Basic elements of the etiology & treatment of eating disorders

By Norman M. Shulman, Ed.D.
September 10, 2014



Basic elements of the etiology and treatment of eating disordersEating disorders are among the most mysterious and complex of psychopathologies. Popular misunderstanding and professional disagreement confuse the picture even more.

Three elements must be present for an eating disorder of any kind to occur: a history of rejection, a tendency toward perfection and a sense of a loss of control. Of course these elements can be a complex function of multiple biopsychosocial factors as with any disorder.

For the purpose of developing a simple theoretical formulation and treatment plan for these individuals, the conceptualization below can be useful, especially for inexperienced psychotherapy trainees as well as for lay persons and family members directly affected by an eating disorder.

The cyclical nature of the disease beginning with the victim’s subjection to chronic negative influences, including parental abuse or peer pressure as a child and adolescent or both, which has had an adverse impact on a person’s developing self-image. In an effort to gain self-approval and secondarily the approval of rejecting significant others, in the vast majority of patients predisposed to an eating disorder, a girl will attempt to attain the Westernized version of a physical ideal.

Since the media and peers influence what it means to be acceptable, the girl strives for perfection through physical appearance at the expense of more substantive values. The girl falsely believes that the closer her body approaches perfection, the more acceptable she will be. But, perfection can never be attained partly because of the distorted body image that worsens with the girl’s frantic attempts to feel acceptable.

Without a reasonable standard of acceptance to attain, the failed efforts to be something that is unattainable causes a sense of a loss of control, which often leads to obsessive-compulsive attempts to reassert control in the same failed manner as previously, including restrictions, purging or both. The victim’s inability to achieve peace of mind leads to frustration that reinforces the feeling of rejection which got the cycle started originally.

In extreme cases, precipitous weight loss as a means of regaining control over one’s life can be a cry for help. It can also occur as a symbol of the patient’s ambivalence about getting well. Normal relationships, especially heterosexual ones, have less of a chance to develop because of the patient’s unsightly appearance. As a result, the individual does not have to cope with a fear of rejection.

Intervention: A case example

Breaking the eating disorder cycle is complicated in that all three elements in the illustration must be addressed during treatment, resolved and used to impact therapeutically on the other two.

K is a 25-year-old female who has struggled with anorexia for 17 years. She was first hospitalized at age 8 for refusing to eat and precipitous weight lost that can be traced back to a rejecting father whom she could never please. Over subsequent years in spite of many attempts to engage the father therapeutically and alter the self-destructive dynamic he was contributing to, he refused to comply.

Despite being repeatedly in and out of intensive treatment, K would relapse and attempt to assume the feminine ideal as a means of gaining self-acceptance and ultimately approval from her father. Rapid, extreme weight loss regularly led to relapse and a return to rehab. Repeated treatment failures only compounded K’s feeling that her life was out of control and in response, K upped the ante and tried even harder to get thinner.

Eating disorders are among the most mysterious and complex of psychopathologies. Popular misunderstanding and professional disagreement confuse the picture even more.

Three elements must be present for an eating disorder of any kind to occur: a history of rejection, a tendency toward perfection and a sense of a loss of control. Of course these elements can be a complex function of multiple biopsychosocial factors as with any disorder.

For the purpose of developing a simple theoretical formulation and treatment plan for these individuals, the conceptualization below can be useful, especially for inexperienced psychotherapy trainees as well as for lay persons and family members directly affected by an eating disorder.

The cyclical nature of the disease beginning with the victim’s subjection to chronic negative influences, including parental abuse or peer pressure as a child and adolescent or both, which has had an adverse impact on a person’s developing self-image. In an effort to gain self-approval and secondarily the approval of rejecting significant others, in the vast majority of patients predisposed to an eating disorder, a girl will attempt to attain the Westernized version of a physical ideal.

Since the media and peers influence what it means to be acceptable, the girl strives for perfection through physical appearance at the expense of more substantive values. The girl falsely believes that the closer her body approaches perfection, the more acceptable she will be. But, perfection can never be attained partly because of the distorted body image that worsens with the girl’s frantic attempts to feel acceptable.

Without a reasonable standard of acceptance to attain, the failed efforts to be something that is unattainable causes a sense of a loss of control, which often leads to obsessive-compulsive attempts to reassert control in the same failed manner as previously, including restrictions, purging or both. The victim’s inability to achieve peace of mind leads to frustration that reinforces the feeling of rejection which got the cycle started originally.

In extreme cases, precipitous weight loss as a means of regaining control over one’s life can be a cry for help. It can also occur as a symbol of the patient’s ambivalence about getting well. Normal relationships, especially heterosexual ones, have less of a chance to develop because of the patient’s unsightly appearance. As a result, the individual does not have to cope with a fear of rejection. Intervention: A case example

Breaking the eating disorder cycle is complicated in that all three elements in the illustration must be addressed during treatment, resolved and used to impact therapeutically on the other two.

K who stands about 5’8” bottomed out at 82 pounds and had to be hospitalized with a nasal gastric tube to save her life. An intensive daily course of cognitive behavioral therapy was started, the goal being to break the life-threatening cycle. Therapy was facilitated by a low dose of anti-psychotic medicine, which helped to dispel much of her distorted thinking about her body as well as a serotonergic agent to slow the obsessive-compulsive thoughts and behavior.

At the same time cognitive behavioral therapy-based reality testing was employed to break the pathological father-daughter bond. for which K always believed demanded overcompensation. Essentially, the bond can be broken by indicating the reality of the patient’s basic worthiness in spite of exposure to contrary influences. Once these bonds were loosened, K started feeling better about herself and discarded her impossible superficial goals of becoming perfect to gain approval, particularly her father’s.

Psychotherapeutic interventions consistently addressed each element of the triangle to challenge K’s value system, which became more substantive based on a reasonable healthy standard of human worthiness.

It is clear that long-term therapy is needed to help the patient maintain a balanced mindset, but there is finally reason after 17 years to be optimistic. Maturity, K’s readiness for a normal life and the proper treatment team are combining to give K the opportunity she never had to free herself from her obsessions.

Norman Shulman, Ed.D., is a clinical psychologist in Lubbock, Texas. His email is: drnshulman@nts-online.net.

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