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Eating Disorder Treatment News

The A’s of Eating Disorders

By Natalie Hutson, M.S., L.P.C.


Eating Disorders

The beginning of eating disorders frequently start with a feeling of inadequacy, or simply “not being good enough.” The feeling of inadequacy can result from high expectations from parents or others, perfectionist personalities, or simply a high value placed upon success at all costs. The struggle with feelings of inadequacy is a difficult one to conquer; it seems like nothing one can do will ever be enough.

Feelings of inadequacy go hand-in-hand with the need for Approval.


People with eating disorders typically look to others to define their worth and go to drastic measures to attain approval from others. The problem is that they never think they are approved of no matter what they do; they could always improve in some way. Sometimes, this is the real message they are given, while other times it is the distortion they have in their thinking that leads them to think they are disapproved of by the people they love and care about most in their lives. Approval from others does not satisfy the intrinsic need to approve of oneself; therefore, they continue to seek approval from others that they will never satisfy. During this process, they engage in All-or-Nothing thinking.

All-or-Nothing Thinking:

If it isn’t done perfectly, it doesn’t count. If I am not selfless, I am selfish… The thoughts of inAdequacy, disApproval, and All-or-nothing thinking create intense feelings of Anxiety.


In order to reduce the anxiety, people with eating disorders Act-out and use the eating disorder behaviors to create a sense of safety and control; however, the control soon spirals them into a lack of control over anything outside of the eating disorder. The anxiety then becomes more intense, which perpetuates the cycle. When the anxiety takes over, it fogs their thinking so they can only focus on the thoughts of inadequacy and disapproval. The eating disorder becomes an escape to temporarily reduce these feelings.


All this being said, I have found that the key to living life free of an eating disorder is about Acceptance- acceptance of who we are as individuals. Each and every one of us has so much to offer the world as difficult as it is to see sometimes. Life with an eating disorder not only prohibits one from enjoying all the gifts life has to offer, but it also inhibits one from sharing all the gifts one has to offer the world.

The Hungry Heart Syndrome

By Susan Parish Walker

What’s eating you? Individuals concerned with their weight report their eating pattern or weight interferes with their relationships, with their work, and with their ability to feel good about themselves. Current research on binge-eating disorder indicates that certain individual’s binge eating may be triggered by dysphoric moods, such as depression and anxiety. Binge-eaters report higher rates of self-loathing, depression, anxiety, somatic concern, interpersonal sensitivity, and disgust about their body size. There may be a higher lifetime prevalence of Clinical Depressive Disorders, Substance-Related Disorders, and Personality Disorders.

Comfort Foods and Eating Disorders“The Hungry Heart Syndrome” describes how emotional eating may be triggered by specific emotions such as loneliness, anxiety, or stress. Why do most people enjoy eating? Specific food cravings are unique to our gender and may result in a positive affect on one’s mood. Seratonin is a chemical released in the brain after eating carbohydrates that transmits mood stability. Similarly, endorphins are chemicals released after eating fat and chocolate that  transmit a food induced euphoric-state. Hence, women are more likely to crave chocolate, bread, and ice cream whereas men are more likely to crave meat, pizza, and potatoes. Therefore, one can learn to moderate food cravings and stabilize mood by balancing food intake and avoiding emotional deprivation. Thus, food deprivation may create more problems in terms of overeating and bingeing episodes.

More than five million American suffer from eating disorders. Anorexia nervosa, bulimia nervosa and binge-eating disorder are diseases that affect the mind and body simultaneously. Three percent of adolescent and adult women and one percent of men have anorexia nervosa, bulimia nervosa, or binge-eating disorder. A young woman with anorexia is 12 times more likely to die than other women her age without anorexia. Approximately, fifteen percent of young women have substantially disordered eating attitudes and behaviors.

