This is an advanced level course. After completing this course, mental health professionals will be able to:
Welcome to Dying to Eat: The Treatment of Severe Eating Disorders. This advanced 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 that 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.
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.
Anorexia is considered severe when a person:
Bulimia is considered severe when a person:
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.
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.
Attention Deficit Hyperactivity Disorder:
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:
At the beginning of every session, you’ll get an idea of what will be the focus of the session. 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.
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.
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).
Facial hair growth
Blisters in mouth
Blood in vomit
Pain around heart/down left arm
Pain around heart/down left arm
Low blood pressure
Low blood pressure
Catches colds or infections easily
Gets chills and can’t warm up
Stomach aches after eating
Food sits in stomach undigested
Racing a mile a minute
Compromised cognitive functioning
Loss of menstrual cycle
Irregular menstrual cycles
Osteopenia or osteoporosis (occurs when menses stop for six months)
Difficulty with attention, retention, and concentration
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 treatment facilities for eating disorders 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:
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 (metoclopramide) 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. Long-term use can lead to tardive dyskinesia. Talk with a physician about the use of this medication because it is not FDA approved for this purpose.
You and the physician monitor the health of your patients. Be honest and straightforward with the patient 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 should only be 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. Having them talk 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 through 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.
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, patients' 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).
Around 40% of patients hospitalized with severe anorexia whose condition is life threatening leave the hospital prematurely without reaching their target weight. For those under age 18, the predictive dropout factors include living in a single-parent family, severe intake restriction, and low patient-reported score on the Eating Disorders Examination Questionnaire (EDE-Q) “restraint concerns” subscale. For those over age 18, the predictive dropout factors include low depression score, low level concern about weight, and lower educational status (Roux, et al., 2016).
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 with 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:
Cognitive-Behavioral Therapy-Enhanced: Cognitive-Behavioral Therapy-Enhanced (CBT-E) is a viable and promising treatment for severe and enduring anorexia nervosa (Calugi, et al., 2017). This is a “transdiagnostic” personalized psychological treatment for people who are underweight and need longer treatment than regular CBT often involving 40 sessions over 40 weeks. This treatment was originally designed for bulimia nervosa and is now being used with anorexia nervosa. CBT-E treatment can involve 20 sessions or 40 sessions over the relative number of weeks, with a follow-up 20 weeks later. CBT-E has four phases:
Dalle Grave, et al. (2013) used CBT-E with adolescents with anorexia nervosa using 40 sessions in 40 weeks with a single therapist and a 60 week follow-up. The results showed a substantial increase in the weight among the 60% who completed the program. Of those, 31% reached 95% of their expected weight. Subjects exhibited a decrease in eating disorder pathology and general psychiatric features, and had minimal residual pathology. With adolescents, parents were involved in the treatment.
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:
In the hospital, dietitians avoid a power struggle over food by starting patients on three to four cans of Ensure® or Ensure Plus® to reach 1,200 calories per 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 per day in the hospital may require 2,400 calories per day after two weeks and 3,000 calories per 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 one to two pounds per 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 toward the perspective that exercise is for physical fitness and overall health, not burning calories. Tell them that 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.
Deep Brain Stimulation: Deep Brain Stimulation (DBS) is a neurological procedure in which a medical device (called neurostimulator or “brain pacemaker”) is implanted in the brain. It sends electrical impulses through implanted electrodes to a specific part of the brain (Wikipedia, 2017). In patients with treatment-refractory anorexia nervosa, one study found that DBS of the subcallosal cingulate is safe and is associated with improvements in depression, anxiety, and affect regulation. Patients received continuous stimulation for the one-year duration of the study (Lipsman, et al., 2017). A number of patients gained weight, with the group BMI increasing from 13.8 to 17.3. There were also significant changes in cerebral glucose metabolism in key anorexia-related structures at both six months and 12 months of ongoing brain stimulation. Since there are no effective treatments for people with long-standing anorexia nervosa, this research opens the door to helping these individuals.
Currently, there is no empirical data to support treating anorexia with medications alone. Historically, anorexia has been resistant to pharmacological interventions. New research shows that “atypical” antipsychotics can be beneficial during recovery and antidepressants can help post-recovery (Flament, Bissada, and Spettigue, 2012). 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).
