Eating Disorders
Definition: Eating
disorders -- such as anorexia, bulimia, and binge eating disorder – include
extreme emotions, attitudes, and behaviors surrounding weight and food issues.
Eating disorders are serious emotional and physical problems that can have
life-threatening consequences for females and males.
Eating Disorders
Statistics
General:
- Almost 50% of people with eating
disorders meet the criteria for depression.1
- Only 1 in 10 men and women with
eating disorders receive treatment. Only 35% of people that receive treatment
for eating disorders get treatment at a specialized facility for eating
disorders.2
- Up to 24 million people of all
ages and genders suffer from an eating disorder (anorexia, bulimia and binge
eating disorder) in the U.S.3
- Eating disorders have the
highest mortality rate of any mental illness.4
Students:
- 91% of women surveyed on a
college campus had attempted to control their weight through dieting. 22%
dieted “often” or “always.”5
- 86% report onset of eating
disorder by age 20; 43% report onset between ages of 16 and 20.6
- Anorexia is the third most
common chronic illness among adolescents.7
- 95% of those who have eating
disorders are between the ages of 12 and 25.8
- 25% of college-aged women engage
in bingeing and purging as a weight-management technique.3
- The mortality rate associated
with anorexia nervosa is 12 times higher than the death rate associated with
all causes of death for females 15-24 years old.4
- Over one-half of teenage girls
and nearly one-third of teenage boys use unhealthy weight control behaviors
such as skipping meals, fasting, smoking cigarettes, vomiting, and taking
laxatives.17
- In a survey of 185 female
students on a college campus, 58% felt pressure to be a certain weight, and of
the 83% that dieted for weight loss, 44% were of normal weight.16
Men:
-
An estimated 10-15% of people with anorexia or bulimia are male.9
- Men are less likely to seek
treatment for eating disorders because of the perception that they are “woman’s
diseases.”10
- Among gay men, nearly 14%
appeared to suffer from bulimia and over 20% appeared to be anorexic.11
Media,
Perception, Dieting:
-
95% of all dieters will regain their lost weight within 5 years.3
- 35% of “normal dieters” progress
to pathological dieting. Of those, 20-25% progress to partial or full-syndrome
eating disorders.5
- The body type portrayed in
advertising as the ideal is possessed naturally by only 5% of American
females.3
- 47% of girls in 5th-12th grade
reported wanting to lose weight because of magazine pictures.12
- 69% of girls in 5th-12th grade
reported that magazine pictures influenced their idea of a perfect body
shape.13
-42% of 1st-3rd grade girls want
to be thinner (Collins, 1991).
- 81% of 10 year olds are afraid
of being fat (Mellin et al., 1991).
Collins, M.E. (1991). Body figure perceptions and
preferences among pre-adolescent children. International Journal of Eating
Disorders, 199-208.
Mellin, L., McNutt, S., Hu, Y., Schreiber, G.B., Crawford,
P., & Obarzanek, E. (1991). A longitudinal study of the dietary practices
of black and white girls 9 and 10 years old at enrollment: The NHLBI growth and
health study. Journal of Adolescent Health, 23-37.
For
Women:
- Women are
much more likely than men to develop an eating disorder. Only an estimated 5 to
15 percent of people with anorexia or bulimia are male.14
- An estimated 0.5 to 3.7 percent
of women suffer from anorexia nervosa in their lifetime.14 Research suggests
that about 1 percent of female adolescents have anorexia.15
- An estimated 1.1 to 4.2 percent
of women have bulimia nervosa in their lifetime.14
- An estimated 2 to 5 percent of
Americans experience binge-eating disorder in a 6-month period.14
- About 50 percent of people who
have had anorexia develop bulimia or bulimic patterns.15
- 20% of people suffering from
anorexia will prematurely die from complications related to their eating
disorder, including suicide and heart problems.18
Mortality
Rates:
- Although eating disorders have
the highest mortality rate of any mental disorder, the mortality rates
reported on those who suffer from eating disorders can vary considerably
between studies and sources. Part of the reason why there is a large variance
in the reported number of deaths caused by eating disorders is because those
who suffer from an eating disorder may ultimately die of heart failure, organ
failure, malnutrition or suicide. Often, the medical complications of death are
reported instead of the eating disorder that compromised a person’s
health.
