Brain-Based ED Treatment Laura Hill Ebook

A Brain-Based Approach to
Eating Disorder Treatment

by Laura Hill, PhD
1
A Brain-Based Treatment Approach to Eating Disorder Treatment,© ® 2017, The Center for Balanced Living, Columbus, OH, USA
Written by Laura Hill, PhD. Permission to photocopy or download and print this page for personal or professional use.
Table Of Contents
Copyright 3
About The Center for Balanced Living 4
About the Author 7
Acknowledgements 10
Dedication 13
Historical Perspective of Eating Disorders and Mental Health 14
A Brain-Based Paradigm Shift in Eating Disorders 26
Brain-Basis to Eating Disorders 42
A Neurobiological Explanation of Eating Disorder Experiences 75
Overview of the 5-Day Treatment for Eating Disorders 95
5-Day Treatment: Day 1 129
Outcome Data: Quantitative & Qualitative 211
Terms 215
References 218
2
Copyright
Copyright ----- Copyright
A Brain-Based Treatment Approach to
Eating Disorder Treatment
Written by Laura Hill, PhD
© ® 2017
The Center for Balanced Living
Columbus, Ohio, USA
The purchaser of this e-text has permission to photocopy, download and print this electronic
text for personal or professional use. The purchaser does not have permission to remove or
conceal the copyright and author information or place any images or text
information onto social media, YouTube or other websites and online
sources. Professional use of the materials is limited to the number of persons who purchase
the license.
The structure, framework and technical design of this electronic text was developed
by Jon Borgman.
3
About The Center for Balanced Living
About The Center for Balanced Living ----- Preface
The Center for Balanced Living was founded in 2000.

To our knowledge, it is the last free-standing, non-profit organization
providing
specialized eating disorder treatment, education and research
services for adolescents and adults
in the United States.
The Mission
4
Provide specialized, evidence-based treatment, education and
research
in the area of eating disorders
and to foster balance in the lives of all persons served.
The Vision
Create strength through balanced living.
The Center for Balanced Living provides treatment to about 2,000

different clients annually via a
Partial Hospital Eating Disorders Program,
three Intensive Outpatient Eating Disorders Programs,
Outpatient Treatment and the
5-Day Treatment for Eating Disorders.
The Center has also published the Family Eating Disorders Manual.
It was written for families and supports of those with eating disorders,
introducing a neurobiological or brain-based approach to eating
disorders. It can be ordered via Amazon.
For more information about The Center for Balanced Living see:
www.CenterforBalancedLiving.org
Address:
8001 Ravines Edge Court, Suite 201
Columbus, Ohio 43235
Phone Number:
614.896.8222
5
6
About the Author
About the Author ----- About the Author
Laura Hill, PhD, FAED
7
8
Dr. Laura Hill is the founder, President & Chief Executive Officer of The Center for Balanced
Living in Columbus, Ohio. She specializes in eating disorder treatment, education and
research. She is also a Clinical Assistant Professor in the Department of Psychiatry at The
Ohio State University.
She is one of the original founders of the Academy for Eating Disorders in 1993 and was
Director of The National Eating Disorder Organization (currently known as NEDA) from 1990
to 1994.
She first began treating eating disorders in 1979 and has been publishing in peer reviewed
journals since the mid 1980s, with increasing focus on biologically based treatments for
anorexia nervosa. She and the University of California, San Diego Eating Disorders Center
for Treatment and Research teams are the recipients of the Feeding Hope Fund by the
National Eating Disorders Association (NEDA). Dr. Hill is not a neuropsychologist, however,
she has been active in the development of brain-based treatment applications since the
early 2000s.
In addition, Dr. Hill is the recipient of Muskingum University’s 2014 Distinguished Service
Award, NEDA’s 2011 Lori Irving Award for Excellence in Eating Disorders Prevention and
Awareness and a 2012 TEDx speaker. Dr. Hill has spoken internationally over the last 35
years.
9
Acknowledgements
Acknowledgements ----- Preface
Sincere appreciation and gratitude to The Center for Balanced Living’s 5-Day Treatment for
Eating Disorders team and The University of California, San Diego Eating Disorders Center
for Treatment and Research colleagues, a research partner which helped in the
development and refinement of the 5-Day Treatment for Eating Disorders.
The Center for Balanced Living
Jason McCray, PhD M Mullan, LPC Erica Temes, BA

Chief Clinical Officer Clinician Psych Tech
Sonja Stotz, RD, LD Amber Scott, BA Jenifer Takats, MD

Director of Food and Nutrition Research Associate Medical Director
10
Summer Lawson Chris Schultz
MSW, LISW, PMHNP-BC PMHNP-BC
Psychiatric Nurse Practitioner Psychiatric Nurse Practitioner
11
University of California, San Diego
Eating Disorders Center for Treatment and Research
Christina Wierenga, PhD Walter Kaye, MD

Clinical Neuropsychologist Founder and Executive Director
Associate Professor Professor
Stephanie Knatz Peck, PhD Laura Greathouse, MPH

Program Director Research Coordinator
Intensive Family Treatment (IFT)
Assistant Clinical Professor
Department of Psychiatry
12
Dedication
Dedication ----- Preface
Dedication
This text is dedicated to

the intelligent, persistent, perfectly created, stubborn and detailed clients
and their supports,
whose input has informed, shaped and tailored
this treatment approach.
Life is a rough draft.

So too are research and treatments.
As a result, this text is ever-changing;
it expresses a neurobiological language,
which is integrated in and through
the clinical interventions.
It was developed from neurobiological research results
with the voices of the clients’ & supports’ feedback,
each step of the way,
as we took turns
leading one another.
13
Historical Perspective of Eating Disorders and Mental Health
Historical Perspective of Eating Disorders and Mental Health ----- Chapter 1
Table of contents
- Summary
"Do you avoid or restrict food daily to prevent weight gain?" "Do you uncontrollably eat a
large amount of food within a discrete amount of time?" "Do you make yourself vomit due to
body image or weight concerns?" Historically, mental health professionals have approached
mental disorders from the outside-in. Prior to 2000, technology had not advanced enough to
explore the depths of the brain and understand mental disorders more completely from the
inside-out. Eating disorders were introduced to the public based on self-reported thoughts,
feelings and behaviors of the illness, with medical sequelae. The field of mental health has
been referred to as behavioral health because of the external focus on problematic,
behavioral expressions.
Since the first diagnostic manual in 1952,1 the American Psychiatric Association has
categorized mental disorders by grouping behavioral expressions of cognitive, emotional,
developmental and perceptual symptoms together to create nosological classifications.
Diagnostic symptoms have been commonly described by self-report instruments that reflect
thoughts, actions and perceptions from the outside-in. Behavioral expressions have been
the focus of mental and social problems that contribute to a decrease in functionality and
quality of life. It has long been understood that behavioral expressions are the outward
manifestation of brain responses, as shown in Figure 1.
14
Figure 1
Figure 1 visually describes how the mental health field has traditionally taken behavioral
symptoms and grouped them together to formulate diagnoses. Symptoms have been
treated from the outside-in via therapies such as cognitive behavioral therapy (CBT),
interpersonal therapy (IPT) and dialectic behavioral therapy (DBT). The figure shows that
medication and nutritional interventions impact brain response upon application, an inside-
out treatment. This does not imply that the behavioral interventions do not alter brain
response. They impact the brain by starting from the outside and moving inward to shift
neurobiological responses, such as behavior, cognition, emotion and movement to change
brain response. The figure demonstrates the focus of treatment outside the brain or on
expressions of the brain.
The psychiatric and mental health fields use the Diagnostic and Statistical Manual of Mental
Disorders (DSM) as a standardized means to discuss, describe and label symptoms. The
DSM uses primarily outward behavioral criteria to describe both internal and environmental
contributing factors. The latest edition, DSM-5, released in May of 2013,2 recategorized
some diagnoses and continued the traditional approach of drawing upon behavioral,
15
cognitive, social and psychological research to describe mental illnesses from the outside-in.
There was little application and inclusion of neurobiological research in the DSM-5. This
primary diagnostic manual has guided clinicians to continue to focus on the outside-in
verses including accrued research to introduce the neurobiological impact on mental
illness from the inside-out.
Many eating disorder psychotherapies today focus on identifying and processing cognitive,
emotional and behavioral expressions, as well as social relationships. The field of evidence-
based, eating disorder treatments includes CBT and enhanced cognitive behavioral therapy
(CBT-E),3, 4, 5 DBT6, 7, 8 for bulimia nervosa and binge eating disorder, IPT for binge eating
disorder and other eating disorders,9, 10 integrative-cognitive affective therapy (ICAT) for
bulimia nervosa11 and acceptance and commitment therapy (ACT). With the rise of brain-
based research, eating disorder research models are pointing away from using solely
“talking and processing” therapies to exploring more neurobiological and psychobiological
interventions.12
Of all the eating disorder diagnoses, anorexia nervosa stands out distinctively as having a
more homogeneous population, the highest death rate of all mental illnesses,45 multiple
complex medical complications and no reliable treatment approach that has been proven
effective over time. The illness ranges from early adolescence through older adulthood.
Studies have shown poorer treatment outcomes for adults in comparison to adolescents
with anorexia nervosa. There have been several psychosocial, behavioral and
pharmacological interventions investigated in adult anorexia nervosa.13, 14, 15, 16, 17, 18,
19, 240
However, evidence supporting currently available treatments is weak, and treatment
effects, when found, are generally small.20, 21, 22, 23, 24, 25, 26, 240
Treatments for adolescent anorexia nervosa are more promising, with a large evidence base
supporting family-based treatment (FBT).27, 28, 29, 30, 31, 32 Janet Treasure and Ulrike
Schmidt have led the development of the MANTRA (The Maudsley Anorexia Nervosa
Treatment for Adults) program, a maintenance model for adults with anorexia nervosa.33,
34, 35
Treating adults with anorexia nervosa is difficult. Finding creative alternatives to
include support persons in the adult treatment is even harder. Support persons can be
agents of change. However, involving supports in treatment with adults who have anorexia
nervosa goes against a mindset that expects autonomy for adult development, and many
have little-to-no support networks. It is also a challenge because therapists are trained to
exclude family and support persons in ongoing adult therapy. This occurs when the client
turns 18 and is legally an adult in the United States. Developmental psychological
approaches advocate that individuation begins at this age.
Behavioral therapy with family involvement has been proven to have a long-term impact on
the reduction of obesity among children.36, 37, 38 However, individual traits and brain
responses have been given little-to-no focus in family treatment approaches. More recently,
radically open dialectical behavioral therapy (RO-DBT)39, 40 has begun to integrate
neurobiological information into treatment for anorexia nervosa and clients with avoidant
traits. In addition, cognitive remediation therapy (CRT) targets cognitive strengths and
weaknesses, drawing upon a neurobiological context.106 Yet the widely used cognitive
behavioral treatment models focus primarily on symptom change. Biological underpinnings
of the cognitions and behaviors have been given less focus.
16
The development of effective treatments that translate the gap between neurobiological
eating disorder research and treatment is of critical importance to explore and interrupt the
persistent course of the illness, given the magnitude of medical and psychological
consequences. The need for both scientists and clinicians to work together to extrapolate
from neurobiological findings to create new and novel treatments is needed.106 Eating
disorder brain imaging research has led to an increased understanding of neurobiological
mechanisms underlying eating disorders and has identified potential targets in the brain.
Despite this new perspective, there have been no interventions (to our knowledge)
integrating current, empirically supported, biogenetic and neurobiological findings into
treatment with adults that include families/supports until the development of the 5-Day
Treatment for Eating Disorders, first published in 2016 under the name NEW FED TR.13
While DSM-5 diagnoses have distinct, categorical descriptions of symptoms, it is not

uncommon for therapists to arrive at different diagnostic conclusions for the same client.
Assessments and diagnoses can be subjective. For example, one therapist may diagnose a
person with major depression while another may diagnose the same person with adjustment
disorder with depressed mood, based on the history and symptoms identified, as well as the
training or the experience of the therapist.
From the historical perspective of mental or behavioral health, the brain is the last of the
uncharted organs in the body. Central to the body, it acts like a conductor of an orchestra.
Yet there is relatively little known about this orchestrating organ. As science and technology
have progressed since 2000, the ability to observe brain patterns has improved through
structural, brain-imaging techniques, such as functional magnetic resonance imagery (fMRI),
positron emission tomography (PET) and single-photon emission computed tomography
(SPECT) scans, providing technical means for researchers to observe the brain in 3-D.
When viewing fMRIs, technicians identify increased brain activity via oxygen flow by
observing areas of the brain “light up” during functional activities.
Thomas Insel, MD, Director of the National Institute of Mental Health (NIMH) from 2002 until
December of 2015, discussed behavioral health and its lack of attention to the brain in his
2013 TED talk, “Toward a New Understanding of Mental Illness.”42 He led NIMH as it
entered the new millennium to explore more deeply the etiology of mental illness in order to
better understand and help shape more effective treatments. As he described in his TED
talk, behavior is the last stage to reveal mental problems. He also addressed the need to
focus more on the source of the behavioral problems, the brain. He urged that mental
disorders be described as brain disorders.43
Dr. Insel advocated that behavioral health problems are in fact brain disorders,
acknowledging the source of the illnesses. Research in areas such as depression, anxiety,
obsessive-compulsive disorder (OCD), schizophrenia and bipolar disorder have made faster
and greater gains in brain research compared to the field of eating disorders. This is in part
due to the amount of research dollars allocated to the various, brain-based illnesses. Eating
disorder research has received about 1/7 of the National Institutes of Health’s research
dollars compared to schizophrenia; yet the prevalence of eating disorders is about 12 times
greater, with a higher mortality rate than schizophrenia and all other mental disorders.44, 45,
46
17
Mental health and psychiatric professionals’ understanding of eating disorders has been
imprinted from the outside-in since first formally diagnosed in 1980 in the DSM-III.47 The
field did not, and could not, know to include information about the fundamental,
neurobiological factors that impact the illness. The DSM-III described what was known - the
psycho-social factors and symptoms that developed into medical complications. It was not
until eating disorder research increased its expansion into the complexities of brain research
around 2000-2006 that genetic and neurobiological factors began to surface and were
identified. This is thanks to increased technology and neurobiological researchers who have
advanced the eating disorder field. This author refers the reader to groundbreaking work by
researchers such as: Walter Kaye, Angela Wagner, Ursula Bailer, Guido Frank, Janet
Treasure, Kate Tchanturia, Martin Paulus, Kelly Klump, Kyle Simmons, Howard Steiger,
Tracey Wade and Eric Stice.
In 2006, NIMH announced that eating disorders are serious, biologically based mental
disorders. That same year, The Academy for Eating Disorders (AED) released a position
paper shifting eating disorders to a brain-based disorder with other brain-based illnesses,
such as bipolar disorder and schizophrenia.48, 49 This shift in understanding the illness
began to direct attention toward more neurobiological eating disorder research. The brain
basis also gave parity to eating disorders politically. This was a turning point in how eating
disorders were viewed by many professionals in the scientific domain, but not in the general
population. Persons in the community have continued to hold the initial social/psychological
imprint that labels eating disorders as an “adolescent white girls’ campaign for control." This
is in part due to the lack of popular articles and movies that have addressed the shift in
etiological understanding.
A social and psychological concern this author cautiously inserts about eating disorders is
the diagnostic name of the illness. Eating is a normal action that is fundamental and
necessary for life. It is primarily not an abnormal action. However, by including the word
"eating" in the diagnosis, it implies abnormality. The diagnostic criteria for eating disorders
draw upon evidence from emotional, cognitive and behavioral symptom expressions.2
Measures record clients' self-reported thoughts, feelings and actions, as well as perceptual
body shape, weight and eating disturbances. Many persons who do not have diagnosable
eating disorders may at times experience disordered eating and worry if they have an eating
disorder. Currently, unless detailed questions are asked during a history and assessment
process of the illness, a person with an eating disorder can easily under report eating
disorder symptoms and persons who do not have an eating disorder could easily over
estimate their symptoms.
This author is going further out on a limb by addressing the confusion that the diagnostic
name of "eating disorders" creates for both the professional and lay communities. Persons
in the community often express discomfort about the diagnostic name “eating disorders,”
sharing they fear they have this disorder because they eat in a disordered manner. Healthy
individuals frequently make comments such as, “I have poor eating habits, do I have an
eating disorder?” or, “I wish I had that illness and could get skinny.”
How does one describe this illness that involves eating, the brain, body disturbance and
self-harming actions without using everyday words like “eating”? There has been no new,
18
neurobiological language of terms to express this. Researchers contributing to the DSM-5
have not yet tackled this diagnostic label as a concern that downplays the severity of the
illness. This author suggests that as research forges further into the neurobiological
understanding of this illness, a descriptive name reflecting brain involvement could be
considered to diagnostically define eating disorders. The current diagnostic name minimizes
and contributes to a misunderstanding of both the severity and brain-basis of the illness to
both the professional and community populations.
Prior to 1900, type I diabetes was a little-understood illness, referred to as the condition of
“sweet pee.” The child or adult’s urine was sweet, containing high concentrations of glucose
compared to those who did not have the illness. High amounts of glucose were peed out
instead of entering the body’s cells to provide energy. Glucose cannot enter body cells alone
- it needs the hormone, insulin, to unlock the cellular door to allow energy to enter, fuel and
strengthen body cells for organ function. Insulin is produced in the pancreas. If there is no
insulin, the body’s cells starve from lack of glucose, or energy.
It was not until the end of the first quarter of the twentieth century that a synthetic insulin
was developed.50 Until that time, if the child’s pancreas made too little insulin, children were
unable to live full and productive lives. Many died from this illness over the centuries.
Between 1900 and 1915, major advances in science identified the cause of diabetes.
Around 1916, the medical field identified what was wrong, but did not know how to produce
insulin to compensate for what the pancreas could not produce (See VisibleBody's Pancreas
in the 3D software included with this text). Diabetic symptoms include severe weight loss,
large consumptions of water and temper outbursts. If type 1 diabetes had been treated
solely from the outside-in during 1905, the treatment provider might have required the client
to eat more food, drink less water and go to anger management group therapy. Yet, none of
those treatments would manage the illness effectively.
From an overall perspective, neurobiological eating disorder research in 2017 is where

diabetic research was in 1917. We are about 100 years behind. It took medical research
about 10 years to effectively produce synthetic insulin and begin dosing it to meet each
person’s daily needs. It is possible that neurobiological eating disorder research is in a
similar interim time period where we are beginning to know more about what is going on
neurobiologically, but we do not yet have the synthetic "insulin" to treat the illness directly.
Eating disorders, like diabetes, are serious, biologically based

illnesses with social and environmental influences.
Eating disorders, like diabetes, are serious, biologically based illnesses with social and
environmental influences.51 However, instead of the pancreas, research is pointing to the
brain as a causal factor. While the brain and pancreas are both organs in the body,
understanding the complexities of the brain compared to the pancreas has just begun. The
brain holds many answers - and even more questions. Due to the rapid progression of brain-
based studies currently, what appears true today may be outdated in a few years.
19
About the same time that NIMH announced that eating disorders are serious, biologically
based illnesses, a research article titled, “New insights into symptoms and neurocircuit
function of anorexia nervosa” was published.52 It identified and introduced areas of the brain
that fired differently when comparing those with anorexia nervosa to those who do not have
eating disorders. Brain misfiring was found to occur in not one, but multiple areas of the
brain.
In addition, genetic research gained momentum to sequence the gene in 2000. Research
has found through genome-wide associate studies (GWAS) that there is not one gene that
triggers eating disorders, but many. Eating disorders are polygenic, with multiple genes
triggering illness expression241 while influenced by environmental factors over time. Genes
map out the human structure, just like a house is framed with major beams that define its
shape and room structure. Genes define eye and hair color, body shape, height, personality
and all major facets of the human being.
Genes determine personality traits. Temperament, an expression of one’s personality, is

imprinted at birth, and yet can alter over time as influenced by environmental and self-
regulatory factors.106 Personality, while considered separate from temperament in the past,
is beginning to merge with the concept of personality, as both focus increasingly on
stabilized cognitive, behavioral and interactive patterns that evolve into adulthood. The
definition of personality has morphed with temperament.106 As epigenetics and the
interactive nature of temperament and personality emerge, there is a trend to view both
temperament and personality as what is “natural’ in an individual’s character expression.
To date, heritability studies estimate that the genetic influence in binge eating disorder,
anorexia and bulimia nervosa ranges from 17-82% of the risk.57, 58, 59, 60, 61 Genetic
causality has been unclear until the first anorexia nervosa GWAS study results were
published in May 2017. Bulimia nervosa and binge eating disorder have not yet had GWAS
studies conducted, due in part to the heterogeneity of the disorders, requiring many more
subjects to be in the studies in order to identify significant findings.
Cynthia Bulik, PhD, at the University of North Carolina, Chapel Hill, has been a leader in an
international, GWAS project to identify all the genes involved in the development and
maintenance of anorexia nervosa. It is called, “The Anorexia Nervosa Genetics Initiative”
(ANGI). The goal, according to Dr. Bulik, has been to increase our understanding of the
genetic influences of this illness. In the past, researchers "fished for genes" and "found the
big ones," said Dr. Bulik. However, finding a gene here and there was not effective to know
the larger picture of genetic influence. The ANGI project intends to “let the body talk to us,”
said Dr. Bulik at a keynote address at the Academy for Eating Disorders' International
Conference in 2015. The project goal was to reveal all the genes involved in anorexia
nervosa. Blood samples of thousands of persons with anorexia nervosa were collected, so
each person’s genetic profile could be analyzed to identify which genes are involved in the
etiology of anorexia nervosa. As of May 2017, the first papers began to be published from
this study.
The new GWAS study discovered one, genome-wide, locus point for anorexia nervosa on
chromosome 12.62, 63 This is an area that has been associated with type I diabetes and
20
autoimmune disorders. What does this mean? The researchers are beginning to live that
question. The GWAS study also found that anorexia nervosa has negative genetic
correlations with body mass index, glucose, insulin and lipid phenotypes. Anorexia nervosa
was positively genetically correlated with educational attainment, neuroticism (such as
anxiety, fear and worry), high density lipoprotein cholesterol and schizophrenia.62, 63
The researchers encouraged the eating disorder field to rethink this illness as having both
psychiatric and metabolic causes.62, 63 These new findings point to both brain and
biological etiological factors, indicating an "interim period of research" that our field is in, just
as the diabetes field was a century ago. We have not identified and tested the "insulin
equivalent" for treatment because we are just beginning to identify the biological contributors
(not one as in diabetes, but multiple) to the illness. New studies have begun to focus on
brain and gut interactions, exploring the microbiome in persons with eating disorders as a
possible contributor and focus for anorexia nervosa treatment and other eating problems.64
In 2013, former President Barack Obama signed a bill called the BRAIN Initiative (Brain
Research through Advancing Innovative Neurotechnologies®). It has been described as one
of science’s most significant projects, comparing it to walking on the moon in 1969 and the
sequencing of the gene in 1999. This initiative gave attention and funding to mapping the
brain. Just three years after this initiative (2016), Nature published an article identifying 97
new and distinct areas of the dorsolateral prefrontal cortex of the brain, using four different,
advanced technologies.53 The search to better understand the brain is, and continues to be,
in forward motion.
However, just as it is hard to help a client with anorexia nervosa change restrictive habits
and shift dominant trait expression, thinking and behavioral patterns, it can also be difficult
to shift mental health systems and professionals’ perspectives to rethink new approaches in
understanding a brain-basis to eating disorders. The debate over nature verses nurture
continues among the eating disorder professional population to this day. The debate keeps
the profession moving toward a greater path of truth, putting the specific genetic and
environmental pieces of the puzzle together.
The nature versus nurture discussion can be approached by considering a forest of trees. A
maple tree can never be a pine tree. However, both trees can be reshaped, broken and
even deformed by changes imposed environmentally. A tree cannot fundamentally change
what it is - an evergreen or a deciduous tree. Nature establishes the fundamental, inherent
features of the collective physical world, upon which environment can shape and reshape
continuously via the epigenetic process.54
This text approaches eating disorders from the perspective that biological and
neurobiological factors are the foundation that establish a significant risk for eating
disorders,106 out of which extreme, restrictive dieting or traumatic, environmental factors
trigger and/or shape the illness. Each client has genetically inherited traits, expressed at
birth and throughout life, that contribute to one’s temperament. Traits do not “go away” like
symptoms. They are genetically imprinted in the DNA within every cell of the body.
Nature/nurture impact also implies that just as a tree can be broken and torn by a storm, so
can a person from traumatic experiences. It is possible that traumatic situations could
impact a genome, triggering reactions and responses that could activate an eating disorder,
21
even when eating disorder-identified genes had not been present.
Biology establishes the natural tendencies of how we respond to our environment via traits.
Behavioral conditioning can help reshape both symptoms and trait expressions. This is like
bending tree limbs to grow differently. So too, dominant trait expressions that develop
destructive habits in anorexia nervosa65, 66 can be “bent” or reshaped via conditioning into
more productive responses. The very traits that are expressed as self-harming, eating
disorder rituals can become healthy rituals evolving into new and different directions. It is the
same trait, but bent to express and evolve differently.
As the BRAIN Initiative continues its progress, new forms of brain treatment for eating
disorders are beginning to be explored. Mapping the brain, identifying neuropathways and
experimenting with brain interventions, such as low-intensity laser therapy,67 deep brain
stimulation, trans-magnetic stimulation, high intensity frequency ultrasound, neurofeedback
and fMRI feedback are in experimental phases. With attention increasingly focused on
neurobiological findings to better understand the brains of those with eating disorders, it
does not mean the eating disorder field should throw out behavioral interventions. They are
the best treatments currently available. Neurobiological findings, however, can better inform
behavioral treatment; they are not a replacement for them. Cognitive, emotional and
behavioral treatments provide highly needed and necessary tools and interventions, offering
structure and guidelines to reshape symptoms that are destructive responses. They help to
refocus rigidified thoughts, while also offering modulating tools for emotional regulation.
As new, brain-based intervention techniques are developed in the next few years, these
techniques may serve as a first step in treatment from the inside, “shifting” or altering brain
response in identified cortical areas, allowing cognitive and behavioral interventions to then
step in to reshape or recondition cognitive and behavioral responses with less
resistance. Perhaps, if the brain is successfully “reset” in identified areas, for example, via
deep brain stimulation for those with anorexia nervosa, there may be more motivation to
change, allowing CBT-E, IPT or DBT to have a potentially greater impact. It is not the
removing of the proverbial puzzle pieces, or therapies, it is adding them to the biological
picture to make them more complete. The eating disorder treatment field appears to be
missing the frame of the puzzle, the neurobiology, within which the cognitive and behavioral
therapies might prove more effective in completing our understanding of and response to
eating disorders.
As the BRAIN Initiative progresses, new questions arise,

such as, which diagnoses have common neuropathways and
overlap in brain response?
Which brain areas have distinctive brain responses?
The future DSM will hopefully include brain-based research
as a part of the foundation to all brain-based illnesses.
22
In the meantime, eating disorder treatment needs to expand to include more research
findings about the brain. Neurobiological eating disorder research is available for all eating
disorder treatment providers, whether clinical, medical or nutritional, to provide to clients and
their families to help explain the impact on the illness. However, as technology and research
explore new brain-based interventions, treatment and science need to find common ground.
Therapists could include what is currently being neurobiologically explored and more
actively describe directions that science is heading when working with their clients and
families to broaden understanding and eating disorder treatment.
A brain-based metaphor can explain how eating disorder treatment is in transition. A

synapse, or space between two brain neurons, is a transitional space for neurochemical
messages to move across. In a similar way, brain-based research is sending new findings
down the axon and releasing the results into the open space of publication. Traditional
behavioral treatments can pick up the messages and carry them forward. Or they could
choose the option to not absorb and receive the findings, resulting in research remaining
apart from treatment. The eating disorder field is in the midst of discovery and change on
how to absorb and integrate brain-based, eating disorder research.
Instead of focusing primarily on cognitive and behavioral symptoms, genetically inherited

traits and newly identified neuropathways could also be included in treatment discussions
with clients and their supports. Client and support feedback can, in turn, guide new
treatments and refine treatment development. The role that the brain, genes and traits have
in the development of eating disorders allows clients and supports to better understand an
etiological context and provide a fundamental dimension to treatment that has been all too
often left out.
Approaching eating disorder treatment as a brain-based illness also takes the unfounded
pressure off the clients, who often think that eating disorders are acts of will. They are not.
When approaching eating disorders from the brain-outward, it becomes clearer they are
quite the opposite. Persons with eating disorders have no control in choosing their traits and
natural brain responses to foods and body image. They are instead desperately trying to find
ways to restore control in their lives from a complex composite of brain misfirings.
As the neurobiology of eating disorders increasingly informs and helps establish new brain-
based treatments, it becomes clearer how CBT-E, DBT, IPT, ICAT and nutrition and
medication interventions need to be an integral part of treatment. If new brain interventions
provide a “jump start” in brain change, then the behavioral interventions might be able to
help manually change clients’ behavior from destructive to more productive expressions,
with less resistance, as shown in Figure 2.
23
Figure 2
Figure 2 visually describes a method of how a new brain-based treatment for eating
disorders called the "5-Day Treatment for Eating Disorders" (green line) integrates
neurobiological findings with trait and symptom expressions to provide clients and their
families/supports with a broader and more comprehensive understanding of the illness. It
also focuses on behavioral patterns and offers a brain-based approach to nutrition and
medication to help change or influence brain response for trait and symptom management.
This text is one step forward in exploring and integrating brain-based research with eating
disorder treatment applications. It focuses primarily on anorexia nervosa and its variants.
Science does not have all the answers to the complex etiology of eating disorders. But great
strides are being made and therapy can be strengthened by learning how brain-based
research can impact treatment. Research colleagues may think this text does not go into
enough detail describing the brain-basis of eating disorders, and therapists may think it goes
into too much detail. Never the less, this text has been written to translate and integrate both
areas. It does not expound on the environmental influences of eating disorders. There are
many more papers and books that have addressed environmental, social and preventative
24
influences than biological influences. The author refers the readers to those sources.
To place the text within a context, it addresses genetic factors that help establish premorbid
temperament and brain response, recognizing there are perpetuating environmental factors
and risks that impact the illness. The text does not have all the answers, because they do
not exist. The text does provide information to explore how the brain appears to impact
eating disorders and offers clinical and educational information, interventions and
interactive, clinical tools that have been tested in open trials. Parts to all of the brain-based,
clinical information and interventions could be added to other therapeutic approaches to
establish a brain-basis in other eating disorder treatments. It recognizes eating disorder
treatment is continuously evolving, and it is hoped that the clinical applications in this text
can be tested further by researchers, clinicians and educators in the field to better establish
efficacy within varying, therapeutic frameworks.
Summary of Chapter 1: Historical Perspective of Eating Disorders
Eating disorders have traditionally been viewed from the outside-in. As neurobiological
research discovers new findings that define and describe eating disorders from the inside-
out, current treatments need to actively reflect and include these findings into their
approaches. Shifting treatment focus from the outside to the inside informs and explores the
research findings with clients and their supports and balances treatment to reflect the status
known about illness. It also removes guilt and doubt that it is the client's or family's fault for
developing an eating disorder.
25
A Brain-Based Paradigm Shift in Eating Disorders
A Brain-Based Paradigm Shift in Eating Disorders ----- Chapter 2
Table of contents
- Summary
Portions of this chapter are published in the following article: Hill, L., Knatz, S., Wierenga, C., Kaye, W.
(2016). Applying Neurobiology to the Treatment of Adults with Anorexia Nervosa. Journal of Eating
Disorders, 4(31), 1-14.
Anorexia nervosa has evolved to be recognized as a severe, biologically based brain

disorder with significant medical risks.70 It has a persistent impact on development over
time. While onset is common during puberty and adolescence, it commonly occurs
throughout adulthood.71, 72 Up to 50% of individuals with anorexia nervosa develop a
chronic course, characterized by significant physical and psychological
impairment.14, 15, 73, 74, 75 Research varies, but in general, when the illness is active for
five or more years, it is seen as chronic and potentially enduring.76 The longer a person has
anorexia nervosa, the harder it is to overcome.77 Our clinic, The Center for Balanced Living,
treats persons ages 16 and above, seeing about 2,000 different clients per year in all levels
of care combined. This includes a partial hospital eating disorder programs (PHP), three
intensive outpatient treatment programs (IOP) and multidisciplinary outpatient therapies.
The average age of those in treatment is 37 years old.
As addressed in chapter 1 of this text, in order to make advances in adult anorexia nervosa
treatment, a paradigm shift is needed that fundamentally includes neurobiological and
genetic factors. Genetic studies indicate that heritability accounts for 17%-82% of the risk for
developing all the eating disorders combined.57 In addition, over 60% of shape and weight
concerns are heritable.58, 59, 60, 61 Recent imaging studies reveal that individuals with
anorexia nervosa tend to have common temperament and personality traits related to neural
circuit function, which are heavily implicated in the development and maintenance of the
disorder.52, 55, 81, 82, 83, 84, 85, 86, 106 Anorexia nervosa temperaments are characterized
by increased trait anxiety87 and state anxiety related to food and eating,88 high incidence of
co-morbid anxiety disorders,87 high punishment sensitivity,89 low reward reactivity,90
elevated intolerance of uncertainty91 and exaggerated harm avoidance (HA). HA is a
multifaceted temperament trait92 that involves difficulty with change, novelty and
uncertainty, impacting anxiety, inhibition and inflexibility.93, 94, 95, 96, 97
Targeting anorexia nervosa symptoms alone has not proven effective. Therefore, targeting
26
underlying neurobiological mechanisms that are core expressions of anorexia nervosa traits
might show promise. Trait analysis for genetic loci involved in anorexia nervosa risk have
been detected.62 It is hypothesized that traits such as perfectionism, harm avoidance,
anxiety, compulsivity and inhibition manage personality and behavioral responses prior to
the development of anorexia nervosa and continue long after recovery.83, 96, 97 These traits
may be core maintaining or perpetuating factors impeding treatment engagement and may
be important in helping those who have long-standing, or severe and enduring, anorexia
nervosa.
There are multiple ways in which these traits may influence the etiology, maintenance and
treatment of the disorder. For example, elevated anxiety and harm avoidance not only
maintain eating disorder symptoms, but may also predict poor treatment
outcomes.95, 98, 99, 100, 101, 102 Higher levels of pre-meal state anxiety predict lower food
intake.88 This is offset by the anxiolytic effect from acute dietary restraint and caloric
restriction.88, 103 Food consumption stimulates a dysphoric mood,104 inhibition and chaotic
thoughts,105 suggesting that individuals with anorexia nervosa may restrict eating to
manage anxiety.
Early research on the development of personality and temperament of persons with eating
disorders began by identifying traits that were present prior to the onset of eating disorders
in community samples.106 Various models emerged that traced the interaction between
eating disorders and personality traits that ranged from traits causing eating disorders
(predispositional model), to both traits and eating disorders having joint causation (common
cause model), to eating disorders causing personality traits (complication model) and to
personality and traits epigenetically altering each other over time (pathoplasty model).106
The field is searching for etiological factors via molecular genetics (ANGI study addressed in
Chapter 1), identifying vulnerable genes and personality and temperamental categories
rather than symptom-based classifications.106 A clinically oriented, comprehensive and
translational model is needed to combine both a top down (theory-led and data-driven) and
a bottom-up (client and clinician-experience and data-driven to develop theories)
approach.106
Nature/Nurture Developmental Model of Anorexia Nervosa
A new, translational, clinical model is presented below that highlights mechanistic pathways,
27
genetically established constructs and traits that underlie anorexia nervosa psychopathology
as one ages, as opposed to clinically approaching a client, focusing primarily on a symptom-
oriented approach. This model is in accord with NIH's recommended Research Domain
Classification (RDoC). This model conceptualizes a bio-genetic, etiological foundation for
anorexia nervosa to inform and guide treatment approaches. The new model was
introduced in a former paper with a revised version shown below in Figure 3. It integrates
genetic and neurobiological influences in relation to social/external influences across the
age span.13
Figure 3
As Figure 3 visually describes, the make up of each person begins with their DNA coding,
28
the basic ingredients, stirred together to make a foundation of heritable traits. Just as a cake
has common ingredients of flour, sugar and eggs, common traits of persons with anorexia
nervosa include harm avoidance, perfectionism, anxiety, compulsivity and inhibition.
Ingredients in cakes vary just as the combinations of traits vary. The combined mixture of
traits "bake" together, flavoring one's temperament. These ingredients or traits imprint a
child's personality.
The DNA molecule is just as relational as the brain is a social organism (Statement by
Michael Strober). Traits are continuously influenced by environmental factors, as shown by
the orange arrows on the right. The epigenetic interaction is the force that stirs
environmental influences into the biogenetic mixture. For those with common anorexia
nervosa traits, vulnerability increases.93, 94, 95, 96, 97, 107 Common temperamental
expressions for children vulnerable to anorexia nervosa include a natural compliance to
rules within the family/school and social settings. However, rules and thought patterns can
all too easily become inflexible and rigid.107 Perfectionism may be expressed by the child's
expectation for high grades and excellent performance. Yet when performance is high, the
child sees the errors over the successes, experiencing little pleasure or reward. The child
tends to be sensitive to punishment, mistakes or criticism. This would be the same as a
specific type of cake that requires more eggs and milk than most cakes. The additional eggs
create a unique and heightened flavor and texture, yet also make it vulnerable for mold to
settle in more quickly. The unique combination of traits in children with anorexia nervosa
brings out higher than usual performance and intellectual pursuit, while they also make the
child vulnerable to erode into rigid rules and rituals.
Figure 3 also illustrates that environmental influences have a greater impact on a child’s
development during pre-puberty compared to post-puberty (by the size of the orange
arrows). The hypothalamic-pituitary gonadal axis initiates biological changes during puberty,
contributing to a shift from nurture to nature (traits assume more power over nature), which
appears to dominate into the mid-twenties.106, 108 Gonadal changes trigger alterations in
neurochemical circuitry, which contribute to changes in thought patterns, emotions and
motor expression (as shown in the gray, brain-like shape).112, 113 Anorexia nervosa
symptoms emerge in adolescents who have inherited the vulnerable traits when restrictive
dieting increases. The restriction is encouraged by social/peer pressures. The shift in brain
response to the impact of too little food intake triggers a shift in brain reaction. Instead of
experiencing more hunger and irritation from too little food intake, the anorexia nervosa
brain shifts to firing an anxiolytic neurobiological effect.103
29
This author's father was a builder. He would say the time to shape the foundation of a
building is while the cement is wet. After that, it takes a lot more time and effort to break
apart and reshape the foundation. The cement consists of traits that are fundamental to
what and how the person acts and expresses thoughts, feelings, behaviors and perception
throughout life. Traits are the foundation, at conception and birth, when the building begins
construction. The traits grow to become structural weight bearing walls that help hold up the
first and second floors of the building. When the foundation cement is wet and being pored,
it is flexible and more easily shaped by the environmental builders. While genes determine
the ingredients of the mixture, how the traits are expressed and shaped during early
childhood is influenced through the building construction process.
The gray, brain-like image in the developmental model illustrates brain response changes as
genes turn on during puberty or at times of gonadal changes, triggering the illness to ignite.
The building construction is provided with resources brought in from the outside, such as
food. As puberty begins to emerge, traits shift from being dominated by environment to now
dominating over environment. At the same time, if supplies become too limited and too few
resources are used, such as restrictive food intake, the body or building development is
impacted and begins to break down.
During puberty, changes in the brain begin to occur as gonadal hormones change. In
addition, mounting evidence indicates that an altered balance of what is rewarding and what
is not contributes to inhibition in many aspects of life, including disordered eating.114 Food
is not experienced as gratifying, which can encourage the inhibition trait to increase its
tendency to hold back (up inhibition arrow). This is in combination with little reward or
pleasure experienced from food and a highly possible sense of decrease in hunger and
satiety (down interoception). Emotional responses increase as fear and anxiety rise (up
emotion arrow),115 which in turn implicates elevated harm avoidance of the dreadfully
perceived food. Cognition becomes a cacophony of “noise,” trying to make sense of the
misfiring signals in the lower brain, impacting the ability to trust decisions about food and
other life issues and increasing cognitive doubt (up cognition arrow).
This would be the same as the first floor of the building being built with too few resources.
The kitchen is not able to fully operate. Some of the first floor rooms are poorly wired,
creating inability to get around the hallways and rooms easily. The second floor conference
room awaits supplies from the first floor, but they are not sent up. Supplies and wiring
received for the second floor room don't make sense based on what is needed for the
conference room to fulfill its function. No internet connections, no wiring for needed lighting.
30
Echoes of incoming supplies are heard in the hallways, but they don't arrive. Distress
increases.
One study suggests the right parietal disturbance,116 which codes for perception of body
image and shape disturbance, increases (up body disturbance arrow), while a second study
found negative activity in serotonin (5-HT2A) receptor activity in the left parietal, contributing
to drive for thinness117 and disturbed body image (up body disturbance arrow). These
changes involve altered dopamine (DA) and serotonin (5-HT) function.106 Imaging data
further suggest that anticipatory anxiety contributes to restricted eating. For example,
individuals with anorexia nervosa report exaggerated anxious and avoidant responses to
food cues,85, 88 creating a disconnect between anticipating and experiencing food, which
likely contributes to even more restrictive eating. Lowered dopamine (pleasure response)
and increased serotonin (inhibition and cognitive doubts) in those with anorexia nervosa
may also contribute to the ability to delay rewards, since rewards are experienced as less
pleasurable.
The second floor of the building begins to think of the first floor and foundation as a building
out of proportion. The first floor is far too large compared to the second floor, based on the
confusing, inadequate supplies received. Due to inadequate signals, it appears to the
second floor that there is more of the first floor than there actually is. The second floor
conference room desperately seeks needed wiring supplies to carry out its function, but
instead gets workers yelling and arguing over the inadequate and confusing supplies
received. The kitchen sends up next to no supplies from which to work, while wiring in the
conference room begins to over and under fire.
Excessive exercise,118 or movement (up arrow), calms the overactive anxiety and body
shape disturbance, while it may simultaneously also be a result of experiencing little pain
(down arrow for interoceptive awareness). All together, these findings have implications on
motivation to eat and ability to evaluate reward and trust decisions. Drawing upon the
building metaphor, the building structure has shifted. The rooms become smaller and the
relationship of one room to another becomes confusing. The pathways throughout the
building do not inform or complement adjacent spaces, creating confusion in simply knowing
how to get around in the building. Lots of running around, but little accomplished. The build's
fundamental traits, such as harm avoidance, perfectionism, anxiety and inhibition, increase
the inclination of compliance toward restrictive rules. Rules are needed to simply maneuver
around the building, which is the brain.
31
Adults with anorexia nervosa often demonstrate a natural preference towards highly
structured and predictable environments, possibly due to difficulty tolerating uncertainty and
an inability to shift thoughts quickly from one topic to another (set-shifting). As such, anxiety
appears to reduce when children, adolescents and adults with anorexia nervosa
temperaments are provided with clear structure versus open-ended and more ambiguous
tasks. These same traits also influence individuals’ with anorexia nervosa response to food.
Many persons with anorexia nervosa experience little to no reward or pleasure from food
intake. Instead, anxiety is experienced. Food restriction becomes an anxiolytic experience,
creating a calmer state.103 The brain "building" has altered, shifted and shrunk.
Maneuvering around it becomes increasingly difficult when faced with many tasks.
The Venus Flytrap: A Nature/Nurture Metaphor for Anorexia

