This is a beginning to intermediate level course. After completing this course, mental health professionals will be able to:
Welcome to Feast or Famine: The Etiology and Treatment of Eating Disorders. This course will help you gain a working knowledge of eating disorders so you can provide better psychological care. The primary focus is the range of factors that contribute to the development of eating disorders along with an understanding of psychotherapeutic and psychopharmacologic treatment. Information includes diagnosis, assessment, and comprehensive treatment planning. Case studies will highlight different aspects of the recovery process to enable you to integrate the course into private practice and clinical settings.
Here is some food for thought:
(Sources: National Institutes of Health, 2010); Horm and Anderson, 1993; Vukovic, 1997; Reiser, BusinessWeek, 2008; The Renfrew Center Foundation for Eating Disorders, 2003; Mehler, 1996; Crow et al., 2009.)
Four factors contribute to the development of an eating disorder. These factors are sociocultural, familial, biogenetic, and intrapsychic.
There is an association between anorexia nervosa and cultures in which thinness is valued. Occupations and avocations that encourage thinness, like modeling, are linked to increased risk for developing the disorder. Internalization of the thin body ideal has been found to raise the chance of developing weight concerns, which heightens the risk for developing bulimia nervosa (American Psychiatric Association, 2013).
Beauty Standard: Every society has a standard of beauty. The media is one of the biggest influences affecting our assessment of attractiveness. Magazines, movies, and television suggest how we should look, act, and achieve. Media images permeate consciousnesses throughout the day. Products and people are packaged in tantalizing ways to induce us to purchase items or see the latest movie or television show. Famous people are offered up for visual consumption to satisfy a seemingly never-ending curiosity. The business of beauty is a fickle one. Over the last sixty years, the beauty ideal has changed with each successive decade. Some of these changes are:
The average American woman is 5'4" and weighs 165 pounds. The average Miss America winner is 5’7” and weighs 121 pounds (Martin, 2010). Only 2% of women look like this thin-ideal model. 98% don't and, in fact, can't do so without resorting to harmful measures.
If Barbie were blown up to human proportions, her measurements would be 31”- 17”- 28”.
Male Gender: Within the last two decades, advertisers have used idealized images of male bodies to target young men. Men have responded by worrying that their bodies don’t measure up. This has, in turn, led to an increase in dieting and weightlifting, and the use of over-the-counter muscle-building supplements and steroids. One study of middle and high school boys and girls found that 40% exercised regularly, 37.5% used protein powders, and 5.9% used steroids in order to increase muscle mass (Eisenberg et al., 2012).
Eating disorders in males are on the rise. In 1990, 10% of individuals with eating disorders were men. Currently, the estimate is 25%. In addition, up to 40% of binge eaters are men (Hudson et al, 2007). One college study supports these percentages. Eisenberg et al. (2011) found that 13.5% of female and 3.5% of male undergraduates had persistent symptoms of anorexia nervosa and bulimia. Compared with the heterosexual population, up to 15% of gay and bisexual men have an eating disorder (Feldman and Meyer, 2007).
Coleman (2010) writes, “One of the side effects of metrosexuality seems to be the affliction of men with the same unrealistic body image that women have been dealing with for years.” He notes that the British mannequin maker Rootstein’s latest male form called the “Homme Nouveau” has a 35-inch chest and a 27-inch waist. He writes, “There’s evidence that the new paradigm has given rise to male anorexia.”
Ethnicity: Eating disorders most commonly start in adolescence. Research looking at adolescent weight control found that Black females are the least likely and White female are the most likely. Although the prevalence of all weight control behaviors is on the rise in the male population, white males are the least likely whereas Hispanic males are the most likely (Chao et al., 2007). Binge eating and binge eating disorder were the most common eating disorder among Black, Hispanic, and Asian adults, with the disorder being higher in women. This behavior increased the risk of becoming obese. Anorexia nervosa and bulimia were the least common disorders among the three groups (Taylor et al., 2007; Algeria et al., 2007; and Nicdao et al., 2007).
Advertising: Advertisements are both the creator and reflection of our culture. Many television and magazine ads are geared towards improving appearances (e.g., skin care, hair care, nail care, clothing, makeup, weight loss, etc.). These ads convey subtle and not-so subtle messages in order to:
The constant emphasis on thinness has negative effects on women. Female undergraduates at Arizona State University were shown images of average-sized models and ultra-thin models. Women exposed to the thin-ideal reported depression, stress, guilt, shame, insecurity, and body dissatisfaction. Analysis of the data indicated that negative affect, body dissatisfaction, and subscription to the thin-ideal predicted bulimic symptoms (Stice and Shaw, 1994). Advertisers target men’s body insecurities by focusing on products to build muscle, lean down, increase athletic performance, replace thinning hair, and sustain sexual vigor.
Diet Industry: Because of pressures to fit in and be thin, many people will try just about anything to lose weight. Weight loss is a $40 billion a year industry (Reiser, BusinessWeek, 2008). The products run the gamut from diet drinks and foods to pills, exercise equipment, and special regimens. Advertisers play on feelings of self-doubt and the burgeoning weight problem in this country. Because 90% of dieters fail to keep weight off for two or more years, they continue to try one product after another with less and less hope of attaining permanent weight loss. Dieting causes more problems than it eliminates.
Snack and Fast Food Industries: On the flip side, these industries are also multi-billion dollar enterprises. High-fat, high-sugar, and high-salt foods and beverages can be found in convenience stores, grocery stores, candy shops, and drive-thru restaurants. In the 1960’s, the average package of fast food French fries contained 200 calories. Currently, extra-large fries have 600 calories. Soft drinks used to come in 12-ounce containers (140 calories). Many places now offer 64-ounce beverages (740 calories). These highly processed, supersized foods and drinks have not only lost much of their nutritional value, they have added an average of 300 calories a day since the 1980’s, creating a weight gain of 25 to 30 pounds a year (Blake and Durschlag, 2004).
Feeding Insecurities: Advertising in general and the diet industry in particular, often play on people’s insecurities and exploit these emotions. A person can wind up feeling like a weak-willed failure for not sticking to a diet, looking like a supermodel, or having the kind of lifestyle that a well-to-do person has.
People think that losing weight as fast as possible will boost self-esteem. Unwittingly, they’re taking an “outside-in” approach to creating joy. Many believe (and are reinforced by cultural values) that material or physical things – money, cars, homes, jewelry, degrees, clothing, appearance, and weight – will bring peace of mind and a sense of well-being. If they can accumulate or accomplish the things they want, then they’ll feel good about themselves.
Nothing external can create long-term happiness when a person believes deep down that he is deficient in some way. Weight loss only temporarily reduces the sense that something is wrong inside. When the weight comes back, the person is thrown into self-recrimination and loathing, eventually seeking the next solution, and beginning the cycle all over again. This doesn't mean that having successes can't add quality to life. They can. But success never fills internal emptiness nor will it change beliefs about not being good enough.
Websites: Pro-anorexia (pro-ana) and pro-bulimia (pro-mia) web sites take a positive attitude towards eating disorders, encouraging the philosophy and behaviors while claiming eating disorders are a lifestyle choice not an eating disorder. Bardone-Cone and Cass found that women who viewed a pro-ana website had greater negative affect, lower social self-esteem, and lower appearance self efficacy than controls who did not view the website (2007).
Stress: Stress has been theoretically identified as a precursor to the onset of an eating disorder. One study now strongly suggests that elevated levels of stress may precede the onset of binge eating disorder. Stress as a causal association has yet to be established (Moore et al., 2007).
Occupations and avocations that encourage thinness, such as elite athletics, are associated with increased risk of developing anorexia nervosa (American Psychiatric Association, 2013). A number of studies have shown that athletes are more likely than non-athletes to exhibit abnormal eating attitudes and behaviors (i.e., fasting, abusing diet medication, using laxatives and diuretics, and vomiting) when they’re involved in sports that place an emphasis on leanness, body image, being scantily clad (Yates et al., 1994).
High-achieving people are more likely to compulsively exercise and diet than people who are less achievement-oriented. While women with eating disorders are dissatisfied with their bodies and strive for an ideal shape, athletes who are overcommitted to their sport are dissatisfied with the body’s strength or efficacy, and strive for an ideal performance (Yates et al., 1994).
Females: There is a difference between someone who exercises for fitness and an athlete who becomes compulsive. One study compared the psychological profiles of athletes and anorexics and the following similarities were found: perfectionism, high self-expectations, drive, competitiveness, hyperactivity, repetitive exercise routines, compulsiveness, body image distortion, pre-occupation with dieting and weight, and tendency towards depression (Bachner-Melman et al., 2006).
Males: Males who are over-invested in their physical appearance and bodies have a higher risk of developing an eating disorder (Franco et al., 1988). When an athlete is expected to maintain a lower than normal body weight to compete, eating disordered behaviors arise. These sports include gymnastics, wrestling, running, jockeying, rowing, and lightweight football playing. Careers such as acting and modeling can also perpetuate unhealthy habits in men.
The common threads shared between individuals with eating disorders and athletes are that both groups are high achievers, persistent, perfectionistic, have a drive for thinness, and engage in endeavors in a compulsive way (Yates et al., 1994). Men with partial or full-syndrome bulimia nervosa were similar to women with the same disorder in terms of functional impairment, however women were more concerned about weight and shape (Mond and Hay, 2007).
Teasing and bullying affect many children and teens. Appearance is one of the most common reasons for teasing, with weight being a major target. Young people understand that thin is pretty and fat is ugly. In fact, 81% of 10-year-olds are afraid of being fat (Mellin et al., 1991). Children who are taunted feel self-conscious and bad about how they look. Some vow to lose the weight no matter what. This can lead to dieting or restricting calories, intense exercising, use of diet pills or street drugs, bingeing after a period of restricting, and purging in some form – all to prevent weight gain.
Some teens can also be influenced by their friends’ unhealthy habits, observing how the friend manipulates weight by engaging in eating disordered behavior. For instance, one friend confides to another friend how she is able to eat so much and not gain weight. She tells her friend that she’s been bingeing on ice cream and throwing it up because ice cream is easy to purge. She avoids nuts and bread because these don’t come up as easily.
Families also have a powerful influence on beliefs people hold about themselves, other people, and the world in general. What a man’s family values, it’s likely that he does, too. For instance, if parents find education important, so do their children. If parents rate making money as the highest goal, so will their offspring. This is similarly true for being thin and attractive.
There are certain family dynamics that are suspected to leave young people more susceptible to developing problems with food, weight, and body image (Fairburn et al., 1997; Taylor and Altman, 1997). The fifteen most salient family factors are:
In addition, a history of food-related teasing from family and friends, negative maternal modeling, and friend's criticism of eating all promoted adult eating disordered behavior and thinness expectancies (Annus et al., 2007). Adolescent girls reported more weight concerns a year later following a period of time when their mothers reported being less accepting and fathers reported having more conflict with their child (Lam and McHale, 2012). Children who experienced a loss of control over eating had greater levels of exposure to parental problems such as underinvolvement, arguments, and depression of family members (Hartmann et al., 2012).
Although research has yet to find characteristics that are specific to families of anorexics, Strober (1991) has found that these factors do apply:
Jacobi et al. (2004) identified a number of correlates that may contribute to the development of anorexia including a parenting style marked by:
Research suggests that three factors are unique to the families of individuals with bulimia nervosa (American Psychiatric Association, 1993). These include a family history of:
There are certain environmental risk factors for the development of Binge-Eating Disorder (Fairburn et al., 1998; Striegel-Moore et al., 2005). These include:
Beliefs shape, and ultimately create, reality. The beliefs, assumptions, and attitudes people hold are developed during childhood and adolescence and stored in the subconscious. These are based on the messages received from parents, other significant persons, and society. Beliefs are the foundation for how people feel and think about themselves, which in turn influence the decisions and choices they make.
Girls (90% of the eating disordered population) and boys (10%) who come from families with the characteristics listed above are more likely to develop a negative belief system. Harsh feedback along with parental role-modeling can make it difficult for them to create a positive self-image. Their desires to be loved, cared for, and accepted by their parents and to fit into the family’s paradigm fuels their drive for perfection and the need to be in control of themselves and their emotions. When they don’t measure up, they become self-critical (in ways similar to how their parents were critical of them). They wind up feeling worthless, inadequate, or defective, and unable to accept their flaws. They will do just about anything to feel good about themselves, often resorting to changing things outside themselves (i.e., weight, appearance, grades, friends, etc.) to feel okay on the inside.
