Eating Issues | Treatment Maps

EATING ISSUES
Diagnosis and Treatment

There are three major forms of eating disorder that are generally agreed to require therapeutic intervention: obesity, bulimia, and anorexia. All three involve extreme and potentially self-destructive or self-damaging behavior that is consistent over time. All have emotional components of which the patient is unaware. All involve cognitive distortions: distorted body image or misunderstanding about the consequences of behavior. Each has implications for interpersonal relationships and self-concept.

The problem of changing eating behavior may be even more difficult than for some addictions, in that the abused substance can’t be avoided completely: a moderate amount is needed for survival. In order to be effective, the treatment must be directed to other aspects of the patient’s life, in addition to the eating behavior itself

This Treatment Map® was originated by Lois Belfiore, Psy.D. [Manhasset, NY], Thad R. Harshbarger, Ph.D. [Martha’s Vineyard], and Marie Oppedisano, Ph.D. [[Old Westbury, NY] in 1995-1998.

MAP 1

This map begins the treatment of a person for an eating issue. It raises issues of how the person got to you and why you think there may be a psychological problem around food or eating, in Section 1 and Section 2. .

Therapy may actually have begun before you get to this point however, and some relevant information may already be available to you. The person may have presented for other issues, and you may already have treated him/her as a new patient. You may also have worked on other issues – anxiety, depression, or substance misuse. If so, some of the answers need not be obtained again from this person.

1. EVALUATION OF EATING ISSUES

The nature of the evaluation you need depends on the way the patient gets to you and the information you start with. If the patient is seeking treatment specifically for an eating disorder, you may need to focus on that directly and treat other issues as secondary. If the patient comes to you for other issues, he/she may or may not consider an actual eating disorder to be a problem that he/she wants to address, and may even resist attempts on your part to talk about it.

1a. Patient Comes for Obesity, Bulimia or Anorexia

Some initial issues include: what is the nature of the patient’s problem, and how severe is it? Should you seek information from others: family, physician, etc.? Should you be in touch with a physician about possible medical complications, psychotropic medications, or monitoring the patient’s weight? Should you be planning to hospitalize this patient?

1b. Patient is in Treatment for Other Reasons

If the patient does not bring up the issue, you may need to be cautious in raising it, possibly waiting until you understand the patient’s defensive structure first, so that you don’t risk driving the patient from treatment.

With any seriously overweight person, if you need a segue into the issue of their weight, many opportunities will present themselves. The patient’s partner may complain. You may listen for derivatives of the weight problem in the patient’s difficulty finding clothes that fit, difficulty sleeping, feeling unattractive, being unable to keep up, etc. Or a patient may self-refer in a way that gives you an opportunity to ask, as for example, the patient who described herself as “poor fat Jane”.

Anorexic and bulimic patients may be more secretive about their disorders, and it may be necessary to infer them from indirect evidence.

2. ASSESSMENT

An initial assessment needs to provide you with enough information to begin working with the patient and his/her family. It will include such factors as.whether the patient in fact has an eating disorder, or is within the normal range with some mild symptoms
―level of severity of the patient’s disorder
—ability to pay, insurance, managed care limitations
—family resources to assist in treatment

Some of these can be specified in advance, and you should be as prepared as possible. However, early contacts with the patient and his/her family may not be as rich in information as you might want, because of the need to establish rapport and help the patient feel comfortable in a difficult and possibly threatening situation.

Also, as you refine your diagnosis and begin to select treatment options, additional information may be needed.

For a clearer indication of what information you may need, follow the map for this guide as far as you can with the information currently available, and look in the corresponding sections of text for the issues that are likely to arise.

As you continue to work with the patient and his/her family, you may want to re-read certain sections of text as a basis for deciding what additional information you need to gather.

2a. General Treatment Goals

3. IS A PATIENT OBESE?

3a. Symptoms

Commonly, obesity is defined in terms of body weight. A person is considered obese if he or she is 20% or more above the optimal body weight as defined by standard tables. One such table is reproduced in Appendix A. It defines optimal body weight in terms of a person’s height, sex and bone structure. In other tables, the last category is not considered.

You ordinarily recognize obese people by the way they look. They may also complain of how they feel and how they are treated by others because of their weight.

In addition, they may…
—have difficulty sleeping
—have difficulty exercising or just getting around, because of their extra weight
—have difficulty breathing: it requires more effort than for most people. They may
—make sounds when they breathe.
—have low self esteem
—feel lonely and depressed

3b. Current Dynamics

Overeating may be considered compulsive or addictive behavior. As with other compulsions, people overeat for many reasons that are not directly related to their bodies’ needs for sustenance.

Many obese people are very needy but unable to satisfy their own needs directly. Eating is a substitute.

The reasons may be out of awareness. Often obese people are trying to resolve an interpersonal or intrapsychic conflict by discharging the feeling through eating.

Many are social phobics, who have difficulty meeting people. They expect to be criticized and rejected. It is often difficult to know which came first: whether their avoidance of other people led them to stay home and eat, or their obesity led to their experiences of rejection.

Reasons to eat could include
—depression
—anxiety
—unhappiness

A person may feel small and helpless, and eat to be big and strong. Some have even heard that very connection voiced by their parents, and take it to an extreme. Being big is safe. This can be part of the dynamic pattern in obese adults who were sexually abused as children.

A person may also eat to be unattractive and try to avoid sexual abuse that way.

Being obese can be the result of identification with one or both parents, or with some other adult who was seen as strong or otherwise desirable.

A person may have self esteem issues as a result of being obese, in a culture such as ours, that places a high value on being thin.

3c. Typical Background and Family

Often obesity begins in childhood and continues throughout life.

We have observed at least three general groups of overweight children, and we think the dynamics may carry on to adulthood:

One kind is nervous and worried all the time, and eats to soothe him/herself. This may have a temperamental component, i.e.: a congenital overreactivity to external stimuli, if the infant can only be calmed by being fed. The parents learn quickly, and it becomes their primary response to the child’s tension as it gets older.

Another group were just overindulged, babied, spoiled. They have a feeling of being entitled to whatever they want whenever they want it, without any restrictions. Often this child comes from a family where the mother feels guilty for some aspect of the child’s life, and tries to compensate. The child may be left with baby-sitters or grandparents a lot, and the rules are not clearly stated or consistently enforced. The child is kept a baby: passive and inept.

