Eating Disorders and their Treatment
How is an eating disorder defined?
Eating disorders are defined as mental illnesses. Meaning that although food is at the forefront of the discussion, mental issues often underlie the expressed physical symptoms. This is the main differentiator to other food related illnesses such as obesity.
Eating disorders often go hand in hand with depressive episodes, anxiety and compulsive disorders. Further root causes may also be of societal nature such as diets and the propagated ideal of a very slim physique. Trying to lose weight or following a vegan or vegetarian diet is not to be interpreted as a disorder. However should food, diet and physique become a prime occupation, should obsessive behavior increase and affect one’s or a loved one’s health, it is advisable to seek professional help.
Which types of eating disorders exist?
Three prominent types of eating disorders exist, which are discussed in the following. However it is noteworthy that symptoms may spill over and that patients may show signs of more than one eating disorder.
People suffering from anorexia have a distorted body image and are obsessed with weight and their physical appearance. Often they can be identified by a very slim physique. The most common practices to lose weight are the drastic reduction of food intake, the misuse of laxatives as well as obsessive exercise. Critical for the diagnosis of anorexia is that the patient’s body weight is 15% below what should be normal for age and height. Anorexia often goes in hand in hand with social isolation, perfectionism, depressive episodes and/or irritability. Long term effects of anorexia are amongst others amenorrhea, osteoporosis and cardiac arrhythmia. The Body Mass Index (BMI) allows for a simplified calculation of normal weight.
BIM = Weight (kg) : (Hight (m) x Hight (m))
A BMI score below 18.5 means that a patient is underweight. A BMI score between 18.5 and 24.9 is generally acknowledged as healthy. Scores from 25 to 29.9 are perceived as overweight. Scores of 30 and above indicate obesity.
People suffering from bulimia binge food on a regular basis and eat vast amounts during these bouts. To avoid gaining weight they try to undo the consumption. The most common ways those affected relieve themselves of the binge is to vomit, exercise excessively, use laxatives or skip following meals. This leads to a vicious circle of binging with subsequent secret, weight decreasing behaviors.
The decisive difference between patients suffering from bulimia in comparison to anorexia is that they usually exhibit normal weight. Nevertheless, thoughts on physique and weight are constant companions such as the fear to gain weight. Long term effects of bulimia can be dental issues, hair loss and insomnia.
Binge Eating Disorder
Characteristic for people affected by binge eating is that they regularly binge on high caloric foods. In contrast to bulimia and anorexia they don’t engage in behaviors of making the consumption undone. Consequently the body weight of those affected increases notably. Furthermore binge eating often goes hand in hand with reduced physical activity what allows for the stark increase in weight. So far binge eating is the least scientifically explored eating disorder, which is why the range of causes and triggers aren’t known yet.
What does treatment for eating disorders look like?
Eating disorders mostly require the cooperation of doctors, psychotherapists and nutritionists. Severe cases often require inpatient treatment whereas milder cases often seek outpatient treatment. Usually treatment contains the following aspects:
Weight gain as well as the treatment of physical symptoms
Parent counselling or family therapy
Treatment of comorbid disorders
Depending on the individual case duration and nature of therapeutic interventions can vary greatly.
How is inpatient treatment defined?
Inpatient treatment for eating disorders is carried out in hospitals specialized in mental or psychosomatic disorders. Treatment duration varies from four to twelve weeks. Patients spend days and nights at the ward and participate in a variety of treatments including psychotherapy, doctoral consultations, group therapy, art therapy, music therapy and drama therapy to name a few. Some clinics also offer cooking therapy and supervised meal times. Information on suitable clinics is available on the website of the German federal association of eating disorders or here. Admission to a clinic must be suggested by a resident doctor or therapist. For urgent admission contact the emergency room of the preferred clinic.
How is outpatient treatment defined?
