Eating Disorders Review
May/June 2015
Volume 26, Issue 3
Scott Crow, MD, Editor-in-Chief
***********
Long-Term Treatment of Eating Disorders: Tools for a
Journey
Part 2: A Perspective from Research
By Kathryn Zerbe, MD
Oregon Health and Science University and Oregon Psychoanalytic Center, Portland, Oregon
Reprinted from Eating Disorders Review
May/June Volume 26, Number 3
©2015 IAEDP
In this article I'll describe four principles I find useful in working with patients who come to us in need of
longer-term psychotherapy, or who tend to stay in our practice for at least one year. Even in an age with
impactful reimbursement constrictions from third parties and pressure to ensure that our efforts are
‘evidence based,' and thereby explicitly scientific and worthy of payment, a significant number of patients
benefit from a treatment process when a “longer dose” from “50 to 100s of visits” is given.4 These
patients tend to have histories of early attachment difficulties, trauma and maltreatment, co-occurring
personality disorders, substance abuse, and severe anxiety or depression. They have not been
adequately helped by less-intensive psychoeducational, or exclusively manualized cognitive-behavioral,
pharmacological, and family-based interventions.5, 6
For these patients, who have many symptomatic difficulties and who have not yet formed a core sense of
themselves, research demonstrates that experienced clinicians consciously and intuitively blend
psychodynamic and cognitive behavioral methods, regardless of the theoretical orientation that we may
consciously espouse.4, 7, 8 This crucial research data from “real-world” practice is beginning to tell us
much about the technical skills, personal attributes, and treatment stance clinicians bring to the
treatment setting that can engage a patient in need of therapy that promotes the development of a sense
of self and heralds better self-care overall.4, 6-8
Four Principles Can Guide Our Therapy
The research perspective also tells us a bit about how we engage with our patients and technically blend
skills to keep the process going. Yet, to fully understand how patients actually get better and change over
time, as well as those quagmires a therapist likely encounters while on the journey with them, continues
to beguile us. The four principles I describe below by no means form an exhaustive list, but they have
helped me to stay sane and somewhat steady when working with eating disorder problems that appear
refractory to intervention or when treatment appears to be at a stalemate. They are also principles that
students and staff members find helpful and salutary, even as they gainsay an easy answer to sticking
with a patient when life itself seems to be on the line, precious monies for care may be limited, and the
treatment process may appear to be deadlocked.
Principle 1: Patience in Practice, or the ‘Resistance Phase' of Treatment
Drawing upon his experience of working intensively on an inpatient unit with highly disturbed adolescent
girls, psychiatrist Donald B. Rinsley coined the term ‘resistance phase of treatment' in the late 1970s.9
He observed that teens with severe interpersonal and family difficulties often needed up to 16 months of
persistence by staff members on the residential unit to help them work through numerous resistances
and behaviors before they could actually begin what he called ‘definitive treatment.' In other words,
resistance is not a single behavior or maneuver to be overcome, such as curtailing one's denial of
emaciation or refusal to stop binge eating, but a multiplicity of self-destructive patterns, secondary gains
from illness, and other impoverished adaptations to constructive living.
Once the therapist understands that resistance is a phase to be weathered more than an action to be
overcome, she is able to wait out and work with the patient's tendency to try to defeat the treatment.
While trying her best to be useful to the patient in providing new tools and simply listening to the
patient's story unfold, she is also inclined to be less self-critical when her patient does not immediately
benefit. She understands that the resistance phase of treatment is where she and her patient are, and
that it cannot be rushed. When a therapist can be less critical of herself, her patient has a new object of
hope to identity with in a constructive way that will serve him better in life. To such patients in this stage
I often find myself saying over and over again, “I can wait longer than you!” and “Remember, we are
aiming at improvement, not perfection.”
During the resistance phase of treatment the therapist is also gaining essential data about the patient
that will be useful later. On the surface the patient may not seem to be taking anything in, but in reality
an attachment relationship is unfolding and gaining strength. As feelings of safety increase, the patient
may reveal a little more about her history. With both a safer attachment and more knowledge of the
patient's life comes the opportunity to speak to the problems with which the person struggles. When the
patient is manifestly resisting in this phase, the therapist is not curtailed from responding in a very
human way by asking questions, making simple observations, nodding and affirming, uttering subtle
“umms” or “ahhs,” and zeroing in on past and present losses. Why is it particularly important to talk
about loss? Loss is the most ubiquitous of psychological issues. None of us escape it. Even positive
changes are filled with a sense of leaving something of value behind. Letting patients know that their
losses can be expressed and not dodged is one of the gifts of the therapeutic process, and may
accelerate movement into a more active treatment phase when grief may be more actively expressed
and worked on.
Principle 2: Permission to Feel and Express Pain
Regardless of our professional discipline, imbued in our training is the concept of reducing suffering to a
minimum. Even as we all appreciate that life is hardly a pain-free enterprise, we undertake our work as
healers to defeat it. Counterintuitive is the notion gaining traction in contemporary psychoanalysis and
psychodynamic psychotherapy that the best way to alleviate suffering is to actually help the patient
“observe, process, speak about, draw attention to, and bear”10 emotional pain in order to eventually
transform it.
