Co-Occurring Features: Depressive and Anxiety Symptoms
In addition, counselors must be aware that female clients with EDNOS are also likely to be experiencing collateral mood and anxiety problems. In turn, when investigating the presence of subthreshold eating problems, practitioners should be certain to evaluate for mood and anxiety symptoms. For example, Schwitzer et al. (2001) found that more than 40% of women in their ED programs had difficulties with moderate depression. Of these women, 14% reported periods of clinically significant suicidal ideation, and 8% said they had previously engaged at least once in some form of suicidal behavior (e.g., swallowing pills) or a form of self-harm (e.g., nonsuicidal cutting; Schwitzer & Rodriguez, 2002). Looking next at anxiety and stress, 75% of the ED clients reported difficulties with at least moderate symptoms of stress or anxiety. Although some of the stress occurred in relation to food and body image (e.g., women reported feeling pressure from other people to eat more), they also endorsed anxiety as a concern in arenas outside of eating and weight control, such as in response to managing various life pressures (Schwitzer et al., 2008; Schwitzer & Rodriguez, 2002). Because clients with EDNOS are relatively likely to have concurrent problems with mood and very likely to have concurrent problems with stress and anxiety, counselors should be certain that evaluation is extended to these areas.
Common Themes and Stressors: Perfectionism, Low Self-Esteem, and Interpersonal Dependence
Moreover, girls and women with EDNOS share common psychological and developmental themes and certain psychosocial, environmental, and family stressors. As with mood and anxiety, these topics contribute to the conceptual picture, and therefore counselors should be sure to examine them as part of a thorough intake and evaluation process to identify critical targets for treatment.
Looking at psychological and developmental themes, clients with EDNOS often express a combination of low self-esteem, perfectionism across domains, and interpersonal dependency (Peck & Lightsey, 2008; Schwitzer et al., 1998, 2001, 2008; Schwitzer & Rodriguez, 2002). They consistently report problems with undue perfectionism associated with body appearance, irrational perfectionism about academic and work performance, and inability to meet the high expectations they set for themselves in personal and social roles such as girlfriend, roommate, and daughter. In fact, they typically experience strong pressure and anxiety about performing well academically in spite of clear objective evidence of their educational ability and track record of obvious success. Along the same lines as misjudging their specific abilities and personal qualities, their overall self-esteem may be unstable or fragile, too. Clients with EDNOS tend to make self-statements such as “I am my own worst critic,” “I am too hard on myself,” and I tend to judge myself too hard” (Schwitzer & Rodriguez, 2002, p. 53). Perhaps as a result, they sometimes tend to behave dependently in interpersonal relationships. They may give away power and decisions to others, be passive and avoid conflicts, or be overly emotionally dependent in their young adult relationships with parents (even considering today's norm of high parent involvement in the lives of their young adult children).
In sum, it is important to explore fears of being able to be psychologically and practically self-sufficient and doubts about effectively managing the pressures and demands of the young adult or adult world. In terms of family stressors, clients in the EDNOS population are likely to confront moderate interpersonal struggles with parents, often enacting the “perfect” role in their family of origin (Schwitzer et al., 1998, 2001, 2008; Schwitzer & Rodriguez, 2002, p. 51). Many clients say someone else in their family currently has an ED or had one in the past. Finally, to round out the topics for exploration, because some women with EDs do sometimes report past incidents of sexual victimization, clinicians should routinely check for (or rule out) this possible aspect of the persons psychological history (Schwitzer & Rodriguez, 2002). The clinician should explore with the client the general theme of parental and family pressures and roles and their influence on young adult psychological maturation.