Thoughts about Appearance

Patients also have strong, shameful, and often biased thoughts about appearance, such as: “Being thin is the most important thing”; “I can only be attractive if I’m thin”; “I am inadequate and flawed”; “My stomach should be completely flat”; “I’m a fat pig”; and “I feel so bloated after that binge, I must have gained 5 pounds.” Thoughts about appearance, in particular, reflect a dichotomized view of oneself and of the world.

Thoughts about Self in Relation to Others

In addition, patients with BN often unfairly compare themselves with others, engaging in a near-constant internal dialogue about their own weaknesses while glorifying others’ attributes. These thoughts about self in relation to others may include: “I’m not any good at this job”; “I must do everything perfectly or else I’m a failure”; “I’ll be abandoned if I don’t please others”; and “I should be thinner than every other woman in the room.”

Once the patient is adept at recognizing her negative automatic thoughts, she is ready to begin cognitive restructuring in session. cognitive restructuring involves evaluating the automatic thought in a systematic way in order to generate a “rational response,” which is a modified interpretation that is less destructive, is less biased, and better reflects the available evidence. With time and practice, cognitive restructuring allows the patient to internalize new thought patterns and more balanced, adaptive beliefs. This technique also is used to help the patient develop more flexible, realistic standards for her body shape, beliefs about certain foods, and interpretations about interactions with others.