Nervosa119
This section was originally published in the following article: Hill, L. & Scott, M. (2015). The Venus Fly
Trap and the Land Mine: Novel Tools for Eating Disorder Treatment. Journal of Treatment and
Prevention, 00, 1-6. The following pictures were retrieved from the following
sites: http://www.mathnasium.com/venus-fly-traps-and-math1 and https://www.flytrapcare.com/
The Venus flytrap serves as a metaphor to understand eating disorder etiology and helps
guide us toward what treatment can offer.
32
The Venus flytrap is a carnivorous flower that has teeth-like projections on the top and
bottom petals. When a fly is drawn to the flower and walks into the depths of its petals, the
flower closes and devours the fly.
Each “tooth” on the top petal represents environmental/social influences such as: “be thin,”
“eat only ‘healthy’ foods,” “be the thinnest,” “eat less than everyone else” or “exercise more
than others.”
33
The “teeth” on the bottom petal represent genetic traits that trigger neurobiological
alterations, increasing one’s vulnerability to develop an eating disorder.83, 120, 121, 122
34
They interact continuously, just as the teeth on both petals demonstrate.
35
The restricted diet is the fly.
36
As the fly lands on the lower petal of the Venus flytrap and walks into the flower, the flytrap
closes, thus capturing the fly and consuming it. So too, as a diet becomes more restrictive,
the body becomes increasingly strained from too little energy intake, triggering the brain to
imprison the thoughts and feelings and shifting behavior to self-destructive responses.
If there are several eating disorder genetic traits, or “teeth,” in place, dietary restriction
triggers identified genes to “turn on,” altering brain and hormonal responses, “entrapping”
thoughts and behaviors and devouring the body.108 As the Venus flytrap closes, an eating
disorder develops. The person is “locked” into destructive perceptions of body image,
feelings and actions that confine daily life.
37
If the Venus flytrap has missing genetic or environmental “teeth,” the fly can maneuver its
way out. In like manner, those who have fewer genetic precursors, or are not exposed to as
many environmental triggers that encourage the diet to increase, have fewer upper and
lower “teeth,” allowing the person to have more ability to step away from brain alterations.
38
The question becomes: how can the person with anorexia nervosa get out?
Caught in the flytrap and held by a wall of genetic and environmental teeth, the person with
anorexia nervosa becomes imprisoned within his/her own thoughts and destructive rituals.
How does this nature versus nurture metaphor inform new treatment?
Psychotropic medications could “soften” the inside tissue of flytrap petals, just as they
impact neurochemical receptors, allowing the person with an eating disorder to have more
cognitive and emotional strength to push harder from the inside to lift the petal and fly
away.123 While some medications may hold promise, they are not currently as effective as
stand-alone treatments for most clients. The client pushing alone with medication is usually
not enough to force the flytrap to release the fly.
39
The environmental and genetic “teeth” hold too much power without equal or increased
force countering the teeth-like hold. Since there is currently no proven device or mechanism
to (mechanically) open the flytrap, it must be opened manually. “We” need to push and pull
from the outside of the flytrap to “pry open the petals,” while the client pushes from the
inside.
This metaphor demonstrates why it is usually not enough for a client to recover on his/her
own. This metaphor also demonstrates why it is so difficult for a clinician to treat a client with
anorexia nervosa solo and assume the Venus flytrap will open easily; even a
multidisciplinary treatment team is sometimes not enough.
The “we” is key in eating disorder treatment. The “we” consists

of a broader treatment team: the clinician, dietitian, medical
clinician, client and supports (family, friends, coworkers, etc.).
The “we” is key in eating disorder treatment. The “we” consists of a broader treatment team:
the clinician, dietitian, medical clinician, client and support (family, friends, coworkers, etc.).
The broader eating disorder treatment team is able to enhance its forces in a united
intervention. Until science develops reliable, brain interventions, a manual method is
required. The force it takes to overcome the trait-empowered resistance of anorexia nervosa
needs a team pushing from the outside while the medication and client, with a detailed meal
plan, pushes from the inside in a combined and united effort to pry open the trap together.
In order to empathically help the client from becoming exhausted or wanting to give up,
brain research is directing us to be more specific, detailed and limited in options verses
having open-ended expectations for a wide variety of foods and encouraging intuitive eating
in early stages of treatment when the illness is severe. The client cannot see the larger
picture when entrapped in the eating disorder, nor identify where to push or know how much
and when. The supports and treatment team can do for their loved one what the client
cannot do for him/herself. “We” need to push, pull and maneuver in coordinated efforts with
the client to help him/her squeeze through, bend the “teeth” or pry open the petal to crawl
out.
40
Otherwise, the client can all too easily become discouraged or upset and the supports might
step back. We have found that in over 90% of the cases in the 5-Day Treatment for Eating
Disorders, the family members and other supports appreciate detailed, brain-based, eating
disorder information and desire neurobiological tools to help inform their actions.13
Neurobiological findings indicate and direct us to what we currently know. However,

research holds little value if therapists, supports and clients do not understand it or know
how to interpret it. Neurobiologically based research is relatively new to the eating disorder
treatment field, and clinicians, dietitians and medical staff need to present similar,
neurobiological messages to adults with anorexia nervosa and their supports in a way that
they can understand, allowing clients to identify and determine how the findings relate to
their own experience. Interpreting research accurately and creatively in a manner that
enhances understanding can lead to increased motivation, instead of resistance, to change.
Summary of Chapter 2: A Brain-Based Paradigm Shift on Eating Disorders
A range of genes set the stage, by forming a profile of traits, that increase vulnerability for
eating disorders to emerge. Nature ignites the genes to shift to a different level of
expression, impacting neurochemical signals that contribute to destructive trait expressions
and eating disorder symptoms. Research is currently discovering WHY and WHAT is
occurring in the brain and biogenetics that address illness etiology. HOW to response is
evolving. Until new, brain-based, "inside-out" treatment interventions are validated, such as
deep brain stimulation or high frequency sound wave mediation, current "outside-in"
treatments such as CBT, IPT, ICAT or DBT must continue. However, integrating
neurobiological research findings into these treatments is critical in order to better inform
clients and supports on the illness and reduce unnecessary guilt.
41
Brain-Basis to Eating Disorders
Brain-Basis to Eating Disorders ----- Chapter 3
Table of contents
- Current Brain-Based Treatments
- Basic Overview of the Brain
- Summary
Current Brain-Based Treatments13

Portions of this chapter are published in the following article: Hill, L., Knatz, S., Wierenga, C., Kaye, W.
(2016). Applying Neurobiology to the Treatment of Adults with Anorexia Nervosa. Journal of Eating
Disorders, 4(31), 1-14.
The brain is the most complex and least understood organ in the body, the last of the
uncharted body organ territory. As science and technology explore brain responses in
greater detail, an overall picture of eating disorder brain responses emerges. Brain images
have shown what and how neurocircuit responses differ when comparing eating disorder
brain patterns with the brain patterns of persons who do not have eating disorders.104,124
These results offer needed information to develop treatments that can raise awareness and
impact identified brain areas.
Medication is currently one of our best methods to alter neural responses in eating disorders
treatment. However, side effects prevent many persons from using them. Psychiatric
medications are not targeted to impact precise brain areas. They follow neurochemical
pathways throughout the brain that they are developed to alter. While one brain area that a
serotonin pathway passes through may need to be balanced by a medication for a particular
mental illness, other brain areas on the same neurochemical pathway that function well are
also impacted. This may be one reason for medication side effects. Medications are
commonly prescribed and validated for many, brain-based, mental health illnesses such as
depression, bipolar disorder and schizophrenia. Eating disorders, however, have few to no
validated medications. Open trials have indicated that atypical antipsychotics in small doses
can decrease acute anxiety in persons with anorexia nervosa.125 Yet, to date, there are no
double blind controlled studies validating medications for anorexia nervosa. The Federal
Drug Administration (FDA) has approved fluoxetine (Prozac) for bulimia nervosa and l
isdexamfetamine dimesylate (Vyvanse) for adults with moderate to severe binge eating
disorder.244, 245 It is a drug that has been approved to treat attention-deficit hyperactivity
disorder.
42
Eating disorders need more than medication alone to help direct and sustain change.
Nutritional interventions are fundamental interventions to strengthen and alter brain
response. While any nutrition might help in brain restoration, there is debate if "a calorie is a
calorie" (or energy) or if calories need to be balanced in macronutrient combinations. The
Center for Balanced Living approaches eating disorder nutrition using a macronutrient and
mineral dietary combination to restore brain and body function. Research findings indicate
that both behavioral interventions and medication appear to offer better eating disorder
treatment results than one or the other alone,12 while nutritional interventions are
fundamental for all eating disorders. Yet, in spite of medication, nutrition and behavioral
treatments, there remains a subset of persons with chronic eating disorders.121, 123, 126
Research studies are exploring direct brain interventions that could take less time than
medication and behavioral treatment interventions and could alter brain responses in
specified brain areas. There are new, brain intervention treatments in experimental stages
that are both invasive and noninvasive. One invasive intervention is deep brain stimulation.
This entails a hairlike coil going through the skull with small projections at the end positioned
into identified areas of the brain to send electrical impulses that alter neuronal response.
Some noninvasive brain interventions include transmagnetic stimulation (TMS) and high
frequency ultrasound and light therapies. They work to alter neural circuit responses via
magnetic or high frequency light or sound waves. In addition, neurofeedback applies
readings from an electroencephalogram (EEG) by measuring electrical impulse levels
measuring beta, alpha, theta and delta patterns primarily nearer the surface areas of the
brain. This could provide clients and clinicians instant brain response feedback. During a
neurofeedback EEG session, clients watch or listen to their own, electrical brain responses
and "try on" alternative responses to explore how that might trigger brain change. Ideally,
this instant feedback could identify what action or thought process alters brain responses
more quickly, targeting what direction to take, allowing clients to repeatedly practice that
thought or method to move forward.
However, research has not reliably determined if the electroencephalographic responses

are valid enough to help clients and clinicians make desired changes in behavioral, thought
and emotional eating disorder responses. More new research is desperately needed to
better inform biologically based eating disorder interventions. Yet, clinical trials take time
and require federal approval and controlled randomized studies with large groups of clients
to prove significance in impact and minimize poor or fatal outcomes. This takes even more
time.
Eventually, it might be an option for clients to monitor their own brain responses in a 3D
format via fMRIs. This method would allow clients to observe an in-depth 3D view of their
brain responses. This more comprehensive method could assist clients and clinicians by
43
testing self-applied thoughts or actions experimentally to see if, how and when alterations
occur. Unfortunately, such a biofeedback method is expensive and complex. Yet, method
has begun to be tested. An example was reported in a British study at the Eating Disorder
Research Society, in Taormina, Italy 2015, during a plenary titled “Beyond RCT’s: How to
make treatment research more impactful for eating disorders.” Clients with eating disorders
were instructed to watch their own brain response while in an fMRI. Both the client and the
technician could see the clients’ brain responses through fMRI visual feedback.
If eating disorder treatment could improve accurate neurofeedback opportunities, it would

allow clients to observe their own brain responses that under and over-fire, and then take
charge of their own treatment by “trying on” different cognitive or movement responses while
observing their brains change. This could increase motivation and client control of their own
brain change process. If, however, eating disorder brain responses do not prove to change
from the less invasive approaches, then possibly more invasive brain interventions will be
needed to help alter or ‘”shift” specified brain patterns. Future medications that target
specified brain areas might impact specified brain area changes as well. These are
questions before us for research to explore.
In the meantime and on the whole,

therapists have what we have –
brain-based research trials that have been conducted,
small sample by small sample, to guide us.
The field could update eating disorder interventions
to include brain studies that have helped carve out a picture of
what is neurobiologically based in this illness.
In the meantime and on the whole, therapists have what we have – outside in interventions
including cognitive, behavioral, emotional and familial behavioral treatments, including
manualized interventions. We also have nutritional treatment, which is both fundamental to
and nonspecific in targeted brain alteration. And, we have brain-based research trials that
have been conducted, small sample by small sample, to guide us. Drawing upon
neurobiological research findings, the field could update eating disorder psychoeducational
interventions to include important brain studies that have helped carve out a picture of what
is neurobiologically based in this illness. As the field grows in its understanding of eating
disorders as a brain-based illness, treatment can also be enhanced when clinicians work
with clients and their supports to better understand the brain and its significant impact on the
illness. The sooner eating disorder psychotherapies integrate brain research into ongoing
treatment approaches, the field becomes more balanced and enhanced by including more
44
parts to the multidimensional puzzle.
Once adolescents turn 18 in the United States, they become legal adults. At that point,
family members and significant others are traditionally excluded from mental health
treatments in general, and eating disorders specifically. This approach needs to be
reconsidered as the field learns more about the biological complexities of the illness. Until
more targeted, biological and therapeutic, individual treatments are validated and reliable,
family, or other significant supports, may need to be considered as an active additional
dimension of treatment intervention. Supports need to learn about the illness, treatment and
clinical tools in the same way the client learns them. Individual therapy between a client and
therapist can more easily impact change when pushing through an adjustment disorder.
However, to push against a tsunami of complex eating disorder biological forces, treatment
needs an equal force to match it. It needs more than one therapist. As described in the
Venus flytrap metaphor, it needs more than a multidisciplinary team of treatment providers.
It needs an active inclusion of family/friends or supports to work in a united force to manually
change and alter the impact of eating disorders both internally and externally.119
For example, this author's father was a builder. He would regularly use large equipment to
lift beams and materials when constructing a major building. However, when he was asked
to build a cabin, located deep in the hills and woods, for a camp, he could not take his
equipment. Instead, he trained the campers and worked with them to build each wall of the
cabin on the ground. Then, together, they put ropes around the walls and hoisted up the
walls to connect one with the other. The cabin needed to be built manually each step of the
way. So too in eating disorder treatment currently. Until direct biological intervention
equipment can be applied, eating disorder treatment needs to be manual and include
clients, support persons and members of the multidimensional treatment team together to
manage and sustain change.
The 5-Day Treatment for Eating Disorders program is a treatment that seeks to integrate
current, brain-based, eating disorder research with evidence-based behavioral treatments,
while empowering both clients and supports to better understand the brain as a primary
source of this illness. It is a “trans-treatment” approach, unifying the experiences of clients
with current, eating disorder, brain research, while allowing clients and supports to better
understand their own experience.
The following chapter explores areas of the brain that research has identified that impact
eating disorders. This text is just beginning to scratch the surface of the roles of brain
regions involved in eating and eating disorders. It describes commonly researched areas to
date while recognizing there are many brain details that are not included in this text. This is
not an all-inclusive, brain-based, eating disorder book, it is a beginning.
45
Basic Overview of the Brain
How it Fires, Organizes and Functions in Relation to Eating and
Eating Disorders
(The reader is encouraged to open the 3D body/brain software by VisibleBody, included with
this text. It provides a 3D view of the brain areas to show clients and students when
discussing brain areas.)
The average adult brain weighs about 3 pounds (1,300 -1,400 g) and is about 2% of total
body weight.127 Purposes of the brain include: management of all body function, thoughts,
feelings and actions/movement, whether conscious or unconscious.128
The human brain is an active network of ongoing communication. It consists of various types
of neuronal cells that fire neurochemical signals continuously, whether awake or asleep. The
amount and intensity of neuronal firing depends on how intently one is thinking, feeling
and/or doing activities. Genetically inherited traits help regulate brain responses, like a
computer programmer codes software. The brain has billions of neurons that code, or
program, its neurochemical messages to communicate. Genes influence neurons to under,
over or moderately fire in specific areas of the brain, influencing inherited personality traits.
Genes guide a natural response to fire in a particular way, while the neuron is also
influenced to fire in a variable response by social and other environmental influences. In
addition, the intensity, or neuronal response, depends on how much energy (glucose) the
cells receive.
Many brain neurons look like branches and roots of deciduous, or leafy trees. As shown in
Figures 4 and 5, neurons consist of: a) dendrites, which serve as roots, taking in
neurochemical signals; b) neuron cell bodies, or round areas that are the center trunk or
core of the neuron. This is the location where one’s food intake provides energy for neurons
to manufacture neurochemical messages to send onward; and c) axons, branches reaching
out to carry the signal away from the cell body to destinations in the body or to other
dendrites in the brain. A neuron can reach from the spinal cord down to fingers and toes,
sending messages to muscles, indicating when to move or not to move.
46
Figure 4 (Image retrieved from Penn State University Eberly College of Science
, https://online.science.psu.edu/bisc004_activewd001/node/1907)
Neuron bodies are gray in color and axons are white, as shown in Figure 5. That is what is
meant when the brain is referred to as gray matter or white matter. The white matter refers
to myelin. It covers the axon strand, just as copper coils in a cord are covered with a rubber-
like substance to assure the electrical current can pass through to the expected destination
and not misfire. When a cord decays, the light blinks on and off from inconsistent flow of
electricity. The same occurs in the brain when axons deteriorate. The neurochemical
message falters, or is interrupted, if the axon is not kept in good repair. Myelin is made of
fats (which this text refers to as “endurance fuels”) from foods eaten throughout the day.
47
Figure 5 (Image retrieved from http://www.google.com/imgres
imgurl=http://www.whatisneuroplasticity.com/images/Axons%2520firing%2520in%2520a%2520neural%
2520cell.jpg&im
grefurl=http://www.whatisneuroplasticity.com/terms.php&h=273&w=439&sz=157&tbnid=H-
uVYFe9FqHKlM:&tbnh=119&tbnw=191&zoom=1&usg=__6 e64m4C18xzihiaEuXh_Ol-dX4Y
=&docid=lNxniFDyAHyi2M&hl=en&sa=X&ei=-RaFUo_zKOOYyAHJ8ICwDw&ved=0CCsQ9QEwAA)
Just as every street in a city has many intersections where persons can turn in one direction
or another, the brain has intersections called synapses. A synapse is the space between the
terminal bulb of the axon and the dendrite buttons. The dendrite absorbs neurochemicals via
receptors located on dendrite buttons (See and click on Figure 6).
48
Figure 6 (Image purchased from Shutterstock)
Axons release neurochemicals that float into the synaptic space. If there is an intensity in
the neuron firing, it more than likely will shoot across the synapse with more force to be
absorbed by the dendrite receptors. The dendrite receptors are programmed to identify
which neurochemicals to absorb. It has been estimated that there are about 86 billion
neurons in the brain, each having about 10,000 connections to other neurons.129
The brain communicates within itself by transmitting neurochemical messages, called
49
neurtransmitters, throughout the billions of neurons in the network, made up of chemical
substances (Click on Figure 7). Different neurons and brain pathways transmit different
kinds of neurotransmitters. Two neurochemical transmitters commonly involved in eating,
body image and decision making are dopamine and serotonin.72, 130, 131, 132 Serotonin, or
5-HT (5-hydroxytryptamine), is biochemically derived from dietary tryptophan, which is
produced from the proteins and some carbohydrates one eats. Tryptophan is the amino acid
that produces serotonin.106 If one does not eat proteins with some carbohydrates, one
cannot produce serotonin and push it across the blood-brain barrier. Serotonin levels impact
anxiety, depression, appetite and even body image.
Figure 7 (Image purchased from Shutterstock)
Dopamine is another neurochemical, which triggers pleasure and reward, contributes to

50
motivation and is involved in movement.133, 134 It’s quite possible that dysfunctional
expressions of anorexia and bulimia nervosa traits are related to altered neurochemicals,
such as serotonin 5-HT levels and dopamine.106 When the brain is first learning new ideas,
concepts or activities, a great deal of brain energy is firing in multiple areas of the brain to
synthesize, apply and integrate the ideas into new actions. This information is stored into
memory.
While it is the neurons that send messages via neurotransmitters, only 10% of the brain
cells consist of neurons. Brain space is dominated by glial cells, which surround the neurons
and help hold them in place. While glial cells are not known to send messages directly, they
hold the neurons in place to support the neuronal structure. Research is now discovering
new roles of the glial cells, such as improving memory.129 Additionally, there is an extensive
vascular system throughout the glial network to keep brain cells fed and deliver supplies to
neuron bodies in the form of oxygen and glucose.135
Returning to the city analogy, there is not a city in the world with as many intersections as
those that exist in the synapses of the brain. They carry out many multifaceted tasks
simultaneously. The endless list of tasks include the brain’s ability to learn, to have the
capacity to speak every language in the world, to see, hear and problem solve, to taste, feel
hungry, remember and experience pain and to perceive. It is miraculous that more does not
go wrong in the brain. When brain illnesses arise, they often involve synaptic
dysfunction and have been referred to as synaptic sicknesses.136
__________________
The reader can continue to read the text about the organization and function of brain areas
involved in eating disorders, or view the training video overview on the "Overview of the
Brain" that explains how to use the 3D software and relates brain areas with eating
disorders (Provided in Supplemental Materials on the Landing Page).
Overall Areas of the Brain
Brain areas are synchronized and wired to carry messages forward, throughout the brain, so
a comprehensive understanding of stimuli and an experience can be registered. The brain
builds upon its memories, which inform and impact thoughts, emotions and behaviors based
on how each memory was experienced. To complete tasks, some brain areas may fire
slightly ahead of others, while other tasks may require multiple areas to fire simultaneously.
The brain has clearly identified priority areas that dominate when fired. To understand where
areas in the brain are located requires three dimensional directions, or biological terms:
dorsal, ventral, anterior and posterior.
51
The ventral area of the brain at the end of brain stem focuses on body function and
sensations. Messages from this lower brain area flow up through emotions to thoughts and
perception. Movement is placed throughout the brain in multiple areas. Conscious thoughts
are dorsal to emotions and body sensation signals. The brain flows out of functional priority
from the bottom up. An emotional flavor is added as the body signals and moves upward to
thoughts. Perception adds to the comprehension of each experience at the dorsal posterior
area of the brain. There are also continuous "top down" brain regulations occurring as a
person thinks through an issue and steps into an action. The brain recalibrates around the
intention. It is parallel to breathing in, signals going up, and breathing out, signals going
down. In actuality, brain response happens so fast it is nearly simultaneous. In addition,
there are millions of pathways flowing horizontally and in every direction to fill in information
from each of the senses and connect one area with another.
Figure 8
52
The brain is divided into two halves, the right and left cerebral hemispheres. The two
hemispheres sit on top of the brain stem, which is a dorsal extension of the spinal cord. The
hemispheres are divided by a great, long fissure and are held together by a bundle of
nerves called the corpus callosum. Each hemisphere shares similar functions in similar
locations on each side, but with a slightly different perspective or expression (See Figure 9).
72, 116, 137, 138, 139
It is important to note that the brain is not one mass for neural
interaction, but two. One balances the other. This is true in therapy as well. A client needs
someone to work with and balance the experience. While therapists often take that role, the
sooner supports are brought in to have that role, the sooner thoughts and experiences can
naturally rewire using two sides.
Figure 9
The brain is the most complex and least understood organ in the body.140 It manages vast
areas of functioning such as our thoughts, emotions, actions, perceptions, our five senses
and problem solving. Our brain stem, on the other hand, is a courier to transport
neurochemical messages back and forth between the brain and body. It focuses on bodily
53
reflexes and internal body functioning.141 As a baby grows and develops, the brain
develops upward, reflecting evolutionary development over centuries. The brain has a
natural hierarchical system; the lower areas of brain functions are fundamental and
necessary to keep the human alive (See Figure 10).142, 143 The higher areas refine the
functions.
Figure 10
At the base of the brain, posterior to the top of the brain stem, is the cerebellum (Figure 11).
It assures body organs are moving properly, such as breathing in and out, speeding up and
slowing down of body systems and coordination. The ventral areas in the brain are active
54
and developed enough at birth to keep the baby alive, moving, breathing, eating, etc.
Movements are not yet refined with hands, arms, feet and legs, but the movement within the
body to keep all body organs moving in rhythm is developed by birth after a full term of
pregnancy. A major function of the cerebellum is gross coordination of movement.144, 145
Figure 11
Emotions reside in the mid-brain area (Figures 10 & 12), with a central area being the
amygdala. This little, bean-shaped area of the brain fires a range of emotions. It can create
a lot of commotion for being such a small part of the brain. The amygdala sits on top of the
hippocampus, which stores the emotional experiences, facts and context of experiences. It
is the cornucopia-shaped object ventral to the amygdala.146, 147
55
Figure 12
The amygdala and its surrounding, mid-area of the brain signal emotional responses that
judge and evaluate situations or experiences instantly. The amygdala is tucked in the
temporal lobe of each hemisphere of the brain.148, 149 Feelings from the amygdala, saved
in the hippocampal memory stores, serve to keep the body alive and to signal instant
actions in response to experiences. In many ways, it could be said that the brain is
fundamentally judgmental. Judgement is biologically programmed to have priority over
reason in order to keep the human alive, a bottom up process. The degree of emotional
intensity impacts the intensity of judgments. Instant judgmental responses can learn to be
delayed and be refined from top down thinking processes during childhood through
adulthood development via social cultural mores and educational processes. Outside-in
lessons can refine automatic judgement that occurs naturally from the inside-out.
56
Emotions impact survival. At its most intense firing, the amygdala is, in essence, a panic
station. When faced with real or perceived danger, the amygdala triggers instant, intense,
neurochemical messages throughout the brain, setting the body's fight or flight response into
action. When panic ignites, thoughts (at the anterior dorsal area of the brain) shut down,
giving movement priority. If the brain had to think about panic to tell the body to act, a
person could be harmed. For example, if a person stepped in front of a speeding car. The
fear response is the brain’s fast and intense reply to signal muscles to move faster and get
away from perceived harm.150, 151 Thinking would slow this emergency action down.
When fear is registered in the brain, the neurochemical norepinephrine (noradrenaline or

adrenalin) fires instantly and intensely throughout all levels of the brain and body, such as
the heart, lungs and muscles.152 Norepinephrine regulates the sympathetic nervous system,
which speeds up, compared to the parasympathetic nervous system, which regulates
slowing down. If fear is extreme and becomes panic, signals are the most intense. The brain
is organized to give fear top priority; all thoughts, actions and body functions shift to respond
to fear.
In response to a fear reaction, the gut slows down to not interfere with the body’s “fight or
flight” response. This means for those with anorexia nervosa, when foods are perceived as
fearful, the stomach tightens. It can hurt or be painful to eat. In addition, the person may
have an avoidant trait genetically programmed to avoid or flee from harm, in this case, food.
Feelings can and do naturally override thoughts in the brain hierarchy.153, 154 Persons with
eating disorders have to teach themselves to act differently to override what is naturally
firing in the ventral and mid areas of the brain. It is like turning a herd of wild stampeding
horses to run in a different direction. No easy task.
“Fear ruled. [I was] [a]fraid of being fat, afraid of changing weight, increasing weight was too
hard to put into words. It was anxiety driven responses as weight was gained. I established
a new homeostasis after 4 years. But it is still in my [head space].”
- Adult recovered from anorexia nervosa
Persons with anorexia nervosa tend to be fear-regulated, not reward-motivated. The brain
stores fearful feelings and the context in which they were experienced in the hippocampus
(See Figure 12). The more intense the emotions, such as fear, anger or even happiness,
more details of the experience are stored. Memories help ensure harm is not repeated and
happiness can be repeated. However, if a food that can be healthy is feared by persons with
anorexia nervosa, the memory is impacted by the faulty experience. This adds up to
persons with anorexia nervosa tending to not learn from what could be a healthy
57
experience, eating. They hold many skewed memories due to altered brain signals.89
Thoughts formulate and refine as the brain develops upward in the skull. A major brain area
where thoughts execute plans and ideas is the dorsolateral prefrontal cortex (DLPFC). This
is the area of the brain that takes body sensation signals in the ventral brain area, filters
them through mid emotional brain areas, weighs pros and cons and compares the
experience with memories to formulate a conscious plan. The plan is executed by sending
the neurochemical messages onto the motor cortex next door, just posterior to the decision-
making DLPFC. The DLPFC also anticipates the future. This brain area plans next steps to
take. In essence, research has found that the DLPFC plans, decides and signals actions to
execute (See Figure 13).155, 156 It is the commander or chief executive of the brain.
Figure 13
58
The motor cortex reaches around the dorsal and lateral sides, via a gyrus, like a hairband
covering both sides. It is located posterior to the dorsolateral prefrontal cortex (thoughts). It
gives action to thoughts and carries out or acts upon the intent or plan created in the DLPFC
(See Figure 14).157, 158
Figure 14
At the dorsal, posterior area of the brain, or the crown of the head, is the parietal lobe (See
Figure 15). It has many purposes, one of which is body perception.159, 160 Its signals
provide a picture of how one sees one’s own body within the space around it. It has many
pathways that send signals directly to the amygdala and the DLPFC. If this area is not
signaling properly, body image can be disturbed and distorted, causing feelings to become
distressed. Thoughts respond by identifying and planning what to do about the problematic
body image perception. Parietal disturbance contributes to the “eating disorder noise,” which
resides in the DLPFC.
59
Figure 15
Anorexia nervosa research has found that lower areas in the mid-brain (ventral striatal and
limbic area) minimally fire, limiting or preventing a sense of reward and pleasure signals to
aid in decision making, while also minimally to not signaling hunger, fullness or taste.106
Overall, the ventral striatal area of the brain tends to under fire for both those with anorexia
and bulimia nervosa.106, 242, 243 The minimal to no signals in the lower limbic area diminish
a sense of reward and emotional significance,106 causing the DLPFC to over fire, or over
60
think, to compensate for minimal essential signals to give guidance to thoughts. Hence,
while many with eating disorders have high intelligence,62, 63 they may not experience
fundamental brain signals that guide us through the day, diminishing their ability to trust
eating, decisions and interactions.
Figure 16
61
Figure 17
Recognizing brain response of those with eating disorders is important so the clinician can
respond more appropriately. For example, if one can't identify hunger, how does the clinician
and dietitian work with that lack of ability to help the client compensate? If persons with
eating disorders can't trust decisions, due to minimal to no dopamine response in the
nucleus accumbens, how does the clinician acknowledge and work with the client to
compensate for the inability to trust decisions? Working with the client, not against their
brain response ability, can reduce resistance and increase motivation. For example,
movement during therapy can increase a momentum to pass through an emotional intensity
to alter thoughts, versus talking about the thoughts and remaining caught in the emotional
intensity.
62
If, on the other hand, a therapist talks about a cognitive idea and does not actually practice
it, such as eating with the client, it is harder for the client to change when alone and not
thinking about it in the moment at a later time. Emotion will override a cognitive desire if
there are not higher levels of intention and cognitive planning to override the emotion and
body sensations. If the action is planned in enough detail, a cognition can override emotions
in the moment. Staying in the moment, the time period that the client has maximum self-
control, is very hard and very important.
(It helps to see each brain area via the 3D Body Atlas software, included with this text. The
video overview is in the Supplementary Materials "Overview of the Brain" teaching video.)
Insula: in·su·la88, 89, 164, 165, 166, 167, 168, 169

(See "Brain Overview" Training Video in Supplemental Materials on the Landing Page).
63
Figure 17 (Image retrieved from Ken Hub, https://www.kenhub.com/en/atlas/insula)
Location and Function:
1. Embedded in the temporal lobe.

2. The left insula receives information on gastric distention (fullness) and the right anterior
insula has been associated with self-recognition of body sensations.
3. It is the site of “interoceptive awareness,” receiving and passing on body sensation
signals, including hunger, fullness, taste, pain and the need to go to the bathroom.
4. The insula transmits body sensation signals to the higher cortex areas where thoughts
reside.
Impact on Eating Disorders:
64
1. For many persons with eating disorders, the insula fires significantly less compared to
those without eating disorders.
2. The body could be sending the brain signals of pain from hunger or fullness, yet the
insula is not transmitting the messages to the DLPFC, where thoughts reside to make a
decision. In essence, a person with an eating disorder is eating “blind” to sensations that are
key to determine if, when and how much to eat.
3. Flavors may be hard to detect from low-firing insular taste signals and may need to be
sharper to compensate.
4. For many who binge eat, taste may be euphoric during initial bites, and then signals
appear to lower or diminish. This encourages eating a wider variety of foods to maintain a
heightened taste sensation.
5. High anxiety can cloud or even drown out lower brain, minimal insular signals, preventing
thoughts from “hearing” or registering the messages to aid in decision making. Reducing
pre-meal anxiety can improve one's ability to identify lower insular body signals.
6. To compensate for insula misfiring and/or overly anxious thoughts, food can be “dosed,”
just like insulin is dosed. Macronutrient amounts of carbohydrates, proteins and endurance
fuels can be assessed using a dietary detailed assessment. The macronutrient "dosages"
can replace the lack of interoceptive insular signals with balanced, individualized
recommendations for adults.
Amygdala: a·myg·da·la or midl12, 109, 110, 170, 171

1. In the temporal lobe within the limbic area in each half of the brain.
2. Site of emotions or feelings.
3. Site of panic (intense firing) and of calm (minimal firing).
Impact on Eating Disorders and Fear Responses:
1. The amygdala is overactive in those with anorexia nervosa.

2. Pleasure and reward decrease as fear increases.
3. Those with an avoidant trait tend to flee when panic fires, this means fleeing from food.
4. During panic, thoughts freeze or focus on one thing - how to get away from the identified
harm, such as food.
5. The sympathetic nervous system springs into action:
65
a. the heart increases its beats, quickly pumping oxygenated blood to the extremities,
b. the lungs breathe fast and shallowly to oxygenate the blood pumping throughout the
body quickly,
c. the eyes dilate, focusing on the object of fear,
d. smell is enhanced,
e. palms may begin to sweat and
f. muscles tense, ready to move fast.
6. When an object is perceived as harmful, such as “unhealthy” foods, thoughts or logic are
not able to “talk oneself through the experience,” only movement or action can be applied in
that moment.
7. Others are needed to help the person act or move in a healthy way in that moment,
instead of automatically turning to an unhealthy action. Thinking through a new plan can
only occur after the panic decreases and thoughts become more flexible again.
Nucleus Accumbens: nucleus ac·cum·bens\--km-bnz86, 111, 120, 172, 173, 174, 175, 176,
177, 178, 179
1. Embedded in the temporal lobe in each hemisphere below and behind the eye area of the
frontal cortex.
2. Site of reward and pleasure.
3. A dopamine terminal in the striatum that impacts movement and reward: "go" pathways.
1. Dopamine response aids in trusting and confirming decisions. "That's a good idea!" may
be experienced when the dopamine spikes in this site.
2. Persons with eating disorders appear to have little to no dopamine firing in the nucleus
accumbens, contributing to difficulty in trusting decisions, even one year after recovery.
3. Binge eating tastes are heightened initially yet appear to have little to no pleasure firing in
the nucleus accumbens.165
4. Anticipation (e.g., of a binge) appears to trigger a greater dopamine reward response than
the actual experience.
5. Area involved in motivation.176
66
6. Too much weight gain is related to reduced dopamine response in the nucleus
accumbens and dopamine pathways.177
Orbitofrontal Cortex (OFC)12, 65, 180, 181

1. Located behind eye sockets.

2. Inhibition serotonin site: "whoa."
1. Contributes to slowing down, delaying or stopping an action, such as inhibiting food

intake. It is a “whoa” or “hold back” brain area that works with nearby areas to weigh in on
both thoughtful and automatic decision making.
2. Neurons in the OFC can code decreasing responses to a specific food (no longer should
eat a certain food), while remaining receptive to other foods.
3. Persons with bulimia nervosa, binge eating disorder or anorexia nervosa, subtype
binge/purge, tend to have an impulsive trait, often delaying food intake for long periods of
time, resulting in less serotonin development, contributing to an inability to hold back and
say no (whoa) to eating. This triggers eating faster and more variety of foods and is similar
to a famine experience.182
Caudate Nucleus183, 184, 185, 186

1. Circular formation originating in lower midbrain at the amygdala and loops up toward the
forebrain.
2. It carries pro/con signals from feelings toward thoughts to aid in decision making.
3. For those with anorexia nervosa, weak caudate signals and other striatal limbic circuits
67
prevent clear pro/con signals to trust decisions. "Do I take the next bite?" "Do I wear these
jeans?" Without an answer, the result is, "I don't know what is best to do!"
4. Includes nuclei that are part of the basil ganglia, which code for movement.
5. It has striped-like formations connecting to the putamen (movement) (Caudate + Putamen
= striatum).
1. For those without an eating disorder, when eating, if the amygdala is calm, hunger and
taste are heightened, and body signals are heightened from low blood sugar. The pleasure
from eating signaled by the nucleus accumbens is high. These signals travel upward via the
caudate nucleus to aid in deciding to take the next bite.
2. It helps formulate pros/cons.
3. Draws from memories of former thoughts, feelings and actions.
Anterior Cingulate Cortex (ACC)104,138,175,187,188,189

(See "Brain Overview" Training Video in Supplemental Materials on the Landing page).
1. Front of the cingulate cortex that circles over and around the caudate, projecting from the
insula.
2. Transfers emotional and body sensation signals from lower limbic areas.
3. Contributes to conceptual reasoning and perceptual organization.
4. Unites signals together to consciously help make decisions.
5. Involved in error monitoring and anticipation of reward, adding information for the
thoughts to anticipate the next decisions.
1. If the insula and lower limbic areas are not firing with enough intensity, then the ACC's
interpretation for the DLPFC's decisions is skewed toward holding back.
2. If the person with an eating disorder has an error detection trait, this area of the brain
68
contributes to finding errors over successes.
3. Low signals in the ACC may contribute toward lower motivation to eat, as well as when,
how and why not to eat.
Dorsolateral Prefrontal Cortex (DLPFC) d r-s - lat- -r l190,191

1. Behind forehead.
2. Site of cognition or "thoughts," drawing from signals in lower brain areas to plan and
execute decisions and anticipate the next action.
3. Site of eating disorder “noise.”
4. Site where much of anxiety resides as thoughts rehearse the future while trying to live the
present.
5. Site of detailed thinking.
1. If ventral limbic signals are under or misfiring, then decisions are doubted and uncertainty
dominates, making it difficult to trust plans, contributing to hesitation to act.
2. Uncertain thoughts compensate for lack of ventral limbic firing by turning outward to
identify detailed instructions from social messages or peers to instruct and confirm
decisions.
3. For those with anorexia nervosa, too many options or open-ended questions can “freeze”
thoughts, immobilizing ability to decide and plan.
4. Persons with anorexia nervosa can think through problems, but have minimal signals for
"gut reactions" to help truly know if the idea is a good one. The pro/con area of the caudate
nucleus under fires. Clinicians should not assume clients can instinctively sense if it is a
pro/con to aid in thoughtful decisions.
5. Persons with anorexia nervosa report wanting to be offered two to three options, which
provides enough information to "think through" a decision.
6. If the amygdala is over firing fear or panic, thoughts freeze.
7. Anxiety resides in this area, preventing confidence when making decisions.
69
Motor Cortex and Putamen: pyootmn192,193,194
(See "Brain Overview" Training Video in Supplemental Materials on the Landing page).
1. Motor Cortex: A gyrus positioned like a hairband at the dorsal and lateral areas of each
hemisphere, posterior to the DLPFC, signals refined movement.
2. Motor Cortex: Contains a "neurobiological map," described as a homunculus,
representing the amount of neuronal assignment provided to move each area of the body.
3. Putamen: refined movement, such as chewing; in midbrain connected to the caudate
nucleus and part of the striatum.
4. Bundles of pathways from the motor cortex connect with the putamen to coordinate
movement or actions.
5. Carries out planned instructions from the DLPFC, as well as emotional actions from the
amygdala and surrounding areas.
6. Refined movement.
1. It appears the putamen's impact on eating disorders involves chewing, potentially freezing
this movement or over stimulating this movement, depending on the emotional intensity,
impulsivity or avoidance traits.
2. Movement can manage intense emotions and thought disturbance. It is fundamental to
brain organization.
3. For those with anorexia nervosa, when the DLPFC over fires, excessive
movement/exercise can numb or calm the intensity of thoughts and ,emotions.
4. Movement signals can force “frozen” thoughts to “thaw” and flow again.
5. When unsure of what to do, move (not excessively) to force emotions to lower intensity
and thoughts to create a plan for action.
6. Yoga draws upon the basic concept that movement is fundamental to managing the
brain.
Parietal Lobe: puh-rahy-i-tl52,117,186,195,196,197,198,199

70
1. At the crown of the head on both sides of the brain.