If the young person is prone to develop an eating disorder, she or he will veer in one of two directions. They will either starve (dieting that has become restrictive with calories and food choices) to attain a faultless appearance and numb out painful emotions. Or they’ll turn to food for comfort or companionship (food is the buddy that never judges). A certain subset of this group will learn to purge in order to prevent weight gain and to cleanse the body not only of food but also of unpleasant feelings (Price, 1999).
Emotional, physical, and sexual trauma profoundly affects a person’s psyche. Traumatic events like bullying at school, being repeatedly humiliated by a teacher in front of classmates, or molestation by a neighbor happen outside the home. Trauma occurs within the family when one or both parents are hostile, verbally attacking, hypercritical, too controlling, uncaring, uninvolved, ignoring or withdrawing from the child, physically violent, or sexually abusive.
Emotional deprivation and abuse, and even excessive coddling, can trigger “psychological growth delay.” Heart rate, blood pressure, and bone structure can be adversely affected. The underdeveloped child may have temper tantrums, reduced IQ, garbled speech, or an eating disorder. The underlying mechanisms have yet to be identified, but it is suspected that emotions and growth are linked to chemical messages in the brain that signals the pituitary gland to release growth hormone. Trauma may block that release. Hormone production can occur again once a child is placed in a healthier environment. After the age of eight or nine, destructive psychological patterns are more difficult to erase, and growth may not catch up to peers (Troiano, 1990).
Research also suggests that girls who are sexually abused have higher levels of catecholamines (epinephrine, norepinephrine, and dopamine) in their urine than did control subjects. Over time, the chemicals lead the body to become stressed and hyperaroused, potentially producing sleep disorders, nervousness, and anxiety (DeAngelis, 1995). Body-hate and distortions are also likely to develop because these girls were exposed to situations that disrespected their bodies and turned sexual contact into an ugly event. Those who experience childhood sexual or physical abuse are at increased risk for developing bulimia nervosa (American Psychiatric Association, 2013). The effects of trauma have to be treated along with the eating disorder.
One study found that 24% of obese patients with binge eating disorder met the criteria for posttraumatic stress disorder (Grilo et al., 2012). Another study states that the majority of women and men with anorexia nervosa, bulimia nervosa, and binge eating disorder reported a history of personal trauma (Mitchell et al., 2012).
There are a number of biological and genetic factors that correlate with the development of eating disorders. Genetic research suggests that 40%-60% of personality traits come from underlying genetic factors (Academy for Eating disorders, 1999). Genetic factors accounted for 55% to 60% of the variance in disordered eating and depressive symptoms, the remaining coming from nonshared environmental effects (Slane et al., 2011).
Listed below are 13 traits that genetic researchers believe are inherited (Academy for Eating Disorders, 1999).
There are a number of traits and characteristics that make individuals more vulnerable to developing an eating disorder.
Research has identified a number of specific premorbid conditions that a young person exhibits prior to the development of an eating disorder (Academy of Eating Disorders, 1999).
Individuals who develop anxiety disorders or display obsessional traits in childhood have an increased risk of developing anorexia nervosa (American Psychiatric Association (2013). From a young age, these individuals are uncompromisingly rigid and compulsive, inhibited in expression, and prone to incessant worry over inconsequential mistakes and uncertainties of the future. With puberty, intense feelings are aroused and future challenges seem insurmountable. Anxious and constrained, these individuals prefer a life rigidly structured to avoid novelty, need, and impulse. Their temperament brings fear of change and a proclivity towards repetitious behavior. (Strober in Grilo and Mitchell, 2010).
According the American Psychiatric Association (2013), a number of temperamental factors are associated with increased risk of developing bulimia nervosa:
Premorbid conditions are also identified for bulimia (Academy for Eating Disorders, 1999):
Johnson and Connors (1987) were two of the first researchers to identify factors, including character structure, which contribute to the onset of bulimia nervosa.
Low frustration tolerance
Highly variable moods
A number of potential risk factors for an eating disorder to develop have been identified (Fairburn et al., 1997, Taylor and Altman, 1997):
The literature on bulimia nervosa suggests that bingeing and purging are strategies to alleviate feelings of fragmentation, disorganization, and self-hatred. Women with bulimia look outside themselves for validation and approval, monitoring their behaviors to please others and avoid conflict. The family environment, combined with predisposed personality traits, makes it harder for these women to develop a strong, positive sense of themselves. This leads to depressed and anxious moods, and then bulimic behavior. The sense-of-self was found to be the mediator between the effects of family dynamics and the development of bulimia nervosa (Price, 1989). Such women have a more stable, yet negative, sense-of-self. As one woman stated, “It’s better to hate yourself than to not have a self at all” (Barth, 1988).
Genetics and environment work in tandem. People are born with certain biological predispositions. The environment in which a person grows up either enhances these traits or minimizes them. It is as if genes are the ammunition in a gun and the environment either pulls the trigger or puts the gun down. Genetics and environment (societal and familial) lay the foundation for how people perceive, feel about, and see themselves as well as their resiliency during stress, constancy of moods, and flexibility to roll with the punches.
Many individuals with eating disorders display a number of the characteristics listed below.
Specific to Anorexia Nervosa:Many anorexics experience depressive signs and symptoms such as depressed mood, social withdrawal, irritability, insomnia and diminished interest in sex. These may be a result of malnutrition. Obsessive-compulsive features are also prominent, with a focus on body weight, shape, and food. Food preoccupation may be exacerbated by malnutrition. Anorexics may also have concerns about eating in public, feeling ineffective, a strong desire to control one’s environment, inflexible thinking, limited social spontaneity, and overly restrained emotional expression. A subgroup engages in excessive levels of physical activity, which predates the disorder. Anorexics may also misuse medications in order to manipulate weight loss or avoid weight gain, such as an anorexic with diabetes who reduces insulin doses to minimize carbohydrate metabolism (American Psychiatric Association (2013).
Specific to Bulimia Nervosa: Cormorbidity with mental disorders is common in individuals with bulimia nervosa. There is an increased frequency of bipolar and depressive disorders. In some individuals, the mood disturbance precedes the development of bulimia nervosa. There may also be increased frequency of anxiety symptoms. The lifetime prevalence of substance use, particularly alcohol or stimulant use, is at least 30% of individuals with this disorder. A substantial percentage of individuals also have personality features that meet the criteria for one or more personality disorders, most frequently borderline personality disorder (American Psychiatric Association (2013).Specific to Binge-Eating Disorder: Binge-eating disorder is related to a number of functional consequences, including social role adjustment problems, impaired health-related quality of life and life satisfaction, increased medical morbidity and mortality, and associated with increased health care utilization compared with body mass index-matched control subjects. It may also be associated with a higher chance for weight gain and the development of obesity (American Psychiatric Association, 2013).
Eating disorders start when the person is young, can last for years, and cost a great deal of money to overcome (National Association of Anorexia Nervosa and Associated Disorders, 1994).
People with eating disorders engage in four harmful and destructive behaviors – starving, bingeing, purging, and grazing. They often get stuck in cycles of starving and bingeing, bingeing and purging, starving and grazing, or grazing and purging. The diagnostic criteria come directly from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5 ™) (American Psychiatric Association, 2013).
Starving: Starving often starts out as dieting. But it is dieting that has spun out of control. Eating less than 1,200 calories a day starves the body. People who undereat are actually obsessed with food. How could they not be when they’re depriving themselves? Their bodies will push them to focus on food with the hope that they’ll finally consume something. They become anorexic by ignoring hunger signals, and therefore losing a significant amount of weight.
Physical Complications: Most medical problems are attributable to starvation (American Psychiatric Association, 2013). The weight of anorexics ranges from underweight to emaciation. Listed below are the signs, symptoms, and complications of anorexia nervosa (Mehler, 1996).
In addition to the symptoms above, other complications include:
Prevalence and Comorbidity Statistics:
Recovery Rates (Mehler, 1996):
Bingeing: Bingeing is often a reaction to food restriction. The body pushes to be fed when it has been deprived of food. So, when people undereat at one meal, they're more likely to overeat at the next meal. They think they have no willpower, but in actuality, their bodies will do anything to make sure they get enough food.
The other reason for bingeing is the desire to numb painful emotions. Most people binge on sugary or salty carbohydrate-filled foods such as breads, cakes, donuts, cookies, chips, and candies. Complex carbohydrates release serotonin in the brain that induces calmness and reduces depression and anxiety. Serotonin is our natural antidepressant. Chocolate has a similar mood-altering effect, reducing depression and anxiety. However, you only need 1/2 ounce, not a whole bag, to do the trick.
Purging: Purging gets rid of unwanted calories after a binge. Some people are so fearful about weight gain that they purge even though what they've eaten is not considered a binge. Purging can also create a sense of being purified or cleansed, not only of the food but also of intolerably painful affect.
Purging is an ineffective form of weight control. Kay et al. (1993) found that an average of 2,131 calories is consumed during a binge and 1,209 calories are kept in the body (57% of total intake) after purging. The body retains about 1,200 mean calories, although researchers are not sure why. Perhaps the stomach and small bowel absorb and process food at a certain rate no matter how much food is available. Another study on laxative use found that only 12% of calories are removed from the body while 88% are retained.
Physical Complications: Medical problems are directly related to the method and frequency of purging. Because most bulimics are within a normal weight range, they look healthy, but may have health concerns that need to be addressed (Mehler, 1996).
In addition to the symptoms above, other complications include:
Prevalence and Comorbidity Statistics:
Recovery Rates (Mehler, 1996):
Relapse for Anorexia Nervosa and Bulimia Nervosa (Keel et al., 2005)
Bingeing: Repeatedly eating large amounts of food can turn into an addictive habit. Some bingers have consumed as many as 20,000 calories in one sitting. The average binge ranges from 1,500 to 3,500 calories (Kaye et al., 1993). Distress comes more from loss of control than from quantity eaten (Spitzer et al, 1991). If bingeing occurs frequently over a period of months, it can turn into binge-eating disorder.
Grazing: This is when someone eats from morning to evening, or for blocks of time, without having designated meals. The day becomes one long munching event. This style of eating presents problems. Grazers do not know how much they’re eating and often choose easy-to-grab snack items like candy or chips. Weight gain is caused by overeating unhealthy foods.
Physical Complications (Berg et al., 1997): The medical conditions listed below are found more often, and are more serious, in people who are overweight and obese.
Prevalence and Comorbidity Statistics:
This category applies to presentations in which symptoms characteristic of feeding and eating disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the feeding and eating disorders diagnostic class. This category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any of the specific feeding or eating disorder. This is done by recording “other specified eating disorder” followed by the specific reason listed below.
Women with purging disorder reported higher levels of restricting (Tasca et al., 2012). They also experienced more anxiety than bulimics when they perceived themselves to have binged and when purging (Brown et al., 2011).
Although body dysmorphic disorder is not classified as an eating disorder, a number of eating disordered patients also struggle with this condition.
One or many body parts can be the focus. Most individuals describe marked distress over their supposed deformity, describing the preoccupation as "intensely painful," "tormenting," or "devastating." Most find their preoccupation difficult to control, make little or no attempt to control it, spend hours a day thinking about it, and seek excessive reassurance about appearance. There is frequent mirror checking, use of lighting or magnifying glasses to scrutinize the "defect," and/or excessive grooming behavior. These behaviors often intensify anxiety instead of diminishing it. Severe distress can lead to suicidal ideation or attempts. Medical, dental, or surgical treatments may also be pursued to rectify imagined defects.
In one study, 33% of subjects with body dysmorphic disorder (BDD) had a comorbid lifetime eating disorder: 9% had anorexia nervosa, 6.5% had bulimia nervosa, and 17.5% had an eating disorder not otherwise specified. They were more likely to be female, less likely to be African American, and had significantly greater body image disturbance and dissatisfaction (Ruffalo et al., 2006).
Training is essential for clinicians to effectively treat eating disorders. For each patient, you will formulate a treatment strategy that addresses all the components and complexities of her/his eating disorder. In addition, you will assess whether psychotropic medications might aid in the recovery process. Taking these factors into account can increase the chances of a successful outcome.
