Eating Disorders: Psychological Characteristics and Psychotherapy

Eating disorders are mental conditions characterised by issues related to eating or weight control. They can present themselves as mental health disorders, but can also be present in the form of less severe psychological issues and unhealthy behavioural patters. Whether eating and weight-control issues are present as an actual eating disorder or whether they are present as traits that do not meet the diagnostic criteria, the underlying psychological causes are believed to be the same. I will here use the term ‘eating disorder’ to describe significant issues related to eating patterns (see also Obadina, 2014) rather than a distinct and diagnosable eating disorder.

The commonly known eating disorders are anorexia nervosa, bulimia nervosa, and bing-eating disorder. Whilst anorexia nervosa and bulimia nervosa have historically been known as the two main distinct disorders, bing-eating disorder has only later been added as a separate eating disorder.

Eating disorders are found to be relatively more prevalent in women, with occurrences in men also on the rise. They commonly begin in adolescence, although there are instances where they are detected earlier in childhood or later in adulthood (Hoek & van Hoeken, 2003; Obadina, 2014). There is often poor detection of eating disorders by healthcare services, resulting in under-diagnosis.

Eating disorders are also tend to occur in parallel with other mental health disorders (Keski-Rahkonen & Mustelin, 2016). They can be accompanied by depression, anxiety, PTSD, and OCD (Woodside & Staab, 2006) and are often comorbid with personality disorders (De Bolle et al., 2011; Martinussen et al., 2017). Eating disorders are, also because of risk of suicide, associated with higher rates of mortality, with anorexia nervosa being associated with the highest rates (Arcelus et al., 2011). They are also considered to be highly resistant to treatment (Fassino & Abbate-Daga, 2013).

In terms of attachment patterns, eating disorders are associated with higher levels of attachment insecurity, whilst at higher levels of symptom severity, higher levels of attachment anxiety were indicated (Tasca & Balfour 2014).

Types of Eating Disorders

Anorexia Nervosa

Anorexia nervosa is characterised by the person pursuing low body weight and thinness which is usually underpinned by fear of excessive weight (Gabbard, 2014). This is accompanied by fear of eating food and gaining weight, which may not be connected to low appetite but rather to fears of consuming food (Treasure & Alexander, 2013).

Anorexia nervosa is commonly associated with perfectionism (Mundo & O'Neil, 2017; Obadina, 2014; Treasure & Alexander, 2013), as well as obsessive-compulsive and narcissistic traits (Mundo & O'Neil, 2017).

Anorexia nervosa also tends to be associated with diminished sexual interest (Mundo & O'Neil, 2017). In clinical setting, this is often evident as a form of sexual infantility—for instance, a person that may otherwise be an adult may seem as though they have not yet matured sexually.

Shame, anxiety, depression, feelings of unworthiness or worthlessness, internal experience of emptiness, and low self-esteem commonly accompany anorexia nervosa (Mundo & O'Neil, 2017).

Fears of abandonment are also common, along with omnipotence, devaluation, and idealisation, which tend to indicate underlying issues with personality functioning and the presence of a potential personality disorder.

Someone battling with anorexia nervosa may also feel powerless and impotent (Gabbard, 2014), which are also the feelings that are often experienced by those close to the anorexic individual as they feel powerless in helping them.

Because individuals with anorexia nervosa often exhibit with the lack of separation from their family of origin, at higher levels of personality functioning, this may mean increased levels of dependency and subsequently codependent relationships. At lower levels, they may, however, at times experience their bodies as separate and not their own (Gabbard, 2014). This often ties the origins of anorexia nervosa to childhood trauma, predominantly such where the child was used to gratify the parent’s own narcissistic or dependency needs and take care of the parent’s emotional needs, such as in the case of parentification.

Bulimia Nervosa

Bulimia nervosa is characterised by binge eating and purging. This may come with dietary restrictions, excessive exercises, and the use of laxatives (Obadina, 2014). There is high co-occurrence between bulimia and anorexia nervosa, whereby a high proportion of anorexic individuals may also present with bulimia nervosa (Gabbard, 2014).

