Transcript WELCOME TO THE EATING DISORDERS TRAINING

WELCOME TO
THE EATING DISORDERS
TRAINING
EATING DISORDERS ARE NOT
ABOUT 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 FEELINGS
1) 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 DISORDER
ABOUT 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 NERVOSA
Diagnostic 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 selfevaluation, 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
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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 selfdiscipline 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
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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:
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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:
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Brittle nails
Carotenodermia (dry, flaky skin)
Lanugolike facial hair (fine hair growth)
Pruritus (itchy skin)
Thinning scalp hair
Cardiovascular:
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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)
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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:
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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 NERVOSA
Diagnostic 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 selfinduced 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
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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:
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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)
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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
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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)
Accompanying
Self-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-thanaverage 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:
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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 BINGE
EATING DISORDER
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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)
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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 bingeeating 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
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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 Food
This 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) SOCIOCULTURAL
MEDIA
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Beauty Standards
Advertising
Diet Industry
Snack and Fast Food Industries
Feeding Insecurities
SOCIOCULTURAL
Ethnic 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 HispanicAmericans 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.
SOCIOCULTURAL
SOCIOECONOMIC 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.
SOCIOCULTURAL
Sports
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.
SOCIOCULTURAL
Peers
• 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/dynamics
15 most salient factors
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•
•
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 FACTORS
Insecure 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 selfesteem 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 ANOREXICS
Problems 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 hungerregulating 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).
ANOREXICS
OBSESSIVE-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 onequarter 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 eatingdisordered 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 nonspoiling 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:
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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:
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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 Therapy
con’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:
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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 therapy
1) art
2) sand tray
3) music
4) dance
5) psychodrama
6) sports
7) 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?)
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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 Therapy
Brief Therapy Model
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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:
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Structure (hierarchy, leadership, behavior control,
guidance/nurturance)
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Resonance (over- or under-involvement)
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Developmental stage (appropriateness of roles
according to their stages of life)
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Identified patient (the extent to which family centralizes
adolescent in their interactions, negativity about and
nurturing/protection of misbehaviors)
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conflict resolution (style of resolving differencesdenial, 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