Working with anxiety and eating disorders in therapy

Often with eating disorders, many people tend to focus on the eating disorder itself, in particular the behaviours, emotions and thoughts associated with them. Most people tend to not understand the other underlying issues that are involved, such as anxiety.

When you experience an ED; anxiety tends to be experienced alongside or as a part of the ED, and often is experienced in some form before the ED takes hold too (though this isn’t always the case). The research shows that approximately 65% of patients with eating disorders meet the criteria for at least one anxiety disorder (Adambegan et al, 2012). Also, according to research from the National Institute of Mental Health, anxiety disorders have the highest rate of comorbidity with eating disorders; 47.9% of adults with anorexia nervosa and 80.6% of adults with bulimia nervosa. This makes sense as eating disorders are often developed through a maladaptive way of coping with stress and anxiety.

It's human nature to feel we need to relieve stress when we begin to experience it and it's natural for us to do this even if it means doing something negative to relieve it. This relates to the anxiety cycle often used in therapy, where the idea is that we start to avoid anxiety by either leaving a situation or turning to a maladaptive coping mechanism, but then the anxiety builds further due to avoiding it. For example, if we are feeling anxious, we may run away from the situation to relieve the anxiety in that moment (think fight or flight) or turn to ED behaviours. This then provides some short-term relief but unfortunately, this will begin to build further having turned to a negative behaviour, therefore increasing the anxiety and guilt/shame in the long-term.

There may be differences between ED behaviours as well. For example, with binge eating, there is often a lack of ability to sit with uncomfortable feelings, and binge eating provides quick relief to that stress. Whether these uncomfortable feelings are something short-term such as being unable to deal with a difficult social situation or whether it is something deeper such as a difficult relationship with a parent or childhood trauma.

With more restrictive and purging behaviours this may be related to not feeling ‘good enough’ and other negative core beliefs driving these behaviours. Restrictive behaviours are a way towards working to feeling ‘good enough’ in the short-term but naturally, this also has the same effect of increasing anxiety in the long run and making ourselves feel worse as a result.

When working with EDs it is ideal to focus as holistically as possible to be able to target not just the ED at the core of the issue, but also the factors driving the anxiety too. Different types of psychotherapy will take different approaches to working with anxiety and eating disorders but here are the ways I, as an integrative psychotherapist tend to work with these issues, but every individual is unique.

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Working from the top

Initially, the psychotherapy session needs to be a safe place for the client to be open, and it's vital a positive relationship is forged between the client and the therapist. As in life, unfortunately, this doesn’t always happen! I always urge people to give therapy a few tries with different counsellors if they are finding it isn’t working for them initially.

I think early in therapy, clients want to notice changes or have some early goals to work towards to encourage engagement and increase hope in therapy. Therefore, providing psychoeducation between the links with our thoughts, feelings and emotions is vitally important to create awareness of working on all three together. This is the basic idea of CBT (Cognitive-Behavioural Therapy):

Anxiety cycle example

Thought: “I have failed”
Emotion: Worry
Behaviour: Withdraw

ED cycle example

Thought: “I feel fat”
Emotion: Sadness
Behaviour: Restriction behaviours

The cycles can be triggered by any of the thoughts, emotions or behaviours initially. Anxiety and eating disorder cycles can become very much intertwined, here is an example. You may begin with an anxious thought in a social situation of “nobody likes me”; this will then lead to emotions such as sadness, worry and anxiety, which could then lead to behaviours such as running away from the situation. Now from this experience, you may turn to negative strategies such as ED behaviours to cope with this, which will naturally lead to negative thoughts and emotions with the ED. It’s complicated right, no wonder we can feel so stuck?!

It's useful to explore these patterns in detail to understand where the thoughts are leading, often down to core beliefs of “I’m not good enough” or “I’m worthless”. As mentioned even just bringing awareness to these patterns can have a big impact on a client who is finding it difficult to understand what’s going on. Also, it’s important to make them aware of just how normal anxiety is to experience.

