Cognitive Behaviour Therapy for Eating Disorders in Young People

A Parents' Guide

Riccardo Dalle Grave, Carine el Khazen

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000506396
• Edition: 1
• Topic: Psicología
• Subtopic: Psicología clínica

Cognitive Behaviour Therapy for Eating Disorders in Young People is a state-of-the-art guide for parents based on enhanced cognitive behaviour therapy (CBT-E), one of the most effective treatments for eating disorders and recently adapted for adolescents.

Part I presents the most current facts on eating disorders. Part II provides parents with guidance on how to support their child's recovery.

The book will be of interestto parents of teenagers with eating disorders treated with CBT-E and also for clinicians using CBT-E with young patients.

Part I

Understanding eating disorders

Chapter 1

General information about eating disorders

DOI: 10.4324/9781003171683-2

Anorexia nervosa and bulimia nervosa are terms that most people know, but they are often trivialized. For example, the terms “anorexic” and “bulimic” have become synonymous with being underweight and eating a large amount of food, respectively. This chapter explains the real meanings of these terms, describes the eating disorders most common in young people, and ends by outlining the theory on which CBT-E for eating disorders in adolescents is based—the so-called transdiagnostic theory.

Eating problem or eating disorder?

Adolescents who diet or occasionally binge eat do not necessarily have an eating disorder, and the majority will not go on to develop one. In most cases, their diet is not extreme or overly strict, and their binge-eating episodes are infrequent. If they are happy, well adjusted, and their physical health and quality of life are not compromised by such behaviours, we would not consider this a problem. If, on the other hand, they themselves are worried and/or upset by these behaviours, they may have what we call an “eating problem”, which can be managed through specific advice from a general practitioner, without the intervention of an eating-disorder specialist. Indeed, we reserve the term “eating disorder”, for those people whose diet is so extreme and rigid and/or their binge-eating episodes are so frequent that they impair their physical health and/or quality of life.

In adolescents, three main eating disorders have been described: (i) anorexia nervosa, (ii) bulimia nervosa, and (iii) binge-eating disorder. However, research shows that a large number of teenagers with an eating disorder of clinical severity do not, in fact, fall into any of these three categories. These people have an eating disorder that, for the purposes of this book, we have decided to group together in the broad category “other eating disorders”.¹

Anorexia nervosa

Contrary to popular opinion, anorexia nervosa is not a modern disorder and was actually first described in 1694 by the English physician Richard Morton. At the time, it was considered a rare disease, but it is known to be much more common today. In fact, the proportion of people who meet the criteria for a diagnosis of anorexia nervosa at some point in their life (aka the “lifetime prevalence”) is approximately 1.4% for females and 0.2% for males. In other words, 1 in every 140 women and 1 in every 2,000 men will suffer from anorexia nervosa during the course of their lives. Anorexia nervosa mainly afflicts adolescents and young adult women, but about one in eight cases occurs in males. It is more commonly seen in white populations, but in the last decade, the number of affected non-whites documented has increased worldwide, particularly in Asia and the Middle East.

People with anorexia nervosa reach a low weight by adopting an extreme and strict diet to reduce their calorie intake and sometimes exercise excessively. About a third of people with anorexia nervosa also experience recurrent binge-eating episodes but at these times tend to eat quantities of food that we, as non-anorexia sufferers, would not consider unduly large (we call these “subjective binge-eating episodes”²). In such cases, binge-eating episodes are often followed by one or more “compensatory behaviours”; these may include self-induced vomiting, excessive exercising, fasting, even more restrictive dieting, and/or using laxatives and/or diuretics in the erroneous belief that they will help them lose weight.³

In some teenagers, anorexia nervosa is short-lived and goes into remission after a short period of treatment or without any treatment at all. However, in other cases, it tends to persist and will require prolonged and complex specialized intervention. About half of people who initially present with anorexia nervosa go on to develop bulimia nervosa (in a phenomenon we call “migration”) or another eating disorder that meets some, but not all, of the diagnostic criteria (“subthreshold eating disorder”). Unfortunately, about 10%–20% of people afflicted with anorexia nervosa do not improve with any treatment available today and experience a lifelong condition known as “severe and enduring” anorexia nervosa. In these cases, the disorder persistently impairs, to a greater or lesser extent, a person’s health and quality of life.

Does my teen have anorexia nervosa?

Two main conditions must be met for an individual to qualify for a diagnosis of anorexia nervosa:

1. The person is significantly underweight (see Box 1.1), and this should be the result of their own efforts.
2. The person should show evidence of placing excessive importance on their shape, weight, or both—which therapists call the “over-valuation” of shape and weight—that is, they judge their self-worth largely, or even exclusively, on their weight or figure, and their ability to control them (this feature is described in detail in Chapter 2). People with anorexia nervosa are not worried about their low weight but rather are terrified of gaining weight and becoming fat, and persistently takes steps to interfere with weight gain, even if their weight is significantly low.

Girls and women who suffer with anorexia nervosa often find that their periods stop (the medical term for this is “amenorrhea”) when their weight drops too low, but this no longer needs to occur for a diagnosis of anorexia nervosa to be made. Indeed, some individuals can be underweight and exhibit all the psychological features of eating disorders but still have normal periods. Besides, this criterion could not be applied to girls who have not yet begun to menstruate, post-menopausal women, those taking oral contraceptives, or, of course, to males. However, the loss of periods in a girl should always be considered a warning sign of the possible presence of an eating disorder (after pregnancy is ruled out).

Box 1.1 When is a person considered having a significantly low weight?

Body mass index (BMI) is a convenient means for representing body weight in people aged 18 and over. A person’s BMI is calculated by dividing their weight (in kilograms) by the square of their height (in meters), using the formula weight/height². If the weight is in pounds and the height is in inches, the ratio in this formulation must be multiplied by 703. Alternatively, you can use BMI calculators on the internet, e.g., www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm.

The threshold for considering adults as having significantly low weight is debated and varies, but a BMI of below 18.5 is the most frequently used. However, in people with eating disorders, we recommend considering a BMI of below 19.0 as the minimum threshold for healthy weight, as below this BMI most people experience some adverse physical and psychosocial effects of being underweight.

For children and adolescents, BMI is age- and sex-specific and is often referred to as a “BMI-for-age percentile”. This can be easily calculated via the Centers for Disease Control and Prevention (CDC) website (www.cdc.gov/healthyweight/bmi/calculator.html). The CDC considers a BMI-for-age below the fifth percentile (i.e., having a BMI lower than 95% of the reference population of the same age) as underweight, but children and adolescents with a BMI above this threshold may also be considered significantly under-weight if they fail to maintain their expected growth trajectory. For this reason, in adolescents with an eating disorder, we recommend considering a BMI-for-age percentile corresponding to about a BMI of 19.0 in adults as the minimum threshold for healthy weight. Note, however, that this is different in different countries but according to the CDC is between the 10th and 25th BMI-for-age percentile.

Bulimia nervosa

Bulimia nervosa is a disorder that, as far as we know, appeared in the early ’70s. It was described for the first time in studies on “bulimarexia” conducted among students at American colleges, and in 1979, Professor Gerald Russell of the London Maudsley Hospital published an article entitled “Bulimia Nervosa: An Ominous Variant of Anorexia Nervosa”. From 1980 onwards, a lot of research has been carried out to assess how common it is, revealing that 1.9% of women and 0.6% of men will develop bulimia nervosa in their lifetime. The disorder mainly affects young women, the majority being in their 20s, but it is important to underline that bulimia nervosa can affect people of all ages, genders, races, and backgrounds. Indeed, public figures who have spoken out about their battles with bulimia nervosa include Princess Diana (the Princess of Wales), Andrew “Freddie” Flintoff (a male England cricketer who reports developing bulimia in his early 20s). The proportion of males with this disorder is uncertain, but it is probably fewer than one in ten cases.

In typical cases, bulimia nervosa begins between the ages of 18 to 25 years, with the adoption of self-imposed strict and extreme dietary rules motivated by excessive concerns about shape and weight. About a quarter of cases will have previously met the diagnostic criteria for anorexia nervosa (see the previous discussion). However, after a certain period of time, their dieting is periodically interrupted by binge-eating episodes, followed by compensatory behaviours such as self-induced vomiting, laxative and diuretics misuse, fasting or strict dieting, and/or excessive exercising. This combination of dietary restriction, binge-eating episodes, and compensatory behaviours rarely produces a persistent calorie deficit, which explains why individuals with bulimia nervosa are typically in the normal weight or overweight range.

Once it manifests, bulimia nervosa tends to be self-perpetuating (a cycle), although it may vary in severity. In about 20% of afflicted individuals, bulimia nervosa transforms into binge-eating disorder or another subthreshold eating disorder, while the transition to anorexia nervosa is less frequent. More than 20% of individuals with bulimia nervosa have a persistent course, and in this case, the eating disorder impairs, more or less markedly and persistently, their health and quality of life.

Does my teen have bulimia nervosa?

Four main conditions must be met to qualify an individual for a diagnosis of bulimia nervosa:

1. The person has recurrent objective binge-eating episodes, eating a large amount of food in a short period of time with a sense of loss of control over eating during the episode (e.g., a feeling that they cannot stop eating or control what or how much they are eating).
2. The person engages in one or more extreme compensatory weight-control behaviours after the objective binge-eating episodes. These include self-induced vomiting, excessive exercising, fasting, restrictive dieting, and/or using laxatives, diuretics, and/or slimming aids in the attempt to “make up” for their bingeing.
3. The person attaches too much importance (overvaluation) to their shape, weight, or both.
4. The person does not currently have anorexia nervosa (see the previous discussion).

N.B. For a diagnosis of bulimia nervosa to be made, the binge-eating episodes and inappropriate compensatory behaviours are required to occur, on average, at least once a week for three months.

Binge-eating disorder

As suggested by the term, binge-eating episodes are the main feature of binge-eating disorder. The diagnosis is a recent addition to the way we classify eating disorders, although people with obesity with recurrent binge-eating episodes were described by Professor Albert Stunkard of the University of Pennsylvania in 1959. This observation was ignored until the mid-to-late 1980s when research assessing the prevalence of bulimia nervosa in the community found that a large number of individuals did not engage in compensatory behaviours after binge eating (i.e., they did not make themselves sick, excessively exercise, or fast, etc.).

Binge-eating disorder can occur at any age, although it typically starts in late adolescence or young adulthood. The lifetime prevalence of the binge-eating disorder is about 2.8% in women and 1.0% in men, and it seems to be the most common eating disorder in adolescents. Unlike other eating disorders—such as anorexia nervosa and bulimia nervosa, where the female to male ratio is 9:1—in binge-eating disorder, the ratio is approximately 6:4. Furthermore, the disor...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Contents Page
• About the authors Page
• Preface Page
• Letter to parents Page
• Part I Understanding eating disorders
• Part II How to help your teen overcome an eating disorder
• Final thoughts
• Resources
• Index