BEHAVIOUR

RESEARCH AND
THERAPY

PERGAMON

Behaviour Research and Therapy 37 (1998) 113

Invited Essay

A cognitive behavioural theory of anorexia nervosa

Christopher G. Fairburn *, Roz Shafran, Zafra Cooper
Oxford University Department of Psychiatry, Warneford Hospital, Oxford, OX3 7JX, UK

Abstract
A cognitive behavioural theory of the maintenance of anorexia nervosa is proposed. It is argued that
an extreme need to control eating is the central feature of the disorder, and that in Western societies a
tendency to judge self-worth in terms of shape and weight is superimposed on this need for self-control.
The theory represents a synthesis and extension of existing accounts. It is `new', not so much because of
its content, but because of its exclusive focus on maintenance, its organisational structure and its level of
specication. It is suggested that the theory has important implications for treatment. # 1998 Elsevier
Science Ltd. All rights reserved.
Keywords: Anorexia nervosa; Treatment; Cognitive therapy; Self-control; Bulimia

1. Introduction
Anorexia nervosa remains a challenge in terms of understanding and treatment. It is still
seen by clinicians as ``one of the most frustrating and recalcitrant forms of psychopathology''
(Vitousek et al., in press). There are many dierent perspectives on the disorder, including
sociocultural views, family views, cognitive behavioural accounts and neurobiological
perspectives (see Brownell and Fairburn, 1995; Szmukler et al., 1995). Similarly there are many
dierent approaches to its treatment, including family therapy, cognitive behaviour therapy
and pharmacotherapy (see Garner and Garnkel, 1997). Some accounts of the disorder focus
on its development; others on its maintenance: often the distinction is either not made or is not
clear (Cooper, 1995). In this paper we present a new cognitive behavioural formulation of the
maintenance of anorexia nervosa. We have chosen this perspective since cognitive behavioural
accounts of the maintenance of other psychiatric disorders have led to important advances in
treatment (see Clark and Fairburn, 1997). For example, this has been true of depression (Beck
* Corresponding author. Tel.: +44-1865-226479; Fax: +44-1865-226244.
0005-7967/98/$19.00 # 1998 Elsevier Science Ltd. All rights reserved.
PII: S 0 0 0 5 - 7 9 6 7 ( 9 8 ) 0 0 1 0 2 - 8

C.G. Fairburn et al. / Behaviour Research and Therapy 37 (1999) 113

et al., 1979; Craighead et al., 1998), panic disorder (Clark, 1986; Barlow et al., 1998) and, most
notably in this context, bulimia nervosa (Fairburn, 1981; Wilson and Fairburn, 1998).

2. Evolution of cognitive behavioural accounts of anorexia nervosa

The origins of cognitive behavioural accounts of anorexia nervosa can be traced back to the
clinical observations of Hilde Bruch. Despite being a psychoanalyst in orientation, she
emphasised the importance of these patients' thinking style; for example, she stressed the
``paralyzing sense of ineectiveness, which pervades all thinking and activities of anorexic
patients'' (Bruch, 1973, p. 254). Bruch's ideas were subsequently rened and extended by
Garner and Bemis in two seminal articles (Garner and Bemis, 1982, 1985) in which they
applied to anorexia nervosa the principles of Beck's cognitive theory and therapy of depression
(Beck et al., 1979). These papers describe what is still the leading cognitive behavioural account
of anorexia nervosa.
The cognitive behavioural view of Garner and Bemis (1982, 1985) has since been elaborated
by Vitousek (previously Bemis) and colleagues in a series of articles that have focused on the
role of information processing (Vitousek and Hollon, 1990), self-representation (Vitousek
and Ewald, 1993), personality variables (Vitousek and Manke, 1994), and motivation
(Vitousek et al., in press) respectively. Vitousek has summarised the account in the following
terms:
Reduced to its essence, the cognitivebehavioural model holds that anorexic and bulimic
symptoms are maintained by a characteristic set of overvalued ideas about the personal
implications of body shape and weight. These attitudes have their origins in the interaction
of stable individual characteristics (such as perfectionism, asceticism, and diculties in aect
regulation) with sociocultural ideals for female appearance. Once formed, the beliefs
inuence the individuals who hold them to engage in stereotypic eating and elimination
behaviors, to be responsive to eccentric reinforcement contingencies, to process information
in accordance with predictable cognitive biases, and, eventually, to be aected by
physiological sequelae that also serve to sustain disordered beliefs and behaviors. (Vitousek,
1996, p. 384.)
Various authors have modied this cognitive behavioural account while retaining its central
premise that the extreme concerns about shape and weight are the core feature that maintains
the disorder (for example, Wol and Serpell, 1998). Other authors have taken a dierent
cognitive behavioural perspective; for example, Guidano and Liotti (1983) proposed that the
central feature of anorexia nervosa is a decit in cognitive structures relating to personal
identity but how this view accounts for the disorder's self-perpetuating and egosyntonic
character was not specied. Of particular interest in the context of the present paper is the
`functional analysis' of Slade (1982) in which he suggested that a need for control is central to
the development and maintenance of anorexia nervosa. This need is expressed in dieting, which
is reinforced both positively through the resultant feelings of success, and negatively through
fear of weight gain and avoidance of other diculties. As a result, the dieting intensies,

