Therapy for Eating Disorders

Theory, Research & Practice

Sara Gilbert, Author

• Publisher: SAGE Publications Ltd
• Year: 2013
• Print ISBN: 9781446240953, 9781446240946
• eBook ISBN: 9781446292914
• Edition: 3
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

'This updated edition provides an excellent overview of the diagnosis, prevalence and causes of eating disorders, as well as a handbook for the application of evidence based interventions. A "must buy" for eating disorder services and individual practitioners!'

Sally Savage, Clinical Lead for Northamptonshire NHS Eating Disorders Lifespan Service

Affecting thousands of people every year with potentially devastating consequences, anorexia, bulimia and binge eating disorders are becoming increasingly evident in today's fast paced, high pressured society.

Drawing on over 20 years' experience as a practitioner, Sara Gilbert takes the reader through the complexities of working with eating disorders, drawing on practical, cognitive behavioural and educational approaches to theory, assessment, treatment and practice. Packed full of new resources for both qualified professionals and trainees, this new edition includes:

·         A summary of new research on the causes of eating disorders, dual diagnosis and co-morbidity.

·         New content on the best treatment for eating disorders and preparing clients for treatment.

·         An updated chapter examining the effects of nutrition on physical and psychological well-being.

·         New content on working with complexity and risk.

·         A fully updated reference section.

This is a vital resource for practitioners in the mental health field, including psychotherapists, psychologists, counsellors, psychiatrists, mental health nurses and dieticians.

Sara Gilbert is a chartered clinical psychologist whose specialist interest in the field of eating disorders spans 20 years. She has worked for 12 years as a clinical lead in an eating disorder service in the NHS and is now in private practice.

1

What is an Eating Disorder?

Treatment of the eating disorders has become a major mental health issue of the twenty-first century. Until the early 1980s, most people knew of the existence of anorexia nervosa, but few mental health professionals or dieticians would have considered it necessary to have more than the ability merely to recognize the disorder so that they could pass a case on to a specialist worker or unit.

In the past thirty years, however, help has become increasingly available for people with specific diagnoses of bulimia nervosa and anorexia nervosa. Mental health professionals have also begun to address the problem of binge eating disorder in both normal weight and overweight people. Awareness of the need for specialist care has meant that someone with an eating disorder is more likely than previously to be referred for psychiatric or counselling help or may at least be able to receive advice from a self-help organization.

Yet, despite increased knowledge and interest in this area, clinicians are often reluctant and sometimes anxious or even negative about working with this group of people. A review of 20 studies between 1984 and 2010 describing reactions to patients with eating disorders listed frustration, hopelessness, lack of competence and worry as reflecting the feelings of clinicians, albeit there was an inverse relationship between the strength of these feelings and clinician experience. Negative reactions to patients with eating disorders were associated with patients’ lack of improvement and personality pathology (Thompson-Brenner et al. 2012). Even among specialist mental health workers there is still some erroneous information about the nature of eating disorders and confusion about the best ways to treat them as evidenced by a recent survey of National Health Service (NHS) psychiatrists in the UK (Jones et al. 2013).

This book is an attempt to provide a practical basis for helping people with eating disorders both for therapists with a mental health or health psychology background and for dieticians. Its aim is not only to describe ways of working with people with a specifiable eating disorder, but also to suggest ways to improve the methods by which nutritional advice and therapy are offered to obese people and to those who by virtue of psychological difficulties are unable to eat in a health-promoting way.

This chapter will describe the behaviour, eating habits and physical symptoms seen in people with disorders of eating. It will define the conditions known as ‘anorexia nervosa’, ‘bulimia nervosa’ and ‘binge eating disorder’, and discuss some of the problems which therapists and mental health professionals may meet in people with atypical, less easily definable eating disorders, such as purging and anorexic behaviour in people of apparently normal weight, or inability to eat for reasons other than fear of becoming fat. It will also discuss the relationship between eating disorder and weight and the question of how far people at a very low weight or a very high weight in relation to height may or may not have an eating disorder.

