach with your best friend when many other people are there, and spend an hour wearing just your swimsuit.
11.) Go to the beach without your best friend and wear a swimsuit the whole time.
Once a patient is able to recognize patterns in her negative body image thoughts, she can choose to focus her attention on people, places, and activities that promote positive thoughts and feelings, while reducing or eliminating the negative influences. For example, if a patient has a friend who engages in a lot of “fat talk,” the patient may be assertive with this friend and ask her to stop talking this way around her, or she may decide to stop spending time with this particular friend and hang out with more supportive friends instead. Likewise, if following fitness Instagram accounts makes the patient feel badly about her body, she may decide to stop following these accounts.
Along these lines, many patients find it helpful to donate their outgrown, tight-fitting, or unflattering clothes to charity. The feeling of tight clothes on the body, or the sight of too-small clothes hanging in the closet, can be very triggering. Most people feel much more confident wearing comfortable, flattering clothes.
Eliminating Body Image Rituals
Some people engage in “body checking” rituals, which may be anything from measuring their wrist circumference with their fingers, grabbing the flesh of their belly, spending excessive time in front of the mirror, or trying on 10 different outfits before finding one that looks “just right.” These types of rituals may reduce anxiety in the short term, but they end up becoming self-perpetuating and increasing body dissatisfaction in the long-term.
CBT for body image can be done with a CBT-oriented therapist who has experience working with eating disorders and body image concerns. In my practice, I sometimes use CBT for body image in weight-restored patients with AN after their family has completed a course of FBT (only if it is needed and requested, of course!). I also use it in patients with Bulimia Nervosa (BN) or Binge Eating Disorder (BED) after eating patterns have been normalized, and with non-eating disordered patients who suffer from anxiety or depression and also happen to have struggles with body image.
However, improving body image does not necessarily require a therapist’s help. A motivated patient may be able to utilize these interventions on her own, or with the help of a parent, using internet resources or a guided self-help workbook. I often recommend Thomas Cash’s The Body Image Workbook, 2nd Edition.
There are other interventions for body image derived from 3rd wave behavioral therapies such as Dialectical Behavior Therapy (DBT) and Acceptance and Commitment Therapy (ACT). These will be the topic of my next post.