COMPLEXITIES OF EATING DISORDERS By Patti Higgins Prevalence Approximately 5-10 million women and 1 million men struggle with eating disorders, such as anorexia, bulimia and binge-eating disorder. Eating disorders (ED) are complex, physiologically and psychologically devastating diseases that require professional treatment (www.nationaleatingdisorders.org). Anorexia Nervosa Refusal to maintain a minimum body weight (85% of the expected weight). Intense fear becoming fat, despite being severely underweight (Hall & Ostroff, 1999). Abnormal self-perception of body image, denial of low weight, and preoccupation with losing weight . Female patients often develop amenorrhea. 90% of anorexic cases are female; 10 % are males. Bulimia Repeated cycles of bingeing (extreme overeating) and purging (fasting, vomiting, exercising) behaviors. After bingeing, the patient attempts to control weight gain by inappropriate means such as fasting, self-induced vomiting, excessive exercise, abuse of laxatives, diuretics, or other drugs. 90% females; 10 % males. ED Assessments Eating Disorder Eating Disorder Examination Inventory (EDI) can Questionnaire (EDE- identify pre-eating Q) accurately assess disorder symptoms. and identify females with anorexia and bulimia. Eating Attitudes Test (EAT-12) can identify pre-eating disorder cases. Etiology of ED Wells and Sadowski (2001) view the etiology of bulimia nervosa as highly complex, involving various biological, psychological, social and family factors. Polivy & Herman (2002) noted family factors such as dysfunctional communication, enmeshment and criticism, family attitudes about food, weight, and body image were related to development of eating disorders. Mothers & daughters Pike and Rodin (1991) “examined features of 77 mothers' attitudes and behavior that relate to disordered eating among their adolescent daughters” (p. 198). Maternal criticism and view of daughter’s unattractiveness were related to ED. Mother / daughter relationship is a risk factor for eating disorders. Study indicated that both anorexics’ and bulimics’ descriptions of their mothers were generally negative (Johnsson, Smith & Amner, 2001). Family relationships Wonderlich, Klein and Council (1996) found bulimic females perceived both parents as hostilely disengaged. Additionally, bulimics related their negative self-concepts with perceptions of paternal attack/friendliness. Humphrey (1989) compared videotapes of 74 family triads with anorexic, bulimic-anorexic, bulimic and normal daughters. The taped were coded using Benjamin's structural analysis of social behavior (SASB). Bulimics and their parents were hostilely enmeshed; parents undermined daughter's separation and self-assertion. Anorexics’ parents gave double messages of nurturant affection combined with neglect of their daughter's needs Parental relationships Wade, Bulik & Kendler (2001) found that poorer quality of the marital relationship predicted the presence of subclinical bulimia nervosa (SBN), generalized anxiety disorder (GAD) and alcohol dependence in offspring. Mood factors ED may represent a way of coping with problems of identity and personal control (Polivy & Herman, 2002, p. 187). Tachi, Murakami, Murotsu and Washizuka (2001) reported binge and purge behaviors may be related to attempts to regulate negative moods. Beebe’s (1994) reported that bulimic behaviors are related to both escapism and feelings of hopelessness. Moods… Fassino, Daga, Piero, Leombruni & Rovera (2001) used State-Trait Anger Expression Inventory (STAXI), Temperament and Character Inventory (TCI) and Eating Disorder Inventory II (EDI- II) to discover high impulsivity among ED clients. Extreme anger was found in bulimic anorexics. American culture 80% of American women are dissatisfied with their appearance and body image. 42% of 1-3 graders want to be thinner (Collins, 1991). 81% of 10 year olds are afraid of getting fat (Mellin et al., 1991). The average American woman is 5'4" tall and weighs 140 pounds. The average American model is 5'11" tall and weighs 117 pounds. Most fashion models are thinner than 98% of American women (Smolak, 1996). Americans obsess on thinness 51% of 9 and 10 year old girls feel better about themselves if they are on a diet (Mellin et al., 1991). 46% of 9-11 year olds are sometimes or very often on diets, and 82% of their families are sometimes or very often on diets (Gustafson- Larson & Terry, 1992). 91% of women surveyed on a college campus had attempted control their weight by dieting. Media factors Guerro-Prado, Barjau-Romero, Chinchilla, & Moreno (2001) found an “undeniable influence of mass media in the genesis and maintenance” (p. 403) of eating disorders. Researchers also speculate that more males may develop the disorder as the media continues to pressure men and boys to strive for ideal body image (Polivy & Herman, 2002). Polivy and Herman (2002) propose that sociocultural factors including the media contribute to the increase of eating disorders among young women. Ethnicity and cultural factors Kuba and Harris (2001) studied 115 Mexican American women and found that contextual variables such as level of acculturation, socioeconomic status (SES), peer socialization, family structure, and immigration status influence the occurrence of eating disorders in women of color. Males Eliot & Baker (2001) collected comprehensive descriptions of 40 eating disordered males and surveyed others. Indications are that many males do have extreme concerns about body image and weight. Treatments Wells & Sadowski (2001) suggest comprehensive, individualized and multifaceted therapy, including both pharmacological and behavioral treatment components. Little (2002) suggests hospitalization to stabilize the patient, behavior modification, family counseling, group counseling, drug therapy and individual psychotherapy. Family Therapy Minuchin and Fishman (1981) emphasized that the anorexic or bulimic patient exhibits these symptoms as a response to the dysfunctional family system. Suggest reestablishing parental heirarchy through structural family therapy. Enhancing parenting skills and communication processes have been helpful with anorexic families (DeAngelis, 2002; Cierpka, Reich & Kraul, 1998). More family therapy… Milan trained therapists may view eating disorders such as anorexia and bulimia as “family games”(Goldenberg & Goldenberg, 2000). Narrative therapists engage in externalizing conversations to demonstrate that the family or client is not the problem: “the problem is the problem” (Goldenberg & Goldenberg, 2000, p. 316). McDaniel, Hepworth and Doherty (1992) proposed medical family therapy, which refers to “the biopsychosocial treatment of individuals and families who are dealing with medical problems” (p. 2). Multi-modal options Goals of therapy include promoting understanding, improving intrapersonal and interpersonal functioning, restoring normal exercise patterns, and addressing comorbid psychopathology and psychological conflicts (Muscari, 2002, p. 22). Bean and Weltzin (2001) suggest multidimensional residential treatment that has cognitive-behavioral, interpersonal, experiential and family therapies. Riess (2002) recommends cognitive-behavioral therapy (CBT), psychoeducation, interpersonal therapy (IPT), and relational therapy (RT). Physical Exercise Sundgot-Borgen, Rosenvinge, Bahr and Schneider (2002) examined the effect of physical exercise as an experimental treatment condition against the well- documented effect of cognitive-behavioral therapy (CBT). Exercise helped reduce drive for thinness, improved change in body composition, enhanced aerobic fitness, and reduced frequency of bingeing, purging and laxative abuse. Pharmacological options Research demonstrated the efficacy of fluoxetine treatment as statistically superior to the placebo treatment. Bulimic patients who received fluoxetine exhibited reduction in frequency of vomiting episodes and frequency of binge eating episodes (Romano, Halmi, Sarkar, Koke & Lee, 2002, p. 671). “Continued treatment with fluoxetine in patients with bulimia nervosa who responded to acute treatment with fluoxetine improved outcome and decreased the likelihood of relapse” (Romano et al., 2002, p. 671). Conclusion ED are complex disorders requiring thorough review of diagnoses, etiologies, family issues, assessment methods, family therapy treatment models and other treatment approaches of eating disorders. The prevalence and seriousness of eating disorders, such as anorexia, bulimia, binge eating disorder warrant improvements in public awareness, psychoeducational techniques and media responsibility. Furthermore, family prevention and intervention have been indicated as highly beneficial.