LEARNING OBJECTIVES

This is a beginning to intermediate level course. After completing this course, mental health professionals will be able to:

INTRODUCTION

Welcome to Feast or Famine: The Etiology and Treatment of Eating Disorders. This beginning to intermediate three-hour course will help you gain a working knowledge of eating disorders so you can provide better psychological care. The primary focus is the range of factors that contribute to the development of eating disorders along with an understanding of psychotherapeutic and psychopharmacologic treatment. Information includes diagnosis, assessment, and comprehensive treatment planning. Case studies will highlight different aspects of the recovery process to enable you to integrate the course into private practice and clinical settings.

CHAPTER I: ETIOLOGY

A. INCIDENCE

Here is some food for thought:

(Sources: Horm and Anderson, 1993; Vukovic, 1997; Brownell and Rodin, 1994; National Center for Health Statistics, 2000; National Association of Anorexia Nervosa and Associated Disorders, 1994; Mehler, 1996; National Association of Anorexia Nervosa and Associated Disorders, 1994)

Four factors contribute to the development of an eating disorder. These factors are sociocultural, familial, biogenetic, and intrapsychic.

B. SOCIOCULTURAL FACTORS

1. MEDIA

Beauty Standard: Every society has a standard of beauty. The media is one of the biggest influences affecting our assessment of attractiveness. Magazines, movies, and television suggest how we should look, act, and achieve. Media images permeate consciousnesses throughout the day. Products and people are packaged in tantalizing ways to induce us to purchase items or see the latest movie or television show. Famous people are offered up for visual consumption to satisfy a seemingly never-ending curiosity. The business of beauty is a fickle one. Over the last sixty years, the beauty ideal has changed with each successive decade. Some of these changes are:

Within the last five to ten years, idealized images of male bodies have been used to target young men in advertising. They have responded by worrying that their bodies don’t measure up. This has, in turn, led to an increase in dieting and weightlifting, and the use of over-the-counter muscle-building supplements and steroids.

In 1958, Miss America pageant contestants were an average of 5’ 8” tall and weighed 132 pounds. By 1980, each weighed around 117 pounds (Wilson, 1996). Their weight is 15% below normal for their height and age, which is the primary diagnostic criterion for anorexia nervosa.

The average American woman is 5'4" and weighs 140 pounds. The average model is 5'11" and weighs 117 pounds. Only 2% of women look like this thin-ideal model. 98% don't and, in fact, can't do so without resorting to harmful measures (Smolak, 1996).

If Barbie were blown up to human proportions, her measurements would be 31”- 17”- 28”.

While 90% of white junior high and high school girls voiced dissatisfaction with their weight, 70% of African American teens were satisfied with their bodies. White teens described body perfection as 5’7” and 100 to 110 pounds (Parker et al., 1995). This reflects the different ethnic views of what is appealing. African American females believe that attaining the “perfect” size is more feasible—round hips, thicker thighs, and curves. In part, they attribute this to their mothers who never diet, whereas white girls know that moms diet and dads eat normally. Even though body acceptance is more prevalent in the African American female community, weight standards may not be healthier if individuals are overweight or obese (Ingrassia, 1995). In one study, dieting and self-loathing were predictors for the drive for thinness in White women and African Americans of either gender. However, intrapersonal anger predicted drive for thinness in White men, suggesting a link between anger and eating disorders (Aruguete et al., 2005).

Advertising: Advertisements are both the creator and reflection of our culture. Many television and magazine ads are geared towards improving appearances (e.g., skin care, hair care, nail care, clothing, makeup, weight-loss). These ads convey subtle and not-so subtle messages in order to:

The constant emphasis on thinness has negative effects on women. Female undergraduates at Arizona State University were shown images of average-sized models and ultra-thin models. The women exposed to the thin-ideal reported depression, stress, guilt, shame, insecurity, and body dissatisfaction. Analysis of the data indicated that negative affect, body dissatisfaction, and subscription to the thin-ideal predicted bulimic symptoms (Stice and Shaw, 1994).

Diet Industry: Because of pressures to fit in and be thin, many people will try just about anything to lose weight. Weight loss is a $30 billion a year industry. The products run the gamut from diet drinks and foods to pills, exercise equipment, and special regimens. Advertisers play on feelings of self-doubt and the burgeoning weight problem in this country. Because 90% of dieters fail to keep weight off for two or more years, they continue to try one product after another with less and less hope of attaining permanent weight loss. Dieting causes more problems than it eliminates.

Snack and Fast Food Industries: On the flip side, these industries are also multi-billion dollar enterprises. High-fat, high-sugar, and high-salt foods and beverages can be found in convenience stores, grocery stores, candy shops, and drive-thru restaurants. In the 1960’s, the average package of fast food French fries contained 200 calories. Currently, extra-large fries have 600 calories. Soft drinks used to come in 12-ounce containers (140 calories). Many places now offer 64-ounce beverages (740 calories). These highly processed, supersized foods and drinks have not only lost much of their nutritional value, they have added an average of 300 calories a day since the 1980’s, creating a weight gain of 25 to 30 pounds a year (Blake and Durschlag, 2004).