- According to a study done by colleagues
at the American Journal of Psychiatry
(2009), crude mortality rates were:
-
4% for anorexia nervosa
-
3.9% for bulimia nervosa
-
5.2% for eating disorder not otherwise specified
Crow, S.J., Peterson, C.B., Swanson, S.A., Raymond,
N.C., Specker, S., Eckert, E.D., Mitchell, J.E. (2009) Increased mortality in
bulimia nervosa and other eating disorders. American Journal of
Psychiatry 166, 1342-1346.
Athletes:
- Risk Factors: In judged sports –
sports that score participants – prevalence of eating disorders is 13%
(compared with 3% in refereed sports).19
- Significantly higher rates of
eating disorders found in elite athletes (20%), than in a female control group
(9%).20
- Female athletes in aesthetic
sports (e.g. gynmastics, ballet, figure skating) found to be at the highest
risk for eating disorders.20
- A comparison of the
psychological profiles of athletes and those with anorexia found these factors
in common: perfectionism, high self-expectations, competitiveness,
hyperactivity, repetitive exercise routines, compulsiveness, drive, tendency
toward depression, body image distortion, pre-occupation with dieting and
weight.21
1. Mortality in Anorexia Nervosa. American Journal of Psychiatry, 1995;
152 (7): 1073-4.
2. Characteristics and Treatment of Patients with Chronic Eating Disorders, by Dr. Greta Noordenbox, International Journal of Eating Disorders, Volume 10: 15-29, 2002.
3. The Renfrew Center Foundation for Eating Disorders, “Eating Disorders 101 Guide: A Summary of Issues, Statistics and Resources,” 2003.
4. American Journal of Psychiatry, Vol. 152 (7), July 1995, p. 1073-1074, Sullivan, Patrick F.
5. Shisslak, C.M., Crago, M., & Estes, L.S. (1995). The Spectrum of Eating Disturbances. International Journal of Eating Disorders, 18 (3): 209-219.
6. National Association of Anorexia Nervosa and Associated Disorders 10-year study, 2000
7. Public Health Service’s Office in Women’s Health, Eating Disorders Information Sheet, 2000.
8. Substance Abuse and Mental Health Services Administration (SAMHSA), The Center for Mental Health Services (CMHS), offices of the U.S. Department of Health and Human Services.
9. Carlat, D.J., Camargo. Review of Bulimia Nervosa in Males. American Journal of Psychiatry, 154, 1997.
10. American Psychological Association, 2001.
11. International Journal of Eating Disorders 2002; 31: 300-308.
12. Prevention of Eating Problems with Elementary Children, Michael Levine, USA Today, July 1998.
13. Ibid.
14. The National Institute of Mental Health: “Eating Disorders: Facts About Eating Disorders and the Search for Solutions.” Pub No. 01-4901. Accessed Feb. 2002. http://www.nimh.nih.gov/publicat/nedspdisorder.cfm.
15. Anorexia Nervosa and Related Eating Disorders, Inc. website. Accessed Feb. 2002. http://www.anred.com/
16. Nutrition Journal. March 31, 2006.
17. Neumark-Sztainer, D. (2005). I’m, Like, SO Fat!. New York: The Guilford Press. pp. 5.
18. The Renfrew Center Foundation for Eating Disorders, “Eating Disorders 101 Guide: A Summary of Issues, Statistics and Resources,” published September 2002, revised October 2003, http://www.renfrew.org
19. Zucker NL, Womble LG, Williamson DA, et al. Protective factors for eating disorders in female college athletes. Eat Disorders 1999; 7: 207-218.
20. Sungot-Borgen, J. Torstveit, M.K. (2004) Prevalence of ED in Elite Athletes is Higher than in the General Population. Clinical Journal of Sport Medicine, 14(1), 25-32.