The third kind are very impulsive, can’t control themselves, may not be mindful enough of physical cues to know when they are full, can’t tell when to stop. Often this child comes from a family where there is a laissez faire attitude toward parenting, so that the child’s internalized structure is inadequate. If they feel like eating, they eat. If they feel like kicking you, they kick you. Usually other family members are similar: they are lacking in internal checks.

3d. Levels of Pathology

From our point of view, level of pathology doesn’t refer only or primarily to the amount that the person is overweight.

Severity of pathology has to do with the amount of body image distortion or loss of self esteem, pervasiveness and rigidity of defenses, inability to form and maintain relationships, etc.

3e. Comorbidity

RETARDATION or PSYCHOSIS may include a lack of internal controls on behavior, including eating behavior. The parents of retarded or disruptive children may have fed them to calm them, leading to a valuing of food and unrestrained eating habits.

PHYSICAL OR SEXUAL ABUSE may lead to obesity in a variety of ways: through a hope of becoming big and strong to fight off an abuser, through a fantasy of becoming unattractive to a sexual abuser, or in compensation for the lack of caring perceived in the abuser’s attitude.

AGORAPHOBIA: Some obese people are afraid of the world and going out into it, stay home and eat to salve their anxiety and compensate for the experiences that they don’t allow themselves. They don’t get any exercise.

Also, HELPLESSNESS, DEPRESSION, ANXIETY DISORDERS, FEARS, PERSONALITY DISORDERS [generally: passive/dependent or passive/aggressive] can underlie obesity.

3f. Insurance Note: You should be aware that the DSM IV does not list obesity as an eating disorder; in fact, the term doesn’t appear in the book’s index. This is important, because DSM numbers are used to justify treatment to insurance companies. It becomes necessary (and usually not too difficult) to justify treatment by another Axis I diagnosis. See Sects 3B and 3F above for ideas.

8. IS A PATIENT BULIMIC?

Follows from Section 30

Bulimia [or bulimia nervosa] can be recognized as a series of eating-related behaviors, rather than by a person’s weight. A person may be bulimic and appear normal.

8a. Symptoms

With bulimics, the behavior is the primary symptom.

The typical bulimic person goes through a cycle. At first there is a need to eat, then he or she eats to the point of getting overly full. At some point, he/she feels fat and has to take drastic action to get rid of the feeling. In this, the disorder is similar to the ego defense of undoing. The behavior may be repeated only occasionally – in times of stress – or as often as several times each day.

A person can attempt to get rid of the excess weight or fat or sense of fullness in a number of ways. He/she can—
—vomit, as often as 10-12 times per day.
—use laxatives, diuretics, or enemas
—exercise
—fast
—go on a strict diet.
—use drugs, such as insulin, amphetamines or cocaine

Symptoms of vomiting can include split lips, sores in the mouth, a hoarse voice, sore throat, loss of tooth enamel, and receding gums. They may also get “chipmunk jaw”: swollen glands under the jawbone, that causes the neck to be swollen, as though the person has mumps. They may try to hide this symptom, e.g., with turtle neck sweaters.

Secretiveness: generally bulimics hide their behavior from others, including their own families. Often the family learns about it indirectly, or after some traumatic event, or because the patient has hid it ineffectively.

[For example, a parent notices a bad smell coming from her teen-ager’s bedroom, finds plastic bags of vomit under the bed. College students notice food disappears regularly from their apartment, and when one of them is sick the others find large stores of food in her bedroom. Parents notice that one child goes to the bathroom immediately after every meal and listening at the bathroom door, hear the child vomiting.] A patient may be in psychotherapy for years without telling the therapist about it.

Other symptoms of bulimia may include [see also Sections 8E and 10A]:
—Preoccupation with food and eating
—Body weight is close to the ideal
—Fear of being fat
—Frequent mood swings
—Compulsions and addictions
—Sexual acting out

8b. Dynamics

Commonly, an emotional issue, such as loneliness, depression, low self esteem, or anxiety is soothed by eating. Over time, the person feels more and more empty, with an increasing need to eat. This is the preparation phase. It culminates in a frenzy of eating, a binge. The person can’t stop until stuffed. At that point, a shift takes place, and the person becomes aware of having gone too far. The food becomes poisonous and must be gotten rid of, through a purge that involves extreme measures like vomiting, fasting, extremes of exercise, or use of laxatives. There may follow a sense of relief, as the person feels once again in control. A successful purge may be accompanied by a pleasant after-feeling of drowsiness, like being drugged, or sleep.

Bulimia is a kind of compulsive or addictive behavior, in that (1) there is an emotional charge, a sexualization, to both the eating and purging phases; and (2) although the binge-purge cycle reduces the person’s internal pressures temporarily, it doesn’t address underlying issues, and so must be repeated again and again.

The bulimic pattern – of craving, overeating, vomiting to undo the overeating, and then feeling disgusted – may be one variation of a more general theme that is also expressed in other areas. Expressed sexually, it could appear in a woman as craving for a man, having sex, being disgusted, and avoiding or rejecting him.

Some patients may binge in order to vomit and feel the pain of vomiting; possibly after a humiliating experience. Others experience a feeling of well-being after vomiting that may be due to increased plasma endorphin levels

For many patients, the bulimic cycle may be related to issues of separation and individuation, as, for example, right after leaving home and arriving at college.

Bulimics generally have a poor body image: they typically see themselves as fat and disgusting, when others see them as normal or only slightly overweight. Many bulimics have a fear of being fat, and equate being fat with being needy, which they see as bad.

8c. Levels of Pathology

Bulimics can range in level of adaptation from neurotic to borderline.

At the high end, a person who is simply unable to lose weight through regular dieting and related behaviors may resort to exercise or laxatives. The reasons for their inability to lose weight may be worth exploring, but in general they may be functioning relatively well in the rest of their lives.

At the low end, many bulimics may be thought of as being in the borderline range: they are anxious, depressed, emotionally labile, they have poor impulse control, they act out in many ways, sexually and otherwise, they resort to drugs. They may be low-functioning: they do poorly in school, they can’t hold down, jobs, they can’t separate from their families, etc.

Some of these behaviors, such as dieting and exercise, can be used by people within the normal range. The extent or degree of use is what identifies them as pathological in bulimics. Other behaviors, such as vomiting or drug use, are clearly in themselves diagnostic of pathology.