It is essential to build a team of allied health professionals to help treat patients with eating disorders. These specialists are necessary for a number of reasons:
The first recommendation you make is for your patient to see a physician for a medical evaluation and ongoing monitoring. I prefer that the patient see an expert who treats eating disorders. Make sure the physician conducts a thorough physical examination along with complete blood tests so both of you have an idea of any damage that’s been done to the patient’s body.
For patients who have a sub-clinical eating disorder or milder symptoms with no associated health problems, you can forgo this referral. Make the referral if it later becomes necessary.
Sometimes, for either financial or loyalty reasons, the patient want to see his own physician. Whether your patient sees the person you suggest or his own doctor, obtain a release so you can talk to the physician before and after the exam. Provide the doctor with information gleaned in the initial visit that may aid in the evaluation. Keep in contact with the physician so you know the medical treatment recommendations and are apprised of temporary or chronic symptoms.
Use medical information as leverage. The development of serious physical consequences can be a motivating factor for change, particularly if your patient doesn’t feel well and is frightened that the condition will worsen. As your patient recovers, lab tests often return to normal, and health rebounds.
Decide case by case whether you have enough training to manage the education and implementation of balanced meal planning. Never recommend any kind of dieting (e.g., low-carbohydrate diets, low- or no-fat diets, calorie restrictive diets, the latest best-selling diet). Stick to sound nutritional guidelines. You may be able to provide this service for patients who:
Nutritional rehabilitation and weight restoration are critical components in the treatment of anorexia nervosa. These bring about the normalization of metabolic problems and a remediation of medical complications (Grilo and Mitchell, 2010).Weekly blind (back to scale) weigh-ins are necessary for patients who need to gain weight, lose weight, or fear they are gaining weight as they reduce purging behaviors. Weigh-ins are very anxiety-producing for the patient, so you’ll need to discuss feelings and fears each time she is required to step on the scale.
Referral to a Dietitian: Once you decide to send your patient to a dietitian, choose someone who has extensive training and experience in working with eating disorders. These specialists understand how to talk about food in ways that are less threatening. They know how food affects the patient’s mood, level of fear, and the body’s ability to digest. They anticipate the dangers of refeeding an anorexic patient. They employ strategies to lower resistance and raise compliance when fats, carbohydrates, and/or calories are reintroduced. A referral is recommended for patients who have:
Make sure your patient signs a permission to release information form. After each meeting, have the dietitian call to tell you the patient’s food and weight goals, areas of struggle, positive changes made during the week, and actual weight (if the dietitian is doing the weigh-ins).
A percentage of eating disordered patients will need psychotropic medications to reduce emotional and behavioral symptoms. If a new patient has a psychiatrist, obtain a release so that you can discuss the case. Ask about the patient’s history and the psychiatrist’s observations. Keep in contact as needed.
If the patient is not taking medications, assess the severity of depressive, anxious, obsessive-compulsive, and bulimic symptoms. Decide whether it is appropriate to make a referral to a psychiatrist who understands eating disorders. Find out what your patient would like to do. Does the person wish to see if symptoms remit with therapy alone, wants or needs medications, or resists the idea of taking medications even if it’s a sound one? If the patient is reluctant and you believe medications would aid recovery, periodically bring up your observations and inform her of the potential benefits of psychotropic medications.
Inpatient Hospitalization: There are six reasons for referring a patient to an eating disorders hospital program or residential facility that provides medical and psychiatric care:
Intensive Outpatient Program: These programs are recommended for the patient who needs more help than what is offered through traditional outpatient treatment, but would benefit from being able to sleep at home, attend school or work in the evenings, and continue some aspects of his life without regressing into destructive behaviors.
Outpatient treatment options include individual, group, family, and couple’s therapies. Patients may require a combination of these to address their unique circumstances. Some need individual psychotherapy along with or more of the following–physician, nutritionist, psychiatrist, group, couple’s, and/or family therapies. Others need to see the psychotherapist, physician, nutritionist, and psychiatrist. And yet others only need individual psychotherapy. You decide what is best for your patient. Factor in the patient’s financial situation and limitations that insurance plans bring.
You are the team leader who tailors treatment and oversees the recovery process. You’ll be in contact with the allied health professionals and therapists who are working with your patient. Your role is to make sure that everyone has the same goals and is informed about pertinent issues (e.g., patient engages in splitting between two practitioners, doesn’t share relevant information with another team member, tells different things to different people). With every team member being on the same page, recovery can move along more smoothly.
Individual Psychotherapy: Some patients can be seen once a week whereas others must be seen twice a week to have any impact. The severity of symptoms, stability of mood and health, and finances will be the defining factors in how often you schedule sessions.
Group Therapy: Therapist-led and self-help groups provide added support. Groups allow patients to meet people with similar problems, reduce isolation, and experience camaraderie. Some people like groups, whereas others are wary about revealing personal information to strangers. Organizations like the National Association of Anorexia Nervosa and Associated Disorders (see Resources) offer free self-help groups throughout the country. If the group is facilitated by a therapist, be sure to obtain permission to release information so you can coordinate treatment.
Family Therapy: Working with the family is especially important with teens because the family environment contributes to the eating disorder. Some families are willing to participate in family therapy; some teens are, too. Others don’t want their families involved, or the parents think it's the teen's problem and your role is to fix it.
The eating disorder serves a wide variety of unconscious or subconscious functions for the family. For instance, the teenager:
Although research identifies certain family characteristics and dynamics that influence the development of an eating disorder, studies have shown that focusing on those issues in therapy do not necessarily aid in recovery (Grilo and Mitchell, 2010).
Family-Based Therapy (FBT) is an emerging therapy for adolescents with eating disorders. Although few studies have been conducted regarding treatment with this population, two studies support the use of this treatment for anorexia nervosa and bulimia nervosa (LeGrange et al., 2007; Schmidt et al., 2007). Research suggests that specific family-based therapy for anorexia is superior to other forms of therapy (Robin et al., 1999). Dropout rates are small for family therapy (4.8%) versus 100% for dietary advice (DeJong et al., 2012).La Grange and Lock (2007) have written a manual on how to use FBT. The treatment is symptom focused and a collaborative effort with parents. Therapy is conducted over 20 sessions in three phases:
Couple’s Therapy: Marriage and live-in partners of the patient are often affected by eating disorders. Patients get so wrapped up in their behaviors and may have such intense body image concerns that relationships suffer. Part of the focus in couple’s therapy is educating the partner about the complexities of an eating disorder and about how recovery will proceed.
Both family of origin members and partners can benefit from guidelines on what to do and not do to assist recovery. Parents and partners can:
Couple’s therapy can also improve communication skills, resolve intimacy concerns, and strengthen the bond between both partners.
Cognitive/ behavioral, interpersonal, and psychodynamic therapies are the most common forms of therapy utilized with eating disordered patients. Newer forms of therapy are currently being researched for efficacy. Therapy often takes six months to many years for the patient to attain partial to full recovery.
Anorexia nervosa is the most difficult eating disorder to treat. There is no established first-choice treatment for adults who suffer from anorexia (National Institute for Health and Clinical Excellence [NICE], 2004). The majority of comparisons from controlled treatment studies fail to identify any psychotherapy as being superior to another for adults with anorexia. The reasons for limited efficacy of existing psychological interventions include high dropout rates, the ego-syntonic nature of anorexia, patient’s inability or unwillingness to confront personal and emotional issues, and the negative influence of low body weight and malnourishment on cognitive processing and stamina (Tchanturia and Hambrook in Grilo and Mitchell, 2010).
Bulimia nervosa and binge-eating disorder are amenable to treatment. Up to 70% of bulimics can enter full remission (Keel et al., 1999). Treatment for binge-eating disorder reduces frequency of binge episodes and improves behavioral and cognitive features but does not generally lead to significant weight loss (in overweight and obese patients) despite high rates of abstinence post-treatment (Wildes and Markus in Grilo and Mitchell, 2010).
Cognitive-Behavioral Therapy: Cognitive-Behavioral Therapy (CBT) is a combination of Cognitive Therapy and Behavioral Therapy. The cognitive component is used to reduce negative thought processes that fuel eating disordered behaviors. Focus is on changing cognitive distortions and negative self-talk that trigger starving, bingeing, purging, or grazing. The role of negative beliefs and their relationship to internal dialogue, defense mechanisms, and the function of eating disordered behaviors are explored. The behavioral component is used to reduce behavioral symptoms and provide healthier alternative behaviors. Strategies help patients set up meal plans and experiment with adding new foods; delay and prevent harmful behaviors; create lists of activities to replace turning to or denying food or purging; and exercise in appropriate amounts.
There is general consensus in the field that CBT is currently the best established form of psychotherapy for bulimia nervosa and binge-eating disorder either in an individual or group therapy format (Mitchell et. al., 2007). CBT is found to be more effective and produces greater overall improvement than other forms of therapy in reducing disturbed attitudes towards shape, weight, dieting, and the use of vomiting to control shape and weight (American Psychiatric Association, 1993). Short-term behavioral therapy alone did not fare as well as CBT (Wilfley and Cohen, 1997). In comparing use of medication and therapy, CBT alone is generally superior to antidepressant medication alone, and there may be some advantages to combining the two treatments (Wilfley and Cohen, 1997).
CBT is also used to treat Night Eating Syndrome (NES). NES is a disorder characterized by a delay in the circadian rhythm of meals along with several neuroendocrine factors. The disorder occurs in people who are genetically vulnerable to stress. One study suggests that there is a disruption in serotonergic system (Stunkard and Lu, 2010). Treatment focuses on shifting the circadian pattern of food intake to earlier in the day, uncoupling the need to eat to fall asleep or resume sleep, attending to cognitions related to eating episodes, using behavioral strategies such as stimulus control, and implementing physical barriers to food (Allison and Stunkard in Grilo and Mitchell, 2010).
The empirical data on CBT for anorexia is extremely limited, however a number of recent investigations offer preliminary support of the utility of CBT to treat anorexia, particularly for weight restored individuals (Grilo and Mitchell, 2010).
CBT is generally provided on an outpatient basis, consisting of 19 sessions over a 20-week period, and is comprised of three stages (Wilfley and Cohen, 1997):
CBT does help all patients with anorexia and bulimia. A number of criticisms have emerged in the broader research community. Clark (1995) summarized the criticisms. CBT has:
CBT-E (enhanced) is one of the leading evidence-based treatments for bulimia nervosa. CBT is “enhanced” for three main reasons (Cooper and Fairburn in Grilo and Mitchell, 2010:
Integrative Cognitive-Affective Therapy: This form of therapy for bulimia nervosa is an emotion-focused intervention that retains some elements of CBT. Integrative Cognitive-Affective Therapy (ICAT) posits that life experience (e.g., criticism, social comparison, rejection, loss) interact with temperamental predispositions (e.g., harm avoidance) to produce mental representations of self and others that organize and guide future interpersonal perceptions and behaviors. Treatment is 20 sessions split into four phases (Wonderlich et al. in Grilo and Mitchell, 2010).
Research is still being conducted to assess the effectiveness of ICAT.
Cognitive Remediation Therapy: This form of therapy is being tailored to treat patients with anorexia nervosa. Cognitive Remediation Therapy (CRT) was originally developed to rehabilitate patients who had brain lesions in order to improve brain functioning. Because anorexics display a trait of cognitive inflexibility (poor set shifting), CRT is an intensive 10 session training that encourages patients to reflect and modify the way they think. Preliminary evidence for efficacy is limited but encouraging (Tchanturia and Hambrook in Grilo and Mitchell, 2010).Interpersonal Therapy: This form of therapy is the only treatment other than CBT where patients maintained change at one- and six-year follow-up evaluations. Interpersonal therapy (ITP) was designed as a short-term treatment for depression and then adapted to treat bulimia nervosa and binge-eating disorder. ITP focuses on disturbances in social functioning that are associated with the onset and maintenance of the disorder. Treatment strategies address four social domains: grief, interpersonal disputes, role transitions, and interpersonal deficits (Wilfley and Cohen, 1997).
Psychodynamic Therapy: This therapy is widely practiced with a variety of disorders, including eating disorders. Although few controlled studies have looked at the effectiveness of psychodynamic therapy, two variants have been studied: Supportive Expressive Psychotherapy (SET) and Supportive Psychotherapy (SPT). CBT was more effective than either of these treatments in reducing purging, dietary restraint, distorted body image, depression, and distress; and in raising self-esteem (Wilfley and Cohen, 1997).