Feeding Insecurities: Advertising in general, and the diet industry in particular, often play on people’s insecurities and exploit these emotions. A person can wind up feeling like a weak-willed failure for not sticking to a diet, looking like a supermodel, or having the kind of lifestyle that a well-to-do people has.

People think that losing weight as fast as possible will boost self-esteem. Unwittingly, they’re taking an “outside-in” approach to creating joy. Many believe (and are reinforced by cultural values) that material or physical things—money, cars, homes, jewelry, degrees, clothing, appearance, and weight—will bring peace of mind and a sense of well-being. If they can accumulate or accomplish the things they want, then they’ll feel good about themselves.

Nothing external can create long-term happiness when a person believes deep down that he is deficient in some way. Weight loss only temporarily reduces the sense that something is wrong inside. When the weight comes back, the person is thrown into self-recrimination and loathing, eventually seeking the next solution, and beginning the cycle all over again. This doesn't mean that having successes can't add quality to life. They can. But success never fills internal emptiness nor will it change beliefs about not being good enough.

2. SPORTS

A number of studies have shown that athletes are more likely than nonathletes to exhibit abnormal eating attitudes and behaviors (i.e., fasting, abusing diet medication, using laxatives and diuretics, and vomiting) when they’re involved in sports that place an emphasis on leanness, body image, being scantily clad (Yates et al., 1994).

High-achieving people are more likely to compulsively exercise and diet than people who are less achievement-oriented. While women with eating disorders are dissatisfied with their bodies and strive for an ideal shape, athletes who are overcommitted to their sport are dissatisfied with the body’s strength or efficacy, and strive for an ideal performance (Yates et al., 1994).

Females: There is a difference between someone who exercises for fitness and an athlete who become compulsive. These athletes are often perfectionistic, getting caught up in extreme dieting and exercise routines. Female athletes resemble eating disordered women in a number of ways. Athletes scored significantly higher than nonathletes did on the Eating Disorders Inventory subscales for bulimia, drive for thinness, ineffectiveness, interoceptive awareness, and perfectionism (Yates et al., 1994).

Males: Males who are over-invested in their physical appearance and bodies have a higher risk of developing an eating disorder (Franco et al., 1988). When an athlete is expected to maintain a lower than normal body weight to compete, eating disordered behaviors arise. These sports include gymnastics, wrestling, running, jockeying, rowing, and lightweight football playing. Careers such as acting and modeling can also perpetuate unhealthy habits in men.

The common threads shared between individuals with eating disorders and athletes are that both groups are high achievers, persistent, perfectionistic, have a drive for thinness, and engage in endeavors in a compulsive way (Yates et al., 1994).

3. 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. In fact, 81% of 10-year-olds are afraid of being fat (Mellin et al., 1991). 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—all 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. For instance, one friend confides to another friend how she is able to eat so much and not gain weight. She tells her friend that she’s been bingeing on ice cream and throwing it up because ice cream is easy to purge. She avoids nuts and bread because these don’t come up as easily.

C. FAMILIAL FACTORS

Families also have a powerful influence on beliefs people hold about themselves, other people, and the world in general. What a man’s family values, it’s likely that he does, too. 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.

1. THE FAMILY ENVIRONMENT

There are certain family dynamics that leave young people more susceptible to developing problems with food, weight, and body image (Fairburn et al., 1997; Taylor and Altman, 1997). The fifteen most salient family factors are:

2. 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 do apply:

3. 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:

4. EFFECTS OF FAMILY DYNAMICS

Beliefs shape, and ultimately create, reality. The beliefs, assumptions, and attitudes people hold are developed during childhood and adolescence and stored in the subconscious. These are based on the messages received from parents, other significant persons, and society. Beliefs are the foundation for how people feel and think about themselves, which in turn influence the decisions and choices they make.

Girls (90% of the 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 makes it difficult for them to create a positive self-image. Their desires 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, and 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.

These young people veer in one of two directions. They will 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 to cleanse the body not only of food but also of unpleasant feelings (Price, 1999).

5. TRAUMA

Emotional, physical, and sexual trauma profoundly affects a person’s psyche. 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. Trauma occurs within the family when one or both parents are hostile, verbally attacking, hypercritical, too controlling, uncaring, uninvolved, ignoring or withdrawing from the child, physically violent, or sexually abusive.

