Ann is a twenty-year-old white female from a middle-class family. She consistently performed well in high school and was involved in many school activities, almost to the point of excess (but no one told her to stop, only complimented her on her success). As an athlete, her weight has always been a concern of hers and of her slightly overbearing parents. During her first year of college, she gained the Freshman Fifteen (ok, maybe twenty), and partly due to pressure from her parents, worked hard to lose it during the summer.
Upon returning to school in the fall, Ann received many compliments from her friends, teammates, and even some of her teachers. In spite of this, she still didn’t like what she saw in the mirror (maybe it had something to do with the bad breakup over the summer). Ann was convinced that losing just a couple more pounds would make her happy. And so she started to skip lunch. And when the homework of seven classes started to accumulate, she skipped breakfast as well.
Fast forward a year and Ann is severely underweight. She rarely goes out, always wears baggy clothing, and weighs herself at least seven times a day. She constantly feels lightheaded and cold, has trouble sleeping, and her hair is dull and thin. At every meal (when she has one), she starts by separating her plate into good foods (vegetables, low fat cottage cheese, mustard) and bad foods (everything else), and cuts her food into very small pieces. When she comes home for Thanksgiving, her parents practically throw a fit, calling her “sickly” and “skeletal.”
Perhaps you have guessed it: Ann suffers from anorexia nervosa (AN). And she is not alone—according to the South Carolina Department of Mental Health, one in 200 American women suffer from AN in the United States (“Eating Disorder Statistics” ). AN is a debilitating mental disease with life threatening physical consequences, and yet it has been notoriously difficult to treat. Why is that the case?
Getting the Skinny: What is Anorexia Nervosa?
According to Hilde Bruch, a psychoanalyst known for her research in eating disorders, AN is the “relentless pursuit of thinness” (qtd. in Rumney 16). The most recent version of The Diagnostic and Statistical Manual of Mental Disorders lists three requirements for a diagnosis of AN:
- Persistent restriction of energy intake leading to significantly low body weight (in context of what is minimally expected for age, sex, developmental trajectory, and physical health).
- Either an intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain (even though significantly low weight).
- Disturbance in the way one’s body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight. (584)
According to the National Institute of Mental Health, AN is often accompanied by “[thin] bones, brittle hair and nails, dry and yellowish skin, growth of fine hair all over the body, mild anemia and muscle wasting and weakness” (2).
What causes anorexia?
There are many factors that can be blamed for Ann’s AN. For example, if we view anorexia as a purely psychological disorder, we would say that Ann starved herself as a way to cope with her overbearing parents, her bad breakup, and her schoolwork. Restricting her diet gave Ann a sense of control when her life seemed out of control.
On the other hand, if we view AN as a “culture-bound syndrome,” it is the result of Western culture and its unhealthy emphasis on thinness (Prescott 106). With the media constantly bombarding everyone with photo-shopped images of “perfection,” who could blame her? But does culture really cause AN? A study done in the Fiji Islands suggests that it might. Avis Rumney, a recovered anorectic and eating disorder specialist, notes in her book Dying to Please that “twenty years ago, anorexia did not exist on the Fiji Islands. But after American television and MTV found their way to this remote region, Fijian adolescent girls began to diet and to develop anorexia” (Rumney 22). But not all stressed people develop AN, nor do all people who are exposed to our culture—so what are we missing?
Both of these models are simplistic in that they ignore the biological mechanisms of AN, as shown through the 1944 Minnesota Starvation Experiment. In this study, as described by June Alexander in her book A Collaborative Approach to Eating Disorders, 36 healthy males were made to lose 25% of their body weight in six months and then brought back to their normal weight in three months (104). During the course of the study, the subjects “developed an intense preoccupation with food, recipes and cooking; they hoarded food, made unusual food mixtures, used salt and spices excessively and dramatically increased their coffee and tea consumption” (104). While the intention of this study was to determine the most effective way to assist starving people in Europe and Asia after World War II, it is often cited in relation to AN because the symptoms of the men are reminiscent of those of anorectics. The study suggests that the obsessive behavior often associated with AN is partially a result of the starvation and not just a psychological manifestation of stress or a media-driven desire to be thin.
