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Eating Disorders

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Eating Disorders: Anorexia  and Bulimia 
Research in Teenage Girls

Judie Brierly
2002

 
I am researching the topic of Anorexia Nervosa and Bulimia Nervosa to learn more about the diseases that appears to be on the increase, touching many young lives.  In the six years that I have counseled junior and high school girls, I have been made aware of 15 cases of extreme eating disorders.  The havoc plays with the lives of the girls and their families. They live with it daily without answers, resources, or insurance coverage.  This disease commands attention because of the demoralizing and debilitating power it has over its victims.  How difficult to see a bright young woman obsessed with her body to the point that she is starving herself to death.   I am grateful to Dr. Sumpter for allowing me to take liberty with the assignment and present this paper that does not completely conform to the assignment schedule. 
 

Introduction 

    This paper concentrates on the eating disorders of young women, especially the devastating modern disease of Anorexia nervosa (AN) and Bulimia nervosa (BN).  The patients diagnosed with anorexia or bulimia present a complex nutritional picture to clinicians. The principal symptoms of both eating disorders are a pathologic fear of being or becoming fat. The extreme desire of thinness in (AN) and (BN) has a wide range of behavior patterns from restrained eating to self-starvation which may be the root of binge eating and certainly purging. To understand the cause of eating disorders, researchers, Heatherington and Roll, Department of Nutrition, Pennsylvania State University studied the personalities, genetics, environment, and biochemistry of people with these illnesses.  Through research, and my own small sample of observation the more that is learned, the more complex the roots of eating disorders appear. 

    Heatherington and Rolls, found that people with anorexia tend to be “too good to be true”.  They rarity disobey, they keep their feelings to themselves, and tend to be perfectionists, good students, and excellent athletes. So what is the problem? Researchers believe that people with anorexia restrict food, particularly carbohydrates to gain a sense of control in some areas of their lives.  They are always complying with the wishes of others, being submissive in an unhealthy way.  They feel that they can control their bodies and will gain approval from others.  However, it eventually becomes clear to others that they are “out-of-control” and dangerously thin; they either will not eat, or they cannot eat!  The addiction can eventually kill them or harm their bodies for life and that is the danger. 

    People who develop bulimia and binge-eating disorders typically consume huge amounts of food; especially junk food.  It is an attempt to reduce stress and relieve anxiety. With the high caloric intake (up to 8000 calories in one setting) comes the guilt and depression.  They purge to bring relief, but it is only temporary.  Individuals with bulimia are also impulsive and more likely to engage in risky behavior such as abuse of alcohol and drugs (Heathermington & Rolls, 2000).

    There are many categories and descriptions of the eating disorders, broken down into three main groups by specialist Dr.Sobel from  San Diego California. In Sobel’s article, What’s New in the Treatment of Anorexia Nervosa,  Sorbel identified 3 eating disorders, anorexia nervosa, bulimia nervosa, and binge eating which occur at a rate frequency greater than usually realized. Anorexia has been found to be present in up to l% of teens and young adult women, and bulimia up to 5%. The binge eating disorder is not known, but may be higher than bulimia. (AN) is characterized by weight loss, body image disturbances and a morbid fear of weight gain.(BN) is characterized by binge eating and compensatory purging by vomiting, use of laxatives, diuretics, and diet pills; exercise to excess or fasting. Binge behavior and loss of control of food intake characterize binge-eating disorder, with an absence of purging. The main concern is the mortality of eating disorders, which may be as high as l5% including deaths from powerless and striving toward perfectionism. The core conflict within the bulimic person appears to be deprivation and dependency.  On a national level, the numbers indicate that (AN) is on the rise over the past thirty years.  In terms of general population, it is estimated that only l.6 per l00, 000 population, but in the population of adolescent girls and young women, as many as l0% are affected.  On some college campuses, the numbers run as high as 20 percent (Sorbel 2000). 

     There is usually much frustration from the parents, and the clinicians that report the girls eating disorder, because of the deception that the girls in general use to cover their anorexia.  Eating disorders such as anorexia nervosa (AN) and bulimia nervosa (BN) increasingly prevalent among children and adolescents. ( AN ) has a peak age of onset in early to mid adolescence, and (BN) typically presents during and after the late adolescence.    The anorexic population tends to be secretive, perfectionist in nature, and introverted. They often have demanding perfectionist parents that they try to please.  They are hard on themselves and have distorted body imaging; no matter how thin they become, they always think they should be thinner. The girls see food as the enemy, they resort to ploys such as drinking a lot of water before a weigh-in, putting weights in their pockets, and see their bizarre food and eating behavior habits as normal, such as only eating “three peas at once setting.” There are a lot of obsessive compulsive behavioral traits on counting the tiny morsels that they ingest or suck on.   There have been reports of girls eating only one food such as celery, yogurt or dry crackers, and will not let anyone watch them eat, or they are caught throwing out their dinner…their entire focus is simply, not to eat. (Sorbel 2000).  The bulimics, on the other hand, eat large qualities of food, then purge by vomiting up everything. This population is difficult to detect, as the girls usually are not as underweight as the true anorexic set. The bulimic girls are often outgoing, demanding, and could have accompanying disorders of borderline, narcissistic, and bi-polar traits. 

     According to historian  Brunburg, and author of the Body Project, raises the question: Is Anorexia nervosa an “epidemic?” 90-95% of anorectics are young and female, and they are disproportionately white and from middle class and upper class families. (There are male anorexics, but very few, it seems to be a cultural issue that mainly affects young women). It is specific to age and gender and also geography, found mainly in the United States, Western Europe, and Japan.  Clinicians and mental health practitioners are in agreement that anorectics are not necessarily a homogenous group and more attention should be paid to the details of the psychological and physiological characteristics; there is often comorbidy with depression and other disorders which mask the eating problems. (Bruburg, 2001, p 56).   Anorexia Nervosa is still under investigation and various therapeutic services view the disease from their own perspective.  According to eating disorder studies,  Bruch reported: “ To date, there is no single psychological therapy or drug that is uniformly effective with anorexia nervosa or bulimia and the victims of this disease and their parents and practicinors are in a difficult predicament. The cures are not imminent, the cost is high.  Some treatments focus solely on weight gain as the absolute first step in recovery; others make weight gain secondary and emphasize psychological growth and awareness. Drug therapy, psychoanalysis, dynamic psychotherapy, family therapy, behavior modification, peer counseling and support groups, social skills training assertiveness, training psychodrama, hypnosis and nutritional education have all been tried with limited success.” Treatment is expensive, on either an outpatient or inpatient basis, and the results reported have not been higher than 50% without relapse. Bruch (1990).
 

Cultural Explanation

    The Fasting Girls, the History of Anorexia Nervosa,   historian  Brunberg reports “Historical, anthropological, and psychological studies suggest that women use appetite as a form of expression, ore often than men, a tendency confirmed by scholars as well as clinicians.” The American women have a preoccupation with overweight that begins before puberty and intensifies in adolescence and young adulthood. There is not a young girl from twelve year of age that looks at a picture of herself without the standard response of “does this make my fanny look too big?” The powerful cultural messages from magazines, TV, movies, fashion trends, and most advertising all explain why eating disorders are essentially a female problem.  In the April, 2000 edition of Glamour magazine has been doing magazine surveys on women and have never come up with statistics that show more than 25% of women are happy with their weight  (p.57).

