WE ARE BOUND TO OUR BODIES BUT WE ARE NOT BOUND TO BE UNHAPPY WITH OUR BODIES Thomas Cash

1. WE ARE BOUND TO OUR BODIES BUT WE ARE NOT BOUND TO BE UNHAPPY WITH OUR BODIES Thomas Cash

4. TERMINOLOGY The concept of body image is complex and multi-faceted ‘extreme shape concern’ (Farrell et al 2005)

5. It refers to an individual’s view of their body size, shape, weight and appearance (total body or specific parts)

6. BODY IMAGE AND EATING DISORDERS • Importance recognised by incorporation into DSM-IV Negative body image: • is a pre-cursor for eating disorders in at risk populations (Killen et al. 1994) • is the main factor in the psychopathology of eating disorders (Gleaves & Eberenz 1993)

7. Historically little emphasis has been placed on body image in therapy • Successful treatment may not bring body image satisfaction • The level of body image distress at the end of treatment for Bulimia Nervosa predicts relapse (Freeman et al. 1985; Fairburn et al. 1993) • The risk of relapse may be enhanced because of inadequate provision of treatment for extreme shape concern within eating disorder treatment (Farrell et al. 2005)

8. COMPONENTS Perceptual distortion Body dissatisfaction Behaviours Cognitions

9. PERCEPTUAL DISTORTION An imagined bodily defect or exaggeration of features in which a discrepancy occurs between actual and perceived size

10. It was recognised as a feature of: Anorexia Nervosa by Hilda Bruch (1962) Bulimia Nervosa by Stice (2004) Size is frequently over-estimated Fairburn et al. (1999) a combination of behaviours e.g. body checking and selective attention to body parts The internalization of a thin ideal (Stice 2004) Body dissatisfaction and the internalization of a thin ideal (Mussap et al. 2008)

11. Perceptual distortion may result from psychosocial stimuli: • Low mood • Hunger • Eating high calorie foods Farrell, Shafran & Fairburn (2003) indicate that distortion varies depending on the measurement technique. It is unclear what is within the normal range of attitudes towards the body (Probst et al. 2008)

12. BODY DISSATISFACTION Features include discomfort and complaint about appearance; whole body or discrete areas frequently described as fat

13. Thighs, buttocks, stomach and breasts Muscular physique

14. Increasing dissatisfaction can predict the onset and elevation in bulimic pathology (Stice 2004) Attention to disliked parts can lead to pre-occupation (Freeman et al. 1999) and maintain the problem

15. Dissatisfaction has been ascribed to cultural/societal views and personality Western media encourages thinness

16. BEHAVIOURS These include avoidance • of situations (fear of attention, self consciousness) • of seeing oneself in the mirror • problem areas may hidden by clothing or posture

17. BEHAVIOURS Body checking • Grooming • Looking in the mirror at perceived defects • Pinching and measuring specific areas • Comparison with media figures

18. Frequent weighing

19. Body dissatisfaction can be maintained by checking behaviours When emotions aroused by checking are extreme, checking may be avoided to prevent discomfort Engagement in avoidance or checking depends on several factors including mood, weight and eating changes (Safran et al. 2004)

20. COGNITIONS • Cognitive biases include selective memory and extreme drive for thinness • Obsessionality and fear of fatness • Pre-occupation with appearance is distressing and time consuming • Intrusive thoughts even if recognised as abnormal or untrue can cause difficulty in functioning

21. Thought- shape fusion is a cognitive distortion associated with eating disorders (Safran & Robinson 2004) Three components: • Likelihood: thinking about food makes it likely that the individual has gained weight even though this is illogical • Moral: thinking about eating forbidden foods is morally equal to eating them • Feeling: thoughts about food increases the feeling of fatness • Thought-shape fusion may help to maintain the disorder

22. Distorted psychological perceptions can occur as cognitions of apparent delusional intensity in direct response to appearance

23. Body image is closely linked to self-esteem

24. THE APPLICATION OF CBT TO BODY IMAGE DISORDERS • CBT is widely acknowledged as a leading treatment for Bulimia Nervosa and Binge Eating Disorder (NICE 2004) • Group CBT has been proposed as the most favourable way to address body image in eating disorder treatment (Cash & Strachan 2004; Reas & Grilo 2004)

25. Improvements in body image, self-esteem, depression & social anxiety were reported by Strachan & Cash (2002), however, improvements in eating pathology were ‘weaker’

26. CBT BODY IMAGE GROUP Use of the Body Image Workbook (Cash 1997) can improve body image CBT group package was designed using components from Cash’s workbook

27. Castle Craig Hospital

28. GROUPS • 6 sessions • once a week • Topics • Personal assessment of the problems, relaxation/distress tolerance • Origins of body disparagement: historical and current • Triggers to body disparagement, NATs, corrective thinking • Practical exercises including rituals and mirror work • Review and repeat questionnaires • Plan for on-going action

