Anorexia isn’t well understood. Many well-intentioned practitioners behave as if the victim chooses to be Anorexic or worse, give such sage advice as “Just eat.” Anorexia is a very serious disorder that takes over the victim’s life, and if treated unsuccessfully may actually end it.
Dr. J. Renae Norton offers an alternative to residential treatment called Intensive Outpatient Program (IOP.)
Dr. Norton’s approach offers several advantages over residential and other semi-residential or IOP programs:
- Patients can usually remain in school, or keep their jobs while in treatment because treatment is more targeted.
- Patients get 5 to 10 hours of actual therapy with a licensed psychologist, Dr. Norton, instead of 1 hour of therapy, as is the case with the majority of residential and semi-residential programs.
- Patients learn to shop for and prepare clean scrumptious foods that heal the body and allow for a slow but steady weight gain.
- Norton has adapted Dialectical Behavioral Therapy by Marsha Lenihan, to the treatment of eating disorders, which many patients have found to be life saving when it comes to regulating emotions
- Norton is a family psychologist, which is critical to the success of treatment. Anorexia begins within the context of the family. Healing takes place there as well.
- A 2010 study compared the success of individual therapy and family-based therapy and family therapy offered a distinct advantage over individual therapy.
Anorexia: How It Starts
In my experience, Anorexia doesn’t just happen, it occurs for a reason, or a combination of reasons, often to correct something that is out of balance in the patient’s life. Perhaps they were injured and had to stop being an accomplished athlete, dancer, or skater. Maybe they were obese as a child and made a decision that it will never happen to them again. Perhaps they feel abandoned and this is the way they get the attention they need to feel safe.
Many people suffering from Anorexia have debilitating anxiety. The Anorexia provides such individuals with a focus, being as thin as possible, and a solution, restricting.
Extreme perfectionism also plays a role with most Anorexics, who aspire to be the best Anorexic ever. To this end they feel ashamed when they are not restricting, or worse, when they are regaining weight, as it means that they are failing.
There is a myth that Anorexia is a disorder that only impacts teenage girls, but the latest research shows that it can begin at any age. Today it is affecting younger children, older women and more men.
Whatever the cause, the primary features of Anorexia nervosa are:
- Refusal to maintain a healthy body weight
- An intense fear of gaining weight
- Distorted body image – called body dysmorphia, such that she may still see herself as “fat” at 60 pounds
How It Feels
Lonely. You have lost your friends. Your parents and/or your significant other go back and forth between begging you to eat and threatening you if you do not. They definitely do not have a clue about the “twisted” way your Anorexic mind is working. Your every waking moment is dedicated to the pursuit of thinness. You (or the vicious voice in your head) never stops. It is relentless. It makes every situation involving food a nightmare for you and your loved ones. But you have to keep all of this to yourself. No one seems to get it how afraid you are. They all think you are being “stubborn”. You are losing everything. But you cannot see a way out, a way back.
What to Look For
- Restricting food intake despite being thin – Following a severely restricted diet. Eliminating “fats” or “carbs”. Eating only certain low-calorie foods. Refusing to eat around others or in public places.Having a “good” and “bad” food list where the “good” foods are fewer and fewer over time.
- Food rituals –Eating in rigid, ritualistic ways, such as cutting food into tiny pieces; eating at certain times and if that time is missed, not eating, eating; eating only with a particular set of utensils; chewing food and spitting; eating alone and if anyone enters the meal is over.
- Pretending to eat or lying about eating –Suddenly becoming vegan, always having stomachaches. Hiding, playing with, or throwing away food. Making excuses to get out of meals.
- Preoccupation with food – Some individuals, especially those suffering from starvation syndrome, cannot stop thinking about food and may engage in food related activities such as cooking for others, collecting recipes, reading food magazines, or making meal plans while still eating next to nothing themselves.
- Obsession with calories, fat grams, and nutrition – Reading food labels, measuring and weighing portions, keeping a food diary, surfing the net for low calorie diets/foods.
- Dramatic weight loss – Rapid or drastic weight loss with no medical cause. It may start out as seeming completely normal, s/he was a bit overweight and went on what appeared to be a “healthy” diet. (Diets are never healthy.) But there was no end and s/he could not stop losing weight.
- Feeling fat, despite being grossly underweight – Many though not all individuals suffering from AN or Bulimarexia suffer from body dysmorphia, or a belief despite all evidence to the contrary that they are fat. Sometimes the focus is a partuclar body part, usually the stomach but it can also be legs, hips, or thighs.