8d. Typical Background and Family

Bulimics can come from a variety of backgrounds and levels of pathology. Like its corresponding defense mechanism, undoing, the constellation of bulimic behaviors can be used by anyone; but some kinds of patients are more likely than others to use it. Especially within the group of high functioning bulimics, there is wide variability in background, age of onset, frequency of episodes.

Lower functioning bulimics may be more stereotypical: they may be in the borderline range, with poor ego functioning, dysfunctional families, etc. The family often is chaotic, or enmeshed in hostile ways. The mother may make a point of her self-sacrifice, while generally lacking empathy for the patient. She may alternatively belittle and blame, appease, or neglect her daughter. The father may exert control while appearing to be sympathetic and understanding.

For some people, there can be a parallel between physical or sexual abuse and bingeing and purging: the bingeing reproduces the danger and excitement of the abuse, by itself being both exciting and abusive. In the purging phase, the person is trying to undo the abuse through vomiting, exercise, etc.

8e. Comorbidity

Bulimics may also be diagnosed with
—Social phobia
—Panic disorder
—Generalized anxiety disorder
—Major depression
—Alcohol dependence or abuse

Bulimia may not be the reason the patient seeks treatment, and may only be reported as an incidental issue by the patient.

13. IS A PATIENT ANOREXIC?

Follows from Section 30

Anorexia, or anorexia nervosa, is a disorder in which the person over-controls his/her weight. About 95% of anorexics are girls and women; so in the following we will assume the patient is female. We will address other patient groups in Sect.16D.

13a. Symptoms:

Anorexics [or, if you prefer, anorectics] are so intent on being thin that they have lost all reasonable sense of what a body should look like. They starve themselves. Their judgment is compromised, and they don’t know when to stop. In the absence of outside intervention, the disorder can easily progress to an extreme form; and in its extreme form, it can be fatal.

The following list gives many of the things to look for. It includes typical methods of weight control, signs of trying to stay a dependent child, and consequences of starvation.

Eating habits:
—preoccupied with eating-or-not-eating
—refuses to eat
—severely restricts diet and denies feeling hungry
—refuses to maintain a normal weight
—secretive, including hiding food to dispose of it

Physical:
—hyperactive
—uses exercise and running for weight control
—low body weight, compared to standard tables
—rapid weight loss
—amenorrhea: missing three periods or more is a marker sign
—constipation
—grayish skin discoloration , circles under the eyes
—growth of fine body hair
—interrupted sleep
—leg cramps
—frequent headaches

Behavior:
—use of laxatives or diuretics
—self-induced vomiting for purpose of weight control
—avoidance of appropriate sexual relationships

Cognitive:
—distorted body image
—avoids making decisions

Emotional:
—child-like dependency on others
—overwhelming fear of becoming fat
—sees food as danger, poison
—any change in life seen as a loss
—frequent mood swings

13b. Typical Background And Family

Commonly anorexia begins in adolescence and is a risk for the remainder of the patient’s life.

As indicated above, about 95% of anorexics are girls and women. For them, one family constellation is especially likely:

They come from a privileged home; family members are intelligent and well-read. Family members appear to be cooperative on the surface, but there is an underlying rigidity. Children are fed on the mother’s schedule and not according to their own needs.

There is a covered-up marital rift, and the parents despise each other.

Father is successful, domineering and authoritarian, runs the show, to cover up his own insecurities. Mother is perfect wife and mother, loving and generous, but with underlying anger at her role, her husband, her children, at being a woman. Mother is seen by the daughter as almost a slave. The girl doesn’t want to grow up and become like her mother. Mother doesn’t allow the child’s hostility to be expressed openly.

13c. Dynamics for the Usual Case

A girl-child doesn’t want to be a woman like her mother
—The mother is perfect, the house is perfect, and the daughter must be perfect if she wants to please her mother.
—The girl turns to her father for support, but must remain a child, else lose her mother [who will become a rival] and father[who also seems to despise women].
—The girl’s solution is to stay small and not grow up; and to do that, she must not eat.

Often anorexia begins after some change occurs in the patient’s life, which is perceived as a loss. (e.g.: problem with boyfriend, leaving for college)

13d. Alternative Patterns and Origins

AGE AT ONSET: Three most common ages for the beginning of the disorder in women would appear to be [1] around 11-13; [2] 17-18; and [3] in the 30’s or later. It is possible that either the different groups are responding to different classes of precipitating events, or they have different dynamics.

MEN: There is some recent literature on gay men and anorexia; possibly because of greater premium on appearance among gay men than among straights, or possibly because gay men are more likely than straight men to seek psychotherapy.

WEIGHT LOSS FOR COMPETITIVE SPORTS: especially among adolescent boys and wrestling, boxing, etc. They may lose their normal eating patterns and self-regulatory awareness.

STEROID USE: among male body builders and competitive athletes. This is another form of obsession with weight, use of external controls.

SPECIAL DIETS: In their extreme form, these can be a sign of an anorexic-like dynamic, if the person is using the diet as a way of controlling self and others [e.g.: a person who eats nothing but pasta]. Depending on the diet, there can be nutritional deficiencies and serious long-term medical consequences in addition to the manipulative aspect of the behavior.

HISTORY OF PHYSICAL OR SEXUAL ABUSE: The sense of being out of control during an abusive episode may lead some people to increase their control over themselves in whatever ways they can, including what they eat. In addition, the foods avoided may represent the abuse in some way.

OPPOSITIONAL BEHAVIOR: Use of restrictive diets, excessive exercise, etc., can bring people into conflict with their families [parents who become worried, a spouse who is annoyed by the patient’s excessive behavior, etc.] breaking the pattern of apparent compliance that so often characterizes anorexics, and sometimes escalating to anger and confrontations.

13e. Levels of Pathology

EXTREME: A person who is extremely anorexic is easy to recognize. He/she looks like a walking stick: the hands and elbows look unnaturally large, face is gaunt. His/her weight is so low that there is a danger of dying. He/she may complain of weakness or dizziness. Walking may be difficult; driving is risky because of poor physical control.

MILD: It should be noted that many people watch their diet and exercise to control their weight. Our culture rewards thin people, and women are especially sensitive to this pressure. Similarly, obsessive/compulsive attitudes and behavior are rewarded in many ways. It is often difficult to draw a line between more moderate forms of anorexia and weight concerns that are within the normal range. See also Section 18.

