Anorexia Nervosa Treatment Overview

Breaking Bulimia

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Hypnosis With Eating Disordered Patients

Hypnotizability and Eating Disorders Although the use of hypnosis with depressed and suicidal patients has been an issue of contention among researchers and clinicians, there appears to be a higher level of agreement regarding the use of hypnosis for the treatment of bulimia. A number of studies have suggested that bulimic patients may be more hypnotizable than those suffering from anorexia, evidenced by a greater capacity for dissociation (Griffiths & Channon-Little, 1995). Pettinati, Home, and Staats (1985) found that hospitalized bulimic patients were not only highly hypnotizable but also significantly more hypnotizable than patients with anorexia nervosa and normal age-matched controls. Research by Griffiths and Channon-Little (1993) found a higher level of hypnotizability in bulimics compared with individuals not suffering from this eating disorder. Sanders (1986) developed the Perceptual Alteration Scale (PAS) for the measurement of dissociation and found that there was a higher...

Hypnosis And Treating Comorbid Depression And Eating Disorders A Rationale

Working hypnotically with depressed patients who are also experiencing eating disorders would, on first consideration, certainly seems to be appropriate and potentially useful. After all, one could reasonably argue that hypnosis, depression, and anorexia and or bulimia all involve a common denominator of some form of altered state. All require some degree of focus and an absorption in a frame of mind that includes some awarenesses and excludes others. In fact, some hypnosis experts have made the distinction between therapeutic hypnosis and symptomatic hypnosis, suggesting that the direction of focus may differ between therapeutic and symptomatic conditions, but not necessarily the quality of the focus (Araoz, 1985, Gilligan, 1987). As Yapko (2003) described, the so-called classical hypnotic phenomena are the building blocks of experience, whether positive or negative. Thus, it has seemed logical to us to consider how hypnosis has played a role in the onset of these comorbid conditions...

Anorexia and Bulimia

Studies of hypnotizability (Pettinati, Home, & Staats, 1985) have now documented that patients with bulimia possess higher hypnotic capacity than othei patients. The greater dissociative capacity may enable these patients, in fact, to more easily induce vomiting. On the other hand, there is tentative evidence (Pettinati et al., 1985) that patients with anorexia nervosa may be less hypnotically responsive than other patients. Naturally these studies reflect averages we sEouM not conclude that all patients with bulimia will be responsive to hypnosis or that anorexics cannot be helped with hypnosis. There are, in fact, case reports of successful outcomes from treating anorexic patients through hypnosis (Thakur, 1984). The last section of this chapter will provide some illustrative suggestions for altering body image and perception, as well as for treating eating disorders through suggestive hypnosis.

Introduction And Contraindications

Yapko (1986) has stressed the potential importance of addressing family enmeshment, perfectionism, poor self-esteem, and distorted body image, and of using behavioral prescriptions as well as hypnosis in treating anorexia. He emphasizes the importance of individualizing treatment to unique dynamics and personality. Metaphors are one important component of his treatment. He stresses, however, that such techniques may be contraindicated in cases when the physical condition of the patient is too poor for meaningful engagement, when the patient is too fragile, unmotivated, or suicidally depressed, or when the patient does not have rapport with the clinician. (Ed.)

Sheryl C Wilson PhD and Theodore X Barber PhD

The following suggestions are illustrative of suggestions that we have used as one part of a broad based program for the treatment of overweight. The suggestions are presented to the client in the office and are simultaneously tape recorded. The client is then given the cassette tape and is asked to listen to the tape daily. These illustrative suggestions, which are presented below in a generalized form, are tailored specifically for each client. These illustrative suggestions are derived from (a) an application of our theoretical framework (see Barber, Spanos, & Chaves, 1974) to the treatment of eating disorders, (b) the many writings

Age Regression Abreactions And Catharsis

This specific technique has been found useful with patients in whom the underlying dynamic for the eating disorder has been found to be related to past trauma. This can be done by using hypnosis as a diagnostic tool with the aid of such techniques as the affect bridge (Watkins, 1978 Channon, 1981) and other methods of hypnoanalytic exploration in conjunction with ideomotor signalling (Cheek & Le Cron, 1968 Barnett, 1981 Brown & Fromm, 1986). Once this has been identified, the patient can be guided with the use of age regression to the original trauma to which the eating disorder is being related. Many patients then have a chance to fully abreact emotions attached to the original trauma, and the emotional catharsis in the abreaction itself already produces some relief. At times, a significant improvement (although not a full cure) of the eating disorder symptoms is apparent. This has been described in previous publications on the special subgroup of patients with eating disorders in...

Dissolving Disturbing Emotions into Underlying Deep Awareness

The self-deprivation associated with anorexia resembles destructive self-denial in favor of others. Both involve a comparison of ourselves with others anorexia, however, does not involve sharing anything. On the other hand, miserliness - the hoarding of money with unwillingness to spend it even on ourselves - does not partake of the same structure as anorexia and self-deprivation in favor of others. This is because miserliness does not entail comparison with someone else. Moreover, as a disturbing and destructive emotion based on confusion, denial of self-entitlement in favor of others differs from the constructive self-sacrifice of a parent for a child that even animals exhibit.

Severely Depressed Individuals Lack The Capacity To Utilize Hypnosis

Pettinati, Kogan, Evans et al. (1990) compared hypnotizability on two measures, the Hypnotic Induction Profile (HIP) and the Stanford Hypnotic Suggestibility Scale C (SHSS C) for five clinical and one normal college populations. The group with a diagnosis of major depression scored higher on the SHSS C than the normal population and only marginally lower, although higher than the anorexia nervosa and schizophrenia groups, on the HIP

What We Know About Depression

Depression is a highly comorbid condition, meaning that it is more often found to coexist with other conditions (medical and or psychological) than it is found existing on its own. Some form of anxiety disorder is the most common comorbid condition, but other disorders are also common, such as substance abuse (especially alcoholism), eating disorders, personality disorders, and scores of medical conditions. The fact that depression is a highly comorbid condition is well represented in this volume, with chapters addressing depression and anxiety, pain, posttraumatic stress disorder, eating disorders, and Asperger's syndrome.

The Scientific Mongraphs

Biofeedback and Self-Control (Aldine Publishing Company), an annual on the regulation of bodily processes and consciousness also has numerous reports on the beneficial effects of biofeedback, relaxation and meditation n hypertension, abnormal heart rate, headaches, chronic pain, asthma, insomnia, epileptic seizures, stroke patients, eating disorders and peripheral blood circulation. This annual is of a highly technical nature, consisting entirely of scientific papers. The Reports will bring you excerpts in layman languge in future volumes.

Cognitive Reframing And Restructuring

Cognitive restructuring is described in detail by the Spiegels in their book, Trance and Treatment (1978), and also by cognitive-behavioral therapists such as Meichen-baum (1977) and Kroger and Fezler (1976). In essence, the patient is taught a new way of looking at an old problem and finding new, creative solutions in situations where the patient was cognitively 'chasing his own tail,' and feeling stuck with no way out. The patient with an eating disorder is first guided into a state of self-hypnotic trance, in which the patient is highly receptive to new ideas and suggestions. Under hypnosis, the patient is asked to signify if willing to fully cooperate in this process of therapy, with the aid of ideomotor signalling. Providing the signal is in the affirmative, the therapist may proceed as follows As you are sitting in this chair, in this special state of extra-receptivity and self-hypnotic trance, you realize that your subconscious mind has now become your ally, and together you...

Hypnosis As A Tool For Therapeutic Abreaction

Sometimes a traumatic event is the source of anorexia. Early trauma, not discussed during regular sessions, might be revealed during hypnotic age regression. Recognition of this childhood event and working through the abreacted feelings can lead to successful resolution of anorexia.