21. Bachner-Melman, R., Zohar, A, Ebstein, R, et.al. 2006. How Anorexic-like are the Symptom and Personality Profiles of Aesthetic Athletes? Medicine & Science in Sports & Exercise 38 No 4. 628-636.
2. Characteristics and Treatment of Patients with Chronic Eating Disorders, by Dr. Greta Noordenbox, International Journal of Eating Disorders, Volume 10: 15-29, 2002.
3. The Renfrew Center Foundation for Eating Disorders, “Eating Disorders 101 Guide: A Summary of Issues, Statistics and Resources,” 2003.
4. American Journal of Psychiatry, Vol. 152 (7), July 1995, p. 1073-1074, Sullivan, Patrick F.
5. Shisslak, C.M., Crago, M., & Estes, L.S. (1995). The Spectrum of Eating Disturbances. International Journal of Eating Disorders, 18 (3): 209-219.
6. National Association of Anorexia Nervosa and Associated Disorders 10-year study, 2000
7. Public Health Service’s Office in Women’s Health, Eating Disorders Information Sheet, 2000.
8. Substance Abuse and Mental Health Services Administration (SAMHSA), The Center for Mental Health Services (CMHS), offices of the U.S. Department of Health and Human Services.
9. Carlat, D.J., Camargo. Review of Bulimia Nervosa in Males. American Journal of Psychiatry, 154, 1997.
10. American Psychological Association, 2001.
11. International Journal of Eating Disorders 2002; 31: 300-308.
12. Prevention of Eating Problems with Elementary Children, Michael Levine, USA Today, July 1998.
13. Ibid.
14. The National Institute of Mental Health: “Eating Disorders: Facts About Eating Disorders and the Search for Solutions.” Pub No. 01-4901. Accessed Feb. 2002. http://www.nimh.nih.gov/publicat/nedspdisorder.cfm.
15. Anorexia Nervosa and Related Eating Disorders, Inc. website. Accessed Feb. 2002. http://www.anred.com/
16. Nutrition Journal. March 31, 2006.
17. Neumark-Sztainer, D. (2005). I’m, Like, SO Fat!. New York: The Guilford Press. pp. 5.
18. The Renfrew Center Foundation for Eating Disorders, “Eating Disorders 101 Guide: A Summary of Issues, Statistics and Resources,” published September 2002, revised October 2003, http://www.renfrew.org
19. Zucker NL, Womble LG, Williamson DA, et al. Protective factors for eating disorders in female college athletes. Eat Disorders 1999; 7: 207-218.
20. Sungot-Borgen, J. Torstveit, M.K. (2004) Prevalence of ED in Elite Athletes is Higher than in the General Population. Clinical Journal of Sport Medicine, 14(1), 25-32.
21. Bachner-Melman, R., Zohar, A, Ebstein, R, et.al. 2006. How Anorexic-like are the Symptom and Personality Profiles of Aesthetic Athletes? Medicine & Science in Sports & Exercise 38 No 4. 628-636.
Types of Eating Disorders:
-Anorexia Nervosa
-Bulimia Nervosa
-Binge Eating Disorder
-Eating Disorders Not Otherwise Specified (ED-NOS)
-Diabulimia
-Orthorexia
-Exercise Bulimia
Anorexia Nervosa:
Anorexia nervosa is a serious, potentially life-threatening eating disorder
characterized by self-starvation and excessive weight loss.
Symptoms
-Resistance to maintaining body
weight at or above a minimally normal weight for age and height.
-Intense fear of
weight gain or being “fat,” even though underweight.
-Disturbance in the experience of
body weight or shape, undue influence of weight or shape on self-evaluation, or
denial of the seriousness of low body weight.
-Loss of menstrual
periods in girls and women post-puberty.
Eating disorders experts have found that prompt intensive
treatment significantly improves the chances of recovery. Therefore, it is important to be aware of
some of the warning signs of anorexia nervosa.
