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Guest Authored by Margo Maine, Ph.D.

Volume 1 Issue 6 November 1999

A supplement to the Family Therapy News

The American Association for Marriage and Family Therapy

Eating Disorders

CLINICAL UPDATE

Contents:

2...Diagnosis & Assessment

3...Terminology

4...Treatment Options

5...BioMedical Issues

6...Professional Resources

7...Sample Consumer Update

8...Collaborating With Other

Professionals

In the past quarter century, eating disorders

have become a major public health problem in

the United States, Canada, and other

Western nations. According to conserva-

tive estimates, .5 percent of adolescent

and young adult women meet the criteria

for anorexia nervosa, and 5 percent for

bulimia. Incidence rates are considerably

higher in subgroups of the performing arts

and athletics, where weight and body

shape are overemphasized. In the past

decade, subclinical or partial-syndrome

eating disorders have increased dramati-

cally and incidence patterns have

changed. Earlier, Caucasian females from high-

er socioeconomic levels were most at risk.

Today, eating disorders are homogenized

throughout classes, races, ethnicities, and

subcultures. Prepubescent children, adults,

women, and men living in non-Western coun-

tries such as the Far East, South America, and

Eastern Europe are developing these problems.

Unfortunately, eating disorders have rapidly

become a global concern.

The treatment of eating disorders is a serious

undertaking. Eating disorders have the highest

morbidity and mortality rates of all psychiatric

disorders. The mortality rate ranges from 5 to

10 percent, including both physical causes and

suicide. Estimates are that approximately one

third of clients with eating disorders will fully

recover. Another third will recover with some

residuals, such as an overemphasis on weight,

exercise, and eating, or periods of relapse.

Finally, one third will remain chronically ill.

The importance of families in the etiology and

treatment of eating disorders has been recog-

nized since their earliest clinical descriptions in

the 1800s. Since then, a considerable body of

knowledge has developed, stimulated by Mara

Selvini Palazzoli, Salvador Minuchin, and many

others. The American Psychiatric Association

(1993) practice guidelines for eating disorders

suggest that family therapy be mandatory for

younger patients and urges marital therapy for

adults. Thus, MFTs have an important role in

the treatment of eating disorders.

The current clinical climate driven by

cost containment, however, is focused on

brief, individual, and fragmented treatment.

Similarly, the majority of clinical research

emphasizes individual prescriptive treatment

like cognitive-behavioral therapy, and psy-

chotropic medication. Research on family

therapy or on multimodal therapy, including

various approaches in a comprehensive

package, is rare today because of the

inherent complications and costs. Although

more clinical and research emphasis is

placed on individual techniques and models,

in the trenches of specialized treatment

programs, family therapy abounds.ν

Review of the Prevalence of Eating Disorders in

Adolescent and Adult Women in the United States1

1Adapted from Shisslak, C. M., Crago, M., & Estes, L. M. (1995). The spectrum of eating disorders. International Journal of Eating Disorders, 18(3), 209-19.

The Gap In Treatment

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bulimic symptoms during the course of the

illness. Trying to control bulimia, for exam-

ple, an individual may severely restrict her

or his eating. Or an anorexic may purge to

deal with distress about eating.

Before the MFT diagnoses an eating

disorder, medical causes for the behaviors

should be ruled out. Many illnesses can

cause some of the symptoms of anorexia,

including brain tumors, hyperthyroidism,

diabetes mellitus, Crohn's disease, celiac

disease, malabsorption disorders, ulcerative

colitis, tuberculosis, AIDS, cancer, medica-

tion-related side effects, or amphetamine

abuse. The differential diagnoses related

to bulimia include tumors, hepatitis, pancre-

atitis, pregnancy, peptic ulcer, viral

About the Author

Eating disorders are determined by multiple

factors. These include individual personality

traits, physiological predispositions, family

patterns, critical experiences such as loss

or abuse, the sociocultural influences of

gender roles, and the meanings ascribed

to food, weight, and appearance. The family

is a factor that mediates all others. Eating

disorders also reflect and coincide with

developmental stressors. Anorexia is most

likely to emerge in adolescence, with an

average age of onset at 17 and bimodal

peaks at 14 and 18. At 14, adolescents are

beginning to deal with a changing sexual

body while meeting increased social, acad-

emic, and interpersonal demands. They are

pressured to separate more from the family

and define themselves individually. Many

adopt the prevailing cultural attitudes that

emphasize the value of lean, fit bodies,

dieting, and appearance, leading teens to

agonize more and like their bodies less. At

18, stress can intensify with the need to

make decisions about the future and leave

the family home. Bulimia, usually emerging

between adolescence and age 25, is also

linked to these developmental passages.