Depression Versus Anxiety

In general, vegetative symptoms (e.g., anorexia, weight loss, and diminished libido) are more conspicuous in depression, and symptoms associated with sympathetic overactivity (e.g., tachycardia, sweating, and hyperventilation) are more prevalent in anxiety conditions (Maser, Weise, & Gwirtsman, 1997). When anxiety is primary, sleep-onset insomnia accompanies a predominantly anxious mood, there are no significant changes in psychomotor activity, and there is no therapeutic response to exercise (Clayton, 1990). In contrast, when depression is primary, depressed mood prevails, and there are indications of terminal insomnia (i.e., early morning awakening), psychomotor agitation or retardation, and a positive therapeutic response to exercise (Clayton, 1990).

Introduction And Literature Review

A review of the recent literature on eating disorders, including anorexia nervosa and bulimia, reveals a remarkable silence on the utilization of hypnosis as a therapeutic tool. It is evident, for example from the book chapters by Walsh (1997) and Yager (1994), as well as journal articles devoted to eating disorders such as that of Doyle (1996), and a whole issue of the Psychiatric Clinics of North America (edited by Yager, 1996) that includes 13 scientific articles on eating disorders. In this special issue, to my surprise, the subject of hypnosis or guided imagery is not even mentioned as a viable option in the treatment of eating disorders. The publications that have appeared in the past decade on the efficacy of hypnotic techniques in the treatment of eating disorders are not even mentioned or cited the subject of hypnosis does not exist in this special issue. This phenomenon reflects a level of ignorance on this subject reminiscent of the old adage 'The eye sees only what the...

The Organization Of This Volume

The third section narrows the focus even further to the use of hypnosis in treating depression that either is comorbid with other conditions or exists in special populations. These include comorbid eating disorders, children and youth populations, comorbid posttraumatic stress disorder and pain patients, and children on the autistic spectrum.

Sample Transcripts Of Futurefocused Interventions

Jessica (not her real name) was a 16-year-old high school student who was suffering from depression associated with bulimia nervosa. She lived in a dysfunctional family with a cold, rigid, withdrawn, and depressed father and an overinvolved, controlling mother. Jessica's mother saw her daughter as a narcissistic extension of herself and had very poor boundaries in her relationship with Jessica. Jessica had previously been in treatment with several counselors and one psychiatrist. A variety of treatments had been used, such as various antidepressant medications, cognitive behavior therapy, family therapy, interpersonal therapy, and psychodynamic therapy. However, Jessica continued to remain depressed, and her feelings of helplessness, hopelessness, and futurelessness persisted and dominated her clinical presentation. When asked to describe how she sees her future, she answered, What future Life sucks this is hell, there is no future. I asked her if she would be willing to learn how to...

Assessment Of Effectiveness

Any treatment modality stands to be tested based on the outcome, and outcome of treatment must be compared to the natural history of the illness. There are insufficient data regarding the natural history of eating disorders. This refers to patients with any one of the three eating disorders mentioned at the beginning of this chapter in terms of what takes place regarding the outcome of their illness when no treatment is used. This needs to be compared to a variety of treatment modalities, and when treatment interventions produce better outcome compared to the natural history of the eating disorder, such a treatment modality may be 1. Symptom relief Patients who come for treatment suffer from a variety of symptoms that can be measured and recorded with the psychiatric interview, the Mental Status Examination, and a variety of scales such as the Eating Disorders Inventory (EDI) (Garner, Olmsted & Polivy, 1983), the Zung Scale for rating Anxiety (Zung, 1971), and the Zung Scale for...

Hypnotizabilityand Clinical Populations

There are further disorders which are characterized by high levels of hypnotiz-ability. These include hysteria, multiple personality, post-traumatic stress disorder and some categories of eating disorders such as bulimia (Coman, 1992). Such high hypnotizable groups stand in contrast to schizophrenics (Spiegel et al., 1982), obsessive compulsives and anorexics (Coman, 1992) who have been found to possess lower levels of hypnotizability.