C.G. Fairburn et al. / Behaviour Research and Therapy 37 (1999) 113

weight falls and the process becomes self-maintaining. Although Slade's view was published in
the same year as the original paper by Garner and Bemis, it has attracted little attention as an
account of maintenance.
The only cognitive behavioural treatment for anorexia nervosa is that originally proposed by
Garner and Bemis (1982, 1985). Its eectiveness remains unknown. The descriptions of this
treatment have tended to be schematic rather than detailed, although two recent publications
have provided more information (Pike et al., 1996; Garner et al., 1997). There has been one
controlled study of a cognitive behavioural treatment (Channon et al., 1989), but it had many
methodological shortcomings (Vitousek, 1996).
In this paper we propose a new cognitive behavioural theory of the maintenance of anorexia
nervosa, the central feature of which is these individuals' extreme need to control their eating.
This theory has been developed for three reasons:
(1) The extreme need to control eating is a prominent feature of anorexia nervosa. It
provides a coherent organising principle that accounts for the maintenance of the disorder, the
inuence of shape and weight concerns, and the presence of many other characteristics
including resistance to change and egosyntonicity.
(2) Issues relating to control over eating barely feature in the cognitive behavioural
perspective of Vitousek and Garner. Conversely, the inuence of concerns about shape and
weight receives little attention in Slade's analysis.
(3) The treatment derived from the cognitive behavioural account of Vitousek and Garner
may be unduly complex. Our clinical experience suggests that a simpler approach focused on
the issue of self-control can be eective.
Our theory is exclusively concerned with the processes that maintain anorexia nervosa. It is
not an account of its development. It is suciently specic to allow testable hypotheses to be
generated and we suggest that it has important implications for treatment. Although our view
diers from the leading cognitive behavioural account in what is seen to be the core of
anorexia nervosa, it is similar (as would be expected) in terms of the features to be explained
and some of the suggested mechanisms. It is a `new' cognitive behavioural account, not so
much because of its content, but because of its focus on maintenance, its organisational
structure, and its level of specication. It is also new because it integrates issues of self-control
with those concerning shape and weight.

3. A cognitive behavioural theory of anorexia nervosa

3.1. Onset of the disorder
In this account of the maintenance of anorexia nervosa it is argued that the central feature is
an extreme need to control eating. Initially there is a need for self-control in general which is
likely to be a product of these individuals' well-recognised and characteristic sense of
ineectiveness and perfectionism, and which interacts with longstanding low self-esteem
(Bruch, 1973; Vitousek and Manke, 1994; Fairburn et al., 1998). At rst, people who develop
anorexia nervosa may experiment with controlling various aspects of their lives, such as work,
sport or other interests (Bruch, 1973), but soon control over eating becomes of pre-eminent

C.G. Fairburn et al. / Behaviour Research and Therapy 37 (1999) 113

importance because it is experienced as ``successful behaviour in the context of perceived

failure in all other areas of functioning'' (Slade, 1982, p. 173).
The need for self-control in general becomes primarily focused on eating for a number of
reasons. First, as will be discussed below, successful dietary restriction provides direct and
immediate evidence of self-control. As Slade (1982) points out, this is not true of other
domains that could potentially be controlled since they are more under the inuence of others.
The reinforcing properties of dietary restriction per se are especially salient for those who value
asceticism, a value system commonly endorsed by people with anorexia nervosa (Bruch, 1973;
Vitousek and Ewald, 1993). Second, controlling eating has a potent eect on others in the
immediate environment, particularly the family, an inuence which may have special
signicance if there are pre-existing dysfunctional relationships, as is often the case
(Vandereycken et al., 1989; Fairburn et al., 1998). Third, the focus on eating may be
encouraged by the fact that in some families eating is already a highly salient behaviour
(Kalucy et al., 1977; Fairburn et al., 1998). Fourth, the fact that the disorder typically starts in
adolescence may also be relevant since controlling eating provides a means of potentially
arresting or even reversing puberty which may itself constitute a threat to self-control (Crisp,
1980; Strober, 1991). Finally, the association of dietary restriction with being in control is
likely to be encouraged by the value placed in Western societies on dieting to control shape
and weight.
3.2. Maintenance of the disorder
It is proposed that once attempts to restrict eating begin, they are reinforced through three
main feedback mechanisms with the result that the disorder becomes self-perpetuating. As will
become clear, these mechanisms evolve over time and their relative inuence changes from
moment to moment. The rst mechanism is a consequence of the fact that control over eating
directly enhances the person's sense of being in control and thereby their self-worth. The
second mechanism is starvation-related and stems largely from the way in which certain of its
physical and psychological eects are interpreted. The third mechanism is peculiar to cases seen
in Western societies. It is derived from control over eating, shape and weight being used as
indices of overall self-control and self-worth. It is this mechanism that lies at the heart of the
leading cognitive behavioural view on the disorder.
3.2.1. Mechanism 1. Dietary restriction enhances the sense of being in control (see Fig. 1)
This is the mechanism highlighted by Slade (1982). Restricting eating directly and
immediately enhances these individuals' sense of being in control. They determinedly set their
minds to restrict their food intake and to a large extent they are successful. The food
restriction typically involves not only the amount eaten but also the types of food consumed
and the times when eating takes place. Perfectionist standards are applied to the dietary
restriction and often these are expressed as extreme dietary rules.
The initial success at restricting food intake and the consequent sense of self-control it brings
is a potent reinforcer of further restriction because it is the act of successful restriction which
confers control rather than its outcome. Vitousek and Ewald (1993) describe patients as feeling
``delighted, inspired, triumphant, proud and powerful'' (p. 223). Some patients also report