    The pages of history as reported by Brumberg, are filled with women obsessed with weight problems starting with the Catholic saints in 1340.  Saint Catherine of Sienna, Mary of Ions, Beatrice of Nazareth, and Saint Veronica were obsessed with only drinking alter wine and eating the wafer representing the body of Christ. Often the saintly, obedient women who would self flagellate themselves, wear course burlap clothing and slept on beds of thorns as part of their sacrificial rituals.  When they were forced to eat, they would throw up, or in the case of Saint Catherine, she shoved twigs down her throat.  Many of them died with their religious fasting. (P.58).  Brunburg followed the eating disorders to the Victorian era, women especially adolescent girls suffered from appetite disorders and sensitive stomachs as well as consumption and tuberculosis the Victorian society of the l800’s, how and what one ate were important indications of femininity of the middle and upper class women. Tight corsets were cinched to show off  l7” waists, and the fainting couch was used when the frail underfed girls needed to rest. Women that did not have the desire to eat were often though of as psychic and many pseudo claims were made as the “fasting girls” were observed as they starved to death, often through the exploitation of their parents who were “running the side show.” Their fragility was linked to a spirituality that transcended the need for food. In a classic oil painting, circa 1855, The Ideal Victorian Woman, painted by T. Eakins, depicts a portrait of a frail young woman on the fainting couch looking pale, underfed, and not able to move about. This was the classic beauty of that era. It hangs in the Metropolitan Museum of Art in New York City. 

    Even today, maladjusted girls that come from unusually strict, austere religious backgrounds, especially Judeo-Christian fundamentalist organizations stress sacrifice, loyalty, and sexual denial as part of their credo.  There are a few incidences in this population of young religious zealot women translating their interaction with their belief system through a contorted view on denial of food.  The department of Sociology and Anthropology, River Falls, Wisconsin produced insightful information on culture. In their article: (2000). “Culture Bound Syndromes “  C.G. Banks looked at the historical roots of the eating disorders.  It is suggested that future cross cultural research might examine asceticism about the body and food in religions other than Judeo-Christian, cultural groups with rituals of fasting and vomiting, and the presence of fundamentalists churches and missionaries in those non-Western cultures are linked to eating disorders according to Banks.

    Anorexia nervosa may be regarded as a culturally determined illness that shapes changes in family structure.  A complex interaction still occurs and a containment of maladaptive behaviors, particularly through prayer and through a sense of belonging to a religious community if a punitive God is interpreted who does not have a favorable view of women. If the theme of the religion is sin, denial and self-punishment connected with original sin, eating and sex may be emphasized in the mind of an anorexic teen.  Both anorexia and asceticism are considered to be connected conceptually to the process of idealization.  It is suggested by studies from Great Britain’s medical journals, that a high population in Anorexics with distorted or extreme religious viewpoints.  This syndrome does not take place in all religious trained children, it is only the rare individual that uses imaginative cultural symbols in notions of asceticism about food and the body that are a part of religion and give their own personal interpretation to it. (Huline & Dixon 2000).

    The committee on Human Development, University of Chicago also tied in religious obsessions with eating disorders. “The imaginative use of religious symbols in subjective experiences of anorexia.   Relations between culture and the individual mind (and between culture and illness, between normal and abnormal) must be viewed as a moving continuum, with culture constantly worked and reworked by individual imagination in innovative and creative ways.”

    As early as 1974, noted psychologist, Minuchin, had on going studies with teens with eating disorders. He looked to the family for answers. Pleasing aster parents has been looked into by many studies going back to Freud father of the psychoanalysis model who stated:” the young woman with the eating disorder was fighting against her sexuality and trying to remain childlike.” Munuchin (1974).  Minuchin’s historic book on  Structural Family Therapy, showed that family roles could contribute to the possible causation or contributory roles. There were extreme methods that still exist today of removing the child from the home in order for treatment to be monitored properly.  Dr. Minuchin only agreed if the family was in touch with the child at all times. His therapy did not break up the family unit under any circumstances.

    The one noted Anorexic that died from complications, in my own era, was Karen Capenter-dead at age 32 in l983.  (She appeared in casinos in South Lake Tahoe, sang for my sisters’ funeral, as they were friends and had worked together).  From Karen’s early days in show business, in the late 60’s, Karen had always fought her obsession to have a perfect stage body.  She was obsessed with her stage appearance, and her tragic death generated a great deal of interest in the disorder and made anorexia nervosa well known among the American public From the data reported, from the historical reports to the present, society is generating psychopathologies that are symptomatic of the culture.  Many factor, interpretations, traditions and ideology pass between cultures, Old World views to modern fads - they are all intertwined. This historical information is important in helping with different cultures, understanding religious ties, or views on self-sacrificing viewpoints.

  Eating disorders are viewed from the: cultural, biomedical, and psychological models, with overlaps in all three groups. It is a multidetermined disorder that depends on the individual’s family and social climate, biological vulnerability, and psychological predisposition. 
 

Medical-Biological model

    There has been considerable progress in understanding anorexia and bulimia, yet the response to treatment has a limited response. The present treatment strategies are adopted from therapies that were devised to treat other psychiatric illnesses. Recent studies suggest that the eating disorders are independently transmitted familial liabilities with a unique pathophysiology.  These new findings raise the possibility that an improved understanding of the pathogenesis of eating disorders will generate more specific and effective psychotherapies and pharmacological interventions. Walsh, an internist from USFC in San Francisco - Mount Zion Division, wrote a complete treatment plan for the eating disorders, featuring the role of the primary care physician (1999).  It is unanimously agreed by all research on the eating disorders that a patient with an eating disorder should involve a multidisciplinary team, including the primary care physician, nutritionist, and a mental health professional all of whom should communicate and confer regularly.  The immediate aim is to normalize eating patterns and add therapy as soon as the patient is able or willing.  Day programs and outpatient treatment are most effective working with a team to help the patient to gain weight.  There are medical challenges with both (AN) and (BN).   According to Dr. Walsh, (AN) patients have special needs.  The weighing techniques include ensuring that the patient has an empty bladder, no shoes, and one layer of clothing.  Urine specific gravity can be assessed to detect water loading.  Weights should be reported to the practitioner.  Patients often misrepresent weights in order to meet a contract weight to avoid hospitalization. Patients take multivitamins from iron and calcium. Zinc supplementation at 50 mg daily is tolerated and may facile weight gain. Metoclopramiide may be helpful if abdominal bloating is present.

    Determining the need for hospitalization is an important role for the physician. The criteria for hospitalization include rapid weight loss of more than 30% recent of ideal body weight. The University of San Francisco’s check list for anorexia:

Cardiovascular
Bradycardia and hypertension
Mitral valve prolaspse (often from forced feeding)
Sudden death (related to QT prolongation)
Peripheral edema
Refeeding syndrome
Dermatologic:
Dry skin
Carotenodermia
Lanugo hair
Starvation-associated prurtis
Gastrointestinal: Constipation
Refeeding pancreatitis
Acute gastric dilation due to refeeding
Endocrine and metabolic:
Amenorrhea
Infertility
Osteoporosis
Thyroid abnormalities
Hypercortisolemia
Hypercholesterolemia due to impaired cholesterol metabolism
Hypoglycemia
Neurogenic diabetes insipidus
Impaired temperature regulation
Fluid and electrolyte abnormalities
Hematological
Pancytopenia due to starvation
Decreased enthrocyte sedimentation rate

    The most significant long-term complication is the increased risk of osteoporosis associated with amenorrhea. Anorectics often have a hypothalamic hypogonadism, which leads to a hypoestrogenemic state; when there is a lack of bleeding.  This condition is associated with low bone density and fractures of multiple sites. 

    Medications in general have not been successful in the controlled studies looking for clues to the treatment of anorexia nervosa.  In the USFC study (1999). cyptoheptadine had shown promise as a treatment drug, but in the results were not conclusive.  The same with the study of floretine, demonstrated relief with bulimia symptoms, but the anxiolytics was not helped.  Depression is often treated in the (AN) population with antidepressants, but the depression is often due to the starvation and improves with the resumption of normal eating habits. 

    According to the study from the University of San Francisco, the medical complications of bulimia nervosa are unique to patients who binge and purge. 

