WELCOME TO

THE EATING DISORDERS

TRAINING

EATING DISORDERS ARE NOTABOUT FOOD

• Eating disorders are primarily a symptom of deeper psychological conflict. It serves to alleviate and/or protect against psychological conflicts and vulnerability.

• Food/the Eating Disorder is a way to have CONTROL, when life feels so out of control.

• Eating Disorders are diseases of IDENTITY, of COPING.• Eating Disorders are diseases of FEELINGS1) Anorexic thinking is such that if I do not eat, I do not feel – life and

emotions slip off me like Teflon. 2) Bulimic sufferers often eat and then purge away all the negativity

they feel to be true about themselves, such as self-loathing or uncomfortable feelings like anger, shame, sadness, longing and neediness.

3) The compulsive eater eats to suppress negative emotions and uses food as a comfort.

THEY ARE A DISORDERABOUT RELATIONSHIPS

• Eating disorders are primarily disorders about relationships – the relationship with oneself and with others.

• Food becomes more reliable and safer than people. It doesn't disappoint, reject or hurt the way people and relationships can.

• The food/body acts as a metaphor and is split into good versus bad (salad is good, chocolate cake is bad). The psychological message expressed via this metaphor is that only 'good' feelings (like happiness) are acceptable. Other normal emotions, such as anger, hurt, envy and sadness, are viewed as unacceptable or 'bad.' If I eat only 'good' foods, I will feel only 'good' feelings. The reality is, however, that just as there are no good or bad foods, there are no good or bad feelings.

INCIDENCE• 4 million Americans actively try to lose weight each year • 90% fail to keep the weight off and often gain back more than they

lost• People spend $30 billion dollars a year on diet foods, pills, and

special regimens• 1/3 of Americans are considered obese• 35% of dieters become eating disordered• 7 million women and 1 million men suffer from anorexia nervosa or

bulimia nervosa• Men are more apt to conceal their EDs than women.• 3%-10% of adolescent and college students have a severe eating

disorder • 150,000 American women die each year from complications

associated with anorexia and bulimia

SOME FACTS ABOUT TREATMENT

• Eating disorders start when the person is young, can last for years, and cost a great deal of money to overcome

• Almost nine out of 10 individuals with eating disorders (86%) report that the onset of their illness occurred before the age of 20.

• Three out of four (77%) said that the duration of their eating disorder ranged from one to 15 years.

• It costs $30,000 per month for an inpatient treatment program and $100,000 for outpatient treatment that includes therapy and medical monitoring.

4 HARMFUL BEHAVIORS

People with eating disorders engage in four harmful and destructive behaviors—starving, bingeing, purging, and grazing. They often get stuck in cycles of starving and bingeing, bingeing and purging, starving and grazing, or grazing and purging.

Can you spot an eating disorder?

• Eating disorders are all but impossible to recognize in their early stages: after all, who isn’t concerned about looking better, eating better, and staying in shape?

• The symptoms of eating disorders do not readily show themselves in a typical physical examination

• The symptoms can be confusing during the adolescent years.

• Paradoxically, it is often much harder to heal an eating disorder once it has progressed to a more advanced stage.

• Educate yourself about eating disorders and be an attentive observer

Is it an eating disorder?

• Symptoms can vary dramatically• The issue is not WHICH excess you may see in

a child, but HOW excessive these behaviors are, and HOW that excess serves the child’s personality and lifestyle: does the child have voluntary control over the behavior? Does it interfere in his/her life functions and roles?

• Watch not necessarily only for behavior, but attitudes and thought patterns.

• Don’t rely only on weight to be concerned• Be prepared for denial.

ANOREXIA NERVOSADiagnostic Criterion:

• Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected).

• Intense fear of gaining weight or becoming fat even though underweight.

• Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.

• In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone administration, e.g., estrogen).

Specify type:

– Restricting Type: during the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or misuse of laxatives, diuretics, or enemas).

– Binge-Eating/Purging Type: during the current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or misuse of laxatives, diuretics, or enemas).

Differential Diagnosis: – General Medical Conditions – person has a disease or illness (i.e.,

gastrointestinal disease, brain tumors, occult malignancies, or AIDS) that causes serious weight loss, but the person does not have a distorted body image and a desire for further weight loss.

– Superior Mesenteric Artery Syndrome – person has postprandial vomiting secondary to intermittent gastric outlet obstruction. Syndrome can also be a result of emaciation in anorexia nervosa.

– Major Depressive Disorder - person has severe weight loss but does not have desire to lose weight nor excessive fear of gaining weight.

– Social Phobia - person feels embarrassed or humiliated to be seen eating in public.

– Obsessive-Compulsive Disorder - person exhibits obsessions or compulsions related to food (i.e., food is contaminated).

– Body Dysmorphic Disorder - person is preoccupied with an imagined defect in bodily appearance.

– Can have major depression, social phobia, obsessive-compulsive disorder, and body dysmorphic disorder along with anorexia nervosa.

– Schizophrenia - person exhibits odd eating behavior or significant weight loss, but rarely shows fear of gaining weight or disturbed body image.

– Bulimia Nervosa - even with bingeing and purging (as in some anorexia nervosa, binge-eating/purging type), person is able to maintain normal weight.

ANOREXIA WARNING SIGNS• Loss of a significant amount of weight • Continuing to diet even when thin • Feeling fat even after losing weight: distorted experience of body weight and size• Intense fear of weight gain: their self-esteem is highly dependent on body shape and

weight. Weight loss is an impressive achievement and sign of extraordinary self-discipline while weight gain is perceived as an unacceptable failure of self-control.

• Loss of monthly menstrual periods • Preoccupation with food, calories, fat content and nutrition; limited foods • Preferring to diet in isolation • Cooking for others but not eating the food • Employ a wide variety of techniques to measure body size or weight, including

excessive weighing, obsessive measuring of body parts, and persistently using a mirror to check for perceived areas of “fat”.

• Typically deny the serious medical implications of their malnourished state.• Will not generally be forthcoming about their behavior. It is thus necessary to ask

parents and other outside sources to evaluate the degree of weight loss and other features of the illness.

OTHER WARNING SIGNS• Hair loss • Cold hands and feet • Fainting spells • Exercising compulsively • Lying about food • Depression and anxiety • Weakness and exhaustion • Periods of hyperactivity • Constipation • Heart tremors • Dry, brittle skin • Insomnia

• Shortness of breath

Physical Complications:• Most medical problems are the direct result of starvation. Anorexics weight ranges

from underweight to emaciation. Listed below are the signs, symptoms, and complications of anorexia nervosa (Mehler, 1996).

• Enlarged Cerebral Ventricles and Sulci in the Brain • Dermatologic:

– Brittle nails – Carotenodermia (dry, flaky skin) – Lanugolike facial hair (fine hair growth) – Pruritus (itchy skin) – Thinning scalp hair

• Cardiovascular: – Arrhythmias (irregular heart beat) – Bradycardia (slowed heart rate, below 60) – ECG abnormalities – Hypotension (low blood pressure) – Left ventricular dysfunction – Mitral valve motion irregularities – Reduced work capacity – Refeeding cardiomyopathy (heart muscle disease that can lead to cardiac collapse due to

food introduction)

• Immunologic: – Reduced bactericidal capacity of granulocyles (reduced ability

for white blood cells to fight infection) – Impaired cell-mediated immunity – Reduced granulocyte adherence – Reduced number of CD4 and CD8 cells (white blood cells) – Reduced serum complement levels

• Hematologic: – Anemia – Leukopenia (reduced white blood cells) – Reduced erythrocyte sedimentation rate (reduced red blood cell

sedimentation rate)

• Endocrine: – Amenorrhea/hypogonadism – Cold sensitivity – Diabetes insipidus – Euthyroid sick syndrome (bone marrow is producing fewer red and white blood

cells) – Hypoglycemia (low blood sugar levels) – Hypothalamic-pituitary-adrenal axis dysfunction (work together through hormone

interaction so body menstruates, has strong bones, and has normal thyroid function)

– Osteopenia/osteoporosis (occurs after six months of not menstruating) • Gastrointestinal:

– Abdominal pain – Constipation – Decreased intestinal motility – Delayed gastric emptying – Duodenal dilation – Postprandial fullness (post-eating fullness) – Refeeding hepatitis – Refeeding pancreatitis

• Metabolic (Electrolyte Imbalance): – Hypercholesterolemia (high cholesterol) – Hypocalcemia (low calcium) – Hypokalemia (low potassium) – Hypomagnesemia (low magnesium) – Hypophosphatemia (low phosphates-mineral

is stored in bones so bones are weakened)

Recovery Rates:

• 50% of patients recover completely

• 40% regain normal weight

• 25% remain emaciated

• 20% remain thin, although not dangerously so

• 15% become overweight

• 10-15% die prematurely due to complications of their illness

BULIMIA NERVOSADiagnostic Criterion:

• Recurrent episodes of binge eating as characterized by: – Eating, in a discrete period of time (e.g., within any 2-hour

period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.