A broad definition of eating disorder is given by Fairburn and Walsh (2002), psychiatrists who have been at the cutting edge of eating disorder research for the past 30 years. They propose: ‘a persistent disturbance of eating behaviour or behaviour intended to control weight, which significantly impairs health or psychosocial functioning. This disturbance should not be secondary to any recognized general medical disorder … or any other psychiatric disorder’ (Fairburn and Walsh 2002: 171). This definition implies an understanding that the eating disorders encompass a range of difficulties. People may also be driven to overeat or under-eat for reasons which do not necessarily include the intention of controlling weight. There is increasing evidence that a disturbance in eating or purging behaviour may reflect a need for some individuals to control or escape from intolerable emotions, and the resulting change in weight is merely a side-effect of that behaviour. Eating disorders are largely defined by characteristic behaviours around food and weight control and attitudes to weight and shape. An eating disorder can never be diagnosed from weight or shape alone, although weight is an important feature of an eating disorder (see text box on the relationship between weight and eating disorder).

Recognition of the widespread nature of problems around food and eating stemmed from three areas. The first and perhaps most public of these was the feminist movement. Susie Orbach’s book Fat is a Feminist Issue (1978) drew a great deal of attention to the movement through its novel discussion of so-called ‘compulsive overeating’ which talked not so much about ‘fat’ itself but about the fear of fat and the place held by that fear in the culture of women in the context of their relationship with men. This led to a rash of books around the area of dieting and body image, most of which carried the implication that dieting and obsession with body image have something to do with the place of women in a sexist society.

Another source of recognition was in mainstream psychiatry. Gerald Russell (1979), known for his work with anorexia nervosa, described an anorexic-like syndrome in women of normal weight. These women had previously been anorexic and, although of normal weight on follow-up, were still obsessed with weight and shape. They binged frequently but went to great lengths to control their weight by means of vomiting, taking laxatives or starving themselves in between binges. He called this syndrome ‘bulimia nervosa’ as opposed to anorexia nervosa.

A third source of recognition came from epidemiological research. ‘Bulimia’, as it was called in the United States, or ‘bulimia nervosa’, as it was called in Britain, was recognized to exist on a wide scale among women who had never approached their doctors for help.

However, there is no doubt that the existence of the popular word ‘binge’, and the phenomenon itself, has its basis in the obsession with dieting that prevails in the Western world. Very many men and women of all ages diet habitually. In this setting, it is sometimes difficult to assess how far someone is actually suffering from an eating disorder. Dieting and a negative attitude to fat are condoned and often highly valued by people as an indicator of self-control both in themselves and in other people. Hence, it is possible for someone who is suffering intensely with an eating disorder to hide the fact not only from themselves but also from the people who might be able to help.

A note about psychiatric diagnosis

Psychological disturbances are generally classified under two parallel classification systems. These are the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM, American Psychiatric Association 2013) or the World Health Organization’s International Classification of Diseases (WHO 1992). In this book, I have used the DSM-5 (2013) classification system as a basis for describing the disorders under discussion and the results of research into the efficacy of their treatment, although most of the research to date is, in fact, based on the DSM-IV and DSM-IV-TR classification systems which have been in use until the time of writing (American Psychiatric Association 1994, 2000).

If we are to work with people and their problems, we need some way of defining the problems so that we all know that we are discussing the same phenomenon. In this regard, psychiatric diagnosis is a useful system. It also helps us to draw conclusions from research into treatment. However, the distinctions between the so-called ‘disorders’ are by no means firm and immutable. There is much overlap of symptoms and characteristics between disorders and there may be limited utility in producing endless classificatory systems and subsystems which describe but do little to explain or predict (see Fairburn and Cooper [2007] with regard to the utility of classification in eating disorder). It is also important to remember that the conditions to which we are referring are not necessarily illnesses or conditions which a person can ‘have’ in the same way as they can ‘have’ multiple sclerosis or epilepsy, or which they can ‘catch’ in the same way that they can ‘catch’ pneumonia or acquire HIV; and there is growing interest in a ‘dimensional’ approach to the classification of eating disorders based on a model where symptoms may vary in severity on a continuum across diagnoses and with normality (see also Wildes and Marcus 2013). There is some emerging evidence of possible links with physiology and brain chemistry, but as yet there are no clear indicators of medical or genetic aetiology of eating disorder that lend themselves to the development of medical treatment approaches; and, as yet, the major treatments of choice have a psychological basis. As John Marzillier, an experienced psychotherapist and research psychologist, has pointed out:

the experiences that lead people to be diagnosed as ‘mentally ill’ are experiences that all of us can have in some form at some stage. This is why, despite over a century or more of research, psychiatrists are no further forward in defining and understanding – let alone successfully treating – any major psychiatric ‘illness’. (Marzillier 2004: 392)

