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Section 5
Developmental Stages

Question 5 | Test | Table of Contents

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in the last section, we discussed four similarities between anorexic and phobic clients.  These four similarities between anorexia and phobia included:  mental distortions; stress; destructive emotions; and rituals.

In this section, we will examine the four stages of the progression of the disorder. These four stages of the progression of the disorder include: achievement; security-compulsion; assertiveness; and pseudo-identity.

One way to view the progression of anorexia is through the four stages of behavior. I have found that each client has progressed through these stages almost without exception. The categorization of these stages I have found helps to understand the client’s motives behind his or her behavior itself and why he or she practices this destructive behavior.

4 Stages of the Disorder

♦ Stage #1 - Achievement
The first stage of the disorder is the achievement stage. Many clients who are predisposed to anorexia start as our perfectionist dieters. As the perfectionist dieter continues to lose weight, he or she is at first rewarded with declarations of praise, admiration, and envy from others. His or her sense of achievement quickly reinforces her restrictive eating pattern.

Hunger pangs seem a small price to pay for the inner feelings of virtue and success, and often are interpreted as proof of success. This first stage of the disorder does not indicate abnormal behavior. Rather, it is in line with the trend most people adopt who consider weight gain as socially unacceptable and an enemy to be fought with an all-out assault. 

Jodi, age 13, had been a straight-A student and a cheerleader before the onset of her disorder.  Jodi had stated, "Before I decided to lose weight, I had put all my energy into being a fantastic cheerleader and an A student. But I kept noticing that my thighs were a little bit rounder than the other girls and my stomach just a little chunkier, so I decided to lose weight. Once I started, I got so many compliments from my squad members that I couldn’t stop. I wanted to be skinnier than them all and prove to them how beautiful I could really be." 

Jodi had already shown a predisposition to anorexia and the adulation shown by her peers encouraged her to continue with the diet. Think of your Jodi. What kind of influence did his or her peers have on him or her during the achievement stage?

♦ Stage #2 - Security-Compulsion
The second stage of the disorder is the security-compulsive stage. At this point, the client has passed beyond the confines of normal dieting and into a different psychopathology altogether.  Weight and body size preoccupy his or her mind and every pound lost no longer feels like an accomplishment, but a failure that constantly needs to be overcome. The client begins to exhibit signs of weigh-loss compulsion. 

It is no longer an active choice to exercise or eat less, but a need to, and this compulsion becomes heightened as the client develops phobias. These phobias incorporate a fear of fat, fear of increased appetite, fear of food, and even fear of liquids such as water. To regulate these fears, the anorexic client exercises more and eats less as this is the only sense of security he or she can achieve, but it is an insufficient security as the client’s fears continually haunt him or her.

Kyleen, age 18, described her security-compulsion stage to me. She stated, "I started noticing these wrinkles where my arms meet me shoulders and behind my knees. Now I know that I had lost more weight than my skin could contract, but at that time, I thought it was fat. I also knew that because I wasn’t eating as much that my metabolism was slowing down, so I was afraid that my body would still gain weight! Every night, I would fall asleep thinking of food and I would believe that I haven’t done enough to lose weight, so I would wake up with an urge to exercise!" 

Kyleen had begun to shift into the stage of anorexia that becomes dangerous and which can now be diagnosed as a mental disorder. Think of your Kyleen. What sort of phobias did he or she develop during this stage of the disorder?

♦ Stage #3 - Assertiveness
The third stage of the disorder is the assertiveness stage. During this phase, the once compliant and pleasant client becomes defiant of attempts to encourage him or her to gain weight. He or she is no longer afraid of conflict, but is only assertive when it comes to the eating disorder.

The client will become argumentative about correct weight requirements and will force parents or loved ones to comply with her own eating habits. Parents become frightened of their child’s change in attitude and are unequipped to handle the sudden burst of assertiveness. The client, however, is thrilled by this new sense of confidence and newfound voice, which ultimately becomes another barrier to cross when treating the client.