Psychodynamic therapy can be used in addition to CBT in long-term therapy to explore:
Thompson-Brenner and Westen (2005) argue that clinicians in the “real world” of everyday practice integrate symptom-focused and personality-focused interventions that may take longer to administer but are actually found to improve outcome. Their findings suggest that some patients will benefit from limited interventions, but the majority of their sample needed additional interventions that psychodynamic therapies specifically address. For bulimic patients, techniques that fall under the “psychodynamic domain” like exploring feelings, conflicts, impulses, significant relationships, defenses, and emotional dysregulation can be helpful.Summary: There are training manuals and seminars designed to help therapists learn CBT, CBT-E, ICAT, ITP, and Psychodynamic Therapy in order to treat individuals with eating disorders.
In addition to psychotherapy, a number of psychotropic medications have been found to aid in the reduction of symptoms and behaviors directly related to eating disorders. There is also a wide variety of medications that treat comorbid symptoms such as depression, anxiety, and obsessive-compulsive tendencies. Some patients will require pharmacologic intervention to reduce symptomatology.
Currently, there is no empirical data to support treating anorexia with medications alone. Anorexia remains quite resistant to pharmacological interventions. However, once weight is restored, antidepressant medications are often used to treat depression, anxiety, obsessive-compulsive symptoms, and bulimic symptoms. A psychiatrist needs to assess whether the depression and anxiety are related to starvation prior to recommending an antidepressant (Keel and McCormick in Grilo and Mitchell, 2010).
Prozac (fluoxetine) is a selective serotonin reuptake inhibitor (SSRI) that blocks the reuptake of serotonin into human platelets and is a more potent inhibitor of serotonin than norepinephrine. This medication has been shown to help anorexics maintain recovery and prevent relapse after weight gain from an inpatient program. The medication reduced depression, anxiety, obsessions, compulsions, and core eating disordered symptoms in weight-restored anorexics (Kay et al., 2001). Prozac is not recommended for underweight anorexics due to the potential anorexic side-effect of the medication (Maxmen and Ward, 2002).
Zyprexa (olanzapine) is considered an “atypical” antipsychotic because of its profile of binding to dopamine receptors which differs from those exhibited in more typical antipsychotic drugs. In randomized controlled studies, anorexics who took olanzapine had faster weight restoration than if they had not taken this medication (Attia et al., 2008). Because many anorexics experience intense dysphoria, anxiety, and hyperactivity, the anxiolytic and mood stabilization properties of this medication can be beneficial. Studies have also shown improvement in cognition, body image and reduced anorexic ruminations. Adherence is a problem due to fears of weight gain (Kaplan and Howlett in Grilo and Mitchell, 2010).
Another atypical antipsychotic, Risperdal (risperidone), is less likely to cause weight gain yet also has the mood stabilizing effects, which makes it more acceptable to anorexic patients (Kaplan and Howlett in Grilo and Mitchell, 2010).
While CBT, CBT-E, and ITP have empirical support in treating bulimia, there have been numerous studies conducted that have examined pharmacotherapy for bulimia nervosa. Most antidepressants have been studied and most have reported positive results in reduction of emotional symptoms compared with placebo (Crow and Brandenburg in Grilo and Mitchell, 2010).
Prozac (fluoxetine) at high doses (60 mg/day) is considered the “gold standard” for treating bulimia nervosa (Fluoxatine Bulimia Nervosa Collaborative Study Group, 1992). Fluoxetine has been found to significantly reduce binge eating and purging behaviors and is the only medication approved by the Food and Drug Administration (FDA) for these purposes. It may be a useful intervention for patients who have not responded to psychotherapeutic treatment (Walsh et al., 2000).
Fluoxetine has also been used for the treatment of depression, obsessive-compulsive disorder, alcohol and drug addictions, and migraines. Side effects start in the first week and often subside. These include anxiety, nausea, insomnia, dry mouth, dizziness, headache, decreased libido, and decreased appetite. Contraindications include potential increased weight loss in anorexics, increase the effects of alcohol, and interference with monoamine oxidase inhibitors (MAOI) (Maxmen and Ward, 2002).
Other Antidepressant Medications have also been found to be helpful with depressed mood. These include Luvox (fluvoxamine), Desyrel (trazadone), Celexa (citalopram), and Norpramin (desipramine) (Shapiro et al., 2007).
Wellbutrin (bupropion) is an antidepressant in the aminoketone class that is a relatively weak inhibitor of the neuronal uptake of serotonin, norepinephrine, and dopamine. It is not recommended for patients with bulimia because a number of women experienced grand mal seizures (Grilo and Mitchell, 2010).
A variety of SSRI antidepressants have been studied to assess their effectiveness in treating BED. The results have been mixed. Prozac (fluoxetine), Luvox (fluvoxamine), Celexa (citalopram) Zoloft (sertaline), and Lexapro (escitalopram) have had uneven results in reducing binge eating episodes. None are helpful in promoting weight loss in overweight or obese patients with BED (Bodell and Devlin in Grilo and Mitchell, 2010).
Anitobesity medications such as Sibutramine and Orlistat have shown positive results with weight loss. A number of studies have shown that Sibutramine also reduced the frequency of binge-eating and depression while producing significant weight loss. One contraindication for use of this medication is uncontrolled hypertension and cardio- or cerebrovascular disease because this medication is associated with increased heart rate. Orlistat did not decrease binge-eating but did enhance weight loss (Bodell and Devlin in Grilo and Mitchell, 2010). When patients stop taking these medications, their effectiveness ceases and weight gain often occurs.
Phone Contact: Your assessment begins on the phone. Initial screening helps you start to discern if this person can be treated on an outpatient basis or needs to be referred to an inpatient or day treatment program. You may not be able to tell how serious the disorder is from a brief phone conversation, but you will be better prepared when the person arrives at your office. There are four questions you will want to ask as part of telephone screening:
The answers will give you some idea of how entrenched the eating disorder is. The longer the person has had an eating disorder and/or the more resistant to treatment he is will make therapy more challenging. You can gauge the amount of work it is going to take to see some recovery.
Assessment Tools: A one- to two-session initial interview is your best assessment tool. If you ask the bulk of the questions provided below, you’ll gain insight into the seriousness of the eating disorder along with satellite issues that need to be addressed (e.g., using street drugs to lose weight, borderline personality disorder, physical complications). Obtaining permission to discuss previous or ongoing treatment with a therapist, treatment program, physician, and/or psychiatrist will also aid in your understanding of this case.
Some practitioners like to use standardized tests to assess eating disordered behaviors, mood, and personality. These therapists are well-trained in using testing materials in their practice. Some practitioners utilize these tests all the time whereas others use them only if they're confused by symptoms that don’t make sense. Some patients are fine with filling out questionnaires; however, others will be turned off by the “clinical-ness” of the process. The most commonly used measurements include:
As you’re conducting the initial interview, the most important question you must ask yourself is, "Do I have the expertise and experience to treat this person?" The most difficult situation for both therapist and patient occurs when the therapist is in over her head. You must understand the nuances of the disorder because the patient will not necessarily reveal them. You will have to know what to look for, as well as what and when to ask questions to get the answers you are seeking. Then you can seize the opportunity to affect change. If you believe you cannot manage the case, refer the patient to someone whom you know has the training!
If an eating disorder is revealed in therapy and you have a strong therapeutic alliance, but do not have the training to treat eating disorders, you can refer the patient to an eating disorders therapist who can focus on cognitive behavioral changes while your patient continues therapy with you. You will need to work closely with the therapist so you don’t contradict each other. This co-treatment model is best for patients who are not prone to defensive splitting.
Throughout the interview, formulate your treatment strategies and decide which allied professionals you will bring on board.
Be compassionate and non-judgmental. The patient is often embarrassed, and even ashamed, to admit engaging in eating disordered behaviors. Not only are you interviewing the patient, you are also being interviewed. Empathy and understanding go a long way in forming the initial bond.
Initial Interview Questions: You will cover these questions in the first couple of sessions. The patient will offer many relevant answers, so you won’t need to ask all of the questions below. Direct your questions towards areas that you want covered.
This list should be modified for use with teens. They cannot answer many of these questions because they don’t have the insight. Parent(s) can fill in some of the information. With teens, keep it simple.
Wrap Up: Ask if the patient has any questions. Answer in ways that foster confidence in your understanding of this person’s unique struggles. Once you have gathered all the information and have started to formulate a diagnosis and treatment plan, inform the patient of what you believe is going on and what it is going to take to recover. You will need to make a number of decisions regarding treatment. Decide if:
Referrals: If you can’t treat this patient, refer to another therapist. If you’re building your treatment team, make referrals to the other specialists.
Assignments: Once you decide to treat the patient, give her two assignments. Ask the patient to:
Decide how often you will see the patient and then set up the next session. Now you will start your assessment of the risks in taking on this patient.
Medical Conditions: Most individuals with an eating disorder have mild to serious medical conditions directly related to their behaviors. The list provided in Diagnostic Criteria, above, offers a comprehensive catalog of possible health-related problems. Listed below are the most common physical complaints that have been reported to me by my patients.
Facial hair growth
Blisters in mouth
Blood in vomit
Pain around the heart or down the left arm
Pain around heart or down left arm
Low blood pressure
Low blood pressure
Catches colds or infections easily
Gets chills and can’t warm up
Osteopenia or osteoporosis
Stomach aches after eating
Food sits in stomach undigested for period of time, creating discomfort and fullness
Diminished cognitive functioning
Energy level alternates between racing a mile a minute and extreme fatigue
Difficulty with attention, retention, and concentration
Irregular menstrual cycles
Loss of menstrual cycle
Comorbidity: There are a number of psychiatric disorders, including severe mood disorders and/or Axis II diagnoses that exist along with an eating disorder. These need to be addressed in therapy at the same time as the eating disorder.
The aforementioned issues have significant treatment implications:
As with all patients, you will need to cultivate a connected working relationship with the eating disordered patient. In building a therapeutic alliance, decide how you’re going to interact with this person. The mental and emotional position you take is crucial. Listed below are a number of stances, some of which are universal with every patient whereas others are specific to this population.
Healing the Hungry Self (1999) is a workbook to be used as an addendum to psychotherapy. In addition to the treatment modality you have chosen, this workbook focuses on aiding individuals overcome food, weight, and body image issues. It utilizes cognitive, behavioral, integrative cognitive-affective, and psychodynamic therapeutic strategies. The condensed version provided below is an overview of the most salient topics you’ll cover with eating disordered patients. Vignettes scattered throughout will pinpoint therapeutic realities that are hopefully humorous and poignant, and will give you a flavor of what you will be working with.
The workbook presents four main areas to address in recovery. They are four aspects of the self: the physical self (physical body), the emotional self (emotional reactions and experiences), the mental self (beliefs and thought processes)and the spiritual self (soul/spirit). All of these are intimately and intricately linked together. Each of these selves played a role in creating and sustaining the eating disorder. Healing must also include the four selves.
Although the four areas are written about separately, you will not be doing therapy in a linear fashion. You will be addressing all the selves during the course of treatment, bouncing back and forth depending on what your patient brings to you.
The recovery process encompasses four major components. Patients must:
Part of your role is educational. You’ll provide accurate information to dispel the myths patients hold about the nutritional value of foods, the effectiveness of dieting, or that they can pick a weight and force their bodies to go there without repercussions. At the same time, you’ll incorporate behavior change techniques to alter dysfunctional eating habits, destructive purging behaviors, and excessive or nonexistent exercise routines.
New Skills: To create a new, lifelong style of eating and exercise, patients must make a number of changes that are incredibly frightening. Ultimately, these changes offer structure, consistency, and predictability each day. Your task is to discuss and walk your patients through each step in the process. You don’t need to tell them the whole laundry list at once; instead, work it into the conversation as they bring up related topics.
Almost all eating disordered patients are trying to lose weight or not gain weight. They are either chronically or periodically undereating, using a structured diet, or keeping track of calories or fat grams. Research suggests that dieting (eating less than 1,200 calories a day) actually makes people heavier! Diets set people up to gain weight for a number of reasons:
Anorexics: Dieting and restraint has worked too well for anorexics. They don’t overeat in response to hunger. They often have endorphin rushes that lead them to feel upbeat (until they crash with fatigue). It’s important to educate them on how starvation affects their physiology (see Physical Complications in Diagnostic Criteria: Anorexia Nervosa) and current level of emotional functioning. Even though they aren’t eating much, they’re obsessed with food. They think and dream about it, watch television cooking shows, and/or prepare food for others but refuse to eat it themselves.
