THERAPIES FOR EATING DISORDERS
BARBARA SMOLER, LMSW
3/17/14
In the DSM-5, the feeding and eating
disorders of anorexia nervosa, bulimia
nervosa, binge-eating disorder,
rumination disorder, and
avoidant/restrictive food intake disorder
are presented so that
despite a number of common
psychological and behavioral features, the
disorders differ substantially from each
other in clinical course, outcome, and
treatment needs.
However, a diagnosis of Pica may be
assigned in the presence of any other
feeding and eating disorder as a
comorbidity. Also, obesity is not included
in the DSM-5 as a mental disorder.
The six types of eating
disorders listed in the DSM-5 :
1. Anorexia nervosa is characterized by
extreme food (energy intake) restriction
that leads to dangerously low body
weight and possible malnutrition or
starvation, among other detrimental
physical effects that can be life
threatening. A person with anorexia is
likely to have a distorted body image,
intense fear of gaining weight, and
obsessive thoughts about food and
weight.
The DSM-5 identifies two subtypes of
anorexia: restricting type and bingeeating or purging type. The restricting
type is the most common and may
include the restricting of types of food
ingested, and maintaining extremely
low caloric intake, or other rigid
restrictions.
The binge-eating or purging type includes
severe restriction interspersed with
periods of binge-eating or purging that
may include compulsive exercising, selfinduced vomiting, or misuse of diuretics,
enemas, or laxatives. Anorexia affects
approximately .6% of the population.
2. Bulimia nervosa is identified as a cycle
of binge eating that results in feelings of
shame, guilt and remorse, and a sense of
loss of control, which further compel a
person to compensate for the binge by
purging or overexercising
Physical effects include dehydration,
chronic sore throat or inflammation of
the esophagus, abdominal pain, and
bowel problems, among others. Bulimia
does not generally result in significantly
low body weight, and sometimes a
person’s weight may be slightly above
average. Bulimia affects approximately
.6% of the population.
3. Binge eating is similar to bulimia in that a
person will consume excessive amounts of food in
a short period of time, followed by feelings of guilt
or disgust. Purging, however, is absent from binge
eating, though the person may engage in periodic
dieting or fasting to compensate for the binge
eating episode resulting in a vicious cycle of binge
eating and depression, using food to cope with the
stress. Binge eating affects approximately 1.2% of
the population.
4. Avoidant/Restrictive food intake
disorder (ARFID) is characterized by a
routine failure to consume adequate
nutritional or daily energy needs that
results in significant nutritional deficiency,
reliance on oral supplements or enteral
feeding, significant (or poor weight gain in
youth), or severely impaired psychological
and social functioning.
5. Rumination disorder is the compulsive
regurgitation of food (over a period of at
least 1 month) followed by either spitting,
re-chewing, or re-swallowing of the food,
which does not occur as a part of another
eating disorder or as a result of a
medication condition.
6. Pica is a relatively rare eating disorder that
is characterized by the persistent eating of
nonnutritive, nonfood substances such as clay,
paper, paste, chalk, mud, soap, or laundry
starch over a period of at least 1 month. A
person may be drawn to consume such
substances due to the texture or flavor of the
item, and the action of eating the substance
may be self-soothing. Pica is more commonly
found among specific populations, including
adults with iron deficiency, pregnant women,
institutionalized people, and children.
Why do people develop issues with food
and eating?
Eating and food issues can develop from
a wide range of psychological, biological,
social, or external factors, and they affect
people of all ages, male or female, although
adolescents and young women develop
eating disorders at higher rates than other
groups.
Food and eating issues are ultimately
expressions of one’s sense of self and
selfworth. People who compulsively starve
themselves, purge, eat to excess, or
exercise unnecessarily may do so out of
feelings of anxiety, inadequacy, needing to
please others, or low self-esteem.
They may feel pressure to succeed and
achieve perfection, especially those in
certain sports and occupations such as
gymnastics, figure skating, acting,
modeling, dancing, elite athletics (jockeys),
and sports with weigh-ins, e.g. boxing and
wrestling.
Adolescents may be more susceptible to
developing issues with food due to the
hormonal, physical, and neural changes they
experience; and sometimes stressful events,
trauma, or troubled relationships can lead a
person to develop an unhealthy relationship
with food.
A family history of eating disorders or other
mental health conditions may also
contribute to a person’s potential for
disordered eating.
TYPES OF TREATMENT FOR EATING
DISORDERS
There are many types of eating disorders
and many different approaches and
therapies. The severity of the eating
disorder may dictate the treatment method
chosen. Help may be found at medical care
facilities, through private practitioners, and
through community or faith-based groups.