– A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

• Recurrent inappropriate compensatory behavior in order to prevent weight gain such as self-induced vomiting, misuse of laxatives, diuretics, enemas, or other medications, fasting, or excessive exercise.

• The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months.

• Self-evaluation is unduly influenced by body shape and weight. • The disturbance does not occur exclusively during episodes of

anorexia.

Specify type:

– Purging Type: during the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

– Nonpurging Type: during the current episode of bulimia nervosa, the person has used inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

Differential Diagnosis:

– Anorexia Nervosa, Binge-Eating/Purging Type - person has lost weight to 85% of what is considered normal and has stopped menstruating.

– Kleine-Levin Syndrome - person has disturbed eating behavior but is not overly concerned with body shape or weight.

– Major Depressive Disorder with Atypical Features - person overeats but does not binge or engage in compensatory behaviors and is not overly concerned with body shape and weight.

– Borderline Personality Disorder – binge eating is included in impulsive behavior criterion. Both diagnoses can be given if bulimic symptoms present.

– Binge First versus Diet First - most people with bulimia nervosa began dieting prior to binge eating, some started binge eating before they dieted. The binge first group more closely resembles individuals with binge-eating disorder than the group that dieted first (Haiman and Devlin, 1999).

WARNING SIGNS OF BULIMIA• Eating uncontrollably • Purging by vomiting (80-90%)• Purging by strict dieting, fasting, vigorous exercise• Abusing laxatives or diuretics (1/3rd of population)• Using the bathroom frequently after meals • Preoccupation with body weight (like anorexics) • Depression (often starts before the development of bulimia) • Mood swings • Feeling out of control • Swollen glands in neck and face • Heartburn • Bloating • Irregular periods • Dental problems • Constipation • Indigestion • Sore throat • Vomiting blood • Weakness and exhaustion • Bloodshot eyes

Physical Complications:

• Medical problems are directly related to the method and frequency of purging. Because most bulimics are within a normal weight range, they look healthy, but may have health concerns that need to be addressed (Mehler, 1996).

• Oral: – Cheliosis (cracking on side of lips due to stomach acid) – Dental Caries – Pharyngeal soreness (sore throat) – Sialadenosis (inflammation of salivary glands)

• Pulmonary: – Aspiration pneumonia (food gets into lungs causing pneumonia)

• Mediastinal: – Arrhythmias – Diet pill toxicity

• Hypertension • Intracerebral hemorrhage • Palpitations

– Hypotension – Syrup of Ipecac toxicity

• Cardiomyopathy (disease of heart muscles) • Heart failure • Ventricular arrhythmias

– Mitral valve prolapse • Gastroesophageal:

– Barrett’s esophagus (precancerous cells due to stomach acid being in esophagus) – Dyspepsia (acid reflux) – Dysphagia (pain or difficulty swallowing) – Esophageal rupture – Esophageal ulcer – Esophagitis (inflammation, a precursor to Barrett’s esophagus) – Hematamesis (throwing up blood) – Mallory-Weiss tears (dry heaves tear lining of esophagus, light blood in vomit) – Sore throat

• Gastrointestinal: – Cathartic colon (irritable bowel) – Constipation – Diarrhea – Hematochezia (blood in the stool) – Pancreatitis (inflammation of pancreas)

• Endocrine: – Diabetic complications – Hypoglycemia – Irregular menses – Mineralocorticoid excess (excessive adrenal-made steroid causes diabetes and increased blood pressure)

• Reproductive: – Low birth-weight infant – Spontaneous abortion

• Neuromuscular: – Diet pill toxicity

• Seizures – Syrup of Ipecac toxicity

• Neuromyopathy (disease of the muscular system) • Fluid, Electrolyte, and Acid-Base (Electrolyte Imbalances):

– Dehydration – Hyperamylasemia (make too much pancreatic enzyme that breaks down sugar) – Hypochloremia (low chloride) – Hypokalemia (low potassium) – Hypomagnesemia (low magnesium) – Hyponatremia (low salt) – Idiopathic edema (swelling of hands, feet, face) – Metabolic acidosis (blood becomes acidic) – Metabolic alkalosis (blood become alkaline) – Pseudo-Bartter’s syndrome (condition of low electrolytes)

AccompanyingSelf-Destructive Behavior

A number of self-destructive behaviors occur with bulimia:• Smoking. Many teenage girls with eating disorders smoke because

it is thought to help prevent weight gain. • Impulsive Behaviors. Women with bulimia are at higher-than-

average risk for dangerous impulsive behaviors, such as sexual promiscuity, self-cutting, and kleptomania. Some studies have reported such behaviors in half of those with bulimia.

• Alcohol and Substance Abuse. An estimated 30% to 70% of patients with bulimia abuse alcohol, drugs, or both. This rate is higher than that of the general population and for people with anorexia. It should be noted, however, that this higher rate of substance abuse may be a distortion because studies are conducted only on diagnosed patients. Bulimia tends not to get diagnosed. And reports of bulimia in the community (where the incidence of the eating disorder is higher than statistics suggest) indicate that substance abuse is actually lower than in people with anorexia.

Recovery Rates

• 80% of patients recover

• 25% of “recovered” patients retain some abnormal eating

4. EATING DISORDERS NOT OTHERWISE SPECIFIED

Diagnostic Criterion:

• For females, all the criteria for anorexia nervosa except the individual has regular menses.

• All the criteria for anorexia nervosa are met except that, despite significant weight loss, the individual’s weight is within the normal range.

• All the criteria for bulimia nervosa are met except that the binge eating and inappropriate compensatory behaviors are less than twice a week or for a duration of less than 3 months.

• The regular use of inappropriate compensatory behaviors by an individual of normal body weight after eating small amounts of food (e.g., self-induced vomiting after two cookies).

• Repeatedly chewing and spitting out, but not swallowing large amounts of food.

• Binge-Eating Disorder: recurrent episodes of binge eating in the absence of inappropriate compensatory behaviors characteristic of bulimia nervosa.

3. BINGE-EATING DISORDER(EDNOS)

• Bingeing: Repeatedly eating large amounts of food can turn into an addictive habit. Some bingers have consumed as many as 20,000 calories in one sitting. The average binge ranges from 1500 to 3500 calories (Kaye et al., 1993). Distress comes more from loss of control than from quantity eaten (Spitzer et al, 1991). If bingeing occurs frequently over a period of months, it can turn into binge-eating disorder.

• Grazing: This is when someone eats from morning to evening or for blocks of time without having designated meals. The day becomes one long munching event. This style of eating presents problems. Grazers don't know how much they’re eating and often choose easy-to-grab snack items like candy or chips. Weight gain is caused by overeating unhealthy foods.

• Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: – eating, in a discrete period of time (e.g., within any 2-hour

period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances

– a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating and control what or how much one is eating)

• The binge eating episodes are associated with three (or more) of the following: – eating much more rapidly than normal – eating until feeling uncomfortably full – eating large amounts when not feeling physically hungry – eating alone because embarrassed by how much one is eating – feeling disgusted with oneself, depressed, or very guilty after

overeating

• Marked distress regarding binge eating is present.

• The binge eating occurs, on average, at least 2 days a week for 6 months.

• Binge eating is not associated with the regular use of inappropriate compensatory behaviors (i.e., purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa.

Differential Diagnosis :

– Bulimia Nervosa, Nonpurging Type – person with binge-eating disorder does not fast or use intense physical exercise as compensatory behaviors rid the body of food.

– Major Depressive Disorder – person may overeat but it is not binge- eating with all the associated emotions.