Vanessa, age 16, would force her parents to leave the room when she ate. Vanessa stated, "I didn’t want them to see how little I ate. I thought that if they really saw what I was doing to myself, they would try to stop me. So I made them leave the kitchen during dinner time, or I left myself! They knew I wasn’t eating enough, so they did anything to please me so that I would eat.  It never worked, though."

Think of your Vanessa. Could his or her parents benefit from being more assertive with their child?

♦ Stage #4 - Pseudo-Identity
In addition to achievement, security-compulsion, and assertiveness, the fourth stage of the disorder is the development of the pseudo-identity. Encouraged by a newly found confidence, the client begins to feel "special" because of her disorder. Those around her begin to pay attention to the client, whether negatively or positively. If the client had been a quiet, reserved person before the onset of the disorder, this new wave of notice fills in the emptiness he or she has secretly felt for some time. The client becomes even more convinced of his or her rightness of behavior. His or her identity becomes wrapped up in the new celebrity of being thin.

♦ Technique:  Personality Picture
To help clients like Jodi, Kyleen, and Vanessa who undoubtedly reach this stage at one point in their lives, I ask them to create a Personality Picture. I asked each of these girls to write out a description of themselves outside of their anorexic persona. I suggested they keep in mind exactly what they wish to accomplish in their lifetime and to understand how anorexia could impede that. 

Vanessa wrote, "I want to become a doctor someday and be able to help people just like me.  I want to be smart and confident, but healthy. Obviously, who is going to want health advice from a wafer thin doctor!? If I died from my disorder, I could never help those people and maybe they would not get healthier because I was not there to help them." 

Think of your anorexic clients.  How would you help them redefine their personality through writing a personality picture?

In this section, we discussed the four stages of the progression of the disorder.  These four stages of the progression of the disorder included:  achievement; security-compulsion; assertiveness; and pseudo-identity.

In the next section, we will examine three concepts of obsession in anorexic clients.  These three concepts of obsession in anorexic clients include:  obsessional behaviors; abbreviations; and internal withdrawal.
Updated 2024

Peer-Reviewed Journal Article References:
Christian, C., Perko, V. L., Vanzhula, I. A., Tregarthen, J. P., Forbush, K. T., & Levinson, C. A. (2020). Eating disorder core symptoms and symptom pathways across developmental stages: A network analysis. Journal of Abnormal Psychology, 129(2), 177–190.

Duffy, M. E., Calzo, J. P., Lopez, E., Silverstein, S., Joiner, T. E., & Gordon, A. R. (2021). Measurement and construct validity of the Eating Disorder Examination Questionnaire Short Form in a transgender and gender diverse community sample. Psychological Assessment, 33(5), 459–463.

Ferber, K. A., Chen, J., Tan, N., Sahib, A., Hannaford, T., & Zhang, B. (2024). Perfectionism and social anxiety: A systematic review and meta-analysis. Clinical Psychology: Science and Practice, 31(3), 329–343.

Lamprianidou, E.-A., Eira Nunes, C., Antonietti, J.-P., & Van Petegem, S. (2025). Intensive parenting among mothers and fathers: Identifying profiles and examining differences in parental involvement. Journal of Family Psychology. Advance online publication.

Mander, J., Wittorf, A., Teufel, M., Schlarb, A., Hautzinger, M., Zipfel, S., & Sammet, I. (2012). Patients with depression, somatoform disorders, and eating disorders on the stages of change: Validation of a short version of the URICA. Psychotherapy, 49(4), 519–527.

Milson, R., & Madigan, D. J. (2024). Picture perfect: Perfectionistic self-presentation, Instagram intrusion, and body satisfaction in young women. Journal of Media Psychology: Theories, Methods, and Applications. Advance online publication.

Obeid, N., Carlucci, S., Brugnera, A., Compare, A., Proulx, G., Bissada, H., & Tasca, G. A. (2018). Reciprocal influence of distress and group therapeutic factors in day treatment for eating disorders: A progress and process monitoring study. Psychotherapy, 55(2), 170–178. 

QUESTION 5
What are the four stages of the progression of the disorder? To select and enter your answer go to Test.

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