Abilify (aripiprazole), used with a small sample of anorexic and low-weight bulimic patients, reduced stress around eating; decreased obsessional thoughts about food, weight, and body image; lessened eating-disordered behaviors; and aided in gradual weight restoration (Trunko, Schwartz, Duvvuri, and Kay, 2011).
Zyprexa (olanzapine) produced faster weight restoration in anorexics 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).
Risperdal (resperidone) is less likely to cause weight gain, yet also has mood-stabilizing effects, which makes it more acceptable to anorexic patients (Kaplan and Howlett in Grilo and Mitchell, 2010).
Prozac and Seraphem (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).
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, on this website).
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:
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.
Cognitive-Behavioral Therapy-Enhanced: CBT-E was originally designed for treatment of bulimia nervosa. Treatment protocol is described under the Anorexia Nervosa treatment section.
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 effects 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.
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 over time (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).
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:
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:
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 per 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 at 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 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 per 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.
Binge eating disorder becomes severe when bingeing episodes occur more frequently than twice per week and often occur daily or multiple times per day. The result is weight gain sometimes to the point of obesity. Childhood trauma, a risk factor for several disorders, is also a risk factor for the development of eating psychopathology and adult obesity. One study found an association between childhood trauma, food addiction, and clinical-level binge eating. The more severe the trauma, the more severe the emotional psychopathology (anxiety and depressive symptoms) and higher BMI (Imperatori, et al., 2016).
Diabetes is associated with increased risk of eating disorders. Binge eating disorder is more common in patients with type 2 diabetes, whereas intentional omission of insulin doses for the purpose of weight loss occurs mainly with patients who have type 1 diabetes. The risk factors for these patients include age, female gender, greater body weight, body image dissatisfaction, history of dieting, and history of depression (Ricicka and Brynska, 2015).
Cognitive-Behavioral Therapy: CBT is the treatment of choice for binge eating disorder. Palaveras, et al. (2017) found that CBT is effective for binge eating reduction but not for weight loss. Behavioral Weight Loss Therapy (BWLT) was also effective for binge eating reduction but the weight loss was not sustained over time.
Vyvanse (lisdexamfetamine) is a stimulant that has been FDA-approved for the treatment of binge eating disorder. It has been used to treat attention deficit hyperactivity disorder. Similar to other stimulants, the side effects can include irregular heartbeat. Many rare side effects include delirium, panic, psychosis, and heart failure. A serious interaction can occur with alcohol.
Almost every person who has an eating disorder also has some form of depression and/or anxiety. The severity of mood disorders makes eating disorder 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.
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).
(Diagnostic criteria in the following sections are provided as a review. Information comes from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, [DSM-5] American Psychiatric Association, 2013.)
Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest in pleasure. Note: Do not include symptoms that are clearly attributable to other medical conditions.
These symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The episode is not attributable to the physiological effects of a substance or to another medical condition.
Note: The above criteria represent major depressive disorder.
The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
There has never been a manic episode or hypomanic episode.
Please refer to DSM-5 for the notes and coding and recording procedures for severity and specifiers to make an accurate diagnosis.
This disorder represents a consolidation of DSM-IV defined chronic major depressive disorder and dysthymic disorder.
Depressed mood for most of the day, more days than not, as indicated by either subjective account or observation by others, for at least two years. Note: In children and adolescents, mood can be irritable and duration must be at least one year.
Presence, while depressed, of two (or more) of the following:
During the two-year period (one for children or adolescents) of the disturbance, the individual has never been without the symptoms listed above for more than two months at a time.
Criteria for major depressive disorder may be continuously present for two years.
There has never been a manic episode or hypomanic episode, and the criteria have never been met for cyclothymic disorder.
The disturbance is not better explained by persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.
The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or other medical condition (e.g., hypothyroidism).
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Note: Because the criteria for a major depressive episode include four symptoms that are absent from the symptom list for persistent depressive disorder (dysthymia), a very limited number of individuals will have depressive symptoms that have persisted longer than two years but will not meet the criteria for persistent depressive disorder. If full criteria for a major depressive episode have been met at some point during the current episode of illness, they should be given a diagnosis of major depressive disorder. Otherwise, a diagnosis of other specified depressive disorder or unspecified depressive disorder is warranted.
Please refer to DSM-5 for the five specifiers to make an accurate diagnosis.
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:
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 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 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 (buspirone) for anxiety, Seroquel (quetiapine) to reduce agitation, and Ambien (zolpidem) 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 – whether 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. In a study by Fedorowicz, et al. (2007), 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 included earlier onset of psychopathology, higher severity of depressive and general symptoms, and more impulse control problems.
