WE ARE BOUND TO OUR BODIES
BUT
WE ARE NOT BOUND TO BE
UNHAPPY WITH OUR BODIES
Thomas Cash
TERMINOLOGY
The concept of body image is complex and
multi-faceted
‘extreme shape concern’ (Farrell et al 2005)
It refers to an individual’s view of their body
size, shape, weight and appearance (total
body or specific parts)
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)
 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)
COMPONENTS
Perceptual distortion
Body dissatisfaction
Behaviours
Cognitions
PERCEPTUAL DISTORTION
An imagined
bodily defect or
exaggeration of
features in
which a
discrepancy
occurs between
actual and
perceived size
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)
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)
BODY DISSATISFACTION
Features include
discomfort and
complaint about
appearance; whole
body or discrete areas
frequently described
as fat
Muscular physique
Thighs, buttocks, stomach and
breasts
Increasing
dissatisfaction can
predict the onset and
elevation in bulimic
pathology (Stice 2004)
Attention to disliked parts can lead to preoccupation (Freeman et al. 1999) and maintain
the problem
Dissatisfaction has
been ascribed to
cultural/societal
views and personality
Western media
encourages thinness
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
BEHAVIOURS
Body checking
 Grooming
 Looking in the mirror at
perceived defects
 Pinching and
measuring specific
areas
 Comparison with
media figures
Frequent weighing
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)
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
 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
Distorted psychological perceptions can occur
as cognitions of apparent delusional intensity in
direct response to appearance
Body image is closely linked to self-esteem
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)
Improvements in body image, self-esteem,
depression & social anxiety were reported
by Strachan & Cash (2002), however,
improvements in eating pathology were
‘weaker’
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
Castle Craig Hospital
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
Group treatment aimed at normalising body
shape concern in people suffering from an
eating disorder
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
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
SESSION ONE
 Questionnaires
 Relaxation/distress tolerance
 Homework
SESSION TWO
 Body image profile constructed from
questionnaires
 Historical and cultural perspectives
 Body image diary, ABCs
 Helpsheet for change
SESSION THREE




Appearance assumptions
Triggers to negative body image
Negative automatic body image thoughts
Mirror desensitization introduced
SESSION FOUR
 Self-defeating behaviours, checking and
avoidance
 Thinking errors
 Mirror desensitization
SESSION FIVE
 Perceptions
 Mirror desensitization
SESSION SIX




My proudest moments
Letter to my body
Relapse prevention
Questionnaires & evaluations
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
‘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’
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. 478486). 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.
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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 and Cognitive 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
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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
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 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), 314322.
 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.