“When we find we can face our fears, a sense of confidence and acceptance begins to grow naturally,”
writes psychoanalyst Jeffrey Eaton.10 He continues to provide balm for therapists as he continues, “I
have no magic answers or solutions. Part of my pain is that I cannot simply remove the pain my patients
must face...Over the years of work together people grow a deeper capacity for loving connections, and
perhaps most importantly, some soften into strength and become curious about, even compassionate
toward, some of the most pained parts of themselves. The pain is not gone, but one has a very different
relationship to it, and to the idea of how others might experience it.”
Sitting with, processing, and containing pain is some of the hardest work that we therapists do. Patients
often want and need to stay in treatment longer because the therapist's office is the safest and really the
only place they have to pour out their angst. We bear witness to their cumulative losses and their life
transitions. How many culturally sanctioned places are available where one's private self is held sacred?
One patient in my practice who made substantial progress early on with her eating problems continues to
make an investment in herself by coming weekly. She calls psychotherapy a place where she “drinks
water from a well,” and likens her thirst to a lifetime draught to speak her truth. Most therapists who do
longer-term work will resonate with this example because they hear similar tales daily and absorb the
shock waves of the other person's anguish and joys. “Today I need containment” is the plaintive cry of
many an experienced clinician who seeks out supervision or consultation less for concrete direction or
specific advice than for the place it provides to feel, to express, and to work on the pain of others that
accompanies our tasks.
Principle 3: Staying the Course. Expectable ‘Plateau Phases'
One of the most valuable lessons I have learned about life from my patients is that there are inevitable
and necessary plateau phases where nothing much seems to be going on in therapy and where patient
and therapist both feel stalled. In part these plateau phases occur because on the surface nothing is
going on. In reality the action is happening below the surface, as a kind of consolidation of gains before a
new growth spurt occurs. The problem for the therapist is that it may be difficult to ‘hold' a patient in
treatment at these times and to have any faith that something will enfold anew with the fullness of time.
In the therapeutic work the patient retreads old ground, may even complain that she is growing bored
and impatient, and wonders if she has achieved maximum benefit, and is ready to quit. The therapist
also has her doubts and is wondering similarly: The pair appear to have caught the same virus — the
‘hurry-up and move-on' virus — but in the best of scenarios they find a way to slow down, to wonder
what is happening, and perhaps to even enjoy a bit of a slower pace. Then, imperceptibly, something
shifts, and the pair is on another incline pathway -- delving into a new issue, confronting an old source of
discomfort with new resources, and deciding on a different venue for work or in personal life. Something
new has sprouted —magically and mysteriously — and we are as amazed as when we were as
preschoolers who left the classroom in the afternoon and returned to school the next morning to find that
a baby pea plant peeks out from the egg carton garden we and the teacher had planted the week before.
Therapists and patients would never fault a farmer who left her garden fallow for a season or two,
because we know that crop rotation is essential to keep the soil vibrant. Yet we expect ourselves to have
no fallow periods of our own, periods when we can replenish our stock and ourselves before something
new can emerge in its season. Supervisors can also be pushy about progress and not see the need and
value of plateau phases. As a result the staff member feels an anxious need to make things happen and
pushes the patient, when exactly the opposite is needed. This can intensify resistance and lead the
patient to experience more shame and guilt even when the therapist is trying her best to be benevolent.
While a plateau phase must be judiciously teased out from an actual resistance to taking a new step,
requiring judgment and tact, pausing in psychological work and making space is part of the process that
has been given too short shrift in psychotherapy.
Principle 4: Noticing Growth/Valuing Grit
One unfortunate legacy of early psychoanalytic theory is the notion that the therapist should ‘maintain
neutrality' except in the most extreme situations, such as a suicidal crisis or medical emergency. Yet
consider how many times, even in Sigmund Freud's most famous cases, the importance of providing
support and affirmation was noted. When Freud failed to understand this need, the case faltered. Also
consider the personal history of Freud himself. Although Freud had difficulty sustaining professional
relationships with some of his creative partners like Alfred Adler and Carl Jung when they differed with
him, his work flourished when he had a partner who served in part as an ancillary therapist and
facilitating other. One need only scratch the surface of the lives of many creative and productive artists,
scientists, and authors to see that there is often a person behind the scenes who is noticing and valuing
an individual's talent and ability long before it is recognized by the public at large.
If this necessary function is sought after and found to be essential to our most able and laudable
achievers, how important might it be for our patients, who come to us with stormy histories bereft of
stable attachment and love? While a therapist or supervisor should never offer false praise, recognizing
steps forward and commenting on perseverance and resolve offer those in our care hope and emotional
sustenance in real time. When I listen to a staff member present a case that is going reasonably well
despite inevitable symptomatic regressions on the part of the patient, I invariably find myself saying,
“Don't forget to comment on how far the two of you have come together. Be as specific as you can be.
