A fundamental attribution error in CBT-e for eating disorders

There is something fundamentally wrong with Cognitive Behavioral Therapy (CBT-E) for anorexia nervosa and other eating disorders. I want to be clear that I think that some form of CBT is useful in treating eating disorders. After all, anorexia nervosa (AN) and bulimia nervosa (BN) are characterized by dysfunctional cognitions and behaviors that maintain the disorders and a CBT approach can profitably focus on changing these cognitions and behaviors.

My concern is with that Fairburn and his colleagues’ CBT-(enhanced) believe the core psychopathology of eating disorders is the “overevaluation of shape and weight”(1). (I think we agree on the behavioral part, people must normalize eating and stop purging.)

This conceptualization ignores history (2) and biology (3). Moreover, it can interfere with recovery (4) and contribute to sufferers’ and observers’ blaming victims for their plight.

History: Before the 1960s people with anorexia nervosa did not give fear of getting fat as their reason for eating little. They said they were full, their stomach was upset, they were not hungry. St Catherine of Siena thought she had difficulty eating earthly food because God had prepared a heavenly table where she would be able to eat. She died of malnutrition at 33 but not before shaking up the Catholic Church. Eleanor Roosevelt, Simone Weil and Virginia Woolf struggled with AN all their lives. They were not trying to be thin.

“Fear of being fat” is the culture-bound explanation that people have given since the 1960s for the chaotic and confusing signals welling up from the ancient, nonverbal hypothalamus. Signals that, in the case of AN, make it hard to eat and drive them to move, and in the case of BN drive them to bingeing and purging. People automatically search for an explanation for any mysterious feelings and readily agree to the currently popular psychological explanations.(5)

Biology: eating disorders are caused by powerful survival mechanisms that will not change as long as the body fears famine. Trad CBT for eating disorders does not reflect what biological researchers have learned about what causes eating disorder symptoms and how to heal them. It treated the brain as a black box, but it shouldn’t.

CBT was developed originally to treat depression. With depression, viewing the brain as a black box was necessary because little was known about the neurophysiology of depression and we have no natural animal model. This is not the case with eating disorders. Many other species spontaneously develop animal anorexias where they stop eating and start moving when starved. Binge eating can be induced in normal weight mice in the lab if they are dieted, refed, stressed and then given access to sugar water. The brain systems that are in charge of eating are highly conserved in mammals so there is no reason not to learn from animal neuroendocrine research.

Neuroendocrine researchers have teased out how ED behaviors are caused by changes in appetite and activity regulators and reward pathways in animals and people(6). This information provides the explanation that patients need for why certain behaviors lead to feeling out of control of binge eating, and why weight loss in people genetically vulnerable to AN can lead to restricting and exercising.

People need to know that only a tiny fraction of the brain is conscious and it cannot take care of deciding most of what we do. Nonconscious brain algorithms initiate most of our eating behavior, but, knowing nothing of that, we automatically assign agency to the conscious part we know.

CBT for eating disorders focuses on the wrong underlying cognitions. An underweight person with AN does not run and restrict because she is vain, but because of same neuroendocrine changes that cause rats, mice (7) and pigs (animals that like humans evolved as opportunistic omnivorous nomadic foragers) to run and restrict. These behaviors would remove them from a food-depleted environment. I believe that these behaviors, as well as binge eating, are adaptations that helped our ancestors from survive famines(3).

Recovery: And treatments based on the conventional CBT assumptions have a dismal success rate. In fact McIntosh and colleagues (4) found that patients in what was supposed to be the control group, given only nutritional counseling and emotional support, did better than those given CBT that assumed anorexia is caused by overvaluing body size.

Our updated CBT for eating disorders explains the powerful compulsions as adaptations to flee famine that borrowed from their body’s future to save their life today. Their body is trying to migrate. It feels so wrong to give up anorexia today because they were selected to persevere through pain and hunger.  I suspect that when they found better lands the band members helped them recover.


  1. C. G. Fairburn, Z. Cooper, R. Shafran, Cognitive behaviour therapy for eating disorders: A “transdiagnostic” theory and treatment. Behaviour research and therapy 41, 509-528 (2003).
  2.  P. K. Keel, K. L. Klump, Are eating disorders culture-bound syndromes? Implications for conceptualizing their etiology. Psychological bulletin 129, 747-769 (2003).
  3.  S. Guisinger, Adapted to flee famine: adding an evolutionary perspective on anorexia nervosa. Psychological review 110, 745-761 (2003).
  4.  V. V. McIntosh, J. Jordan, F. A. Carter, S. E. Luty, J. M. McKenzie, C. M. Bulik, C. M. Frampton, P. R. Joyce, Three psychotherapies for anorexia nervosa: a randomized, controlled trial. Am J Psychiatry 162, 741-747 (2005).
  5.  P. G. Zimbardo, in Advances in experimental social psychology, M. P. Zanna, Ed. (Academic Press, San Diego, CA 1999), vol. 31, pp. 345-486.
  6.  J. Hebebrand, T. Muller, K. Holtkamp, B. Herpertz-Dahlmann, The role of leptin in anorexia nervosa: clinical implications. Molecular psychiatry 12, 23-35 (2007).
  7.  W. F. Epling, W. B. Pierce, Activity based anorexia: A biobehavioral perspective. Int J Eat Disord 5, 475-485 (1988).


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Social support was probably crucial in the Pleistocene for AN recovery

I just watched a Dr. OZ show with an extremely emaciated woman who had had anorexia for most of her adult life. It is another illustration of why we need a new paradigm. Dr. OZ seemed to think she chose her illness and he moved quickly to a facile psychological interpretation—she wants to be taken care of—that blames her for the AN. He naively urged her to get well so she can see him again and perhaps he believes for him she will. If she doesn’t get well his narcissistic injury will lead him to blame her. He’s a good proxy for every person who interacts with her.

He presents her with a new therapist who says they will get to the bottom of why she doesn’t eat and then she will get better. As though she hasn’t tried to do this so many times over the last twenty years.

Oz comments that in contrast to other seriously ill people he has had on the show, she has no one in the audience rooting for her. She lost her mother to sudden cancer, which exacerbated weight loss that began trying to lose the freshman fifteen in college. Presumably 20 years ago her grieving father was counseled to keep his distance. Her husband had no way to understand AN except that she was willfully killing herself and he left. Friends, probably thinking she cared more about her figure than about getting well also left. Without a village to help her recover she became chronically ill.

I think anorexia nervosa is so deadly today because we blame victims for their plight and expect them to get well on their own. AN evolved in the context of deeply social bands and I believe the whole tribe helped their anorexic scout recover. Anorexia outside of the environment in which it evolved can be deadly. Starving rats and mice will run themselves to death in a lab cage, but in the wild their anorexic behaviors would have brought them to a better foraging area.

Evolution doesn’t have to fix what the tribe can fix. For example, when you have nursing problems you find they happen a lot. This makes one wonder why natural selection didn’t weed out these mistakes long ago. Without the La Leche League’s wise counsel my son would have been on formula and before formula he might have died. I think that when we lived in bands there was usually an informal “La Leche League” of wise old women who carried such knowledge. Like the old mare that shows their wild horse herd where to eat, drink, bed down, old women carried precious knowledge for the tribe. Foolproof nursing did not have to evolve.

By the same reasoning, if the family and tribe helped her recover, it didn’t matter if a solitary person couldn’t because there were no solitary people in the Pleistocene.

Next time: What is wrong with CBT for eating disorders.

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