– Night Eating Syndrome – person frequently awakens during night and has a compulsion to eat and/or drink. Health consequences include obesity, diabetes, and hypertension. The reasons people give for night eating include (Pietralata et al, 2000):

• to combat insomnia by nibbling to “kill time.” • to have a small meal before ending the day and going to sleep. • waking up once or several times a night to get up and eat moderate

to excessive amounts of food when not hungry.

WARNING SIGNS OF BINGEEATING DISORDER

• Episodes of binge eating • Eating when not physically hungry • Frequent dieting • Feeling unable to stop eating voluntarily • Awareness that eating patterns are abnormal • Weight fluctuations • Depressed mood • Feeling ashamed • Antisocial behavior • Obesity

Physical Complications: The medical conditions listed below are found more often and are more serious in

people who are overweight and obese.

• Dermatologic: – Yeast/fungal infections – Naval infection – Rashes – Skin ulcers – Dermatitis (inflammation of the skin, like eczema)

• Cardiovascular: – Coronary heart disease – Hypertension – Circulatory problems – Vascular insufficiencies (lack of blood flow to legs and feet) – Varicosities (bulging veins, like hemorrhoids) – Tissue dependencies (accumulation of fat beneath skin)

• Gastrointestinal: – Hiatus hernia (stomach moves into the chest) – Esophageal reflux – Gall bladder disease

• Endocrine: – Diabetes – Edema – Stein-Leventhal syndrome (polycystic ovarian disease) – Cushing’s disease (tumor in adrenal gland releases to much steroid causing abnormal hair growth and hump on

lower part of neck) • Reproductive:

– Cancer of breast, uterus, and ovaries – Preeclampsia/eclampsia (high blood pressure during pregnancy and the dumping of protein through the urine) – Infertility – Irregular menses or amenorrhea – Incontinence

• Respiratory: – Sleep apnea – Obesity hyperventilation – Pickwickian syndrome (trouble with breathing) – Asthma Degenerative Diseases:

• Arthritis • Joint disease • Lower back pain

Prevalence and Comorbidity Statistics:

• 0.7%-4% of overall population which equals1 to 4 million Americans (American Psychiatric Association, 1994)

• Females are 1.5 times more likely to have this eating pattern than males (American Psychiatric Association, 1994)

• 15%-50% (with a mean of 30%) of individuals in weight-control programs (American Psychiatric Association, 1994)

• 20% or more of overweight or obese individuals seeking obesity treatment report significant problems with binge-eating (Kinzl et al., 1999)

• 39.4% indicated they dieted before binge-eating; 46.5% did binge-eating before first attempt to diet (Haiman and Devlin, 1999)

• 53.7% reported onset of binge eating by age 10 (Abbott et al., 1998) • 15.6% report chemical dependency (Santonastaso et al., 1999)

5. BODY DISMORPHIC DISORDER

• Although body dismorphic disorder is not classified as an eating disorder, a number of eating disordered patients also struggle with the disorder.

• Diagnostic Criterion:• Preoccupation with a defect in appearance. The defect is either imagined, or if a

slight anomaly is present, the individual's concern is markedly excessive. • The preoccupation must cause significant distress or impairment in social,

occupational, or other important areas of functioning. • The preoccupation is not better accounted for by another mental disorder (e.g.,

dissatisfaction with body shape and size in Anorexia Nervosa). • One or many body parts can be the focus. Most individuals describe marked distress

over their supposed deformity, describing the preoccupation as "intensely painful," "tormenting," or "devastating." Most find their preoccupation difficult to control, make little or no attempt to control it, spend hours a day thinking about it, and seek excessive reassurance about appearance. There is frequent mirror checking, use of lighting or magnifying glasses to scrutinize the "defect," and/or excessive grooming behavior. These behaviors often intensify anxiety instead of diminishing it. Severe distress can lead to suicidal ideation or attempts. Medical, dental, or surgical treatments may also be pursued to rectify imagined defects.

Other Disordered Eating Behavior You May Encounter

• Hoarding Food• Stealing Food• Overeating • Hiding FoodThis is common for children who have been

neglected, abandoned, or not fed regularly. It has do to with inner insecurity and may lessen only when the child feels stable and cared for.

4 Contributing Factors

Four factors contribute to the development

of an eating disorder. These factors include

1) Sociocultural

2) Familial

3) Biogenetic

4) Intrapsychic.

1) SOCIOCULTURALMEDIA

• Beauty Standards

• Advertising

• Diet Industry

• Snack and Fast Food Industries

• Feeding Insecurities

SOCIOCULTURALEthnic Factors

• Most studies of individuals with eating disorders have been conducted using Caucasian middle-class females. Studies are now reporting, however, that minority populations, including Hispanic- Americans and African-Americans, are significantly affected. There is some indication that African-American girls and young women may be at particular risk for eating disorders because of poor body images caused by cultural attitudes that denigrate the physical characteristics of minorities.

• In one study, bulimia was equally common among both Caucasian and African American women, although the latter were more likely to binge recurrently, to fast, and to use laxatives and diuretics to control weight. Binge eating may be an even more severe a problem in Hispanic Americans. A 2000 study on Asian women also reported rates of dieting and body dissatisfaction that were similar to those in other cultures, but Asian women had much lower percentages of actual eating disorders.

SOCIOCULTURALSOCIOECONOMIC FACTORS

• Living in any economically developed nation on any continent appears to pose more of a risk for eating disorders than belonging to a particular population group. Symptoms remain strikingly similar across high-risk countries.

• Income Levels. Oddly enough, within developed countries there appears to be no difference in risk between the rich and the poor. Some studies suggest that those in lower economic groups may be at higher risk for bulimia.

• Urban Life. City living is a risk factor for bulimia but it has no effect on the risk for anorexia.

• Intelligence. In one sample, people with eating disorders scored significantly higher than average on IQ tests. People with bulimia, but not anorexia, had higher nonverbal than verbal scores.

SOCIOCULTURALSports

Athletes are more likely than nonathletes to exhibit abnormal eating attitudes and behaviors when they’re involved in sports that place emphasis on leanness, body image, being scantily clad. High achieving people are more likely to compulsively exercise and diet than people who are less achievement oriented.

SPORTS (Con’t)• Female Athletes and Dancers. Women in "appearance" sports,

including gymnastics and figure skating, and in endurance sports, such as track and cross-country, are at particular risk for anorexia. Success in ballet also depends on the development of a wiry and extremely slim body. Estimates for episodes of eating disorders among such athletes and performers range from 15% to over 60%.

• Male Athletes. Male wrestlers and lightweight rowers are also at risk for excessive dieting. One-third of high school wrestlers use a method called weight-cutting for rapid weight loss. This process involves food restriction and fluid depletion by using steam rooms, saunas, laxatives, and diuretics. Although male athletes are more apt to resume normal eating patterns once competition ends, studies show that the body fat levels of many wrestlers are still well below their peers during off-season and are often as low as 3% during wrestling season.

• Of concern is a recently recognized body-image disorder, referred to as muscle dysmorphia, which occurs mostly in men who are preoccupied with weight lifting and who perceive themselves as puny.

SOCIOCULTURALPeers

• Teasing and bullying affect many children and teens. Appearance is one of the most common reasons for teasing, with weight being a major target. Young people understand that thin is pretty and fat is ugly.

• 81% of 10 year olds are afraid of being fat. Children who are taunted feel self-conscious and bad about how they look. Some vow to lose the weight no matter what. This can lead to dieting or restricting calories, intense exercising, use of diet pills or street drugs, bingeing after a period of restricting, and purging in some form to prevent weight gain.

• Some teens can also be influenced by their friends’ unhealthy habits, observing how the friend manipulates weight by engaging in eating disordered behavior.

2) FAMILIAL FACTORS

Families also have a powerful influence on beliefs people hold about themselves, other people, and the world in general. Whatever their families value, it’s likely they do to. For instance, if parents find education important so do their children. If parents rate making money as the highest goal, so will their offspring. This is similarly true for being thin and attractive.

