Wednesday, March 25, 2009

Eating Disorder

A Vicious Circle

An eating disorder is not simply a problem with eating. It is a vicious circle of low self-esteem, extreme concerns about shape and weight and strict dieting. An eating disorder has been called a “low self-esteem disorder”. Issues around body image are often more to do with self image and low self-esteem. Most people who develop an eating disorder are only unhappy about their bodies because they are unhappy about themselves. Controlling their eating habits, either by not eating or restricting their eating (anorexia), or by eating and then making themselves sick (bulimia), or over-eating(compulsive eating), is their way of trying to control their feelings of low-self esteem. These bad eating habits are usually a symptom of deeper issues. A way to recovery, is to come to a level of self-acceptance and to become aware of and challenge low self-esteem and to stop the bad eating behaviours. The following model shows the pattern of this vicious circle:

Eating Disordered Thinking

Cognitive Distortions Of Eating Disorders

  • If I eat something at night, it will all turn to fat because I will not have time to burn it off before I go to sleep
  • If I lose more weight I will be much more attractive.
  • If I was thinner, I would be happier.
  • If I was thinner, I would be more successful.
  • Vomiting gets rid of all the calories I ate earlier.
  • If I eat lunch I won’t be able to eat dinner later.
  • If I eat eg 2 pieces of pizza, people will think I am a pig.
  • If my clothes feel tight after eating it means I have put on weight.
  • My clothes are tighter, I know I have gained weight.
  • If I gain 2lbs it means I am going to continue to gain weight every day and get fat.
  • I ate breakfast and that was ok, but then I had a cake at 10.00am so I had to vomit.
  • But, cake (or popcorn, or ice cream or whatever) are a bad food.
  • Eating normally (i.e, breakfast, lunch and dinner and snacks), even if it amounts to only 1200 Calories when I am 5’4” will, make me fat.
  • I am a bad person (weak, selfish, greedy, irresponsible, inadequate, stupid, dull, etc, etc,) If I lose weight I will be different.
  • I can’t cope with feeling bad, I have to be sick.
  • I deserve (eg chips, biscuits, ice cream etc) because I have had a hard day.
  • I didn’t binge or purge because I was afraid of gaining weight. I just wanted to space out.
  • I have an obsessive craving to binge. After I have eaten I want to eat more.
  • I feel fat, therefore I am fat.
  • I feel so lonely, I should eat more.

Panic Attacks

Model of Panic Attacks

The cognitive model of panic claims that panic attacks arise when patients become anxious about the actual bodily sensations of anxiety itself. For example, in a panic state, a normal anxiety sensation is breathlessness. People can misinterpret this as “my breathing will stop !”, “I am going to die !”, “I will lose control !” or, “I am going insane !”

Stimuli of panic attacks may be external (such as a situation in which an attack has previously been experienced ) or, internal (thoughts, images, or bodily sensations). Where these stimuli are perceived as a threat, a state of apprehension results and the bodily sensations are misinterpreted in a catastrophic fashion and apprehension is reinforced and gets worse, building up to a panic attack.

Another important factor maintaining a panic disorder, is avoidance.

Comparing Depression, Anxiety and Anger

Dennis Greenberger and Christine Padesky give a very helpful comparison of how to understand Depression, Anxiety and Anger. Out of the five areas mentioned above, they only look at four of the areas (typical thoughts, physical reactions, behaviours, and moods and do not mention the situations) to describe these problems. They describe each of them as ‘profiles’, which means they want to describe their particular characteristics.


Thoughts Physical Reactions

No hope for the future Tiredness, loss of energy

Others have disappointed me Loss of appetite

Life won’t change Trouble concentrating

I am a failure / worthless Irritable mood

Behaviours Moods

Withdraw sad

Low activity hopeless

Change in sleep pattern self-critical

Suicide attempts guilty


Thoughts Physical Reactions

Overestimation of danger Sweaty palms

Underestimation of your ability Muscle tension

to cope. Racing Heart

Underestimation of help available Flushed cheeks

Worries and catastrophic thoughts Light-headedness

Behaviours Moods

Avoiding situations where anxiety Nervous

might occur Irritable

Leaving situations when anxiety Anxious

begins to occur Panicky

Trying to do things perfectly or

trying to control events to prevent danger


Thoughts Physical Reactions

Others are threatening or hurtful Tight muscles

Rules have been violated Increased blood pressure

Others are treating me unfairly Increase heart rate

“It’s not fair” Tension

Behaviours Moods

Defend/Resist Irritable

Attack/Argue Angry

Withdraw (to punish or protect) Enraged


Problems with anger can also be understood by how a person is affected in the five areas of being in a specific situation, having negative thoughts, feelings, behaviours and physical reactions.