Warning
Signs
-Dramatic weight
loss.
-Preoccupation
with weight, food, calories, fat grams, and dieting.
-Refusal to eat certain foods,
progressing to restrictions against whole categories of food (e.g. no
carbohydrates, etc.).
-Frequent comments
about feeling “fat” or overweight despite weight loss.
-Anxiety about
gaining weight or being “fat.”
-Denial of hunger.
-Development of food rituals (e.g.
eating foods in certain orders, excessive chewing, rearranging food on a
plate).
-Consistent
excuses to avoid mealtimes or situations involving food.
-Excessive, rigid exercise regimen--despite
weather, fatigue, illness, or injury, the need to “burn off” calories taken in.
-Withdrawal from
usual friends and activities.
-In general, behaviors and
attitudes indicating that weight loss, dieting, and control of food are
becoming primary concerns.
Health
Consequences of Anorexia Nervosa
-Anorexia nervosa involves
self-starvation.; The body is denied the essential nutrients it needs to
function normally, so it is forced to slow down all of its processes to
conserve energy. This “slowing down” can have serious medical consequences:
-Abnormally slow heart rate and
low blood pressure, which mean that the heart muscle is changing. The risk for heart failure rises as heart
rate and blood pressure levels sink lower and lower.
-Reduction of bone density
(osteoporosis), which results in dry, brittle bones.
-Muscle loss and
weakness.
-Severe dehydration,
which can result in kidney failure.
-Fainting,
fatigue, and overall weakness.
-Dry hair and
skin, hair loss is common.
-Growth of a downy layer of hair
called lanugo all over the body, including the face; in an effort to keep the
body warm.
Some
Facts About Anorexia Nervosa
-Approximately 90-95% of anorexia
nervosa sufferers are girls and women.
-Between 0.5–1% of
American women suffer from anorexia nervosa.
-Anorexia nervosa is one of the
most common psychiatric diagnoses in young women.
-Between 5-20% of individuals
struggling with anorexia nervosa will die.
The probabilities of death increases within that range depending on the
length of the condition.
-Anorexia nervosa has one of the
highest death rates of any mental health condition.
-Anorexia nervosa
typically appears in early to mid-adolescence.
Bulimia Nervosa: Bulimia
nervosa is a serious, potentially life-threatening eating disorder
characterized by a cycle of bingeing and compensatory behaviors such as
self-induced vomiting designed to undo or compensate for the effects of binge
eating.
Symptoms
-Regular intake of large amounts
of food accompanied by a sense of loss of control over eating behavior.
-Regular use of inappropriate
compensatory behaviors such as self-induced vomiting, laxative or diuretic
abuse, fasting, and/or obsessive or compulsive exercise.
-Extreme concern
with body weight and shape.
The chance for recovery increases the earlier bulimia
nervosa is detected. Therefore, it is important to be aware of some of the warning
signs of bulimia nervosa.
Warning
Signs of Bulimia Nervosa
-Evidence of binge eating,
including disappearance of large amounts of food in short periods of time or
finding wrappers and containers indicating the consumption of large amounts of
food.
-Evidence of purging behaviors,
including frequent trips to the bathroom after meals, signs and/or smells of
vomiting, presence of wrappers or packages of laxatives or diuretics.
-Excessive, rigid exercise
regimen--despite weather, fatigue, illness, or injury, the compulsive need to
“burn off” calories taken in.
-Unusual swelling
of the cheeks or jaw area.
-Calluses on the back of the hands
and knuckles from self-induced vomiting.
-Discoloration or
staining of the teeth.
-Creation of lifestyle schedules
or rituals to make time for binge-and-purge sessions.
-Withdrawal from
usual friends and activities.
-In general, behaviors and
attitudes indicating that weight loss, dieting, and control of food are
becoming primary concerns.
-Continued
exercise despite injury; overuse injuries.