Fight or flight is a part of our genetic makeup and is designed to keep us safe from danger. It's our brain’s way to react quickly to situations without having to weigh up whether we need to do anything. Imagine a wild bear attacking you, it wouldn’t end well if you had to weigh up whether it was a dangerous situation or not! Unfortunately, our brains are not developed enough to understand what is life-threatening and what isn’t. Due to this, we often trigger ourselves with our own thoughts and perceptions of situations.

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Exposure and grounding

The good news is though, that by working on any of our thoughts, feelings and behaviours it influences the other aspects too as if we start to reduce the negative behaviours this will have a positive effect on our thoughts and feelings, and vice versa. Therefore, it can be a good place to start by trying to reduce the behaviours by creating targets and providing skills in place such as ‘urge surfing’ where the client learns to sit with uncomfortable feelings associated with wanting to turn to negative behaviours.

Another good tool is a ‘thought record’, where the client can write down triggering thoughts and learn to balance them with more rational thoughts. Introducing grounding techniques to deal with the anxiety is vitally important for clients as well as to be able to expose themselves to triggering situations. As the anxiety cycle shows, by avoiding difficult situations the anxiety only grows stronger.

Unfortunately, working on both anxiety and eating disorders requires the client to be comfortable with being uncomfortable in some ways. This can naturally be very overwhelming for clients wanting to work towards changing these behaviours, and without safe preparation, it can lead to significant steps back and even panic attacks.

Often clients will want to get more comfortable eating at restaurants for example, it's useful to begin by talking through the scenario beforehand such as the set-up at the restaurant and what they’re likely to want to try on the menu. It can help to visualise the scenarios that the client wants to expose themselves too and introduce controlled breathing and other distractions to combat anxiety.

When it comes to exposure to anxiety, a ‘graded exposure ladder’ is good to introduce to give a clear target of something to work towards and the steps needed along the way. With this, the client rates the situations and scenarios around food on a scale in terms of how anxious they make the client. The client then systematically begins to work from the lowest rated to the highest rated whilst processing any learnings, setbacks and achievements along the way.

As with any goals in therapy, these should ideally be flexible and with a focus on what the client wants to achieve. This can be especially useful for sufferers of ARFID (Avoidant Restrictive Food Intake Disorder), where the client can begin with foods that bring a small amount of anxiety and work their way up to the more difficult steps at the top of the ladder. Ideally, exposure to ED anxiety should be a gradual but challenging process where the client feels in control of the work they are doing.

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The deeper issues

Whilst working on the thoughts, feelings and behaviours in a practical sense is a good place to begin to start making progress, it can also be useful to delve into the origins of these patterns. For some people it can be a negative experience around food that triggers this pattern, for others, it could be a traumatic experience or difficult social or family situations concerning body image.

Often our anxieties around eating can be traced back to difficult memories and experiences that shaped the way we view both ourselves and the world around us. Understandably, our early attachments with parents, siblings, family members and early friendships can have the most significant effect on our anxieties and relationship with food and our body image.

If we have a parent who places a significant spotlight on body image, we naturally learn to take that anxiety on as our own; similarly, if we have parents who are over-focussed on health and fitness we may repeat their behaviours to a further extreme. It can be useful to bring awareness to these for the client to understand how those patterns have been created, as we often tend to ignore these experiences due to how painful they can be to us (another example of the anxiety cycle!). The client needs to explore these in their own time and when they are ready, as again as with any aspect of anxiety and ED recovery, it needs to be small steps that stick rather than a big jump that is too difficult to maintain.

These experiences and relationships can be explored in detail to develop a deeper understanding and motivation to change the current negative cycles in place. It's important to remember though, that every individual is unique and some of the above may not apply to some clients and other clients may need other tools to help progress through ED and anxiety, but what remains consistent is the need to face anxiety rather than hide away from it (as difficult as that can be!).

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References

Adambegan M, Wagner G, Nader IW, Fernandez-Aranda F, Treasure J, Karwautz A. Internalizing and externalizing behaviour problems in childhood contribute to the development of anorexia and bulimia nervosa: A study comparing sister pairs. European Eating Disorders Review. 2012;20:116–120

National Institute of Mental Health.