Medical Complications of Bulimia Nervosa: (USFC)

Gastrointestinal
Dental erosion
Parotid gland swelling
Esophageal rupture
Gastroesophageal reflex due to the chronic relaxation of the sphincter
Acute gastric dilation
Post-bing pancreatitis
Constipation due to laxative abuse
Cathartic colon
Pulmonary/mediastinal
Aspiration pneumonitis
Pneumomediastinum with weight loss or caused by vomiting
Pneumothorax or rib fracture

Cardiac:
Arrhythias
Diet pill toxicity: palpitations, hypertension
Emitene cardiomyopathy
Mitral valveprolaspe
Endocrine
Irregular menses
Hypoglycemia
Mineralocorticoid excess
Metabolic
Electrolyte imbalances
Dehydration
Nephropathy

    Gastrointestinal complications are a real concern in the bulimic girls. Dental erosion from gastric acid may occur and be irreversible.  Brushing the teeth after a binge can worsen the problem as it spreads the stomach acid.  Rinsing with baking soda after vomiting alleviates some of the acid-related complications. Parotid gland swelling occurs from repeated vomiting. The reflex due to chronic relaxation of the sphincter and esophageal rupture from vomiting. Constant laxative abuse can render the colon unable to perform normal peristalsis without large does of laxatives.  The bulimic also have low bone mineral density.  The goal is focus on elimination of the binge/purge cycle and normalization of eating patterns and resumption of normal menses. Bulimics can be managed as outpatients easier than their anorexic sisters can. The criteria for inpatient hospitalization includes depression and sucidality, marked fluid and electrolyte imbalances, and the need to withdraw form laxatives, diet pills and significant substance abuse. The best drug to date is till fluxetine, but only helps with the symptoms in bulimia.  It was suggested that imipramine was helpful in the treatment of bulimia nervosa, but the medication of choice is still fluxetine. 

   Other groups that are high risk and may not have all the criteria for a full blown eating disorder, but still at risk for complications are Diabetics with disordered eating patterns and competitive female athletes with obsessive/compulsive tendencies about their weight and performance.  The medical model only has a success rate of 50% through the many studies cited.  There was little information on follow up to check on the re-occurrence after five years.  It is expensive, often requires a full team, hospitalization, and disruption of a family system to have their children away from the family.  Depression almost always is comorbid in hospitalized eating disorder. Handbook of Eating Disorders, Beaumont, Touyz (l995).

Pharmacological treatment for anorexia nervosa

Though most of the research, there is not a class of drugs that seem to help the neurobiological disturbances in anorexia nervosa. The etiology remains unknown.  Through medication studies, several drugs have been investigated both in the United States, and through out Europe. The research team of .Lehmkuhl, Poustka, Schmidt, Herman, & Herpertz-Dahlmann (l998) reported from the department of child and adolescent psychiatry in Marburg, Germany. Their study gave an update on pharmacology used throughout Europe. The classes of drugs investigated were antipsychoitics, mood stabilizers, antidepressants, and appetite enhancers.  The selective serotonin reuptake inhibitors (SSRIs) have replaced the older group of antidepressants such as fluoxetine.  It works in bulimia, but not anorexia. 

    Anorexics have a low amount of dietary zinc intake and zinc supplementation. According to the University of Marburg report, monitored patients to see what would be helpful in weight gain.  As with findings around the world, the best results were witnessed in the bulimic population. 

    Bulimia nervosa does have significant progress in both psychopharmacological and psychotherapeutic treatments. The German study showed that selective serotonin reuptaker inhibitors have shown improvement in the bulimic population. The results were the same from Italy, Denmark, England, Japan and Canada.  A very direct summary covering the role of pharmacotherapy came from Internal Medicine, University of Turin in Italy (1998). stated the same information that most of the research cited in the treatment of eating disorders with one final comment that summed it all up:”Although drug therapy plays a limited role in the treatment of eating disorders, drugs are commonly prescribed anyway, even when they do not help in the long run. They give only short bouts of relief. It is notable that the antidepressant agents have repeatedly failed courses of therapeutic approaches.   Therefore, the nutritionist on the team should be familiar with the basic pharmacology and the side effects related to drug therapy.”  There is always a high incidence of depression in-patients with the bulimic population, and this is just a short list of the common antidepressant medications usually prescribed and antidepressant medication is often ordered, according to the Italian research team. (p4). 

    Specific Bulimic drug therapy: The most common antidepressants prescribed for the bulimic are imipramine (Tofranil) desipramine (Norpramin) and the drugs that have the best results are the serotonin reuptake inhibitors (SSRIs) fluoxetine (Prozac)(***always the drug of choice in most of the reports to date), sertraline (*Zoloft) paroxetine (Paxil) venlafaxine (Effoxor) and fluvoxamine (Luvox). About 20% of the patient’s withdrawal from treatment because of the side effects.  Prozac is effective at higher doses (60 mg) but has little impact on the binge-purge cycle at low doses (20 mg) There are trials underway using naltrezone or naloxone medications to block natural opiod created by the bingeing. The goal is to find a drug that will reduce natural opiods that are released during binges.

    Specific Anorexia drug therapy: Reports form the Department of Psychiatry of Wayne State University of Medicine, Marrazzi, Bacon, Kinzie, and Luby review any finds throughout the world concerning anorexia drug therapy. They state: “ There is not any significant news, nor has there been from the many reports around the world.  No drug therapy has been proven to be very effective in treating anorexia or the depression that usually accompanies and perpetuates the disorder. The effects of starvation intensify side effects and reduce the effectiveness of antidepressant drugs. Also most antidepression drugs suppress appetite and contribute to weight loss!”  SSIR antidepressants are recommended as the first line of treatment for the obsessive compulsive disorder and may help some people with anorexia who seem to be part of the Obsessive-Compulsive behavioral disorder. Depression and though disorders will improve with weight gain. 

    Researchers have on-going concerns with the many complications connected with the girl’s normal growth pattern. Through the complications of malnutrition, there is bone loss as the weight drops below a normal range, the bone mass diminishes, and menses stops. This has damaging consequences even after the eating disorder is under control. 

    Normalizing reproductive hormone balances is more important that weight gain in the girls with menstrual cessation. The use of estrogen therapy to reverse osteoporosis has been discouraged as the estrogen progesterone combination as it did not prove to be effective in bone density as reported in the studies from Harvard  Medical School. (Simon, Etkin, 1989).

  The list of abnormal mechanisms from the shut down of the starving systems`continues, affecting every part of the body and the brain. The abnormal mechanisms that investigators look for in the eating disorders in the brain mechanism is what controls the eating instincts. Hetherington, Rolls (1988 pp l4l-160).  conducted studies that showed opioids were present. The study also pointed out differences in peptide neurotransmitters involved in eating and metabolism. An Anorexia patient avoids food, even though they are preoccupied with measuring, looking for recipes and preparation, their insulin levels rise when there is a morsel of food that is stimulating to them.  The research team of Hetherington and Rolls noted that endocrine levels change when an (AN) patient is underweight to a critical degree, and again change when the weight goes back to normal. Another indicator in anorexics is that high levels of neuropeptide Y indicates that there is metabolism disorder.

    The University of Pittsburgh study on anorexia and bulimia, researcher Strober noted that protein was an indicator of the eating disorders (1999).  The clinical signs of (AN) are those of protein calorie malnutrition.  Children and adolescents are best managed with a team effort if the signs are serious enough for hospitalization. Metabolic decompensation must monitored by testing to determine if hospital admission is necessary.  The biological model will aggressively take steps to promote body weight gain and nutritional recovery.   Testing is usually though hydrodensitometry (underwater weighing) and anthropometry (12-skinfold thickness) and assessed body composition and subcutaneous fat before and after a refeeding program and a multifaceted program of therapy specializing in inpatient unit. Most hospitals in the United States and through out Europe monitor electrolyte disturbances, especially in hypoposphataemia. In the (AN) female, restoration of gonadotropins, oestradiol and resumption of menses is a main indicator of nutritional recovery.  There is a large body of work on the bone loss and absence of menses in women being conducted out of Michigan State University. According to article, Temperament and Character in Women (2001) Klump who is offering a fee for women suffering from bone loss due to (AN) to give their reports for the researcher’s investigation.

