LEARNING OBJECTIVES

This is an advanced level course. After completing this course, mental health professionals will be able to:

• Determine the level of severity of anorexia nervosa and bulimia nervosa
• List common medical conditions which compromise patients' health and influence treatment decisions
• Conduct a clinical assessment for collateral or comorbid problems such as severe mood disorders, personality disorders, PTSD, and self-mutilation
• Establish the course of treatment, create realistic goals, and chart patients’ progress for complicated cases of anorexia and bulimia

INTRODUCTION

Welcome to Dying to Eat: The Treatment of Severe Eating Disorders. This advanced three-hour course will help you gain a working knowledge of the complexities of hard-to-treat eating disorders so you can provide better psychological care. The course focuses primarily on the various medical, psychiatric, and collateral problems that complicate the recovery process along with the best psychotherapeutic and psychopharmacologic strategies to help these patients. Case studies will highlight four different areas that make an eating disorder more acute or full recovery difficult, and what can be reasonably expected from treatment.

Prerequisite: The Feast or Famine: The Etiology and Treatment of Eating Disorders course which includes etiology, diagnostic criteria, comprehensive treatment planning, assessment, and the holistic treatment approach. It is highly recommended that you complete the introductory course first, although with appropriate experience and knowledge of the topic you may jump directly to this advanced course. You can review Feast or Famine: The Etiology and Treatment of Eating Disorders at any time if you have questions about the general treatment of eating disorders.

CHAPTER I: DEFINITIONS OF SEVERITY

Eating disorders range from mild to severe. For some individuals, it takes years for their eating disorders to become acute. For others, they fall quickly into extreme behaviors. Frequency, intensity, and chronicity are the factors that define severity. The lists below offers examples of the ways in which eating disorders become serious and potentially life threatening.

1. ANOREXIA NERVOSA

Anorexia is considered severe when a person:

• Eats less food as time goes on, sometimes consuming as few as 200 calories a day
• Spends multiple hours a day exercising (e.g., running hard for over an hour, taking 10-mile walks, going to the gym twice a day, exercising in the middle of the night to tone separate body parts)
• Drops weight well below the 15% mark, sometimes to 30% below what is considered normal
• Frequently vomits or uses large amounts of laxatives, diuretics, enemas, or Syrup of Ipecac even though little food is ingested
• Refuses to gain weight even when health is compromised
• Lets work, school, and/or relationships suffer
• Has to be hospitalized for medical and psychiatric conditions associated with anorexia nervosa, mood disorders, and/or personality disorder(s)
• Does not reduce anorexic behavior in spite of previous outpatient treatment or hospitalization

2. BULIMIA NERVOSA

Bulimia is considered severe when a person:

• Binges and purges anywhere from two to 20 times a day
• Binges on large amounts of food, up to 20,000 calories in one sitting
• Tries multiple times to purge every calorie from one binge episode
• Take increasingly large amounts of laxatives, diuretics, Syrup of Ipecac, diet pills, legal or illegal drugs—even though these substances make the person ill
• Refuses to stop purging even when health is jeopardized
• Lets work, school, and/or relationships suffer
• Has to be hospitalized for medical or psychiatric conditions associated with bulimia nervosa, mood disorders, and/or personality disorder(s)
• Does not reduce bulimic behaviors in spite of previous outpatient treatment or hospitalization

CHAPTER II: COMORBIDITY ASSESSMENT

During the initial clinical intake, you will assess the spectrum of issues related to the eating disorder (as described in the Feast or Famine: The Etiology and Treatment of Eating Disorders course). In addition, you will also need to determine if there are singular or multiple collateral problems.

1. ASSESSMENT OF COMORBIDITY

Initial Interview Questions: These are the questions you will want to cover in the first couple of sessions, along with the questions related to the eating disorder. What the patient tells you will direct you to an area on which to focus. You won’t have to ask all these questions, only the ones relevant to the areas of concern that emerge through your interactions with the patient.

1. Medical Conditions:
1. How is your overall health?
2. Have you had a recent physical?
3. What did your doctor tell you?
4. Are you experiencing any problems you think are related to your eating disordered behaviors?
5. Do you get a racing heart, chest tightness or arm pain (heart damage or electrolyte imbalance)?
6. Do you have diarrhea, constipation, cramping, or abdominal distress?
7. Do you get dizzy or have you passed out (low blood pressure or low blood sugar levels)?
8. Are you fatigued?
9. How is your concentration level?
10. Can you focus on work or school?
11. Do you have blisters in your mouth or eroding tooth enamel?
12. Do you feel bloated (cells holding onto water after purging)?
13. Are you cold all the time (low amount of body fat)?
14. Have you been losing hair (low protein intake)?
15. When was your last menstrual cycle?
16. Do you menstruate regularly?
2. Depressive Disorders:
1. Have you been previously diagnosed with a mood disorder?
2. Are you currently depressed?
3. How depressed, on a scale of 1-10?
4. Discuss severity of depression and how it’s affecting the patient’s life.
5. Notice expression of affect (tearful, flat affect, anger, etc.).
6. Watch for grandiosity, pressured speech, racing thoughts, flight of ideas, psychomotor agitation, or distractibility (i.e., signs of mania).
7. Do you still find activities interesting?
8. How well do you sleep at night?
9. How is your energy level?
10. What is your social life like?
11. Do you feel hopeless or helpless?
12. Is your depression affecting work, school, or your relationships?
13. Does depression run in your family?
14. Do you feel bad about or critical of yourself (e.g., negative beliefs of worthlessness, unlovability, unattractiveness, unintelligent)?
15. Are there any events that have led you to feel depressed?
16. Are you having thoughts of harming yourself now (if depression is rated high)?
17. Have you had thoughts of harming yourself in the past?
18. When you tried to hurt yourself (commit suicide), when and how did you carry it out?
19. How do you feel now about having tried to commit suicide?
20. Are you aware of using food, restricting, or purging to feel less depressed?
21. Do bingeing and/or purging make you feel more depressed, distressed, or disgusted with yourself?
22. If you could change one thing in your life, what would that be?
3. Anxiety Disorders:
1. Are you anxious?
2. How anxious, on a scale of 1-10?
3. Is there a family history of anxiety?
4. Discuss severity of anxiety and how it’s affecting the patient’s life.
5. Are you having obsessive thoughts about food, weight, or body shape?
6. Are you compulsively using food, restricting, or purging to stop the obsessive thoughts?
7. Are you having obsessive thoughts about other things?
8. Do you have compulsive behaviors in areas other than food?
9. Are you restless?
10. Do you get tired easily?
11. Are you having difficulty concentrating at work or school?
12. Do you become irritable more often than usual?
13. Is your chest or body tense?
14. Does it make you panicky to think about being in a social situation?
15. Have you ever had a panic attack?
16. What are your panic symptoms (e.g., racing heart, sweating, trembling or shaking, shortness of breath or smothering sensation, choking, chest pain or discomfort, nausea or abdominal distress, feeling dizzy or faint, derealization, fear of losing control or going crazy, fear of dying, numbing or tingling, and/or chills or hot flushes)?
17. Have you ever been in a situation in which your got anxious because you felt you couldn’t escape?
18. Do you avoid situations that make you anxious?
19. Have you ever gone through something traumatic?
20. Have you ever been emotionally, physically, or sexually abused? (Ask if the patient offers information or you suspect there might have been abuse, and feel it will not breach any trust that is beginning to develop. Otherwise, you may want to save the topic for later.)
1. What happened?
2. With whom did it happen?
3. When and where did it take place?
4. How frequently did it occur?
5. Is the perpetrator currently in your life (assess whether you need to make a report to child protective services)?
6. How is it affecting you now?
7. Are you having distressing memories or dreams?
8. Do events trigger responses similar to how you felt during or after the trauma?
9. Do you try to avoid thoughts, feelings, or conversations associated with the trauma?
10. Do you try to avoid activities, people, or places that remind you of the trauma?
11. Do you feel detached from others?
12. Do you feel emotionally shut down?
13. Are you worried that you won’t live very long?
14. Are you aware of being hypervigilant?
15. Do you startle easily and is that upsetting to you?
16. Are you having ongoing health problems?
17. Are you feeling shame, despair, or permanently damaged?
4. Attention Deficit Hyperactivity Disorder:
1. Do you have difficulty focusing on details, organizing, sustaining attention, or following through on tasks?
2. Do you lose things or become forgetful?
3. Notice if the patient is fidgety, squirming, restless, blurts out answers, or interrupts.
4. Do you feel like you’re not living up to your own standards?
5. Do you feel bad about yourself because of it?
6. Are you easily frustrated or impatient?
7. Do you get easily bored or distracted?
8. Do you get into conflicts with superiors or authority figures?
9. Are you using drugs, alcohol, or other medications to slow you down and help you focus?
10. Is there a family history of ADHD/ADD, bipolar disorder, depression, or substance abuse?
5. Personality Disorders:
1. Avoidant Personality Disorder:
1. What was it like growing up in your family?
2. Tell me about your current relationships.
3. Do you find it hard to interact with others?
4. Are you afraid of being criticized, disapproved of, or rejected?
5. Do you see yourself as having limited social skills?
6. Do you avoid situations in which you think you might become embarrassed?
2. Borderline Personality Disorder:
1. What was it like growing up in your family?
2. Tell me about your current relationships.
3. What is the biggest problem that comes up in relationships?
4. How do you handle it?
5. Are you afraid that people you care about will leave or abandon you?
6. How is work or school?
7. Do you have angry outbursts and don’t know why you react so strongly?
8. Do you at times feel like your going to have an emotional meltdown?
9. How does it make you feel about yourself?
10. Are you depressed or anxious?
11. What leads you to feel depressed or anxious?
12. Listen for statements pointing to impulsivity with binge eating, sex, spending, substance abuse, suicidal behavior, self-mutilation, or reckless driving.
13. When, where, and how often do you engage in the behavior (from the list above)?
14. Have you ever felt suicidal or though about harming yourself?
15. Do you ever punish yourself when you think you’re bad or not good enough?
16. Do you use food, restrict, or purge to stop the intensity of emotions?
17. How do you feel about your body?
18. Do you want to lose weight?
19. How do you go about it?
20. Are you trying to lose weight to feel better about yourself?
3. Dependent Personality Disorder:
1. What was it like growing up in your family?
2. What are your current relationships like?
3. What is your biggest concern in your relationship(s)?
4. Are you afraid of being abandoned or left?
5. How easy it for you to make decisions?
6. Do you find that you rely on others to make decisions for you?
7. What is it like to be alone?
8. Can you be okay without being in a relationship?
9. Are you depressed or anxious when not in a relationship?
10. How do you feel about yourself?
11. Do you use food to comfort yourself?
12. Do you purge to prevent weight gain?
13. Do you restrict in order to create an attractive appearance for your partner?
4. Histrionic Personality Disorder:
1. What was it like growing up in your family?
2. Tell me about your relationships.
3. What are your current relationships like?
4. What bothers you most about other people?
5. Is it hard for you when you’re not getting attention from others?
6. Do you have to dress or act in a certain way to be noticed?
7. Observe if your patient wears seductive clothes, has seductive mannerisms, is dramatic or theatrical, or exaggerates emotions.
8. Do you use food to numb out or comfort yourself?
9. Do you purge to prevent weight gain?
10. How do you feel about your body?
11. Do you starve or restrict to lose weight?
12. How would you feel if you gained weight?
5. Obsessive-Compulsive Personality Disorder:
1. What was it like growing up in your family?
2. What are your current relationships like?
3. How is work or school?
4. What is your biggest struggle?
5. Do you perceive yourself as perfectionistic?
6. Is control important to you?
7. What happens when things don’t go the way you think they should?
8. Do you use food to comfort or distract yourself?
9. Do you purge to prevent weight gain?
10. How do you feel about your body?
11. Do you starve or restrict to lose weight?
12. Pay attention to comments about your fees and how expensive it is to be in therapy.
6. Self-Destructive Behaviors:
1. Self-Injuring Behavior:
1. Ask these questions if you see signs such as scarring or bruises, or the patient implies or outright tells you about self-mutilation.
2. How do you feel about yourself (e.g., negative beliefs of unworthiness, unlovability, unimportant, unintelligent)?
3. How do you handle disappointment?
4. Have you ever cut, burned, scratched, or stabbed yourself?
5. What kinds of situations make you turn to this behavior?
6. How do you feel before, during, and after?
7. When did you start this behavior?
8. Do you think you can stop the behavior?
9. What has happened when you’ve tried to stop in the past?
10. Do any of your eating disordered behaviors feel like self-mutilating (vomiting multiple times after a single binge, running for hours until exhausted, etc.)?
11. Are you aware of trying to stop internal pain by shifting it to external, physical pain?
2. Substance-Related Disorders:
1. Are you drinking alcohol?
2. Which kind? How often? When and where?
3. Are you using drugs?
4. Which ones? How often? When and where?
5. Can you stop now and never use the substance again?
6. Why do you use the substance?
7. Have you built up a tolerance where you need more to get the same effect?
8. Do you experience withdrawal symptoms when you stop?
9. Is your use affecting relationships, work, or school?
10. What problems are being created by your use?
11. Do you engage in risky behavior while using (e.g., saying something you would normally not say, driving under the influence, having unprotected sex)?
12. Are you using drugs or alcohol to help you avoid eating?
13. Do you use the substance to reduce depression or anxiety?
14. How do you feel when not using?
15. Is your health affected by your use?
16. What is your previous substance abuse treatment?
17. When and where? Was it helpful?
18. Are you currently in treatment for substance abuse? Is it helping?
19. Would you be willing to go into treatment for substance abuse?
3. Shoplifting and Compulsive Shopping:
1. If your patient broaches the subject or hints at engaging in either behavior, ask about it.
2. Why do you think you shoplift or compulsively shop?
3. How often?
4. Have you ever been caught or arrested for shoplifting?
5. Do you think you can stop at any time?
6. Has compulsive shopping affected your financial situation?
7. Have you told anyone about your behaviors?
8. How have your behaviors impacted relationships?
9. Would you be willing to attend Debtors Anonymous meetings (for compulsive shoppers)?
10. Do these behaviors serve as a substitute for starving, bingeing, purging, or grazing when these don’t stop unwanted feelings?
4. Promiscuity and/or Unprotected Sex:
1. Tell me about your relationships.
2. Are you intimately involved with one person or many?
3. Do you have protected sex?
4. Have you caught an STD?
5. Have you been tested?
6. Why do you think you are sleeping with many people or are having unprotected sex?
7. Are you worried about the consequences?

2. TREATMENT CONSIDERATIONS

When a person enters therapy, an eating disorder is rarely the only problem. As you’re assessing type and severity, keep in mind additional concerns presented to you. You’ll want to gain an understanding of the patient’s range of issues. Most individuals have some form of mood disorder. In addition, physical complications, personality structure, and other kinds of impulsive behaviors complicate treatment, yet need to be addressed. The eating disorder is the surface coping mechanism for all underlying mood and personality disturbances. The eating disorder cannot effectively be treated without treating the rest. Prognosis is guarded when more areas are affected. A full recovery from the eating disorder may not be possible. Reducing symptomatology in each area may be the best possible outcome. Therapy is often long-term, demanding, and time consuming.

Below is a flow chart for treating complicated cases from the beginning of therapy onward.

• Identify the range of eating disordered behaviors, mood disorders, level of ego functioning, personality traits or disorder(s), health problems, underlying belief system, internal dialogue, defense mechanisms, other coping strategies, and support system.
• Assess whether this patient can be treated on an outpatient basis.
• Determine if patient needs medication(s).
• Make referrals to appropriate allied health professionals.
• Look at ego organization (neurotic versus borderline) to gauge how quickly you can zero in on issues and move towards making changes versus providing mainly basic mirroring and empathic understanding.
• Find a way to connect, build trust, and form a therapeutic alliance.
• Use behavioral strategies to reduce eating disordered behaviors.
• In every session, ask about starving, bingeing, purging, grazing, exercise, examples of a typical day of eating, and what techniques did and didn’t work to decrease eating disordered behaviors.
• Offer other coping strategies.
• Identify the relationship between negative beliefs, cognitive distortions, critical internal dialogue, and painful affect.
• Utilize cognitive strategies to alter self-statements.
• Pinpoint thoughts or situations that produce depression and/or anxiety.
• Use time in session for patient to talk about and experience affect, and to increase healthy expression and release of emotions.
• Explore personal history.
• Discuss relationships and how expectations, communication skills, and emotional responses affect significant others.
• Talk about how the eating disorder influences work or school.
• Decide at any point when patient needs substance abuse treatment or inpatient hospitalization.
• Have clear boundaries regarding when and how the patient contacts you, cancels sessions, pays fees, etc.
• Discern transference and countertransference along with the ways you’re going to deal with what arises.
• Give assignments at the end of each session to promote change.

At the beginning of every session, you’ll get an idea of on what you’ll be focusing. Because you are aware of comorbidity, be open and flexible so you can work on whatever the patient brings you. At times, when symptoms are distressing and/or out of control, you will focus mainly on the eating disorder . At other times, you will discuss intrapsychic issues or relationship problems. With broad training and experience, you will have the ability to offer guidance, support, and practical tools no matter what is presented. If you’re unsure, consult a colleague or expert.

CHAPTER III: MEDICAL CONDITIONS

Severe medical conditions arise when individuals with eating disorders ignore how their behaviors affect their health. It takes time for the body to be affected, but once it is, the damage can be irreparable. More extreme behaviors cause more damage. For some, illness or injury is not enough to convince them to stop. They’re trapped in a cycle that seems impossible to break. Before you treat someone as an outpatient, make sure the person’s health is stable.

A. COMMON MEDICAL PROBLEMS

Most individuals with eating disorders have mild to serious medical conditions directly related to their behaviors. These lists give you the most common physical complaints mentioned to me by my patients. For a complete patient self-report checklist, refer to The Body Factor in Healing the Hungry Self: The Diet-Free Solution to Lifelong Weight Management (Price, 1999).

