In-Depth Information On: All Aspects of Anorexia, Bulimia, Binge Eating

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An in-depth report on the treatment and prevention of eating disorders.

Alternative Names

Anorexia; Bulimia; Binge eating

Treatment:

Treatment goals for eating disorders include:

• Restore normal weight for anorexia nervosa
• Reduce, and hopefully stop, binge eating and purging for bulimia nervosa
• Treat physical complications and any associated psychiatric disorders
• Teach patients proper nutritional habits and how to develop healthy eating patterns and meal plans
• Change patients� ' dysfunctional thoughts about the eating disorder
• Improve self-control, self-esteem, and behavior
• Provide family counseling
• Prevent relapse

The first major difficulty in treating eating disorders is resistance by everyone involved:

• The anorexic patient often believes that the emaciation is normal and even attractive.
• The bulimic patient may feel that purging is the only way to prevent obesity.
• Even worse, the anorexic condition may be encouraged by friends who envy thinness or by dance or athletic coaches who encourage low body fat.
• The family itself may deny the problem and be obstructive or manipulative, adding to the difficulties of treatment.

It is very important that the patient and any close friends and relatives be informed about the serious potential of these conditions and the importance of receiving immediate help.

A multidisciplinary team approach with consistent support and counseling is essential for long-term recovery from all severe eating disorders. Depending on the severity and type of disorder, team members may include:

• Doctors specializing in relevant medical complications
• Dietitians
• Cognitive-behavioral therapists
• Psychotherapists
• Nurses

All should be skilled in treating eating disorders. Studies have found that people treated by such specialists have a lower mortality rate than those treated only as psychiatric patients.

Getting Rid of Unrealistic Expectations

Patients may drop out of programs if they have unrealistic expectations of being "cured" simply through the therapists' insights. Before a program begins, the following possibilities should be made clear:

• The process is painful and requires hard work on the part of the patient and family.
• A number of therapeutic methods are likely to be tried until the patient succeeds in overcoming these difficult disorders.
• Relapse is common but should not be greeted with despair.

Although the outcome for bulimics is generally more favorable than for anorexics, long-term studies are showing recovery in many people treated for anorexia. Studies indicate that about 70% of people with bulimia and 27 - 50% of patients with anorexia nervosa are free from eating disorders within 10 years of treatment.

General Treatment Approaches

Psychotherapies. Eating disorders are nearly always treated with some form of psychiatric or psychologic treatment. Depending on the problem, certain psychologic approaches may work better than others.

Medications. Various medications may be helpful for patients depending on the type of eating disorder, psychiatric state, and severity of the condition.

Nutritional Rehabilitation. Nutritional counseling can help patients regain weight and learn normal expectations concerning hunger and eating patterns.

Choosing a Treatment Site

The patient ' s condition, social circumstances, and health insurance coverage determine the type of treatment facility -- inpatient hospitalization, residential hospitalization, partial hospitalization, or outpatient care. Weight is not the sole determining factor. The patient ' s overall physical condition, psychological state, behavior patterns, and family support are all factors. Patients and their families should discuss with their doctors the various options available and how structured and intense the treatment should be.

Highlights:

Eating Disorders Overview

• Eating disorders typically occur among young women.
• Bulimia nervosa involves a pattern of bingeing and purging. Many people with bulimia nervosa also suffer from depression.
• Anorexia nervosa involves a pattern of self-starvation. Patients often have an accompanying anxiety disorder (such as obsessive compulsive disorder) or depression. Patients who have anorexia and depression have a high risk for suicide.

Complications of Bulimia Nervosa

Many medical problems are directly associated with bulimic behavior, including:

• Tooth erosion, cavities, and gum problems
• Water retention, swelling, and abdominal bloating
• Acute stomach distress
• Low potassium levels
• Irregular menstrual periods
• Swallowing problems and esophagus damage

Complications of Anorexia Nervosa

Anorexia nervosa can increase the risk for serious health problems such as:

• Hormonal changes, including reproductive, thyroid, stress, and growth hormones
• Heart problems such as abnormal heart rhythm
• Electrolyte imbalance
• Fertility problems
• Bone density loss
• Anemia
• Neurological problems

Treatment of Bulimia Nervosa

• Bulimia nervosa is treated with a combination of psychotherapy and medication.
• Cognitive behavioral therapy, which is given along with nutritional counseling, is the preferred psychotherapeutic approach.
• Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac), are the first choice for drug therapy.

Treatment of Anorexia Nervosa

• Unlike bulimia nervosa, anorexia nervosa does not respond as well to drug treatment, although SSRIs are sometimes used as an adjunct to psychotherapy.
• Therapy that includes the entire family -- not just the patient -- is an important part of the treatment process, as is nutritional education.
• Patients who are severely underweight and who have other physical risks may need to be hospitalized while weight is restored. Recovery is a long process that can take 5 - 6 years to achieve.

