Eating Disorders | Child Healing

Eating Disorders: Anxiety and Excessive Anger

The relationship between eating disorders, intense anxiety and excessive anger is described in this chapter. The origins of the anxiety/mistrust and excessive anger are presented and often arise from severe family and marital conflicts or peer rejection with resultant low self-esteem and poor body image. Treatment protocols are recommended that include the use of forgiveness therapy in the treatment of these youth and also often of their parents (Enright, R. & Fitzgibbons, R. 2014. Forgiveness Therapy: An Empirical Guide for Resolving Anger and Restoring Hope, American Psychological Association Books).

Eating Disorders and Anxiety

In a 2012 study of women in treatment of an eating disorder 69% of these reported the onset of the anxiety disorder to precede the onset of the eating disorder. Sixty-five percent met criteria for at least one other anxiety disorder Of the anxiety disorders diagnosed, social phobia was most frequently diagnosed (42%) followed by post-traumatic stress disorder (26%), generalized anxiety disorder (23%), obsessive-compulsive disorder (5%), panic/agoraphobia (3%) and specific phobia (2%), (Swinbourne, J., et al.).

A 2017 European study of 181 female patients hospitalized for anorexia revealed that one half had at least one anxiety or depressive disorder before the onset of anorexia. The authors noted that the link between anxiety and depression and anorexia has been poorly studied (Carrot, B., et al.)

A 2004 study reported in the American Journal of Psychiatry examined the relationship between anxiety and eating disorders in 672 people with anorexia, bulimia, or both disorders. The results of the study showed that approximately two-thirds of those who had an eating disorder also suffered from an anxiety disorder,. (Kaye WH, et al.)

Forty percent of the study participants were diagnosed as having obsessive-compulsive disorder (OCD) in addition to an eating disorder, and 20% were diagnosed with SAD. The majority of those with both an anxiety disorder and an eating disorder reported that their anxiety symptoms came first.

Individuals with eating disorders often report that their anxiety generally centers on fear of criticism or humiliation when in public or social situations. Typically, they fear being judged in both body shape and size and for how and what they eat (i.e. eating rituals like cutting up food in to little pieces or avoiding foods with certain ingredients, particularly fat.) Often, the self-loathing, shame and self-criticism that eating disorder sufferers typically feel with respect to their own body, is projected on to other people who they imbue with the power to hurt them or make them not feel safe or valued. If the assumption is that someone else is thinking negative thoughts or will make critical statements, then the environment is not safe, whether this is based on perception or reality.

Anorexia nervosa and bulimia nervosa are serious disorders often run a chronic course and are associated with serious impairment in meeting the demands of daily life. that have an outcome which that can be severe. The anger in eating disorder patients often originates from negative life events with parents (Horesh1995) and with peers. Anorectic patients showed significantly more negative life events concerning parents than patients in other psychiatric diagnostic categories.

Disorders that are comorbid (present) with AN include disorders include major depression, obsessive-compulsive disorders (Hecht, and personality disorders. Herzog and colleagues (1992) reported a prevalence of 63% for lifetime major depression in anorexia nervosa and bulimia nervosa patients.

Please identify any symptoms of anxiety and mistrust in your child or in yourself on this mistrust checklist.

Eating Disorders and Excessive Anger

As is the case with most other psychiatric disorders, little is known about the relationship between anger and eating disorders. However, in a 1995 study of 132 women with eating disorders, 31% of the patients reported anger attacks with 4.8 per month on average (Fava, et al.). The patients with anger attacks had significantly more depressive symptoms than patients without these attacks. Among bulimic patients there was a trend for anger attacks to be associated with greater severity of their illness.

In a study of adolescent females eating disturbances were significantly associated with aggressive behaviors (Thompson, et al., 1999) . Girls who endorsed binge eating and purging or dietary restrictions had odds of aggressive behavior 2 to 4 times higher than those who did not endorse these items. Also, the constellation of eating disturbances and aggressive behavior was associated with a greater risk of drug use and attempted suicide.

