Program 7



  1. What is Anorexia Nervosa?
  2. How Does AN Affect People?
  3. What Causes Anorexia Nervosa?
  4. Treating Anorexia Nervosa
  5. Problem Assessment
  6. Monitoring Your Eating Patterns
  7. Targets of Normal Eating
  8. Dealing with Restrictive Eating Patterns
  9. Dealing with a Distorted Body Image
  10. Conclusion

                  1. What is Anorexia Nervosa?

Anorexia Nervosa is an eating disorder common in women and physical features are an abnormally low body weight and amenorrhoea (the cessation of menstrual periods) in girls. Principally AN is a psychological disorder with a fear of fatness or even being the normal body weight. Individuals have a distorted body image and see themselves as fat even when others think them to be extremely underweight. Sufferers may use starvation, exercise and vomiting/purging to maintain low body weight.

As well as being prevalent in women, anorexia occurs in children, men and the elderly. AN occurs in women and men of all ages and across all social classes. Pressure from the media to be thin is not the sole cause of AN which has multiple causes. Most problems in families are the result of AN rather than the cause of it. The majority of women have dieted but only a minority get AN as a result of simple dieting.

AN is a serious disorder and often very difficult to treat. Recovery from AN is possible even after many years of continuous severe symptoms. It needs to be your decision to change your eating habits and it is necessary you are motivated to work toward regaining weight. Making a list of the pros and cons of changing and and considering how your future will be like without AN can provide the impetus to change. Reviewing your reasons for changing will maintain your motivation.  

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2. How Does AN Affect People?

Physical Effects:

As you continue to undernourish your body your metabolic rate slows down and you will lose weight more slowly. Sufferers of AN become deficient in important minerals such as calcium, magnesium, potassium and sodium, resulting in symptoms which include weak muscles, back pain, development of osteoporosis, fatigue, heart problems, severe dehydration and dangerously low blood pressure.

Dry skin with an orange tinge and fine hair all over the body may occur due to starvation. When you severely reduce your food intake your body metabolizes its fat reserves then muscle – this can result in muscle wasting and muscle weakness (myopathy). Lack of muscle support to the spinal column results in low back pain and is frequent in AN.

The brain may shrink if starvation is severe and brain functioning may be maintained by utilizing amino-acids usually required for essential body proteins, so causing other tissues to be increasingly weakened.  The heart becomes weaker and its efficacy becomes reduced – blood pressure becomes lower and cardio myopathy can develop where the heart muscle fails to function efficiently.

Low blood pressure due to starvation can affect the efficient functioning of the kidneys. Continuous starvation can lead to the shrinking of the gastro-intestinal system causing poor absorption, constipation and abdominal pain. The immune system and the healing of wounds is very much impaired and fungal infections can be common. Sufferers are more sensitive to cold temperatures and hypothermia is frequent with AN.

The uterus and ovaries shrink and amenorrhoea (cessation of menstruation) occurs. In the unlikely event of pregnancy, there is an increased risk of miscarriage. When the foetus survives the baby is liable to impairment in later life.

Some AN sufferers develop a high activity level in response to starvation while others lack energy. Repeated vomiting can result in dental damage, a constant sore throat, heart burn, stomach ulcers and potassium deficiency. Laxative abuse can lead to severe dehydration, water retention, bloating and chronic constipation. Nearly all the physical changes due to AN are reversible by maintaining a normal weight but is a slow process.

Behavioural Effects:

People with AN have daily routines dominated by physical activity and excessive exercise. Other weight loss behaviours include purging, by vomiting or using laxatives/diuretics after eating, to remove from the body the food consumed.

Psychological Effects:

AN sufferers become extremely preoccupied with food. As well as worrying about the food consumed or to be consumed they may develop a love for cooking for others while they themselves eat separately. Always having to watch what they eat when food is very much a part of social occasions can lead to hostility toward others, increased isolation and loneliness which causes the disease to develop further.

Thinking becomes rigid and inflexible with starvation and sufferers tend to have only ‘black-and-white’ thinking. Individuals with AN tend to revert to immature thinking. AN can result in increased obsessions about not only food but other areas such as compulsive neatness and cleanliness. Sometimes these obsessions are imposed on others making the anorexic intolerant of people who do not comply with the obsession and increases their isolation.  

As AN progresses it reduces the ability to think and sufferers tend to do and say things repetitively. Anorexia may be associated with other disorders such as bulimia, depression, obsessional disorders and anxiety.

