Eating Disorders and Marital Relationships

Jan Norre, Stephan Van den Broucke, Walter Vandereycken

• Publisher: Routledge
• Year: 2006
• Print ISBN:
  9780415133319
• eBook ISBN:
  9781134752119
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Anorexia and bulimia are on the increase in the Western world and the disease is now recognised to no longer be only a problem for teenage girls, but older women as well. Most older women either do now or did previously live with a partner and much attention has been paid to these relationships in devising therapeutic regimes.
Eating Disorders and Marital Relationships takes a critical look at the evidence behind the assumption of psychiatric illness in the patients and their partners and comes up with some surprising results. Van den Broucke, Vandereycken and Norre carefully describe both the theoretical and practical implications of their work, making this book important reading for both practitioner and researcher.

1 The nature of eating disorders in married patients

Over the past decades, eating disorders have become relatively well known both to health professionals and to the wider public. Yet in spite of this notoriety, many people have a wrong or incomplete idea of what an eating disorder actually represents. The popular view is that it stands for an ‘eating problem’, characterized either by overeating and being overweight or by restricted food consumption and emaciation, the latter usually affecting young teenage girls or women in their early adulthood. While this view certainly reflects the clinical features of some eating disorders, it also disregards their clinical complexity and diversity. The term ‘eating disorders’ is indeed a very broad one, which has reference to a variety of pathologies including obesity, binge eating, pica or self-induced vomiting. In many instances, however, it is used more restrictively to refer particularly to anorexia nervosa and bulimia nervosa, two syndromes which have gained prominence in the psychiatric literature of the past decades (see Vandereycken and Meermann, 1987; Vanderlinden, Norré and Vandereycken, 1992; Herzog, Deter and Vandereycken, 1992).

In this book, we will consider the eating disorders in the latter, more restrictive sense. To familiarize the reader with the syndromes of anorexia and bulimia nervosa, their main clinical characteristics and diagnosis will be summarized in the first part of this chapter. Because both syndromes occur predominantly in women, we shall refer only to female patients, noting that the characteristics and treatment of these disorders in males are essentially the same (Andersen, 1990; Vandereycken and Van den Broucke, 1984).

While it is true that the majority of patients with anorexia or bulimia nervosa are teenagers, it is increasingly recognized that these disorders occur in older women as well. In point of fact, the average age of onset in the population of diagnosed eating-disordered patients seems to be gradually increasing (Garfinkel and Garner, 1982; Szmuckler, 1985). Many of these older patients live with a partner or did so previously, officially married or otherwise. Since these relationships are the focus of this book, the second part of this chapter will specifically address the incidence and clinical characteristics of the disorders as they occur in married women, as a preamble to the more in-depth analysis of the relationship characteristics and processes offered in the next chapters.

DEFINING ANOREXIA AND BULIMIA NERVOSA

Anorexia nervosa

Anorexia nervosa (AN) is probably the better-known type of eating disorder, and also the easier one to recognize. Its core characteristic is an irresistible urge to strive for thinness, as is eloquently expressed by the German term Magersucht. The term ‘anorexia nervosa’ itself is in fact a misnomer, for ‘anorexia’ means literally ‘lack of appetite’, whereas AN patients do not ‘lack’ appetite or hunger, but rather repress these feelings. In essence, their disorder is not a matter of being unable to eat, but of not wanting to eat, although most patients will frame this differently by referring to ‘something that keeps them from eating normally and from achieving a normal body weight’.

The idea of a refusal to maintain a normal body weight is central to the diagnostic criteria for AN as proposed in DSM-IV (American Psychiatric Association, 1994) (see Table 1.1). As these criteria indicate, the root of the disorder is an all-dominating, abnormal attitude towards nutrition, body size and weight. AN patients are so preoccupied by these issues that they spend large parts of the day counting calories, thinking about food and weight, and preparing meals for others. Food is selected according to its caloric value and/or conceptions about its effect on weight, which implies that sweets and fatty foodstuffs are taboo. In addition, social situations in which one is expected to eat together with others are carefully avoided.

In association with the above symptoms, AN patients also suffer from a disturbed perception of their own body weight and shape. They typically perceive their normal weight for their age and height as ‘much too fat’, while their aspired weight level is far below the norm. To achieve and/or preserve an unusually low weight is considered as a form of self-mastery or self-control. However, the accomplishment of this goal yields only a temporary satisfaction: in spite of the attained weight loss the fear of growing fat remains, and the slightest weight increase is experienced as a terrifying sign of imminent loss of control. To avoid this, continued efforts are made to lose weight, and the subjective ‘ideal’ weight declines accordingly. Thus, the search for a slender figure becomes infinite.

Table 1.1 DSM-IV diagnostic criteria of anorexia nervosa

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A. Refusal to maintain body weight over a minimal normal weight for age and height (e.g. weight loss leading to maintenance of body weight 15% below that expected; or failure to make expected weight gain during period of growth, leading to body weight 15% below that expected).