Emotional deprivation and abuse, and even excessive coddling, can trigger “psychological growth delay.” Heart rate, blood pressure, and bone structure can be adversely affected. The underdeveloped child may have temper tantrums, reduced IQ, garbled speech, or an eating disorder. The underlying mechanisms have yet to be identified, but it is suspected that emotions and growth are linked to chemical messages in the brain that signals the pituitary gland to release growth hormone. Trauma may block that release. Hormone production can occur again once a child is placed in a healthier environment. After the age of eight or nine, destructive psychological patterns are more difficult to erase, and growth may not catch up to peers (Troiano, 1990).

Research also suggests that girls who are sexually abused have higher levels of catecholamines (epinephrine, norepinephrine, and dopamine) in their urine than did control subjects. Over time, the chemicals lead the body to become stressed and hyperaroused, potentially producing sleep disorders, nervousness, and anxiety (DeAngelis, 1995). Body-hate and distortions are also likely to develop because these girls were exposed to situations that disrespected their bodies and turned sexual contact into an ugly event.

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; a sense of being 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 (American Psychiatric Association, 1994). The effects of trauma have to be treated along with the eating disorder.

D. BIOGENETIC FACTORS

There are a number of biological and genetic factors that correlate with the development of eating disorders. Genetic research suggests that 40%-60% of personality traits come from underlying genetic factors (Academy for Eating disorders, 1999).

1. ANOREXIA NERVOSA

2. BULIMIA NERVOSA

3. BINGE-EATING DISORDER

4. INHERITED TRAITS

Listed below are 13 traits that genetic researchers believe are inherited(Academy for Eating Disorders, 1999).

  • Depression
  • Anxiety
  • Obsessiveness
  • Compulsiveness
  • Inhibitedness/shyness
  • Dissocial behavior/schizoid
  • Lability/emotional disregulation
  • Narcissism
  • Pessimism
  • Worrying
  • Perfectionism
  • Low frustration tolerance
  • Sociopathy

E. INTRAPSYCHIC FACTORS

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

1. 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

Bulimia Nervosa

Johnson and Connors (1987) wrote about a number of factors, including character structure, which contribute to the onset of bulimia nervosa.

  • 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

2. RISK FACTORS

A number of potential risk factors for an eating disorder to develop have been identified (Fairburn et al., 1997, Taylor and Alman, 1997):

3. SENSE-OF-SELF

The literature on bulimia nervosa suggests that bingeing and purging are strategies to alleviate feelings of fragmentation, disorganization, and self-hatred. Women with bulimia look outside themselves for validation and approval, monitoring their behaviors to please others and avoid conflict. The family environment, combined with predisposed personality traits, makes it harder for these women to develop a strong, positive sense of themselves. This leads to depressed and anxious moods, and then bulimic behavior. The sense-of-self was found to be the mediator between the effects of family dynamics and the development of bulimia nervosa (Price, 1989). Such women have a more stable, yet negative, sense-of-self. As one woman stated, “It’s better to hate yourself than to not have a self at all” (Barth, 1988).

4. 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 genes 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 their resiliency during stress, constancy of moods, and flexibility to roll with the punches.

F. PORTRAIT OF AN EATING DISORDER

1. THE PERSON WITH AN EATING DISORDER (PRICE, 1999):

Not every person with an eating disorder has all these characteristics. However, many of your patients will have a high percentage of them. You can use this list to identify each person’s individual struggles.

CHAPTER II: DIAGNOSTIC CRITERIA

A. FOUR HARMFUL EATING BEHAVIORS

Eating disorders start when the person is young, can last for years, and cost a great deal of money to overcome (National Association of Anorexia Nervosa and Associated Disorders, 1994).

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. The diagnostic criteria listed below come directly from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American Psychiatric Association, 1994).

1. ANOREXIA NERVOSA

Starving: Starving often starts out as dieting. But it is dieting that has spun out of control. Eating less than 1,200 calories a day starves the body. People who undereat are actually obsessed with food. How could they not be when they’re depriving themselves? Their bodies will push them to focus on food with the hope that they’ll finally consume something. They become anorexic by ignoring hunger signals, and therefore losing a significant amount of weight.

Diagnostic Criteria:

Physical Complications: Most medical problems are the direct result of starvation. The weight of anorexics ranges from underweight to emaciation. Listed below are the signs, symptoms, and complications of anorexia nervosa (Mehler, 1996).

In addition to the symptoms above, other complications include:

Prevalence and Comorbidity Statistics:

Recovery Rates (Mehler, 1996):

2. BULIMIA NERVOSA

Bingeing: Bingeing is often a reaction to food restriction. The body pushes to be fed when it has been deprived of food. So, when people undereat at one meal, they're more likely to overeat at the next meal. They think they have no willpower, but in actuality, their bodies will do anything to make sure they get enough food.

The other reason for bingeing is the desire to numb painful emotions. Most people binge on sugary or salty carbohydrate-filled foods such as breads, cakes, donuts, cookies, chips, and candies. Complex carbohydrates release serotonin in the brain that induces calmness and reduces depression and anxiety. Serotonin is our natural antidepressant. Chocolate has a similar mood-altering effect, reducing depression and anxiety. However, you only need 1/2 ounce, not a whole bag, to do the trick.

