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).