Remember the initial sessions and recall some developmental leap that you have witnessed.” Almost
invariably the staff member will return and let me know that the patient lit up at being recognized for the
progress and was “amazed” or “touched” that the therapist had cared enough to notice. The universal
need for recognition, particularly when undertaking all the difficult tasks inherent in deeper
psychotherapeutic work, needs to become an essential part of our everyday practice.
Increasing evidence from neurobiology supports the concept that support is good for the brain as much
as the soul. When the brain's seeking,' ‘loving,' and ‘playing' regulatory systems are aroused at the level
of the prefrontal cortex, positive affective circuits of the brain are strengthened.11 While each of these
systems has highly specific individual pathways still to be completely ferreted out, current data suggest
that they culminate in dopaminergic neurons at the level of the prefrontal cortex and oxytocin release in
the medial subcortex. Dopamine generates enhanced self-esteem, and oxytocin promotes social bonding
and nurturance. Both neurochemicals facilitate emotional readiness for prosocial growth we hope to help
induce in our patients. Noticing our patients' growth and valuing their grit is both a neurobiological and
psychological intervention and bedrock upon which lasting change is likely built. And, like our patients,
therapists also derive similar benefits from having those in our circle that value these qualities in us.
Creative partnerships in the form of peer supervision, ongoing consultation, and study groups are just
some of the arenas that enable therapists to value ourselves, and that have the potential to nurture our
growth by mirroring grit and determination.
Conclusion
These four principles that guide longer-term treatment of eating disorders are offered to assist therapists
in negotiating stalemates and fallow periods of the work. Sometimes we are unable to help patients
relieve their suffering directly but we can assist them in changing their relationship to their pain and
sense of loss. This process is more difficult than it appears because remediation of symptoms and relief
of suffering are what we are taught to do in our training and encouraged to try to emulate from studying
the scientific literature.
Cultivating a therapeutic stance wherein the patient can bring forth inner pain that may not be
superficially apparent fosters resilience over time. Recent studies in neuroscience support this approach
as having substantial benefits for the brain. Both therapist and patient are likely to maintain a healthier
sense of well-being when we pay attention to our need for secure spaces to process emotional needs,
respect phases of resistance when not much may be directly happening in the therapeutic work, and
cultivate supportive people and ‘creative partnerships' who value and encourage us during the most
inscrutable periods of the journey.
About the Author
Dr. Zerbe is professor of psychiatry and obstetrics and genecology at the University of Oregon School of Medicine,
Portland. She also is the author of numerous books, including the best-seller, The Body Betrayed.
References
1. Bakewell, S. (2010). How to Live: Or a Life of Montaigne. New York: Other Press.
2. Zerbe, K. J. (1995). The body betrayed: Woman, eating disorders, and treatment. Carlsbad, CA:
Gurze Books (original edition published 1993, American Psychiatric Press).
3. Â Zerbe, K. J. (2008). Integrated treatment of eating disorders: Beyond the body betrayed: New
York: W. W. Norton.
4. Â Tobin, D. L. (2012). The rationale for psychodynamic psychotherapy of eating disorders: An
empirically constructed approach. In D. Stein & Y. Latzer (Eds.), Treatment and Recovery of Eating
Disorders (pp. 97-108). New York: Nova Science Publishers.
5. Tasca, G. A., Ritchie, K., & Balfour, L. (2011). Practice review: Implications of attachment theory
and research for the assessment and treatment of eating disorders. Psychotherapy, 48, 249-259.
6. Tobin, D. L., Banker, J. D., Weisberg, L., & Bowers, W. (2007). I know what you did last summer
(and it was not CBT): A factor analytic model of international psychotherapeutic practice in eating
disorders. International Journal of Eating Disorders, 40, 754-757.
7. Thompson-Brenner, H. & Westen, D. (2005a). A naturalistic study for
bulimia nervosa, Part 1, Comorbidity and therapeutic outcome. Journal of Nervous and Mental
Diseases. 193:9, 573-584.
8. Thompson-Brenner, H. & Westen, D. (2005b). A naturalistic study for bulimia nervosa, Part 2:
Therapeutic interventions in the community. Journal of Nervous and Mental Diseases. 193:585595).
9. Rinsley, D.B. (1980). Treatment of the severely disturbed  adolescent. New York: Aronson.
10. Eaton, J. L. (2011). The Fate of Pain. In A Fruitful Harvest: Essays after Bion. Seattle. Alliance
Press.
11. Panksepp, J., Biven, L. (2012). The Archaeology of Mind: Neuroevolutionary Origins of Human
Emotions. New York: W. W. Norton.
UPDATE: Topiramate May Trigger Eating Disorder
Symptoms
An anticonvulsant used for migraine deserves careful
monitoring.
In 2014, the US Food and Drug Administration approved the use of the anticonvulsant topiramate
(Topamax®) for treating migraine in adolescents. One well-known side effect of the drug is appetite
suppression. Despite the fact that topiramate has been studied for treating binge eating disorder (BED)
and bulimia nervosa (BN), the drug's appetite-suppressant effect raises the possibility of development of
or worsening of disordered eating among young patients. This risk may be further highlighted by the fact
that while symptoms improved in the published BN topiramate trial, weight loss was also observed (in a
fairly lean sample; Hoopes et al., J Clin Psychiatry. 2003; 64:1335).
Researchers at the University of Miami and the Mayo College of Medicine, Rochester, MN, recently
evaluated seven cases of teens who developed disordered eating patterns after treatment with
topiramate (Pediatrics.2015; 135:1). Dr. Jocelyn Lebow and her fellow researchers used a retrospective
chart review of adolescent patients taking topiramate who were seen at the Mayo Clinic Eating Disorder
Program between November 2008 and June 2013. During that time, 7 topiramate-treated female
adolescents 13 to 18 years of age were diagnosed with eating disorders: 4 with eating disorder not
otherwise specified, 2 with anorexia nervosa, and 1 with BN. All had been given topiramate for migraine
or chronic headache, and the dosages ranged from 25 mg twice daily to 150 mg daily.
Three of the girls estimated that their eating disorder had preceded treatment with topiramate; 1 was in
remission from an eating disorder when the agent was prescribed and then the disorder recurred, and 3
other girls developed their eating disorder only after starting topiramate. In all cases, dietary restriction
was the primary eating disorder symptom; 5 also reported purging and 3 had binge eating. One young
patient had marked weight gain after taking the anticonvulsant but all others reported weight loss.
The authors note that migraine is very common among individuals with eating disorders, and that results
of one study showed that at least 74% of patients with eating disorders also had migraines (Neurol Sci.
2009; 30 (suppl): S5). Thus, the potential for exposure in teens with an established eating disorder (or
risk for one) exists. Inherent in a case series of this sort is that the group of teens receiving topiramate
without developing symptoms is not represented, so the actual frequency of this is unknown. The authors
suggest that careful monitoring of patient weight gain and eating behaviors continue after topiramate is
given and weight loss should not be dismissed as a temporary side effect of the anticonvulsant.
Personality and Eating Disorders
Swedish researchers: Better understanding of
personality could improve outcome.
Personality can play several major roles for those with eating disorders: as a risk factor, as a moderator
of symptomatic expression, in choice of treatment, and also as a predictive factor in outcome. Some
personality traits are common to all eating disorders, while others are strongly related only to certain
types of eating disorders, such as high perfectionism in anorexia nervosa (AN) and increased sensationseeking in binge eating disorder.
Researchers at Sweden's largest eating disorder center, the Stockholm Centre for Eating Disorders,
recently explored ways in which patients with non-anorexic eating disorders differ from controls in
personality, and to examine whether facets of personality can be paired with psychopathology (J Eat
Disord. 2015; 3:3). The Stockholm Centre admits about 700 patients each year to its inpatient,
outpatient, day, and family units, and it also has a mobile acute treatment team.
Patients with non-anorexic eating disorders who were treated at the Stockholm Centre between 2010 and
2013 were enrolled in the study. This group had severe disease, as shown by mean scores on the Eating
Disorder Examination (EDE) corresponding to the 95th percentile in young adult women. Potential
participants had either been enrolled in a randomized control trial of Internet-based cognitive behavior
therapy (n=150) or were enrolled in a multimodal day—patient treatment program (n=129). All patients
were females and had a DSM-IV diagnosis of bulimia nervosa (BN) or eating disorder not otherwise
specified (EDNOS). After eliminating 3 patients (2 who failed to complete the personality inventory and 1
who was diagnosed with AN), 208 persons were enrolled in the study.
The participants completed a series of online questionnaires, including the Eating Disorder Questionnaire
(EDE-Q), the Comprehensive Psychiatric Rating Scale-Self-rating Scale for Affective Syndromes (CPRS),
and the Structured Eating Disorder Interview, a 20- to 30-question instrument based directly on DSM-IV
eating disorder criteria. They also completed the NEO Personality Inventory, Revised, a 240-item selfreport measure designed to assess five dimensions and 30 facets of the Five Factor Model. The FiveFactor Model is comprised of five personality dimensions: openness to experience, conscientiousness,
extraversion, agreeableness, and neuroticism.
Personality differed between patients and controls
Compared to the controls, the patient group was characterized by pervasive negative affect and
vulnerability, and displayed few positive emotions such as joy, warmth, or love. They were also
significantly less sociable and showed less trust, competence, and self-discipline. While they were more
closed to feelings, ideas and new experiences, they were more open in expressing their values. Patients
also reported a tendency to doubt their own capacity to deal with life challengers, were self-effacing, and
believed other people could not be trusted. They rated themselves as non-dogmatic and as less
traditional than others. They also reported having a tendency to procrastinate and had trouble controlling
their desires, which led to rash action, often followed by regret.
The authors stressed that knowledge of facets of personality, especially trust, striving to achieve, and
neuroticism, can lead to better understanding of eating disorders. By identifying and focusing on
personality traits, it might be possible to enhance the treatment alliance, address underlying problems,
and improve outcomes.
