The Role of Cognitive Factors in the Maintenance of Bulimia - Essay Example

Critically Examine the Evidence for the Role of Cognitive Factors in the Maintenance of Bulimia Cognitive-behavioural therapy (CBT) for bulimia indicates that cognitive factors play significant role in the maintenance of bulimia. As Trompeter (2006) points out, CBT as a treatment for bulimia targets cognitive abnormalities as well as abnormal behaviour in patients suffering from bulimia. Put another way, CBT targets cognitive factors designed to remove or at the very least lessen the cognitive symptoms manifested by binging and purging, and exaggerated self-perceptions about weight (Trompeter, 2006, p. 102). A number of researchers have concluded that cognitive factors play a significant role in maintaining the symptoms associated with and manifested by bulimia (Mines & Merrill, 1987). Strauss and Ryan (1988) conducted a study assessing cognitive dysfunctions in individuals with various forms of eating disorder. The cognitive dysfunctions assessed were cognitive dysfunctions that have not received sufficient attention in the literature and included cognitive slippage, logical errors and conceptual complexity. The subjects were comprised of an experimental group and a control group. The experimental group included 19 individuals with anorexia nervosa, 14 with bulimia, 17 bulimia subjects with normal-weight, and 15 patients with subclinical eating disorders. The control group consisted of 17 subjects with no eating disorders. The subjects were tested by the use of the Cognitive Error Questionnaire, Thought Disorder Index, Friedman’s Developmental Level, Sentence Completion Test, Dysphoria Questionnaire, and Beck Depression Inventory (Strauss & Ryan, 1988). The results of the study indicated that the anorexia and bulimic groups showed results manifesting a greater propensity for logical errors than the control group. However, the groups consisting of bulimia subjects with normal weight and subclinical eating disorders did not demonstrate logical errors significantly different from the control group. Tests for conceptual complexity and cognitive slippage were essentially the same among the experimental groups and the control group. However, dysphoria and depression were significant indicators among all members of the experimental groups. Struass and Ryan (1988) concluded however, that since mood and cognitive factors function in tandem, the presence of dysphoria and depression in all subjects with eating disorder indicate that the combined influence of logical errors, depression and dysphoria play a significant role in the maintenance and escalation of eating disorders generally. Hayaki, Friedman, Whisman, Delinsky and Brownell (2003) conducted a study identifying the link between sociotropy (a cognitive-personality indicator of the acquisition and maintenance of depression) and bulimia. Hayaki et. al., (2003) explained that sociotropy is a cognitive dysfunction manifested by an individual’s abnormal need to obtain the approval of others. The study involved 141 undergraduate female taking psychology courses and 74 females who were being treated for “eating and weight disorders” (Hayaki, et. al., 2003, p. 173). The participants were tested by virtue of the 36-item Bulimia test (BULIT) instrument developed by Smith and Thelen in 1984. Other instruments for testing included the Beck Depression Inventory, and the Sociotropy and Autonomy Scale. Results indicated that sociotropy is linked to bulimia among both undergraduate women with varying ranges of bulimia and among women with more significant ranges of bulimia seeking treatment for the disorder. However, the relationship between bulimia and sociotropy existed independent of any connection to depression. Hayaki, et. al., (2003) therefore concluded that individuals with sociotropy are more likely to focus on obtaining approval from others which influences the engagement in and maintenance of eating behaviour that “can trigger bulimic episodes” (p. 175). On the other hand, Hayaki, et. al., (2003) conclude that it is also possible that individuals with sociotropy who find themselves confronting particularly “stressful interpersonal events”, are “more likely to experience negative mood and engage in binging and purging behaviour in part for mood regulation” (Hayaki, et. al., 2003, p. 175). Waters, Hill and Waller (2001) conducted a study challenging the claim that cognitive dysfunctions contribute to the development and maintenance of bulimia. Waters’ et. al., (2001) study involved 15 bulimic women and targeting their binge-eating conduct. The subjects were required to document their eating behaviour and keep a Craving Record self-monitoring their hunger, eating behaviour and “affective state” (p. 877). Findings indicate that cravings that gave way to binging were linked to increased