10.1177/0145445503259853 BEHAVIOR MODIFICATION / November 2004 Williamson et al. / CONCEPTUAL MODEL Cognitive-Behavioral Theories of Eating Disorders DONALD A. WILLIAMSON MARNEY A. WHITE EMILY YORK-CROWE TIFFANY M. STEWART Louisiana State University Our Lady of the Lake Regional Medical Center Thisarticlepresentsanintegratedcognitive-behavioraltheoryofeatingdisordersthatis basedon hypotheses developed over the past 30 years. The theory is evaluated using a selected review of the eating disorder literature pertaining to cognitive biases, negative emotional reactions, binge eating, compensatory behaviors, and risk factors for eating disorders. In general, hypotheses derived from cognitive-behavioral theories have been supported by a variety of research studies. The implicationsof these findingsfor treatment and prevention of eating disorders are discussed. This review of the literature serves as a conceptual base for some of the other articles that are included in this special issue of Behavior Modification. The article concludes with an introduc- tion to six articles that discuss issues related to psychiatric classification, assessment, treatment, and prevention of eating disorders. Keywords: cognitive-behaviortherapy theoryofeatingdisorders cognitivebias risk factors This special edition of Behavior Modification summarizes some of the recent advances in the field of eating disorders and provides some of the details of treatment, prevention, and assessment protocols that are not often available in research articles and book chapters on eating disorders. This initial article is written to provide an overview of research pertaining to cognitive-behavioral theories of eating disor- ders and to introduce the special series. When reading the other arti- cles in this special issue on eating disorders, it may be useful to refer to this article for an understanding of the theoretical underpinnings of assessment and treatment strategies that have been developed by 711 BEHAVIOR MODIFICATION, Vol. 28 No. 6, November 2004 711-738 DOI: 10.1177/0145445503259853 �� 2004 Sage Publications

cognitive-behavior therapists. Most of the articles in this special edi- tion were selected because they provide details of the clinical methods that have been developed for the treatment and prevention of eating disorders. Because of space limitations, the theoretical rationales for these interventions were not presented in detail. We hope that this article will serve as a conceptual guide for the other articles of this special edition. COGNITIVE-BEHAVIORAL THEORIES Behavior therapists have developed many conceptual models of eating disorders over the past 30 years. Theories of eating disorders during the 1970s emphasized fear of fatness and disturbances of body image as primary motivational factors for self-starvation and behav- iors to compensate for the weight gain associated with binge eating (Bruch, 1973 Russell, 1979). By the 1980s and early 1990s, concepts from dietary restraint theory (Polivy & Herman, 1985) and escape from negative affect (Heatherton & Baumeister, 1991) were hypothe- sized as the primary determinants of binge eating. In the 1990s, cogni- tive or information-processing theories of eating disorders were for- mulated (Fairburn, 1997 Fairburn, Cooper, & Cooper, 1986 Vitousek & Hollon, 1990 Williamson, 1996 Williamson, Muller, Reas, & Thaw, 1999). Figure 1 illustrates a model that integrates the perspectives of cognitive and behavioral theorists over the past 30 years. Central features of this model are as follows: (a) the body self- schema, (b) cognitive biases, (c) binge eating, (d) compensatory behavior, (e) negative reinforcement of compensatory behavior by reduction of negative emotion, and (f) psychological risk factors that are hypothesized to define people who are vulnerable for the develop- ment of eating disorders. According to this model, factors such as fear of fatness and body image are aspects of broader constructs. For example, overestimation of body size is conceptualized as a cognitive bias that stems from a self-schema that includes memory stores related to body size/shape and eating that are easily activated and readily accessible for retrieval from memory. 712 BEHAVIOR MODIFICATION / November 2004

713 Psychological Risk Factors 1. Fear of Fatness 2. Overconcern with Body Size/shape 3. Internalization of Thin Ideal Shape 4. Perfectionism/ Obsessionality Stimulus Increased probability of cognitive bias: 1. Body/Food-related information 2. Ambiguous stimulus 3. Self-referent task Self-Schema related to body size/shape or eating Cognitive Bias 1. Attention Bias 2. Selective Memory Bias 3. Selective Interpretation Bias 4. Body Size Overestimation 5. Extreme Drive for Thinness Increased Negative Emotion Reduction of Negative Emotion Behavior 1. Body Checking 2. Avoidance of Body/ Food Stimuli 3. Restrictive Eating 4. Compulsive exercise 5. Self-induced vomiting 6. Laxative abuse Confirmation of: 1. Fear of Fatness 2. Overconcern with Body Size/Shape 3. Internalization of Thin Ideal Shape 4. Need for Perfectionism/ Obsessionality Binge Eating Dietary Restraint Figure 1. Integrated cognitive-behavioral theory of eating disor ders.