The Heimlich Maneuver, But with a New Twist
Young patients try a new way to purge.
There is ample precedent for people with eating disorders adopting established medical treatments as
part of eating disorder symptoms—the use of diuretics, laxatives, and ipecac come to mind. Forty years
after thoracic surgeon Henry Heimlich first published his technique for using a series of upward
abdominal thrusts to stop choking, Canadian researchers have reported 5 cases of children and teens
using the Heimlich maneuver to purge (Int J Eat Disord. 2015; Apr 2. doi:10.1002/eat.22408.[Epub
ahead of print].
Ahmed Boachie MD, FRCPC, and fellow clinicians at Southlake Regional Health Centre, Newmarket,
Ontario, and the University of Toronto, recently described 5 independent cases of children and teens who
revealed they used the Heimlich maneuver to purge. The hidden practice emerged when the young
patients were asked to elaborate on techniques they were using to purge. The authors also note that
medical complications for the Heimlich maneuver (described when it has been used for choking) can help
uncover the use of the maneuver, including rib fractures, hemorrhages, abdominal organ trauma and
other forms of blunt abdominal trauma. Clinicians may wish to consider screening for this behavior.
Tracking the Night Eating Syndrome
A host of approaches, but not much consensus, on this
elusive syndrome.
The hidden nature of night eating syndrome, or NES, is one reason this disorder is frequently overlooked
by health care professionals and patients alike. Although the syndrome of morning anorexia, evening
hyperphagia and/or insomnia was first reported by Stunkard and his colleagues at least 60 years ago,
lack of a standard definition has impeded recognition of NES comparison and comparison of study results.
The DSM-5 has helped somewhat by listing three main diagnostic criteria for NES: (1) recurrent episodes
of night eating, shown by eating after awakening from sleep or by excessive eating after the evening
meal; (2) awareness of those eating episodes; and (3) significant distress or impairment brought on by
the disorder. Another disorder, sleep-related eating disorder, or SRED, is also characterized by recurrent
episodes of involuntary eating or drinking during sleep, but is considered as a type of parasomnia, or
primary sleep disorder in which physiology or behaviors are affected by sleep, the stage of sleep, or the
transition from sleeping to waking, rather than to an eating disorder.
A new instrument designed to detect NES
Suat Kucukgoncu, MD, and colleagues at Yale University recently evaluated the assessment and
management of NES (Neuropsychiatr Dis Treat. 2015; 11:751). The authors note that although the Night
Eating Questionnaire (NEQ) is widely used to detect NES, it often yields false-positive results in selected
groups, such as obese patients and those who have had gastric bypasses, and thus a second interview
component may be helpful. The Night Eating Syndrome History and Inventory is one useful addition to
existing tests. This semi-structured interview also includes questions about the history of night eating
symptoms, the amount of food eaten per day, sleep patterns, mood symptoms, life stressors, weight and
diet history, and previous treatment for NES.
A multitude of treatment approaches
Treatment approaches for NES have included pharmacologic agents, cognitive behavioral therapy, light
therapy, and muscle relaxation therapy, according to Dr. Kucukgoncu and his coauthors. The serotonin
system was a natural target for pharmacologic treatment, and just as for bulimia nervosa, clinical trials
have primarily involved antidepressants, particularly the selective serotonin re-uptake inhibitors (SSRIs)
sertraline and escitalopram.
Uncontrolled studies with sertraline showed that the SSRI improved NES symptoms, mood, and quality of
life. Subsequently, an 8-week blinded, randomized trial of sertraline significantly improved both NES
symptoms and quality of life (Am J Psychiatry. 2006; 67:1568). Caloric intake after the evening meal
also decreased in patients receiving sertraline compared to those receiving a placebo. A randomized trial
with escitalopram showed improvements in night eating symptoms as well as modest weight loss, but the
active drug results were not significantly better than with placebo (Eat Behav. 2013; 14:199).
Topiramate, a glucocerebrosidase (GBA) agonist and glutamate antagonist, has also been beneficial for
treating NES. [See “Update,” earlier in this issue.] However, in one study, once the drug was
discontinued, symptoms of NES returned (Sleep Med. 2003; 4:243). Because to date there are no
guidelines or data on the duration of the therapeutic benefit of medications for NES, Dr. Kucukgoncu and
colleagues recommend that any medication be used at least 8 weeks before reaching conclusions about
its effects. They also suggest considering a total treatment period of at least one year if a medication
proves beneficial before determining if it is successful or unsuccessful for treating NES.
Psychological interventions
Psychological interventions have also been used with some success to treat patients with NES. In
particular, Allison and colleagues have developed a cognitive behavioral therapy program for NES. During
an uncontrolled CBT trial conducted in patients with NES (Am J Psychother. 2010; 64:91), 14 of 25
patients participated in 10 hours of CBT sessions over 12 weeks. CBT treatment led to significant
reductions in evening hyperphagia, reduced the number of nocturnal eating episodes and total caloric
intake, and diminished depressive symptoms. Interestingly, the authors noted that CBT reduced
excessive eating most markedly during the night but not right after the evening meal.
