Enduring Change in Eating Disorders

Interventions with Long-Term Results

H. Charles Fishman

• Publisher: Routledge
• Year: 2005
• ISBN:
  9781135944735
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychopathologie

Enduring Change in Eating Disorders provides a unique perspective on the successful treatment of eating disorders, which are among the most debilitating and recalcitrant psychiatric diseases. Unique in the field, this book details effective Structural Family Therapy with qualitative follow-ups of up to 20 years. A practical approach providing concrete tools to the clinician to creating change that holds over time with bulimia, anorexia, and compulsive overeating.

The text draws on cases from the author's practice of over twenty-five years and follows his approach in the theoretical tradition of Intensive Structural Family Therapy (IST). Chapters discuss the nature and significance of eating disorders, a review of current treatment approaches, and the importance of the family in the therapeutic process. Cases of eating disorders in youths and adults are provided as well as instances of bulimia, anorexia, and compulsive overeating.

Three appendices provide the reader with information regarding the scientific basis of the IST model, the effectiveness of the approach in treating conditions other than eating disorders and preventing eating disorders.

CHAPTER 1

The Nature of Eating Disorders

Eating disorders are ironically cruel problems, in which one of the most pleasurable, eminently life-sustaining functions has gone awry. They are terrible problems in their consequences. Although anorexia nervosa (AN) has a much lower incidence in the population in comparison with other psychiatric diseases such as depression and schizophrenia (American Psychiatric Association, 2000; Murphy et al., 2000), it is most likely to prove fatal (Vitiello & Lederhendler, 2000). These problems are recalcitrant in terms of treatment, tending to become chronic and resistant. The cause of these disorders is not entirely known, but it is the premise of this book that they are maintained by the patient’s social context. A brief look at their occurrence in history supports this premise.

A SHORT HISTORY OF EATING DISORDERS

It is thought that Gull (1873) and Laségue (1873), almost simultaneously, were the first to describe anorexia. The first case mentioned in medical literature may have been over 300 years ago, however, in Morton’s 1689 report of “nervous consumption.” Even earlier references from the Middle Ages report evidence of syndromes that strongly resemble anorexia. Bell, in his book Holy Anorexia (1985), relates the disease to religious impulses of medieval nuns, who believed starvation to be a form of purification. Parry-Jones (1991) describes references in the literature as far back as ancient Greece and Rome to food refusal as well as gorging followed by vomiting.

In her book Fasting Girls (2000), Joan Jacobs Brumberg details the origins and history of anorexia nervosa alongside the sociocultural influences that have shaped it into what has become, in modern times, an increasingly pervasive disease. Between the thirteenth and the sixteenth centuries, fasting was common among women, and prolonged fasting was thought to be a “female miracle.” Saint Catherine of Siena claimed she was “incapable of eating normal earthly fare” (p. 43), and her daily intake of food consisted of a handful of herbs; if she was made to eat other food, she would force a stick down her throat to bring it back up. As food abstinence became extremely common among women of the High Middle Ages, medical science expanded on the religious theme by coining the terms inedia prodigiosa (a great starvation) and anorexia mirabilis (miraculously inspired loss of appetite). During the early modern period, under the influence of the Protestant Reformation, abstinence from eating was seen as the work of the Devil rather than of God; however, where Catholicism was still widespread, “miraculous maids” were supposedly surviving on as little as the smell of a rose: “The symbolic diet of the maiden underscored her purity” (p. 49).

Though Brumberg sees the routes to anorexia mirabilis and anorexia nervosa as quite different, the former does aid our understanding of the modern-day disease, for both reflect important values or beliefs of their times. “In the earlier era, control of appetite was linked to piety and belief; through fasting, the medieval ascetic strove for perfection in the eyes of her God. In the modern period, female control of appetite is embedded in patterns of class, gender, and family relations established in the nineteenth century; the modern anorexic strives for perfection in terms of society’s ideal of physical, rather than spiritual, beauty” (p. 48).

By the turn of the 20th century, the importance placed on being thin had become a widespread phenomenon. As early as 1905, Albutt wrote, “Many young women, as their frames develop, fall into a panic fear of obesity, and not only cut down on their food, but swallow vinegar and other alleged antidotes to fatness” (quoted in Brumberg, 2000, p. 184). Furthermore, middle-class girls made efforts to obtain a small, slim body in order to be recognized as distinct from working and rural youth.