What are the causes and roots of eating disorders?  In a study of children aged 8-10, approximately half the girls and one third of the boys were dissatisfied with their size. However, most dissatisfied girls wanted to be thinner while about equal numbers of dissatisfied boys wanted to be heavier. Boys wanted to grow into their bodies, whereas girls were more worried about their bodies growing. Additionally, approximately half of black and white girls chose ideal body sizes thinner than their current shape compared to approximately one third of black boys and white boys. Recent findings indicate that girls who smoke to suppress their appetite are the highest group of new nicotine addicts. The cigarette industry is aggressively targeting the vulnerability of girls who want to lose weight. Girls who participate in elite competitive sports where body shape and size are a factor (gymnastics, ice skating, dance) are three times more at risk for eating disorders. Boys, who participate in similar sports, or in wrestling, are also at increased risk.

Eating Disorders, binge eating, or weight management issues can cause a partner to experience shame about one’s body image. Methods of prevention such as addressing mood stability and assessing precipitating factors of emotional eating are reviewed carefully. Furthermore, partners may avoid sexual activity and intimacy due to feeling uncomfortable with their body or having body shame. In essence, this chapter will focus on specific psychological issues that may contribute to weight management, healthy body image, and the intimacy in relationships.

Metabolic Rate and Eating Disorders

By: Philip Walker, M.S.

Metabolism refers to the sum of all vital processes in which energy and nutrients from food are made available to and utilized by the body.  The minimum level of energy to sustain the body’s vital functions, not including the energy cost of digesting and absorbing, or engaging in physical activity, is referred to as the resting metabolic rate (RMR).  Metabolism differs from person to person, depending on a variety of factors.  Metabolism slows down with age, and gender differences play an apparent part in the function of the metabolism.  The average RMR for a woman is between 5-10% lower than that of men, due partly to the fact that women have a larger percentage of body fat and smaller muscle mass than most men.

There is a substantial decline in metabolism in underweight people who have restricted their food intake.

Research shows that the metabolism adapts to different conditions in order to defend a particular level of weight or energy balance.  If a person begins to restrict, or undertakes a fast of more than a week or two his or her metabolism slows down.  In a person who has a history of restricting, metabolism has been shown to have a greater “slow down” effect.  Studies have shown a decrease in RMR of up to 30-50% in underweight people.  Further studies found individuals on a constant reduced caloric intake lost an average of 40 grams of fat a day in the first month, 20 grams per day the second month, 10 grams per day the third month, until fat loss stopped altogether.  Therefore, a drop in metabolic rate is counterproductive in individuals trying to lose substantial amounts of body fat.  This is another example of the physiological adjustments inherent in the human body to sustain life.

The RMR declines within 24-48 hours after caloric restriction and is followed by a rapid decline after one week.  The RMR will then stay relatively unchanged throughout the remainder of the food restriction period.  The RMR of underweight exercisers have the same effects as underweight individuals who are sedentary.  Consequently, exercise appears to have no effect on RMR during restrictive periods.

Therefore, the resting metabolic rate should be a major concern for professionals treating anorexia and bulimia. This is apparent, not only during the restrictive phase itself, but also during refeeding and especially during the maintenance period.  The Walker Wellness Clinic objectively measures energy expenditure, nutritional intake, body composition, and resting metabolic rate to determine an accurate physiological status.  Therefore, the patient’s current physiological condition, nutrition requirements, and healthy weight range are established based on a number of individualized assessments to avoid guesswork, an excessive weight gain, and uncertainty.

The Barbie Doll Body Image

“The first problem for all of us, men and women, is not to learn, but to unlearn.” Gloria Steinem

Barbie just turned 47. She simply has not aged a bit and she still has that fabulous figure. Get real! We are living in the age of reality TV. Let’s get a dose of reality with our own expectations for our body image. A distorted body image is analogous to being colorblind. If you take a look into the mirror, what do you see? Perhaps forgotten compliments and condescending remarks such as your face is too round or you have an awesome six-pack stomach!  Do you read the latest trends about weight loss and what celebrities do to lose or maintain their beautiful bodies? Do you attempt to incorporate this into your lifestyle? It is simply a waste of your time because no two bodies are alike and will not respond in the same manner to the weight loss.

Who are our role models for having the perfect body?

Barbie Doll Body Image and Eating DisordersOver the years women have compared their body types to professional models, actresses, and Miss America pageant contestants. Maybe that is why Cindy Crawford once said, “I don’t even look like Cindy Crawford.” Comparing body types is like saying that you would like for your lovely brown eyes to turn blue. Of course one may purchase colored contact lenses and change the color of their eyes.