B. HOSPITALIZATION

A number of your patients are going to need to be referred to an inpatient or residential program for psychiatric and/or medical care. Some eating disorders treatment facilities are not equipped to handle serious medical problems. In this case, patients will have to be admitted to a hospital to stabilize their health before being placed in an eating disorders treatment program or released for outpatient therapy. Grounds for hospitalization include:

• The disorder is too serious to be treated outpatient
• The patient’s symptoms seriously worsen during therapy and stay that way for over a month
• The patient’s symptoms show no sign of improvement over a three- to four-month period, and you believe a program is the only hope
• The patient’s health is medically compromised
• Debilitating depressive disorder, anxiety disorder, substance abuse, or other self-injurious behavior where patient risks suicide or cannot function

1. SPECIFIC TO ANOREXIA NERVOSA

• Anorexic symptoms (dangerously compromised weight, excessive exercise addiction, extreme calorie restriction, etc.) are so severe and entrenched that outpatient treatment will have no impact
• The patient’s weight is 25%-30% below healthy body weight at the start of treatment and little weight gain will be achieved in outpatient treatment (American Psychiatric Association, 2000)
• Joyce Adams, M.D. (1999) lists five additional indications for inpatient medical treatment:
• Acute refusal to eat
• Bradycardia (resting heart rate less than 45 beats per minute)
• Electrolyte disturbances (rare)
• Hypothermia (body temperature is less than 36.5 C)
• Significant dehydration with orthostatic changes in pulse and blood pressure

Refeeding Syndrome: Severely anorexic patients may experience refeeding syndrome, a potentially catastrophic complication that occurs during the initial stages of food introduction and causes severe fluid retention and cardiac failure. Too much food too quickly overwhelms the body. This is why it is necessary for anorexic patients to be monitored by a physician. The chance of this happening outpatient is small because most anorexics refuse to drastically increase what they’re eating. However, caution is advised. Severe anorexics often need to be hospitalized and monitored closely during the refeeding process.

Nasogastric tube feeding is rarely used and only with patients who are in a life-threatening situation due to acute malnutrition. This kind of forced feeding may lead to refeeding syndrome. Some patients may be more willing to accept nasogastric feeding than eat real food, especially during the early stages of renourishment (American Psychiatric Association, 2000). Tube feeding is a choice of last resort when all other refeeding endeavors have failed and the patient is so ill that her life hangs in the balance.

Reglan is a medication that stimulates motility of the gastrointestinal tract and is sometimes prescribed on a short-term basis to help anorexic patients digest food and reduce feelings of fullness. Talk with a physician about the use of this medication because it is not FDA approved for this purpose.

2. SPECIFIC TO BULIMIA NERVOSA

• Bulimic symptoms (i.e., successive bingeing and purging in a short period that disrupt daily activities, unremitting laxative abuse, etc.) are so severe and entrenched that outpatient treatment will have no impact
• Aspiration pneumonia
• Bradycardia (resting heart rate less than 45 beats per minute)
• Diet pill, laxative, diuretic, or Syrup of Ipecac toxicity
• Electrolyte disturbances
• Significant dehydration with orthostatic changes in pulse and blood pressure

C. TREATMENT STRATEGIES

You and the physician monitor the health of your patients. Be honest and straightforward with them about their physical condition. Do not minimize, exaggerate, generalize, or talk down to them. To break through their denial, help them see how destructive the eating disordered behaviors have been and continue to be.

When a patient meets any of the above criteria, hospitalization is the appropriate course of action. Patients often resist because they don’t know what to expect, worry it will interfere with work or school, have concerns about the cost, or fear the stigma of “mental illness.” Therefore, with the backing of the physician, you have to persuade them that it’s in their best interest to be hospitalized.

The stay in a medical hospital is only long enough to bring the patient out of danger. Eating disorders programs require a commitment of four or more weeks. Address the patient’s realistic concerns and illogical fears. Talking to an intake coordinator can alleviate some apprehensions. You will have to guide your patients through their uneasiness to get them ready to be admitted.

During an initial assessment or when a longer-term patient’s situation becomes life-threatening, have the patient transported to the hospital by ambulance or a family member. If it is not an imminent emergency but you believe the patient must be hospitalized, work with resistance by talking about how a program can benefit recovery. Some therapists inform the patient upfront that they will initiate therapy only if the patient agrees to hospitalization if it becomes necessary during treatment.

1. ANOREXIA NERVOSA

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 patient 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).

a. Psychotherapy

Cognitive-Behavioral Therapy: The empirical data on Cognitive-Behavioral Therapy (CBT) for anorexia is extremely limited, however a number of recent investigations offer preliminary support of the utility of CBT to treat anorexia, particularly weight-restored individuals (Grilo and Mitchell, 2010).

Cognitive strategies are employed to reduce negative beliefs, critical internal dialogue, and distortions in thinking regarding misperceptions about appearance. Behavioral interventions include positive reinforcement (e.g., praise), negative reinforcement (e.g., bed rest or exercise restriction), and informal feedback (e.g., actual weight gain and caloric intake) (American Psychiatric Association, 2000).

Goals for physical recovery are established with the patient at the beginning of therapy. Goals include:

• Stopping starvation
• Improving nutrition
• Restoring weight
• Reducing exercise and eliminating other purging behaviors
• Recovering health

Cognitive Remediation Therapy: Cognitive Remediation Therapy (CRT) was originally developed to rehabilitate patients who had brain lesions in order to improve brain functioning. Because anorexics display the trait of cognitive inflexibility (poor set shifting), this form of therapy is being tailored to treat these patients. 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).

Patients with severe eating disorders respond more slowly to intervention because of intense weight gain fears. As food is introduced, obsessive thinking spikes along with awareness of unpleasant emotions. Starvation stops the chatter and the pain. Giving up what has worked for a long time seems risky. They wonder, “Why would I want to feel unpleasant feelings and gain weight?” They need to understand that their anorexia enslaves them, keeping them from maturing and moving forward in life.

Become creative in finding ways to promote individual changes. For instance:

• To reduce the fear of reintroducing grain carbohydrates, suggest that your patient start out with rice cakes instead of bread.
• A patient continues to run even though exercise is banned. Have the patient hand over his running shoes until weight gain is achieved.
• A patient resists keeping track of daily food intake to stay in denial of how little is actually eaten. Have the patient leave a message each night on your answering machine or fax a list of all foods eaten that day.

In the hospital, dietitians avoid a power struggle over food by starting patients on 3 to 4 cans of Ensure® or Ensure Plus® to reach 1,200 calories a day. Food is optional in the beginning (Adams, 1999). This can be adapted to outpatient treatment. The dietician designs meal plans that include liquid meals with food added in at a measured pace.

A patient who is gaining weight on 1,200 calories a day in the hospital may require 2,400 calories a day after 2 weeks and 3,000 calories a day after six weeks (Adams, 1999). Once the metabolic rate increases, so do caloric needs. This is quite shocking to patients who don’t understand why they need so much food to continue to gain weight. The adjustment is difficult and patients often respond by shaving calories. This is why a weekly weigh-in is vitally important. It is the only way to tell if your patient is eating everything required by the dietitian.

Bed rest can be an effective tool in promoting weight gain. In the hospital, the patient must rest if weight does not increase. When it does, the patient spends more time out of bed (American Psychiatric Association, 1993). Teens in outpatient therapy can be taken out of school and placed on bed rest if they do not gain weight. They can only join regular activities when their weight increases by 1 to 2 pounds a week. It’s harder to instigate with adults who have to work to support themselves and/or take care of their children.

Exercise abuse is common with anorexics. Therefore, exercise must be adapted to the amount of calories ingested each day, which the dietician can calculate. Patients will oppose your recommendation to adjust exercise downward. In fact, if they’re expected to eat more, they will want to exercise more. Those who have an actual exercise addiction cannot stop compulsively engaging in their sport of choice. A physical exam will give you and your patient information about how her health is compromised and the role exercise plays. Guide patients towards the perspective that exercise is for physical fitness and overall health, not burning calories. The way they exercise makes them ill. Recommend that your patients stop exercising or cut back greatly until they gain weight and their physician gives permission to proceed to start exercising again. In an ideal world, they would follow your advice. In reality, they sneak in exercise when no one is watching and say they aren’t. Develop behavioral contracts tying eating to exercise so that they know exactly what they can and cannot do. Success will vary depending on your patient’s level of motivation, trust in the therapeutic process, and/or the ability to regulate affect once refeeding begins.

You will use behavior change techniques and cognitive therapy to force a wedge between the individual and the anorexia. Denial and resistance run high throughout therapy until long-term weight gain, coping strategies, and a sense of emotional control are achieved.

b. Medications
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 (Keek and McCormick in Grilo and Mitchell, 2010).

Prozac (fluoxetine) is an SSRI that 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 patients (Kay et al., 2001). Fluoxetine is not recommended for anorexics who have not yet gained weight as fluoxetine has an anorexic side-effect (Maxmen and Ward, 2002).

Zyprexa (olanzapine) is considered an “atypical” antipsychotic. 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 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 (resperidone), 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).

2. BULIMIA NERVOSA

a. Psychotherapy

Cognitive-Behavioral Therapy: There is general consensus that CBT is the best established form of psychotherapy for bulimia nervosa either in an individual or group therapy format (Mitchell et al., 2007). Other forms of therapy are being developed and researched to assess effectiveness with bulimia (see Feast of Famine:The Etiology and Treatment of Eating Disorders course).

Cognitive and behavioral strategies are utilized to address the eating disordered behaviors and the underlying cognitions that fuel the eating disorder (American Psychiatric Association, 2000). Goals include:

• Reducing binge-eating and purging behaviors
• Improving eating disorder-related attitudes
• Minimizing food restriction
• Increasing variety of foods eaten
• Encouraging healthy but not excessive exercise patterns

Hospitalization is rarely used for uncomplicated bulimia nervosa. It is considered only when the eating disordered behaviors have such a hold on the person that outpatient treatment has no impact (American Psychiatric Association, 2000).

Patients with severe bulimic symptoms struggle to reduce bingeing and/or purging. Movement in any direction makes a difference. For instance, cutting back on bingeing removes the reflexive reaction to purge. Less purging motivates the person to think twice about bingeing since there is no way to get rid of unwanted calories. One permanent change fosters great hope and opens the door for patients to attempt making another change.

Lack of, or extreme, amounts of exercise need to be addressed. Again, the focus shifts from exercise as purging to exercise as physical fitness. Patients benefit from structured exercise goals so they know exactly what they can and cannot do each day. The amount and kind of exercise depends on how much they’re eating, how often they’re purging, and how healthy they are according to a physical exam. Inquire during each session so you can modify exercise routines to bring the patient into a more normal range.

b. Medications

Prozac (fluoxetine) at high doses (60 mg/day) is considered the “gold standard” for treating bulimia nervosa (Fluoxetine Bulimia Nervosa Collaborative Study, 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 intervention (Walsh et al., 2000).

Fluoxetine has also been used for the treatment of depression, obsessive-compulsive disorder, alcohol and drug addictions, and migraines. Contraindications include potential increased weight loss in anorexics, increase in affects of alcohol, and interference with monoamine oxidase inhibitors (MAOI) (Maxmen and Ward, 2002).

Wellbutrin (bupropion), an antidepressant, is not recommended for patients with bulimia because a number of women have had grand mal seizures.

3. CHRONICITY

Some patients will never recover fully. There are a number of factors that contribute to low recovery rates. Research suggests that women with bulimia nervosa who had a history of anorexia nervosa were more likely to have a protracted illness and relapse into anorexia. Bulimics with no history of anorexia were more likely to move into partial and then full recovery (Eddy, et. al., 2007). Anorexics who have obsessive compulsive personality disorder (OCPD) traits, including perfectionism, had a poorer prognosis. Reducing these traits may mediate change (Crane, et. al., 2007).

What is insidious about the psychopathology of anorexia is that it is sustained, in part, by the powerful allure of the safety it creates―the mock sanity fostered by extreme discipline and a distinct sense-of-self that the individual embraces. Pleasures and interests narrow, leaving delusive ideas such as, “My illness is my friend” (Strober in Grilo and Mitchell, 2010).

Anorexics who have obsessive compulsive personality disorder (OCPD) traits, including perfectionism, had a poorer prognosis. Reducing these traits may mediate change over time (Crane, et. al., 2007).

These patients will continue to starve; binge; vomit, take laxatives, diuretics, or enemas; take diet pills; over-exercise; chew and spit food out; etc. Some behaviors lessen and stay that way whereas others come and go, depending on how well the person is dealing with emotional upsets and body-image disturbances. These patients can benefit from ongoing therapy where they can make small changes over time. Goals for these patients are much more modest and include:

• Reduce eating disordered behaviors
• Function at work or school
• Stabilize health
• Interact appropriately with others
• Build coping skills to handle stress better over time
• Develop trust in another individual
• Broaden activities and interactions with others

Strober (Grilo and Mitchell, 2010) presents a paradigm for treating the chronic anorexic. The goal is to create a palliative, holding management of carefully measured intensity with support and comfort to the individual. Steps are taken to cushion the effects of the illness. The 7-step approach includes:

• Providing a sufficiently long consultation to explain the developmental model of chronicity before undertaking intervention.
• Offering unambiguous reassurance that weight gain is not the principle objective unless patient feels otherwise.
• Establishing routines of social activity, however minimal, to prevent further invalidism and isolation.
• Encouraging hobbies, intellectual pursuits, and any activity that allows for pleasure and mastery.
• Monitoring health through regular physical exams with a psychologically informed collaborating physician.
• Encouraging increases in nutrition that does not risk significant weight change. Do not show excitement or relief is weight gain is achieved.
• Meeting adjunctively with family members and others to educate them on the psychopathology of anorexia, to provide solace and support, and discourage overt displays of irritation or disparagement.

Relapse during therapy occurs. Getting back on track to healthy eating at the next meal is the optimum outcome. For severe patients, relapse can go on for days or weeks. Being supportive while introducing methods to return to healthier habits becomes primary. Exploring blocks to this is equally important. They’re frustrated and angry with themselves. They may even blame you for not “fixing” them. Your compassionate response is vital in helping them move forward.

You will have to decide your level of risk tolerance in taking on patients who have serious medical conditions. They may need to be hospitalized periodically and not make much movement no matter how much energy you put into their care. There is also the risk that they may die while they’re in therapy with you. It takes patience, care, understanding and an ability to tolerate the repetitiveness of your interactions to effectively conduct therapy with these individuals.

Case Vignette 1: Sandy, a 48-year-old anorexic, has been starving herself since the age of 11. She entered therapy because she experienced depression after being fired from her job as a bank manager. In her mind, treating the anorexia was secondary. She had been hospitalized ten years prior for anorexia nervosa, binge-eating/purging subtype. The bingeing and purging were in remittance. However, Sandy continued to starve, eating as little as 300 to 400 calories a day. She chewed food and spit it out. She also drank lots of coffee. Her body had long ago adjusted to the reduced caloric intake, with her weight staying around 88 pounds and a height of 5’2”.

Sandy came to therapy with little hope that she would ever feel better again. She had struggled with depression on and off all of her life. In the first session, Sandy agreed to see her physician for a physical exam to make sure her health was stable enough to begin outpatient treatment. It had been a year since she had an exam. Back then, she was diagnosed with chronic renal (kidney) failure that was not life threatening. The doctor met with her a week later and told her that her condition was the same. She also had osteoporosis, elevated liver enzymes, low blood pressure, dry and thinning hair, and skin rash. When her therapist talked to the physician, she gave the okay for Sandy to start treatment.

The focus of Sandy’s therapy was two-fold: reduce depression and increase healthy food behaviors. Sandy explored her long history of depression, how family genetics and negative beliefs both contributed to her depression, and what she tells herself that makes her more depressed. Sandy was not very open to making even modest changes in her eating habits (she’d been anorexic for 37 years and hadn’t had much success in overcoming the disorder). Sandy was very open to discussing her job loss and blamed herself completely for being fired. Time was spent exploring the dynamics at work that led to the firing and to reframe the experience so that Sandy didn’t shoulder all the responsibility. She could see that starvation was her coping mechanism to not feel and to be in control. She did not want to entertain the idea of changing food habits until she was informed that the 100 packets of the Aspartame® she was putting in her coffee might contribute to her kidney failure (too much chemical for the kidneys to process), depression, headaches, mental confusion, itching skin, and sabotaging her weight loss. She cut back immediately, not for any reason other than reduced weight loss. If she wasn’t going to consume 400 calories of artificial sweetener, she would need other sources. So she agreed to cut back to 10 packets of sweetener a day in two cups of coffee, make an all vegetable salad with tuna for lunch, and reduce chewing and spitting out. That’s as much as she was willing to do. She wanted to get back to work, so she utilized therapy to address her fear of conflict, passive communication style, people-pleasing behaviors, difficulty with delegation, never asking for help when overwhelmed, and withdrawing when emotionally upset. She also paid attention to what she said in her head that let negative beliefs get the best of her.

Slowly Sandy became less depressed and, within nine months, she found another job. She was armed with knowledge about what she didn’t do well at the other job in order to avoid repeating the same mistakes. Concerning her food, Sandy was able to stick with the original changes and add a rice cake for dinner. She saw her progress. She rarely chewed food and spit it out, her calories came from healthy sources, her weight stayed the same, and she gave herself credit for all the changes. Her last lab work showed that her kidneys functioned better, liver enzymes were closer to normal range, and blood pressure had increased slightly. Sandy knows that reducing eating disordered symptoms and depression are going to be an ongoing process.

CHAPTER IV: MOOD DISORDERS

Almost every person who has an eating disorder also has some form of depression and/or anxiety. The severity of mood disorders makes eating disordered symptoms more acute and complicates the recovery process. Multiple comorbid conditions multiply the problems. For instance, an anorexic patient who seeks cocaine during manic phases to diminish appetite and slow down the scattered thought processes associated with attention deficit disorder is going to have difficulty recovering from anorexia without addressing the bipolar disorder, attention deficit disorder, and accompanying substance abuse.

A. DEPRESSIVE DISORDERS

Depression is the most common mood disorder in patients with eating disorders. The question as to whether depression provokes an eating disorder or vice-versa has not been fully answered. In my clinical practice, most patients have an underlying depression (stemming back to childhood or adolescence) that fuels the eating disorder. A new layer of depression comes from the disgust felt after bingeing, purging, or gaining weight. Depression is also caused by prolonged starvation. Estimates of depression and dysthymia in individuals with anorexia and bulimia range from 50% to 75% (American Psychiatric Association, 2000).

1. MAJOR DEPRESSION

(Diagnostic criteria in the following sections are provided as a review. If you are already familiar with the criteria and would like to scroll past, click SKIP to move directly to the next section. Information comes from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, American Psychiatric Association, 1994.)

SKIP Diagnostic Criteria: The essential feature of a major depressive episode is a period of at least two weeks in which the person either has depressed mood or loss of interest in pleasure. These symptoms impair social, occupational, and/or other areas of functioning. In children and teens, the mood can be irritable rather than sad. Five (or more) of the following symptoms are present:

• Depressed mood for most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful)
• Markedly diminished interest or pleasure in all, or almost all activities most of the day, nearly every day
• Significant weight loss when not dieting or weight gain (i.e., a change of more than 5% of body weight in a month)
• Insomnia or hypersomnia nearly every day
• Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
• Fatigue or loss of energy nearly every day
• Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
• Diminished ability to think or concentrate, or indecisiveness, nearly every day
• Recurrent thoughts of death (not just a fear of dying) or suicidal ideation without a specific plan, a suicide attempt, or a specific plan for committing suicide

2. DYSTHYMIA

SKIP Diagnostic Criteria: The essential feature of dysthymia is chronically depressed mood for most of the day more days than not for at least two years. In children and teens, the mood looks more irritable than sad. Additional symptoms (at least two to make a diagnosis) include:

• Poor appetite or overeating
• Insomnia or hypersomnia
• Low energy or fatigue
• Low self-esteem
• Poor concentration or difficulty making decisions
• Feelings of hopelessness

There is also a prominent presence of low interest and self-criticism, seeing the self as uninteresting or incapable.

