Treatment

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Treatment

By their own nature Eating Disorders are very self-destructive and potentially life
threatening behaviors. They appear to be symptoms of underlying problems. These symptoms
can grow out of control to become life threatening disorders. The DSM-IV provides the
diagnostic criteria for Anorexia Nervosa and Bulimia Nervosa as well as research criteria
for Binge-Eating:

307.1 Anorexia nervosa

Refusal to maintain body weight at or above a minimally normal weight for age ad height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading body weight less than 85% of that expected).
Intense fear of gaining weight or becoming fat. Even though underweight.
Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. ( A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.)

Specific Type:

Restricting Type: During the current episode of Anorexia Nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

Binge-Eating/Purging Type: During the current episode of Anorexia Nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics or enemas)

307.51 Bulimia nervosa

Recurrent episodes of binge eating, An episode of binge eating is characterized by both of the following:
1. eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances
2. a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)
Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induces vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.
The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months.
Self-evaluation is unduly influenced by body shape and weight.
The disturbance does not occur exclusively during episodes of Anorexia Nervosa.

Specific Type:

Purging Type: during the current episode of Bulimia Nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas

Nonpurging Type: during the current episode of Bulimia Nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas

307.50 Eating Disorders Not Otherwise Specified

The Eating Disorders Not Otherwise Specified category is for disorders of eating that do not meet the criteria for and specific Eating Disorder. Examples include:

For females, all of the criteria for Anorexia Nervosa are met except that the individual has regular menses.
All of the criteria for Anorexia Nervosa are met except that, despite significant weight loss, the individual's current weight is in the normal range.
All of the criteria for Bulimia Nervosa are met except that the binge eating and appropriate compensatory mechanisms occur at a frequency of less than twice a week or for a duration of less than 3 months.
The regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food (e.g., self-induced vomiting after the consumption of two cookies).
Repeatedly chewing and spitting out, but not swallowing, large amounts of food.
Binge-eating disorder: recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviors characteristic of Bulimia Nervosa

Research criteria for binge-eating disorder

Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
1. eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances
2. a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)
The binge-eating episodes are associated with three (or More) of the following:
1. eating much more rapidly than normal
2. eating until feeling uncomfortably full
3. eating large amounts of food when not feeling physically hungry
4. eating alone because of being embarrassed by how much one is eating
5. feeling disgusted with oneself, depressed, or very guilty after overeating
Marked distress regarding binge eating is present.
The binge eating occurs, on average, at least 2 days a week for 6 months.
The binge eating is not associated with the regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise) and does not occur exclusively during the course of Anorexia Nervosa or Bulimia Nervosa (DSM-IV, 1995).

Although Eating Disorders often have their origins in adolescence a great percentage of those suffering with the disorder are not treated at the time of onset. All three disorders tend to be secretive in nature especially initially. While anorexia and binge-eating eventually have visual side effects or indicators such as steady or dramatic weight loss or weight gain, bulimia can go undetected for years. The denial of the person suffering also plays an important role in the delaying of treatment for such disorders. Therefore; the percentage of adolescent-aged eating disorder clients seen in treatment is lower than the actual statistical cases. Generally those suffering from an eating disorder will seek help when their denial drops enough to see that their lives are being disrupted by the destructive behaviors which accompany eating disorders.

Eating disorders can and do have an impact on significant others in the person's (who is suffering with an eating disorder) life. The obsessions with weight, exercise, food, calories, scales, sneaky behavior, increased isolation and dishonesty are very destructive to relationships. What seems so simple to fix by just stopping the behavior' possibly becomes an ongoing struggle and battleground. Parents of children or adolescents who are aware of the eating disorder often are left in very hard positions. This occurs especially if the denial of the individual is in tact, because the parents can offer treatment however; it may not be taken advantage of. A key frustration point can be the fact that no one but the person suffering from the eating disorder can fix the problem and the solutions are not as simple as they may appear to be.

Not everyone requires treatment. There are some who are able to overcome the disorder on their own. However there are a great number of people suffering from eating disorders who are unable to recover without at least some assistance. Very often depression is associated with eating disorders. Depression by it's very nature decreases one's ability for motivation and possibly the energy to change. If someone is fortunate enough to seek and obtain good treatment for an eating disorder, the depression can be evaluated simultaneously in that process.

Treatment can come in a variety of methods depending especially upon the severity of the symptoms surrounding the eating disorder itself. If the client is in a health-compromising position (i.e., hemorrhaging possibly from internal bleeding caused from purging activity, decreased body weight to the point of complete malnutrition and associated physiological symptomology, or weight increases that are causing physiological stressors on specific organs of the body such as the heart or lungs) a medical hospitalization may be necessary for stabilization of health concerns. This can be followed up with an in-patient psychiatric hospitalization.