Familial factors/dynamics15 most salient factors

• Parent(s) expect their children to be successful and achievement oriented • Parent(s) push their children to be perfect in attitude and appearance • Parent(s) chronically criticize their children and/or each other • There are a great many conflicts without the ability to resolve them • The expression of painful or “negative” emotions is discouraged • Children feel disconnected from one or both parents • Parent(s) are either overinvolved or underinvolved with children • Parent(s) are controlling • Parent(s) emphasize weight and thinness • There is a family history of eating disorders (i.e., parent(s) diet; use food to

cope; are obsessed with their size, shape, or weight; talk about weight concerns; express body hate; judge people with weight problems; etc.)

• Children are given food to soothe painful feelings • There is physical, emotional, and/or sexual abuse (Studies have reported

sexual abuse rates as high as 35% in women with bulimia.)

FAMILIAL FACTORSInsecure Infancy.

Some experts theorize that parents who fail to provide a safe and secure foundation in infancy may foster eating disorders. In such cases, children experience so-called insecure attachments. They are more likely to have greater weight concerns and lower self-esteem than are those with secure attachments.

SPECIFIC TO FAMILIES OF ANOREXICS

Although research has yet to find characteristics that are specific to families of anorexics, Strober (1991) has found that these factors below apply. There is:

• A limited tolerance of disharmonious affect or psychological tension

• An emphasis on propriety and rule-mindedness • An overdirection of the child or subtle

discouragement of autonomous strivings • Poor conflict resolution due to ineffective skills

SPECIFIC TO ANOREXICSProblems Surrounding Birth

• In some studies people with anorexia have reported a higher than average incidence of problems during the mother's pregnancy or after birth. These problems include the following:

• Infection. • Physical trauma. • Seizures. • Low birth weight. • Older maternal age.• Some experts believe that such patients experienced an injury to

the brain while in the womb that predisposed them to eating problems in infancy and to subsequent eating disorders later in life. Studies have suggested that people with anorexia often had stomach and intestinal problems in infancy.

SPECIFIC TO FAMILIES OF BULIMICS

Research suggests that three factors are unique to the families of individuals with bulimia nervosa (American Psychiatric Association, 1993). These include a family history of:

• Substance abuse (e.g., parent(s) use substances to deal with life’s problems)

• Obesity and/or migraines: People with bulimia are more likely than average to have an obese parent or to have been overweight themselves during childhood.

• Affective disorders (i.e., depression)

Consequences of family dynamics

• Girls (90% of eating disordered population) and boys (10%) who come from families with the characteristics listed above are more likely to develop a negative belief system.

• Harsh feedback along with parental role-modeling make it difficult for them to create a positive self-image.

• Their desire to be loved, cared for, and accepted by their parents and to fit into the family’s paradigm fuels their drive for perfection and the need to be in control of themselves and their emotions.

• When they don’t measure up, they become self-critical (in ways similar to how their parents were critical of them). They wind up feeling worthless, inadequate, or defective, unable to accept their flaws.

• They will do just about anything to feel good about themselves, often resorting to changing things outside themselves (i.e., weight, appearance, grades, friends, etc.) to feel okay on the inside.

Consequences of family dynamics

• These young people veer in one of two directions: • They’ll either starve (dieting that has become restrictive

with calories and food choices) to attain a faultless appearance and numb out painful emotions.

• Or they’ll turn to food for comfort or companionship (food is the buddy that never judges).

• A certain subset of this group will learn to purge in order to prevent weight gain and cleanse the body not only of food but also of unpleasant feelings.

Abusive/Neglectful homes

• Children who come from abusive or neglectful homes have developed their own ways to survive.

• Some become "parents," caring for themselves and their siblings. Others are "in-home paramedics," taking care of parents with substance abuse problems, mental health issues or physical disabilities. Still others learn to raise themselves or exist for much of their young lives as sources of comfort or pleasure for their parents.

• They usually have unmet dependency needs such as inadequate or sporadic attention and physical care. They may have gone without basic physical necessities or may have received minimal amounts of food, attention and shelter.

Abused/Neglected Children

• Many of these children believe they are at fault.

• They may think they caused their caregivers to neglect them.

• Therefore, they change their behavior, either hoping to receive approval and attention or in an effort to obtain the necessities they were lacking.

Abused/Neglected Children

• They may beg or steal food, hoard food, or complain of constant hunger.

• They may exhibit “Hypher-phagia”, unable to stop eating to the point of vomiting, because of an obsession to survive.

• They may demonstrate neurotic traits and are at high risk for substance abuse.

• They may have difficulty in many relationships, including parental, peers, schools…

TRAUMA Emotional, physical, and sexual trauma profoundly affects a person’s psyche.

Trauma occurs within the family when one or both parents are hostile, verbally attacking, hypercritical, too controlling, uncaring, uninvolved, ignoring or withdrawing from child, physically violent, or sexually abusive.

Traumas Outside the Home

• Traumatic events like

* bullying at school

* being repeatedly humiliated by a teacher in front of classmates

*or molestation by a neighbor happen outside the home.

CONSEQUENCES OF TRAUMA

• A person exposed to sustained and/or excessive trauma may exhibit symptoms of posttraumatic stress disorder with impaired affect modulation; self-destructive and impulsive behavior; dissociative symptoms; somatic complaints; feelings of ineffectiveness, shame, despair, or hopelessness; feeling permanently damaged; a loss of previously sustained beliefs; hostility; social withdrawal; feeling constantly threatened; impaired relationships with others; or a change from the individual’s previous personality characteristics.

• The effects of trauma have to be treated along with the eating disorder.

3) BIOGENETIC FACTORS

There are a number of biological and genetic factors that correlate with the development of eating disorders.

ANOREXIA NERVOSA• There is an increased risk of anorexia nervosa

among first-degree biological relatives of individuals with anorexia

• An increased risk of mood disorders has been found among first-degree biological relatives of individuals with anorexia nervosa, particularly anorexics with binge-eating/purging type of the disorder – There is a correlated genetic liability between

anorexia nervosa and major depression. – The heritability of anorexia is estimated to be

58%

ANOREXIA NERVOSA

• Research suggests that anorexia may occur, in part because of a chemical malfunction in the brain. Individuals with anorexia nervosa have increased levels of serotonin which reduces appetite, impulsiveness, and aggressiveness but may also boost perfectionism, obsessiveness, and negative affect. Anorexics may “diet” in an attempt to lower serotonin levels in order to decrease anxiety, obsessiveness, and perfectionism ). Starving also increases endorphins and cortisol, creating an opiate response that results in feeling energized when starving and tired when eating.

BULIMIA NERVOSA

Several studies have suggested a higher frequency of bulimia nervosa, mood disorders, and substance abuse and dependence in first-degree biological relatives of individuals with eating disorders.

- 43% of sisters and 26% of mothers of women with bulimia nervosa had an eating disorder diagnosis

- 22% of bulimics have a first-degree biological relative with major depression

- 9%-33% of bulimics have a first-degree biological relative with history of alcohol abuse

• One study suggests that bulimia may also be influenced by brain neurochemistry. Lowered brain serotonin can trigger some of the clinical features of bulimia nervosa in individuals who are susceptible to the disorder. Recovered bulimics, compared with nonbulimics, suffered more from the effects of being deprived of tryptophan, an amino acid that is used by the body to make serotonin. They showed bigger dips in mood, greater worries about body image, and more fear of losing control of eating). With reduced serotonin, there is increased likelihood of overeating, depression, anxiety, obsessions, aggressive-impulsive behaviors, suicidality, and substance abuse.

BINGE EATING DISORDER• The rate of obesity (Body Mass Index > 30) is higher in first-degree

relatives of females with binge-eating disorder (BED) than in those females without BED (26.8% vs. 18.7%).

• Morbidly obese subjects are more likely than a comparison group to have first-degree relatives with a history of depression, bipolar disorder, antisocial personality disorder, and other psychiatric disorders.

• In comparing females with and without BED, the overall prevalence rates of various psychiatric disorders in first-degree relatives are as follows. – Affective disorders: 10.5% (BED), 8% (non-BED) – Substance use disorders: 18.4% (BED), 15.2% (non-BED) – Anxiety disorders: 4% (BED), 2.7% (non-BED)

BINGE-EATING DISORDER

• One study focused on a gene linked to obesity to see if it plays a role in binge eating behavior. Melanocortin 4 receptor gene makes a protein by that name which helps stimulate a person’s appetite in the brain’s hunger-regulating hypothalamus. Too little protein is made if the gene is mutated, which leaves the body feeling overly hungry. Of the 469 severely obese participants, 25% were binge eaters. Five percent of the total group had the mutated gene. All members of this subgroup were binge eaters, compared with only 14% of the rest of the group who did not have the mutated gene (Branson et. al., 2003).