Italian Researchers: Poor Sleep Predicts Poorer Outcome
A recent study of 562 patients with eating disorders showed that when patients reported
having poor sleep when they were first admitted for treatment, their poor quality of sleep
predicted the severity of eating disorder symptoms.
Persistence of poor sleep 6 months later directly predicted the severity of eating disorder
symptoms and suggested that addressing poor sleep early may benefit patients because its
presence and persistence increase comorbidity and failure on standard treatment (Eat
Behav. 2015; 18:16).
Saliva May Hold Clues to Undiagnosed Eating Disorders
Levels of two chemicals were particularly helpful.
Clues to an undetected eating disorder may literally be on the tip of the tongue, according to Dr. AnnKatrin Johansson and a team of clinical dentists at the University of Bergen, Norway (Eur J Oral Sci.
2015; Mar 17. Doi:10.1111/eos.12179 [epub ahead of print]. Dr. Johansson and her colleagues recently
compared the biochemical composition of saliva from 54 women and 4 male outpatients with eating
disorders (mean age: 21.5 years). Fifty-four sex- and age-matched healthy controls were added from a
dental health clinic. All participants in the study filled out a questionnaire, underwent dental
examinations, and had laboratory analysis of their saliva. Hyposalivation, or low saliva production, was
less common in the eating disorders group.
Significant differences were found
The composition of saliva was quite different in the two groups. Albumin, inorganic phosphate, aspartate
aminotransferase (AST; formerly known as serum glutamic oxaloacetic transaminase, or SGOT), chloride,
magnesium, and total protein levels were all significantly higher in the eating disorders group than in
controls. The researchers were particularly interested in the higher-than-normal AST and total protein
levels.
Statistical analyses (using logistic regression) showed that higher AST and total protein concentrations
were relatively good predictors of an eating disorder (sensitivity, 65%; specificity, 67%). Thus, elevated
salivary AST and total protein levels may be two more useful markers of an eating disorder.
Short-term Intensive Family Therapy
A helpful approach, particularly when access to a
specialist is limited.
Accumulating evidence supports family-based therapy (FBT) for treating eating disorders during
adolescence. However, just as for other manualized therapies, successful FBT depends on the availability
of trained FBT therapists. Unfortunately, trained FBT therapists are not widely distributed, even though
adolescents with eating disorders are found everywhere.
One approach to this problem is to have families travel to specialized centers for short-term, intensive
treatment. To test the concept, researchers at the University of California-San Diego (UCSD) developed a
5-day intensive treatment program for teens, designed around the principles of FBT (Eur Eat Disord Rev.
2015 Mar 16. Doi:10.1002/erv.2353[Epub ahead of print].
Testing the concept in two types of family settings
Erica Marzola, MD, and her colleagues retrospectively examined the long-term efficacy of intensive family
therapy in both single-family and multi-family settings. Their subjects were 74 adolescents with eating
disorders who participated in a 5-day intensive treatment program at UCSD between 2006 and 2013. A
stringent definition of full remission was used: ≥95% of weight expected for gender, age, and height; a
global score on the EDE-Q within 1 standard deviation of norms; and absence of binge-purge behaviors.
Partial remission was defined as weight ≥ 85% of expected weight or ≥ 95% but with an elevated
EDE-Q global score and presence of binge-purge symptoms less than once per week.
The researchers followed the adolescents for 30 months. During that time, 60.8% of the teens reached
full remission, and 27% got to partial remission. Poor outcome occurred in 12.2%. The program used
single-family and multifamily formats, and these appeared comparable. These preliminary results suggest
that intensive FBT may be a useful strategy, particularly when access to specialized treatment is limited
by geography.
A New Scale Measures Compulsive Food Restriction
The Self-Starvation Scale may be very helpful for
patients with extreme food restriction.
Self-starvation by patients with anorexia nervosa (AN) is one of the most striking features of the disorder.
It has been viewed as rewarding or habit-based, and at times is likened to compulsive drug-seeking
behavior. Drs. Lauren R. Godier and Rebecca J. Park, of Oxford University, developed a novel measure of
self-starvation, the Self-Starvation Scale (SS), to better understand the extent to which self-starvation
may show addiction-like qualities (Eating Behavior. 2015. 17:10). The scale was partially adapted from
the Yale Food Addiction Scale (YFAS) (Appetite. 2009; 52:430).
The SS asks a series of 17 questions about behavior during the previous 4 weeks, and each question has
a different factor loading. The SS uses a 7-point Likert-like rating scale, from 0 (never) to 6 (every day)
to record how many of the previous 28 days a behavior has occurred. For example, Question 8 states, ‘I
have restricted my food intake so much that I have concentrated on this instead of doing other activities.'