13f. Comorbid Conditions

Obsessive-compulsive disorder is common; in fact, these patients seem obsessed with self-control.

13g. Gathering Information

Often you will get information from other family members: a parent, spouse, etc., rather than the patient. If you consult with the patient’s physician, you may find that the physician is already aware of the problem. Or you may notice danger signals yourself, if he/she is in psychotherapy already. Some patients will admit to the behavior when confronted directly. Others will cover up the disorder and/or deny it when confronted.

18. NORMAL WITH WEIGHT CONCERNS?

When you think a patient is not obese, anorexic, or bulimic

It is difficult to exist in this culture without being exposed constantly to issues of weight and diet: being too fat or too thin or not eating the right foods. Diets abound.

Many patients who do not have diagnosable eating disorders do have serious concerns about their weight, that affect their self-image and self-esteem, their internal lives and their interpersonal relationships, and that they want to address in treatment.

People in this category are relatively high-functioning, with some issues around their weight, but for whom weight is not a central focus. They may be 5-10# overweight; their blood pressure may be up. They are not at risk because of their eating habits.

Being overweight may service other issues:
—avoiding one’s own sexuality and the fear that one would act out if he/she were more attractive
—avoiding risky sexual interest from the opposite sex
—having an excuse for competitive failures
—identification with an overweight parent

Being overweight may be a consequence of overeating, which in turn may service other issues:
—rewarding oneself for successes
—consoling oneself for failures
—comforting oneself when lonely or hurt
—being defiant

Being underweight may service other issues:
—trying to match an ideal shape to be more popular
—wanting to arouse envy in one’s social enemies
—trying to be more attractive
Being underweight may be a consequence of not eating, which may be in reaction to other issues, such as being depressed or anxious

18a. Overweight and Constantly Dieting

This is clearly the largest [!] treatment category, because issues of being overweight and dieting and losing weight are of concern to so many people in general.

18b. Underweight and Constantly Dieting

3. IS A PATIENT OBESE?

3a. Symptoms

You ordinarily recognize obese people by the way they look. They may also complain of how they feel and how they are treated by others because of their weight.

3b. Current Dynamics

Overeating may be considered compulsive or addictive behavior. As with other compulsions, people overeat for many reasons that are not directly related to their bodies’ needs for sustenance.

Many obese people are very needy but unable to satisfy their own needs directly. Eating is a substitute.

The reasons may be out of awareness. Often obese people are trying to resolve an interpersonal or intrapsychic conflict by discharging the feeling through eating.

Reasons to eat could include
—depression
—anxiety
—unhappiness

A person may also eat to be unattractive and try to avoid sexual abuse that way.

Being obese can be the result of identification with one or both parents, or with some other adult who was seen as strong or otherwise desirable.

A person may have self esteem issues as a result of being obese, in a culture such as ours, that places a high value on being thin.

3c. Typical Background and Family

Often obesity begins in childhood and continues throughout life.

We have observed at least three general groups of overweight children, and we think the dynamics may carry on to adulthood:

3d. Levels of Pathology

From our point of view, level of pathology doesn’t refer only or primarily to the amount that the person is overweight.

Severity of pathology has to do with the amount of body image distortion or loss of self esteem, pervasiveness and rigidity of defenses, inability to form and maintain relationships, etc.

3e. Comorbidity

Also, HELPLESSNESS, DEPRESSION, ANXIETY DISORDERS, FEARS, PERSONALITY DISORDERS [generally: passive/dependent or passive/aggressive] can underlie obesity.

3f. Insurance Note: You should be aware that the DSM IV does not list obesity as an eating disorder; in fact, the term doesn’t appear in the book’s index. This is important, because DSM numbers are used to justify treatment to insurance companies. It becomes necessary (and usually not too difficult) to justify treat by another Axis I diagnosis. See Sects 3B and 3F above for ideas.

4. MEDICAL EXAMINATION OF OBESE PATIENT

This section follows after Section 3

Once the person’s weight has become a focus of the treatment, a consultation with an internist should be considered.

4a. Reasons for Making a Referral

It is important to check the patient’s general health for at least five reasons.

1. you need to know whether the weight problem is the result of a medical condition that needs to be addressed.

2. you need to address any other medical problem that may be related to or affected by the person’s excessive weight.

3. you need to know the patient’s general health before any recommendations can be made concerning diet, exercise or other techniques for losing weight.

4. you need to know whether the patient is at risk because of extreme weight, as a basis for deciding whether to recommend hospitalization, either for treatment of complications or for a medically supervised weight loss program. If you are aware of risks, part of your referral may include suggestions to the physician about watching for these issues.

5. Any information you get from the physician or from the patient as a result of having had a check-up can lead to important treatment issues that the patient might otherwise have denied the importance of or not even known about. You may need to process with the patient his/her reactions to new information, as well as the reasons that it was previously unknown or denied.

4b. Special Risks

IMMEDIATE HEALTH AND SAFETY RISKS

Urgent health risks could include risk of heart attack, heart failure, or stroke. If the patient suffers from associated sleep apnea, there are both immediate and long term risks to that condition as well.

LONG TERM HEALTH AND SAFETY RISKS

There are many increased physical risks associated with obesity, including risks of high blood pressure, stroke, coronary heart disease, diabetes, circulatory problems, sleep apnea, and joint pain. In men there is greater risk of prostate, colon and rectal cancer. In women there is greater risk of cancer of the breasts, uterus and cervix.

In obesity, all of the internal organs are enlarged, leading to a variety of risks of malfunction.

4c. Making the Referral

You should be in touch with the physician before (to state your concerns) and after (to learn the findings) the patient is seen, if possible.
5. LEVEL OF CARE DECISION FOR OBESITY

Follows Section 3 [Obese?] and Section 4 [Medical Consultation]

Here we are considering the question of what we should recommend as the initial level of care for a patient. Choices include hospitalization [Sect.21], day care treatment [partial hospitalization: Sect.22], or outpatient psychotherapy [Sect.6].

However, hospitalization and partial hospitalization are relatively short-term treatments, and most patients will eventually be seen in outpatient psychotherapy.

Most of the treatment considerations in this guide will have to do with aspects of outpatient treatment [Sects. 6 and 7].

5a Issues to Consider

Your recommendation about level of care will be affected by your assessment of the risks the patient faces, treatment effectiveness, the patient’s responsibilities, and the patient’s general attitude.

