Contents
About the Author
Foreword
Acknowledgements
Introduction
When have Eating Disorder Patients Recovered?
Can All Patients Recover from their Eating Disorder?
Recovered Patients as Guides and Role Models
Content of the Book
A Book for Both Clinicians and Clients
How Therapists and other Professionals may Use this Book
How Eating Disorder Patients may Use this Book
How Parents, Partners and Friends may Use this Book
1 Problems in the Period before the Eating Disorder
Introduction
Lack of Self-Esteem and Negative Self-Evaluation
Compliant and Pleasing Behaviour
Hiding Real Thoughts and Opinions from others
Sensitivity to the Needs of others
Perfectionism and Fear of Failure
Inner Criticism and Negative Self-Evaluation
Impaired Identity Development
Negative Body Attitude
Summary
2 First Stage: Extreme Dieting
Introduction
How does an Eating Disorder Start?
Differences Between Healthy and Extreme Dieters
From Healthy to Extreme Dieting
Why Continue Dieting?
Eating Disorder or Identity Disorder?
Control over Food and Body
Denial of Problems
Summary
3 Negative Consequences of Eating Disorders
Introduction
Losing Control over Eating Habits
The Trap of Extreme Dieting
Eating Disorder: From Friend to Enemy
Rigid Rules and Obsessive-Compulsive Behaviour
Indoctrination and Brainwashing
Inner Criticism and Critical Voices
The Toxic Effects of Starvation
Depression and Suicidal Thoughts
Isolation
Physical Consequences
Summary
4 Turning Point and Motivation for Recovery
Introduction
The Deep Pit
Turning Point
Ambivalent Motivation for Change
Fear of Asking for Help
Questionnaires to Improve Motivation for Treatment
Motivation for Physical Recovery
Motivation for More Self-Esteem
Motivation for a more Positive Body Attitude
Motivation for Better Emotion Regulation
Motivation for Better Social Relationships
Motivation for Reducing Financial Problems
Summary
5 Normalizing Eating Habits
Introduction
Overcoming the Fear of Increasing Food Intake
Changing Cognitions about Food
Three Regular Meals a Day
Regular Mealtimes
Reduction of Binges
Reduction of Purging
Healthy and Sufficient Food
Reduction of Laxatives, Diuretics and Slimming Pills
Drinking Water and other Liquids
No Extreme Exercising
Treatment of Comorbidity
Summary
6 A Positive Body Attitude
Introduction
Not Feeling Fat
No Longer Obsessed by Food and Weight
Being Able to Listen to Feelings of Hunger and Satiety
Developing a Positive Body Attitude
Learning Defence Strategies against Teasing
Losing the Urge to Diet
Summary
7 Physical Recovery
Introduction
Normal and Stable Weight
Regular Periods
Normal Body Temperature
Normal Heartbeat and Pulse
No Anaemia
No Constipation
No Problems with Bowels and Stomach
No more Swollen Salivary Glands and Sore Throat
Healthy Skin
Healthy Teeth
Enough Sleep
Enough Energy
Reduction of Osteoporosis
Summary
8 Developing More Self-Esteem
Introduction
More Self-Esteem
Empowering Yourself
Become More Assertive
Less Emphasis on Pleasing others
Having Less Fear of Rejection
Showing Less Compliant Behaviour
Having Less Perfectionism and Fear of Failure
Summary
9 Expressing Emotions
Introduction
No Longer Avoiding Negative Emotions
Reduction of Critical Thoughts and Inner Voices
Recognizing and Expressing Emotions
Dare to Express Different Opinions
No Longer Feeling Depressed
Summary
10 Improving Social Relations
Introduction
Learning to Trust other People
Participating in Social Activities
Education and Career
Intimate Relations
Pregnancy and Children
Summary
11 The Most Important Questions and Answers about Recovery
Introduction
When have Eating Disorder Patients Recovered?
How many Patients Recover from their Eating Disorder?
Why do Not All Patients not Recover?
How can the Recovery Rate Increase?
Do All Patients have a Relapse?
How long does it Take to Recover from an Eating Disorder?
What are the Important Goals for Treatment?
Which Treatments are Most Effective?
What Makes a Good Therapist?
Summary
12 Checklist for Full Recovery
Introduction
Conclusion
References
Index
This edition first published 2013
© 2013 John Wiley & Sons, Ltd
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Library of Congress Cataloging-in-Publication Data
Noordenbos, Greta.
Recovery from eating disorders : a guide for clinicians and their
clients / Greta Noordenbos.
pages cm
Includes bibliographical references and index.
ISBN 978-1-118-46920-0 (cloth) – ISBN 978-1-118-46919-4 (pbk.)
1. Eating disorders–Risk factors. 2. Eating disorders–Treatment. I. Title.
RC552.E18N64 2013
616.85′2606–dc23
2012036588
A catalogue record for this book is available from the British Library.
Cover image: Diana Ong, Abstract #10, 1965. Private collection. © Diana Ong/SuperStock.
Cover design by Nicki Averill Design & Illustration.
Dr. Greta Noordenbos is a senior researcher in the Department of Clinical Psychology, Leiden University, the Netherlands. She completed her doctoral thesis on cultural and gender factors in the development of anorexia nervosa in 1987. She then conducted research on several topics in the field of eating disorders: risk factors and prevention, long-lasting and chronic patients, criteria for recovery, quality of treatment, emotion regulation and alexithymia, inner criticism and self-esteem. In 1994, she founded the Dutch Committee for Prevention of Eating Disorders and participated in the Specialized Interest Group for Prevention of the Academy of Eating Disorders. She has written several books and articles on eating disorders. Together with Professor Walter Vandereycken from Leuven University in Belgium, she edited the Dutch version of the Handbook of Eating Disorders. She was also a member of the Task Group of the Dutch Guidelines for Eating Disorders and became an honorary member of the Dutch Academy of Eating Disorders in 2010.
Address for correspondence:
Dr. Greta Noordenbos: Department of Clinical Psychology,
Leiden University. Wassenaarseweg 52
2333 AK, Leiden, The Netherlands.
Noordenbos@FSW.Leidenuniv.nl
This book describes in a unique way the conditions necessary to recover from an eating disorder. Greta Noordenbos is one of the few experts in this field who has done research into these aspects. This book reflects the knowledge and insights she developed about the recovery process of eating disorder patients. What makes this book unique is that she writes from the perspective of the patients and the way they think and feel. The stories of many such patients are given in detail here. The author makes very clear how important it is to listen to eating disorder patients carefully and with respect, and try to understand what is going on in their minds.
The information provided in this book will be very useful not only for patients, but also for their families and the therapists involved in the process of recovery from the eating disorder. It becomes clear that recovery is much more than ensuring enough food intake, weight recovery and reducing binging and purging. Although they are necessary conditions for recovery, it is also important that eating disorder patients gain insight into their own feelings, needs and wishes and learn to express their emotions. They also have to improve their body image and develop more self-esteem and empower their identity. Moreover, they have to improve emotion regulation and social relationships. Many quotations from former patients illustrate which factors helped them to recover. This book will certainly motivate eating disorder patients to ask for help and so take the first steps towards recovery. For that reason, I would advise every patient, parent and therapist to read this book.
Dr. Johan Vanderlinden
Psychologist-psychotherapist
University Psychiatric Centre of Catholic University in Leuven,
Psychological Faculty of Leuven University,
Belgium
I would first like to thank all the eating disorder patients I interviewed. This book could not have been written without their inputs about their process of recovery. They inspired me to write this book, because they are the best guides to inform clinicians, professionals, parents and friends what it means to develop an eating disorder and to recover from it. They have shown that full recovery is indeed possible. Recovered patients are also important role models for all those who continue to suffer from eating disorders.
The first edition of this book, entitled Gids voor herstel van Eetstoornissen, was published in 2007 in the Netherlands by De Tijdstroom, Utrecht. Many readers stimulated me to publish an English version of this book. I would like to thank Joanna Kortink, Liesbeth Libbers, Carmen Netten, Ellen Spanjers, Johan Vanderlinden and many other professionals for their support and De Tijdstroom for their permission to publish an English version of this book.
The English version, entitled Recovery from Eating Disorders: A Guide for Clinicians and Their Clients, has been completely rewritten and updated with new assignments and questionnaires. I am very grateful for all the useful comments of my international colleagues to improve this book: Tabita Björk, Runi Börreson and Rachel Bryant-Waugh. Darren Reed was very helpful in getting this book published. Many thanks also to Ineke Smit who carefully corrected my English. Without their support and valuable suggestions, I would never have been able to publish this book.