The people we meet in therapy for eating disorders may have symptoms in common, but the way they respond to therapy will be a function of the complex interaction between their symptoms and many other factors, including physiology, brain chemistry, personality, past experience and current circumstances. Therapists may experience some discomfort in trying to attach labels to the real people they meet in their consulting rooms. However, psychiatric ‘diagnosis’ is merely a starting point from which to explore the individual needs of clients, develop an individual formulation or ‘case conceptualization’, and apply the general principles and individual techniques of evidence-based psychological therapy.

The relationship between weight and eating disorder

Body mass index

Degree of overweight or underweight is commonly described by a measure known as the body mass index (BMI).

This is derived from the formula W/H² (weight in kilograms divided by the square of height in metres).

Weight is plotted in relation to height and the resulting graph has been reproduced in widely available table form depicting the upper and lower limits of the weight range.

Normal weight

The normal range for the BMI of adults is 20–25.

Low weight

BMI measurements below 18.5 represent increasing degrees of underweight.

The Maudsley Body Mass Index table (Janet Treasure) defines underweight as follows:

17.5–20	underweight
15–17.5	anorexia nervosa
13.5–15	severe anorexia nervosa
12–13.5	critical anorexia nervosa
> 12	life-threatening anorexia nervosa

Overweight

A BMI of 26 and above indicates increasing degrees of overweight:

26–30	grade 1 (overweight)
30–40	grade 2 (clinical obesity)
≥ 40	grade 3 (severe obesity)

Note: BMI varies through childhood and adolescence, decreasing in early childhood and then gradually increasing through adolescence. So, for children, BMI on its own is not a good measure of thinness. A chart is used to depict BMI in boys and girls aged 2 to 20, and individual BMI is expressed as a percentile.

A BMI above the 95th percentile is considered overweight, and below the 5th percentile is considered underweight (WHO 1996; Dietz and Bellizzi 1999).

Anorexia nervosa

Anorexia nervosa is a state in which the sufferer, usually female, refuses to eat enough to maintain normal body weight for her height. Usually she claims to want to lose weight to be slimmer; sometimes she says that she does not feel hungry or that it is uncomfortable to eat.

A currently accepted definition of anorexia nervosa is given in the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-5, 2013) and has three criteria. The first specifies that the person takes in less energy than needed to maintain a weight that is normal for their height and age; or for a child or adolescent, their weight is less than expected. The second criterion specifies an ‘intense’ fear of weight gain or attempts to prevent weight gain. A third criterion specifies a disturbance in the person’s experience of their body weight or shape, or the implication that the person refuses to recognize the risks of being seriously underweight (see American Psychiatric Association 2013).

A weight criterion by which to define anorexia nervosa is given in the tenth edition of the International Classification of Diseases (WHO 1992), which specifies that weight is maintained at least 15 per cent below that expected or, in adults, body mass index (BMI) is below 17.5 kg/m². In younger people, instead of actual weight loss, there may be failure to gain weight as expected during puberty or childhood. According to DSM-5, the current level of severity of anorexia nervosa is based on current body mass index for adults and on BMI percentile for children and adolescents. Most young women with anorexia nervosa will stop menstruating; and a previous version of the DSM, DSM-IV (American Psychiatric Association 1994) stipulated the absence of at least three consecutive menstrual cycles when otherwise expected to occur. However, this stipulation has now been removed as children with an eating disorder may have not yet reached puberty; some women, including those who take the contraceptive pill, may continue to menstruate even at a low weight; and amenorrhoea can be experienced by people with all types of eating disorder (see also the review by Pinheiro et al. 2007).

People suffering with anorexia nervosa refuse food or eat very little. Some may count calories or exclude certain food groups from their diet, and many eat as little as 200–300 calories per day. They may also take strenuous exercise, apparently as a means of maintaining a low weight, but also perhaps as a means of keeping warm according to some recent evidence which showed a negative correlation between ambient temperature and physical activity in anorexics who exercise (Carrera et al. 2012). For many people, excessive exercise is maintained as a means of regulating mood. Anorexics also often appear ‘faddy’ with their food. Some take an immense interest in cookery and in cooking for other people, although they will themselves avoid eating the food they cook.