2. Site of body image perception and how the body is perceived in the space around it.
1. Integrates sensory input.

2. Formulates a perception of one’s bodily sensation experience.
3. For those with eating disorders, the serotonin and dopamine disturbance pathways that
pass through this area fire significantly greater than the disturbance of those with
schizophrenia.
4. Neuropathways link with the ventral striatum and DLPFC. When its signals misfire, it
intensifies body image perceptual disturbance.
5. Recovered persons with bulimia nervosa showed significantly elevated receptor signals in
the parietal, contributing to disturbed body image.
6. Recovered persons with anorexia nervosa demonstrated decreased parietal response,
suggesting continued body image disturbance after recovery.
Neurobiology gives meaning to eating disorder intentions and actions. Realizing and seeing
the 3-D brain, where areas misfire and fire accurately, opens the door to experiment in
changing habits and harmful rituals into healthy rules and rituals.
(The reader is encouraged to use the 3-D brain included with this text to concretely observe
the areas of the brain identified above that impact eating and eating disorders, and share
the visual information with your clients, supports or students.)
Brain Function Summary
71
Figure 18
Recent research, including our own, has implicated neural subareas in the ventral limbic
circuitry, dorsal cognitive circuitry and insula underlying altered reward processing,81,164,
175
cognitive or self-regulatory control,200,201,202,203 and interoception85,204,205,206 in the
pathophysiology of anorexia nervosa (Figure 18). The ventral area of the limbic neural circuit
includes the nucleus accumbens, putamen and caudate, as well as the OFC and amygdala.
These regions code for the reward and motivational value of eating and contribute to the
approach or avoidance of objects.
Areas of the brain that appear to be actively involved in eating, body image and decision
making are summarized in Figure 17. The dorsal cognitive network (in black) makes and
executes decisions, such as controlling food consumption, based on considerations of both
short and long-term outcomes (e.g., perceived weight gain). It includes the dorsal caudate
and the dorsal ACC, the lateral prefrontal cortex, and the parietal cortex.
The ventral areas (in red) are involved with body sensations that inform and provide
72
fundamental body, emotional and physical sensation signals. They provide the needed
information for the dorsal thoughts to make, trust and execute decisions.
Persons with anorexia nervosa have difficulty seeing the larger picture, often having a trait
that directs attention to details.75,201 For example, a child who has obsessive and/or
perfectionistic traits may repeatedly focus on details in school assignments and become
overwhelmed when faced with a multitude of choices. Uncertainty sets in, as concern about
making the “right” decisions increases. It appears traits establish a stronger influence during
adolescence, increasing the uncertainty of what is the perfectly right thing to do.108,207 To
maximize impact, when environment has a higher influence during childhood over genes, a
child may demonstrate difficulty in making decisions and become overwhelmed or anxious.
If offered too many options, parents and instructors intensify the child's sense of being
overwhelmed, contributing to thoughts that become “frozen.” If instead the child was offered
two or three options, narrowing selections, anxiety decreases. This approach could shift trait
expression during childhood from problematic, overwhelmed reactions to productive
responses by consistently offering two to three options to help the child function better.
Similarly, the ability to make and trust decisions is critical for adolescents and adults to
function autonomously in everyday life situations. The inability to make and trust decisions is
reported during post-testing by over 70% of the adult clients with anorexia nervosa in our 5-
Day Treatment for Eating Disorders program. A verbal poll taken during group sessions
revealed that over 95% of the clients reported lack of trust in various types of decisions.
Trust in one’s decisions is diminished when a reduction of pleasure or confirmation in ventral
limbic dopamine signals occurs.52,208,209 If, through treatment, clients learned the
neurobiological contribution to their inability to trust decisions, they can feel empowered to
shift their understanding from self-blame to focus on what is needed to compensate for their
brain misfiring.106
As in all research findings, there are subgroups who vary from majority group findings. fMRI
findings confirm most persons with anorexia nervosa experience over and under firing in the
brain areas identified above, yet some do not do not experience misfirings in all areas
described. The clinical team at The Center for Balanced Living tests research results
clinically by asking clients, “While research is pointing in certain directions of brain response,
we need to know what is true for you. Can you taste foods? (insula) "Can you tell if you are
hungry?" (insula) "Do you experience eating disorder noise? (DLPFC)" Some clients report
acute taste, yet no hunger signals and/or feelings of fullness (insular signals in subareas
and not others). Some clients who can taste tend to report higher fear (amygdala), while
some also report they don’t experience pleasure (nucleus accumbens) with the taste.
Almost every client reports high body disturbance (parietal) and ever ongoing eating
disorder noise (DLPFC). It is not one brain area, but the complexity of multiple areas that
synthesize the combinations of misfiring individually.
73
Each of the multiple brain areas involved in eating disorders have their own volume of signal
intensity. For those who don’t have an eating disorder, the brain signals create a
harmonious symphony of sounds or firing in response to fundamental stimuli such as hunger
and food. For those with eating disorders, the “music” or brain signals are dissonant,
awkward and piercing, with each client having a slightly different variation on the discordant
theme. This is what makes the illness difficult to treat. There is no one set of instruments, or
parts of the brain, that need fixed. It is all the areas identified that need adjustment in
different amounts of volume (or signals) and in different combinations.
If and when therapists explain the brain basis of eating disorders, it can help clients shift
fault from the difficulty and inability to eat, to a biological response that impacts their eating
and decision-making ability. Identifying what it takes to compensate for brain misfiring
makes planning and structure a natural, therapeutic consequence to compensate,
coupled with more motivation and understanding.
Chapter 3: Summary of Brain-Basis to Eating Disorders
Areas of the brain fire differently for those who have eating disorders compared to those
who do not have eating disorders. Fundamental ventral mid and temporal brain areas
underfire removing key information needed for decision making and eating. Clients with
eating disorders tend to "eat blind," unable to sense hunger, or fullness or taste and
experience pleasure from food or to confirm decisions. Higher brain areas such as the
DLPFC over fire trying to make sense of the faulty ventral signals, confused and unsure of
what to do after each bite and step of the way through activities. Understanding eating
disorder brain response becomes critical for both clients and clinicians/educators in order to
"wade through the mess" of misfiring and contradictory circuit responses, which creates ED
noise. The cacophony of disturbed and conflicting signals can best be managed by simply
not eating. It quiets anxious noise, lowers emotional panic, and joins with the lack of signals,
creating a calm in the brain. Clients and supports need to know the counter affect food has
on the brain, so that when one eats, the negative "side affects of food" can be understood in
order to enter the painful steps needed for recovery.
74
A Neurobiological Explanation of Eating Disorder Experiences
A Neurobiological Explanation of Eating Disorder Experiences ----- Chapter 4
Table of contents
- Difficulty Making and Trusting Decisions
- Eating Disorder “Noise”
- High Pain Threshold and Over Exercising
- Body Image, Shape and Size Disturbance
- Food Restriction
- Binge Eating
- Relief after Self-Induced Vomiting (one type of purging)
- I Can’t Imagine My Life without My Eating Disorder
- Inability to See the Big Picture – Central Cohesion
- Summary
Eating disorder harmful behaviors and cognitive experiences can be described from a brain
based approach drawing upon research described above and inform this chapter.
Difficulty Making and Trusting Decisions
It takes many areas of the brain working together to carry a message clearly enough to
make a new decision that can be trusted as good or bad, in order to take action and carry it
out. Lower brain areas tend to under fire for those with anorexia nervosa, preventing higher
brain areas, where thoughts reside, from receiving clear signals to inform a decision. (See
the clinical tool, "Telephone" description and/or training video in the Supplemental
Materials.)
In addition, dorsal brain areas, such as the DLPFC appear to compensate for the lack of
needed body signals and over firing of emotional signals by overthinking, or perseverating in
the attempt to make and trust decisions. Anxious thoughts reside in the same brain area
while trying to plan and execute decisions. The over-firing, perseverating signals lower the
ability for thoughts to “hear” or register ventral brain signals to inform plans and decisions.
Detailed if/then instructions are often created by clients with anorexia nervosa to
compensate for the inability to make and trust decisions. The brain compensates by defining
specific cognitive rules to guide and direct doubtful thoughts and compensate for indecision.
75
Rules wired together plan specific actions together, creating over time strong neural
pathways that serve as default action plans (See the Wire-Rewire clinical tool written
detailed description and/or training video in the Supplemental Materials).
Difficulty in decision making applies to all areas such as food, clothing, activities, work,
school, etc. Over seventy-two percent of the clients who have been in the 5-Day Treatment
for Eating Disorders report having difficulty making and trusting decisions on their feedback
instruments and 98% report the inability to trust decisions when verbally responding in
groups.
Anxious thoughts in the DLPFC appear to be a core site for what could be described as
eating disorder “noise.” These perseverating thoughts vary among clients, yet have common
themes around food, body shape and self blame. The cognitive noise can all too easily
drown out thoughts needed to reason and focus on tasks in the moment, leaving a chronic
sense of doubt and uncertainty.
“I don’t know what to do!” - Adult recovered from anorexia nervosa
Rituals develop from sets of rules combined to become default behavioral patterns,
circumventing momentary areas of indecision for those with anorexia nervosa. Rituals also
compensate and reduce cognitive perseveration. Once established, a ritual needs little
thought when enacted. Once wired into action, the brain has a clear plan of action and
indecision is reduced. For example, a rule might be established to wear a certain color or
type of clothing on Mondays and a different set of clothes for Tuesday, etc. This eliminates
the daily need to decide what to wear which raises anxiety and uncertainty each time a new
decision is faced, for many with anorexia nervosa. Rituals on what to eat, how, and when
become natural reactions established by rules that had been thought through to reduce
anxiety.
Changing rules changes rituals. It violates the structural walls that held anxiety from
invading. Many support persons want their loved ones with anorexia nervosa to act flexibly
and “take the responsibility to decide.” However, for those with anorexia nervosa, decisions
need to be thought through with precision, option by option. It is not because they want to do
76
it this way, it is because they have to use this method to compensate for the lack of lower
brain signals firing strongly enough to inform and validate thoughts in decision making.
When a therapist asks, "How do you feel? or a support person asks, "What do you want to
do tonight?" it opens the door for endless options to be considered. The ability to reason
through each option becomes impossible and thoughts freeze. Since there is no “gut
response” signals coming through the insula and nucleus accumbens, bodily and pleasure
signals do not provide confirmation to affirm decisions. This triggers anxiety to rise.
Psychologically, anxiety could be defined from a Gestalt perspective as rehearsing the

future while trying to live the present. Anxiety rises in persons with anorexia nervosa when
faced with too many options that encompass both present and future. In addition, while
trying to concentrate on each option, perseveration increases and persons with anorexia
nervosa may experience difficulty shifting from one set of thoughts to another set
flexibly.211 This diminishes motivation to change from a safe clearly defined rule. It sets up
rules that too easily become rigidified over time.83
When clients with anorexia nervosa are asked open-ended questions, doubt and uncertainty
usually result. If therapists, physicians, dietitians, and supports offer two to three options,
instead of open-ended questions, it appears to reduce anxiety and allows the person with
anorexia nervosa to think through each option to decide. Neurobiologically it would be the
same if the doctor asked a blind person, "What do you see in the room?" Due to the optic
nerves not firing properly, nothing can be seen. The same with those with anorexia nervosa,
only instead of optic nerves it is ventral limbic nerves not firing, creating varying degrees of
blindness to aid in daily decisions. Also, just as blindness varies, so does the ability to trust
decisions among different clients. Some report the ability to sense signals in some ventral
limbic areas and not others. Others report the inability to sense and trust brain response in
all brain areas. A mild blindness would be color blind, able to see all things but not all colors.
The same appears true in the range of neural response in decision making among those
with anorexia nervosa.
Decisions become top down neural processes instead of a balance of bottom up and top
down for those with anorexia nervosa. The bottom up signals are minimally to not present,
so half of the information needed to make and trust decisions is not present. Hence, using
rules and appearing rigid, is not a self-choice, it is a necessary compensatory response to
brain misfiring.
77
Another way to describe this is the ability to know and trust one’s own sensations to guide
decisions is expected by one’s family, friends, teachers, therapists, doctors and work
colleagues. The assumption is to simply “decide what is best for you.” Yet this appears to be
neurobiologically limited to nearly impossible for those with anorexia nervosa. Supports,
teachers, and even other therapists often say to “eat mindfully” or “listen to your gut.” That
would be the same as asking someone who is farsighted to read a book without glasses to
compensate for the vision problem. The optic nerves fire inaccurately and reader glasses
are needed to see words clearly, in the same way neurocircuits fire inaccurately for those
with eating disorders. In eating disorders, however, the misfiring occurs in different and
multiple areas of the brain. Instead of glasses to compensate, rituals are developed to guide
and compensate for “blurry” indecision. Therapists, doctors and supports can help
compensate for eating disorder indecision by offering 2-3 options, whether it is in relation to,
"do you want your next appointment next week or the week after?" instead of "When do you
want to meet?" or "What college do you want to attend?"
It feels awkward at first for anyone to change rituals, e.g., brushing one’s teeth with one’s
non-dominant hand. It is overwhelming for those with anorexia nervosa to change rituals
while the brain misfires in multiple areas, increasing doubt when faced with new options. To
decrease uncertainty around food, persons with anorexia nervosa tend to develop rituals
before, during and after eating. Anxiety can become so acute that nothing less than making
the food go away decreases anxiety. This can range from avoiding the food to doing harmful
actions, such as self-induced vomiting. Both lower anxiety for a short period of time.
However, it quickly becomes ritualized.
Rules begin for those with eating disorders by defining methods to lower anxiety, such as "If
“X” is eaten, then remove it by self-induced vomiting." The more the harmful rule is applied,
the less thoughts have to focus on the issue, and conditioned behavioral rituals become
established. For those with anorexia nervosa, self-harming actions don't necessarily feel like
or are experienced as self-harming. They are a means to lower anxiety and restore calm.
Eating disorder rituals tend to be simple and practical. If the self-harming ritual has lowered
overwhelming indecision, doubting, and questioning, then to the person with an eating
disorder, it feels successful.
The more the brain is explored, one realizes that persons with eating disorders have to
reason backwards. Details to whole, small to big. Decisions are not reward based on results
of clear signals of weighing pro/cons. They tend to be fear and avoidance driven responding
to painful anxiety or discomfort. It is not the case of, "OK, that felt right to do," it is more "It is
78
less distressing to do that."107, 212 with little certainty of what is the "right" thing to do. It is
more ability to identify what not to do to find a sense of calm.
To compensate for indecision, a person with anorexia nervosa could seek help from trusted
individuals and therapists to think through pros and cons. For example, the support could list
the pros and cons of new foods, new restaurants, new classes at school, to help the person
with anorexia reason through the options. The supports and therapists become the “glasses”
who can see the pros and cons more clearly, compensating for the caudate nucleus’ pro
and con signals misfiring when transferring messages from other lower midbrain area to the
DLPFC.
However, adults with anorexia nervosa are often unwilling to seek support from others. “Can
you help me think though this?” is evaluated as being too needy or dependent, allowing
others to “hover” too much. This concern can be magnified if one has an avoidant trait, as
have many with anorexia nervosa. Persons with anorexia nervosa tend to be intelligent
having developed the upper areas of the brain well over life to compensate for lower brain
areas' under performance. In addition, work and school performance or productivity within
structure is usually high. Hence, it can be humiliating to ask for support over daily,
fundamental decisions, such as what to eat when they could be doing surgery daily in their
work tasks. When working within clear structure, however, persons with anorexia nervosa
perform better. Structure guides actions and can serve as a framework for healthy and
productive actions. Structure becomes central when shifting harmful rituals to new and
healthier ones.
Just as food restriction can be ritualized to diminish decision making, so too binge eating
can be ritualized at certain times of day or night. Deciding when to eat can be overwhelming,
especially if one senses little to no hunger and fullness signals, as research attests for those
who binge eat (described above). The DLPFC do not get messages of satiety or body pain
from the large amount of food intake due to low to no insular and nucleus accumbens
signals. Thus thoughts do not think to stop. The result is that many will avoid food as long as
possible throughout the day, since they sense little to no hunger and know that eating brings
uncontrollable actions, as a mechanism or desperate way to compensate for an inability to
know when to stop eating.
How to manage daily food intake takes a lot of mental energy for those with eating
79
disorders. Attention to food expectations and simultaneously doing other daily tasks at work
or school becomes overwhelming. Thus, a person with an eating disorder may restrict foods
throughout the day to give full attention to daily work, family, and school tasks and then eat
when no other tasks or persons are around. Binge eating, restrictive and purgative actions
become ritualized to manage anxiety.
Rules compensate for brain misfiring in recovery just as they do in maintaining the illness.
Rituals are both harmful and productive, just like one’s traits. If a healthy ritual is developed
in detail, applying clear and accurate rules, it can reap productive solutions. If there is not a
clear structure to guide the when, what, and where of eating, the person with an eating
disorder has to think through every detail, each time they eat. New actions require new rules
to compensate for brain misfiring both for recovery or perpetuating the illness.
Repetition, over time, becomes safer and easier. Decreasing expectations from a wide
variety of options to allowing variety to enter in slowly, one ritual at a time, may be
necessary to manage both temperamental eating disorder traits and brain responses. The
fewer the options, the less the distress in decision making.
Since rules tend to become the avenue to guide eating disorder behaviors to establish calm
to the stressed brain, then rules and their corresponding rituals can be the foundation for
healing. For example, The Center for Balanced Living approaches food as medicine, dosing
macronutrients based on detailed nutritional assessments and activity needs for each client.
A body composition scale could also be used to provide current body composition status
when determining food intake needs. Dosing macronutrients assures balance while allowing
the person with anorexia and bulimia nervosa, binge eating and other variations to decide
what to eat, the "dosage" of the macronutrients and timing. This compensates for brain
misfiring by providing rules to establish healthy food and eating rituals. See information on
the new phone app, “Balanced Life,” to aid in this process.
Eating Disorder "Noise"
Listen to ED Noise
80
The DLPFC is the area of the brain where thoughts establish and execute a plan. This is
also the site where eating disorder (ED) "noise" resides. ED "noise" is the continuous, self-
abusive thoughts about things such as food, how much, when and why eat, body shape and
size, or doubts about interactions, all shouting in one’s mind. Neurobiologically, ED noise
could be interpreted as trait anxiety coupled with state anxiety. Serotonergic brain signals
misfire in circuits through the DLPFC trying to make sense from misfirings from the parietal
(body image), caudate (pro/cons), and orbitofrontal cortex (inhibition), and amygdala
(feelings).213 The research findings about these brain areas is explained above. ED noise is
acute mental distress. Clients in the 5-Day Treatment program and other eating disorder
programs at The Center for Balanced Living, report that ED noise is not someone talking to
them in their head, as a hallucination would be defined. It is more a cacophony of words
shouting in their minds, intense debasement of, e.g., their eating actions or for not meeting
all of an exercise regimen. It clouds and distracts the person with an eating disorder from
the ability to focus on needed decisions and maintaining interrupts concentration. It
contributes to doubt when making decisions and helps sustain the illness.
Eating disorder noise increases, not decreases, as persons with anorexia nervosa consume
increased amounts of food to restore body mass. When ill, the neurotransmitter serotonin 5-
HT concentrations are significantly reduced,214 contributing to low eating disorder noise. As
body mass restores, serotonin disturbance becomes exaggerated among 5-HT serotonergic
secretions outside the cells.52 When persons with anorexia nervosa are near a healthy
weight, research findings show that serotonin (5-HT) metabolites are increased by 50% from
the ill state.106, 125 Serotonin 5-HT abnormality can be worse in anorexia nervosa than in
schizophrenia.125
In essence, eating disorder noise is the 5-HT exaggerated neurochemical response. Not
eating decreases the brain’s ability to make serotonin metabolites, lowering anxiety in the
DLPFC pathways. This may be why some persons with anorexia nervosa relapse when they
leave structured, higher levels of care treatment settings. Starvation decreases serotonin
metabolites, lowing anxiety and allowing thoughts to focus on tasks, not the eating disorder
noise. This increases the ability to return to work, school, or focus on other structured
activities and think more clearly. That is effective for the person with an eating disorder until
the body begins to break down its own mass again.
Again, this illness is truly backwards. When eating, those with anorexia nervosa experience
81
mental pain, or eating disorder noise. When not eating, there is less thought disturbance
experienced by the client in spite of acute starvation and abnormal biological sequelae. To
feel stronger, brain response reinforces less. It appears that ED noise may be one of the
first brain symptoms that increases during food restoration and the last symptom to
decrease after body stabilization. Among clients at The Center for Balanced Living, there
appears to be a correlation that the older the client, the longer it takes for ED noise to
become quiescent.
It is critical that therapists, doctors and supports know and understand this backward,
neurobiological response of eating disorders to better understand the suffering experienced
by the client when weight restoring. As anxiety increases, less can be said to the client that
seems logical. Clients in the program report it is more effective to move for a short amount
of time or simply reboot and reroute to a different action until anxiety decreases. (See Red
Light Green Light and Anxiety Wave clinical tool in the Supplemental Materials). As one
support person summarized it:
“When anxiety is up, shut up! Move when stuck!!” - Support person of adult with anorexia
nervosa
The Supplemental Materials have a recording that is an example of ED noise that has been
affirmed by the clients with anorexia nervosa. This could be used to play for one's classroom
or supports or clients to empathically demonstrate that the therapist or educators know an
overall example of ED noise, and to then assess the specifics of the individual client's ED
noise.
High Pain Threshold and Over-Exercising
Many male and female persons with anorexia nervosa exercise excessively.
Neurobiologically, this could in part, be due to low interoceptive awareness, originating via
low to no insular signals. Clients with anorexia nervosa report that excessive exercise calms
both their thoughts and feelings. Movement is a central way for the brain to organize,
change, and bring the mind to a calmer state. Most persons without eating disorders feel
body pain increasing when exercise becomes too excessive. So they stop. However, if the
82
insula is sending weak to no signals of body pain, the message does not get through to the
DLPFC or the area where thoughts reside in the brain. This contributes to little to no
motivation to stop exercising. In addition, if there are low to no hunger signals from the
insula, then there is less reason to eat. The client can be told that excessive exercise and
lack of eating impacts bones, shin splints and fractures. But it appears to not be
"experienced" or registered in the brains of those with anorexia nervosa. Painful shin splints
can be present, but the pain is not experienced until acute enough to get signals through the
insula to the DLPFC for the brain to decide to stop.
If thoughts are clearer and pain is not felt, and perfectionistic and competitive traits are
present, as in many with anorexia nervosa, the need to set a higher and higher bar on what,
when, and how much exercise to do becomes a rule. Pain cannot set a boundary to stop if it
is not communicated in the brain. The client with anorexia nervosa may find exercise to be a
natural and easy method to find mental calm and reduce stress, allowing it to be rule-bound
and ritualized. When a person has a compulsive trait, it locks in the need to continue doing
the activity over and over. Excessive exercise becomes habitual, even when limits are set. It
is very difficult to interrupt or stop moderate to severe compulsions, and yet the only way to
do so is to interrupt the action or not do the compulsive action day after day. Even if one has
not done the compulsive activity for months, doing the action again can reignite the
compulsive trait.
This does not mean a person with an eating disorder should not exercise or engage in
healthy movement.215, 217 Healthy balanced movement needs to be different from the
compulsive, harmful, excessive, eating disorder actions. The compulsive trait is not going to
go away, so therapeutically sublimate it. Therapists, dietitians and physicians can work to
establish different movement menus with clear plans, clear limits, and with supports when
possible.
The 5-Day Treatment for Eating Disorders “doses” movement the same way that it “doses”
macronutrients and medications. In addition, body composition is taken on each client to
determine muscle, fat, interstitial water, intracellular water, and cellular integrity in each arm,
leg, and body trunk to help determine how much movement is healthy for body restoration.
All clients are allowed some movement in the 5-Day Treatment, since this is not an inpatient
or residential treatment program, unless medical symptoms on a particular day are acute.
Five to ten minutes of “walking tall” after meals can be anxiety-reducing and models dosed
amounts of movement in a pace and time frame that is balanced and builds strength. Forms
of yoga are also a natural method of movement toward which clients could shift their
83
compulsions.
Body Image, Shape and Size Disturbance
Body image, size and shape disturbances appear to reside in the parietal lobe of the brain.
Parietal disturbance has neural pathways interacting the DLPFC and the amygdala and
surrounding areas contributing to magnifying the disturbed experience. Coupled with
probable traits of seeing errors over successes, perfectionism, and compulsivity, the
disturbance gains momentum as neuropathways send signals through and around the brain
repeatedly. Thoughts become increasingly overwhelmed as one tries to make sense of the
body image disturbance and the emotional reactions to it.
Another way of neurobiologically describing body image and size disturbance is to parallel
anorexia nervosa’s body disturbance with farsightedness. The parietal signals a perception
of how persons experience their own bodies in the space around them. If the right parietal is
disturbed or misfiring, their own body is experienced in a distorted manner,116 similar to
those who cannot see objects clearly when they are close up. However, clients with
anorexia nervosa report that they can see others’ body sizes and shapes accurately, similar
to seeing objects far away clearly. It is a “farsighted” parietal response.
CBT-E or ICAT could be applied to alter cognitive and emotional self-statements in regard to
body distortions. They do not change the neurobiological default of misfiring biological
signals immediately. A person that is farsighted needs glasses to correct vision. Glasses
can correct vision in that moment. However, science has not yet developed “glasses” to
correct body image distortions. If clients with anorexia nervosa are made aware of the
neurobiological contributions to their illness, then they may be more motivated to try to
compensate by turning to CBT-E or ICAT to develop cognitively refocused plans upon which
to act. For example, some clients in the 5-Day Treatment for Eating Disorders have decided
that it is better for their quality of life to not look in full body mirrors. Why focus on body size
and detailed areas of the body when the brain fires distorted images close up and
contributes to “blurred body vision?” It helps give clients permission to push themselves
away from the visual distortions, which are as neurobiological as farsightedness. Forcing
themselves to focus on other non-body objects, away from themselves, they can "see" more
clearly.
84
Food Restriction
Combining the section above titled, "A Neurobiological Explanation of Body Image, Shape,
and Size Disturbance" with avoidant and anxious traits, common among persons with
anorexia nervosa, food restriction becomes a natural biological response. When coupled
with anxiety over the next meal (state anxiety), the desire to avoid and restrict food
dominates and becomes the simple calming solution. Food restriction is anxiolytic, lowering
ED “noise.” Harm avoidance is a trait that imprints a natural response to avoid distress.
Avoidance could include foods, activities, friends, confrontation or social events.
Helping clients with eating disorders understand the neurobiology of restriction may help
them reason through the desire to not eat. However, it often takes more than the client alone
to get through all the brain-based obstacles to avoid perceived harm. Having supports and
therapists eating along beside the client, whether adolescents or adults, helps. Clients report
they want themselves to want to eat. However, the neurobiological misfirings do not support
the ability to easily eat. Unless motivation is so high that it can surpass the neurobiological
barriers, it is usually not enough. Additional support is needed through a long recovery
process. Motivation often lasts a few minutes to a few days. The motivated client is then hit
with ongoing rising neurobiological oppositional responses to eating, as described above,
and the motivational wall begins to crumble.
Holding onto long-term desires and intentions that have purpose to life helps and is often
needed. This is a primary focus of ACT. It is important to encourage clients to focus on the
end goals identified to give reason to keep fighting the illness. However, if structure is not
clear, such as a tight structure provided in higher levels of care, indecision sets in when
returning home and the client is faced with new decisions throughout the day. This
intensifies the need to restrict food to stay calm to "live the day." (See Difficulty Making
Decisions above). An important bridge from higher levels of care to outpatient and returning
home is to assure the client daily-plans are initially as structured as the daily treatment and
that the supports are included in the detailed planning, or the potential for relapse to
restrictive eating increased more quickly.
85
Binge Eating
Many persons who binge eat may not sense hunger and fullness due in part to little to no
insular signals. While the body may send signals of pain from not eating throughout the day,
the pain may not be sensed interoceptively, due to low insular firing. Likewise, the insula
may signal no pain to the higher brain areas even when the gut is stretched beyond
imagination from eating a large amount of food in a relatively short amount of time. If the
person also has an impulsive trait, the impulse to binge eat can bring relief that is similar to
excessive exercise for those with anorexia nervosa.
Serotonin dysregulation or depletion is caused by not eating carbohydrates and proteins

throughout the day. Serotonin becomes imbalanced and contributes to dysfunctional mood,
trait, and personality manifestations.106 Irritability, tiredness, impatience, and impulsivity can
be intensified when there is too little brain serotonin or 5-HT. The "whoa" is taken away.
Lowed serotonin impedes one’s ability to be cautious and wait.106 It opens the flood gates
to let all foods in In addition, serotonin mediates anxiety reactions, contributing to an
increased sense of avoidance.106 If a person has an impulsive trait and withholds or avoids
eating all day, the serotonergic and dopamine neurochemical imbalance triggers depression
and impulsively to binge eat. The consumption of large amounts of food can be
anesthetizing to correct mood and restore neurochemical imbalances from undereating.
Another way to say this is if the body has had no food all day, neurotransmitters decrease,
from loss of food intake throughout the day, creating depressed symptoms such as difficulty
concentrating, impatience, and irritability. This impacts the impulsive trait to trigger a binge.
While the body intensifies its signals of hunger to the brain, the insula does not let those
signals through. It under fires, preventing thoughts from “knowing” the hunger state and
cloud the decision of what to do. Eating a large amount of food can be calming to the body
and thoughts in the DLPFC, just as restricting and excessive exercise can be calming. Lack
of lower brain response with a trait profile that includes impulsivity, coupled and mood
changes, create a sense of increased numbness that calms daily stressors and anxiety.
Dosing macronutrients throughout the day, just as medications are dosed gives structure to
healthy rules to follow. Structure by "dosing food" in amount and time frames can replace
indecisiveness on how much, what, and when to eat. Working with an eating disorder
86
dietitian to "dose" macronutrients compensates for uncertainty, even though the brain
continues to have eating disorder noise. It assures clients that they are getting balanced
food combinations and that they will not get objectively fat (even though their own
perception may experience fat). It takes daily use of the three macronutrients to maximize
the body's metabolism to burn at its best preventing excessive fat from developing (See
Clinical Story: The Wood-Burning Stove, in Supplemental Materials).
Relief After Self-Induced Vomiting (one type of

purging)
After a person vomits, whether from the flu or from an eating disorder, a temporary relief is
often experienced. The relief appears to come from the release or surge of vasopressin.
One role of vasopressin is to serve as an antidiuretic. It is a hormone released from the
pituitary gland to prevent the body from losing too much water. For that reason, it is
fundamentally lifesaving. When a person loses too much water from vomiting, the body
becomes dehydrated, losing valuable water stored between and within the cells that hold
electrolytes. Electrolytes are chemical compounds that conduct electrical responses. They
are necessary to keep cells active. Electrolytes have positive and negative charges. They
include potassium (+) and chloride (-). Potassium is one of the electrolytes necessary to
keep the cells in the heart beating.
When a person vomits frequently and is unable to drink enough water to replace that which
is lost, the body dehydrates, causing the heart to become arrhythmic, or irregular, due to low
amounts of potassium (called hypokalemia). This could cause the heart to stop. For those
who self-induce vomit repeatedly, as a part of the eating disorder, it becomes life
threatening as in Russian roulette. The more one vomits, the worse it becomes. A person
who vomits with anorexia or bulimia nervosa, may vomit many times in one episode and
have many episodes of self-induced vomiting through the day and/or week. Each time one
vomits, the heart muscle breaks down more and the body loses more potassium. It is not if
one could die, it is potentially when.
Then, why don’t more persons die from self-induced vomiting? The body's hero is
vasopressin. The brain surges vasopressin when one vomits to assure the body retains as
much water as possible. While vasopressin’s purpose is to keep the person alive, the
87
vasopressin surge creates a calm sensation. Some clients describe it as almost a morphine
like high. This calming response sets those with compulsive and impulsive traits into action.
A self-induced calm from self-induced vomiting after a stressful day’s storm can become
addictive. In addition, while self-induced vomiting can be influenced by an impulsive trait in
the beginning, the impulse to vomit becomes ritualized or learned over time,106 setting into
motion the compulsive action to continue vomiting to feel “calm.” This can result in the
desire to vomit even small amounts of food.
I Can't Imagine My Life Without My Eating

Disorder
"I can't imagine my life without ED” is the same as “I can’t imagine my life without my traits.”
The fact is, one cannot exist without traits. Traits are our genetic ingredients for our
personality or temperament. They are a part of us from birth till death and establish the
basis of who we are as individuals. While traits persist, they can be expressed in a range of
different ways. If one was a sculptor, a trait would be marble while symptoms would be clay.
The sculptor would need to chisel and use much force to shape the marble to become a
figure desired.
From another perspective, just as some salt is needed, too much is unhealthy. How
therapists help clients identify and carve out healthy trait expressions is important to sustain
change. Symptoms are more malleable. Attitude and actions can change with intention. Yet,
traits persist and require more force to redirect a trait driven destructive behavior to become
constructive. This is similar to the sculptor using more force to chisel away at marble. It is
how; how long and how strong the chiseling occurs that impact a transformation from living
with "ED" to living with one's traits carved to be an expression of strength and balance.
Traits do not go way, symptoms do. If traits can work against a person, such as avoidance
or anxiety traits, they can also work for a person. How to shift traits to bend their
expressions to healthier responses requires following the methods of the sculptor. What
tools does it take to chisel traits verses symptoms? How much force? How much time? The
default response of a trait, such as impulsivity, will always be impulsive. Yet, when and how
to express impulsivity productively through healthy spontaneity, or when to draw upon
support to help reshape the trait in a different direction is part of the sculpting process. The
88
hard and intense process can twist the trait from an impulse to self-induce vomit to an
impulse to spontaneously walk with a friend or hit a punching bag hanging outside of the
bathroom, or impulsively step into a healthy action instead of away from it.
It is critical that therapists work with clients and their supports to identify and visually
imagine what the very traits that define their makeup, and what their strengths look like.
What do their traits look like when vulnerable? What eating disorder actions make the
person weaker? In an equal and opposite approach, what might it look like, to the client if a
trait was expressed productively? On one hand, it is impossible to expect oneself to say, “I
will try to not be avoidant.” That is expecting the trait to go away like a symptom. The trait
can change, however, one may decide that the productive expression is to ask another
"artist to help," such as "I will ask for support during X time when I am more impulsive to
self-induce vomit." To ask the impulse to go away, is beyond possible.
Traits establish a dominant response in daily expression. It feels natural to avoid, be

anxious, or see errors over successes for those with eating disorders. The person with those
traits don't have to try, they simply do that expression. It simply happens without thinking
about it. Clients will find their natural tendencies to not eat a meal, impulsively vomit brings
relief. This feels even better than to eat or not vomit, to the client. It is when the therapist
asks the person with an eating disorder to act in ways counter to the dominant expression of
their traits, that it gets difficult.
To eat like "everyone else who don't have eating disorders" is as nearly impossible for a
person with an active eating disorder as it is to write with one's non-dominant hand. Food is
the non-dominant object. Clients cannot eat with ease while ill. It takes looking down the
road to what is purposeful and meaningful in life, and holding onto that image, or doing
(chiseling) projects that one finds purposeful, to struggle through the pain. Much more force
is needed to shift one’s own genes and brain responses to a less self-destructive action.
When "treating to the traits,” clients need to be informed that they will experience massive
amounts of annoying mental discomfort to move toward healthy trait expression. The painful
blisters are a part of the artist's sculpting process.
Therapeutic teams need to include supports to help shift trait expression. Supports may
know how traits were expressed during childhood. What worked then and what could be
retried again. As stated earlier, drawing upon nature, which models what is natural, the gene
89
determines the type of tree. The limbs may grow naturally one way but it may not be a
productive way to enhance the strength of the tree. The limbs can be gently forced to hold
firm, to grow differently. As the reinforced change is kept in place over time, the tree limbs
begin to grow naturally in the new direction. More purposeful responses or activities can
then be experienced and remembered, and new healthier rituals can be established for
persons with eating disorders. New directions carved into daily living broadens the
experiential world. Just as the tree trunk is bent in this picture, the distortion could have
been greater if not sheltered by the trees around it. So too, supports can help clients bend
away from their eating disorder behaviors to naturally express new actions of their own over
time.
90
Figure 19 (Image retrieved from http://www.forestpests.org/vd/376.html)
It is hard to imagine life without an eating disorder because life cannot be lived without one’s
traits. Traits make up our natural temperament, which serve both as a weakness and as a
91
stage for eating disorders. Strength is developed from the chiseling process. A life that has
taken a lot of effort to become all that one can be. In the field of construction, when building
a house, there are primary weight bearing walls that cannot be moved or the building will fall
down upon itself. However, other walls can be torn down and constructed in other places in
the house. This is similar to symptoms and traits. Traits are the “life-bearing” walls of one’s
temperament. Symptoms can be more easily torn down and rebuilt in other places.
Treatment is reconstruction in action. It is working with the weight bearing walls that hold the
house, while redesigning the weight bearing walls to be practical and helpful to serve for a
better lifestyle. The shift is done with action: the labor (a crew) and tools (clinical and
support tools) with lots of support.
Inability to See the Big Picture - Central

Cohesion
Many persons without eating disorders approach a topic, or walk in a room and see the
overall picture first, then zoom to the details. Seeing details over the big picture is the
tendency for those with anorexia nervosa.216 Each tree, or the details of each tree are seen
instead of the forest as a whole. Overall, there are two cognitive approaches to think through
issues: inductive and deductive reasoning. Both are valid ways to approach problem solving.
Deductive reasoning starts with an overall picture and deduces details and how they fit into
the whole. Inductive reasoning starts with details and induces to a larger picture. Inductive
reasoning turns to each puzzle piece, trying to figure out how each piece relates to the
unknown total picture. Eventually inductive thinkers position each piece together to complete
the bigger picture puzzle. Deductive reasoning begins by framing the overall picture and
works from the larger picture to fit the pieces together. It is not that one chooses to approach
issues inductively or deductively. It is a genetically influenced process.
Persons with anorexia nervosa tend to be inductive reasoners to the extreme. This means
there is less central coherence for those with anorexia nervosa, or less ability to know where
the detail fits in the whole. This can be the case whether it is the next bite of food in relation
to the whole meal, or the class one takes in relation to a major, or the actions one does in a
day. All too often the actions feel random to those with anorexia nervosa. Creating clear
plans, or using structure or technology to outline where the details fit within the whole,
allows the client to see what they cannot see neurobiologically. This helps reduce anxiety.
For example, to help compensate for how much to eat, The Center for Balanced Living has
92
developed a new app that allows clients to scan in their food purchases, monitor what they
ate or movements they did. Each food or movement is then charted to see where it fits
within the larger dietary or movement picture in a concrete way to compensate for what the
client cannot induce. The app is called "Balanced Life." Clients have begun to test its
practicality and ease to use in the moment wherever they go, while their dietitians can see
what is happening in the moment.
To balance an inductive detailed cognitive approach, it can be helpful to have trusted

supports who think deductively, or look at the big picture first. Both help one another with the
opposite approach, allowing life's puzzle pieces to come together. For persons with anorexia
nervosa, it tends to be one detail followed by the next detail. Puzzle pieces can begin to
come together as one ages into later 20's allowing one to be more comfortable with patterns
established. Time helps one see a larger picture compared to a new action followed by
another new action as one leaves school to go into college. It could also be possible that
many have practiced enough healthy rituals by one's later 20's that daily patterns become
stabilized. Practice and healthy repetition allows the brain to rewire.
Yet for the adults and adolescents in the active or chronic state of anorexia nervosa,
structure is needed. Choosing from fewer options, helps the detailed thinker with anorexia
nervosa. For example, our clients report they do well when given structured assignments
and multiple choice test questions, instead of open ended questions. Many clients in the
treatment program report that when given open-ended questions to decide, such as on
tests, they write continuously, unsure of the main point and hoping that they address it in the
mass of details they compose. Higher levels of care provide higher levels of structure, taking
away the big picture while the brain and body begin to restore.
“I need rules and rituals to structure daily activities." - Client with anorexia nervosa
Structure and rules are fundamental to shaping eating disorders; and are fundamental to
reshaping actions into healthy behaviors. Structure can occur from the outside, via clear
class assignments, or internally, via cognitively determined rules that can lead to rituals.
Initially, rules require increased attention and focus, enhancing neuroplasticity to wire new
brain pathways, which increases the tendency for the pathways to strengthen each time the
action is completed. When rules are repeated over and over, rituals develop. Rewired
healthy rituals become automatic actions in the brain. Little thought is eventually needed as
the rituals are repeated whether for adolescents or adults. It just takes longer for adult brain
93
to rewire. (The reader is referred to Wire-Rewire clinical tool description or the training video
in the Supplemental Materials.)
Chapter 4: Summary of Neurobiological Explanations to Eating Disorder Experiences
Since eating disorders have a fundamental neurobiological & genetic foundation,

understanding what is happening in the brain helps address WHY eating disorder
experiences occur, such as why it is difficult to trust decisions or why there is ED noise and
how the brain becomes calmer when turning to eating disorder behaviors such as binge
eating, or purging or restricting. This chapter describes the why. In addition, explaining how
clients with anorexia nervosa approach the world around them in detail, verses a global
overall perspective, contributes to a lack of central cohesion which helps ground and
balance information intake. This is in part due to the genetic traits, fundamental in triggering
eating disorders. Traits are with us through life, from birth to death. They are not eliminated,
like symptoms, but they can be approached on continuums from productive to destructive
expressions. How to intentionally shift traits that influence eating disorders from destructive
to productive expressions is critical for treatment to be successful over time. Otherwise, one
could not "imagine a life without ED."
94
Overview of the 5-Day Treatment for Eating Disorders
Overview of the 5-Day Treatment for Eating Disorders ----- Chapter 5
Table of contents
- Core Constructs
- Body Mass Index
- Treatment Integration into Other Programs
- Program Development
- Role of “Treat to the Trait”
- Role of “Food as Medicine”
- Role of Movement
- Role of Experiential Clinical Tools
- Role of Behavioral Agreement as a Clinical Tool
- Role of Transitions
- Role of Story Telling
- Daily Sessions
- Daily Session Descriptions
- 5-Day Treatment Schedule
Overview of the 5-Day Treatment for