Bulimics and Binge Eaters: Neither group diets successfully. They begin a diet, fall off, go back to unhealthy eating habits, gain back all the weight plus more, become frustrated, and start dieting all over again. They would actually weigh a decent weight if they stopped under- and overeating. Bulimics could then give up the purging that they use to get rid of unwanted calories.
According to Mindy Gottesman, R.D., three meals a day are important. The body becomes hungry about every four to five hours. It is imperative for patients to eat when hungry and stop when full. The most often skipped meal is breakfast. People stop feeling hungry in the morning if they’ve been waiting to eat until later on in the day. Eventually, a ravenous hunger hits and they can’t seem to get enough food. Reintroducing breakfast reignites the hunger signal, which may panic some patients. Reassure them that this is a good thing. It means their metabolic rate has increased to burn off breakfast, and the body is now ready for lunch. People who eat the same amount of calories in three meals versus two meals actually have a higher metabolic rate. The information below matches the United States Department of Agriculture‘s (USDA) recommended daily allowance (2013).
Sample Meal Plan (Price, 2013)
|2 Ounces of Grain||2 Cups Oatmeal with Honey|
|1 Cup of Fruit||1 Banana|
|1 Cup of Dairy||1 Cup Yogurt|
|1 Cup of Fruit (Optional)||1 Pear|
|2 Ounces of Grain||2 Slices of Sandwich Bread|
|3 Ounces of Protein||3 Ounces of Turkey|
|1 Cup of Vegetables||Lettuce, Tomato, and Avocado|
|1 Cup of Dairy||2 Slices of Cheese|
|1 Ounce of Protein||1/4 Cup Trail Mix|
|2 Ounces of Grain||1 Cup Pasta Noodles|
|3 Ounces of Protein||3 Ounces of Beef for Sauce|
|1-2 Cups of Vegetables||1-2 Cups Tomato/Vegetable Sauce|
|1 Cup of Dairy||1 Cup Grated Cheese|
|1 Dessert (Optional)||1 Cup Rice Pudding|
This sample meal plan is similar to ones used in inpatient hospital settings. In the first or second session, I show patients this plan and ask for their honest opinion. You will receive a variety of reactions that will tell you about their food fears. Common sentiments include, “It’s too much food,” “I’ll gain weight if I eat like that,” “There are too many breads,” “It looks like a diet,” and “How reasonable, but I’ll never be able to do it.” Take note of these comments so you can address their concerns.
Plan Meals: Talk to your patients about healthy eating. The food Guide Pyramid (United States Department of Agriculture, 2006) recommends:
Offer simple rules to help patients start planning meals:
Consume a Minimum of 1,200 Calories a Day: For reasons mentioned under Why Diets Don’t Work, dropping below 1,200 calories reduces the body’s ability to burn calories efficiently. It also increases hunger and bingeing. The 1,200 calories are broken down into 400 calories per meal. Some people like to eat only three meals and no snacks. They’ll need to make sure they eat enough to carry them to the next meal without becoming famished.
Six small meals work best for patients who can tolerate only small amounts of food in their stomachs. Feeling full scares and overwhelms them. Mini-meals prevent them from reverting to shaving calories.
Three meals with snacks in between is the best solution for patients who graze, have hypoglycemia, or like to eat something every few hours.
Teens, young adults, active adults, athletes, and males will need to eat more than 1,200 calories a day. Their calorie requirement may range from 1,500 to 5,000. A dietitian can calculate the individual amount of calories required and identify the best food sources to obtain these calories.
Patients who are eating large amounts of food and have a resulting weight problem will need to reduce their caloric intake and choose healthier foods. It is not advisable for them to drastically cut calories. All it takes is 100 fewer calories a day to lose 10 permanent pounds a year with little or no effort at all. Eliminating bingeing alone is often enough to create permanent weight loss.
Case Vignette: Ann, a 23-year-old college student, entered therapy because she was bingeing and then using laxatives and exercise to purge calories. She was able to eliminate laxative abuse within one month of entering therapy. She compensated by exercising one-and–a-half hours a day while watching what she ate. She continued to binge every three to four days. When I asked Ann how she was dealing with food, she would say, “I’m doing fine. I’m eating three meals a day, like we’ve discussed.” Yet she kept bingeing, and sometimes we could not make an emotional link to the behavior. In her next session, I asked Ann to make a list of all the foods she ate the day before. We calculated that she had consumed a total of 950 calories. She explained that this was a typical day with food. We went over the principle of eating a minimum of 1,200 calories a day. After a lengthy discussion of how restricted eating set her up to binge, Ann reluctantly agreed to increase calories as an experiment to see if this would reduce bingeing without causing weight gain. She ate 1,200 calories a day for a week, did not binge, and did not gain weight. She was astonished that both occurred. Ann knows that she is still undereating in terms of the amount of exercise in which she’s engaging; she has, however, removed one reason for bingeing. Now when she binges, we are able to trace it to some emotional reaction that felt overwhelming. Ann understands that she will have to eventually eat more during the day and reduce the time she spends exercising.
Measure Moderation: The best way to measure serving size is to have patients use the palms of their hands. Everyone’s hand fits her or his body size. Anything that will fit into one hand is one serving.
In the beginning phases of therapy, patients must plan to have enough “safe” foods in the house, snacks in their purse or car, and/or simple meal fixings in the refrigerator at work so they’re not caught without healthy foods nearby. Otherwise, they’re likely to reach for something less healthy. Shopping can occur as needed or on a weekly basis; planning meals can take place the night before shopping or the morning of the same day. Eventually, they’ll have to grapple with restaurant menus where food choices are broad, portions large, and ingredients unknown. Developing structure creates a sense of predictability and comfort.
Create an Eating Environment: Encourage the patient to set the table, put food on a plate, and sit down to eat without watching television or reading. Discourage eating from the refrigerator or while cooking. When she is finished with her meal, she should clean up and leave the kitchen. The next time she can eat is snack- or mealtime.
Most bingeing is done rapidly, which makes food tasteless after a few bites. Bingers don’t recognize when they’ve had enough and become overly stuffed. Explain to the patient that it takes 20 minutes for the stomach to register fullness, so when she eats slowly and consciously, she will not only savor the food, she’ll eat less.
Keep Food in the House: Many bulimic and binge eaters cannot keep certain foods in the house because they binge on them. Foods like cereals, breads, sweet or salty snack foods, peanut butter, and ice cream are usually the most difficult for them to have around.
These foods can be reintroduced (one at a time) once overeating lessens and a consistent habit of three meals a day is in place. If the person continues to binge on foods brought into the house, have him remove the items and try again at a later date.
Learn to Eat Out: Some patients avoid eating in restaurants or at parties because they do not know exactly what is in the dishes. Other patients will use get-togethers as an excuse to eat everything they don’t normally allow themselves. Some patients intend to eat normally, but lose control and eat everything in sight.
Learning to eat out is often a slow and measured process. Depending on what the fear is, you can guide your patient towards taking small steps when an event comes up. For example, at buffets, have your patient take only one plateful of food and use the hand technique to guide moderation. When the plate is filled (not overfilled), that’s the meal. At restaurants, the patient can make a special request to keep sauces or salad dressings on the side, and then add the amount he feels comfortable eating. If too much food comes, the patient can eye how much is a normal amount, and the put the rest on the side of the plate, or onto another plate for the waiter to take away.
You can also give the patients an assignment to eat in a restaurant. In session, talk about what she’s going to do from the time she walks in the door until she leaves the restaurant, monitoring and facing her feelings throughout the meal. It will take practice, practice, practice.
Anorexics are too adept at changing their orders, pushing food aside, or avoiding restaurants altogether. They’ll need to work on going to a restaurant, eating a more normal amount of food, and dealing with fears of having eaten too much or the wrong kinds of foods. As they go through these emotions, they’ll see that the intensity eventually dissipates. Doing something after the meal will also help them stop hyper-focusing on what they’ve eaten and what it’s doing to their bodies as long as it's not exercise.
Make One Change at a Time: Many patients are hesitant to increase calories, eat from a variety of food sources, or change their rituals. Even if they’re overeating, they resist eating 1,200 calories because they have a diet mindset. If they’re starving themselves, the meal plan above seems totally unfeasible.
Encourage patients to undertake one change at a time, choosing the easiest first so they’ll see some success. Then build on that by changing the next easiest behavior. For example, many patients eat very little during the day and binge at night. Encourage them to eat either breakfast or lunch. In the beginning, they may not be able to make a meal using three food groups because it appears to be too much food. If they can eat one or two food group items and then increase it to three, they’ll have created a full meal. At breakfast, if your patient can imagine eating only oatmeal, add milk later, and then fruit. Within weeks, breakfast is a complete meal.
If patients eat more calories during the day without experiencing extreme hunger, they have removed one of the main reasons for bingeing.
Work with patients to expand food choices so that “forbidden” foods are slowly incorporated into normal eating. It is important for patients to differentiate between foods they fear and foods they’d prefer not to eat. Make sure they don’t confuse the two.
It takes 21 days to form a habit and 6 weeks until the new behavior is fully ingrained. You will see change happen more slowly because your patients won’t be doing the new behavior every day, and emotional upsets will periodically knock them off track.
Case Vignette: Mark, a 41-year-old software executive, came to therapy because his psychiatrist recommended that he address his binge eating and resulting obesity. He had struggled with weight problems most of his life. All of his family members are overweight; some are extremely obese. Mark’s weight fell into the mild obesity category. From the time he was a child, his mother made large, fat-laden meals – ribs, steaks, gooey potato salad, cream pies, and cookies of all kinds. His family rarely ate vegetables unless they were drowned in butter. Mark continued to choose these kinds of foods. The thought of “dieting” was incredibly unappealing. Mark regularly skipped breakfast, had a big lunch, an even bigger dinner, and then ate uncontrollably until bedtime. By missing breakfast, he was famished when lunch rolled around, wanting to eat everything in sight. Dinnertime was worse. If he could have eaten a horse, he said he would have. I encouraged him to make one change – have breakfast in the morning. Mark was willing to fix himself a peanut butter sandwich and have a glass of skim milk. Within days, he discovered he wasn’t dying of hunger at lunchtime and could consider some different options. Instead of buying a large hamburger, fries, and soda, he went to a deli and bought a turkey and cheese sandwich and soda. The effect carried throughout the day. He felt like he could pick something less fattening for dinner. Over a three-month period, Mark was able to move his calories to earlier in the day and reduce the total amount of daily calories consumed. He dropped 11 pounds. That one change opened the door for him to alter what he ate the rest of the day. And with effort, he did. Mark was also able to distinguish eating at night because he was hungry from eating because it felt good. The next hurdle for Mark is to address the stress eating at the end of the day and his lack of exercise.
Choose Whole Grains: Many patients worry about eating white flour or sugar (even though bingers regularly consume foods laden with these). Explain that the healthiest foods are the least processed and closest to their natural form (e.g., brown rice vs. white rice, whole grain bread vs. sourdough). Reinforce the fact that they can eat either whole grains or processed grains. They have the option to choose the healthiest foods and, after eating them for a while, will like and gravitate toward them. The idea is to not be worried about food in any form. Use the example that France doesn’t have a national obesity problem yet the French eat baguettes and croissants all the time – in moderation.
Go For the Right Fats: Fats come from natural sources (e.g., nuts, avocados, meats) or added sources (e.g., butter, salad dressing, mayonnaise). While eating fats that occur naturally in plants and animals is healthy and necessary for overall functioning, partially hydrogenated oils (margarine and vegetable shortening) may be harmful. Heart disease is less prevalent in countries where hydrogenated oils and margarine are not available. Crayhon (1997) wrote that these fats:
Animal fats (e.g., butter, lard) used to be blamed for these problems. They may not be the culprits.
Snack food, fast food, and desserts all contain fat and are unhealthy in large quantities. The right kinds of fats in appropriate amounts are good for the body. Fats build cell walls, cushion organs, and in women, produce estrogen, which aids in the shedding of uterus lining during menstruation. Estrogen also keeps bones strong.
Satisfy Cravings: People binge on cookies, cakes, candies, and chips – not lettuce. These snack foods are physiologically and emotionally satisfying. It is important for patients to eventually include the foods they love and crave in moderation, meaning once a week to once a day, and then only one handful. Otherwise, they will binge on them later on in the day or week.