tension, poor moods and lower levels of hunger than cravings that did not give way to binging. It therefore follows that, “levels of tension and hunger were the critical discriminating variables” (Waters, et. al., 2001, p. 877). Waters, et. al., (2001) also concluded that emotions play a significant role in the maintenance of bulimia and therefore casts some doubt on the cognitive “starve-binge” models of bulimia (p. 877). However, as Strauss and Ryan (1988) suggests, depression and emotions do not function independently of cognition. It would therefore appear that Waters, et. al. (2001) study cannot rule out the possibility that cognitive dysfunctions of one sort or another contribute to the emotional factors in that cognitive pathways in the subjects tested did not mediate between high levels of tensions, poor moods and the corresponding cravings. Moreover, eating disorders have been linked to cognitive dysfunctions in many studies and is well documented and supported in the literature. The cognitive dysfunctions are typically associated with obsessive thinking, imprecise judgments and rigidity in thinking trends. These cognitive dysfunctions have been found to be linked to eating disorders generally. Cognitive pathology is linked to self-evaluation based on weight and body assessments which contribute to both anorexia and bulimia (Polivy & Herman, 2002). Tchanturia, Anderluh, Morris, Rabe-Hesketh, Collier, Sanchez and Treasure (2004) conducted a study designed to ascertain if there were any distinctions between cognitive flexibility among individuals with anorexia nervosa and bulimia nervosa. The study consisted of 53 subjects with eating disorders: 34 with anorexia nervosa, 19 with bulimia nervosa, 35 healthy individuals in the control group. Neuropsychological tests for identifying cognitive flexibility were conducted and included Trail Marking B, the Brixton Test, Verbal Fluency, the Haptic Illusion Test, a Cognitive Shifting Task and a picture test. With the use of an exploratory factor analysis, four factors were identified: simple, mental flexibility, preservation, and perceptual shift. The study found that the anorexia nervosa subjects manifested scores consistent with simple and perceptual shift factors while the bulimic subjects demonstrated “significant impairments in mental flexibility and perceptual shift. Tchanturia, et. al., (2004) therefore concluded that “differential neuropsychological disturbance in the domain of mental flexibility/rigidity may underlie the spectrum of eating disorders” in general (p. 513). Mobbs, Van der Linden, d’Acremont and Perroud (2008) conducted a study involving 18 individuals with bulimia and 18 healthy individuals (control group). The study involved the adoption of the go/no-go affective shift task. The go/no-go task permits an observation of the impulse controls, mental flexibility relative to stimuli in the context of food and the body and attention. The study revealed that the bulimic individuals responded more rapidly to the go/no-go tasks. The bulimic subjects also demonstrated poorer impulse control than the members of the control group especially in relation to food. Mental flexibility however, was primarily the same for both groups of participants. The results of the study indicate that bulimics have cognitive impairment coupled with less impulse control in relation to responses to food stimuli. The cognitive deficits present in the bulimic patients indicate that cognitive dysfunctions can contribute to the development and maintenance of bulimia (Mobbs, et. al., 2008). A study on eating disorders was conducted on a sample population of adolescent females from three private schools in Brazil, one of which was a military school (Darnall, Smith, Craighead, & Lamounier, 1999). The sample was comprised of 161 females who took the Eating Attitudes Test (EAT) which is comprised of 26 items measuring abnormal eating and related behaviour. The study also involved the Body Esteem Scale (BES) comprised of 35 items designed for self-reporting measures of cognition and body perceptions. The Rosenberg Self-Esteem Scale (RSE) was also used for measuring self-esteem among adolescents. The Figure Rating Scale for self-reporting measures of body image among adolescents was also used. An additional question was added pursuant to the Eating Disorder Examination (EDE): How important is your weight and body shape in determining how you feel about yourself as a person? (Darnall, et. al., 1999, p. 50). The results of the study indicated that by virtue of a path analysis, when there is a distinction between actual body weight and ideal body weight and image, there is a greater likelihood of concerns about weight. This kind of cognition may lead to bulimia. However, perceptions of discrepancies between perceived ideal body weight and perceived actual weight may perpetuate bulimia. As