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Section 23
Eating Disorders: The Role of Hypnosis

Question 23 | Test | Table of Contents

Adolescence may be seen as 'a discrete and significantly different stage from that of childhood or adulthood' (Needham 2000). It is a time of great emotional, social and physical upheaval and while a good number of young people weather the change with little disturbance, others have a more problematic time. It is a time of changing relationship, exploring new values and a period in which they are preparing for major choices in their life in terms of deciding on a career or leaving home for the first time.

Growth work in adolescence involves the development of self esteem, the establishment of identity and psychological disengagement from family. These are identified precursors to the development of eating disorders. A range of interventions has been demonstrated to be of value in the treatment of eating disorders as well as underlying psychological problems such as anxiety and depression, and these may be augmented by the use of hypnosis. Evidence for this is presented in this article, following an introduction to eating disorders, which affect one per cent of all young women in the UK.

Vulnerability
An integral part of growing into a mature adult is the development of a good self-image, the foundations of which are laid in early childhood and is dependent on social interaction with adults and peers. Physical and emotional changes can leave adolescents feeling awkward and self conscious, leading to a lack of confidence. As Abraham and Llewellyn-Jones (2001) point out, before menarche most gifts feel good about themselves and are content with relationships and their appearance. However, the natural weight gain around menarche can cause them to lose self confidence and experience a decrease in self esteem.

Bruch (1973) argues that this would explain why anorexia, for example, so typically emerges in adolescence -- a period during which the development of autonomy, mastery and competence is crucial in attaining maturity and gaining independence from parents. In a number of studies quoted by Abraham and Llewellyn-Jones (2001) it would seem that over-perception of body size among adolescents is a global problem, particularly in the western world.

Overweight and obese adolescents are particularly vulnerable to low self esteem, which has an effect on their performance at school and personal relationships. Many adolescents feel that their changing body is out of control. Unfortunately this 'out of control' feeling and alterations of body size and shape can result in eating disorders linked with the young person's refusal to grow up and accept her or his developing body shape. Young people with these disorders are known to present with a number of personality disorders as well as having a high incidence of coexisting psychiatric conditions, specifically mood disturbances, major depressions and obsessive compulsive disorders. In addition, they suffer from feelings of inadequacy, lack self confidence, have poor self esteem and poor coping mechanisms.

Eating disorders
Most eating disorders are triggered by a desire to lose weight and involve a fear of feeling full or loss of control around food. Presenting symptoms of anorexia include:

• a refusal to maintain normal body weight
• intense fear of weight gain and fatness
• dysmorphic body image (Kohn and Golden 2001)
• amenorrhoea (DSM-IV draft criteria (American Psychiatric Association 1994)).

Treatment of this condition is far from simple and requires a long-term commitment from the patient and the family.
Like anorexia nervosa, bulimia nervosa is best understood as a developmental disorder, although it tends to emerge later than anorexia and centres around issues of personal identity, independence and self-assertion, leading to the development of the false self to cover a low self esteem. DSM-IV draft criteria (American Psychiatric Association 1994) for bulimia nervosa include:

• recurrent episodes of binge eating
• recurrent, inappropriate compensatory behavior, i.e. self-induced vomiting or purging, fasting or excessive exercise at least twice weekly
• self evaluation influenced by body shape.

Coman (1992) highlighted the personal characteristics of bulimic patients as having feelings of shame, self criticism, immediate gratification needs, and a strong need for approval and heightened interpersonal sensitivity.

Whether obesity is an eating disorder is open to debate. In the 1970s and 1980s it was noted that many obese people eat normally and obesity was defined as a medical rather than a psychological disorder. However, it became clear during the 1990s that a subgroup of obese individuals, and some of normal size, have a pattern of episodic binge eating that is similar to people with bulimia nervosa.

People who binge eat are not suffering from anorexia nervosa, since their body mass index (BMI) is more than 17.5; nor do they have bulimia nervosa, since they do not use dangerous methods of weight control such as purging or vomiting on a regular basis. It appears that binge eaters use food to regulate mood or difficult emotions, particularly sadness, anger and feelings of inadequacy (Telch and Agras 1996).

Binge eating episodes are associated with at least three of the following:

• rapid eating
• eating until uncomfortably full
• eating large amounts of food when not hungry
• eating alone
• feeling disgusted with self, depressed and very guilty about over eating
• feeling very distressed with regard to binge eating
• binge eating occurs on average at least two days a week.

Treatment
Treatment of the person with an eating disorder centres around encouraging an achievement and acceptance of a weight which lies in the normal range or a higher realistic weight if the person is obese (Abraham and Llewellyn-Jones 2001). Patients need to relearn normal eating and gain insight into their eating behavior and why it is persisting. Nutrition education and dispelling myths about food and eating are necessary, as is appropriate lifestyle modification. A major aim is to get the patient to desist from potentially dangerous eating behaviors, part of which requires dealing with underlying problems (Abraham and Llewellyn-Jones 2000.

The overall aim of treatment is not necessarily to cure the condition but to control it, since the eradication of all eating disordered behaviors is unrealistic and the goal of therapy is the maintenance of healthy, controlled eating patterns (Coman 1992).

Techniques used in treating eating disorders aim to restore normal eating behaviors. Behavioral approaches alone or combined cognitive behavior therapy may be used. Behavioral techniques might include simply not buying trigger foods or avoiding certain shops; that is, building up new habits to replace existing ones. Another example would be modifying eating behavior such as eating in the same place each day, or concentrating solely on eating and not watching television at the same time.

Eating behaviors are learned behaviors therefore they can be unlearned, although this can take some time. Rehearsal, age progression or assertiveness training may be used. Control of binge eating may include eating regular meals, avoiding addictive foods, instigating a controlled binge and delaying tactics.