Individual sufferers vary widely in their presentation, and attempts to characterize types of anorexic have their limitations. For example, it has been assumed until recently that all anorexics have a ‘drive for thinness’ and fear weight gain, but as now reflected in the most recent version of the DSM (American Psychiatric Association 2013), fear of weight gain is not a prerequisite for meeting diagnostic criteria. Several authors have pointed out that up to 20 per cent of anorexics, in particular in the Far East, do not appear to be afraid to get fat: these patients are more likely to attribute fear of eating to some other phenomenon, such as stomach bloating or pain, loss of appetite or lack of hunger (see Ramacciotti et al. 2002 for a discussion). In addition, studies in children and adolescents have pointed to the fact that fear of weight gain is not always endorsed in this group, despite a clear refusal to eat (WCEDCA 2007). The authors of this latter study explain this observation in terms of ‘limited verbal capacities, fewer abstracting abilities, less awareness of emotions … compared with adults.’ (p. S117). However, the same could be said for some adult eating disorder clients too, people in whom the ‘breadth and complexity of emotion regulation strategies’ may be limited just as it is in individuals at an earlier stage of development.

Anorexics are also thought to have a distorted body image, in that they often appear to grossly overestimate their own size or weight. A great deal of research in the 1970s was devoted to the question of how far anorexics overestimate their body size. This is in common, however, with many other people with abnormal eating habits, and the emphasis more recently has been on sufferers’ attitudes to weight and shape. Peter Cooper and Christopher Fairburn (1993) have pointed out the distinction between ‘dissatisfaction with body shape’, which may or may not be experienced by women with eating disorders, and ‘overvalued ideas about body shape and weight’, which they hold are a necessary diagnostic feature for both bulimia nervosa and anorexia nervosa.

Anorexics are specified as ‘restricting types’ or ‘binge eating/purging types’. Some anorexics keep their weight down solely by restricting their food intake and are not currently purging or binge eating, while others also binge eat and purge themselves by vomiting or by taking laxatives, diuretics or enemas. Some patients may develop the habit of chewing and spitting out food as a means of purging or of avoiding food intake. The relative number of bingers vis-à-vis restrictors is on average about 50 per cent across studies, which have pointed to some consistent differences between the two groups: more of the bulimics have had heterosexual experience and are married, although their social adjustment is no better than that of the restrictors, as they also describe themselves as more anxious and depressed, more guilty about their eating habits, and more aware of difficulties in interpersonal relationships. The bulimics are significantly older when they present for treatment and have been ill for longer. More of the bulimics appear to seek help for themselves, while the restrictors often deny that they have a problem at all. However, the bulimics also appear to carry a worse prognosis, and, in addition, are more likely to exhibit impulsive behaviours, such as stealing, drug abuse, suicide attempts and self-mutilation. Garner and his colleagues (1993) have suggested an entirely different division of anorexics, between those who purge and those who do not. They have suggested that this avoids the problems of defining a binge. It also makes sense in that many anorexics purge without bingeing, and there is a strong association between purging behaviour and level of psychopathology, chronicity and length of illness (Favaro and Santonastaso 1996).

The disorder takes a physical toll on sufferers. Long-term starvation causes muscle weakness and loss of muscle strength, which also affects the heart. Sufferers may develop cardi...

Table of contents

• Cover Page
• Halftitle
• Therapy in Practice
• Title
• Copyright
• Contents
• About the Author
• Preface
• Acknowledgements
• 1   What is an Eating Disorder?
• 2   Causes of the Eating Disorders
• 3   Treatment for the Eating Disorders
• 4   A Cognitive Behavioural and Integrative Approach to Eating Disorders
• 5   Beginning the Therapy Process
• 6   Preparing for Change
• 7   Nutritional Aspects of Helping the Client with an Eating Disorder
• 8   Behavioural Techniques
• 9   Cognitive Techniques
• 10   Adapting to Different Situations and Dealing with Endings
• 11   Conclusion
• Appendix 1: Some Useful Web Pages
• Appendix 2: Eating Problems: Resources for Clients
• Appendix 3: Guidelines for Normal Healthy Eating
• Appendix 4: Controlling What You Eat
• Appendix 5: Giving Up Vomiting as a Way to Control your Weight or Deal with Stress
• Appendix 6: Learning to be Assertive about What You Eat: A Bill of Rights
• References
• Index