MacLeod (1981) states people with anorexia are notoriously difficult persons who are determined to hang on to their symptoms at all costs. This is a common view throughout the medical profession and related fields, possibly due to the ego-syntonic nature of eating disorders – the person is comfortable with the disorder and views it as consistent with their goals and wishes.
It is therefore important for counsellors to develop an understanding of these disorders in order to develop empathy and the ability to validate the client’s experience. This involves realising that letting go of the eating disorder may represent a significant loss for the person, and that there may be a fear that recovery will come at too high a price. Therefore the initial goal of treatment is simply for people to begin thinking about change. At this point, the enhancement of motivation is crucial.
The two categories which will be looked at here are Anorexia Nervosa and Bulimia Nervosa due to the ego-syntonic nature of these disorders. This post will focus on Anorexia Nervosa.
There are a number of essential features associated with a clinical diagnosis of Anorexia Nervosa. These include a refusal to maintain a minimal body weight considered normal for the person’s age and height, an intense fear of gaining weight, and a significant disturbance in the person’s perception of their body shape and size. In addition, females with this disorder have a condition known as amenorrhea, resulting from abnormally low levels of estrogen, where they have either ceased menstruation or, in younger females, it has been delayed. Also when the disorder occurs in a young person during childhood or early adolescence, rather than a significant drop in weight, there may instead be a failure to make expected weight gains consistent with a continued growth in height. For a clinical diagnosis of Anorexia Nervosa to be made according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the person must weigh less than 85% of the weight considered normal for his or her age and height.
An alternative guideline used by the ICD-10 Diagnostic Criteria for Research (World Health Organization, 1993) suggests a body mass index (BMI) equal to or less than 17.5 for a diagnosis. The BMI is calculated by dividing weight in kilograms by height in squared metres. These are regarded as guidelines only as a person’s individual body build and weight history also need to be taken into account.
Usually weight loss associated with Anorexia Nervosa is maintained primarily through restricted food intake. Sufferers may begin by excluding foods believed to be high in calories or specific food groups such as meat. This often leads to continued restriction resulting in a very narrow choice of foods. Further weight loss is often attempted via purging, such as self-induced vomiting or the misuse of laxatives or diuretics and excessive exercise.
An intense fear of gaining weight and becoming ‘fat’ is usually not alleviated by weight loss; in fact weight concerns often increase as body weight decreases. This leads to a distorted body image wherein the experience and significance of body weight and shape are distorted, either overall or in one or two specific areas of the body, such as the abdomen, buttocks or thighs. A person with a distorted body image will often engage in a variety of ‘checking’ techniques, including excessive weighing, obsessive measuring of body parts, and persistently using a mirror to check for perceived areas of ‘fat’. Not all Anorexia sufferers experience a distortion of body image, however even those who can acknowledge being underweight may still deny the serious medical implications arising from this. Individuals with Anorexia Nervosa frequently lack insight into the problem and may even deny the presence of the problem.
As a result, it is often necessary to obtain information from parents or other outside sources to evaluate the degree of weight loss and other aspects of the illness. Anorexia is often brought to professional attention by family members after marked weight loss has occurred. It is rare for an individual with Anorexia Nervosa to seek help themselves, although they may do so due to the distressing nature of other features associated with the disorder, such as depression and self-loathing.
Subtypes and Associated Features
The following subtypes are used to specify clinical features of the current episode of Anorexia Nervosa:
- Restricting Type: This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, or excessive exercise. During the current episode, these individuals have not regularly engaged in binge eating or purging.
- Binge-Eating / Purging Type: This subtype is specified when the individual has regularly engaged in binge eating or purging (or both) during the current episode. Most individuals with Anorexia Nervosa who binge eat also purge through self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
Some individuals included in this subtype do not binge eat, but do regularly purge after the consumption of small amounts of food. It appears that most individuals in the Binge-Eating/Purging Type engage in these behaviours at least weekly, but sufficient information is not available to specify a minimum frequency.
Not surprisingly the self-esteem of a person with Anorexia Nervosa is highly linked to their body shape and weight. Weight loss is generally viewed as a positive step and an indication of self-discipline, whereas weight gain is perceived as failure and a complete lack of self-control. When seriously underweight, many individuals with Anorexia Nervosa manifest depressive symptoms such as depressed mood, social withdrawal, irritability, insomnia, and diminished interest in sex. Such individuals may have symptomatic presentations that meet criteria for Major Depressive Disorder.
Obsessive-compulsive features are often prominent. Most individuals with Anorexia Nervosa are preoccupied with thoughts of food. Some collect recipes or hoard food. Observations of behaviours associated with other forms of starvation suggest that obsessions and compulsions related to food may be caused or exacerbated by undernutrition. Other features sometimes associated with Anorexia Nervosa include concerns about eating in public, feelings of being inept, a strong need to control the surrounding environment, inflexible thinking, limited social spontaneity, and overly restrained emotional expression (Garner and Garfinkel, 1997; APA, 2000).
“Therefore the initial goal of treatment is simply for people to begin thinking about change.”
I would argue that motivation to change is a sign of, not a method to achieve, recovery.
People eating even a fraction less than their body requires will suffer from disordered thoughts about food and eating. Only when free of that medical impediment can the patient truly engage in therapy and learn skills and gain insight – or motivation.
Treatment that does not require full nutrition from the beginning has a very poor track record. Patients deserve better.
Good point Laura. It is important to acknowledge the impact of nutrition on the mind and how this affects recovery… and as such advocating a multi-disciplinary approach would be the way to go.
But as the post stated, “people with anorexia are notoriously difficult persons who are determined to hang on to their symptoms at all costs”. Thus, the mental health professional plays an important role in motivating the client towards change – and that change will start with their new eating habits.
As the author of this article, I would like to just add that the initial quote about people with anorexia being ‘notoriously difficult’ was meant to highlight the unhelpful light in which they are often viewed, rather than presenting this as a fact.
The full article was actually on the topic of stages of change, and while the first ‘goal’ is outlined as the person beginning to think about the need for change, that does not mean that nutritional rehabilitation is not taking place while moving towards this first goal. In this sense, motivation IS a sign of recovery, ie. first goal achieved.