Assessment Strategies

Sometimes the hopelessness is related to age and age-related circumstances, and the assessment focuses on whether to employ first- or second-order change intervention strategies. For example, many teenagers who live in dysfunctional family environments develop a variety of psychopathological conditions, including depression, with the associated feelings of hopelessness and helplessness, and sense of futurelessness. Teenagers are generally more responsive to future-focused interventions because many of them already daydream about the future and have specific events they look forward to (e.g., obtaining their driver's license and graduating from high school). I have used future-focused hypnosis interventions with eating disorders, depression, anxiety, panic, and other conditions in the teenage population with positive results.

Case 6 Change

It is far beyond the scope of this work to get into all of the ramifications, subtleties and surprises. One of the surprises I hope that you will soon discover is this All systems, from anxiety to depression, anorexia to obesity, will have certain set patterns or systems. I will go more out on a limb and state that the majority of people with each symptom will have the same patterns. Once you recognize the pattern and its loop, you need to help the individual break it, and form a choice of patterns.

Ego State Therapy

Ego State Therapy has become a frequent focus in the hypnosis literature (Watkins, 1984 Watkins & Watkins, 1981, 1982 Edelstein, 1982 Beahrs, 1982 Newey, 1986). Ego State Therapy is defined by Watkins and Watkins (1982) as the 'utilization of family and group treatment techniques for the resolution of conflicts between the different ego states which constitute a ''family of self'' within a single individual.' This method is aimed at conflict resolution and may employ any of the directive, behavioral, psychoanalytic, supportive, existential, and even relaxation and biofeedback techniques of therapy. This method of therapy concerns a notion of how much the individual's behavior is the result of dissociated ego states in a state of conflict. According to Helen and John Watkins, the experience with ego state therapy shows that activating, studying and communicating with various ego states decreases the patient's tendency to dissociate. The patient who used to dissociate and experienced...

Dabneym Ewin

Seriously burned patients run the gamut of negative emotions. (Ewin, l978). Both the burn and its treatments are excruciatingly painful, and fear of the next treatment sets in early. The accident is usually caused by carelessness (of the patient or someone else), so either guilt or anger intervenes. A sense of helplessness and hopelessness resulting in depression is common. Metabolic rate increases as much as 100 , and nausea and anorexia hinder the increased food intake necessary to meet metabolic demands. It is easy for these patients to become sullen, obstinate, and uncooperative. Curtis Artz, first President of the American Burn Association and one of the early advocates of separate burn centers, is quoted (Dahinterova, l967) as follows

Training In Hypnosis

Both Dr Torem and Dr Vanderlinden comment that with anorexia nervosa and bulimia there has been remarkably little utilization of hypnosis as a therapeutic tool, whereas hypnotherapists have been intensively engaged in the treatment of obesity. Nevertheless, the effectiveness of hypnotic interventions in patients with eating disorders has been recorded in the literature over and over again since the time of Pierre Janet. The clinical literature identifies a variety of psychodynamics attributed to the psychopathology of eating disorders. Many patients with these disorders feel helpless, hopeless, and ashamed of having to seek psychological help. Ego-strengthening suggestions are therefore an important part of most hypnotherapy interventions. Assignments which they are asked to complete are designed so that the patient will metaphorically and concretely experience a feeling of success, as well as a sense of gaining mastery, control, and exercising new choices and options. Ego State...