Individuals presenting with bulimia tend to struggle with more emotional dysregulation (compared to those with anorexia nervosa) and may experience internal sense of emptiness (Mundo & O'Neil, 2017). It is also common for them to experience lack of identity and other symptoms of personality disorder, such as impulsivity, idealisation and devaluation, as well as depression, anxiety, dependency, and a sense of infantility.

Clinical psychotherapy experience shows that the origins of bulimia nervosa, similar to anorexia nervosa, tend to be in childhood trauma. This may entail issues with boundaries, as well as sexual and psychological abuse (Gabbard, 2014). Commonly, the parent’s own dependency results in violation of the child’s psychological boundaries and in parentification of the child. This causes difficulties in the child’s separation from their emotionally dependent parent. Individuals who struggle with bulimia nervosa were commonly treated as a scapegoat either by their parents or by their entire family of origin.

The lack of support in separating and individuating during their childhood then transfers into the difficulties in adult relationships. This is why individuals struggling with bulimia nervosa tend to engage in relationships characterised by dependency and codependency. They often shift from an experience of engulfment to fears of abandonment.

Binge-Eating Disorder (BED)

Binge-eating disorder is characterised by recurring episodes of binge-eating. DSM-5 (APA, 2013) defines the diagnostic threshold for these episodes at once per week in the period of at least three months. However, it should be noted that this threshold is arbitrary and that a person may suffer from traits of binge-eating disorder even without meeting this threshold.

Episodes of bing-eating are often experienced with a lack of control over them. Because those struggling with binge-eating disorder tend to be overweight or obese, they may experience a general dissatisfaction with the resulting body image and often experience shame in relation to that. Shame is, in fact, an over-arching feeling for someone struggling with binge-eating disorder and can also be experienced in relation to being embarrassed of how much one consumes.

Some people who struggle with binge-eating disorder may plan their binge eating episodes in advance. For instances they may plan in the morning what they will buy, where, and how they will binge eat later on. Often there is a sense of thrill and satisfaction associated with the planning and preparation itself.

Eating Disorders and Psychotherapy

In the case of an anorexia nervosa, whilst cognitive behavioural therapy (CBT) is considered as the treatment of choice, the evidence base is, nonetheless, weak (Gabbard, 2014). Zipfel et al. (2014) found that psychodynamic psychotherapy was more advantageous in terms of recovery, whilst CBT was associated with the fastest rate of weight gain and improvement in eating disorder psychopathology. Also, Abbate-Daga et al. (2016), despite sparsity of research, found support for effectiveness of psychodynamic interventions in the treatment of eating disorders, especially in the case of anorexia nervosa.

It is important to keep in mind that because eating disorders are symptomatic disorders, they may be underpinned by underlying personality disorders, often borderline personality disorder (BPD), which may stem from adverse childhood experiences and childhood trauma. As such, treatment should, ideally, take into account also other issues that a person may be presenting with and also attend to the underlying trauma rather than the eating disorder symptoms as such.

Ales Zivkovic, MSc (TA Psych), CTA(P), PTSTA(P), Psychotherapist, Counsellor, Supervisor

Ales Zivkovic is a psychotherapist, counsellor, and clinical supervisor. He holds an MSc in Transactional Analysis Psychotherapy awarded by Middlesex University in London. He is also a Provisional Teaching and Supervising Transactional Analyst (PTSTA-P) and a Certified Transactional Analyst in the field of Psychotherapy (CTA-P). Ales gained extensive experience during his work with individuals and groups in the UK National Health Service (NHS) and his private psychotherapy, counselling, and clinical supervision practice in central London, UK. He was also a member of the United Kingdom Council for Psychotherapy (UKCP). Ales works with individuals, couples, and groups. In clinical setting, he especially focuses on the treatment of issues of childhood trauma, personality disorders, and relationship issues. A large proportion of his practice involves online psychotherapy as he works with clients from all over the world. Ales developed a distinct psychotherapeutic approach called interpretive dynamic transactional analysis psychotherapy (IDTAP). More about Ales, as well as how to reach him, can be found here.

References:

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American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Press.

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