However, no matter how much one compares their body types, food intake, and/or exercise regimen to others, their body will not adapt or become their role models. A patient who suffered from an eating disorder once said that she wanted her body to look just like Paris Hilton’s body. The patient’s body was beautifully toned with muscle development due to the years of dancing and her percentage of body fat indicated that she was in a healthy and normal range. Regardless of her nutrition and exercise habits, due to her genetic predispositions and muscular body type she will never have a body like Paris Hilton. Unfortunately, many formal eating disorders or disordered eating actually begins with someone comparing their food intake, body type, or exercise habits to another persons. It is very irrational and one may always become frustrated because they will not be able to adapt to their role models body type.

For example, as girls and women began to age our metabolism slows down about 2 to 3 % every decade but we may not be changing our food intake, exercise regimen, or behaviors. Chronic dieting and restricting leads to a significant weight gain for most individuals. It slows down the metabolic rate and makes one very vulnerable for a significant weight gain. Furthermore, deprivation typically is the number one reason why most people have binge episodes. If you go for a very long period of time and omit some of your favorite foods that can be eaten in moderation such as pizza or chocolate chip cookies you may find that you will began to overeat these foods.

Therefore, the good news for those blues about weight gain is that if we continue to exercise and eat moderately throughout our life span, it is more likely that we will maintain a healthy body weight. Therefore, learning to normalize your dietary intake and exercise regimen is one of the healthiest ways to avoid dramatic weight changes and establish a healthy body image. The first step is to complete your resting metabolic rate test to determine how many calories your body needs to maintain, lose, or gain weight.  It may be important to establish the diagnostic criterion of the difference between a formal eating disorder and disordered eating.

Genetic Epidemiology and Risk Factors of Formal Eating Disorders

By: Susan Parish-Walker, M.S., L.P.C.

In regards to eating disorders, the possible role of hereditary factors has not been without historical precedent. As early as 1860, Louis Victor noted that inherited psychopathologies were prominent in families of young women with anorexia nervosa, and that the rearing environment was often disturbed.  More recently, reports of peculiar feeding habits in families are evident.  For example, it is not uncommon for family members to have a history of trying a myriad of diets such as Atkins or South Beach diets. Certain genetic factors may also contribute to comorbidity diagnoses and influence the risk of both major depression and bulimia nervosa.  Although there are higher prevalence rates of substance use and abuse among patients with eating disorders who engage in binge episodes, the  following are also critical factors that may lead to bulimia nervosa:  (1). premorbid dieting and related risk factors (i.e., critical comments by the family regarding body shape or weight); and (2). general risk factors for psychiatric disorders.There is also a genetic component that increases the risk for developing anorexia nervosa.  A predisposition for having a low body weight or percentage of adipose tissue (body fat), may play a role. Moreover, genetic predispositions are clearly apparent with the personality traits of a patient who has developed anorexia nervosa. These personality traits include higher IQ than the normal population, perfectionism, obsessionality, negative self-evaluation, and overly compliant. Other risk factors that may contribute are psychiatric disorders and childhood adversity such as physical or sexual abuse or death of a close relative. In addition, there is a lack of research on the risk factors for binge eating disorder, but adverse childhood experiences, potential for obesity, and repeated derogatory comments about one’s weight, shape, or size appear to contribute.

It is suggested that the increased vulnerability of high risk groups may stem from the sociocultural pressure to be thin.  Highly competitive people develop a relentless pursuit to be thin to enhance their performance and aesthetic appeal. Therefore, sports or extracurricular activities that may require weight restriction such as lightweight rowing, wrestling, volleyball, distance running, gymnastics, ballet, and figure skating may fall into this category as risk factors.

In closing, the growing need for more research on family systems may need to be examined to identify genetic factors.  Currently, more organizations and wellness programs are educating participants on the risk factors of developing an eating disorder as a means of prevention.  The need for more mental health professionals, dietitians, and other healthcare professionals to be educated on assessing the early symptoms of disordered eating is essential to prevention. With prevention and early detection, the disordered eating may be kept from developing into a full blown eating disorder.