Health
Consequences of Bulimia Nervosa: Bulimia nervosa can be extremely harmful
to the body. The recurrent
binge-and-purge cycles can damage the entire digestive system and purging
behaviors can lead to electrolyte and chemical imbalances in the body that
affect the heart and other major organ functions. Some of the health consequences of bulimia
nervosa include:
-Electrolyte imbalances that can
lead to irregular heartbeats and possibly heart failure and death. Electrolyte imbalance is caused by
dehydration and loss of potassium and sodium from the body as a result of
purging behaviors.
-Inflammation and possible rupture
of the esophagus from frequent vomiting.
-Tooth decay and staining from
stomach acids released during frequent vomiting.
-Chronic irregular bowel movements
and constipation as a result of laxative abuse.
-Gastric rupture is an uncommon
but possible side effect of binge eating.
Facts
About Bulimia Nervosa
-Bulimia nervosa
affects 1-2% of adolescent and young adult women.
-Approximately 80%
of bulimia nervosa patients are female.
-People struggling with bulimia
nervosa usually appear to be of average body weight.
-Many people struggling with
bulimia nervosa recognize that their behaviors are unusual and perhaps dangerous
to their health.
-Bulimia nervosa is frequently
associated with symptoms of depression and changes in social adjustment.
-Risk of death from suicide or
medical complications is markedly increased for eating disorders
Binge Eating Disorder:
Binge Eating Disorder (BED) is a type of eating disorder not otherwise
specified and is characterized by recurrent binge eating without the regular
use of compensatory measures to counter the binge eating.
Symptoms
-Frequent episodes of eating large
quantities of food in short periods of time.
-Feeling out of
control over eating behavior during the episode.
-Feeling
depressed, guilty, or disgusted by the behavior.
-There are also several behavioral
indicators of BED including eating when not hungry, eating alone because of
embarrassment over quantities consumed, eating until uncomfortably full.
Health
Consequences of Binge Eating Disorder
-The health risks of BED are most
commonly those associated with clinical obesity. Some of the potential health consequences of
binge eating disorder include:
-High blood
pressure
-High cholesterol
levels
-Heart disease
-Diabetes mellitus
-Gallbladder
disease
-Musculoskeletal
problems
Facts
About Binge Eating Disorder
-The prevalence of BED is
estimated to be approximately 1-5% of the general population.
-Binge eating disorder affects
women slightly more often than men--estimates indicate that about 60% of people
struggling with binge eating disorder are female, 40% are male
-People who struggle with binge
eating disorder can be of normal or heavier than average weight.
-BED is often
associated with symptoms of depression.
-People struggling with binge
eating disorder often express distress, shame, and guilt over their eating
behaviors.
-People with binge eating disorder
report a lower quality of life than non-binge eating disorder.
Eating Disorders Not
Otherwise Specified (EDNOS): Eating disorders such as anorexia and bulimia
include extreme emotions, attitudes, and behaviors surrounding weight and food
issues. They are serious disorders and can have life-threatening
consequences. The same is true for a category of eating disorders known as
eating disorders not otherwise specified or EDNOS. These serious eating
disorders can include any combination of signs and symptoms typical of anorexia
and bulimia. EDNOS is the most common category of eating disorder found in clinical
settings. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2785872/)
Examples
-Menstruation is still occurring
despite meeting all other criteria for anorexia nervosa
-All conditions are present to
qualify for anorexia nervosa except the individual’s current weight is in the
normal range or above.
-Purging or other compensatory
behaviors are not occurring at a frequency less than the strict criteria for
bulimia nervosa
-Purging without Binging—sometimes
known as purging disorder
-Chewing and spitting out large
amounts of food but not swallowing
The
commonality in all of these conditions is the serious emotional and
psychological suffering and/or serious problems in areas of work, school or
relationships. If something does not seem right, but the client’s experience
does not fall into a clear category, they still deserve attention.
Diabulimia: Diabulimia
is an eating disorder which may affect those with Type 1 Diabetes.