Although still disproportionately a female

condition, the incidence of eating disorders

in men has risen from one out of twenty

cases to one out of twelve. The factors

contributing to eating disorders are similar

in men and women, though most cases in

men begin as exercise abuse. The increase

in men is due to many factors, in addition to

greater awareness of the disorder. Based

on messages from cultural images and the

media, and the pressures of a demanding

job market, men may try to achieve the cul-

tural ideal of physical attractiveness as a

sign of competence and success. With the

transformation of gender roles and the

progress of feminism, old definitions of mas-

culinity no longer fit. The pursuit of the ideal

body type answers the confusing questions

about what it means to be a man or a

woman today.

The DSM-IV (1994) identifies three types

of eating disorders. In anorexia nervosa

(DSM-IV 307.1), characterized by a refusal

to maintain a normal weight, individuals

either fail to gain weight during puberty or

lose weight, weighing 15 percent less than

expected for height and age. Some weigh

even less. Despite this, they are terrified of

gaining weight, feel fat, and deny any relat-

ed problems. Females stop menstruating. In

the restricting type, people rigorously limit

their food intake. In the purging type, they

may also binge and purge by vomiting and

exercising, or by using laxatives, diuretics,

enemas, or other pathogenic weight control

techniques.

In bulimia nervosa (DSM-IV 307.51), people

experience a lack of control over their eating

and consume excessive food. Purging fol-

lows. Like anorexia, bulimia is characterized

by preoccupation with weight and shape,

and having a negative self-image. Most

often a secret, it causes great guilt, shame,

and self-loathing. In the purging type, peo-

ple regularly use vomiting or medications

to get rid of what they ingested. In the non-

purging type, they use fasting or exercise.

The term eating disorders not otherwise

specified or “EDNOS” (DSM-IV 307.50)

applies when individuals meet some but

not all of the criteria for anorexia or bulimia.

For example, women may be anorexic but

still have periods, may have lost a significant

amount of weight but are still in the normal

range, or may purge without bingeing or

binge without purging. The common ground

between these disorders is a fragile identity

and excessive self-doubt that are focused

on the body. Many, about 40 percent, will

move back and forth between anorexic and

Margo Maine, Ph.D., is a clinical psy-

chologist and family therapist who

has specialized in the treatment of

eating disorders for 20 years. She

serves as the director of eating dis-

orders at the Institute of Living in

Hartford, Connecticut. Author of

Father Hunger: Fathers, Daughters,

and Food and recently Body Wars:

Making Peace With Women's Bodies,

she is a senior editor of Eating

Disorders: The Journal of Treatment

and Prevention. Maine is an Affiliate

Member of AAMFT, and a board

member and past president of the

organization Eating Disorders

Awareness and Prevention, Inc.

The Clinical Update is published bi-monthly by

the American Association for Marriage and Family

Therapy Research and Education Foundation

(1133 Fifteenth St., NW, Suite 300, Washington,

DC 20005-2710).

To order issues, contact: AAMFT (202) 452-0109

For reprinting and duplication information, con-

tact: Professional Development Administrator

(202) 452-0109.

reserved. Printed in the USA. No part of this

publication may be reproduced, stored in a

retrieval system, or transmitted, in any form

or by any means, electronic, mechanical,

photocopying, recording, or otherwise, with-

out the prior written permission of the publisher.

Diagnosis & Assessment

or bacterial infections, certain cancers, and body dissatisfaction. These tools should

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Below are definitions of words that are not defined elsewhere in this issue.

Lanugo: A layer of fine downy hair that covers the body in an attempt to keep the

body warm.

Hypometabolic: A state that occurs when the body slows down or stops processes

that are not essential to human life so the body can preserve energy.

Bradycardia: A slow heart rate.

tuberculosis, toxic medications, and dia-

betes. Several medical illnesses frequently

coexist with eating disorders, including dia-

betes, cystic fibrosis, tuberculosis, inflam-

matory bowel disease, and thyroid disor-

ders. By manipulating their medications,

eating disordered individuals with these

conditions can easily lose weight. Mental

health clinicians should understand the

medical ramifications of these problems

and work closely with medical providers.