Purging: Purging gets rid of unwanted calories after a binge. Some people are so fearful about weight gain that they purge even though what they've eaten is not considered a binge. Purging can also create a sense of being purified or cleansed, not only of the food but also of intolerably painful affect.

Purging is an ineffective form of weight control. Kay et al. (1993) found that an average of 2,131 calories is consumed during a binge and 1,209 calories are kept in the body (57% of total intake) after purging. The body retains about 1,200 mean calories, although researchers are not sure why. Perhaps the stomach and small bowel absorb and process food at a certain rate no matter how much food is available. Another study on laxative use found that only 12% of calories are removed from the body while 88% are retained.

Diagnostic Criteria:

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).

In addition to the symptoms above, other complications include:

Prevalence and Comorbidity Statistics:

Recovery Rates (Mehler, 1996):

Relapse for Anorexia Nervosa and Bulimia Nervosa (Keel et al., 2005)

3. BINGE-EATING DISORDER

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 1,500 to 3,500 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 do not 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.

Diagnostic Criteria:

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994) decided that there was insufficient information on binge-eating disorder to warrant inclusion as an official diagnosable mental disorder. It was proposed as a new category with the following criteria:

Physical Complications (Berg et al., 1997): The medical conditions listed below are found more often, and are more serious, in people who are overweight and obese.

Prevalence and Comorbidity Statistics:

4. EATING DISORDERS NOT OTHERWISE SPECIFIED

Diagnostic Criteria:

5. BODY DYSMORPHIC DISORDER

Although body dysmorphic disorder is not classified as an eating disorder, a number of eating disordered patients also struggle with this condition.

Diagnostic Criteria:

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.

In one study, 33% of subjects with body dysmorphic disorder (BDD) had a comorbid lifetime eating disorder: 9% had anorexia nervosa, 6.5% had bulimia nervosa, and 17.5% had an eating disorder not otherwise specified. They were more likely to be female, less likely to be African American, and had significantly greater body image disturbance and dissatisfaction (Ruffalo et al., 2006).

CHAPTER III: 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 might aid in the recovery process. Taking these factors into account can increase the chances of a successful outcome.

A. 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:

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 examination 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 it later becomes necessary.

Sometimes, for either financial or loyalty reasons, the patient want to see his own physician. Whether your patient sees the person you suggest or his own doctor, obtain a release so you can talk to the physician before and after the exam. Provide the doctor with 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, particularly 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 (e.g., low-carbohydrate diets, low- or no-fat diets, calorie restrictive diets, the latest best-selling diet). Stick to sound nutritional guidelines. You may be able to provide this service for patients who:

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 the patient, so you’ll need to discuss feelings and fears each time she is 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:

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 the patient’s 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, wants or needs medications, or resists the idea of taking medications even if it’s a sound one? If the patient is reluctant and you believe medications would aid recovery, periodically bring up your observations and inform her of the potential benefits of psychotropic medications.

4. INPATIENT AND INTENSIVE OUTPATIENT PROGRAMS

Inpatient Hospitalization: There are six reasons for referring a patient to an eating disorders hospital program or residential facility that provides medical and psychiatric care:

  1. 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.
  2. Patient’s symptoms seriously worsen during therapy and stay that way for over a month.
  3. Patient’s symptoms show no sign of improvement over a three to four month period, and you believe a program is the only hope.
  4. Patient’s health is medically compromised.
  5. Patient’s weight is 25%-30% below healthy body weight at the start of treatment and little weight gain is likely to be achieved in outpatient treatment (American Psychiatric Association, 2000).
  6. Debilitating depression or anxiety in which the patient is suicidal or cannot function.

Intensive Outpatient Program: These programs are recommended for the patient who needs more help than what is offered through traditional outpatient treatment, but would benefit from being able to sleep at home, attend school or work in the evenings, and continue some aspects of his life without regressing into destructive behaviors.

B. THERAPEUTIC TREATMENT MODALITIES

1. PSYCHOTHERAPY OPTIONS

Outpatient treatment options include individual, group, family, and couple’s therapies. Patients may require a combination of these to address their unique circumstances. Some need individual psychotherapy along with or more of the following–physician, nutritionist, psychiatrist, group, couple’s, 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.

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 (e.g., patient engages in splitting between two practitioners, doesn’t share relevant information with another team member, tells different things to different people). 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.

Group Therapy: Therapist-led and self-help groups provide added support. Groups allow patients to meet people with similar problems, reduce isolation, and experience camaraderie. Some people like groups, whereas others are wary about revealing personal information to strangers. Organizations like the 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, be sure to 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 the 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 will 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 unconscious or subconscious functions for the family. For instance, the teenager:

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 is 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 make a referral to a colleague.