There is a myth in the diet industry that grain carbohydrates are “bad.” In actuality, they are good for the body. These carbohydrates activate the release of serotonin in the brain. Serotonin is the neurotransmitter that calms people down, reduces mood swings, and puts people to sleep at night. Patients who do not eat enough carbohydrates are more likely to be irritable, depressed, and anxious. Serotonin is the neurotransmitter on which Prozac and all the other SSRI antidepressants work. In other words, serotonin is a natural antidepressant. In addition, carbohydrates are broken down and converted in the liver to glucose, which is sent to the rest of the body and used by cells to produce energy.
Eating protein releases dopamine in the brain, heightening alertness and concentration. Both serotonin and dopamine regulate hunger and satiety. So when patients eat these foods throughout the day and in combination, they feel full and satisfied.
Chocolate enhances mood and acts as a natural tranquilizer. There are over 400 chemicals in chocolate. Phenylethylalamine is believed to reduce depression and anxiety. It contains lipids (fats) that are chemically related to anandamide, a brain lipid thought to relieve pain, heighten senses, and produce a euphoric feeling. Chocolate activates the same brain cells as THC (tetrahydrocannabinol) in marijuana (Tomaso et al, 1996). Marijuana just delivers it in greater quantities.
Avoid Dehydration: Many patients do not drink enough water. They’re worried it will make them weigh more so they stay away from most liquids. They will drink coffee or tea for their diuretic effects.
Water reduces post-purge bloating and rehydrates the body. Sports drinks like Gatorade® or Powerade® replenish the sodium and potassium lost with purging. Until a bulimic can cease vomiting, using laxatives, diuretics, or Syrup of Ipecac, drinking a sport drink after purging will lessen the harmful side effects of an electrolyte imbalance.
For patients who are overweight or obese, inform them that drinking water can actually help reduce fat deposits. When the body is fully hydrated, it is better able to transport fat to the muscles for burning. Encourage your patients to drink water and avoid sugar-free drinks.
Aspartame (NutraSweet®) is found in 5,000 sugar-free foods and drinks. Hays (1991) contends that aspartame may be a neurotoxin. The synthetic chemical contains 50% phenylalanine, 40% aspartic acid, and 10% methyl alcohol (methanol), which is a deadly poison. The body attempts to detoxify methanol by oxidizing it into formaldehyde, then formic acid, then carbon dioxide, which is exhaled. Complaints about the use of aspartame include:
Anorexia: Many anorexics overuse and abuse sugar substitutes, using 20 to 100 individual packets a day, drinking many cans of diet soda, or eating sugar-free foods. Some of their compromised cognitive functioning may be due to a high intake of these artificial chemicals. They will need to wean themselves off, and eventually stop, the use of these substances.
Bulimics and Binge-Eaters: If these patients are overusing artificial sweeteners, encourage them to reduce and then eliminate them completely. It would be healthier for all patients who are overcoming eating disorders to use sugar or honey instead of sugar substitutes.
Overview of Recovery Process with Food
Anorexics: These patients are hesitant to increase calories partly because they fear, and therefore have eliminated all kinds of foods, from their meals. Anorexics who begin the refeeding process report fatigue, bloating, abdominal discomfort, depressed mood after eating, and anger which reignites starvation to regain a sense of emotional and physical control.
They often resist making changes and you may find yourself pulled into a control battle over what they will and will not eat. Diffuse the fight. Figure out which foods are more tolerable physiologically and psychologically for the patient. She can introduce new foods at a measured pace as long as she continues modest weight gain. At some point, the person will have to bite the bullet and eat the foods she’s been avoiding. Explain that the refeeding side effects will remit within a number of months.
Anorexics despise the changes their bodies go through when food is reintroduced. Rounder breasts, curvy hips, and larger legs and arms can send them into an emotional tailspin. Slow weight gain (˝ to 2 pounds a week) eases them into the changes. When emotions are too intense, they may return to restricting calories, fat, or carbohydrates. It’s all a part of the recovery process.
Severely anorexic patients may experience refeeding syndrome, a potentially catastrophic complication that occurs during the initial stages of food introduction and can cause cardiac collapse. It was first described in World War II concentration camp victims (Mehler, 1996). Ingesting too much food too quickly overwhelms the body. This is why anorexic patients need to be monitored by a physician and weight gain taken slowly. The chance of this happening to patients who do not have severe anorexia is small because they refuse to drastically increase what they’re eating; however, caution is advised. Severe anorexics may need to be hospitalized and watched closely during the refeeding process.
Bulimics and Binge-Eaters: These patients also struggle with refeeding. They’re afraid of gaining weight so they don’t want to eat foods that contain fat, “bad” carbohydrates, or what they perceive as high calories. They’re concerned that they are going to balloon up because they’re still bingeing. Bulimics rectify this by purging.
Some patients initially gain weight if they’ve been undereating more than bingeing. Some patients’ weights stabilize. They may not like this, but most admit that it’s better than never being able to predict what clothes will fit. Other patients lose weight right away because normal eating contains fewer calories than does repeated bingeing.
Adding extra food seems impossible in the beginning. Reassure the patient that what starts to happen is that she will no longer be bingeing because of hunger, and that her emotional eating will lessen as she builds up her ability to cope with internal pain.
In general, anorexics are underweight, bulimics are normal weight, and binge-eaters are overweight. Bulimics maintain a normal weight because even though they are overeating, the compensatory behaviors to rid the body of calories keep them within a normal weight range.
Patients Weighing Themselves: It is imperative that patients cease weighing themselves. Some can stop cold turkey, whereas others will have to cut back more slowly. Most people know how much they weigh by the way their clothes fit. Relying on how comfortable their clothes feel, and not on a number on the scale, reduces the obsession with weight.
These patients use the scale to measure their weight and worth. If they lose a pound, their self-esteem is artificially boosted. When they gain a pound, they feel self-hatred and loathing. Once they throw out the scale, they can work on liking themselves regardless of their weight.
They also need to get rid of benchmark clothing–the smaller clothes they try on to see how far away they are from their target size. These reminders act like a scale, pushing their buttons of inadequacy.
Shift the focus from weight loss to changing eating and exercise habits (which will produce a healthy weight). For overweight or obese patients, their weight will fall off naturally at its own pace. Bulimics may not lose weight if they’re within a normal range. They may even gain a few pounds during the refeeding process until their metabolism functions more efficiently. That’s why the spotlight is not on weight loss but balanced eating and exercise habits.
Every person has a natural weight that her/his body wants to weigh. This weight may not fit the number in the person’s head, which is chosen for superficial (vanity) reasons. Encourage your patients to let their weight adjust itself according to their new eating and exercise behaviors. Forcing their bodies to weigh less is no longer an option, so they will have to see what their bodies do without extreme interventions.
Therapist Weighing Patients: For anorexic and obese patients, either you or the dietitian will need to weigh the patient weekly, at least in the beginning. If the dietitian does the job, have her call you with the weight. As your patient’s weight changes in the appropriate direction and stabilizes, reducing weigh-ins to every other week and then once a month is appropriate.
Do blind weigh-ins so patients can’t look at the number on the scale. You can set up an agreement to let patients know if their weight has gone up or down. This offers them psychological comfort. Set up parameters so they know if they’ve increased or decreased weight and gone over the high goal of two pounds a week. Over time, they can see that what they are expected to eat is not making their weight spin out of control.
Anorexics: Most anorexics HATE being weighed, especially if they cannot know the number. Be aware that the patient may be weighing herself at other times and not telling you. Don’t hesitate to ask about this. Encourage her to stop and let you monitor her weight. After each weigh-in, discuss how distressed she is and what she fears. To address distortions, ask what she thinks she weighs. If the patient is way off, let her know that without revealing a specific number. Anorexics can be sneaky in that they will wear heavy clothing, layer clothes, or place objects in their pockets. Request that they wear something that is made of thin fabric so you can get an accurate weight.
Case Vignette: Susan, a 17-year-old high school student, entered therapy for anorexia nervosa after being in an inpatient hospital program. Susan did not want to be weighed, but reluctantly agreed when she learned it was a condition of treatment. She started therapy in the summer and wore shorts and a tee shirt. As fall approached, she wore khaki’s and a cotton shirt. Then she came to therapy in loose jeans and a baggy turtleneck. Although she struggled with keeping to her dietitian-supervised meal plan, her weight stayed within two pounds of her original entry weight. Mom reported that her daughter was eliminating a food item from each meal. So, I asked Susan what she thought. She said her weight seemed to be staying the same, so why did she need all those calories? At the next weigh-in, I asked her if she had anything under her jeans. She didn’t want to answer me. We did not leave the weigh-in area until she showed me the thick long underwear she was wearing under her jeans and turtleneck along with a cell phone and heavy set of keys stuffed in her pants pocket. Susan had lost five pounds but was masking it. Susan now has to wear the same outfit to every session cotton pants and a tee shirt.
Bulimics and Binge-Eaters: If they’re normal weight, you do not need to weigh them. You can look at someone to see if he is above or below weight. For overweight or obese patients, weighing in will help you chart weight fluctuations and eventual weight loss so you can encourage them to continue with positive changes.
Every change you’re advising your patients to make brings up fear. Even though their behaviors are potentially destructive, charting untraveled territory with food and weight (as well as emotions, maturity, responsibility, relationships, et al.) are enough to keep them stuck in what they’re doing now. Fears can seem so big that patients spend their lives running from them. The result is that they keep repeating the same behaviors over and over because it’s too scary to do something different.
The only way your patients will change is to face their fears. Most fears are unfounded, even irrational. Avoiding fear makes the intensity grow and takes up much more energy than if the patient went through, and got over, the fearful experience. The way to extinguish a fear is to have your patient do the very thing she fears and feel the resulting feelings until they dissipate.
For instance, if a patient fears that eating anything sweet will make her gain weight, encourage the patient to order dessert in a restaurant the next time a special occasion is planned. Eat one serving size of, say, chocolate cake (using the hand as measurement of moderation). The next day, the patient goes back to the regular meal plan. Have the patient pay attention to body size to see that no weight gain occurred. These kinds of experiences help to extinguish fear.
It takes courage and commitment to make changes. You want your patients to engender trust in the therapeutic process until they can trust themselves and their bodies. To recover, they have to be willing to do whatever it takes to change even when they don’t know all the steps involved. For awhile, patients enter a space of “not knowing” how it’s going to turn out. With time, they will know the outcome. As one change is made, ask your patient if the “feared thing” happened. Most likely, the answer is “No.” Reinforce this success in doing something healthy, and that he survived and even thrived.
It is very important for patients to learn to distinguish physical hunger from emotional hunger. They’ll want to feed their bodies when physically hungry and take care of their emotions when emotionally hungry. When patients eat regularly and consistently throughout the day and over the weeks, they’ll notice the difference.
Physical Hunger Signs
Emotional Hunger Signs
Food as reward/punishment
Patients have a mental list of all the forbidden foods from which they should stay away. Of course, these are usually the foods that bingers binge on and anorexics wholeheartedly refuse to eat. “Bad foods” are usually high-fat, sweet, or salty snack foods or desserts. What they do not realize is that people who eat low-fat and nonfat items don't tend to be any thinner than people who eat moderate amounts or regular-fat foods. People who eat less fat often eat the same amount of calories as other people.
Anorexics: The “bad foods” lists of anorexics are often so extensive that they’ll eat only three or four different items. With severe anorexics, dietitians often have leverage as nutritional experts and provide strategies to help these patients broaden their choices. With less extreme cases, you can introduce and reinforce the patient’s’ decision to try new foods with the added guarantee that his weight won’t shoot up (because you’re weighing him to make sure this doesn’t happen).
Bulimics and Binge-Eaters: These patients would really like to have all the foods they binge on but not gain weight. Because they’re attracted to these foods, incorporating them in moderation into meal plans is not only satisfying for the patient but brings sanity back into eating.