C.G. Fairburn et al. / Behaviour Research and Therapy 37 (1999) 113

Fig. 1. A schematic representation of the core processes involved in the maintenance of anorexia nervosa. Processes
that take place over an extended time are represented by dashed lines.

obtaining control over their feelings and they may experience a heightened sense of alertness.
Gradually control over eating becomes an index of both self-control in general and self-worth,
and this is encouraged by the narrowing of interests that accompanies starvation (see below).
As a result, by successfully controlling their eating these individuals are controlling all that is
important in their lives (Bruch, 1973; Slade, 1982). In this way they are also avoiding having to
face other diculties, such as family problems, forming relationships and the issue of sex.
Successful control in the context of perceived failure and the resulting increase in the sense
of self-worth makes the dietary restriction highly rewarding. This explains in part why the
behaviour is resistant to change. In the longer term it results in some people beginning to
dene themselves in terms of anorexia nervosa (Garner et al., 1997). They describe their
identity as being intrinsically associated with dietary restriction and `being anorexic'. This
linking of identity and disorder contributes further to the disorder's egosyntonic character.
3.2.2. Mechanism 2. Aspects of starvation encourage further dietary restriction (see Fig. 1)
The dietary restriction results in weight loss which eventually leads to the development of a
state of starvation characterised by a variety of physiological and psychological changes
(Garner, 1997). Some of these changes promote further dietary restriction by undermining the
person's sense of being in control. For example, the intense hunger experienced by some people

C.G. Fairburn et al. / Behaviour Research and Therapy 37 (1999) 113

may be perceived as a threat to control over eating, and the heightened sense of fullness may
be viewed as a failure of self-control. The impaired concentration seen in starvation may also
threaten the person's sense of control since people who have diculty concentrating are less
able to follow events and are therefore prone to perceive them as unpredictable and hence
uncontrollable. Finally, the preoccupation with food and eating and narrowing of interests that
characterise starvation exaggerate the tendency to use control over eating as an index of selfcontrol and self-worth.
3.2.3. Mechanism 3. Extreme concerns about shape and weight encourage dietary restriction (see
Fig. 2)
It is proposed that the third mechanism is culturally specic and prominent among most
cases seen in Western societies today. It operates in societies in which thinness is sought after

SHAPE AND WEIGHT

SHAPE AND WEIGHT

WEIGHT LOSS
DECREASE IN RATE
OF WEIGHT LOSS

AND WEIGHT

HYPERVIGILANT
BODY CHECKING

AVOIDANCE OF
BODY CHECKING

SHAPE AND WEIGHT

Fig. 2. A schematic representation of the processes involved in the maintenance of typical Western cases of anorexia
nervosa. Shaded areas represent those processes that are peculiar to Western cases. Processes that take place over an
extended time are represented by dashed lines.