Furthermore, Rumney notes that there are neurobiological defects that can cause AN. These defects usually are associated with dopamine, a neurotransmitter that controls the reward and pleasure system in our brain. According to Rumney, anorectics tend to be “deficient or have abnormal functioning” of dopamine (18). Starvation tends to increase production of dopamine, which “improves [the sufferer’s] mood, leading her to repeat food-restricting behaviors” (Rumney 19).
So what is the cause of AN? Even if we accept that AN is a result of psychological, biological and cultural factors, it is difficult to unravel the web of interactions among the three. I believe that most people who develop anorexia are biologically predisposed to it. Western ideals of thinness provide a channel through which these people can express any psychological distress they are dealing with and exert control: starvation. As the anorectic loses weight, the dopamine produced and the (initial) compliments usually received when losing weight reinforces this behavior, making it a “self-perpetuating condition” (Utermohlen 88).
Back to Ann: The day before she’s supposed to go back to school, her parents confront her about her dramatic weight loss. She spouts the excuses she has told her friends (the ones she still has left, anyway) at college many times before: “I’m too busy,” “I’m a vegetarian/vegan/lactose intolerant,” “I had a stomach bug,” etc. Nonetheless, Ann doesn’t go back to school—instead, she’s admitted into a residential treatment program.
Here we see the first obstacle to recovery: denial. Many anorectics deny that they are “underweight or unable to maintain (or work toward) a normal weight,” notes Carlos M. Grilo in Eating and Weight Disorders (67). Thus, one of the primary goals of recovery is acknowledgement of the problem. Other goals, as stated by the NIMH, are “restoring the person to a healthy weight,” “treating the psychological issues related to the eating disorder,” and “reducing or eliminating behaviors or thoughts that lead to insufficient eating and preventing relapse” (4). Now the question is, how do we best achieve those goals?
Nutritional Therapy. Ann’s treatment team decides that the first order of business is for her to gain weight. This is not unusual, as the first step to recovery is usually weight gain, especially in severe cases. As shown in the Minnesota Starvation Experiment, a low body weight will only hinder the psychological recovery of the patient. Grilo also points out that “a consistent finding is that greater weight regain and higher weight at discharge from hospitalization predicted better eventual outcome” (80).
Ann is set a goal of one pound of weight gain per week and is supervised at every meal. When planning her meals, her treatment team has to consider many factors: how often, and how much she should eat, and what kinds of foods. A possible complication in this phase is called re-feeding syndrome. Re-feeding syndrome occurs when re-feeding is done too quickly, essentially shocking the body and causing physical distress. Symptoms include “confusion, chest pain and heart failure” (Alexander 109). In this stage it is also important to monitor the patient to make sure that she does not find ways to reduce her calorie intake, either through excessive exercise or tricks to avoid eating enough during meals, such as hiding food in napkins or clothing, or smushing food (Utermohlen 89).
As Ann begins to meet the goals, she finds that all her weight gain has gone to her stomach, much to her discomfort. Her treatment team assures her, however, that this is normal and that within nine months her weight and fat distribution will normalize to what they were before starvation ( ( Rumney 96).
Psychological Treatment. In addition to nutritional therapy, Ann is assigned individual and family therapy to address her psychological issues. What are her options?
A common form of individual therapy is called cognitive behavioral therapy (CBT). CBT views AN as a set of habits of “food restriction and avoidance” that become integrated into the patient “independent of the circumstances that initiated them” (McIntosh 742). Therefore the primary goal is to control the habit or behavior. Rumney offers the following example:
An anorexic commonly believes that eating new foods will cause her to lose control and get fat. This belief triggers a behavior: she limits her intake to a small number of “safe” foods. The job of the therapist is to (very patiently) help the anorexic understand that the needs of her body will change when it is no longer malnourished and that she will lose the urge to eat uncontrollably… that, in fact, control implies choice and she has no choice with her current eating regimen… As the anorexic understands that eating new foods can actually increase her control… she can experiment with eating different foods. (103)
CBT has been demonstrated to be effective in the treatment of bulimia nervosa, a related disorder in which the sufferer oscillates between binging (consuming large amounts of food in one sitting) and purging (trying to rid oneself of the excess calories consumed, whether through self-induced vomiting, misuse of laxatives, or excessive exercise) (Miller and Mizes 61; Utermohlen 90). It had not, however, been as well tested for AN as of 2000 (Miller and Mizes 61). According to a review published by Rebecca Murphy in 2010, the studies testing the effectiveness of CBT on AN “suffer from small sample sizes and some from high rates of attrition” (617). There was, however, a rather large study that used an enhanced form of CBT to treat AN (Murphy 617). The study found that 60% of qualified patients had a positive outcome from CBT-E with a low relapse rate.