An optimal in-patient hospitalization at a psychiatric facility varies in length of time and is dependent upon the clients condition and goals or criteria set up with the client and the treatment team. The treatment team consists of the client's Medical Doctor, Psychiatrist, Case Manager, Staff Psychologist, Nurses, Recreational or Art Therapists as well as a Dietician. All of these disciplines work together towards helping the client to attain a workable individualized approach for recovery. This often is a very controlled environment for the client, which can allow the client to break the destructive cycle of behaviors and develop healthier new coping strategies.

Research shows that eating disorder clients benefit greatly from group therapy. While on the unit the client has some individual therapy, most of the programming involves group-centered work. The benefit from feedback and hearing the experiences of others can be immeasurable in terms of recovery for the client. Often eating disorder clients express an overwhelming aloneness with regard to their eating disorder.

Unfortunately unless the individual has unbelievable insurance coverage, the client and treatment team really have little to say regarding the length of stay. Insurance companies today more often than not, are dictating treatment. There appears to be little flexibility regarding level of care. Often the client experiences a significant amount of pressure to get better as a result of this. This may or may not be beneficial. The client also may or may not be moved to a lower level of care prior to their being ready. The average in-patient hospitalization stay is 7-10 days and that requires dire circumstances. Without insurance coverage the client must go to a self-pay situation to remain in the hospital which is costly and adds additional stress. There are relatively few specifically designated Eating Disorder Units in Psychiatric Hospitals across the country anymore. This is a partly a result of changes regarding insurance.

Aside from in-patient treatment there are four additional forms of treatment considered as out-patient care. These treatment modalities are presented in descending levels of care. The first and most intensive out-patient treatment is Partial Hospitalization. This is very similar to in-patient care however; the patient goes home at night and returns to treatment the next day. This allows the patient to experience some aspects of their normal life on their own without the hospital staff. Often this uncontrolled time helps the client to identify times of trouble and concern as well as what went well. When they return to treatment the next day they can then process these experiences with the staff. Treatment planning remains the same as an in-patient hospitalization. The next level of care is the Intensive Out-Patient Program. This consists of approximately three meetings a week for a period of three hours each. Generally this type of programming is offered in the evening. This allows the patient to carry on with their normal daily obligations (i.e., work, school) and still receive a significant amount of intensive treatment for the eating disorder. It is highly suggested that the medical doctor do a physical prior to admission and if the client is bulimic, a visit to the dentist is recommended. In both cases if the client has not already disclosed the eating disorder this is encouraged. Otherwise the treatment team other than nurses remains the same as the two previously mentioned treatment modalities.

The next two types of treatment are significantly less time consuming and are not considered a form of hospitalization. Individuals suffering from less severe eating disorders or who have completed a more intensive form of treatment often consider individual and or group therapy. Generally depending on the need this is accomplished in 1-3 sessions per week. Hopefully this is also provided with a treatment team approach including the counselor/therapist, dietician, clients medical doctor, psychiatrist, family members if appropriate as well as the client.

The use of medication is a major part of the APA guidelines, but not all patients will respond to or even accept a recommendation to begin psychopharmacological treatment (Zerbe, 1993). The most widely used and researched medication for eating disorders are antidepressants. This includes: tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), and the serotonin reuptake inhibitor fluoxetine (Prosac,Paxil). Other groups of drugs have been tried including; antipsychotics, lithium carbonate, appetite stimulants, anticonvulsants, zinc, naloxone as well as neuroleptics extensively because of the anorexic's bizarre eating patterns and their delusional qualities (Zerbe, 1993).

It is not uncommon that clients presenting with an eating disorder also have additional diagnosis' concurrently. Depression is seen accompanying and eating disorder. But often times the stopping of the destructive behaviors as well as the client's being able to express feelings regarding their own pertinent issues may help to lift the depression with the use of medications. The evaluation of depressive symptoms needs to be done by the patient's Physician/Psychiatrist with respect to severity and need regarding medications. Other common diagnosis' include: Mood disorders, chemical dependency, obsessive-compulsive disorder, as well as some personality disorders. These require special attention during treatment planning to accommodate for the dual-diagnosis recovery.

Research has shown to date that the most effective treatment for Eating Disorders involves a combination of modalities. Additionally it points out that no one single form of treatment is necessarily effective especially for all individuals. The research suggests that the combination of: antidepressants, group therapy, nutritional counseling, a cognitive-behavioral approach, and psychodynamic techniques provide the most beneficial treatment approaches in terms of recovery for the client (Zerbe, 1993). Researchers as well as therapists who work with this population are aware however; that this illness is very difficult at best to treat. It generally involves a long-term approach and commitment by both the client and therapist. Often for the client there are disappointing relapses that accompany the recovery process. Although there are always exceptions the general time frame of recovery is approximated to be no less than one year.