Bulimic and anorectic patients have been shown to be more depressed, anxious, and angry than non disordered participants . However, bulimics and anorectics did not differ significantly from each other in depression, anxiety, and anger. Researchers have found that hostility was significantly greater in anorectic patients than in normal controls Also, bulimia nervosa is associated with behaviors involving poor impulse control, such as kleptomania and substance abuse . One study found that 23% of women with bulimia reported a history of substance abuse and another that 24% of bulimic patients met the diagnostic criteria for kleptomania.

Lacey and Evans (1986) observed in their review of the literature that there is much evidence suggesting that impulsivity is common in eating disorders. The Minnesota Multiphasic Personality Inventory profile of bulimic patients showed elevated scores on impulsivity and anger (Hatsukami, 1982).

In clinical experience it has been noted that bulimic and anorectic patients express their anger in markedly different ways. Bulimic patients are more likely to be honest about their anger and release it in an active manner, whereas anorectic patients tend to mask their resentment and release it in a passive-aggressive manner. This clinical view is supported by the study of Fava et al. (1995) that patients with severe bulimia may be prone to develop irritability and anger attacks. However, that research did not measure the passive-aggressive expression of anger in the anorectic patients.

Please address any symptoms of active or passive-aggressive anger in your child or in yourself on this anger checklist.

Passive-Aggressive Anger in Anorexia

Passive-aggressive anger is a method of expression by which the individual attempts to hurt or provoke others and to obtain revenge, while acting as though one is not angry. This expression of resentment in eating disorder patients can be evaluated regularly by having patients and family members complete an anger checklist. (See angry child chapter).

Common manifestations of this passive-aggressive anger include: refusing to be responsible, acting helpless or sick, deliberate forgetfulness, tardiness, refusing to do what is reasonably expected, withholding love, deliberately failing and refusing to care for serious health problems, and refusing to eat.

Such anger can be used as a defense mechanism against their fears of being hurt by others by upsetting them and thereby distancing them.

The identification of passive-aggressive anger is difficult with anorectic patients because they display denial, great restraint in emotional expression and they manifest strong behavioral and emotional control (Casper, Hedeker, & McClough, 1992). Bulimic patients and patients with mixed anorexia nervosa/bulimia nervosa are much less defensive and more readily admit and express their anger, although at times such expression is excessive and inappropriate.

At the present time passive-aggressive anger has yet to be measured empirically in eating disorders. When that happens, we anticipate that the prevalence of this type of anger will be more clearly recognized as a major clinical issue in those with eating disorders.

Origins of Anxiety

The foundation for trust and for feeling safe in adult life depends first and foremost on a securely attached loving relationship with one’s mother. This relationship is essential to establishing the basic ability to trust and to feel safe in childhood, adolescence and adult life. Fortunately, most youth have had stable mother relationships, although this is changing due to harmful cultural trends that encourage selfish individualism at the expense of self-giving. Children who did not have a close, relax mother relationship may develop difficulties with excessive anxiety and mistrust. In our clinical experience, hurts in the father relationship are a more common source of anxiety and mistrust in the lives of youth.

We have worked with a number of young women who developed intense anxiety, mistrust, sadness, controlling behaviors and then anorexia after the divorce of their parents in their youth.

An important source of anxiety to consider from one’s childhood is that of modeling unconsciously after an anxious parent.

The growth of narcissism in the culture and the obsession with the body has resulted in significant trauma in peer relationship as a result of not being treated in a kind and respectful manner. We have treated a number of young women who developed severe anxiety, mistrust, low self-esteem and later anorexia as result of being bullied because of being overweight, being small in stature or having small breasts.

Also, significant damage to trust and subsequent anxiety can arise from hurts with siblings. Siblings can misdirect anger or overreact in anger at one another from conflicts outside their relationship with a parent or peers or from sadness, insecurity, jealousy, anxiety or a tendency to control.