C.G. Fairburn et al. / Behaviour Research and Therapy 37 (1999) 113

and fatness avoided, and it is associated with the tendency of certain individuals to judge their
self-worth largely, or even exclusively, in terms of their shape and weight.
In this environment the person's sense of self-control is enhanced by the actual weight loss
that results from restricting eating. Indeed, weight loss is often their main index of self-control,
and the major goal of food restriction is quantiable weight loss. Most suerers closely
monitor their weight and by doing so they may further perpetuate the disorder. This is because
very frequent weighing results in them becoming concerned about inconsequential weight
uctuations and it maintains distorted beliefs about weight. Even slights dips in weight can be
powerfully reinforcing since they are seen as evidence of successful self-control. In contrast,
any weight gain, or even the absence of weight loss, is interpreted as evidence of poor control
with the result that eorts to restrict eating are further intensied.
Shape change too may be used as an index of self-control, and therefore the goal of food
restriction, although it is less easy to quantify. Concerns about shape lead some people to
think that their whole body or parts of it is too large with the result that they repeatedly check
aspects of their shape (Rosen, 1997). Their aim is to obtain objective information about shape,
but the information received is far from objective. Perception of body shape has been shown to
be subject to a variety of inuences, including negative mood (Taylor and Cooper, 1992), the
consumption of food believed to be highly caloric (Thompson et al., 1993), and seeing thin
women in media images (Hamilton and Waller, 1993). We propose that a further important
inuence is the presence of conrmatory information processing biases. Such biases distort
data so that individuals obtain information that reinforces their concerns, especially when in
high arousal states. For example, spider-phobics have a bias for processing information about
the threatening nature of spiders (Rachman and Cuk, 1992; Thorpe and Salkovskis, 1997).
Similarly, people with panic disorder tend to magnify the importance of minor normal
uctuations in bodily sensations believing that they herald imminent physical catastrophe
(Clark, 1997). We hypothesize that an equivalent conrmatory bias operates in anorexia
nervosa. The frequent but brief checking of shape, while in a state of high arousal, magnies
perceived bodily imperfections. This hypervigilant checking in turn increases arousal, selffocused attention and anxiety, which encourages further monitoring, thereby establishing a
vicious circle. The result is that individuals come to think that they are failing to control their
shape and so persist with their dietary restriction.
Over time, the hypervigilant monitoring of shape and weight (`body checking') may become
highly aversive. Some individuals are no longer able to tolerate the repeated self-examination.
As a consequence they come to actively avoid monitoring altogether. This avoidance maintains
their shape and weight concerns in part because they no longer have a potential means of
disconrmation. Consequently, they continue to believe that they are failing to control their
shape and weight, and as a result their food restriction is maintained.
As body weight falls, these people nd that they have to eat progressively less in order to
meet their perfectionist standards for weight loss. Eventually the rate of weight loss declines
which is perceived as a failure of dietary control. In response to this sense of failure, some
become increasingly reliant upon additional weight control behaviour including excessive
exercising, self-induced vomiting and the misuse of laxatives or diuretics, each of which can be
self-perpetuating in its own right. For example, successfully engaging in a strict exercise regime
directly increases the person's sense of self-control, much in the same way that restricting

C.G. Fairburn et al. / Behaviour Research and Therapy 37 (1999) 113

eating has this eect. In contrast, self-induced vomiting and the misuse of laxatives and
diuretics tend to erode control over eating. This is because belief in their eectiveness leads to
a relaxation of control over eating, thereby establishing a vicious circle (see Fairburn, 1995).
This may lead on to the development of the binge eating/purging type of anorexia nervosa and
eventually bulimia nervosa.

4. Strengths of the proposed theory

It was claimed earlier that this is a `new' cognitive behavioural account. To what extent is
this claim warranted? In common with Slade (1982) we see issues relating to self-control as
being at the heart of anorexia nervosa. These people's extreme need to control their eating
provides a simple organising principle which accounts for many features of the disorder
including its resistance to change and egosyntonicity. However, a limitation of Slade's account
is that it pays little attention to the concerns about shape and weight that are so prominent
among cases today. In contrast, the cognitive behavioural account of Vitousek and Garner (see
Vitousek and Orimoto, 1993) could be seen to be too general and inclusive. While it places
emphasis on concerns about shape and weight, it also embraces many other aetiological and
maintaining factors. How this multitude of factors operate and interact is not specied. We
share their view that the overevaluation of shape and weight is an important maintaining
factor (in Western cases) and acknowledge that it is associated with information processing
biases (Vitousek and Hollon, 1990), but we see it as operating largely through issues of selfcontrol (as illustrated in Fig. 2).
It has been suggested that the characteristic concerns about shape and weight are a recent
culture-specic addition to the psychopathology of anorexia nervosa (for example, Palmer,
1993; Russell, 1995). Two lines of evidence support this view. First, these concerns do not
appear to have been part of the psychopathology of many cases reported in the historical
literature (for example, Casper, 1983; Shorter, 1987; Habermas, 1992; Parry-Jones and ParryJones, 1994). While it could be argued that this is because they were overlooked, this seems
most unlikely given the richness of the clinical descriptions. Habermas (1996) suggests that they
must have been present since there is no other way of accounting for the features of the
disorder. This is not a satisfactory line of argument and, as Palmer (1993, p. 460) points out,
``it seems unduly arrogant for us to assume that they missed such important observations''.
The second line of evidence arises from the observations of clinicians working in developing
countries. They have reported the absence of concerns about shape and weight among many
otherwise typical cases of anorexia nervosa (for example, Lee et al., 1993; Khandelwal et al.,
1995). It should be noted that such concerns are also not invariably present in Western cases
(Palmer, 1993) and this may be especially true of young patients (Fosson et al., 1987; Gallelli
et al., 1997)1. Taken together, these observations suggest that shape and weight concerns may
1

Some patients with anorexia nervosa have unexpectedly low scores on measures of anorexic features and this is
generally taken as evidence of `denial' (Vandereycken and Vandereycken, 1983; Greeneld et al., 1991). An alternative explanation is that it is a consequence of the relative absence of shape and weight concerns.

