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Section 11

CEU Question 11 | CEU Test | Table of Contents | Eating Disorders CEU Courses
Counselor CEUs, Social Worker CEUs, Psychologist CEs, MFT CEUs

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On the last track, we discussed three concepts related to anorexic clients who are survivors of incest.  These concepts of anorexic clients who were victims of incest included:  inability to trust; skewed sexuality; and learned defenses.

On this track, we will examine three manifestations of anger in anorexic clients.  These three manifestations of anger in anorexic clients include:  repression; acting-out; and defense mechanisms.

3 Manifestations of Anger

Manifestations #1 - Repression
The first manifestation of anger in anorexic clients is repression.  Although, as discussed in track 5, anorexic clients become more assertive during the onset of the disorder, there are many anger issues still left under the surface.  First and foremost, the motive behind this repression is a personality trait.  The client, a people pleaser, refuses to express the anger and frustration about his or her own body image, his or her relationships with family members, or the inability to stop losing weight. 

Because of this, the anorexic client becomes anxious and scared about the angry thoughts that continually pop into his or her head.  These thoughts can sometimes call for violence and shouting and these emotions are then transferred into exercise and undereating. 

One of the conundrums or a paradox of anorexia is the conflicting patterns of wishing to be accepted and at the same time beliefs in worthlessness.  They wish to appear normal but still don’t believe they are worthy of acceptance.  If the client has underlying issues such as mental or physical abuse, these sources of anger may never be revealed because of the client’s wish to appear normal and under control. 

Delilah, age 20, weighed eighty pounds, and had been under the thumb of her controlling mother, Martha, for her entire life.  Martha had once been a pageant queen and therefore demanded perfection in every aspect of her life, including her daughter.  Since an early age, Martha forced Delilah into beauty pageants for toddlers.  Each week was full of activities and every day was a ritual of makeup, exercise, and priming. 

Delilah stated, "I don’t think I ever had a childhood!  That woman was crazy!  She stole everything that ever meant anything to me!  I wanted to write, she threw out my novels.  She told me real women don’t need to think, their husbands think for them.  She always told me I was too heavy.  All the time!  Whenever I lost a contest, she would say, ‘Did you see how skinny the winner was?  Winners are always skinny.’  I became wafer thin to threaten her with my death, but I don’t think she even noticed." 

Delilah had repressed her anger for years and to express it, stopped eating.  Think of your Delilah.  Is he or she repressing any anger that is causing his or her anorexia?

Technique:  Shout It Out
In order to help Delilah find a less destructive means of expressing her anger, I suggested she Shout It Out.  I asked her to stand up in the middle of her living room every morning and scream at the top of her lungs.  Sometimes she would scream actual phrases and other times she would just scream into a pillow. 

Delilah stated, "I feel so much better after all that!  I feel relaxed and a bit foolish, really.  Which is good.  It showed me how irrational anger can be so dumb at times."  By using other outlets besides anorexia to express anger, Delilah can also learn to be more assertive and less livid at the memory of her mother.  Think of your Delilah.  What other ways could he or she express anger?

Manifestations #2 - Acting Out
The second manifestation of anger in anorexic clients is acting out. This manifestation is especially common in teenagers whose hormones provide extra fuel to the flames. Clients who act out their anger display unwarranted shows of anger or outrageousness. As discussed in track 5, these displays can become even more heated when the topic is the client’s anorexia. These anger episodes serve to keep the anorexic in control of those around him or her. No one wants to set off a ticking time bomb. Thus, everyone does as the client asks.

Tommy, age 16, had been acting out at home.  At five-foot-six, he weighed about 105 pounds.  However, in a joint session with his mother, it was clear that Tommy ran the household.  Whenever his mother, Elsa, answered, she looked to Tommy for confirmation.  Tommy’s posture was slouched and his gaze seemed almost internal.  It was apparent from his body language that he did not wish to be in therapy. 