Brumberg points out that even as early as the 1870s Laségue recognized the role that the family environment played in anorexia. Although his contemporary Gull focused on identifying the disease in medical terms, Laségue described the relations between his anorexic adolescent patients and their families. In Brumberg’s words,

Among the bourgeoisie, adolescent girls who refused to eat had the power to disrupt their families. A girl who declined the food provided by her family became the focus of conversation and concern; her appetite, her diet, and her body became a preoccupation in the child-centered family…. Laségue’s attention to his patients’ relations with her family and friends confirmed what Gull’s work only suggested: that anorexic women came from families willing and able to expend emotional and financial resources on them. Laségue was the first nineteenth-century physician to suggest that food refusal constituted a form of intrafamilial conflict between the maturing girl and her parents. (p. 126)

In one sense, Laségue was the world’s first family therapist.

EATING DISORDERS DESCRIBED

Increasingly, the literature on various diseases describes spectrums within a given disease, and with eating disorders this has certainly been the case. As with anything else in nature, there is variability, and varying degrees of pathologic presentation are to be expected, while the overall patterns of these diseases remain the same. In my experience, although there is some latitude regarding the presentation, these problems yield to the psychosomatic family model conceptualization as well as to the treatment interventions described in this book. Of course, the caveat is that my experience is with severe cases; one cannot be certain that these interventions would work with mild or subclinical cases.

The diagnostic signs of anorexia nervosa have been well established. As described in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), AN is “characterized by a refusal to maintain a minimally normal body weight” (p. 583). A person may be one of two subtypes: restricting food intake or binge eating followed by purging (either vomiting or use of laxatives) and must meet the following diagnostic criteria (p. 589):

• weigh less than 85% of expected weight for height and age
• fear becoming fat
• manifest disturbance in body image or deny seriousness of weight loss
• in postmenarcheal females, miss three consecutive periods

Similarly, in the International Classification of Diseases, 10^th edition (ICD-10) (p. 31), the World Health Organization states that a diagnosis of AN includes all of the following criteria (p. 177):

• body weight at least 15% lower than expected, or body mass index (BMI) 17.5 or less
• self-induced weight loss
• body image distortion from dread of fatness
• widespread endocrine disorder—amenorrhea in women, and loss of sexual interest and/or potency in men
• with prepubertal onset, delay or arrest of pubertal events

As with most other psychiatric syndromes, there is a spectrum of severity of anorexic presentations. Cecile Herscovici (2002) has described three types (p. 135):

• imitative anorectics, who “have had a healthy development in a favorable family context, go onto an ‘innocent’ diet with the goal of looking better and then become trapped in the biological vulnerabilities to food restriction and the psychopathology of starvation. Many of these cases remit spontaneously or with little therapeutic effort, if detected early. These are the ones that prove most amenable to self-help and psychoeducational strategies.”
• those for whom the disorder evolves in the context of a dysfunctional family, whose “members are immersed in the tension derived from unresolved issues of the past. Often their equilibrium is threatened by the exogamy inherent in adolescence. They will benefit most from family therapy.”
• those with an eating disorder in the context of a dysfunctional family system where the patient has experienced a pervasive developmental impairment resulting in a personality problem and reflecting a disorder of the self. Some of the cases in this book demonstrate that the intensive structured therapy (IST) approach addresses these lacunae by transforming the patient’s present system and accessing additional contexts, such as vocation, to augment deficits.

The term “bulimia nervosa” (BN) was introduced in 1979 by Russell, who described it as an “ominous variant of anorexia nervosa.” According to DSM-IV (p. 594), bulimia nervosa is “characterized by repeated episodes of binge eating followed by inappropriate compensatory behaviors.” Again, two subtypes are possible, according to the compensatory behavior: purging (by vomiting or use of laxatives, diuretics, or enemas) and non-purging (such as fasting or excessive exercise). The following diagnostic criteria must be met:

• recurrent episodes of binge eating
• recurrent inappropriate compensatory behavior
• occurrence of this behavior at least twice a week for 3 months
• self-evaluation unduly influenced by body shape and weight
• occurrence of behavior not exclusively during an episode of AN

The ICD-10 (pp. 178–179) states that BN is “characterized by repeated bouts of overeating and an excessive preoccupation with the control of body weight” and lists the following diagnostic criteria:

• persistent preoccupation with eating and an irresistible craving for food
• attempts to counteract the “fattening” effects of food through behaviors such as self-induced vomiting
• sharply defined weight threshold well below a healthy weight range, because of a morbid dread of fatness

ICD-10 also mentions that BN “may be viewed as a sequel to persistent AN.” This view is supported by a follow-up study of 41 AN patients; 20 years later, 15% of the group had developed BN (Ratnasuriya et al., 1991).

Binge eating disorder (also known as compulsive overeating) was first described in 1992 (Spitzer et al.) and is newly recognized in DSM-IV, classified under “Eating Disorders Not Otherwise Specified.” It is characterized by “recurrent episodes of binge eating in the absence of regular use of inappropriate compensatory behaviors characteristic of BN” (p. 595). ICD-10 classifies overeating as an eating disorder only when it occurs along with other psychological disturbances. Furthermore, obesity, as a cause of psychological disturbance, is not coded under the eating disorders category. In binge eating disorder (BED), eating binges are much like those of BN, but the “hallmark feature distinguishing BN and BED is inappropriate compensatory behavior subsequent to binge eating [in BN]” (Pike et al., 2001, p. 1459).

In terms of treatment, chapter 9 will detail my approach to this problem, focusing on the psychosomatic family characteristics, IST, and the patient’s broader social context. My review of the literature supports the difficulty in treating this problem: for example, Walsh and Devlin (1998) mention that with clinical trials a distinction needs to be made between obese binge eaters and nonobese binge eaters. Devlin, Yanovski, and Wilson’s (2000) review states that appetite suppressant medications clearly promote weight loss but their use in suppressing binge eating has yet to be studied specifically. Similarly, in obese BED patients, psychotherapy (particularly cognitive behavioral therapy and interpersonal therapy) is effective in normalizing eating and reducing distress, but is not associated with significant weight loss. Devlin (1996) also mentions another area that needs to be addressed, other than normalizing eating and improving physical health, which is enhancement of a patient’s acceptance of his or her body image. This issue of self-esteem is crucial when exploring the sociocultural factors that contribute to the existence of this disorder.

Clearly the social context is significant in terms of etiology. Fairburn et al. (1998) found those with BED were more exposed to negative comments from family members about shape, weight, and eating.

SHORT-TERM AND LONG-TERM HEALTH CONSEQUENCES OF EATING DISORDERS

The medical consequences of AN are many and varied. Individuals differ in the sequelae they present, but as Goldbloom and Kennedy (1995) expressed it most succinctly, “no organ system is spared” (p. 269). The effects of anorectic behavior include:

• amenorrhea (a mandatory diagnostic criterion in females in DSM-IV)
• fainting, fatigue, and muscle weakness
• discoloration of skin
• hair loss and growth of lanugo (downy layer of hair) over body
• abnormally slow heart rate and low blood pressure, leading to risk of heart failure
• reduction in bone density leading to osteoporosis
• severe dehydration and risk of kidney failure
• structural abnormalities of the brain
• gastrointestinal difficulties

Specific medical complications for adolescents include:

• changes in growth hormone, resulting in significant growth retardation
• pubertal delay or interruption
• peak bone mass interruption

Indeed, the sequelae years later include profound problems resulting from the behavioral manifestations, such as the debilitating condition osteoporosis. Chronic ED sufferers may die because of lack of calcium and electrolyte imbalances that create abnormal heart rhythm patterns (Noordenbos et al., 2002). Many long-term patients have been found to be susceptible to alcohol and/or drug addiction (see, for example, Lammers, 1995 and Homgren et al., 1983 cited in Noordenbos et al., 2002).

The health consequences of bulimic behavior are as severe in both the short and long term as those of anorexia. They include:

• dehydration, resulting in loss of potassium and sodium
• electrolyte imbalances that can lead to irregular heartbeats and even to heart failure
• a risk of gastric rupture
• inflammation and possible rupture of esophagus
• tooth decay and staining
• chronic irregular bowel movements and constipation
• peptic ulcers and/or pancreatitis
• neuroendocrine and metabolic abnormalities

For a fuller description of the sequelae of BN, see Halmi (1995). Daluiski et al. also mentions the likelihood that the BN patient will manifest a characteristic sign called Russel’s sign: calluses on the hand indicative of the act of stimulating a gag reflex.