INHERITED TRAITS

• Below are 13 traits that genetic researchers believe are inherited:

Depression Anxiety Obsessiveness Compulsiveness Inhibitedness/shyness Dissocial behavior/schizoid Lability/emotional disregulation

Narcissism Pessimism Worrying Perfectionism Low frustration tolerance Sociopathy

4) INTRAPSYCHIC FACTORS

• There are a number of traits and characteristics that make individuals more vulnerable to developing an eating disorder.

PERSONALITY FEATURES

Research has identified a number of specific premorbid conditions that a young person exhibits prior to the development of an eating disorder (Academy of Eating Disorders, 1999).

Anorexia Nervosa

• Perfectionism – Overly compliant – Obsessive-compulsive – Exacting – Self-control

• Harm avoidance – Worrier – Pessimistic – Shy

• Easily fatigued • Low level of novelty seeking • Negative affect

AVOIDANT PERSONALITY DISORDER

• Some studies indicate that as many as a third of anorexic restrictors have avoidant personalities. This personality disorder is characterized by the following:

• Being a perfectionist. • Being emotionally and sexually inhibited. • Having less of a fantasy life than people with bulimia or

those without an eating disorder. • Not being rebellious, or being perceived as always being

"good.” • Being terrified of being ridiculed or criticized or of feeling

humiliated. People with anorexia are extremely sensitive to failure, and any criticism, no matter how slight, reinforces their own belief that they are "no good.”

The person with both anorexia and an avoidant personality disorder may develop a behavioral

and eating pattern as follows:

• For such individuals, achieving perfection, with all that that involves, is the only way they believe they can obtain love.

• Part of the drive for perfection and love is being trouble-free and attaining some ideal image of thinness. Eating is also associated with lower animal drives, so fasting has been linked historically to saintliness. The individual is driven to demand nothing, including food.

• Failure is inevitable, since being loved has nothing to do with being perfect. (In fact, people who are always seeking perfection often alienate others around them.)

• This failure to achieve love is followed by a sense of being even more imperfect (which is equivalent to being fat) and a renewed sense of striving for perfection (i.e., becoming even thinner).

ANOREXICSOBSESSIVE-COMPULSIVE

• Obsessive-compulsive personality defines certain character traits (e.g., being a perfectionist, morally rigid, or preoccupied with rules and order). This personality disorder has been strongly associated with a higher risk for anorexia. These traits should not be confused with the anxiety disorder called obsessive-compulsive disorder (OCD), although they may increase the risk for this disorder.

Bulimia Nervosa

• High level of novelty seeking • Negative affect • Affective Instability

– Low frustration tolerance – Low moods – Highly variable moods – High anxiety – Impulsive

• Low Self-esteem – Ineffectiveness – Body dissatisfaction – Interpersonal sensitivity – High achievement – Self-critical

Borderline Personalities. Studies indicate that almost 40% of people who are diagnosed with bulimic anorexia (losing weight by bingeing

and purging) may have borderline personalities. Such people tend to:

• Have unstable moods, thought patterns, behavior, and self-images. People with borderline personalities have been described as causing chaos around them by using emotional weapons, such as temper tantrums, suicide threats, and hypochondriasis.

• Be frantically fearful of being abandoned. • Be unable to be alone. • Have difficulty controlling their anger and impulses. (In fact, between one-

quarter and one-third of people with bulimia have impulsive symptoms.) • Be prone to idealize other people. Frequently this is followed by rejection

and by disappointment.• Some research has suggested that the severity of this personality disorder

predicts difficulty in treating bulimia, and it might be more important than the presence of psychological problems, such as depression.

Narcissism.

Studies have also found that people with bulimia or anorexia are often highly narcissistic and tend to:

• Have an inability to soothe oneself.

• Have an inability to empathize with others.

• Have a need for admiration.

• Be hypersensitive to criticism or defeat.

Accompanying Emotional Disorders

• Between 40% and 96% of all eating-disordered patients experience DEPRESSION AND ANXIETY disorders. Depression, anxiety, or both is also common in families of patients with eating disorders.

• Childhood anxiety disorder usually starts before 8 years of age.

Obsessive-Compulsive Disorder (OCD).

• Obsessive-compulsive disorder is an anxiety disorder that occurs in up to 69% of patients with anorexia and up to 33% of patients with bulimia. In fact, some experts believe that eating disorders are just variants of OCD.

• Obsessions are recurrent or persistent mental images, thoughts, or ideas, which may result in compulsive behaviors (repetitive, rigid, and self-prescribed routines) that are intended to prevent the manifestation of the obsession.

• Women with anorexia and OCD may become obsessed with exercise, dieting, and food. They often develop compulsive rituals (e.g., weighing every bit of food, cutting it into tiny pieces, or putting it into tiny containers).

• The presence of OCD with either anorexia or bulimia does not, however, appear to have any influence on whether a patient improves or not.

Other Anxiety Disorders. A number of other anxiety disorders have been associated with

both bulimia and anorexia.

• Phobias. Phobias often precede the onset of the eating disorder. Social phobias, in which a person is fearful about being humiliated in public, are common in both types of eating disorders.

• Panic Disorder. Panic disorder often follows the onset of an eating disorder. It is characterized by periodic attacks of anxiety or terror (panic attacks).

• Post-Traumatic Stress Disorder. One study of 294 women with serious eating disorders reported that 74% of them recalled a traumatic event and more than half exhibited symptoms of post-traumatic stress disorder (PTSD), which is an anxiety disorder that occurs in response to life-threatening circumstances.

5) Other factors

Being Overweight

• A 2002 study reported that among American teenagers 18% of overweight girls and 6% over overweight boys reported extreme eating disorder behaviors, including use of diet pills, laxatives, diuretics, and vomiting. With the increasing epidemic of obesity in America, such behaviors will only compound the health problems in obese young people.

VEGETERIANISM• In general, vegetarianism, with careful planning, is a healthy practice for

both adults and adolescents. Studies report, however, that vegetarianism in adolescence may be a risk factor for eating disorders in both males and females. In one study, while vegetarian teens ate more fruits and vegetables, they were also twice as likely to diet frequently, four times as likely to intensively diet, and eight times as likely to use laxatives as their non-vegetarian peers.

• This study does not mean that being a vegetarian equates with having an eating disorder. It does suggest, however, that parents with children who suddenly become vegetarian, should be sure that their children are eating a balanced meal with sufficient protein, calories, and important minerals, such as calcium. Parents also might suspect anorexic behavior in their child under certain conditions:

• If the child has stopped eating meat only to avoid fat rather than from other motives, such as love of animals or to improve health.

• If vegetarian diet coincides with rapid weight loss. • If the child avoids important vegetable products because of calories (such

as whole grains) or because of fats and oils (such as tofu, nuts, and dairy products).

Diabetes or Other Chronic Diseases

• According to one survey, 10.3% of teenage girls and 6.9% of boys with chronic illness, such as diabetes or asthma, had an eating disorder. Some recent research suggests an endocrinological link between obesity, diabetes, and eating disorders.

• Diabetes. Eating disorders are particularly serious problems for people with either type 1 or type 2 diabetes.

• Binge eating (without purging) is most common in type 2 diabetes and, in fact, the obesity it causes may even trigger this diabetes in some people.

• Both bulimia and anorexia are common in type 1 diabetes. Some experts report that one-third of insulin-dependent patients have an eating disorder, most often because diabetic women omit or underuse insulin in order to control weight. If such patients develop anorexia, their extremely low weight may appear to control the diabetes for a while. Eventually, however, if they fail to take insulin and continue to lose weight, these patients develop life-threatening complications.

Early Puberty

• There is a greater risk for eating disorders and other emotional problems for girls who undergo early puberty, when the pressures experienced by all adolescents are intensified by experiencing, possibly alone, these early physical changes, including normal increased body fat. One interesting study reported the following:

• Before puberty, girls ate quantities of food appropriate to their body weight, were satisfied with their bodies, and noted their depression increased with lower food intake.