The Weekender Outpatient Program at The Walker Wellness Clinic

Question and Answer Session with Susan Parish-Walker, M.S., L.P.C.

Describe the “The Weekender” outpatient program at The Walker Wellness Clinic.

The program is clinically and custom designed for patients who are medically stable and unavailable to pursue treatment during the weekdays due to their schedule conflicts with academics, occupational, extracurricular or family activities.

Is the program available for local patients as well as ones from out of the city, state or country and if so what accommodations do you have for the patients that are not local?

The program is available for all of the aforementioned patients and airport transportation will be provided for patients who are not local. The Cooper Guest Lodge is located on campus and is within walking distance to The Walker Wellness Clinic.

What types of clinical services will be offered to patients during the weekend and will they be permitted to have flexibility in scheduling their appointment times?

Clinical services will be offered such as psychological and career testing as well as individual, group, and family psychotherapy. In addition, intuitive eating, nutrition sessions, and meal therapy will be offered.

Adjunct therapy will also be available such as cooking classes, art therapy, and music therapy. Yes, there will be flexibility with scheduling appointments with the exception of the group psychotherapy. We believe everyone deserves some downtime during the weekend so there will be no weekend night schedule for patients. However, we will provide an entertainment list of fun activities to pursue in Dallas and make recommendations.

What do I do during my downtime and will I be bored?

We have adopted the philosophy that it is imperative to have a balanced lifestyle and that means not all work and no play! Therefore, you may choose to have a spa appointment such as a facial, manicure and pedicure, or massage at the Cooper Spa on campus. We can schedule these appointments for you in advance.

Moreover, if you are medically stable you may want to have a fitness guest pass at The Cooper Aerobic Center where you can pursue an exercise regimen with a personal trainer or play a game of tennis. You can also run or walk on the lovely track that surrounds the campus and view the beautiful pond.

What about my meals and if I don’t have transportation?

Fortunately, there are two great restaurants on campus. One is The Colonnade which is attached to the Cooper Guest Lodge and overlooks the swimming pool. The other is Tyler’s which is adjacent to the Cooper Fitness Center. If you are participating in meal therapy there will opportunities for you to travel to nearby restaurants at the Gallaria Mall.

Does this program involve family psychotherapy and is it mandatory that parents participate or other family members?

We encourage all of our adult patients to enroll in family therapy and we require that our adolescent patients be enrolled. The clinical rationale is to educate the family on the prevention of formal eating disorders and to help foster  healthy family functioning.

What will my parents do if they are staying with me during the course of treatment?

Perhaps mom and dad would like to enroll in the Cooper Wellness Program that also has classes available on the weekends. They too are permitted to get weekend guest passes at Cooper Fitness Center or visit the Cooper Spa. If parents arrive during the week they may want to complete a comprehensive physical exam at Cooper Clinic or seek out a dermatology appointment from the dermatologist on campus. There is never a dull moment if you are on campus at Cooper Aerobics Center and it is our mission to make your weekend stay a memorable and healthy one.

Interview Questions for The Book: Rock What You’ve Got by Catherine Schwarzenegger By: Susan Walker, M.S., L.P.C

1. What are the current trends in eating disorders you are seeing?In the US, as many as 10 million females and 1 million males are fighting a life and death battle with an eating disorder such as anorexia or bulimia. Millions more are struggling with binge eating disorder (NEDA). Prevalence estimates tend to range from about 3% to 10% of at-risk females (those between 15 and 29 years of age) with bulimia patients outnumbering anorexia patients by at least 2 to 1. The prevalence of partial eating disorders is at least twice that of full-symptom eating disorders (Causes of Eating Disorders. Annual Review of Psychology (2002): 53: 187-213).a. Age groups most affected: 40% of newly identified cases of anorexia are in girls 15-19 years; however, according to DSM-IV (the Diagnostic Statistical Manual used for making clinical diagnosis for mental disorders) anorexia nervosa typically begins in mid to late adolescence (ages 14-18 years). The onset of this disorder rarely occurs in females over age 40 years. The patients who are admitted at The Walker Wellness Clinic that are 30 and over appear to have had their eating disorder (either bulimia or anorexia) for 10-20 years and have typically not sought out treatment or have had many trials of failed outpatient and/or inpatient treatment).