A risk factor for BED is obesity (Devlin et al., 2000), and therefore the disorder entails some of the health risks associated with clinical obesity. According to the National Eating Disorders Association (2002), these include

• high blood pressure
• high cholesterol levels
• heart disease from high triglyceride levels
• secondary diabetes
• gallbladder disease

The BED and obesity populations are not necessarily contiguous, however. While BED is most commonly found in the obese population, it is not exclusively found there (de Zwaan, 2001). Moreover, Fairburn et al. (1998) put the percentage of the obese population that suffers from frequent bouts of binge eating at about 25%. Therefore a distinction between obese binge eaters and nonobese binge eaters needs to be made in clinical trials, according to Walsh and Devlin (1998).

EPIDEMIOLOGY OF EATING DISORDERS

Although the incidence of eating disorders is relatively low, the tenacity of these problems and the health dangers they pose make them major mental health problems. It is significant, therefore, that as more of the world becomes westernized and increasingly middle class, the incidence of these diseases is increasing (Gordon, 2001).

The sentinel study of the incidence and prevalence of AN, to my knowledge, is the work of Lucas and colleagues (1991). Their study of 181 patients (166 females and 15 males) in Rochester, Minnesota, spanned 50 years. They noted that AN is 9 to 10 times more common in girls, with prevalence rates of approximately 0.27% for females and 0.02% for males. They also found an overall incidence rate per 100,000 person-years of 14.6 for females and 1.8 for males. During the years of the study, the overall incidence rate for female adolescents and young adults (15 to 24 years old) has increased. More specifically, the incidence rate for females 10 to 19 years old decreased from 16.6 in the 1935–1939 period to 7.0 in the 1950–1954 period but then increased to 26.3 in the 1980– 1984 period.

Commenting on this study, Gordon (2000) calculated, “If [Lucas’s] study can be extrapolated to the US…using 1980 census figures, then the number of anorexic women residing in the United States would be roughly 300,000” (p. 70). Of course, that was in 1980, and I have not found studies to support or disqualify this figure.

DSM-IV notes that females have a lifetime prevalence rate of 0.5% and males onetenth that rate. In Gordon’s view, the prevalence per 100,000 population in terms of overall incidence is misleading; what is most relevant is the incidence in the at-risk population. According to DSM-IV, over 90% of AN cases occur in females, and as the ICD-10 notes, these are most commonly adolescent girls and young women. Gidwani and Rome (1997) set this figure for girls and women at 95%. Gordon also points out that AN affects a population that is otherwise relatively healthy and thus has a much greater health significance because it is so chronic, debilitating, and potentially lethal.

The overall prevalence rate for BN is 1% to 3% (Johnson et al., 1996). DSM-IV gives the rate for females as 1% to 3% and for males one-tenth of that (0.1% to 0.3%). According to both DSM-IV and ICD-10, the gender distribution of BN is similar to that of AN, with 90 percent of the cases occurring in females. Gidwani and Rome (1997) set that figure at 80% and note that the onset of BN tends to occur later, in women aged 17 to 25 years.

Binge eating disorder is thought to be the most common eating disorder, with a prevalence rate of 2% to 5% of the population (Johnson et al., 1996). It is also more evenly distributed over gender and age groups than are AN and BN (Walsh & Devlin, 1998).

Pike et al. (2001) found interesting cultural differences. Black women are as much at risk for developing BED as white women, but among those with BED, black women were much less concerned about body weight, shape, and eating, and therefore at less risk of developing BN.

There are studies, less well substantiated, suggesting that the incidence of eating disorders is much higher than the figures described in the previous paragraphs. Naomi Wolf, for example, states in The Beauty Myth (2002) that the rate of bulimia among college girls is about 60%. There is no way of knowing how many cases of the less severe phenomena there are. It may be that we as professionals see only the extreme cases and that subclinical cases of eating disorders appear transiently in people’s lives, even as discrete episodes that spontaneously remit.

COMORBIDITY

The most common disorders to covary with EDs are depression, obsessive-compulsive disorder (OCD), anxiety disorders, and vari...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Acknowledgments
• Foreword
• Introduction
• Chapter 1
• Chapter 2
• Chapter 3
• Chapter 4
• Chapter 5
• Chapter 6
• Chapter 7
• Chapter 8
• Chapter 9
• Chapter 10
• Chapter 11
• Chapter 12
• Appendix
• References