A Collaborative Approach to Eating Disorders

June Alexander, Janet Treasure, June Alexander, Janet Treasure

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9780415581455
• eBook ISBN: 9781136723940
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

While many aspects of eating disorders remain a mystery, there is growing evidence that collaboration is an essential element for treatment success. This book emphasises and explains the importance of family involvement as part of a unified team approach towards treatment and recovery.

A Collaborative Approach to Eating Disorders draws on up-to-date evidence based research as well as case studies and clinical vignettes to illustrate the seriousness of eating disorders and the impact on both the sufferer and their loved ones. Areas of discussion include:

• current research including genetic factors, socio-cultural influences and early intervention
• clinical applications such as family based dialectical and cognitive behavioural treatments
• treatment developments for both adolescents and adults with a range of eating disorders
• building collaborative alliances at all levels for treatment and ongoing recovery.

With contributions from key international figures in the field, this book will be a valuable resource for students and mental health professionals including family doctors, clinicians, nurses, family therapists, dieticians and social workers.

Part 1

Understanding risk and
resilience for eating disorders

Introduction

Carrie Arnold

A revolution in genetics and neuroscience is dramatically altering the way eating disorders are understood and treated. We know now that eating disorders are illnesses, not a lifestyle choice. This knowledge, while a giant step forward, opens the door to many new challenges. In the United States, about 11 million people suffer from an eating disorder, and about one in every twenty people will suffer an eating disorder during their lifetime. The causes remain unclear, but numerous risk factors have been identified, including exposure to the thin body ideal, body dissatisfaction (Stice et al., in press), negative affect (Rivinus et al. 1984), female gender (Jacobi et al. 2004), and variations in serotonin genes (Calati et al., in press). Yet some of the strongest risk factors are the presence of an anxiety disorder, such as social anxiety disorder and obsessive-compulsive disorder, and a family history of eating disorders. Research reveals that genetics comprise up to 86 per cent of the reason a person develops an eating disorder (Klump et al. 2001; Lilenfeld et al. 1998). Together, these studies indicate a strong biological basis for eating disorders.

Ramifications are far-reaching. When researchers presented eating disorders as biologically based mental illnesses, caused primarily by genetics, college students viewed sufferers with more compassion than if they were told eating disorders were essentially a cultural phenomenon (Crisafulli et al. 2008: 333). And the biological basis of anorexia can determine who gets treatment. In the state of New Jersey in the United States, health insurers could legally deny paying for anorexia treatment because it wasn't classified as a biologically based mental illness. A recent class action lawsuit caused this provision to be overturned and anorexia and bulimia treated on a par with depression, bipolar disorder, and schizophrenia (Rothman 2008).

When I began treatment for anorexia nervosa a decade ago, treatment providers didn't inform me of these biological studies. They didn't explain that something in my brain was compelling me to starve, purge, and over-exercise. They said my eating disorder was a choice, and so was my recovery. From the inside, however, my eating disorder was a Byzantine array of rules and rituals that paralyzed me with fear of food. Following numerous hospital admissions, several lengthy stays in residential treatment, and multiple trips to the emergency room, therapists said I would recover ‘when I was ready’.

Their theories colored how my eating disorder was treated and how I viewed my illness. Ultimately, I blamed myself: I should be able to pull myself out of this; I shouldn't need help to eat. But all the insight in the world couldn't overcome my fear of food. After essentially kissing my twenties goodbye, food is simply food again. It's food because I found a therapist who didn't waste time on ‘why’. Well-versed in the latest evidence-based treatment for eating disorders, she said: ‘You need to eat, and eat regularly.’ I needed to normalize my eating and exercise habits now, not later. And my parents were the best people to help me. I began to realize my eating disorder was driven not by society or some error in my psyche, but by something deeper and more primal. As explained in the following chapters, my eating disorder was a biologically based mental illness that I didn't choose and my parents (and society) didn't cause.

References

Calati, R., De Ronchi, D., Bellini, M., and Serretti, A. (2011) ‘The 5-HTTLPR Polymorphism and Eating Disorders: A Meta-Analysis’, Int J Eat Disord 44, 3: 191–9.

Crisafulli, M., Von Holle, A., and Bulik, C. (2008) ‘Attitudes Towards Anorexia Nervosa: The Impact of Framing on Blame and Stigma’, Int J Eat Disord 41, 4: 333–9.

