Although each patient is different, there are certain typical errors of thinking that they usually fall prey to. Let me describe some of these errors.
Black-and-white thinking: By this I mean the “all or nothing” attitude. For the anorexic, fat is hell, the ultimate nightmare, the horror of horrors. Thinness, however, is heaven, bliss, a goal worth dying for. There is no middle ground. Did she gain a pound this week? Then obesity is just around the corner. “If I can’t be one hundred percent perfect,” she tells herself, “then I am a total failure.”
A bulimic sees certain foods as “good” and others as “bad.” Bad foods must be absolutely, totally banished from her diet. Her characteristic thought is, “If I eat a little of this food then I’ll lose control. I won’t be able to stop until I become extremely fat.” But if she gives in to temptation and takes even a single bite of the forbidden food, then all is lost. She goes ahead and stuffs herself until she can hold no more. For her, there is no such thing as eating in moderation. All or nothing. Black or white.
She thinks the same way about other areas of life. She considers a grade of “B” on a school assignment to be a failure, since it is not perfect. Becoming sexually involved with someone means she is a loose woman. One patient saw herself as an “angry monster- if I’m not totally in control, then I’m totally out of control.”
One clue to black-and-white thinking is the fact that many of the patient’s statements contain such phrases as “I must” or “I should.” A patient might remark, “I must eat the same foods every day or I’ll swell up like a blimp.” Another might say, “I should exercise at least three hours a day.” The psychoanalyst Karen Horney coined the phrase “the tyranny of the ‘Shoulds” to describe this state of mind.
When patients divide everything into such extreme categories, they reveal their need for certainty in their lives. Because they mistrust their own feelings, their own ability to judge, they look outside themselves for guidance. The drive to be perfect shows their inability to determine when they are good enough. In cognitive therapy we spot the “should” and “must” thought-tyrants and challenge their right to rule the patient’s life.
Some time ago, researchers devised an ingenious experiment that revealed black-and-white thinking in action. They asked a group of dieters to drink milk shakes and then eat some ice cream. What the dieters didn’t know was that the “milk shake” was actually a ringer-it had a relatively low calorie content. Surprisingly, the dieters who were told that the shakes were high-calorie went ahead and ate more ice cream than those who were told the truth. Why? Well, the researchers called the dieters’ action “counterregulation.” The dieters felt that drinking a high-calorie shake had caused them to “blow” their diet. They had already failed, so why bother holding back while eating ice cream?
Magnification: This word describes the patient’s tendency to blow things, especially negative things, all out of proportion. Most prominent in their minds, of course, is body size. Many of my patients say they know perfectly well they are thin-they can see it in the mirror, their friends all tell them-but they feel fat. That feeling overrides and distorts any logical arguments to the contrary.
Similarly, patients distort their impressions of food itself. A case in point: A twenty-one-year-old, eighty-six-pound woman named Ondine swore up and down that at home she always ate three good-sized, nutritionally balanced meals, plus snacks, a day. I admitted her to the hospital. Yet when the first tray was brought to her, Ondine panicked. “I can’t eat all this!” she cried. “This is more than I eat in a week!” Obviously, her perception of a “good-sized” meal was somewhat skewed.
Magnification occurs in other areas as well. A certain homework assignment temporarily becomes the be-all and end-all of the girl’s life. An interest in sports turns into the compulsion to jog ten miles a day and play tennis to the point of exhaustion. A broken date becomes a billboard announcing the patient’s un-desirability to the world.
Personalization: A fifteen-year-old bulimic told me she had been too afraid to go to the beach during the previous summer. “I knew they’d all be staring at me and thinking that a whale had washed up on the beach.” This patient was personalizing-assuming that everyone’s undivided attention was focused on her and her alone.
Patients sometimes personalize an otherwise innocent remark. “You’re looking good,” an office colleague might say. The patient twists this to mean, “You looked so bad before.” The idea that people might observe and comment on a patient’s appearance can occupy her mind the rest of the day, and trigger a binge when she gets home that night.
Magical thinking: Examples include such statements as, “Bread is poison,” or, “With my metabolism, everything I eat after lunch turns into fat.” One patient told me, “If I eat one Oreo cookie at ten o’clock at night I’ll be all right, but if I give in and eat it earlier I know I’ll binge.” Magical thinking about eating, exercise, or interpersonal relationships is very common, especially among anorexics.
Sensory distortions: A lot of patients report that their senses become keener during their illness. One patient fought constantly with her brother because he kept his stereo turned up too high. Maybe he did, but there was no doubt that her hearing had become much sharper during starvation. Some patients wear sunglasses, even indoors, because average light has become too bright. Many report that colors are more vivid, smells more potent. Often, these cognitive distortions are direct, physical consequences of starvation itself.
Errors of attribution: These are mistakes in figuring out the relationship between cause and effect. For example, a patient may gain a pound and believe it is because she ate a chocolate-chip cookie the week before. When we look at the facts, however, we may find that her weight gain is actually the result of premenstrual water retention.
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