Eating Disorders
The 5-Day Treatment for Eating Disorders is a 45 hour experiential practical brain-based
program over five days for females and males with a current or past diagnosis of anorexia
nervosa, or persons with traits common to anorexia nervosa, or persons with other specified
feeding or eating disorders (OSFED). It was initially called NEW FED TR for
Neurobiologically Enhanced With Family Eating Disorders Trait Response. You can see why
we changed the title.
The treatment has been tested on persons aged 16 and above. At least one family member
or support person must be present through all 45 hours. Each client can have up to four
family members or friends. Two meals and two snacks are prepared by clients and their
supports daily. A behavioral agreement or treatment plan is developed with each client and
their supports in one hour sessions daily. Neurobiological research has been integrated into
treatment tools. In addition, the program “treats to the traits" of clients. Clients and supports
work together to learn a brain-basis for the illness and explore why and how the supports
are needed. The program jump-starts treatment from multiple dimensions to augment higher
levels of care to lower levels of treatment.13
Core Constructs: The program integrates five constructs into and through the
95
treatment process, tools, handouts, feedback forms, activities, and program
information during each of the five days of treatment.
The program is experiential throughout the day integrating neurobiological information into
almost every activity. It strives to provide a clear, reliable, and repeatable structure to lower
anxiety and establish a foundation for safety. All of this occurs while learning and practicing
approaches to manage eating disorder traits and symptoms.217 Information is presented in
the manner that clients with anorexia nervosa tend to think - in detail, not in generalized
points. This approach may not be comfortable for some clinicians who prefer ongoing
process therapy over structured therapy. However, the bottom line is what the anorexia
nervosa clients need to better understand and manage their illness. In this treatment
program, clients are approached as the “experts” who know their illness well, and have
much to offer when specific questions are asked by therapists on how the neurobiological
research findings are experienced by, or apply to, them. This appears to transform client
resistance into client motivation.
Clinical tools and portions of this program and information have been applied and integrated
into other levels of treatment at The Center for Balanced Living and at the University of
California, San Diego's Eating Disorders Center for Treatment and Research. Treatment
results, from over 100 clients and 175 supports, from open trials have found that 98% of the
clients and 98% of the supports reported that the brain-based clinical tools were very to
exceptionally helpful (The reader is referred to Chapter 11 on quantitative and qualitative
outcome data on the 5-Day Treatment for Eating Disorders program.)
96
The open trials conducted from May 2014 through June 2017 have tested three to six clients
per program with up to four supports per client each totaling up to 24 persons per treatment
program. More clients and supports could be included in treatment as long as there are
enough staff to provide daily one hour individual sessions to develop the Behavioral
Agreement.
Body Mass Index (BMI)
Body mass index is one of the most common and most contested methods of measuring
body mass in adolescents and adults. It is a formula that calculates body “mass,” which in
this formula, it is a generalized mathematical measure of body fat. The 5-Day Treatment for
Eating Disorders uses BMI as a standardized measure to communicate and compare with
other treatment sites and providers. The 5-Day Treatment for Eating Disorders has had
clients with BMIs ranging from 13.81 to 30.4.
To more accurately measure body mass composition, The Center for Balanced Living also
uses the seca mBCA bioelectrical impedance scale. It measures body fat and muscle in
each arm, leg, and the body trunk, intercellular and intracellular water and cellular integrity.
Individual body composition graphs are instantly plotted that describe each client’s body
composition on bimodal continuums of body mass, ranging from unhealthy to healthy,
compared with healthy cohorts. Most clients report that seeing the graphs and print outs of
their own body mass helps them understand their actual body composition more accurately.
Also, if the body is dehydrated, overly hydrated, or constipated, body mass index is skewed
while the bioelectrical impedance scale readings indicate the actual lean and fat mass and
water levels. It is biological measurement to help treat the biological dimension of the
illness.
Treatment Integration into Other Programs
How to best offer the 5-Day Treatment for Eating Disorders over time is being studied. The
program, as a whole, is thought that it is ready to be introduced and could potentially be
integrated into ongoing eating disorder higher levels of care at other sites. Clients who have
attended the program have met criteria for partial hospital program (PHP), intensive
outpatient program (IOP), or outpatient (OP) levels of care. To date, the 5-Day Treatment for
Eating Disorders appears to “boost” treatment at the beginning, middle, or end of an
ongoing partial hospital program, intensive outpatient program, or outpatient eating disorder
care, based on client symptom severity. In addition, clients have been transferred to
97
residential treatment after the 5-Day Treatment, having been highly resistance to needed
highly structured care. The 5-Day Treatment reduced resistance to the need for more highly
structured care after 5 days with their supports. Portions of the program and many of the the
clinical tools have also been used separately to augment other eating disorder treatment
modalities at both The Center in Ohio and UCSD in California.
The 5-Day Treatment for Eating Disorders has also served as a stand-alone treatment
because no other eating disorder treatment was available for some adult clients. Supports
can be significant agents of change especially in these cases. In those cases, supports
assume a greater role in ongoing assistance to help contain eating disorder behaviors and
to shift anorexia nervosa traits that have been expressed injuriously to constructive
expressions over time. They also can apply and integrate the importance of increased
healthy structure, planning, rules, and rituals into daily patterns. Follow-up data are still
being gathered to determine the full impact of the 5-Day Treatment for Eating Disorders in
these multiple roles and over time. Clients and supports have attended from over 35 states
and three countries.
Program Development
The development of the 5-Day Treatment for Eating Disorders program began in 2011 and
has been in preliminary open trial testing since 2014. Client and support feedback have
been fundamental in refining and developing the client/support manual, group sessions, and
neurobiological clinical tools. Suggestions for changes have evolved from many
recommendations initially in development, ranging from alterations to the schedule, clinical
activities, tools, and the manual, to very few to no recommendations for change in 2017.
Example of 2017 comments are, “I liked everything,” “I would keep it as it is.” “No changes
are needed.”
The clinical program reliability has been established over the past two years, using the
results from the pre-, post-testing, and client/support feedback to refine the schedule,
neurobiological content, approach to meals, movement, and Behavioral Agreement until
they were consistently reported by clients and supports as being above average to excellent
as presented. Similarly, this text offers instruments, handouts, and clinical tools that have
been refined until qualitative feedback forms have repeatedly stated that “no changes are
recommended.” That was when we knew the information was ready to share with the larger
public via this text.
Role of "Treat to the Trait" in the 5-Day Treatment for Eating Disorders
98
How does a therapist “treat to the trait” in eating disorders? There appears to be little in the
eating disorder treatment literature that helps address this concern. Outside of
psychoanalysis, treating symptoms has been the status quo. As discussed above, since it
appears that traits are primary contributors in the development and etiology of eating
disorders, they also need to be actively addressed in treatment. Unlike symptoms, traits do
not disappear over time. Infants are born with their inherited set of traits and carry them
throughout their lifetime. Traits are embedded in one’s personality and temperament
throughout life.
However, hope rises when realizing that change can be impacted over time when treating to
the trait. Traits can alter with greater variability of trait expression during specific times
during development.108 A meta-analysis of personality stability described that there is
variability in personality expression over one’s lifetime. Childhood is a significant time in
development that personality can be shaped and altered. Older adolescents begin to
develop a more stable personality as influence from genetic expression increases, with
personality becoming even more stable through adulthood.106
Genes are the proverbial stage, that is furnished by traits (nature). Traits are in turn
impacted by how the actors move the furniture around the stage (environment). The
audience (also environment) can influence the intensity of trait or temperamental changes.
Temperament and personality traits persist before, during and after persons with eating
disorders are fully weight restored or eating disorder behaviors have stabilized.106 The need
to increase clients' and their supports' awareness of their own traits, what is within their
control to change and what is not, is essential.106
Most eating disorder models include personality variables with the emergence of eating
disorder symptoms.218 While there is no single gene that triggers eating disorders, genetic
markers have just begun to be identified.62, 63 Genes influence neurotransmission,
impacting symptom responses,52, 219 which can be exacerbated when malnourished.220 A
new, international, collaborative, genome-wide study that was released in May 2017 found
there is a significant focus for anorexia nervosa on chromosome 12, an area also associated
with type 1 diabetes and autoimmune illnesses. This study also found strong genetic
correlations with schizophrenia and neuroticism, validating the brain-basis of anorexia
nervosa.62, 63
Traits tend to be approached from a pathological perspective in treatment, with unclear

recommendations from research on how to approach traits in the clinical setting.
Personality disorders, formerly defined in the Diagnostic Statistical Manuals prior to DSM-5,
associated traits from a dysfunctional perspective verses a constructive perspective. This
99
does not bode well for sustaining a healthy life if it is not clear what constructive trait
expressions look like during treatment. For example, how does an eating disorder therapist
apply identified, anorexia nervosa traits, such as harm avoidance, perfectionism, anxiety,
and inhibition to help clients shift trait expression from destructive to productive expressions
as a part of treatment? Unlike symptoms, traits won't go away. Eating disorder personality
traits are discussed by Wonderlich, who addresses the need for trait expression to be
charted on continuums verses discrete categories.221 This is an important foundation for
change over time.
What could a client’s expression of perfectionism or avoidance look like on a continuum

from destructive to productive expressions? Some persons with anorexia nervosa, and
almost all persons with bulimia nervosa, have an impulsive trait that is challenged within a
society that encourages extreme dieting.106 If the clinician hasn’t explored traits as a
fundamental therapeutic issue, how can therapists help their clients become aware and
manage their impulsive temperament over time? If clients can’t picture productive
expressions of their own traits that underlie eating disorders, how can they alter their
temperamental expressions away from the destructive eating disorder tendencies?
In working with the clients to refine trait change in daily life, clients at The Center for
Balanced Living have helped refine many trait expressions to create continuums ranging
from destructive to productive. This has occurred both in group sessions and during the
Behavioral Agreement session where trait expressions are explored from destructive to
productive with each client individually. For example, the Behavioral Agreement describes
perfectionism as ranging from “mostly insisting everything is flawless, impeccable, or without
fault and/or rarely completing a task on time (-2), to mostly insisting flaws are reduced and
committing to completing tasks on time, even if imperfect (+2).” Each of the common
anorexia nervosa traits is described on a continuum, which has continued to be refined as
more clients add their voice to the defined trait continuums. (An earlier version of the
Behavioral Agreement is published in: Hill, L., Knatz, S., Wierenga, C., Kaye, W. (2016).
Applying Neurobiology to the Treatment of Adults with Anorexia Nervosa. Journal of Eating
Disorders, 4(31), 1-14.)
Describing how the trait is expressed destructively is the easy part. It becomes more difficult
to identify how some of the traits can be expressed productively, such as an anxiety trait or
an inhibited trait. How can traits be practically expressed productively in daily life? If the
productive side of the continuum of anorexia nervosa traits are not operationalized, the
destructive expression will be the default, sustained, and primary influence in the
development and maintenance of the illness over the years. Without actively helping clients
and supports identify and explore how to productively live their traits, relapse will most
certainly occur and symptoms that are temporarily reduced or eliminated will increase once
again.
100
The 5-Day Treatment for Eating Disorders continues to refine how to “treat to the trait,” as
feedback and ideas emerge from clients in the treatment. Each revision of the Behavioral
Agreement has increasingly integrated trait expression and temperament into the treatment
program. On page one of the Behavioral Agreement, clients identify their strengths, by
reading aloud, “My own strengths are tools and traits that serve as my armor to manage this
illness. To commit to the daily battle of overcoming ED, I draw upon my following strengths
and traits (T).” Traits are included in the “strengths” section so that clients can see from day
one that their traits serve as their strengths, just as they can serve as their limitations or
weaknesses. A client’s traits are the foundation of their character strength, which is needed
to manage this illness.
The same traits are in the “limitations” section of the behavioral agreement. This sets the
stage for clients and supports to realize the same traits and characteristics are both
strengths and limitations. The treatment does not approach traits as dichotomous, but as a
continuum. However, realizing that a strength can be a limitation is not enough to change
and manage one’s temperament. Knowledge about what directs traits is fundamental to
change. Throughout the week, clients learn about the genetic influences of eating disorders
and the predisposition of traits in the development of eating disorders.
Adult and adolescent clients identify their inherited traits, with their supports, while exploring
how their traits have been molded by environmental influences and their own intentions,
over time. This raises both hope and concern. Traits dominate and are natural expressions
of how persons approach tasks. If traits influence destructive tendencies, such as restricting,
it can be discouraging that this is the dominant natural response. However, this also raises
hope when realizing that traits can shift if a person is intentional to alter the environmental
factors and is determined to shift their traits' direction. Altering trait expression, however, is
not easy. It is like changing the direction of a tree limb. It takes a lot of structure and
continuously holding to the new structure to grow the same branch in a new direction. The
program relies upon and encourages the clients to use their stubborn and persistent traits to
help alter their destructive traits and encourages supports to “hold the line” to keep the new
structure in place WITH the adult and adolescent clients.
When unsure of what or how to approach something, turn to nature as a guide since there is
nothing more natural than nature. Traits, in their most natural expression, are like a woods
growing without domestic interruption. Drawing from nature, as was discussed earlier in the
text, a maple tree will always be a maple tree. The genetic structure cannot be changed any
more than traits can be eliminated. Limbs grow in a direction based on both genetic
programming and environmental surroundings, e.g., out and up if in an open field or the
limbs can be directed to bend and grow in a different direction by a gardener.
The same is true for the client. Clients with anorexia nervosa will grow, as their traits direct,
101
creating their “natural” temperament and character expression. Trait expression cannot
change by “wanting it to be so;” it takes a constant and intense environmental force to shift
and alter traits, just like a constant intense wind can alter the direction of tree limbs. Unlike
trees, the client has to want the trait to shift or resistance will prevent growth to move toward
a healthier direction. Clients with anorexia nervosa most likely cannot direct or bend their
own “limbs” or actions in a desired direction alone, but they can ask for trusted supports to
help hold behaviors and expressions accountable.
An internal method to alter trait expression takes a great deal of intention, rules, rituals and
determination. For example, an anxiety trait contributes to a common feeling of being
overwhelmed. Anxiety directs focus to rehearse the future, while trying to live the present. If
clients with anorexia nervosa begin to understand the nature of their anxiety trait, in a
constructive expression, it will take forcing themselves to practice focusing on the present
moment by doing one or two things in that present moment to capture and hold their
attention.
Shifting an anxiety trait expression from dominating one’s thoughts and preventing
productive work or activities from being accomplished, also means humbling oneself and
asking a support person to help them redirect their attention to the present. Interaction and
healthy amounts of movement help bring clients more fully into the present moment. This
could potentially reduce destructive trait anxiety. Focusing on one moment at a time, instead
of all moments in the future, takes practice both alone and with supports. The client may
also need SSRIs or antianxiety mediation, if all personal or manual methods fail from
keeping attention in the present and preventing one from thinking, feeling, and acting in a
calmer and more focused manner. It is not easy to reshape trait anxiety to be more
productive in the moment AND it can only be done in the moment. Medication may be
necessary to reduce state anxiety in order to better manage trait anxiety. One client
identified the following when exploring ways to express her anxiety productively. One client
reported that a method she uses to manage her trait anxiety while drawing upon her detailed
trait in a productive manner was to:
“Take a topic of my anxiety and break it down to plan it forward.”

- Adult client with anorexia nervosa
Adult clients with anorexia nervosa are told in the 5-Day Treatment for Eating Disorders that
molding their personality traits, which have developed destructive expressions, takes time
and practice, moment by moment. The tools taught are simple and functional relating to
everyday life.222 The irony is that the 5-Day Treatment for Eating Disorders is possibly the
shortest eating disorder treatment currently being tested for higher levels of care, and yet it
addresses core lifelong qualities of temperament.
102
Adult clients with anorexia nervosa are told it will not feel “natural” to alter the destructive
expressions of their traits into productive ways, for one or two years. This is parallel to the
tree with branches being redirected to grow in a different direction. Eventually the limbs
grow in the new direction without support and guidance. But it takes time and lots of
structure before that change can naturally occur. Since adolescent and young adult brains
are actively growing new white matter, it takes less time to shift trait expressions than it does
for adults over 30 with eating disorders. Yet, an amazing thing about the brain is, as long as
one is living, change is happening.
How does a therapist integrate neurobiological information with "treat to the traits" into the
eating disorder treatment setting? The 5-Day Treatment for Eating Disorders does this by
sharing neurobiological research findings directly with clients and supports and asking for
their help. Just as the clients are encouraged to ask for help as a tool to compensate for
brain response, so too therapists model asking clients and supports for help throughout the
week. For example, clinicians might say, “I need your help to bring life to the research we
are following. While research continues to explore the depths of eating disorders, I offer you
what I know and need to know if these findings are true for you or how it compares to what
you experience.”
The Role of "Food as Medicine"
(Input in this section is provided by the dietetic team at The Center for Balanced Living.)
Clients with eating disorders receive a nutrition assessment during the week prior to
entering the 5-Day Treatment for Eating Disorders program. Their current body weight,
weight history, healthy goal weight and medical stability serves as a foundation in
establishing their meal plans, along with their value/philosophy around food. Integrating
brain-based research into the nutrition approach is as important as it is for the therapeutic
and medical approaches to treatment. Applying neurobiological research findings and
integrating it into their nutritional approach is described in Chapters 3 and 4, addressing why
it is difficult for persons with eating disorders to trust their decisions.
Dietitians at The Center for Balanced Living recognize that hunger and fullness, and at times
even taste are not signaling in the brain. As a result, they recognize that eating
spontaneously and intuitively is an understandable desire. However it is not realistic for
many clients acutely ill. Dietitians integrate neurobiological information on the lack of brain
103
signaling in the ventral limbic area, preventing clear interoceptive awareness. Hence, a
dietary process needs to recognize and compensate for this.
When clients are eating within a highly structured setting, such as residential and partial
hospital eating disorder programs, the structure of when, where and why are set clearly and
are nonnegotiable. Options of what to choose becomes easier within the structure and with
a limitation of choices. When clients return home, they often report they were able to eat
intuitively and want to continue to do so. A few are able to sustain this approach. However,
many report relapse to staff at The Center because their daily life structure is significantly
less clear, many options and variations are before them, and anxiety increases in trying to
make new daily decisions resulting in the inability to continue to know what to eat intuitively.
Perhaps their ventral brain areas were under firing throughout their higher levels of care and
yet they could make choices, because they could think through the limited options while
structure for other decisions was clear and repetitious. Or, perhaps they were able to sense
brain signal responses, that may have been weak or moderate signals, but when returning
home to daily new and different demands, anxiety over clouded the strength of the brain
signals and they could no longer be identified.
The Center for Balanced Living has developed

a brain-based nutritional philosophy.
Food is medicine and macronutrients are “dosed.”
Due to this neurobiological probability in persons who have anorexia nervosa, The Center
for Balanced Living has developed a brain-based nutritional philosophy. Food is medicine
and macronutrients are “dosed.”223 Neurochemically, nutrition status impacts serotonin or 5-
HT function in significant ways and seems to preferentially affect females.106 Brain
neurochemical response is dependent on what is eaten - carbohydrates, proteins, and fats
(called endurance fuels at The Center). How much and the correct balance of
macronutrients are needed to assure a steady neurotransmission flow, brain repair and
growth. As clients become stronger, and stabilize, more choices, and flexibility is structured
into the process. Each client receives and works from their own individualized meal plan.
The ultimate goal is to work with each client to follow their own nutritional needs, with
flexibility and with as many choices as each person can tolerate in their own work and home
settings. Since brain studies have identified that eating disorder brains have neurobiological
misfiring, approaching food as medicine compensates for what the brain is unable to
communicate or sense. For example a person may be recommended to have a lunch that is
104
a “4,3,2” meal. That means: 4 servings of carbohydrates, 3 servings of proteins and 2
servings of endurance fuels.
“For me, a meal is a formula. This takes the anxiety away.”

- Adult client
Clients are taught to review labels and measure in practical ways to meet their
recommended “doses,” such as using one’s hand. For example the palm of one’s hand is
the size for meat that equates to 3 protein servings. One’s thumb digit is about a
teaspoon. Food labels provide macronutrient information and serving sizes. (See a sample
of the nutrition hand handout in the Supplemental Materials on the Landing page.)
Some will say monitoring labels increases their obsessive compulsive tendencies. This is
one reason the “Balanced Life App” was developed. If clients use the Balanced Life app, the
macro servings are broken down for the foods, preventing the clients and supports from
reading all food labels. Monitoring is done for the client, via scanning the bar code, and the
client can know if they are eating the recommended levels, not too much or too little.
Adolescents and adults need different approaches to dietary intake. The Center for
Balanced Living trains families about macronutrient brain and body needs so they are able
to also know more about how their own meals at home could be balanced and strengthening
for all family members. The more families are involved to eat and prepare foods with their
loved ones, the better. Evidence based family therapeutic approaches are recommended for
adolescents.16, 30, 31 Introducing a variety of foods may be tolerated sooner with
adolescents than adults, since their white matter is growing and rewires faster during this
development time frame. Food is a key medicine to complete the brain growth process that
is fundamental for adolescent growth.
For adults, The Center for Balanced Living approaches food as medicine in doses to help
each adult client have a means to know if they are eating too much or too little, and enough
balance to help metabolism burn better. The meal plan recommends macronutrient
combinations, which are matched to the client’s activity and goal body weight, with the aim
to establish a healthier body for the identified life purposes, established in the Behavioral
Agreement.
105
“I will never be able to approach a restaurant for its pretty foods.
I need to take the meal, break it down to see where the proteins are,
where the carbs are and where the EF’s are.
I put them together and have the formula down.
Then I can force myself to take the next bite while of talk with my friends that I care about
more than food.”
- Adult client
It is understood and recognized that dietitians (RD/CDN) do not technically “prescribe” diets.
Most state licenses allow dietitians to recommend dietary interventions based on a diet
prescription. 225 This term is used to make the analogy to the biological dimension of the
illness.
In response to what helped the most during the 5-Day Treatment for Eating Disorders
week:
"The structure of the meal plan and approach to food as medicine.”

- Adult client
Two meals and two snacks are provided within each treatment day. Clients and supports
select snacks from a specified number of multiple options. Clients prepare their own meals
and select their own snacks each day of treatment, with their supports learning and assisting
beside them. Supports also prepare their own meals.
The clients prepare and apply the macronutrient “doses” that are recommended by the
eating disorder dietitian. For example, a breakfast may be a “3,2,1” dose recommendation,
consisting of three carbohydrates, two proteins, and one fat (endurance fuel). In the
program, fats are referred to as “endurance fuels” or “EFs” to circumvent the stigma of the
word “fat” and to shift the term into a functional, more biologically based description.224
After each meal is completed within 30 minutes, everyone cleans the tables and puts dishes
into the dishwasher to practice movement and distraction, while lowering post-meal anxiety.
106
Foods used in the program are foods the clients could purchase at their home grocery
stores to help with the transition from treatment to home. As one client reported in the end of
the week feedback:
“I loved that I had the ability to choose the foods that fit my meal plan.
It was more realistic to have normal grocery store foods to simulate what it would be like at
home.”
- Adult client
In another response to what helped the most during the week:
“The completely new approach to the meal plan and nutrition.

I did not feel patronized and felt for the first time that my treatment team really heard me.”
- Adult client
As clients and supports learn about macronutrients and brain responses to food and eating,
food is described as medicine that may have “side effects” in the brain, creating “noise” that
is invasive, accusative, anxious, and continuous. Clients are told that this illness is
backwards. Their food is medicine, and is contributing to side effects in their brain making
things seem worse. It's similar to having a “reaction” to food.
Depending on a client's traits, they may turn away from food (avoidant trait expression),
binge eat, or purge (impulsive trait expression) in order to stop the eating disorder “noise”
and mental discomfort. When brain research is explained, most adult clients with anorexia
nervosa in the program report that they feel understood. This increases their motivation and
drive to learn more and respond differently in spite of the “mental pain."
In accordance with ACT and DBT, the 5-Day Treatment for Eating Disorders' intent is to
increasingly live life with purpose. This fundamentally takes energy. Food is energy
and medicine to fuel the body. It may not be pleasurable to eat, as some medicines are not
pleasant to take, but it is necessary. Clients may not like the taste of food, feel hungry, or
107
feel fullness and pain. (See A Brain-Based Approach to Eating Disorders, Chapter 4; or the
Neurobiology of Eating Disorders lecture notes and power point in the Supplemental
Materials on the Landing Page.)
Overall, the 5-Day Treatment for Eating Disorders acknowledges that to eat and (using
“and” instead of “but” is a DBT tool) to face life stressors can result in acute anxiety and
increased eating disorder “noise.” Thus, at times, chemical medications are needed to treat
the “side effects” of their primary medication, food. Hence, anorexia nervosa appears to be
an illness that induces an ongoing complex struggle. If one progresses toward health, they
may feel overwhelmingly anxious, disturbed, and distressed. When relapse is occurring, it
may feel calmer and thoughts more focused. It is truly a backward illness.
(A copy of the nutrition assessment administered prior to entering the program is provided in
the Supplementary Materials.)
The treatment program uses macronutrient servings to assure a balance in energy intake
and daily nutrient needs. This dietary philosophy was developed from the American Diabetic
Exchange List (Exchange Diet).223 Nutrition facts used in the questionnaire are based on
macronutrients “dosed” servings. Both clients and supports are tested on nutrition facts
applied in the treatment to assure the same information is learned and practiced at home by
both parties and to encourage consistency. By dosing foods with the supports’ oversight,
there may be less risk for clients to cut back on needed macronutrients.
As stated above, currently brain-based interventions are new in development and testing,
requiring therapists, clients, and supports to manually force or push change forward. To help
with that process, the development of new, technological, support tools can help push from
the outside-in. To augment support, The Center for Balanced Living has created a nutrition
app called “Balanced Life.”225 This app is currently being beta tested with clients at The
Center. It will be expanded to dietitians who treat eating disorders internationally to help
guide, monitor, and sustain balanced eating, as well as monitor mood, movement, and
more. In the first round of testing, client meal plans are entered into the app by a dietitian.
Clients can scan purchased foods from stores or search for menu items at restaurants; add
recipes, allowing the app to show the “dose” the foods; and report how they fit into the
personalized meal plan. The app provides an easy tool to shape each meal plan to match
an individual’s needs.225
(See information on the “Balanced Life” phone app. It provides dietitians and clients a
means to track their food intake and movement, mood and tools to reduce anxiety.)
108
Role of Movement in the 5-Day Treatment for Eating Disorders
Movement is integrated into the 5-Day Treatment for Eating Disorders both within and
between group sessions. Post-meal movement is a time to walk with the clients across the
transitional gap” between structured groups. In addition, movement occurs while working
with clinical tools and applying client tools, such as walking beside their loved one for
distraction.
Post-meal movement is referred to as “walk-abouts.” The conversations that arise during

walk-abouts can be as therapeutic as individual client/support sessions. Defenses decrease
as bodies unite in a common goal through motion. The movement helps to lower anxiety. It
also helps to integrate and synthesize information, reduce and distract clients from their
eating disorder “noise,” try on clinical tools to better manage symptoms and traits and to
respond and alter the illness.
The brain uses movement to organize ideas and emotions. The 5-Day Treatment for Eating
Disorders program uses it for the same reasons. The program “doses” movement via
recommendations based on the medical stability and restoration of each client body state.
Functional forms of movement are practiced in the program such as using the steps instead
of the elevator. Other practices include walking tall for 10 minutes after meals and
movement during therapeutic groups.
Experiential clinical tools are movement based to allow clients to try on and move into a
different paradigm to problem solve. They are encouraged to “keep moving.” This is different
from excessive exercise. It is intentional, within their movement limits and mindful. Also,
refined, small movements are encouraged to enhance focus, such as knitting, coloring,
doodling, and many other uses of simple objects/toys that encourage hand movements. This
can encourage the need to move through thoughts as solutions are processed and
explored.
Movement is also experienced when clients and supports are asked to practice new client
tools during each of the five days. Neuronal circuits become stronger each time they fire,
whether for eating disorders actions or healthy actions. The more an action is repeated, the
sooner it becomes ritualized. Healthy behaviors are introduced to replace eating disorder
actions. They, too, can become ritualized through repetition. The groups do not talk "about"
a behavior without new actions also being practiced in every group throughout the week.
109
Movement enhances neuroplasticity, the ability for the brain to change and develop new
neural connections and pathways. Neuroplasticity occurs naturally as part of the brain's
structure and function.222 Brain derived neurotropic factor (BDNF) and, secondarily,
glutamate are involved in brain neuroplasticity.222 Brain derived neurotropic factor is a
protein coded by the brain derived neurotropic factor gene, one of the neurotrophin family of
growth factors, which induces the survival, development, and function of neurons. They
belong to a class that is capable of signaling particular cells to survive, differentiate, or grow.
226
They have an important impact on synaptic neurotransmission and plasticity.227 Brain
derived neurotropic factor helps the neurotransmitter, glutamate, to release an excitatory
current across the synapse to the dendrite receptors, working in cooperation to regulate
synaptic transmissions.227
Brain derived neurotropic factor strengthens neuron connections, promotes myelin growth,
and establishes an elastic brain-state to strengthen new connections while focused and
learning.222 Research suggests that moderate physical activity may promote neuroplasticity
in the brain among those who are at healthy weight levels, with the caveat that many of the
current cohorts focus on the elderly.228, 229, 230, 231, 232 Malnourishment can change the
relationship between these factors.
Moderate movement (typically 30-45 minutes of walking three times weekly) has been
shown to increase brain derived neurotropic factor levels in the hippocampus (memory) in
both human and rat studies. It has also been linked to increased memory volume, with
exercise interventions ranging from 14-26 weeks.229, 230 Healing and health include
movement in moderation, not in extreme or to promote compulsive over-exercise. In equal
measure, doing no movement diminishes change in brain response. Unless the body is
biologically and medically evaluated to confine movement in order to restore needed brain
and body mass, via refeeding, the program uses individually "dosed" amounts of movement.
This follows new movement guidelines established in 2016.213
Yoga is a structured form of movement that enhances brain response and lowers anxiety.
233
GABA, a neurotransmitter that works to decrease dendrite neuron binding in designated
synapses, is found to decrease anxiety and fear reactions in the brain. In one study, a 12-
week course of Iyengar yoga increased GABA in the thalamus and decreased anxiety.234
Role of Experiential Clinical Tools in the 5-Day Treatment for Eating Disorder
Neurobiological clinical tools have been developed by this author with ongoing input from
110
The Center for Balanced Living’s research partner, Eating Disorders Center for Treatment
and Research at University of California, San Diego, since 2009, as well as ongoing input
from clients and supports. The clinical tools were developed for both the 5-Day Treatment
for Eating Disorders program and other eating disorder program levels of care. The first tool
developed was the Brain Wave. It was developed as a way to help clients and their supports
better understand the areas of the brain that research has identified are involved in eating.
The tool was developed as an experiential activity to better understand identified roles of
brain areas and how they appear to fire differently for persons who do not have an eating
disorder compared to persons with anorexia nervosa, and persons who binge eat. A banana
is used in the "Brain Wave."
In response to what helped the most:
“Banana activity [Brain Wave] and adjustment of symptoms per client -

I feel like it was very helpful in helping my mom in understanding how my brain works.”
- Adult client
The clinical tools were developed to integrate research and client feedback so that the
activities play out the average brain experience of clients with anorexia nervosa. Client
handouts in the Client and Support Manual provide a means to individualize adult client
experiences while allowing them to record and describe their experiences with their
supports. This allows supports to better understand what their loved ones are undergoing
from the inside-out.
As research progresses, the tools continue to be revised and updated. Clients frequently
offer helpful feedback that has allowed the author to improve and tweak the clinical tools to
more accurately reflect ore accurately client experiences and neurobiological research. Over
90% of the 5-Day Treatment for Eating Disorders clients and supports have reported that
the clinical tools opened a door that shifted their paradigm of understanding eating disorders
from self-blame to a biological basis, followed by a desire to better manage their brain-
based responses.
111
Ninety-eight percent of the 5-Day Treatment for Eating Disorders clients and supports have
reported in the End of Week Program Evaluation that the clinical tools were helpful. (See
Outcome Data in Chapter 11.)
Role of Behavioral Agreement as a Clinical Tool in the 5-Day Treatment for Eating
Disorder*
See complete Client & Support Manual in Supplement Materials.
The Behavioral Agreement (BA) is a comprehensive, 16-page treatment plan. It is a

document that has been developed and written for and by the clients, supports, and
therapists over a three-year period to establish a clear structured, detailed plan in response
to common anorexia nervosa traits and symptoms. It serves as a treatment plan, a client
daily plan and a plan for supports to use. It is the central document that binds all concepts in
5-Day Treatment for Eating Disorders together (See Figure 21). The Behavioral Agreement
provides structured plans that clients and their supports agree to do (or not do) to help
manage the eating disorder symptoms and reroute traits to be productively expressed.
112
Figure 21
All sessions during the treatment day endorse and augment the Behavioral Agreement while
simultaneously. It has been designed in the manner that clients with anorexia nervosa think
and tend to approach problems, in detail. It provides clients and supports structure to face
problems and options that have been validated by client feedback. Congruent with brain-
based, anorexia nervosa research, the Behavioral Agreement offers limited options instead
of open-ended questions.
The Behavioral Agreement is read aloud by adult clients, who correct “errors” or
inaccuracies in the wording to make it true for themselves. This process is used to both
113
improve the BA and to work empathically with the clients' "error detection trait, to have it
practiced in a productive way. A portion of the BA is addressed each day with each client
and their supports to explore together a clear plan, with the therapist, to identify the primary
goal and how they intend to operationalize the intention. The Behavioral Agreement
identifies tools to integrate into the detailed plans to better manage anorexia nervosa
symptoms and traits.
“The completion of the treatment agreement is an important goal, and achieving it is a

cathartic experience. Keep the formality.”
Support person of adult with anorexia nervosa in response to “What helped the most" on the
5th day
The Behavioral Agreement provides a setting for the client to be the leader in establishing
his/her goals and objectives. It also serves as a transitional treatment tool when leaving the
5-Day Treatment for Eating Disorders. It is encouraged to be used in other treatment
programs outside of the 5-Day Treatment for Eating Disorders, establishing a
comprehensive, transitional aftercare plan to the 5-Day Treatment for Eating Disorders for
the following 3 months.
114
In the Behavioral Agreement, as in Acceptance and Commitment Therapy (ACT), adult
clients with anorexia nervosa identify what is purposeful in day two, after identifying their
strengths and limitations on day one. Purpose serves as a core focus to get them through
their goals to manage the illness. The identified purposeful actions provide enhanced
meaning in life and serve to be a focus for the client to reach to attain. Goals identify what
needs to change to move forward toward a purpose-filled life. Objectives identify how to
accomplish the goals. The Behavioral Agreement integrates neurobiological concepts into
the information and tools while drawing upon the ideas and feedback from the supports and
the clients.
It takes five hours to complete the Behavioral Agreement, one hour a day for each of the 5-
day treatment. The clients and supports identify and practice newly learned client tools to
better manage anorexia nervosa traits and symptoms at home and ongoing treatment.
Supports are an asset in treatment to learn and practice the tools, both for themselves, as
well as the clients. Clients report fearing their supports will “take over” or be overly
monitoring. The Behavioral Agreement actually prevents that from happening, as supports
realize what helps and what does not as they go through the document together. To not
change destructive behaviors is not an option.
Therapists from the clients’ home setting who accept clients back into their care are asked
to adopt the comprehensive Behavioral Agreement established during the 5-Day Treatment
for Eating Disorders and integrate it into ongoing treatment. The Behavioral Agreement is a
three-month agreement. Additional copies are provided for therapists at home, supports,
and clients to review and revise during the three months. In addition, therapists from the
clients’ home sites are invited to participate as one of the treatment team members for a day
in the program to better understand how to integrate the Behavioral Agreement and a brain-
based treatment approach. The clients’ home therapists are not to be the support person
replacement. Both home therapists and supports enhance continuity of care.
Therapists’ responses from the clients’ home settings have been varied, ranging from
participating in a day and actively engaging in developing a brain-based approach in their
practice: from openly welcoming the client treatment tools and Behavioral Agreements when
brought back to the home site; and/or including family and supports in ongoing treatment; to
rejecting and ignoring the Behavioral Agreement and supports in their practice. It has been
stated repeatedly by adult clients with anorexia nervosa leaving the 5-Day Treatment for
Eating Disorders that therapists at their home sites know little-to-no anorexia nervosa
neurobiological information to help them better manage and continue with a new, brain-
based paradigm of the illness. This is a central reason why this text has been written.
115
The Behavioral Agreement instrument integrates supports, therapists, medical, and
nutritional clinicians into the Behavioral Agreement for better outcomes. Client feedback has
refined the Behavioral Agreement to the place that the majority report, “I would not change a
word. This is what I think is true for me.” Hence, the reader has the most current copy.
*Note: An earlier version of the Behavioral Agreement is published in: Hill, L., Knatz, S.,
Wierenga, C., Kaye, W. (2016). Applying Neurobiology to the Treatment of Adults with
Anorexia Nervosa. Journal of Eating Disorders, 4(31), 1-14.
The Role of Transitions in the 5-Day Treatment for Eating Disorder
A transition is a process of changing from one state or condition to another.235 Transitions

are a natural part of living and central to a functional and effective life. A person faces
transitions when there is a shift in activities, ranging from getting up in the morning, to
brushing one’s teeth, to the less frequent yet major transitions in life such, as entering
college, marriage, or divorce. Transitions are the malleable moments where change occurs.
Transitions are also biological, such as in the trillions of synapses, or spaces, which transmit
neurochemical/electrical messages across spatial, synaptic gaps between dendrites and
axons. Transitions can also be programmatic, such as the time between one therapy group
and another.
The role of transitions in treatment is just as important to effective treatment as in the role of
synaptic transitions in the brain. The time, space, and activities that occur as clients walk
from the waiting room into a therapy session, or the time between two group sessions in a
treatment program are transitional in nature. How the therapist approaches and works with
these transitions can impact the treatment session process and impact how clients
transform their destructive behaviors into more productive, daily patterns. Transitions can
also occur in the clinical setting when the client experiences insight that holds the potential
to shift one’s thoughts to a different, more productive plan of action.
Clinical programs that offer Intensive Outpatient Programs (IOP), Partial Hospital Programs
(PHP), and Residential levels of care have many transitional opportunities for intervention
and change to occur in a treatment day. If the transitional “down” time is ignored
therapeutically, opportunities to introduce change decreases. The gaps between therapy
groups are typically less structured and open-ended, with few-to-no therapy activities. Yet, it
is in the treatment day’s transitions, e.g., when clients use the restroom, that healthy or
destructive actions can be practiced. Instead of using open-ended down time to impulsively
116
vomit at home, clients may be better helped if they have practiced using the transitional time
to simply use the restroom for its healthy purpose and then move to another activity to
relieve stress, such as a “walk about.”
Objects in a room are the first things most persons notice, compared to the spaces between
the objects. Yet, there are more space than objects. In the brain, it is the neurons consisting
of white and gray matter that stand out to the observer. So too in therapy, group sessions
are the obvious place to focus on treatment interventions. Yet, just as the synapses in the
brain are central to times and places that shift, alter, refine, or change neurochemical
messages, the time gaps between treatment groups become mini shifts, alterations, and
opportunities to change thoughts and actions instead of sustain them.
In the brain, the moment a neurochemical leaves the axon terminal it enters open space that
is, in essence, transition in action. The space holds open-ended options. For example, the
neurochemical message could dissipate while in the synapse, return to the axon where it
was released, or move across the synaptic gap and be absorbed by the receptors of a new
dendrite. The synapse is the vulnerable site of change. When problems persist, this is the
site where medication has impact, such as selective serotonin reuptake inhibitors (SSRIs).
They act to alter the flow, via reuptake or temporarily accumulate neurochemicals, to
increase momentum as they pass through the synapse, increasing receptor ability to assist
neurochemical flow along a brain pathway.
As described above, persons with eating disorders have difficulty making and trusting
decisions. The brain-basis of low-to-no dopamine firing in the ventral striatum and limbic
areas of the brain, lowers pleasure/satisfaction to confirm decisions. Low dopamine firing in
the ventral limbic area leaves clients with anorexia nervosa with uncertainty and doubt about
what to do or say. Clients with anorexia nervosa typically enter moments of transitions
wondering, “What do I do?” Uncertainty dominates. Practicing transitional moments with
clients to apply new client tools seizes key opportunities to “fill in the gaps” by practicing
(actively doing) healthier behaviors.
The 5-Day Treatment for Eating Disorders approaches group transitions as opportunities for
clinical interventions to occur. They are times the clinical team observes, participates,
explores, and practices with clients and their supports the treatment tools learned and tries
on during the structured groups. Practicing the tools in less structured space/time is similar
to life outside of treatment. It can help clients begin to alter brain response toward healthier
behaviors. The 5-Day Treatment for Eating Disorders' therapists use therapeutic transitional
times to:
117
1. Move with, while also observing if, and how, the clients initiate, act, react, and interact in
the transitional moments of the treatment day.
2. Participate in client conversations.
3. Actively practice new tools with the clients and supports perpetuating change in critical
short gaps of time.
To continue to draw the parallel of brain response to the 5-Day Treatment for Eating
Disorders treatment, just as it is important for a neurotransmitter to be strong enough to
transmit across the synaptic gap in the brain, it is important for the clinical staff to encourage
momentum during open-ended time gaps. The 5-Day Treatment for Eating Disorders' after
meal “walk-abouts” are transitional, less structured activities that acknowledge that new
actions can be tried on to replace ritualized, post-meal purging or post-meal anxiety and
sitting. They are planned by asking one person to lead, allowing others to follow through the
“unknown” path chosen. Practicing a change in post meal activities in these 10 minutes
appears to impact just as during the focused group sessions.
The 5-Day Treatment for Eating Disorders helps both clients and their supports understand
the neurobiology of difficulty trusting decisions. The brain needs to compensate for low
ventral limbic firing, and detailed planning fits the need. Clients can plan in detail how to
avoid the food, or they can plan in detail how to approach the food. The program addresses
that when a plan is established between the clients and supports, a new healthy habit can
develop that may eventually become a transitional ritual. Once ritualized, doubt can
decrease as the brain turns down dorsal intense response to let movement via the motor
cortex and putamen take over. The ritualized action increases momentum to cross through
the open-ended time gaps and move forward. A client facing what to do next without a plan
can all too easily return to the former, habituated, eating disorder actions, just as the brain’s
neurochemical may not cross the synapse. Neurochemicals can all too easily return to the
former axon or dissipate in the synapse preventing the message from moving forward.
Bottom line, clinicians follow the lead of how the brain performs and transmits is messages
to grow toward health. It is an excellent neurochemical recipe for the change process.
The 5-Day Treatment for Eating Disorders program addresses that persons with anorexia
nervosa require intentional direction, clear planning, and/or a strong desire that is different
from doing a destructive behavior to make it safely across the open-ended, daily transitions.
The program “treats to the traits” by addressing, in the transitional moments, the importance
that traits include stubbornness and determination just as much as anxiety and avoidance. It
takes nothing less than stubbornness and determination or a driven state to move away
from an eating disorder behavior, across the gap of uncertainty.
118
Another brain-based analogy that the 5-Day Treatment for Eating Disorders applies is, just
as selective serotonin reuptake inhibitors augment and aid in the flow and direction of the
neurotransmitters in the synaptic gaps, supports ARE parallel to the selective serotonin
reuptake inhibitors. They help clients with anorexia nervosa through momentary to
significant life transitions. Supports can offer multiple choice options that are healthy
alternatives to compensate for the clients’ inability to make and trust decisions. In the 5-Day
Treatment for Eating Disorders, spontaneity is out, planning is in. The simpler and more
practical, the better.
The Role of Storytelling in Treatment
Storytelling has been in existence as long as humans have interacted and shared ideas with
one another. Their stories passed on events in history, religion, philosophy, family traditions,
and cultural experiences through time. Stories help provide a context for memory. Clients
have many eating disorder stories that they have experienced, which have ingrained into
memory and rituals. However, they often have few stories that describe what health looks
like. The therapist can help replace their unhealthy stories with healthier ones. The reader is
referred to the work of Milton Erickson for expert information on storytelling. His ability to tell
stories was, in part, hypnotic, and his work informs the reader how to tell the story in order to
have a therapeutic impact.
Stories can be fun, creative, and heuristic methods for problem solving. They can sketch a
picture and a solution without being direct and increase defenses. Stories can bring
intervention into the foreground for consideration. They can be metaphors of the condition
discussed, with solutions drawn into the landscape of the story.
Therapeutic stories should be told, not read.224 They are imaginative methods of making a
point instead of lecturing with didactic points, which can raise client defenses or encourage
one to “zone out.” Stories can be more engaging and can involve the clients interactively by
asking them to help “finish the story.” Their ideas for solutions allow them to inventively
problem solve their own dysfunctional condition. Therapeutic stories are recommended IF
they have a purpose in the therapeutic moment. They can accentuate a clinical point or aid
in picturing what behavioral changes might look like in a complex situation.
Stories are not recommended to fill time or to simply tell a tale the therapist likes for no
therapeutic reason. Arnold Andersen, MD, told stories throughout his treatment with clients
who suffered with eating disorders. Eating Disorders: The Journal of Treatment and
Prevention by Taylor and Francis featured “Stories I Tell” by Dr. Andersen in their
therapeutic approach for many years. The reader is encouraged to turn to this resource.
119
Stories are shared within this text, such as the “Wood-Burning Stove,” which serves as a
metaphor to understand how eating impacts metabolism. (See also, “Tootsie and the Butt
Strap” and other stories shared in the Supplemental Materials on the Landing Page.)
Short story points are made throughout this text that sketch simple examples of how to
enhance a point. The stories in this text have been developed by this author and refined by
listeners’ feedback. If the stories are useful for the reader, then you are welcome to use
them. If you, as the reader or therapist, have your own stories that make the same
therapeutic point, use your own stories, or develop new stories that can be passed on for
others to use. When telling a story, adjectives that describe the clients’ emotions or
situations should be integrated into the story, creating a means for the listener to connect
and a method to outline a possible solution.
A therapeutic story should be comfortable to tell and not bogged down in unnecessary
details. The story is told to create a poignant context, with points within the story that parallel
the clients’ experiences, emotions, and thoughts with which the therapist wants to
empathically relate. The conclusion of the story holds the therapeutic intervention or
solution, whether the stories are classic Greek myths, such as Medusa, or a simple story
about a garden (see Stories in the Supplemental Materials on the Landing Page). Key lines
of the stories that have a therapeutic impact should be stated while looking in the eyes of
the clients/supports, with a slower pace and greater emphasis.
After a therapeutic story is told, it can be helpful to ask the client and/or supports, “What did
you hear?” or “What is your take home message from this story?” This helps provide needed
feedback to see if the clients and supports made a connection with their own experience
and accepted implied suggestions to strengthen their responses. The story is therapeutic if
key points register and engage the client who is able to integrate a key point into a
behavioral intervention.
Most of all, when telling stories, make them your own. The therapist or educator may read a
story in this text with which you relate. Use it, tell it, and then retell it, integrating it into your
own experience and making it your own. This is the same as the clients trying on new client
and clinical tools. They may like the tools and yet at first the tools may feel awkward.
However, if they relate to the tools or stories, they may more likely return to them
repeatedly. The more the client uses a tool, the more natural it is to refine and make their
own. The story can give them a picture to help transform destructive tendencies into
productive images. Your story can become their story.
Daily Sessions
120
Daily Session Descriptions
Multi-Client/Support Input Session
See complete Client & Support Manual found in the Supplementary Materials.
Treatment team includes: clients, supports, therapists, and medical team
Goals for this 1 ½ hour session are:
1. To increase active interaction among the total therapy team: clients, supports, and
therapists/medical staff, serving as a fundamental factor of change.
2. To empathically identify and respond to another person’s needs while also attending to
one’s own needs.
3. To present factual, eating disorder information in interactive methods to increase

engagement and integration of brain-based research.
This session draws upon and integrates input from clients, supports, and the
therapy/medical team regarding identified daily themes. The session establishes the
foundation for the “treatment team” to be the clients and supports, with the therapists,
dietitian, and medical staff. It provides input from the clients/supports when addressing
clinical tools such as “Self-Critique” that has three questions in a set order: “What would you
121
do the same?,” “What would you do differently?” and, “How would you do it differently?”
Psychoeducational, eating disorder facts are presented in an experiential manner. This
session also mobilizes supports to be active agents in the clients’ recovery through the
discussions and interactions and daily plans of actions at home.
Neurobiological Interactive Session
Goals for this 1 ¼ hour daily session are:
1. To help clients and supports understand eating disorders as a brain-based disorder and
explore the neurobiological explanation behind the illness’ temperament and symptoms.
2. To offer clinical tools that provide experiential exercises developed to interpret brain
imaging findings and eating disorder research in a playful and interactive method.
3. The brain-based exercises serve to heuristically circumvent defenses while exploring and
experimenting to identify individual responses.
4. Each client and support member can formulate responses to the complex interplay
between the clients, the eating disorder and their supports.
5. Facilitate bonding and cooperation to work towards meeting treatment goals.
6. Empower both clients and supports.
7. To shift the etiological paradigm from social/family causality of eating disorders to a
biological/brain-based foundation.
8. Assist clients and supports in identifying, interpreting, and visualizing the brain basis that
contributes to the illness to aid in overcoming guilt and shame on the part of both the clients
and their supports.
Behavioral Agreement Session
Goals for this 1 hour session are:
1. For clients and supports to develop an individualized treatment plan for actions that
structure healthy responses and diminish eating disorder behaviors and destructive trait
expressions with input and feedback from supports.
122
2. To prepare a clear and concrete plan/agreement that is linked to the brain basis of the
illness and everyday practical living activities.
3. To identify and prioritize goals and objectives for symptom/trait change.
4. To apply and integrate the use of repairs, which provide contingencies when unable to
accomplish the objectives.
5. This is used to enhance motivation, increase accountability and increase compliance to
an identified purpose.
6. To establish mutual buy-in between both clients’ and supports’ for the agreement.
●
Behavioral Agreement sections:
1. Diagnoses
2. Identify Supports in the room and those who could call in during the session
3. Strengths of clients
4. Strengths of supports
5. Limitations of clients
6. Limitations of supports
7. Honesty
8. Purpose
9. Traits
10. Goals
11. Objectives
12. Repairs
13. Tools
14. Signed Commitment from the total team
123
Tools for Symptom/Trait Management - Clients & Supports Daily Session
Goals for this ¾ hour session are:
1. To provide peer support via two groups offered simultaneously: one for the clients, one for
the supports.
2. To identify and practice client tools each day from the Tool Box list. Each group learns
and practices the same tools.
3. To integrate how to apply tools at home while practicing client tools.
4. To provide opportunities to express difficulties in applying tools during recovery
experiences.
5. To provide opportunities for both clients and supports to become active consultants and
leaders in the groups alongside the therapists.
6. Offer opportunities for every group participant to learn with both the therapist and other
individuals who have expertise and experience in managing or struggling to use the tools for
an eating disorder.
Food as Medicine - Dosing Macronutrients Session
Goals for the 1 hour meals and ¼ hour snacks:
1. Offer two meals and two snacks during the treatment day.
2. Simulate the structure needed in real life situations and when going home.
3. Evening meal and snack are practiced off site with supports to practice tools learned in
the day.
4. Clients, supports, and therapists eat 100% of meals and snacks together uniting the
teams and circumventing defenses.
5. Use treatment foods that can easily be purchased at clients' home sites to decrease
anxiety when determining what to eat when living at home.
6. Foods at treatment are common foods to fall back on at home.
7. Honor individual preferences for those who are vegetarian, vegan, or who have food
allergies, while still meeting dietary balance and energy intake needs.
8. Apply “food is medicine” as the first level of medication, with synthetic medications added
124
when needed.
9. Clients and supports receive dietary training daily for one hour outside of the meals and
snacks to question, practice, and plan food choices, amounts, balance, and to do
calculations for meals.
10. Clients and supports learn together how to plan meals, apply macronutrients to their
local grocery stores and tracking intake by using “Balanced Life,” the new nutrition app.
11. Clients and supports learn together how to practically measure macronutrients, while
using “Balanced Life.”
5-Day Treatment Schedule
125
Pre-testing
126
At The Center for Balanced Living, where the open trials for adults have been primarily
conducted, pretesting is scheduled the Sunday prior to entering the 5-Day Treatment for
Eating Disorders
Pre-testing includes:
1. Eating disorder clinical nutritional assessment

2. Portions of the MINI International Neuropsychiatric Interview and The Structured Clinical
Interview SCID-5 are a part of the diagnostic assessment materials.
3. Nursing assessment (IF at Partial Hospital Level of Care).
4. Medical and psychiatric assessments if the client is at a partial hospital level of care.
5. Survey monkey standardized instruments measuring anorexia nervosa traits, eating
disorder behaviors, anxiety, and depression taken online prior to the treatment week.
6. Nutritional Facts Questionnaire taken online prior to the treatment week. (See the
instrument sample and scoring instructions in Supplemental Materials on the Landing page.)
Post-testing
1. Post-testing is administered Friday evening after programming.