Couple’s Therapy: Marriage and live-in partners of the patient 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 couple’s therapy is educating the partner about the complexities of an eating disorder and about how recovery will proceed.

Both family of origin members and partners can benefit from guidelines on what to do and not do to assist recovery. Parents and partners can:

Couple’s therapy can also improve communication skills, resolve intimacy concerns, and strengthen the bond between both partners.

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 increase depression and/or anxiety, which in turn trigger 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.

Behavioral Therapy: This therapy is used to reduce behavioral symptoms and provide healthier alternative behaviors. Strategies are developed to help patients set up meal plans and experiment with adding new foods; delay and prevent harmful behaviors; create lists of activities to replace turning to or denying food or purging; and exercise in appropriate amounts.

Cognitive therapy is often combined with behavioral therapy to become cognitive behavioral therapy (CBT). It is generally provided on an outpatient basis, consisting of 19 sessions over a 20-week period, and is comprised of three stages (Wilfley and Cohen, 1997):

CBT is found to be more effective and produces 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 (American Psychiatric Association, 1993). Short-term behavioral therapy alone did not fare as well as CBT (Wilfley and Cohen, 1997).

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 (Wilfley and Cohen, 1997).

Many therapists use CBT with the two other therapies mentioned below. Therapy will often take six months to many years for partial to full recovery.

Interpersonal Therapy: This form of therapy is the only treatment other than 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 (Wilfley and Cohen, 1997).

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 either of these treatments in reducing purging, dietary restraint, distorted body image, depression, and distress; and in raising self-esteem (Wilfley and Cohen, 1997).

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

3. PSYCHOPHARMACOLOGIC 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. Listed below is an overview of commonly used medications, although not all possible medications (Physicians Desk Reference, 2000, Maxmen and Ward, 2002).

Depressive Disorders

Prozac (Fluoxetine) is a selective serotonin reuptake inhibitor (SSRI). It blocks the reuptake of serotonin into human platelets and is a more potent inhibitor of serotonin than norepinephrine.

Zoloft (Sertraline) is a SSRI that is chemically unrelated to other SSRs. It blocks the reuptake of serotonin into human platelets with only weak effects on norepinephrine and dopamine neuronal reuptake.

Paxil (Paroxetine) is a SSRI that blocks the reuptake of serotonin into human platelets with weak effects on norepinephrine and dopamine reuptake.

Celexa (Citalopram) is an SSRI that blocks the reuptake of serotonin into human platelets with minimal effects on norepinephrine and dopamine.

Wellbutrin (Bupropion) is an antidepressant in the aminoketone class that is a relatively weak inhibitor of the neuronal uptake of serotonin, norepinephrine, and dopamine.

Antidepressants are ineffective with most anorexics until they gain weight. Their depression is often tied to food deprivation, and it will lift once they refeed. If the depression does not remit at this point, then antidepressant medication can be considered.

Generalized Anxiety and Panic Disorders

Paxil (see above)

Buspar (Buspirone) is an antianxiety agent in which the mechanism of action is unknown. Differs from benzodiazepine anxiolytics in that it is not a muscle relaxant, sedative, anticonvulsant, mildly euphoric, and does not have a rapid onset.

Xanax (Alprazolam) is an antianxiety agent in the benzodiazepine class that presumably binds at stereospecific sites within the central nervous system. The exact mechanism of action is unknown.

Klonopin (clonazepam) is an antipanic and antiseizure agent in which the mechanism is unknown, although it is believed to be related to its ability to enhance the activity of gamma aminobutyric acid (GABA), the major inhibitory neurotransmitter in the central nervous system.

Obsessive-Compulsive Disorder

Prozac (see above)

Paxil (see above)

Luvox (Fluvoxamine) is a SSRI that blocks serotonin reuptake in brain neurons.

Opiate Antagonist

ReVia (Naltrexone) is a pure opioid receptor antagonist.

Atypical Antipsychotics

Risperdal (Risperidone), Seroquel (Quetiapine), Clozaril (Clozapine), Zyprexa (Olanzapine), and Geodon (Ziprasidone) are considered “atypical” because their profile of binding to dopamine receptors differs from those exhibited in more typical antipsychotic drugs.

Gastrointestinal Disorders:

Reglan (Metoclopramide) stimulates motility of the gastrointestinal tract without stimulating gastric, biliary, or pancreatic secretions.

CHAPTER IV: ASSESSMENT

A. INITIAL CLINICAL INTAKE

1. INTERVIEW TECHNIQUES

Phone Contact: Your assessment begins on the phone. Initial screening helps you start to discern if this person can be treated on an outpatient basis or needs to be referred to an inpatient or day treatment program. You may not be able to tell how serious the disorder is from a brief phone conversation, but you will be better prepared when the person arrives at your office. There are four questions you will want to ask as part of telephone screening:

The answers will give you some idea of how entrenched the eating disorder is. The longer the person has had an eating disorder and/or the more resistant to treatment he is will make therapy more challenging. You can gauge the amount of work it is going to take to see some recovery.