Other common sources of anxiety arise from hurts with peers because of the hookup culture. The belief that others can be used as sexual object has damaged the ability of many adolescents to trust because of giving themselves repeatedly to others who were not trustworthy. Dr. Miriam Grossman, a clinical psychiatrist formerly practicing at the University of California?Los Angeles student center, has documented in her book Unprotected the damage done particularly to young women who have been treated as sexual objects.

Other experiences in the family of origin that can damage trust and cause anxiety are a traumatic family moves, serious illness and the death of a loved one.

Harm from Anxiety

Anxiety is a common psychological conflict in youth that harms youth. In the first major study of psychiatric disorders of American adolescents, almost 32 percent of the 10,000 teenagers met the criteria for an anxiety disorder (Merikangas et al., 2010).

The harm caused by anxiety can be manifested in many ways including

Controlling behaviors
Excessive expressions of anger
Catastrophic thinking (fear that something bad is going to happen)
Social anxiety, isolation, loneliness and depression
Emotional overreactions to minor life events
Compulsive habits including avoiding food in an unconscious attempt to control & to try to diminish anxiety
Excessive fears, including fear of one’s responsibilities
Emotional rigidity or withdrawal
Intermittent mistrust of parents, siblings, peers, health professionals, etc.

Anxiety Progressing to more Dangerous Mistrust

As anxiety increases over time it can lead can lead to excessive independence emotionally and the loss of the ability to trust others. Conflicts with thinking can develop, such as “My parents and peers not trustworthy.” This thinking can be associated with high levels of anger that is often directed in passive-aggressive ways. Anxiety, like anger, needs to be addressed regularly in marriages, rather than being denied, in order to prevent strong mistrust from developing and wreaking havoc in the youth and in the family.

Symptoms of severe mistrust include the following

Anorexia
Numerous psychosomatic symptoms including dizziness and rapid heart beat
Thoughts such as, “my parents, siblings and peers are not trustworthy”
Severe overreactions in anger
Difficulty in receiving help or advice
A tendency to avoid others
Harsh, disrespectful speech
Excessive criticism of others
Failure to treat one’s spouse as a best friend
Inability to see the good in others
Inability to go to school
Failure to consult spouse in making important decisions
Difficulty in trusting God

Addressing Errors in Thinking – Cognitive Distortions

Youth with AN are encouraged to identify and attempt to correct against anxious, mistrustful and controlling thinking patterns (cognitive distortions) and anxious emotional and behavioral responses, particularly when stressed. Negative thinking patterns include

No one is trustworthy and therefore have to control;
My parents and peers do not wish the best for me;
Something terrible is going to happen unless I am in total control (catastrophic thinking);
There is no hope for my fears of being hurt/rejected;.
Family and friends will betray me;
If I am extremely thin, I am less likely to be hurt by others.

Change in Eating Disorder Diagnoses

Previously, the three major eating disorders from DSM IV were Anorexia Nervosa, Bulimia Nervosa and Eating Disorder, Not Otherwise Specified. In the new DSM 5 Diagnostic Manual there are now 8 feeding and eating disorders.

They are:

Anorexia Nervosa
Bulimia Nervosa
Binge-Eating Disorder
Avoidant/Restrictive Food Intake Disorder
Rumination Disorder – food may be re-chewed, re-swallowed or spit out.
Night eating syndrome
Purging Disorder
Pica – eating non food substances

The criteria for making the diagnosis of anorexia nervosa include: low weight, fat phobia and weight loss behaviors and body image disturbance.

The criteria for bulimia nervosa include: binging, compensatory behaviors, duration of at least three months and an overvaluation of weight of body shape.

Feeding and eating disorders are often associated with anxiety/mistrust and anger that arise from traumatic experiences. There conflicts are often unconscious due to the excessive energy spent in attempting to control food intake, weight and appearance. Forgiveness Therapy can be effective in the treatment of these emotional conflicts which often precede the development of these disorders.