C.G. Fairburn et al. / Behaviour Research and Therapy 37 (1999) 113

not be an essential feature of anorexia nervosa. If true, this would pose problems for existing
cognitive behavioural accounts. We suggest that the present control-based theory provides an
alternative psychological account of the disorder that has equivalent explanatory power and is
compatible with the notion of anorexia nervosa occurring in the absence of concerns about
shape and weight (as illustrated in Fig. 1).
We regard our cognitive behavioural theory as being more than a synthesis of the views of
Slade with those of Vitousek and Garner. It is a synthesis in that it incorporates the core
features of both accounts within a single organising framework, but it is an extension in that
not only is the framework new but so is the integration of the component parts. It is also new
in its level of specication. This has the advantage of allowing testable hypotheses to be
derived. The central predictions are as follows:
Predictions derived from mechanism 1 Compared to normal control subjects, dieters and
those with other psychiatric disorders, people with anorexia nervosa are more likely to derive a
sense of self-control from successfully restricting eating and controlling shape and weight. They
are also more likely to judge their self-worth in terms of success at restricting eating and
controlling shape and weight.
Predictions derived from mechanism 2 In people with anorexia nervosa who are severely
underweight, hunger is interpreted as a threat to self-control and fullness is interpreted as a
failure of control.
Predictions derived from mechanism 3 Distorted beliefs about weight and perceived bodily
imperfections are maintained by hypervigilant body checking and by secondary avoidance, and
they are interpreted as failures of control over eating, shape and weight.
Predictions about treatment and natural course To achieve a full and lasting recovery from
anorexia nervosa, treatment must not only tackle the concerns about shape and weight but it
must also successfully address the use of dietary restriction to achieve a sense of self-control. In
terms of natural course, factors that decrease the person's sense of self-control (such as adverse
life events) will result in an increase in dietary restriction.
Certain predictions may also be made regarding the characteristics of `cases' in which
concerns about shape and weight are not present. First, such cases will be mostly found in
non-Western countries. Second, it is predicted that issues relating to self-control will be
prominent (as illustrated in Fig. 1) since they will be driving the disorder and will not be
masked by concerns about shape and weight. Third, it is predicted that hypervigilant body
checking will not be a feature. Fourth, it is predicted that such patients will have a better
prognosis than those who also have concerns about shape and weight (i.e., typical Western
cases) since in the former group one of the three major maintaining mechanisms will not be
operating.
5. Implications for treatment
This theory of the maintenance of anorexia nervosa has two major implications for
treatment. The rst is that treatment could be considerably more focused than it is at present.
We suggest that treatment should be directed at the core maintaining mechanisms specied by
the present theory (illustrated in Figs. 1 and 2) and only broadened if other issues prove to be
an obstacle to change. Thus the principal focus of treatment should be on the issue of self-

