Eating disorders are psychologically based disorders in which the fear of fat becomes overwhelming and begins to cause clinically significant distress in social or occupational functioning. Although these are the symptoms, it is merely the surface of a much larger underlying problem involving self-esteem, depression and a problematic family of origin. People with eating disorders do respond to counseling and medication.
Anorexia and bulimia are predominantly seen in middle to upper middle class, high achieving, white, 13-24 year old females who usually have been slightly overweight 3.9% (Brownell & Fairburn, 1995; Garfinkel et al., 1983; Holleran, Pascale, & Fraley, 1988; Kog & Vandereycken, 1985; Lask & Bryant-Waugh, 1993). Nevertheless, in the past decade, the incidence of this disorder in men and women of color has skyrocketed. Binge-eating disorder is estimated to affect another 15%-20%. Anorexia Nervosa and Related Eating Disorders (ANRED) estimates that 20% population females between 12 and 30 suffer from a major eating disorder (Nagel & Jones, 1992), 33% – 50% of white, college females has a subclinical eating disorder, and between 3% and 10% of men have some degree of eating pathology. People with eating disorders differ from people who are naturally thin because the preoccupation with body image and fear of fat are absent in people who are just “thin.”
At the beginning of the disorder, anorexics are usually in their early teens and their weight is average or slightly above. Some have suggested that the symptoms of anorexia serve to distract from larger family problems (Castelnuovo-Tedesco & Risen, 1985). For example, if there is an impending divorce, an anorexic's symptoms may rapidly become worse in order to make everyone work toward a common goal. Bulimics on, on the other hand, are usually of normal weight, and early in their college career. Bulimia is much harder to detect, so it mainly serves to pacify the person, not to involve the family. Most people with bulimia battle with the disorder for at least ten years before they either choose to seek help or do such physical damage as to be evident to others.
Eating disordered families are highly structured, and members have either have no boundaries, overly rigid boundaries or their boundaries are on “roller skates.” There are three common examples of this. Sometimes children are expected to be children and parents are able to be parents, but other times the roles are switched and nobody knows how to act at any given time. The second example is when parents “see no evil, hear no evil, speak no evil.” They refuse to accept that anything is wrong with their “perfect” child. In these families, children are told exactly what is expected for love. Lessons of various types abound. The children are always dressed in the best clothes and expected to maintain the façade of perfection. The third example occurs when a parent, usually Mom, has to be the child's best friend. Parents are often “friendly” with their children and their friends, but in these families, it is taken to an extreme.
Children with the propensity to develop eating disorders interpret everything personally, that is, their attributions are internal and usually global and stable. They decide that, if they could make their parents proud of them, they would be worthy of love and everyone would be happy. Sometimes they subconsciously realize that they can never make their parents happy, so they look for a mate/partner who they can “convince” they are worthy of love. This relationship never mends the wound caused by lack of parental approval, but it provides the external validation necessary to survive.
Early in the disorder, there is an experience of exhilaration over the praise for losing weight and being perfect. This provides a sense of mastery and control and stable, global attributions are made about the situation. “If I lose weight and look perfect, then I deserve love and everyone will be happy.” They have finally discovered something at which they can be perfect and therefore can make themselves worthy of love (Katz, 1990).
When the new-found weight loss does not continue to make everything “all better,” the person with the eating disorder tries to start losing weight again. This disruption of family harmony does not “fit” into the schema that says: “When I am perfect, I am not an embarrassment to my family, and everyone will be happy.” Therefore, people with eating disorders conclude that they are no longer perfect. The behavior that “made everyone happy” last time was losing weight, so it becomes necessary to regain that recognition.
Compounding this fear that they have started failing to be perfect again, is an increase in lethargy and depression. People with eating disorders often attribute this to being fat when, in actuality, it is their body shutting down due to lack of nourishment. Their self esteem is low and getting lower by the minute. Their entire self-worth is dependent upon approval from others, and they believe they do not deserve approval unless they are perfect. This sets up a terrible downward spiral. They need external validation to believe they are worthy of the air they breathe, but they feel so unworthy that they cannot accept any praise that they are given.
When parents do show concern for their children’s ever decreasing weight it is interpreted as another attempt at sabotage them and keep them fat so they can never be happy, and yet another example of their inability to please her parents. They are caught in a persistent double bind. First they thought that their parents wanted them to lose weight, now their parents are telling them to stop. Since people with eating disorders cannot see the physical changes in their bodies, this message is extremely confusing. Now, the one thing they thought they had mastered, they are being told they are doing wrong.
