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Dying to Eat: The Treatment of Severe Eating Disorders
by Deirdra Price, Ph.D.

4 Credit hours - $59

Last revised: 04/27/2008

Course content © copyright 2004-2008 by Deirdra Price, Ph.D.. All rights reserved.

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LEARNING OBJECTIVES

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

INTRODUCTION

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

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

CHAPTER I: DEFINITIONS OF SEVERITY

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

1. ANOREXIA NERVOSA

Anorexia is considered severe when a person:

2. BULIMIA NERVOSA

Bulimia is considered severe when a person:

CHAPTER II: COMORBIDITY ASSESSMENT

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

1. ASSESSMENT OF COMORBIDITY

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

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

2. TREATMENT CONSIDERATIONS

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

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

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

CHAPTER III: MEDICAL CONDITIONS

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

A. COMMON MEDICAL PROBLEMS

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

Anorexia Nervosa

Bulimia Nervosa

Hair loss

Dental erosion

Facial hair growth

Blisters in mouth

Dry skin

Blood in vomit

Pain around heart/down left arm

Pain around heart/down left arm

Heart palpitations

Heart palpitations

Low blood pressure

Low blood pressure

Catches colds or infections easily

Esophageal burning

Anemia

Constipation

Gets chills and can’t warm up

Diarrhea

Stomach aches after eating

Hypoglycemia

Food sits in stomach undigested

Kidney problems

Fainting

Dehydration

Dizziness

Dizziness

Racing a mile a minute

Compromised cognitive functioning

Extreme fatigue

Fatigue

Loss of menstrual cycle

Irregular menstrual cycles

Osteopenia or osteoporosis (occurs when menses stop for six months)

Difficulty with attention, retention, and concentration

B. HOSPITALIZATION

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

1. SPECIFIC TO ANOREXIA NERVOSA

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

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

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

2. SPECIFIC TO BULIMIA NERVOSA

C. TREATMENT STRATEGIES

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

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

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

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

1. ANOREXIA NERVOSA

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).

Cognitive strategies are employed to reduce negative beliefs, critical internal dialogue, and distortions in thinking regarding misperceptions about appearance.

Establish goals for physical recovery with the patient at the beginning of therapy. Goals include:

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

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

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

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

You will bounce between using 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.

2. BULIMIA NERVOSA

In the case of bulimia nervosa, 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.

3. CHRONICITY

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

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 may include:

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. Continually 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, and understanding to conduct therapy with these individuals.

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

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

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

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

CHAPTER IV: MOOD DISORDERS

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

A. DEPRESSIVE DISORDERS

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

1. MAJOR DEPRESSION

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

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

2. DYSTHYMIA

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

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

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

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

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

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 for anxiety, Seroquel to reduce agitation, and Ambien to promote sleep.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

3. BIPOLAR DISORDER

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

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

A depressive episode is described in the Major Depression category.

4. CYCLOTHYMIC DISORDER

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

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

There are three different categories of bipolar disorder:

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

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

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

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

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

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

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

Stages of Treatment:

Components of Treatment:

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

B. ANXIETY DISORDERS

1. OBSESSIVE-COMPULSIVE DISORDER (OCD)

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

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

Obsessions are defined as:

Compulsions are defined as:

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

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

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

Medication: Prozac, Zoloft, Paxil, Celexa, Luvox, 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 a day. In addition to teaching dance, she ran every morning for an hour and went to the gym in the afternoon for bike spinning classes. When we explored her history, she had been anorexic from the ages of 17 to 25. Her eating became healthier after two years of therapy. Nevertheless, she continued to think too much about weight and food intake. As time went on, she became hyper-focused on food. Bingeing was the only thing that brought reprieve from thoughts about chocolate cake or cinnamon rolls. To counteract weight gain, she exercised three to four hours a day.

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

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

2. GENERALIZED ANXIETY DISORDER

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

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

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

3. SOCIAL PHOBIA

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

4. PANIC DISORDER

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

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

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

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

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

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

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

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

Medications: Buspar and Paxil are prescribed for generalized anxiety disorder. Zoloft, Paxil, Buspar, Xanax, and Klonopin 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.

5. POSTTRAUMATIC STRESS DISORDER (PTSD)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

C. ATTENTION-DEFICIT/HYPERACTIVITY DISORDER

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

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

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

Symptoms of impulsivity include:

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: