EATING DISORDERS

OVERVIEW &
ASSESSMENT
LAURA BAUMAN, MA, PLPC, NCC
OBJECTIVES

• Obtain knowledge on the various types of eating and feeding disorders and learn how to
decipher disordered eating from an eating disorder
• Understand the etiology and maintenance of eating disorders
• Learn recommended treatment strategies and interventions
WHAT DO YOU KNOW
ABOUT EATING
DISORDERS?
EATING DISORDERS AND THE MEDIA
WHAT EATING DISORDERS ACTUALLY LOOK
LIKE
(2:29 - 5:27) https://youtu.be/UEysOExcwrE
DSM-IV CRITERIA:
ANOREXIA NERVOSA

A.) Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age,
sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than
minimally normal or, for children and adolescents, less than minimally accepted.
B.) Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though
at a significantly low weight.
C.) Disturbance in the way in which one’s body weight or shape experienced, undue influence of body weight or shape on self-
evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
Specify whether:

Restricting type: During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or
purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes
presentations in which weight loss is accomplished primarily through dieting, fasting, and/ or excessive exercise.
Binge-eating/ purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge
eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas
SIGNS THAT SOMEONE MIGHT BE
STRUGGLING WITH ANOREXIA:
• Dramatic weight loss in a short period of time
• Isolating
• Dressing in layers to hide weight loss or stay warm
• Preoccupation with weight, food, calories, fat
grams, and dieting
• Complaints of constipation, abdominal pain, cold
intolerance, lethargy
• Development food rituals (e.g., eating foods in
certain orders, excessive chewing, rearranging food
on a plate)
• Cooking meals for others without eating
• Consistently making excuses to avoid mealtimes or
situations involving food
• Maintaining an excessive, rigid exercise regimen –
despite weather, fatigue, illness, or injury
• Limited social spontaneity (emergence of rigid thought
patterns)
• Menstrual irregularities, amenorrhea
• Exhibiting a strong need for control
• Difficulties concentrating
• Fainting and dizziness
• Feeling cold all the time
• Dry skin, brittle nails, thinning of hair
• Development of fine hair on body (lanugo)
• Yellow skin (in context of eating large amounts of carrots)
• Cold, mottled hands and feet
• Poor wound healing
DSM-IV CRITERIA: BULIMIA NERVOSA

A.) Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
1.) Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger
than most people would eat in a similar period of time under similar circumstances
2.) A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control
what or how much one is eating)
B.) Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse
of laxatives, diuretics, or other medications; fasting, or excessive exercise.
C.) The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.
D.) Self-evaluation is unduly influenced by body shape and weight.
E.) The disturbance does not occur exclusively during episodes of anorexia nervosa.
SIGNS THAT SOMEONE MIGHT BE
STRUGGLING WITH BULIMIA:
• Menstrual irregularities
• Cuts and calluses across the top of finger joints (a result of inducing vomiting)
• Dental problems, such as enamel erosion, cavities, and tooth sensitivity
• Swelling around area of salivary glands
• Preoccupation with weight and body
• A strong negative self-image
• Excessive use of laxatives, diuretics, diet pills
• Stained teeth (from stomach acid)
• Excessive exercise
• Withdrawal from normal social activities
• Evidence of binge eating, including disappearance of large amounts of food in short
periods of time or lots of empty wrappers and containers indicating consumption of large
amounts of food
• Evidence of purging behaviors, including frequent trips to the bathroom after meals,
signs and/or smells of vomiting, presence of wrappers from laxatives or diuretics, or
pectin
• Drinking excessive amounts of water or non-caloric beverages, and/or uses excessive
amounts of mouthwash, mints, gum
DSM-IV CRITERIA:
BINGE EATING DISORDER
A.) Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
1.) Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger
than most people would eat in a similar period of time under similar circumstances
2.) A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control
what or how much one is eating)
B.) Binge-eating episodes are associated with three (or more) of the following:
1.) Eating much more rapidly than normal
2.) Eating until feeling uncomfortably full
3.) Eating large amounts of food when not feeling physically hungry
4.) Eating alone because of being embarrassed by how much one is eating
5.) Feeling disgusted with oneself, depressed, or very guilty after overeating
C.) Marked distress regarding binge eating is present.
D.) The binge eating occurs, on average, at least once a week for 3 months.
E.) The binge eating is not associated with the regular use of inappropriate compensatory behavior (e.g., purging, fasting,
excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa.
 ABOUT BINGE EATING DISORDER

The MOST common eating disorder

Over 4.2 million women and 2.3 million men in the US have a
diagnosis of BED
BED is more common than breast cancer, HIV, and schizophrenia
~3.5% women, 2% men, & 1.6% adolescents have a diagnosis of
BED
Seen among all age groups, races, and income levels

It is important to note that these facts refer to those who have been officially diagnosed with binge eating
disorder and do not include those who binge eat but do not meet full criteria. Additionally, just because someone
overeats does not mean that they have BED.

(Alsana, 2013; Hudson, Hiripi, Pope, & Kessler, 2007)

COMMON MYTHS ABOUT BINGE EATING

You have to be obese to have Binge Eating Disorder

Actually, 55% of those with BED are of normal weight or somewhat “overweight.”

Only women struggle with binge eating; men do not have eating disorders
While more women are diagnosed with Binge Eating Disorder and other eating disorders overall, BED is the
most common eating disorder for men.

Everyone binge eats from time to time; it is a normal part of life

While everyone overeats from time to time, everyone does not binge. Binge eating is incredibly distressing and
life-interrupting and attempting to comfort someone with Binge Eating Disorder with statements such as, “well,
everyone overeats from time to time,” can be incredibly invalidating.

People end up with Binge Eating Disorder because of family problems

BED is not caused by any single factor, but rather from a mix of genetic and environmental factors.

(Camps et al., 2013 ; DeLany et al., 2014; Goldschmidt et al., 2011;

Grodstein et al., 1996; Leibel, 1995 ;
MacLean, et. al., 2011; Tomiyama et al., 2010)
COMMON MYTHS ABOUT BINGE EATING
The appropriate treatment for individuals with binge eating is going on a diet
Being that calorie restriction is the leading cause for the development of binge eating behavior, dieting is
simply prescribing the problem rather than a solution.

Individuals who binge eat should focus on losing weight

Actually, weight loss treatments for BED deem ineffective and can actually exacerbate symptoms in the long-
term. The overarching problem in BED is not the weight, but the binge eating behavior. Furthermore, weight is
sometimes attributed to binge eating, and other times not. By treating the weight, we completely miss the core
issue.

Larger people can’t lose weight because they don’t try hard enough
We know that this notion is wrong because of Weight Set-point theory. Furthermore, being that naturally
larger-bodied individuals are so commonly encouraged to diet, this then initiates the development of binge eating,
and survival mechanisms that prompt weight-regain.

All in all, binge eating disorder is a serious mental illness with a biological base. It has nothing to do with willpower
and everything to do with genetic traits; neurobiological differences; and environmental risk factors such as dieting,
bullying & body shaming, trauma, and pressure from diet culture.
(Camps et al., 2013 ; DeLany et al., 2014; Goldschmidt et al., 2011;
Grodstein et al., 1996; Leibel, 1995 ;
MacLean, et. al., 2011; Tomiyama et al., 2010)
 SIGNS THAT SOMEONE MIGHT BE
STRUGGLING WITH BINGE EATING:
• Appearing uncomfortable eating around others
• Withdrawing from usual activities, friends, etc.
• Eating in secrecy
• Disappearance of large amounts of food w/ no explanation
• Frequent dieting
• Fear of eating in public; anxiety around social gatherings that will
involve food
• Extreme concern with weight & body shape
• Change in normal eating habits (e.g. cutting out an entire food
group, eating extremely small portions at mealtimes, repetitive
dieting, preoccupation with fad diets, etc.)
WHAT MIGHT A BINGE LOOK LIKE?
• Eating in secrecy
• Eating a large amount at a rapid pace
• Eating until feeling uncomfortably full
• Eating large amounts of food when not feeling physically hungry
• Experiencing extreme guilt and shame surrounding eating habits
• Hoarding food items
• Strange food combinations

Examples of a binge:
• Eating half of a cake in one sitting
• Having a few slices of pizza, then going on to eat several things in the pantry until feeling miserably sick
• Consuming half of a pan of brownies, a row of Oreos, some Little Debbie cakes, some spoonfuls of cold meatloaf and
mashed potatoes from the fridge, a few pieces of chocolate & a bowl or two of cereal
 “Everyone binges now and then.”
HOW NOT TO
COMFORT Refrain from saying anything about weight
SOMEONE • worries about weight or dieting can make a person more
likely to have a binge, not to mention reinforces the
STRUGGLING concepts of diet culture such as the body size hierarchy

WITH BINGE Avoid discussing your own weight or eating

habits in front of
EATING:
Refrain from criticizing, praising, or judging
food choices
DECIPHERING BINGE EATING FROM
OVEREATING
Large amount of food

Objective Binge Eating Subjective Binge Eating

Loss of control

Abnormally large amount of food Felt out of control, but did not consume
consumed, plus felt unable to stop an abnormally large amount of food

Overeating Life

Large amount of food consumed, but Honoring hunger and fullness cues,
could stop if wanted to – consciously eating when hungry and stopping when
chose to eat more after feeling full full and satiated

(Wisniewski, 2017)
THE KINDS OF OVEREATING

• Overeating – eating Oreos and continuing beyond the point of satisfaction

• Compulsive Overeating – habitual overeating (e.g., eating only
because others are eating, eating just because something is offered/ free,
eating past fullness on a regular basis)

• Emotional Eating – eating a whole sleeve of Oreos when feeling upset,

angry, stressed, etc.

• Binge Eating – eating a whole sleeve of Oreos, then going on to eat

other things even though feeling miserably full
DSM-IV CRITERIA:
AVOIDANT RESTRICTIVE FOOD INTAKE
DISORDER (ARFID)
A.) An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the
sensory characteristics of food; concern about aversive consequences of eating as manifested by persistent failure to
meet appropriate nutritional and/ or energy needs associated with one (or more) of the following:
1.) Significant weight loss (or failure to achieve expected weight gain or faltering growth in children)
2.) Significant nutritional deficiency
3.) Dependence on enteral feeding or oral nutritional supplements
4.) Marked interference with psychosocial functioning
B.) The disturbance is not better explained by lack of available food or by an associated culturally sanctioned
practice.
C.) The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and
there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.
D.) The eating disturbance is not attributable to a concurrent medical condition or not better explained by another
mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of
the eating disturbance exceeds that routinely associated with the condition or disorder , the severity of the eating
disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical
attention.
DSM-IV CRITERIA:
PICA

A.) Persistent eating of nonnutritive, nonfood substances over a period of at least 1

month.
B.) The eating of nonnutritive, nonfood substances is inappropriate to the
developmental level of the individual.
C.) The eating behavior is not part of a culturally supported or socially normative
practice.
D.) If the eating behavior occurs in the context of another mental disorder (e.g.,
intellectual disability, autism spectrum disorder, schizophrenia, or medical condition
such as pregnancy), it is sufficiently severe to warrant additional clinical attention
DSM-IV CRITERIA:
RUMINATION DISORDER

A.) Repeated regurgitation of food over a period of at least 1 month. Regurgitated food may be re-
chewed, re-swallowed, or spit out.
B.) The repeated regurgitation is not attributable to an associated gastrointestinal or other medical
condition (e.g., gastroesophageal reflux, pyloric stenosis).
C.) The eating disturbance does not occur exclusively during the course of anorexia nervosa, bulimia
nervosa, binge eating disorder, or avoidant/ restrictive food intake disorder.
D.) If the symptoms occur in the context of another mental disorder (e.g., intellectual disability or
another neurodevelopmental disorder), they are sufficiently severe to warrant clinical attention
DSM-IV CRITERIA:
OTHER SPECIFIED FEEDING OR EATING
DISORDER (OSFED)

This category applies when symptoms characteristic of a feeding or eating disorder cause clinically
significant distress or impairment in social, occupational, or other important areas of functioning
predominate but do not meet the full criteria for any of the disorders.
EATING DISORDERS CAN SERVE MANY
FUNCTIONS
• A false sense of control
• A way to privately be out of control
• A way for numbing emotions
• An attempt to keep oneself from growing up
• A coping mechanism for anxiety, depression, or other emotional
distress
• A form of self-punishment or self-harm
• A response to trauma to feel grounded and safe
• A way to replay old patterns from childhood as a means of
seeking connection, avoiding waste, or secrecy around eating
• An escape from boredom, dissatisfaction, or constant chatter in
your head

(Sarah Dosanjh, 2020)

HIGH RISK GROUPS

• People between the ages of 12 and 25 years

• Those going through major life transitions (e.g., new school, puberty,
pregnancy, menopause)
• Women with Polycystic Ovary Syndrome
• Athletes in sports where much emphasis is placed on shape and weight
• Individuals with family history of eating disorders or disordered eating
• Individuals who chronically diet or try to lose weight
• The LGBTQ+ population

(Waterhous, 2019)
WHAT AN EATING DISORDER MIGHT LOOK LIKE
• Change in daily behaviors
• Change in personality
• Irritability
• Secrecy
• Difficulty concentrating
• Withdrawing from normal activities
• Signs of physical deterioration (brittle hair
& nails, dry, cold skin, etc.)
• Loss of energy
• Lack of emotional display and/ or irritability
and outbursts

• Excessive exercise
• Dramatic shifts in weight
• Avoiding atmospheres where food is present
• No longer wanting to eat around others
• Preoccupation with weight, food facts, meal
rituals
WHY DOES SOMEONE
DEVELOP AN EATING
DISORDER?
 ETIOLOGY OF AN EATING DISORDER

“Genetics loads the gun; environment pulls the trigger.”

• Genetic traits predisposition

• Perfectionism, compulsiveness, impulsivity, avoidance,
neuroticism, anxiety, low frustration tolerance

• Triggered by environmental factor

• E.g., trauma, bullying, diet culture, media, family
pressure/ diet talk, stress, sports and activities
with a weight focus, overt parental control during
developmental stages, poverty, etc.

Laura L. Hill & Marjorie M. Scott (2015): The Venus Fly Trap and the Land Mine: Novel Tools for Eating
Disorder Treatment, Eating Disorders: The Journal of Treatment & Prevention
 THE CHANGE IN EATING BEHAVIOR
SERVES A ROLE

• Any time we change our eating, we change our brain

chemistry
• We actually feel different after periods of both restricting
our caloric intake or bingeing on large amounts of food

• Motivation behind dieting can vary

• Attempting to manipulate emotional state
• Choosing to eat less/ diet in hopes of changing something about
oneself, feel happier, be accepted, etc.
 DIETING SETS THE EATING DISORDER
INTO ACTION
• Limbic system in brain controls body weight Bingeing = the biological response to dieting
• Brain views dieting as a threat to survival
• When dieting, individual undergoes significant metabolic, hormonal, and
neurobiological changes to promote food consumption and weight regain

(Kissileff et al., 2012; Kizer, 2018; MacLean et al., 2011; Redman et

al., 2009; Rosenbaum & Liebel, 2013; Shaw, 2012; Stotz, 2019)
REGULATION
(MacLean, et. al., 2011)
THE PERVASIVE
IMPACT OF DIET
CULTURE
 DIET CULTURE
• Focuses on and values weight, shape, and size over wellbeing
• Assigns hierarchical value to bodies
• Assigns moral value to food
• Drives one from their values and persuades to conform to external
commands
• Glorifies the thin-ideal
• Influences unrealistic and many times unhealthy body goals such as
“thigh gap,” flat tummy, anti-cellulite, etc.
WHAT DOES DIET CULTURE LOOK LIKE?
• Eating patterns that on the surface appear in the name of health but in reality, are about weight and
size
• Assigning labels such as “good” or “bad” to lifestyles and choices, attempting to give these things
morality
• Restrictive and/or rigid diets
• Making food and exercise choices based on external things rather than one’s internal desires and needs
• Using terminology such as “cheat days,” “junk food,” “clean,” “detox,” etc. when describing foods and
lifestyle choices
• Cutting out entire nutrients or food groups for purposes unrelated to taste or cultural preferences
• Manifestations of “food rules” such as
• I don’t eat white bread
• I don’t eat after 8pm
• I can’t eat THAT type of cereal

• Not the foods themselves that signify their worth, but the meanings attached to them
“Diet culture encompasses all the messages that
tell us that we’re not good enough in the bodies
we have, and we’d be more worthwhile and
valuable if our bodies were different. Our culture
is SO embedded with body and weight-centric
messages that they’re sometimes imperceptible.
Diet culture is deeply ingrained in our everyday
existence and prevents us from living our most full
and meaningful lives. To break away from diet
culture, we need first to expose it, then find
alternative ways to feel connected to ourselves,
each other, and the world in a way that moves
away from defining our worth according to our
body shape, weight or appearance.”

– Fiona Sutherland
DIETING: WHAT DOES THE RESEARCH SAY?
Dieting leads to increased focus on all things, food
• Research demonstrates that dieters experience increased food-related thoughts, cravings, and overall
preoccupation with food. Brain scans on individuals who are restricting their calories show increased
activity in areas related to hunger, motivation, and desire, while those done on individuals who are properly
nourishing themselves indicate increased activity in areas related to satiation and memory. Dieters also
report significantly more food and eating-related thoughts than non-dieters.
https://pubmed.ncbi.nlm.nih.gov/19685956/
https://pubmed.ncbi.nlm.nih.gov/15971244/#:~:text=Results%3A%20Restrained%20participants%20in
structed%20to,mentions%20to%20food%20and%20eating.

Dieters experience more cravings than non-dieters

• An ample amount of research has been done on the impact of dieting, each indicating that restricting
foods leads to increased cravings and increased consumption of these very foods. “Compared with non-
dieters, dieters experienced stronger cravings that were more difficult to resist, and for foods they were
restricting eating.” Furthermore, it is found that trying to suppress food-related thoughts leads to
thinking about them even more. https://pubmed.ncbi.nlm.nih.gov/22306437/,
https://onlinelibrary.wiley.com/doi/full/10.1002/oby.21098
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3779532/
DIETING: WHAT DOES THE RESEARCH SAY?
Forcing oneself to eat “healthy” results in a competing motive to eat whatever
• The desire to eat “healthy” is shown to compete with the desire to fulfill one’s appetite, thus creating a
conflict between one’s eating what they think they “should” and what they actually want. Research
attributes this to both diets requiring restrictions and people’s belief that “healthy” food is generally less
fulfilling. Furthermore, it is found that eating something solely for the purpose of “health” results in
remaining just as hungry or, even more hungry afterwards. “Put simply, imposed healthy eating would
make people feel hungrier than not eating at all or eating the same food without an emphasis on its
healthiness.” Additionally, because humans are wired to resist external controls, diets create an increased
desire for whatever items are “off-limits.” https://academic.oup.com/jcr/article/37/3/357/1826407

Dieting and voluntary weight loss prompts the development of binge eating as well as
creates and/ or further complicates pre-existing mental health concerns
• Dieting consistently shows to be a precursor for binge eating and other disordered eating behaviors.
Moreover, dieting is associated with increased symptoms of depression, anxiety, and other mental health
complications. “Independent of the effect of body weight itself, dietary restraint is correlated with
feelings of failure, lowered self-esteem, and depressive symptoms. Dieting has also been shown to predict
stress.” http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.1020.2319&rep=rep1&type=pdf
DIETING: WHAT DOES THE RESEARCH SAY?
Weight cycling is strongly linked to health complications and disruptions in overall wellbeing
• Not only is frequent dieting and weight regain associated with a heightened risk of heart disease, type 2
diabetes, and overall death rate, but the chronic stress of worrying about weight and dieting further
contributes to adverse health outcomes. https://www.hindawi.com/journals/jobe/2014/983495/

Dieting leads to increased body fat stores

• Not only does dieting teach the body to store fat, but the risk of this happening is more likely in lean
people than those naturally in larger bodies.
https://www.researchgate.net/publication/223957474_How_dieting_makes_some_fatter_From_a_persp
ective_of_human_body_composition_autoregulation

It is what we tell ourselves about the food, not the food itself that causes our guilt.
• Studies suggest that it is the dieting itself that causes eating-related guilt, rather than the food that
was consumed. “Those who associated chocolate cake with guilt (vs. celebration) reported unhealthier
eating habits and lower levels of perceived behavioral control over their eating.”
https://pubmed.ncbi.nlm.nih.gov/25186250/
ASSESSMENT &
SCREENING
SCOFF

Answering "yes" to two or more of the following questions indicates a possible eating disorder:

• Do you make yourself Sick (induce vomiting) because you feel uncomfortably full?
• Do you worry you have lost Control over how much you eat?
• Have you recently lost more than One stone [approximately fifteen pounds] in a 3 month period?
• Do you believe yourself to be Fat when others say you are too thin?
• Would you say that Food dominates your life?

(Morgan et al., 1999)

QUESTIONS FOR RULING IN AN
EATING DISORDER
• Do you worry that you have lost control over how much you eat?
• Do you make yourself sick when you feel uncomfortably full?
• Do you currently suffer, or have you ever suffered in the past with an eating disorder?
• Do you ever eat in secret?

• Over the past four weeks, to what extent have your concerns about your weight/ shape or eating
behaviors interfered with your schoolwork, social life, or caused you to have bad feelings about
yourself?
• Not at all
• A little
• Quite a bit
• A lot

(Waterhous, 2019; Taylor et al., Stanford-Washington University)

 SCREENINGS

• Eating Attitudes Test (EAT-26)

• Garner et al., 1982

• Eating Disorder Examination Questionnaire (EDE-Q)

• Fairburn & Beglin, 2008

• Questionnaire on Eating and Weight Patterns-5 (QEWP-5)

• Yanovski, 1994

• Binge Eating Disorder Screener-7 (BEDS-7)

• Takeda, 2019
STRUCTURED CLINICAL INTERVIEW
1.) Binge Eating (amounts & types, frequency, objective vs. subjective)
2.) Purging/ compensatory behavior (self-induced vomiting, laxatives, diet pills, compulsive exercise, fasting)
3.) Eating Patterns and Dietary Restriction (frequency & timing b/w meals & snacks, food avoidance, rituals &
rules)
4.) Weight Hx (current weight, lowest & highest weights, pattern of weight fluctuation)
5.) Body Image (body dissatisfaction, influence of weight & shape on self-evaluation, preoccupations, rituals, body
checking & avoidance behaviors)
6.) Previous Treatment (level of care, age, length of treatment, individual and/ or group therapy, medications)
7.) Family Hx (medical & psychiatric)
8.) Cultural Considerations (can provide insight into ideal body type, importance of food, etc.)
9.) Social and Developmental Hx (childhood, adolescent, adult social & academic functioning, abuse & trauma)
10.) Current Psychosocial Functioning and Impairment (relationships, occupational, academic, leisure time &
hobbies, impulsivity)

(Robinson, 2019)
TREATMENT
STRATEGIES
RECOVERY FROM AN EATING DISORDER
INVOLVES 2 PARTS

Psychological
• Underlying issue(s)

Behavioral
• The disordered eating behavior(s) itself

Healing from an eating disorder

requires a multidisciplinary approach
LEVELS OF CARE

• Inpatient
• Residential
• Partial Hospitalization (PHP)
• Intensive Outpatient (IOP)
• Outpatient
OUTPATIENT: WHAT TO EXPECT

A multidisciplinary team approach including:

• Individual counseling
• Group counseling
• Nutrition therapy
• Medical monitoring
• Psychiatry services (if needed)

(Zoe Bisbing)
 • Family-Based Treatment (FBT) / Maudsley Approach

ANOREXIA
• Enhanced Cognitive Therapy (CBT-E)
• Acceptance and Commitment Therapy (ACT)
NERVOSA • Cognitive Remediation Therapy (CRT)
 • Dialectical Behavior Therapy (DBT)

BINGE-TYPE • Enhanced Cognitive Therapy (CBT-E)

• Integrative Cognitive-Affective Therapy for Bulimia Nervosa
EATING (ICAT-BN)

DISORDERS • BED-focused self help

• Acceptance and Commitment Therapy (ACT)
AVOIDANT/ RESTRICTIVE • Exposure Therapy
FOOD INTAKE • Cognitive Behavioral Therapy
DISORDER (ARFID) • Dialectical Behavior Therapy
 • Correcting nutrient deficiencies
PICA • Medication often required for individuals with special needs
 • Changes in posture before and after meal
• Removing distractions while eating
RUMINATION • Reducing stress while eating

DISORDER • Working on triggers

• Learning new behaviors for stomach muscles
• Psychotherapy
 OTHER
SPECIFIED
FEEDING OR • Use treatment most resembling the diagnosis
(also including each unique aspect to meet the client’s
EATING specific needs)

DISORDER
(OSFED)
 Some eating disorders are
egosyntonic
Shame and stigma

COMMON Not wanting to give up the function

BARRIERS eating disorder serves
Being entrenched in diet culture

Facing familial or other external

pressures
HELPFUL THINGS TO WORK ON IN
EATING DISORDER RECOVERY

Encouragement Detaching from

Learning to feel all
and accountability Coping skills unhelpful thinking
emotions
for regular eating patterns

Prioritizing self- Expanding other

care and Establishing areas of life and
Body image
pleasurable supports pursuing one’s
activities values

Boundaries Self-compassion
COPING SKILLS

• Coping skills are unique to each individual

• Helpful to choose activities that require strategy and are of

interest to the client
• Higher likelihood of follow-through
• Strategy requires brain to work constructively to wire new routines, while
depriving undesired neural pathways of the attention they need to stay
strong
ENGAGE THE MIND IN SOMETHING

By doing something else, we steal away neurons that are maintaining the overwhelm and
get them focused on a new activity.

• Make your mind work (ex. crossword or sudoku puzzles, read, fix something, etc.)
• Use your imagination
• Create strong sensations with the 5 senses
• Do something active
• Play an instrument
• Do something with your hands such as organizing
• Do something you enjoy that keeps you busy
• Watch a movie or show that captures your attention
REFRAMING UNHELPFUL THOUGHTS
When I eat fast food, I must order the “healthiest” option. → When I eat fast food, I will honor
both my cravings and what feels best for me in the moment. I understand that enjoyment of food
impacts my health as well, so I am going to order what I truly want.

I can’t eat sweets because I can’t control myself around them. → Actually, by allowing myself to have
sweets, I train my brain to respond to them as it would to any other food, thus I don’t crave them
constantly and then binge on them later.

I shouldn’t snack between breakfast and lunch → I will honor my hunger whenever it arises,
understanding that hunger looks different from day to day and trusting that when my “fuel is running
low,” it’s time to refuel. I can trust my body!

I’ve been good today. → I feel energized after eating the way that I have today.

I feel like crap after eating so badly. I should have never eaten so much. → I don’t feel the best
after the choices I made this evening. It is not the end of the world however, and I learned from
this experience. Each meal is a new experience to tune into myself and my eating experience.
 “As soon as words like ‘shouldn’t’ or
‘naughty’ are used, we begin to absorb
a sense that sweet, calorific foods have
a specific status and are mixed up with
complex feelings about the self.”
- Jo Cormack

• Aim is to have the same emotional response to all foods. This means that whether we eat an apple or a
bag of chips, we have a neutral response.
CHANGING RELATIONSHIP WITH
UNHELPFUL THOUGHTS Rather than changing our thoughts,
cognitive defusion involves changing our
Name and acknowledge the thoughts, feelings & urges relationship to them
• Here’s an urge to binge, I am noticing a judgment, I am feeling sad
Add the statement “I am noticing I am having the thought that…” (can be adapted to any inner experience [e.g. “I am noticing the urge
to…”])
• I am noticing I am having the thought that I am a failure, I am noticing the urge to binge
Sing the thought to the tune of a silly song (e.g. “Happy Birthday”)
Imagine the thought being spoken in the voice of a cartoon character, comedian, sports commentator, or unfavorite politician
Imagine that you are reading the thought as words on a computer screensaver, seeing it in different colors, fonts, animations, etc. (close your
eyes and really visualize it)
Observe the thought as though it were an object: describe its location, size, color, solidity, volume, texture, speed, etc.
• If this thought had a color, what would it be? If it had a speed, what would it be – is it fast or slow?
Write down the thought(s); paint, type, sculpt, dance it, act it out, mime it, text it, etc.
In your imagination, place the thoughts one by one onto leaves as they “float down the stream” at their own pace – whatever pace they
choose
Genuinely thank your mind for producing the thought while choosing to engage with your present experience rather than the thought
• Thank you Mr. Mind; I appreciate you trying to help but I actually have other things to do right now such as this project I am working on (then use
mindfulness skills to connect to your present experience whether that be feeling the pencil in your hands, noticing the feel of your feet pressing into the
floor, the sounds in your environment, etc.)
Stop and ask yourself, “Who is talking here; me or my mind?”
Say the thought v e r y s l o w l y
• I am noticing I am having the thought that I w i l l g e t f a t i f I e a t t h i s
WRITING & NAMING THE URGE

• On an index card, write down each of the thoughts surrounding the urge/ anything your mind tells you
that is not helpful
• Ex: “I am having the urge to binge eat large amounts of food”
• “I must eat well at ALL times” etc.
• On the back, give the story a name
• Ex: Ope, there goes my brain sending an “Urge” again
• Aha! There it is again, the “All-or-Nothing voice;” I know this one
• Anytime you notice this unhelpful thinking showing up, call out the story by its “name,” then ground
yourself & engage w/ the world around you
• Additional step: fold up the card & carry it with you everywhere you go. Ever so often, unfold it & read
through the thoughts, then flip it over and read the “name” on the back, calling it what it is.

(Harris, 2019)
URGE 911

• STEP ONE: NAME IT

• STEP TWO: FRAME IT
• STEP THREE: EXPLORE IT
• STEP FOUR: SEE RECOVERY
• STEP FIVE: REFOCUS
 EXPOSURE THERAPY

• Create a list of fear foods &

rankings
• Plan & carry out exposures
• Keep record
• Behavioral Experiments (did • Excellent handout to use with clients!
your fears come true?) • https://www.cci.health.wa.gov.au/-/media/CCI/Mental-Health-
Professionals/Eating-Disorders/Eating-Disorders---Worksheets/Eating-
Disorders-Worksheet---02---Tackling-Avoided-Foods.pdf
CONTAINMENT

(Susan Albers, 2013)

DISTRESS TOLERANCE

T – Thought replacing (phrases you can tell yourself that bring about a positive mindset, singing a
song you find uplifting, etc.)
A – Activities (actively engaging the mind in something else such as going for a walk, calling a friend,
or drawing)
G – Guided imagery (closing your eyes and going to your “happy place” in your mind, wherever that
might be, also fully imagining each sensation involved from the smells, sights, and sounds of the place)
S – Sensations (activating the senses through things such as holding an ice cube, splashing your face
with water, putting a breath mint in, smelling a candle or lotion, doing a wall sit, etc.)

(*adapted from Dawn-Elise Snipes, 2021)

 Follow this link for a “Ride the Wave script!
➢ https://improbablyoverthinkingthis.files.wordpress.com/2018/

“RIDING THE WAVE”

02/62a68-dbtridingthewaveofemotions.pdf

• As we practice being with urges, they die down over time

• Frequency & intensity of urges decrease, we become better at waiting them out, & we become
more confident with “riding it out”

What we think: the urge will rise in intensity Reality: Urges rise to a peak then if waited out,
until I satisfy it or stop it somehow will naturally subside

• Satisfying an urge results in stronger future urges

• Attempting to fight wears self down & strengthens urge (suppressed things become stronger)
IMAGERY AND
“SAFE PLACE”
• Guided imagery is a powerful tool
that involves intentionally thinking
of a peaceful place in order to calm
your mind. With imagery, it can help
to close your eyes and to really focus
on recreating the sights, scents,
sounds, and all of the other
important details of the place. The
goal is to create a relaxed, peaceful
state right where you are by
visiting this “place” in your mind.
FOCUSING ON A NATURAL OBJECT

• Choose a natural item from within immediate environment and focus on

watching it for a moment or two
• Do not do anything except notice the item. Relax into a harmony for as
long as your concentration allows. Look at it as though seeing it for the
very first time. Allow yourself to be consumed by its presence
• Ex: flower, plant, insect, clouds, moon
BOX BREATHING

• Powerful coping skill that aims to return breathing to its normal

rhythm, and in the process, slow one’s racing thoughts
• Always available at any point in time and in any situation!

• The method:
1.) Breathe in through your nose while slowly counting to four
2.) Hold your breath as you again slowly count to four
3.) Slowly exhale trough your mouth as you count to four
4.) Again, hold your breath as you slowly count to four

Repeat these steps until a sense of calm arises

“PLAYING THE TAPE THROUGH”

• This skill involves simply pausing when noticing the urge to

binge eat. After pausing, think through how bingeing
typically goes. “Play the tape through” in your mind; consider
how you usually feel after the binge is over – what about
the next day? Think about all of the typical things that
result from a binge such as discomfort, guilt, sadness, even
pain in your throat or abdomen area.
• Since the mind likes instant gratification, we usually do not
think through the consequences until we have already
started bingeing. For this reason, “playing the tape
through” can be a helpful skill to get us in touch with all of
the things we later regret after bingeing.
 Copies can be found at
➢ https://cls.unc.edu/wp-
CHAIN ANALYSIS content/uploads/sites/3019/2016/
06/Chain-Analysis-Worksheet.pdf

“Awareness without action,

is not awareness at all.”
– David Daniels, MD
 SELF-DISCOVERY THROUGH
JOURNALING

• When an urge arises

• After a binge
• When feeling “off” or uncomfortable
• Writing out what you wish you would have done
differently
• By pausing not only to think about how you wish things
would have gone and what you want to do in the future,
but writing it down, you further strengthen the new
beneficial pathways that support the desired behavior!
EXPANDING OTHER LIFE AREAS

As individual expands other life areas,

eating disorder takes up less space, thus
becomes less important

Eating Disorder Family School Hobbies

THE SPIRAL OF
HEALING

• A compassionate way to envision your journey

• Reminder that progress does not move in a straight line
• Returns to previous patterns are not setbacks
• When the forward progress loops around an old pattern of
thinking or behavior, explore it with curiosity
• Use these “old pattern” loops to examine your beliefs and self-
talk and consider what you need for self-care
FREE RESOURCES
AND TRAININGS!
• Missouri Eating Disorders Council “360 Trainings”
• Visit http://www.moedc.org/training/online-training/ to obtain
access

• CBT-E for Eating Disorders

• https://www.cbte.co/self-help-programmes/digital-
cbte/#:~:text=CREDO%20are%20developing%20a%20digital%
20form%20of%20CBT-
E%2C,in%20the%20early%20stages%20of%20an%20eatin
g%20disorder.
• Email cbte.training@gmail.com to request access

• Balance Eating Disorder Centre – free virtual trainings!

• Contact webinars@balancedtx.com to get added

• Receive monthly eating disorder trainings straight to your inbox!

• Contact 360EDtraining@wustl.edu to get added
RECOMMENDED READINGS FOR RESTRICTIVE
EATING DISORDERS
For client:
For clinician/ family:
 RECOMMENDED READINGS FOR BINGE
EATING
For client:
For clinician:
RECOMMENDED READINGS FOR ALL
GET INVOLVED
• Missouri Eating Disorders Association
• Missouri Eating Disorders Council
• National Eating Disorders Association
• The Alliance For Eating Disorders Awareness
• Multi-service Eating Disorders Association
• National Eating Disorder Information Centre
• Academy for Eating Disorders
• AEDRA Eating Disorder Centre
• National Association of Anorexia Nervosa and Associated
Disorders