Applied Behavior Analysis in the Treatment of Eating Disorders

Eating disorders are recognized as extreme attitudes, emotions, and behaviors regarding food and weight issues, and in the U.S., 20 million women and 10 million men suffer from an eating disorder at some point in their lives.

The National Eating Disorders Association (NEDA) describes eating disorders as “real, complex, and devastating conditions,” not phases or lifestyle choices. Eating disorders are serious, often affecting a person’s emotional and physical health. They are also potentially life-threatening. The earlier a person seeks treatment, the greater the likelihood of recovery.

Behavioral assessments for the treatment of disorders like anorexia and bulimia are often preferred over a psychologist or physician clinical diagnoses, which tend to be more general and abstract. Eating disorders involve the interaction between genetics and the learned behaviors affected by the environment, making them often difficult to understand. Though a clinical diagnosis must be made for general purposes and for insurance reimbursement in the healthcare system, it does not always provide clinicians with enough information or understanding to be able to treat eating disorders effectively.

A diagnosis does not explain what behaviors patients with eating disorders are performing and how these behaviors can vary between situations or contexts. Instead, developing a functional analysis of the behavior allows applied behavior analysts to better understand the actual eating behaviors, the initiation of eating, and the physiological states of the body.

Understanding the Nature of Eating Disorders: Types, Symptoms, and Risk Factors

The American Psychiatric Association recognizes four major classifications of eating disorders:

Anorexia Nervosa – Characterized as inadequate food intake causing a low body weight. Individuals with anorexia nervosa have an intense fear of gaining weight and often obsess and engage in behavior associated with preventing weight gain.

Binge Eating Disorder – Characterized by frequent episodes of consuming very large amounts of food. Those with binge eating disorders often feel out of control and have feelings of strong shame or guilt following a binging episode. Individuals with binge eating disorders eat when not hungry, eat to the point of discomfort, and often eat alone due to shame and guilt.

Bulimia Nervosa – Individuals with bulimia nervosa consume very large amounts of food and then engage in behaviors in an attempt to avoid weight gain, such as self-induced vomiting and the use of laxatives.

Other Specific Feeding or Eating Disorder: Classified as Eating Disorder Not Otherwise Specified (EDNOS) – EDNOS is characterized as a feeding or eating disorder that causes significant suffering or harm, yet does not meet the criteria of another eating disorder. A few examples include:

  • Atypical anorexia nervosa: Low BMI or body weight
  • Binge-eating disorder with less frequent or intermittent behaviors
  • Bulimia nervosa with less frequent or intermittent behaviors
  • Night eating syndrome: Excessive eating at night
  • Purging disorder: Purging without first binge eating

Additional eating disorders include pica (eating non-food items, such as dirt or paint), rumination disorder (bringing back up and rechewing partially digested food), and avoidant/restrictive food intake disorder (restricting food intake without a drive for thinness).

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Risk Factors for Eating Disorders

Because eating disorders are complex conditions, risk factors vary. Risk factors do not cause eating disorders, although they may contribute to their development:

  • Body dissatisfaction
  • Dieting/fasting
  • Lack of family supports
  • Unrealistic notion of thinness
  • Low self-esteem
  • Solitary eating
  • Social pressure for thinness
  • Social problems
  • Social withdrawal
  • History of psychiatric disorders

Some factors, although not necessarily predictive, may contribute to the onset of eating disorders:

  • Biological: Recent research reveals there may be significant genetic contributions in play among those with eating disorders.
  • Psychological: Low self-esteem, depression, anxiety, anger, loneliness or stress
  • Social: Cultural pressures glorifying thinness and valuing the perfect body
  • Interpersonal: Trouble in personal relationships; difficulty expressing emotions; a history of physical or sexual abuse, and a history of being ridiculed for size or weight

How Applied Behavior Analysis is Becoming Recognized as an Effective Form of Therapy in the Treatment of Eating Disorders

Applied behavior analysis (ABA) allows applied behavior analysts and other clinicians to better understand eating disorders so they can formulate a treatment plan that best matches each client’s specific needs.

ABA seeks to understand the chains of respondent behaviors associated with eating disorders, such as:

  • Respondent behaviors: Emotional responses to food
  • Operant behaviors: Actual eating behaviors
  • Derived relational behaviors: Behavior associated with food, eating, and body image

Using a “chain” analysis allows applied behavior analysts to identify important antecedent and reinforcing stimuli for critical behaviors. An example of this type of analysis involving an individual with anorexia may resemble:

  1. When food is at the table, the individual experiences unpleasant thoughts associated with gaining weight.
  2. Anxiety and unpleasant thoughts are associated with gaining weight.
  3. The individual eats a small portion while feeling thoughts of fear and anxiety.
  4. Not eating decreases the unpleasant thoughts and feelings.
  5. Feelings of disappointment remain.

Once an analysis has been made, the applied behavior analyst will have a better understanding of how environmental events influence the behavior in desirable ways.

For example, when treating a client with anorexia, after identifying the target behavior of not eating, the applied behavior analyst then identifies and works to remove reinforcers that maintain the target behavior in effort to achieve extinction of that behavior.

Reinforcers may include receiving attention from the family when the individual talks about not eating or weight. Withholding that reinforcement by encouraging the family to ignore these behaviors will help discourage the associated behaviors.

Applied behavior analysis may also be used to restore a normal eating pattern in an individual with anorexia. In this example, positive reinforcement is used to increase the frequency of the target behavior of eating. Positive reinforcement may include praises or providing the patient with privileges. Natural reinforcers are also often used, with the applied behavior analyst asking the patient about how much better they feel after eating food. Positive reinforcement must be consistent and immediate.

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Additional Resources Related to Treating Eating Disorders with ABA

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