Assessment Tools: A one- to two-session initial interview is your best assessment tool. If you ask the bulk of the questions provided below, you’ll gain insight into the seriousness of the eating disorder along with satellite issues that need to be addressed (e.g., using street drugs to lose weight, borderline personality disorder, physical complications). Obtaining permission to discuss previous or ongoing treatment with a therapist, treatment program, physician, and/or psychiatrist will also aid in your understanding of this case.

Some practitioners like to use standardized tests to assess eating disordered behaviors, mood, and personality. These therapists are well-trained in using testing materials in their practice. Some practitioners utilize these tests all the time whereas others use them only if they're confused by symptoms that don’t make sense. Some patients are fine with filling out questionnaires; however, others will be turned off by the “clinical-ness” of the process. The most commonly used measurements include:

As you’re conducting the initial interview, the most important question you must ask yourself is, "Do I have the expertise and experience to treat this person?" The most difficult situation for both therapist and patient occurs when the therapist is in over her head. You must understand the nuances of the disorder because the patient will not necessarily reveal them. You will have to know what to look for, as well as what and when to ask questions to get the answers you are seeking. Then you can seize the opportunity to affect change. If you believe you cannot manage the case, refer the patient to someone whom you know has the training!

If an eating disorder is revealed in therapy and you have a strong therapeutic alliance, but do not have the training to treat eating disorders, you can refer the patient to an eating disorders therapist who can focus on cognitive behavioral changes while your patient continues therapy with you. You will need to work closely with the therapist so you don’t contradict each other. This co-treatment model is best for patients who are not prone to defensive splitting.

Throughout the interview, formulate your treatment strategies and decide which allied professionals you will bring on board.

Be compassionate and non-judgmental. The patient is often embarrassed, and even ashamed, to admit engaging in eating disordered behaviors. Not only are you interviewing the patient, you are also being interviewed. Empathy and understanding go a long way in forming the initial bond.

2. ASSESSMENT OF THE EATING DISORDER

Initial Interview Questions: You will cover these questions in the first couple of sessions. The patient will offer many relevant answers, so you won’t need to ask all of the questions below. Direct your questions towards areas that you want covered.

This list should be modified for use with teens. They cannot answer many of these questions because they don’t have the insight. Parent(s) can fill in some of the information. With teens, keep it simple.

