“Weight discrimination and the resulting obsession with thinness are rampant and recalcitrant. I believe that, in order to make any kind of a dent in this field, we all need to combat these pernicious influences.” (Netherton, Holmes, & Walker, 1999, p. 412) Amen. The weight of the media, the “diet food industry,” and the purveyors of a “healthy lifestyle” propagate this issue… without a doubt. Losing weight is BIG BUISINESS, and there are huge profits to be made for those that offer obese people the glimmer of a stereotypically thin body.
I also appreciated the acknowledgement on the pressure exerted by managed care. Eating disorders appear to be particularly “deep seated” and ill suited for half a dozen one hour sessions. Correcting inaccurate perceptions, relabeling cognitions of visceral and affective states, and redrawing boundaries… this kind of work takes time… more time than managed care often provides. This is yet another example of the effect managed care will continue to have for as long as it is the primary method of seeking out psychological assistance.
I was suitably surprised at the long-term mortality rate… suggested to be over 10%. (Netherton et al., 1999, p. 399) With a roughly 1 in 10 shot of succumbing to starvation, suicide, or electrolyte imbalance; you would think this particular set of disorders would get more research attention. The fact that there is still limited epidemiological data is frustrating… perhaps the difficulty obtaining the data is related to the relative secrecy and shame associated with the disorders themselves?
Like the BM text, NHW jumps on the multi-determined etiology bandwagon. It’s hard to disagree with since biological, familial, sociocultural, and personality factors all seem to be plausible. The differences in family characteristics were particularly interesting. “Bulimic families tend to be characterized as disengaged, chaotic, and highly conflictual and as having a high degree of life stress.” Conversely, “anorexic families tend to be characterized as enmeshed, overprotective, and conflict avoidant.” (Netherton et al., 1999, p. 400) That’s a strange clinical picture that seems to suggest that there might be a single underlying biological cause for EDs in general, but that familial and personality factors may play a role in its manifestation.
The list of comorbid disorders we need to consider during the assessment process is long and fairly inclusive. “Depression, anxiety disorders, dissociative disorders, substance abuse, and personality disorders” are on the forefront of the disorders we should be checking for. (Netherton et al., 1999, p. 401) Furthermore, NHW suggest we assess treatment history, as well as suicide attempts and self mutilative behaviors (cutters).
Pharmacological interventions employing antidepressants have been particularly successful. This text only cites 3 studies that have employed SSRI class antidepressants, but they report “significant improvement with 60-80 mg dosages (of Prozac) compared to placebo.” (Netherton et al., 1999, p. 407) I think I am going to dig deep into some more recent research to see of this trend holds up, there has to be more than three studies on it by now.
I like the idea of a behavioral contract… not just for eating disorders, but for any disorders which involve “behavior.” I am inclined to agree with the statement “the contract provides structure and predictability. Expectations, rewards, and consequences are delineated so that all people involved (patient, treaters, families) know what is expected at all stages of treatment.” (Netherton et al., 1999, p. 407) My question is this… realistically, what “consequences” are there if we are dealing with outpatient treatment?
Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.
“Eating disorders (EDs) are polysymptomatic syndromes, defined by maladaptive attitudes and behaviors around eating, weight, and body image.” (Blaney & Millon, 2009, p. 431) The primary disorders in this category are anorexia nervosa (AN), bulimia nervosa (BN), and eating disorders no otherwise specified (EDNOS). Examples of EDNOS might include “AN-like” with preoccupations with thinness, normal-weight people purging food without binging or simply binging without purging (Binge Eating Disorder, or BED). (Blaney & Millon, 2009, p. 432)
Epidemiological data suggests that EDs occur more often in women than in men (by a factor of roughly 10); although there is some evidence indicating that the gender gap is closing. Although AN/BN tend to be most prevalent in late adolescence and early adulthood, BED defies the stereotype by manifesting in an older age group (typically around 40 years of age). There is also little linkage to socioeconomic status, despite the common belief that Eds are disorders of the affluent. (Blaney & Millon, 2009, p. 433) This totally astounds me… how can people who are already undernourished give up what sustenance they are offered?
EDs frequently co-occur with mood, anxiety, substance-abuse, personality, and other psychiatric disorders. There are so many comorbid mood disorders noted in individuals with EDs that it is easier to exclude mood disorder (singular) that is unrelated… bi-polar disorders. Personally, I believe the single mood disorder that is currently excluded should be considered. “The disorders are believe to depend on similar family/developmental determinants (e.g., attachment problems or trauma), and both have been thought to have similar neurobiological substrates.” (Blaney & Millon, 2009, p. 434) Social phobias and OCD were among the most prevalent anxiety related comorbid disorders. Since anxiety disorders often precede ED onset, it has been suggested that an anxious or obsessive-compulsive attitude predisposes an individual to ED development. (Blaney & Millon, 2009, p. 435)
Not only are PTSD and substance abuse disorders often comorbid with EDs, but they are often comorbid with each other. “Substance abusers in an eating-disordered population show significantly more Social Phobia, Panic Disorder, and Personality Disorders. In addition, comorbid substance abuse was found to predict elevations in Major Depression, Anxiety Disorders, Cluster B personality disorders, as well as greater impulsivity and perfectionism.” (Blaney & Millon, 2009, p. 435)
Finally, personality disorders are frequently present in individuals whom suffer from EDs. Restrictive type EDs seem to be associated with Anxious-Fearful PD diagnosis (anxiousness, orderliness, introversion, preference for sameness and control). Binge-purge types have a pronounced affinity for the dramatic-erratic PDs including attention/sensation seeking, extroversion, mood lability, and proneness to excitability or impulsivity. (Blaney & Millon, 2009, p. 435)
EDs are assumed to be multiply determined by complex interactions including constitutional factors, psychological/developmental processes, social factors, and secondary effects in the biological, psychological and social spheres of maladaptive eating practices themselves. (Blaney & Millon, 2009, p. 443) All of the above features generally manfest in eating-specific cognitions related to bodily appearance and appetite regulation, body image or weight considerations, and social values that heighten concerns with all of the above. As a result, it is currently conceived that EDs represent a “tightly woven” expression of causes and symptoms that have an interrelationship between and among each other.
Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.