The drive to starve, binge, purge, or graze often seems like it comes out of nowhere. People with eating disorders are actually triggered by cues in the environment, emotional pain and insecurities, and/or repeatedly engaging in their destructive habits. When the thought of food or losing weight enters their minds, they cannot stop themselves from taking some form of action. Then one behavior snowballs into another, starving leads to bingeing, bingeing leads to starving, bingeing leads to purging, grazing leads to starving. If they can recognize what sets them off, they can then decide what to do to prevent it. Triggers include the following (Price, 1999):
Patients will need to learn to delay and eventually prevent eating disordered behaviors. The goal is to put time between the thought of starving, bingeing, purging, or grazing, and actually doing it. Have them start out slowly so that the first time they delay for 5 minutes, the next time10 minutes, then 20 minutes, and finally not engage in the behavior at all. During these time lags, patients will be working on building their internal capacity to cope. They will have to get comfortable in their physical and emotional skins, meaning that they’ll learn to accept their body’s size and shape as well as sit with feelings and tolerate them (see Healing the Emotional Self).
Every patient reverts to old eating disordered behaviors during the recovery process. Have your patients make a rule that they will try to get on track the very next meal. If they start over as soon as possible, it is less likely that the backward slide will last for days or weeks.
Anorexics: These patients have to delay and prevent themselves from starving, which means they must actively seek out food and make sure they eat. If they follow a schedule in which they eat three meals and snacks in between (even if the meal size is initially small), they will prevent starvation. They also have to delay and prevent overexercising (see Exercise Routinely).
Bulimics and Binge-Eaters: When they get the urge to binge, it is because they are either physically hungry or wanting to numb out. Explain to them that if they're hungry, eat. If they want to numb out, they will practice delaying the binge by doing something else to take care of their emotions. Physically removing themselves from, or not going to, a place where food is starts the process.
Only 20% of Americans exercise three times a week or more; 80% do it less than that. For all the information on exercise programs and equipment, we as a culture aren't exercising on a consistent basis.
Benefits of Exercise: Exercise is the number one activity that helps people maintain healthy weight. Muscle continually burns fat. More muscle mass means more calories are used during the day. The metabolic rate rises during exercise and can extend for six hours post-exercise. One pound of muscle burns 35 calories whereas one pound of fat burn 2 calories.
Exercise also increases fat-burning enzymes, oxygenates blood, lowers blood pressure, and releases endorphins and the neurochemical norepinephrine, which aids in making the exerciser more resilient when stress arises.
As written previously, restrictive dieting and starvation causes the body to lose as much muscle as it does fat. That is one reason why dieting makes dieters gain weight once they’re off the diet and back to old eating patterns. When someone loses muscle, it never comes back. Once muscle is gone, it’s gone for good.
Exercise and Weight Control: Exercise is the best tool to create and maintain a healthy, desirable weight for all the reasons mentioned above. Exercise alone can produce weight loss in people who never change their eating habits. When they do alter how they eat, the results are more dramatic.
Starting at age 40, women begin to lose 1/2 a pound of muscle per year while replacing it with fat. By the age of 80, they have only 1/3 of their total muscle mass. Unused (unexercised) muscle atrophies and the percentage of body fat increases. Regular strength training (weight lifting) can reverse the effects of aging as measured by muscle mass, body fat content, bone density, flexibility, and balance. Through cardiovascular exercise and strength training, the body can burn 15% more calories a day (Williams, 1997).
Recommendations: Moderate exercise means doing some form of cardiovascular workout (e.g., walking, running, swimming, biking, hiking, boat rowing) 3 to 7 times a week for ˝ to 1 hour a day. Strength training (e.g., weight lifting) is an important addition to these other workouts.
Encourage your patients to choose an exercise that interest them and they can see doing long-term. Sometimes an exercise buddy can help them stay committed. If they haven’t been exercising and you’re concerned about overall health, recommend that they get medical clearance first. Patients who are just starting out will have to begin slowly in order to avoid injury.
Anorexics: These patients are often overexercising, pushing themselves to do more and go for longer. It is not uncommon for anorexics to stay up late at night so no one knows they are doing stomach crunches, leg lifts, or pushups. Each night, they see if they can do more – 100, 200, 300 and up. They’ll walk for 10 miles plus visit the gym, even if they’re in pain. These extremes point to an exercise addiction.
Some anorexics cannot exercise during the initial stages of recovery where weight gain and/or reducing the addiction to exercise are the goals. You can get into a therapeutic turf war when you require anorexic patients to cut back or curtail exercise. They don’t want to give up the one way they feel in control of their bodies and weight. Your role is to be a master negotiator in which they can return to exercise IF they make progress with weight gain. You will have to monitor this by inquiring weekly about exercise routines. If they trust you, hopefully they’ll be honest with you. Parents of teens can tell you how their child is doing with reducing or eliminating exercise.
Bulimics and Binge-Eaters: These patients exercising habits can range from doing nothing at all to excessive exercise. If a patient is not exercising, encourage her or him to consider doing something. Work with overexercising patients the same way you do anorexic patients.
Cognitive therapy focuses on helping patients identify, understand, and process unpleasant affect, thereby increasing their capacity to cope and self-soothe in ways that are more functional. Behavioral therapy offers them hands-on tools to move them through their emotions.
Patients must figure out all the emotional reasons why they are starving, bingeing, purging, or grazing. Remember, at the end of the first session, you have assigned your patient to keep food charts and identify any emotions that correspond to eating or purging behaviors. This strategy opens up awareness of the link between affect and food abuse. Ongoing charting can facilitate awareness. Patients cannot change what they’re doing unless they can manage their moods in better ways. Explore with your patients why they turn to or deny food or purge:
As patients alter how they eat, many of the aforementioned reasons become even more apparent. Food is no longer a bandage that covers up emotions.
There are a number of factors that keep an eating disorder in place but are not obvious. Secondary gains are important to recognize and deal with openly in therapy. Eating disordered patients continue their behaviors in order to:
Patients ignore their rich emotional life, forgetting that their emotions are what make them human and humane. They disown their emotional selves because it’s just too unpleasant to feel. They experience few joyful moments and would rather be without affect, functioning as a robot with only mental processes.
Patients who believe they are unlovable, ugly, imperfect, stupid, weak, or a “mess” are highly self-critical. Few things are as chronically painful as “knowing” they are hopelessly flawed. Every “failure” or misstep rekindles internal suffering, so they resort to changing that over which they have full control – their bodies – in order to feel better on the inside. Experiencing trauma can lead to these kinds of feelings along with depression and anxiety.
Dieting seems like the answer to improve their external presentation and garner praise. Either it works too well and anorexia emerges or bingeing takes place to make up for lost calories. Purging is the response to overeating. And voila, a destructive cycle has begun. These behaviors now become a coping mechanism to deal with the stresses and strains of everyday life. Alcohol, drugs, sex, and gambling can serve the same purpose, and often do when food abuse does not take the edge off of the emotions.
Strategies to Cope With Emotions: The only way patients are going to stop using food to cope is to learn to tolerate feelings and do something constructive (not destructive) with them. These strategies include:
When your patients become more consciously aware of what they’re doing and why, then they can make different choices. Consciousness gives them many more possibilities.
The ultimate goal is for the patient to sit through her feelings from beginning to end without turning to the old destructive behaviors. As she abuses food less, she’ll feel more. Ask her to explore a situation that occurred outside of session in which emotions led to, for example, bingeing. Have the patient practice in session to feel those feelings from start to finish with as much intensity as possible. This will show her that she has the internal fortitude to put up with these feelings.
Case Vignette: Kerry, a 57-year-old nurse, came to therapy for uncontrolled eating which led her to gain 35 pounds in two years. She never binged on large amounts of food, yet she never really stopped eating. She had struggled with generalized anxiety for most of her life and now felt depressed about the weight increase. Kerry didn’t know why she ate constantly though, when questioned, she said eating put her into an emotional fog. The anxiety finally became manageable. At work, she kept candy or pretzels in her pocket, munching as she charted patients’ progress. Her hands and feet bloated, and her stomach often ached. Kerry could not remember the last time she ate a meal – perhaps with her kids when they were growing up. Kerry agreed to try to follow a meal plan with designated meal times. She started with dinner because she could eat with her husband. In the evenings, when she didn’t pick at food, she felt anxious. We discussed the option of her seeing a psychiatrist for a medication consultation. She wanted to see if she could deal with the anxiety on her own. If she couldn’t, then she’d consider medication. Kerry explored why she got so anxious whenever she had time between meals. She revealed that she felt guilty if she wasn’t busy and productive all the time. She had to do more and be better or her anxiety level shot up. Her parents’ credo was that Kerry needed to always be improving herself. Sitting around or having fun was not an option. So, if she wasn’t making herself better or accomplishing something, she felt anxious. Kerry’s goal in therapy was to pick a pleasurable activity in the evenings, like reading a book or watching a movie. She had to sit with the anxiety of not being productive and not eat over it. She hated feeling the anxiety, but did the exercise anyway. With practice, she was able to permit the feelings to flow through her and not seek out a snack. She understands intellectually how ridiculous it is to think she should be productive all the time, yet realized it will take time to let go of her parents’ (and now her own) distorted belief.
Improve Body Image and Self-Acceptance: Patients will be working to make peace with their bodies and overall appearance. Part of what fuels starving and purging is intolerance with weight, size, and shape. Patients may also wish to undertake plastic surgery to alter their faces, breasts, or remove cellulite. Before they seriously consider going under the knife, they will need to address why they cannot appreciate themselves the way they are. Steps to improve body acceptance include:
Over time and with concerted effort, patients can see a marked improvement in how they perceive themselves. They will discover that they don’t have to change their weight, only their perspective, to feel better about their bodies. Some body image issues may endure, taking time to overcome. Patients will also have to accept that they won’t always feel good about how they look. They will be sensitive to cultural pressures to be a different size or shape than what they are.
Interpersonal and psychodynamic therapeutic strategies are helpful when working with the underlying factors that produced an eating disorder. The focus becomes the relationship with the self as well as with other people.
Beliefs are the underpinnings of the sense-of-self. They are formed in childhood and adolescence, and reinforced through life experiences. The more traumatizing an experience, the more likely that strong negative beliefs will develop. Once a belief is solidified, incoming information is skewed to fit the belief, affecting how a person feels, thinks and ultimately, which decisions are made. In this way, beliefs create reality.
Happiness and peace of mind are intimately related to beliefs. When people hold positive beliefs about themselves, they're going to feel good about who they are. Conversely, if they possess negative beliefs, they're much more likely to put themselves down, experiencing depressed moods and anxious moments.
Beliefs and Attitudes --> Feelings and Thoughts --> Decisions and Choices
Beliefs directly affect the attitudes, feelings, thoughts, decisions, and choices people make (Lazaris, 1986). A chain reaction occurs, creating the same process and outcome again and again.
A number of internal parts play a role in the development and reinforcement of a negative belief system. The critic, child, and adolescent actively participate in the maintenance of beliefs. The healer is the counterbalance, prompting the person to see herself in a different light.
The Critic: This part strengthens negative beliefs and makes sure the belief system is followed. The critic is merely being loyal to beliefs that parents and significant others handed down. The critic is not smart, but it is powerful (as long as it’s given power) because it does just one job. If you only did one thing all day long, you'd be an expert, too!
Negative beliefs are formed in an atmosphere of shame. Shame is passed on from one person to another. When people have their own unresolved issues, they often shame someone else in much the way they were shamed.
Appropriate amounts of shame help children learn right from wrong. When there's too much shame, children begin to feel bad about who they are – flawed to the core. As an adult, they reject the undesirable aspects of themselves and strive to be perfect in hope of finally liking themselves. Critical thoughts become automatic and are taken as fact. Each harsh thought strengthens the negative belief system.
Starving, bingeing, purging, and grazing are used to stop internal pain, but their effects don’t last long. So these behaviors have to be repeated over and over again. Distress due to engaging in these behaviors becomes a secondary layer of pain. Most patients will say that they would rather feel the disgust from bingeing or purging than the deep-seated sense of being worthless, unlovable, unimportant, unintelligent, unattractive, etc.
The Child: Childhood is full of pleasurable and painful experiences. People cannot make it throughout childhood without being wounded. It's a natural part of growing up. All wounding experiences seem to have similar themes. Through mean judgments, adults or other significant persons point to a child’s inadequacies. The child clearly feels the adult's disappointment.
Some wounds are bigger than others are. For most people, one or two wounds stand out as the most definitive. These wounds include divorce, teasing, death of family member, pressures to be perfect, parental anger for not measuring up, neglect, emotional or physical abandonment; and emotional, physical, or sexual abuse.