- Fixation on body image – Most patients really believe that other people are harshly critical of the way they look. They may obsess about every aspect of their appearance or something specific such as body shape, or clothing size.
- Harshly critical of appearance – In some cases the individual spends so much time in front of the mirror that they cannot function. It may take hours to get ready. Others cannot bear to look in a mirror and must cover the bathroom mirror up in order to shower. There’s always something to criticize. You’re never thin enough.
- Denial – The denial is fierce. It is one of the reasons that this disorder is considered to have psychotic-like symptoms, because the break with reality is so significant. It is very sad to see how this plays out. Many people are frightened of Anorexia. Unaware or unable to express their fear, they appear instead to be offended by the person who refuses to eat. But the Anorexic/bulimarexic misinterprets their disgust and believes that they are disgusted with her for being too fat.
Residential Treatment vs Outpatient Treatment
Treatment Outcomes for Anorexia Nervosa
Well at: 2 years/whole group 5 years/whole group
Inpatient 17.2% 33.3%
(Ind & Fam)
Outpatient 20.0% 47.1%
(Ind & Fam*)
The Impact Families Have
Although there is research showing a correlation with an overprotective mother and a critical father, this is certainly not always the underlying dynamic. In my experience, parents are never neutral. They are either helping or hurting, no matter how well-intended they are. In fact the “best” parents usually have the worst impact, because they try harder. It’s just that what they do naturally has an effect opposite of what they intend, making matters worse.
This is why it is so important to involve the family and significant others in the process. Research consistently points to the value of family involvement and yet the vast majority of professionals treating these disorders do not appear to include family members as part of the treatment. Some practitioners go to great lengths to prevent family involvement in a misguided effort to protect the privacy and confidentiality of the patient. While both privacy and confidentiality are of the utmost importance, they do not have to be violated in order to use a family-based approach.
A Family Systems Way to Look At Anorexia
Another reason that Dr. Norton has had such unprecedented success, is that her training and orientation is Family Systems Theory based. Systems theory tells us that in order to solve a problem we have to use the right set of assumptions. Further, it tells us that if we use the wrong assumptions, the problem will continue to get worse. In other words, if you do not understand the Anorexic’s assumptions, (and most do not) everything you do makes the problem worse. Sound familiar?
For example, for many suffering from this terrible disorder, the problem is surviving in spite of an intense and irrational fear of maintaining a weight that is sufficient for survival. The assumption may sound like “No matter how much weight I lose, I can still cheat death.” Based upon this assumption, systems theory, which looks at duration, frequency and intensity might dictate the following thoughts about eating:
- Duration of eating – “I will only eat for 30 minutes….. I will only eat for 20 minutes…. I will only eat for 5 minutes out of every day…”
- Frequency of eating – I will only eat once a day……I will only eat every two days……I will only eat once a week.
- Intensity of restricting – I will only eat 700 calories….. I will eat only 500 calories…. I will eat only 100 calories today.
In other words the restricting escalates out of control. This is because the “solution” is based upon an incorrect assumption, i.e. I can restrict my calories indefinitely and not die.
A new underlying assumption would take into consideration that the body must have fuel to function and that survival is more important than relentlessly losing weight. It would sound like: I cannot continue to restrict all calories or I will die.
“This is one of the first questions I ask my Anorexic patient: Do you want to die? They almost always say no. Once we have this established, we can begin to challenge the original assumption.” Dr. Renae Norton
This is known as reframing the problem. When the new assumption is applied, restricting all food intake in order to continue losing weight is no longer an option.
Where Things Run Amok in Recovery
Note, however, that if the new underlying assumption only goes as far as survival, (and not as far as attaining good health) the individual will now eat only enough to maintain his or her weight at a level sufficient to sustain life, and not enough to gain the additional weight needed for good health.
This happens a lot and it causes problems for the novice therapist as well as for the family, who have different definitions (underlying assumptions) of “recovery.” If the therapist assumes “recovery” means achieving a normal weight, and the patient assumes that “recovery” means achieving only enough weight to survive, the two could be 20 or 30 pounds apart, and light years away from solving the problem together. When I am coaching other therapists, this is one of the most common scenarios. If the underlying assumptions of the therapist and the patient differ, they can seriously disrupt the therapeutic relationship, sometimes to the point of no return.
If your loved one has been in treatment with a therapist that seemed very judging, that is probably what was happening. If the actual weight the patient is willing to gain is significantly less than the weight the therapist deems necessary, it may cause the therapist to feel frustrated and/or angry. Most therapists get very anxious when their patient almost dies, and some handle the anxiety better than others. Treating AN is not for the feint of heart. It is distressing to sit across from a 70-pound person who politely refuses to eat.