  1. Motivation for Change (Part I):
    1. Why are you seeking help NOW?
    2. What physical or emotional factors have become unbearable?
  2. Eating Disordered Behaviors:
    1. Which eating disordered behaviors do you engage in?
    2. Do you diet or restrict food?
      1. When was the last time you dieted?
      2. Which diet were you on?
      3. How much weight did you lose?
      4. How much weight did you permanently keep off?
      5. Would you describe the diet as a success?
      6. Did you end up overeating at some point?
    3. Do you binge or graze?
      1. How often?
      2. What are your binges like?
      3. Can you stop them if you want to?
      4. How do you feel after a bingeing or grazing session?
    4. Do you throw up your food?
      1. How often?
      2. Do you purge every time you binge?
      3. Can you stop yourself from throwing up?
      4. How do you feel after throwing up?
    5. Do you take laxatives? (Also, ask about diuretics and enemas)
      1. Which ones?
      2. How often?
      3. Do you take them after every binge?
      4. Can you decide to not take them and then carry through with this decision?
      5. How do you feel after taking them?
    6. Do you take diet pills?
      1. Which ones?
      2. How often do you take them?
      3. Are they making you lose weight?
      4. How do you feel while taking them?
    7. Do you take Syrup of Ipecac?
      1. How often?
      2. How is it affecting your health?
    8. How often do you exercise and what do you do?
    9. Do you take other drugs to reduce your appetite?
    10. Do you use sugar substitutes (e.g., Aspartame/NutraSweet®, saccharine, Splenda®)
      1. Is it in soft drinks and/or food?
      2. How much and how often?
    11. Do you have any eating rituals (Price, 1999)?
      1. Do you count bites?
      2. Do you count the number of times each bite is chewed?
      3. Do you separate foods on the plate into distinct piles?
      4. Do you eat only one kind of food at a time?
      5. Do you make food last as long as possible?
      6. Do you eat so quickly that you don't taste food?
      7. Do you chew food and spit it out instead of swallowing it?
      8. Do you binge on “junk food” and diet on “healthy food”?
      9. Do you wait until evening to eat your first meal?
      10. Do you eat “forbidden” foods in secret?
    12. Why do you practice these behaviors (Price, 1999)?
      1. Because you're physically hungry and feel deprived of food?
      2. To numb your feelings?
      3. To comfort and nurture yourself?
      4. To distract yourself and avoid difficulties?
      5. To alleviate boredom?
      6. To feel in control when life seems beyond your control?
      7. To calm down and create relaxation?
      8. To momentarily fill an internal emptiness?
      9. To procrastinate attending to responsibilities?
      10. To feel energized?
      11. To punish yourself or someone close to you?
      12. To reward yourself?
    13. Can you see how many functions your eating disorder has?
    14. What is your biggest fear about giving up your eating disordered behaviors?
    15. How much do you weigh?
      1. What is your height?
      2. How much do you wish you weighed?
      3. When was the last time your weight stayed stable and you didn’t have to take extreme measures to keep it there?
      4. For how long was it stable?
    16. What have you eaten today?
    17. Describe what you eat on a typical day.
  3. Eating Disorder History:
    1. When did your eating disorder begin?
    2. What was going on in your life at that time?
    3. Take me through your eating disorder from the start up until now.
  4. Previous Treatment History:
    1. How often have you been in treatment?
    2. What kind of treatment (e.g., individual, inpatient, intensive outpatient, groups)?
    3. How did the treatment help you?
    4. What changes have you made and continued?
    5. What was not helpful?
    6. What changes are the hardest to make?
    7. Assess the source of the resistance to change.
  5. Family Structure and Support Systems:
    1. Tell me about your family.
    2. Are your parents married?
    3. What was it like to grow up in your family?
    4. Do you have siblings?
    5. What is your relationship like with your mother?
    6. What is your relationship like with your father?
    7. What is your relationship like with your siblings?
    8. With whom are you the closest?
    9. With whom do you have the most difficult relationship?
    10. How were you treated in your family?
    11. What family factors do you think contributed to your developing an eating disorder?
    12. What message did you get in your family about your worth or lovability?
    13. Were you expected to be perfect?
    14. Does your family know about your eating disorder?
    15. How are they reacting to it?
    16. Does or did anyone in your family have an eating disorder, weight problems, or worry about weight or appearance?
    17. Does or did anyone have depression and/or anxiety?
    18. Does or did anyone use alcohol or drugs?
    19. Were you emotionally, physically, or sexually abused? (Ask if the patient offers information or if you suspect there might have been abuse and feel it will not breach any trust that is beginning to develop. Otherwise, you may want to save the questions for later.)
      1. What happened?
      2. With whom did it happen?
      3. When and where did it take place?
      4. How frequently did it occur?
      5. How is it affecting you now?
      6. Is the perpetrator currently in your life (assess whether you need to make a report to Child Protective Services)?
      7. Assess for signs of posttraumatic stress disorder.
  6. Current Relationships:
    1. Are you in a relationship?
    2. How is that working out?
    3. Is your eating disorder affecting your relationship with family members, husband, wife, or partner?
    4. How is your relationship with your children?
    5. How are your relationships with friends?
    6. How are your relationships at work?
  7. School and Work History:
    1. What was school like for you?
    2. Did you do well in school?
    3. Did you like school?
    4. Do you have a degree?
    5. Are you currently working?
    6. How do you like your job?
    7. Is your eating disorder affecting your school or work?
  8. Medical Status Evaluation:
    1. When was the last time you saw a doctor?
    2. Is she/he an eating disorders specialist?
    3. What did the doctor tell you?
    4. May I have you sign a release form?
    5. Are you having any physical symptoms?
    6. Do you have chest or arm pain (heart damage or electrolyte imbalance)?
    7. Do you have diarrhea, constipation, cramping, or abdominal distress?
    8. Do you get dizzy or have you passed out (low blood pressure or low blood sugar levels)?
    9. Are you fatigued?
    10. How is your concentration level?
    11. Can you focus at school or work?
    12. Do you feel bloated (cells holding onto water after purging)?
    13. Are you cold all the time (low amount of body fat)?
    14. Have you been losing hair (low protein intake)?
    15. When was your last menstrual cycle?
    16. Do you menstruate regularly?
    17. Are you on any medications?
      1. Which one(s)?
      2. Are they helping?
  9. Mood Disorders:
    1. Have you been previously diagnosed with a mood disorder?
    2. Are you depressed?
      1. How depressed on a scale of 1-10?
      2. Discuss severity of depression and how it’s affecting the patient’s life.
      3. Are you having thoughts of harming yourself now (if depression is rated high)?
      4. Have you had thoughts of harming yourself in the past?
      5. When you tried to hurt yourself (commit suicide), when and how did you carry it out?
    3. Are you anxious?
      1. How anxious on a scale of 1-10?
      2. Discuss severity of anxiety, whether it’s generalized or panic attacks, and how it’s affecting the patient’s life.
    4. Are you having obsessive thoughts about food, weight, or body shape?
    5. How well are you sleeping at night?
    6. If symptoms of manic-depression or attention deficit hyperactivity disorder are brought up by the patient, ask further about symptoms and effect on person’s life.
  10. Self-View:
    1. How do you see yourself?
    2. Do you like yourself?
    3. Would you describe yourself as a perfectionist?
    4. What would you change about yourself?
    5. Could you imagine being able to accept your weight and appearance?
    6. Do things in your life feel out of control?
    7. How do you cope with disappointment?
  11. Substance Use and Abuse:
    1. Are you drinking alcohol?
      1. What do you drink?
      2. How often?
      3. When and where?
      4. Can you stop now and not drink again?
    2. Are you using drugs?
      1. Which ones?
      2. How often?
      3. When and where?
      4. Can you stop now and not use drugs again?
    3. What, if any, was your previous substance abuse treatment?
      1. Was it helpful?
      2. Are you in any substance abuse treatment now?
      3. Is it helping?
  12. Self-destructive Behaviors:
    1. Have you ever shoplifted?
    2. Have you ever cut, burned, or stabbed yourself (self-mutilation)?
    3. Have you been sexually promiscuous?
    4. Are you overworking?
  13. Personality Disorders:
    1. Start to assess the information you are being given to see if any characteristics of a personality disorder stand out.
    2. Ask how these factors influence the patient’s relationships and work situation.
  14. Motivation for Change (Part II):
    1. Are you doing this for yourself or for someone else?
    2. Do you think you are willing to do whatever it takes to recover, even if you don't know what that is?