     The general consensus of the biomedical investigations conclude that anorexia nervosa is associated with an organic abnormality, the hypothalamus is the most plausible site for the origin of the dysfunction. (The hypothalamus controls or modifies a variety of homeostatic processes including respiration, circulation, food and water intake, digestion, metabolism, and body temperature.) The hypothalamus plays a vital role in food intake and satiety. (Brumberg, 2000).  It has been shown to some exert the homeostatic function enter the system via peptidergic neuronal circuits.  The major peptide that is identified as orexigenic, neuropeptide Y (*NPY) is suppressed by leptin, an adipocyte-derived hormone in a potential circuit that seems to function as an adipostat according to researcher, Dr.Tollis, presiding in Athens, Greece.  Since 1998,  Tollis has studied eating disorders, concentrating on energy balancing when there is not enough food intake and the effect it has on the thyroid glands. The information regarding energy balance which is feed back to the paraventricular nucleus of the hypothalamus when a complex interplay between thyrotropin releasing hormone (TRH) and corticotrophin releasing hormone (CRH) determine consequent effects in thermogenesis and stress reduction.  It is not fully understood, but it appears that (TRH) is directly involved in the complex hypothalamic networks that establish energy balance by modulation of food intake, saliety, thermogensis, and autonomic responses.

    There are so many indicators that when the chemicals of the body are not in balance because of poor nutrition, it has a domino effect and spreads through the system-causing harm along the way. There are studies of cerebral atrophy with patients with anorexia nervosa. There are several recorded events around the world.  Several findings have been reported by Dr. Capristo and Dr. Gasbarrini from the department of internal medicine in Rome Italy (1998).  A 20 year old woman with (AN) was admitted to the hospital  with brain abnormalities.  Several other  similar cases have let the doctors and researchers to believe that some form of brain alteration could be secondary to undernutrition. The Italian team also looked to the serotonin function where studies of neuroendocrine and behavioral responses show those levels of neurotransmitter metabolite in cerebrospinal fluid change and alter the brain level of leptin, which leads to neuroendrocine abnormalities in starvation. 

    All of the research is sensitive to cultural pattering, and even the most zealous advocates of biomedicine acknowledge that environmental stress can result in emotional arousal and endocrine changes that eventually lead to pathologic changes in the organ. The etiology of (AN) could originate from the starvation causing damage to the hypothalamus, interfering with the hypothalamic function, or that there is an unknown etiology that affects the hypothalamus when a certain amount of weight is lost from the normal range of a body.   The organic cause of anorexia nervosa has a wide variety of somatic remedies and drugs. To date thyroid extract, implants of calf pituitary, vitamins, insulin, corticosgteroids, testosterone, lithium carbonate, and l-dopa have been used.  Shock therapy, and forced feeding as desperate means. (Brunsberg 2000).

    Brunsberg also mentioned the studies with leptin. (2000).  Serum levels of leptin are decreased in underweight (AN) patients and increase with weight restoration. To assess the relationship of the decreased leptin levels with other hormonal abnormalities in (AN) and to evaluate the possible role of the increasing leptin levels, alone or in combination with other hormones is all part of study which ties in the resumption of the menses when the weight loss is restored to a normal base. Leptin is necessary to the body and an indicator of endocrine balance. 

    Psychologist and author, Morrison (1995). Stated in his studies on eating disorders: “Understanding the neurology and pharmacology of the (AN) and (BN) patient boggles the mind with the wide variety of possibilities and combinations. The patient changes with the amount of food ingested as the body quickly responds.  The amount and dosage of drugs ingested from week to week can change and monitoring on an outpatient basis is very difficult.  The general population of young girls involved with the pharmacology are usually not willing patients and often do not take their drugs, so the results are difficult at best to monitor for results.” 

DSM IV Criteria for The Eating Disorders
307.l Anorexia Nervosa:
Criteria for Anorexia Nervosa

    a) The patient will not maintain a minimum body weight (85% of expected weight for height and age).
    b) Despite being underweight, the patient intensely fears weight gain or obesity.
    c)Self-perception of the body is abnormal, as shown by at least one of these
           1) Unduly emphasizes with or shape in self-evaluation
           2) Denies seriousness of low weight
           3) Has a distorted perception of own body shape or weight
    d) Due to weight loss, a female patient has missed at least three consecutive
         menstrual periods (or periods occur only when she is given hormones).

Coding Notes:
Specify whether:
Binge-Eating/Purging Type, During an anorectic episode, the patient often purges (vomits, uses laxatives or diuretics) or eats in binges.
Restricticting Type.  NO bingeing and purging during an anorectic episode.
This is the more usual type.(DSM-1V Made Easy 1995).

Vignette: Anorexia Nervosa:    Pillar Moreles

    Pillar is in her sophomore year; she lives with her family in a small rural community.  She looks like a “Keene Painting” with her large brown eyes and her long hair which is starting to break off and no longer has luster to it.  Pillar is 5’8” and weighs less than 90 lbs. She has lost over 27 lbs. this year. Her goal is to be a model. She fainted at school and complained about always being short of breath. After checking her vital signs and barely able to find a pulse, the nurse had her rushed to the hospital. Pillar was dressed in her cross country training outfit with her parka, scarf, hat, gloves and it was hard to tell what she looked like under all the heavy protective outdoor gear.  She was known for “pushing to the max” and ran year around.  Her brother Pedro was very protective of Pillar.  He was a senior and insisted on staying with her.  He accompanied Pillar to the hospital as her parents could not be found immediately, nor did Pedro seem willing to help find the parents stating that: ‘ they fight about this all the time and nothing ever gets resolved.”

    Pillar’s parents were from Jalisco, Mexico and she is bi-lingual.  Her dad works as a supervisor in construction for one of the resorts.  He makes good money and takes care of the family financially, but also has the vices of a 24-hour gaming resort.  He is a heavy drinker, and had been in trouble with the authorities on several occasions.  Pillar often came to school with bruises and there was an incident where Pedro beat up the father and told him to stay away from Pillar; there was inconclusive accusations of the father molesting Pillar, as reported by the brother, but Pillar would not back up his claims.  It was not always this way, when dad was sober, Pillar was the apple of his eye and he doted on her wanting her to be very successful as a beautiful model.  Pillar was tall and thin and the pride of the family, the baby girl with four older brothers. Pillar’s dad often compared his daughter to his wife who very overweight and always on a diet that never seemed to work.  Mom paid attention to Pillar but in a negative way, feeling jealous of the attention given to Pillar by the dad.  Pillar made a pact to grow up with her own life as a model, and not be like either of her parents.  She wanted to please them and was driven by her own need for success.  She wanted to be the thinnest most beautiful model ever.  She would often cut out pictures of her favorite models and was determined to be “even thinner” than her thinnest picture in her scrapbook. 

    Her entire life revolved around her appearance, her clothing, her diet and her excessive exercise.  She would not stop moving, running in the morning and in the evening besides her school gym training.  She was so happy to see the weight come off of her already thin 125 lb. frame. Even when Pillar weighed less than 100 lbs. she still criticized her body in the mirror feeling that she could get down even lower; she always felt fat. At times Pillar fell into what she called the “lure of food” when  pizza, chips, sodas, tacos, ice cream was calling her until she could not say “no!”  When these attacks came on, she would gorge herself with anything that she could get her hands on at the 7-ll  store across from the school.  She would take money out of her mothers’ change purse, and on one occasion, she even stole an ice cream bar.  She would then gorge until everything was gone and then in another fit of shame and guilt; she would stick her fingers down her throat and throw everything up.  It was difficult at first, but after awhile, she could vomit at will.  It was starting to hurt her throat and her gums were starting to bleed.  She hated doing this, it was last resort, but losing weight was more important than anything else. She was obsessed by the thought of food.

