One of the problems with the Symptom Whack-A-Mole Syndrome (hereafter SWAMS) is EXACTLY that "what do we do first?! o_0 thing. I think a common thread here is how INEFFECTIVE whacking at which ever random symptom happens to be (percieved to be) worst right now, turns out to be in the long run.
Marsha Linehan (developer of DBT) started with a clientele of patients who were suicidal, chronic and almost all had multiple diagnoses. These were women who'd endured years of SWAMS, so she developed a formal hierarchy, allowing the clinical team to focus on a few things, then move to the next issue, & etc. Instead of endless random whacking at moles as they pop-up repeatedly, you systematically target the WORST offending mole (or two). Once that problem is manageable, you target the NEXT mole.
The standard hierarchy is:
- Decreasing suicidal behaviors.
- Decreasing therapy interfering behaviors.
- Decreasing behaviors that interfere with the quality of life.
- Increasing behavioral skills.
- Decreasing behaviors related to post-traumatic stress.
- Improving self esteem.
- Individual targets negotiated with the patient.
So you see, in either case, under the DBT model, ED behaviors merit full treatment attention and highest priority. The only exception being, as in Foodsupport's situation, when even MORE threatening behaviors are in play, THOSE get priority. Anxiety (as a common for instance) is typically more like a #3. If your ED is fairly well in the recovery process, and anxiety spikes up, and starts interfering with eating (I bet a lot of us know this cycle) ... well, then the anxiety becomes #2, and you target therapy at it, to keep the progress you've made on the other more serious stuff.