10

C.G. Fairburn et al. / Behaviour Research and Therapy 37 (1999) 113

control. Within this context features which need to be addressed (in typical Western cases) are
the use of eating, shape and weight as indices of self-control and self-worth, the disturbed
eating itself and the associated extreme weight-control behaviour, the body checking and, of
course, the low body weight. In contrast, we suggest that low self-esteem, diculty recognising
and expressing emotions, interpersonal problems and family diculties, all of which are targets
of the leading cognitive behavioural approach (Garner et al., 1997), do not need to be tackled
unless they prevent change. We recognise the central importance of involving the family in the
treatment of young cases, but this can be done as part of addressing self-control.
An analogy may be usefully drawn with the cognitive behavioural treatment of bulimia
nervosa. In bulimia nervosa a wide range of problems could be the target of treatment, including
most of those addressed by the current cognitive behavioural treatment for anorexia nervosa, yet
the cognitive behavioural treatment for bulimia nervosa focuses almost exclusively on the
concerns about shape and weight and the disturbed eating (Fairburn et al., 1993a,b). This focused
approach has been shown to be sucient to produce full recovery in a half to two-thirds of cases
and to be superior to every treatment to which it has been compared (Wilson and Fairburn,
1998). It is also of note that, despite its focus on eating, shape and weight, it produces changes in
a broad range of areas, including mood, self-esteem and interpersonal functioning (see for
example, Fairburn et al. (1993a,b). These changes appear to be a consequence of successfully
addressing the core eating disorder. In our experience equivalent secondary changes also occur in
anorexia nervosa. It is conceivable that the response rate might be higher in bulimia nervosa were
the treatment to be broader in scope but there is no evidence to support this view. Of course,
some problems may not resolve despite the successful treatment of the eating disorder. For
example, some patients retain perfectionist standards. If this is a problem, and often it is not, it
can be subsequently addressed in its own right.
The second major implication of the present theory is that treatment should focus on the
patient's need for self-control in general, as well as their application of control to eating, shape
and weight. Slade (1982) also stressed the need to address control, although he did not
highlight the important interactions between the need for control and the use of shape and
weight to judge self-worth. The patient's need for self-control has to be redirected and
moderated, and this can be done both directly and indirectly. The focus of control can be
gradually shifted away from eating by helping patients derive satisfaction and a sense of
achievement from other activities, and by demonstrating that control over eating does not
provide what they are seeking. The patients' actual need for control can be addressed directly
using cognitive restructuring procedures. In our view the theme of self-control needs to be
considered at all stages in treatment. For example, it is relevant to initial engagement in
treatment, decisions regarding the setting in which treatment takes place, the weight restoration
process, and relapse prevention. The particular aspect of self-control that is most pertinent
diers at dierent points. For example, when patients are at a very low weight the starvationrelated threats to self-control and sense of having lost control need to be the focus, as should
the narrowing of interests that reinforces identication with the disorder. On the other hand
with patients who have reached a higher weight the relationship between self-worth and
controlling shape and weight is more salient.
It is important that work on self-control is integrated with other aspects of treatment since
control issues are activated by changes in other areas. A particularly good example is weight

C.G. Fairburn et al. / Behaviour Research and Therapy 37 (1999) 113

11

restoration. The process of helping patients eat more and gain weight can be used to explore
and examine a variety of control issues2, since it brings to the fore the links between dietary
restriction, weight loss and the need for self-control, and since it usually provokes potent fears
of loss of control. Equivalent considerations apply to work on body image. For example,
tackling hypervigilant body checking invariably involves threatening the patient's sense of
control over shape and weight. As always, treatment should encourage patients to change their
behaviour, the aim being to help them examine the implications of these changes for the way
that they interpret their experiences (for example, in terms of their perceived sense of control
and self-worth). As Teasdale (1997) has stressed, behaviour change is a major means of
achieving cognitive change, and this is not only through the use of nely honed behavioural
experiments, but also through the opportunity it provides for the replacement of dysfunctional
`mind-sets' (such as the anorexic identity) with more adaptive ones.
We believe that this control-based approach to treatment merits examination. It oers hope
of a simpler and more focused treatment than the current cognitive behavioural approach. It is
to be expected that the systematic study of its eects will not only help rene the treatment
itself but will also inform the cognitive behavioural theory from which it has been derived.

Acknowledgements
CGF and ZC are supported by the Wellcome Trust (046386). We are grateful to the
following colleagues for their comments: Nicky Boughton, Rachel Bryant-Waugh, David
Clark, Anke Ehlers, Bryan Lask, S. Rachman, Paul Salkovskis, Anne Stewart and Linette
Whitehead.

References
Barlow, D.H., Esler, J.L., & Vitali, A.E. (1998). Psychosocial treatments for panic disorders, phobias and generalized anxiety disorder.
In P.E. Nathan & J.M. Gorman (Eds.), A Guide to Treatments that Work (pp. 288318). New York: Oxford University Press.
Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive Therapy of Depression. New York: Guilford Press.
Brownell, K.D., & Fairburn, C.G. (1995). Eating Disorders and Obesity: A Comprehensive Handbook. New York: Guilford Press.
Bruch, H. (1973). Eating Disorders: Obesity, Anorexia Nervosa and the Person Within. New York: Basic Books.
Casper, R. C. (1983). On the emergence of bulimia nervosa as a syndrome. International Journal of Eating Disorders, 2, 316.
Channon, S., de Silva, P., Hemsley, D., & Perkins, R. (1989). A controlled trial of cognitive-behavioural and behavioural treatment of
anorexia nervosa. Behaviour Research and Therapy, 27, 529535.
Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24, 461470.
Clark, D.M. (1997). Panic disorder and social phobia. In D.M. Clark & C.G. Fairburn (Eds.), Science and Practice of Cognitive
Behaviour Therapy (pp. 121153). Oxford: Oxford University Press.
Clark, D.M., & Fairburn, C.G. (1997). Science and Practice of Cognitive Behaviour Therapy. New York: Oxford University Press.
Cooper, Z. (1995). The development and maintenance of eating disorders. In K.D. Brownell & C.G. Fairburn (Eds.), Eating Disorders
and Obesity: A Comprehensive Handbook (pp. 199206). New York: Guilford Press.
Craighead, W.E., Craighead, L.W., & Ilardi, S.S. (1998). Psychosocial treatments for major depressive disorder. In P.E. Nathan & J.M.
Gorman (Eds.), A Guide to Treatments that Work (pp. 226239). New York: Oxford University Press.
Crisp, A.H. (1980). Anorexia Nervosa: Let Me Be. London: Academic Press.