3. ENDING THE INITIAL INTERVIEW:

Wrap Up: Ask if the patient has any questions. Answer in ways that foster confidence in your understanding of this person’s unique struggles. Once you have gathered all the information and have started to formulate a diagnosis and treatment plan, inform the patient of what you believe is going on and what it is going to take to recover. You will need to make a number of decisions regarding treatment. Decide if:

Referrals: If you can’t treat this patient, refer to another therapist. If you’re building your treatment team, make referrals to the other specialists.

Assignments: Once you decide to treat the patient, give her two assignments. Ask the patient to:

Decide how often you will see the patient and then set up the next session. Now you will start your assessment of the risks in taking on this patient.

B. RISK ASSESSMENT

1. MEDICAL RISK FACTORS

Medical Conditions: Most individuals with an eating disorder have mild to serious medical conditions directly related to their behaviors. The list provided in Chapter II: Diagnostic Criteria offers a comprehensive catalog of possible health-related problems. Listed below are the most common physical complaints that have been reported to me by my patients.

Anorexia Nervosa

Bulimia Nervosa
  • Hair loss
  • Facial hair growth
  • Dry skin
  • Pain around the heart or down the left arm
  • Heart palpitations
  • Low blood pressure
  • Catches colds or infections easily
  • Anemia
  • Gets chills and can’t warm up
  • Osteopenia or osteoporosis
  • Stomach aches after eating
  • Food sits in stomach undigested for period of time, creating discomfort and fullness
  • Dizziness
  • Fainting
  • Energy level alternates between racing a mile a minute and extreme fatigue
  • Difficulty with attention, retention, and concentration
  • Loss of menstrual cycle
  • Dental erosion
  • Blisters in mouth
  • Blood in vomit
  • Pain around heart or down left arm
  • Heart palpitations
  • Low blood pressure
  • Esophageal burning
  • Constipation
  • Diarrhea
  • Hypoglycemia
  • Kidney problems
  • Dehydration
  • Diminished cognitive functioning
  • Dizziness
  • Fatigue
  • Irregular menstrual cycles

2. PSYCHIATRIC RISK FACTORS

Comorbidity: There are a number of psychiatric disorders, including severe mood disorders and/or Axis II diagnoses that exist along with an eating disorder. These need to be addressed in therapy at the same time as the eating disorder.

3. ADDRESSING COLLATERAL PROBLEMS

The aforementioned issues have significant treatment implications:

C. GETTING STARTED

1. TREATMENT STANCE

As with all patients, you will need to cultivate a connected working relationship with the eating disordered patient. In building a therapeutic alliance, decide how you’re going to interact with this person. The mental and emotional position you take is crucial. Listed below are a number of stances, some of which are universal with every patient whereas others are specific to this population.

2. TREATMENT GOALS

3. DEFENSE MECHANISMS

CHAPTER V: HOLISTIC TREATMENT APPROACH

Treatment information provided below is based on my book, Healing the Hungry Self (1999), and clinical experience. The book pulls together research and information on how people overcome food, weight, and body image issues. The condensed version provided below highlights the most salient topics you’ll cover with eating disordered patients. Vignettes scattered throughout will pinpoint therapeutic realities that are hopefully humorous and poignant, and will give you a flavor for that with which you’ll be working.

When you conduct therapy with an eating disordered patient, you must address the whole person. Four important parts or “selves” make up an individual—the physical self (physical