2. End of Week Feedback Forms. (Samples in Client and Support Manual provided in
Supplemental Materials on the Landing page.)
3. Survey monkey standardized instruments measuring anorexia traits, eating disorder
behaviors, anxiety, and depression. (Same measure offered at pre-test.) Takes about 20
minutes.
4. Nutritional Facts Questionnaire. (See the instrument sample and scoring instructions in
Supplemental Materials on the Landing Page.)
5. Clinical Information organized for each client to have sent to home treatment team or as
directed in the Behavioral Agreement to:
a. Home physician or medical or eating disorder treatment facility.
b. Home therapist.
c. Home dietitian.
6. What to send per consent and written release of information forms identified in the
Behavioral Agreement:
127
a. Body composition graphs with explanation.
b. Weight graphs
c. Meal Plan dosed into micronutrients.
d. Treatment notes.
128
5-Day Treatment: Day 1
5-Day Treatment: Day 1 ----- Chapter 6
Day 1: Monday
Note: Goals are WHAT a person wants to achieve. Objectives are HOW one gets to the
goal.
Overall goals for the day
1. Identify how the brain functions and why it responds differently for those with eating
disorders compared to those without eating disorders.
2. Distinguish that eating disorders are brain-based illnesses impacted by environment
versus purely environmentally based illnesses as is thought by the community and many
families.
3. Explore how extremes in symptoms, trait expression or interpersonal interactions can find
a balance in thoughts, feelings, and movement.
Rules and Preparation

Session 1
The program practices the same constructs that it instructs both clients and supports to
practice. By establishing structure and rules before the day/week begins, the treatment team
demonstrates that anxiety can be decreased by entering into an activity in which a structure
established.
Monday morning, while medical check-ins are occurring with one client leaving at a time,
rules are shared with all clients and supports in the room. Medical check-ins include blood
pressure and weight. On Monday, clients’ are told their body composition will be measured
using the seca mBCA.
129
Review Nutrition Rules and Expectations for the 5-Day Treatment for Eating Disorders in
Supplemental Materials on the Landing Page.
Food as Medicine: Dosing Macronutrients - Breakfast Session

Session 2
Goals for Meals/Snacks
1. Offer two meals and two snacks during the treatment day program. Evening meal and
snack practiced off site with supports.
2. Clients, supports, and the therapists eat 100% of recommended meals and snacks
together.
3. Use treatment foods that could be easily purchased at client home sites.
allergies while still meeting dietary balance and energy intake needs.
when needed.
7. Clients and supports learn how to plan meals, applying macronutrients to their local
grocery stores using “Balanced Life,” the new nutrition app.
Session Objectives
1. (Prior to entering program) Assess individualized client food plans based on movement
and daily client activity that can be applied and practiced at each meal in treatment and
home.
2. Each client and support learn practical ways to measure macronutrients recommended
for each individual client.
130
3. Clients and supports prepare the meal together, to practice involvement with food instead
of avoidance.
4. On first day, provide prepacked meals that meet clients’ individualized meal plans,
“dosed” via macronutrients determined by nutrition assessments.
5. Provide two to three food choices at meals and snack for clients to prepare, using foods
similar to home grocery stores, so meals practiced at treatment can be applied at home.
6. Clients prepare their own meals.
7. Develop and practice pre-meal and post-meal movement and anxiety reduction rituals.
8. Supports observe, assist when needed, and can be next to clients during food
preparation.
9. Practice pre- and post-meal rituals that aid in anxiety reduction and healthy movement.
As clients begin the first hour of the day, they enter the room where they will prepare and
eat their meals for the week. A variety of breakfast foods are presented on an open counter
for all clients and supports to choose and prepare themselves for their breakfast.
Each client is given individually calculated breakfast foods that meet each client’s
macronutrient needs for his/her personalized meal plan. The breakfast is planned by the
dietitian and prepared by the assistant for the first day, only to introduce the recommended
meal plan without adding the additional stress of calculating the foods by macronutrients on
the first morning.
The dietitian explains to both clients and supports that the foods selected on this first day for
clients based on the pre-testing nutritional assessment, with exact foods that clients report
are in a nearby grocery store at his/her home. All dietary preferences are honored when
menus are prepared, including vegetarian and vegan (providing the correct amount of
protein can be consumed).
The amount of carbohydrates, proteins, and endurance fuels (the term endurance fuels is
used instead of fats to circumvent fearful connotations of fat and to use a more biologically
accurate term) are premeasured the first day to reduce anxiety. This point is explained
openly as a recognition that transitions are very difficult for persons with anorexia nervosa
traits and that a limited number of choices at each step will help contain a rise in anxiety,
while giving as much control as possible to the adult client. Eating with supports may be
highly stressful; some clients may not have eaten with their spouse, parents, children, and
friends for years. In addition, the adult clients may be used to avoiding or minimizing the
131
amount and food types when eating at home on his/her own.
The first day, when anxiety is at its highest, one choice is offered, via the bagged meal that
was individually prepared based on each client’s food approach, (vegetarian, vegan, etc.).
The individualized approach aids in motivation to eat and is more likely to be applied at
home.
Each client is asked to take out their foods and prepare their breakfast. Microwaves, a
stove, and a refrigerator are near for the client to use in meal preparation. The basic
breakfast foods are set out for the supports, who have the choices to prepare their own
meals, such as eggs, bacon, toast, juice, fruits, cereals, etc. The supports are near to hear
the dietitian guiding the clients, while they prepare their own breakfast. The tables are set by
the clients and supports.
When everyone is ready, the dietitian or therapist leads the clients and supports in a deep
breathing exercise. During all other meals, a client or family member leads the deep
breathing. Breakfast is eaten together with clients, supports, and the treatment team.
When breakfast is over, the clients are asked to show their plates or containers to their
supports to witness that 100% has been eaten. The client may not like the “side effects” of
the foods, but taking in the foods is fundamental to restoring health and body strength.
Deep breathing pre-meal exercise:
In order to help decrease pre-meal anxiety/panic, clients and supports are told the following
information to help approach the anxiety from a biological perspective.
1. Take a deep breath through the nose, hold it for four seconds.
2. Slowly exhale for four seconds from the mouth.
3. Repeat four times.
When breathing in, the lower part of the abdomen should be extending outward to assure
one is breathing deeply. It is the deep breathing, versus shallow breathing, that calms the
mind. When exhaling, the lower abdomen should be contracting. This takes about one
minute. This exercise has been nicknamed the “4 X 4.”
132
A person with anorexia nervosa can experience stomach pain from eating if there is high
anxiety while eating. The dietitian or therapist explains that deep breathing stretches the
opening of the gut into the duodenum to help the food leave the stomach. The stomach
often becomes tight from increased anxiety. Slower breathing forces the heart to slow down,
which slows down circulation, and helps the gut relax.
Distraction, “mind games,” and other fun activities that actively involve the clients can also
help reduce anxiety during the meal
Post meal “walk about”
The brain organizes itself through movement. If one is moving slowly, it forces the heart,
breathing, and thoughts to slow down. For those with anorexia nervosa, or a history of
anorexia nervosa, it is common for anxiety to rise after eating all of one’s meal plan.
Movement with the supports is introduced after the first meal as a post-meal ritual. Clearing
the table and putting dishes in the dishwasher, while talking together is the beginning of the
movement. Then all are asked to “walk tall,” allowing their head and spine to stretch up,
trying to make themselves as tall as possible as they walk. A path that the therapists use is
led and all follow, “walking tall” and talking to distract. The “walk about” lasts about 10
minutes.
As of the second meal, a client or support is asked to initiate and lead the “walk about.” This
is to practice both the movement post-meal and the client initiating an activity to face and
“move through” the avoidant trait and tendency.
In 5-Day Treatment for Eating Disorders, the therapist asks one person (client or support) to
lead the 10 minute “walk-abouts,” so they can experience leading others across the gap of
time or space. The typical client question is, “Where do I go?” The answers are key to how
the therapist chooses to practice transitions. The responses could be:
● Offer a limited number of options (paralleling a proverbial limited number of axons

available to receive the message). This is the most common response because it is the
method that compensates for what the eating disorder brain cannot decide on its own.
Limited options gives momentum to the decision.
133
● “You decide,” triggers increased anxiety over the unknown and asks clients to walk
proverbially blind in the many unknowns, with little-to-no dopamine response to reward
or confirm the decision.
● Ask the clients to seek a support person to co-lead, modeling the importance to turn to
trusted supports to help lead or guide them across the transitional unknowns.
● Plan a structure before leaving the meal with the client to model that the unknowns need
structure and practice leading through the planned structure. (For example, “Do you
want to go outside or stay inside? If inside, you could go right at the end of the hall, up
the stairway and across to the other side.”)
Restroom Breaks
When clients use the restroom, whether adolescent or adult, the 5-Day Treatment for Eating
Disorders requires that the clients go with one of their supports to prevent self-induced
vomiting. This is a way to practice removing the ritualized action to purge. This establishes a
“reroute” that offers a means to divert anxiety and self-harm behaviors and proactively
practice potential purge interruption.

Session 3
Goals
one’s own needs.
Objectives
134
1. Practice empathy and active listening.
2. Build comfort and safety among group members in the multi-family format to facilitate
participation through sharing and receiving feedback.
3. To orient group members to the multi-family context by illustrating inter-family activities
that require active participation with all group members.
4. To facilitate group member bonding and credibility by highlighting similarities in
experiences.
Activity 1: Molecule Activity
Group members are asked to get up from their chairs and move around like molecules. The
facilitator is to encourage the clients/supports to move frequently in different directions, not
in one direction. Like molecules move, brush by one another and keep moving. After about
two minutes, they are asked to stop by someone whom they do not know and find a place in
the room for the pair to introduce themselves to one another. Clients may be with a new
support person or with another client and that does not matter.
This game is played to introduce a biological focus from the get-go and to introduce
movement as a tool to respond to anxiety and avoidance among clients. The facilitator
encourages frequent change of direction to introduce and model that every day activities
force us to shift directions frequently, addressing that there is no harm in doing so, and there
is no right or wrong direction to go within a range of safe space. It also introduces with
movement, not words, that solutions and progress do not need to be linear.
Activity 2: Participant Introductions
The paired group members are asked to introduce themselves to their partners and ask one
another questions based on their interests. The only rule that the therapist provides is that
they can talk about anything, with the exception of topics related to eating disorders or
recovery. Teams are then given 10 minutes to converse and learn about the other person.
This activity requires each member to actively listen in a fun way. The questions each
person asks of the partner, and later shares in the group, are reflective of the focus and
135
manner of the person introducing and can be noted by the therapist, as personal
psychodynamics are expressed.
After about 10 minutes, the dyads are brought back to a central circle. The therapist asks
each person to share their first name and then introduce their partner to the group by saying
their name and a couple things that they learned about that person. To facilitate this, a ball
is thrown to someone in the group. Once that person has made their introduction, they
choose someone else to throw the ball to, who will then introduce their partner, until
everyone has been introduced. Therapists introduce one another in the same way.
As supports and clients introduce one another, the second purpose of the introductions is
implemented. A therapist transitions the introductions by asking each person an eating
disorder question taken from the list for this activity. See Introduction Eating Disorder
Questions below. Prior to the game, the therapist matches a question to each person, based
on issues s/he wants to know, having had some initial interactions from the pre-testing and
the admissions process. Specifically, therapists direct questions to learn more about topics,
such as support person involvement, the effect of the eating disorder on family members,
the history of illness, and hopes and expectations for the week. Doing so allows group
members to learn about each other and start making connections based on their
similarities.
This style of sharing also illustrates the active nature and format of the multi-support context,
where group members, clients and supports alike, will take an active role in participating in
recovery and discussion of the eating disorder in a non-taboo fashion. Circular questioning,
a technique employed frequently in the multi-family format, is used to allow supports and
clients to talk about each other.
Session Questions
The questions below were developed by Stephanie Knatz Peck, PhD, at University of
California, San Diego.
Questions related to the eating disorder that could be directed to supports or clients:
1. What effect has the eating disorder had on___?

2. What changed for ____ since the eating disorder joined the family?
136
3. What approach does ____ take to the eating disorder?
4. What relationship does ___ have with the eating disorder?
5. How has life changed since the eating disorder?
The last cluster of questions focuses on gathering information on the individuals’ hopes and
expectations for the week.
Prompt questions include:
1. What does ___ hope to get out of the week?

2. Does ____ want things to change, and if so, how?
3. What would _____ like you to learn this week?
4. How does ____ feel about being here?
Questions directed to supports, such as spouses, parents, siblings or clients’ children:
1. How did s/he (the client) feel about coming to 5-Day Treatment for Eating DisordersDay
Treatment for Eating Disorders this week?
2. What questions go through your mind when you are concerned your loved one has a
behavior?
3. What have you seen the eating disorder take away from your loved one?
4. Examples of support answers: friends, engagement with school, belief in him/herself; the
eating disorder has pushed him/her into “unpleasant, dark corners.”
5. The therapist may ask the client, “Do you agree?”
6. Client answer: “Yes.”
7. Therapist response: “Doesn’t make recovery any easier though.”
8. Have you heard anything from your loved one what s/he wants to get out of this week?
9. [To group]: “Raise your hand if you are a support that has had to get past the fear of
eating with your loved one.”
10. What qualities does your loved one have as a person, and what qualities does the eating
disorder have?
11. Is your loved one able to see what parts are him/herself and what parts are the eating
disorder? Can your loved one separate out the eating disorder?
12. How does the eating disorder mask over your loved one’s joy?
13. What is your loved one looking forward to getting back of him/herself the most?
14. What has helped the most in the last few weeks?
137
15. What is ______ like as a person?
16. What has it been like for your wife to watch your daughter/son go through this (the
eating disorder/recovery)?
17. What skills most impressed you that your spouse has used to help your daughter/son
with the eating disorder?
18. What is something you want to practice this week in order to move your family forward
with recovery?
19. How have you come to the realization that you as supports have to use the same skills
(be a united front)?
Questions directed to clients:
1. What is your reaction to hearing what your supports have just said?
2. Has your relationship with your support changed because of the eating disorder? How
so?
3. What does your support want you to get out of this week?
4. One of the things I ask persons in this group to do is to tell on your eating disorder. What
do you (or your supports) need to do to move forward with your recovery?
5. What do your supports need to do to get you to eat what you need?
6. Anything you do not want your supports to do – not the eating disorder, just you – things
that aren’t helpful?
7. What’s your favorite thing about your support?
8. Are you like your support? Are there traits that you two share in common?
9. What does your support think and feel about the eating disorder?
10. Client answer: “He hates it and wants it gone.”
11. Therapist response: “Do you feel that way?”
12. Client answer: “Yes.”
13. Therapist response: “It seems that you are all on the same team.”
14. How has your support helped you beat the eating disorder?
15. What would your support say to you to make you comfortable to share if you were
struggling?
Activity 3: Eating Disorder Facts

See Q&A ED Facts in Jeopardy Style Part I game and instructions in Supplemental
Materials on the Landing Page.
Instructions of the Game:

138
A. The therapist(s) ask the clients and supports to help move the chairs into two half circles
to create two teams in front of the screen.
B. Divide the group into two equal teams.
C. Each team is to establish their own “team name.”
D. Choose a number and let the team guess, to determine who the first team to begin is.
E. Establish the rules:
a. This game is to playfully learn basic neurobiological facts about eating disorders and to
set a foundation for the week.
b. There are four categories in this game from which to choose.
c. The answers are to be stated in the form of a question, like Jeopardy and parallel to the
fact that we “live the questions” (Rilke) in research, not the answers.
d. Each team requests a category and amount and then is to work together to form the
answer.
e. If the answer is not correct, based on current research, then the other team has the option
to answer. If they do and miss, they lose the same amount as the first team, the amount
identified on the board category.
f. Points are added or deleted based on how well the current eating disorder research facts
are known and answered.
g. There are “Bonus Questions” that have the letters “ED” in them. Each team can decide
how much to wager on the bonus question, which will be added to their score if correct and
deleted if incorrect.
F. Go as far as time allows, stopping when snack is scheduled for a “commercial break”.
G. Everyone gets their snack, and depending on the timing of this, they go from snack
session to Session 3. They are asked to record their snack in their client/support manual
Section 8.
Food as Medicine: Dosing Macronutrients - Snack Session

Session 4
139
Objectives
1. Snacks are pre-selected for the clients.

2. Supports and the treatment team eat snack with the clients.
Individualized, dosed snacks are brought in a bag for each client on day one only. Supports
are offered a tray of snack foods from which to choose. Each client’s snack is an easily
accessible food/drink that meets the client’s macronutrient needs. Snack is eaten together
with clients, supports, and therapists. As of day two, clients choose their snacks from about
five options that could be easily obtained at their home grocery store. By day two, they are
to know their individualized “dose” of macronutrients for their snack and choose accordingly,
while the dietitian is present to coach.
At the start of the group, clients and supports are given instruction to practice the completion
of food logs to monitor food and fluid intake daily. See the client/support manual Section 8.
Appendix A has this same information for therapists to refer for future snack instruction.
Neurobiological, Interactive Session

Session 5
Goals
140
Objectives
1. Present PowerPoint: Strength in Connections: From Brain to Friends & Family by Laura
Hill, PhD, found in the Supplemental Materials on the Landing Page.
2. Use talking points, found in the Supplemental Materials on the Landing Page., for each
slide to assure content is neurobiologically based, accurate and reliably covers needed
points.
3. Experience the neurobiologically based treatment tool, Telephone, found in the
Fundamental information presented this first day addresses an introduction to the brain and
how/why eating disorders appear to develop. The analogy of the Venus flytrap is used, as
described in the Journal of Treatment and Prevention in 2015.119
Food as Medicine: Dosing Macronutrients - Lunch

Session 6
Objectives
for each client.
2. Clients and supports prepare the meal together to practice involvement with food, instead
of avoidance.
3. On the first day, provide prepacked meals that meet clients’ individualized meal plans and
are “dosed” macronutrients determined by nutrition assessments.
6. Develop and practice pre-meal and post-meal movement and anxiety reduction rituals.
7. Supports observe, assist when needed, and can be next to clients during food
preparation.
141
8. Practice pre- and post-meal rituals that aid in anxiety reduction and healthy movement.
Behavioral Agreement
See complete Client and Support Manual found in the Supplementary Materials.
Session 7
Goals
Objectives
1. Direct the client and supports to turn to section 10 (click on) in client/support manual. This
is the Behavioral Agreement that will be the central resource in this session. The client is
asked to take the lead and fill out the Behavioral Agreement based on his/her own answers
and that of the supports. The document becomes the resource to bring all parties in the
treatment team together on “the same page.”
2. Explain that the supports and the therapist will follow and take notes as the client reads
the text and takes notes in his/her own document. Explain that the client’s copy will be the
one scanned into our files and sent to their treatment team. In addition, the client’s copy will
be copied on Friday and be given to their supports.
3. At each paragraph, the therapist stops the client from reading and asks the client to
rewrite any word or part that is not true for him/her and to make it true for him/her.
4. Model how all parties contribute to the development and details of the Behavioral
Agreement.
5. The therapist provides the clinical diagnoses that were identified from pre-testing and the
documents that arrived prior to 5-Day Treatment for Eating Disorders from prior treatment
142
providers or facilities. Questions and answers may occur between the client, supports, and
therapist about these diagnoses. The therapist asks the client if those diagnoses seem true
to him/her. If so, they are entered by the client into the Behavioral Agreement.
6. The client is asked to read each paragraph along the page, one section at a time, and
share his/her answers, while filling in the behavioral agreement. The client records both their
answers and their supports’ answers on his/her Behavioral Agreement.
7. Cover the follow topics on day one:
a. Diagnoses.
b. Strengths.
c. Limitations.
d. Honesty between the client, support(s) and therapist.
Behavioral Agreement Introduction and Overview
The Behavioral Agreement sessions include the client, his/her support(s), and a therapist.
Supports often want to raise other dynamics and “talk about” support/family and client
problems before approaching the agreement. However, the priority of the session is to enter
into the agreement and move through a portion each day. Many of the problems raised are
addressed in the Behavioral Agreement. The therapist actively listens to concerns raised,
while redirecting the discussion to the agreement and stating when these concerns may be
addressed in the agreement. The client and family quickly discover that the family issues are
identified within the agreement, while simultaneously identifying actions for solutions.
The Behavioral Agreement is designed to provide multiple choice options and a high level of
structure, so that clients and supports can choose from frequently identified options on how
to manage challenges under each of the sections. The structure of the document models the
importance of structure in the clients’ daily lives. Due to anorexia nervosa’s brain responses,
multiple choice options are given throughout the document to lower anxiety and increase a
sense of security, while allowing for individual flexibility.
The Behavioral Agreement has multiple purposes; the document serves as a road map to
ensure that both clients and supports continue to uphold the structure practiced throughout
the week. Additionally, it provides a means for clients and supports to work through
strategies, situational responses, and voice what would help or not help, thus bringing
clients and supports together on the same page.
143
The agreement also stipulates ways in which relapses and deviations from the recovery plan
will be managed by both clients and supports. Reaching a mutual agreement on these
topics enhances the likelihood that appropriate decisions are made and then avoids
emotion-based decisions. Further, the written document allows for certainty on the part of
the support in continuing to assume their role in the recovery process.
The Behavioral Agreement serves as a motivational tool. The plan is written under the
framework of goals important to clients and specifically delineates the strategies, or
objectives, used to achieve those goals. This assists with motivation by deliberately framing
recovery in terms of what is important to the clients and it provides a method to determine
how to achieve what is important. As such, the agreement assumes that goals will not be
achieved should progress be stunted. Given the unique nature of responses to reward and
punishment in anorexia nervosa, it is important to clearly delineate the consequences of
failing to progress in recovery i.e., when engaging in excessive physical activity.
The Behavioral Agreement provides a means by which clients empower their supports to
take agreed actions to help the clients through distressful experiences of eating, excessive
exercise, or purging. The agreement, metaphorically, provides permission and responsibility
for supports to enact mutually identified rewards and consequences. Therapists should
demonstrate encouragement for supports’ involvement, while clients are given the lead to
follow the structure of the Behavioral Agreement.
A section of the template is worked through each day, providing an organized document that
is safe and addresses identified client needs, desires, and commonly identified options from
which to help make decisions. Each day includes discussions of how the objectives
identified can be implemented at home, including challenges and barriers that may arise.
Each section outlines the roles and responsibilities of both clients and supports, so that,
upon finishing the agreement, both parties have a clear, mutually agreed upon role for the
client’s top one to three goals. Tools identified and practiced in Session 4 are integrated into
the Behavioral Agreement discussions to serve as resources for clients and supports.
The therapist facilitates and encourages the client to take the lead in reading, revising, and
selecting a purpose, setting goals, and filing out their objectives. Supports help generate
solutions regarding potential barriers related to each of the goals. They also often raise
important questions and point out patterns that have occurred throughout the client’s life,
which help confirm the client’s traits. Enlisting both the client and supports serves as the
144
foundation to move successfully towards the client living true to their traits and being
accountable to the eating disorder symptoms.
Tools for Symptom/Trait Management - Clients and Supports Session

Session 8
Goals
the supports.
experiences.
Objectives
1. Practice tools that increase balance in thoughts, feelings, and actions, via active listening.
2. Learn the concept of the “trialectic,” which brings a balance between opposite, or
opposing, thoughts, feelings, and actions.
a. Practice using the “trialectic” in examples the group members identify. This may
include practicing walking while sharing what one feels AND thinks AND what one is doing.
3. Use of “I” statements vs. “we or “you” statements.
4. Practice honesty (as identified in the Behavioral Agreement).
5. Practice movement during the group.
Tool Box - Client and Supports are directed to:
145
1. The Tool Box located in the Client & Support Manual, found in Supplemental Materials
on the Landing Page.
2. The Feeling Wheel236 in the Client & Support Manual, found in Supplemental Materials
on the Landing Page.
Client Group
1. Begin the group in the same way the brain organizes itself, from beginning to end,
through movement. As the therapist takes the group into the group room, tell them to move
“freely around the room, as there is not a right or wrong direction to move in the room.”
a. Ask the clients at the very beginning of their movement to rate their anxiety form 0-10,
0=no anxiety and 10=frozen in anxiety. Ask each client, by name, to respond one at a time,
as they all move together.
b. After they walk and before you have them sit down, ask them to rate their anxiety
again. Ask each client by name, one at a time. Addressing each client by name offers an
implicit recognition of the client as a person and honors the client, while you are helping
each client begin to realize that each one has their own
experience, even when they are uncomfortable. Continuing to “move through the
discomfort,” literally, helps the clients experience what it takes to lower anxiety in a simple
way. It may take longer to sit, process, and talk “about” the anxiety, instead of simply moving
it along to a different level of intensity.
2. Then, as the group continues to move, ask a question to the group as a whole. It can be
anything about any of the topics that they have begun to explore in the sessions prior to this
group. For example, “What was your take home message from the neurobiology session
today?”
a. As the therapist, note who moves where and how quickly, how slowly, or if they are
barely moving.
b. Notice the pace of each client’s movement, which may be indicative of their avoidant
trait (i.e. slowing down or trying to not participate) in action. Comment that their pace and
physical movement is a simple means to keep themselves moving “forward,” while working
through questions about “what to do.”
3. Practice the tool “Active Listening.” As the clients move, identify one client, after another,
to share, “What did you hear _____ (client’s name) say?”
a. Ask another client what his/her take home was from a group and then turn to another
client, “What did you hear _____ (client’s name) say?”
146
b. Repeat this over and over as they move. Shift from the therapist asking the question to
assigning a person, who appears to have a determination trait, the task of taking the lead to
ask the “Active Listening” question.
4. Ask the clients to sit down anywhere in the group room they choose, as long as they
remain an active part of the group interactions. Offer that they can sit on the furniture, take a
pillow to sit on the floor, etc. Encourage them to move around till they find a place where it
feels “comfortable for each of them,” or empathically acknowledging their trait of seeing
errors over successes, which could be said as, “Find a place that provides the least
discomfort.”
5. As part of the first group together, empathically join with the clients in the way they tend to
approach issues, via error detection.
a. Introduce the session by telling the clients, “Help me explore what the research is
finding with what you experience to be true for you.” Address their trait of
“error detection” (page 14 of the Behavioral Agreement???). Ask the clients, “Do any of
you tend to see errors before you see what is working, what is OK, or what is successful?”
b. Follow the client responses, synthesizing their responses with active listening, “_____
(client’s name), what did you hear _____ (client’s name) say? And is any of that the same or
different for you?”
c. You are now moving into a two part question. If their anxiety has been lowered from
the walking, they may be able to enter into a discussion that processes the traits and tools
you have begun to introduce and have them try these tools on.
d. At this point, therapists could share the metaphorical story of “The garden: What are
flowers and what are weeds?” This can be done with coaching on how to tell the story to
highlight the therapeutic points.
e. Therapists could also share a second story on error detection.
6. Point out the feeling wheel238 in the manual and the Tool Box Tab 3.
a. Review how to use the feeling wheel238, addressing core feelings in the middle and
how emotions develop and evolve to more refined emotional states. Address that, during
infancy, a baby experiences one emotion at a time. The baby is happy in one moment,
angry in the next, and then onto a different emotion. As the brain develops and life activities
are accrued, the older child, adolescent, or adult grows to experience multiple feelings
simultaneously. This is a natural and complicated process, which signifies the evolution of
the growth and development of the brain, in response to life experiences. For example, a
person can
naturally be happy and frustrated at the same time.
7. Point out the Tool Box in Tab 3. Point out that the tools from this list will be identified and
practiced each day during this session. At the end of the session, point out the tools that
were practiced during the hour.
147
8. As the therapist facilitating the process, it is important the method of the group activities
matches the way clients with anorexia nervosa take in new information - starting with details
and working up to a larger picture. Persons with anorexia nervosa tend to see detail more
easily than the overall picture. Starting the client group with a specific activity and detailed
questions works with the client with anorexia nervosa’s trait of preferring an inductive
approach; first focusing on details, instead of a deductive approach, which first focuses on
the overall picture.
9. Point out the importance of using “I” statements to help clients be honest and accountable
for their own feelings, thoughts, and actions. When actively listening, they can begin to
realize that when using “you,” they actually are referring to another person and, while using
“I,” they are owning their own position. Using “I” statements is a fundamental method to
begin to build confidence in oneself.
Supports Group
1. Supporting an adult loved one with an eating disorder requires a diverse skill set that
includes emotional support, patience, structure, planning, and willingness to “hold the line”
on stopping symptoms upon which both client and supports have agreed.
2. Eating disorders are unique in that they require a deep and genuine stance of non-blame
and acceptance, noting that these illnesses are biologically driven and thus not choices.
This stance is critical to engendering empathy, support, and validation. However, it is not
sufficient on its own. Even though the client is an adult, supports must simultaneously
uphold a firmness to challenge their loved one to avoid engaging in eating disorder
behaviors and setting appropriate boundaries to ensure that client is using their tools to live
their purposeful life, with help from their supports. For the clients, seeing and helping others
in the group is the first step to realizing one’s own symptom expressions and the beginning
to help oneself.
3. The therapist points out the tools and sections in the Client/Support Manual upon which
the supports can draw to apply support for their loved ones.
a. The “Feeling Wheel”238
i. Review how to use the feeling wheel238, addressing core feelings in the middle and
how emotions develop and evolve to more refined emotional states.
ii. Address that during infancy, a baby experiences one emotion at a time. The baby is
happy in one moment, angry in the next, and then onto a different
emotion.
iii. As the brain develops and life activities are accrued, the older child, adolescent, or
adult grows to experience multiple feelings simultaneously. This is a
148
natural and complicated process, signifying the evolution of the growth and
development of the brain, in response to life experiences. For example, a person can
naturally be happy and frustrated at the same time.
b. The “Tool Box” in tab 3. Point out that tools from this list will be identified and
practiced each day during this session. At the end of the session, point out the tools that
were practiced during the hour.
4. Supports are asked what role they have played in their loved ones' eating disorder to
date, whether successfully or not.
a. After one person responds, ask another support person, “What did you hear him/her
say? (practicing Active Listening tool)
b. Do this repeatedly throughout the hour so all supports are both sharing and actively
listening to one another.
5. The definition and concept of a “Trialectic” is introduced by the therapist, drawing upon
the dialectic literature by Marsha Linehan, and adding a dimension of movement to achieve
a more completely balanced and stronger mind.
a. Drawing upon the former discussion question, supports are validated for upholding
accountability, while offering support and validation.
b. Discuss what it might look like to “express a trialectic” of what appears as opposite in
each dimension of thoughts, feelings, and action, and explore where they intersect in the
middle when a balanced whole.
c. Opposite thoughts are identified from the conversation and placed within a continuum.
d. Opposite feelings are identified from the conversation and placed within a continuum.
e. Opposite actions are identified and placed within a continuum.
f. The word “and” unites the opposing thoughts, feelings, and actions into one continuum,
instead of the word “but.”
g. The thought may appear to be contradictory to their feelings. The dialectic is described
as bringing the larger truth together, acknowledging that thoughts and feelings are both a
part of a whole. For example, “I think I am able to push through this, AND I feel discouraged
right now, as I face this again,” instead of, “I think I am able to push through this, BUT I feel
discouraged right now, as I face this again.” This places thoughts in a separate dimension
from feelings and renders the individual less able to begin to live the question more fully.
h. A third dimension is also introduced to the dialect: actions. Actions add an important
dimension to the dialect, making it a “trialectical” model for balanced living. This parallels the
brain. The brain begins at the base, continues to the middle, and evolves to the top,
including action at every state of growth. Actions are critical to carry out thoughts, emotions,
and help change both thoughts and emotions in the moment. If one “sits” with an emotion, it
continues to intensify. If one begins to move with a thought, the emotion will evolve to a
149
different emotion more quickly.
i. Have the supports get up and move around the room, practicing active listening and
trying on a “Trialectic” of what they are thinking AND feeling AND doing in that moment, as
they walk in pairs. For example, as a two supports walk around side by side, one may say, “I
think my wife is able to push through this AND I feel discouraged as I face this again AND I
am walking as I experience this, which is helping me to begin to think out loud with you and
explore new alternatives.”
j. Point out that when being fully honest, what appears to be opposing positions within
one’s self are really a part of the whole. The whole includes comfortable and uncomfortable,
strong and weak, good and bad.
Figure 20
The dialectic becomes a Trialectic whole; when a brain’s integration
of thoughts/feelings/actions are discussed, and bring balance by integrating all three
dimensions.
Food as Medicine: Dosing Macronutrients - Snack and End of Day Summary

Session 9
150
Objectives
1. Snack: Clients are provided with a snack that individually matches their recommended
meal plan, with supports close by to observe what is shared by the dietitian about why that
snack meets their macronutrient needs. Supports are then asked to choose a snack for
themselves.
2. Practice “Non-Dominant Hand”237 clinical tool.
3. Complete the End of Day feedback forms and share take-home messages from the day.
Non-Dominant Hand Activity237 found in Supplemental Materials on the Landing Page.

1. Actively summarize and have both supports and clients experience that to eat and to work
through their traits that hold them back is a non-dominant and unnatural experience. The
dominant thing to do is to not eat. It is “awkward, frustrating, irritating, and difficult” (all words
reported by supports and clients doing this activity) to push forward to eat, while actively
living a life with purpose.
2. Process the activity as a metaphor that reflects that health and strength will require the
client to intentionally think and act in a “non-dominant” way. The activity helps supports to
build empathy for the difficulty of recovery, and it helps identify what it will take to move
forward for both clients and supports. The complexity of emotions surrounding the change
process involved with recovery brings out the “trialectical” dilemma.
Background
The clients discover through neurobiologically based experiential tools that improving their
health means there is an increased struggle mentally, interpersonally, and perceptually.
While other diagnoses, such as depression and anxiety, bring greater peace and calm as
the person improves, anorexia nervosa does the opposite; more distress is experienced the
more one eats to improve their physical health state.
This struggle is explained through several different experiential activities, such as the “Non-
Dominant Hand.” The clients and supports participate in a guided activity writing different
phrases with their non-dominant hands. All clients and supports are asked to share what
they feel as they write with their non-dominant hand. Common responses include: awkward,
stupid, slow, incapable, irritated, inept, and frustrated. The analogy is made that eating, for
those with anorexia nervosa, is a non-dominant action and response. During the activity, the
clients consistently validate that the eating experience encompasses the very feelings the
151
supports reported when writing with their non-dominant hand. The supports report realizing
the difficulty that their loved ones feel when eating what appears to be “normal foods” and
“normal amounts of food.”
Supports are asked what they would do if they were told they had to write with their non-
dominant hand the rest of their life. Many report they would stop writing and the analogy is
then realized regarding the day after day struggle their loved ones experience when eating.
Clients with anorexia nervosa report they do not feel better when eating what is needed for
their bodies, but they feel worse and that this activity helps them to help the supports better
understand and begin to explore what actions are needed to cope with and manually help
the clients to eat. Practice becomes the identified and proverbial key to tolerate the foods.
The clients are expected to eat enough food an average of six times a day for the rest of
their lives, even though it is a “non-dominant” brain response.
End of Day Forms

Sample Client/Support Responses from End of Day Feedback:
“What was most helpful today?"
“It doesn't matter how far or fast I go,

as long as I keep moving, even on days that means sideways.
I am "enough" because I am alive.
All I can do is fight on the days I can fight and accept the "pause" days where holding the
line is the progress.”
“The explanation of (and visuals) exercises used to reinforce) the neurobiological basis of
ED.
The information/structure of the meal plans which will be very helpful/integral to recovery.
Stressing of the need for good nutrition and detriment of ED behaviors.”
Client response
152
“The experiential exercise. (Non-dominant hand).
So important for support persons to get a taste of what persons with anorexia go through on
a daily basis.”
Support response
“[The] illustration of the difficulty experienced by my daughter -

in how learning what she is feeling and thinking
- her response and those of others when it came to the surface in the group discussion.”
Support response
“What was least helpful today?”
“I think an overview during the first hour - so we know what to expect and the material we
will cover. Might want to close with a 5 min overview outlining those same topic. E.g. - "here
is what you will learn" - learn then - "here is what you learned."
Client response
“Really…nothing. Sorry but it was all good.”

Support response
Homework
1. Each client is given a bag that contains the foods individually dosed for their dinner and
snack that night.
2. Each client is to record food intake, movement and emotions on Balanced Living phone
app (it translates into the macronutrient equivalents and compares to their recommended
meal plan.) OR
3. Each client is given two meal plan handouts and asked to record their dinner and evening
snack based on their macronutrient doses and to review their dinner and evening snack with
their supports. This encourages supports to learn what the doses look like, what is included
153
in the meal plan, and how to support the meal plan. The second meal plan handout is to
plan the next day’s meals based on doses.
4. The meal plan log is due Tuesday at 9:00 AM.
5. Complete “End of Day Feedback Form,” due 9:00 AM Tuesday.
a. The clients and supports are directed to turn to Tab 9 in client/support manual.
b. The questions are: “What was most helpful today?”
c. “What was least helpful today?” and
d. “What is your take-home message today?”
e. The take-home message of the day is shared by each person before they leave while
they eat their snack and fill out the rest of the “End of Day Feedback Form”.
6. E-Text Readers can turn to a summary of all End of Day Feedback that have been in the
program open trials that the author has client/support permission to share. See more
examples of End of Day Feedback in Outcome Data Section.
154
Day 2: Tuesday
Goals for Day 2

1. Identify and learn how anxiety overrides pleasure, dominating brain response.
2. Learn and practice tools that can help manage trait and state anxiety.
Preparation Grounded in Prior Day's Facts

Session 1
1. Medical check-ins are administered to each client, which include blood pressure and
weight. Clients’ body composition is measured using the seca mBCA.
2. Meal intake from the prior evening is reviewed.
3. Clients and supports use this time to finish recording their food intake from prior night,
from the dietitian’s assignment for practice.
4. Clients and supports share their “take-home messages” from the day before. A sample of
how this is done is:
5. A facilitator leads this by beginning with a positive attitude, looking the clients and
supports directly in the eyes and saying, “Good morning. I would like you to share with one
another your take-home message from yesterday. This day begins by building on what you
learned and want yourself to remember from yesterday. I would like us to learn from one
another, by sharing and teaching one another.”
6. The facilitator sets the structure by indicating who will go first and then has each person
share.
7. If there is a point that a person shares that the facilitator wants to stress because of how it
was worded, or it emphasized a point from yesterday that the facilitator wants to accent, or if
it is a good foundation for this day’s information, the facilitator may repeat the point or ask
the client/support to repeat it to emphasize it.
8. At the end, thank everyone for their points, affirming the facilitator’s appreciation in
learning from or with the clients and supports.
155
Food as Medicine: Dosing Macronutrients - Breakfast
Session 2
Goals
2. To give clients individualized meal plans, “dosed,” via macronutrients, by the eating
disorder trained dietitian, after nutrition assessments.
3. To provide two-to-three food choices at meals and snacks that are foods clients can
prepare and are similar to foods carried at home grocery stores, so meals practiced at
treatment can be applied at home.
4. For clients to prepare their own meals in order to practice food preparation to apply at
home.
5. For clients, supports, and the therapist team to eat 100% of recommended meals and
snacks together.
6. For clients and supports to learn together how to plan meals, while applying
macronutrients to their local grocery stores using “Balanced Life,” the new nutrition app.
7. For clients and supports to learn together how to practically measure macronutrients,
while using “Balanced Life.”
8. To develop and practice pre-meal and post-meal movement and anxiety reduction rituals.
9. For supports to observe, assist when needed, and be next to clients during food
preparation.
10. For clients and supports to receive dietary training daily for one hour outside of the
meals and snacks to question, practice and plan food choices, amounts, balance, and
practice calculations for meals.
11. To honor individual preferences for those who are vegetarian, vegan, or who have food
12. To apply “food is medicine” as the first level of medication, with synthetic medications
added when needed.
Objectives
156
1. Tuesday is the first day for clients to measure their own recommended macronutrients,
while being coached by the dietitian.
2. Foods are set out for clients to choose from, prepare. and eat.
4. The dietitian coaches and answers questions, while offering practical ways to measure
“doses” of carbohydrates, proteins, and endurance fuels.