The Oxford researchers tested the scale among four groups of volunteers. The first group included 126
healthy volunteers with no prior eating disorders. Then, 78 individuals between 18 and 65 were recruited
in three study groups: (1) persons with acute AN (n=41); (2) weight-restored individuals with a history
of AN (n=18); and (3) individuals fully recovered from AN (n=19) The questionnaire was created using
Bristol Online Surveys (University of Bristol, England). In addition to the SS, the Eating Disorder
Examination Questionnaire (EDE-Q) and the Clinical Impairment Assessment, the Patient Health
Questionnaire, and the Generalized Anxiety Disorder Assessment were included. Other questionnaires
measured food addiction, excessive exercise, and impulsivity, and participants also provided demographic
information, including height and weight (to calculate body mass index, or BMI, kg/m2); in addition,
patients in the AN sample reported their lowest BMI, age of onset of the disorder, duration of illness, and
treatment received.
The scale showed good reliability
The SS, which was developed to provide a tool to further assess the concept of compulsive dependence
on starvation, showed good reliability and was significantly related to measures of eating disorder
symptoms, compulsive exercise, depression, and anxiety. SS scores also correlated significantly with
scores of food addiction, as measured by the Yale Food Addiction Scale. Because that scale centers on the
rigid control of eating behavior seen in eating disorders, they add that “the result is likely to reflect the
compulsive and rule-driven nature of self-starvation.” The predictive ability was greatest for the group
with current AN, suggesting that the SS may be particularly helpful as an index of extreme food
restriction in AN. The availability of this scale should increase attention on the potentially addictive
qualities of self-starvation.
Outpatient Treatment, from the Adolescent Patient's
Viewpoint
Any progress involved trust.
When Swedish researchers evaluated adolescents' perceptions of their experience with outpatient
treatment, two clear results stood out. The first was the importance of involving parents in treatment,
particularly with anorexia nervosa (AN), and the second was the importance of trust. Dr. Katarina
Lindsted and colleagues at Orebro University, Sweden, reported the results of their small study of 15
eating disorders patients recruited from four specialized eating disorder units. The researchers' goal was
to develop an understanding of the treatment experience, this time from the patient's viewpoint (J Eat
Disord. 2015; 3:9)
Dr. Lindsted and colleagues used a hermeneutic phenomenological approach with the subjects, which
involves an attempt to understand how people give meaning to their experiences of significant events,
and depends on narratives gained from interviews (M. van Manen, Researching lived experience: Human
science for an action sensitive pedagogy, 2nd ed. Ontario: Althouse Press, 1997). The 15 patients
enrolled in the study were 13 to 18 years of age; 6 had been treated for AN, and 9 had been treated for
restrictive-type eating disorders not otherwise specified (EDNOS). Most had been in treatment for 1 to 2
years and had participated in 11 to 30 therapy sessions. Most of the authors' interviews were conducted
1 to 3 years after the individual had completed treatment. All interviews were recorded and transcribed
verbatim; participants were allowed to read the transcripts and were invited to add or change any part of
the transcript.
The interviewees were asked to speak openly about their treatment experience, and the interviewer
started with the question, “Can you tell me about your time in treatment?” To carry the interview
forward, the therapists had follow-on questions such as asking about the parents' role and the patient's
relationship with the therapist. Most interviews lasted from 45 to 90 minutes.
Overall themes that emerged
According to the authors, the one overriding theme that emerged was the importance of family
participation in treatment, especially at the very beginning of treatment. Most patients felt that they were
more or less forced into treatment, and they had strongly ambivalent feelings about whether and how
they should participate. Many reported that their first encounter with the therapist produced shame,
relief, frustration, and exhaustion. Typically, parents brought their child to treatment, and many teens
were angry and strongly resistant. Initially patients recalled having strong feelings of denial and
resistance to change. Some also reported that they wished their siblings were involved in some way,
since siblings were rarely involved in the family sessions.
Strong alliance was built on trust
As to be expected, a strong therapeutic alliance based on trust was very important to the outcome. The
first meeting was especially significant, and the teens reported that the manner in which the therapist
acted, spoke, and treated them made a huge difference in generating trust. They noted that when the
therapist issued an invitation to cooperate, and continued to do so during their sessions, along with
clarifying treatment goals and creating a shared view of the situation, there was a much greater chance
of overall success. One notable finding was that focusing on weight gain as a goal for treatment did not
sit well with the teens. Some felt unprepared to end treatment and expressed disappointment that the
therapist was not more interested in their thoughts and feelings.
Honesty and respect also emerged as important ingredients in the patient-therapist relationship; the
teens needed to feel competent and to have their feelings validated. The results of these analyses
reinforce the important role of nonspecific therapy factors in treatment outcome.
Teens' Favorite Television Character Shape: Thin
Thin was definitely in in middle school students
In a survey of 756 Israeli students in grades 7/8 and 10/11, the teens' favorite same-gender television
characters were typically thin or of average body size. Adolescents self-compared with characters more
as the identified characters became thinner. The authors noted that as the mismatch between favorite
characters' body size and their own body size grew, the teens' body image worsened (J Health Commun.