Depressive Disorders and Eating Disorders: Appetite is affected by mood disorders. It can be tricky to sort out whether the depression or the eating disorder is causing problems with food. Look for intentionality (e.g., is the person deliberately starving or bingeing?). Someone who is seriously depressed may lose her appetite but not be driven to be thinner to boost self-esteem. In addition, someone may be overeating without noticing how much is eaten, but is not using food to erase internal pain or turning to compensatory behaviors to get rid of calories. Depressed individuals may crave carbohydrates (e.g., high-fat, sugar, or salty snacks such as cookies, candy, cakes, or chips) because serotonin is low and these foods release serotonin. For people who also have an eating disorder, cravings are extremely distressing. They do not want to binge. Their goal is to lose weight and these foods knock them off course.

Individuals with eating disorders feel depressed about all their perceived flaws. They dislike who they are and alter their appearance (through weight loss, clothing and makeup choices, plastic surgery, etc.) because it’s something they can take charge of. They hope that changing the outside will make them feel better on the inside. Losing weight, in particular, momentarily removes self-loathing. Starving, bingeing, purging, and grazing all numb out painful emotions. Each is a different mechanism of using food to cope. As you can see, the mood disorder and eating disorder are highly intertwined. Both must be addressed throughout therapy.

It is important to differentiate between three kinds of depression. Individuals may be experiencing more than one at the same time. The categories are:

• Biological-based depression
• Assess family history for mood disorders
• Explore when depression arose and what instigated it
• Look at the effectiveness of antidepressant medication
• Treatment includes medication and psychotherapy
• Negative belief-based depression
• Assess for childhood trauma
• Identify negative belief system
• Pinpoint cognitive distortions
• Listen for harsh internal dialogue
• Recognize perfectionistic attitudes
• Treatment includes psychotherapy and/or medication
• Situation-based depression
• Assess for some kind of loss (e.g., death of a loved one, job is outsourced, home burns down)
• Treatment includes psychotherapy and sometimes medication

Some researchers have theorized that patients with deep-seated negative beliefs can develop a biological-based depression because the serotonin system may be affected by constant self-deprecation. Long-standing depression from a loss may also instigate a biological depression. Consultation with a psychiatrist can help the patient determine if an antidepressant is an appropriate form of treatment.

Medications: Most patients with major depression need medication to regulate affect. Individuals with dysthymia may decide to forgo medication and see whether therapy alone can ameliorate the depressive symptoms. A psychiatrist well-versed in the treatment of eating disorders can prescribe medication(s) that best treat the symptoms of both the eating disorder and mood disorder.

Prozac (fluoxetine) is often prescribed to reduce not only depression but also bulimic symptoms. Occasionally, it is used for obsessive-compulsive disorder in anorexics. Caution is advised because undereating and weight loss are common side effects. Increased weight loss is seen in anorexics who have not yet recovered. Anorexia can also be reignited in someone who is in the process of recovery.

Wellbutrin (bupropion) is not recommended for bulimic patients because this medication can induce seizures. Other selective serotonin reuptake inhibitors (SSRIs) are appropriate for treatment for depression. A brief overview of SSRI medications is provided in the Feast or Famine course.

Patients who have multiple comorbid issues may need a variety of medications to manage moods. For instance, a seriously depressed and anxious bulimic patient may be prescribed Prozac for depression and obsessive-compulsive symptoms, Buspar for anxiety, Seroquel to reduce agitation, and Ambien to promote sleep.

Antidepressants are ineffective with most anorexics until they gain weight. Depression is often tied to food deprivation and will lift once they refeed. If the depression does not remit, then antidepressant medication can be considered.

Treatment: Cognitive strategies have been proven to reduce depressive symptoms and eating-disordered thinking. Cognitive distortions that produce depression also keep the eating disorder in place. Eating-disordered patients are judgmental about how they look, act, and feel. If they’re not perfect, they become upset and tormented with shame for not measuring up to unrealistic standards. Depressed patients (without an eating disorder) have fewer body image complaints, although they may be highly self-critical about other areas of their lives.

Internal dialogue affects the patient’s outlook, attitude, and mood. For example, a 29-year-old normal-weight bulimic patient looks in the mirror and says, “I’m so fat and ugly!” This belittling has gone on since junior high school and is now fully entrenched in her thinking. All the starving and purging to lose weight haven’t reduced this harsh assessment. The patient is continually depressed about her appearance. No matter how much she changes her looks, it’s never fully satisfying. A one-pound weight gain, a pimple, cellulite, or a newly-discovered wrinkle can send her into a deep funk.

In therapy, her automatic thoughts can be brought to light. The patient can then start to consciously catch these statements and change them into something that is more realistic and balanced. The patient can begin to say, “I’m okay the way I am today,” “I’m not going to beat myself up for how I look,” or “I’m not going to scrutinize myself in the mirror.” Exploring where and when the underlying negative beliefs developed, how they produce a barrage of insults, and feeling the associated pain can eventually help shake loose old beliefs and create space for new ones. (For an overview of changing negative beliefs, review Healing the Mental Self in the Feast or Famine course. For complete information, read Healing the Emotional Self and Mental Self in Healing the Hungry Self: The Diet-Free Solution to Lifelong Weight Management, Price, 1999.)

Severely depressed eating disordered patients make very slow progress in modifying thought processes, expanding their ability to handle painful affect, and undoing unhealthy food habits. They feel hopeless, helpless, and defeated. The worse they feel about themselves the more they starve, binge, purge, or graze—anything to stop the suffering. Their behaviors have such a hold on them that they can’t remember how they functioned before the eating disorder. With patience and perseverance, they have to constantly monitor their internal chatter and stop it. They will also have to develop the skills to deal with all the feelings they haven’t wanted to feel, both current ones and those tied to deep wounding experiences. Some patients have a limited capacity to revisit the past because their depression deepens. Those with a personality disorder cannot bear the intensity of affect. If they can learn to sit with their feelings, even for short periods, they’ll see that their emotions eventually dissipate. At the same time, they’ll be working on changing their dysfunctional food habits (more detailed information is provided in the Feast or Famine course).

Suicidality: This is a direct consequence of depression. Assess how critical the situation is—if the patient is fantasizing about doing self-harm or has a set plan of action. Patients turn to suicide when they believe there is no other solution to relieve emotional pain. Anorexic patients who attempted suicide were older, had a longer duration of illness, were at a lower weight, and more likely to use substances. Among bulimics, they had a comorbid psychiatric history and were more likely to report sexual abuse. Other factors include earlier onset of psychopathology, higher severity of depressive and general symptoms, and more impulse control problems (Fedorowicz, et. al., 2007).

There are a number of signs and symptoms to look for to alert you to suicidal ideation and action (Brager, 1987)

• Dysphoria and excessive tearfulness
• Sudden shifts in affect (e.g., irritability, anger, hostility, euphoria)
• Sudden and unexplained recovery from depression
• Changes in appetite, sleep, hygiene, or grooming routines
• Loss of interest and pleasure in typical activities
• Loss of esteem and confidence, and the development of negative introspection
• Expressed feelings of worthlessness, hopelessness, helplessness, victimization, and pessimism
• Absolute statements (e.g., must, never, always, or only)
• Social withdrawal, isolation, or indifference, or hostility about a relationship
• Apathy toward, or decrease in, school or work performance
• Limited tolerance or inability to endure frustration or distress
• Impulsivity
• Inadequate judgment with respect to appreciating consequences of behaviors
• Inability to identify or express emotions
• Explosive outbursts
• Giving away prized possessions, suddenly putting affairs in order, or irresponsibility towards obligations
• Verbally indirect expression of threat (e.g., “You’d be better off without me,” “Nobody needs me anymore,” “I don’t want to do anything anymore.”)
• Verbally direct expression of threat (e.g.., “I’m going to kill myself,” “I wish I were dead,” “I can’t go on,” “I don’t want to live.”)
• Statement of actual plan with access to availability and lethality of method

Assure patients that suicidal feelings are temporary. Whether the depression is biological, belief-based, or situational, intense dysphoria usually abates. Therapy and/or medication, support, and time all work together to help patients feel better. They can view their suicidal ideation as an escape fantasy, but they do not have to follow through. Address how their negative self-view and corresponding cognitive distortions are intensifying their suffering. A pessimistic outlook makes the depression worse. They hold the power to transform how they view—and therefore feel about—themselves along with whatever unpleasant situation is adding to the unhappiness. For patients who are taking medication, adjusting the dosage can alleviate some of the suicidal tendencies.

When patients tell you they’re feeling suicidal and have a plan of action (versus expressing distress with no formulated plan), request that they sign a clearly spelled out no-suicide contract (e.g., “I will not do anything to harm myself in any way and if I do consider hurting myself, I will call my therapist and wait for her/him to call me back before I take any steps.”).

A careful watch is placed on seriously suicidal patients. When the depression begins to lift, patients have the energy to carry out a threat. Know your state laws. If your patient is imminently serious about attempting suicide, you may have to break confidentiality to keep her/him safe. One step may be contacting a family member, police, or crisis unit to transport your patient to a hospital.

It is preferable to admit your patient to an eating disorders program. General psychiatric facilities address depression and save lives. They aren’t set up to treat eating disorders, yet both must be the focus otherwise the patient will continue the behaviors as an inpatient. Staff members are seen as untrustworthy pushovers—they let the patient get away with his eating disorder. If the only option is a general program, have the patient admitted and when emotionally stabilized, the patient can transfer to an eating disorders program or back to outpatient therapy.

Patients who are acutely depressed and have a personality disorder are more likely to be suicidal. Their depression is more chronic, diffuse, and long-standing. When these patients feel rejection or failure, their despondency intensifies. Their impulsivity (especially those with borderline personality disorder) pushes them to act out their suicidal ideation. To address treatment for these patients, see Chapter V: Personality Disorders, Borderline Personality Disorder.

For patients who are neurotically ego-organized, their ideation often stays just that. They have more internal resources to lean on when life becomes stressful and uncertain. With enough traumas, however, these individuals can also become suicidal.

If you believe your patient is not a danger to himself, then outpatient therapy can continue. Intervention includes helping the patient (Brager, 1987):

• Understand the specific problem
• Identify unmet psychological need(s) that have lead to the idea that suicide is the only option
• Consider alternatives for reducing emotional pain and offer new choices
• Develop perspective
• Negotiate and let go of thinking in absolutes (never, always, etc.)
• Reduce the level of lethality by diminishing the level of perturbation
• Focus on the current crisis and reduce the chances that the patient will carry out the suicidal act (e.g., having the patient go to a safe place)
• Identify support and resources
• Involve others in treatment (supportive family members, friends, or other professionals)

Case Vignette 2: Ellen, a 28-year-old bulimic, entered therapy after completing a six-week stay at an inpatient eating disorders program. She successfully stopped bingeing, vomiting, starving, and over exercising. With her meal plan in hand, Ellen initially followed all the guidelines as if she were still in the program. Within a month, she binged once, and was freaked out, vowing to never do that again. After two months, she was bingeing once a week and had thrown up twice. She also increased her time at the gym and skipped breakfast the day after bingeing the night before. Her weight dropped and she liked it.

Ellen knew she was in trouble but felt ashamed that she’d wasted time and money on an inpatient program. So, she decided not to tell her therapist about her slip-ups. She just kept hoping she’d stop. Her therapist pointed out that Ellen seemed sullen, appeared gaunt, and sounded strained. She denied that she had returned to old habits. After two months, she finally told her therapist that she was bingeing and purging every other day, and going to the gym for two hours after work. They came up with a number of strategies to halt the downward spiral. Ellen would come in twice a week, pull out her hospital meal plan, chart her food, cut back to one hour at the gym, keep a journal to write down what she was feeling at the end of the day or whenever she got stressed at work, and spend time in session going through the feelings that she’d been trying to avoid with her eating disordered behaviors.

Her psychiatrist also changed her medication from Celexa to 60 mg. of Prozac, the treatment dosage for bulimia. Within a month, her behaviors seemed to reverse, but then the bingeing reemerged with full force. Ellen couldn’t imagine gaining back the weight she’d lost. In her mind, this made it impossible to stop vomiting or spend less time working out. She was back to bingeing and purging multiple times a day. Her physician said Ellen’s body was holding up well for what she was doing. None of her labs showed serious signs of health complications other than low potassium. The therapist broached the subject of Ellen going into another treatment program. Ellen refused. She was sure she’d be fired from her accounting firm. How could she take more time off from work, when she’d done that last year? She became more depressed and hopeless. She even said she wanted to end it all. She thought about many ways to do it, but said she didn’t have the guts to carry it out. Her morose mood deepened.

Her therapist insisted Ellen take a look at what she was doing and where she was heading. She wasn’t recovering. She was backsliding every day. Ellen broke down and sobbed uncontrollably. This really scared her. She’d always been able to take charge of her emotions. Now that was a disappointment. Ellen admitted she’d contemplated jumping off a freeway overpass. At the end of the long crying jag in session, she reluctantly agreed to enter an inpatient program. In spite of her doubts, she started a program a number of days later and actually had some hope that a second round of inpatient therapy would undo her old behaviors and reinforce the ones she had learned the first time around.

3. BIPOLAR DISORDER

SKIP Diagnostic Criteria: A manic episode is defined as a distinct period during which there is an abnormally and persistently elevated, expansive, or irritable mood lasting for at least one week. These symptoms impair social or occupational functioning, require hospitalization, or have concomitant psychotic features. During a period of mood disturbance, three (or more) of the following symptoms have persistent and have been present to a significant degree:

• Inflated self-esteem or grandiosity
• Decreased need for sleep (e.g., feels rested after only three hours of sleep)
• More talkative than usual or pressure to keep talking
• Flight of ideas or subjective experience that thoughts are racing
• Distractibility (e.g., attention drawn to unimportant or irrelevant external stimuli)
• Increased goal-directed activities (either socially, at work or school, or sexually) or psychomotor agitation
• Excessive involvement in pleasurable activities with a high risk for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

A hypomanic episode meets all the criteria for a manic episode except that the symptoms are not severe enough to affect social or occupational functioning, require hospitalization, or have accompanying psychotic features. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic. The disturbance in mood and the change in functioning are observable by others. In hypomania, an individual has an elevated mood, feels better than usual, and is more productive. These feel-good episodes can cause some individuals to stop taking their medication, which can cause an escalation to mania or crash to depression (Kahn et al., 1996).

A depressive episode is described in the Major Depression category.

4. CYCLOTHYMIC DISORDER

SKIP Diagnostic Criteria: The essential feature is a chronic, fluctuating mood disturbance involving numerous hypomanic symptoms and numerous periods of depressive symptoms for at least two years. During this period, the person is never without the symptoms but there are no signs of a major depressive episode, manic episode, or mixed episode. The hypomanic and depressive symptoms are of insufficient number, severity, pervasiveness, or duration to meet the full criteria for a manic episode or depressive episode.

Bipolar Disorder, Cyclothymic Disorder, and Eating Disorders: The average person with bipolar disorder has four episodes during the first ten years of the illness. Men are more likely to start with a manic episode, whereas women begin with a depressive episode. Without treatment, most people will have more frequent episodes. Sometimes these follow seasonal patterns (e.g., hypomanic in the spring and depressed in the winter). Episodes can last days, months, or even years. Without treatment, manic or hypomanic episodes generally last a few months, while depression can go on for over six months (Kahn et al., 1996).

There are three different categories of bipolar disorder:

• Bipolar I Disorder: a person has manic or mixed episodes and almost always has depression
• Bipolar II Disorder: a person has hypomanic and depressive episodes, not full manic episodes
• Rapid Cycling Bipolar Disorder: a person has at least four episodes per year in a combination of manic, hypomanic, mixed, or depressive episodes. This affects around 5%-15% of patients with bipolar disorder

There is no single proven cause of this disorder. Research strongly suggests that it is often inherited and related to a lack of stability in the transmission of nerve impulses in the brain, making these individuals more vulnerable to emotional and physical stresses. For instance, if there is an upsetting event, substance abuse, lack of sleep, or excessive stimulation, the normal brain mechanisms that restore calm don’t always work properly (Kahn et al., 1996).

In the eating disorder population, at least 13% of anorexics and bulimics have bipolar disorder (American Psychiatric Association, 2000). Both mania and depression affect appetite. When the individual is happy, up, and racing around, eating isn’t a priority. For those who overvalue thinness, the resulting weight loss adds to the excitement. When depression hits, he either loses interest in food or overeats as a way to blunt affect. When weight gain occurs, the person may decide to do something to get rid of the calories (e.g., over exercising, vomiting, taking laxatives or diuretics, diet pills) The eating disordered behaviors often follow the mood cycles.

These individuals have a heightened chance of turning to substances to self-medicate. More than 50% of those with bipolar disorder abuse alcohol or drugs during their illness. The risk for suicide is highest in the initial years of the illness (Kahn et al., 1996).

Medications: Lithium is effective in 60%-75% of individuals with bipolar depression, although it can take six to eight weeks for a full response. SSRIs can be added to further fight the depression. Rapid-cycling patients may respond better to either Depakote or Tegretol (anticonvulsants). Cyclothymia or bipolar II (hypomania and major depression) may improve on Lithium alone (Maxmen and Ward, 2002). Klonopin (antiseizure and antipanic medication) and Ativan (antianxiety) may be used for insomnia or agitation.

Some patents with eating disorders avoid taking Lithium and Depakote for two reasons. First, they like the manic highs and second, these medications can cause weight gain (Kahn et al., 1996). Once they discover this, they refuse to take medicine that makes it hard to lose or keep off weight.

Treatment: Evidence suggests that the more mood episodes individuals have, the harder it is to treat each subsequent episode, and the more frequent the episodes may become. This is referred to as a “kindling effect.” A misdiagnosis of depression and incorrect prescribing of antidepressants without antimanic medication can trigger manic episodes and make the overall course of illness worse (Kahn et al., 1996).

Kahn et al. (1996) proposes different stages and components of treatment for bipolar disorder:

Stages of Treatment:

• Acute treatment is aimed at ending the current manic, hypomanic, depressive, or mixed episode.
• Preventive treatment uses medication on a long-term basis to prevent future episodes.