Greta Noordenbos
Leiden University,
The Netherlands
Can eating disorder patients recover? What changes should they make in order to recover? For a long time, the most important goals for recovery were normalizing their eating habits and weight. Although these goals are necessary steps in the process of recovery, they are not enough. Eating disorder patients struggle not only with food and weight, but also with very negative thoughts about their bodies and themselves. They are often very critical about themselves, and if they are not able to cope with their own high standards, they think they have failed and blame themselves. They also have problems with emotion regulation and social relationships. In order to recover from their eating disorder, they have to change many aspects of their lives: not only their eating habits and weight, but also their self-evaluation and body attitude, their feelings and emotions, and their relations with others.
To find out what changes are necessary for eating disorder patients in order to regain full health, I interviewed nearly a hundred former female and male patients about their process of recovery. They talked about the difficult period before their eating disorder and the first stage of their dieting regime, which was often felt as a solution to their problems. The positive feelings in this first stage of the eating disorder encouraged them to continue their dieting behaviour. However, the longer they continued dieting, the more severe were the negative physical, psychological and social consequences, which made their lives very difficult and lonely. Confronted with all these negative consequences, they slowly realized that they had to change their eating habits in order to recover.
Although the first steps on the path to recovery were very difficult, they finally succeeded to eat in a healthy way and to enjoy food. They developed a positive attitude towards their body, had better self-esteem, and were able to express their emotions and have a worthwhile social life. They were very proud of having overcome their eating disorder. This is very clear from what Caroline says:
Each new day I am so glad to be alive and I really enjoy my life. It is a great pleasure to go to work, and to feel the wind in my hair when I walk or bike. I have much more energy and enjoy each ray of sunshine on my skin. I now see food as a rich source of energy and I really like it, instead of being scared of it. I am also grateful to my lovely friends and parents. The way to recovery was not easy and sometimes I almost lost the courage to continue, but the reward is very high. I really hope that all people who struggle with an eating disorder are able to recover, because they have so much to gain.
The experiences of recovered patients offer much hope, as they show that full recovery is possible. Their stories make clear that the process of recovery is not easy, but the result is worthwhile. This should inspire people who continue to struggle with eating disorders and therapists who try to help them recover.
In the literature on recovery from eating disorders, it is difficult to find a clear definition of recovery (Noordenbos, 2011). For a long time, the criteria for recovery from an eating disorder were restricted to the reduction of symptoms, such as disturbed eating habits and weight. However, even when these symptoms have alleviated, the underlying factors remain. As long as these factors are not addressed, the risk of relapse is quite high. Strober, Freeman, and Morrell (1997) evaluate the reduction of symptoms as partial recovery. For full recovery from an eating disorder, not only should the symptoms be reduced, but the underlying factors which have contributed to the development of the eating disorder should also be alleviated. Full recovery implies eating the right amount of food and maintaining a healthy weight, having a positive body attitude, increased self-esteem, and better emotional and social coping strategies (Björk & Ahlström, 2008; Deter, 1992; Noordenbos, 2011; Noordenbos & Seubring, 2006; Pettersen & Rosenvinge, 2002). Moreover, co-morbidity also needs to be reduced, such as alcohol abuse, depression, fear disorders, personality disorders, and so on (Steinhausen, 2002).
Research shows that most patients can recover quite well from their eating disorder, and full recovery is possible for many patients. In general, 50% of the patients with anorexia and bulimia nervosa recover, 30% improve and 20% stay ill (Steinhausen, 1999, 2002). The percentage of patients who recover from bulimia is somewhat higher and those who recover from binge eating disorder is even more so. Recently, the percentage of patients who have recovered has increased because of earlier diagnosis and better treatment. In case of adolescents, eating disorder recovery percentages are as high as 85% (Nilsson & Hagglöf, 2006).
Unfortunately, not all patients can recover from their eating disorder. Factors that severely hamper their recovery are a late diagnosis, patient’s and doctor’s delay, late and inadequate treatment which focuses only on partial recovery such as food and weight increase, combined with a lack of attention to the reduction of the underlying factors, lack of aftercare and no strategies to prevent relapses. The longer patients have had an eating disorder, the more difficult it is to change their eating habits and to reduce the physical, psychological and social consequences. When treatment is not adequate and effective, patients lose their hope of improvement and recovery (Noordenbos, Oldenhave, Muschter, & Terpstra, 2002). However, this book shows that even after many years of having had an eating disorder, patients were able to improve the quality of their lives and some were able to recover.
