Wednesday, March 25, 2009

Eating Disorder

A Vicious Circle

An eating disorder is not simply a problem with eating. It is a vicious circle of low self-esteem, extreme concerns about shape and weight and strict dieting. An eating disorder has been called a “low self-esteem disorder”. Issues around body image are often more to do with self image and low self-esteem. Most people who develop an eating disorder are only unhappy about their bodies because they are unhappy about themselves. Controlling their eating habits, either by not eating or restricting their eating (anorexia), or by eating and then making themselves sick (bulimia), or over-eating(compulsive eating), is their way of trying to control their feelings of low-self esteem. These bad eating habits are usually a symptom of deeper issues. A way to recovery, is to come to a level of self-acceptance and to become aware of and challenge low self-esteem and to stop the bad eating behaviours. The following model shows the pattern of this vicious circle:

Eating Disordered Thinking

Cognitive Distortions Of Eating Disorders

  • If I eat something at night, it will all turn to fat because I will not have time to burn it off before I go to sleep
  • If I lose more weight I will be much more attractive.
  • If I was thinner, I would be happier.
  • If I was thinner, I would be more successful.
  • Vomiting gets rid of all the calories I ate earlier.
  • If I eat lunch I won’t be able to eat dinner later.
  • If I eat eg 2 pieces of pizza, people will think I am a pig.
  • If my clothes feel tight after eating it means I have put on weight.
  • My clothes are tighter, I know I have gained weight.
  • If I gain 2lbs it means I am going to continue to gain weight every day and get fat.
  • I ate breakfast and that was ok, but then I had a cake at 10.00am so I had to vomit.
  • But, cake (or popcorn, or ice cream or whatever) are a bad food.
  • Eating normally (i.e, breakfast, lunch and dinner and snacks), even if it amounts to only 1200 Calories when I am 5’4” will, make me fat.
  • I am a bad person (weak, selfish, greedy, irresponsible, inadequate, stupid, dull, etc, etc,) If I lose weight I will be different.
  • I can’t cope with feeling bad, I have to be sick.
  • I deserve (eg chips, biscuits, ice cream etc) because I have had a hard day.
  • I didn’t binge or purge because I was afraid of gaining weight. I just wanted to space out.
  • I have an obsessive craving to binge. After I have eaten I want to eat more.
  • I feel fat, therefore I am fat.
  • I feel so lonely, I should eat more.

Panic Attacks

Model of Panic Attacks

The cognitive model of panic claims that panic attacks arise when patients become anxious about the actual bodily sensations of anxiety itself. For example, in a panic state, a normal anxiety sensation is breathlessness. People can misinterpret this as “my breathing will stop !”, “I am going to die !”, “I will lose control !” or, “I am going insane !”

Stimuli of panic attacks may be external (such as a situation in which an attack has previously been experienced ) or, internal (thoughts, images, or bodily sensations). Where these stimuli are perceived as a threat, a state of apprehension results and the bodily sensations are misinterpreted in a catastrophic fashion and apprehension is reinforced and gets worse, building up to a panic attack.

Another important factor maintaining a panic disorder, is avoidance.

Comparing Depression, Anxiety and Anger

Dennis Greenberger and Christine Padesky give a very helpful comparison of how to understand Depression, Anxiety and Anger. Out of the five areas mentioned above, they only look at four of the areas (typical thoughts, physical reactions, behaviours, and moods and do not mention the situations) to describe these problems. They describe each of them as ‘profiles’, which means they want to describe their particular characteristics.


Thoughts Physical Reactions

No hope for the future Tiredness, loss of energy

Others have disappointed me Loss of appetite

Life won’t change Trouble concentrating

I am a failure / worthless Irritable mood

Behaviours Moods

Withdraw sad

Low activity hopeless

Change in sleep pattern self-critical

Suicide attempts guilty


Thoughts Physical Reactions

Overestimation of danger Sweaty palms

Underestimation of your ability Muscle tension

to cope. Racing Heart

Underestimation of help available Flushed cheeks

Worries and catastrophic thoughts Light-headedness

Behaviours Moods

Avoiding situations where anxiety Nervous

might occur Irritable

Leaving situations when anxiety Anxious

begins to occur Panicky

Trying to do things perfectly or

trying to control events to prevent danger


Thoughts Physical Reactions

Others are threatening or hurtful Tight muscles

Rules have been violated Increased blood pressure

Others are treating me unfairly Increase heart rate

“It’s not fair” Tension

Behaviours Moods

Defend/Resist Irritable

Attack/Argue Angry

Withdraw (to punish or protect) Enraged


Problems with anger can also be understood by how a person is affected in the five areas of being in a specific situation, having negative thoughts, feelings, behaviours and physical reactions.