29. Group treatment aimed at normalising body shape concern in people suffering from an eating disorder

30. CASH’S STEPS Body Image Workbook p9 Step 1 Discover your own body image and set your goals for change Step 2 Understand the causes of your discontent Step 3 Get comfortable with your body through body-and-mind relaxation and body image desensitization Step 4 Discover your appearance assumptions and challenge their control over your body image

31. Step 5 Change your faulty Private Body Talk with corrective thinking Step 6 Defeat your self-defeating behaviour by facing what you avoid and by eliminating your appearance preoccupied rituals Step 7 Treat your body right with affirming and enhancing activities Step 8 Continue to improve and prevent relapse by preparing today for tomorrow

32. SESSION ONE • Questionnaires • Relaxation/distress tolerance • Homework

33. SESSION TWO • Body image profile constructed from questionnaires • Historical and cultural perspectives • Body image diary, ABCs • Helpsheet for change

34. SESSION THREE • Appearance assumptions • Triggers to negative body image • Negative automatic body image thoughts • Mirror desensitization introduced

35. SESSION FOUR • Self-defeating behaviours, checking and avoidance • Thinking errors • Mirror desensitization

36. SESSION FIVE • Perceptions • Mirror desensitization

37. SESSION SIX • My proudest moments • Letter to my body • Relapse prevention • Questionnaires & evaluations

38. All areas indicated an improvement. At follow up improvements remained but were less marked. With extra mirror work and behavioural tasks improvements have been greater

39. ‘I determined how I perceived my body and that had a huge impact on the way I thought about myself. I could choose to see bad things or I could choose to see good things’ ‘I would love this friend regardless of what they looked like. If my body were an estranged friend why shouldn’t I love that….I gave it such a hard time’

40. REFERENCES • Bruch, H. (1962). Perceptual and conceptual disturbances in anorexia nervosa. Psychosomatic Medicine, 24, 187-194. • Cash, T.F. (1997). The body image workbook: an 8-step program for learning to like • your looks. Oakland, CA. Harbinger Fairburn, C.G., Peveler, R.C., Jones, R., Hope, R.A. & Doll, H.A. (1993). Predictors of 12-month outcome in bulimia nervosa and the influence of attitudes to shape and weight. Journal of Consulting and Clinical Psychology, 61, 696-698. • Cash, T.F., & Strachan, M.D. (2004). Cognitive behavioral approaches to changing body image. In T.F Cash, & T. Pruzinsky (Eds.), Body Image a handbook of theory, research and clinical practice (pp. 478-486). New York. Guilford. • Fairburn, C.G., Shafran, R., & Cooper, Z. (1999). A cognitive behavioural theory for anorexia nervosa. Behaviour Research and Therapy, 37, 1-13.

41. Farrell, C., Shafran, R., & Fairburn, C.G. (2003). Body size estimation: testing a new mirror based assessment method. International Journal of Eating Disorders, 34, 162-171. • Farrell, C, Shafran, R., Lee, M., & Fairburn, C.G. (2005a). Testing a brief cognitive-behavioural intervention to improve extreme shape concern: A case series. Behavioural andCognitive Psychotherapy 33, (2) 189-200. • Freeman, C., Beach, B., Davis, R., & Solyom, L. (1985). The prediction of relapse in bulimia nervosa. Journal of Psychiatric Research, 19, 349-353. • Gleaves, D.H., & Eberenz, K. (1993). The psychopathology of anorexia nervosa: a factor analytic investigation. Journal of Psychopathology and Behavioural Assessment, 15, 141-152. • Killen, J.D., Taylor, C.B., Hayward, C., Wilson, D.M., Haydel, K.F., Hammer, L.D., Simmonds, B., Robinson, T.N., Litt, I., Varady, A., & Kramer, H. (1994). Pursuit of thinness and onset of eating disorder symptoms in a community sample of adolescent girls: A three-year prospective analysis. International Journal of Eating Disorders, 13, 227-238.

42. National Institute for Clinical Excellence (2004). Eating disorders: core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. Nice Clinical Guideline No 9. London: National Institute for Clinical Excellence. Available from: http://www.nice.org.uk • Reas D.L., & Grilo, C.M. (2004). Cognitive behavioural assessment of body image disturbances. Journal of Psychiatric Practice 10 (5), 314-322. • Shafran, R., Fairburn, C.G., Robinson, P., & Lask, B. (2004). Body checking and its avoidance in eating disorders. International Journal of Eating Disorders, 35, 93-101. • Shafran, R., & Robinson, P. (2004). Thought-shape fusion in eating disorders. British Journal of Clinical Psychology, 43, 399-408. • Stice, E. (2004). Body image and bulimia nervosa. In T.F Cash, & T. Pruzinsky (Eds.), Body Image a handbook of theory, research and clinical practice (pp. 304-311). New York. Guilford.