In this book, many former patients talk about the process of recovering from their eating disorder. Although most of the patients quoted are female, there are also some male patients who tell us about their recovery process. To preserve patients’ privacy, their names have been changed.
All recovered patients sooner or later found a way out of the prison of their disorder. They talk about the stages they have gone through and all the adjustments they had to make in order to recover. They also tell us about the problems, traps and pitfalls they had to overcome and how they survived. Their stories are the best evidence that it is possible to recover from an eating disorder. Recovered patients, whether female or male, are therefore role models for all those who continue to struggle with their eating disorder.
This book begins by describing the most important stages in the development of eating disorders, from problems and risk factors in the period before the actual start of the eating disorder (Chapter 1) to the first stage of dieting and slimming, which is often experienced as very positive (Chapter 2). However, patients are soon confronted with all kinds of negative psychological, physical and social consequences, which are described in Chapter 3. When the negative consequences become very severe and dominate patients’ lives, they reach a turning point after which they feel motivated to recover, as described in Chapter 4.
The process of changing eating habits and overcoming the fear of a healthy diet is described in Chapter 5, and the development of a more positive body attitude is dealt with in Chapter 6. In Chapter 7, the process of recovering from all negative physical consequences is described, while Chapter 8 deals with the development of self-esteem and a more positive self-evaluation. Chapter 9 focuses on how patients learn to express their emotions and feelings. Chapter 10 deals with how patients developed better social relations. In Chapter 11, the most relevant questions about recovery are answered. In the final chapter, Chapter 12, a checklist for all relevant aspects of recovery is presented.
This book is important for all therapists and professionals who work with eating disorder patients. It offers them a clear insight into the changes which are necessary in order to recover from an eating disorder, such as normalizing eating habits and weight, increasing self-esteem and body attitude, and learning to express emotions and develop better social relations.
This book will be very useful for all those who struggle with an eating disorder, whether they be female or male, have just been afflicted by their eating disorder, or have already had an eating disorder for many years. They can be motivated to change when they read the stories of former patients who succeeded in recovering from their eating disorder. Recovered patients are the best guides to show the way out of the prison of the disorder. Eating disorder patients will find many assignments and questionnaires in this book which can help them overcome their eating disorder.
This book will also be very informative for parents and friends, who may learn from it not only why this disorder is so difficult to overcome, but also that full recovery is possible.
Therapists and other professionals who work with eating disorder patients can use this book as a guide to help their patients in the recovery process. You can follow this book together with your clients. You can ask them to take up the tests and assignments in this book and discuss the results. This book will help your clients to talk about their problems in the period before their eating disorder and about their reasons to start dieting. You can have an insight into all the consequences of their eating disorder. They may even be motivated to change when they fill in the questionnaires about motivation to recover. In the following chapters, there are all kinds of assignments for the client in order to normalize their eating habits, to develop a positive body attitude, to recover from the physical consequences of the eating disorder, to develop more self-esteem and a positive identity, to learn to express emotions and to improve social relationships.
In order to take up the tests and assignments in this book, it is important that your clients use a diary or a notebook. Although the information in a diary is often meant to remain secret, you should make it clear to your patients that you will discuss the tests and assignments with them in order to support them in their recovery process.
This book is not a protocol and can be used in a flexible way, depending on the stage of recovery your client is in. Moreover, this book can be combined with all kinds of treatments such as self-help groups, group therapy, cognitive behavioural therapy, interpersonal therapy, acceptance and commitment therapy or compassion-focused therapy.
For full recovery, it is essential that all relevant goals in this book are realized: normalizing eating habits, developing a positive body attitude, recovering from the physical consequences, developing more self-esteem and a positive identity, learning to express emotions and improving social relationships. Chapter 12 contains a checklist for recovery which can help you find out which criteria have already been realized and which criteria need more attention.
If you have an eating disorder, it is often very difficult to admit that you have severe problems, and even more difficult to accept that you need help. In this book, you can read about many patients who have recovered: they had the same problems but were able to overcome them. They are the best guides out of the prison of the eating disorder and important role models for recovery. You can read this book alone, but it might be helpful to ask a therapist or clinician to support you on your way to recovery.
It is useful to buy a diary or notebook in which you can write down your experiences, feelings and thoughts about having an eating disorder and discuss them with your therapist. In this book, you will find several assignments which you can answer in your diary or notebook. The results can be discussed with your therapist. With the support of your therapist, this book will help you recover step by step from your eating disorder.