The content of negative thinking when people are angry has to do with something not being fair, or because PERSONAL RULES HAVE BEEN BROKEN. We can call these the ‘RULES OF ANGER’. People usually get angry because they think something is unjust or that things aren’t the way they should be. We become angry if we think we have been treated unfairly and may feel hurt and damaged, but anger is not so much about the hurt or damage, but that RULES HAVE BEEN VIOLATED.

Most angry feelings are normal and part of life, but problems arise when these rules and expectations are unrealistic or exaggerated. What are fair and reasonable expectations varies greatly among people. CBT can help to challenge these and try to see these in perspective.

Anger can be maintained by these negative thoughts. It is made worst by negative behaviour and then worse still, when people realize this behaviour doesn’t help solve the problem or ‘fix’ the rules that were broken. We can explain this by the following ...


Sunday, March 22, 2009

Trauma and PTSD

Trauma is described as a ‘shock’, or when anxiety has become so extreme it is as if it becomes ‘locked’ in the brain, like a horrifying memory is ‘locked’ in the brain or it has got ‘stuck’ there. People can lose a sense of time, forgetting events and memories before the events and seeing the future clouded by the experience of the past.

for a person to be traumatized,

A person would have “experienced, witnessed, or been confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others. The person’s response would have involved intense fear, helplessness, or horror..”

Various events can traumatize a person. Personal assault, car accidents, natural or man made disasters, rape, abuse, or being a witness to such events.

40-50 % of people recover themselves from traumatic experiences. Others recover from everyday sharing of events with their family and community.

Common symptoms that people experience after a traumatic event are:

  • Involuntary re-experiencing of aspects of the event.
  • Hyper arousal
  • Emotional numbing
  • Avoidance of stimuli.

Trauma becomes a serious problem once it is diagnosed as PTSD. (Post traumatic Stress Disorder). A person is only diagnosed with PTSD if the above symptoms persist after a month.

Anke Ehlers and David Clark has explained that PTSD only persists if there is a sense that there is still a CURRENT THREAT.

Cognitive Behavioural Therapy

To understand behavioural therapy it is best to understand the meaning of each words...


every aspect of mental life – our thoughts, memories, mental images, reasoning, decision making, and so on...

Simply put it means ‘thought processes’; that is what goes on in our minds; our ‘thoughts‘. It also means ‘knowledge’; what we ‘know’, ‘believe’ or ‘think’. It can also mean ‘perception’; or how we ‘see things’ or ‘interpret’ or ‘understand’ them.


Any observable action or reaction of a living organism- everything from overt actions through subtle changes electrical activity occurring deep inside our brains

means what we ‘do’ or how we ‘respond’ or ‘react’

CBT also refers to feelings, physical reactions and the environment.




Part of therapy and counselling work involves helping the client to identify and express their feelings. However, many people avoid their feelings rather than express them. Sri Lanka has one of the highest suicide rates in the world. Part of this might be due to the fact that people avoid talking about their feelings, but suppress them instead. Any long term avoidance of feelings leads to problems.

How do we avoid and why?

Avoidance is another name for “safety behaviour”, that means, something we do in order to keep ourselves safe. Avoidance is a natural or normal safety response to a threat like heights, illness, heat, blood, animals, strangers etc…However, avoidance becomes unreasonable and unhealthy when in the longer term it affects people’s self-esteem and confidence. Avoidance is the key factor which maintains generalized anxiety. For example, a person who is anxious about socializing because he may feel self-conscious or inadequate might avoid going out when asked by friends. This may bring short- term relief when he doesn’t have to face his fear, but in the long-term he will not overcome his anxieties around socializing and not improve his confidence. Challenging avoidance, therefore, is about facing up to the situation or people we fear.

Below is a list of different ‘methods’ we use to avoid, only to bring relief in the short - term:

How do we avoid?

Here is a list, suggested by patients in a psychiatric ward and their staff, of different unhelpful ways people use avoidance to keep themselves safe in the short -term.