Introduction:

Eating disorders are behavioral problems brought on by a complex interplay of factors, which may include emotional and personality disorders, family pressures, a possible genetic or biologic susceptibility, and a culture in which there is an overabundance of food and an obsession with thinness. There are four general categories of eating disorders:

• Bulimia nervosa
• Anorexia nervosa
• Binge eating
• Eating disorders not otherwise specified

These are not new disorders. Although anorexia nervosa was first defined as a medical problem in the late 1800s, descriptions of self-starvation have been found even in medieval writings.

Bulimia Nervosa

Bulimia nervosa is more common than anorexia, and it usually begins early in adolescence. It is characterized by cycles of bingeing and purging, and typically takes the following pattern:

• Bulimia is often triggered when young women attempt restrictive diets, fail, and react by binge eating. (Binge eating involves consuming larger than normal amounts of food within a 2-hour period.)
• In response to the binges, patients compensate, usually by purging, vomiting, using enemas, or taking laxatives, diet pills, or drugs to reduce fluids.
• Patients then revert to severe dieting, excessive exercise, or both. (Some patients with bulimia follow bingeing only with fasting and exercise. They are then considered to have non-purging bulimia.)
• The cycle then swings back to bingeing and then to purging again.
• Some studies have reported that patients with bulimia average about 14 episodes of binge-purging per week. To be diagnosed with bulimia, however, a patient must binge and purge at least twice a week for 3 months. (Some doctors believe that going through the cycle only once a week is sufficient for a diagnosis.)
• In some cases, the condition progresses to anorexia. Most people with bulimia, however, have a normal to high-normal body weight, although it may fluctuate by more than 10 pounds because of the binge-purge cycle.

Young people who occasionally force vomiting after eating too much are not considered bulimic, and most of the time this occasional unhealthy behavior does not continue beyond youth.

Anorexia Nervosa

The term "anorexia" literally means absence of appetite. Anorexia nervosa involves an aversion to food that leads to a state of starvation and emaciation. It is a very serious illness that some doctors believe is an entirely different condition from bulimia and should be not be diagnosed as a simple eating disorder.

Facts associated with anorexia nervosa:

• At least 15% to as much as 60% of normal body weight is lost.
• The patient with anorexia nervosa has an intense fear of gaining weight, even when severely underweight.
• Individuals with anorexia nervosa have a distorted image of their own weight or shape and deny the serious health consequences of their low weight.
• Women with anorexia nervosa miss at least three consecutive menstrual periods. (Women can also be anorexic without this occurrence.)

Patients with this condition are often characterized as anorexia restrictors or anorexic bulimic patients. Each type is equally prevalent.

• Anorexia restrictors reduce their weight by severe dieting.
• Anorexic bulimic patients maintain emaciation by purging. Although both types are serious, the bulimic type, which imposes additional stress on an undernourished body, is the more damaging.

Severe anorexia is common in the elderly, who may experience weight loss because of social isolation, impaired gastrointestinal function, or loss of certain chemicals related to the feeding drive. Such age-related anorexia, however, is not synonymous with anorexia nervosa, which is a psychologic disorder.

Binge Eating (Binge Eating Disorder)

Bingeing without purging is characterized as compulsive overeating (binge eating) with the absence of bulimic behaviors, such as vomiting or laxative abuse (used to eliminate calories). Binge eating usually leads to becoming overweight.

To be diagnosed as a binge eater, a person typically has the following characteristics:

• Bingeing at least twice a week for 6 months
• Consuming 5,000 - 15,000 calories in one sitting
• Eating three meals a day plus frequent snacks
• Overeating continually throughout the day, rather than consuming large amounts of food during binges

Since binge eating disorder is generally associated with weight gain, it will not be further discussed in this report. [For more information, see In-Depth Report #53: Weight control and diet.]

Eating Disorders Not Otherwise Specified

A fourth category called eating disorders not otherwise specified (NOS) has been established to define eating disorders not specifically defined as anorexia or bulimia. This category includes:

• Infrequent binge-purge episodes (occurring less than twice a week or having such behavior for less than months)
• Repeated chewing and spitting without swallowing large amounts of food
• Normal weight and anorexic behavior

Such patients tend to be older at diagnosis. Although less serious than other eating disorders, these patients still face similar health problems, including a higher risk for fractures and other conditions.

Risk Factors:

Many factors contribute to the risk of developing an eating disorder. In the United States, about 7 million females and 1 million males suffer from eating disorders.

Age

Eating disorders occur most often in adolescents and young adults. However, they are becoming increasingly prevalent among young children. Eating disorders are more difficult to identify in young children because they are rarely suspected.