Darnall, et. al. (1999) observed, both the fact of being heavy and the perception of being heavier than the ideal weight (actually being bigger/having an illusionary “thin ideal”) lead to weight concerns which can be perpetuated in the case of the unrealistic thin ideal scenario (p. 47). Darnall, et. al. (1999) concluded that weight concerns have a direct connection to feelings of low self-esteem, which is linked to attaching significant meaning to weight and body image. The significance of weight and body image “contributes most powerfully to eating pathology through dieting” and thus as long as perceptions are shaped by unrealistic goals and thin ideal, eating pathologies will be maintain (Darnall, et. al., 1999, p. 47). Darnall, et. al. (1999) concluded that the results of their study supports the identified variables found in cognitive models of bulimia. Zakzanis, Campbell and Polsinelli (2010) conducted a meta-analysis of the literature on the link between cognitive dysfunction and anorexia and bulimia. Zakzanis, et. al., (2010) concluded that it is well documented in the literature that there is a connection between cognitive dysfunction and eating disorders. The bulk of the literature generally reveals that individuals with bulimia and anorexia have some level of cognitive impairment. However, what was lacking in the literature was a quantification of the extent of the cognitive impairment of the subjects with anorexia or bulimia. Nor was there an indication of the difference in cognitive pathologies between anorexic and bulimic subjects (Zakzanis, et. al., 2010). By “quantitatively synthesizing the existing literature using a meta-analytic methodology”, Zakzanis, et. al. (2010) tested the extent to which cognitive dysfunction persists in individuals with anorexia and bulimia. Research findings indicate that there was only moderate evidence of cognitive dysfunction “specific to” anorexia and bulimia in relation to “body mass index” in anorexia with respect to “its severity” and is “differentially impaired between disorders” (Zakzanis, et. al., 2010, p. 89). Cumulatively, the results of the study demonstrate that “disturbed cognition is figural in the presentation of eating disorders and may serve to play an integral role” in its creation and perpetuation/maintenance (Zakzanis, et. al., 2010, p. 89). Lena, Fiocco and Leyenaar (2004) conducted a review of the literature and identified a significant number of reports supported by empirical evidence linking the development and maintenance of bulimia and eating disorders generally to cognitive impairments. According to Lena, et. al., (2004) the most commonly recurring cognitive impairments impacting the development and maintenance of eating disorders are: visuospatial dysfunctions, organizational dysfunctions, tactile-perceptual dysfunctions, psychomotor coordination deficits, nonverbal problem-solving problems, memory difficulties and attention problems. Even so, the list of other cognitive deficits contributing to eating disorders is “exhaustive” (Lena, et. al., 2004, p. 101). When cognitive dysfunction is characterized by low self-esteem, “poor social functioning”, “depression” and “maladaptive coping strategies” the risk of developing and maintaining eating disorder is significantly higher. For instance: Executive functioning deficits may render one with poor problem-solving abilities necessary for adaptive coping, and nonverbal problem-solving deficits may lead to the faulty interpretation of other’s body language, giving rise to poor interpersonal relationships and poor self-esteem (Lena, et. al., 2004, p. 101). A review of the literature therefore suggests that arguments connecting cognitive deficits with the maintenance of bulimia are well-documented and supported. Evidence-based studies such as the studies reported in this paper indicate that cognitive difficulties impact both coping and problem-solving abilities and also contribute to unrealistic perceptions. Therefore, just as these cognitive deficits give rise to eating disorders such as bulimia, they also contribute to the maintenance of these eating disorders. Bibliography Darnall, B. D.; Smith, J.E.; Craighead, L. W. and Lamounier, J. A. (1999). “Modification of the Cognitive Model for Bulimia Via Path Analysis on a Brazilian Adolescent Sample.” Addictive Behaviors, Vol. 24(1): 47-57. Hayaki, J.; Friedman, M.A.; Whisman, M. A.; Delinsky, S. S. and Brownell, K. D. (2003). “Sociotropy and Bulimic Symptoms in Clinical and Nonclinical Samples.” International Journal of Eating Disorders, Vol. 34: 172-176. Lena, S. M.; Fiocco, A. J. and Leyenaar, J. K. (2004). “The Role of Cognitive Deficits in the Development of Eating Disorders.” Neuropsychology Review, Vol. 14(2): 99-113. Mobbs, O.; Van der Linden, M.; d’Acremont, M. and Perroud, A. 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