The Four Phases of Forgiveness Therapy that Reduces Anger and Anxiety

The four phases of forgiveness therapy are uncovering, decision, work and acceptance.

1. Uncovering anger and anxiety

The goal in the uncovering phase is to help youth to both recognize their life hurts in relationships and the anger and anxiety associated with those hurts. Family therapy is essential in this process because of the degree of denial and control in these youth.

Anorectic youth employ strong denial or obsessive-compulsive defenses in order to cope with intense emotional pain that often includes a severe fear of being betrayed, intense anger against those who have hurt them and sadness. Their strong need for emotional control offers a major challenge to the uncovering of the anger associated with the emotional trauma in their lives. In addition, they use their passive-aggressive anger as a tool to distance others because of fear of betrayal and an unwillingness to become vulnerable. Even though they can often identify their important life hurts and disappointments, most are reluctant to admit feeling angry as a result of these conflicts.

Studies have described a strong relationship between anorexia and OCD with the combination of marked obsessive-compulsive and anorectic behaviors coinciding with more severe disturbances and chronicity. Casper and colleagues (1992) suggest that treatment efforts focus on addressing the patient’s shyness and fear of relationships and on offering the hope that self-actualization can take place through expression of feelings and thoughts and not exclusively through self-control.

However, some anorectic patients are reluctant to admit the depth of their anger and are unwilling to work toward change because of secondary gains obtained from passive-aggressive anger. These include: a sense of pleasure in seeing others agonize over their weight loss, their ability to distance others and limited vulnerability to others, or a lack of desire to be in good health.

Other patients have been hurt so deeply that they refuse to give up their compulsive behaviors because, in themselves, they provide a sense of safety and control.

In the uncovering phase of treatment one approach to these resistances is to challenge their compulsive need for control by suggesting that if they do not resolve their anger with those who have hurt them, they will be prisoners of their past. Also, psychodrama techniques are helpful in the uncovering phase when denial is very strong and when anger is vented primarily in a passive-aggressive manner. In attempting to break through this denial, the therapist has the option of role playing the patient and verbalizing the emotional pain that the patient cannot or will not express toward offenders.

An example of role playing was with Chad who was a severely anorectic, withdrawn 13 year old boy who had been the victim of intense peer ridicule and physical abuse for years. In this case, the therapist role-played his peers. In doing so the therapist stated, “You were the smartest boy in class and we were jealous of you because you made me feel dumb.” The patient responded by crying quietly. The therapist continued, “Chad, you must want to get even with me because I was rotten to you. I don’t have any excuse; I used you to make myself feel big with the rest of the guys. If it does any good, I’m sorry.” For the first time as a result of role playing, Chad became emotionally expressive of his sadness, anger and fears.

At this time the 3 ways of forgiving we presented to Chad: emotionally, cognitively (willing to forgive) or spiritually, that is, God take my anger or help me to forgive. Chad considered the third option because he had difficulty in thinking of forgiving and certainly did not feel like forgiving.

In family therapy sessions when youth cannot express the anger associated with identified life hurts, the parent at times can engage in the role playing intervention by playing the offender and asking for forgiveness for inflicting hurts. The parent may also play the role of the youth and express anger at the offender followed by a statement of desire to begin the work of forgiving the offender.

Powerful angry feelings and the impulses for revenge can overwhelm youth leading them to misdirect their anger by punishing themselves or by punishing others.

2. Decision Phase

In the decision phase, youth are presented with the three options of dealing with anger, that is, denial, expression or forgiveness. The benefits of beginning the work of engaging in forgiveness therapy are presented. These benefits include a decrease in anxiety and mistrust, that influences restrictive food intake, as well as a decrease in sadness. These benefits have been empirically proven in the use of forgiveness therapy as described in our book, Forgiveness Therapy, an Empirical Guide for Resolving Anger and Restoring Hope.

In this phase it is important to remind youth that unresolved anger interferes with the resolution of the excessive anxiety, anger and sadness that influences controlling and obsessive-compulsive behaviors restrictive eating and binging in youth.