Outpatients participate in weekly sessions with either a psychotherapist, doctor or nutritionist. Depending on the specialization of your practitioner, content and duration of therapies can vary greatly. Cognitive behavioral therapists often implement food or mood diaries to track contingencies between thoughts, mood and behavior. Also therapists and patients agree on contracts concerning weight gain and purging behaviour. Psychodynamic therapy and Psychoanalysis on the other hand focus less on symptoms but rather work towards identifying intra- and interpersonal conflicts that cause impaired wellbeing.
Which therapy options exist?
Cognitive Behavioral Therapy
Basic Assumptions: Cognitive Behavioral Therapy (CBT) assumes that there is a correlation between what we think, how we feel and how we act. Consequently this means that changing established thought patterns can lead to changes in behavior and feelings.
Goals: In comparison to other therapy forms CBT focuses less on a patient’s past. The aim is to highlight problems that affect the present and to develop solutions and strategies how to deal with these. For instance patients are asked to practice everyday tasks whilst applying new behavioral patterns. Someone suffering from anxiety gradually learns how to deal with his fears by continuously confronting himself with these.
Sessions per Week: normally once a week
Therapy Duration: 25 - 80 Hours
Basic assumption: Analytic psychotherapy dates back to Sigmund Freud’s Psychoanalysis (PA). This theory assumes that specific memories and life events generate negative emotions that have been pushed back to the unconscious and consequently aren’t readily accessible. However, these repressed emotions can lead to difficulties in mastering development steps - for instance handling the transition from childhood to puberty. Resulting from repressed emotions symptoms can develop over time and affect the present.
Goals: The focus of PA is to make patients aware of repressed thoughts and emotions. The aim is to experience stressful life events once again, whereas now the therapist functions as a projection surface. The therapist guides patients throughout this process and interprets situations and points out complex interrelations. Generally patients identify pain points which they want to talk about without the therapist shaping or directing the session’s direction or outcome.
Sessions per Week: normally 2-3 per week
Therapy Duration: 160 - 300 Hours
Basic Assumptions: Psychodynamic Psychotherapy was developed on the idea of Psychoanalysis.This branch of Psychotherapy is equally built on the assumption that previous life events are critical for the way we feel today. In Psychodynamic Therapy patients and therapists jointly seek to identify stressful childhood conflicts that shape the way we see ourselves today and how we conduct relationships. Conflicts arise when hopes and desires can’t be met due to prevalent fears. For instance a patient’s wish for independence might be hindered due to an overwhelming fear of loneliness. Underlying inner conflicts may be triggered by a hurtful incident today which can lead to the development of symptoms.
Goal: Psychotherapists working with the psychodynamic approach assist patients in accessing the underlying reasons for the mental health issues they’re experiencing. Knowledge of our inner conflicts is supposed to implicitly bring about change that empowers patients to lead healthier and happier lives. In contrast to Psychoanalysis, psychodynamic therapists actively shape the session and define tangible goals.
Sessions per Week: normally 1-2 per week
Therapy Duration: 25 - 100 Hours
Foods as a Lifestyle Trend
Vegetarianism is defined as a diet which includes neither meat nor fish. This diet is rooted in some Asian cultures where religious beliefs prohibit the consumption of animal produce. Large groups of Buddhists or Hindus for example are vegetarians. Since the 1980s when Yoga and meditation became increasingly popular in Europe and the public started to put a stronger emphasis on environmental sustainability, the conditions of livestock farming, vegetarianism was also established in western societies.
Veganism is derived from vegetarianism. Because of ethical reasons veganism disapproves of all animal related products including meat, eggs, honey and diary. Especially millennials are open to a vegan lifestyle which has contributed to the fact that this kind of diet is perceived as cool and fashionable.
Paleo, also referred to as the caveman diet, states that the sole or predominant nutritional source of humans should resemble that of the Paleolithic era. This entails the consumption of mostly raw, unprocessed foods such as wild berries, nuts, grains and mushrooms. Additionally Paleo has a heavy focus on meat and fish. Wheat, dairy and sugar are strictly forbidden. This diet has become increasingly popular with those striving towards a very slim beauty ideal.
Allergies & Intolerances
Allergies and intolerances have become a big issue over the last years. The most common intolerances are lactose and gluten intolerance. Allergies and intolerances must be taken seriously and should be discussed with your general practitioner. Apart from the proven fact that both health conditions are on the rise, clean eating has become quite modern and in some instances these newly acquired eating habits involve stripping the consumption of dairy, gluten and wheat from the diet. People suggest that they feel better and that they’re relieved of symptoms. However, in most cases these statements aren’t backed by medical evidence of a diagnosed allergy or intolerance.
Low/No-carb & High-Protein Diet
Recently low carb diets in conjunction with the conscious consumption of protein have become very popular. The substitution of carbs with foods high in protein is thought to reduce body weight and allow for a more toned physique. Especially young adults who follow a strict regimen of maintaining a certain body shape and fitness routine are prone to low carb diets. As many fitness influencers are testimonials for such products, many aspiring health freaks are encouraged to adopt these patterns.
The mediterranean diet is high in fiber, vegetables and olive oil. It is said that this diet facilitates a healthy lifestyle and decreases risk of coronary heart disease. They mediterranean way of life propagates mindful eating which helps us notice when we are full. Furthermore the fibres in vegetables, fruit and salad support a healthy digestion. As breakfast in most mediterranean countries only consists of coffee and pastries, it is recommended to substitute with muesli and yoghurt.
The nordic diet focuses on regional foods like berries, root vegetables, whole wheat or rye, salmon and rape oil. Butter, red meat and white flour on the other hand are avoided. It is said that the nordic diet has a positive influence on blood fat and inflammatory parameters.
How do I find a spot for outpatient psychotherapy?
The website of the Association of German Psychologists offers a search function for therapists.
How do I make a an appointment for initial consultation?
Since April 1st 2017 German patients under a statutory insurance plan are entitled to an appointment placement for psychotherapeutic treatment. The Association of Statutory Health Insurance Physicians supports patients in arranging initial consultation and if need be acute treatment options. Within the first consultation the therapist evaluates if a mental ailment is given and if the patient is in need of psychotherapeutic treatment or if other support and counselling services are sufficient. To avail of an initial consultation no medical referral from your doctor is needed. The waiting period between patient outreach and a first appointment is no longer than four weeks.
Acute treatment may subsequently follow initial consultation. The aim is to offer relief to patients who are suffering from acute mental symptoms and prevent a chronification of these. In order to avail of acute treatment options patients require a report issued by a psychotherapist who explicitly recommends such an approach. Such reports are issued to patients after psychotherapeutic consultation session.
Which services do health insurances pay or reimburse?
Psychotherapy is a service offered by statutory health insurances. This means that therapy costs are paid by health insurances. However not all psychotherapists are eligible to have costs reimbursed by statutory health insurances. In order to have costs reimbursed psychotherapists have to be a) approbated b) accepted by the Association of Statutory Health Insurances c) apply psychotherapeutic techniques that are scientifically validated. Techniques approved by German health institutions are: 1) Cognitive Behavioral Therapy 2) Psychoanalysis 3) Psychodynamic Psychotherapy
Which help services do counselling centres provide?
Outpatient counselling centres provide those affected as well as their relatives with information und individual support. For instance counselors can help evaluate if it’s necessary to consult a psychotherapist and which treatment approach is most promising. Counseling centres assist with issues such as finding availabilities for outpatient or inpatient therapy and cost reimbursement. Some counseling centres offer psychotherapeutic treatment themselves. These services can be used to bridge waiting periods before a therapy spot becomes vacant. Counselors are bound to professional confidentiality. Nevertheless one can still avail of counseling services whilst staying anonymous, for instance by using telephone services or by not revealing one’s name. Public institutions such as communal health services as well as independent sponsors offer ambulatory counseling services. Counseling sessions offered by public institutions are mostly cost free.
How can I support my spouse/child/friend in his/her eating disorder
Counseling centers specialized in eating disorders provide lots of helpful information on how to support your loved one. Trying to persuade or force him or her to seek treatment or help are mostly futile. The most important thing might be to show unconditional support.
Where can carers find help?
Caring for a loved one suffering from eating disorder may have a large impact on the wellbeing of carers and spouses too. Peer support groups offer the possibility to talk to other parents or siblings who have experienced similar difficulties. Advice on handling crisis or difficult situations can be exchanged. Besides carers can talk about their feelings, worries and fears. Peer support is also available via support hotlines or e-mail.
What is a healthy diet?
The definition of a healthy diet is a complex one. The german association of nutrition suggest three meals and two healthy snacks per day. Nutrition should include vitamins, minerals and dietary fiber. Also it is very important to drink enough water or tea. More information on the essentials of a healthy diet are available here and here..
What is orthorexia nervosa?
Orthorexia nervosa is not yet recognized as an eating disorder by the American Psychiatric Association. Nevertheless the incidence rate is on the rise and the scientific community is heavily discussing this phenomenon. Those affected by orthorxia are excessively preoccupied with a healthy diet. Typically an orthorectic person will only eat those foods that he perceives as pure and of high quality. Often those affected will try to convince family and friends to adopt their standard of eating. Their obsessive nature can lead to social conflict and isolation. Orthorexia is considered to be a risk factor for developing an eating disorder.
Does an eating disorder need treatment?
Eating disorders are serious mental illnesses, which can lead to long term physical and psychological suffering. It often goes hand in hand with anxiety disorders and expresses a comorbidity to depression. Those affected are in need of professional help and guidance as they are not able to overcome symptoms on their own. Both inpatient and outpatient care are possible treatment options. Often a combination of psychotherapy, medical and nutritional counselling is recommended.
Does a loss of appetite indicate an eating disorder?
Usually people who suffer from eating disorder still experience hunger which they try to repress, for example by drinking a lot of water or eating very slowly. The loss of appetite is not exclusively linked to an eating disorder but might rather be a symptom of other mental illnesses like depression. Also appetite might be influenced by varying hormone levels.
How does relapse prevention work?
In order to prevent relapse, patients as well as their carers and spouses must learn to identify early warning signs which might indicate an aggravation of wellbeing. Suitable measures can be undertaken like regular medical checkups or psychological counseling. Furthermore it is very important to identify potential risk factors that foster harmful behaviors as well as define strategies how these can be avoided.
How is binge eating defined?
Binge eating attacks are defined by the intake of huge amounts of foods high in calories and the loss of control over eating. After the attack those affected experience guilt, disgust for what happened and fear of gaining weight. This often leads to purging behaviour.
Validierte Tests (interaktiv!)
The abbreviation BMI stands for Body-Mass-Index. The index evaluates a person’s weight in respect to his or her height. The BMI is often used to differentiate between healthy and unhealthy weight categories. A BMI score below 18.5 is considered underweight. Scores between 18.5 and 24.9 are considered normal. BMI scores from 25 to 29.9 are categorised as overweight. Scores from 30 upwards signify obesity. However the index is not universally applicable and is subject to limiting factors. The BMI for instance does not differentiate between fat or muscle content. Therefore it is important to interpret the Body-Mass-Index as an indicator.
Do you make yourself sick because you feel uncomfortably full?
Do you worry you have lost control over how much you eat?
Have you recently lost more than one stone [approximately fifteen pounds] in a 3 month period?
The SCOFF questionnaire is a validated screening instrument that is used internationally to identify eating disorder symptoms. The name is an acronym of the five questions used within the questionnaire. The screening result is not comparable to an assured diagnosis by a medical professional. Irregularities require further examination. Furthermore the SCOFF questionnaire gives no insight into which eating disorder is prevalent.
Your result appears here as soon as you have taken the test.
Do you believe yourself to be fat when others say you are too thin?
Would you say that food dominates your life?