In our experience this is best achieved if treatment is on an outpatient basis.

12

C.G. Fairburn et al. / Behaviour Research and Therapy 37 (1999) 113

Fairburn, C. G. (1981). A cognitive behavioural approach to the management of bulimia. Psychological Medicine, 11, 707711.
Fairburn, C.G. (1995). Overcoming Binge Eating. New York: Guilford Press.
Fairburn, C. G., Jones, R., Peveler, R. C., Hope, R. A., & O'Connor, M. (1993a). Psychotherapy and bulimia nervosa: The longer-term
eects of interpersonal psychotherapy, behaviour therapy and cognitive behaviour therapy. Archives of General Psychiatry, 50, 419
428.
Fairburn, C.G., Marcus, M.D., & Wilson, G.T. (1993). Cognitive-behavioral therapy for binge eating and bulimia nervosa: A comprehensive treatment manual. In C.G. Fairburn and G.T. Wilson (Eds.), Binge Eating: Nature, Assessment and Treatment (pp.
361404). New York: Guilford Press.
Fairburn, C.G., Cooper, Z., Doll, H.A., & Welch, S.L. (1998). Risk factors for anorexia nervosa: Three integrated case control
comparisons. Submitted for publication.
Fosson, A., Knibbs, J., Bryant-Waugh, R., & Lask, B. (1987). Early onset anorexia nervosa. Archives of Disease in Childhood, 621, 114
118.
Gallelli, K. A., Solanto, M. V., Hertz, S. H., & Golden, N. H. (1997). Eating-related and comorbid symptoms in premenarchal anorexia
nervosa. Eating Disorders, 5, 309324.
Garner, D.M. (1997). Psychoeducational principles in treatment. In D.M. Garner & P.E. Garnkel (Eds.), Handbook of Treatment for
Eating Disorders (pp. 145177). New York: Guilford Press.
Garner, D. M., & Bemis, K. M. (1982). A cognitive-behavioral approach to anorexia nervosa. Cognitive Therapy and Research, 6, 123
150.
Garner, D.M., & Bemis, K.M. (1985). Cognitive therapy for anorexia nervosa. In D.M. Garner & P.E. Garnkel (Eds.), Handbook of
Psychotherapy for Anorexia Nervosa and Bulimia (pp. 107146). New York: Guilford Press.
Garner, D.M., & Garnkel, P.E. (1997). Handbook of Treatment for Eating Disorders. New York: Guilford Press.
Garner, D.M., Vitousek, K.M., & Pike, K.M. (1997). Cognitive-behavioral therapy for anorexia nervosa. In D.M. Garner & P.E.
Garnkel (Eds.), Handbook of Treatment for Eating Disorders (pp. 94144). New York: Guilford Press.
Greeneld, D. G., Anyan, W. R., Hobart, M., Quinlan, D. M., & Plantes, M. (1991). Insight into illness and outcome in anorexia
nervosa. International Journal of Eating Disorders, 10, 101109.
Guidano, V.F., & Liotti, G. (1983). Cognitive Processes and Emotional Disorders. New York: Guilford Press.
Habermas, T. (1992). Further evidence on early case descriptions of anorexia nervosa and bulimia nervosa. International Journal of
Eating Disorders, 11, 351360.
Habermas, T. (1996). In defense of weight phobia as the central organizing motive in anorexia nervosa: Historical and cultural arguments for a culture-sensitive psychological conception. International Journal of Eating Disorders, 19, 317334.
Hamilton, K., & Waller, G. (1993). Media inuences on body size estimation in anorexia and bulimia: An experimental study. British
Journal of Psychiatry, 162, 837840.
Kalucy, R. S., Crisp, A. H., & Harding, B. (1977). A study of 56 families with anorexia nervosa. British Journal of Medical Psychology,
50, 381395.
Khandelwal, S. K., Sharan, P., & Saxena, S. (1995). Eating disorders: An Indian perspective. International Journal of Social Psychiatry,
41, 132146.
Lee, S., Ho, T. P., & Hsu, L. K. G. (1993). Fat phobic and non-fat phobic anorexia nervosa: a comparative study of 70 Chinese patients
in Hong Kong. Psychological Medicine, 23, 9991017.
Palmer, R. L. (1993). Weight concern should not be a necessary criterion for the eating disorders: A polemic. International Journal of
Eating Disorders, 14, 459465.
Parry-Jones, W. L., & Parry-Jones, B. (1994). Implications of historical evidence for the classication of eating disorders: A dimension
overlooked in DSM-III-R and ICD-10. British Journal of Psychiatry, 165, 287292.
Pike, K.M., Loeb, K., & Vitousek, K. (1996). Cognitive-behavioral therapy for anorexia nervosa and bulimia nervosa. In J.K.
Thompson (Ed.), Eating Disorders, Obesity and Body Image: A Practical Guide to Assessment and Treatment. Washington D.C.
American Psychological Association.
Rachman, S., & Cuk, M. (1992). Fearful distortions. Behaviour Research and Therapy, 30, 583589.
Rosen, J.C. (1997). Cognitive-behavioural body image therapy. In D.M. Garner & P.E. Garnkel (Eds.), Handbook of Treatment for
Eating Disorders (pp. 188201). New York: Guilford Press.
Russell, G.F.M. (1995). Anorexia nervosa through time. In G. Szmukler, C. Dare, & J. Treasure (Eds.), Handbook of Eating Disorders:
Theory, Treatment and Research (pp. 617). Chichester: Wiley.
Shorter, E. (1987). The rst great increase in anorexia nervosa. Journal of Social History, 21, 6996.
Slade, P. D. (1982). Towards a functional analysis of anorexia nervosa and bulimia nervosa. British Journal of Clinical Psychology, 21,
167179.
Strober, M. (1991). Disorders of the self in anorexia nervosa: An organismic-developmental paradigm. In C.L. Johnson (Ed.),
Psychodynamic Treatment of Anorexia Nervosa and Bulimia (pp. 354373). New York: Guilford Press.
Szmukler, G.I., Dare, C., & Treasure, J.L. (1995). Handbook of Eating Disorders: Theory, Treatment and Research. Chichester: Wiley.