There are a number of signs and symptoms to look for to alert you to suicidal ideation and action (Brager, 1987):
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 PERSONALITY DISORDERS, Borderline Personality Disorder, below.
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):
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 per 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 per 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 per 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.
For a diagnosis of Bipolar I disorder, it is necessary to meet the following criteria for a manic episode. The manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes.
A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least one week and present most of the day, nearly every day (or any duration if hospitalization is necessary).
During a period of mood disturbance and increased energy or activity, three or more of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a notable change in behavior:
The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least four consecutive days and present most of the day, nearly every day.
During a period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a notable change in behavior:
The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic.
The disturbance in mood and the change in functioning are observable by others.
The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic.
The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition.
Note: All above criteria constitute a manic episode. At least one lifetime manic episode is required for the diagnosis of Bipolar I disorder.
Major Depressive Episode
See criteria listed earlier under Major Depressive Disorder.
For a diagnosis of Bipolar II disorder, it is necessary to meet the criteria for a current or past hypomanic episode and the criteria for a current or past major depressive episode (see criteria above).
In a study by Tseng, et al. (2017), patients with Bipolar I or II and an eating disorder displayed significantly poorer weight regulation, more severe impulsivity, increased emotional lability, and higher rates of co-occurring alcohol-use disorders than patients with major depressive disorder and an eating disorder.
Please refer to DSM-5 for the notes and coding and recording procedures for the specifiers to make an accurate diagnosis.
For at least two years (at least one year in children and adolescents) there have been numerous periods with hypomanic symptoms that do not meet the criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet the criteria for a major depressive episode.
During the above two-year period (one year for children and adolescents), the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than two months at time.
Criteria for a major depressive, manic, or hypomanic episode have never been met.
The symptoms in the first criterion are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum disorder.
The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition.
The symptoms cause clinically significant distress or impairment in social or occupational functioning.
Specify if: With anxious distress
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 more than six months (Kahn et al., 1996).
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% to 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 (divalproex sodium) or Tegretol (carbamazepine), both 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 (lorazepam), used to treat anxiety, 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:
Components of Treatment:
Treatment with patients who also have an eating disorder uses these same 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).
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). One study found that the comorbidity of OCD was almost exclusively associated with anorexia nervosa. 37% of subjects with anorexia versus 3% of subjects with bulimia had OCD (Thornton and Russell, 1997).
Presence of obsessions, compulsions, or both: The essential features of obsessive-compulsive disorder are recurrent obsessions or compulsions that are severe enough to cause marked distress, are time-consuming (i.e., more than one hour per 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 by both:
Compulsions are defined by both:
The obsessions or compulsions are time-consuming (e.g., take more than one hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition.
The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania (hair-pulling disorder); skin picking, as in excoriation (skin-picking) disorder; stereotypes, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertions or delusional preoccupations, as in schizophrenia spectrum or other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).
Please refer to DSM-5 for the specifiers to make an accurate diagnosis.
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 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 1,000 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, Zoloft, (sertaline) Paxil, (paroxetine), Celexa, (citalopram), Luvox, (fluvoxamine), and Buspar 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:
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 per 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 per 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 per 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.
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).
Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of activities or events (such as work or school performance).
The individual finds it difficult to control the worry.
The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past six months):
The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition.
The disturbance is not better explained by the symptoms of another mental disorder (e.g., anxiety or worry about having panic attacks, as in panic disorder; negative evaluation, as in social anxiety disorder [social phobia]; contamination or other obsessions, as in obsessive-compulsive disorder; separation from attachment figures, as in separation anxiety disorder; reminders of traumatic events, as in posttraumatic stress disorder; gaining weight, as in anorexia nervosa; physical complaints, as in somatic symptom disorder; perceived flaws, as in body dysmorphic disorder; fear of having an illness; as in illness anxiety disorder; or the content of delusional beliefs, as in schizophrenia or delusional disorder).
Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people). Being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech).
The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others).
The social situations almost always provoke fear or anxiety.
The social situations are avoided or endured with intense fear or anxiety.
The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.
The fear, anxiety, or avoidance is persistent, typically lasting six months or more.
The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The fear, anxiety, or social avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or to another medical condition.
The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.
If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.