B. Intense fear of gaining weight or becoming fat, even though underweight.

C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or denial of the seriousness of current low body weight.

D. In females, absence of at least three consecutive menstrual cycles when otherwise expected to occur (primary or secondary amenorrhoea; a woman is considered to have amenorrhoea if her periods occur only following hormone administration, e.g. oestrogen).

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Source: American Psychiatric Association (1994)

Despite these emotional turmoils, AN patients try to keep up the appearance that they feel physically healthy and even in top condition for as long as they can. Many of them display hyperactivity and perform strongly in their studies, work or sports. Initially, they are mostly unaware of their problem, so that they do not often request help. Instead, they defend their eating behaviour and hyperactivity as ‘normal’ or ‘healthy’ and do not allow anyone to interfere with it.

To determine the seriousness of AN, the percentage of weight loss (as compared to the statistically normal weight according to age and length) is only a relative criterion. A more important aspect is the manner and speed of losing weight, along with the degree of preoccupation with body size. Patients with ‘classic’ or ‘pure’ AN, who slim only by restricting their food intake and through physical hyperactivity, appear to have a better prognosis than patients with a ‘mixed’ type, who also resort to self-induced vomiting and/or use of laxatives, often combined with binge eating. The latter symptoms resemble those of bulimia nervosa, which will be outlined below. However, in the case of a low body weight the diagnosis of AN must be given priority.

Bulimia nervosa

Bulimia nervosa (BN) is a relatively ‘new’ disorder, for it was only officially recognized as a separate diagnostic entity (simply referred to as bulimia) in DSM-III (American Psychiatric Association, 1980). Bulimia comes from the Greek words ßovs (bous, ‘bovine’) and λιμoσ (limos, ‘hunger’), and means roughly ‘gluttony’. Like anorexia, it is rather a misleading term, for the patient’s tendency to consume large quantities of food is only one of the symptoms of BN, which occurs in a variety of other somatic and mental disorders as well. The extension ‘nervosa’ not only aims to differentiate between the syndrome and the symptom, but also underscores the relationship with AN. The correspondence between both disorders appears from the DSM-IV criteria for bulimia nervosa (Table 1.2).

Like AN patients, subjects suffering from BN are strongly preoccupied with their weight and afraid of growing fat. However, while the former manage to restrict their food intake in order to lose weight, BN patients surrender to frequent episodes of binge eating. To eliminate the effect of these binges on their weight, they resort to compensatory behaviours such as vomiting (mostly self-induced), use of laxatives or diuretics, periods of fasting or rigorous dieting and excessive physical activity. These behaviours temporarily reduce the fear of weight increase, yet the preoccupation with nutrition, body size and weight persists. While initially the vomiting and purging are often experienced as signs of regained self-control after a binge, in the long run they result in an increasing loss of control, whereby the binges ‘justify’ the vomiting. This is expressed in the often-heard statement by patients that they ‘are forced to vomit when they have eaten so much’. In this way, a vicious circle of self-destructive behaviour is installed.

Table 1.2 DSM-IV diagnostic criteria of bulimia nervosa

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A. Recurrent episodes of binge eating, characterized by both of the following:

(1) eating, in a discrete period of time (e.g. within any 2 hour period), an amount of food that is definitely larger than most people would eat during a similar period of time in similar circumstances; and,

(2) a sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating).

B. Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as: self-induced vomiting, use of laxatives, diuretics or other medications, fasting or excessive exercise.

C. A minimum average of two episodes of binge eating and inappropriate compensatory behaviours per week for at least three months.

D. Self-evaluation is unduly influenced by body shape and weight.

E. The disturbance does not occur during episodes of anorexia nervosa.

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Source: American Psychiatric Association (1994)

BN patients usually have wrong conceptions of the effectiveness of these weight-reducing behavioural patterns (Mitchell, Specker and de Zwaan, 1991), and underestimate the health risks that are involved. The bingeing and purging can indeed lead to serious medical complications, such as laceration of the esophagus, swollen parotid glands and dental caries or damage to tooth enamel due to irritation by the acids emitted when vomiting. Excessive laxative abuse may lead to alternations between constipation and diarrhoea. Probably the most harmful effect of frequent vomiting and/or purging, however, is a disturbed electrolyte balance, in the form of a lack of body salt potassium (hypokalaemia), which may cause mortal heart rhythm disturbances.

Diagnosis of anorexia and bulimia nervosa

Although many clinicians will consider the possibility of AN on account of the patient’s emaciated state, the diagnosis of AN should be based on the patient’s behaviour rather than on her physical condition. When paying attention to the behavioural characteristics mentioned in DSM-IV (see Table 1.1 ), the diagnosis of AN is relatively easy to make, especially when not only the patient’s but also the parents’ or partner’s story is attended to.