Eating disorders also frequently co-occur

with depressive disorders, anxiety, obses-

sive-compulsive disorder, posttraumatic

stress disorder, personality disorders,

and less frequently, psychotic disorders.

As many as 50 percent of bulimics suffer

chemical dependence, and 40 to 50 per-

cent of women with eating disorders have a

history of sexual trauma. Eating disordered

behaviors help the person set boundaries,

develop a false sense of control, express

complicated emotions, and cope with a

desire to punish themselves or fade away.

With less research available for men, the

incidence of sexual abuse is unclear but

quite likely.

Because of the profound impact of starva-

tion on mood, ability to regulate affect,

thought patterns, problem solving, con-

centration, and attention, the clinician

needs to determine if such problems are

separate diagnostic issues or are due to

the eating disorder.

Due to limited professional knowledge

and a culturally shared preoccupation with

appearance and weight control, anorexia is

often not diagnosed until two to three years

after symptoms have appeared. Likewise,

bulimia often goes unnoticed for as long

as five years. By the time many people are

diagnosed, the disorder has taken hold and

become both a way of life and an identity.

Generally, it is easier to diagnose anorexia

due to the obvious weight loss. Although

bulimics are literally starving and nutritional-

ly depleted, they may maintain a weight

at or above normal due to hypometabolism

secondary to starvation, and are not

determined to be at risk physically. In

anorexia, the body adjusts slowly to the

depletion of fat, muscle, and eventually

organs, so it continuously readjusts and can

withstand years of starvation. In contrast,

bulimics' dramatic fluctuations of input and

output place their bodies in chemical chaos.

Unfortunately, less is known about the long-

term outcome of bulimia. Even estimates of

the mortality rate associated with eating dis-

orders are limited because the cause of

death is listed as the physical symptom,

such as cardiac arrest, kidney failure, or

esophageal bleed, rather than the eating

disorder itself.

Assessment. A number of self-report ques-

tionnaires are available for the assessment

of eating disorders. Most used are the

Eating Attitudes Test (EAT) (Garner,

Garfinkel, Olmstead, & Bohr, 1982), the

abbreviated version EAT-26, the Eating

Disorder Inventory (EDI), and the EDI-2

(Garner, 1991), which measure a variety of

attitudes and behaviors contributing to eat-

ing disorders. These instruments assess

the severity of the illness and can reflect

improvement during treatment. They may

provide helpful prognostic information by

assessing variables like drive for thinness

not be used alone because they do not

address underlying issues, contributing

dynamics, or interpersonal and family rela-

tionships. They are limited by self-report,

and cannot necessarily provide the history,

impact, and severity of the symptoms.

The Eating Disorders Examination (EDE)

(Fairburn & Cooper, 1993) is a well-

researched structured interview, but also

limits its scope to dimensions related to

eating and weight rather than to systemic

or family issues.

A comprehensive assessment to evaluate

the acuity and type of care required should

include an exploration of the following

areas: contact with the primary care

physician to rule out a medical cause and

to assess the physiological impact of the

eating disorders; history, duration, and fre-

quency of symptoms; physical complaints;

co-existing medical problems; mental

status; occupational, vocational, and educa-

tional status; suicidal ideation or other risk to

self or others; stresses contributing to the

illness; history of abuse or neglect; family

history of chemical dependence and

psychiatric illness; availability of a support

system or other resources; current relation-

ship to family; family's attitudes toward food,

weight, and appearance; previous treatment

and response; motivation; family willingness

to participate or support treatment; and

strengths and goals for treatment. The MFT

should also assess the role of food, appear-

ance, weight, dieting, and exercise in this

family. What are the customs, rituals, duties,

and meanings of mealtime? What are meals

like? How has the eating disorder affected

their meals? What are the health and exer-

cise habits of others family members? Have

people dieted frequently? ν

Terminology

Treatment Options characterized by anorexia is a perfect metaphor. In contrast, the bulimic family

is apt to be more open to admitting prob-

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Family Patterns. A family member's eat-

ing disorder can be particularly terrifying

to other family members because it often

seems to be a willful or intentional behav-

ior. Common family patterns seem to

reappear for both men and women with

eating disorders. In adult clients, unre-

solved family dynamics will play out with

significant others and, untreated, will

serve to maintain the symptoms. Eating

disordered individuals have usually

played a very central role in the family,

often as the caretaker of others. In this

adultified, parentified, other-directed

script, they are unable to focus on their

own feelings and needs, even for food.