Session 3
Goals
one’s own needs.
Objectives
1. Practice the “Self-Critique” tool: “What would I do the same? What would I do differently?
How would I do it differently?”
2. Practice the Hold the Line tool found in Supplemental Materials on the Landing Page on
the Landing Page
3. Use “I” statements.
4. Q&A ED Facts in Jeopardy style: Part II found in Supplemental Materials on the Landing
Page.
Self-Critique Tool Group Activity Instructions
157
1. Everyone is asked to work together to arrange chairs in a large circle.
2. The therapist asks everyone to join the circle.
3. “Self-Critique”: The therapist introduces the “Self-Critique” tool, sharing that all will be
asked to try it on during this group. The therapist shares, “I am seeking input from each of
you based on your experience from last night,” approaching the group in a collaborative
manner.
4. Brain-based points:
a. The brain critiques itself automatically by identifying first what went “wrong,” what it
didn’t like, or what did not work. It is the brain’s natural tendency to first
identify what didn’t go well to prevent or reduce the likelihood of it happening again. The
brain is programmed to look for problems and focus on the problems in
order to survive what it identifies as the problems.
b. Drawing from the “Non-Dominant Hand” exercise, to say something positive first is a
non-dominant approach, or less natural to do, and it is essential for the brain to hear and
process.
5. Ask the group to individually identify an action or a situation to critique. For example, the
therapist might say, “After you left last night, you did many things together. Choose one part
of last night or the total evening overall to apply the ‘Self-Critique’ tool.”
a. The order of the questions is as important as the questions. FIRST identify what the
persons would do the same, to affirm and begin to build confidence on new actions, even if
they felt doubt and awkwardness. It is a “non-dominant response” (even if it did not feel
good). Acknowledge that it is difficult AND (DBT approach to bring the different responses to
one dimension) that discomfort is the way it feels when changing to a different response.
b. The “Self-Critique” questions, in order, are:
i. a) “What would you do the same?” Repeat is same question again until every area
of the action or situation being critiqued has been identified by what would be repeated or
done the same. While it is less dominant to answer “what worked” first, and there is a
tendency to hurry to the next question of what did not
work, it is fundamental to start with what the person wants to repeat, in order to clearly
identify aspects of his/her own actions that build confidence and affirm the actions that the
person did, even if it was painful to do so. Then go to b) “What did not work,” or “What would
you do differently the next time?” And, c) “How
would you do it differently next time?”
6. “’I’ statements”: The therapist asks everyone to use “’I’ statements” throughout the
158
discussion. Set a guideline that if anyone says “you” when meaning “I” that the therapist will
kindly ask them to repeat the statement using “I” to practice owning one’s own thoughts,
feelings, and actions. This is fundamental to developing awareness and confidence.
7. Active listening: The therapist facilitates members in practicing “Active Listening" and
honesty.
Food as Medicine: Dosing Macronutrients – Snack

Session 4
Objectives
2. Foods are set out for clients to choose from, prepare. and eat.
Neurobiological Interactive Session

Session 5
Goals
159
Objectives
1. Complete the Q&A ED Facts in Jeopardy Style: Part II found in Supplemental

Materials on the Landing Page, to learn brain-based, eating disorder facts together, applying
the productive side of clients’ competitive trait.
2. Continue with the Tuesday section of the PowerPoint, Strength in Connections: From
Brain to Friends & Family, utilizing the Lecture Notes, both of which are found in
3. Play the three neurobiologically based, experiential treatment tools found in Supplemental
Materials on the Landing Page:
a. Red light-Green light.
b. Stop, Reboot, Reroute.
c. Anxiety Wave Activity.
i. Anxiety Wave Symptoms handout.
ii. Anxiety Wave Responses handout.
Background on the neurobiology of anxiety and anticipation
1. For those with anorexia nervosa, anxiety may be related to an altered balance between
reward and inhibition.
a. This brain response is the same with obesity and addictions.
i. Lower areas of the brain, such as the nucleus accumbens, under fire reward.
ii. The orbitofrontal cortex signals under fire inhibition that may lead to impulsive
responses.
iii. Research has made substantial advances in understanding the circuitry that makes
drugs and food rewarding, as well as self-control mechanisms that may inhibit their use, by
observing brain responses in these areas.
160
b. In addition, other signals from ventral or lower area of the brain, such as the
hypothalamus, along with adjacent regions, help regulate energy metabolism to help drive
hunger and satiety.
c. However, as Dr. Walter Kaye explains, animals in the wild and, most likely, our
ancestors did not simply eat when hungry. Seeking food often involves risks, such as
becoming someone else’s lunch. Thus, animals are able to inhibit the search for food and
eating, depending on the degree of perceived risk.
d. Food seeking behavior coupled with survival in the wild involves the ability to use
higher-cortical pathways in order to learn from previous reward and punishment
experiences, allowing one to develop strategies to maximize food intake, minimize risk, and
use previous experiences to calculate and anticipate reward and risk.
e. Eating studies36 suggest that anticipated reward from food intake is a stronger
determinant of caloric intake than the reward experienced when the food is actually
consumed. Studies show that planning a binge can create a higher dopamine spike of
reward than actually feeling the pleasure when eating the food. The more frequently one
binge eats, the less the pleasure response.167, 168, 238
f. Perhaps this is the neurobiological explanation of motivation. The anticipation, or
planning, of what is to come tends to initiate more of a dopamine spike of pleasure than the
actual activity, whether eating or going to a concert. The heightened dopamine spike may
help the higher cortical thinking areas to plan and execute the action, via the motor cortex.
238
g. The difference between the anticipation and the actual reward is the reward prediction
error contributing to motivation.238
h. An action is then completed based on the analysis of the dorsal, or higher area of the
brain (i.e. dorsolateral prefrontal cortex). Once the brain analyzes or
critiques both the gain and loss of the plan or action, the individual’s future actions are
then shaped based on the gains and losses experienced, and thus learned, as
demonstrated by the self-critique.
i. If the self-critique only sees the negative, as is the case of many who have anorexia
nervosa, and holds an inhibited trait, then actions and plans become increasingly inhibited,
avoided, and eliminated. This can easily lead to such things as less planning of what foods
to eat, less food eaten, and less engagement in social interactions.
2. Individuals with anorexia nervosa have a reduced response of the ventral regions of the
brain, including the insula and nucleus accumbens, when eating palatable food. However,
recent studies83 suggest that both ill and recovered individuals with anorexia nervosa have
heightened anticipatory responses to food cues in the insula, striatal, and frontal regions of
the brain.
3. Normally, in a risky situation, persons may anticipate something awful may happen and
they are anxious and cautious. However, if they find that the risk is minimal, they learn from
161
that experience and the next time they are exposed to that risk, they have less anticipatory
anxiety.
4. The Center for Balanced Living and University of California, San Diego think that
individuals with anorexia nervosa have great difficulty learning from experiences. They tend
to have high levels of anticipatory anxiety, even in situations where most persons would
think there is lower risk. Each time seems to be “new,” in that they have a maximum anxious
response. This seems particularly true in regards to food because the thought of food
appears to generate high levels of anticipatory anxiety.
5. Normally, emotions in humans play a role in the coding of stimulus anticipation and
receipt. For example, when hungry, persons tend to present in a mildly irritable, tense state
and experience pleasure when eating.
a. In comparison, there is a poorly understood and puzzling relationship between
emotion and anticipation of food and eating in anorexia nervosa. For example, anxiety
actually goes down when NOT eating and when the client with anorexia nervosa reduces
daily caloric intake,88, 103 whereas eating, or anticipating eating, stimulates uneasiness and
dissatisfaction, or a dysphoric and anxious mood or anxious thoughts.104, 105
b. The anxious anticipation appears to simulate avoidance, to the point that individuals
with anorexia nervosa starve themselves. The starvation appears to be related to both the
minimal firing in ventral circuits in the insula and nucleus accumbens, while food is
consumed and when anticipating eating.
c. These neurobiological responses of low to no firing in the ventral area and too high of
firing in the dorsal area is what neurobiological anxiety looks like for those with anorexia
nervosa. The levels of anxiety are so aversive and intolerable that persons will do whatever
is necessary in the short term to reduce their anxiety, even if the long-term consequences
are malnourishment and starvation.
d. The emotional consequences of eating food in those with anorexia nervosa are so
powerful that it becomes very difficult to experience any reward from eating, making it very
difficult to change behavior.
Treatment Tool Instructions
The PowerPoint and talking points set the neurobiological foundation of anxiety. To help the
clients and supports experience how anxiety can effectively be redirected, two games are
proposed, Red light-Green light and Stop, Reboot, Reroute.
1. Ask all clients and supports to return to their seats and turn to the handout Anxiety Wave:
Symptoms and Anxiety Wave: Response in Supplemental Materials on the Landing Page.
162
2. During the Neurobiology PowerPoint discussion, clients are asked to think about how
their anxiety changes, as their anxiety rises and lowers throughout the day. (In Supplmental
Materials on the Landing Page.)
3. The Anxiety Wave: Symptoms offers a list of behavioral symptoms that many former
clients with anorexia nervosa have reported experiencing as their anxiety increases. (In
Supplementary Materials on the Landing Page.)
a. Clients are asked to:
i. Review the list of symptoms.
ii. Choose from the list or identify their own symptoms that describe their own LOW,
MEDIUM, and HIGH levels of anxiety. How does their anxiety express itself as it increases?
Clients are told they can add any symptoms they experience that are not on the list. The list
is simply an example from which to help identify their own symptom expression.
4. The therapist should point out:
a. As anxiety rises, symptoms become less interactive. Little to no talking occurs and
action, such as restriction and self-induced vomiting, is the focus to diminish the feeling of
anxiety.
b. Thoughts freeze and cannot process, plan, or provide rationale solutions when anxiety
is high.
5. Have the clients turn to the next handout, Anxiety Wave: Responses.
a. The list on this handout are responses that former clients with eating disorders have
reported that they would like their supports to offer, based on the level of anxiety. The
response list is simply a means to help the clients in the group.
b. Clients are asked to identify what responses they would appreciate or need from their
supports at the:
i. LOW level of anxiety: bottom line.
ii. MEDIUM level of anxiety: middle line.
iii. HIGH levels of anxiety: top line (The others lines can be filled in later).
c. Clients are to turn to their supports and share their symptoms expression wave and
their response wave.
d. The supports are to ask questions and operationalize how they could practice this for
the rest of the day and week.
Food as Medicine: Dosing Macronutrients – Lunch Session

163
Session 6
Objectives
2. Foods are set out for clients to choose from, prepare, and eat.
the “doses” of carbohydrates, proteins, and endurance fuels.

Session 7
Goals
Objectives
1. Client leads, reads, corrects the Behavioral Agreement pages 4-5.
Instructions
164
1. With client and supports’ strengths, limitations, and honesty agreed upon in the
Behavioral Agreement on Monday, the therapist facilitates the client to take the lead and
begin reading the next section of the agreement
a. The client is to correct any sentence that does not accurately describe what is true for
them.
b. Supports listen.
2. The therapist is to work with the client and supports in offering support, empathy, and
structure, while moving forward to help the client identify his/her purpose over the next three
months.
3. Purpose Section: The client leads, with the supports reading from their own notebooks,
“on the same page,” to determine the client’s purpose.
a. Review and ask, “What purpose are you reaching for over these next three months?”,
“What is important to you and what do you value?”, “How might you do any part of that in the
next three months to give you something you value to reach for, while you are working
through the pain and difficulties of the eating disorder?”
i. The client and supports discuss this together.
ii. The client records what s/he identifies.
iii. This can be overwhelming and too much of a “big picture” for the client with
anorexia nervosa, thus it helps to reduce the questions to, “Between now and three months,
I will be upset with myself if I have not done ____ by ____ date.” The therapist can also ask
about any small action that the client could do that would help fulfill what is purposeful to
them.
iv. If the client is unable to identify anything purposeful, it is assigned as homework to
discuss that night with his/her supports. It appears indicative of a poorer outcome if the
client cannot identify anything purposeful because there appears to be nothing beyond the
eating disorder that the client wants or hopes for.
4. Clients are to identify and explore with supports their own traits from the trait list offered.
5. Rate themselves where on a range from destructive to constructive, based on how they
have expressed those traits over the prior month.
6. Write on the line provided for each trait, what each client can imagine his/her own
productive expression of each trait would look like to use as a self-identified guide and for
supports to realize.
Tools for Symptom/Trait Management Session

165
Session 8
Goals
the supports.
experiences.
Objective
1. Explore and try on the tools.
Client Group Tools
1. “Stop, Reboot, Reroute.”

2. “Planning.”
Supports Group Tools
1. “Red Rover, Red Rover.”

2. “Validation.”
3. “Stop, Reboot, Reroute.”
166
4. “Planning.”
5. “Structure.”
Client Group Activities
1. The client group begins with movement and action. Emotions and thoughts can then
focus on the past, the present, and the future, but actions can only exist in the present.
Thus, to help ground a client, begin with an action and the thoughts and emotions may
realign with the action, bringing the person more fully to the present.
2. Educate the clients on the neurobiology of anxious thoughts.
a. For persons with anorexia nervosa, the dorsal striatum and dorsolateral prefrontal
cortex over fires, creating an endless stream of thoughts that are trying to make decisions.
Because the information from the lower area of the brain and the ventral area, where
feelings and sensations are registered, are minimally firing, doubt resides and the thoughts
cannot execute decisions with a sense of trust.
b. This may contribute to why persons with anorexia nervosa run extensively. They state
that they feel calmer as they turn to running; an intense action to refocus intense thoughts
back to the present moment.
c. The overactive thoughts are in response to the underactive emotional response. The
higher center of the brain will keep thinking until they can execute an action to resolve the
anxious feelings.
d. If the feelings are not resolved, and they cannot resolve, since the firing is abnormal,
the thoughts will continue to process, plan, and think about objects that reflect the anxiety,
such as food.
e. While moving, practice the tool “Stop, Reboot, Reroute” with the clients again.
i. Stop.
ii. Reboot, turn to a different direction.
iii. Reroute, move in that direction.
f. Have clients move into dyads.
i. One partner is assigned to begin talking about his/her anxiety or what makes
him/her anxious.
ii. Assign the partner to interrupt the client talking and say, “Stop”.
iii. Then introduce a different topic WHILE moving OR do a simple activity together.
167
iv. Then support the client to do or talk about the different topic.
g. Have both partners practice interrupting and changing the subject to help the client
who is trying on anxiously talking. Educate the clients that persons with anorexia nervosa
have a common trait of difficulty set shifting. This means thoughts get stuck on one thing,
such as vomiting. Then, the brain is not able to naturally, or flexibly, shift thoughts to a
different topic without help. The support can be the “set shifters.” To describe this, the
analogy is made of moving the needle on an old vinyl record that had a scratch, causing the
music to repeatedly play over and over.
h. Explain that the supportive client is to “Do for the other client what they cannot do for
themselves; helping them shift their thoughts manually, since they cannot do it
automatically.”
h. Practice “Stop, Reboot, Reroute” throughout the session, while teaching and practicing
the tools planning and creating structure for each of their evenings, to decrease the doubt of
“what they going to do.”
3. Optional: Planning via Using Multiple Choice Options instead of open ended questions.
a. For example, it is less effective to ask, “What do you want to do?” and more effective
to ask, “Do you need to spend the next few hours: 1. Doing homework, 2. Taking a time out,
or 3. Packing your dinner?”
b. Clients are to plan the remainder of the day after treatment, drawing upon support
from their group partners and helping one another identify actions with the structure of
multiple choice. Due to the anorexia nervosa brain’s inability to trust decisions, a support is
needed to take ideas and put them into a structured plan for the clients to trust and walk
through during the evening.
Supports Group Activities
1. Ask supports to turn to the Tool Box and view the tools “Validation,” “Planning,”
“Structure,” and “The Feeling Wheel” (Developed by Dr. Gloria Wilcox)236.
2. Define “Validation” (See the Tool Box and Tool Definition Sheet in the Client and Support
Manual).
a. “Validation” is acknowledging one’s internal experience.
b. Remember – each emotion is valid because a person feels what they feel. We cannot
feel what we want to feel, or make ourselves feel something else, unless under extreme
trauma, which shuts down feelings. Feelings simply exist based on how the brain is firing in
response to the signals, found in the pathways that we are learning about this week.
c. Regardless of why we feel an emotion, we are feeling it.
168
d. During infancy and early childhood, the brain is developing and fires simply one feeling
at a time.
e. As the infant grows into childhood and adolescence, the brain develops new neural
circuits. Feelings then become more complex, as emotions are recorded with life
experiences. Multiple feelings can become experienced at the same time, like multiple
colors in a painting. The multiplicity creates more depth in the visual image, just as
numerous feelings create a multifaceted experience of emotions.
f. Explain that by demonstrating how, in adulthood, feelings are a constant mixture of
many emotions, simultaneously. There appears to be an exception when an adult may
simply feel one feeling at a time. This can occur during play or during emotional extremes,
such as times of significant calm or high distress.
g. To identify our many feelings, which occur at the same time, is difficult. The most
acute feelings tends to stand out.
h. Validation can include acknowledging the complexities of your loved one’s feelings, as
they attempt to sort out what they are feeling.
i. Educate the supports that neurobiologically, while it is hard for anyone to sort out the
complexities of their emotions at any given time, for those with eating disorders, the ventral
striatum may be under firing, making it even more difficult for their loved ones to know their
feelings in the moment. However, their brains may over fire when they anticipate issues,
creating intense and exaggerated feelings about the future.
j. Helping their loved one identify possible emotions is a first step in “Validation” or
acknowledging what they are feeling.
k. If one or more of the emotions is/are uncomfortable for their loved ones, then supports
can offer a tool to help manage the emotion.
l. Tools such as “Distraction” and “Deep Breathing” slow the heart rate, allowing emotions
to decrease in intensity.
m. Two tools that can help prevent the rise in emotional intensity in their loved ones are
“Planning” and increasing “Structure.”
n. They reduce anxious thoughts, anxiety about the unknown, and doubt about what to
do.
o. “Planning” and establishing “Structure” with and for your loved ones can help validate
what they need and may not be able to do by themselves, even though they are adults.
p. “Never leave home without a plan.”
q. Use two to three Multiple Choice Options when planning and fewer open ended
questions, to compensate for diminished ventral brain response, which prevents affirmations
when making decisions needed to create a plan. For example, ask, “Do you want to go to
the grocery or gas station first?” instead of, “What do you want to do for errands?”
169
3. Play “Red Rover, Red Rover” to recognize how emotions play a role in the balance of
thoughts and actions, as a whole, in the brain and in interpersonal interactions.
a. This game is about feelings and emotional expressions.
b. Help supports realize the range of emotions that a person can experience by assigning
common emotions that have been expressed during treatment thus far, ranging from happy
to sad and hopeful to depressed.
c. Point out that opposing emotions can be experienced simultaneously.
d. Emotions can be both “good and bad.”
e. Explore the change process of one emotion to another via the game.
f. Experience how movement impacts emotions.
4. Note: Thoughts and feelings can shift to and from past, future, and present. Movement
grounds a person in the present and cannot fire for the future or past.
5. Have the supports move around the room in dyads. As they move together, walking
beside their partner, each person is to identify a situation when they observed their loved
one have an intense emotional reaction. Have the partner validate their partner by a)
describing or working with their loved one to identify the emotion, and b) using the tool
“Stop, Reboot, Reroute” by saying, “Stop,” or using a hand motion to signify stopping,
turning the client in a different direction and redirecting them to a new action.
a. This validates the feeling and offers support that any feeling is valid. When an emotion
is intense, as one father summarized it, “When anxiety is up, shut up” and simply move.
6. Reverse roles and ask the partners to keep moving, while validating feelings and trying on
the “Stop, Reboot, Reroute” tool.
a. Supporting clients to move in a different direction, to release intense emotions, helps
provide an alternative for the client from doing an eating disorder behavior, which is the
natural tendency to release the intensity of the emotion, such as anxiety.

Session 9
Objectives
1. Clients choose a snack that individually matches their recommended meal plan, with
supports close by to confirm that the snack meets their macronutrient needs. Supports are
170
then asked to choose a snack for themselves.
2. Initiate completing the End of Day feedback forms while eating snack.
Sample Client and Support Responses from the End of Day Feedback
“What helped the most?
“Showing my parents (supports) my wave of anxiety symptoms and responses. It really

helped them to see where I'm at anxiety-wise when I exhibit certain symptoms and what is
the best way to respond to me at that time. They really had no idea about a lot of it.”
Client response
“Working on client-support agreement.”

Support response
“What would you do differently?"
"I felt rushed at meal prep time. Indecision and frustration peaked. I should have thought
ahead about what I wanted.”
Client response:
“All good”
Support response
Homework
1. Each client is to record food intake, movement, and emotions on Balanced Living phone
app (it translates into the macronutrient equivalents and compares to their recommended
meal plan.) OR
2. Each client is given two meal plan handouts and asked to record their dinner and evening
snack based on their macronutrient doses and to review their dinner and evening snack with
171
their supports. This encourages supports to learn what the doses look like, what is included
in the meal plan, and how to support the meal plan. The second meal plan handout is to
plan the next day’s meals based on doses, due Wednesday at 9:00 AM.
3. Complete “End of Day Feedback Form,” due at 9:00 AM Wednesday.
a. The clients and supports are directed to turn to Tab 9 in Client/Support Manual.
b. The questions are: “What was most helpful today?”
c. “What was least helpful today?” and
d. “What is your take-home message today?”
4. E-Text Readers can turn to a summary of all End of Day Feedback that have been in the
program open trials that the author has client/support permission to share. See all End of
Day Feedback in Outcome Data Section
5. Eat 100% of their meal plan for the evening with supports.
6. Practice “Stop, Reboot, Reroute”
7. Practice “Use 2-3 Multiple Choice Options” when deciding what to do together.
8. Complete the Label Reading Exercise.
172
Day 3: Wednesday
Goal for Day 3

See complete Client & Support Manual found in the Supplementary Materials on the
Landing Page.
To provide clients a means to explore how to better manage their traits and eating disorder
symptoms each day in unexpected situations via the importance of planning, practice, and
structured experimentation.
Preparation Grounded in Prior Day’s Facts

Session 1
weight.
share.
173
Session 2
Goals
when needed.
9. Clients and supports learn together how to plan meals, apply macronutrients to their local
grocery stores and tracking intake by using “Balanced Life,” the new nutrition app.
Objectives
1. Assess individualized client food plans based on movement and daily activity that can be
applied and practiced at each meal in treatment and home.
for each client.
of avoidance.
174
6. Practice pre-meal and post-meal movement and anxiety reduction rituals.
7. Supports observe, assist when needed, and are next to clients during food preparation.
8. Practice pre-meal deep breathing 4 X 4 ritual to aid in anxiety reduction.
Client/Support Multifamily Input Session

Session 3
Goals
one’s own needs.
Objectives
1. Empower the clients to be consultants in what they know and experience.

2. Have the clients consult with a different assigned support/family to practice using the
following tools in times of high, medium and low anxiety: Stop, Reboot, Reroute, Active
Listening, and Validating.
Practicing Tools
1. Assign each client to a different set of supports. Do not assign a client to their own
support/family.
a. Decide who to assign to whom.
175
b. Try to assign a client to a different support, who most matches his/her own family
dynamics.
c. Identify which client might connect or relate with another support/family.
2. First, clients are instructed to describe to the supports what that client’s own eating
disorder noise is like, or sounds like. They are asked to describe it and how it impacts
her/him.
a. The family can ask questions.
b. The family is to practice actively listening (tool), rephrasing what they heard the client
saying.
c. The client is to correct the supports if they did not hear accurately.
3. Second, clients are to consult with supports on how to apply Stop, Reboot, Reroute, as
the client demonstrates the eating disorder noise.
a. The supports are to practice the client’s advice.
b. The client tells the supports what helped and what did not help (Critique tool).
4. The supports are to turn to their own loved one’s anxiety wave sheet they completed with
their loved one on Tuesday.
a. Discuss what their loved one’s responses look like.
b. The consulting client is to draw upon the loved one’s Anxiety Symptoms/Responses at
each level and consult with the family, as the family describes what each level looks like,
since they have observed it often.
c. The consulting client takes the Anxiety Responses of the family’s loved one and
explains and practices the low, medium, and high responses that their loved one identified
would help, as his/her anxiety increases. The consulting client teaches the supports ways to
respond.
d. The supports practice responses to the anxiety symptoms at low, medium, and high
levels, as the consulting client demonstrates their loved one’s anxiety
symptoms at each level.
e. The consulting client is to use the Critique tool: what helped, what did not help, and
what to try differently, based on what the supports said or did.
f. Even if the responses may be different from what the consulting client had written on
his/her own form, the consulting client addresses the selected responses of the supports’
loved one.
g. The feedback offered by the consulting client can offer a valid perspective to help the
176
supports better understand their loved one.
h. The consulting client is to help the supports identify what helps, what doesn’t help, and
what to try differently. Practice this among the subgroups.
5. In the final 30 minutes, each client/support subgroup is to identify one of the tools
practiced and act it out for the whole group.
a. The client of origin watches their family from the distance of the outer circle, as the
supports show their loved one their new way to respond, using tools.
b. The client of origin is to use the critique tool and offer feedback to his/her own
supports on what to do again, what to not do, and recommend what to do
differently.
c. Thanks is given to the clients for the consultation.

Session 4
Objectives
1. Snacks are set out for clients to choose from.

4. If time: an additional movement session is offered:
a. Brisk walking. Requires a pre-designated route nearby for a five minute walk.
b. Yoga: Requires a pre-sequenced flow of light asana. Sequence should be fast paced
and practiced for five minutes.
c. Tai-Chi: Requires a pre-sequenced flow of tai chi poses paired with breathing
exercises. Sequence should be fast paced and practiced for five minutes.
177
Optional movement activity
Clients are provided with a rationale for using movement (See Role of Movement in 5-Day
Treatment for Eating Disorders). Care is taken to emphasize movement as a healthy
method to help thoughts and emotions flow, a distraction technique, and/or a tool to reroute
an eating disorder behavior, rather than a method for altering caloric intake. Group leaders
should emphasize that movement will focus on engaging movement, but not include
activities that are considered to be strenuous.
In this group, clients are taught five minute sequences of a walking route, a tai-chi exercise,
and a yoga flow sequence. Initially, sequences are practiced and learned through
demonstration by the group leaders. Following this practice, group leaders explain that the
client will be led through an exercise to practice using movement to distract from distressing
thoughts.
Clients are asked to identify one mildly stressful topic NOT related to their eating disorders
(something is a 4-5 on a 1-10 Likert rating scale, ex. a difficult relationship with a friend).
Clients are then led to think about their designated topic before engaging in the movement
sequence (two minutes). Leaders then prompt clients to begin using their pre-designated
movement sequence to distract away from thinking about their stressful topic.
After practice, leaders facilitate a discussion to allow clients to share their findings on this
exercise. Leaders emphasize the importance of continued, sustained practice in bolstering
the ability to “move” away from distressing thoughts. These movement activities are then
included in the schedule before and after meals and snacks and done as a group to
encourage client practice.
Playful games are a structured, fun way to lower anxiety while solving problems. Because
movement can be fundamental to problem solving, acting out while in play can be an outline
for solutions the clients and supports are seeking.

Session 5
178
Goals
3. To shift the etiological paradigm from social/family causality of eating disorders to
Objectives
1. Share the Wednesday lecture points from the PowerPoint Strength in Connections: From
Brain to Friends & Family by Laura Hill, PhD found in Supplemental Materials on the
Landing Page.
2. Use PowerPoint talking points for Wednesday: Addressing the neurobiological underlying
factors, found in Supplemental Materials on the Landing Page.
3. Use clinical tools:
a. Land Mine Exercise (written instructions and teaching video found in Supplemental
Materials on the Landing Page).
b. Movement as a coping mechanism
Group Activity
1. Clients and supports play the Land Mine Exercise to aid in identifying a structure for
supports to follow in planning and getting through difficult meals.
2. Draw from the insights of the client, their supports, and all other clients and supports to
help the client apply the responses s/he has and the help s/he sought in similar, daily
activities in life.
3. Identify the responses the client used to get through the land mines and integrate the
actions within a simple structure that the clients and supports can apply in their lives.
4. Point out it took movement to keep going.
Food as Medicine: Dosing Macronutrients – Lunch

179
See complete Client and Support Manual found in the Supplementary Materials.
Session 6
Same Objectives as breakfast.

Session 7
Goals
Objectives
1. Client Goals: After purpose and traits are explored, the focus turns to goals (written in
RED). What goals does the client want to do in order to help him/herself reach the identified
purpose(s)?
a. Goals define “WHAT.”
b. Objectives define “HOW.”
c. The client is instructed to prioritize the 2 goals from the list offered. A therapeutic
question could be, “If all else fails, which goal will most likely help you reach your purpose in
the next three months?”
180
d. Explain to the client that s/he may be able to complete the details of one or two goals
during the program week. These one or two goals are to help plan actions to reduce eating
disorder behaviors and shift trait expression to help move the client forward toward purpose
in life.
e. These goal(s) are to be the primary focus over the next three months.
f. The client proceeds to read the goals and correct any words or phrases to make them
more accurately describe what is true for him/her.
g. The supports are witnessing and participating in the discussion, while it is the clients
who choose the rank order. Yet, the support and therapist input often aid in the client
choices.
2. Client Objectives: Identify “how” the goal will be accomplished, or the strategy they can
use to move forward.
a. Note that offering multiple choice vs. open ended questions helps provide structure
and compensates for the client’s inability to trust decisions and the client’s avoidant traits.
3. Begin with the client identified #1 goal that the client identified Ask the client read that full
section of the Behavioral Agreement out loud for the group. The client is asked to change
the wording in any way to make it true for him/herself in the paragraphs before, after, and
within the goal grid itself.
4. The objectives within the goal are discussed with the client and supports and worked out
together, addressing how it will be applied at home or other settings after the 5-Day
Treatment for Eating Disorders.
5. If the client and supports cannot “picture” the actions of what they are agreeing to do, it is
not specific enough.
6. (Note: a structured approach allows the client to feel safe, choose within the tight
structure and begin to build confidence, using methods that work well for his/her needs.)
7. Process and identify how the supports can encourage and help the client live the goal
each day after this program, while living at home with the supports, at a different home
setting, in a different state, or when together with their supports.
8. The therapist facilitates the conversation to move forward, finding a balance that identifies
detailed strategies upon which supports can draw and act, while assuring the overall goals
are addressed during the time allowed.

Session 8
181
Goals
the supports.
Objectives
1. Practice tools Hold the Line or the Nonnegotiable
Client Group
1. Act with intention and practice non-negotiables via the game Mother May I.
First activity
Begin the group with the clients moving and create a line in the room beyond which they are
told they cannot go. They can move anywhere, with anyone in the group, but they are not to
step beyond the line. Put a chair behind the line and prop it precariously at an angle, so that
if anyone pushes on it too hard, or tries to sit in it, the chair may fall over.
As adult clients, there are eating disorder or self-harm behaviors that the clients may identify
as “non-negotiables” with themselves. They may realize that there is a line beyond which
they cannot go, or they will relapse. As the clients walk around for a few minutes, ask them
what would happen if they went behind the line and tried to sit on the chair in the position it
currently is leaning.
The answers are obvious and they are an active way to lead into the discussion of what their
eating disorder behaviors do to them and, when they engage in them, they are putting their
182
body in a precarious position.
The therapist then facilitates a group discussion, asking clients to identify what eating
disorder behaviors they are able to hold the line on and keep themselves from doing, then
identifying which ones they will engage in without the required help and support.
Direct the clients to help one another tease out the behaviors. The therapist plays “devil’s
advocate,” questioning the clients’ intentions, asking in increasing detail how they can keep
themselves from stepping over the line. Ask the other clients to help each other answer the
question, not each client by him/herself.
The therapist leads the discussion in what it may take to keep oneself from doing the eating
disorder behaviors:
1. Planning the time period when vulnerability rises.

2. Setting up structure to help oneself through the vulnerable time.
3. Identify who they can call upon for support.
4. Identify what would they ask and how would they ask it.
The brain is “wired” to do the eating disorder behavior. In essence, the brain is currently
working against their intentions to stop and reroute the behavior.
Discuss the distress they feel if they do not do the ED behaviors when they think too much
has been eaten, or they have to eat something different than planned.
Remind the clients that their brains are currently wired to act out the eating disorder
behavior in response to their feelings. The mid brain becomes emotionally distressed when
the eating disorder behaviors are not acted upon. Cognitive Behavioral Therapy tells clients
to cognitively challenge the eating disorder thought. This can be difficult because the brain is
wired to act and feel before it thinks. Eating disorder noise resides in the dorsal, or upper,
front, of their brain. The eating disorder noise can be loud if the client has eaten different
foods or more food than their eating disorder thoughts have defined as an acceptable
amount. Trying to think through the eating disorder noise is very difficult and at times nearly
impossible. When the eating disorder noise continues to be so loud that it blocks one’s
183
ability to function effectively with those around them, medication may need to be discussed
this week to “lower the volume” of the eating disorder noise. The medical staff in the eating
disorder program can offer medication information to clients and families. Medication may
help the client to think more clearly through the eating disorder noise.
It can take a lot of energy, determination, and focus to think through the eating disorder
noise. Distraction with supports can help.
1. Ask which tool helps to distract them when eating disorder noise is high.
2. The clients may state the tool Stop, Reboot, Reroute.
a. For example, the client may be walking to the bathroom to make themselves vomit,
and force themselves to “stop,” turn 180 degrees, and walk in a different
direction, WHILE they then try to think about something else.
3. If they can’t force themselves to think of a distraction, use action. These can include
walking or turning on music and listening via earphones, so the music drown out the eating
disorder noise. Then, at least, the action is saving them from the eating disorder behavior.
It takes a high level of intentionality to keep oneself from doing an eating disorder behavior.
Having enough intentionality and determination every moment of every day is impossible
and it is necessary to compete with the eating disorder thoughts and behaviors. As a result,
support is needed, especially over the next two years while their brains are rewiring, every
time the act is avoided and they override their thoughts with distraction.
Share that the clients will be asked to initiate a discussion with their support tonight of what
self-harm behaviors the clients do not want themselves to do and what they will do
themselves to try to hold the line.
Inform the clients that the supports are also identifying “non-negotiables” that they feel they
cannot tolerate and that it is in the client’s best interest to take the lead and ask their
supports what their “non-negotiables” are.
The areas that each identify are to be brought back to the individual/support session on
Thursday and aligned with the goal/objectives in the agreement, so they are clearly stated
as the objectives that are “non-negotiables” by the client, support, or both.
184
Supports Group
1. Review the Non-negotiable Handout in the Client and Support Manual.
2. Review the Tootsie Butt-Strap Story.
a. What was the non-negotiable in the story?
b. How did it help Tootsie to move forward toward success?
c. How easy/hard was it?
d. How often was it used?
3. Explore qualities of nonnegotiables the supports want to raise and how nonnegotiables
may vary per event or over time.
a. Address that supports work WITH their adult loved ones to identify the nonnegotiables,
i. e.g., “What is your non-negotiable as we head to this restaurant?”
ii. Follow-up by asking, as was done in the Land Mine Activity, “What do you need
from me to help?”
iii. The supports need to decide if they can do what is requested. If the supports
cannot do the requested action, then the supports need to identify with the
client on how the need could be met.
iv. Whether it is one situation, such as a holiday dinner, or over the three-month
behavioral agreement, it is important that the client has identified the
nonnegotiable and the supports know what to do or not do to help.
4. Critique (what worked, what did not work, and what they would do differently) one another
in the supports group and practice active listening (what they heard the support say).
5. Therapist, point out that loving firmness and consistency about behavioral expectations
for recovery are important.
6. Reinforce the point that supports may need to possess firmness, while simultaneously
remaining neutral, nonjudgmental, and empathic about the challenge clients’ face in
following through with recovery-oriented behaviors, AND this is very, very hard to do.
7. Point out that just as the clients are learning to do non-dominant behaviors, such as eat,
the supports are learning non-dominant behaviors when holding the line. Both sides are
facing hard actions that may need to be applied daily.
8. Review ways supports need to hold the line over time, not just for three months.
a. When supports help identify a plan for an event or the purposeful direction the client
wants to take, the supports can know and encourage, “The plan is a good one, it is taking
you forward. The non-negotiable is to keep you from going backward.”
185
b. Reminding oneself of the progress made toward the purposeful goal.
c. Recognizing that non-negotiables need to be brought into the open regularly, just as
one says to a loved one who has diabetes, “Do you have your insulin?”
when preparing to leave for an event. So too, a support can say, “What’s your non-
negotiable for this event?” and then, “What do you need from me?” for event after event for
six months, a year, or even two years. It is necessary to keep this language and non-
negotiables identified and part of the conversation.
d. If the client ended up doing an eating disorder behavior, then as long as the client’s
health is not in jeopardy and s/he does not need to go to an emergency
room, affirm the “repair,” because the client called him/herself out and shared what s/he
did.
e. Affirm or state objectively for the client to do the repair, agreed upon in the Behavioral
Agreement if s/he stepped “over the line”.
f. Refer to the Behavioral Agreement for specific client commitments and ask the client
to jointly construct a plan for increased support involvement, if necessary (ex. being present
during snack time to ensure that snack is consumed).
g. Supports draw upon other supports for back up, via online support organizations, such
as FEAST, or individuals, such as Tabitha Farrar.
Food as Medicine: Dosing Macronutrients - Snacks and End of Day Summary
Session 9
1. Clients choose a snack that individually matches their recommended meal plan, with
supports close by to confirm that the snack meets their macronutrient needs. Supports are
then asked to choose a snack for themselves.
End of Day Feedback
186
“What helped the most?”
“Role playing with other client's families and planning out what to do in certain situations.
Discussing as a group beneficial ways for supports to respond to anxiety on my part.”
Client response
"Walking thru mines" exercise helps me to understand visually what our loved one is going
thru,
without some senses, her journey of ED, yet often unable to seek help and to remove
obstacles.”
Support response
“What helped the least?”
“I just wish we had more time.
This is such a safe and happy space for me and my mom.”
Client Response
“Leaving :) didn't want to go home.
Wanted to stay longer.
Time seemed to fly.
Today (and each day) are so packed with exciting new moments -
187
you can't help but want to stay. It makes getting healthy…happy!
I wish all moments of education could be so profound.”
Support response
Homework
1. Client and supports are asked to talk together to discuss WHAT non-negotiables each
wants to “hold the line” or uphold. For example, the client and support may agree on a meal
at an identified restaurant that meets the client’s servings. The meal is planned. The support
can ask, “Before we get out of the car, what is the non-negotiable for you at tonight’s meal?
What do you need from me to hold the line?”
2. Eat 100% of meal plan with supports.
3. Identify one go-to safe meal and one power out meal plan that meets serving
recommendations.
4. Meal plan logs.
5. Tuesday’s label reading exercise is due tomorrow morning.
188
Day 4: Thursday
Goal for Day 4

Landing Page.
Clients and supports explore and experience brain rewiring through an experiential activity
identifying the importance of matching the simplicity of new actions with the simplicity of
eating disorder actions.

Session 1
weight.
share.
189
Session 2
Goals
when needed.
Objectives
for each client.
of avoidance.
190
Client-Support Multifamily Input Session

Session 3
Goals
one’s own needs.
Objectives
1. To learn about the physical impact of eating disorders.

2. To learn how medication can be used to treat eating disorder symptoms, through
targeting co-occurring mental health disorders.
3. To experiment and learn what it takes to develop new methods to rewire the brain to do
healthier behaviors
Activity
1. A medical team member provides clients and supports information on key points
regarding biological and medical complications that develop as a result of anorexia nervosa.
191
2. This session is offered with all sitting in a circle, while the medical staff member facilitating
and answers questions.
3. The clients and supports both ask questions and offer input when relevant.
4. Some questions may include:
a. How does medication impact one’s personality?
b. Are medications addictive?
c. How do medications lower the eating disorder noise?
d. What are biological side effects of purging?
e. What are side effects of medications that lower anxiety?
f. What is the biological consequences of ongoing laxative abuse? Diuretic abuse?
Restriction? Excessive exercise without sufficient energy input?
g. Any questions about biology and neurobiology are open to be asked.
5. If the medical provider does not know the answer, then offer to research the answer and
get the current evidence back to the group by Friday.
6. In many cases, there may be no answers or researched solutions. Remind clients and
supports how relatively new eating disorder science is to understanding and responding to
the illness as a biologically based illness.
7. See training video on the Key’s Study.
8. Introduce outcome research for the 5-Day Treatment for Eating Disorders.
a. The clients and supports meet the research associate who will be calling them to
follow up on their status at three months, six months, and twelve months post-treatment.
b. The research associate explains the importance of research in the field of eating
disorders.
c. The research associate verbally explains the information from the consent form and
answers any questions the clients or supports may have.

Session 4
192
Objectives
1. Snacks are set out for clients to choose from.
a. Brisk walking. Requires a pre-designated route nearby for a five minute walk.
b. Yoga: Requires a pre-sequenced flow of light asana. Sequence should be fast paced
and practiced for five minutes.
c. Tai-Chi: Requires a pre-sequenced flow of tai chi poses paired with breathing
exercises. Sequence should be fast paced and practiced for five minutes.
Session 5
Goals
Objectives
1. Share the Thursday lecture points from the PowerPoint Strength in Connections: From
Brain to Friends & Family by Laura Hill, PhD found in Supplemental Materials on the
Landing Page.
2. Use PowerPoint talking points for Thursday found in Supplemental Materials on the
Landing Page.
193
3. Use clinical tool Wire-Rewire in Supplemental Materials on the Landing Page.

Session 6
Same objectives as breakfast.
Session 7
Goals
Objectives
1. This session is to complete goal 1 or begin goal 2. Only if there is time.

2. The Tool Box is to be review and instructions followed today.
3. Clients/supports identify their non-negotiables.
4. Identify how the primary goal/objectives align with the non-negotiables.
194
Session 8
Goals
the supports.
experiences.
Client Group
1. Apply the Distraction tool.

a. Ask each client to rate their anxiety from 0 to 10 in that moment. (0=no anxiety).
b. Start by passing the ball around in a circle. Have each client identify who they are
going to pass the ball to ahead of time and instruct each client to pass the ball to the same
person each time. After a few minutes, the therapist will add another ball into the game to be
passed in a round (ex., think of a choir singing a song in “rounds”), so that two balls are
being passed at the same time. After a few more minutes, the therapist will add another ball
into the game. The therapist may add up to four balls to the game before choosing to stop.
After the ball passing is complete, the therapist is to ask the clients if they have
been hearing their eating disorder noise during the game. Clients often respond that after
more balls were added to the game, it was hard for them to think of much
else besides passing the ball. This is to illustrate that sometimes it takes a
complicated/engaging distraction to effectively quiet eating disorder noise.
c. Play “I Spy.”
d. Each client is to rate their anxiety again from 0 to10.
2. Apply Grounding Tool by having the group walk around the room and:
195
a. Identify two things you see.
b. Identify two things you hear
c. Identify two textures you feel.
d. Than have each client is to rate their anxiety again 0 to10.
Supports Group
1. Facilitate a group discussion on self-care: how, when, where, and why.