This does not imply, however, that physical symptoms are of no interest. Along with amenorrhoea (which the patients mostly do not experience as a problem) AN patients do have several physical complaints, such as constipation, sleeping disorders, cyanosis (blue discolouration of fingers and toes), coldness, hair loss and lanugo (downy body hair). All these symptoms are secondary to the patient’s malnutrition and do not require separate treatment, although unfortunately enough this still happens. For example, laxatives are sometimes prescribed for constipation or hormones for amenorrhoea. An inexperienced physician may also be misled by certain somatic symptoms, such as a slow pulse rate (less than 60 per minute), low body temperature, anaemia, leucopenia (lack of white blood cells) and various disorders in hormonal functions, the most striking of which is the repression of the female hormones.

While a physical examination of the patient may not always be necessary to decide on the diagnosis, it does have its importance in evaluating the physiological state of malnutrition and in deciding on the need for hospitalization. Although the degree of emaciation is only a relative item in this regard, a weight loss of more than 20 per cent below the normal minimum should act as the alert for extreme caution. In this case, treatment should be entrusted to the hands of an experienced clinician. The need for medical attention applies even more strongly to AN patients of the ‘mixed’ type, who in addition to the low body weight present with extra risks for complications, comparable to those mentioned for BN. So, as a rule, a medical examination should precede therapy of AN patients regardless of the gravity or duration of the disorder.

Unlike AN, the diagnosis of BN is rather complex and often causes errors. Many clinicians, especially in the USA, apply the diagnosis too liberally, to include all sorts of disorders in which a form of binge eating is involved. To avoid overdiagnosis, a strict adherence to the DSM-IV criteria mentioned in Table 1.2 is required. An additional inspection may therefore be necessary, not only for diagnostic purposes but also to help the patient overcome the barrier of asking for medical assistance. Indeed, out of shame or guilt most bulimic patients will not spontaneously talk about their eating behaviour, but when direct and specific questions are asked they may feel that the interviewer is familiar with the problem and be more inclined to confide in him or her.

A first issue to investigate in this respect is whether the patient is actually suffering from bulimia. When someone claims ‘to eat too much’, it is often concluded without further ado (including by the patients themselves) that bulimia is involved, but this is not always the case. In order to find out the exact significance of the complaints, three important questions must be addressed: (1) Is the claim to ‘eat too much’ justified? (2) Did the overeating take place within a short period of time? (3) Did the patient experience a loss of control? (See Table 1.3. )

The first question concerns the objectivity of the overeating. To answer this question, one must get an idea of the exact quantities consumed, for example by asking the patient to monitor her food intake until the next session. Attention must be paid to the patient’s subjective norm, i.e. what she considers as ‘normal’. In our society, where many women diet or adopt an anorectic attitude, the violation of self-imposed dieting rules may already be experienced as a form of ‘overeating’. After inquiry, it often appears that what is reported as a binge is in fact an ordinary meal. This perceptual malformation is very typical for AN patients in particular.

Table 1.3 Diagnosis of bulimia

When the amount of food eaten does appear to be exaggerated, the next question is whether the excess was consumed in a short period of time. A ‘genuine’ binge involves large quantities of food (e.g. 2,000 to 10,000 Kcal) eaten quickly (e.g. within 30 minutes to an hour). Very often, the so-called ‘overeating’ is the result of many small consumptions over an extended period of time, such as a whole day. In that case one should talk of ‘objective overeating’ or ‘food addiction’ rather than a binge. This is a pattern that is often found in obese people, whereas binges, or fits of gorging, imply a characteristic suddenness and a short period of time.

The third question concerns the feeling of loss of control. Bulimic subjects no longer experience conscious control over the eating behaviour, as expressed by the typical statement that ‘once they start eating, they cannot stop’. This loss of control is very often triggered by particular foodstuffs, notably sweets.

If the above items apply, one may conclude that the patient suffers from objective binge eating. To decide on the diagnosis of BN, however, it must also be established that the patient wants to avoid weight increase and attempts to keep her weight under control (see Figure 1.1 ). Not all patients suffering from bulimia are concerned about their weight, as for example is the case in depression. On the other hand, bulimia may occur without compensating behaviour, in which case the patient’s weight will increase after each binge and induce overweight. Some clinicians refer to this syndrome as the binge eating disorder, but this notion is still controversial. Only when compensatory behaviours such as vomiting, uses of laxatives or di...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Illustrations
• Preface and Acknowledgements
• 1 The Nature of Eating Disorders in Married Patients
• 2 The Marital Relationships of Psychiatric Patients
• 3 The Husbands of Eating-Disordered Patients
• 4 Marital Satisfaction and Intimacy
• 5 Communication
• 6 Marital Conflicts
• 7 Sexuality, Fertility and Parenting
• 8 Assessment and Treatment of Eating Disorders
• 9 Assessment of the Marital Relationship
• 10 Involving the Husband in the Therapy
• Appendix 1
• Appendix 2
• Appendix 3
• References