Components of Treatment:

• Medications are prescribed for nearly all patients during the acute and preventive stages.
• Education is crucial in helping patients and families learn how to best manage the disorder (e.g., reduce mood swings) and prevent its complications. Patients are advised to:
• Become an expert on their illness
• Maintain a stable sleep pattern
• Keep a regular pattern of activity
• Avoid alcohol or illicit drugs
• Be very careful about everyday use of small amounts of alcohol, caffeine, and some over-the-counter cold medications
• Seek support from family and friends
• Reduce stress at work
• Psychotherapy is helpful for many patients and families in solving problems and dealing with stress. Therapy is much more likely to be beneficial for treating depression than for mania since patients in a manic phase often have trouble retaining what they learn.
• Behavioral therapy focuses on behaviors that decrease stress and on ways to add pleasurable experiences that lessen depressive symptoms
• Cognitive therapy focuses on identifying and changing the pessimistic thoughts and beliefs that lead to depression
• Interpersonal therapy focuses on reducing the strain a mood disorder places on a relationship
• Group therapy offers mutual acceptance, understanding, and self-discovery

Treatment with patients who also have an eating disorder uses these modes of therapy. The added dimension is how negative beliefs, cognitive distortions, and varied moods fuel bipolar disorder and eating disorders. These patients use starving, bingeing, grazing and/or purging to reduce affect. They’ll take advantage of manic or hypomanic phases to lose weight. Persuading them to see this as unhealthy is difficult. They don’t want to give up this perk. Taking medication means that they have to forgo not only the expansive feelings but also the weight control mechanism. Once their moods are more stable, they can address all the components of their eating disorders, as has been discussed previously. If they’re abusing or dependent on substances, therapy will have to include chemical dependency treatment (see Substance-Related Disorders).

B. ANXIETY DISORDERS

1. OBSESSIVE-COMPULSIVE DISORDER (OCD)

Obsessions and compulsions are the hallmark of eating disorders, particularly anorexia. Repetitive thoughts about food, weight, or appearance compel the person to act compulsively (starving, over exercising, bingeing, etc.) to stop distressing thoughts. Approximately 10%-13% of anorexics have obsessive-compulsive disorder with a lifetime prevalence of 25% (American Psychiatric Association, 1993). The comorbidity of OCD was almost exclusively associated with anorexia nervosa. One study found that 37% of subjects with anorexia versus 3% of subjects with bulimia had OCD (Thornton and Russell, 1997).

SKIP Diagnostic Criteria: The essential features of obsessive-compulsive disorder are recurrent obsessions or compulsions that are severe enough to cause marked distress, time consuming (i.e., more than one hour a day), or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships. At some point during the course of the disorder, the person has recognized that the obsessions and compulsions are excessive and unrealistic (unless the person has poor insight).

Obsessions are defined as:

• Recurrent and persistent thoughts, impulses, or images that are experienced as intrusive and inappropriate, causing anxiety or distress These are not simply excessive worries about real life problems
• The person attempts to ignore, suppress, or neutralize them with some other thought or action
• The person recognizes that the obsessional thoughts, impulses, or images are a product of her own mind (not imposed from without as in thought insertion)

Compulsions are defined as:

• Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession or according to rules that must be rigidly applied
• The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or are clearly excessive

Obsessive-Compulsive Disorder and Eating Disorders: These individuals see their obsessive thoughts and compulsive behaviors as irrational and initially try to resist the obsession or the compulsion. Their anxiety is not always apparent. The usual age of onset for obsessive-compulsive disorder is late adolescence or early adulthood. These individuals are often bright, meticulous, and highly verbal. In a society that values achievement, compulsive patterns are quite efficient and productive. What starts out as a way to gain control becomes extreme, which is embarrassing for the individual. The disorder can become so chronic that there is some disruption in personal functioning (Meyer, 1989).

Most individuals can pinpoint the age they developed obsessive thinking. They describe a building momentum in which they repeated thoughts that used to be random over again and again until a new pattern took hold. They’ve spent years honing their obsessive thinking. Compulsive behaviors grew in response to these intrusive thoughts.

Some individuals channel their obsessive thoughts into food, weight, or body image concerns. When overwhelmed, they employ compulsive behaviors to stop the unwelcome cognition. For instance, a person thinks, “I’m too heavy to run fast during track meets. I’m going to cut back on what I eat to get leaner. That way, I’ll be more aerodynamic.” Over time this is morphed into, “I’m fat, I’m fat, I’m fat.” So, the person decides, “I have to watch everything I eat to stay thin and win competitions.” Later on, the patient refines the decision to, “I will count every calorie I eat so I stay below 1000 calories. I can’t eat out because I don’t know what’s in that food so I’ll prepare everything at home.” The person has ongoing internal dialogue about being fat, which pushes its way to the forefront and interrupts other thoughts. To stop the barrage, the person severely limits food choices and no longer goes to restaurants. The obsession with being fat now includes calories. The corresponding compulsive behaviors only momentarily stop the worries. The person hopes to have a sense of control and mastery, yet actually feels controlled by her thoughts and behaviors.

Medication: Prozac (fluoxetine), Zoloft (sertaline), Paxil (paroxetine), Celexa (citalopram), Luvox (fluvoxamine), and Buspar (buspirone) are prescribed for obsessive-compulsive symptoms. The first four SSRIs are also used to treat depression. Prozac has the added advantage of potentially reducing bingeing and purging. As a cautionary note, withdrawal from Paxil can lead some people to experience serotonin syndrome, a worsening of original symptoms due to reduced serotonin in the brain. A psychiatrist can guide patients in the best medication for their symptoms.

Treatment: Patients do not realize that they have power to change what they think and how they act. The same determination that built up obsessions and compulsions can be used to undo old thinking and repetitive actions. Cognitive techniques diminish obsessive thinking. For instance, patients who practice thought stopping by saying “STOP!” see a reduction in obsessive thoughts. Often, when the obsession lessens, so do the concomitant behaviors.

A clear and consistent plan of response prevention can reduce compulsive behaviors. Examples include:

• Removing the scale from the house to prevent the patient from compulsively weighing in
• Giving away clothing that’s too small but used as a way to gauge how far the patient is away from a goal weight
• Limiting exercise to one hour a day
• Eliminating non-fat food items from the refrigerator
• Making a rule that no exercise can take place right after a meal

Patients can make lists of things they’re fretting over to remove obsessions from their minds and place it onto paper. They refer to the list instead of remembering and reviewing all the things about which they’re worried. They can also place a pad on their bedside table to write down nagging concerns, tasks to do the next day, or unprocessed emotions that wake them up in the middle of the night.

Behavioral strategies in and of themselves can decrease unhealthy food behaviors. Further details on how you can help patients to stop weighing themselves, practice delaying and preventing behaviors, and work on self and body acceptance are provided in the Feast or Famine course.

One study found that behavior therapy which exposes individual to what is feared and helps them avoid a ritual response physically alters brain function, reducing activity in the caudate nucleus. This deep-lying structure acts as a gatekeeper for controlling impulses prompted by stimuli involving disturbing thoughts and threats. In a normal subject, only appropriate impulses make it past the threshold. In individuals with obsessive-compulsive disorder, there appears to be some defect in which lower intensity stimuli are not screened out. On PET scans, this brain structure appears overactive (Lewis, 1993).

Reducing hunger by normalizing eating removes one layer of obsession with food. People who are full don’t think about food as much as those who are hungry. Patients will also obsess about being too full, reviewing everything they ate, and how they’re going to gain weight. Finding a “comfortable” fullness is important because patients will be able to deal with food in their systems more easily and continue the refeeding process.

Some patients are so consumed with obsessive thoughts that they feel tormented. Their behaviors become more extreme but that doesn’t stop the obsessions. They feel incredibly frustrated and out of control. Medications may reduce the symptoms only slightly or not at all. With these patients, it will take a great deal of time and effort on their part to employ cognitive and behavioral methods, sometimes with measured results. The goal for these patients is to turn down the volume of obsessive thinking rather than eliminating it altogether.

Negative beliefs, cognitive distortions, a drive for perfection, and the need for control all play a role in maintaining obsessions and compulsions. Identifying the circumstances surrounding the development of obsessions and compulsions, and working to resolve feelings about the past can lessen their hold over time.

Case Vignette 3: DeAnna is a 37-year-old dance instructor and a mother of three small children. She entered therapy because she continually thought about food and binged constantly throughout the day. She was very lean even though she sometimes ate 2,000 extra calories a day. In addition to teaching dance, she ran every morning for an hour and went to the gym in the afternoon for bike spinning classes. When we explored her history, she had been anorexic from the ages of 17 to 25. Her eating became healthier after two years of therapy. Nevertheless, she continued to think too much about weight and food intake. As time went on, she became hyper-focused on food. Bingeing was the only thing that brought reprieve from thoughts about chocolate cake or cinnamon rolls. To counteract weight gain, she exercised three to four hours a day.

Prior to entering therapy this time, DeAnna took Luvox, which helped for nine months and then stopped working. After six months of therapy and with many cognitive and behavioral strategies under her belt, her obsessions did not decrease significantly. In fact, infrequent night eating turned into large binges every night at 2 a.m. She would sob uncontrollably in session saying she was at her wits end. I assigned her to talk with her mother about her early years of feeding. She discovered that she failed to thrive for a period of time, not responding to her mother’s attempts to feed her.

DeAnna was aware of a fear of death and saw how the fear intensified every time her body was starved. Her obsession with food made total sense. Her over exercising kept stirring death fears, so she’d overeat. She had been looking at the situation in reverse. She thought she had to exercise three times a day to burn off all the extra calories from bingeing. So, in addition to working on stopping her obsessive thoughts in the moment, creating a normal eating schedule, and reducing exercise, DeAnna started to face her long-term fear of dying. She let herself feel the fear when it arose and held off from bingeing as long as possible in order to move through her feelings. Months of processing the fearful feelings and changing behaviors had an impact in reducing the obsession.

2. GENERALIZED ANXIETY DISORDER

Just under half of bulimic patients (43%) report experiencing anxiety (American Psychiatric Association, 1993). Social phobia is also commonly experienced by anorexics and bulimics (American Psychiatric Association, 2000).

SKIP Diagnostic Criteria: The essential feature of generalized anxiety disorder is excessive anxiety and worry about a number of events or activities for more days than not over a period of six months. The person finds it difficult to control the worry. Anxiety, worry, or physical symptoms cause clinically significant distress in social, occupational, or other important areas of functioning. Anxiety or worry is associated with three (or more) of the following:

• Restlessness or feeling keyed up or on edge
• Being easily fatigued
• Difficulty concentrating or mind going blank
• Irritability
• Muscle tension
• Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

The intensity, duration, or frequency of the anxiety and worry is far out of proportion to the actual likelihood or impact of the feared event. The person finds it hard to keep worrisome thoughts from interfering with tasks at hand and struggles to stop worrying.

3. SOCIAL PHOBIA

SKIP Diagnostic Criteria: The essential feature of social phobia is a marked and persistent fear of social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The person fears that he will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Exposure to either of these events almost invariably provokes an immediate anxiety response, which may take the form of a panic attack. The person realizes the fear is excessive or unreasonable, but avoids these situations anyway. This often interferes with the person’s normal routine, occupational functioning, social activities, or relationships. The phobia may generalize to most social situations.

4. PANIC DISORDER

SKIP Diagnostic Criteria: The essential feature of panic disorder is the presence of recurrent, unexpected panic attacks followed by at least one month of persistent concern about having another attack or its consequences (losing control, having a heart attack, “going crazy,” etc.), or behavioral changes related to the attacks. It is diagnosed with or without agoraphobia.

Panic attack is defined as a discrete period of intense fear or discomfort in which a number of symptoms abruptly develop and reach a peak within 10 minutes. Symptoms (at least four to make a diagnosis) include:

• Palpitations, pounding heart, or accelerated heart rate
• Sweating
• Trembling or shaking
• Sensations of shortness of breath or smothering
• Feeling of choking
• Chest pain or discomfort
• Nausea or abdominal distress
• Feeling dizzy, unsteady, lightheaded, or faint
• Derealization (feelings of unreality) or depersonalization (being detached from oneself)
• Fear of losing control or going crazy
• Fear of dying
• Paresthesias (numbing or tingling sensations)
• Chills or hot flushes

Agoraphobia occurs with and without panic disorder. Agoraphobia has the following symptoms:

• Anxiety about being in places or situations in which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd or standing in a line; being on a bridge; and traveling in a bus, train, or automobile.
• The situations are avoided (e.g., travel is restricted) or else are endured with a marked distress or with anxiety about having a panic attack or panic-like symptoms, or require the presence of a companion.
• The anxiety or phobic avoidance is not better-accounted for by another mental disorder, such as social phobia, simple phobia, obsessive-compulsive disorder, posttraumatic stress disorder, or separation anxiety disorder.

Generalized Anxiety Disorder, Social Phobia, or Panic Disorder and Eating Disorders: Eating disordered patients worry about food and weight, how other people perceive them, and/or whether they’ll fail at some task and be humiliated. They develop a fear of fear and avoid food, people, places, or events that stir fear. When they “feel fat,” they won’t go to parties, shop for clothes, head for the beach, see family members or friends from the past, show up for work, or have sex. Instead, they isolate. They create a small, safe box in which to live where they can attempt to control what happens to them.

Internal dialogue fuels anxiety because patients tell themselves how awful they look or how they’re going to be judged by others. They’re highly self-critical and assume others are too. Shame, humiliation, and trauma while growing up make them more prone to experiencing anxiety. It’s as if their psyches and bodies have become primed to feel this emotion.

Research suggests that people with panic disorder, obsessive-compulsive disorder, and social phobia are rated extremely high on an anxiety-sensitive index. People fall into three response categories: not disturbed by anxiety symptoms, uncomfortable and therefore avoid stimuli, and sure that the symptoms will harm their health. Theorists aren’t sure why some people are more anxiety-sensitive than others are although they do agree that there is a complex interaction between psychological and biological mechanisms (Azar, 1996).

Individuals who present with panic disorder usually do not have agoraphobia. Although they may have some features, they rarely have the full disorder. These individuals experience some disruption in work, school, or relationships. They feel demoralized, discouraged, ashamed, and unhappy about the difficulties of carrying out their normal routines. They blame it on a lack of “strength” or “character.” Around 50%-65% of these individuals develop major depression. For one-third of them, the depression came first. For two-thirds, depression occurred simultaneously or afterwards. Substance abuse may be a consequence of trying to treat anxiety with alcohol or drugs (American Psychiatric Association, 1994).

Psychoanalytic theory posits that anxiety is caused by repressed conflict about sex or aggression. Behaviorists believe that anxiety is a learned reaction to anxiety-provoking situations or thoughts. Biological theorists suggest that anxiety is due to some unidentified imbalances in brain chemistry.

Medications: Buspar (buspirone) and Paxil (paroxetine) are prescribed for generalized anxiety disorder. Zoloft (sertaline), Paxil, Buspar, Xanax (alprazolam), and Klonopin (clonazepam) are prescribed for panic disorder with or without agoraphobia. Stopping the use of Paxil and Xanax can produce unpleasant withdrawal symptoms.

Treatment: Cognitive techniques focus on helping patients look at thoughts that stir anxiety and then shifting those thoughts to ones that are less anxiety provoking. Anxiety causes worry, worry is about fear, and fear is about loss. So if a patient fears losing something important (i.e., a job, partner, self esteem, etc.), anxiety increases.

Eating disordered patients in particular fear they won’t be perceived as attractive so they engage in behaviors that promote weight loss. They’re afraid of food and its effects on their bodies. Cognitive strategies help them to challenge:

• Their faulty thinking around dieting
• How thin they think they must be to be happy
• What they perceive other people expect of them
• The perfection they expect from themselves
• The idea that everything should go their way or they’re a failure

Once patients identify fears, they can observe how their thinking produces anxiety, and why they choose certain behavioral responses to combat the fear. Once they grasp that the feared event rarely if ever happens, they can begin to sit with and process these feelings. Every time they don’t engage in eating disordered behaviors, they’re breaking the chain that has kept them stuck in either anorexia or bulimia. Even patients with debilitating anxiety can learn to do this. With practice and patience, they can significantly reduce anxiety and fear.

To avoid intensely distressing emotions, people will convert those feelings to anxiety. Not only are they distracted from the original feelings, the anxiety seems more palatable (believe it or not). To reduce anxiety, they’ll have to feel the deeper feelings–again and again and again.

5. POSTTRAUMATIC STRESS DISORDER (PTSD)

SKIP Diagnostic Criteria: The essential feature of posttraumatic stress disorder is the development of characteristic symptoms following exposure to an extreme traumatic stressor by responding with intense fear, helplessness, or horror for more than one month. In children, this may be expressed as disorganized or agitated behavior. The symptoms must last for one month and impair social, occupational, or other areas of functioning. The traumatic event is persistently reexperienced through one (or more) of the following:

• Recurrent and intrusive distressing recollections of the event including images, thoughts, or perceptions
• Recurrent distressing dreams of the event
• Acting or feeling as if the traumatic event were recurring (i.e., includes a sense of reliving the experience, illusions, hallucinations, or dissociative flashback episodes)
• Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
• Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness as indicated by three (or more) of the following:

• Efforts to avoid thoughts, feelings, or conversations associated with trauma
• Efforts to avoid activities, places, or people that arouse recollections of the trauma
• Inability to recall an important aspect of the trauma (e.g., a “psychic numbing” that occurs soon after the event)
• Markedly diminished interest or participation in significant activities
• Feeling of detachment from others (e.g., those emotions associated with intimacy, tenderness, or sexuality)
• Restricted range of affect (e.g., unable to have loving feelings)
• Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

• Difficulty falling or staying asleep
• Irritability or outbursts of anger
• Difficulty concentrating
• Hypervigilance
• Exaggerated startle response

The following constellation of symptoms is commonly seen with an interpersonal stressor such as childhood sexual or physical abuse, or domestic battering. These include:

• Impaired affect modulation
• Self-destructive and impulsive behavior
• Dissociative symptoms
• Somatic complaints
• Feelings of ineffectiveness
• Shame, despair, or hopelessness
• Feeling permanently damaged
• A loss of previously sustained beliefs
• Hostility
• Social withdrawal
• Feeling constantly threatened
• Impaired relationships with others
• A change from the individual’s previous personality characteristics

There may be an increased risk for panic disorder, agoraphobia, obsessive-compulsive disorder, social phobia, specific phobia, major depressive disorder, somatization disorder, and substance-related disorders.

Posttraumatic Stress Disorder and Eating Disorders: Emotional, physical, and sexual trauma profoundly affects a person’s psyche. Events such as bullying at school, being repeatedly humiliated by a teacher in front of classmates, or molestation by a neighbor happen outside the home. It also occurs within the family when one or both parents, siblings, and/other relatives are hostile, verbally attacking, hypercritical, too controlling, uncaring, uninvolved, ignoring or withdrawing from child, physically harmful, or sexually abusive.

Emotional abuse is defined as parental behaviors that are perceived as ridiculing, insulting, threatening, blaming, or unpredictable in nature. Physical abuse (both parental and nonparental) includes unexpected beatings, harsh or unexplained punishment, and a strict and inflexible home atmosphere. Neglect is defined broadly as feeling lonely, unwanted, of no interest to others, and largely responsible for one’s own needs. Sexual abuse is defined as any sexual experience with an adult (not necessarily a parent or relative) that occurs before the age of 14 and includes witnessing sexual abuse of another family member, traumatic sexual experiences, and being fearful of sexual mistreatment when parent(s) are under the influence of alcohol (Kent et al., 1999).