    Pillar was starting to break away from the family.  She always wore baggy clothing with large scarves and would not eat the typical Mexican food served in the Moreles household.  She would claim that she ate at a friends house, or take small portions of fruit or vegetables to her room.  At times she would obsessively count every morsel down to three small carrots, one piece of celery and one tablespoon of rice as a full meal.

    She loved the Lenten rituals of her family church and vowed to give up even more food, fasting for days on end.  She prayed for the strength to stay away from food and to be thin which would lead her to her goal as a model. She also prayed to stay out of the clutches of her family, especially her father when he was drunk.

    During her hospital stay, the clinicians noted her unusual thinness and pallor.  She tested as anemic and malnourished. There were also burn marks on the back of her hand from the stomach acid that she forced up through her esophagus. brought up, her throat was raw.   She was not allowed to exercise, but did ask if she could at least go “for walks.”Pillar stayed single minded in her quest to keep her weight under control and analyzed every morsel of food brought to her on her tray.  She was fascinated by the new flavors and said that besides being a model, she would like to learn more about nutrition and diet. She loved looking at recipes and figuring out how to make them tasty “but non fattening.”Through several tests, she had good understanding, was not delusional or hallucinating, except for the “fear of gaining weight.” She appeared bright and had a high score on the Mini Mental State Exam.  Physically, she had not had a period in one year. 

    Pillar would fit Axis 1  307.l Anorexia Nervosa with Binge-Eating/Purging Type.  Starving herself was her primary weight control, she seldom used the bingeing and purging techniques, and suffered from her weak will when she resorted to these methods.

    She did not have a major depressive order, or specific personality disorder even though she was a perfectionist, her entire focus was connected with her distorted view of her body and losing weight.  When first examined, there was only a very small amount of adipose tissue on her body, but her menses has stopped for six months.

    There were underlying family problems and on going therapy would reveal Pillar’s role in the family, how she saw herself, her parents and her brothers. Although Pillar’s condition was considered moderate, it was advised by a team of therapists, doctors, and nutritionists that Pillar stay in the hospital until she regained her weight, and she and her family would receive therapy on out patient basis. 

    Structural Family Therapy: Considering Pillar’s background, Minuchin’s form of structural family theory would be the one chosen as there is so little good information from the other models of therapy, Minuchin was known for his work in this field.  His techniques are simple, inclusive, and practical.  Each person in the family has a role.  Families & Family Therapy, The classic text written by  Minuchin (1974). Dr. Minuchin’s main focus is on structure, or organization within a family.   The overall goals of structural family therapy are to reduce symptoms of dysfunction and to bring about structural change within the system by modifying the family’s transactional rules and develop more appropriate boundaries. When the family members are released from their stereotyped roles and functions, the system is able to improve and is able to cope with stress and conflict. The therapist observes transactions and patterns.  Each family member is involved in joining, accepting, and respecting the family in its efforts to reorganize and to achieve its goals as a whole.  The first session would start with each family member in a genogram process or in Minuchin terms, Family Mapping.  It is a method for mapping the structure of the family, to identify the boundaries as rigid, diffuse, or clear.  The therapist would be joining the family unit to see if the Moreles family had enmeshed or disengaged relationships. The Moreles family had several personal relationships that did work well as a family unit. The family subsystems had to be looked at. This was the various categories of spousal, parental, sibling and extended family and extending into community, church and school views.  Everything had an effect on the overall family system. 

     The structural model takes into account the individual, family and social context, and provides clear organizational framework for understanding and treating the structure of the family first. Pillar’s anorexia; was viewed as a family problem. ( P266). 

    Minuchin first created his technique while working with disorganized families from the inner cities, with situations similar to the Moreles household.) In order to gain entrance to these families, his technique of joining was his therapy of action.  As an effective listener to the Moreles, it would be important to gain their confidence and offer hope to their frustrations.  It would be interesting on how the family would stray from the immediate problems of Pillar’s health to blaming eachother.  This could be seen as a “positive” as there were protective manager parts to the parents.  It would be important to show the family that they could control the outcome of Pillar’s condition, help her with a better role in the family.  In the Morles family, and in all families according to Munichin model, there were a set of boundaries between the family and the extrafamilial system. The family’s major psychosocial task was to support its members to become more important than ever.  Even though there were cultural issues with being “strangers in a strange land” the family rooted firmly enough could grow and adapt.  There had to be a sense of belonging to the family and also a sense of selfhood and being separate.  In spite of Mr. Moreles’s addiction to alcohol and allegations of hurting his family, it was the first step to tell him that he could be in control as a good father and husband. He had worked hard, supported the family and he did love them. However, when he drank the old voices of his past, of his own abuse from his father came up.  He was not proud of it, but did not know how to change.  It was important to listen to his history; his strive for a better life and hating himself because he was falling into the same trap that he grew up with. He did want to change the pattern but it was not his way to ask for help. In his culture “men did not admit mistakes” liquor helped ease this part of his frustration. His wife also had a story of being left out, never feeling special, never pretty, always the solid workhorse of her family of origin.  She was the oldest of 14 brothers and sisters, the one in charge, but never received any credit. Pillar felt helpless in the sessions.  She did not want to be anything but 'the‘good girl" an” did feel awful about her obsession to keep her weight down.  Sometimes, it was the only thing she felt that she had control over.  The brothers all felt compromised as they often were called upon to keep the peace and play the role of the father and husband as the protectors.  They resented both the parents and Pillar at times for putting them in this position. At time they isolated themselves from the family and when it came to Pillar, they were glad that the attention was not directed at them. Each family spoke up and gave their version on how they were connected to the problems. It would be questioned in therapy as to Pillars role among the parents; did she keep them together or pull them apart? What could be done for the parents to operate as a couple with a common goal for their family?   In the Structural Family therapy model, it helps to label this “what part of you feels…..” instead of attacking the entire person. The implication being that beyond those parts, they have many other resources or feelings and they can figure out how to control the part that is not working for family unity. It is important to note that the family problems and Pillars problems were very serious and they were not to be minimized or denied, but recognized that there was so much that could be done as a family unit, and knowing that the family was only as strong as its weakest link.  It is selling hope for a better family system all the way through therapy. Each family member would own up to the hurt they had suffered, much of the hurt reacting to the father drunken part. What part of the father would make Pillar want to be thin to please him, and also perhaps to keep her body in a childlike form so “he would not be so attracted to it.”  The mother would state that her hurt part was the thinner Pillar became, the fatter she saw herself.  It was almost as if Pillar was doing this to point out how out of control and ineffective she was as a mother.  Also the mother saw the bond between the father and the daughter in a way that she could never feel special to him. The dad felt ineffective and unappreciated when his wife always seemed too busy for him, too critical of his loss of income over the years of gambling and drinking.  He would turn to his daughter for her laughter and acceptance. Hearing this, Pillar could be strengthened at this part in the therapy sessions for not feeling like the scapegoat for her parent’s problems. She was culturally compromised.  She felt that she had to be totally obedient to the mixed messages of her family, yet yearned for being autonomous and having the approval of the girls she hung around with at school.  She loved looking at the fashion magazines, which represented a better life, someone to love her, money and power. It was her secret way of breaking away from her family that at times embarrassed her. She looked at her mother as being fat and not knowing what was going on in the world. food out of her system fast.