b. In clinical studies of Bulimia Nervosa in the United States, individuals presenting with this disorder are primarily white, but the disorder has also been reported among other ethnic groups. In clinical and populations samples, at least 90% of individuals with Bulimia Nervosa are female according to DSM-IV.

c. However, at The Walker Wellness Clinic will have noticed a more recent trend in terms of admission for outpatient treatment to have increased among young female adults with Anorexia Nervosa and Bulimia Nervosa such as ages 18-30 and particularly college aged students. Moreover, we have seen an increase in heterosexual males in our enrollment more recently and the majority of them have been heterosexual males with Anorexia Nervosa. This was predicted by a Harvard study done (see and quoted on our website due to the history of heterosexual males being misdiagnosed with a formal eating disorder. Historically, males that were treated at WWC were primarily adolescent homosexual males who had experienced trauma and this precipitated the onset of the eating disorder.

d. Socio-economic background: In our clinical experience we have observed in our Dallas and Houston clinic that the patient population is primarily upper middle class to affluent that are typically admitted. Perhaps this is due to the fact that we are a self-pay clinic and we provide documentation for them to file for third party reimbursement fees. Often times we will attempt to offer some pro bono services such as psychological testing or meal therapy or group psychotherapy for patients who may be struggling financially and we offer a scholarship at no cost as well to a limited number of patients.

e. Ethnicity: Both Anorexia Nervosa and Bulimia Nervosa appear to be more prevalent in industrialized countries. Both disorders are most common in the United States, Canada, Europe, Australia, Japan, New Zealand, and South Africa; but little systematic work has examined prevalence in other cultures (DSM-IV). At The Walker Wellness Clinic we have observed an increase enrollment for outpatient treatment among college students from outside of the United States who are enrolled at a local university close to our clinic in Dallas and Houston.

2. What are the signs that a young girl may be suffering from an eating disorder?

AN: refusal to sustain minimally normal body weight, intense fear of gaining weight despite being underweight, distorted view of one’s body or weight or denial of the dangers of one’s low weight; dieting despite being thin, obsession with calories, fat grams, and nutrition, pretending to eat or lying about eating, preoccupation with food, strange or secretive food rituals; dramatic weight loss, feeling fat despite being underweight, fixation on body image, harshly critical of appearance, denies being too thin (NEDA and WebMD).

Clinical observations and impressions that I have observed in the last 28 years that may impact AN and BN in addition to the aforementioned are as follows: chronic stress, significant or profound loss (breakup of a relationship, divorce in a family system, loss of a loved one or animal, feeling powerless and losing control over situations, trauma such as date rape, rape, molestation, or any type of sexual abuse, depression, anxiety that may lead to panic attacks, chronic worrying, and obsessive-compulsive tendencies).

In addition, personality traits such as having a higher IQ than the normal population, rigidity and unable to be spontaneous, perfectionism, low self-esteem, and eagerness to please others are often present with AN patients and sometimes with some BN patients. (Please visit our website at if you are interested in the diagnostic criterion for all clinical diagnoses that are used by DSM-IV).

BN: using diet pills, laxatives, or diuretics, purging after eating, compulsive exercising; repeatedly eating large amounts of food in a short period of time (less than 2 hours); frequently getting rid of the calories you’ve eaten (purging) by making yourself vomit, fasting, exercising excessively, or misusing laxatives, diuretics, ipecac syrup, or enemas. Misuse of these medicines can lead to serious health problems and even death ; feeling a loss of control over how much you eat; having binge-purge cycles; feeling ashamed of overeating and very fearful of gaining weight; basing your self-esteem and value upon your body shape and weight (NEDA and WebMD).

BED: frequent episodes of eating what others would consider an abnormally large amount of food; frequent feelings of being unable to control what or how much is being eaten; eating much more rapidly than usual; eating until uncomfortably full; eating large amounts of food, even when not physically hungry; eating alone out of embarrassment at the quantity of food being eaten; feelings of disgust, depression, or guilt after overeating; fluctuations in weight; feelings of low self-esteem; loss of sexual desire; frequent dieting (NEDA and WebMD).