Anywhere from 20%-50% of anorexics and bulimics report sexual abuse (rates similar to other psychiatric populations). Childhood sexual abuse is seen more often in women with eating disorders than the general population. Eating disordered women with a sexual abuse history have higher rates of comorbid conditions compared with other eating disordered women (American Psychiatric Association, 2000).

Grant (2002) described trauma as a developmental occurrence in which there are character injuries brought on by “abandonment or annihilation anxiety” through child abuse, domestic violence, abandonment, or death of a parent. Trauma falls into two categories.

• Type I is short term, extreme, unexpected, horrific, or threatening event
• Type II is chronic, prolonged, repeated, or ritualistic

Emotional deprivation, abuse, and excessive coddling can lead to “psychological growth delay.” Heart rate, blood pressure, and bone structure are affected. The underdeveloped child has temper tantrums, reduced IQ, garbled speech, or an eating disorder. The 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 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 do control subjects. Over time, the chemicals lead the body to become stressed and hyper-aroused 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.

A single incidence of overwhelming terror can alter brain chemistry, making the individual more sensitive to adrenaline surges even decades later in life. Biological changes occur in three areas of the brain (Goleman, 1995).

• Locus ceruleus, which regulates two catecholamines (the hormones that get the body ready for emergencies), becomes hyperactive, secreting too much of these chemicals even when there is no threatening situation.
• Hypothalamus and pituitary gland increases secretions of corticotrophin-releasing factor (CRF) to mobilize the body in an emergency even when there is none.
• Opioid system, which blunts pain, is hyperactive, accounting for emotional numbing and an inability to experience tender feelings (as in the case of individuals with PTSD).

Horowitz (1976) described two groups of trauma symptoms.

• Short-term symptoms (arousal/intrusion):
• Increased startle reaction
• Hypervigilance
• Intrusive thoughts, feelings, and behaviors
• Difficulty concentrating
• Emotional lability
• Sleep and dream disturbances
• Physical symptoms related to chronic arousal (e.g., nausea, diarrhea, sweating)
• Compulsive repetitions
• Various forms of self-medication (alcohol, drugs, food, etc.)
• Other activities designed to avoid internal and external triggers
• Long-term symptoms (avoidance/denial):
• Emotional numbing
• Inability to appreciate significance of internal/external stimuli
• Avoidance of certain topics or situations
• Amnesia
• Constricted or inflexible thinking
• Use of fantasy to counteract reality
• Sleep disturbances
• Physical complaints (e.g., bowel problems, fatigue, headaches, hyper-arousal)
• Impulsivity
• Overactivity as a means of distraction
• Social isolation
• Self-blame
• Phobic responses
• Depression
• Anxiety
• Diminished self-care
• Foreshortened sense of future
• Reenactment of original trauma in play, work, or at home
• Substance abuse

An initial post-trauma response is not predictive of who will have a chronic disorder. Immediate problems such as difficulty sleeping, nightmares, or obsessive thoughts about the trauma are inevitable. The rule of thumb is that if the person continues with short-term symptoms for four months, she will probably have the symptoms after four years. If left untreated, they can last a lifetime (Henig, 2004).

Most studies have investigated the impact of childhood sexual abuse on eating psychopathology and found a strong relationship. Physical abuse, emotional abuse, and neglect have now been researched to assess their effects on food behaviors. All forms of trauma have an element of emotional abuse. Both depression and anxiety are common sequelae of sexual, physical, and emotional abuse and neglect. Kent et al. (1999) found that emotional abuse is the form of trauma that most clearly influences eating psychopathology. While physical abuse and neglect also appeared to predict eating attitudes, their impact seems to be through their intercorrelations with emotional abuse.

Medication: Buspar (buspirone) is often prescribed for PTSD. Antidepressants such as Zoloft (sertaline) or Paxil (paroxetine), which also treat anxiety, may be appropriate. Klonopin (clonazepam) is another option. Propranolol, a beta blocker given to heart patients (to inhibit the action of adrenaline on the beta-andrenergic receptors in the heart) is being researched to see if starting this medication soon after a trauma can reduce the chances of someone developing PTSD, or whether symptoms can be lessened once stirred up by another life event (Henig, 2004).

Treatment: The effects of trauma and resulting PTSD symptoms will have to be treated along with the eating disorder. The key approach to treatment is assimilating and accommodating traumatic material into a wider organization of self, world, and God. Treatment modalities include (Grant, 2002):

• Cognitive therapy to reframe beliefs that inaccurately portray traumatic events or responses, undo counterfactual thinking, expand former beliefs to incorporate trauma-generated awareness, and construct a new narrative.
• Behavioral therapy to systematically and gradually increase exposures to traumatic stimuli so as to decrease sensitivity to material that once threatened to overwhelm. Change is rewarded and self-care encouraged.
• Psychodynamic therapy to address early childhood traumas, internalized object relations (especially bad objects), countertransference, transference, and defenses.
• Existential therapy to look at, face, and own truths and vulnerabilities inherent in human existence.
• Spiritual therapy to integrate the traumatic experience into a new organization of self, life, and a sense of God.

Grant (2002) discusses the two phases of treatment:

• Phase One-Stabilization:
• Establish parameters (short- and long-term goals, therapeutic contracts, etc.)
• Develop trust and a working alliance
• Create a safe and understanding environment
• Normalize reactions to an unusual event
• Stabilize PTSD and comorbid symptoms
• Depathologize patient’s reactions
• Provide psychoeducation to reframe posttraumatic reactions
• Offer understanding and support
• Prevent further trauma (e.g., by legal and medical institutions)
• Identify triggers
• Debunk myths
• Enhance coping skills and stress inoculation
• Determine need for medication
• Develop outside support
• Nurture hope
• Phase Two-Retrieval:
• Remember the details
• Accept that things could not have happened differently
• Accurately integrate material into wider frames of understanding
• Manage symptoms
• Develop empowerment
• Manage uncontrolled catharsis
• Discover new meaning and direction

The therapist determines the patient’s capacity to do trauma work. If it is too destabilizing (e.g., therapy precipitates flooding and breakdown) then treatment shifts to psychological support, symptom management (e.g., psychoeducation, supportive counseling, and self-care), and drug therapy (Grant, 2002).

Traumatic events influence the development of negative beliefs, cognitive distortions, perfectionism, and the need for control. Patients use starving, bingeing, grazing, and/or purging to numb the emotional effects of trauma. Patients often feel fear, anxiety, anger, frustration, guilt, remorse, shame, self-disgust, and sadness (Donaldson and Gardner, 1985). As patients explore their histories and experience pain associated with the memories, their eating disordered behaviors may intensify. They will need adequate coping skills to deal with depression, anxiety, sleep interruption, and heightened emotionality. That’s why the initial focus of therapy is to reduce unhealthy food habits while increasing strategies to handle feelings. Trauma work occurs when the patient has more of an ability to explore the past.

Therapy needs to become a safe environment where patients experience emotions linked with trauma without automatic denial and numbing. Memories, perceptions about the memories, and emotional catharsis must be done in doses, often being repeated. Find the balance between denial and emotional expression so defenses are not overwhelmed by strong content. When patients recall events with less intense reactions, they can experience increased esteem and confidence (Donaldson and Gardner, 1985).

Case Vignette 4: Angela, a 33-year-old nonpurging bulimic, entered therapy to address her eating disorder, depression, and frequent phobic responses to work, social isolation, and the dark She also suffered from lupus that flared up under emotional stress. Her joints ached, she developed a fever, and a skin rash reappeared. Angela was 100 pounds over her ideal weight, although she claimed she wasn’t eating much during the day, except for bingeing a couple of times a week. In fact, she counted calories one day, and found that she consumed 450 calories. Her job as archivist for a museum ensured she didn’t interact with others on a regular basis. When she attended staff meetings or presented reports, the lupus often worsened, leading her to stay at home feeling depressed, relieved, and mad at her body. During sessions, if an ambulance drove by, she winced and covered her ears. At home, she slept with a night light on, never went out after dark, and locked herself in her house as soon as dusk fell.

Angela described a childhood in which she was overweight, dressed in hand-me-downs, and liked to play by herself in the park next door. Peers taunted and teased her unmercifully in grade school. When she told her parents, they didn’t believe her and didn’t take any action. Mom was the dominant figure and dad was passive, so what mom said was law. Mom ignored Angela’s distress and, therefore, her dad did, too. By junior high school, Angela was beaten up a number of times in the schoolyard, but when she said something to her teacher, it was Angela’s word against the other kids, who claimed she fell down while running. Her parents never asked why the knees on her pants were torn or her lip was swollen. Angela just stopped telling them anything. In high school, she was pushed so hard that when she hit the ground, she broke her wrist. Her parents blamed her for being clumsy. They didn’t believe she was that hurt so they decided not to take her to the hospital. They waited until it was so evident that she couldn’t use her hand that they finally visited the family doctor who put her arm in a cast. Angela silently endured the bullying, all the while trying to figure out how to avoid her tormenters. That’s when she decided to help out in the library during recess and after school, reducing her contact with those students.

She blamed herself for being picked on because she was “fat and ugly.” She must be worthless; otherwise her parents would rescue her. By the time Angela got to college, she was traumatized and avoided people. At least she was away from her parents and old school mates. However, she continued to have difficulty making friends and felt either invisible or stared at. The only saving grace was meeting her husband-to-be who was a very shy, quiet, and studious guy who liked her shy, quiet, and studious personality.

Therapy was a slow, unfolding process. Angela didn’t deal well with her emotions. She was easily overwhelmed, which would bring on the lupus and shut her down for a few days. We started therapy with figuring out her food intake-to- weight ratio. She kept track of everything she bought, what she ate, and what was left over the next day. We did this because her husband complained that his favorite treats were disappearing, although Angela swore she hadn’t eaten them. Then one morning, she noticed crumbs on her nightgown. She realized she must have eaten during the night but didn’t remember doing that. Her husband slept like a log and never heard her get up. She took a survey of food and realized she had eaten a whole bag of cookies and potato chips along with 1/3 of a loaf of bread with jam, adding 3,000 to 5,000 calories to what she was eating during the day. We worked towards her eating meals during the day. She had a starvation mindset. Yet her extreme calorie restriction instigated bingeing in the middle of the night. She slowly increased calories during the day and installed a bell over her refrigerator (where all snack items were kept) to wake her up from sleep eating; it worked.

She began to talk about her history but with little emotion. If she felt too much, her lupus worsened. With over a year of therapy and slow changes in food habits, Angela lost weight. She discussed events from childhood or adolescence with some emotion and reported feeling relief at being able to confide in someone who understood and cared. At the two-year mark, Angela could deal with more pain while relaying stories from her past without instigating a lupus attack. She worked on learning basic social skills to build her confidence in interacting with colleagues. She also grappled with the idea that maybe nothing was wrong with her, but that her parents were deficient in their ability to love, have empathy, protect, believe, or be her advocate. This was a hard pill to swallow, although it did bring comfort to see that maybe she’s not flawed to the core. She is still afraid of the dark and startles when there are loud sounds. Therapy has given Angela hope for a more normal life.

C. ATTENTION-DEFICIT/HYPERACTIVITY DISORDER

SKIP Diagnostic Criteria: The essential feature of attention-deficit/hyperactivity disorder (ADHD or ADD) is persistent inattention and/or hyperactivity-impulsivity that is more frequent and severe than observed in individuals at a comparable level of development. Symptoms must have been present before the age of seven, although diagnosis may occur years afterwards. Impairment must show up in at least two areas (e.g., school, home, or work) and interfere with social, academic, or occupational functioning.

Symptoms of inattention (at least six to make a diagnosis) include:

• Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
• Often has difficulty sustaining attention in tasks or play activities
• Often does not seem to listen when spoken to directly
• Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace
• Often has difficulty organizing tasks and activities
• Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
• Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
• Is often easily distracted by extraneous stimuli
• Is often forgetful in daily activities.

Symptoms of hyperactivity (six or more of either category below to make a diagnosis) include:

• Often fidgets with hands or feet or squirms in seat
• Often leaves seat in classroom or in other situations in which seating is expected
• Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
• Often has difficulty playing or engaging in leisure activities quietly
• Is often “on the go” as if “driven by a motor”
• Often talks excessively

Symptoms of impulsivity include:

• Often blurts out answers before questions have been completed
• Often has difficulty awaiting turn
• Often interrupts or intrudes on others (e.g., buts into conversations or games)

Hallowell and Ratey (1994) suggest diagnostic criteria for adults with attention deficit disorder. A chronic disturbance is met only if the behavior is considerably more frequent than that of most people of the same mental age and at least 12 of the following are present:

• A sense of underachievement or not meeting one’s goals (regardless of how much one has actually accomplished)
• Difficulty getting organized
• Chronic procrastination or trouble getting started
• Many projects going on simultaneously though trouble following through
• A tendency to say what comes to mind without necessarily considering the timing or appropriateness of the remark
• A frequent search for high stimulation
• An intolerance of boredom
• Easy distractibility, trouble focusing attention, tendency to tune out or drift away in the middle of a page or conversation, often coupled with an ability to hyperfocus at times
• Often creative, intuitive, and highly intelligent
• Trouble with going through established channels or following “proper” procedure
• Impatient and low tolerance of frustration
• Impulsive, either verbally or in action (e.g., spending, changing plans, enacting new schemes or career plans, hot-tempered)
• A tendency to worry needlessly and endlessly, looking for something to worry about alternating with inattention to or disregard for actual dangers
• A sense of insecurity
• Mood swings or lability, especially when disengaged from a person or project
• Physical or cognitive restlessness
• A tendency towards addictive behaviors
• Chronic problems with self-esteem
• Inaccurate self-observation
• Family history of ADD, bipolar disorder, depression, substance abuse, or other disorders of impulse control or mood

Attention Deficit Hyperactivity Disorder and Eating Disorders: Individuals who have both an eating disorder and ADHD/ADD feel insecure and badly about themselves because of negative self-perceptions about their ability to succeed. For those who develop anorexia, they starve to like something about themselves—their thin bodies. They feel a sense of accomplishment for being able to take charge of their weight.

Individuals with eating disorders like the anorexic side effect of ADHD/ADD medications. Ritalin, Adderall, and Cylert are stimulants that have a calming effect. They also reduce appetite, making it easier to starve. These individuals will increase their dosage to maximize weight loss. They may turn to stimulant street drugs like cocaine, crystal methamphetamine, or crack. When they need to come down, they drink alcohol. Starvation, drugs, and alcohol also numb them out. The abuse of legal or illegal drugs and alcohol leaves many poly-addicted.

Most individuals cannot maintain the anorexic stance, even with the help of stimulants, so they wind up bingeing and/or purging. The get caught up in alternating patterns between the three behaviors. They feel disgusted, adding to their prevailing belief of being a failure.

There are a number of conditions that may accompany, resemble, or mask ADHD/ADD including anxiety disorder, bipolar disorder or mania, caffeinism, depression, chronic fatigue, hyper- or hypothyroidism, obsessive-compulsive disorder, posttraumatic stress disorder, seizure disorder, situational disturbances like divorce or job loss, substance abuse (e.g., cocaine, alcohol, marijuana) or personality disorders such as narcissistic, borderline, or antisocial (Hallowell and Ratey, 1994).

Medications: As stated previously, Ritalin, Adderall, Cylert, and Strattera are prescribed to reduce inattention, distractibility, and impulsivity. Adderall is an amphetamine that has been extensively abused. Extreme psychological dependence, tolerance, and severe social disability have occurred (Physicians Desk Reference, 2000). Cylert is known to be hard on the liver, even causing hepatic failure. Strattera is a non-stimulant medication that is a selective norepinephrine reuptake inhibitor. Dexedrine, a short-acting stimulant, is considered a first-choice medication for children. Wellbutrin has also been shown to reduce symptoms. Effexor can improve attention and concentration in normal adults (Maxmen and Ward, 2002). A number of other medications help lessen mood disturbances or harmful behaviors. Lithium is used for reducing outbursts of rage; Depakote for violent behaviors; Buspar, Prozac, or Zoloft for irritability, anxiety, or depression; Anafranil, Prozac, and Zoloft for obsessive-compulsive symptoms; and Corgard or Inderal for the jittery side-effects of stimulants (Hallowell and Ratey, 1994).

Many of these patients require a medication cocktail to address all of their symptoms. Refer your patient to a psychiatrist who knows how to treat complex cases and has an expertise in ADHD/ADD and/or eating disorders.

Treatment: Individuals with ADHD/ADD believe they have less will, drive, or maturity than other people do. They don’t realize that their condition is genetically transmitted. They actually have faulty neurological wiring. In order to function better, they will need to make some important changes (Hallowell and Ratey, 1994). These include:

• Creating external structure
• Handling paperwork right away instead of placing items in a “to do” pile that never gets done
• Breaking large tasks down into small ones
• Making deadlines
• Prioritizing rather than procrastinating
• Anticipating that some projects will fall through
• Noticing how and where they work best
• Setting up a system of rewards rather than punishments
• Acceptance of fears that things won’t go well
• Allowing themselves to do two things at once
• Keeping a note pad around to write down ideas
• Doing what they’re good at even if it seems too easy

To overcome the eating disorder along with managing ADHD/ADD, patients will have to address the thoughts, feelings, and reactions that push them to starve, binge, purge, or graze. The first step is to point out the connection between negative beliefs, low self-esteem, eating disordered behaviors, and ADHD/ADD. They use or restrict food to alter appearance and mood, thus feeling better about themselves. The second step is to expand their ability to handle intense affect, learn to think before they act, organize their external world to promote success, and work to change negative beliefs about being flawed.

Hallowell and Ratey (1994) discuss healthier ways ADHD/ADD patients can cope. These techniques also help with eating disordered behaviors.

• Setting time aside each week to let loose without being destructive (e.g., blasting loud music, going dancing, attending a road rally)
• Choosing “helpful” addictions such as moderate exercise
• Building a tolerance for cyclical mood shifts by understanding that all emotions eventually pass
• Dealing with panicky feelings that arise in response to seemingly trivial, as well as large, events
• Using hyperfocusing to complete projects without turning to obsessing or ruminating over an imagined problem
• Avoiding prematurely closing a deal, project, or conversation
• Dealing with depression after a success because the conflict and chase are over with
• Letting successful moments last as long as possible

Some patients will need treatment for substance abuse if they cannot stop using drugs and/or alcohol on their own. Once they quit self-medicating, they can be prescribed appropriate medications to minimize their symptomology. For more detailed formation on ADHD/ADD, consider taking one of the three courses offered by Russell Barkley, Ph.D.