Health risks can best be evaluated by a physician. Some such risks have been indicated in Section 4.

Safety risks could include danger of driving a car or operating complicated equipment, especially if the person is drowsy or likely to fall asleep.

Other risks may have to do with employment, where obesity itself can be a drawback, and where associated symptoms can affect job performance.

Effectiveness of inpatient vs outpatient treatment
The effectiveness of any inpatient treatment facility must be evaluated on a unit-by-unit basis. You should probably keep a record of experiences with various facilities to which you might refer.

Cost must be evaluated relative to the patient’s resources. It includes considerations of insurance and limitations imposed by managed care.

Comorbid Conditions commonly include depression and alcohol dependency. You should look for these when deciding on level and form of treatment.

Insurance
Because obesity is not considered a diagnosable mental or emotional condition by most insurance companies, psychotherapy must be justified on other grounds in order for a patient to be covered.

Your diagnosis will need to justify the level of treatment you think the patient needs. For suggestions, see Sect.3A [Symptoms], 3B [Current Dynamics] and 3E [Comorbidity]

Interpersonal Relationships
It may be difficult for some patients to separate from their families. At the same time, the patient’s normal relationships and settings may encourage overeating, and removal from them may help greatly in weight loss and related pathology.

Restrictiveness of Setting
The more restrictive the setting, the better control you have on compliance to both diet and medication prescriptions. However, more restrictive settings also limit the person’s ability to carry out normal responsibilities, including earning a living, child care, etc.

5b. The Choices

There are basically three possible levels of treatment that may or may not be available, depending on local resources, cost, insurance coverage, etc. Ideally, your choice would depend solely on the patient’s need, but the situation is seldom that simple.

OUTPATIENT PSYCHOTHERAPY (cf. Sect.6)

Advantages:
least expensive
allows patient to continue normal life

Disadvantages:
diet and medication can be suggested but not controlled
harder to monitor medical status
PARTIAL HOSPITAL OR DAY HOSPITAL [cf.Sect.22]

Advantages:
some control over diet and medication
close monitoring of medical status
allows some continuance of normal life
more intense therapy and education

Disadvantages:
may not be available
may be too costly or not covered by insurance
may interfere with normal responsibilities

HOSPITAL: [cf.Sect.21]

Advantages:
control over diet and medications
close monitoring of medical status
relatively safe environment
greatest short-term effectiveness

Disadvantages:
most costly
normal responsibilities can’t be carried out
possible risk to employment
may be prematurely terminated by insurance or managed care

6. OUTPATIENT PSYCHOTHERAPY FOR OBESITY

Follows level of care decision, Section 5

Here we are considering the question of what we should recommend as the sole or primary form of treatment for a patient. Once we resolve that issue, we can go on to consider the remaining treatment modalities for their value as supplementary to the primary treatment form.

6a. Treatment Goals and Issues

One goal of treatment is to help the patient make a connection between his/her emotional state and use of food. Many people eat because they can’t deal with feelings. Identification of feelings helps the patent separate the two, and break the automatic connection. Special attention should be paid to hurt and anger as antecedents to eating excessively.

Obese patients need to learn to express these feelings directly, rather than eat.

Many obese people have a history in which they were quieted by their caretakers with food, rather than being fed when they were hungry. They got the message, “Don’t feel, eat.” As adults, they continue to try to manage their emotions the way their caretakers tried to manage them.

A second goal is to reduce the patient’s degree of body image disturbance. The person needs to perceive him/herself accurately in order to make reasonable judgments about his/her weight and its impact on his/her life. Some people seem unaware of their excessive weight; others lose weight and still don’t see themselves as thin. To do this, you can ask the person for a self-description, and judge whether it matches your own perception of the patient, or ask the patient whether it matches the way others seem to perceive him/her. Once the person is aware that self perception doesn’t match the perceptions of others, work can be done to explore the person’s history of body awareness.

A third goal is to help patients increase their general self-esteem, if food is being used as a technique for feeling better. They need to examine the assumption that thin=good and fat=bad. They must learn to deal with their own self-loathing, other people’s loathing of them, and feelings of being out of control and bad.

Often a patient’s self esteem is felt in reaction to his/her weight: when the weight goes up, the self esteem goes down, and vice versa. However, the reverse may also be true: if the patient is able to gain in self-control and self-esteem through treatment, his/her ability to lose weight may be increased.

A related issue is that overeating may be a form of self medicating for depression. In this case, the depression must be addressed, including the possibility of medication.

There is evidence that treatment can help many obese people tolerate painful emotions more effectively, especially feelings of abandonment and loneliness. Along with increased tolerance, they may have less need to self medicate with food.

With many patients, it pays to examine the secondary gain from being overweight, especially when the patient starts to lose weight successfully. Loss of weight may lead to anxiety and an urge to eat to reduce the anxiety.

Being obese may seem to be good, because then the person feels bigger and more powerful. His/her weight can feel like insulation, keeping other people at a safer distance. This may be especially likely in people who have been victims of abuse.

Many obese people are sexually inactive. They want relationships but avoid them in ways that they are not aware of. There are many possible connections here. If being obese means being more powerful, then a sexual relationship may make a person feel vulnerable, and so must be avoided. If the person has been abused, that could lead both to being obese and to having issues with sexuality. Obese men may have difficulty performing sexually for purely physical reasons.

Feeling unattractive can also feel safer to people who feel socially awkward or inadequate, or who fear being used or abused sexually. For example, some obese women may be unable to refuse men’s sexual advances, and may use their extra weight to protect themselves from compromising situations. In such cases, weight loss may be seen as dangerous. Others may fear their own impulses and remain unattractive to avoid temptation: “This way, I’m not tempted to leave my husband.”

Part of the treatment may consist in helping patients defend themselves in more effective ways, and/or in helping them find pleasure and value in a wider range of experiences.

Diets in themselves are usually only temporarily effective, if effective at all. Most dieters rebound, once they stop dieting. Most obese people have been very thin at times. For a therapist to get involved is tricky and potentially undermining to the therapeutic relationship. Diets are best recommended and monitored by others; See Section 7A.

6b. Outpatient Treatment Choices

Each of the following has been recommended as the primary form of treatment for obesity. We list them here, with some of their advantages and disadvantages.