Eating disorders may go through several phases. The first is the subclinical eating disorder where people lose weight rapidly, receiving praise for their achievement and have not yet begun to manifest the psychological and physiological symptoms of starvation, and overwhelming fear of being fat. The first phase of the clinical eating disorder is characterized by increases in suspiciousness and ritualistic behaviors. Since anorexics are usually young enough to still be living at home, and since anorexia is so much more outwardly apparent, it is often intercepted in the first or second phase.
The second phase is characterized by an increasing fear of fat, judgementalism, problems with cognitive tasks such as concentration and problem solving, and rapidly deteriorating health that manifests itself through lethargy, irritability, increased illnesses and difficulty getting sufficient restful sleep.
The third phase of the eating disorder can be seen when and if people want to try to recover. The prevailing feeling is fear of fat. They are terrified of beginning recovery, because everybody is so determined to make them eat. They know that if they begin to eat, they will not be able to stop, and, as a result, will get fat. In their mind, fat means: unlovable, lazy, disgusting, angry, ugly, depressed, lonely and a host of other negative things. What people in recovery, and the therapists, often fail to recognize is the underlying reasons for people's unwillingness to comply with treatment.
If they start to eat, one of two things will happen. Either they will start to eat and not be able to stop, or the physical pain of starvation will go away as will the persistent ruminations about food. If these disappear, then they are forced to face the psychological pain and anger they have been running from for years. Since the eating disorder is the chief, and possibly only, coping mechanism which these people have to deal with intense negative feelings, taking the food-related issues away leaves them with no way to cope.
Relationships Between the Eating Disorders It has long been suggested that there is continuum of eating disorders. This is supported by significant overlap of characteristics between the groups. The continuum can be conceptualized as:
Adjustment:
____/____________/________________/___________________/______________/
Anorexic- Bulimics binge-eaters Anorexics normals/obese
bulimics
Although anorexics outwardly appear to have fewer adjustment difficulties than bulimics, it should be noted that part and parcel of their disorder is to present a perfect, happy facade. This could also explain why there is a lower reported rate of depression and other psychiatric difficulties in anorexic families. Seeking help breeches the code of secrecy. Further, anorexics become so good at dissociation from their internal sensations, and repressing their feelings that it is possible that they are much worse off than they appear. It is likely that bulimic-anorexics are still the worst off, because they have failed at being anorexic, a condition which is predicated on perfection and control.
Personality Characteristics of Eating Disordered PatientsEating disorder clients have several common personality traits.
They present a false self that is high functioning, highly successful and extremely accommodating (Castelnuovo-Tedesco & Risen, 1985; Gordon, 1989; Norman, Blais, & Herzog, 1993; Schaef, 1986; Williams et al., 1993).
They will be everything anyone wants them to be in order to please due to their extreme need for external approval and nurturance.
Eating disordered people demonstrate heightened industriousness and responsibility, highly regimented behavior, rigid adherence and excessive conformance to rules and standards, interpersonal insecurity and a minimal range of emotions (Garfinkel, Moldofsky, & Garner, 1980; Kleifield, Sunday, Hurt, & Halmi, 1994).
Interpersonally, they are impulsive, suspicious, highly sensitive, guilt prone, anxious and cannot interact with others in ways which meet their needs (Dunn, 1981; Kleifield et al., 1994; Kuehnel & Wadden, 1994; Rosen et al., 1989).
Their self-esteem and self-awareness is low, but they are highly sensitive to their external environment.
Perfection is the yardstick by which eating disordered clients compare themselves. They must appear perfect, avoid appearing imperfect and avoid disclosure of imperfection (Hewitt, Flett, & Ediger, 1995). It's all about image.
Eating disordered people endorse the “superwoman stereotype”. They feel obligated to excel in everything, yet view their accomplishments as being hollow and false (Clark et al., 1988; Garfinkel et al., 1980; Gordon, 1989; Katz, 1990; Lask & Bryant-Waugh, 1993; Touyz & Beumont, 1985; van Strien, 1996).
Given their typical external locus of control, eating disordered clients become rigid, passive-aggressive, and self-centered.
Since adequate role performance is somewhat ambiguous, weight/appearance becomes a tangible parameter by which to measure adequacy. If someone else is thinner, you lose!
Food and weight become a reference for everything. As their weight fluctuates, so do their moods with alternating bouts of over-compliance with stubbornness recurring periods of dejection, anger, anxiety and euphoria (Andersen, 1987; Castelnuovo-Tedesco & Risen, 1985; Garner, Garfinkel, Stancer, & Moldofsky, 1976; Gordon, 1989; Harding & Lachenmeyer, 1986; Katz, 1990; Kleifield et al., 1994; van Strien, 1996; Williams et al., 1993; Zwaan et al., 1994).