• After puberty, girls ate about three-quarters of the recommended calorie intake, had a worse body self-image, and noted their depression increased with higher food intake.

• This study reported on girls without eating disorders, but it certainly suggests patterns that can lead to eating problems, particularly in girls who go through puberty early.

THE BIG QUESTION: NATURE VS. NURTURE?

• Genetics and environment work in tandem. People are born with certain biological predispositions. The environment in which a person grows up either enhances these traits or minimizes them. It is as if genetics are the ammunition in a gun and the environment either pulls the trigger or puts the gun down. Genetics and environment (societal and familial) lay the foundation for how people perceive, feel about, and see themselves as well as resiliency during stress, constancy of moods, and flexibility to roll with the punches.

• PS Insurance would cover more treatment were eating disorders seen as biological diseases…

SOME FACTS ABOUT TREATMENT

• Eating disorders start when the person is young, can last for years, and cost a great deal of money to overcome

• Almost nine out of 10 individuals with eating disorders (86%) report that the onset of their illness occurred before the age of 20.

• Three out of four (77%) said that the duration of their eating disorder ranged from one to 15 years.

• It costs $30,000 per month for an inpatient treatment program and $100,000 for outpatient treatment that includes therapy and medical monitoring.

COMPREHENSIVE TREATMENT PLANNING

• When you treat patients with eating disorders, you’ll need to consider how you’re going to address all the components of the eating disorder, what kind of therapeutic treatment modalities you’ll employ, and how psychotropic medications aid in the recovery process. Taking these factors into account can increase the chances of a successful outcome.

OVERALL TREATMENT GOALS

• Treat/remediate physical complications – Restore healthy eating patterns – Provide education regarding healthy nutrition and eating patterns – Correct core eating disorder related dysfunctional thoughts, attitudes, and

feelings – Treat associated Axis I and Axis II psychopathology including deficits in mood

regulation, self-esteem, and behavior – Enlist family support and provide family counseling and therapy where

appropriate – Prevent relapse

• In addition to the above: – Build coping strategies and self-regulatory skills – Teach assertiveness and communication skills – Address body disturbance – Encourage exploration of sexuality fears – Instigate steps towards separation and individuation – Focus on maturity fears

TEAM APPROACH

• It is essential to build a team of allied health professionals to help treat patients with eating disorders. These specialists are necessary for a number of reasons.

• They address components of the recovery process that are beyond your scope of training.

• They focus on areas that you won’t have adequate time to cover in one or two sessions a week.

• They provide authority to support the changes you’re proposing.

1. PHYSICIAN

• The first recommendation you make is for your patient to see a physician for a medical evaluation and ongoing monitoring. I prefer that the patient see an expert who treats eating disorders. Make sure the physician conducts a thorough physical along with complete blood tests so both of you have an idea of any damage that’s been done to the patient’s body.

• For patients who have a subclinical eating disorder or milder symptoms with no associated health problems, you can forgo this referral. Make the referral if and when it becomes necessary.

• Sometimes, for either financial or loyalty reasons, patients want to see their own physician. Whether your patient sees the person you suggest or her/his own doctor, obtain a release so you can talk to the physician before and after the exam. Provide information gleaned in the initial visit that may aid in the evaluation. Keep in contact with the physician so you know the medical treatment recommendations and are apprised of temporary or chronic symptoms.

• Use medical information as leverage. The development of serious physical consequences can be a motivating factor for change, especially if your patient doesn’t feel well and is frightened that the condition will worsen. As your patient recovers, lab tests often return to normal, and health rebounds.

2. DIETITIAN

• On Your Own: It is not always necessary to refer a patient for nutritional counseling. Decide case by case whether you have enough training to manage the education and implementation of balanced meal planning. Never recommend any kind of dieting (i.e., low-carbohydrate diets, low- or no-fat diets, calorie restrictive diets, the latest best-selling diet, etc.). Stick to sound nutritional guidelines. You may be able to provide this service for patients who:

• Have come from a treatment program where they worked with a dietitian and are following those meal plans

• Are beginning eating disordered behavior and have not strayed far from normal eating

• Have binge-eating disorder or chronically diet and are ready to follow your advice

• Blind (back to scale) weigh-ins are necessary for patients who need to gain weight, lose weight, or fear they are gaining weight as they reduce purging behaviors. Weigh-ins are very anxiety-producing for patients, so you’ll need to discuss feelings and fears each time they are required to step on the scale.

Referral to a Dietitian:• Once you decide to send your patient to a dietitian, choose someone who has

extensive training and experience in working with eating disorders. These specialists understand how to talk about food in ways that are less threatening. They know how food affects the patient’s mood, level of fear, and the body’s ability to digest. They anticipate the dangers of refeeding an anorexic patient. They employ strategies to lower resistance and raise compliance when fats, carbohydrates, and/or calories are reintroduced. A referral is recommended for patients who have:

• Anorexia nervosa and the refeeding process is complicated, dangerous, and slow • Bulimics and anorexics need help with a wide variety of changes in food habits • Multiple comorbid issues that must be addressed which leaves little time for

comprehensive reeducation around food behaviors • Sneaky ways of hiding food behaviors and denying the gravity of their disorder • Doubts about your expertise with nutrition • Faith in a dietitian’s knowledge base • Make sure your patient signs a permission to release information form. After each

meeting, have the dietitian call to tell you the patient’s food and weight goals, areas of struggle, positive changes made during the week, and actual weight (if the dietitian is doing the weigh-ins).

3. PSYCHIATRIST:

• A percentage of eating disordered patients will need psychotropic medications to reduce emotional and behavioral symptoms. If a new patient has a psychiatrist, obtain a release so that you can discuss the case. Ask about their history and the psychiatrist’s observations. Keep in contact as needed.

• If the patient is not taking medications, assess the severity of depressive, anxious, obsessive-compulsive, and bulimic symptoms. Decide whether it is appropriate to make a referral to a psychiatrist who understands eating disorders. Find out what your patient would like to do. Does the person wish to see if symptoms remit with therapy alone, want or need medications, or resist the idea of taking medications even if it’s a sound one? If the patient is reluctant and you believe medications would aid recovery, work with and periodically bring up your observations and inform her/him of the potential benefits of psychotropic medications.

4. INPATIENT PROGRAMS

• There are several reasons why you would refer your patient to an eating disorders hospital program or residential facility that provides medical and psychiatric care.

• Anorexic symptoms (i.e., dangerously compromised weight, excessive exercise addiction, extreme calorie restriction) or bulimic symptoms (i.e., multiple daily binges and purges that disrupt daily activities, unremitting laxative abuse) are so severe and entrenched that meeting one to two times a week will have no impact.

• Patient’s symptoms seriously worsen during therapy and stay that way for over a month.

• Patient’s symptoms show no sign of improvement over a three to four month period and you believe a program is the only hope.

• Patient’s health is medically compromised. • Patient’s weight is 25%-30% below healthy body weight at the start of

treatment and little weight gain will be achieved in outpatient treatment.• Debilitating depression or anxiety in which the patient is suicidal or cannot

function.

INVOLUNTARY HOSPITALIZATION

In some severe cases, patients with anorexia may need to be hospitalized involuntarily. A 2000 study reported that such patients respond as well as patients who were admitted voluntarily. And most later agreed that such treatment had been necessary.

Duration of Inpatient Treatment

• It usually takes 10 to 12 weeks of hospitalization with full nutritional support to reach normal body weight.

• Insurance usually only allows 15 days.• This places patients with severe anorexia

at great risk for relapse and serious health consequences.

• It is critical that they achieve 100% of ideal weight before being released.

Intensive Outpatient Program:

• These programs are recommended for patients who need more help than what is offered outpatient, but benefit from being able to sleep at home, attend school or work in the evenings, and continue some aspects of their lives without regressing into destructive behaviors.

B. THERAPEUTIC TREATMENT MODALITIES

1. PSYCHOTHERAPY OPTIONS

• Outpatient treatment options include individual, group, family, and couples therapies. Patients may require a combination of these to address their unique circumstances. Some need individual psychotherapy with any of the following: physician, nutritionist, psychiatrist, group, couples, and/or family therapies. Others need to see the psychotherapist, physician, nutritionist, and psychiatrist. And yet others only need individual psychotherapy. You decide what is best for your patient. Factor in the patient’s financial situation and limitations that insurance plans bring.