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                  3. What Causes Anorexia Nervosa?

Anorexia stems from a mixture of social, environmental, psychological and biological factors.

Vulnerability Factors:

There may have been feeding problems in childhood perhaps due to a mother with an eating disorder or from comparing with cultural ideals. Research has shown a strong genetic predisposition in the occurrence of AN. Biologically starvation affects the levels of chemicals in the brain, in particular serotonin which is released when we eat. Low levels of serotonin stimulate hunger.

Features of family life linked to the formation of anorexia include:

Families that avoid conflict.

One parent tends to be over involved while the other is passive with the child.

Too strong family rules and identity such that individuality is hard to express.

Sexual, physical or emotional abuse.

Highly successful parents who expect similarly for their children.

Extreme sibling rivalry.

Adolescence is the time when a person develops a sense of identity. If at this time parents prevent the teenager from having control over life, the adolescent may feel that their weight is the only thing they have control over and losing weight may be used to reject the family and gain a sense of empowerment. There is immense social pressure to be slim – in films and in the media women are portrayed as an ultra-slender ideal. Many women feel that being slim will solve all their other problems.

From adolescence we begin the search for autonomy – if this is denied then controlling eating may be the only way to exercise self-will and express individuality.

Low self-esteem can lead to AN where an individual associates gain of self-esteem with weight loss.

See Program 16: Overcoming Low Self-Esteem.

Sexual abuse victims may develop eating disorders as a means of gaining control over their life, to make themselves less desirable, as self-punishment or to influence/punish those who have failed to protect them.

See Program 10: Overcoming Childhood Abuse.

Separation and loss can lead to the development of AN.

Triggering Factors:

Negative remarks about appearance.

Separation and loss.

Pressure to be successful.

Family and sexual conflicts.

Feeling overweight and dieting.

Maintaining Factors:

Fear of fatness.

Rewards of weight loss.

Sense of self-control and approval from others before extreme loss is apparent.

Concerns from others.

Avoiding difficult changes of adolescence.

Increasingly distorted body image.

Preoccupation with food and reduced interest in socializing.

It is important to remember that no one factor is the cause of the condition.

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          4. Treating Anorexia Nervosa

The earlier treatment is sought for AN, the quicker the route to recovery. In advanced stages AN can require intensive and long-term treatment. The AN sufferer needs to accept that there is a problem, be willing to receive help from someone and take steps to break free of their extreme dietary restrictions.

To seek help you should discuss your problem with your GP. If this is not possible, contact your nearest hospital psychiatry or clinical psychology department, or a local community mental health team. Most people may receive successful treatment as out-patients, getting some form of counselling.

Any treatment program will aim to increase weight to normal range; enable the individual to resume normal eating patterns; avoid resorting to vomiting, laxative/diuretic abuse and over exercising to control weight. It will also try to give an understanding of the physical symptoms caused by AN. Hospitalization is resorted to if a person’s condition becomes critical.

No drugs will directly relieve the symptoms of anorexia but drugs can be prescribed for associated disorders such as depression and include: minor tranqillizers, anti-psychotics and anti-depressants. Zinc supplements may be prescribed by a medical doctor and can double weight gain. There are various forms of group therapy for AN and cognitive behaviour therapy (CBT) has been found to be effective in treating AN.

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          5. Problem Assessment

Altering your behaviour and body image will be a gradual process. In this program you need to congratulate yourself for successes and not feel too despondent about setbacks. First you need to establish your position now. Write down answers to and any related thoughts about, what caused you to diet and why the diet was so successful.

What stage of AN are you at?

Pre-anorexia nervosa – food causes panic but does not dominate your thoughts and you may have lost some weight but are not severely low in weight.

Clinical anorexia nervosa – food dominates your thoughts, you are obsessed with weight gain and have lost considerable weight.

AN has become an illness if you have been living on severely reduced food intake for six months. You may feel trapped in anorexic behaviour.

When AN is long standing it may have become a way of life for you.

If you are in the last two stages, consider what caused you to proceed through the first two categories. If you have AN you should seek professional help as well as following this program.

Be aware of and list the things that stand in the way of change – these include: lack of motivation; fearing loss of control and change; being isolated; realizing that you will have to fight to give up your anorexia. To motivate you for altering your behaviour write down the advantages and disadvantages of anorexia nervosa – do not panic if at this stage the pros outweigh the cons.

Look at the statements in your list above and do experiments using CBT methods.

See Program 1: Coping Strategies Counselling Advice – Modifying Maladaptive Thinking.

Change each statement to a question, for example: change ‘I feel in control of my body in this way’ to ‘Do I feel in control of my body in this way?’and test it out for a few days noting the evidence that arises.

Try imagining what it would be like 1-10 years from now for yourself with AN and for a friend who does not have AN. How might your lives be as time progresses – you could imagine meeting and talking about your lives with your friend or do this in real life.

To distance yourself from AN – write a goodbye letter to your anorexia nervosa about the ways it helped and how you will cope in future.

Consider the positive and negative changes that might occur within your family if you recover from AN. Take a positive aspect and set it as an aim and get your family involved (e.g. you may feel that without AN, you would enjoy activities with your family). Set this as a target and start by trying to enjoy a family activity. Attempt to get your family to focus on the positives.

If you think that you are using anorexia to punish others and feel you cannot approach your family about this, then seeing a family therapist may be helpful. AN is destructive to all relationships and physical relationships may become terminated. Partners need to be made aware of the illness and asked to be supportive when you are ready to alter your behaviour.

Learn to deal effectively with relationship problems.

See Program 1: Coping Strategies Counselling Advice – Troublesome Emotions, Making Your Love Last and Program 13: Overcoming Destructive Relationships.  

The following coping skill may be helpful.

See Program 1: Coping Strategies Counselling Advice – Problem-Solving.

Try writing distracting activities on small index cards to keep at hand for when you need them.

See Program 1: Coping Strategies Counselling Advice – Distraction Techniques.

Build a good support network.

See Program 1: Coping Strategies Counselling Advice – Social Skills Training, Communication Training and Negotiation Training.

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  6. Monitoring Your Eating Patterns

You need to record, test and control your present eating habits before you attempt to alter anything. Easing your dietary restrictions and giving food less priority is necessary for recovery, which will involve taking risks and challenging your old eating habits. At each stage keep in mind how miserable you were when you first sought help.

In a notebook make a food diary to record daily everything you eat and drink including any binges and what was consumed in these, the latter written in brackets. Also, note the number of portions you eat, how many times you vomit, take laxatives/diuretics or exercise after eating.

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                  7. Targets of Normal Eating

Aim for the targets of normal eating in steps:

Do not eat alone.

Apart from socializing, do not do anything to distract you from concentrating on enjoying your meal, even if you are bingeing.

Plan a regular eating pattern with breakfast, lunch and dinner plus snacks between each meal.

You can make the task ahead easier:

Try to take up an activity you enjoy and do not involve food or exercise.

Endeavour to recognize triggers that may result in you eating less – write down reasons for you not to be affected by them.

Avoid letting food and weight dominate your thoughts.

Weigh yourself only once a week – try not to weigh yourself at all.

Anxiety and depression associated with AN will improve with weight gain but if you can, deal with these particular problems.

Try to exercise for enjoyment rather than to purely burn calories.

Do not worry about amenorrhoea – your periods will return when you reach a healthy weight.

Allocate time to consider whether you need alternative strategies.

Be realistic in your goals and note your successes in your diary.

Try to aim for one of the Targets of Normal Eating each week by writing it down in your diary.

Analyze your diary at the end of each week and note any changes in your eating patterns. Reward yourself for any successes.

See Program 1: Coping Strategies Counselling Advice – Forgiveness, Program 6: Overcoming Anger, Program 8: Overcoming Anxiety, Program 12: Overcoming Depression, Program 15: Overcoming Grief And Bereavement, Program 22: Overcoming Stress and Program 23: Overcoming Stress At Work.    

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                  8. Dealing with Restrictive Eating Patterns

An individual’s weight will fluctuate daily. With the return to a normal eating pattern your metabolic rate will increase from being slow due to starvation.

Food eaten in ‘portions’ can be used to gradually increase your food intake. Carbohydrate foods are eaten in ‘portions’ aiming for 15 ‘portions’ a day. When your eating patterns have improved, this can be adjusted to control your weight change.

One portion includes foods such as: one slice of bread; one chocolate biscuit; one bowl of cereal; one piece of fruit; one small potato; one bowl of soup; two tablespoons of pasta or rice; one glass of fruit juice.

Two portions include foods such as: one bag of crisps; one single helping of pudding; one croissant; one fruit yoghurt.

Ask your doctor to refer you to someone who can give you detailed information about the ‘Portion System’.

Continue with your food diary and aiming for the Targets of Normal Eating.

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                  9. Dealing with a Distorted Body Image

Anorexics tend to have a negative body image – they feel parts of their body to be fat and this makes them believe that they are fat.

See Program 1: Coping Strategies Counselling Advice – Improving Your Self-Image and Combating Self-Harm and Coping with the Need for Approval.

As a result their self-confidence is seriously undermined.

See Program 1: Coping Strategies Counselling Advice – Assertiveness Training, Neuro-Linguistic Programming (NLP), Building Confidence I, Building Confidence II, Building Confidence III and Building Confidence IV.

Perfectionism – striving for the unobtainable ‘ideal body’ can lead to a negative body image.

See Program 1: Coping Strategies Counselling Advice – Competitiveness and Perfectionism, Frustration, Procrastination and Persistence.  

General negative feelings such as depression or boredom may be replaced by feeling fat. Behaviours such as body checking and comparison making also trigger feeling fat, as can physical sensations that heighten body awareness such as feeling hot or bloated. Using a monitoring record identify instances of feeling fat and note the common triggers. Use a problem-solving approach to deal with these triggers and modify negative interpretations of sensations associated with feeling fat.

Try to resist the urge to repeatedly check your body for ‘flaws’ as this maintains dissatisfaction with shape and weight. Note that changes in size can only be evident by examining how your weight is changing over time – so merely frequently touching or viewing yourself is ineffective.

Generate a list of areas of your life that are important to the way you judge/evaluate yourself. For example, you may judge yourself in terms of the quality of your relationships with others; what you achieve at work; sports/musical accomplishments; appearance (shape, weight) and controlling your eating. Draw a pie chart in which each slice represents the relative importance of that area of your life. It is likely that you over evaluate the importance of shape, weight and control over eating – this will be your dominant slice. You need to learn to decrease the size of this slice and increase the value of the other aspects of your life. Continue to draw these pie charts at regular intervals as you proceed with this program, to see your progress.

Avoid and confront not looking at or not touching your body, to prevent phobia about your body.

Analyze your diary: How are your feelings and eating linked? What negative thoughts tend to persist? Can you challenge these thoughts and if so, how does your behaviour alter? Consider which coping strategies are most helpful to you so far.

See Program 1: Coping Strategies Counselling Advice – Modifying Maladaptive Thinking.

Understanding the root of your negative body image will help you to gradually alter it. Write your body’s history: Take specific ages such as 6, 9, 12, and 16. Use old family photos to remember how you felt about yourself and your body at the time, the state of relationships, and family circumstances. Begin when you felt comfortable with your body then write how your negative body image formed. Continue to include your feelings after developing AN and use any photos you may have of this stage.

It may help to:

Re-write your story as if you had not formed a negative body image.

Create a positive body image you can keep with you and listen to when you have negative thoughts.

Try not to take notice of the media.

Keep a positive diary for a week noting only positive bodily experiences, to combat the biased thinking of AN.

Some helpful activities are:

Imagine how you will be 10-20 years from now. What will your goals be and will you need to make any alterations to achieve them?

Consider and compare how you see yourself and how others see you. How would you like to see yourself and be seen by others? What changes are required for this and how would you make them?

Think of someone you respect who is not overly thin. What qualities do they have that impress you and can you develop these in yourself? What do you think matters to them?

Consider your reflection and for each negative thought, substitute a positive thought. Write these down and repeat them when you feel critical about your body.

See Program 1: Coping Strategies Counselling Advice – Criticism and Countering Self-Criticism.

Think of situations you avoid (e.g. looking at your full length reflection), and confront them. Look at other people’s bodies and note why you prefer your body. Make time to physically indulge yourself and as you do so alter negative thoughts to positive ones. Exercise for enjoyment. Prioritize your activities by rating them from 1-10 for enjoyment.

See Program 1: Coping Strategies Counselling Advice – Nutrition, Exercise, Managing Your Time and Sleep Management.  

Continue working on your diary.

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                  10. Conclusion

Be prepared for setbacks. The skills you have learned will need to be continued to be applied. Identify early warning signs of relapse (e.g. delaying eating, skipping meals, increasing exercising) and if you notice any of these, take immediate action to prevent relapse by using the techniques from this program.

Do not be discouraged if you notice little change in your behaviour – finding alternatives to your usual coping methods will be difficult. Keep up the effort because freedom from AN will enable you to cope better with life, in the future.

See Program 1: Coping Strategies Counselling Advice – Relapse Prevention.

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