The decision to move to work on forgiveness can also be motivated by the realization that the controlling behaviors have not really been helpful.

3. Work Phase

The major difficulty in the work phase of forgiveness is the emergence of intense fear at the beginning of the process. First, patients worry that if they forgive they might have to become vulnerable to others who has hurt them deeply. This anxiety can be managed by explaining that forgiveness and trusting are two different processes and that one can forgive to help oneself and not necessarily trust others who are not trustworthy. The therapist and parents can make this distinction.

The work of forgiveness involves thinking about trying to understand the offender (s) and then making a decision to forgive him/her even though one may not feel like forgiving (emotional forgiveness). This forgiveness therapy, as with CBT, involves a daily commit to attempt to uncover and let go of anger with those who inflicted hurts and damaged the ability to trust that has led to a need to control.

The work involves the use of past forgiveness exercises in which youth picture himself/herself at the time of a hurt and think of wanting to understand and to forgive the offender. As youth make a commitment to this daily forgiveness therapy, they regularly note a diminishment in their anxiety and in their anger.

An obstacle encountered in the work of forgiveness is the strong fear of life betrayal. This fear is much more difficult to treat, but through the work of forgiveness, these youth begin to feel less fearful and depressed and more healthy. Because many have felt somewhat safe from betrayal in relationships as anorectics, they need to make a decision to return to the mainstream of life and abandon the sick role where they experienced a degree of safety.

In the midst of this conflict even though they have begun to experience some benefit from forgiveness, many youth need growth in their ability to trust so that they can maintain healthy relationships with others before they can commit themselves fully to the process. This growth in trust can begin to occur in the relationship with loved ones in family therapy sessions, friends and the therapist.

These youth often first experienced an anxiety and a fear of betrayal in relationships which progressed into symptoms of loss of appetite, social isolation and anorexia, as documented in research studies. These youth are often so completely obsessed with their weight and food intake that they have no conscious awareness of how much they had been hurt previously in one or more relationships. In the course of their therapy, most are surprised at the depth of their fears, anger and, in some cases, their desire to strike back.

The cycle continues, however, because after deciding to forgive their offenders to overcome the hurts of the past and to deal with their anorexia, they often become fearful of being hurt again if they become healthy and return to ordinary socialization. Growth in trust is facilitated by the support of loving parents and by a growth in the ability to trust reliable peers.

When powerful inner rage in anorectic patients is a result of severe betrayal experiences, the therapist can discuss the possibility of spiritual forgiveness exercises. Each person approaches such forgiveness in his/her own way. We find that encouragement from loved ones and a past history with spiritual/religious education is helpful to the person who wishes to explore spiritual forgiveness. A key feature is the development of trust in God and a willingness to seek the help needed to overcome the hurt and anger.

Also, the healing process is facilitated when Faith is pursued by meditating upon asking the Lord to help deepen the ability to trust and to feel safer in relationships and to let go of the desire to control. Giving up the desire to control is a challenging issue. Fortunately, the need to control can be dislodged by a growth in trust and in the sense that one is protected in life.

As a result of forgiveness therapy, youth often grow in their ability to be assertive with insensitive people and to grow in their ability to master their anxiety, anger and insecurity. However it is not unusual for them to spend 18 to 24 months or longer in intensive therapy.

Unfortunately, some anorectic patients are unwilling to make a decision to give up either their passive-aggressive resentment, their compulsive need for control, their mistrust of others or their chosen isolation from the world in the sick role. These patients often have a burning, sick desire for revenge within themselves. Some fantasize attendance at their own funerals and enjoy imagining the suffering of those who have hurt them. We have seen some patients take quiet inner delight in seeing the shocked faces of those who look at their emaciated frames.

Letting go of the need to control

Casper and colleagues (1992) suggest that treatment efforts focus on addressing the patient’s shyness and fear of relationships and on offering the hope that self-actualization can take place through expression of feelings and thoughts and not exclusively through self-control.