    Pillar did not know that her mother also yearned for a better life and did have her own set of dreams.  A lot of these feelings got translated into a view on food.  It was mealtime, and if Pillar did not want to be with her family, it was easier just not to eat. It was also her main control of something that the family could not make her do-eat!   The mother felt rejected as preparing delicious large homemade meals as an expression of giving love to her family.  When they all fought at mealtime. (everyone) showed up drunk, (dad) or went to their room without eating, (Pillar) mom took offense. Dad would usually start the interaction with his drinking and the blaming circle would began, each picking on the other for the lack of family unity and who started the on going fight. It was always the same without a resolution. The more Pillar heard her family bickering, the more determined she was to escape, to be the thinnest model know on the planet, and she actually got to a point where she could not eat.  When she heard them fight, she became nauseated and food would not go down, it was a chain reaction. Each family member was protecting a part of them that had been hurt. 

    The substructure of the Moreles family had to be changed.  The roles had to be clear.  One of the first things under Structural rules would be redefining the roles in the family “family members are suppose to protect eachother” would be a set of covert rules that would govern the transactions in the family.   The hierarchical structure would dictate what the father’s role should be.  He could drink or fight during the family meals.  He could not hit or molest any members of his family-ever!  He would sign a contract to state his intentions.  Mr. Moreles had to be strengthened to be the head of his family in a functional role. The goal of Structural Therapy is to reorganize dysfunctional families. In the Munician style, it would be OK to tell Mr. Moreles that the way he was running his family business was wrong and not productive. All issues would be direct and clear.  To be the head of the family, he had to treat them with respect and he had to lead with sobriety. The same was true of the mother’s role.  Even though the mother felt sorry for Pillar’s abuse, she felt helpless against the raging father any. The mother had to come to the conclusion that this was not Pillar’s fault and the mother had to support Pillar and not compete with her.  At the same time, the mother had to join with the father as a unit with clear rules of the house. As each member becomes willing to change in steps of depolarization, each person sees their adversary begin to back down, and it chain reacts to all the members of the family to feel it may be safe to do the same. As one member works on wholeness and change, the rest follow.  Mom could not react when praise was given to Pillar, and she would address that part of her that felt ugly, fat and left out.  This had nothing to do with her daughter. Mom could now see that she loved her daughter but was giving her mixed signals and pushing her away.  Parts of mom were getting upset about Pillars starving herself, and parts were angry at Pillars manipulation of the family for attention. When Pillar saw her mom getting agitated, her vow to abstain from food, to be thin, and get out of the family would take over, Pillar had to address this issue.   The brothers had to stop taking the role of “protectors” and give the power to a father willing to change.  The sons had to take their place as siblings in the family. The family could not split into camps as it was doing with children against the father, or the mother against the daughter.  The boundaries serve to protect the autonomy of the family.  Pillar would be told to come to the table to eat with the family.  She may not be forced to eat everything, but her presence was necessary to feel part of the family.  The rigid boundaries would be softened to very clear boundaries and boundaries that could finally bend and change. 

    The father could not have an enmeshed relationship with Pillar wanting her to be successful to take up the emptiness of his own failures. The family also had to learn to talk to Pillar when she was shutting herself in her room during the conflict-avoidance phase. Disengaged families avert conflict by avoiding contact; enmeshed families avoid conflict by denying differences, which allow them to vent feelings without pressing each three for change or resolution of the conflict. 

    Once there was an amount of stabilized self leadership in the room and the veils of fixed believes and angry emotions are under control, the mother and daughter were asked if they wanted to work on parts of the father/husband to help him with his temper, and his drinking, the brothers during this session watched and observed.  In the next session, the brothers addressed Pillar explaining that “they felt left out at times” and did not want to feel they had to always protect her, she could go to the mother, they were not her parents.  The mother had to address her own childlike state and go to her children to reestablish her new roles.  She had to embrace Pillar as her daughter and not her competitor; she had to make Pillar feel her trust and love.  Pillar had to address her father’s side of abuse and let him know she would not put up with it.  The father had to ask forgiveness of all the family members and individually work on his addiction, as well as with the support of his family members.

    As with all family dynamics, the roles will change as with any form of new knowledge and a family that wants to work toward a more positive outcome, some results will be assured.  The downside is not being ready for the relapse.  This is why 50% of  (AN) and (BN) families see a relapse in their daughters, because the family relaxes, goes back to their old ways of operating the family and old patterns set in again.  There will be relapses, slight shifts, and parts’ reactions.  As the explored and resolved past traumas are explored and redefined, it is not the time to beat up on anyone or to feel hopeless with failure. It is a shift into reframing and different interpretations to old problems solved with new family rules.  Blame and guilt have to be replaced with compassion and support. The entire framework of Structural therapy is to have framework for the family to help them to join in strength, but also to give each member room to grow indivdually. 

    The role of the therapist during the therapy is to have each member of the family examine their own lives and see how they view theirselves in the family.  The strength of the client must grow individually, and also be nurtured by the help of others in the family.  It is interesting to hear the stories of the family members and to see the reaction as they spin their life stories to eachother, but the therapist must keep in mind that the task at hand is to keep the family together as a unit.  The therapist must constantly pull them back to the family core to address the issues at hand and how they can all solve any problem together.  It is a system of trust in the wisdom of the selves of the clients and their yearling to have a better, stronger family unit.  It is the belief that family members yearn for rules and may not have any model to go by.  It is a way of getting the family to move toward their pain in order to heal it.  Of facing the unspoken, the hurtful, the taboo subjects. During this therapy, family members are able to let go of their grip of their history and to know they don’t have to constantly struggle to hold on to they’re past beliefs. It empowers clients to do their own inner work after the therapist is not in the picture.  It gives the broken family tools to heal themselves.  Minuchin’s model works well with a strong patricial culture such as the Moreles family. Joining successfully with the father would be key to this type of therapy.  Pillar would also do well with on going individual therapy along the behavioral model such as:

      Cognitive Behavior Modification, (Meichenbaum 1986). Was first introduced as cognitive restructuring which focuses on the way a client self verbalizes. Behavior therapy offers various action-oriented methods that could be used to help Pillar change the way she was doing things and the way she thought. Meichenbaum’s particular spin is called Cognitive behavior modification or (CBM) The emphasis for Pillar would be to acquire practical coping skills for problematic situations and not turn to food.  It would help to change her thoughts, and even culturally her prayers through her internal dialogue.  Asking God to “help her accept herself” instead of “praying to be thin” would be a start. The interventions are very diverse and are designed to fit the needs of the client. The focus is on helping the client become aware of their self-talk. It is a comphrenhensive approach that changes the thinking, judging, and deciding and doing of old behaviors. When the clients’ disturbed emotions and behaviors have irrational thoughts, they hare given activities and directive techniques such as teaching, suggestions, and homework’s assignments that challenge them to a rational belief system. Pillar might study nutrition and studies on what a normal healthy girl of l6 is suppose to look like. It is demonstrated on why irrational beliefs lead to negative emotional and behavioral results.  At all times, this is not shoved down the girl’s throat, as she will gag as if the therapy were food.  It has to be gentle, accepting and tolerant. It is an art form of the therapist gently guiding the client, giving her room to work on changes from behavioral assignments. Pillar might be asked to write down full weeks worth of meals, the calorie content and when she will be eating with a check list and food diary. It helps her to have control.  Stress management training also has a place in therapy for eating disorders. Applications include anger control, anxiety management, assertion training, creative thinking, depression prevention and coping with health problems. (Corey, l985).