CHAPTER V: PERSONALITY DISORDERS

According to the Diagnostic Statistical Manual of Mental Disorders, Fourth Edition (American Psychological Association, 1994), a personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the person’s culture; is pervasive, inflexible, and stable over time; has an onset in adolescence or early adulthood; and leads to distress or impairment. The pattern must manifest in two or more areas:

• Cognitions (e.g., ways of perceiving and interpreting self, other people, and events)
• Affectivity (e.g., the range, intensity, lability, and appropriateness of emotional response)
• Interpersonal functioning
• Impulse control

Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are shown in a wide variety of social and personal contexts. For instance, an average of 60% of bulimics and recovered bulimics have narcissistic traits (Lehoux et al, 1999), but they do not have narcissistic personality disorder. Only when these traits become rigid and maladaptive, cause significant impairment, or are upsetting do they constitute a personality disorder. Individuals may not consider the characteristics that define their personality disorder as problematic because the traits are ego-syntonic.

Personality disorders stem largely from childhood attachment problems, leading to developmental arrest. Research has not teased out how much is due to parental abuse, childhood pathology that elicits a negative parental reaction, or interplay of both. In relationships, individuals with personality disorders often act out early abuse, neglect, violence, and other forms of attachment failures. What was done to them, they now do to others (Murray, 2004).

Ten personality disorders are clustered into three groups based on similarities. Individuals frequently present with co-occurring personality disorders from different clusters:

• Cluster A includes paranoid, schizoid, and schizotypal. These individuals often appear odd or eccentric.
• Cluster B includes antisocial, borderline, histrionic, and narcissistic. These individuals often appear dramatic, emotional, or erratic.
• Cluster C includes avoidant, dependent, and obsessive-compulsive. These individuals often appear fearful or anxious.

Approximately 42%-75% of individuals with eating disorders also have personality disorders (American Psychiatric Association, 2000). Listed below are the most common personality disorders for each eating disorder.

A. AVOIDANT PERSONALITY DISORDER

SKIP Diagnostic Criteria: The essential feature is a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation in a variety of contexts as indicated by four (or more) of the following:

• Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection
• Is unwilling to get involved with people unless certain of being liked
• Shows restraint within intimate relationships because of the fear of being shamed or ridiculed
• Is preoccupied with being criticized or rejected in social situations
• Is inhibited in new interpersonal situations because of feelings of inadequacy
• Views self as socially inept, personally unappealing, or inferior to others
• Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

Avoidant Personality Disorder and Eating Disorders: These individuals often describe themselves as being shy. Some say they’ve been this way all their lives, whereas others contend it started after isolating themselves when their eating disordered behaviors took over.

Assess family history for avoidant personality disorder or some type of abuse based on harsh judgments or outright repudiation. People who grow up in these kinds of environments decide that people cannot be trusted. They don’t develop the skills to interact effectively with others in a way that is satisfying. They want a guarantee ahead of time that they will be accepted before they take the risk. However, guarantees are seldom available in healthy relationships (Meyer, 1989).

These individuals have no close friends or confidants, except for first-degree relatives. Their depression, anxiety, and low self-esteem are related to perceived rejection and criticism from others, which keeps them from forming meaningful relationships, even though they desire this (which distinguishes them from schizotypal personality disorder) (Meyer, 1989). They tend to be shy, quiet, inhibited, and ”invisible” because they fear any attention would be degrading or rejecting (American Psychiatric Association, 1994).

Often they will turn to cyberspace chat rooms to get their connection needs met. They like the safety and anonymity. Some hole themselves up in their homes without ever reaching out to others. They become so debilitated that they avoid social activities, even refusing to work or attend school.

These individuals use their eating disorder to escape from the painful awareness that they have no close friends and/or family members. For anorexics, starving brings mastery—over themselves and their world—creating a false sense of personal power. They rationalize their solitary confinement as a way to practice their eating disorder. They can exercise whenever they want because nobody is checking up on them, and when they lose more weight no one will comment on it.

Bulimics want to numb out. When they gain weight through bingeing, they tell themselves they can’t go out with people because of the way they look. Purging can be accomplished at any time without scrutiny.

Medications: SSRIs such as Prozac, Zoloft, or Celexa can be prescribed for depression or anxiety symptoms. Buspar and Paxil are used to treat social phobia, however, as mentioned previously, the withdrawal effects from Paxil can be difficult and prolonged.

Treatment: Treatment focuses on social and assertiveness skills training along with managing anxiety around rejection. Explore how negative beliefs developed, as well as their influence on self-perceptions and the ability to have relationships. Link their eating disordered thinking and behaviors to the avoidant personality.

Some patients do not have much capacity to make positive changes. Their level of functioning stays about the same. For them, it’s a huge accomplishment to maintain a relationship with you. Often you are the first person in a long time with whom they interact in a meaningful way. The relationship can be a role model for future friendships. They will often “pooh-pooh” the relationship as not being real because they pay for your time. You will have to refute this rebuff.

Other patients can improve enough to take the risk and meet new people. It depends on how severe the symptoms are, how well they function, and how motivated they are to work on their fears. By improving communication skills, taking steps to reach out to others, and knowing they might be rejected, they can build connections with others.

As the eating disorder is addressed, patients will become aware of how much they stay away from others, how lonely they feel, how depressed or anxious they are, and how inadequate they feel in general. When they get in touch with their feelings, they can easily return to harmful habits to cope with the discomfort.

In tandem, you’ll help them reduce starving, bingeing, purging, or grazing, while nudging them to face that keeping people at bay may bring a sense of safety but also makes them forlorn. With your support and encouragement, they can take small steps to incorporate activities that will place them in a social context. Sometimes an eating disorders support group is the place to start. Patients will tell you when they’re overwhelmed. Pushing them to go beyond what they can do will reignite the eating disorder. Accept your patients’ limitations. Some cannot overcome much of their avoidant behavior. Knowing when to back off will let them know you respect their internal restrictions.

B. BORDERLINE PERSONALITY DISORDER

SKIP Diagnostic Criteria: The essential feature is a pervasive pattern of instability of interpersonal relationships, self-image, and marked impulsivity in a variety of contexts as indicated by five (or more) of the following:

• Frantic efforts to avoid real or imagined abandonment
• Pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
• Identity disturbance with markedly and persistently unstable self-image or sense-of-self
• Impulsivity in at least two areas that are potentially self-damaging (e.g., sex, spending, substance abuse, reckless driving, binge eating)
• Recurrent suicidal behavior, gestures, or threats; or self-mutilating behavior
• Affective instability due to a marked reactivity to mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
• Chronic feelings of emptiness
• Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
• Transient, stress-related paranoid ideation or severe dissociative symptoms

Borderline Personality Disorder and Eating Disorders: Maltreatment, neglect of emotional needs, and maternal verbal abuse all have an impact on the development of personality disorders. For instance, children who experienced verbal abuse, compared with those who did not, were three times more likely to be diagnosed in adulthood with borderline, narcissistic, obsessive-compulsive, or paranoid personality disorder. Interestingly, a close bond with a grandmother can offset the negative influences of a dysfunctional family (Huff, 2004).

Research investigating the severity of personality disorders and the number and type of childhood traumas found that individuals with borderline personality disorder reported high rates of sexual abuse, with 55% describing forced and unwanted sexual contact (Huff, 2004).

Genetic research suggests that the heritability rate for borderline personality is .69. These individuals also had brain abnormalities including non-localized brain dysfunction on EEG’s, smaller frontal lobes, a 16% reduction in hippocampus, and an 8% reduction in amygdala, altered serotonergic function producing impulsive aggression, and cholinergic system malfunction increasing affective instability (Hoffman Judd, 2002).

Hoffman Judd (2002) outlines the role of child maltreatment in the development of borderline personality disorder. Normal attachment to mother (and others) is impacted by emotional abuse (e.g., inconsistent treatment, denial of thoughts and feelings, parentification, and failure to protect), physical abuse by caretaker, sexual abuse by non-caretaker, and bi-parental neglect. Recurrent and intensely stressful conditions have a kindling effect on the child’s biological-behavioral system. Anxiety and fear (around safety and survival) affect the adrenal system (see Posttraumatic Stress Disorder and Eating Disorders).

Individuals with borderline personality disorder develop behavioral dysregulation in which they:

• Have developmental delays
• Have poor pragmatic language
• Let action modulate affect
• Are impulsive
• Are compulsive with food, sex, drugs, alcohol, cigarettes, and/or work
• Have limited self-care skills
• Have comorbid medical conditions such as chronic pain or fibromyalgia

In addition, they develop emotional dysregulation in which they:

• Have intense and unmodulated affect
• Either feel good or feel bad with nothing in between
• Feel chronically depressed, angry, numb, or empty
• Have poor distress tolerance

These individuals have identity diffusion in which there is no strong concept of self. They say it feels like something is missing inside. They don’t feel in control of their responses and therefore cannot predict how they’ll act. They don’t hold an integrated image of others either, which makes it difficult to assess their behaviors across time. They only read another’s behavior in the present moment.

These individuals have great difficulty managing their moods. There appears to be problems with cognitive abilities like logical verbal reasoning, abstraction, concept formation, flexibility of thought, and problem-solving. These abilities underlie the capacity to modulate affect, empathize, analyze interpersonal situations, and devise an effective interactional strategy (Hoffman Judd, 1987).

Many of these individuals are chronically depressed and/or anxious and can become easily riled leading to outbursts of rage. At times, they feel like they’re on the edge of an emotional meltdown. They feel incredibly insecure and flawed. Any slight feels like rejection, and they respond by lashing out or crumbling. They engage in eating disordered behavior to take the edge off of what they’re experiencing and to momentarily fill the internal emptiness that never goes away.

Anorexics use starving, over-exercising, or pills to keep their weight low in order to like themselves and cut off disturbing affect. Bulimics use food as a comforting friend. They also turn to food as punishment when they perceive they’ve messed up or feel abandoned by others. If food doesn’t do the trick, other substances will, which is why these individuals use many things outside of themselves to soothe. Their eating disordered symptoms often become severe and entrenched.

Suicidal ideation and action turns into a coping strategy that serves a number of purposes including momentary relief from suffering, a manipulative threat to get people to react, acting out how they feel on the inside, feeling compelled to do themselves in, or a way to say, “I screwed up and am utterly worthless.”

Medications: Any of the SSRIs can be prescribed to modulate depression. Buspar (buspirone) or antidepressants that also treat anxiety may be needed. Klonopin (clonazepam) can be used for panic disorder and atypical antipsychotics like Respirdal (resperidone), Seroquil (quetiapine), Clozaril (clozapine), or Zyprexa (olanzepine) can reduce agitation.

Treatment: To understand what kind of positive impact treatment can have on your patient, you will need to assess how impaired he is (i.e., mild, moderate, or severe). The same is true for eating disordered behaviors. You will be addressing destructive tendencies that are played out through food abuse, suicidality, poor communication and people skills, self-mutilation, promiscuity, or other self-defeating behaviors.

Hoffman Judd (2002) describes treatment goals for patients with borderline personality disorder:

• Prevent suicide or homicide
• Develop emotional and behavioral regulation
• Reduce or eliminate harmful addictive behaviors
• Stabilize and integrate attachment patterns
• Facilitate development of a sustaining psychological environment
• Preserve/build social and work functioning
• Therapist’s role is to:
• Be the stable, secure base that maintains connection
• Offer clear guidelines around availability
• Be flexible, kind, and consistent
• Be straightforward
• Focus on here and now
• Encourage use of voice mail, art, or writing as a means to maintain connection and promote use of language
• Seek consultation when needed
• Be the leader of the treatment team
• Hold the perspective when patient cannot

These are accomplished with individual therapy, group therapy, medication, hospitalization or day treatment, and substance abuse treatment.

Linehan has developed Dialectical Behavior Therapy (DBT) for individuals with borderline personality disorder. Through individual and group training sessions, patients learn distress tolerance, interpersonal effectiveness, emotion regulation, and mindfulness strategies. These patients turn to addictive behaviors in an effort to stabilize emotions and reduce arousal. They’re taught alternative ways to control overwhelming and confusing feelings. Rarely were their feelings accepted as a child. Therapy is a place to experience acceptance. Mindfulness techniques allow patients to step outside themselves and observe emotions without reacting or seeking instant relief through self-harm (Dingfelder, 2004).

Linehan’s DBT is comprised of three stages (Sleek, 1997):

• The therapist focuses on reducing the most dysfunctional and out-of- control features of the disorder like suicide attempts or self-injury. Patients discover alternatives to extreme thoughts and behaviors. Therapist emphasizes developing a good working relationship.
• Once destructive behaviors are under control, patients explore the invalidating and traumatic events, as well as their impact on emotional experiencing and processing.
• Patients start to value themselves and trust their responses versus relying on others to validate them.

Cognitive therapy can reduce emotional overload including depression, anxiety, and feelings of being worthless, unlovable, unimportant, etc. Patients explore their childhood and work to reinterpret events so that they don’t blame themselves for parents’ bad behaviors. These techniques are used with the eating disordered thinking around body image.

Behavioral therapy can lessen eating disordered behaviors and must occur in tandem with increasing the patient’s ability to calm himself down. Harmful behaviors cannot be eliminated without having something to put in their place.

Constant empathic understanding is vital so that patients can form a healthy bond with you. This is challenging because these patients have a very difficult time getting along with other people, and that will include you. They have poor boundaries and want to take up your time, energy, and interest. If you let them, they will take advantage of your availability. You must set appropriate limits as to when and how they can contact you out of session.

You may initially be idealized where you can do no wrong. Then when you say or do something that is perceived as abandoning, they turn hostile and you become the devalued object who wounded them. Without a concept of “me-ness,” they experience themselves as bad much of the time. Now the “badness” is projected on to you. With compassion, listening, boundaries, and exploring their feelings, they can begin to see the projection as a reflection of themselves. With a strong bond, you will be able to work out these impasses.

The more severe the personality disorder, the more impulsive and extreme the self-destructive tendencies can be. Depression is often driven by external circumstances (harsh feedback from others, failing at a task, experiencing rejection, etc.). They may become so depressed that their sense of reality becomes distorted. Some can have delusions or hallucinations. When they cannot keep themselves safe, consider hospitalization.

Borderline patients will compare you with other treatment team members. It is not uncommon for them to engage in “splitting,” which is an attempt to avoid intrapsychic conflicts. They see one person as a good object and the other as a bad object and will try to play one practitioner against the other. Your role is to manage the relationships with all practitioners, including informing them of splitting. Pay attention to transference and countertransference. You have to be the consistent, stable rock for them to lean on and play out their relationship dramas. Be clear and honest with everything you tell them. Timing is everything. There are occasions when they will be able to hear feedback, and also moments when the most appropriate response is mirroring and empathic understanding.

Therapeutic accomplishments are slow and patience is essential. Many of these patients never fully recover from their eating disorder, struggling with some aspect of it for the rest of their lives. If their physical health is stable, they can continue in outpatient therapy long-term.

Case Vignette 5: Holly, a 25-year-old bulimic, entered therapy after the breakup of a serious relationship. She refused to see a psychiatrist for a medications consultation. She was taking Lexapro prescribed by her female physician, whom Holly had known for years and trusted. Holly was suicidal, but had no concrete plan. She was so distraught that she was bingeing uncontrollably and vomiting during the day and then getting drunk with friends at night. She only drank to excess whenever she thought she was going to be, or actually was rejected, by her boyfriend. At work the next day, she would pull it together masking that she felt out of sorts. The children at the day care center where she worked never seemed to notice her fatigue or depression.

Holly had a hard time building a therapeutic relationship because she said she didn’t trust most people, especially therapists. It’s their job to care. The first few sessions were structured to support Holly through the crisis. She talked about a series of relationships in which things would be going well and then she would freak out that the boyfriend might leave. She went into what she called her “drama mode” in which she would tell her partner she was sure he was going to leave, so he might as well do it now. No matter how he tried to reassure her he wasn’t going anywhere, he eventually broke up with her after days of draining fights. She’d tell herself, “See, everyone leaves.” Holly binged and purged until she felt exhausted.

In therapy, she watched for signs of disapproval—a look, a gesture, a tone. If she perceived criticism, she would withdraw and not talk, saying she wanted to go home. She left therapy early, only to call that evening or a day later, asking to talk about what happened and what was said or done to offend her. She also called every weekend when she was drunk and threatened suicide. In session, Holly complained that the therapist wasn’t demonstrative, so how could Holly know if the therapist really cared. Building boundaries and clear guidelines for contact became an important therapeutic goal. Initially, Holly said she didn’t like the rules and again withdrew. She didn’t call and waited until the next session to bring up her grievances, which were thoroughly discussed. At the same time, Holly was encouraged to step outside herself and observe what was happening that had stirred such powerful emotions, then pull back from reacting to let the emotions dissipate.

While working with the borderline personality symptoms, the eating disorder and substance abuse symptoms were also addressed. Holly felt so flooded by feelings that food and alcohol were the quickest ways to make feelings bearable. Purging not only prevented weight gain, but also served as punishment for being unlovable. If her weight went up, she berated herself, which created intensely dysphoric moods. A dietician designed meal plans to foster structure and predictability. Holly was sure she couldn’t follow the plan. She couldn’t even get herself to grocery shop consistently. Part of every session was reserved to discuss the struggles with bingeing and purging. Particular emphasis was placed on three meals to reduce bingeing from hunger. She had to call her best friend, write down her feelings (she had been a literature major in college), or get herself out of the house if she thought she might binge or purge. It took Holly over two years to make significant changes in food habits, like going to the grocery store weekly and eating meals regularly. Her purging was cut in half.

For a couple of years, Holly continued her pattern of dating, breaking up, and becoming suicidal until she met a patient and unique man. She didn’t want to lose this one, so when she panicked, she employed a technique taught to her in therapy. She would not bait him into a fight. Instead, she would tell him she would talk to him later and deal with her feelings on her own. She began by looking at the fact that he showed her loving, caring behaviors. Holly went through her emotions and then called him back when she was calmer. She made conscious attempts to stay at home instead of drinking with friends. Sometimes she was successful and sometimes she gave in and partied. Then she reminded herself that she easily feels abandoned. When Holly was three-years-old, her mother started to lock herself in her bedroom for hours when Holly did something her mother didn’t like. Her father was in the military and deployed often. When he was in town, he hung out with his buddies. After five years of therapy, Holly was not yet free from bulimia, although she had days—even weeks—at a time in which she didn’t binge or purge. Her excessive drinking became less frequent, as did her relationship sabotaging behaviors. She even admitted that she was handling her emotions better. She still claimed not to trust her therapist and may never do so, although she continues therapy.