The body self-schema is a key concept for the cognitive aspects of the model. Cognitive theorists (e.g., Fairburn, 1997 Vitousek & Hollon, 1990 Williamson, 1996) have postulated that overconcern with body size/shape can result in a body self-schema that is readily activated by external and internal cues. This self-schema is presumed to direct the person���sattention to body- and food-related stimuli and to bias interpretations of self-relevant events in favor of fatness interpre- tations. For example, feelings of fullness may be interpreted as ���feel- ing fat.��� Similarly, innocuous comments from others may be inter- preted as negative evaluation of one���s body size, or shape. As a function of these cognitive biases, the person comes to a conclusion on the basis of experiential ���evidence,��� but the conclusion is one that is not shared by most people, because they do not process the same information in a biased fashion. The model assumes that cognitive biases occur without conscious awareness and that the person experiences the cognition as ���real��� (Williamson et al., 1999). As shown in Figure 1, the model hypothesizes that certain types of stimuli are more likely to activate cognitive biases in people with a highly developed body self-schema. The key stimulus characteristics that have been found to activate cognitive biases are (a) body- or food- related information, (b) ambiguous stimuli, and (c) situations that require the person to reflect on themselves, especially their body, eat- ing, and so on. The psychological risk factors (of the model) are (a) fear of fatness, (b) overconcern with body size/shape, (c) internaliza- tion of a thin ideal size/shape, and (d) perfectionism/obsessionality. The model hypothesizes that negative emotion interacts with the self- schema to activate some cognitive biases. The model also postulates that the activation of cognitive bias elicits negative emotion. Thus, it is possible for cognitive biases to activate negative emotion and the self- schema for body size/shape or eating, which in turn activates cogni- tive bias. This feedback loop may be experienced as an obsession and/ or overwhelming anxiety. These negative emotions are often labeled anxiety, feelings of fatness, depression, body disparagement, anger, and self-loathing. The individual experiences this negative emotion as an aversive experience that must be escaped or avoided. The obsession with body size, eating, and so on serves to exacerbate the emotional state in such a manner that the person feels that he or she must do 714 BEHAVIOR MODIFICATION / November 2004

something (anything) to escape these feelings that will ���persist for- ever.��� This reaction is best conceptualized as an ���urge,��� that is, an urgent feeling that one must do something to ���undo��� this affective state. It is difficult to overstate the intensity of this urgent state. From the perspective of someone captivated by the experience, there is no alternative but to engage in various behaviors to escape/avoid these aversive experiences (i.e., purgative behaviors, restrictive eating, and excessive exercise).In such instances, the body self-schemaof the eat- ing disorder patient is so pervasive and so powerful that it is the experiential reality of the person. Williamson et al. (1999) referred to this experience as ���apparent reality.��� Binge eating is viewed as one possible consequence of this increased emotionality. Dietary restraint (the intent to restrict energy intake) is viewed as being derived from extreme drive for thinness and other cognitive biases. It has been suggested that binge eating is deter- mined by the ���dual pathway��� of dietary restraint and regulation of negative affect (Stice, 2001). However, the relationship between dietary restraint and binge eating is unclear some research indicates that dietary restraint does not predict binge eating (Byrne & McLean, 2002). In response to anxiety, feelings of fatness, and so on, the person feels compelled to engage in compensatory or other behaviors to escape/avoid this aversive condition (Rosen & Leitenberg, 1982). As shown in Figure 1, common behaviors include body checking, avoid- ance of body/food stimuli, restrictive eating, compulsive exercise, self-induced vomiting, and laxative abuse. The effect of this behavior is the reduction of negative emotion, which negatively reinforces (and strengthens) the behavior (Williamson, 1990) and also serves the function of confirming the necessity (a cognitive outcome) of engag- ing in this escape/avoidant behavior. According to this view, the nega- tive emotional experience is viewed as ���normative��� (or reasonable) therefore, actions that nullify the experience are viewed as ���helpful��� or ���useful,��� even ���sensible.��� In this process, compensatory behaviors are negatively reinforced and they confirm the belief that one should fear fatness and worry about body/size shape. This process is viewed as similar to the concept of ���emotional reasoning.��� Williamson et al. / CONCEPTUAL MODEL 715