Treating Complex Eating Disorders
Eating disorders are complex. The presence of other psychiatric conditions—most commonly anxiety (in up to 62% of individuals with eating disorders), mood disorders (up to 54%), post-traumatic stress disorder (up to 27%) and substance use (up to 27%)—can drive diagnostic complexity and create challenges in the treatment of eating disorders.
“Patients with co-occurring disorders struggle with higher levels of psychological dysfunction and often require multiple interventions at once,” says Kris Ramos, MSW, LCSW (she/they), clinical director at Eating Recovery Center and Pathlight Mood & Anxiety Center (ERC Pathlight). “They also may experience several readmissions, circulating throughout outpatient and residential care.”
Elizabeth Wassenaar, MS, MD, CED-S (she/her/hers), regional medical director at ERC Pathlight, agrees. “Patients with co-occurring conditions, especially obsessive-compulsive disorder (OCD) or mood disorders, can present additional treatment challenges and may struggle to stay in treatment.” The age at which someone develops an eating disorder or co-occurring condition and the length of time they struggle can both contribute to the complexity of their disease and impact the recommended course of treatment.
Step 1: An Accurate Diagnosis
To help patients find relief as quickly as possible, diagnosing co-occurring disorders is key. “It’s harder to diagnose mood and anxiety disorders in patients with eating disorders because you’re asking which came first,” says Em Markovich, MEd, LPC-S (they/them/theirs), clinical director at ERC Pathlight. “These conditions exist within each other. In my work with kids, we see the OCD symptoms shift away from food to other things once their weight has stabilized. At that point, we have a better chance of diagnosing the anxiety disorder.”
Step 2: Physical, Mental and Emotional Stability
Ramos calls the push and pull between eating disorders and mood and anxiety disorders the “whack-a-mole” effect, where addressing the eating disorder leads to something else cropping up. This is often because the patient is no longer using food behaviors to cope. “Once we stabilize the eating disorder, self-harm may increase; or if substance use is under control, then the eating disorder may flare up,” she says. “We see this process repeat itself again and again.”
At ERC Pathlight, one reason we can effectively treat these patients is that we treat them in a setting where we can monitor their ability to engage in maladaptive behaviors. At the same time, we provide the medical, psychiatric and psychological support they need to create long-lasting behavior change.
Step 3: Collaborative Treatment Team Planning
For complex cases, it’s especially important that a multidisciplinary team be in place. ERC patients have a team that includes a primary care physician, psychiatrist, therapist and dietitian collaborating every step of the way. “Our team meets at least once a week independently and with the patient once or twice a week,” says Ramos.
Exposure Therapy for Eating Disorders
Typically, the treatment plan includes different modalities to address the patient’s specific symptoms. For example, if a patient is diagnosed with OCD, which can be more common in patients with anorexia nervosa or avoidant restrictive food intake disorder (ARFID), exposure and response prevention (ERP) therapy is often effective. Recognized as an evidence-based, first-line treatment for OCD, ERP carefully exposes patients to the thoughts, images and situations that provoke their obsessions and compulsions, with the goal of reducing the anxiety associated with them.
DBT for Eating Disorders
If a patient presents with cooccurring self-harm or emotion dysregulation, dialectical behavior therapy (DBT) may be the treatment of choice. This model guides patients through a series of steps in which they analyze their thoughts and behaviors and come to terms with painful elements in their lives that they cannot change. Patients then learn how to cope with their feelings and are equipped with tools to build strong, healthy relationships.
Family-Based Treatment for Eating Disorders
For children and adolescents, therapeutic interventions for cooccurring conditions augment family-based treatment, an evidence-based approach for the treatment of eating disorders that is highly effective for young people. “We empower parents and caregivers to lead the weight restoration process for their child,” explains Markovich. “During this process, we educate the parents and caregivers as well as the patient. When feelings such as fear, grief and frustration come up, we integrate an innovative modality called emotion-focused family therapy. In addition to behavioral strategies to address the disordered eating, caregivers learn how to identify and support both their emotions and their child’s. It’s a powerful form of therapy.”
“Eating disorders and accompanying symptoms are like layers of an onion,” says Ramos, “and the more layers you uncover, the closer you get to identifying their root causes. This can be an overwhelming process, which is why treatment at higher levels of care is so specialized—where therapists should be trained in multiple treatment modalities, and where patients should expect their psychiatrist, therapist, dietitian and physician to be working together at all times to guide them toward recovery.”
Referrals and Consultations for Complex Eating Disorders
We excel at treating patients with complex eating disorders across our continuum of care including inpatient, residential, PHP and IOP (in-person and virtual). To make a referral or schedule a free assessment with a master’s-level clinician, call 1-877-825-8584.
Flying Under the Radar: One Woman’s Story of Anorexia in a Larger Body
From the time Joanna Nolen (she/her/hers), ERC alumnus and Recovery Ambassador Council member, was a child, she constantly heard about her weight. As a child in a larger body, her parents worried she would develop diabetes or cancer—diseases that ran in her family—and strongly encouraged her to watch what she ate and to exercise.
On top of the pressure she felt at home, she was also made fun of at school because she didn’t look like the other girls in her class. By the time she graduated from high school, she had internalized the message that the only way to fit in was to be thinner.
“I started exercising a lot, and when my peers started recognizing me because of my weight loss, I started restricting my food, and then I got hooked on laxatives and diet pills,” Nolen recalls. “There was even one Christmas when I spent the evening on the elliptical machine. I was determined to be the person society wanted me to be.”
Nolen started to realize that something was wrong when, as a sophomore in college, she developed a severe pain in her stomach and had to go the emergency room. “The doctor asked me if I had a history of an eating disorder, but he didn’t follow through. There was no diagnosis or treatment plan. He just told me to eat more.”
Even after that episode, a few years went by before Nolen sought treatment. It wasn’t until her anxiety, depression and eating disorder behaviors became unmanageable that she went to see her doctor, who referred her to a cognitive behavioral therapist. The therapist recommended that she go to ERC for the treatment of her complex eating disorder and co-occurring conditions.
“The therapists at ERC pushed me out of my comfort zone,” Nolen says. “Learning to live with being uncomfortable was an essential part of the treatment. As I opened up, I became more vulnerable, but I felt less alone.
“Living in a larger body allowed me to fly under the radar for a long time,” she continues. “I didn’t look like what both the medical community and society deemed someone with an eating disorder should look like. But I got past that, and now I have the tools to be in charge of my life and not let my eating disorder control it.”
1. Hambleton, A., Pepin, G., Le, A., Maloney, D., National Eating Disorder Research Consortium, Touyz, S., & Maguire, S. (2022). Psychiatric and medical comorbidities of eating disorders: Findings from a rapid review of the literature. Journal of Eating Disorders, 10(1), 132
This article first appeared in Luminary, A Magazine for Mental Health Professionals. Find more articles for additional tips, resources and insights from leading experts in the field.