INDIVIDUAL PSYCHOTHERAPY [cf.Sect.20]

Generally speaking, patients get to psychotherapists because they want individual treatment and believe they can get it from us. In most cases, that is also what we recommend, because it has the greatest likelihood of effecting lasting change for relatively low cost. There is evidence that individual treatment can be especially helpful relative to tolerating painful emotions, increasing self esteem, and developing a more realistic body image. The evidence appears to be that individual treatment affects self esteem even more than it has a lasting effect on the person’s weight. Self esteem issues are more easily dealt with individually.

Other Advantages:
—You can pursue the individual patient’s underlying issues around weight and weight loss
as much as needed.
—Unconscious motives are more easily explored

GROUP PSYCHOTHERAPY [cf. Sect 28]

Advantages:
—Can help a person develop interpersonal skills and feel more comfortable with other
people. This can help a person whose eating is a reaction to social rejection and
awkwardness. It can also be of value to a patient who has worked on intrapsychic issues
for a while and needs to focus more interpersonally.
—Group treatment can provide support to the patient, provide an opportunity to observe
the patient interacting with others, using defenses in peer interactions, assuming a role or
position, etc., all of which can help understand the pressures driving that patient to
overeat.
—A person who can’t lose weight can develop a sense of identity and belonging with
others who have a similar problem.
—Increased sense of empowerment and self acceptance

Disadvantages:
—generally not effective for long-term weight loss by itself

FAMILY THERAPY, INCLUDING PATIENT [cf.Sect.24]

Advantages
—Might be indicated for a younger person, from an enmeshed family or a family that is out
of control, is infantalizing or failing to set limits.
—Allows you to observe directly some of the interactions among the patient and members
of his/her family. These observations can reflect some of the pressures that help to
sustain the patient’s weight problem.
—Input from other family members can validate or challenge the patient’s perceptions, add
information that the patient may not be aware of, and help fill out the family history.
—To the extent that the patient is expressing the pathology of the whole family, it may be
more effective to attempt change at the level of the family, rather than to ask the patient
both to change and to fight family pressures as well.

A TEAM APPROACH includes at least two therapists and either: INDIVIDUAL PLUS FAMILY; or INDIVIDUAL PLUS GROUP [cf.Sect.23]

Advantages
—Involving the patient’s family can clarify the ways in which family structure, attitudes,
patterns, etc. contribute to the patient’s obesity; the patient’s role in the family; issues of
co-dependency; whether the patient is similar to – or different from – other family
members in terms of eating, etc.
—Sometimes issues raised in one treatment modality can be explored from a different
perspective in the other. The two modalities may raise different and complimentary
issues. Collaboration among therapists may enrich their treatment perspectives.

Disadvantages to a team approach are that
—It can stretch the patient’s time and financial resources
—It involves ongoing communication between the individual therapist and the group
leader.

SELF-HELP GROUPS [cf.Sect.29] provide knowledge of the disorder and support for a person in dealing with the difficulties of changing habits. They cannot provide sufficient new awareness of the patient’s specific difficulties to effect lasting change in themselves. They are not staffed by trained professionals. Treatment groups and self-help groups are often only effective for as long as the patient continues to participate. We have not yet ever recommended a self-help group as a primary form of treatment.

COMMERCIAL WEIGHT LOSS PROGRAMS also provide some support, along with a specific, detailed plan for losing weight. They generally try to fit all patients into a single plan, and it works with varying success with different patients. The cost is paid by the patients themselves, and the fee that can be charged is not great enough in general to turn a profit and also provide structure and offer the kind of professional counseling needed to effect lasting change. If such plans are effective, the effect is almost always temporary. Once the patient stops going, any weight lost returns, contributing to “yo-yo dieting”, further long-term weight gain, discouragement and loss of self esteem.

6c. Course of Treatment

Sometimes a person appears and you can tell he/she is obese and that that is problem, whether he/she is talking about it or not.

Sometimes a person will come to you and not look obese, but will tell you that overeating is a problem, that he/she has put on a lot of weight recently, is out of control, unhappy about it, doesn’t know how to get back into control.

If the person is concerned, then you need to gather information about his/her current state and expectations:
—current weight
—ideal weight
—how long since he/she has been at ideal weight

You also need to know the patient’s history of weight fluctuations and attempts to deal with weight
—what weight control methods or programs has the person tried, and how
successful/unsuccessful were they? [diets, Weight Watchers, etc] —how and why did previous efforts at weight control fail?
—what happened to precipitate the present weight gain? Is this what happened in previous
weight gains?
—How does the patient undermine his/her own attempts at weight loss? How do others
undermine it?

This will give you information about the person’s strengths and weaknesses, defenses [successful and otherwise] and environmental influences.

The patient’s experience of eating is important:
—is there a mood or feeling that the patient is attempting to handle by eating?
—are there certain experiences that may lead to overeating? [e.g.: being left alone and
lonely; making a mistake at work, a phone call from mother; a fight with a friend; etc.] —when does the person eat? What kinds of foods does he/she crave?
—What does the person feel after eating?

This will give you more informaiton on the patient’s defenses, the stimulus triggers for overeating, and underlying urges, drives, moods, etc.

MAKING SUGGESTIONS

You could suggest Weight Watchers or if the person is very overweight, Overeaters Anonymous. These provide encouragement and external support along with specific plans for the conscious control of weight. However, while they might be well-suited to a small number of patients, they generally miss the underlying issues that interfere with the self-control of any one patient. Those issues need to be addressed therapeutically in a way that allows expresion and treatment of the person’s individual dynamic.

When you make such a suggestion and the person fails to follow it, it can lead to information about the person’s feelings about you, about being controlled, about group participation and shyness, etc.

Most people have tried a number of diets already, and have their own idea of what works and what doesn’t. The primary function of psychotherapy is to help them do what they want to do. This can be done by dealing with the patient’s resistance to dieting or to weighing less.

To do this, focus on the patient’s expectations of success: what are the negative consequences of actually losing the weight? [e.g.: being more attractive than a jealous sister; being criticized by mother for being too thin; getting too attractive to someone dangerous, like a sexually abusing father] The patient may or may not be aware of the expectation.

It is often most helpful to follow an eclectic approach that addresses both the behavior and the underlying issues. This can include:

Behavioral:
—Have the patient keep a food diary, as a way of understanding his/her eating patterns.
Review it with the patient, to look for consistent behaviors and their antecedents. The
diary should include:
—everything eaten
—when
—what was eaten
—quantities
—What feelings were present at the time.