Specify if: Performance only: If the fear is restricted to speaking or performing in public.
Recurrent unexpected panic attacks. A panic attack is an abrupt surge or intense fear or intense discomfort that reaches a peak within minutes and during which time four or more of the following symptoms occur:
At least one of the attacks has been followed by one month or more of one or both of the following:
The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or to another medical condition.
The disturbance is not better explained by the symptoms of another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder; in response to traumatic events, as in posttraumatic stress disorder; or in response to separation from attachment figures, as in 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: 1) not disturbed by anxiety symptoms, 2) uncomfortable and therefore avoid stimuli, and 3) sure that the symptoms will harm their health. Theorists aren’t sure why some people are more anxiety-sensitive than others, although they do agree that there is a complex interaction between psychological and biological mechanisms (Azar, 1996).
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 and Paxil (paroxetine) are prescribed for generalized anxiety disorder. Zoloft, 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:
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.
A. Exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways:
B. Presence of one or more of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two or more of the following:
E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
Duration of disturbance (Criteria B, C, D, and E above ) is more than one month.
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition.
Please refer to DSM-5 for the specifiers to make an accurate diagnosis.
Posttraumatic Stress Disorder and Eating Disorders: Emotional, physical, and sexual trauma profoundly affect 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, physically harmful, sexually abusive, or ignore or withdraw from a child.
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% to 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:
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):
Horowitz (1976) described two groups of trauma symptoms:
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 is often prescribed for PTSD. Antidepressants such as Zoloft or Paxil, which also treat anxiety, may be appropriate. Klonopin is another option. Propranolol (inderol), 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):
Grant (2002) discusses the two phases of treatment:
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 non-purging 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 per 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 tormentors. 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 toward 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 more than 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.
A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development as characterized by the two categories below:
Inattention: Six or more of the following symptoms have persisted for at least six months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
Hyperactivity and impulsivity: Six or more of the following symptoms have persisted for at least six months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
Several inattentive or hyperactive-impulsive symptoms were present prior to age 12.
Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., home, school, or work; with friends or relatives; in other activities).
There is clear evidence that the symptoms interfere with or reduce the quality of social, occupational, or other important areas of functioning.
The symptoms do not occur exclusively during the course of schizophrenia or other psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).
Please refer to DSM-5 for the specifiers to make an accurate diagnosis.
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:
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 (methylphenidate), Adderall, and Cylert (pemoline) 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 such as 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 (atomoxetine HCI) 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 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:
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.
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 courses offered on this website by Russell Barkley, Ph.D.
According to the Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (American Psychological Association, 2013), 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 of these areas:
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:
Approximately 42% to 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.
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:
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, 2013).
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 the fact 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.
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity in a variety of contexts as indicated by five or more of the following:
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 EEGs, smaller frontal lobes, a 16% reduction in hippocampus, 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 earlier section on Posttraumatic Stress Disorder and Eating Disorders).
Individuals with borderline personality disorder develop behavioral dysregulation in which they:
In addition, they develop emotional dysregulation in which they:
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 or antidepressants that also treat anxiety may be needed. Klonopin can be used for panic disorder and “atypical” antipsychotics such as Risperdal, Seroquil, Clozaril, or Zyprexa 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:
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):
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 daycare 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. She figured, "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 more than two years to make significant changes in food habits, such as 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 often deployed. 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.
A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts as indicated by five or more of the following:
Dependent Personality Disorder and Eating Disorders: Individuals with dependent personality disorder have a pervasive need to cling to people who have stronger personalities and who will make a wide range of decisions for them. They have little initiative and are rather naive. 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):
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, individuals may urgently seek another relationship to provide the care and support they need (American Psychiatric Association, 2013).
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:
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 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 then therapy – and the therapeutic relationship – 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.
A pervasive pattern of excessive emotionality and attention-seeking, beginning in early adulthood and present in a variety of contexts as indicated by five or more of the following:
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 such as 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 is 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.
A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning in early adulthood and present in a variety of contexts as indicated by four (or more) of the following:
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 and Zoloft. Anxiety is the more common mood disorder, and either an SSRI or Buspar 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.
Many patients with eating disorders have a variety of impulsive behaviors including self-mutilation, overspending, shoplifting, promiscuity (American Psychiatric Association, 1993), and substance abuse.
