At ten percent mortality rates, eating disorders are the deadliest of any disorder in the Diagnostic and Statistical Manual (DSM). Only a quarter of those who suffer from eating disorders recover. Another half continues to struggle with relapses. The other quarter never recover. The average age of people with eating disorders is getting younger and younger. More boys are starting to develop them as well as women well into middle age.

Culture plays a huge role in this phenomenon. Although eating disorders have been documented from the 1800s the occurrence of them was very rare. Even in the 1970s they were not common, and were not yet a classified disorder in the DSM. Then, the women’s movement started to change women’s roles. And media came to have a large impact on the way women view themselves. This was evident from the example of Fiji. When this remote island country had no media access, people were quite large and obesity was not looked down upon. However, when television and magazines were introduced incidences of eating disorders skyrocketed over 100%.

Dr. Herb described the impact of television, magazines and the Internet as being brainwashed by the media. She gave the example of New Year’s resolutions being to lose weight so for a while in January everyone seems to be on a diet and going to the gym. There is a sense of pressure for a while to lose weight and become thin. That sense of urgency that we feel then for a limited time, is what adolescents feel constantly. They face pressure every day when they are at school, sports, dance, other extra-curricular activities, social or peer groups. The pressure to be thin has created a phobia, and prejudice, about being fat.

Cultural influences are only one factor of many that lead to a person developing an eating disorder. There are family issues to be considered, genetic factors, environmental factors, unresolved abuse or trauma, individual factors, as well as stress and other factors. The key variable is that something has caused an obsession with a person’s body image.

There is a spectrum of eating or body-image issues. People suffering from anorexia nervosa have a distorted body image where they truly do not see how thin they are. Eventually after starving themselves enough, their sense of hunger goes away so they are not ever aware of their own need for food. People with bulimia eat to make themselves feel better. Not only is the food a source of comfort, but there is also a chemical that is released in the brain after vomiting that makes the person feel better. Binge eating disorder, which is currently in the appendix of the DSM, helps the person numb themselves from the food. There are also sub-clinical features such as yo-yo dieting, skipping meals, using diuretics and pills, among other types.

Assessment

One helpful assessment tool is to have the person draw a “weight life line” on a piece of paper. They should indicate points in their lives for which they remember how much they weighed at the time. This can be a good tool to find out about events that may have triggered any large weight changes. By finding out the triggers or the patterns you will be able to do the deeper work necessary. Because these disorders have an obsessive-compulsive component the person will know this specific information.

Eating behavior should be explored, not only currently but also ask about when they were younger. Have them recall what dinner time was like in their home. Get a description of where everyone in the family was, what relationships the people had, where they were eating, what has happening during dinner, and the like. Dinner time is the worst time for people with eating disorders. Finding out about their early dinners or memories around food and eating will help uncover unresolved issues.

Other histories should be taken such as dieting behavior, food cravings or their relationship with food, emotional/affective histories, especially around depression, phobias, anxiety, anger and past traumas. A cognitive assessment should be done regarding self-esteem, their negative self-talk or criticisms, cognitive distortions (especially around body size/weight), family history of emotional problems, abuse issues, family communication and dynamics, especially regarding an emphasis on family cohesion and control or restrictive values. Also look for impairment in relationships, poor communication skills, lack of assertiveness, inability to handle conflict and whether the person is able to receive nurturance from others. Because of the potential of physiological damage there should be a medical assessment.

Treatment

In treating people with eating disorders the therapist should think of themselves as a case manager. Dieticians, psychiatrist, physicians, physical trainers (who know eating disorders), and massage therapists should all be included as a team caring for the individual. Working with the person’s significant other and family systems would be beneficial, especially if they can be a source of support for them. Group and individual therapy would be good concurrently, if possible. Treatment plans should be highly individualized though, as the needs of each person will be very different.

People with eating disorders feel they have no choice but to persist with their behavior. We cannot take away their symptoms without giving them another way to cope. Teach them that they have another choice. You should not tell the person they have to give up their eating disorder behavior. Instead, you should tell them that they do not have to give it up, which paradoxically will let them be able to. Empower them by giving them choice. Dr. Herb said the most important thing is to get them “living in their own body and feeling power.”

Help them build new cognitions instead of the negative/critical ones that tell them they are not good enough, not thin enough. Write out affirmations and tell them to “fake it until you make it.” Behaviorally they have a lot of anxiety so they need to learn how to relax. Using guided imagery or meditation would be good. Remember that treating eating disorders is a long process so each of these things should be done in very small steps. Also, we should normalize relapse because perfectionism is rampant in this population. By admitting mistakes of their own, the therapist can be a role model to those with eating disorders.

Work toward resolving the deeper issues that drive the person toward eating disorder behavior. If a client cannot talk about something, use art therapy with them. Allow them to be creative because this will give them a voice. This is especially useful for those who may have cognitive impairment due to physiological damage from the disorder. If they are intimidated by artwork, allow them to put together collages. Cutting things out and pasting them can be less threatening.

In order to be able to do this work we need to be comfortable with our own bodies and our own eating behaviors. Dr. Herb indicated that, for general eating disorders, therapists who take the time to become educated on these issues will be able to treat them. However, those suffering from chronic eating disorders that have had many relapses should be referred to a specialist. To get more information about eating disorders visit www.bulimia.com. For more information on Dr. Herb’s “Health at Every Size” approach visit www.therapy4women.com.

Presented by Ellyn Herb, Ph.D., CEDS

Reviewed by: Amy Sargent