Jacobi, C., Hayward, C., de Zwaan, M., Kraemer, H.C., and Agras, W.S. (2004) ‘Coming to Terms with Risk Factors for Eating Disorders: Application of Risk Terminology and Suggestions for a General Taxonomy’, Psychol Bull 130, 1: 19–65.

Klump, K.L., Miller, K.B., Keel, P.K., McGue, M., and Iacono, W.G. (2001) ‘Genetic and Environmental Influences on Anorexia Nervosa Syndromes in a Population-Based Twin Sample’, Psychol Med 31, 4: 737–40.

Lilenfeld L.R., Kaye, W.H., Greeno, C.G., Merikangas, K.R., Plotnicov, K., Pollice, C., Rao, R., Strober, M., Bulik, C.M., and Nagy, L. (1998) ‘A Controlled Family Study of Anorexia Nervosa and Bulimia Nervosa: Psychiatric Disorders in First-Degree Relatives and Effects of Proband Comorbidity’, Arch Gen Psychiatry 55, 7: 603–10.

Rivinus, T.M., Biederman, J., Herzog, D.B., Kemper, K., Harper, G.P., Harmatz, J.S., and Houseworth, S. (1984) ‘Anorexia Nervosa and Affective Disorders: A Controlled Family History Study’, Am J Psychiatry 141, 11: 1414–18.

Rothman, C.J. (2008) ‘Insurer Agrees to $1.2M Settlement in Anorexia Lawsuit’, New Jersey Star-Ledger, 25 November.

Stice, E., Ng, J., and Shaw, H. (2010) ‘Risk Factors and Prodromal Eating Pathology’, J Child Psychol Psychiatry 51, 4: 518–25.

Chapter 1

The family context: cause, effect
or resource

Anna Konstantellou, Mari Campbell and Ivan Eisler

Introduction

Historically, interest in families of people with eating disorders developed from clinical accounts of ‘anorexic families’ (Minuchin et al. 1978), suggesting such families were rigid, had poor communication and parents who were overinvolved with their children's lives (Yager 1982). These accounts were often persuasive and seemed to offer a way of understanding an important part of the causal pathway in development of the illness, and some research studies appeared to support the conclusions (Latzer and Gaber 1998; McGrane and Carr 2002). However, as many authors indicate, generalizing from clinical accounts or small cross-sectional studies about the nature of aetiological processes is highly problematic, does little to improve our understanding of treatments and can undermine the positive role the family can have in helping the ill patient (Eisler 1995; Le Grange et al. 2010). From a research perspective, the findings also tend to oversimplify complex mechanisms and take little account of reciprocal processes between development of the illness and family functioning (Eisler 1995).

In 1995, Eisler conducted a review which examined family factors and their relationship with eating disorders. He found few consistent differences between families who had a son or daughter with an eating disorder (ED) and those who did not (Eisler 1995). The review also highlighted methodological issues with the research, including a lack of prospective data and comparison groups, samples consisting largely of chronically ill patients treated in specialist services, and lack of control for influences from other relevant factors such as depression. This chapter will update readers on research examining the family and eating disorders.

Personality and psychopathology in family members

Increasingly, research has studied parental and family psychopathology and personality traits in relation to eating disorders (see Chapter 2, on genes and personality). For instance, higher levels of overall psychopathology have been found in parents and relatives of patients with eating disorders when compared to parents of healthy individuals (Fassino et al. 2003, 2009; Lilenfeld et al. 1998; Steiger et al. 1995, 1996). In particular, higher levels of perfectionism have been reported in parents of patients with anorexia nervosa (AN) and bulimia nervosa (BN) when compared to parents with healthy offspring (de Amusquibar and De Simone 2003; Lilenfeld et al. 2000; Woodside et al. 2002). Raised levels of perfectionism in parents could indicate a genetic predisposition to a trait considered a risk factor for eating disorders but could also have an effect through its influence on parenting (Woodside et al. 2002). Other traits reported in mothers of daughters with AN behaviour include alexithymia (the inability to identify and process emotions; Espina 2003), depression (de Amusquibar and De Simone 2003) and lack of empathy (Guttman and Laporte 2000). Parental behaviour-related psychopathology will be covered in the next section. The above studies are predominately cross-sectional in nature and therefore no causal inferences can be made. Our understanding of the potential impact of parental psychopathology on offspring and in particular its contribution to development of behaviour psychopathology remains limited.