C. DEPENDENT PERSONALITY DISORDER

SKIP Diagnostic Criteria: The essential feature is a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation in a variety of contexts as indicated by five (or more) of the following:

• Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others
• Needs others to assume responsibility for most major areas of her life
• Has difficulty expressing disagreement with others because of fear of loss of support or approval
• Has difficulty initiating projects or doing things on his own (because of lack of self-confidence in judgment or abilities rather than a lack of motivation or energy)
• Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant
• Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for herself
• Urgently seeks another relationship as a source of care and support when a close relationship ends
• Is unrealistically preoccupied with fears of being left to take care of himself

Dependent Personality Disorder and Eating Disorders: Individuals with dependent personality disorder have a pervasive need to cling to people who have stronger personalities and will make a wide range of decisions for them. They have little initiative and are rather naïve. They have successfully found a way to elicit a desired relationship, even if the cost is their own expression of themselves. Anxiety and depression arise when they’re not in a dependent relationship. Anxiety also surfaces when they think they’re being abandoned (Meyer, 1989).

Dependent personality disorder seems to be more environmentally influenced than other personality disorders, such as antisocial, borderline, or obsessive-compulsive, which have genetic links (Huff, 2004). There are a number of family scenarios that foster dependency. When parent(s):

• Do everything for their child so the child doesn’t know how to, or think it is necessary, to take care of himself
• Withhold affection or attention causing their child cling to them out of fear
• Role model dependency as a way to keep the marital relationship intact

Dependent personality is found most often in women who ascribe to a traditional female role in relationships. They make extraordinary sacrifices or put up with verbal, physical, or sexual abuse. When a relationship ends, they quickly and indiscriminately seek another one to provide care and support because they don’t think they can function on their own (American Psychiatric Association, 1994).

These individuals may become “addicted” to another person. There may be an addictive element in all love relationships. Nevertheless, when “I need you” becomes a controlling force and inner coercion, the relationship turns the addictive corner. Maintaining connection is the main goal and is accomplished through control so that attachment needs are met. Control is accomplished through power, weakness, servitude, guilt, and jealousy. Halpern (1982) describes five signs of addiction to a person:

• Objective judgment (and the judgment of others) says that the relationship is bad and improvement cannot be expected, yet no steps are taken to break off the relationship.
• Reasons are given for staying that do not hold water or are not strong enough to balance the negatives in the relationship.
• Thinking about ending the relationship brings feelings of dread, even terror, and leads to clinging to the relationship.
• When steps are taken to end it, acute withdrawal symptoms, including physical distress, can only be relieved by reestablishing contact.
• When the relationship is really over, feelings of being lost, alone, and empty are followed by a feeling of liberation.

Their eating disorder keeps them dependent on their partner, parents, therapist, and other professionals. In their minds, recovering from their eating disorder means that they will have to become self-sufficient, which is too anxiety-provoking, so they stay unwell.

Medications: Any of the SSRIs can help to alleviate the depression, and some of them can pinpoint the anxiety. Buspar (buspirone) can also alleviate anxiety symptoms.

Treatment: Dependent behaviors are ego-syntonic. These patients don’t feel distress unless they’re not in a relationship or have just broken up with someone. They don’t see a problem being dependent, even if they’re treated poorly. What matters most is that their partner stays. Any show of independent thinking or action threatens the relationship, either in actuality or in their minds.

Breaking an addiction to a person means that all the fears about losing the (unhealthy) relationship must be faced and felt. Foster exploration of the realities of the relationship along with the path the patient must walk to break up and move on. This is a slow and, at times, arduous process. All the early attachment and abandonment issues surface and have to be worked through as well.

Explain how their eating disorder keeps them dysfunctionally attached in relationships. They will have to face their fear that recovery means people will stop caring. They don’t understand that they can have a fulfilling relationship without holding the other person hostage by an eating disorder. Explore the family history to grasp the roots of the personality disorder. Examine the messages they received or the experiences they had that ignited the eating disorder. Help them to deal with wounding events and the resulting emotions.

It’s likely that the patient will become dependent upon you. It can be very flattering to have the patient hang on every word, wanting to follow your advice. However, if they do, they will recover and therapy will end. Therefore, they don’t make much effort to change. Recovering becomes secondary. Maintaining the relationship with you is much more important. As you encourage self-sufficiency, you will receive resistance, even anger. These aspects of therapy must be explored so the patient can be conscious of unconscious motivations.

Depending on how severe the personality and eating disorder are, these patients can reduce eating disordered behaviors while increasing their awareness and ability to deal with abandonment worries. Assertiveness training teaches them to get needs met in ways that are more functional. As patients show more independence, parents and partners may be resistant. They will also have to adjust and make changes. Family and/or couples’ therapy can help all involved to make the transitions necessary to support your patient’s recovery.

D. HISTRIONIC PERSONALITY DISORDER

SKIP Diagnostic Criteria: The essential feature is a pervasive pattern of excessive emotionality and attention-seeking in a variety of contexts as indicated by five (or more) of the following:

• Is uncomfortable in situations in which she is not the center of attention
• Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior
• Displays rapidly shifting and shallow expression of emotions
• Consistently uses physical appearance to draw attention to self
• Has a style of speech that is excessively impressionistic and lacking in detail
• Shows self-dramatization, theatricality, and exaggerated expression of emotion
• Is suggestible, e.g., easily influenced by others or circumstances
• Considers relationships to be more intimate than they actually are

Histrionic Personality Disorder and Eating Disorders: Most individuals with histrionic personality disorder are women. Anecdotal evidence suggests that this personality disorder is also seen in homosexual males. These individuals have dramatic and intense behaviors, seeking attention by being sexually seductive. Forming new relationships is relatively easy because they come off as empathic and socially able. However, they tend to be temperamentally and emotionally insensitive. With little insight, they avoid blame for any difficulties in relationships. They overreact and respond more intensely and dramatically than is appropriate for the situation. For instance, after flirting with a man, a woman feels insulted or even attacked if he responds to her sexual overtures (Meyer, 1989).

These individuals use starving and/or purging to manage weight and create an attractive appearance. They are highly invested in being sexually appealing. Their makeup and clothing is flamboyant and often inappropriate for work, school, or social functions. The message is, “Look at me!” It is not uncommon for them to turn to plastic surgery (sometimes multiple times over the years) to enhance their figure or to stop signs of aging.

Eating disordered behaviors also reduce the intensity of painful affect concerning flaws in appearance or rejection from others. Anorexics like being the thinnest girl around. Bulimics binge to stop feeling. Potential or actual weight gain drives them to purge, starve, use diet pills, or other substances to reduce their appetite. Staying a normal weight is not acceptable.

Their investment in their image as a people magnet is very ego-syntonic. They see nothing wrong with being sexually seductive. When relationships fail, they don’t think their behaviors influenced the situation.

Medications: If the patient is depressed, any of the SSRIs can be prescribed. Anxiety can be managed with some of the SSRIs or medications like Buspar.

Treatment: These individuals enter therapy when their eating disorder spins out of control, especially when they cannot stay underweight. Sometimes they come in when a relationship fails and their distress to too much to handle. Their lack of insight or willingness to take responsibility for their actions can hamper productive therapeutic work.

These patients are very engaging, but ultimately, their relationship with you will seem superficial, even shallow. Their dramatic stories are entertaining, but insight into how they contribute to the problems in their lives is lacking. They often don’t have much desire to look at their role.

The goals of therapy are twofold The first is to address their eating disorder. Their efforts to lose weight and appear sexually appealing add to their false image used to attract people. Many of these patients are not willing to give up their destructive eating habits if that means gaining weight. They’d like a guarantee that this won’t happen. You’ll have to be patient with them when they show little interest in changing. Explore their upbringing to gain an understanding of what led to the development of their personality disorder and eating disorder. Addressing early wounds can be beneficial for these patients.

The second goal is to raise their conscious awareness of how their shallow interactions affect others and don’t meet their emotional needs. Better coping and communication skills may lead to more meaningful relationships that have a chance of surviving for a longer period. These patients have to be willing to tone down their inappropriate sexualized presentation (especially in work, school, or church situations), finding other ways to draw people to them.

You’ll have to assess their willingness to make changes. For some, their personality disorder has solidified. They cannot improve their ability to have healthier relationships, whereas others are able and want to make shifts in thinking and behaviors. Any reduction in harmful food or relationship responses along with increasing functional coping strategies is considered a success.

E. OBSESSIVE-COMPULSIVE PERSONALITY DISORDER

SKIP Diagnostic Criteria: The essential feature is a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency in a variety of contexts as indicated by four (or more) of the following:

• Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost
• Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because her own overly strict standards are not met)
• Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity)
• Is over-conscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification)
• Is unable to discard worn-out or worthless objects even when they have no sentimental meaning
• Is reluctant to delegate tasks or to work with others unless they submit to exactly his way of doing things
• Adopts a miserly spending style towards self and others; money is viewed as something to be hoarded for future catastrophes
• Shows rigidity and stubbornness

Obsessive-Compulsive Personality Disorder and Eating Disorders: Obsessive-compulsive personality disorder is often confused with obsessive-compulsive disorder. The person with a personality disorder seldom becomes obsessed with issues. Rather it is a lifestyle in which obsessive-compulsive features are pervasive, chronic, and ego-syntonic. They rarely enter therapy unless coerced for some reason. These personalities are preoccupied with rules, duties, productivity, and efficiency. They’re unable to express warmth or caring except in limited situations. They’re generally emotionally insensitive and distant. Their compulsivity works for them (in completing tasks) and only becomes a problem when it overwhelms the rest of their personality. Ironically, they are often indecisive and poor planners of their time as a result of too narrow a focus and concern with precision, even when precision doesn’t matter. They are inclined to be excessively moralistic, litigious, and hyperalert to criticism or perceived slights from other people (Meyers, 1989).

This personality disorder is most often found in those with anorexia. One study stated that 35% of anorexic patients met the diagnostic criterion for obsessive-compulsive personality disorder whereas only 5% of bulimic patients did so (Thornton and Russell, 1997).

Anorexic thinking and behaviors fit well into this personality organization. These individuals focus on creating and following rules and then carrying them out in the most productive manner. For instance, an anorexic patient will decide to do sit ups, pushups, and leg lifts in the evening after everyone else has gone to bed. The routine can never be postponed, and the amount of repetitions done for each exercise must always be observed. Increasing the amount is allowed, decreasing never is. Once a new rule is made, it must be followed. They fall into the same trap with food. Once an item is eliminated from meals, it cannot be reintroduced, which is why their food choices become narrow and rigid. Bulimics rarely have obsessive-compulsive personality disorder. When they do, their rule structure is similar to anorexics. Invariably, they binge or purge which means they’re breaking the rules. They feel horrible about not being able to stay in control.

These individuals are the same way with work, school, and hobbies. They make rules and shoot for efficiency, even though this can get in the way of actually accomplishing tasks in a timely manner or sometimes at all.

Their relationships suffer because they’re so rule-oriented. Rules matter more than people do, which is why they devalue and shun relationships. Their moralistic and rigid attitudes alienate others and they’re not fun to be around. They do not invest in other people and people avoid them.

Medications: To treat accompanying depression, many of the SSRIs may be appropriate including Prozac (fluoxetine) and Zoloft (sertaline). Anxiety is the more common mood disorder, and either an SSRI or Buspar (buspirone) may be beneficial.

Treatment: The primary focus is reducing anorexic or bulimic behaviors. Their anxiety increases when you propose relaxing food and exercise rules. They have organized themselves around these directives, which provide them with consistency, control, and structure.

Some patients will be able to shift one set of unhealthy rules for a set of healthier ones. The fear of weight gain is monumental and they will take it very slowly. Your input may not be regarded positively because they don’t invest much in other people’s opinions. Therefore, fostering a therapeutic alliance may not happen easily or smoothly. The more you encourage change, the more rigid they become.

If a patient stays in therapy and forms some attachment to you, this bodes well for the person developing connections with others. Some patients are so impaired that few personality or eating disorder traits diminish. Sometimes it is an accomplishment for them to continue therapy and have a limited relationship. As long as they are not in physical danger from their eating disorder, long-term care may have an effect of chipping away at their dysfunctional personality characteristics and eating disordered thinking and behaviors.

CHAPTER VI: SELF-DESTRUCTIVE BEHAVIORS

Many patients with eating disorders have a variety of impulsive behaviors including self-mutilation, overspending, shoplifting, promiscuity (American Psychiatric Association, 1993), and substance abuse.

A. SELF-INJURIOUS BEHAVIOR

There are a number of ways individuals self-injure. Behaviors range from picking, cutting, scratching, burning, or digging holes (in the skin, scalp, or genital area) to hitting, punching, or breaking their own bones. These individuals hurt themselves in places where no one can see so they don’t have to account for the injury. It is a very shame-based action, which is kept secret.

These individuals have few internal resources to modulate affect. Their misery is so intense that they cannot rely on effective coping strategies to turn down the volume of their anguish. Any kind of loss, disappointment, or failure can instigate self-injury. It also serves as punishment for being flawed. They believe things won’t go their way. They deserve nothing better. Self-injury is effective in transferring internal suffering to external pain, which can be easier to handle.

More often than not, those who self-injure are depressed and often have a personality disorder (e.g., borderline). Those who are neurotically ego-organized rarely turn to self-injury because their distress is less severe, their beliefs less negative, and their coping skills more diverse and effective.

Eating disordered behaviors don’t always work as intended, so self-injury adds to the repertoire of dysfunctional techniques used to manage moods. Starving, bingeing, or purging can turn into a kind of self-injury. For example, a woman who cannot calm herself down after a heated fight with her husband binges and purges twenty times that day until she throws up blood, blows blood vessels in her eyes, and barely moves from the bathroom floor because her heart rate is so irregular that she thinks she’s having a heart attack. Her focus shifts from being distraught over the fight to being a listless body that aches.

The family environment may play a role in the comorbidity of eating disorders and self-injurious behavior (SIB). Claes et al. (2004) found a significant difference between patients who have an eating disorder and SIB and those with only an eating disorder. Families of individuals with both an eating disorder and SIB were less expressive, less cohesive, and less socially oriented. In addition, they were found to be more conflicted and disorganized.

Medications: Any of the SSRIs can be used to treat depression and anxiety symptoms. Buspar (buspirone) can be used as well. Klonopin (clonazepam) can be prescribed for panic symptoms. Atypical antipsychotics like Respirdal (resperidone), Seroquel (quetiapine), Clozaril (clozapine), and Zyprexa (olanzepine) can reduce agitation.

Treatment: These individuals are not going to reveal that they self-injure. Patients who have addressed this in therapy before may let you know. Otherwise, it stays hidden. They are embarrassed and worried that you’ll judge them. They won’t risk changing whatever positive opinion you have about them. If you suspect or notice hard evidence like scars, ask them about it.

These patients may be reenacting traumatic experiences and hurting their bodies in the same way they were was abused. The intensity and severity of trauma gives you an idea about the reasons for, and forms of self injury.

These patients act out what they’re feeling because they have difficulty identifying, expressing, or regulating affect. They resist talking about what’s going on because they don’t really trust others. Early life experiences taught them not to. If they tell a family member or friend, the reaction and advice they receive often is not beneficial. Their emotions are so intense, floridly descriptive, and illogical that they scares people, especially when they don’t seem to end from day to day or week to week. They may not talk about self-mutilation because they don’t want to give up the one sure-fire strategy that mitigates their agony.

Cognitive, behavioral, insight-oriented, and process-oriented therapies are effective in reducing self-injury and eating disordered behaviors at the same time. These patients will have to become strong enough to handle a wide range of emotions and not take them out on their bodies.

Therapy helps patients to:

• Identify when and where they engage in self-injury
• Understand why they choose a certain form of self-injury
• Connect self-injury to starving, bingeing, and/or purging
• Decipher beliefs, thoughts, and feelings that foster self-injury
• Learn cognitive strategies to reduce intensely painful affect (thought stopping, healthy self-talk, refuting the critical voice, etc.)
• Develop behaviors to replace self-injury (e.g., call a support person; write, draw, sculpt, or dance feelings; punch or scream into a pillow; go for a walk; leave the place where behavior takes place; sit with feelings as long as possible; stand on toes until a charley horse develops; hold a book out at arm’s length until the pain is unbearable; write on the body with markers instead; use other calming techniques such as taking a bath, swimming, go to funny movie; exercise moderately)
• Draw up a step-by-step plan to prevent behaviors (i.e., from the moment the thought of harming self enters the mind to the point when an alternative behavior is chosen)
• Create a contract with you to reduce destructive behaviors including permission to call you instead of acting on the impulse to self-injure
• Learn healthy expressions of affect
• Accept hospitalization to be kept safe

Your empathy, understanding, and nonjudgmental approach will bring comfort to your patients even when what they are doing is dangerous. Self-injury is a learned behavior and can be unlearned when new ways of dealing with the past and present are introduced.

Case Vignette 6: Adam, a 20-year-old binge-eating, purging anorexic, entered therapy because his college gymnastics coach was worried about his dramatic weight loss. Adam began the sport in high school and liked the rush he got, not only from the exercise, but also from the praise he received from his parents. Dad had been a competitive gymnast throughout his school years but injured his back and had to stop. Adam wanted to please his parents. He’d received little approval from them. Both parents were harsh taskmasters and strict disciplinarians. Rarely did Adam feel like he measured up. Dad was especially brutal if Adam made mistakes like not cleaning his room to certain specifications, spilling his milk or juice at mealtime, or getting rough with his younger brother while playing in the back yard. Dad pulled out the belt and would not only threaten but would use it if Adam didn’t respond quickly enough. Mom never intervened. She also believed in a well-ordered house and perfectly behaved children.

Adam took up gymnastics (just as Dad had) and worked diligently to become the best. During his sophomore year in college, he read a diet book that said athletes could improve performance by eating fewer carbohydrates and increasing protein and fat. He started to follow one of these diets. Initially, he performed better when he ate fewer carbohydrates. His weight dropped. Within a few months, he felt fatigued and his muscles ached. He couldn’t complete his routines as he had before. Adam felt distraught. He binged on a whole bag of chocolate-covered nuts his roommate had in the pantry. This was new and quite unsettling! He went out and bought some laxatives. Afterwards, he vowed never to let that happen again. Yet he continued to binge, first infrequently, then weekly. He limited himself to three or four chocolates and always took laxatives afterwards.

Between over-exercising, dieting, bingeing, and taking laxatives, Adam’s weight continued to drop, as did his athletic ability. One night when he was extremely frustrated, he took out his pocket knife and carved a hole in his inner thigh. He went into a dissociative state in which he didn’t feel connected to his actions, although it did take his mind away from his blue mood. Afterwards he was horrified and told himself he would stop. Of course, that didn’t happen. He cut his leg to cut off feelings that came every time he thought he’d failed. The scars were hidden under his clothing so no one suspected and he liked that. What was evident was the weight loss.

When Adam entered therapy, he came for his eating disorder, not the cutting. He was ashamed and thought he could discontinue on his own. Adam was referred to a dietitian who understood eating disorders and athletes’ nutritional needs. He was shocked at how many calories he should be eating, including carbohydrates. His obsessional side took over and he followed the meal plans precisely. He knew he had to gain weight and was willing to because he wanted to be a better athlete. He realized this was, in part, to get approval from his parents. He couldn’t waver from the plan but couldn’t eat out because of the unknowns. His bingeing and purging lessened as his hunger abated.