    The main forms of therapy that have been popular in the treatment of eating disorders are psychoanalysis, family systems theory, and social psychology. (AN) and (BN) are seen as pathological responses to the developmental crisis of adolescence.  The refusal of food can been viewed as an expression of the adolescent’s struggle over autonomy, individuate, and sexual development.  Freud regarded anorectics as frustrated young girls who feared adult womanhood and heterosexuality. 1895 he wrote,”The famous anorexia nervosa of young girls seems to me to be a melancholia where sexuality is underdeveloped” Freud felt that all appetites are an expression of the libido of sexual drive. Anorectics are generally not sexually active adolescents, as reported by eating disorder therapist,  Bruch (2000). Bruch argued that the anorectic makes her body stain in for life that she cannot control. The adolescent can experience a disturbance of delusion proportions with respect to her body image and eating in peculiar and disorganized fashion views.  The young girl can refuse food until her menses stops and her body remains childlike. The preoccupation with control of food directs the young woman inward and she becomes estranged form the outside world.  She lives a bizarre life, obsessed with thoughts of food while struggling with her parents over her right to eat (Bruch, H.2000).  Anorexics are often classified with schizophrenia, depression and obsessional neurosis or classical obsessive compulsive disorder. The patients are usually stubborn, rigid, and strongly defensive about their behavior. As within the confines of the obsessive-compulsive disorder, there are often traits of perfectionism, excessive orderliness, cleanliness, meticulous attention to detail, and self-righteousness. They enjoy being viewed as “good girls” and alternate between compliance and rebellion.  Mothers of anorectic girls are often typed as frustrated, depressed, perfectionist, passive and dependent, and unable to allow her child to lead an independent life. (p49).

    Testing and clinical interventions are often used with patients with eating disorders.  A valued set of guidelines are found in The Therapist’s Guide to Clinical Intervention (S.Johnson,1900). Tests that have divided for the eating disorders are EATl eating attitudes Test and EDI, eating DisordersInventory.  They evaluate an individual on a number of subscales showing a drive for thinness, body dissatisfaction, and sense of ineffectiveness, perfectionism, interpersonal distrust, and maturity fears.  There are comparisons of eating habits, weight related symptomsand psychological characteristics of anorectics with two other groups: women who were highly weight preoccupied and those who aware not. The tests often show anorexics personalities testing with the same way addiction and substance abuse personality tests.  It is an extreme range with no definite guidelines, only general and the psychological model does not give a full explanation of anorexia nervosa.  There are also indications that many of the girls suffering from (AN) or (BN) have been sexually abused in some form, but a dangerous assumption to generalize that all (AN) or (BN) clients have been sexually abused. It is only an indicator that may lead to future investigation.(.Johnson 2000).
 

Clinical intervention for the eating disorders (EDO) (Therapists guide to Clinical Intervention)

    Due to the physical etiology and consequences of the serious nature of the eating disorders, a person with all of the danger signs would be referred to a physician and monitored if necessary to rule out organic problems associated with the endocrine system, gastrointestinal complications, cancer, hypothalamus brain tumor, electrolyte imbalance, and general assessment for hospitalization needs, inpatient or outpatient. 
The Goals for treatment:

l. Medical stability
2. Assess for referral for medication evaluation
3. Improved coping skills
4. Facilitate appropriate autonomy (may mean removal from family)
5. Improve body image
6. Improve rational thinking
7. Improve interpersonal relating
9. Improve communication
10. Identify feeling states
11. Differentiation between internal sensations and emotional states
12. Family intervention
13. Self-monitoring

Treatment Focus and Objectives

    Inadequate Nutrition: Evaluation by dietitian, physician to determine adequate fluid intake and number of calories required for adequate nutrition and realistic weight goals. Monitoring of the patient may be necessary. It is not the role of the therapist to monitor this portion of the treatment. When adequate nutrition and normal eating patterns start to normalize, the client-patient may then start looking at the emotions connected with their behavioral problem. 

    A nutritionist may be useful at this stage to give dietary education if the condition is not extreme. The therapist can back up the new information which should include 1) what the body needs to function, 2) the effects of starvation (short and long term) 3) what purpose the illness serves 4) a contract for weight gain and normal eating patterns.  If the patient-client is compliant, continue with therapy, if not, forced medical intervention may been needed as last resort to save their lives.

DSM-IV Possible Signs and Symptoms of Anorexia Nervosa, Bulimia Nervosa, and Compulsive Overeating (Age 13 to Adults)

                             Physical symptoms                    Psychological symptoms

Anorexia             skin rashes                                 perfectionist expectations
Nervosa              blueness in extremities             avoidance of relationships
                            poor circulation                           preoccupation with weight
                            fainting spells                              history of sexual abuse/assault
                            anemia                                        euphoria
                            chronic low body weight            sense of omnipotence
                            irregular thyroid                          views self as “fat”
                            postpubic absence of menses overly compliant
                            decreased gastric emptying     highly motivated
                            water retention                           ritualized behaviors

Bulimia               swollen glands                           impulsive behaviors
Nervosa             susceptibility to infections         intense attachments
                            Irregular heart rate                     preoccupation with weight
                            persistent acne                          alcoholic parent(s)
                            menstrual irregularity                depression
                            frequent diarrhea/constipation   suicidal thoughts
                            water retention                          poor self-esteem
                            dental erosion                           extreme sense of guilt
                            Ipecac-poisoning                      mood swings
                            aspiration pneumonia              history of excessive exercise

Compulsive      shortness of breath                    compulsive behavior
                          frequent constipation                  dependent attachments
                          irritable bowel syndrome            preoccupation with weights
                          elevated blood sugar                  alcoholic parents(s)
                          water retention                            depression
                          nausea                                         suicidal thoughts
                          sleep disturbance                       distorted perception of body
                          weight fluctuation                        sense of inadequacy
                          joint inflammation                        history of frequent dieting
 
 

A checklist of physical signs of poor nutrition and inadequate self-care of the Anorexic and Bulimic clients-patients: (Clinical Intervention 2000).
Physical Signs of Poor Nutrition and Inadequate Self-Care:

 Body Areas                Nutrient deficiency                    Signs associated with 
                                Or other cause of problem        poor nutrition or other causes

Hair                                Protein                                      Lack of natural shine: hair dull
                                                                                             and dry; thin and sparse; hair                                                                                              fine; color changes, easily
                                                                                             plucked

Face                             Protein, Calories, Niacin,        Skin color loss; skin dark over
                                      Zinc, Riboflavin, Vit. B6               cheeks and under eyes;
                                      Essential Fats (AD, E&K)           lumpiness or flakiness of skin
                                                                                             on nose and mouth; scaling of
                                                                                             skin around nostrils

Eyes                            Vitamin A                                    Dryness of eye membranes.
                                                                                             Night blindness 

Lips                             Riboflavin, Vit. B, Folate            Redness and swelling of mouth
                                                                                            or lips, especially at  corners of
                                                                                             mouth

Tongue                        Riboflavin, Niacin                        Swelling; scarlet and raw
                                                                                             tongue; magenta color;                                                                                                         Swollen sores

Teeth                          Fluoride, Sugar                            Missing or erupting abnormally;
                                                                                             gray or black spots; cavities

Gums                         Vitamin C                                    “Spongy” and bleed easily;
                                                                                             recession of gums

Glands                        Iodine, Protein                            Thyroid enlargement; parotid
                                                                                             (cheeks) enlargement

Skin                            Protein, Niacin, Zinc,                   Dryness; and paper feel of skin;
                                   Vit B6,C,&K Essential                     red swollen pigmentation of
                                   Fats (A, D, E, &K)                            exposed areas; excessive
                                                                                               lightness or darkness; black
                                                                                              and blue marks due to skin
                                                                                              Bleeding; lack of fat under the
                                                                                              skin

Muscles                    Protein, Calories                            Lack of muscles in temporal
                                                                                             area, hand between  Thumb
                                                                                             and index finger and calf
                                                                                             muscles
                                  Thiamin                                            Pain in calves; weak thighs

     Eating Disorders cover so much and it is helpful to have a check list to know what to look for, the eating disorders can be hidden so easily under large clothing, and all the other methods the unwilling patients have to disguise what is really going on.  Client-patients may be suffering from comorbid complaints and ineffective coping mechanisms. It helps to identify the person’s anger or feelings associated with loss of control with their eating pattern.  This often explores the family dynamics and to see if there is maladaptive behavior related to emotional problems due to family functioning and their structure. It is necessary in this phase of discovery to have family meetings to understand how the entire family views the (AN) or (BN) member of their family and what effect it has on the family dynamics. It is encouraged to have an honest appropriate expression of emotion, and talk about the eating rituals of the family and the role they play.  There may also be fears associated with eating, they have to be discovered and dealt with. Once this is done, assertive communication can take place addressing the maladaptive behavior.  Relaxation training often helps with progressive muscle relaxation, visualization and meditation. 