Family eating behaviours and comments about weight and shape

Many studies have examined family members, particularly mothers, and the effect of their eating behaviours or comments about weight and shape on behaviour symptoms or dieting and weight concerns in children and adolescents. As we will explain, evidence is conflicting. We look first at the relationship between parental eating-related factors in eating disorders and behaviour-related symptoms, and then at the effect of such parental factors on dieting and weight concerns in offspring.

Parental scores on the Eating Disorders Inventory (EDI) were found to be related to the development of behaviour symptoms in young adolescents in a two-stage community study (Canals et al. 2009), although associations were relatively weak and the parental EDI scores were generally considerably lower than those found in clinical populations. Adult patients with AN behaviour have also been found to more often have mothers who dieted or restricted their food intake than healthy individuals (Andrews and Brown 1999). Some studies have found that family preoccupation with weight and appearance and pressure to diet either by friends or family are associated with body dissatisfaction, restrained eating and bulimic behaviours (Fairburn et al. 1997; Keel et al. 1997; Leung et al. 1996; Pauls and Daniels 2000; Vincent and McCabe 2000; Young et al. 2004).

While these studies contain a fair degree of consistency, there are several caveats. First, the methodological quality of the studies was variable. While some larger, community-based studies were well designed, others, in particular those comparing a patient's recollections of parental behaviours with controls, were not always well matched or did not control for possible confounding variables. Second, the association between parental (particularly mothers’) behaviours and attitudes appears clearer for patients with BN than for patients with AN (Benninghoven et al. 2007). Third, several studies found that the role of family factors was either mediated by other factors such as anxiety (Davis et al. 2004) or was reduced to non-significance when other factors such as depression, body dissatisfaction and peer influences were controlled for (Young et al. 2004).

Many studies have examined the effect of parents’ own eating behaviours and attitudes towards weight and food on the dieting and weight and shape concerns of their offspring. For instance, female body image was predicted by levels of negative feedback from mothers, maternal disapproval of their daughter's figure, and the mothers’ own eating behaviours and attitudes as perceived by daughters (Cooley et al. 2008). Body dissatisfaction and restrained eating have been associated with children's perception of mothers’ encouragement to be thin (Anschutz et al. 2009). Furthermore, negative comments from mothers regarding their child's weight have been associated with weight-controlling behaviours in adolescents (Tremblay and Larivière 2009). It has also been identified that emotional eating (eating more in response to stress) is more present in daughters whose mothers emotionally eat (Blissett and Meyer 2006; Elfhag and Linne 2005; Snoek et al. 2007). Mothers and daughters have been found to share similar eating concerns and to place the same amount of importance on thinness (Steiger et al. 1996; Stice 1998). An internalized thin ideal appears to mediate the relationship between family concern about weight and looks, and body dissatisfaction, in a non-clinical sample of girls with low self-esteem (Senra et al. 2007). In a large prospective study, children's perception of the importance that fathers and mothers placed on being thin was found to be a factor that influenced dieting in both girls and, albeit less so, boys, and had a stronger influence than the attitudes of their peers, although surprisingly the perception of mothers’ attitudes seemed to have a smaller role than that of fathers’ (Field et al. 2001). Another study found a moderate association between comments about weight from parent to child, and losing weight and body esteem, in both boys and girls (Smolak et al. 1999). However, body mass index (BMI) was not controlled for and it has been shown that BMI mediates the relationship between parental comments on weight and dieting behaviours in children (Thelen and Cormier 1995). Possibly some children may have needed to lose weight and comments from parents may have been appropriate. There has been suggestion that socio-cultural influences could mediate the effects of parents’ critical comments about weight and shape on children (Cordero and Israel 2009).

In contrast to the above literature, other studies fail to find an association between parents’ and children's weight-restricting behaviours and body dissatisfaction (Davison et al. 2000; Ogden and Elder 1998; Ogden and Steward 2000). Parental v...

Table of contents

• Front Cover
• A Collaborative Approach to Eating Disorders
• Title Page
• Copyright
• Contents
• Notes on contributors
• Preface
• Foreword
• Acknowledgements
• PART 1 Understanding risk and resilience for eating disorders
• PART 2 Treatment: creating a common language of care
• PART 3 Clinical presentations of subgroups
• PART 4 Changing the culture
• Index