Eating Disorder Diagnostic Criteria and Treatment Challenges
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Part of a 12 part series of courses at AllCEUs.com resulting in the receipt of a certificate in eating disorders counseling. Addresses bulimia, binge eating, anorexia, obesity. Uses The Body Betrayed by Zerbe and Brief Therapy with Eating Disorders by McDonald in addition to Dr. Snipes clinical experiences.
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Eating Disorder Diagnostic Criteria and Treatment Challenges
- 1. Dr. Dawn-Elise Snipes PhD, LPC, LMHC, CRC, NCC Clinical Director, AllCEUs.com Unlimited CEUs for $99 per year. Copyright AllCEUs.
Notes de l'éditeur
- Displacement: hurting the self Sublimation: dieting, exercising, focusing on appearance instead of acting out
- Discuss how each of these patterns is or can be present in the eating disordered patient
- The feared abandonment can be imaginary ; that is, virtually anything at all can and may be interpreted as abandonment or 'intent to abandon' by someone with BPD. Borderlines appear to have a hair-trigger response to what they perceive as 'invalidation' of any kind . This becomes extremely frustrating for those who interact with the Borderline, since at times every single word or action (real or referential) may be interpreted as secretly harboring malicious intent Tragically, the off-kilter behaviors that accompany this foregone conclusion in their minds are very often the sole cause of relationships and interpersonal attachments falling apart. Many folks ask why, if a person with BPD is so afraid of abandonment, they are so often the one to terminate the relationship and flee voluntarily. This "first strike" behavior is actually quite logical from the Borderline's perspective: abandon or be abandoned . This subjective sense of personal 'control' over intimate circumstances appears to be very appealing to many with this disorder, all the more so because of a general tendency to perceive so many other life factors as beyond their control. What etiological factors in eating disorders might prompt the same control/strike first behavior???
- Folks with BPD appear to have been deeply damaged in their early emotional attachment ("bonding") processes; this finds its expression in the inability to realistically assess the limits and boundaries of interpersonal relationships. A black-and-white pattern of relating to others -- often called the abandonment/engulfment cycle -- results in the premature idealization of a new friend or partner. This idealization may be unconsciously intended to replace an absent or damaged relationship to a parental caretaker. Adults with BPD can move extremely quickly into revelations of a very personal nature and soon become extremely demanding of the time, resources and loyalty of new partners or acquaintances. As reality sets in, the Borderline is often extremely disappointed and discouraged that this new relationship does not (and cannot) replace their subconscious ideal of parental unconditional love. Additionally, intimacy and trust have an inversely proportional relationship in BPD; this is the least intuitively rational aspect of the disorder. As personal closeness grows, so does the irrational fear that the new loved one/friend will reject the "real" person underneath the complex of BPD. The Borderline begins placing demands of loyalty on the other that get increasingly irrational -- all in the semi-conscious attempt to "prove" that the other will inevitably reject them. These incredibly deep-rooted fears, alas, too often wind up becoming a self-fulfilling prophecy. Unable to retain a balanced view of the other person (and frightened by the encroaching intimacy they are not emotionally equipped to handle), the Borderline then "splits" the other person into an all-evil representation and demonizes them as utterly uncaring, disappointing, abusive, etc. Often this results in the Borderline completely and arbitrarily severing the relationship (which in turn is extremely hurtful to the person on the receiving end of the dynamic). When another person is split 'bad', they can do no right. All arguments begin and end with an assignment of blame to the other participant(s). This can reach irrational levels quite quickly -- a Borderline can be so invested (consciously or not) in their self-image as "abandoned victim" that they literally re-write personal history to place themselves in this role. Whereas this tendency is irritating enough in most normal scenarios, it can reach the level of actual legal damage to the other, as in false accusations of abusive or criminal acts. This splitting can reverse itself with surprising speed. There is no predicting when or how a partner or friend will be "split back" to sainthood; often this happens when the Borderline has left for another idealized relationship, only to return begging forgiveness when the new person inevitably disappoints. Unfortunately, the cycle is ongoing and, without appropriate treatment intervention, will last as long as the relationship is able to. American culture places inordinate value on so-called "true romance", which is well simulated by the jealously exclusive Borderline idealization process. This can make it very difficult to distinguish its pathological dimensions at first blush. As the relationship proceeds, many non-Borderline partners who have failed to register the early warning signs of emotional dysfunction are caught very unhappily by surprise in this dynamic when their partner begins cruelly devaluing or abusing them, engages in infidelities, or sometimes suddenly vanishes. Many non-Borderlines have noticed this idealization pattern quite markedly in the Borderline's relationship to family members and close friends, who may be idealized beyond reason one moment and utterly discarded the next. Possessions, places, pets, philosophies, politics, religious or political beliefs can also be "split" good or evil. It is very common for Borderlines to express their emotional ambivalence via withholding or rationing of affection, sexual activity, financial support, or other sensitive components of a relationship. There is a specific form of "Borderline Sulk" known among non-Borderline spouses that manifests as an age-inappropriate, aggressive walling-off from all communication with loved ones. Yet when the other is split 'good' again, no one can be a more generous, supportive or understanding partner than a Borderline. This leads loved ones to frequently comment on the Dr. Jekyll/Mr. Hyde persona of folks with BPD. Perhaps most importantly of all, Borderlines primarily split themselves . This fundamentally shaky relationship to self is the backbone of many clearly identifiable BPD behaviors and feelings. A person with BPD often finds it near-impossible to take accountability for small errors without vilifying themselves completely and risking utter self-hatred. They tend to hold themselves to a standard of inhuman perfection -- and to fail in even the smallest way, in their minds, is to court justified self-annihilation. The often-noted inability of those with BPD to apologize for (or even acknowledge) mistakes they've made can be related back to this splitting mechanism.