The families of those with eating disor-

ders often have similarities. Fathers tend

to be disengaged and emotionally

unavailable. Mothers tend to be either

over- or underinvolved, and the sibling

subsystem is often underdeveloped.

These families have difficulty communi-

cating and managing conflict directly,

so food and weight become the lan-

guage. Marital conflicts often exist or, in

separated or divorced families, persist

but are not addressed. The identified

client becomes the peacemaker, pal,

or confidant to one or both parents.

Typically, the anorexic family is constrict-

ed emotionally and there are unspoken

rules that family members are not to

identify conflicts or flaws. The denial

lems but never resolves them. The eating

disorder instills order amidst this chaos.

The task of treatment is to deal with con-

flicts directly so that no one has to be ill.

The parenting style of eating disordered

families tends to extremes: either

enmeshed and overprotective, or chaotic

and underinvolved. The eating disordered

individual responds by either feeling guilty

and frightened of separating and individu-

ating, or by feeling overwhelmed by dis-

connection and loneliness. The symptoms

allow some separation while simultane-

ously asking for closeness, comfort,

and care. The MFT's task is to help

clients see how the eating disorder

functions to solve these problems, and

to reorganize relationships to end such

desperate measures.

When families are either unavailable

or resistant to family therapy, individual

therapy with a systemically informed

therapist can help the client understand

the family context of the eating disorder.

This will help the client overcome the

shame, isolation, and feelings of inade-

quacy that accompany the symptoms.

A client can understand how the eating

disorder makes sense as a response to

other family issues.

Phases In Treatment. After meeting and

evaluating the client and family, it is useful

to develop a contract with them that out-

lines an explicit treatment plan. Include

the family's input to set shared goals and

define expectations. At the outset, the

client's physical and psychological safety

must be assured. Contact with the other

professionals involved is time consuming

but essential. The MFT must know the

issues, experiences, and needs being

discussed in individual therapy to guide

the pace and tone of family sessions.

The MFT must also be certain that med-

ical providers and dietitians are oversee-

ing the physical status and health restora-

tion. By communicating well with other

professionals, the MFT models important

behaviors: the value and necessity of

relationships, listening to others, and

jointly solving problems.

Initially, family or marital therapy must

be problem-focused. The symptoms and

potential long-term side effects of eating

disorders are frightening and, without

proper guidance, family members may

be overcontrolling, underreactive, or

rejecting. At this point, psychoeducation

is critical. Reading materials, a session

devoted to a discussion of the illness

process, a meeting with the dietitian,

or referrals to a family support group

can help (see the Consumer Update for

suggested resources). The next step is

to define who is responsible for what.

By clarifying what medical and nutritional

monitoring and interventions are in

place, the MFT assures safety so the

family can stop intruding. Clarify what

help the client needs from the family.

Discuss who grocery shops, what foods

must be available, who prepares food,

whether the client should eat alone or

with others, and how to talk about these

issues outside of sessions. Another fac-

tor to discuss is the kind of support the

eating disordered person needs after

eating, since anxiety and desires to

purge usually increase at that time.

Be sure that both parents have a role

in these tasks. Too often, fathers are

excused and mothers feel overly

burdened and alone.

This attention begins to reorganize

the roles and relationships. The eating

disordered individual needs to be

responsible for her or his eating, but at

The parenting style of

eating disordered families

tends to extremes.

Serious but often misunderstood,

anorexia and bulimia are health-impair-

to the lack of protein and fat;

decreased core body temperature;

sensitivity to cold; appearance of

lanugo; fatigue and weakness; sleep-

ing problems; poor concentration and

BioMedical Issuesthe same time, feel like she or he is not completely alone. Tailor these recom-

mendations to developmental needs: a

12-year-old needs more structure than

someone who is 18 or 25. Help

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anorexia and bulimia are health-impair-

ing and potentially life-threatening. In

both disorders, the individual enters a

starvation state because adequate nutri-

ents are either not consumed or not

completely digested. The body defends

against starvation by becoming

hypometabolic. These changes happen

gradually and organ damage occurs

very late in the process. Medical assess-

ment, monitoring, and intervention are

critical components to effective treat-

ment due to these consequences,

although alone they are insufficient. In

acute situations, intravenous rehydration

or tube feeding may be necessary.

The newer antidepressants, selective

serotonin reuptake inhibitors (SSRIs), are

frequently used with both anorexia and

bulimia. They can lift mood and some-

times help to control the obsessive think-

ing associated with eating disorders.

While this group of drugs has fewer side

effects than previous antidepressants,

low-weight anorexics may have a harder

time gaining weight due to a potential

increased metabolic rate. Medication

can certainly enhance treatment. Used

alone, it will have a limited impact.

Occasionally, short-acting antianxiety

agents are used to manage intense anxi-

ety around mealtime, and low doses of

antipsychotics may be used to address

severely distorted thought patterns.

Health consequences of anorexia ner-

vosa include: bradycardia; thinning of

the heart wall; decreased blood pres-

sure; increasing risk for cardiac arrhyth-

mia or heart failure as heart rate and

blood pressure decrease; dehydration

due to limited fluids; gradual changes in

kidney function possibly resulting in kid-

ney failure or need for dialysis; hormonal

changes; loss of menstrual cycle; poten-

tial fertility problems even after weight

restoration; decreased bone density; risk

for early osteoporosis and stress frac-

tures; fainting, dizziness, and blackouts;

dry skin and cuticles, and hair loss, due

problem-solving; constipation and

other gastrointestinal distress; multiple

abnormalities in blood work secondary

to starvation; and stunted growth in

younger patients.

Health consequences of bulimia

nervosa include: electrolyte imbal-

ances leading to irregular heart beats,

arrhythmia, and potential cardiac

arrest; dehydration contributing

both to cardiac and kidney problems;

inflammation, tears causing bleeding,

and potential rupture of esophagus

from vomiting; potential gastric

rupture due to bingeing; constipation,

diarrhea, and other gastrointestinal

problems, especially in laxative

abusers; heartburn, reflux, and

ulcers; loss of dental enamel and

increased decay due to vomiting;

decreased heart rate, blood pressure,

and body temperature; muscle cramp-

ing and weakness; fatigue; fainting,

dizziness, blackouts; menstrual irregu-

larities, increasing risk for fertility

problems and osteoporosis; and prob-

lems sleeping, concentrating, and

problem-solving.ν

Serious but often

misunderstood, anorexia

and bulimia are health-

impairing and potentially

life-threatening.

family members to see how they can

be useful aside from symptom man-

agement, by talking about other issues

and feelings. Family therapy aims at

extracting the eating disorder from the

center of relationships so true intimacy

can develop.

As symptoms subside, families often

choose to leave treatment. Discuss

what else family therapy could achieve,

but if they choose to terminate, provide

relapse prevention information,

acknowledge their progress and

strengths, and help them to define

what signs should prompt a return to

treatment. For those who remain

involved, the real work of role revision

and insight can take place. Then the

prospects of full recovery are much

higher. Minuchin's model, applying

the principles of treatment for psycho-

somatic families, resulted in a positive

outcome for 80 percent of cases (Dare

& Eisler, 1997). Other family research

reports similar success.

Family therapy puts the eating

disorder in the context of a family

system, relieving the blame, self-

degradation, and confusion for the

individual and giving loved ones clear

guidelines of how to help. It can accel-

erate the self-acceptance, feelings of

self-worth, ability to express feelings

directly, and development of satisfying

connections with others, all essential

to the recovery process.ν

As symptoms subside,

families often choose to

leave treatment.

The sources cited throughout the text, and

the references listed below, include clinical

books and research which should be help-

ful when undertaking family treatment for

References and Bibliography:

American Psychiatric Association (1993).

Practice guidelines for eating disorders.

American Journal of Psychiatry, 150 (2),

212-228.

American Psychiatric Association

(1994). Diagnostic and statistical manual

treatment of anorexia nervosa. New Jersey:

Jason Aronson.

Root, M., Fallon, P., & Friedrich, W. (1986).

Bulimia: A systems approach. NY: W. W.

Norton.

Van Den Broucke, S., Vandereycken, W., &

Professional Resources

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ful when undertaking family treatment for

eating disorders.