In response to emotional trauma the person with an eating disorder can often seek to restore unconsciously a safe feeling by trying to control certain aspects of her life that can include food intake and weight. The same psychological process can occur in youth traumatized by parental divorce or alcoholism who develop obsessive-compulsive behaviors in reaction to trauma.

The excessive control over food and low weight can give those with an eating disorder a false sense of safety. They fear letting go of this control because unconsciously the restoration of normal weight could make them more vulnerable to further betrayals. This excessive control also makes them fearful of engaging in the work of forgiveness, in part, because they fear they may lose the sense of control over their emotional lives.

Parents, family members, good friends and therapists can reassure such individuals that their ability to feel safe in life can grow by trusting more in their parent’s and doctor’s recommendation for increased caloric intake and by explaining that the offender(s) is, in fact, continuing to have a harmful influence in their lives by restricting caloric intake and maintaining low weight. In those with faith, progress has been reported when a decision is made to give the control to the Lord and to trust more in his protection in relationships.

Letting go of the compulsive need for control is one of the most challenging aspects of treating those with eating disorders.

Family and Marital Therapy

Marital and family therapy are often indicated when serious conflicts are uncovered in the parents' marriage. A major focus of such therapy is to attempt to reduce the expression of anger in the home and to educate parents in forgiveness therapy so they can process and reduce their anger without giving expression to it (see angry spouse chapter at www.maritalhealing.com). Parents are encouraged to identify the primary emotional weakness they have brought from their family of origin into their marriage and then to try to work to resolve this weakness (see parental legacies: strengths and weaknesses at www.maritalhealing.com). Such interventions decrease the level of stress in the home and help the youth to grow to feel safer and to trust more. Today, the fear of parental divorce is a common emotional response in youth whose parents argue frequently and who lack the ability to address their anger in a mature, not childlike, manner.

When anorexia develops after parental divorce, we attempt to work with each parent to see if a reconciliation might be possible. Many parents are open to consider this suggestion because of their desire to help their child with her eating disorder.

Forgiveness Therapy in Bulimia Nervosa

In bulimic patients who are often very emotionally expressive, the challenge as Casper and colleagues (1992) suggest is to learn to establish controls over the emotions. This can involve exploring the limitations of expressing anger as the sole method for handling resentment (Enright and Fitzgibbons, 2015) and examining the benefits of forgiveness as a way to both control, master and resolve their anger.

Difficulties with impulse control are indicators that these patients struggle with strong anger. Although they often have difficulty trusting in relationships, they tend to be much more open, vulnerable, and less controlling than anorectic patients. Because they are able to be more trusting of the therapist and are more able to identify the major disappointments and traumatic events of their lives, therapists do not need to rely as much upon family therapy.

After disappointments and betrayal experiences are identified, forgiveness therapy is recommended as a method to help them in the treatment of their eating disorder and their comorbid condition(s). Most patients are willing to try using forgiveness, in part, because they want to overcome the hurts of the past and also because they have come to understand the limitations of reliance upon expression for dealing with their angry feelings.

Cognitive forgiveness exercises can be assigned in which the therapist gives written instructions for the patient to think of understanding and forgiving offenders for both recent and past disappointments and hurts in relationships. In working on forgiving others, many youth with BN also become anxious about giving up the use of their anger as a defense mechanism to distance or to control others. In this phase they struggle, too, with the fear that by resolving their anger they will risk becoming vulnerable. This process of forgiving and struggling to grow in trust can take years of work in therapy.

Case History

Abbie, a young woman, developed bulimia during college after the death of her mother. The loss of her mother resulted not only in intense loneliness and sadness but also in feelings of intense isolation and fear. She had never felt close to her father and described him by saying, “He thinks he’s the center of the world. He really doesn't’t care about anyone except himself.”