A psychiatric consultation yielded the decision for Adam to take Zoloft. Within a month, his depression and obsessive-compulsive tendencies decreased. He dealt with the weight gain by acknowledging that his performance improved and he felt stronger and healthier. Adam finally brought up the cutting after he had read an article about self-mutilation. He said he found it really hard to give it up because it’s “what I do when I’m stressed.” Even though he reduced eating disordered behaviors, somehow this seemed different. Everyone noticed the weight loss, no one knew about this. He said he could continue forever, except that he was worried the sores would become permanent scars. And it did upset him that he resorted to this behavior. The momentary escape from reality was very seductive. We discussed the possible link between his father physically punishing him for failures and Adam physically hurting himself for failing. Time was spent exploring his childhood while instigating behavior change techniques to reduce the cutting. He got rid of his knife and agreed not to find a replacement. He identified the situations that led him to cut. At those times, he had to do something else when the urge arose. He sat with the discomfort as long as he could. When that wasn’t enough, he went for a half-hour walk or shot hoops. If he was overwhelmed, he reluctantly called his therapist to walk him through without harming himself.

Adam found the behavior very difficult to give up—and he did replace his knife. If he didn’t cut as much, his restricting reemerged. For months, the two behaviors seesawed. They intensified when he talked about his father and mother. Once he could see the relationship between how he was raised, what he believed about his worth, how this affected his thinking, the feelings it produced, and his harmful habits, he was amazed at the chain reaction. With many more months of behavioral strategies, shoring up his capacity to cope, and feeling the pain of the past, his cutting and restricting began to remit. Adam has a ways to go, although he has learned that he can make it through what he thought was intolerable.

B. SUBSTANCE-RELATED DISORDERS

Substance-related disorders include the abuse of a drug or alcohol, the side effects of a prescribed or over-the-counter medication, and accidental or intentional exposure to a toxin such as fuel, paint, antifreeze, or pesticides. These disorders are divided into two categories: Substance Dependence and Substance Abuse. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition outlines both criteria (American Psychiatric Association, 1994).

1. SUBSTANCE DEPENDENCE

SKIP Diagnostic Criteria: The essential feature of substance dependence is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite substance-related problems. It is a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

• Tolerance, as defined by either of the following:
• A need for markedly increased amounts of the substance to achieve intoxication or desired effect
• Markedly diminished effect with continued use of the same amount of the substance
• Withdrawal, as manifested by either of the following:
• The characteristic withdrawal syndrome for the substance
• The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms
• The substance is often taken in larger amounts or over a longer period than was intended
• There is a persistent desire or unsuccessful efforts to cut down or control substance use
• A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects
• Important social, occupational, or recreational activities are given up or reduced because of substance use
• The substance use is continued despite the knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)
• Specify if:
• With Physiological Dependence: evidence of tolerance or withdrawal
• Without Physiological Dependence: no evidence of tolerance or withdrawal

2. SUBSTANCE ABUSE

SKIP Diagnostic Criteria: The essential feature of substance abuse is a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

• Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
• Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
• Recurrent substance-related legal problems (e.g., arrests for substance-related conduct)
• Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
• The symptoms have never met the criteria for substance dependence

Substance-Related Disorders and Eating Disorders: Drugs and alcohol serve much the same purpose as food. When starving, bingeing, and/or purging are not powerful enough, other stronger substances do the job.

Depression and/or anxiety commonly underlie substance abuse and eating disorders. Ingesting something is a temporary escape that has to be repeated. This leads to emotional and psychological dependence. Withdrawal causes these emotions to intensify, pushing the person to ingest the substance of choice.

Some individuals start using drugs before they develop their eating disorder. Illegal stimulants like cocaine, crack, crystal methamphetamine, speed, and ecstasy produce an intense euphoric state, boundless energy, and sleepless nights. Legal stimulants like Ritalin, Dexedrine, Adderall, and Preludin increase alertness, energy, and attention span. Stimulants also reduce appetite. Many users (especially females who buy into the socially-sanctioned anorexic image) like the weight loss. However, hunger returns once the drug effects wear off so they take more of the substance. Others already starve themselves. They discover through casual use that these drugs make it easier to restrict. Those who abuse stimulants will often turn to alcohol to bring them down so they can sleep. Either path can lead to an inability to stop at will.

Marijuana is chosen for its euphoric and mellowing effects. OxyContin, Vicodin, Lortab, Percocet, and Percodan are addictive painkillers that obliterate physical (and emotional pain). OxyContin and Percodan are considered the most powerful painkillers. People become physically and emotionally dependent, and then addicted (Kalb, 2001).

Alcohol, though, is often the substance of choice. Teens experiment with drinking because it’s legal. They can get it at home or persuade someone to buy it for them. Alcohol is a central nervous system depressant that initially evokes pleasurable sensations and relaxes inhibitions. Much like food, alcohol soothes and numbs. Only one in nine drinkers becomes an alcoholic, and of those, 50%-60% have a genetic predisposition. Research suggests that once excessive drinking begins, alcohol resculpts the brain regardless of family history, creating addiction. Alcohol affects the amygdala, a part of the brain that aids the body is stress reduction (Brink, 2001).

Drinking one or two drinks a day causes weight gain by increasing overall caloric intake, burning calories less efficiently, and promoting fat storage. Alcohol also contains few vitamins or minerals (UC Berkeley Wellness Letter, 1997).

Addictions are not uncommon for those with an eating disorder. Approximately 30%-37% (American Psychiatric Association, 2000) of bulimics become addicted to some kind of substance. They have poor impulse regulation. Only 12%-18% (American Psychiatric Association, 2000) of anorexics become addicted. They value being in control at all times. Childhood trauma, family history of substance abuse, and/or having a personality disorder (especially borderline) portends the use and abuse of drugs or alcohol.

In one study, one fourth (27%) of the female subjects who had an eating disorder also reported a lifetime history of an alcohol use disorder (abuse or dependence). The study lasted 8.6 years, and over that time, 10% of the subjects developed an alcohol use disorder suggesting that the influence of eating disorders on alcohol abuse or dependence appears to be greater than the reverse. Poor psychosocial functioning and history of substance use predicted the onset of abuse or dependence. Also, having an alcohol use disorder did not influence recovery from either anorexia or bulimia (Franko et al., 2005).

Research has investigated the neuroscience behind addiction. The instant an individual ingests a substance (e.g., alcohol, cocaine, marijuana, heroin, nicotine, even chocolate), a neurological chain reaction occurs. Potent molecules surge from the bloodstream into the brain releasing dopamine in the nucleus accumbens, a key pleasure circuit region. Dopamine is associated with pleasure and elation, and may be what is described as the “master molecule of addiction.” The exhilarating rush reinforces the drive to take drugs repeatedly (Nash, 1997).

People, places, and objects associated with a substance use can become imprinted on the brain. Each cue sets off cravings. Several dopamine genes have been tentatively (and controversially) linked to alcoholism and drug abuse. Researchers theorize that variations of these inherited genes modify the efficiency with which nerve cells process dopamine, making the synapses dopamine-poor. Labeled by some researchers as the reward-deficiency syndrome, they hypothesize that low dopamine caused by the D2 gene may be involved in severe alcoholism, pathological gambling, binge eating, and attention deficit hyperactivity disorder (Nash, 1997).

Different substances affect the dopamine system in different ways:

• Alcohol opens the neurotransmitter floodgates by releasing dopamine, serotonin (governing the sense of well-being), and brain opioids. Alcohol disturbs glutamate, which brings about the initial high, and GABA, which dampens neuronal firing and makes the drinker sleepy (Begley, 2001). Now researchers believe that the frontal cortex, the brain’s executive branch responsible for decisions and memory, holds a memory of pleasure as strong as the original pleasure and demands another drink. Alcohol may put a stamp on areas of the frontal cortex involved in judgment and impulse control (Brink, 2001).
• Amphetamines block the transporter molecule that mops up dopamine sloshing around neurons. They also push dopamine out of the sacs called vesicles, where neurons store this neurotransmitter. More dopamine means more neurons firing in the pleasure circuit (Begley, 2001).
• Cocaine also blocks the transporter molecule. It fills the area so that dopamine cannot be removed, leaving it to continue firing (Begley, 2001).
• Heroin stimulates dopamine-containing neurons to fire, releasing dopamine into the nucleus accumbens and excites some of the same neurons that our brain’s natural opioids do (Begley, 2001).

Chronic use of substances reduces dopamine receptors. Therefore, with fewer receptors, the hit that used to produce a high no longer does. A physiological tolerance develops. Simple activities no longer bring pleasure. With abstinence, the brain is deprived of its one source of dopamine. To escape the withdrawal dysphoria, the person has to use again, pointing to why addiction is a brain disease (Begley, 2001).

Medications: Two medications help alcoholics stop drinking. Antabuse makes the user physically sick but it doesn’t lessen cravings. Naltrexone (ReVia) removes cravings. Anorexia is a side-effect in 1%-9% of individuals who take Naltrexone. SSRIs are prescribed for alcoholism because they may prevent relapse in nondepressed alcoholics, reduce the impulsive drive to drink, and reduce depression (Maxmen and Ward, 2002). Anxiety can be managed with some SSRIs or Buspar. Seroquel, Respirdal, Clozaril, or Zyprexa (atypical antipsychotics) can decrease agitation. Klonopin can be prescribed for panic disorder.

Treatment: In the initial clinical intake, ask about alcohol, and legal as well as illegal drug usage. You may or may not receive a truthful answer depending on whether the person wants to admit to, or would even define her/his consumption, as a problem.

Once you have an idea of the kind and quantities of substance(s) consumed, assess how this interplays with the eating disorder. Are amphetamines used to sustain starvation? Does alcohol serve as liquid meals (to avoid food calories) when drinking with friends? Does marijuana cause munchies leading to unwanted bingeing? Casual use is vastly different from chronic abuse.

Discuss with your patient how the substance(s) are affecting her:

• Eating disorder
• Moods
• Health
• Work or school
• Relationships
• Overall functioning
• Ability to cope with stress
• Sense-of-self

Once you’ve gathered all this information, decide if you can treat the substance use and eating disorder on an outpatient basis. You will also have to decide if you have the expertise to work with both issues, or whether you need to bring on board a therapist to manage the substance abuse treatment.

Put together a treatment team that will support your patient’s recovery. The more the psychiatrist, physician, and dietitian have experience in the treatment of both, the easier the coordination and goal setting will be.

• Psychiatrist: Even if the patient is currently on some form of psychotropic medication, you may decide to request an evaluation so that the eating disorder, mood disorders, and addiction are all addressed.
• Physician: A thorough physical exam will give you and your patient information about health consequences of both disorders (e.g., raised liver enzymes from alcohol abuse, osteoporosis from prolonged starving)
• Dietitian: Nutritional counseling with an expert who understands both disorders will help the patient restore nutrients that are lacking due to protracted substance use and the eating disorder (e.g., hypoglycemia and vitamin/mineral/amino acid deficiencies in alcoholics, electrolyte imbalances in bulimics)

Twelve-step or other addiction recovery groups like Women for Sobriety will also give added support.

If your patient is has a substance-related disorder and cannot stop while in outpatient therapy, consider inpatient treatment. The ideal solution is to find a program that treats both problems. These are not always available or are prohibitive because of out-of-pocket costs. If your patient is admitted to a substance abuse treatment facility, combine your treatment with the program’s so you focus on the eating disorder while they address the addiction. Work with the treatment team to inform and educate them on the interaction of the two disorders (if they’re open to your input, which may or may not be true).

You’ll utilize cognitive, behavioral, interpersonal, and psychodynamic therapies (just as you do with the eating disorder). Therapy focuses on:

• Breaking through the denial of the seriousness of the substance-related disorder (and eating disorder)
• Dealing with withdrawal symptoms (varies according to substance with most symptoms being the opposite of those observed during intoxication)
• Acute withdrawal occurs within 6-48 hours, lasting up to 10 days
• Delayed withdrawal lasts six months to two years
• Handling physiological and psychological complaints that include:
• Fatigue
• Dizziness
• Headaches
• Confusion
• Short attention span
• Sleep problems
• Bad dreams
• Irritability
• Emotional lability
• Depression
• Anxiety
• Poor judgment
• Cravings
• Exacerbation of the eating disorder (e.g., bingeing on sugar after alcohol withdrawal; starving while on amphetamines, bingeing when abstaining, purging to prevent weight gain)
• Endorsing behavioral changes to reduce and eliminate drinking behaviors
• Increasing coping strategies to deal with emotional upsets
• Reducing impulsive behaviors and responses to cues that stir cravings
• Promoting daily structure with work or school, family, food, and sleep
• Teaching stress management skills
• Identifying and altering cognitive distortions and critical internal dialogue
• Linking distortions to negative beliefs
• Learning new people skills
• Developing social networks with non-substance users
• Utilizing meditation, relaxation, and/or alternative treatments like acupuncture

Ultimately, patients will have to figure out how to deal with all aspects of their lives in healthier ways. Treatment is confounded when there are personality disorder(s) and multiple comorbid mood disorders. Some patients cycle in and out of addictions as well as in and out of treatment. Others are determined and able to make positive changes that become permanent. The road to recovery is long and complicated. Your dedication aids the process, but you cannot do it alone. The patient must be willing to do whatever it takes, and then take those steps.

C. SHOPLIFTING AND COMPULSIVE SHOPPING

Shoplifting and Compulsive Shopping and Eating Disorders: Some individuals with eating disorders also engage in shoplifting and/or compulsive shopping. They do not shoplift because they’re too impoverished to afford the items, although that is what they may tell themselves. It becomes another mechanism to:

• Alter moods
• Distract
• Seek an adrenaline rush
• Act rebellious
• Fill up an emotionally empty space inside
• Have items that will create an image of success
• Acquire “things” to replace love
• Obtain < large amounts of food

Both acts become destructive when there is a possibility of being arrested or ending up in serious financial debt. Often these consequences are not enough to stop the behaviors. The immediate reward is too compelling and any damaging outcome seems far off.

Bulimics (50%-65%) are much more likely than restricting anorexics (versus binge-eating/purging anorexics) to engage in impulsive behaviors (Johnson and Connors, 1987). Anorexics like the more subtle “high” of starvation, not the adrenalin rush that comes from getting away with a petty crime or amassing large amounts of purchased items. You may also see borderline personality disorder in which impulsivity is one of the nine essential diagnostic criteria.

Medications: Depending on whether depression, anxiety, obsessive-compulsive disorder, or some other mood disorder is contributing to the shoplifting or compulsive shopping behaviors, appropriate medication (as described in those sections) can be prescribed.

Treatment: If your patient is involved in one of these behaviors, weave recovery into the eating disorders treatment. Remember that shoplifting and compulsive shopping numb and distract like starving, bingeing, grazing, and purging.

You’ll be using similar cognitive, behavioral, and psychodynamic techniques to help patients stop destructive habits. Set up contingencies to reduce behaviors such as structured rules regarding shopping. For example, your shoplifting patient takes only a wallet and doesn’t wear a jacket into the store so there’s no place to hide stolen objects. Compulsive spenders take a shopping list and make cash purchases. Focus on impulse control, management of emotions, preventing behaviors, and underlying issues (e.g., feeling deprived of food, love, attention, or material things when young). Debtors Anonymous can offer added support along with specific tools to reduce debt for patients who compulsively shop.

D. PROMISCUITY AND/OR UNPROTECTED SEX

Promiscuity and/or Unprotected Sex and Eating Disorders: Individuals with eating disorders, more predominantly bulimics, get caught up in seeking attention, affection, and the rush that comes from sexual contact. They flaunt their bodies to prove they’re attractive. They also want to avoid loneliness and emptiness. The desire to be beautiful, feel “special,” and be perceived as unique has narcissistic underpinnings. When bulimics gain weight, they withdraw from social and sexual activity (Johnson and Connors, 1987).

Restricting anorexics (versus binge-eating/purging anorexics) are less likely to be impulsive in this manner. Some bulimic women who are not sexually impulsive are similar to anorexics in that they tend to be sexually active, but unresponsive. This “passive sexuality” means that these women appear to be dependent on men and to crave relationships, and long to be held more than to have sexual intercourse (Johnson and Connors, 1987).

Having a borderline personality disorder increases the likelihood of engaging in sexually-impulsive behaviors. Substances may be used to reduce inhibitions. There may also be a history of sexual abuse that may have created confused ideas about sex and intimacy. They even engage in the risky behavior of having sex without protection (from pregnancy or sexually transmitted diseases).

Medications: Depending on whether depression, anxiety, obsessive-compulsive disorder, or some other mood disorder is contributing to the sexually promiscuous behavior, appropriate medication can be prescribed.

Treatment: These patients are looking outside of themselves to garner approval, attention, avoidance of unpleasant affect, and an attempt to refute negative beliefs about not being good enough (e.g., attractive enough). Therapeutic goals include helping patients experience loneliness, emptiness, depressed moods, anxious moments, and feeling unattractive without turning to inappropriate or dangerous sexual situations in order to numb out.

Exploring and changing negative beliefs about appearance is important because their behaviors are driven by the desire to feel good about themselves. Cognitive and behavioral strategies move patients from destructive sexual behaviors to healthier ones. Patients who have been sexually abused will have to explore how this trauma affected their sense-of-self and body image. Again, impulse control, management of emotions, and preventing behaviors altogether are essential components to recovery.

Final Thoughts: Thank you for taking this course. I hope you found it helpful and useful. If you would like to know more about the basics on treating eating disorders, consider taking Feast or Famine: The Etiology and Treatment of Eating Disorders. For information on obesity treatment, consider taking Weight Matters: The Etiology and Treatment of Obesity.

Resources

Alcoholics Anonymous
www.alcoholics-anonymous.org

American Anorexia/Bulimia Association of Philadelphia (AA/BA)
P.O. Box 1287
Langhorne, PA 19047
(215) 221-1864
www.aabaphila.org

Anorexia Nervosa and Related Eating Disorders (ANRED)
www.anred.com

Debtors Anonymous
www.debtorsanonymous.org

Eating Disorders Referral and Information Center
www.EDReferral.com

National Association of Anorexia Nervosa and Associated Disorders (ANAD)
Box 7
Highland Park, Il 60035
(847) 831-3438

National Eating Disorders Association (NEDA)
603 Stewart Street, Suite 803
Seattle, WA 98101
(206) 382-3587
www.nationaleatingdisorders.org

Women for Sobriety
www.womenforsobriety.org

Additional Reading

Dellaverson, V. (1997). The Desomatizing Selfobject Transference: Analysis of an Eating Disorder. Clinical Social Work Journal, 25 (1), 107-119.

Farber, S.K. (1997). Self-Medication, Traumatic Reenactment, and Somatic Expression in Bulimic and Self-Mutilating Behavior. Clinical Social Work Journal, 25 (1), 87-106

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