Of course it is even more difficult for the family members, when they realize that their loved one is not going to gain more than necessary to barely maintain life. If they do not understand the underlying assumption of the patient, they may misinterpret the patient’s behavior as manipulative. What they observe is that, while in the hospital, (or residential treatment center) the patient suddenly becomes compliant about eating. The erroneous assumption practitioners and family members often make is that s/he must have seen the light.
That is generally not what is happening. The patient is often simply trying to get out of the residential setting so that they can feel in control again. When family members realize that the compliant behavior lasts only long enough for the individual to get out of the hospital, off the IV feed, or feeding tube, and back home where s/he has total control, they feel manipulated and/or angry.
If this is the reaction, the timing couldn’t be worse for the patient, who has actually had a breakthrough. In these circumstances, s/he recognizes that there is a point beyond which it is not safe to continue losing weight. In addition, it takes guts for any patient suffering from AN or Bulimarexia, to eat enough to gain weight, no matter what his/her intentions are for maintaining it. In treatment, I help family members understand that this is a good start, as it breaks the relentless pattern of losing weight and it means that their loved one is not suicidal.
But the fear is so great for family members that they may express disappointment. It isn’t uncommon for parents to say: “If you don’t care about yourself, why should we?” This is more likely to happen when it isn’t the first time that their loved one has had to be hospitalized and/or if paying for treatment comes at great personal sacrifice for the family.
Solution: In the alternative, Dr. Norton, as a family systems therapist, and someone that understands the underlying assumption(s) of the individual suffering from Anorexia, can reframe what is happening for the family, reassuring them that this is normal and a good first step towards recovery.
This is only one of the reasons that residential treatment does not generalize well to the patient’s life at home. Other reasons include that the skills to survive in residential treatment centers are very different from the skills needed to survive in one’s real life. Polluted foods, school or work stressors and unresolved relationship issues must also be a part of treatment.
Starving Mind Syndrome
“My patients learn to trust food again, because it doesn’t hurt, it heals.”
Because Anorexic patients are starving, their thought processes are skewed. Another assumption that must be understood is the assumption that any eating will lead to uncontrollable eating. “If I let myself eat this, I will never be able to stop eating. I will lose control of everything!” There are a couple of reasons the individual suffering from AN or Bulimarexia believes that any eating will lead to uncontrolled eating. First s/he is starving. Research on the neuro-psychology of starvation demonstrates that the starving mind is fixated on food almost every waking moment.
This “obsession” with thoughts of food sets up another very vicious cycle, in which the less they eat, the more they think about food, and the more they think about food, the more frightened they become, and the less they eat.
Explaining this dynamic and how a biological condition can drive irrational beliefs, helps some patients to push through their fear. Once their calorie intake approaches normal, and they are no longer physically starving, this underlying assumption has much less power over them.
Another reason the Anorexic patient fears rapid weight gain is that traditional treatment, especially residential treatment, mandates rapid weight gain, sometimes as much as 20 pounds in 21 days. (This is the length of time insurance will cover.) This usually results in rebound and/or the development of new symptoms. It may even be driving the onset of Bulimarexia, a disorder that combines Anorexia (restricting) and bulimia (purging by vomiting, over exercising, or abuse of laxatives). This may be the most dangerous disorder of all. Because it is so new, there is not much research data on it, but in my experience it causes far more complications that are life-threatening than the other two disorders by themselves.
When I first put up this survey, this percentage of Bulimarexia was significantly lower at 15%.
But the most important reason they fear weight gain is that polluted food causes rapid or unpredictable weight gain. Teaching patients to eat clean allows them to trust food again. It gives them control over what they eat, which empowers them and it is predictable, which reassures them.
Resting Metabolism Rate (RMR)
Another assumption, that often accompanies the one above, is the assumption that any eating will lead to uncontrolled weight gain. “If I eat (or keep down) any solid food, it will cause me to gain weight.” It is easy for individuals with AN to prove this theory by simply weighing themselves every time they eat something. With scales as sensitive as they are these days, a glass of water shows up on the scale immediately after you drink it. Although it doesn’t represent real weight gain, it is interpreted as such by those suffering from these disorders. (One of the first steps towards recovery for such individuals is giving up their scale. I have 50 plus scales waiting to be reclaimed that probably never will be as my patients and former patients do not need them anymore.)