This book provides a great deal of information about and insight into the behaviour, thoughts and feelings of your child, partner or friend who has developed an eating disorder. It makes it clear that an eating disorder is a severe problem from which it is not easy to recover. It is therefore very important to motivate patients to find professional treatment.
At the same time, the book offers hope and sends a positive message, because many former patients show that it is possible to recover from an eating disorder. They reveal the importance of changing their eating habits, recovering from the negative physical consequences, developing more self-esteem and a positive body attitude, learning to express their emotions and improving their social relations. Your support as a parent, partner or friend is very important for their recovery process.
To understand why recovery from an eating disorder is so difficult and takes so much time, it is important to understand how and why the eating disorder developed in the first place.
Eating disorders never come out of the blue; they are preceded by many problems and risk factors (Fairburn et al., 1997; Jacobi, de Zwaan, Hayward, Kraemer, & Agras, 2004; Stice, 2002; Striegel-Moore & Bulik, 2007). The risk factors can be divided into genetic and biological, psychological and sociocultural factors. These factors make patients vulnerable to starting a diet and developing a disturbed eating pattern which can result in an eating disorder.
Many eating disorder patients have family members who have or have had an affective disorder such as depression, alcohol problems, drug addiction or an eating disorder (Keel, 2005). Although these genetic factors never predict the development of an eating disorder, they make the person more vulnerable than people without these risk factors.
The psychological risk factors mentioned most often by eating disorder patients are low self-esteem and negative self- and body-evaluation (Cervera et al., 2003; Noordenbos, 2007). Perfectionism and fear of failing in the eyes of others are also important risk factors for developing an eating disorder (Jacobi et al., 2004). Eating disorder patients set high standards for themselves and feel that they have failed when they do not achieve their goals. A major risk factor is having a negative body attitude and the fear of becoming overweight or fat. Negative comments about their body or being teased about their weight and appearance are important factors in the development of a negative body attitude. Sociocultural factors, such as the slimming ideal and dieting behaviour of mothers, sisters and friends or strict weight standards in ballet schools and in sports such as skating and athletics in which weight plays an important role (Levine & Smolak, 1998; Pinhas, Toner, Garfinkel, & Stuckless, 1999), can also contribute to these negative feelings.
Risk factors, however, are never predictors for eating disorders, but only increase vulnerability. Moreover, no single risk factor is in itself enough to develop an eating disorder; the more the risk factors, the greater the possibility of starting to diet in a culture where being slim is the ideal for the female body. What were the most important risk factors which preceded former patients’ eating disorder?
The psychological problems mentioned most often by eating disorder patients are lack of self-esteem and negative self-evaluation (Noordenbos, 2007). Because of their low self-esteem, they feel insecure about themselves and need support from others. In order to receive approval and support, they do their best to comply with the expectations of others. However, they are very insecure about their own opinions and find it difficult to express their own thoughts and feelings, as they want to avoid any criticism. They do their best not to be criticized by others, because they experience censure as rejection. This is clearly described in the following quote:
ANGELIQUE: ‘I was strongly dependent on the approval of others and tried to avoid any criticism or negative comments, because I was very afraid of not being accepted. When I got critical remarks from others I had the feeling that I was being completely rejected. In order to prevent other persons from having a negative opinion about me or criticizing me I always did my best to comply with their expectations.’
In the period before the development of an eating disorder, many patients are kind and obedient children who do their best at school and at home. However, at the root of this compliant behaviour is the fear of not being able to cope with the expectations of their parents and teachers. According to Bruch (1978), they do not feel that they may be who they are, and hence they try to comply with the image they think others have of them. When they try to comply, they receive approval and affirmation and feel accepted.
Pleasing behaviour is very often found in anorectic patients. The famous author Jane Fonda therefore labels anorexia nervosa as ‘the disease to please.’
Patients spend most of their time trying to discover what other persons expect from them because of their low self-esteem and need for support and acceptance. However, this prevents them from exploring their own feelings and opinions and expressing these to others. The following quotation from one of Bruch’s patients clearly shows how much she conformed to others:
I was sitting with these three people but I felt a terrible fragmentation of myself. There wasn’t a person inside at all. I tried with whoever I was with to reflect the image they had of me, to do what they expected me to do. There were three different people, I had to be a different person to each, and I had to balance that. It was the same when I was a child and had friends. It was always in response to what they wanted (Bruch, 1978, p. 49).