- Some Borderlines have an almost eery chameleon-like quality to their social interactions: voice, gestures, clothing, opinions can change according to the person or group being idealized at the moment. Lacking a stable relationship to self, it is common for folks with this disorder to exhaustively question every fundamental belief others may take for granted: their religious convictions, sexual orientation or preferences, moral precepts, goals and purpose in life. Unable to provide it for themselves, Borderlines consistently seek external validation of their self-value. Often, the assimilation into a group with strict guidelines and principles (military, religious or even Greek organizations) can substitute for this acceptance.
- Some studies have found that over 60% of those with addictive problems also suffer comorbid personality disorders. There is some biochemical evidence that the same neural pathways involved in BPD are also those which can render a person prone to addictions of all kinds There is some biochemical evidence that the same neural pathways involved in BPD are also those which can render a person prone to addictions of all kinds. Certainly alcoholism, sexual addiction, and substance abuse are commonly found in this clinical population. Life-threatening road rage and a yen for aggressive public confrontation with service persons or strangers can be displayed by folks of both sexes with BPD. This appears to relate to an extremely short fuse for tolerating delay or apparent dismissal. Eating disorders (in particular) and impulsive behaviors such as spending sprees, shoplifting, gambling or hair-pulling are often comorbid with BPD. Compulsive behaviors such as situation-inappropriate hoarding of food or clothing, extreme skin-picking or Body Dysmorphic Disorder (an unrealistically negative image of one's body) are commonly co-diagnosed as well.
- Cutting or burning one's own skin with knives, pins, razors, cigarettes or cigarette lighters are the most commonly known expressions of self-injury. Abuse of alcohol and controlled substances or street drugs, bingeing and purging, emaciation could also be considered self-injury, extreme amounts of tattoos or piercings, constant skin-picking or extreme shaving, severe restriction of diet or sleep according to arbitrary rules, fanaticism for the questionable "quick-results" promises of non-mainstream health fads -- these may all be indicative of self-injurious tendencies when observed in the presence of other diagnostic criteria for BPD .
- How would Alexthymia play into this????
- Only a few "primitive" emotions are easily accessible to someone suffering from BPD -- and situationally inappropriate anger is chief among them. Unfortunately, this rage is then aimed at anyone in an intimate relationship with this person, transforming it from merely regrettable emotional underdevelopment into true interpersonal or domestic violence. Rages can come on with astonishing speed and violence, and are very difficult to explain to anyone who is only nominally acquainted with the person with BPD. The person with BPD tends to dissociate during periods of rage, during which they are not responding to the current surroundings and situation, but rather to a traumatic incident in their past. This can render them virtually oblivious to the effect of their rage on others. A Borderline in a full-blown rage is not a person to be reasoned with or otherwise tolerated. Rages are in general brought on by a triggered suspicion of abandonment or an intimation of criticism/invalidation, and can include (as in Criterion 1): shouting uncharacteristic cursing harsh verbal abuse physical abuse, domestic violence threats to children or bystanders the destruction of property self-injurious episodes Although raging is certainly one of the more universal hallmarks of the disorder, some folks with BPD do not appear to rage as violently or frequently as others. Some researchers characterize these tendencies as "outward-acting" and "inward-acting" -- the former taking their anger out on those around them and the latter on themselves in the form of self-injury. Many cases appear to be a mix of both, depending on the situation.