Gender

Studies indicate that eating disorders occur predominantly among girls and women. About 90 - 95% of patients with anorexia nervosa, and about 80% of patients with bulimia nervosa, are female.

Ethnic Factors

Most studies of individuals with eating disorders have been conducted using Caucasian middle-class females. However, eating disorders also affect people of other races.

Socioeconomic Factors

Living in any economically developed nation on any continent appears to pose a risk for eating disorders. Within nations, eating disorders can affect people of all socioeconomic levels.

Personality Disorders

People with eating disorders tend to share similar personality and behavioral traits, including low self-esteem, dependency, and problems with self-direction. Specific psychiatric personality disorders may put people at higher risk for eating disorders.

Avoidant Personalities. Some studies indicate that many patients with anorexia nervosa have avoidant personalities. This personality disorder is characterized by:

• Being a perfectionist
• Being emotionally and sexually inhibited
• Having less of a fantasy life than people with bulimia or those without an eating disorder
• Being perceived as always being "good," not being rebellious
• Being terrified of being ridiculed or criticized or of feeling humiliated

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

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

Borderline Personalities. Borderline Personality Disorder (BPD) is associated with self-destructive and impulsive behaviors. People with BPD tend to have other co-existing mental health problems, including eating disorders.

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

• Have an inability to soothe oneself
• Have an inability to empathize with others
• Have a need for admiration
• Be hypersensitive to criticism or defeat

Accompanying Emotional Disorders

Many patients with eating disorders experience depression and anxiety disorders. Depression, anxiety, or both is also common in families of patients with eating disorders. It is not clear if emotional disorders, particularly obsessive-compulsive disorder (OCD), cause the eating disorders, increase susceptibility to them, or share common biologic cause.

Obsessive-Compulsive Disorder (OCD). Obsessive-compulsive disorder is an anxiety disorder that occurs in up to two thirds of patients with anorexia and up to one third of patients with bulimia. In fact, some doctors believe that eating disorders are variants of OCD. Obsessions are recurrent or persistent mental images, thoughts, or ideas, which may result in compulsive behaviors (repetitive, rigid, and self-prescribed routines) that are intended to prevent the manifestation of the obsession. Women with anorexia and OCD may become obsessed with exercise, dieting, and food. They often develop compulsive rituals (weighing every bit of food, cutting it into tiny pieces, or putting it into tiny containers). The presence of OCD with either anorexia or bulimia does not, however, appear to have any influence on whether a patient improves or not.

Obsessive-compulsive disorder is an anxiety disorder characterized by an inability to resist or stop continuous, abnormal thoughts or fears combined with ritualistic, repetitive, and involuntary defense behavior.

Other Anxiety Disorders. A number of other anxiety disorders have been associated with both bulimia and anorexia, including:

• Phobias. Phobias often precede the onset of the eating disorder. Social phobias, in which a person is fearful about being humiliated in public, are common in both types of eating disorders.
• Panic Disorder. Panic disorder often follows the onset of an eating disorder. It is characterized by periodic attacks of anxiety or terror (panic attacks).
• Post-Traumatic Stress Disorder. Many women with serious eating disorders report a past traumatic event, and many exhibit symptoms of post-traumatic stress disorder (PTSD) -- an anxiety disorder that occurs in response to life-threatening circumstances.

Depression. Depression is common in people with eating disorders, for both anorexia and bulimia. Major depression is unlikely to be a cause of eating disorders, however, because treating and relieving depression rarely cures an eating disorder. In addition, depression often improves after anorexic patients begin to gain weight.

Being Overweight

Extreme eating disorder behaviors, including use of diet pills, laxatives, diuretics, and vomiting, are reported more often in overweight than normal weight teenagers.

Body Image Disorders

Body Dysmorphic Disorder. Body dysmorphic disorder (BDD) involves a distorted view of one's body that is caused by social, psychologic, or possibly biologic factors. It is often associated with anorexia or bulimia, but it can also occur without any eating disorder. People with this disorder commonly suffer from emotional disorders, including obsessive-compulsive disorder and depression. As part of obsessive thinking, some people with BDD may obsess about a perceived deformity in one area of their body, and may repeatedly seek cosmetic surgery to "correct" it. People with BDD are also at higher risk for suicidal thinking and attempts.

Muscle Dysmorphia. Muscle dysmorphia is a form of body dysmorphic disorder in which the obsession involves musculature and muscle mass. It tends to occur in men who perceive themselves as being underdeveloped or "puny," which results in excessive body building, preoccupation with diet, and social problems. Such individuals are prone to eating disorders and other unhealthy behaviors, including the use of anabolic steroids.

Excessive Physical Activity

Highly competitive athletes are often perfectionists, a trait common among people with eating disorders.

Female Athletes. Excessive exercise is associated with many cases of anorexia (and, to a lesser degree, bulimia). In young female athletes, anorexia postpones puberty, allowing them to retain a muscular boyish shape without the normal accumulation of fatty tissues in breasts and hips that may blunt their competitive edge. Many coaches and teachers compound the problem by overstressing calorie counting and loss of body fat.

In response, people who are vulnerable to such criticism may lose excessive weight, which has been known to be deadly even for famous athletes. The term "female athlete triad" is a common and serious disorder that affects young female athletes and dancers. It includes:

• Eating disorders, including anorexia
• Amenorrhea (absent or irregular menstruation)
• Osteoporosis (bone loss, which is related to low weight)

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

Men and Women in the Military. Studies also show a higher-than-average risk for eating disorders in men and women in the military. A study of eating behavior on one Army base reported that 8% of the women had an eating disorder, compared to 1 - 3% in the civilian female population.

Vegetarianism

In general, vegetarianism, with careful planning, is a healthy practice for both adults and adolescents. Studies report, however, that vegetarianism in adolescence may be a risk factor for eating disorders in both males and females. Vegetarian teens have been found to be twice as likely to diet frequently, four times as likely to intensively diet, and eight times as likely to use laxatives as their non-vegetarian peers.

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

• If the child has stopped eating meat only to avoid fat rather than from other motives, such as love of animals or to improve health.
• If the vegetarian diet coincides with rapid weight loss.
• If the child avoids important vegetable products because of calories (such as whole grains) or because of fats and oils (such as tofu, nuts, and dairy products).

Diabetes or Other Chronic Diseases

Early Puberty

There is a greater risk for eating disorders and other emotional problems for girls who undergo early menarche and puberty, when the pressures experienced by all adolescents are intensified by experiencing these early physical changes, including normal increased body fat.

Eating disorders may be more common in teenagers with chronic illness, such as diabetes or asthma. Some recent research suggests an endocrinological link between obesity, diabetes, and eating disorders.

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

• Binge eating (without purging) is most common in type 2 diabetes and, in fact, the obesity it causes may even trigger this diabetes in some people.
• Both bulimia and anorexia are common among young people with type 1 diabetes. The combination of diabetes and an eating disorder can have serious health consequences. Some women with diabetes often omit or underuse insulin in order to control weight. If such patients develop anorexia, their extremely low weight may appear to control the diabetes for a while. Eventually, however, if they fail to take insulin and continue to lose weight, these patients develop life-threatening complications.

Causes:

There is no single cause for eating disorders. Although concerns about weight and body shape play a role in all eating disorders, the actual cause of these disorders appear to result from many factors, including cultural and family pressures and emotional and personality disorders. Genetics and biologic factors may also play a role.

Negative Family Influences

Negative influences within the family may play a major role in triggering and perpetuating eating disorders. Some studies have produced the following observations and theories regarding family influence.

• Parental Behaviors or Attitudes. Poor parenting by both mothers and fathers has been implicated in eating disorders. One study found that 40% of 9- and 10-year-old girls trying to lose weight generally did so with the urging of their mothers. A maternal history of eating disorders can be a factor in development of eating disorders in young girls, while paternal criticism of weight can lead to bingeing and purging in young males.
• Family History of Addictions or Emotional Disorders. Studies report that people with either anorexia or bulimia are more likely to have parents with alcoholism or substance abuse than are those in the general population. Parents of people with bulimia appear to be more likely to have psychiatric disorders than parents of patients with anorexia.
• History of Abuse. Women with eating disorders, particularly bulimia, appear to have a higher incidence of sexual abuse. Studies have reported sexual abuse rates as high as 35% in women with bulimia.
• Family History of Obesity. People with bulimia are more likely than average to have an obese parent or to have been overweight themselves during childhood.

The most positive way for parents to influence their children's eating habits and to prevent weight problems and eating disorders is to have healthy eating habits themselves.

Genetic Factors

Anorexia is eight times more common in people who have relatives with the disorder, and some doctors believe that genetic factors are the root cause of many cases of eating disorders. Twins had a tendency to share specific eating disorders (anorexia nervosa, bulimia nervosa, and obesity). Researchers have identified specific chromosomes that may be associated with bulimia and anorexia. In particular, regions on chromosome 10 have been linked to bulimia as well as obesity. Some evidence has reported an association with genetic factors responsible for serotonin, the brain chemical involved with both well-being and appetite. Researchers have also pinpointed certain proteins such as brain-derived neurotrophic factor (BDNF). This protein may influence an individual's susceptibility to developing an eating disorder.

Cultural Pressures

The approach to food in Western countries is extremely problematic. Enough food is produced in the U.S. to supply 3,800 calories every day to each man, woman, and child, far more than are needed for good nutrition. Obesity is a global epidemic, and few people living in this over-fed and sedentary culture eat a meal guiltlessly.

One interesting anthropologic study reported the following observations:

• During historical periods or in cultures where women are financially dependent and marital ties are stronger, the standard is toward being curvaceous, possibly reflecting a cultural or economic need for greater reproduction.
• During periods or in cultures where female independence has been possible, the standard of female attractiveness tends toward thinness.

The response of the media to the cultural drive for thinness and the overproduction of food both likely play major roles in triggering obesity and eating disorders.

• On the one hand, advertisers heavily market weight-reduction programs and present anorexic young models as the paradigm of sexual desirability.
• Clothes are designed and displayed for thin bodies in spite of the fact that few women could wear them successfully.
• On the other hand, the media floods the public with attractive ads for consuming foods, especially "junk" foods.

Hormonal Abnormalities

Hormonal abnormalities are common in eating disorders and include chemical abnormalities in the thyroid, the reproductive regions, and areas related to stress, well-being, and appetite. Many of these chemical changes are certainly a result of malnutrition or other aspects of eating disorders, but they also may play a role in perpetuating or even creating susceptibility to the disorders.

The primary setting of many of these abnormalities originate in a small area of the brain called the limbic system. A specific system called hypothalamic-pituitary-adrenal axis (HPA) may be particularly important in eating disorders. It originates in the following regions in the brain:

• Hypothalamus. The hypothalamus is a small structure that plays a role in controlling our behavior, such as eating, sexual behavior and sleeping, and regulates body temperature, emotions, secretion of hormones, and movement.

The pituitary gland. The pituitary gland is involved in controlling thyroid functions, the adrenal glands, growth, and sexual maturation.

Amygdala. This small almond-shaped structure lies deep in the brain and is associated with regulation and control of major emotional activities, including anxiety, depression, aggression, and affection.

Stress Hormones. The HPA systems trigger the production and release of stress hormones called glucocorticoids, including the primary stress hormone cortisol. Chronically elevated levels of stress chemicals have been observed in patients with anorexia and bulimia. Cortisol is very important in marshaling systems throughout the body (including the heart, lungs, circulation, metabolism, immune systems, and skin) to deal quickly with any threat.

Release of Neurotransmitters. The HPA system also releases certain neurotransmitters (chemical messengers) that regulate stress, mood, and appetite and are being heavily investigated for a possible role in eating disorders. Abnormalities in the activities of three of them, serotonin, norepinephrine, and dopamine, are of particular interest. Serotonin is involved with well-being, anxiety, and appetite (among other traits), and norepinephrine is a stress hormone. Dopamine is involved in reward-seeking behavior. Recent research suggests that people with anorexia have increased activity in the brain's dopamine receptors. This overactivity may explain why people with anorexia do not experience a sense of pleasure from food and other typical comforts.

Ghrelin. High levels of ghrelin, a hormone that increases the feeling of hunger and slows metabolism, have been noted in patients with anorexia and bulimia.

Low Levels of Reproductive Hormones. The hypothalamic-pituitary system is also responsible for the production of important reproductive hormones that are severely depleted in anorexics. Although most doctors believe that these reproductive abnormalities are a result of anorexia, others have reported that in 30 - 50% of people with anorexia, menstrual disturbances occurred before severe malnutrition set in and remained a problem long after weight gain, indicating that hypothalamic-pituitary abnormalities may precede the eating disorder itself.

 

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Maintaining Change Following Intensive Eating Disorder Treatment

It is a relatively well known fact that eating disorders have

 a high relapse rate and many people, myself included,

 find themselves in multiple intensive – residential,

 inpatient, even partial hospitalization – treatments. One

 may ask if such intensive treatments really work or if 

long term intensive care is just a band-aid of sorts. I know

 I’ve had to ask myself, “why is this going to work this

 time when it hasn’t worked in the long run before.”

There is even debate in the field on whether residential

 treatment actually has evidence supporting its 

effectiveness (see Tetyana’s post here). I can speak from

 experience that the various intensive treatments I’ve

 personally done have saved my life and given me more

 perspective, skills training, and support than I could have

 had otherwise. However, despite having made

 significant changes, I’ve had more than my share of slips

 and relapses.

I am willing to bet I’m not alone.

Maintaining change after intensive treatment is a little-discussed topic. (Although it’s pretty important, I think. I mean, making the changes is difficult, but the changes need to be sustainable if the work is going to be worth it!) Cockell and colleagues explored the topic in their 2004 paper.

The article begins by acknowledging the common concern that both patients and treatment providers have when an intensive treatment comes to an end, which is: how does the patient maintain the changes that were made during her treatment [note: this article speaks only of females, I personally am not making that judgement] in an outpatient setting. Despite motivation, there is question about the patient’s “ability to choose non-eating disorder coping strategies when her[/his] distress level runs high.” Furthermore, the transition from treatment to “real life” is inherently destabilizing and stressful, which almost seems to set the patient up for high-risk situations. Thus, “learning more about this critical phase of change [i.e the maintenance of change] is important, as relapse rates in the eating disorders are reported to range from 33% to 63% (Field et al., 1997; Herzog et al., 1999; Keel & Mitchell, 1997; Olmstead, Kaplan, & Rockert, 1994), and repeated admissions to treatment programs are common (Woodside, Kohn, & Kerr, 1998).”

The authors go on to cite several challenges in treating eating disorders that lead to high relapse and readmission rates. These can be grouped into three categories:

• Eating disorders are mental disorders with physical consequences, as such the coordination of mental and physical care is necessary or optimal treatment, however integrated care is not always available outside of an intensive treatment setting, and this may lead to poor prognosis.
• Comorbid disorders (such as anxiety, depression, PTSD) complicate and impede treatment of the ED
• Many patients with eating disorders feel ambivalent toward recovery. Despite negative consequences of the disorder, EDs can serve as a coping mechanism, and in pursuing recovery, the patient loses not only the negative aspects of the disorder but also the functional value of it (which can be quite high).

So, WHAT WORKS?

Although recovery from an eating disorder is an enormous challenge, many individuals do attain partial or full recovery. While it is well understood that the course of recovery from an eating disorder is slow, what remains unclear is an understanding of what factors support a favorable outcome.

A small number of studies in the past several decades shed some light on this, but the work, which is dated anyway (from the late 80′s to the early 90′s!) most definitely left room for further investigation. And so, the present study aims to “identify factors that help or hinder the maintenance of change and the ongoing promotion of recovery during the critical 6 months immediately following eating disorder treatment.”

Cockell et al studied 32 women who had been admitted to (and completed) a 15 week residential treatment center (mean age 27.9 years (with a standard deviation of 10), mean duration of eating disorder was 11.6 years (with a standard deviation of 9)). Diagnoses were made by a clinical psychologist according to the DSM-IV. Prior to treatment, 21 women met diagnostic criteria for anorexia nervosa, and 11 met criteria for an eating disorder not otherwise specified (EDNOS).

Immediately following completion of the treatment program “all 32 reported a decrease in eating disorder symptoms  but continued to meet criteria for an eating disorder not otherwise specified [italics mine]”

Specifically, most women had reported reduced behavioral symptoms (including maintaining an objectively healthy weight; no participants met the diagnostic weight criteria for AN) but not reduced cognitive symptoms, thought patterns, and so on..

This isn’t too surprising as the treatment center in this study (as with most others, in my experience) impose weight/behavioral guidelines that are generally adhered to at the facility and cognitive changes are slower to occur (and require, in my experience, more extensive/different/long-term work to change).

Six months after treatment was completed, the diagnoses were reassessed.” At that point, 5 women met diagnostic criteria for anorexia nervosa, 1 met criteria for bulimia nervosa, 21 met criteria for EDNOS, and 5 no longer had an eating disorder diagnosis.” These numbers are consistent with what is generally observed in studies looking at partial recovery, full recovery and relapse (Strober et al., 1997).

To find out what helped or hindered recovery for the women in this study, in-depth, open-ended interviews were conducted with participants in which they were asked to identify what assisted or sabotaged their recovery, in their own words.

Analysis allowed the responses was broken down into specific factors, summarized in the table below.

Table 1: Summary of Assisting and Inhibiting Factors from Cockell et al. (2004).

Cockell et al  break their findings down into three working categories: effective coping, social support and higher values. They further go one to provide treatment recommendations on how to incorporate their findings into outpatient treatment to facilitate the transition from intensive treatment to real life. Their recommendations are valid and seem to follow accordingly based on their results.

The basis of most of their ideas seems to be: have a treatment team that communicates with each other, encourages and facilitates building effective social support, helps prepare you for times of distress and works with you on building a life outside of the eating disorder that incorporates values you hold for yourself.

If you’re like me you may be thinking that this sounds like good practical advice based on first-hand accounts of research. You also may be thinking DUH. I’ve, personally, been in solid treatment programs that have incorporated everything mentioned in this study and beyond. I also have a treatment team (currently and in the past) that is well versed in eating disorders, communicate well with each other, with me, AND with my former treatment center(s).

I’ve also relapsed and gone back to treatment. In spite having all of this in place. (And I’m aware that no one on this project said that this is a fool-proof plan, but hang in there with me for a second.)

Although this study is valid, it fails to mention something pretty significant (in my opinion): in order for everything that they cite as “helpful” to in fact be helpful, the patient has to fight for it.  Fight really hard. For example, having  a treatment team that works with you on interpersonal skills and building meaningful relationships isn’t going to help if the patient doesn’t get out there, be vulnerable and do the work it takes to build relationships. Same with nutritional counseling and coping skills. I learned a lot of things in treatment and I continue to learn a lot of things that would be very helpful in maintaining recovery. For instance, I know that meal-planning is helpful.  I know the importance of nutrition. I also know that getting through the anxiety, time and energy it takes to do the plan and eat is sometimes huge. I know I’m not alone.

Bottom line: I certainly think that everything Cockell et al report is useful. But I also think that another HUGE problem in maintaining change coming out of intensive treatment is doing the recovery behaviors long enough so that they become habit, less of a job, more of a way of life. This research cites one way in which that can happen which involves the support of others, but misses the other side of the coin that involves the work the patient must do themselves.

5 Responses to “Maintaining Change Following Intensive Eating Disorder Treatment”

1. 

   Good topic. I agree that fighting for recovery is crucial. In order to fight, we need a whole lot, like the skills, the motivation, the hope that it will be worth it and a cheer squad/advisory board/treatment team helps a bit too.

   I often wonder if intensive treatment takes the patient too far too quickly. In my experience, the treatment team asserts that the best model of treatment is to get me to 20bmi, with inpatient then intensive outpatient care, in the space of 4 or so months, and then it’s discharge and cross fingers that I can maintain the weight and the eating pattern. Of course they taught me skills etc.

   This puts a lot of pressure on to maintain recovery. It’s a lot of change in a relatively short space of time, in an environment unlike home and normal life. And the change has been created by the treatment team and not by choices that I’ve had a great deal of say in.

   I’m sure that approach is quite ok for some patients.

   I wish the pace of treatment could be more variable, rather than ‘one size fits all’, where the patient is involved in goal setting. In this way, recovery could be intentionally staged, ie. progressive in stages. Assuring of course, medical stability. One way this would help, as I see it, is increasing confidence in one’s ability to consolidate progress and reducing feelings of failure and discouragement from not being able to meet overly high expectations.

   Anyone else ever thought this kind of approach would help?

   POSTED BY LOVINGMYFAITH | SEPTEMBER 26, 2012, 6:22 AM  | QUOTE COMMENT
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   • 

     I agree that having flexibility in the pace of treatment could be really beneficial. I think in residential, inpatient, php, iop etc, a lot of the pace is determined by insurance (i.e. why should we pay if progress is going so slowly). When there’s a time limit, I think Tx centers want to do as much as they possibly can, which is usually physical =/

     I experienced a *little* more flexibility in residential this time … not at all with weight restoration which went at a ridiculously fast pace, but in terms of integrating other recovery behaviors. Also, DEFINITELY having a team that is encouraging/believes in your ability to do it.
     The biggest lesson I learned in treatment this time was after I purged and told the RD at the treatment center. I was expecting to be put on some crazy observation or something and I was already pissed at myself for doing it. She said something along the lines of, “If it wasn’t relieving in the same way it used to be, then I’m sort of glad you did it, what a great lesson to learn in a safe environment. You need to be able to make mistakes and learn from them in a safe way.”

     I was mind blown. That I could process a slip and not get in trouble for failing was huge. It also was kind of a red flag that I needed to have more support from staff/my therapist etc. We definitely need more of that.

     POSTED BY GINA | SEPTEMBER 26, 2012, 11:24 AM  | QUOTE COMMENT
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2. 

   I think there sound like there are huge differences in treatment here in Australia to other countries, so my experiences probably won’t be the same as others. But for me, it’s been a vicious cycle. The more inpatient treatment I’ve had, the sicker I’ve actually gotten all round. And this cycle just kept feeding itself for years, a pretty horrible situation.

   Treatment in Australia seems to be more in theory than in practice. Apart from the scary shortage of actual beds for people with ED, if you manage to get in, you will find yourself looked after by a large percentage of staff who don’t know the first thing about eating disorders, and find you frustrating, because the ED unit will be a few beds on a general ward and short staffing/funding means they do need to use general staff, take them aside and give them a few (quickly forgotten) general pointers and consider them trained ED staff.

   Lack of staff and funding also means that program content doesn’t happen. The programs I’ve been on mostly ended up having more than half their scheduled groups become video watching sessions (in order to ‘babysit’ the patients in after meal time by keeping them in one place but not having the staff to actually engage with them.) Any groups that do happen, there is no continuity and if you a repeat patient as many are, you do the same groups several times over.

   And then there is the factor of being ‘forced’ to be there. In public hospital units in Australia, it seems these days that pretty much everyone there has been forced there under the mental health act. That makes for a unit full of angry people there against their will with their minds set on fighting the treatment any way they can – the attitude of the patients can often get very ugly and anti-authoritarian, groups are openly scoffed at and participation rates very low (and rudeness factor high since they still have to be in the group even if they are refusing to engage.)

   My hospital has a good meal support program now – and by ‘good’ I mean very strict with all avenues of cheating limited. But I’ve never felt I’ve learnt how to eat ‘appropriately’ there because the meals are on a whole, much larger than would be normal since we are all on weight gain regimes, also there is the feeling of being held hostage because you have less than 20 minutes to eat every bite on your tray or you will drink your entire prescribed supplement. Even for one bite left. You aren’t listening to your body or tasting the food, you are shovelling it in like a robot and racing against the clock. My own treatment meant I mostly ate in bed – and I felt that I was completely clueless as to how to feed myself when I returned home, and clueless as to how to cope out there in the big overwhelming world after another few months on bedrest in a little white room.

   Every unhelpful and even deadly behaviour I’ve learnt has been from fellow patients or dreamed up in reaction to something imposed by staff.

   I’m not blaming my treatment for how sick I became, I have only myself to blame for that, but I sincerely do not think inpatient treatment is good for people with eating disorders unless they are critically ill and need urgent stabilisation. I think transition house style treatment and day patient treatment would be the best way to go, try to keep people as engaged in the real world as possible, doing as much for themselves to practice valuable skills as possible, and to avoid their whole world and group of social contacts from diminishing into an ED world. the more disengaged we become from real life and real people, the harder it is for us to get out there and be part of it and that in turn negatively affects the patient’s chances of freeing themselves from the disorder.

   POSTED BY FIONA | SEPTEMBER 26, 2012, 10:18 AM  | QUOTE COMMENT
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     I definitely think this is geared toward treatment in the states (although I guess I’m not too well versed on international treatment besides, like, the UK). Anyway, just from personal experience my treatments here have been vastly different than what you described, but mostly because I think I’ve been lucky enough to have some treatment providers that were/are very-well versed in eating disorders…I know that revolving-door of Tx exists here too, especially when you enter the realm of psych ward/inpatient treatment. I do think, despite having subjectively “good” treatment, some things remain. I definitely also learned a lot of behaviors from fellow patients and became much MUCH more sneaky after playing games with staff during my first couple of intensive treatments.

     You say it pretty well…the most effective things I learned in treatment were how to put a meal together for myself. (In residential, we cooked/prepared a lot of meals for ourselves in an actual kitchen, very helpful). And also, having the opportunity to follow a meal plan with treatment support AFTER I had restored weight. Eating a normal amount of food is still hard, but it’s REALLY different from weight restoration amounts.

     Really interesting differences (and still similarities in outcomes despite some really big differences in Tx approach).

     Cheers.

     POSTED BY GINA | SEPTEMBER 26, 2012, 11:15 AM  | QUOTE COMMENT
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   • 

     Fiona:
     And then there is the factor of being ‘forced’ to be there. In public hospital units in Australia, it seems these days that pretty much everyone there has been forced there under the mental health act. That makes for a unit full of angry people there against their will with their minds set on fighting the treatment any way they can

     This is the one of the major faults in a system that limits or denies access to treatment resources until the patient is severely ill. By the time they reach that point, it is almost impossible to expect patients to participate in treatment in a meaningful way, from
     what we know about eating disorders and the effects of starvation on the brain. Hence setting the program up for failure and the individuals for recidivism and relapse.

     POSTED BY SAREN | SEPTEMBER 26, 2012, 12:12 PM  | QUOTE COMMENT
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3. 

   This article supports my 31 years of experience in successfully treating those with eating disorders into recovery.

   Throughout my entire career working with ED Clients I have been aware of several important facets to the real recovery process. 1) as research states recovery from an eating disorder takes from 3-10 years! 2) It is my belief that while there is a need for inpatient treatment – PURPOSE: Primarily to stabilize life-threatening out of control behavior associated with the ED – Period. 3) A long-term group therapy course + individual care as needed allows for the establishment of invaluable healthy relationships/support that focuses/addresses the cognitive distortions/faulty thinking clients present with. 4) This type of group provides a safe environment for the client to try new social behavior such as setting boundaries, new ways of thinking, finally addressing the SHAME that underlies all disordered eating behavior and ALL the though process distortions. 5) Ultimately our clients display interesting and universal outcome – ED behavior simply melts away w/o the constant ‘battle’ described by clients. (Yes I did just say our clients symptoms simply fade away!) 6) During the course of treatment our clients learn effective coping skills for life’s challenges, attain a healthy support group of people, are able to learn to express themselves and their feelings within a very emotionally safe environment!

   After 31 years of research, education & experience this has been the MOST SUCCESSFUL method of treatment for these life-threatening disorders! So I whole-heartedly agree with the this article’s main positions!

   Your comment is awaiting moderation.

   POSTED BY DEB - EDRC (EATING DISORDER RECOVERY CENTER) | SEPTEMBER 30, 2012, 8:24 AM  | QUOTE COMMENT
   So Please Share YOUR Thoughts about all
    of this!!!