Tommy stated, "I’m the one with the problem, and if anyone’s going to do anything about it, it’s me! I don’t need your babble bullshit to tell me I don’t eat enough!  Tough titties. That’s my decision!  Mom isn’t going to do anything about it either, so don’t bother looking at her."  Tommy wanted to be in control of his environment and used his anger to do so.  The introduction of myself caused a small ripple in Tommy’s world and this caused him to act out further. 

Think of your Tommy.  How is he or she using his or her anger to control those around him or her?

Manifestations #3 - Defense Mechanism
In addition to repression and acting out, the third manifestation of anger in anorexic clients is anger used as a defense mechanism.  Unlike clients like Tommy who use their anger to control their surroundings, clients who use anger as a defense mechanism do so in order to alienate others from their own world.  While Tommy wished everyone to do exactly as he wanted them, defense anger clients would prefer to be left alone and use anger to do so.  These types of clients rarely form friendships and isolate themselves in order to prevent others from coming too close and interfering with his or her anorexia. 

Haley, age 18, was a straight-A cheerleader who was president of her class government.  In a few months, however, she had lost twenty pounds and her mother, Beth, had begun to worry about her.  Whenever Beth approached her daughter about her weight, she was met with unprecedented hostility.  Beth stated, "And it’s not just with me either!  Her friends have stopped coming over.  No one wants to spend time with her!  She’s in her room all day, and I know she’s doing exercises." 

Haley stated, "I’m just exercising my independence.  Everyone just needs to get off of my back!  I’m not doing anything wrong!  I don’t drink, I don’t have promiscuous sex.  No one knows what it’s like to be a teenager in this day and age!  I look normal."  I then asked Haley why she had started to lose weight.  She stated, "Usual peer pressure stuff.  I wanted to ‘fit in.’"  I then stated, "If you wanted to be accepted by your peers, then why are you pushing them away?  Could it be that it’s not you but your illness that is controlling your anger and your reactions?" 

Think of your Haley.  What kind of defense mechanism is his or her anger serving?

On this track, we discussed three manifestations of anger in anorexic clients.  These three manifestations of anger in anorexic clients included:  repression; acting-out; and defense mechanism.

On the next track, we will examine three difficulties in employing the family of an anorexic client for treatment.  These three family treatment difficulties include:  inability to dissociate; eating strategies; and allowing for client independence.

Peer-Reviewed Journal Article References:
Criscuolo, M., Marchetto, C., Chianello, I., Cereser, L., Castiglioni, M. C., Salvo, P., Vicari, S., & Zanna, V. (2020). Family functioning, coparenting, and parents’ ability to manage conflict in adolescent anorexia nervosa subtypes. Families, Systems, & Health, 38(2), 151–161.

Haynos, A. F., Berg, K. C., Cao, L., Crosby, R. D., Lavender, J. M., Utzinger, L. M., Wonderlich, S. A., Engel, S. G., Mitchell, J. E., Le Grange, D., Peterson, C. B., & Crow, S. J. (2017). Trajectories of higher- and lower-order dimensions of negative and positive affect relative to restrictive eating in anorexia nervosa. Journal of Abnormal Psychology, 126(5), 495–505.

Jochman, K. A., Newman, S. M., Kalin, N. H., & Bakshi, V. P. (2005). Corticotropin-releasing factor-1 receptors in the basolateral amygdala mediate stress-induced anorexia. Behavioral Neuroscience, 119(6), 1448–1458.

Solomon-Krakus, S., Uliaszek, A. A., & Bagby, R. M. (2020). Evaluating the associations between personality psychopathology and heterogeneous eating disorder behaviors: A dimensional approach. Personality Disorders: Theory, Research, and Treatment, 11(4), 249–259.

Wong, T. K. Y., Konishi, C., & Zhao, K. (2018). Anger and anger regulation among adolescents: A consideration of sex and age differences. Canadian Journal of Behavioural Science / Revue canadienne des sciences du comportement, 50(1), 1–8.

Online Continuing Education QUESTION 11
What are three manifestations of anger in anorexic clients? To select and enter your answer go to CEU Test.

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