Cognitive:
—explain the issues and common difficulties dealing with them
—{body stuff} Work on body image; Obese patients have a distorted body image. Ask
how fat they think they are, etc—
—Review the diary to look for consistencies of meaning

Psychodynamic:
—provide an empathic holding environment where the patient feels valued and understood.
—look at the various issues raised in this section and in Sect.3B above

6d. Treatment Modifications

Each patient will bring his/her own history and dynamic that must be understood and dealt with.

There are certain periods of life in which weight gains can be expected:
—women going through menopause can gain
—men and women as they get older tend to gain weight

Certain medications can lead to weight gain, leading to a need to decide on a course of reaction. If the patient is taking any prescription medications, this can be a good opportunity to consult with his/her physician about the weight problem, the possible effects of the medication on that problem, and possible alternative medications.

6e. Termination

Obesity is a symptom with many causes. Treatment should be terminated when the sources have been dealt with and [if possible] the weight brought under control

If the weight can’t be reduced to the point that the patient feels comfortable, then treatment should terminate when the patient has come to accept and learned to cope with the results.

6f. Follow-Up

7. ADJUNCTIVE TREATMENT DECISION FOR OBESITY

This section follows from and depends on Sect.6

7a. Professional Consultations

You may want to bring in other professionals to refine the diagnosis, or to handle issues that would dilute your treatment or are outside your range of competance. Discussions with them can also suggest treatment issues.

MEDICAL CONSULTATIONS: [cf.Sect.26] to follow up on the risks from being overweight [cf. Section 4] and to determine whether there are any increased risks due to dieting or other changes in the patient’s life.

PSYCHIATRIC CONSULTATION [cf Sect.25] —A psychiatric referral for medication may be helpful, if eating is used to deal with
chronic anxiety or depression.
—As an obese patient starts losing weight, other emotional issues may become
accentuated, and psychiatric backup may be necessary.

NUTRITIONAL CONSULTATION [cf. Sect.27] —If people are going to modify their eating habits, they need help to determine the kind of
diet, in terms of both safety and effectiveness. This is the cognitive side of treatment.
—Can be with a nutritionist or physician
—A nutritionist is a good person to be monitoring the patient’s weight, so that the
therapist can focus more on the dynamic aspects of treatment.

7b. Additional Treatment and Support

All of the following can be helpful, in addition to individual treatment. They offer the patient information, social skills, etc., that either the therapist can’t provide directly or that free the therapist to focus more on intrapsychic issues.

GROUP THERAPY [cf. Sect.28] can help people develop a sense of identity and belonging and acceptance of themselves, help them improve their interpersonal skills, help them feel less helpless and more empowered. They can learn to express feelings directly instead of feeding themselves as a substitute.

SELF-HELP GROUPS: [cf. Sect.29] Provide support and knowledge about the disorder.
—Overeaters Anonymous provides directly related help. It also gives the patient a sponsor
when he/she fears losing control, from whom help can be obtained
—Other groups can also be helpful: groups for incest victims; Al-Anon if there is alcohol
abuse in the family.

FAMILY THERAPY: [cf. Sect.24] —If the entire family is obese, family therapy can help all the family members face and
work on the problem together
—If the patient is the only obese family member, family treatment can deal with the group
pressures that are brought to bear on the deviant member, as well as the pressures that
maintain the system status quo.

SEPARATE TREATMENT FOR PARENTS
Especially helpful when a child is playing out or reacting to parental conflicts by overeating

COMMERCIAL WEIGHT-LOSS PROGRAMS
These vary considerably regarding their programs. Their purpose is to make money. They often provide a temporary sense of effectiveness.

20. INDIVIDUAL PSYCHOTHERAPY

Follows from Section 5, Section 10, or Section 15

20a. Exploratory Psychotherapy

20b. Treatment from the Perspective of Defenses

—isolation of affect
—denial
—intellectualization
—avoidance

Work to help the patient admit to feelings, express them, deal with them.
20c. Treatment from a Developmental Perspective

Focus on issues of self-control of impulsive urges, self-soothing of anxiety and depression, dealing with feelings of loneliness and separateness.

20d. Cognitive-Behavioral Treatment

—Self-monitoring
—keeping a diary
—get the person to become aware of patterns of eating
—antecedents, reinforcers
—counter-conditioning: teach other ways of coping
—relaxation
—assertiveness training
—problem solving

21. HOSPITALIZING A PATIENT WITH AN EATING DISORDER

Follows from Section 5, Section 10, or Section 15

Advantages: there are several ways in which hospitalization can be of benefit to a patient with an eating disorder, who is becoming ill and out of control.
—Medically, to deal with dehydration, electrolyte imbalance, or severe gastro-intestinal problems.
—Psychiatrically, to deal with depression and the risk of suicide, or to deal with comorbid alcohol or substance abuse.
—Behaviorally, to attempt to change eating patterns.
—Interpersonally, to help the patient separate from his/her family, and get help and support from others outside the family.

Disadvantages to Hospitalization:
—Expense: For most patients, the cost of hospitalization is so great that they can only afford it for as long as their insurance pays. If they don’t have insurance or if sufficient justification can’t be found to convince their insurance company to cover the costs,this option may be out.
—Length of Stay: Many insurance companies are limiting coverage for hospital care to the point that release is mandated before treatment can be more than minimally effective.
—Services actually offered may be far from optimal. The hospital may focus on crisis intervention and stabilizing the patient, while offering very little psychotherapy.

21a. Choosing a Hospital

Look for a hospital with a specialized program for the treatment of eating disorders. There should be a multimodal approach, including group and individual psychotherapy, behavioral techniques, use of appropriate medications, and family involvement. Patients should be carefully monitored. Staff should include general practitioners and nutritionists, to deal with health issues, as well as psychiatrists, psychologists and social workers. Attention should be paid to explaining the disorder to patients, and to outpatient transition.

Some hospitals are welcoming to outside therapists who visit patients for the purpose of maintaining contact, and make a point of referring patients back to their prior therapists when the program is completed.

Also important are hospital attitudes and policies about returning patients to referring therapists. The likelihood that a patient will be returned to you may be enhanced if you have ties with hospital staff and make contact about the specific patient.