The content of negative thinking when people are angry has to do with something not being fair, or because PERSONAL RULES HAVE BEEN BROKEN. We can call these the ‘RULES OF ANGER’. People usually get angry because they think something is unjust or that things aren’t the way they should be. We become angry if we think we have been treated unfairly and may feel hurt and damaged, but anger is not so much about the hurt or damage, but that RULES HAVE BEEN VIOLATED.

Most angry feelings are normal and part of life, but problems arise when these rules and expectations are unrealistic or exaggerated. What are fair and reasonable expectations varies greatly among people. CBT can help to challenge these and try to see these in perspective.

Anger can be maintained by these negative thoughts. It is made worst by negative behaviour and then worse still, when people realize this behaviour doesn’t help solve the problem or ‘fix’ the rules that were broken. We can explain this by the following ...


Sunday, March 22, 2009

Trauma and PTSD

Trauma is described as a ‘shock’, or when anxiety has become so extreme it is as if it becomes ‘locked’ in the brain, like a horrifying memory is ‘locked’ in the brain or it has got ‘stuck’ there. People can lose a sense of time, forgetting events and memories before the events and seeing the future clouded by the experience of the past.

for a person to be traumatized,

A person would have “experienced, witnessed, or been confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others. The person’s response would have involved intense fear, helplessness, or horror..”

Various events can traumatize a person. Personal assault, car accidents, natural or man made disasters, rape, abuse, or being a witness to such events.

40-50 % of people recover themselves from traumatic experiences. Others recover from everyday sharing of events with their family and community.

Common symptoms that people experience after a traumatic event are:

  • Involuntary re-experiencing of aspects of the event.
  • Hyper arousal
  • Emotional numbing
  • Avoidance of stimuli.

Trauma becomes a serious problem once it is diagnosed as PTSD. (Post traumatic Stress Disorder). A person is only diagnosed with PTSD if the above symptoms persist after a month.

Anke Ehlers and David Clark has explained that PTSD only persists if there is a sense that there is still a CURRENT THREAT.

Cognitive Behavioural Therapy

To understand behavioural therapy it is best to understand the meaning of each words...


every aspect of mental life – our thoughts, memories, mental images, reasoning, decision making, and so on...

Simply put it means ‘thought processes’; that is what goes on in our minds; our ‘thoughts‘. It also means ‘knowledge’; what we ‘know’, ‘believe’ or ‘think’. It can also mean ‘perception’; or how we ‘see things’ or ‘interpret’ or ‘understand’ them.


Any observable action or reaction of a living organism- everything from overt actions through subtle changes electrical activity occurring deep inside our brains

means what we ‘do’ or how we ‘respond’ or ‘react’

CBT also refers to feelings, physical reactions and the environment.




Part of therapy and counselling work involves helping the client to identify and express their feelings. However, many people avoid their feelings rather than express them. Sri Lanka has one of the highest suicide rates in the world. Part of this might be due to the fact that people avoid talking about their feelings, but suppress them instead. Any long term avoidance of feelings leads to problems.

How do we avoid and why?

Avoidance is another name for “safety behaviour”, that means, something we do in order to keep ourselves safe. Avoidance is a natural or normal safety response to a threat like heights, illness, heat, blood, animals, strangers etc…However, avoidance becomes unreasonable and unhealthy when in the longer term it affects people’s self-esteem and confidence. Avoidance is the key factor which maintains generalized anxiety. For example, a person who is anxious about socializing because he may feel self-conscious or inadequate might avoid going out when asked by friends. This may bring short- term relief when he doesn’t have to face his fear, but in the long-term he will not overcome his anxieties around socializing and not improve his confidence. Challenging avoidance, therefore, is about facing up to the situation or people we fear.

Below is a list of different ‘methods’ we use to avoid, only to bring relief in the short - term:

How do we avoid?

Here is a list, suggested by patients in a psychiatric ward and their staff, of different unhelpful ways people use avoidance to keep themselves safe in the short -term.

· Being late · Sleeping · Missing appointments · Restricting food · Binge/vomiting · Over-exercising · Preoccupation with food · Hiding · Drinking · Minimizing situations · Making routines · Using drugs · Running away · Putting things off · Choosing safe food · Making excuses · High activity levels · Ignoring, e.g., phone calls · ‘Forgetting’ · Focusing on others at own expense. · Agreeing when you don’t · Supporting others and not meeting own needs · Theorizing · Not talking about the things you need to talk about · Being slow about things. · Not saying what you want /feel · Changing the subject · Misusing alcohol · Pushing things to back of mind · Speak slowly · Heavy make-up · Cleaning · Stare at things · Sucking sweets/chewing gum · Cigarettes · Over checking things · Medication before/after · Telling jokes/not · Smart clothes · Relating to pets · Looking at the floor · Hiding behind long hair · Going out in the rain · Hiding behind net curtains · Only relating by mobile phone · Hiding behind sunglasses · Fidgeting · Checking toilets/exits · Gossiping