Using hypnosis in treatment
In their review of the use of hypnosis for treating eating disorders, Coman and Evans (1995) emphasise that many eating-disordered patients tend to be resistant to treatment. They deny that they have a problem and it is necessary to devise an eclectic approach to treatment tailored to suit the individual. They also point out that, given the high hypnotisability of most eating-disordered patients, the adjunctive use of hypnosis is very appropriate. A number of uncovering techniques such as ego state therapy, age regression, age progression and idio motor signalling can be used to identify the origin of the patient's disordered cognitions and emotional conflicts which are precipitating their associated eating disorders.

Heap (2002) cautioned that uncovering distressing material during these sessions may be particularly difficult for depressed patients who will make up a significant portion of this group. Hypnosis may also be used to help patients develop feelings of control and mastery over their thoughts and behaviors. Cognitive and behavioral techniques for weight management have increased efficacy when combined with ego strengthening, imagery, systematic desensitisation, and cognitive restructuring (Fairburn 1985, Gross 1992, Hartland 1966, Heap (2002), Vandenlinden and Vandereycken 1990). Coman (1992) has suggested that, because of the need for control within this patient group, the use of indirect and permissive suggestions for trance are more effective since they serve to enhance rather than challenge the patient's need for control.

Bulimia nervosa
Patients with Bulimia nervosa have been noted to score higher hypnotisability levels than anorexic patients or controls. Groth-Marnat and Schumaker (1990) argue that extreme weight control behaviors may be similar to hypnotic-like states such as dissociation, which is a reported characteristic of bulimics during binge eating. This dissociation might be related to cognitive and perceptual distortions reported by many eating-disordered patients. Treatment of bulimics with hypnosis would include techniques described earlier and may involve supportive intervention during cognitive and behavioral change, dealing with underlying triggers to the condition and as long-term maintenance therapy.

Underlying problems
Deep et al (1995) indicate that depression and anxiety, particularly social phobia, were both noted precursors to anorexia and a concomitant problem within all eating disorders. Although the use of hypnosis in depression has been treated with caution, cognitive and behavioral procedures, both of which can be augmented by the use of hypnosis, have been identified as being of value.

One example is Alladin's (1992) disassociative theory of depression, which concentrates on the behavioral aspects of depression rather than the feelings of depression. Alladin seeks to identify what it is in the client's behavioral repertoire that initiates the feelings of depression. He then seeks to change the precipitating behavior. Intervention involves four sessions of routine cognitive therapy, with hypnosis introduced in the fifth session.

Techniques include rehearsal with cognitive restructuring, ego strengthening, age progression and post-hypnotic suggestions, as well as assertiveness training. Depressed patients, however, may respond less well to the traditional hypnotic inductions emphasising as they do, a relaxed, more passive effect which may be counter-productive in patients who are already passive. Therefore the use of the active alert method may be more appropriate, as described by Banyai et al (1993).

Prevention
Gordon (2000) reviewed the results of a number of interventions instigated to help reduce the incidence of eating disorders. Unfortunately, some interventions have had the effect of instigating the very symptoms that they were hoping to prevent. For example, Mann et al (1997) initiated a programme involving recovering bulimics and anorectics who told their stories during a 90-minute session. Evaluation showed an initial increase in eating disorder symptoms among the audience but this appeared to resolve three months later. Unfortunately these results, and some from Oxford (Carter et al 1997) which also had negative results, have led to a more sceptical approach to prevention.

The use of hypnosis as a preventative intervention has not been assessed. It is suggested that it could be directed, not overtly at addressing eating disorders, but to address the underlying aetiology, for example anxiety, control, self esteem, assertiveness and identity development.

Conclusion
Eating disorders are multifactorial, complex, learned behaviors, which are an integral part of the patient's defence system, which is why they can be very difficult to treat. However, conventional treatment may be augmented by hypnosis although patients may have varying levels of hypnotisability. Whether hypnosis can be an effective agent in the prevention of eating disorders when precipitating factors have been identified remains to be seen since conventional interventions used to date appear to be of limited value. A controlled trial of hypnotic interventions with vulnerable groups compared with controls would go a long way in indicating if hypnosis does indeed have a preventative value.
-Mantle, Fiona; Eating disorders: the role of hypnosis; Paediatric Nursing; Sept 2003; Vol. 15; Issue 7.

Personal Reflection Exercise #9
The preceding section contained information about the role of hypnosis in eating disorders.  Write three case study examples regarding how you might use the content of this section in your practice.

Update
Direct Comparisons between Hypnosis
and Meditation: A Mini-Review

Penazzi, G., & De Pisapia, N. (2022). Direct comparisons between hypnosis and meditation: A mini-review. Frontiers in psychology, 13, 958185.

Peer-Reviewed Journal Article References:
Farstad, S. M., & von Ranson, K. M. (2021). Binge eating and problem gambling are prospectively associated with common and distinct deficits in emotion regulation among community women. Canadian Journal of Behavioural Science / Revue canadienne des sciences du comportement, 53(1), 36–47.

Gunstad, J., Sanborn, V., & Hawkins, M. (2020). Cognitive dysfunction is a risk factor for overeating and obesity. American Psychologist, 75(2), 219–234.

Radin, R. M., Epel, E. S., Daubenmier, J., Moran, P., Schleicher, S., Kristeller, J., Hecht, F. M., & Mason, A. E. (2020). Do stress eating or compulsive eating influence metabolic health in a mindfulness-based weight loss intervention? Health Psychology, 39(2), 147–158.

QUESTION 23
What are some examples of behavioral techniques used with bulimic clients? To select and enter your answer go to Test.

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