No one in the family provided support or helped her cope with the loss of her mother. Abbie began to feel increasingly isolated, frightened, mistrustful, lonely, and depressed. After several disappointing dating relationships, symptoms of bulimia intensified and resulted in several hospitalizations. She responded fairly well to cognitive-behavioral interventions during the hospitalizations but relapsed quickly. During her hospitalizations she was encouraged to express anger at her father, but feared that, if she did, she would lose the fragile relationship with him completely.

She was treated with antidepressants and later developed poor impulse control and almost lost her job as a result of stealing food.

Initially, she had little conscious awareness of the depth of her anger with those whom she felt had betrayed her. However, she slowly came to view her bulimic symptoms as a way of isolating herself from others, especially men. As long as she was binging and vomiting several times weekly, she could not possibly consider involvement in a romantic relationship.

Attempts at family therapy were fruitless because of her father’s narcissistic conflicts and his inability to be sensitive to her. In spite of his behavior, she committed herself to forgive him because she did not the deep hurts with him to make her fearful of ever trusting a man.

The most difficult aspect of the forgiveness process was that of accepting and absorbing the pain of betrayals with her father and another man she had loved. There were times when she committed herself intellectually to forgiving these men, but shortly afterwards she would feel strong anger that prevented her from continuing the process. At those moments she would tell herself that she had to give up her resentment if she wanted to be healthy. This cognitive step provided symptomatic relief over time.

After several years of therapy the slow resolution of her anger and intense fear of betrayal enabled her to risk becoming more vulnerable in relationships. She no longer felt as strong a pull to hide from the world in her bulimic illness. Abbie came to realize that the resolution of her bitter feelings toward her father and a former boyfriend gave her a new lease on life and protected her from the toxic effects of resentment and mistrust.

The Role of Faith

As cited in other sections of this web site, faith can play a beneficial role in the healing of anxiety disorders and compulsive behaviors. (See Healing and Faith at the National Library of Medicine web site, www.ncbi.nlm.nih.gov/pubmed/.) A number of spiritual interventions help in resolving anxiety and compulsive behaviors and in building stronger trust. These include employing daily a modification of the first two steps of Alcoholics Anonymous and thinking, "I am powerless over my anxieties, my anger or my tendency to control and want to turn them over to God."

Meditating upon asking the Lord and Our Lady to help one to feel safe has also been helpful to some youth with severe mistrust and a tendency to control and to isolate. Others report that they have been helped in overcoming their compulsive need to control by meditating that the Lord is in control of their lives - not them.

Catholic patients have reported that going to the Sacrament of Reconciliation with their betrayal anger has helped in its resolution as well as the use of spiritual forgiveness, that is, reflecting, "Lord take my anger."

Those youth with low-self esteem related to poor body image have been helped by growing in the virtue of gratitude for their God-given gifts and body.

Saint Francis de Sales accurately described the dangers of anxiety in his Introduction to the Devout Life:

With the single exception of sin, anxiety is the greatest evil that can happen to a soul. Just as sedition and internal disorders bring total ruin on a state and leave it helpless to prevent a foreign invader, so also if our heart is inwardly troubled and disturbed it loses both the strength necessary to maintain the virtues it had acquired and the means to resist the temptations of the enemy. There is nothing that tends more to increase evil and to prevent enjoyment of good than to be disturbed and anxious (pp. 251-252).

Conclusion:

Excessive anxiety, fears of betrayal, obsessional thoughts of trying to control and anger are a serious conflicts in many youth with eating disorders that interfere with treatment and recovery. Forgiveness therapy has value in diminishing what the intense active and passive-aggressive anger in youth with eating disorders and in treating the anxiety disorders that preceded the onset of eating disorders in many youth, particularly social anxiety disorder, obsessive-compulsive disorder and post-traumatic stress disorder. Hopefully, our new APA Books textbook, Forgiveness Therapy: An Empirical Guide for Resolving Anger and Restoring Hope, will contribute to forgiveness therapy being incorporated into treatment plans for feeding and eating disorders in youth and young adults.