The Adolescent: Adolescence is filled with change, confusion, and excitement. Everyone goes through a period of time when he feels invincible. Then something happens to take that feeling away. Another layer of wounding leaves the young person feeling insecure, hesitant, guarded, mistrustful, depressed, anxious, or hurt. Adolescent woundings give the critic more power and strength because earlier beliefs are confirmed.
During adolescence, teens decide what’s acceptable and unacceptable about themselves. Their perceived flaws are definitely distasteful. To fit in, feel special, and be noticed by others, teens often decide to change their bodies. Girls have gone through physiological changes due to hormones and may not like the results. They hope that by losing weight, they’ll win admiration and thus build self-esteem and worth. This is when perfectionism rears its head and demands that they strive to reach it (in one or many areas). That's why it's not unusual to see eating disorders arise in adolescence.
The Healer: Everyone has a healer within who believes she is fine just the way she is. The healer doesn't expect perfection. Instead, the healer continually pushes for the development of self-acceptance and self-love.
Sometimes the critic can be so loud that the gentle voice of the healer can’t be heard. It’s the thought that says, “Stop engaging in this unhealthy behavior,” or “Go easy on yourself.” When the volume of the critic is turned down, the healer’s message can be heard. These patients have very little self-compassion, so you’ll have to encourage them to make a conscious effort to say compassionate statements to themselves whenever they don’t measure up in their own heads.
Anorexics: Separation and individuation scares many anorexics. They keep their body weight low to look and feel preadolescent. In part, their un- or subconscious desire to be taken care of fuels starvation. As children, they were given either too much responsibility or not enough. Some were coddled or emotionally abandoned. Once they saw their parent(s) struggle to meet obligations, they shied away from this as they matured. Fears about making decisions, navigating intimate and sexual relationships, or earning a living all seem insurmountable. So they retreat to an earlier age. And, of course, the eating disorder sets up a situation in which they have to be taken care of by their parents and outside professionals.
Bulimics and Binge-Eaters: They may also have some maturity fears, similar although not as extensive as the ones listed above for anorexics.
Treatment focuses on nudging patients toward making decisions and being responsible for their actions. Track their resistance to taking charge of situations. Encourage them to deal with feelings prior to and after making a decision. Both of you can survey the outcome of choices so the patient can gauge success and start to see that she has what it takes to live in the adult world.
At some point in therapy, patients will explore their history. Identifying events, circumstance, and the people who instigated the wounding experiences are necessary pieces of the recovery process. Once they have figured out how their beliefs developed, they are going to have to go through all the pain they’ve been avoiding.
Permanently changing negative beliefs entails that patients be willing to tolerate negative feelings such as worthlessness, unlovableness, and unimportance every time these emotions are stirred up. They must consciously decide to let these beliefs go. Freedom from pain is a powerful motivator.
Tapping into the deep hurt and/or trauma that led to a sense of not being good enough will take time. Trauma associated with emotional, physical, or sexual abuse makes few patients want to jump in and tackle their feelings. Some cannot even find them, though they can talk about them intellectually. As you guide patients deeper into this territory, be aware that eating disordered behaviors may worsen depending on how many new coping skills they have developed. They need to talk and feel in order to heal.
Patients who are emotionally fragile or have a personality disorder may not fare well when exploring these deep pains. Decide if your patient has the capacity to do this kind of work.
Relapse offers a prime opportunity to link past events with present emotions and current behaviors. As patients become more adept at tolerating and releasing intensely painful emotions, they won’t have to resort to their old eating disordered behaviors. At times, your patience will be sorely tested. Your hang-in-there reassurance will foster a growing sense of security and trust in you, the therapeutic process, and ultimately themselves.
Case Vignette: Lila, a 29-year-old hotel manager, entered therapy for bulimia nervosa. She alternated between rarely eating, running 15 miles a day, and losing control by bingeing on a dozen maple bars from her neighborhood donut shop. After bingeing, she ran until her lower back ached. She was stuck in a cycle that seemed impossible to break. Lila hated her body and herself whenever she put on weight. When asked where she thought her weight obsession came from, she said her mom dieted constantly. She talked non-stop about needing to lose weight. Mom also commented on Lila’s weight, fussing over Lila’s meals and refusing to buy the treats that her friends had in their kitchen pantries. Over time, Lila vowed to achieve the perfect body thus erasing nagging self-doubts about her appearance. Within a few sessions, Lila admitted she wanted to cut back on exercise because she feared her injuries would become permanent. After a full physical, her doctor backed up this decision. We calculated that each binge contained about 8,000 calories. So if she spread out those calories in a healthier form over a four-day period, she could eat 2,000 calories a day without gaining weight. She did not believe it until her dietitian came up with a plan to allow her to run moderately, eat real food, and not gain weight. Lila was reluctant yet willing to try. But she didn’t want to stay the same weight; she wanted to lose weight. After weeks of trial and error, she ate more normally and binged less frequently. She agreed to put weight loss on a back burner and explore where she developed body hate. She noticed she felt bad about herself every day, wanting to starve or go out for a long run. But she liked how her body functioned when she ate meals. Once Lila understood the dynamics that set up her beliefs and the internal talk that reinforced it, she focused on identifying the “not good enough” feelings every time they surfaced, telling herself she feels this way and not is this way. She even had the fleeting thought that maybe her body was okay the way it is.
Patients try to be perfect because they don't like what they see and/or who they are. They’re either comparing themselves to an ideal person who doesn’t exist or to people whom they perceive as being better in some way. If someone else is superior, that leaves your patient in an inferior position. Because perfection does not exist, chronic low-self esteem rears its head every time your patient makes a mistake, says the wrong thing, or catches an unflattering glimpse of her body in the mirror.
Patients can reduce perfectionism by exploring why they are driven to change themselves. They’ll need to ask themselves three questions:
The critic within reminds your patients of how flawed they are. Patients can learn to talk back to the critic. Realistic self-talk does not include flattery or false statements; otherwise, the statements will be disregarded. Affirmations that are untrue have no effect for this very reason. The five components of healthy self-talk are (Price, 1999):
The critic is likely to get louder the more it’s challenged. It's trying to get your patient to change back (much like co-dependent partners of alcoholics unconsciously try to do the same thing). So he needs to hang in there and persist. Eventually the critical voice will become softer as the healthier voice becomes stronger. Combining this strategy with addressing the core reasons for holding core negative beliefs reduce perfectionism.
In order to be accepted by others and avoid conflict, eating disordered patients wear a mask and act like a chameleon, changing their actions to suit a situation. In addition, they engage in people-pleasing behaviors. They don’t trust that by being themselves, people will want to be with them. They can get so caught up in the masquerade that they lose contact with a sense of themselves.
Patients will need to figure out how to be true to themselves. They are keenly aware that they risk disapproval from others who may not agree with their choices. Over time, patients can build trust in their ability to make good decisions and learn to live with the fact that sometimes they’ll make poor ones.
Negative beliefs distort thinking. Patients will say things like, “If I don’t lose weight, I’ll die of humiliation,” I can’t go out on a date looking like this,” “Everyone is talking behind my back about my weight,” and “I hate myself for getting an A-; that grade is going to ruin my chances of getting into graduate school.” Provided below are some common distortions in thinking (Price, 1999).
Black and white thinking means that patients see events as falling into one of two extreme categories: all/none, everything/nothing, good/bad. This leaves little room for gray areas, which is really where most of life operates. Diets exemplify black and white thinking – good and bad foods, losing weight is good and gaining is bad, lose all the weight expected or the person’s a failure.
Shoulds come from unbending rules patients create on how they and other people need to act. The “shoulds” list is a remedy for flaws that patients think need fixing. However, once they accomplish a “should,” they just add another one to the list so they’re never done.
Filtering is a process by which patients reject incoming information that does not fit their negative belief system. So when they receive compliments, they take them as false flattery. However, when negative feedback is offered, they take it as factual.
Personalizing takes place when patients assume everything people say is directed at them and usually it’s a criticism. This makes your patients defensive, angry, and either withdrawn or attacking.
Self-Blame is one way patients take responsibility for everything bad that goes on around them, even when it’s not their fault.
Catastrophizing is when patients expect the worst. Viewing the world as an unforgiving place feeds this. They want some predictability, so they expect the worst. When it doesn’t happen, they feel relief.
Being in control means that patients either feel that they can control everything in their environment (overcontrol), including other people, or they have no control at all (undercontrol). Of the two, undercontrol is the most harmful because it leads to feelings of helplessness, hopelessness, depression, and/or anxiety. The truth usually lies somewhere in between.
When patients identify their distortions, they can begin to catch themselves playing these mind games. Patients often disregard other relevant information that would bring a balanced view to the situation. Once they see the bigger picture, they’ll lessen the role of cognitive distortions.
By being nonassertive, patients hope that they won’t make waves or upset people. This style of communication has an element of people-pleasing to it. However, resentment builds because your patients’ needs aren't being met, yet they’re not asking to have them met. Patients often assume that people should mind read and anticipate their needs. After all, that’s what they do. If they become frustrated enough, they can become either passive/aggressive or all-out aggressive.
Being either nonassertive or aggressive are dysfunctional ways of dealing with others. Patients can benefit from building a repertoire of communication skills to resolve conflicts, make requests, express emotions, and connect with others. In session, situations can be discussed and new alternatives role-modeled.
Anticipation is a mind set in which patients live in the future, not in the present moment. It's the “when I...then I...” frame of thinking. A common one for these patients is, “When I get thin, then I'll be happy.”
Thinking about unresolved issues from the past often produces depression. Worrying about the future stirs fear and anxiety. Making peace with past events opens the door to concentrating on the “now.” Patients also have to work on building trust: in themselves and the universe. Trust and fear are opposites. If someone is trusting that things will work out somehow, there is little fear. Worrying is really about fearing something important will be lost (e.g., love, job, esteem).
Living in the moment is so valuable. Whether the moment brings pleasure or pain, it’s what makes people feel alive. So many patients get stuck in feeling only the pain without moving through and beyond it so they can feel the joy. They do have a choice as to what they give importance – all the aspects of life that they perceive are wrong or the ones that are right.
The past is gone and the future isn't here yet. The only reason patients will want to go back to the past is to heal the wounds so they can live more fully in the present. The most pleasure in life comes from being in the moment – whatever it brings. It's what is.
There are other strategies you can offer your patients to help them recover from their eating disorders and concomitant emotional issues. These include:
Use the techniques that you have found helpful in your practice. What works with other patients can also help these individuals.
Many people search for the meaning, purpose, and reasons why they are here on this planet. They also want to explain why they suffer. Defining their spirituality, whether it is religious or nondenominational, can bring them comfort and reassurance in times of confusion and strife.
So many patients with eating disorders describe feeling empty inside. Part of what is missing is a strong positive sense-of-self. What may also be lacking is a spiritual connection to something outside themselves. Seeking a spirituality that honors their spirit and tends to their soul places their struggles in a larger context.
Tending to the soul means respecting the entire self: body, emotions, and mind. When patients decide that they hate parts of themselves, they wind up feeling disconnected from who they are.
The mind, body, and emotions are all interrelated. Thoughts produce emotions and emotions are felt in the body. The spiritual self communicates through emotions. When people turn inward and listen to the whispers of their souls, then follow the guidance offered, they experience an alignment with the purpose of why they are here. Often their decisions based on these rumblings turn out to be pretty good ones. People describe feeling more peaceful. Helping patients accept the duality of their personality – the dark side (flaws) and light side (strengths) – allows them to see their complete selves.
People may need to find a vehicle in which to hear the whispers of the soul such as attending church, praying, meditating, hiking in nature, gardening, watching a sunset, etc. Being contemplative gives them an opportunity to check in with how they’re doing now instead spending the bulk of their mental and emotional energy plotting and planning what they’re going to do in the next hour, week, month, or year.
Patients will let you know when they are grappling with these issues. You can guide them in their explorations without prescribing what they should believe. As they define what makes sense to them and then live in accordance with those principles, they will feel much more centered. Their drive to engage in eating disordered behaviors can shrink and their importance recedes.
Final Thoughts: Thank you for taking this course. I hope you found it helpful and useful. If you would like to know more about how to treat severe eating disorders or obesity, consider taking the courses, Dying to Eat: The Treatment of Severe Eating Disorders and Weight Matters: The Etiology and Treatment of Obesity.
American Anorexia/Bulimia Association of
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Anorexia Nervosa and Related Eating
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National Association of Anorexia Nervosa and
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National Eating Disorders Association (NEDA)
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