Medical treatment for eating disorders,
particularly acute, inpatient admission, is not
generally required. The exception is when
an eating disorder is so severe that the
physical damage must be handled
immediately, as in the case of an esophageal
tear in a bulimic or in the case of severe
starvation in an anorexic.
Medical treatment of an eating disorder
that includes prescription medication is
needed in cases of severe side effects from
the disorder. Medications are prescribed,
generally by a psychiatrist and may be
intended to help treat the eating disorder
itself or any possible co-occurring mental
illnesses, such as depression, which is
common in those with anorexia or bulimia.
Medications used in the treatment of
eating disorders typically include:
Selective serotonin reuptake
inhibitors (SSRIs) - the preferred type of
antidepressant; to help decrease the
depressive symptoms often associated with
some eating disorders. Eg. Fluoxetine
(Prozac).
Tricyclics (TCAs) – another type of
antidepressant thought to help with
depression and body image. TCAs are
generally only used if SSRIs treatments fail.
Eg. Desipramine (Norpramin).
Antiemetics – drugs specifically designed to
suppress nausea or vomiting. Eg.
Ondansetron (Zofran).
According to Reuters, 3/12/14, recent research
by British and Korean scientists suggests
oxytocin, a brain chemical known as the “love
hormone”, is showing promise as a potential
treatment for people with anorexia. Researchers
found oxytocin altered the tendencies to
become fixated on images of fattening foods
and large body shapes, suggesting it could be
developed as a treatment to help them
overcome unhealthy obsessions with diet, and
social difficulties, including anxiety and
hypersensitivity to negative emotions.
HOW PSYCHOTHERAPY CAN HELP WITH
EATING AND FOOD ISSUES
Typically, recovery from disordered eating is a
long and arduous process. Some therapies
are relatively short term, requiring
approximately four months, but when the
process lasts for years, many clients struggle
with the motivation and energy required to
commit to the work involved.
It is important to recognize that recovery
not simply attaining the absence of
disordered thoughts and behaviors about
food and body, but recovering one’s self:
developing a sense of authentic identity,
and cultivating self-acceptance and
reverence for one’s self.
Many different types of psychotherapy have
demonstrated effectiveness in treating eating
and food issues, including interpersonal
psychotherapy, cognitive-behavioral therapy,
family therapy, and dialectical behavioral
therapy.
INTERPERSONAL PSYCHOTHERAPY (ITP)
ITP has shown some success for bulimia and
for binge eating, but has not proven effective
for anorexia nervosa. Unlike ITP for
depression, there is a lack of focus on the
primary symptoms of the illness, (Fairbanks,
Jones, Peveler, Hope, & OConnor, 1993).
“ In ITP-BN the therapist tries to steer
discussion away from eating disorder topics
and toward their interpersonal context and
to explore with the patient the affective and
interpersonal problems that may be
triggering and maintaining eating disorder
symptomology.”
So, “Rather than addressing eating problems
head on (like CBT), IPT helps patients
improve their interpersonal problems driving
their illness, which then leads back to
reduction in disordered eating.”
Stress and Self-Hatred Causes Weight Gain –
Case Example, ITP
Yvonne, 38, is an elementary school
teacher who has been overweight since
childhood. She has tried innumerable diets,
repeatedly losing weight and gaining it back,
and she berates herself for being a “fat pig.”
Ashamed of her lack of willpower, Yvonne
soothed herself with food when her nowformer husband made nasty remarks about
her weight.
After such a binge, she experienced remorse
and vowed to be strong and disciplined from
THEN ON. She enters therapy because she
feels defeated by her lack of commitment to
herself and wonders if she has a problem
with emotional eating, although she fears
this might just be an excuse for her
weaknesses.
Yvonne’s therapist explains the relationship
between painful emotional states and the
misuse of food as an antidote and provides
Yvonne with tools for tuning into her body’s
hunger and satiety signals to dictate her
eating, rather than following a weight loss
plan. At the same time, the therapist teaches
Yvonne to recognize the urge to overeat as a
sign of emotional distress left
unacknowledged.
Through therapy, Yvonne recognizes the effects
of her father’s alcoholism on her family and
herself. She had unknowingly learned from her
father to stuff painful feelings down. Yvonne
developed the habit of reaching for food to
comfort herself when her father was drunk and
arguing with her mother who was timid and
didn’t argue back. As Yvonne’s eating became
more in tune with her body’s needs and she
developed greater emotional self-care skills,
her body dropped much of the excess weight.
