One interesting development in eating disorders treatment is the increasing awareness of how often eating disorders go hand-in-hand with anxiety and/or mood disorders, and how seldom they occur in isolation.
Anxiety disorders are the most common "comorbid disorder" found with eating disorders. A 2007 national survey found that 80.6 percent of people suffering from bulimia suffered from an anxiety disorder at one point. Depression is another commonly seen disorder among bulimics. Both anxiety and depression are frequent comordid conditions among those suffering from anorexia as well.
One theory suggests that eating disorders occur on a spectrum of "emotional disorders" that include anxiety, depression and related disorders. The 2013 Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which includes a listing of diagnostic criteria for every psychiatric disorder recognized by the U.S. healthcare system, will reflect this evolving view.
So it's no surprise that clinicians are devising treatment approaches that take into account eating disorders as well as the mood and anxiety disorders that often accompany them. In an article for the Winter 2011 edition of The Renfrew Center Foundation's professional journal "Perspectives," David Barlow, PhD and Christina Boisseau, PhD., discuss a "transdiagnostic" treatment protocol they've developed called UP, for Unified Treatment Protocol, designed for use with eating disorders and anxiety and depressive disorders. What makes it unique, they explain, is the emphasis it places on how patients experience and respond to their emotions.
As an example, they tell the story of Brian, a 20-year-old college student experiencing difficulties related to social phobia and bulimia. Here's how his treatment unfolds with UP:
Step one: Focus on emotional awareness of experiences as well as secondary judgments. For example: "I'm pathetic for feeling anxious in this situation." A series of mood reduction exercises helps Brian become aware of his emotions and learn how to avoid negatively labeling them. A key is to "actively do nothing" in response to emotions that normally might lead him to binge and purge or avoid a social situation.
Step two: "Cognitive reappraisal" or focusing on identifying and then challenging Brian's core beliefs about his bulimia and social phobia. Instead of believing that he will gain lots of weight or look awkward if he eats dinners cooked by his roommates, he learns to question this assumption. The aim of this part of treatment is to foster flexible thinking.
Step three: To focus on "emotion-driven behaviors" such as avoidance and bingeing and purging. Brian learns that these behaviors are inappropriate responses to various situations, and practices more situation-appropriate behaviors. One example would be putting himself in an high anxiety-provoking situation rather than dodging it, and then refraining from purging afterward to numb the distress that results. Instead of avoiding making eye contact with a professor, or avoiding participating in a class, he learns to place himself in these uncomfortable situations and gradually gets used to feeling the negative emotions they trigger.
Step four: Brian is asked to actively engage in a series of exercises that evoke the intense emotions he might feel along with social anxiety. For example, running in place to mimic the flushing or rapid heart rate of extreme social discomfort. As Drs. Barlow and Boisseu explain, these exercises help Brian recognize how physical sensations interact with his thoughts and behaviors, intensifying them and making them feel overpowering.
Step five: Patients work on increasing their tolerance of intense or uncomfortable emotions by exposing themselves to both internal and external emotional triggers. Rather than focusing on a specific situation, "the goal is to help patients experience emotions fully and reduce the avoidance that has served to maintain their disorder(s)," explains Drs. Barlow and Boisseau. In Brian's case, this means talking more with his roommates, or asking questions in class.
What is interesting about this method is that it is directly parallel to what Marcia and I encourage in our book when it comes to eating what we call "forbidden foods" or "fear foods" (see Chapter 15, pp. 271-272) These are foods that trigger fear, anxiety or other negative emotions, often related to memories of bingeing on them and then purging. The idea is to slowly incorporate these fear foods back into the patient's food plan so as to normalize them, or strip them of negative associations. Although it is much more emotion-focused, the UP protocol, like our approach, exposes patients to trigger situations and gradually reduces their power to induce avoidance, fear, anxiety and eating-disordered behaviors.
On an intuitive level, this approach to treating a spectrum of mood, anxiety and eating disorders with one overarching protocol seems to makes sense. I hope that further research bears out Drs. Barlow and Boisseau's theories.