They are unable to interact with others in ways which meet their needs. Bulimics and bulimic anorexics are over-separated from their parents in their attitudes and under-separated in terms of guilt and conflict about separation/growing-up (Smolak & Levine, 1993).
Coping Skills
People who display addictive behaviors often have few, if any, healthy coping mechanisms. Therefore, internal distress is defended against, but rarely coped with. Repression, denial, idealization, intellectualization, depersonalization and repression are the most common of these defenses (Andersen, 1987). In support of this notion, bulimic and binge-eating clients have reported a fugue like state during bingeing. Food represents love and comfort and bingeing is initiated to provide comfort in times of emotional distress (Elmore & deCastro, 1990; Kuehnel & Wadden, 1994; Richman & Flaherty, 1985; Robbins & Fray, 1980).
The addictive quality of eating-disordered behaviors is used to regulate mood; although, it appears that food loses it’s effectiveness to make people feel better after a while. In a study by Johnson (1982), the average duration of eating disorder was five years. At this point, bingeing was no longer relieving, and the clients had resorted to the use of alternate substances such as alcohol, shopping, exercise, or use of cocaine or amphetamines (Beary et al., 1986; Yates, 1991).
Treatment Considedrations
Do not have or set unrealistic expectations when dealing with this population (Thompson & Sherman, 1989). In bulimic families there are extremely high expectations without support or encouragement, and in anorexic families, the expectations are so high that they can never be achieved perpetuating the sense of failure and ineffectiveness. One of the most common unrealistic expectations therapists have is weight gain. Gaining too much too fast simply confirms her worst fears that eating produces rapid weight gain. Also focusing too much on eating mistakes communicates the idea, to the person who thinks dichotomously, that eating must be perfect. It would better help people to learn that normal eating is not perfect, and that they will be able to tolerate these mistakes without self depreciation (Thompson & Sherman, 1989).
The counselor, friend or parent who allows the eating-disordered person to change for anyone but him- or herself is maintaining the mental conditions which precipitated the disorder (Thompson & Sherman, 1989). These people should be encouraged to participate in treatment decisions (Yager, 1989). Further the therapist, friend or parent should be careful not to assume too much control. The eating disordered person will try to get the therapist, parent or friend to make decisions for them. In this way, they know what is wanted and can dutifully accommodate, or, if they are feeling threatened, subversively resist (Thompson & Sherman, 1989).
Thompson & Sherman (1989) state that helper's approach is less important than the relationship. One must form a cooperative working alliance and take charge of the situation through establishing credibility without triggering control issues (Sallas, 1985). The helper should aim to develop a firm, empathic, non-critical attitude, avoiding confrontation. Initially, an agreement to disagree can assist in avoiding resistance. Helpers should also be cautioned against confronting the eating disordered person's underlying hostile feelings and aggressions which would only confirm their feelings of inadequacy and shame.
Dependent communications, communications which require people to reassure the helpers they are doing a good job, or “right” are the most destructive of all helper behaviors. Asking these people when they think they will be able to gain weight or begin therapy would be an example of dependent communication (Thompson & Sherman, 1989). Also, talking too much about weight and food confirms that these issues are as important as the people imagined.
Instead, engage in goal clarification helping people identify what will make them happy. Too much emphasis on behaviors allows them to avoid the emotions which generate these protective defenses. Focusing on behaviors emphasizes that they are valued for what they do not how they feel or who they are (Sallas, 1985; Werne & Yalom, 1996).
Summary
Eating disorders represent a complex interaction between biological, behavioral and environmental forces. There are psychological, biological, social and family factors which need to be addressed (Andersen, 1987; Woodside et al., 1993). The eating disorder represents the best adjustment individuals can make. Eating disordered clients have lived much of their lives trying to fulfill their families unrealistic expectation in an effort to please, and therefore bring this mentality into the therapy session.
Individual psychotherapy should be instituted only when the person/customer is motivated and capable of meaningful participation. Goals of individual treatment include acquiring new attitudes toward food and weight, controlling weight, avoiding inappropriate methods of losing weight, learn to recognize/label emotions and needs, learn how to accept and receive emotional support and recognize relapse warning signs and triggers (Touyz & Beumont, 1985). Treatment should be tailored to the cognitive and personality styles and psychological and developmental levels of the clients.