In the period before the eating disorder, patients often struggle with the following questions: What do other people think of me? Do they like me? How do I have to behave in order to be accepted? How can I prevent people from criticizing or rejecting me? In order to be accepted, they always try to adjust to the expectations of others, hiding their own feelings and opinions (Miller, 1981).
Children who suffer from lack of self-esteem, insecurity and fear of failure often try to adapt to the expectations of their parents and teachers in order to be accepted. They are afraid to express their real feelings and opinions and hide them from others when they feel these views might be different from what others feel or think. They adjust to others as much as possible and feel valued for their pleasing behaviour. Much before the development of their eating disorder, they learn that their outward behaviour and appearance is important to gain approval from others, and they hide their inner insecurity and negative feelings as much as possible.
ANN: ‘When I was a teenager I always tried to hide my real inner feelings from others. By adjusting to the expectations of my parents and teachers I hoped to be accepted and valued. I always did my best at school and tried to be the perfect daughter. Unfortunately I did not realize that my pleasing behaviour did not bring me what I really longed for: attention and acceptance of my real self.’
Many patients told me that in the period before the development of their eating disorder, they were very sensitive to the needs and feelings of others. They were able to register subtle signals from their parents, especially signals of sorrow, disappointment, anger, depression, fear or stress.
This is clearly described by Hilde Bruch (1978): ‘They try to fulfil the needs of others as best they can and do their best to give no problems. This psychological worrying about their parents and especially their mothers makes that they feel obliged to help their mothers as much as possible and to be the sunshine in their home.’
However, being so sensitive to the expectations and needs of others often has a price: patients learn to neglect their own needs and feelings. They become experts in caring about others, but do not learn to express their own needs, hiding their problems from their parents. When one of their parents is unable to fulfil the emotional needs of the other parent, they try to compensate; but behind this adjusting and pleasing behaviour is a deep lack of self-esteem.
LINDA: ‘I remember clearly that during my puberty I worried much about my mother, who was very ill and finally died of cancer. I felt so much sorrow for her ongoing decline and her disappointment when the treatment was not successful. I also saw how my father suffered because of my mother’s cancer. I tried to fulfil their needs as much as possible and suppressed my own troubles and need for attention. I could not blame them for not spending enough attention on me. But I became more and more depressed and felt very lonely and empty with all my sad feelings, knowing that my mother would die of her cancer. For that reason I never dared to ask attention for my own emotions and show my feelings of disappointment, sorrow, or anger. I felt very alone, but I could not blame my parents because they had so many serious problems and were completely absorbed by their own feelings of sorrow.’
Patients with bulimia nervosa often say that they felt emotionally empty, because their parents never asked how they felt. In order to comfort themselves and to suppress their negative and sad feelings, they developed binges.
MARY: ‘As soon as I got feelings of distress I started to eat in order to avoid and suppress them. But even after a huge binge my feeling of hunger never went away and I never felt really satisfied. It felt as if there was a huge hole around my hearth and stomach. I was really longing for emotional comfort, and the only way I could comfort myself was by eating plenty of food.’
In the period before the eating disorder, anorectic patients are often extreme perfectionists. They set very high standards for themselves and are never satisfied with their performances. They feel they are not good enough and always think they need to be better. At school, they try to please their parents and teachers by doing their best and aiming for the highest grades.
SUZAN: ‘at home I always wanted to be the most loved child, and in school I wanted to be the best student. I really needed to hear from my parents that I did my best and to be valued for that, because I felt so insecure about myself. I was often afraid that I did something wrong and my parents would no longer love me. When I received a high grade in school I felt reassured for a short time, but always was afraid I would fail the next time, and my parents would be disappointed with my performances.’
Even when they always have high grades, patients often feel that this is not good enough.
NATASCHA: ‘When I made even the smallest mistake, there was always a critical voice in my head that said: “you did not do your best, everybody can see that you made mistakes and that you failed”.’
Eating disorder patients are often very critical about themselves. This self-criticism already starts in the period before they start to diet, but increases when they have developed an eating disorder. This inner criticism is described by several therapists, such as Bruch (1978), as an ‘inner dictator’; Claude-Pierre (1997) refers to this as an ‘inner negativist’ and Kortink (2008) labels it as an ‘inner saboteur.’
It is especially children who are very insecure about themselves who run the risk of developing this inner criticism and negative self-evaluation. They have a very strict superego and high standards and blame themselves for every mistake.