YOUR ROLE

• You are the team leader who tailors treatment and oversees the recovery process. You’ll be in contact with the allied health professionals and therapists who are working with your patient. Your role is to make sure that everyone has the same goals and is informed about pertinent issues (i.e., patient engages in splitting between two practitioners, doesn’t share relevant information with another team member, tells different things to different people, etc.). With every team member being on the same page, recovery can move along more smoothly.

Individual Psychotherapy:

• Some patients can be seen once a week whereas others must be seen twice a week to have any impact. The severity of symptoms, stability of mood and health, and finances will be the defining factors in how often you schedule sessions.

• It should be noted that people with severe anorexia have mental deficits and may not respond well to psychological therapies until they regain their weight.

Group Therapy:

• Therapist-led and self-help groups provide added support. Groups allow patients to meet people with similar problems, reduce isolation, and offer camaraderie. Some people like groups, whereas others are wary about revealing personal information to strangers. Organizations like National Association of Anorexia Nervosa and Associated Disorders (see Resources) offer free self-help groups throughout the country. If the group is facilitated by a therapist, obtain permission to release information so you can coordinate treatment.

Family Therapy:

• Working with the family is especially important with teens because the family environment contributes to the eating disorder. Some families are willing to participate in family therapy; some teens are too. Others don’t want their families involved or parents think it's the teen's problem and your role is to fix it.

• Ask both parents to come in with their teen for the initial session. If parents are divorced, have the custodial parent bring the teen. Know your state laws. Some states require that both parents give signed permission for treatment to begin. Ideally, you’ll want to meet both parents (unless one lives out of town) to assess family dynamics. As you get to know the parents and the relationship with their child, you’ll see patterns that contributed to the development of the eating disorder and now continue to maintain it.

• The eating disorder serves a wide variety of un- or subconscious functions for the family. For instance, the teenager:

• Becomes the identifiable patient, distracting the family from deeper issues

• Is the voice of pain and dissatisfaction that no one else expresses

• Exhibits the wounds of childhood abuse on her/his outside presentation

• Is trying to be the best to make the parents happy • Is rebelling against the dysfunctions, trying to get the

parents’ attention • Therapy can address dysfunctional family dynamics so that

shifts occur in how members interact, solve problems, express love or disapproval, and offer support.

• My personal preference is to meet with the teen for 30 minutes and then bring in the primary parent for the remaining 20 minutes. What the parent and teen each observe at home is very useful information. This parent (usually the mother) may be involved in the refeeding process by preparing meals and overseeing what is eaten. As long as the parent is not critical or judgmental but firm, this is an asset to therapy even if the teen is resistant. Periodically bring together family members willing to come in for a session. If additional family therapy is required, decide if you will do it once a week, every other week, or refer to a colleague.

Foster Families

• Requires creating a relationship of trust

• Require MUCH patience

• Requires allowing the child to grieve his/her losses

• Requires teaching the child to express his/her feelings, constantly assuring the safety of doing so.

For Foster Families

• Do not punish the child for hoarding, stealing, hiding food…

• Provide reassurance that there will be enough• Designate a special snack shelf and keep it filled• If insecurity is severe, let the child keep non-

spoiling food in his/her room• Have healthy snacks available to the child• Have regular, healthy meals so that child learns

to trust he/she will be cared for.

Above all…

• Eating habits take a long time to change. Try to make the sharing of food a pleasant and nurturing time.

• Do not make food a means of punishment or try to control children by threatening or bribing with food. A child’s eating is not a reflection of how good a parent you are.

• Think of eating as a habit. You are trying to get all your children to get into the habit of eating well. Some children may have a harder time learning and need your patience and guidance.

Couples Therapy:• Marriage and live-in partners are often affected by eating disorders. Patients

gets so wrapped up in their behaviors and may have such intense body image concerns that relationships suffer. Part of the focus in couples therapy is educating the partner about the complexities of an eating disorder and how recovery will proceed.

• Family of origin members and partners can benefit from guidelines on what to do and not do to assist recovery. Both parents and partners can:

• Avoid criticism, contempt, or comments concerning behaviors, weight, or appearance

• Stop monitoring eating and other related food behaviors (unless this becomes a part of the treatment plan)

• Offer support and encouragement for change • Point out where the patient is regressing as long as patient agrees to this

feedback • Set up structure so joint meals are around the same time each day and food

preparation is a low stress experience • Use children’s set meal times to eat together as a family • Couples therapy can also improve communication skills, resolve intimacy

concerns, and strengthen the bond between both people.

2. FORMS OF TREATMENT

• Cognitive, behavioral, interpersonal, and psychodynamic therapies are the most common forms of therapy utilized with eating disordered patients.

• Cognitive Therapy: This form of treatment is used to reduce the negative thought processes that fuel the eating disordered behaviors. The focus is on changing cognitive distortions and negative self-talk that increases depression and/or anxiety, which in turn triggers starving, bingeing, purging, or grazing. Patients learn to expand their ability to tolerate and cope with overwhelming emotions. The role of negative beliefs and their relationship to internal dialogue, defense mechanisms, and the functions of the eating disordered behaviors are also explored.

Cognitive-Behavioral Therapy:• Cognitive therapy is often combined with behavioral therapy to become

cognitive behavioral therapy (CBT). It is generally provided outpatient, consists of 19 sessions over a 20-week period, and is comprised of three stages (Wilfley and Cohen, 1997).

• Phase 1: behavioral strategies are introduced to interrupt the cycle of food restraint, binge eating, and purging

• Phase 2: cognitive strategies are used to challenge dysfunctional attitudes and beliefs that perpetuate disordered eating

• Phase 3: relapse prevention techniques are employed to consolidate and facilitate maintenance of changes after treatment

• CBT is found to be more effective and produced greater overall improvement than other forms of therapy in reducing disturbed attitudes towards shape, weight, dieting, and the use of vomiting to control shape and weight . Short-term behavioral therapy alone did not fare as well as CBT.

• In comparing use of medication and therapy, CBT alone is generally superior to antidepressant medication alone, and there may be some advantages to combining the two treatments.

Cognitive-Behavioral Therapycon’t

One approach for bulimia is the following:• Over a period of four to six months the patient builds up to three meals a

day, including foods that the patient has previously avoided. • During this period, the patient monitors and records the daily dietary intake

along with any habitual unhealthy reactions and negative thoughts toward eating while they are occurring.

• The patient also records any relapses (binges or purging). Such lapses are reported objectively and without self-criticism and judgment.

• The patient discusses the responses with a cognitive therapist at regular sessions. Eventually the patient is able to discover the false attitudes about body image and the unattainable perfectionism that underlies the opposition to food and health.

• Once these habits are recognized, food choices are broadened and the patient begins to challenge any entrenched and automatic ideas and responses. The patient then replaces them with a set of realistic beliefs along with actions based on reasonable self-expectations.

CBT’s effectiveness

• CBT is successful in approximately 60% of the bulimic cases.

Interpersonal Therapy:

• This form of therapy is the only other treatment besides CBT where patients maintained change at one and six year follow-up evaluations. Interpersonal therapy (ITP) was designed as a short-term treatment for depression and then adapted to treat bulimia nervosa. ITP focuses on disturbances in social functioning that are associated with the onset and maintenance of the disorder. Treatment strategies address four social domains: grief, interpersonal disputes, role transitions, and interpersonal deficits.

INTERPERSONAL THERAPY

• Interpersonal therapy deals with depression or anxiety that might underlie the eating disorders along with social factors that influence eating behavior. This therapy does not deal with weight, food, or body image at all.

The goals are the following:• To express feelings. • To discover how to tolerate uncertainty and change. • To develop a strong sense of individuality and

independence. • To address any relevant sexual issues or traumatic or

abusive event in the past that might be a contributor of the eating disorder.

Psychodynamic Therapy:• This therapy is widely practiced with a variety of disorders, including eating

disorders. Although few controlled studies have looked at the effectiveness of psychodynamic therapy, two variants have been studied: Supportive expressive psychotherapy (SET) and Supportive psychotherapy (SPT). CBT was more effective than both of these treatments in reducing purging, dietary restraint, distorted body image as well as depression and distress; and raising self-esteem (Wilfley and Cohen, 1997).