21b. Making a Referral

Specific procedures may depend on the hospital, and it would be a good idea to be in touch first. One possibility is to call the appropriate ward and speak to the resident in charge there. If there is a bed available, arrangements can be made to send the patient to Emergency, where he/she will then be met by an appropriate staff person that you have already arranged for. The treatment could actually take place in Medicine, Adolescent Medicine, or Psychiatry, depending on the seriousness of the psychological disorder and the availability of a bed.

If the patient refuses to go, an intervention may be necessary. The patient is confronted with the evidence of risk to self and others, generally in confrontation with a group that includes family and/or friends and a trained therapist. The case is made forcefully. Arrangements are made in advance for space in an appropriate unit of a local hospital. A successful conclusion occurs when the patient agrees to hospitalization and is taken directly to the facility that expects him/her.

Another possibility is to call a crisis intervention team, who will come and forcibly take the patient to a hospital.

On returning after the hospital, the patient may resent the referral or the hospital treatment. This resentment needs to be addressed if individual psychotherapy is to continue, and may require referral to another therapist.

22. PARTIAL HOSPITAL

Follows from Section 5, Section 10, or Section 15

A partial hospital is conceptually similar to rehabilitation for an alcoholic patient: it is a structured environment that the patient goes to for several hours per day, the purpose of which is to help change eating behaviors and habits.

However, most partial hospitals are intended primarily to provide transition following hospitalizations. You may not be able to refer directly to them.

Can be very helpful in
—getting the behavior under control
—helping the patient separate from family, especially a dysfunctional family, where there may be abuse or alcoholism; or where other family members continue to bring home “trigger” foods, etc.
—restructuring the environment, providing structure, discipline, organization; helping break self – destructive patterns

This is usually not your first choice when there are medical issues that need to be addressed.

There may not be a day hospital convenient to your patient. When there is one, it may not accept referrals other than from an associated hospital program.

23. TEAM APPROACH TO TREATMENT

This is the approach of choice in a hospital, partial hospital, and possibly clinic setting. Within those settings, the expression refers to a complex set of relationships among a number of professionals working together.

However, logistical problems make it difficult for the outpatient therapist to carry out.

When we refer to a team approach in outpatient psychotherapy, we mean it to refer to a combination of treatment approaches with different therapists who remain in regular contact. The team then consists of the therapists who share responsibility for the case. The most common form of a team approach would probably be individual and family therapy, although the combination of individual and group treatments is another possibility.

Other professionals may also be involved cooperatively in any treatment, but we would not consider it to be a team approach unless there is a full sharing of responsibility. We discuss the roles of professionals who are less central to the treatment in the Adjunctive Care Sections for each disorder.

24. FAMILY THERAPY

Follows from Section 5,Section 7, Section 10, Section 12, Section 15, or Section 17

Here we are referring to any treatment which involves more than one family member in session together.

24a. Patient in Treatment with Family of Origin

May be indicated to help the parents or other family members deal with their interpersonal issues and at the same time assist the patient in separating from them.

24b. Patient and Family of Origin Treated Separately

Useful to help the patient separate from an enmeshed family situation.

Risk is that the other family members will join in excluding the patient. May be helpful to address this issue directly in treatment with the others.

May be helpful if the same therapist treats patient and others, because of therapist sensitivity to potential for others’ blaming the patient. Or, team approach in which the family therapist and patient therapist are in regular contact.

Can help the other family members with issues of co-dependency, so they are less likely to contribute to the patient’s condition. Some family members can also learn to stop taking inappropriate responsibility for the patients’ condition, reducing their sense of being manipulated and ineffective. If other family members stop being so worried about the patient, the patient may feel greater pressure to deal with his/her own issues.

24c. Adult Patient in Couples Treatment
25. PSYCHIATRIC CONSULTATION

Follows from Section 7, Section 12, or Section 17

A psychiatrist can help decide whether medication is likely to be helpful to a patient, and, if so, to determine the type of medication, dosage, expected reactions, etc., and to monitor the medication once it has been prescribed. With eating disorders, the most common need is for treatment of depression or anxiety.

A psychiatrist can also be helpful in estimating the risk of suicide, in deciding whether to hospitalize a patient, and in determining whether further medical attention is needed. [cf. Sect 26].

26. MEDICAL CONSULTATIONS

Follows from Section 7, Section 12, or Section 17

Useful if there are symptoms of depression or anxiety

Bulimia: antidepressants help deal with the addictive quality of the disorder.

26a. Choosing Between and Internist and a Psychiatrist

Many clinicians find this a difficult choice to make, and you may choose differently for different patients. Some factors that can influence your choice are:

—A patient may fear psychiatrists and refuse to go to one.
—Or you may fear termination if you insist.
—Your own feelings and experiences with the patient’s regular physician. The physician’s knowledge and comfort with psychotropic medications.
—The availability of a psychiatrist you trust and respect
—The level of complexity of the case. More difficult cases would normally be referred to a psychiatrist.
—Your own familiarity with medications and ability to collaborate with an internist about the prescription.
—If it becomes necessary to hospitalize a patient, then connections with a local hospital can be valuable, both in arranging admission and providing continuity of treatment. Most psychiatrists have affiliations with inpatient psychiatric units.

27. NUTRITIONAL COUNSELING

Follows from Section 7, Section 12, or Section 17

A nutritional counselor can develop special diets for patients with particular needs.
―An obese person may need help in losing weight in a healthy way.
―An anorexic may need help in gaining weight effectively and safely.
―A bulimic might need help in dealing with a biochemical imbalance resulting from poor eating habits

A nutritionist can test for deficiencies and excesses, and prescribe supplementary medications, vitamins, etc.

They might also manage a diet for a person with an eating disorder [including weigh-ins for the anorexic], freeing the psychotherapist to examine the patient’s reactions without also being involved in supervising a regimen that the patient is reacting to.

28. GROUP THERAPY

Follows from Section 5, Section 7, Section 10, Section 12, Section 15, or Section 17

Can help a patient admit to having an issue, express feelings in an open and supportive environment

Group therapy can be useful in addressing cognitive distortions around body image, acceptance, confidence. For anorexics, it can be very useful to have a group in which each one thinks she is overweight and the others are not. Some experiential work can be helpful, in which the patients test their self perceptions. Family sculptures can express relationships within the patients’ families that they may not be able to express verbally.

Overweight people can support each other when trying to lose weight.

29. SELF-HELP GROUPS

Follows from Section 7, Section 12, or Section 17

Includes the Anorexia-Bulimia Association and Overeaters Anonymous.