There is no one reason why an individual develops an eating disorder. For the most part however; those who do develop the disorder often present with above normal obsessive-compulsive traits. It is also suggested quite frequently that culture plays an important role in eating disorders. Through all the research presented there appears to be no universal precipitating event for an eating disorder to develop. There does not need to be a deep seated psychologically traumatic event. As a matter of fact, a significant number of clients report after reviewing their own history with the eating disorder, that the eating disorder developed during or shortly after a diet they were following.

Society pays a significant amount of attention to body image and physical attractiveness, youthfulness, sexuality and appearance. This can be experienced by placing oneself in front of a magazine stand. The covers display pictures of men and women alike, whose images are offered as near perfection in society's consensus. Never mind the fact that these photographs are often additionally computer enhanced and taken in near perfect circumstances. The average man or woman could not possibly compete with these images. Perhaps the models themselves cannot live up to these expectations. Eating disorders are not foreign illnesses to the modeling industry. What is unfortunate but interesting is that society is fluid and changing all the time. The impact of these changes can be enormous to those who strive for that perfection. It guarantees they may never quite be able to reach those goals and almost ensures a sense of failure.

Interestingly enough however; even though the disorders are quite different they all tend to share in common the use of the eating disorder as a means of coping with life stressors. Eating disorder clients share in common very low self esteem issues, distorted body image problems, obsessive thoughts and compulsions involving food, weight, calories, restricting, bingeing, or purging, difficulties with relationships, increased isolative and sneaky behaviors, ritualistic behaviors regarding food and eating, mood swings, feelings of self-loathing, hopelessness, despair as well as feelings of being out of control. Because of these similarities all three eating disorders (aside from each individual's own presenting problems and treatment goals) are able to be treated together and can provide a tremendously supportive environment for the client. Once the denial defense is able to be let go of in a safe manner, enormous growth is possible, especially because there are others who truly understand available. Perhaps due to the isolative nature of an eating disorder often clients report a sense of uniqueness and being alone with the disorder. A group setting helps to calm these feelings for the client.

Other similarities eating disorder clients may share with each other involve difficulties with relationships; friends as well as significant others. They tend to not feel comfortable expressing their own feelings or getting some of their primary emotional needs met. Often they express the fact that they put the needs of others before their own. After any length of time doing this the clients state they no longer know what they do need, or how they actually feel anymore. Supportive therapy can provide a safe environment for the client to try new ways of behaving while learning or relearning how to take care of themselves in a healthier manner. It also helps alleviate any frustrations, resentments or anger the client carries with them as a result of not allowing themselves to be themselves. Once clients feel safer issues of; spirituality, sexuality and body image often surface.

There is minimal attention paid to the issues surrounding food other than by the dietician. Therapists may find themselves in a battle for control with too much focus on the symptoms or food related issues. Repeatedly in the research it points out that the symptoms are just that and represent underlying problems for the client. It is important however to stress to the individual that restricting, bingeing, or purging are extremely unhealthy while encouraging the client's stopping of these behaviors. To focus on these issues may be a way of avoiding the real problematic areas for the client. Other than using presenting difficulties associated with restricting, bingeing or purging as learning tools it appears avoiding these issues can be therapeutically sound according to research.

Helping the client to develop and use healthier coping strategies is valuable to aid with letting go of the destructive behaviors which accompany eating disorders. A significant amount of time and energy is invested in the illness. Healthier substitutes appear necessary to help the client provide some structure and support in their lives especially initially. Relapses appear to be a part of the recovery process and can be used as valuable learning tools. Initially the client does not perceive relapses in this manner however. Unlike other illnesses, those suffering with eating disorders must confront eating and food several times on a daily basis. Patience and gentleness towards oneself are very helpful. As uncomfortable as eating disorders must be for the client, it takes time to develop into a disorder and requires time and patience to recover also.

The statistics regarding full recovery from an eating disorder are not uplifting. Although the disorder appears to go into remission, which can last for significant amounts of time, there appears to remain the possibility for relapse at latter dates. This can be disappointing for the client which is easily understood. Again no universal reason for these set-backs is known. Recovery from an eating disorder is extremely individual. Every client ultimately develops through trial and error their own path to health. Having a following a plan is imperative. It is an admirable journey requiring much courage. Eating disorder clients are intelligent, creative, brave and industrious people who should never be underestimated by anyone.

References

First, M.B.,M.D., (1995). Diagnostic and Statistical Manual of Mental Disorders,
4th Edition, Washington, D.C., American Psychiatric Association.

Zerbe, Kathryn J., (1995). The Body Betrayed, Carlsbad, California. Psychiatric American Press: Gurze Books, pp. 357, 365-372.

DSM-IV