The Therapist’s Guide to Clinical Intervention publishes the following recommendations for family members of Anorexic Individuals:

l. With child/ adolescent anorexics, demand less decision making from the anorexic.  Offer fewer choices, less responsibility.  For example, they should not decide what the family eats for dinner, or where to go for a vacation. 

2. With child/ adolescent anorexics, in conflicts about decisions, parents should not withdraw out of fear that their child/ adolescent will become increasingly ill. 

3. Seek to maintain a supportive, confident posture that is calming yet assertive.  Do not be controlling.

4. Express honest affection, both verbally and physically.

5. Develop communications/ discussion on personal issues rather than on food and weight. 

6.    Do not demand weight gain or put down the individual for having anorexia. 

7.    Do not blame.  Avoid statements like, “your illness is ruining the family.” This person is not responsible for the family functioning. 

8.    Do not emotionally abandon or avoid the anorexic family member.  Remain emotionally available and supportive.  Utilize clear boundaries.

9.    Once the individual is involved in treatment, do not become directly involved with the weight issues.  If you see a change in the individual appearance, contact the therapist or other pertinent professional such as their physician and dietitian.

10.    Do not demand that they eat with you, or do not allow their eating problems to dominate the family’s eating schedule or use of the kitchen.  Be consistent.

11.    For child/adolescent anorexic, do not allow the individual to shop or to cook for the family.  This puts them in a nurturing role and allows them to deny their own needs for food by feeding others. Increase giving and receiving of both caring and support within the family. Develop clear boundaries, and allow each person to be responsible for themselves and setting their own goals. (These techniques are repeated in the Clinician’s handbook as well) 

Altenative methods

    There has been marked success with Bulimic through relaxation, breathing, and hypnotherapy techniques.   The results have not been as noticeable with Anorexics.   When a client is sent to a practicnor there is often much stress with all the changes and the strangeness of therapy.  The cognitive-behavioral model is usually helpful because it is so structured that the client “does not have to invent or think, but just follow the new rules.  On the interior of this person, their nervous system may be responding with palpitations, anger, internal stress and many other physical symptoms. Relaxation techniques are usually a safe way of developing a self-care plan for a positive sense of well being. Deep Breathing:

    Usually lasts for a five-minute session until the client is comfortable to build up the time.  The client is to be in a comfortable position, usually eyes closed and attention to the breathing process begins.  The suggestion is to “think about nothing but your breathing, let it flow in and out of your body slowly, inhale and exhale with the same pace.” The client might say “ I am relaxing, breathing smoothly and I see myself relaxing as fresh oxygen comes into my body, and my troubles leave my body.” The goal is to have the client get in touch with breathing and block out all other thoughts.

 Hypnotherapy techniques:

    As the client can relax and slowly breath for up to l0 minutes, they will be ready to deepen to a trance like state.  It is important to let the client know that all suggestions are positive, and that they have total control to continue or stop at any time. The only form of hypnosis is “self hypnosis” they will not do anything that they are not comfortable with.   Now the client is asked to think of a beautiful place where he/she can relax. Slowly the clinician asks each part of the body to relax and watches as the client sinks into this state of relaxation.  The eyelids may flutter and fingers may twitch during this process, it is the body unwinding from stress.   The client usually feels a peaceful, pleasant and comfortable feeling as they make their way to a beautiful place.   They may think of beautiful colors, sounds, scents and stay in touch with this peaceful and calming image. 

    More description of the environment, the ocean, the clouds help the client to drift even further into a state of alpha brain waves. The clinician now takes the client on a pleasant journey where everything is peaceful and calm.  The client becomes part of the image drifting to the mountain lake, the forest, a happy time in their life, and enjoying the feeling of relaxation. During this period, suggestions are offered for the subconscious mind.   Positive suggestions such as “ you see yourself wanting to eat healthy foods that satisfy you.  You chose water as your choice of drink, you enjoy the feeling of cool clear water going down your throat and refreshing each cell in your body with this gift of life.” Other suggestions such as: “You are in control of your body at all times.  It is your vehicle to take you through many journeys and you chose to take good care of it.” You may notice that you enjoy the way you feel when your body has just the right amount of food.  As you nourish your body, you are amazed at the energy you have the clearness of thought and how good it feels to be able to move without being tired.  You think clearer with delicious nourishing meals fueling your body.  You now have time to think of many other things. You are pleased on how you look your newfound joy of taking care of yourself and when you look in the mirror, you like the way you look. Each day you get stronger, more relaxed, and your world is tranquil and peaceful. You feel more and more in control of all situations.  You do this by centering yourself with three deep breaths whenever you need to feel relaxed according to the famous tape by O. McGill, hypnotherapist of 95 years.

    After the induction, and the suggestion, the client is slowly brought back the same way the client entered the trance like state.  Suggestions such as “ you have taken time to relax, to enjoy a beautiful trip and you have a new way of looking at yourself that is very pleasing to you.  Now it is time to return to the present to be with your friends and your family.  You can return to this blissful stage whenever you wish you had the tools and the power to do whatever you wish.  At the count of ten, you will slowly start coming back.  You feel relaxed and alert, you like the way your body looks, and you chose to nourish it with delicious nourishing meals eating only until you are full.  You are now aware of the room and where you are, your fingers and toes are starting to move and you feel as if your eyes have been rinsed in clear stream water.  You feel refreshed, invigorated and alert.  You are in such a great mood ready to face the world with vigor and a clear alert mind.  Now slowly open your eyes when you are ready.(Churchill & Muller 1998).

    Another great master in the field of relaxation, and brave enough to tackle the eating disorders, chronic pain, and situations that no medicine could touch was Gil Boyne. He was a massive ex-wrestler, and would grab the girls, push them back with his hand and bluntly state: “your eating habits have to change, you are making yourself sick, stop this now! It was enough to shock the girls into reality, and useful in some cases. (Boyne 1990).  However, the classic master in the hypnotherapy field is always Milton Erickson. He had the ability to read people, give them wonderful inductions to change the way their say their reality. His breathing techniques, visions of a better healthier life, and selling the hope of a better future showed promising results.  He had great success with young girls, convincing them in such a fatherly fashion that they really needed to take care of themselves, they were beautiful inside, and “perhaps, they were mistaken on how they looked, and how much weight they really needed to lose.” (Erickson 1978).

    In summary, this paper only scratched the surface on the complexities of the Anorexic and bulimic mindset.  No two cases are alike and not one therapy works for all.  Throughout the entire review of reports from the United States, Europe, and Japan, there is only speculation on what is going on with the clients both physically and psychologically. Drug therapy has limited success, and therapy works fairly well with motivated clients with Bulimia, but not Anorexia. It is time consuming, involves an entire family system, and often requires in patient care. Although only a small population is severely affected, it is on the rise, and the results can be deadly.  The main hope is listening to the client from every angle, understanding their pain, helping them through the physiological and psychological trip back to wholeness. This takes commitment and is a long lonely trip and a lifetime work in progress for these girls and their families.  The relapse rate is high, only 50% at best will not slip back into their old eating disorders.  The girls with the best chances of recover are found in the girls with strong support systems.  It is there that they fine the “the nourishment” that they are truly starving for.

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