· Being late · Sleeping · Missing appointments · Restricting food · Binge/vomiting · Over-exercising · Preoccupation with food · Hiding · Drinking · Minimizing situations · Making routines · Using drugs · Running away · Putting things off · Choosing safe food · Making excuses · High activity levels · Ignoring, e.g., phone calls · ‘Forgetting’ · Focusing on others at own expense. · Agreeing when you don’t · Supporting others and not meeting own needs · Theorizing · Not talking about the things you need to talk about · Being slow about things. · Not saying what you want /feel · Changing the subject · Misusing alcohol · Pushing things to back of mind · Speak slowly · Heavy make-up · Cleaning · Stare at things · Sucking sweets/chewing gum · Cigarettes · Over checking things · Medication before/after · Telling jokes/not · Smart clothes · Relating to pets · Looking at the floor · Hiding behind long hair · Going out in the rain · Hiding behind net curtains · Only relating by mobile phone · Hiding behind sunglasses · Fidgeting · Checking toilets/exits · Gossiping


Aaron Beck developed a model of understanding addictions. This can again be seen in a cyclical view and CBT can intervene at any stage by challenging behaviours and thoughts. This model can be used for alcohol addiction, drug misuse and even eating disordered behaviour:

Situation - Stress at work

Negative Thought about Situation-“I can’t cope”

Positive Thought about substance/habit-“If I drink I will feel better”

Craving-Memory of light headedness after drinking alcohol.

Urge-Desiring the drink, appetite, sensation.

Preparation-Getting to the liquor store

Action-Using the substance (drink) or habit. Gives short term relief.

Tuesday, March 17, 2009


Often challenging our thoughts is not enough. We have to change how you act and respond to situations as well. That is, people have to change the way they behave. There are ways to help to change behavior.

Sometimes it is difficult to be aware of what our behaviors are and how they change when our mood changes. This exercise helps people identify what they do when they feel positively (high) and negatively (low):

So far we have been looking at various tools to challenging negative thinking. However, people also act or respond negatively which are not helpful behaviors. CBT claims that even without challenging thoughts and just by challenging or changing how we behave can change our mood.

Low moods are often about being inactive. The goal of behaviour change in CBT is to activate people again so that they can find motivation and purpose. Positive activity is very important for mental health.

Positive Highs/ Negative Lows

Positive Highs/ Negative Lows. How to do it:

(See worksheet)

1. Moods

List two examples of when you last felt high and low.

  1. Behaviours.

Describe how you react when you feel this way, how you respond and how you are.

  1. Thoughts.

Write down what you were thinking at these times

  1. Changing the behaviours

Once you have identified these areas, you become aware of what you are like or what you do when you are low and how different you are when you are happier. It’s a simple technique – make yourself do what you would do if you were happier even when you don’t feel like doing it. For example seeing your friend may be something you do when you feel happy. So, when you feel sad, make yourself go out and see that friend, even if you don’t feel like it. Changing your behaviour can change the way you feel and think.

Behavioural Experiments

Arguing against our negative thoughts is usually not enough by itself to convince us that they are incorrect. We will need to build up a body of experience which contradicts them. The best way to do this is to act on our rational beliefs, that is, our new realistic and more helpful beliefs, and discover whether they are true or not - whether we can believe in them or not. The best way to test out a new belief is by setting up an experiment. The following can help people to do that:

How to do it?

  1. Write the thought you want to test in THOUGHT TO BE TESTED.

  1. In the EXPERIMENT column, write down what you have planned to do.

  1. In the PREDICTION column, write down how you think it will go, positively.

  1. In the POSSIBLE PROBLEMS column, write down what you think might go wrong, or areas you think you might struggle with.

  1. In the STRATEGIES TO OVERCOME THESE PROBLEMS, list positive coping strategies you could use to overcome these problems.

  1. In the OUTCOME OF EXPERIMENT column, report how you think it went.

  1. In the last column, rate how much the experiment supports the new thought, that is, rate how much the experiment proves to you that you can believe this new thought – percentage (0% - 100%).

  1. There are more boxes for you to plan further experiments. It will take several experiments to convince you of thoughts and for you to overcome anxieties or discomfort about doing new things. Be patient.

Finally, write what you learned from these experiments

Activity Scheduling

The aim of Activity Scheduling:

When people feel low and depressed usually they slow down mentally and physically. People lose concentration and the desire to do anything that is pleasurable. Often a sure cure for depression (as well as medication and CBT) is to rediscover pleasure. This not only lifts moods, but will engage people in rediscovering a sense of self-worth, deserving and self-esteem.

Activity makes you feel better! Activity motivates you to do more!