Self-injurious behavior is common among adolescents and has been associated with eating disorders. One study found that 40.8% of female adolescents who self-injured had symptoms of bulimia nervosa, a co-morbid mood disorder, and substance use or abuse. Patients who engaged in both binge eating and purging were more likely to self-injure than those who did either behavior alone or restricted (Peebles, Wilson, and Lock, 2010).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 can be used as well. Klonopin can be prescribed for panic symptoms. “Atypical” antipsychotics including Respirdal, Seroquel, Clozaril, and Zyprexa 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 scare 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:
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 such as 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. Afterward, 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. Afterward 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 still has a ways to go, although he has learned that he can make it through what he thought was intolerable.
Substance-related disorders encompass 10 separate classes of drugs: alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics and anxiolytics, stimulants, tobacco, and other substances. All drugs that are taken in excess have in common direct activation of the reward system, which is involved in the reinforcement of behaviors and the production of memories. They produce such intense activation of the reward system that normal activities may be neglected. The pharmacological mechanisms by which each class of drugs produces reward are different, but the drugs typically activate the system and produce feelings of pleasure, often referred to a “high.” The substance-related disorders are divided into two groups: substance use disorders and substance-induced disorders. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) outlines both criteria (American Psychiatric Association, 2013).
The essential feature of substance use disorder is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite substance-related problems. An important characteristic of substance use disorders is an underlying change in brain circuits that may persist beyond detoxification, particularly in individuals with severe disorders.
Overall, the diagnosis of substance use disorder is based on a pathological pattern of behaviors related to the substance including: impaired control, social impairment, risky use, and pharmacological criteria. Within pharmacological criteria are tolerance and withdrawal.
Substance use disorders can range in severity, from mild to severe, with severity based on the number of symptom criteria endorsed. Course specifiers address level of remission.
Please refer to the DSM-5 to review the full description, list of criteria, and specifiers for the substance in question in order to make an accurate diagnosis.
The overall category of substance-induced disorders includes intoxication, withdrawal, and other substance or medication induced mental disorders (e.g., substance-induced psychotic disorder, substance-induced depressive disorder). Criteria for substance intoxication are included within the substance-specific sections of the DSM-5.
Substance Intoxication and Withdrawal:
Substance intoxication is common among those with a substance use disorder but also occurs frequently in individuals without substance use disorder. The most common changes in intoxication involve disturbances of perception, wakefulness, attention, thinking judgment, psychomotor behavior, and interpersonal behavior. Short-term, or “acute,” intoxications may have different signs and symptoms than sustained, or “chronic,” intoxications.
The criteria for substance withdrawal are included within the substance-specific sections of the DSM-5. The essential feature is the development of a substance-specific problematic behavioral change, with physiological and cognitive concomitants, that is due to the cessation of, or reduction in, heavy and prolonged substance use. The substance-specified syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms are not due to another medical condition or better explained by another mental disorder. Withdrawal is usually, but not always, associated with a substance use disorder. Most individuals with withdrawal have an urge to re-administer the substance to reduce the symptoms.
Please refer to the DSM-5 to review the full description, list of criteria, and specifiers for the substance in question in order to make an accurate diagnosis.
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 including cocaine, crack, crystal methamphetamine, speed, and ecstasy produce an intense euphoric state, boundless energy, and sleepless nights. Legal stimulants such as 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% to 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 in stress reduction (Brink, 2001).
Drinking one or two drinks per 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% to 37% (American Psychiatric Association, 2000) of bulimics become addicted to some kind of substance. They have poor impulse regulation. Only 12% to 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, about 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 a 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 it produces 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:
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% to 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, and Buspar. Seroquel, Respirdal, Clozaril, or Zyprexa 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 a problem, 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:
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.
Twelve-step or other addiction recovery groups such as Women for Sobriety will also give added support.
If your patient 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:
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.
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:
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 above) 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.
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. See earlier sections on each disorder for medications used.
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 patients' behaviors are driven by the desire to feel good about themselves. Cognitive and behavioral strategies move them 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.
American Anorexia/Bulimia Association of
P.O. Box 27156
Philadelphia, PA 19118
Anorexia Nervosa and Related Eating
Eating Disorders Referral and Information
National Association of Anorexia Nervosa and
Associated Disorders (ANAD)
750 E. Diehl Rd
Naperville, IL 60563
National Eating Disorders Association (NEDA)
National Eating Disorders Association
165 West 46th Street
New York, NY 10036
Women for Sobriety
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