The relationship between problematic childhood eating behaviors and subsequent development of eating disorders later in life is of concern. A 17-year longitudinal study of 800 children showed that eating conflicts, struggles with food, and unpleasant meals were risk factors for the development of an eating disorder in adolescence or young adulthood (Kotler et al., 2001) (“Nutrition in Eating Disorders”Krausse’s Food and Nutrition Therapy 12th Edition (2008).

3. What triggers are most common for an eating disorder?

There is no “one thing.” Predisposing factors include: genetic (perfectionism/OCD traits/ anxiety), pressures for thinness, gender (female). Precipitating factors include: puberty, life stressors, peer pressure, media messages. Perpetuating factors include: starvation effects, cognitive distortions, and cultural effects (Brewerton, T. Overview of Evidence on The Underpinnings of Bulimia Nervosa, In Evidence-Based Treatment for Eating Disorders, 2009 [from Remuda Ranch powerpoint]).

I like the metaphor that I heard at a national conference for eating disorders by a prominent speaker, Craig Johnson, PhD. that basically said that genetic predispositions load the gun (i.e. higher levels of stress, anxiety, depression, perfectionism, etc.) and what actually pulls the trigger (the onset of the eating disorder) are the stress or situations such as trauma (i.e., loss of a loved one or date rape).

Studies find that groups with body dysmorphic disorder and eating disorders and those with shape/weight concerns scored significantly higher than the group with not significant body image concerns on measures of anxiety and suicidality (Body Dysmorphic Disorder and Other Clinically Significant Body Image Concerns in Adolescent Psychiatric Inpatients: Prevalence and Clinical Characteristics. Child Psychiatry Human Development (2006): 36: 369-382).

Studies find higher levels of perfectionistic self-presentation predict greater eating disturbance only for women who are dissatisfied with how they look (Perfectionistic Self-Presentation, Body Image, and Eating Disorder Symptoms. Elsevier: Body Image 2 (2005): 29-40).

Cultural factors: Thinness is equated with morality, goodness, and virtue, financial success, positive relationships, and self-esteem and respect from others.

Risk factors for AN: body dissatisfaction, dieting, low self-esteem, perfectionism, childhood sexual abuse, family history of eating disorder, obesity, or mood disorder (i.e. anxiety or depression) (NEDA and WebMD).

Risk factors for BN: combination of family history, social values (such as admiring thinness), and certain personality traits (such as perfectionism) (NEDA and WebMD).

Risk factors for BED: history of depression, impulsive behavior, family history, history of overeating or putting an unnatural emphasis on food (using it as a reward or means to soothe or comfort) (NEDA and WebMD).

4. Why do girls fall into these habits?

Coping mechanism, combination of personality traits and social/cultural pressures may contribute the development of a formal eating disorder (NEDA and WebMD).

Physical, sexual and laxative abuse: Sexual abuse occurred in 29%, physical abuse in 57% and laxative abuse in 46% within the whole sample of eating disorders. Studies find significantly more severe body image distortions in patients who had been physically abused and significantly more severe body image distortions in those patients with a history of laxative abuse. Physical abuse and laxative abuse were the most frequent in the binge eating/purging type of anorexia; these patients also had the worse rates on sexual abuse and body image distortion items (The Impact of Physical and Sexual Abuse on Body Image and Eating Disorders. European Eating Disorders Review (2005): 13: 106-111).

BDD: Studies find that 32.5% of patients with body dysmorphic disorder had a comorbid lifetime eating disorder: 9% had anorexia, 6.5% had bulimia, and 17.5% had an eating disorder not otherwise specified. The comorbid group was more likely to be female, less likely to be African American, had more comorbidity, and had significantly greater body image disturbance and dissatisfaction (Comorbidity of Body Dysmorphic Disorder and Eating Disorders: Severity of Psychopathology and Body Image Disturbance. International Journal of Eating Disorders (2006): 39: 11-19).



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