Diabulimia is the reduction of insulin intake to lose weight. Diabulimia
is considered a dual diagnosis disorder: where one has diabetes as well as an
eating disorder. While diabulimia is generally associated with use of
insulin, an individual with diabetes may also suffer from another eating
disorder as well.
Health
Risks of Diabulimia
-High
glucose levels
-Glucose
in the urine
-Exhaustion
-Thirst
-Inability
to think clearly
-Severe
dehydration
-Muscle
loss
-Diabetic
Ketoacidosis (unsafe levels of ketones in the blood)
-High
Cholesterol
-Bacterial
skin infections
-Yeast
infections
-Menstrual
disruption
-Staph
infections
-Retinopathy
-Neuropathy
-Peripheral
Arterial Disease
-Atherosclerosis
(a fattening of the arterial walls)
-Steatohepatitis
(a type of liver disease)
-Stroke
-Coma
-Death
Warning
Signs
-Hemoglobin
level of 9.0 or higher on a continuous basis
-Unexplained
weight loss
-Persistent
thirst/frequent urination
-Preoccupation
with body image
-Blood
sugar records that do no match Hemoglobin Alc results
-Depression,
mood swings and/or fatigue
-Secrecy
about blood sugars, shots and or eating.
-Repeated
bladder and yeast infections
-Low
sodium/potassium
-Increased
appetite especially in sugary foods
-Cancelled
doctors’ appointments
Orthorexia Nervosa:
Those who have an “unhealthy obsession” with otherwise healthy eating may be
suffering from “orthorexia nervosa,” a term which literally means “fixation on
righteous eating.” Orthorexia starts out
as an innocent attempt to eat more healthfully, but orthorexics become fixated
on food quality and purity. They become
consumed with what and how much to eat, and how to deal with “slip-ups.” An iron-clad will is needed to maintain this
rigid eating style. Every day is a
chance to eat right, be “good,” rise above others in dietary prowess, and
self-punish if temptation wins (usually through stricter eating, fasts and
exercise). Self-esteem becomes wrapped
up in the purity of orthorexics’ diet and they sometimes feel superior to
others, especially in regard to food intake.
Eventually food choices become so restrictive, in both
variety and calories, that health suffers – an ironic twist for a person so
completely dedicated to healthy eating.
Eventually, the obsession with healthy eating can crowd out other
activities and interests, impair relationships, and become physically
dangerous.
Is Orthorexia An
Eating Disorder?
Orthorexia is a term coined by Steven Bratman, MD to
describe his own experience with food and eating. It is not an officially recognized disorder,
but is similar to other eating disorders – those with anorexia nervosa or
bulimia nervosa obsess about calories and weight while orthorexics obsess about
healthy eating (not about being “thin” and losing weight).
Why Does Someone Get
Orthorexia?
Orthorexia appears to be motivated by health, but there are
underlying motivations, which can include safety from poor health, compulsion
for complete control, escape from fears, wanting to be thin, improving
self-esteem, searching for spirituality through food, and using food to create
an identity.
Do I Have Orthorexia?
Consider the following questions. The more questions you respond “yes” to, the
more likely you are dealing with orthorexia.
-Do you wish that occasionally you
could just eat and not worry about food quality?
-Do you ever wish you could spend
less time on food and more time living and loving?
-Does it seem beyond your ability
to eat a meal prepared with love by someone else – one single meal – and not
try to control what is served?
-Are you constantly looking for
ways foods are unhealthy for you?
-Do love, joy, play and creativity
take a back seat to following the perfect diet?
-Do you feel guilt or self-loathing
when you stray from your diet?
-Do you feel in control when you
stick to the “correct” diet?
-Have you put yourself on a
nutritional pedestal and wonder how others can possibly eat the foods they
eat?
So What’s The Big
Deal?
The diet of orthorexics can actually be unhealthy, with
nutritional deficits specific to the diet they have imposed upon
themselves. These nutritional issues may
not always be apparent. Social problems are more obvious. Orthorexics may be socially isolated, often
because they plan their life around food.