• Psychodynamic therapy can be used in addition to CBT in long term therapy to explore:

• The powerful effects of the family on the patient • How, where, and when negative beliefs developed • Sense-of-self • Identity issues • The role of defense mechanisms • Transference • Countertransference • Unresolved issues created in childhood and adolescence.

3. PSYCHOPHARMACALOGIC TREATMENT

• There are a wide variety of psychotropic medications that the psychiatrist can choose from to treat depression, anxiety, obsessive-compulsive tendencies, and eating disordered behaviors. Some patients will require pharmacologic intervention to reduce symptomatology.

Medications for Bulimics

• The drugs commonly used for bulimia are anti-depressants known as SSRIs (selective serotonin reuptake inhibitors).

• They include: Prozac, Paxil, and Luvox.

• A combination of CBT and SSRI is particularly effective, if CBT on its own is not helpful.

Alternative Approaches to Bulimia

• Hypnosis: Bulimics seem to have a high susceptibility for hypnosis, suggesting it might be a beneficial part of their treatment. Anorexics are very resistant to the state of vulnerability engendered by this process.

• Guided Imagery: A study showed it reduced the frequency of bines and vomiting by almost 75%. This method uses audiotapes to evoke images which reduce stress and help achieve specific goals.

Medications for Anorexics

• There are not many reported benefits associated with SSRIs for anorexics, though they may help prevent relapsed for anorexics who have restored weight.

• Anti-anxiety agents: Patients with anxiety disorders and anorexia may benefits from agents that treat anxiety

• Atypical Antipsychotics: Certain agents usually used for schizophrenia and bipolar disorder have been shown to stabilize mood and produce significant weight gain. Zyprexa is such an agent for severe treatment-resistant anorexia.

HOLISTIC HEALING

Physical Self

Emotional Self

Mental Self

Spiritual Self

THERAPIST“Heal Thyself”

• Examining your own attitudes towards food, body image, eating disorders, addiction…

• Exercise: Self-portrait

Physical Self

• Eating Disorder are diseases of the body, affecting nutrition and physical health

• Work with a nutritionist who is knowledgeable in eating disorders

• Help them connect to the wonder of their physical bodies and the painful consequences of the eating disorder onto their bodies

• Encourage them to avoid mirrors and scales. The mantra is not “How do I look?” but “how do I feel?”

EXERCISE

Journey into the Body

Emotional Self

• Eating disorders are diseases of the psyche, affecting feelings and emotions

• Provide a safe space for the clients to examine and express their emotions, current and/or past

• Slowly encourage clients to EMBODY, for that is where their feelings lie. GO SLOW. You don’t want to rewound.

• As they learn to connect to sensations, guide them in not repeating a story but rather staying present to what they are feeling NOW.

• Help them become aware how their distorted thoughts often create distorted feelings. Work with the thoughts.

EMOTIONAL HEALING

• Help the client understand that they are trying to communicate deeper needs and feelings through their eating disorder.

• Congratulate them for finding the best way they knew how and invite them to find a less costly way to communicate

• Invite their own creativity to surface in order to safely express their feelings and needs.

Exercise

• Family Sculpting, Virginia Satir• Uncovering other forms of communication: for

individual therapy and/or family therapy1) art2) sand tray3) music4) dance5) psychodrama6) sports7) puppets/animals

Mental Self

• Eating disorders are diseases of the mind, affecting cognition (thinking) and attitudes (with severe anorexia, you cannot work on cognition until weight gets stabilized).

• Actively work with reframing distorted thoughts and belief systems

• Discuss sociocultural factors and invite them to become discerning viewers; make media collages: “ideal” versus “varied body shapes”.

• Make an art poster of “FAMILY RULES”. Balance it with a poster of new, healthier rules.

• Practice “reality checking”. A great example of this is Byron Katie’s The Work.

EXERCISE The Work, by Byron Katie.

1. Is it true?

• (Close your eyes, be still, go deeply as you contemplate your answer.If your answer is no, continue to Question 3.)

2. Can you absolutely know that it's true?

Can you know more than God/reality?

• Can you really know what's best in the long run for his/her/your own path?

• Can you absolutely know that you would be happier if you got what you wanted?

 

3. How do you react when you think that thought? (When you believe that

thought?)• Where does the feeling hit you, where do you feel it in your body when you believe that thought?

How far does the feeling travel? Describe it. • What pictures do you see when you believe that thought? Watch it, be still, notice. • When did that thought first occur to you? • How do you treat others when you believe that thought? What do you say to them? What do you

do? Whom does your mind attack and how? Be specific. • How do you treat yourself when you believe that thought? Is this where addictions kick in and you

reach for food, alcohol, credit cards, the TV remote? Do thoughts of self-hatred occur? What are they?

• How have you lived your life because you believed that thought? Be specific. Close your eyes, watch your past.

• Does this thought bring peace or stress into your life? • Where does your mind travel when you believe that thought?

(List any underlying beliefs, and inquire later.) • Whose business are you in when you think that thought? • What do you get for holding onto that belief? • Can you find a peaceful reason to keep that thought? • What terrible thing do you assume would happen if you didn't believe that thought? Write down

the terrible thought, and turn it around to the opposite and test it for yourself - is the opposite as true or truer?

4. Who would you be without the thought?

• How would you live life differently if you didn't believe that thought? Close your eyes and imagine life without it.

• Imagine you are meeting this person for the very first time with no story. What do you see?

• Who are you right now, sitting here without that thought?

Turn the thought around.

• (Statements can be turned around to yourself, to the other, to the opposite, and to "my thinking," wherever it applies. Find a minimum of three genuine examples in your life where each turnaround is as true as or truer than your original statement.)

• If you lived this turnaround, what would you do, or how would you live your life, differently?

• Do you see any other turnarounds that seem as true or truer?

Spiritual

• Eating disorders are diseases of the Soul• There is an emptiness, a numbness inherent in all eating

disorders.• Healing in the spiritual dimension is about inviting

wholeness for the client. • To ‘heal” means to “make whole”• Healing means finding your Center and trusting it will

help you contain ANYTHING that comes up. • Art therapy is a wonderful tool to work with the spiritual

dimensions• Encourage prayer, meditation, yoga,…Any centering

practice will bring you into your Wisdom and Higher Self

• Teach the client that finding their true Selves has to occur THROUGH the Body.

• Help the client see the body as sacred (BodyBeloved); help him/her understand they need to be in relationship with their bodies; that what they act out onto their bodies is painful to their bodies; that they can use their hearts to foster a healthy, loving relationship.

• Help the client connect to the sacredness of the Eating Disorder Journey. It is its own spiritual path.

Family TherapyBrief Therapy Model

• Insurance covers brief therapy.

3 Skills for Brief Therapy

1) Joining

2) Assessment

3) Restructuring

Brief Therapy Skills 1) Joining

- Establish a working relationship with each member and enter the family system as a member and leader.

- This can be challenging, as there is often resistance, either from the eating disordered patient, or from certain family members.

2) Assessment

Examine interactions along five interactional dimensions: • Structure (hierarchy, leadership, behavior control,

guidance/nurturance)• Resonance (over- or under-involvement)• Developmental stage (appropriateness of roles

according to their stages of life)• Identified patient (the extent to which family centralizes

adolescent in their interactions, negativity about and nurturing/protection of misbehaviors)

• conflict resolution (style of resolving differences- denial, avoidance, diffusion, resolution…)

3) Restructuring

a) work in the present: Enactments then restructure to facilitate more positive interactions.

b) reframe: allows family to perceive interactions or situations from a different perspective (anger towards a child is based on love, for ex.). Helps them interact more positively

c) work with boundaries and alliances: shift boundaries to appropriate levels (more solid bond between parents; more solid parenting from both parents…)

TO CONCLUDE

Eating disorders are complex diseases with many contributing factors and many concurrent imbalances.

Please be patient, with your client, his or her family, and most of all, yourself.

Compassion, warmth, genuiness, and openness will serve you better than any technical brilliance.

TRUST YOURSELF!

THANK YOU!

ISABELLE TIERNEY, M.A.

www.bodybeloved.com

www.thehabitexperts.com

303-817-6912