COGNITIVE THERAPY (CBT) – (BECK, A.T.,
FREEMAN, A., DAVIS, D., & ASSOCIATES, 2004)
Anorexia and bulimia represent a constellation
of maladaptive beliefs that revolve around one
central assumption: “My body weight and
shape determine my worth and/or my social
acceptability,” Revolving around this assumption are such beliefs as “I will look ugly if I gain
more weight,” “The only thing in my life I can
control is my weight,” & “If I don’t starve myself
I will let go completely and become enormous.”
Anorexics show typical distortions in
information processing. They misinterpret
symptoms of fullness after meals as signs that
they are getting fat. And they misperceive
their image in a mirror or photograph as being
much fatter that it actually is. (Beck &
Weishaar, 2004).
CBT is a collaborative enterprise between the
patient and therapist to explore dysfunctional
beliefs and interpretations and try to modify
them, chiefly through logical examination and
behavioral experiments. CBT is evidence
based, focused around triggers, behaviors,
and consequences of the eating disorder.
There is also focus on irrational and harmful
beliefs, such as believing they are fat when
they are severely underweight.
The therapist asks questions and the patient
describes how he or she would like things to be
different and what he or she might do to help
create change, (Padesky, 1993). The technique
is aimed at identifying and correcting errors in
information processing, biases and beliefs, and
testing out new beliefs to see if they are more
accurate and functional. CBT also uses skills
training (assertiveness, social skills, behavioral
rehearsal) as behavior techniques.
“Perfectionist” Personality Type Leads to
Anorexia – Case Example – CBT
Cathy, a 25 year old second-year medical
student, came to therapy because some fellow
students expressed concerns about Cathy’s
extreme weight loss and increasing lack of
participation in social events. Cathy maintains
that she is simply stressed out about school,
putting grades ahead of socializing.
She has recently lost about 15 pounds, and at
5’4” and 96 pounds, her BMI is 16.5. She is
menstruating regularly, though very lightly,
and has been on birth control pills for the last
four years. Furthur questioning reveals that
Cathy still has an intense fear of becoming
“the fat kid that no one likes,” after having
been teased for being chubby in middle
school.
. As a teenager, she induced vomiting after
meals for a few years, and more recently she
has been cutting back on her food portions,
eliminating fats from her diet, and avoiding
social events that include food, because she
doesn’t “know what’s in it.”
In addition to referring her to a physician for
medical monitoring and a dietician for help
devising an appropriate meal plan, Cathy’s
therapist helps Cathy view anorexia an an
unwelcome guest who has taken over Cathy’s
brain.
She helps Cathy challenge the distorted,
anorexia-driven thinking about her body’s
needs for nutrients and energy, and as Cathy’s
eating improves and her brain is better
nourished, she begins to acknowledge her
tremendous fear of being less than perfect
stems in part from her parents’ intense focus
on her academic achievements, rather than
her inner emotional experiences.
Cathy learned to ignore her emotional needs
after her parents divorced in an effort to
please them, as they seemed happier when
she did well in school. She also wanted to
make sure that she wasn’t a burden or an
unhappy reminder of their failed marriage.
The therapist helps Cathy access her feelings
and learn to manage painful emotions rather
than starving them away, and Cathy becomes
more comfortable in her body.
PSYCHOTHERAPY
This is the most in-depth eating disorder
therapy, delivered one-on-one with a
therapist. Eating disorder psychotherapy
focuses on past life events (often traumas like
abuse), personality issues, eating triggers and
initial causes of the eating disorder. It is
crucial in cases where the patient has a
history of trauma or where the eating
disorder is particularly severe or longstanding.
FAMILY THERAPY
This therapy deals with the effects the eating
disorder has had on a family. Family therapy
may include the parents of the patient, the
children of the patient or other family
members. It aims to address the damage
done by the eating disorder and put into place
new, healthy ways of dealing with family stress
and creating a healthy family environment.
FINAL THOUGHTS
Eating disorder therapy can be delivered in
many formats and while always focusing on
the patient, the therapy may focus also on
the way eating disorders affect relationships
and family as well as patient-specific issues.
It is important to take into account the
relationships and environment of the patient
during therapy for eating disorders, so the
work the patient does is not undone by those
around her or him.
Bibliography
Wedding, D., & Corsini, R.J., (2014, 2011.)
Current Psychotherapies
American Psychiatric Association, (2013)
Dsm-5
Acknowledgement
WEB MD