2. Have supports sit in a circle or go outside to walk to a quiet place within nature.
3. Self-care points: Ask the supports what they used to do that was fun and gave them a
sense of renewal?
a. Just like their loved ones are identifying two to three “safe meals,” the supports need
to have simple things that are accessible to do when they need some energy, in order to
take care of themselves.
b. It may be a short period of time, such as an hour
c. Like the Wire-Rewire exercise, the supports need to wire in simple activities that give
them joy. If not, they will burn out.
d. Supports need to “wire in” and model self-care activities on a regular bases, either
daily or weekly. If not, they will burn out, just as their loved ones can relapse into their eating
disorders.
e. Self-care takes in new, refreshing energy that is needed regularly. If the supports don’t
give themselves specific time to care for themselves, they will be unable to keep supporting
and continuing to “hold the line” for their loved one.
f. Self-care is as necessary for the supports, as eating regularly is for their loved ones.
g. Even if it seems there is no time, or the demand of the loved one seems endless, it is
important to be honest, owning that they are exhausted or tired, by saying, “I need to go to
yoga class for the next 2 hours. I know you also need me to be with you right now, and Aunt
Bea is willing and able to text you while I am gone. I will be back and we can pick up from
there.”
4. Encourage each person to own their own thoughts, feelings, and ideas by using “I,”
instead of “you.” This shifts the locus of control internally and increases the potential to own
one’s own ideas and discoveries, instead of holding them outside themselves, via “When
you think” or “When you feel.”
196
5. Practice Honesty with Self tool.
6. Practice the Grounding tool at end of group.
a. Identify two things you see.
b. Identify two things you hear.
c. Identify two textures you feel.

Session 9
Objectives
1. Clients choose a snack that individually matches their prescribed meal plan, with supports
close by to confirm that the snack meets their macronutrient needs. Supports are then
asked to choose a snack for themselves.
End of Day Feedback

“Having the visual of our brain wiring and rewiring.

Redacted] said that the more we think and do something different the easier it will be to do it
instead of ED behavior.
It was awesome to see it physically represented before us with the string.”
Client response
197
“The family/support aspect is an incredible aspect -
especially for families that have been battling ED for a long time.
Equally important and helpful was the neurological basis for explaining the disease.
It's the first time I had heard of it and it made so much sense.
I knew [redacted] needed to come here to reset and reboot!
The practically mixed with the therapeutic aspects is an ideal method.”
Support response
“Being in my head a lot - not good - and I got through day.”

Client response
“I thought the whole program was incredibly engaging! This is working - keep it up!”
Support response
Homework
1. Eat 100% of meal plan.

2. Practice tools used Monday through this day.
3. Meal plan logs.
4. Safety meal plan and Power outage meal plan.
198
Day 5: Friday
Goals for the Day:

Landing Page.
1. Explore how, when, and where to use newly leaned tools to manage illness symptoms
and shift destructive traits toward recovery. Use ideas from one another.
2. Confirm commitment to the eating disorder Behavioral Agreement plan of action with total
client/support and treatment team signing the form
3. Summarize the role of the brain in eating disorders.

Session 1
weight.
learned and want yourself to remember from yesterday.
6. I would like us to learn from one another, by sharing and teaching one another.”
share.
199

Session 2
Goals
when needed.
Objectives
for each client.
of avoidance.
200
Client/Support Multifamily Input

Session 3
Goals
one’s own needs.
Objective
1. Provide an interactive activity that allows clients and supports to ask one another
questions that they want to explore further answers to help integrate ideas into their Tool
Box.
Group Activity
1. Provide clients and supports post-it notes on which they can write questions.
2. If the group is between five to eight people, each group member is instructed to write one
anonymous question for every other member of the group.
201
3. If the group is over eight people, the therapist divides the group into two halves and
separates family members from one another. The same action above is assigned for both
subgroups.
4. The leader could ask the following question of the clients and supports:
a. “What would you like to know about each person in the group regarding their treatment
experience this week?”
b. “Or their use of tools?”
c. “Or their plans for post treatment?”
d. “…that would help them better apply and picture how they might use the tools and
concepts from the 5-Day Treatment for Eating Disorders forward?”
5. The name of the person to whom the question is directed is written on the top of the
paper.
6. All of the questions are placed in a basket.
7. The clients, supports, and therapists pass the basket around, taking out one paper at a
time, reading it aloud.
8. This activity serves as a closing multi-family, interactive, input experience, where group
members are encouraged to reflect, share, plan, and be honest regarding their experiences
throughout the week and their feelings about transitioning home.
Food as Medicine: Dosing Macronutrients – Snack

Session 4
Objectives
1. Snack practical options are set out for clients to choose from.
a. The dietitian coaches and answers questions, while offering practical ways to measure
202
Session 5
Goals
Objectives
1. Share the Friday lecture points from the PowerPoint Strength in Connections: From Brain
to Friends & Family by Laura Hill, PhD found in Supplemental Materials on the Landing
Page.
B. Use PowerPoint talking points for Friday found in Supplemental Materials on the Landing
Page.
C. Use clinical tool Brain Wave found in Supplemental Materials on the Landing Page.

Landing Page.
Session 6
Same objectives that were stated for breakfast.
203
Session 7
Goals
Objectives
1. Review the 1-2 goals/objectives clients and supports plan to practice on page 13.
2. Discuss final discharge plans.
3. All parties sign Behavioral Agreement.
4. Make copies of the Behavioral Agreement for each party and for follow-up treatment
providers.

Session 8
Goals
204
the supports.
experiences.
Clients Tools
1. Address what to do when faced with transitions, as they prepare to leave the 5-Day
Treatment for Eating Disorders
2. Point out that clients with anorexia nervosa tend to have difficulty making and trusting
decisions and how their perfectionist trait increases their doubts.
a. WW__D: Discuss ways to compensate for their tendency to not trust their decisions by
using the following tool. All clients are asked to identify a person they highly admire for their
certainty and ability to make and trust decisions. Whoever that person is, the therapist asks,
“What would ____ person do in _____ (identified challenging time for the client) or when
challenges this weekend arise?” The client may be able to use this tool to help them plan
and decide what to do.
b. Review how their brain’s ventral striatum area, such as the nucleus accumbens, is not
firing a strong enough dopamine response to validate their decisions and, thus, doubt
persists for a long time.
c. Clients need to compensate for what they cannot trust themselves, just as a blind
person compensates for what they cannot see by using a Seeing Eye dog or walking by a
formula, or asking others to help guide them.
3. As clients choose a seat, rotate around the group with the same question and self-
identified application through the WW__ D tool, drawing in other clients to help when
needed.
4. As clients are beginning to reach out and help one another with applications for their
challenges, introduce the WWID4___ (what would I do for ___) tool.
a. Point out how clients know what to do for other clients, but have difficulty knowing
what to do for themselves.
b. Explain that this is understandable based on anorexia nervosa brain responses. The
brain appears to be “far sighted;” the sensitivity and detailed thinking of a person with
anorexia nervosa can detect what others need better than what they need themselves. It is
like having a far sighted brain.
205
5. Have each client practice WWID4___ (another client in the room) and have them self-
assess the amount of confidence they felt in helping another person with their uncertainty,
compared to helping themselves through their own uncertainty.
a. Practice and process their responses.
6. Apply WW__D and WWID4____ to the weekend ahead, addressing that, when in doubt,
and they can’t “see” what do to in the current situation (it is too near), the clients can use
these tools to think through the situation.
a. Using the analogy that clients with anorexia nervosa have good, proverbial “far
sightedness”, or a sense of knowing what another needs to do. WW___D helps them with
their own proverbial “nearsighted” problem.
b. Using tools like WW__D and WWID4____ helps the clients use their ability to see
clearly what others might do and apply that, as opposed to doubting themselves. This allows
them to retroflect their own approach by projecting it onto the ideal person and introject their
idea back into their own decision.
c. Discuss asking for help or advice regarding their questions or concerns.
d. Be honest that their anorexia nervosa brain appears to not fire strong enough in the
ventral area to confirm and trust decisions.
e. Plan ahead. The structure provides the proverbial bridge across the chasm of the
unknown.
f. The clients may feel angry that they need to ask for help. Drawing upon a dialectic of
their emotions, it can be said, “Yes, you are angry AND humbled that you need to ask for
help. Both are true and both make up your truth. You need your anger to energize you to
take action, since anger is an action emotion, AND you need your humility to ask.”
g. A biological parallel could be shared to normalize the need to compensate for what the
brain is not firing in the ventral striatum. “If you need to wear glasses, it is because your
optic nerves are not firing in a manner that allow you to see all things around you clearly.
You may feel angry that you have to wear glasses or contacts. And you still need to seek
help, by getting your sight assessed, then creating the structure, and also the ritual of
wearing your glasses or contacts daily, to compensate for what your brain cannot fire
accurately.”
7. Facing transitions: Asking for help could be applied productively, such as, “I am brain
blind in trusting my decisions. Would you help me think this through?”
8. Clients may, at initial stages, recognize the need for ongoing planning and detailed
structure. A typical question posed by the clients has been, “How long will I need to ask for
help?” A typical, biologically oriented response can be, “How long will you need to wear
glasses or contacts?” Some grow out of the need and others need them forever, but
wearing glasses has never stopped anyone from living a successful and healthy life. It
simply needs to always be a part of the one’s life to ‘see’ better.”
206
a. The great thing about optics is that now surgery has been developed for certain
conditions to insert lenses in the eyes that permanently correct for far sightedness or near
sightedness. The field of eating disorders is not yet there. It has just begun to identify the
areas of the brain where the misfiring is occurring. They are multiple, not singular.
b. In the meantime, the client needs to seek help, to compensate for ventral misfiring,
and ask for help from one who can “see the decision more clearly.
9. Clients with anorexia nervosa tend to see their mistakes over their successes (trait) and
expect themselves to be perfect (trait). This complicates their decision making and makes
their ability to trust new transitions harder.
a. Acknowledge their traits by pointing out that it takes their own determination, with their
support persons, to help them with decision making.
b. Remind clients of the self-critique tool that forces them to see what they would do
again, BEFORE they focus on what they would not do again.
10. A story could also be told here to address that perfection is imperfect. See “The Perfect
Diamond” story.
11. Regarding transitions, the first time a new structure is planned, just like the wire-rewire
exercise, the client may need help. A person cannot build a bridge across a chasm alone.
Asking for help means the clients must humble themselves. Not being able to structure the
bridge alone seems weak. It takes humility to ask for help. Asking for help is the carbon in
the diamond. Humility is a foundation for strength.
a. Responding in the same way, repeatedly builds the bridge across the transitional
chasm and allows them to be able to focus on other things instead of their doubts.
b. Repetition is not only an option, it is an excellent way for the clients to move forward.
Supports Group
1. The therapist leads a variation of the game Charades to try on, practice, and remember
the tools used this past week.
2. A package of Tool Magnets is given to each support. The client/support tools are put on a
word documents and printed on magnetic sheets.
a. All supports are asked to take out the magnets and put them face up on their table.
b. The therapist calls upon one support and asks him/her to choose a tool they’d like to
“try on” and “do it live,” by moving or saying something that they would say if using that tool.
c. The therapist asks one support to the front and demonstrate the tool.
207
d. The other supports look at their magnet options and guess which tool is being
expressed.
e. Once the tool has been demonstrated, all supports are to turn it over to not use it
again during the game.
f. Whoever guesses correctly gets to do the next tool of their choice.
g. This is played among the supports until all tools are practiced.
3. The therapist asks each support to put the top three tools they plan to use the most.
a. State that, when they get home, they are to take out their magnets and put them on
their refrigerator with the top three tools at the top.
b. Arranged them by the day or week as they use them, to keep the tools active and the
magnets to remind them of the tools.
Food as Medicine: Dosing Macronutrients - Snack and End of Day/Week Summary

Session 9
Objectives
1. Clients choose a snack that individually matches their prescribed meal plan, with supports
close by to confirm that the snack meets their macronutrient needs. Supports are then
asked to choose a snack for themselves.
2. Closing Clinical Tools: Two Clinical Tool games are played as a culmination of the week
and to address social pressures that lay ahead. The first is directed to the clients and the
second to supports.
3. Running the Gauntlet (See written instructions and video).
4. “Holding the Line”
a. All supports and treatment team form a “C” and the clients are asked to step inside the
“C”
b. The “”C” stands for “Centered.”
c. The line of the “C” is the line the team is holding together, so that the clients do not go
backwards, but are encouraged to work with the support provided by all standing around
208
them and move forward out to other activities in life, not back into their eating disorder.
d. The team forming a “C” is “Tootsie’s butt strap.”
e. The team encourages, believes, and works with the clients to continue to sustain and
use the tools that work for them to best direct their traits and manage their symptoms.
f. It is not an option to go backwards, they must move forward into the proverbial trailer
that takes the clients to their desired places.
5. End of Day Forms:
a. Fill out the End of Day and End of Week Feedback Forms.
b. Clients and supports take home their the 5-Day Treatment for Eating Disorders
Manuals to use as ongoing reminders of information, tools, their personal notes, and forms.
6. Complete post-testing.
End of Day Feedback

"The questions to other families was incredible! Definitely, definitely keep that, very
powerful."
Client response
“The best part was learning and "trying on" the tools we learned to help support our
daughter.”
Support response
“The multi-family Q&A was a good time to reflect on the week and the support my family has
shown over the years.
I've really appreciated the collaborative approach CBL encourages,
and how it takes into account the preferences of the client as well as the supports…” -
209
Support person of an adult with AN
Left blank.
Post-Treatment Testing
1. Actions completed by program associate post-treatment within one working day.

2. ROIs are to have been collected before or during the program orientation. Any additional
ROIs are signed at the time the Behavioral Agreement is filled out.
3. Email via encrypted message the following:
a. Behavioral Agreement sent to: (pending on how the client indicates on page 16 of the
Behavioral Agreement)
i. Home physician or treatment program into which the client is entering.
ii. Home therapist.
iii. Home dietitian.
210
Outcome Data: Quantitative & Qualitative
Outcome Data: Quantitative & Qualitative ----- Chapter 11
Quantitative Data
All clinical quantitative data is in publication. Find below data for end-of-week program
component ratings and average change from pre to post-testing for clients and supports'
nutrition knowledge.
Chart 1 Average end-of-week ratings of clients and supports through May 2017.
211
From pre to post-test, clients (n=90) saw an average of a 40% increase in nutrition
knowledge. Supports (n=133) saw an average of a 66% increase.
Qualitative Data
Responses to the questions below were chosen at random and consist of client and support
feedback from January 2017 - May 2017.
What helped the most?
1. "ED noise sound clip, handwriting activity... and history of eating disorder research (we
are 100 years behind)."
2. "I appreciate the 2p-3p session, where we finalized and challenged the [Behavioral
Agreement]."
3. "Good day overall - very informative...medical effects of ED and expectations during
recovery."
4. "Everything we did today was extremely useful. Loved going outside/the talk about
medication was great. (Nurse practitioner)'s personality is very open and her knowledge is
impressive."
5. "I really enjoy all of the interactive activities that you incorporate to help us understand
skills and the way the brain works. I also really like how much each team member validates
everything I say and feel. It makes me feel like I am not crazy or thinking in a way that is
deemed that way."
6. "I liked everything about today. I was amazed at the knowledge and commitment of the
staff and the willingness to (adapt) the program to each client's needs."
7. "1. Planning for the day after with food. Thoughts and plans for our trip home. Question
and answer to the clients and supports. 3. Talks all week with (case manager) were
amazing."
8. "Being able to practice choosing and portioning our meals and snacks on our own."
9. "It definitely was helpful to not have to make food choices (on the first day of treatment)."
10. "The landmine activity turned out to be surprisingly deep! We all keep referring back to it
with new insights."
212
11. "Reimagining ED as a biological disease was really helpful, especially when it comes to
specific practices and treatment."
12. "Anxiety wave mapping and supports wave mapping. Neurobiology discussion and
nucleus accumbens. Kid-swap and discussion. Behavior contracting. Hold the line training."
What helped the least?
1. "I'm sure it's a matter of logistics but we were told to be here at 8 (waking up at 7:30) but
also that we should eat no more than an hour after waking up."
2. "(blank)."
3. "More time with (psychologist)? As far as the studies and research go. Earlier in the week
as well."
4. "Wish we could extend the program!"
5. "Honestly can't think of anything right now."
6. Today the team did everything wonderfully - I honestly would not have wanted the day to
go any differently.
7. "Nothing."
8. "The [P]ower[P]oint in the afternoon - it was dull and repetitive. I fell asleep."
9. "Nutrition calculations."
10. "All extremely helpful."
11. "Not a rest break. I got sleepy in the afternoon!"
12. "(blank)."
What is your take home message?
1. "While I have every trait predisposing me to AN, I can use those to my benefit. I am my
traits and that is not bad. This is the first time I've heard my traits are 'good,' not 'bad.'"
2. "To make a deep mental path, we must think over and over the kind of thoughts we wish
to dominate our lives. We are capable of change! Who knew?"
213
3. "Many new facts - esp. that malnutrition proceeds and causes the psychological
symptoms of ED."
4. "Distraction is key."
5. "My take home message is that when my anxiety is so high that I can't function, I need to
use the stop, reboot, reroute skill to stop the cycle of thoughts ruminating."
6. "It's biologically based. Food is medicine. Healing a dose at a time."
7. "My wife needs help and support. I need to be there for her all the time - not just when
she needs me for her ED."
8. "Stop, reboot, reroute to disrupt ED behaviors."
9. "I think although I had read that ED's are brain based, it helped to really understand the
biology/neuroscience."
10. "As a support, be aware of their noise and times that it is going to be its loudest."
11. "ED's are brain/biologically based."
12. "It is important to have open communication between myself and supports."
214
Terms
Terms
Term Definition
ACC Anterior Cingulate Cortex
ACT Action and Commitment Therapy
AED Academy for Eating Disorders
Amygdala The brain's "fear hub," which activates our natural "fight-or-flight" response to confront or escape from a dangers situation. A
central site of emotional responses.
ANGI Anorexia Nervosa Genetics Initiative
Anterior Toward the front.
Anterior Cingulate Abbreviated as ACC. "[H]as many different roles, from controlling blood pressure and heart rate to responding to when we sense
Cortex a mistake, helping us feel motivated and stay focused on a task, and managing proper emotional reactions."
https://www.nimh.nih.gov/health/educational-resources/brain-basics/brain-basics.shtml
Anxiolytic Lowering or reducing anxiety.
Axon "Sends impulses and extends from cell bodies to meet and deliver impulses to another nerve cell. Axons can range in length
from a fraction of an inch to several feet." https://www.nimh.nih.gov/health/educational-resources/brain-basics/brain-basics.shtml
Axon The long, fiber-like part of a neuron that sends information out from the neuron body.
Behaviors Actions that can be healthy, destructive or neutral. By using "behaviors" to indicate "eating disorder behaviors," the therapist is
implicitly removing the very resource that is the desired treatment goal: healthy behaviors. This can repeatedly sabotage the
treatment direction. When adding the accurate adjective that describes the behavior being addressed, the therapist is
therapeutically directing the course of treatment.
CBT Cognitive Behavioral Therapy
CBT-E Enhanced Cognitive Behavioral Therapy
Cell The central part of the neuron, "which includes the nucleus...that contains DNA and information that the cell needs for growth,
metabolism, and repair." https://www.nimh.nih.gov/health/educational-resources/brain-basics/brain-basics.shtml
Cell Body The nucleus or core of a cell filled with cytoplasm, the chemical substance and parts needed for the cell to work properly.
Client The term The Center for Balanced Living uses to refer to patients. A poll has been taken in the 5-Day Treatment for Eating
Disorders, and persons with eating disorders ask to be addressed as clients (not patients), reporting they feel more a part of the
team verses a passive agent being treated for the illness.
Clinical Tool the detailed brain-based interactive intervention developed and described in Supplemental Materials
Corpus Callosum A wide band, or neuron fibers, connecting and relaying signals from one hemisphere to the other.
DBT Dialectical Behavioral Therapy
Dendrite The point of contact that receives the neurotransmitter or electrical message in a neuron. It is like the branches of a tree, having
many dendrites branching off from the cell body. "[B]ranch[es] off from the cell body and act[s] as a neuron's point of contact for
receiving chemical and electrical signals called impulses from neighboring neurons."
Dendrite button Round projection extended from the dendrite that takes in the neurochemical message.
DLPFC Dorsolateral Prefrontal Cortex: Brain area behind the forehead where cognitive thoughts reside that work to establish a plan of
action and makes decisions. Seat of the brain's executive functions, such as judgement, decision making and problem solving
DNA The "recipe of life," containing inherited genetic information that helps to define physical and some behavioral traits.
Dopamine "[A] neurotransmitter mainly involved in controlling movement and aiding the flow of information to the front of the brain, which is
linked to thought and emotion. It is also linked to reward systems in the brain." https://www.nimh.nih.gov/health/educational-
resources/brain-basics/brain-basics.shtml
Dorsal The upper side, or toward the top.
DSM Diagnostic and Statistical Manual for Mental Disorders
ED Eating Disorder
EF Endurance Fuels, aka dietary fats or fat.
Endurance Fuel Term used at The Center for Balanced Living to replace the term "fats" in order to remove the stigma clients with eating
disorders have for the macronutrient.
Environmental "...[O]our physical surroundings...and factors that can affect our bodies, such as sleep, diet, or stress."
Influences https://www.nimh.nih.gov/health/educational-resources/brain-basics/brain-basics.shtml
Epigenetics "The study of how environmental factors like diet, stress and post-natal care can change gene expression (when genes turn on
or off) - without altering DNA sequence." "[T]he study of how environmental factors can affect how a given gene operates. But
unlike gene mutations, epigenetic changes do not change the code for a gene. Rather, they effect when a gene turns on or off to
produce a specific protein." https://www.nimh.nih.gov/health/educational-resources/brain-basics/brain-basics.shtml
Family Parents are the most common support for children and adolescents, while for the adult, the term "family" includes parents,
children, aunts, uncles, grandparents and spouses.
fMRI Functional Magnetic Resonance Imaging. A 3-D neuroimaging procedure that tracks functional activities using MRI technology to
measure brain activity by detecting changes associated with blood and oxygen flow.
Gene "[A] segment of DNA that contains codes to make proteins and other important body chemicals. DNA also includes information to
control which genes are expressed and when, in all the cells of the body." https://www.nimh.nih.gov/health/educational-
Genotype The genetic portion of a person's makeup, determined via the DNA in each cell.
215
Glutamate "The most common neurotransmitter, glutamate has many roles throughout the brain and nervous system. Glutamate is an
excitatory transmitter: when it is released it increases the chance that the neuron will fire. This enhances the electrical flow
among brain cells required for normal function...It may also assist in learning and memory."
GWAS Genome-Wide Associate Studies
GWAS Genome-Wide Association Study
Hippocampus A part "of the brain involved in creating and filing new memories." "Helps create and file new memories."
Homunculus A distorted image of a human being.
ICAT Integrative Cognitive-Affect Therapy
Impulse "An electrical communication signal sent between neurons by which neurons communicate with each other."
Inside out For the purpose of this book, "inside out" refers to interventions that directly impact and alter the brain
IPT Interpersonal Therapy
Lateral Toward the side, away from the middle.
Limbic A complex group of brain areas where emotions reside and are remembered. Means "ring."
Movement "Communication between neurons can also be electrical, such as in areas of the brain that control movement."
MRI Magnetic Resonance Imaging "An imaging technique that uses magnetic fields to take pictures of the brain's structure."
myelin Substance that covers axons, made from fats or endurance fuels
NEDA National Eating Disorders Association
Neural Circuit "A network of neurons and their interconnections." https://www.nimh.nih.gov/health/educational-resources/brain-basics/brain-
basics.shtml
Neuron "A nerve cell that is the basic, working unit of the brain and nervous system, which processes and transmits information."
Neuron Body The central part of the neuron, "which includes the nucleus...that contains DNA and information that the cell needs for growth,
metabolism, and repair." https://www.nimh.nih.gov/health/educational-resources/brain-basics/brain-basics.shtml
Neurotransmitter "A chemical produced by neurons that carries messages to other neurons." https://www.nimh.nih.gov/health/educational-
NIH National Institute of Health
NIMH National Institute of Mental Health
OFC Orbitofrontal Cortex
Outside in For the purpose of this text, "outside in" refers to interventions that focus on behaviors, cognitive and emotional brain outward
expressions
Perseverating Overthinking, caused by over-firing in the dorsolateral prefrontal cortex.
Personality One's stabilized character patterns that evolve over time, developed from both genetic and environmental influences,
establishing one's fundamental character expression. Personality has been defined separately from temperament int he past, yet
can be used complimentarily.
PET Positron Emission Tomography
Phenotype A person's characteristics that include both genetic and environmental influences.
Posterior Toward the back.
RO-DBT Radically Open Dialectical Behavioral Therapy
Serotonin "[A] neurotransmitter that helps control many functions, such as mood, appetite, and sleep."
Skill For the purposes of this text, a "skill" is a competency one learns or acquires to improve one's health or ability to function; and a
"tool" is the method to learn or acquire the skill.
SPECT Single-Photon Emission Computerized Tomography
Striatum Consists of the caudate (area that contributes to pros and cons) and putamen (refined movement, including chewing, which
functions automatically).
Supports This text uses "Supports" instead of "Family" or "Carers" because it extends beyond family members and does not assume that
the supports will be taking care of the client. Supports include: parents, spouses, partners, friends, ministers, work colleagues,
school/college friends, neighbors and anyone who the client chooses to share with and learn together new treatment tools and
will be an active support in the client's life.
Synapses "Tiny gaps between neurons, where messages move from one neuron to another as chemical or electrical signals."
Temperament Individual differences in response to external and internal, self-regulated, genetic and environmental influences over time.
Temporal Lobe Located at the temple area of the forehead.
Terminal button Rounded area at the end of the axon that sends the neurochemical into the synaptic space.
TMS Transcranial Magnetic Stimulation
Tool For the purposes of this text, a "skill" is a competency one learns or acquires to improve one's health or ability to function; and a
Tool Box List and explanation of both client and supports simple daily tools they can use to help manage traits and symptoms.
Tools For the purposes of this text, a "skill" is a competency one learns or acquires to improve one's health or ability to function; and a
216
Trait A feature that has a relatively enduring, behavioral disposition, established and shaped genetically and environmentally. Also
referred to as "character."
Vasopressin Pronounced (v-z-pre-sn). A hormone, released form the pituitary gland, which is an antidiuretic. It keeps the body from losing too
much water.
Ventral The lower side, or toward the bottom.
Ventral Striatum Consists of the nucleus accumbens (signals reward and pleasure) and the olfactory sensation nerves, both of which function
automatically.
217
References
References
1:
American Psychiatric Association. (1952). Diagnostic and Statistical Manual of Mental

Disorders (1st ed.). Washington, DC: American Psychiatric Association.
2:

Disorders (5th ed.). Washington, DC: American Psychiatric Association.
3:
Fairburn, C. G. (2013). Overcoming Binge Eating, Second Edition: The Proven Program to
Learn Why You Binge and How You Can Stop. New York, NY: The Guilford Press.
4:
Agras, W. S. & Apple, R. F. (2008). Overcoming Eating Disorders: A Cognitive-Behavioral

Therapy Approach for Bulimia Nervosa and Binge-Eating Disorder (Treatments That Work)
(2nd ed). New York, New York: Oxford University Press, Inc.
5:
Fairburn, C. G. (2008). Cognitive Behavior Therapy and Eating Disorders. New York, NY:
The Guilford Press.
6:
Linehan, M. M. (2015). DBT Skills Training Manual (2nd ed.). New York, NY: The Guilford
Press.
7:
McKay, M., Wood, J. C., Brantley, J. (2007). The Dialectical Behavior Therapy Skills
Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness,
Emotion Regulation, & Distress Tolerance (1st ed.). Oakland, CA: New Harbinger
Publications, Inc.
8:
Linehan, M. M. (2015). DBT Skills Training Handouts and Worksheets (2nd ed.). New York,
NY: The Guilford Press.
9:
Wilfley, D. E., Welch, R. R., Stein, R. I., Spurrell, E. B., Cohen, L. R., Saelens, B. E.,
Dounchis, J. Z., Frank, M. A., Wiseman, C. V., Matt, G. E. (2002). A randomized comparison
of group cognitive-behavioral therapy and group interpersonal psychotherapy for the
treatment of overweight individuals with binge-eating disorder. Archives of General
218
Psychiatry, 59(8), 713-721. doi: 10.1001/archpsyc.59.713
10:
Murphy, R., Straebler, S., Basden, S., Cooper, Z., Fairburn, C. G. (2012). Interpersonal
psychotherapy for eating disorders. Clinical Psychology & Psychotherapy, 19(2), 150-158.
doi:10.1002/cpp.1780
11:
Wonderlich, S. A., Peterson, C. B., Smith, T. L. (2015). Integrative Cognitive-Affective

Therapy for Bulimia Nervosa: A Treatment Manual. New York, NY: Guilford Publications.
12:
Treasure, J., Zipfel, S., Micali, N., Wade, T., Stice, E., Claudino, A., Schmidt, U. Frank, G.
K., Bulik, C. M., Wentz, E. (2015). Anorexia nervosa. Nature Reviews Disease Primers, 1, 1-
21. doi: 10.1038/nesp.2015.74
13:
Hill, L., Knatz, S., Wierenga, C., Kaye, W. (2016). Applying Neurobiology to the Treatment of
Adults with Anorexia Nervosa. Journal of Eating Disorders, 4(31), 1-14.
14:
Hay, P. J., Touyz, S., Sud, R. (2012). Treatment for severe and enduring anorexia nervosa:
a review. Australian & New Zealand Journal of Psychiatry, 46(12), 1136-1144. doi:
10.1177/0004867412450469
15:
Touyz, S., Le Grange, D., Lacey, H., Hay, P., Smith, R., Maguire, S., Bamford, B., Pike, K.
M., Crosby, R. D. (2013). Treating severe and enduring anorexia nervosa: a randomized
controlled trial. Psychology Medicine, 43(12), 2501-2511. doi: 10.1017/S0033291713000949
16:
Bulik, C. M., Berkman, N. D., Brownley, K. A., Sedway, J. A., Lohr, K. N. (2007). Anorexia
nervosa treatment: A systematic review of randomized controlled trials. International Journal
of Eating Disorders, 40(4), 310-320. doi: 10.1002/eat.20367
17:
Brown, T. A. & Keel, P. K. (2012). Current and emerging directions in the treatment of eating
disorders. Journal of Substance Abuse, 6, 33-61. doi: 10.4137/SART.S7864
18:
Galsworthy-Francis, L. & Allan, S. (2012). Cognitive Behavioural Therapy for anorexia

nervosa: A systematic review. Clinical Psychology Review, 34(1), 54-72. doi:
219
10.1016/j.cpr.2013.11.001
19:
Rigaud, D., Brondel, L., Poupard, A. T., Talonneau, I., Brun, J. M. (2007). A randomized trial
on the efficacy of a 2-month tube feeding regimen in anorexia nervosa: A 1-year follow-up
study. Clinical Nutrition, 26(4), 421-429. doi: 10.1016/j.clnu.2007.03.012
20:
McIntosh, V. V. W., Jordan, J. Carter, F. A., Luty, S. E., McKenzie, J. M., Bulik, C. M.,
Frampton, C. M. A., Joyce, P. R. (2005). Three Psychotherapies for Anorexia Nervosa: A
Randomized, Controlled Trial. The American Journal of Psychiatry, 162(4), 741-747. doi:
10.1176/appi.ajp.162.741
21:
Channon, S., de Silva, P. Hemsley, D., Perkins, R. (1989). A controlled trial of cognitive-
behavioural and behavioural treatment of anorexia nervosa. Behavior Research and
Therapy, 27(5), 529-535. doi: 10.1016/0005-7967(89)90087-9
22:
Ball, J. & Mitchell, P. B. (2004). A Randomized Controlled Study of Cognitive Behavior

Therapy and Behavioral Family Therapy for Anorexa Nervosa Patients. Eating Disorders, 12
(4), 303-314. doi: 10.1080/10640260490521389
23:
Dahlgren, C. L., Lask, B., Landrø, N. I., Rø, Ø. (2013). Neuropsychological functioning in
adolescents with anorexia nervosa before and after cognitive remediation therapy: A
feasibility trial. International Journal of Eating Disorders, 45(6), 576-581. doi:
10.1002/eat.22155
24:
Steinglass, J. E., Albano, A. M., Simpson, H. B., Wang, Y., Zou, J., Attia, E., Walsh, B. T.
(2014). Confronting fear using exposure and response prevention for anorexia nervosa: A
randomized controlled pilot study. International Journal of Eating Disorders, 47(2), 174-180.
doi: 10.1002/eat.22214
25:
Tchanturia, K., Lloyd, S., Lang, K. (2013). Cognitive remediation therapy for anorexia
nervosa: Current evidence and future research directions. International Journal of Eating
Disorders, 46(5), 492-495. doi: 10.1002/eat.22106
26:
Zuchova, S., Erler, T., Papezova, H. (2013). Group cognitive remediation therapy for adult
anorexia nervosa inpatients: first experiences. Eating and Weight Disorders, 18(3), 269-273.
220
doi: 10.1007/s40519-013-0041-z
27:
Lock, J. (2015). An Update on Evidene-Based Psychosocial Treatments for Eating

Disorders in Children and Adolescents. Journal of Clinical Child & Adolescent Psychology,
45(5), 1-15. doi: 10.1080/15374416.2014.971458
28:
Lock, J. & le Grange, D. (2001). Can Family-Based Treatment of Anorexia Nervosa Be

Manualized? The Journal of Psychotherapy Practice and Research, 10(4), 253-261.
29:
Lock, J., le Grange, D. (2005). Family-based treatment of eating disorders. International

Journal of Eating Disorders, 37(S1), S64-S67. doi: 10.1002/eat.20122
30:
Loeb, K. L., & le Grange, D. (2009). Family-Based Treatment for Adolescent Eating
Disorders: Current Status, New Applications and Future Directions. International Journal of
Child and Adolescent Health, 2(2), 243-254. doi: 10.2147/AHMT.S115775
31:
Lock, J. & le Grange, D. (2015). Treatment Manual for Anorexia Nervosa: A Family-Based
Approach, Second Edition. New York, NY: The Guilford Press.
32:
Murray, S. & Anderson, L. (2016). Innovations in Family Therapy for Eating Disorders: Novel
Treatment Developments, Patient Insights, and the Role of Carers. New York, NY:
Routledge.
33:
Allen, K. L., O’Hara, C. B., Bartholdy, S., Renwick, B., Keyes, A., Lose, A., Kenyon, M.,
DeJong, H., Broadbent, H., Loomes, R., McClelland, J., Serpell, L., Richards, L., Johnson-
Sabine, E., Boughton, N., Whitehead, L., Treasure, J., Wade, T., Schmidt, U. (2016). Written
case formulations in the treatment of anorexia nervosa: Evidence for therapeutic benefits.
International Journal of Eating Disorders, 49(9), 874-882. doi: 10.1002/eat.22561
34:
Schmidt, U., Oldershaw, A., Jichi, F., Sternheim, L., Startup, H., McIntosh, V., Jordan, J.,
Tchanturia, K., Wolff, G., Rooney, M., Landau, S., Treasure, J. (2012). Out-patient
psychological therapies for adults with anorexia nervosa: randomized controlled trial. The
British Journal of Psychiatry, 201(5), 392-399. doi: 10.1192/bjp.bp.112.112078
35:
221
Schmidt, U., Wade, T. D., Treasure, J. L. (2014). The Maudsley Model of Anorexia Nervosa
Treatment for Adults (MANTRA): Development, Key Features, and Preliminary Evidence.
Journal of Cognitive Psychotherapy, 28(1), 48-71. doi: 10.1891/0889-8391.28.1.48
36:
Epstein, L. H., Valoski, A., Wing, R. R., McCurley, J. (1994). Ten-year outcomes of
behavioral family-based treatment for childhood obesity. Health Psychology, 13(5), 373-383.
37:
Knatz, S., Murray, S. B., Matheson, B., Boutelle, K. N., Rockwell, R., Eisler, I., Kaye, W. H.
(2015). A Brief, Intensive Application of Multi-Family-Based Treatment for Eating Disorders.
Journal of Eating Disorders, 23(4), 315-324. doi: 10.1080/10640266.2015.1042318
38:
Marzola, E., Knatz, S., Murray, S. B., Rockwell, R., Boutelle, K., Eisler, I., Kaye, W. H.
(2015). Short-Term Intensive Family Therapy for Adolescent Eating Disorders: 30-Month
Outcome. European Eating Disorders Review. doi: 10.1002/erv.2353
39:
Lynch, T. R., Gray, K. L. H., Hempel, R. J., Titley, M., Chen, E. Y., O’Mahen, H. A. (2013).
Radically open-dialectical behavior therapy for adult anorexia nervosa: feasibility and
outcomes from an inpatient program. BMC Psychiatry, 13(293). doi: 10.1186/1471-244X-13-
293
40:
Lynch, T. R., Hempel, R. J., Dunkley, C. (2015). Radically Open-Dialectical Behavior

Therapy for Disorders of Over-Control: Signaling Matters. American Journal of
Psychotherapy, 69(2), 141-162.
41:
Treasure, J., Nazar, B. (2016). Interventions for the carers of patients with eating disorders.
Current Psychiatry Reports, 18(16). doi: 10.1007//S11920-015-0652-3
42:
Insel, T. (2013, January). Toward a new understanding of mental illness [Video file].
Retrieved from
https://www.ted.com/talks/thomas_insel_toward_a_new_understanding_of_mental_illness?l
anguage=en
43:
TEDx. (2013, February 8). Mental Disorders as Brain Disorders: Thomas Insel at
TEDxCaltech [Video file]. Retrieved from https://www.youtube.com/watch?v=u4m65sbqbhY
44:
222
Schizophrenia. Retrieved from
https://www.nimh.nih.gov/health/statistics/prevalence/schizophrenia.shtml
45:
What Are Eating Disorders? Retrieved from https://www.nationaleatingdisorders.org/get-

facts-eating-disorders
46:
Estimates of Funding for Various Research, Condition, and Disease Categories (RCDC).
(2017, May 26). Retrieved form https://report.nih.gov/categorical_spending.aspx
48:

Disorders, Third Edition. Arlington, VA: American Psychiatric Association.
49:
Chavez, M. & Insel, T. R. (2007). Eating Disorders: National Institute of Mental Health’s
Perspective. American Psychology, 62(3), 159-166. doi: 10.1037/0003-066X.62.3.159
50:
Klump, K., Bulik, C., Kaye, W. H., Treasure, J. L., Tyson, E. (2009). Academy for Eating
Disorders Position Paper: Eating Disorders Are Serious Mental Illnesses. International
Journal of Eating Disorders, 42(2), 97-103. doi: 10.1002/eat.20589
51:
Swidorski, D. (2014, January 22). Diabetes History. Retrieved from

https://www.defeatdiabetes.org/diabetes-history/
52:
Brain Basics. Retrieved from https://www.nimh.nih.gov/health/educational-resources/brain-

basics/brain-basics.shtml
53:
Kaye, W. H., Fudge, J. L., Paulus, M. (2009). New insights into symptoms and neurocircuit
function of anorexia nervosa. Nature Reviews Neuroscience, 10(8), 573-584. doi:
1038/nrn2682
54:
Glasser, M. F., Coalson, T. S., Robinson, E. C., Hacker, C. D., Harwell, J., Yacoub, E.,
Ugurbil, K., Andersson, J., Beckmann, C. F., Jenkinson, M., Smith, S. M., Van Essen, D. C.
(2016). A multi-modal parcellation of human cerebral cortex. Nature, 536(7615), 171-178.
doi: 10.1038/nature18933
223
55:
Campbell, I. C., Mill, J., Uher, R., Schmidt, U. (2011). Eating disorders, gene-environment
interactions and epigenetics. Neuroscience & Biobehavioral Reviews, 35(3), 784-793. doi:
10.1016/j.neubiorev.2010.09.012
56:
Kaye, W. H. & Bailer, U. F. (2011). Understanding the Neural Circuitry of Appetitive

Regulation in Eating Disorders. Biological Psychiatry, 70, 704-705. doi:
10.1016/j.biopsych.2011.08.018
57:
Atiye, M., Miettunen, J., Raevuori-Helkamaa, A. (2015). A meta-analysis of temperament in

eating disorders. European Eating Disorders Review, 23(2), 88-99. doi: 10.1002/erv.2342
58:
Bulik, C. M., Sullivan, P. F., Tozzi, F., Furberg, H., Lichtenstein, P., Pedersen, N. L. (2006).
Prevalence, heritability, and prospective risk factors for anorexia nervosa. Archive of
General Psychiatry, 63(3), 305-312. doi: 10.1001/archpsyc.63.3.305
59:
Munn, M. A., Stallings, M. C., Rhee, S. H., Sobik, L. E., Corley, R. P., Rhea, S. A., Hewitt, J.
K. (2010). Bivariate analysis of disordered eating characteristics in adolescence and young
adulthood. International Journal of Eating Disorders, 43(8), 751-761. doi: 10.1002/eat.20854
60:
Wade, T., Martin, N. G., Tiggermann, M. (1998). Genetic and environmental risk factors for
the weight and shape concerns characteristic of bulimia nervosa. Psychological Medicine,
28(4), 761-771.
61:
Kothari, R., Barona, M., Treasure, J., Micali, N. (2015). Social cognition in children at familial
high-risk of developing an eating disorder. Frontiers in Behavioral Neuroscience, 9(208). doi:
10.3389/fnbeh.2015.00208
62:
Spanos, A., Burt, S. A., Klump, K. L. (2010). Do weight and shape concerns exhibit genetic
effects? Investigating discrepant findings. International Journal of Eating Disorders, 43(1),
29-34. doi: 10.1002/eat.20666
63:
Hinney, A., Kesselmeier, M., Jall, S., Volckmar, A. L., Focker, M., Antel, J., Heid, I. M.,
Winkler, T. W., Grant, S. F., Guo, Y., Bergen, A. W., Kaye, W., Berettini, W., Hakonarson,
224
H., Herpertz-Dahlmann, B., de Zwaan, M., Herzog, W., Ehrlich, S., Zipfel, S., Egberts, K. M.,
Adan, R., Brandys, M., van Elburg, A., Boraska Perica, V., Franklin, C. S., Tschop, M. H.,
Zeggini, E., Bulik, C. M., Collier, D., Scherag, A., Muller, T. D., Hebebrand, J. (2017).
Evidence for three genetic loci involved in both anorexia nervosa risk and variation of body
mass index. Molecular Psychiatry, 22(2), 192-201. doi: 10.1038/mp.2016.71.
64:
Duncan, L., Yilmaz, Z., Gaspar, H., Walters, R., Goldstein, J., Anttila, V., Bulik-Sullivan, B.,
Ripke, S., Eating Disorders Working Group of the Psychiatric Genomics Consortium,
Thornton, L., Hinney, A., Daly, M., Sullivan, P. F., Zeggini, E., Breen, G., Bulik, C. M. (2017).
Significant Locus and Metabolic Genetic Correlations Revealed in Genome-Wide
Association Study of Anorexia Nervosa. American Journal of Psychiatry. doi:
10.1176/appi.ajp.2017.16121402
65:
Kleiman, S. C., Watson, H. J., Bulik-Sullivan, E. C., Huh, E. Y., Tarantino, L. M., Bulik, C.
M., Carroll, I. M. (2015). The Intestinal Microbiota in Acute Anorexia Nervosa and During
Renourishment: Relationship to Depression, Anxiety, and Eating Disorder Psychopathology.
Psychosomatic Medicine, 77(9), 969-981. doi: 10.1097/PSY.0000000000000247
66:
Wagner, A., Simmons, A. N., Oberndorfer, T. A., Frank, G. K., McCurdy-McKinnon, D.,
Fudge, J. L, Yang, T. T., Paulus, M. P., Kaye, W. H. (2015). Altered sensitization patterns to
sweet food stimuli in patients recovered from anorexia and bulimia nervosa. Psychiatry
Research, 234(3), 305-313. doi: 10.1016/j.psychresns.2015.10.010
67:
Humbert, I. A. & Joel, S. (2012). Tactile, gustatory, and visual biofeedbackstimuli modulate
neural substrates of deglutition. Neuroimage, 59(2), 1485-1490. doi:
10.1016/j.neuroimage.2011.08.022
68:
Doidge, N. (2015). The Brain’s Way of Healing: Remarkable Discoveries and Recoveries
from the Frontiers of Neuroplasticity (pp. 139). New York, NY: Penguin Books.
69:
Bulik, C. M., Sullivan, P. F., Tozzi, F., Furberg, H., Lichtenstein, P., Pedersen, N. L. (2006).
Prevalence, heritability, and prospective risk factors for anorexia nervosa. Archive of
General Psychiatry, 63(3), 305-312. doi: 10.1001/archpsyc.63.3.305
70:
225
28(4), 761-771.
71:
McKenzie, J. M. & Joyce, P.R. (1992). Hospitalization for anorexia nervosa. International
Journal of Eating Disorders, 11(3), 235-241. doi: 10.1002/1098-
108X(199204)11:3<235::AID-EAT2260110306>3.0.CO;2-T
72:
Ackard, D. M., Richter, S., Egan, A., Cronemeyer, C. (2014). Poor outcome and death
among youth, young adults, and midlife adults with eating disorders: an investigation of risk
factors by age at assessment. International Journal of Eating Disorders, 47(7), 825-835. doi:
10.1002/eat.22346
73:
Frank, G. K. (2015): Recent advances in neuroimaging to model eating disorder

neurobiology. Current Psychiatry Reports, 17(4), 559. doi: 10.1007/s11920-015-0559-z
74:
Herzog, D. B., Keller, M. B., Lavori, P. W., Kenny, G. M., Sacks, N. R. (1992). The
prevelance of personality disorders in 210 women with eating disorders. Journal of Clinical
Psychiatry, 53(5), 147-152.
75:
Keel, P. K., Mitchell, J. E., Miller, K. B., Davis, T. L., Crow, S. J. (1999). Long-term outcome
of bulimia nervosa. Archives of General Psychiatry, 56(1), 63-69. doi:
10.1001/archpsyc.56.1.63
76:
Klein, D. A. & Walsh, B. T. (2003). Eating disorders. International Review of Psychiatry, 15