CBT has been tested against other forms of therapy in a study done by McIntosh et al. Three forms of psychological therapy—CBT, interpersonal psychotherapy, and nonspecific supportive clinical management (the control)—were used on 56 women with AN. Interpersonal psychotherapy views the patient’s relationships as the basis of the problem and thus does not specifically target the eating aspects of the disorder (Miller and Mizes 138; 33). Nonspecific supportive clinical management focuses on educating the patient “on weight maintenance strategies, energy requirements and relearning to eat normally” (McIntosh 743).
Taking into account the small sample size, the researchers found that nonspecific supportive clinical management was the most effective, “while CBT and interpersonal psychotherapy did not differ significantly from one another” (744). They proposed that nonspecific supportive clinical management was the most effective because the therapist focused on “detailed discussion of ways to increase food choices and quantities in order to gain weight,” which gives the patient “an increased sense of patient autonomy and control” (746). Rumney addresses this study in her discussion of CBT, and suggests that despite the results, CBT has “earned a place in a comprehensive approach to the treatment of anorexia” and would be most effective “in combination with client education…about starvation and nutrition” (106).
Family Based Therapy. One promising kind of family-based therapy is called the Maudsley Approach. The Maudsley Approach views AN as being perpetuated by the relationship between the individual and the family (Rumney 147). AN affects both the family and the individual, and in turn, the family and the individual shapes the AN symptoms (Rumney 147). Therefore, the involvement of the family, in particular the parents, is necessary for recovery.
The Maudsley Approach is divided into three stages. In the first, the focus is weight gain, the difference being parents are given almost all control and responsibility over their child’s food. Parents must plan and be present for all meals. The second stage focuses on dealing with possible stressors and triggers such as social events. The third stage focuses on returning autonomy to the patient and dealing with any problems between the family and the patient (Rumney 148).
The Maudsley Approach has been shown, in multiple studies, to be effective. In a study done by Russell in 1987, “Maudsley Method family therapy was more effective than individual supportive psychotherapy in younger patients (before age 19) whose illness was not chronic” (cited in Grilo 83). In a 2010 study, Lock et al. found that family-based therapy such as the Maudsley Approach is “more effective in facilitating full remission at both follow-up points” (2).
Despite the optimism offered by the Maudsley Approach, it is not without its disadvantages. On the side of the parents, the Maudsley Approach requires an enormous time commitment that they might not be able to afford. In a New York Times article describing the method, journalist Roni Rabin describes the parental involvement in the initial stage: “at least one parent must be available around the clock to supervise meals and snacks, and monitor children between meals to make sure they do not burn off the calories with excessive exercise.” It can also be emotionally exhausting for the parents since their child will initially be very resistant. The method also requires a certain level of cooperation on the part of the anorectic, since parents cannot force their child to eat. If the AN is too deeply entrenched, this method may not be effective and could cause a deepening rift between the parents and child. This method may also be effective only for adolescents, as Russell found, which limits its usefulness.
Pharmacological Options. Ann’s current treatment plan does not involve any drugs, and perhaps for good reason. Despite the biological mechanisms behind AN, no drug has been empirically proven to facilitate recovery. Drugs typically proposed to help recovery are anti-depressants and atypical anti-psychotics. In several studies, antidepressants have not shown much success in “alleviating eating disorder symptoms or facilitating the weight restoration process” (Alexander 115). A common antidepressant used is the class of compounds known as SSRIs (selective serotonin reuptake inhibitors), which are supposed to target “body image alteration,” “fear of gaining weight” and “obsessive-compulsive behaviors,” with not much success (Rumney 140). Atypical anti-psychotics like olanzapine “have fewer neurological side effects than some other antipsychotic medications” and cause “dramatic weight gain,” which is why are they are used to treat AN (Rumney 140). There are still, however, negative side effects including insulin resistance and high cholesterol levels (Rumney 140). In addition, the rapid weight gain cause by olanzapine can cause severe anxiety in some anorectics (Rumney 140). It is not well documented whether anti-psychotics have been used treat to dopamine deficiency in AN patients.