Activity makes you feel less tired! Activity improves your ability to think!

Two methods:

The two methods of using Activity Schedules are:

1. To self-monitor i.e., people record what they have been doing and they record their moods.
2. To plan ahead i.e., they plan to do more of the things that give them pleasure and help them to become active again so that their moods will be lifted.

Using the Weekly Activity Schedule:

1. Write in each box the activity – what they were doing that hour.
2. Also write in each box a mood rating (0% - 100%)
1. They can rate any mood, e.g., depression, anxiety, anger, even loneliness.
2. They can rate any behaviour.

The aim is self- monitoring. People record what they were doing and how it made them feel. Boxes should look like this:

The numbers in the example are rating ‘stress’. At breakfast the stress was felt a little (low score). The stress was felt more at work (score goes up).

3. Thinking about patterns:

Once people have a Weekly Activity Schedule completed, they can use the “Working with Activity Schedule” sheet to identify which activities affected their mood for the better and for the worse and which they could plan to do more of next week. The aim is to build up pleasurable activities, not tiresome cores, or destructive behaviours.

Working with Activity Schedules

1. Intense Moods (describe the rate and range of rate, both positive and negative)

2. Activities affecting moods:

Write down the activities that made you feel better

(Describe any awareness and thoughts you had at those times)

Write down the activities that made you feel worse

(Describe any awareness and thoughts that you had at those times.)

3. Coping Activities

(Describe what you used to cope with when experiencing activities that made you feel worse – healthy and unhealthy coping strategies)

Other activities (that made you feel better)

4. Times – any noticeable pattern :

Best Times:

Worst Times:

5. Action Plan

When: Where: With Whom:

6. Key Thoughts to challenge:

Planning Ahead with Activity Schedules:

Once people have discovered a pattern of their moods and what activities affect them they can then plan ahead – that is , they can plan more pleasurable activities. They plan to do more of the things that lift their mood. These may literally be pleasurable activities, like self-care activities or spoiling yourself, or, they may be activities like doing a Flashcard Heading, where people choose to face their negative thoughts rather than avoid or try to ignore them.

Assumptions and Core Beliefs

Our negative thoughts come from far deeper and from earlier life experiences. CBT is about challenging our daily negative thoughts and mainly about our ‘here and now’. However, there are often deeper assumptions and core beliefs which underlie the surface every day negative thoughts.

There are several ways to identify underlying assumptions and Core beliefs.

  1. There may be recurrent themes which emerge during treatment.
  1. Global self-statements such as ‘stupid’ and/or ‘weak’ may reflect self-expressions .
  1. Memories of childhood experiences may ‘match’ current beliefs.
  1. The Dysfunctional Attitude Scale will high-light areas of vulnerability and give examples of specific attitudes.
  1. The Downward Arrow Technique .

Assumptions and Core Beliefs.

Underlying Assumptions are the rules we hold, usually recognized if we use

‘I should’ statements, or

‘If’……. ‘Then’

Core Beliefs are the absolute statements we make about ourselves. These come from very deep down, from experiences in the past and from the negative (or positive ) messages we received from others.


‘I am a failure’

‘I am loved’

‘I am valued’

‘I am accepted’


The following questions can be used to challenge negative assumptions.

1. In what way is the attitude unreasonable?

How does it fit into the way the world works?
How does it reflect reality?

2. What is the effect of this attitude on my life?

Does it help or hinder my getting what I want from life?
What are the advantages or disadvantages of this attitude?

3. Where did the attitude come from?

How relevant is this attitude to the here and now?

4. What alternative attitudes are there?

Am I making extreme or unrealistic demands of myself/others/life?
How would someone else view this?

5. What action can I take?

What can I do to test out a new, better attitude?

Core Beliefs

The “Flashcard Healing” tool can be used for challenging Core beliefs. There is also a technique called the “Downward Arrow Technique.” A core belief can be questioned in the following way:

Negative Automatic Thought.....
Analyze the thought in the following way.

Supposing that was true, what would that mean to me or say about me?

Supposing that was true, what would that mean to me or say about me?

Supposing that was true, what would that mean to me or say about me?

The aim is to help the client arrive at a negative absolute statement about them in the form of “I am………..”

Once such a thought is identified we can challenge the evidence and truth of such statements. They are often deeply felt meanings, which are held with a lot of emotion. Identifying them alone can be very emotional. Some statements however are irrational and can be challenged in order to bring the client to a more realistic and healthy view of themselves and their situations