They may have little room in life for anything other than thinking about
and planning food intake. Orthorexics
lose the ability to eat intuitively – to know when they are hungry, how much
they need, and when they are full.
Instead of eating naturally they are destined to keep “falling off the
wagon,” resulting in a feeling of failure familiar to followers of any diet.
Exercise Bulimia:
Exercise bulimia is a subset of the psychological disorder called bulimia in
which a person is compelled to exercise in an effort aimed at burning the
calories of food energy and fat reserves to an excessive level that negatively
affects their health. The damage normally occurs through not giving the body
adequate rest for athletic recovery compared to their exercise levels, leading
to increasing levels of disrepair. If the person eats a normally healthy and
adequate diet but exercises in levels they know require higher levels of
nutrition, this can also be seen as a form of anorexia.
Ways to help someone with an eating disorder
At their
core, eating disorders involve distorted, self-critical attitudes about weight,
food, and body image. It’s these negative thoughts and feelings that fuel the
damaging behaviors.
People with
eating disorders use food to deal with uncomfortable or painful emotions.
Restricting food is used to feel in control. Overeating temporarily soothes
sadness, anger, or loneliness. Purging is used to combat feelings of
helplessness and self-loathing. Over time, people with eating disorders lose
the ability to see themselves objectively and obsessions over food and weight
come to dominate everything else in life.
People with
eating disorders need to be understood.
How to
talk to someone about their eating disorder: Be careful to avoid critical or accusatory statements,
as this will only make your friend or family member defensive. Instead, focus
on the specific behaviors that worry you.
-Focus on feelings and relationships, not on weight and food.
Share your memories of specific times when you felt concerned about the
person’s eating behavior. Explain that you think these things may indicate that
there could be a problem that needs professional help.
-Tell them you are concerned about their health, but respect their privacy.
Eating disorders are often a cry for help, and the individual will appreciate
knowing that you are concerned.
-Do not comment on how they look. The person is already too
aware of their body. Even if you are trying to compliment them, comments about
weight or appearance only reinforce their obsession with body image and weight.
-Make sure you do not convey any fat prejudice, or reinforce their desire
to be thin. If they say they feel fat or want to lose weight, don't say
"You're not fat." Instead, suggest they explore their fears about
being fat, and what they think they can achieve by being thin.
-Avoid power struggles about eating. Do not demand that they
change. Do not criticize their eating habits. People with eating disorders are
trying to be in control. They don't feel in control of their life. Trying to
trick or force them to eat can make things worse.
-Avoid placing shame, blame, or guilt on the person regarding
their actions or attitudes. Do not use accusatory “you” statements like, “You
just need to eat.” Or, “You are acting irresponsibly.” Instead, use “I”
statements. For example: “I’m concerned about you because you refuse to eat
breakfast or lunch.” Or, “It makes me afraid to hear you vomiting.”
-Avoid giving simple solutions. For example, "If you'd
just stop, then everything would be fine!"
Treatment:
The
most effective and long-lasting treatment for an eating disorder is some form
of psychotherapy or psychological counseling, coupled with careful attention to
medical and nutritional needs. Ideally, this treatment should be tailored
to the individual and will vary according to both the severities of the
disorder and the patient’s particular problems, needs, and strengths.
Psychological counseling must address both the
eating-disordered symptoms and the underlying psychological, interpersonal, and
cultural forces that are contributing to the eating disorder.
-The individual needs to learn how
to live peacefully and healthfully with food and with her or himself.
-Typically care is provided by a
licensed health professional, including but not limited to a psychologist,
psychiatrist, social worker, nutritionist, and/or medical doctor.
-Care should be coordinated and
provided by a healthcare professional with expertise and experience in dealing
with eating disorders.
Many people with eating disorders respond to outpatient
therapy, including individual, group, or family therapy and medical management
by their primary care provider. Support groups, nutritional counseling,
and psychiatric medications under careful medical
supervision have also proven helpful for some individuals. Hospital-based care
(including inpatient, partial hospitalization, intensive outpatient and/or
residential care in an eating disorders specialty unit or facility) is
necessary when an eating disorder has led to physical problems that may be life
threatening, or when it is associated with severe psychological or behavioral
problems. The exact treatment needs of each individual will vary. It is
important for individuals struggling with an eating disorder to find a health
professional they trust to help coordinate and oversee their care.