C.G. Fairburn et al. / Behaviour Research and Therapy 37 (1999) 113

13

Taylor, M. J., & Cooper, P. J. (1992). Experimental study of the eect of mood on body size perception. Behaviour Research and
Therapy, 30, 5358.
Teasdale, J.D. (1997). The relationship between cognition and emotion: The mind-in-place in mood disorders. In D.M. Clark & C.G.
Fairburn (Eds.), Science and Practice of Cognitive Behaviour Therapy (pp. 6793). Oxford: Oxford University Press.
Thompson, J. K., Coovert, D. L., Pasman, L. R., & Robb, J. (1993). Body image and food consumption: Three laboratory studies of
perceived calorie content. International Journal of Eating Disorders, 14, 445457.
Thorpe, S. J., & Salkovskis, P. M. (1997). Information processing in spider phobics: The stroop colour naming task may indicate strategic but not automatic attentional bias. Behaviour Research and Therapy, 35, 131144.
Vandereycken, W., & Vandereycken, J. (1983). Denial of illness and the use of self-reporting measures in anorexia nervosa patients.
International Journal of Eating Disorders, 2, 101107.
Vandereycken, W., Kog, E., & Vanderlinden, J. (1989). The Family Approach to Eating Disorders. New York: PMA Publishing
Corporation.
Vitousek, K.M. (1996). The current status of cognitive-behavioral models of anorexia nervosa and bulimia nervosa. In P. Salkovskis
(Ed.), Frontiers of Cognitive Therapy (pp. 383418). New York: Guilford Press.
Vitousek, K., & Manke, F. (1994). Personality variables and disorders in anorexia nervosa and bulimia nervosa. Journal of Abnormal
Psychology, 103, 137147.
Vitousek, K., Watson, S., & Wilson, G.T. (in press). Enhancing motivation for change in treatment-resistant eating disorders. Clinical
Psychology Review.
Vitousek, K.B., & Ewald, L.S. (1993). Self-representation in eating disorders: A cognitive perspective. In Z.V. Segal & S.J. Blatt (Eds.),
The Self in Emotional Distress: Cognitive and Psychodynamic Perspectives (pp. 221266). New York: Guilford.
Vitousek, K. B., & Hollon, K. B. (1990). The investigation of schematic content and processing in eating disorders. Cognitive Therapy
and Research, 14, 191214.
Vitousek, K.B., & Orimoto, L. (1993). Cognitive-behavioral models of anorexia nervosa, bulimia nervosa, and obesity. In K.S. Dobson
& P.C. Kendall (Eds.), Psychopathology and Cognition (pp. 191243). San Diego: Academic Press.
Wilson, G.T., & Fairburn, C.G. (1998). Treatments for eating disorders. In P.E. Nathan & J.M. Gorman (Eds.), A Guide to Treatments
that Work (pp. 501530). New York: Oxford University Press.
Wol, G., & Serpell, L. (1998). A cognitive model and treatment strategies for anorexia nervosa. In H. Hoek, J. Treasure, & M.
Katzman (Eds.), Neurobiology in the Treatment of Eating Disorders (pp. 400421). Chichester: Wiley.