In Rumney’s personal struggle with AN, she found that while finding the correct antidepressant was difficult, ultimately, drug therapy was worthwhile. Her opinion is that “despite the fact that no medication seems to address the core issue of body image distortion, relieving coexisting mood problems can at least improve the individual’s overall functioning… If unnecessary pain can be alleviated and quality of life improved, then perhaps other healing can commence as well” (142).
Alternative Treatments. The therapies mentioned above cover a lot of the “traditional” aspects of a treatment plan. Rumney also discusses several alternative treatments in her book, including art therapy, music therapy, poetry therapy and psychodrama. One method she has personal experience in is hypnotherapy. Rumney mostly refer to the work of Dr. Meir Gross, former chairman of the Child and Adolescent Psychiatric Department at the Cleveland Clinic Foundation. Gross used hypnotherapy to not only “make [patients] aware of [their] extreme thinness” and “unblock perceptions of hunger and fullness” but also taught patients to use self-hypnosis as a calming method (Gross cited in Rumney 116). Rumney adds that self-hypnosis “is particularly useful in the treatment of anorexia because it allows the client to maintain control of the process” (118). Self-hypnosis is a subset of hypnotherapy in which “the client is shown how to put herself into a trance state” (Rumney 115). The self-induced trance state can help the anorectic calm herself and “take charge of the issues she wishes to address” (Rumney 115). Rumney says that she uses self-hypnosis to “calm [herself] during anxious times” (118).
Rumney also mentions 12-Step programs as a “power adjunct to therapy” (155). The group aspect of 12-Step programs embraces the “it takes a village” philosophy, providing a supportive community and group sessions to help cope with behaviors (Rumney 155). There are four 12-Step programs related to food disorders: Overeaters Anonymous, Food Addicts Anonymous, Eating Disorders Anonymous, and Anorexics and Bulimics Anonymous (Rumney 155). The twelve steps are almost identical across all programs, except for the first step in which one admits the problem. Rumney participated in Overeaters Anonymous for a sugar addiction fifteen years after her treatment for AN. Despite initially hating the meetings, she found that she “felt understood in a new way” and learned about gratitude and acceptance (159).
After five months Ann is discharged. She is now at a healthy weight and while she has to meet with a therapist regularly, she is free to enter college again. Not too long after, however, the stress starts to build and she finds more and more excuses not to eat. Not long after that, her therapist begins to notice her weight loss. Ann has relapsed.
Unfortunately, Ann’s experience is common. AN sufferers come to depend on AN as a way to control their life and in a sense, relieve stress. Although symptoms may subside, the sufferer remains vulnerable and may relapse during periods of high stress or during triggering situations (Mayo Clinic Staff). In general, “fewer than 50% of patients recover, roughly one-third improve and 20% show a chronic and disabling life course” (Steinhausen cited in Grilo 42). A study done by Patrick F. Sullivan shows that people who no longer fit the DSM-V criteria for anorexia still struggle with body image issues, perfectionism and obsessiveness (cited in Grilo 42).
Every treatment plan tries to avoid relapse. Common methods include teaching patients to recognize warning signs and appropriate “behavioral plans” and “coping mechanisms” (Miller and Mizes 350). Therapists also emphasize that one is never cured from AN and that it is an “ongoing” process (Miller and Mizes 350).
Even if Ann is able to recover and successfully avoid relapse, her family is faced with one more problem: cost. According to the South Carolina Department of the Mental Health, inpatient treatment can cost on average $30,000 a month, with the average patient requiring approximately three to six months of care. Outpatient treatment can cost $100,000 or more. A New York Times article describing this problem notes that insurance companies tend to not cover treatment “on the grounds that there is not enough evidence on how best to treat [AN patients]” (Alderman). The article suggests the Maudsley Approach for those families particularly concerned with cost because the “parents takes primary responsibility,” making costs “minimal” (Alderman).
While Ann is not real and her situation is merely hypothetical, anorexia nervosa is a real disease, with real sufferers. Grilo states that “eating disorders, along with substance use disorders, have the highest mortality rates of all psychiatric disorders” (42). Recovery is essential to survival, but every part of a treatment plan has to be personalized, from the meals to the therapy. Unfortunately, since therapists and parents have no way of knowing which treatment will work, usually time, money or motivation runs out before an effective plan can be found. Instead of trying to find more methods of treatment, the focus should now be on more efficient ways to determine the most effective plan.
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