Areas of Application

Hypnosis has been used with a tremendous diversity of childhood problems text anxiety, problems with studying and concentration, reading difficulties suggestions on these topics may be found in Chapter 14 , phobias (e.g., of school, animals), sleep disorders, social skill training and anxiety, conversion reactions, psychogenic amnesia, seizures, pain, bulimia and anorexia, enuresis (bedwetting), encopresis (soiling), stuttering, trichotillomania (hair pulling), nailbiting, thumbsucking, obesity, sleepwalking, tics, learning disabilities, chronic and acute pain, preparation for surgery, burns, gastrointestinal complaints, asthma, hives, allergies, warts, hyperhidrosis (excessive sweating), to increase compliance in diabetics, hemophilia, juvenile rheumatoid arthritis, dentistry, headaches, urinary retention, cerebral palsy, Tourette syndrome, cancer and terminal illness, and sports. You will find suggestions concerning some of these areas of application in the pages to follow.

Research On Hypnosis

The literature on obesity has been swamped in recent years with very pessimistic and negative treatment results, especially regarding the long-term outcome of treatment (Garner & Wooley, 1991). Unlike the situation with anorexia nervosa and bulimia, hypnotherapists have been intensively engaged in the treatment of obesity (see Vanderlinden & Vandereycken, 1988). Many success stories have been reported in the hypnotherapeutic literature, but these are often reports on a very small number of patients. In addition, they deal with short-term treatment results, and long-term follow-up data are almost completely lacking (Mott & Roberts, 1979 Wadden & Anderton, 1982). Apart from this, most researchers use only one criterion for evaluation, namely weight reduction, while alterations in psychological characteristics such as body image, self-esteem and other criteria are totally

Patient Assessment

The comprehensive and in-depth assessment of patients with an eating disorder is of great value for understanding the underlying dynamics of the condition, the patient's character, and the crafting of an effective treatment plan. The clinical literature identifies a variety of psychodynamics attributed to the psychopathology of eating disorders such as In listening to the patient I specifically explore the possibility of ambivalence and internal conflicts regarding the eating disorder symptoms and behaviors, looking for any clues that the behaviors are ego-dystonic. In previous publications (Torem, 1989a), I have delineated the following examples of clues to an underlying dissociative mechanism in the patient's description of her symptoms An additional method for identifying a possible underlying dissociation in patients with eating disorders is the administration of a dissociation scale. The Dissociation Experiences Scale (DES Bernstein & Putnam, 1986), is easy to administer and has...


Ego-strengthening suggestions are an important part of most hypnotherapy interventions. The technique was named by John Hartland (1965, 1971), and further elaborated by Stanton (1975, 1979, 1989). In this intervention the patient follows a set of general hypnotic suggestions to promote healing, strength, a sense of well-being, competence and mastery. The following verbatim example may be used in patients with eating disorders

The Case Of Julia

At about the same time that Hilde Bruch published a well-known book on eating disorders called The Golden Cage (1978), Julia appeared in our office very early one morning without an appointment. She announced that she was only willing to see Norma and that Phil must stay away as far as possible. She had been referred by her therapist, a student of ours who had taken several of our hypnosis classes, but was apprehensive about using hypnosis with her because Julia was so severely depressed. I had just finished reading The Golden Cage and several articles about anorexia, now labeled the affliction of the privileged, and about bulimia, the very close relative of anorexia. Perhaps it was mere coincidence, but within a month we had three more cases involving eating disorders two painfully thin, emaciated teenagers who were starving themselves, and one slim, well-proportioned college-age girl who ate and purged. Now there were four such patients in my caseload, and we were rapidly learning a...

Ideas For Metaphors

Phenomenon engages the conscious mind, for the individual with an eating disorder who engages in the bulimic behavior of bingeing and purging, a pattern not at all unrelated to the eating disorder of anorexia (in fact, some refer to these patterns that frequently occur in tandem as bulimorexia ), the unconscious mind can begin to work on developing the recognition of seemingly strange behavior as purposeful, a strategy of reframing. In the author's own clinical practice, this same metaphor has been used successfully on numerous occasions, with the following additions to the metaphor cues as a goal of treatment of the anorectic is necessary not only to successfully treat the anorexia, but also to reduce the chance of an overcompensatory weight gain from occurring once the client begins to eat more normally again.