(3), 205-216. doi: 10.1080/0954026031000136839
77:
Hibbs, R., Rhind, C., Leppanen, J., Treasure, J. (2015). Interventions for caregivers of
someone with an eating disorder: a meta analysis. International Journal of Eating Disorders,
48(4), 349-361. doi: 10.1002/eat.22298
78:
Robinson, P. H., Kukacska, R., Guidetti, G., Leavey, G. (2015). Severe and enduring
anorexia nervosa (SEED-AN): a qualitative study of patients with 20+ years of anorexia
nervosa. European Eating Disorders Review, 23(4):318-326. doi: 10.1002/erv.2367
79:
226
Munn, M. A., Stallings, M. C., Rhee, S. H., Sobik, L. E., Corley, R. P., Rhea, S. A., Hewitt, J.
K. (2010). Bivariate analysis of disordered eating characteristics in adolescence and young
adulthood. International Journal of Eating Disorders, 43(8), 751-761. doi: 10.1002/eat.20854
80:
28(4), 761-771.
81:
Kothari, R., Barona, M., Treasure, J., Micali, N. (2015). Social cognition in children at familial
high-risk of developing an eating disorder. Frontiers in Behavioral Neuroscience, 9(208). doi:
10.3389/fnbeh.2015.00208
82:
Bischoff-Grethe, A., McCurdy, D., Grenesko-Stevens, E., Irvine, L. E., Wagner, A., Yau, W.
Y., Fennema-Notestine, C., Wierenga, C. E., Fudge, J. L., Delgado, M. R., Kaye, W. H.
(2013). Altered brain response to reward and punishment in adolescents with Anorexia
nervosa. Psychiatry Research, 214(3), 331-340. doi: 10.1016/j.psychresns.2013.07.004
83:
Kaye, W. H., Wagner, A., Fudge, J. L., Paulus, M. (2011). Neurocircuity of eating disorders.
Current Topics in Behavioral Neurosciences, 6, 37-57. doi: 10.1007/7854_2010_85
84:
Kaye, W. H., Wierenga, C. E., Bailer, U. F., Simmons, A. N., Bischoff-Grethe, A. (2013).
Nothing tastes as good as skinny feels: the neurobiology of anorexia nervosa. Trends in
Neuroscience, 36(2), 110-120. doi: 10.1016/j.tins.2013.01.003
85:
Kaye, W. H., Wierenga, C. E., Bailer, U. F., Simmons, A. N., Wagner, A., Bischoff-Grethe, A.
(2013). Does a shared neurobiology for foods and drugs of abuse contribute to extremes of
food ingestion in anorexia and bulimia nervosa? Biological Psychiatry, 73(9), 836-842. doi:
10.1016/j.biopsych.2013.01.002
86:
Oberndorfer, T. A., Frank, G. K., Simmons, A. N., Wagner, A., McCurdy, D., Fudge, J. L.,
Yang, T. T., Paulus, M. P., Kaye, W. H. (2013). Altered insula response to sweet taste
processing after recovery from anorexia and bulimia nervosa. The American Journal of
Psychiatry, 170(10), 1143-1151. doi: 10.1176/appi.ajp.2013.11111745
87:
Wierenga, C. E., Ely, A., Bischoff-Grethe, A., Bailer, U. F., Simmons, A. N., Kaye, W. H.
227
(2014). Are Extremes of Consumption in Eating Disorders Related to an Altered Balance
between Reward and Inhibition? Frontiers in Behavioral Neuroscience, 8(410). doi:
10.3389/fnbeh.2014.00410
88:
Lilenfeld, L. R., Wonderlich, S., Riso, L. P., Crosby, R., Mitchell, J. (2006). Eating disorders
and personality: a methodological and empirical review. Clinical Psychology Review, 26(3),
299-320. doi: 10.1016/j.cpr.2005.10.003
89:
Steinglass, J. E., Sysko, R., Mayer, L, Berner, L. A., Schebendach, J., Wang, Y., Chen, H.,
Albano, A. M., Simpson, H. B., Walsh, B. T. (2010). Pre-meal anxiety and food intake in
anorexia nervosa. Appetite, 55(2), 214-218. doi: 10.1016/j.appet.2010.05.090
90:
Chan, T. W., Ahn, W. Y., Bates, J. E., Busemyer, J. R., Guillaume, S., Redgrave, G. W.,
Danner, U. N., Courtet, P. (2014). Differential impairments underlying decision making in
anorexia nervosa and bulimia nervosa: a cognitive modeling analysis. International Journal
91:
Harrison, A., O’Brien, N., Lopez, C., Treasure, J. (2010). Sensitivity to reward and
punishment in eating disorders. Psychiatry Research, 177(1-2), 1-11. doi:
10.1016/j.psychres.2009.06.010
92:
Frank, G. K., Roblek, T., Shott, M. E., Jappe, L. M., Rollin, M. D., Hagman, J. O., Pryor, T.
(2012). Heightened fear of uncertainty in anorexia and bulimia nervosa. International Journal
93:
Cloninger, C,. R. Przybeck, T. R., Svrakic, D. M., Wetzel, R. D. (1994). The Temperament
and Character Inventory (TCI): A Guide to Its Development and Use. St. Louis, MO: Center
for Psychobiology of Personality.
94:
Cassin, S. E. & von Ranson, K. M. (2005). Personality and eating disorders: a decade in
review. Clinical Psychology Review, 25(7), 895-916. doi: 10.1016/j.cpr.2005.04.012
95:
Fassino, S., Amianto, F., Gramaglia, C., Facchini, F., Abbate Daga, G. (2004).
Temperament and character in eating disorders: ten years of studies. Eating and Weight
Disorders, 9(2), 81-90. do: 10.1007/BF03325050
228
96:
Klump, K. L., Strober, M., Bulik, C. M., Thornton, L., Johnson, C., Devlin, B., Fichter, M. M.,
Halmi, K. A., Kaplan, A. S., Woodside, D. B., Crow, S., Mitchell, J., Rotondo, A., Keel, P. K.,
Berrettini, W. H., Plotnicov, K., Pollice, C., Lilenfeld, L. R., Kaye, W. H. (2004). Personality
characteristics of women before and after recovery from an eating disorder. Psychological
Medicine, 34(8), 1407-1418. doi: 10.1017/S0033291704002442
97:
Lilenfeld, L. R. (2011). Personality and temperament. Current Topics in Behavioral

Neuroscience, 6, 3-16. doi: 10.1007/7854_2010_86
98:
Wagner, A., Barbarich-Marsteller, N. C., Frank, G. K., Bailer, U. F., Wonderlich, S. A.,
Crosby, R. D., Henry, S. E., Vogel, V., Plotnicov, K., McConaha, C., Kaye, W. H. (2006).
Personality traits after recovery from eating disorders: do subtypes differ? International
99:
Bloss, C. S., Berrettini, W., Bergen, A. W., Magistretti, P., Duvvuri, V., Strober, M., Brandt,
H., Crawford, S., Crow, S., Fichter, M., Halmi, K., Johnson, C., Kaplan, A. S., Keel, P.,
Klump, K. L., Mitchell, J,. Treasure, J., Woodside, D. B., Marzola, E., Schork, N. J., Kaye,
W. H. (2011). Genetic association of recovery from eating disorders: the role of GABA
receptor SNPs. Neuropsychopharmacology, 36(11), 2222-2232. doi: 10.1038/npp.2011.108
100:
Bulik, C. M., Sullivan, P. F., Fear, J. L., Pickering, A. (2000). Outcome of anorexia nerovsa:
eating attitudes, personality, and parental bonding. International Journal of Eating Disorders,
28(2), 139-147. doi: 10.1002/1098-108X(200009)28:2<139::AID-EAT2>3.0.CO;2-G
101:
Kaye, W. H., Bulik, C. M., Thornton, L., Barbarich, N., Masters, K. (2004). Comorbidity of
anxiety disorders with anorexia and bulimia nervosa. American Journal of Psychiatry, 161
(12), 2215-2221. doi: 10.1176/appi.aip.161.12.2215
102:
Lock, J., Agras, W. S., Bryson, S., Kraemer, H. C. (2005). A comparison of short- and long-
term family therapy for adolescent anorexia nervosa. Journal of the American Academy of
Child and Adolescent Psychiatry, 44(7), 632-639. doi: 10.1097/01.chi:0000161647.82775.0a
103:
Crane, A. M., Roberts, M. E., Treasure, J. (2007). Are obsessive-compulsive personality

traits associated with a poor outcome in anorexia nervosa? A systematic review of
randomized controlled trials and naturalistic outcome studies. International Journal of Eating
229
104:
Kaye, W. H., Strober, M., Klump, K. L. (2003). Neurobiology of eating disorders. In Martin,
A., Scahill, L., Charney, D. S., Leckman, J.F., editors, Pediatric Psychopharmacology,
Principles & Practice (pp. 224-237). New York, NY: Oxford University Press.
105:
Frank, G. K.,Kaye, W. H. (2012). Current status of functional imaging in eating disorders.

International Journal of Eating Disorders, 45(6), 723-736. doi: 1002/eat.22016
106:
Ely, A. V., Wierenga, C. E., Kaye, W. H. (2016). Anxiety Impacts Cognitive Inhibition in
Remitted Anorexia Nervosa. European Eating Disorders Review, 24(4), 347-351. doi:
10.1002/erv.2451
107:
Thornton, L. M., Mazzeo, S. E., Bulik, C. M. (2011). “The heritability of eating disorders:
Methods and current findings” In Adan, R. A. H., Kaye, W. H., editors. Behavioral
Neurobiology of Eating Disorders (Current Topics in Behavioral Neurosciences) (pp. 141-
156). New York, NY: Springer.
108:
Halmi, K. A., Bellace, D., Berthod, S., Ghosh, S., Berrettini, W., Brandt, H. A., Bulik, C. M.,
Crawford, S., Fichter, M. M., Johnson, C. L., Kaplan, A., Kaye, W. H., Thornton, L.,
Treasure, J., Blake Woodside, D., Strober, M. (2012). An examination of early childhood
perfectionism across anorexia nervosa subtypes. International Journal of Eating Disorders,
45(6), 800–807. doi: 10.1002/eat.22019
109:
Klump, K. L., Burt, S. A., Spanos, A., McGue, M., Iacono, W. G., Wade, T. D. (2010). Age
differences in genetic and environmental influences on weight and shape concerns.
110:
Wable, G. S., Barbarich-Marsteller, N. C., Chowdhury, T. G., Sabaliauskas, N. A., Farb, C.

R., Aoki, C. (2013). Excitatory synapses on dendritic shafts of the caudal basal amygdala
exhibit elevated levels of GABAA receptor a4 subunits following the induction of activity-
based anorexia. Synapse, 68(1), 1-15. doi: 10.1002/syn.21690
111:
Joos, A. A., Saum, B., van Elst, L. T., Perlov, E., Glauche, V., Hartmann, A., Freyer, T.,
Tüscher, O., Zeeck, A. (2011). Amygdala hyperreactivity in restrictive anorexia nervosa.
230
Psychiatry Research, 191(3), 189-195. doi: 10.1016/j.pscychresns.2010.11.008
112:
Kelley, A. E. & Berridge, K. C. (2002). The neuroscience of natural rewards: relevance to

addictive drugs. Journal of Neuroscience, 22(9), 3306-3311. doi: 20026361
113:
Booij, L., Casey, K. F., Antunes, J. M., Szyf, M., Joober, R., Israel, M., Steiger, H. (2015).
DNA methylation in individuals with anorexia nervosa and in matched normal-eater controls:
A genome-wide study. International Journal of Eating Disorders, 48(7), 874-882. doi:
10.1002/eat.22374
114:
Steiger, H., Labonté, B., Groleau, P., Turecki, G., Israel, M. (2013). Methylation of the
glucocorticoid receptor gene promoter in bulimic women: associations with borderline
personality disorder, suicidality, and exposure to childhood abuse. International Journal of
Eating Disorders, 46(3), 246-255. doi: 10.1002/eat.22113
115:
McKenzie, J. M. & Joyce, P.R. (1992). Hospitalization for anorexia nervosa. International
Journal of Eating Disorders, 11(3), 235-241. doi: 10.1002/1098-
108X(199204)11:3<235::AID-EAT2260110306>3.0.CO;2-T
116:
Pruis, T. A., Keel, P. K. and Janowsky, J. S. (2012). Recovery from anorexia nervosa
includes neural compensation for negative body image. International Journal of Eating
117:
Nico, D., Daprati, E., Nighoghossian, N., Carrier, E., Duhamel, J. R., Sirigu, A. (2010). The
role of the right parietal lobe in anorexia nervosa. Psychological Medicine, 40(9), 1531-1539.
doi: 10.1017/S0033291709991851
118:
Bailer, U. F., Price, J. C., Meltzer, C. C., Mathis, C. A., Frank, G. K., Weissfeld, L.,
McConaha, C. W., Henry, S. E., Brooks-Achenbach, S., Barbarich, N. C., Kaye, W. H.
(2004). Altered 5-HT(2A) receptor binding after recovery from bulimia-type anorexia
nervosa: relationships to harm avoidance and drive for thinness.
Neuropsychopharmacology, 29(6), 1143-1155. doi: 10.1038/sj.npp.1300430
119:
Eisler, I. & le Grange, D. (1990). Excessive exercise and anorexia nervosa. International
Journal of Eating Disorders, 9(4), 377-386. doi: 10.1002/1098-108X(199007)9:4<377::AID-
231
EAT2260090403>3.0.CO;2-O
120:
Hill, L. & Scott, M. (2015). The Venus Fly Trap and the Landmine: Novel Tools for Eating
Disorder Treatment. Journal of Treatment and Prevention, 23(4), 387-392. doi:
10.1080/10640266.2015.1044353
121:
Compan, V., Walsh, B. T., Kaye, W., Geliebter, A. (2015). How Does the Brain Implement
Adaptive Decision Making to Eat? The Journal of Neuroscience, 35(41), 13868-13878. doi:
10.1523/JNEUROSCI.2602-15.2015
122:
Sun, B., Li, D., Liu, W., Zhan, S., Pan, Y., Zhang, X. (2015). Surgical Treatments for
Anorexia Nervosa. Neurosurgical Treatments for Psychiatric Disorders, 175-187. doi:
10.1007/978-94-017-9576-0_15
123:
Stiles-Shileds, C., DclinPsy, B. B. Lock, J., le Grange, D. (2015). The Effect of Driven
Exercise on Treatment Outcomes for Adolescents with Anorexia and Bulimia Nervosa.
124:
Peterson, C. B. & Mitchell, J. E. (1999). Psychosocial and pharmacological treatment of

eating disorders: A review of research findings. Journal of Clinical Psychology, 55(6), 685-
697. doi: 10.1002/(SICI)1097-4679(199906)55:6<685::AID-JCLP3>3.0.CO;2-Y
125:
Spangler, D. L. & Allen, M. D. (2012). An fMRI investigation of emotional processing of body

shape in bulimia nervosa. International Journal of Eating Disorders, 45(1), 17-25.
doi: 10.1002/eat.20899
126:
Kaye, W., Frank, G. K., Bailer, U. F., Henry, S. E. (2005). Neurobiology of anorexia nervosa:
clinical implications of alterations of the function of serotonin and other neuronal systems.
International Journal of Eating Disorders, 37, S15-S19. doi: 10.1002/eat.20109
127:
Frank, G. K. (2016). Aripiprazole, a partial dopamine agonist to improve adolescent anorexia

nervosa – A case series. International Journal of Eating Disorders, 49(5), 529-533. doi:
10.1002/eat.22485
128:
232
Brain Facts that make you go, “Hmmmmm”. Retrieved from
https://faculty.washington.edu/chudler/ffacts.html
129:
Pandya, S. K. (2011). Understanding brain, mind and soul: contributions from neurology and
neurosurgery. Mens Sana Monogr, 9(1), 129-149. doi: 10.4103/0973-1229.77431
130:
Insel, T. (2013, May 11). Post by Former NIMH Director Thomas Insel: Brain Awareness.
Retrieved from https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/brain-
awareness.shtml
131:
Goodwin, G. M., Fraser, S., Stump, K., Fairburn, C. G., Elliott, J. M., Cowen, P. J. (1987).
Dieting and weight loss in volunteers increases the number of alpha 2-adrenoceptors and 5-
HT receptors on blood platelets without effect on [3H]imipramine binding. Journal of
Affective Disorders, 12(3), 267-274.
132:
Smith, K. A., Fairburn, C. G., Cowen, P. J. (1999). Symptomatic Relapse in Bulimia Nervosa
Following Acute Tryptophan Depletion. Archives of General Psychiatry, 56(2), 171-176. doi:
10.1001/archpsyc.56.2.171
133:
Kaye, W. H., Gwirtsman, H. E., George, D. T., Ebert, M. H. (1991). Altered Serotonin Activity
in Anorexia Nervosa After Long-term Weight Restoration - Does Elevated Cerebrospinal
Fluid 5-Hydroxyindoleacetic Acid Level Correlate with Rigid and Obsessive Behavior?
Archives of General Psychiatry, 48(6), 556-562. doi:
10.1001/archpsyc.1991.01810300068010
134:
Robinson, T. E. & Berridge, K. C. (2008). The incentive sensitization theory of addiction:

some current issues. Philosophical Transactions of the Royal Society London Series B.,
Biological Sciences, 363(1507), 3137-3146. doi: 10.1098/rstb.2008.0093
135:
Hamid, A. A., Pettibone, J. R., Mabrouk, O. S., Hetrick, V. L., Schmidt, R., Vander Weele, C.
M., Kennedy, R. T., Aragona, B. J., Berke, J. D. (2065). Mesolimbic dopamine signals the
value of work. Nature Neuroscience, 19, 117-126. doi: 10.1038/nn.4173
136:
Hillman, E. M.C. (2014). Out for Blood. Scientific American Mind, 25, 58-65. doi:
10.1038/scientificamericanmind0714-58
233
137:
LeDoux, J. (2003). Synaptic Self: How Our Brains Become Who We Are (pp. 260). New
York, NY: Penguin Books.
138:
Frank, G. K., Shott, M. E., Keffler, C., Cornier, M. A. (2016). Extremes of eating are
associated with reduced neural taste discrimination. International Journal of Eating
139:
McCormick, L., Keel, P., Brumm, M., Sowers, W., Swayze, V., Andersen, A., Andeasen, N.
(2008). Implications of starvation-induced change in right dorsal anterior cingulate volume in
anorexia nervosa. International Journal of Eating Disorders, 41(7), 602-610. doi:
10.1002/eat.20549
140:
Pinel, P with Edward, M. (2008) A Colorful Introduction to the Anatomy of the Human Brain.
(2nd Edi.) Allyn & Bacon, MA.
141:
Garrett, M. D. (2014, February 25). Complexity of Our Brain. Retrieved from

https://www.psychologytoday.com/blog/iage/201402/complexity-our-brain
142:
Pinel, J. P. J. & Edwards, M. (2007). A Colorful Introduction to the Anatomy of the Human
Brain: A Brain and Psychology Coloring Book (2nd Edition). London, England: Pearson.
143:
Pinel, J. P. J. (2013). Biopsychology (9th Edition). London, England: Pearson.

144:
145:

146:
147:
234
148:
149:

150:
151:

152:
153:
Goldstein, D. S. (2010). Andrenaline and Noradrenaline. eLS. doi:

10.1002/9780470015902.a0001401.pub2
154:

155:
156:

157:
158:

159:
235
160:

161:
162:
163:

164:
Huang, J. S., Terrones, L., Simmons, A. N., Kaye, W., Strigo, I. (2016). Pilot Study of
Functional Magnetic Resonance Imaging Responses to Somatic Pain Stimuli in Youth With
Functional and Inflammatory Gastrointestinal Disease. Journal of Pediatric Gastroenterology
and Nutrition, 63(5), 500-507. doi: 10.1097/MPG.0000000000001390
165:
Wagner, A., Aizenstein, H., Venkatraman, V. K., Fudge, J., May, C., Mazurkewicz, L., Frank,
G. K., Bailer, U. F., Fischer, L., Nguyen, V., Carter, C., Putnam, K., Kaye, W. H. (2007).
Altered Reward Processing in Women Recovered From Anorexia Nervosa. The American
Journal of Psychiatry, 164(12), 1842-1849. doi: 10.1176/appi.ajp.2007.07040575
166:
Frank, G. K. W., Reynolds, J. R., Shott, M. E., Jappe, L., Yang, T. T., Tregellas, J. R.,
O’Reilly, R. C. (2012). Anorexia nervosa and obesity are associated with opposite brain
reward response. Neuropsychopharmacology, 37(9), 2031-2046. doi: 10.1038/npp.2012.51
167:
Craig, A. D. (2004). Human feelings: why are some more aware than others? Trends Cogn
Sci. Trends in Cognitive Sciences, 8(6), 239-241. doi: 10.1016/j.tics.2004.04.004
168:
Burger, K. S. & Stice, E. (2014). Greater striatopallidal adaptive coding during cue-reward
learning and food reward habituation predict future weight gain. Neuroimage, 99, 122-128.
doi: 10.1016/j.neuroimage.2014.05.066
236
169:
Burger, K. S. & Stice, E. (2012). Frequent ice cream consumption is associated with
reduced striatal response to receipt of an ice cream-based milkshake. The American Journal
of Clinical Nutrition, 95(4), 810-817. doi: 10.3945/ajcn.111.027003
170:
Craig, A. D. (2009). How do you feel—now? The anterior insula and human awareness.
Nature Reviews Neuroscience, 10(1), 59-70. doi: 10.1038/nm2555
171:

172:
173:

174:
175:
Cavedini, P., Bassi, T., Ubbiali, A., Casolari, A., Giordani, S., Zorzi, C., Bellodi, L. (2004).
Psychiatry Research, 127(3), 259-266. doi: 10.1016/j.psychres.2004.03.012
176:
Wierenga, C. E., Bischoff-Crethe, A., Melrose, A. J., Irvine, Z., Torres, L., Bailer, U. F.,
Simmons, A., Fudge, J. L., McClure, S. M., Ely, A., Kaye, W. H. (2015). Hunger does not
motivate reward in women remitted from anorexia nervosa. Biological Psychiatry, 77(7),
642-652. doi: 10.1016/biopsych.2014.09.024
177:
Frank, G. K., Reynolds, J. R., Shott, M. E., O’Reilly, R. C. (2011). Altered temporal
difference learning in bulimia nervosa. Biological Psychiatry, 70(8), 728-735. doi:
10.1016/j.biopsych.2011.05.011
178:
Stice, E., Yokum, S., Blum, K., Bohon, C. (2010). Weight gain is associated with reduced
striatal response to palatable food. Journal of Neuroscience, 30(39), 13105-13109. doi:
10.1523/JNEUROSCI.2105-10.2010
237
179:
McClure, S. M., Laibson, D. I., Loewenstein, G., Cohen, J. D. (2004). Separate neural
systems value immediate and delayed monetary rewards. Science, 306(5695), 503-507. doi:
10.1126/science.1100907
180:
Breiter, H. C., Aharon, I., Kahneman, D., Dale, A., Shizgal, P. (2001). Functional imaging of
neural responses to expectancy and experience of monetary gains and losses. Neuron, 30
(2), 619-639. doi: 10.1016/S0896-6273(01)00303-8
181:

182:
183:
Boggiano, M. M., Turan, B., Maldonado, C. R., Oswald, K. D. and Shuman, E. S. (2013).
Secretive food concocting in binge eating: Test of a famine hypothesis. International Journal
of Eating Disorders, 46(3), 212–225. doi: 10.1002/eat.22077
184:
185:

186:
Bodell, L. P., Keel, P. K., Brumm, M. C., Akubuiro, A., Caballero, J., Tranel, D., Hodis, B.,
McCormick, L. M. (2014). Longitudinal examination of decision-making performance in
anorexia nervosa: before and after weight restoration. Journal of Psychiatric Research, 56,
150-157. doi: 10.1016/j.psychires.2014.05.015
187:
Bailer, U. F., Price, J. C., Meltzer, C. C., Wagner, A., Mathis, C. A., Gamst, A., Kaye, W. H.
(2017). Dopaminergic activity and altered reward modulation in anorexia nervosa-insight
from multimodal imaging. International Journal of Eating Disorders, 50(5), 593-596. doi:
10.1002/eat.22638
188:
238
189:

190:
Uher, R., Brammer, M. J., Murphy, T., Campbell, I.C., Ng, V. W., Williams, S. C., Treasure,
J. (2003). Recovery and chronicity in anorexia nervosa: brain activity associated with
differential outcomes. Biological Psychiatry, 54(9), 934-942. doi: 10.1016/S0006-
3223(03)00172-0
191:
192:

193:
194:

196:
197:

198:
Santel, S., Baving, L., Krauel, K., Münte, T. F., Rotte, M. (2006). Hunger and satiety in
anorexia nervosa: fMRI during cognitive processing of food pictures. Brain Research, 1114
(1), 138-148. doi: 10.1016/j.brainres.2006.07.045
199:
200: 239
201:
Lock, J., Garrett, A., Beenhakker, J., Reiss, A. L. (2011). Aberrant brain activation during a
response inhibition task in adolescent eating disorder subtypes. American Journal of
Psychiatry, 168(1), 55-64. doi: 10.1176/appi.ajp.2010.10010056
202:
Oberndorfer, T. A., Kaye, W. H., Simmons, A. N., Strigo, I. A., Matthews, S. C. (2011).
Demand-specific alteration of medial prefrontal cortex response during an inhibition task in
recovered anorexic women. International Journal of Eating Disorders, 44(1), 1-8. doi:
10.1002/eat.20750
203:
Zastrow, A., Kaiser, S., Stippich, C., Walther, S., Herzog, W., Tchanturia, K., Belger, A.,
Weisbrod, M., Treasure, J., Friederich, H. C. (2009). Neural correlates of impaired cognitive-
behavioral flexibility in anorexia nervosa. American Journal of Psychiatry, 166(5), 608-616.
doi: 10.1176/appi.ajp.2008.08050775
204:
Wierenga, C., Bischoff-Grethe, A., Melrose, A. J., Grenesko-Stevens, E., Irvine, Z., Wagner,
A., Simmons, A., Matthews, S., Yau, W. Y., Fennema-Notestine, C. (2014). Altered BOLD
response during inhibitory and error processing in adolescents with anorexia nervosa. PLoS
One, 9(3), e92017. doi: 10.1371/journal.pone.0092017
205:
Kerr, K. L., Moseman, S. E., Avery, J. A., Bodurka, J., Zucker, N. L., Simmons, W. K.
(2016). Altered Insula Activity during Visceral Interoception in Weight-Restored Patients with
Anorexia Nervosa. Neuropsychopharmacology, 41(2), 521-528. doi: 10.1038/npp.2015.174
206:
Oberndorfer, T., Simmons, A., McCurdy, D., Strigo, I., Matthews, S., Yang, T., Irvine, Z.,
Kaye, W. (2013). Greater anterior insula activation during anticipation of food images in
women recovered from anorexia nervosa versus controls. Psychiatry Research, 214(2),
132-141. doi: 10.1016/j.pscychresns.2013.06.010
207:
Strigo, I. A., Matthews, S. C., Simmons, A. N., Oberndorfer, T., Klabunde, M., Reinhardt, L.
E., Kaye, W. H. (2013). Altered insula activation during pain anticipation in individuals
recovered from anorexia nervosa: evidence of interoceptive dysregulation. International
208:
240
Klump, K. L., Keel, P. K., Sisk, C., Burt, S. A. (2010). Preliminary evidence that estradiol
moderates genetic influences on disordered eating attitudes and behaviors during puberty.
Psychological Medicine, 40(10), 1745-1753. doi: 10.1017/S0033291709992236
209:
Bergen, A. W., Yeager, M., Welch, R. A., Hague, K., Ganjei, J. K., van den Bree, M. B.,
Mazzanti, C., Nardi, I., Fichter, M. M., Halmi, K. A., Kaplan, A. S., Strober, M., Treasure, J.,
Woodside, D. B., Bulik, C. M., Bacanu, S. A., Devlin, B., Berrettini, W. H., Goldman, D.,
Kaye, W. H. (2005). Association of multiple DRD2 polymorphisms with anorexia nervosa.
Neuropsychopharmacology, 30(9), 1703-1710. doi: 10.1038/sj.npp.1300719
210:
Wagner, A., Alzenstein, H., Venkatraman, V. K., Bischoff-Grethe, A., Fudge, J., May, J. C.,
Bailer, U. F., Fischer, L., Putnam, K., Kaye, W. H. (2010). Altered striatal response to reward
in bulimia nervosa after recovery. International Journal of Eating Disorders, 43(4), 289-294.
doi: 10.1002/eat.20699
212:
Bühren, K., Mainz, V., Herpertz-Dahlmann, B., Schäfer, K., Kahraman-Lanzerath, B., Lente,
C., Konrad, K. (2012). Cognitive flexibility in juvenile anorexia nervosa patients before and
after weight recovery. Journal of Neural Transmission (Vienna), 119(9), 1047-1057. doi:
10.1007/s00702-012-0821-z
213:
Yau, W. Y., Bischoff-Grethe, A., Theilmann, R. J., Torres, L., Wagner, A., Kaye, W. H.,
Fennema-Notestine, C. (2013). Alterations in white matter microstructure in women
recovered from anorexia nervosa. International Journal of Eating Disorders, 46(7), 701-708.
doi: 10.1002/eat.22154
214:
Schubert, F., Kühn, S., Gallinat, J., Melke, R., Ittermann, B. (2017). Towards a
neurochemical profile of the amygdala using short-TE 1H magnetic resonance spectroscopy
at 3 T. NMR in Biomedicine, 30(5). doi: 10.1002/nbm.3685
215:
Kaye, W. Strober, M, Jimmerson, D. (2004). The neurobiology of eating disorders. In:

Charney DS. Neslter EJ, (Eds.) The neurobiology of mental illness (pp.1112). New York,
NY: Oxfort.
216:
Cook, B., Wonderlich, S., Mitchell, J., Thompson, R., Sherman, R. and McCallum, K.
(2016). Exercise in Eating Disorders Treatment: Systematic Review and Proposal of
Guidelines. Med Sci Sports Exerc. 2016 July ; 48(7): 1408–1414.
241
doi:10.1249/MSS.0000000000000912.
217:
Fonville, L., Lao-Kaim, N. P., Giampietro, V., Van den Eynde, F., Davies, H., Lounes, N.,
Andrew, C., Dalton, J., Simmons, A., Williams, S. C. R., Baron-Cohen, S., Tchanturia, K.
(2013). Evaluation of Enhanced Attention to Local Detail in Anorexia Nervosa Using the
Embedded Figures Test; an fMRI Study. PLoS ONE, 8(5), e63964. doi:
10.1371/journal.pone.0063964
218:
Kaye, W. H., Wierenga, C. E., Knatz, S., Liang, J., Boutelle, K., Eisler, I. (2015).
Temperament-based treatment for anorexia nervosa. European Eating Disorders Review,
23(1), 12-18. doi: 10.1002/erv.2330
219:
Vitousek, K. & Manke, F. (1994). Personality variables and disorders in anorexia nervosa
and bulimia nervosa. Journal of Abnormal Psychology, 103(1), 137-147. doi: 10.1037/0021-
843X.103.1.137
220:
Akkermann, K., Paaver, M., Nordquist, N., Oreland, L., Harro, J. (2008). Association of 5-
HTT gene polymorphism, platelet MAO activity, and drive for thinness in a population-based
smaple of adolescent girls. International Journal of Eating Disorders, 41(5), 399-404. doi:
10.1002/eat.20516
221:
Bailer, U. F., Bloss, C. S., Frank, G. K., Price, J. C., Meltzer, C. C., Mathis, C. A., Geyer, M.
A., Wagner, A., Becker, C. R., Schork, N. J., Kaye, W. H. (2011). 5-HT1A receptor binding is
increased after recovery from bulimia nervosa compared to control women and is
associated with behavioral inhibition in both groups. International Journal of Eating
222:
Wonderlich, S. (2002). “Personality and Eating Disorders” In Fairburn, C. G. & Brownell, K.

D. (eds). Eating Disorders and Obesity, Second Edition: A Comprehensive Handbook (pp.
204-209). New York, NY: The Guilford Press.
223:
Doidge, N. (2007). The Brain That Changes Itself: Stories of Personal Triumph from the
Frontiers of Brain Science. New York, NY: Penguin Group.
224:
The Exchange Lists are the basis of a meal planning system designed by a committee of the
242
American Diabetes Association and the American Dietetic Association.
225:
Hill, L. (1993). The woodburning stove: A metaphor for dietary regulation for persons with
eating disorders. Eating Disorders: The Journal of Treatment & Prevention, 1(2), 156-166.
doi: 10.1080/10640269308248283
226:
For those who wish to receive information about the nutrition app "Balanced Life," go to
www.TheCenterforBalancedLiving.org
227:
Pruunsild, P., Kazantseva, A., Aid, T., Palm, K., Timmusk, T. (2007). Dissecting the human
BDNF locus: Bidirectional transcription, complex splicing, and multiple promoters.
Genomics, 90(3), 397-406. doi: 10.1016/j.ygeno.2007.05.004
228:
Martin, J. L. & Finsterwald, C. (2011). Cooperation between BDNF and glutamate in the
regulation of synaptic transmission and neuronal development. Communicative & Integrative
Biology, 4(1), 14-16. doi: 10.4161/cib.4.1.13761
229:
Erickson, K. I., Gildengers, A. G., Butters, M. A. (2013). Physical activity and brain plasticity
in late adulthood. Dialogues in Clinical Neuroscience, 15(1), 99-108.
230:
Erickson, K.I., Voss, M. W., Prakash, R. S., Basak, C., Szabo, A., Chaddock, L., Kim, J. S.,
Heo, S., Alves, H., White, S. M., Wojcicki, T. R., Mailey, E., Vieira, V. J., Martin, S. A.,
Pence, B. D., Woods, J. A., McAuley, E., Kramer, A. F. (2010). Exercise training increases
size of hippocampus and improves memory. Proceedings of the National Academy of
Sciences, 108(7), 3017-3022. doi: 10.1073/pnas.1015950108
231:
Neeper, S. A., Gómez-Pinilla, F., Choi, J., Cotman, C. (1995). Exercise and brain
neurotrophins. Nature, 373(6510), 109. doi: 10.1038/373109a0
232:
243
Real, C. C., Ferreira, A. F., Hernandes, M. S., Britto, L. R., Pires, R. S. (2010). Exercise-
induced plasticity of AMPA-type glutamate receptor subunits in the rat brain. Brain
Research, 1363, 63-71. doi: 10.1016/j.brainres.2010.09.060
233:
Bland, S. T., Gonzales, R. A., Schallert, T. (1999). Movement-related glutamate levels in rat
hippocampus, striatum, and sensorimotor cortex. Neuroscience Letters, 277(2), 119-122.
doi: 10.1016/S0304-3940(99)00855-1
234:
Pacanowski, C. R., Diers, L., Crosby, R. D., Neumark-Sztainer, D. (2017). Yoga in the
treatment of eating disorders within a residential program: A randomized controlled trial.
Eating Disorders, 25(1), 37-51. doi: 10.1080/10640266.2016.1237810
235:
Streeter, C. C., Whitfield, T. H., Owen, L., Rein, T., Karri, S. K., Yakhkind, A., Perlmutter, R., Prescot,
A., Renshaw, P. F., Ciraulo, D. A., Jensen, J. E. (2010). Effects of Yoga Versus Walking on Mood,
Anxiety, and Brain GABA Levels: A Randomized Controlled MRS Study. Journal of Alternative and
Complementary Medicine, 16(11), 1145-1152. doi: 10.1089/acm.2010.0007
236:
Transition. Retrieved from https://www.google.com/#q=transition+definition

237:
Willcox, G. (1982). The Feeling Wheel: A Tool for Expanding Awareness of Emotions and
Increasing Spontaneity and Intimacy. Transactional Analysis Journal, 12(4), 274-276. doi:
10.1177/036215378201200411
239:
Broft, A., Shingleton, R., Kaufman, J., Liu, F., Kumar, D., Slifstein, M., Abi-Dargham, A.,
Schebendach, J., Van Heertum, R., Attia, E., Martinez, D., Walsh, B. T. (2012). Striatal
dopamine in bulimia nervosa: A pet imaging study. International Journal of Eating Disorders,
45(5), 648–656. doi: 10.1002/eat.20984
240:
Frank, G. K., Reynolds, J. R., Shott, M. E., O’Reilly, R. C. (2011). Altered temporal
difference learning in bulimia nervosa. Biological Psychiatry, 70(8), 728-735. doi:
10.1016/j.biopsych.2011.05.011
241:
Watson, J. J. & Bulik, C. M. (2013). Update on the treatment of anorexia nervosa: review of
clinical trials, practice guidelines and emerging interventions. Psychological Medicine, 43
(12), 2477-2500. doi: 10.1017/S0033291712002620
244
242:
Wang, K., Li. W. D., Zhang, C. K., Wang, Z., Glessner, J. T., Grant, S. F., Zhao, H.,
Hakonarson, H., Price, R. A. (2011). A genome-wide association study on obesity and
obesity-related traits. PLoS One, 6(4), e18939. doi: 10.1371/journal.pone.0018939
243:
Frank, G. K. W. & Kaye, W. H. (2012). Current status of functional imaging in eating

disorders. International Journal of Eating Disorders, 45(6), 723-736. doi: 10.1002/eat.22016
244:
McCormick, L. M., Keel, P. K., Brumm, M. C., Bowers, W., Swayze, V., Andersen, A.,
Andreasen, N. (2008). Implications of starvation-induced change in right dorsal cingulate
volume in anorexia nervosa. International Journal of Eating Disorders, 41(7), 602-610. doi:
10.1002/eat.20549
245:
Walsh, S. (2015). FDA expands use of Vyvanse to treat binge-eating disorder. U.S. Food &
Drug Administration.
https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm432543.htm
246:
Shapiro, J. R., Berkman, M. D., Brownley, K. A., Sedway, J. A., Lohr, K. N., Bulik, C. M.
(2007). Bulimia nervosa treatment: a systematic review of randomized controlled trials.
245

Brain-Based ED Treatment Laura Hill Ebook

Uploaded by

Copyright:

Available Formats

You might also like

Brain-Based ED Treatment Laura Hill Ebook

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Brain-Based ED Treatment Laura Hill Ebook

Uploaded by

Copyright:

Available Formats

A Brain-Based Approach to

Eating Disorder Treatment

A Brain-Based Treatment Approach to

Eating Disorder Treatment

Written by Laura Hill, PhD

The Center for Balanced Living

Columbus, Ohio, USA

The Center for Balanced Living was founded in 2000.

The Center for Balanced Living provides treatment to about 2,000

Laura Hill, PhD, FAED

The Center for Balanced Living

Jason McCray, PhD M Mullan, LPC Erica Temes, BA

Sonja Stotz, RD, LD Amber Scott, BA Jenifer Takats, MD

Christina Wierenga, PhD Walter Kaye, MD

Stephanie Knatz Peck, PhD Laura Greathouse, MPH

This text is dedicated to

Life is a rough draft.

While DSM-5 diagnoses have distinct, categorical descriptions of symptoms, it is not

From an overall perspective, neurobiological eating disorder research in 2017 is where

Eating disorders, like diabetes, are serious, biologically based

Genes determine personality traits. Temperament, an expression of one’s personality, is

As the BRAIN Initiative progresses, new questions arise,

A brain-based metaphor can explain how eating disorder treatment is in transition. A

Instead of focusing primarily on cognitive and behavioral symptoms, genetically inherited

Summary of Chapter 1: Historical Perspective of Eating Disorders

Anorexia nervosa has evolved to be recognized as a severe, biologically based brain

Nature/Nurture Developmental Model of Anorexia Nervosa

The Venus Flytrap: A Nature/Nurture Metaphor for Anorexia

The “we” is key in eating disorder treatment. The “we” consists

Neurobiological findings indicate and direct us to what we currently know. However,

Summary of Chapter 2: A Brain-Based Paradigm Shift on Eating Disorders

Current Brain-Based Treatments13

However, research has not reliably determined if the electroencephalographic responses

If eating disorder treatment could improve accurate neurofeedback opportunities, it would

In the meantime and on the whole,

The brain communicates within itself by transmitting neurochemical messages, called

Figure 7 (Image purchased from Shutterstock)

Dopamine is another neurochemical, which triggers pleasure and reward, contributes to

Overall Areas of the Brain

When fear is registered in the brain, the neurochemical norepinephrine (noradrenaline or

Insula: in·su·la88, 89, 164, 165, 166, 167, 168, 169

Location and Function:

1. Embedded in the temporal lobe.

Impact on Eating Disorders:

Amygdala: a·myg·da·la or midl12, 109, 110, 170, 171

Location and Function:

Impact on Eating Disorders and Fear Responses:

1. The amygdala is overactive in those with anorexia nervosa.

Location and Function:

Impact on Eating Disorders:

Orbitofrontal Cortex (OFC)12, 65, 180, 181

Location and Function:

1. Located behind eye sockets.

Impact on Eating Disorders:

1. Contributes to slowing down, delaying or stopping an action, such as inhibiting food

Caudate Nucleus183, 184, 185, 186

Location and Function:

Impact on Eating Disorders: