By: Jennie J. Kramer, LMSW

As in life’s stages of development, eating disorders also have various stages. It is often difficult for the one suffering from symptoms or their loved ones to know what treatment is needed and where one falls in the vast continuum of eating disorders.

The universal first step is for one to make the emotional and mental commitment to at least find out more; to explore whether one in fact has an eating disorder, to what degree and what the treatment options are. Here is a preliminary guide to help in that decision making process:

Identifying an Eating Disorder:

The following guidelines are compiled from www.something-fishy.org, www.helpguide.org and www.renfrewcenter.com and may be quite useful in recognizing whether there is in fact cause for concern:

Signs of Anorexia

• Is thin and continues to get thinner and wishes to keep getting thinner
• Wears big or baggy clothes or dressing in layers to hide body shape and/or weight loss.
• Diets even though not overweight
• Obsession with calories, fat content of foods and continuous exercise
• Has a distorted body image, i.e. feeling fat even when thin
• Loses or experiences thinning hair as well as a gray pallor
• Use of unusual food rituals and/or hiding of food
• Talks excessively about food, cooking, baking or dieting
• Loss of menstrual cycle
• Low self-esteem
• Tends to be a perfectionist

Signs of Bulimia

• Eating unusually large amounts of food, with no apparent change in weight.
• Uses the bathroom frequently after meals
• Reacts to stress by overeating and then possibly purging in a variety of ways
• Has noticeably depressive and/or anxious moods
• Low self-esteem
• Tooth Decay and/or and Mouth Problems
• Irregular Menstrual Cycle
• Mood Swings

Signs of Binge Eating Disorder

• Eats large amounts of food when not physically hungry
• Eats quite rapidly
• Chronic Dieting
• Mood Swings
• Decreased Mobility
• Eats to the point of feeling uncomfortably full
• Often eats alone and socially isolates in general due to shame or embarrassment
• Has a history of marked weigh fluctuations

OK…Now What??

If you or someone you know is believed to fit many of these criteria, it is important to first have a comprehensive and confidential bio-psychosocial evaluation by a licensed professional. This is an extensive interview that will cover a wide range of issues including onset of symptoms; past treatment if any; recent medical/physical symptoms that may or may not be associated with any eating disorder symptoms; medications one may be taking (past or present); education and developmental issues (past or present depending on one’s age); typical daily food intake of late (both “good days” and “bad days”); whether there is consumption of alcohol and/or any other substances as well as how often and in what amounts; family history of any addictions, eating disorders or psychiatric challenges; cultural influences i.e. family and relationship issues, the perceived roles of food and/or gender roles in one’s family or culture;  any significant events or trauma that may have occurred; one’s present living situation and/or supports and many, many more such questions.

Such a comprehensive evaluation can be extraordinarily helpful in and of itself, even if one does not choose to pursue treatment, as it may open up questions or insights never talked about before or it may normalize one’s situation i.e. “well at least I know I’m not alone and I’m not crazy – this seems to be routine for others, as well”.

If on the other hand, one chooses to act now, there are criteria that are generally accepted in our field which can best determine the care needed. This process is part science, part art; meaning that with the exception of severe and obvious symptoms or medical complications, one may take a number of paths to get to the same goal. This may depend on how long one has been symptomatic, how much the symptoms interfere with quality of life and, in many cases, financial limitations may also influence one’s decisions.

Choosing The Level of Care

• An Outpatient Team usually consists of some or all of the following:

 (1)   A Licensed Psychotherapist: 1-2x/week to explore some of the underlying issues, perceptions and habits that drive the very behaviors that are harmful, as well as to teach new coping skills. Both Individual and Family Psychotherapy can be critical to the process of uncovering some of these issues in a very effective way.

(2)  Nutritionist/Dietician: a nutritionist who is specifically trained in eating disorders can gently and effectively help monitor one’s weight changes and also offer a safe variety of safe food choices.  These food choices will ultimately be less likely to contribute to cravings or symptom use and are introduced at a very individualized pace. This is not meant to put one on a “diet”, but rather, to support one’s basic nutritional needs and help keep one clinically safe.

 (3)   Psychiatry/Psychopharmacology: Medications are not for everyone. But in some cases, small amounts of medications can make a tremendous difference in reducing depressive or anxious feelings, which are so often potent triggers. No, this is not “numbing”; that’s what the eating disorders are meant to accomplish much of the time. Instead, this is meant to take the edge off, whether temporarily or long-term, in an effort to give one the best possible odds of staving off symptom use and triggers.

 (4)   Family Physician/PCP: In many cases, it does become necessary for one to be monitored with some frequency, especially since physicians may be the first to be consulted on such matters, (especially in the case of an adolescent) and may know the patient’s medical history and norms well enough to know when something irregular or potentially harmful has arisen with regard to blood pressure, blood level fluctuations, etc.

 (5)   Group Support: this may take the form of a weekly outpatient group meant to provide peer support as well as additional coping skills. Since many who are afflicted with eating disorders are also socially isolated, the group can be an invaluable part of the treatment picture as both socialization and normalization are encouraged.

 While these are the most common components of a treatment team, others may be involved, as well. The team may or may not be affiliated with one agency, as they are at   CEDAR Associates, but in general, the psychotherapist or psychiatrist will coordinate the efforts of the team.

 Higher Levels of Care:

 When all of this is simply not enough to contain symptom use or medical complications, or when symptoms have escalated to the point of greater despair or, in some cases, to the point of interfering with going to work, school or running a family, for instance, a higher level of care may in fact be needed.

 (Please note: these explanations are not meant to self-treat or self-diagnose and should be viewed merely as helpful guidelines when making treatment decisions with your team or agency):

 In-Patient/Residential Level of Care:

 This may occur in a hospital setting in a designated ward or floor or, in many cases, on a designated residential campus. The focus is to provide what is called a “holding environment” or a safe place to be monitored and treated while temporarily stepping away from one’s everyday life and potential triggers. The idea is to provide in a 24/7 setting, many forms of group treatment, (i.e. peer support, body image issues, family issues, creative arts expression, body movement, symptom management, treatment planning, nutrition, stress management, coping skills, and, when necessary, groups which may have a specific focus on other addictions or past trauma), individual therapy multiple times per week, psychiatry/psychopharmacology to evaluate and monitor whether medications will ultimately be helpful in the process, individual nutritional guidance, especially to help one make choices for food that will be served while in this environment, and medical support if needed. Last but not least is the very important role of Family Therapy, whether it be through sessions between the patient and various family members by phone or in-person, or whether it be through the Multi-Family Support Groups that meet, as well.

In all cases, the idea of the in-patient or residential level of care is to interrupt all of the eating disorder behavior cycles and start to provide new routines and skills.

Day Treatment or Partial Hospitalization Level of Care:

This is an out patient treatment setting, usually meeting all day, 5 days per week. It is very much like what is described above – just less of it. It is the ideal step-down for someone who has been in an inpatient or residential setting for a month or more. It is simply unrealistic to expect one to take all of what is learned at the highest level of care and then step right back in to one’s world at full throttle. This provides one foot in a high level of care, while the other foot tip-toes back into one’s world.

This level of care may also be ideal for one who must be treated at a much higher level than the outpatient team described earlier, but who may not quite fit the psychiatric and medical criteria for inpatient care.

IOP or Intensive Outpatient Level of Care:

This is in an outpatient setting, as well and often takes place three evenings per week. It is meant as a further step-down after one has completed Day Treatment and/or Inpatient levels of care. Once again, it may not be used as a step-down, but rather as a point of entry into care if it is believed that the severity of symptoms and their duration cannot best be contained simply by straight outpatient services as described earlier. The modalities and the focus are the same as with the other higher levels of care. It merely meets less often and for a shorter period of time. It is assumed that the step-down after IOP is in fact back to some of the outpatient components discussed earlier.

Some Final Thoughts

Regardless of what one’s final decision may be about whether to seek treatment or not and at the level of care that is the most clinically and medically responsible, please keep in mind that all treatment is an ongoing process. There is no “fast cure”. After all, why does an eating disorder develop to begin with? As a way to cope. It may be a maladaptive and potentially harmful way to do so, but it is nonetheless a long-standing coping mechanism. It is also important to remember that any eating disorder is never about food. It is simply a metaphor for other things; merely the “weapon of choice” if you will. Time, patience and compassion are essential to facilitating the most steady treatment and recovery.

Lastly, please also keep in mind that attending the various levels of care is not necessarily linear like when we progress through various grade levels in school, presuming never to return to that grade again. The trajectory of the long-term treatment of an eating disorder may in fact require returning to various levels of care at any given time. This is not a sign of failure. Quite to the contrary, it is a sign of very hard work being done to battle a tenacious disorder.

For more information, contact CEDAR Associates.