2015; Apr 2:1-9. [Epub ahead of print]
QUESTIONS AND ANSWERS:
Type 2 Diabetes and Eating Disorders
Q. Several of my patients have type 2 diabetes (T2DM) but, unlike the case with type 1 disease, I rarely
see much in the literature about T2DM and eating disorders. What do we know about T2DM and ED? (VM,
Cincinnati)
A. You are right; there has long been a marked focus on T1DM. It is natural for the spotlight to remain on
patients with type 1 diabetes because these patients may be especially vulnerable to over-concern about
weight and shape, body dissatisfaction, preoccupation with food, and dietary restraint. Furthermore,
disordered eating has been shown to increase risk for diabetic complications. However, three recent
studies have added more to our knowledge about T2DM and EDs, particularly binge eating disorder
(BED).
Dr. Joana Nicolau and colleagues reported the results of a study of 320 randomly selected primary care
clinic or endocrine clinic patients with T2DM. After screening all subjects with the Eating Attitudes Test-26
(EAT-26) and the Questionnaire of Eating and Weight Patterns-Revised (QEWP-R), the researchers found
that, overall, 14% of the volunteers also had eating disorders. The most prevalent disorder was BED,
which was diagnosed in 12.2% of the subjects, based on the QEPW-R (Acta Diabetol. 2015; Apr 5. Doi
10.1007/s00592-015-0742-z. Epub before print]. Those with a positive screening for BED also were
younger, had a shorter duration of T2DM symptoms, and greater body mass indexes. Among those with
BED, depression and EAT scores were significantly higher.
Individuals with a positive screening for an eating disorder had higher triglyceride levels than did subjects
without T2DM. In contrast, glycemic control was not different between those with and without BED.
Metabolic and immune disorders
In a second and much larger study, Dr. Anu Raevuori and colleagues at Helsinki General Hospital
examined the prevalence and incidence of T2DM in 2342 patients treated for AN, BN, or BED over 16
years at Helsinki University Central Hospital's eating disorders unit, and 9,638 matched controls;
additionally, the authors examined development of autoimmune disease (Int J Eat Disord. 2014; July 25.
Doi: 10.1002/eat.22334. [epub ahead of print].
The lifetime prevalence of T2DM was 5.2% among ED patients and 1.0% among controls. The prevalence
was higher in male patients than in females. In terms of autoimmune disease, the authors found that
8.9% of patients with eating disorders, compared with 5.4% of control patients, had prior diagnoses of
one or more autoimmune diseases. T1DM accounted for most of the increase in endocrinologic diseases,
and Crohn's disease explained most of the risk of gastroenterologic disease.
The authors suggest that their findings support a link between immunologic factors and development of
eating disorders. Future studies are needed to explore the risk of autoimmune factors in individuals with
eating disorders and their family members.
Depression and glycemic control
A third study evaluated the prevalence of BED in T2DM patients, in an attempt to learn more about the
correlation of BED with the level of depression and glycemic control (Gen Hosp Psychiatry. 2015;
37:116). With an age range from 18 to 75 years, 81 females and 71 males with T2DM were evaluated
with a Structured Clinical Interview for DSM-IV Axis I Disorder and the EAT, and depression was
determined with the Beck Depression Scale. In contrast to the Nicholau study, all participants came from
a diabetes clinic.
The percentage of patients found to have BED was 5.26%, or about half that of the previous study.
Depression and EAT scores were higher in those with BED. Glycosylated hemoglobin A1C levels (a
measure of long-term blood sugar control) did not differ between BED and non-BED participants.
Authors of all three studies remind us that it is easy to overlook underlying eating disorders in diabetic
patients, particularly those with T2DM. The diagnostic workup should always include the possibility of
disordered eating patterns, particularly BED.
— SC
Also in This Issue
May/June 2015
Volume 26, Number 3
Update: Topiramate May Trigger Eating Disorder Symptoms
Personality and Eating Disorders
The Heimlich Maneuver, But with a New Twist
Tracking the Night Eating Syndrome
Saliva May Hold Clues to Undiagnosed Eating Disorders
Short-term Intensive Family Therapy
A New Scale Measures Compulsive Food Restriction
Outpatient Treatment, from the Adolescent Patient's Viewpoint
Teens' Favorite Television Character Shape: Thin
Q&A: Type 2 Diabetes and Eating Disorders
Coming in the July/August Issue
Comorbid Eating Disorders and Posttraumatic Stress Disorder: Etiology and Treatment
Implications
By Karen S. Mitchell, PhD
Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, and
Department of Psychiatry, Boston University School of Medicine
Eating disorders have high rates of comorbidity with other disorders, including PTSD. However, to date
there are no established treatments for eating disorders and comorbid PTSD. Thorough psychiatric
evaluations, including assessment for trauma histories, in patients with eating disorders, may help
determine what, if any, role trauma may play in the onset of the patient's eating disorder.
PLUS
Augmentation Therapy for Inpatients with Anorexia Nervosa
A Risk and Maintenance Model for Bulimia Nervosa
Shared Genetic Risk, Suicidality, and Eating Disorders
And much more
Reprinted from: Eating Disorders Review
IAEDP
www.EatingDisordersReview.com