On the other hand, there is some basis for their fear of uncontrolled weight gain from a biological perspective. Victims of AN and Bulimarexia have often suppressed their metabolism, by restricting for years, to the point that rapid weight gain may begin with relatively low caloric intake. This is, of course, part of another very vicious cycle. The less they eat, the less they can eat without gaining weight. If left unaddressed, this underlying assumption, which is based on a biological reality, will undermine recovery.
Research demonstrates that rapid weight gain is counterproductive with this population. I find that re-feeding goes much better when it begins with my client’s current resting metabolism rate (RMR) and systematically, but very slowly, steps up the calories over a period of 12 to 18 months. I am comfortable with one or two pounds per month, as long as s/he is medically stable and her/his calories are consistently going up each month.
The focus is on increasing the calories each week with clean food. The focus is not on the weight gain per se. Of course, there is weight gain, but it is reassuringly slow from the patient’s perspective, despite the fact that the calories are going up fairly quickly. A typical scenario is that of patient LL. For this particular patient, her initial RMR was 693 calories per day, and her weight was 79 pounds, while her RMR at the end of the eleven months was 1940 calories per day and her weight was 108.
I often see such dramatic changes in the resting metabolism rate, which I track for every patient that is re-feeding. The graphs are both convincing, as well as reassuring to the client and her loved ones. The value of this approach is that it does not ask for a change that would challenge all of his/her underlying assumptions and create resistance (by triggering tremendous anxiety). Instead, it accepts the patient’s underlying assumptions, and leverages them into progressively more healthy behavior. As a result, there is less danger of setting up resistance (not eating), which often leads to rebounding (weight loss).
Unfortunately, this is exactly what happens in residential treatment centers. Even in outpatient therapy, many therapists communicate a similar expectation to their patients, i.e. that s/he should gain weight rapidly. To this end, the patient is weighed every visit and the criteria for a successful week is based solely upon his/her weight gain. It may have the unintended side effect of forcing the patient to lie to avoid the negative consequences of telling the truth.
Source: National Women’s Health Information Center
- Behaviours focused around food preparation and planning (e.g. shopping for food, planning, preparing and cooking meals for others but not consuming meals themselves; taking control of the family meals; reading cookbooks, recipes, nutritional guides)
- Strong focus on body shape and weight (e.g. interest in weight-loss websites, dieting tips in books and magazines, images of thin people)
- Development of repetitive or obsessive body checking behaviours (e.g. pinching waist or wrists, repeated weighing of self, excessive time spent looking in mirrors)
- Social withdrawal or isolation from friends, including avoidance of previously enjoyed activities
- Change in clothing style, such as wearing baggy clothes
- Deceptive behaviour around food, such as secretly throwing food out, eating in secret (often only noticed due to many wrappers or food containers found in the bin) or lying about amount or type of food consumed
- Eating very slowly (e.g. eating with teaspoons, cutting food into small pieces and eating one at a time, rearranging food on plate)
- Continual denial of hunger
- Physical warning signs
- Sudden or rapid weight loss
- Frequent changes in weight
- Sensitivity to the cold (feeling cold most of the time, even in warm environments)
- Loss or disturbance of menstrual periods (females)
- Signs of frequent vomiting – swollen cheeks/ jawline, calluses on knuckles, or damage to teeth
- Fainting, dizziness
- Fatigue – always feeling tired, unable to perform normal activities
- Psychological warning signs
- Increased preoccupation with body shape, weight and appearance
- Intense fear of gaining weight
- Constant preoccupation with food or with activities relating to food
- Extreme body dissatisfaction/ negative body image
- Distorted body image (eg. complaining of being/feeling/looking fat when actually a healthy weight or underweight)
- Heightened sensitivity to comments or criticism about body shape or weight, eating or exercise habits
- Heightened anxiety around meal times
- Depression or anxiety
- Moodiness or irritability
- Low self-esteem (eg. feeling worthless, feelings of shame, guilt or self-loathing)
- Rigid ‘black and white’ thinking (viewing everything as either ‘good’ or ‘bad’)
- Feelings of life being ‘out of control’
- Feelings of being unable to control behaviors around food
 Arch Gen Psychiatry. 2010; 67(10):1025-1032
 Eur. Eat. Disorders Rev. 9, 229±241 2001)
 Informal survey of _____ independent treatment providers in the Ohio, Kentucky, Indiana area.
  Arch Gen Psychiatry. 2007;64(9):1049-1056 Psychosom Med. 1987 Jan-Feb;49(1):45-5
Int J Adolesc Med Health 2002;14(2):269-274. Int J Obes Relat Metab Disord 13(suppl 2): 39–46.
 See Chapter _______ for re-feeding strategies and sample patient charts