Treatment must address the eating disorder symptoms and
medical consequences, as well as psychological, biological, interpersonal and
cultural forces that contribute to or maintain the eating disorder.
Nutritional counseling is also necessary and should incorporate education about
nutritional needs, as well as planning for and monitoring rational
choices by the individual patient.
Many people with eating disorders
respond to outpatient therapy, including individual, group or family therapy
and medical management by their primary care provider. Support groups,
nutrition counseling, and psychiatric medications administered under careful
medical supervision have also proven helpful for some individuals. Family Based
Treatment is a well-established method for families with minors.
Inpatient care (including
hospitalization and/or residential care in an eating disorders specialty unit
or facility) is necessary when an eating disorder has led to physical problems
that may be life threatening, or when an eating disorder is causing severe
psychological or behavioral problems. Inpatient stays typically require a
period of outpatient follow-up and aftercare to address underlying issues in
the individual’s eating disorder.
The exact treatment needs of each
individual will vary. It is important for individuals struggling with an
eating disorder to find a health professional they trust to help coordinate and
oversee their care.
Psychotherapy
Psychotherapy needs to focus on a number of issues,
after a therapeutic, trusting relationship has been established. The most
powerful issue is the obsession with body-image, which is also the most
difficult to change. The client’s preoccupation with body-image can make any
clinician shake their heads in frustration; therapists must therefore carefully
monitor counter-transference issues. These individuals can be an extreme
challenging group to work with.
If the client is being seen in an inpatient
facility or presents to an outpatient center in a severely emaciated state,
basic nutritional needs must first be met. This is often done through an IV,
because the individual will refuse to eat. This is certainly not an ideal way
to start therapy or build a trusting relationship with the patient. The client
may need immediate attention to ward off medical complications, yet restoring
the body to a normal nutritional state may be the ultimate goal of therapy
overall. Gains will be slow and progress may be uncertain. The individual may experience
many relapses into anorexia before finally succeeding in therapy.
If the individual is not in immediate crisis or
suffering from medical complications from the disorder, individual
psychotherapy is usually a good starting basis of treatment. Cognitive-oriented
therapies, focusing on issues of self-image and self-evaluation, are likely to
be the most beneficial to the client. Distorted self-body images are most
common amongst people who suffer from this disorder and should be the initial
focus of treatment. The client should be instructed on how to recognize
appropriate weight and body fat proportions of a normal body and relate that to
theirs. Psychoeducational materials and approaches may be helpful in some
cases.
Often negative self-image is created by specific
traumatic events or memories within the individual’s developmental stages of
childhood. Parents may play an important role in helping to inadvertently
nurture a negative self-image in the individual. These are appropriate and
important issues in which to touch upon in therapy. Family therapy is therefore
sometimes beneficial in uncovering the reinforcers the individual is receiving
from significant others in their lives to remain thin. Family therapy can also
be very helpful in educating the family about the child’s disorder and how to
ensure the patient’s compliance with treatment recommendations. An individual’s
prognosis for recovery from an eating disorder is increased if the person does
not binge or purge and they have only had the disorder for less than 6 months.
A good support system is essential to quick recovery.
Group therapy is not only an appropriate modality,
but often a chosen modality for its cost-savings as well as its powerful
effects. In groups specifically devoted to issues of eating disorders, a
patient can gain not only support for the gradual gains they accomplish, but
also be confronted on issues more easily than in individual therapy.
Children and adolescents can also suffer from this
disorder. Treatment for this population needs to emphasize and increase the
positive reinforcements granted for each incremental weight gain. These should
occur on a daily basis and different rewards should be given for different
increments gained (e.g., a reward for 1/4 lb. should be different than a reward
for a 1/2 lb.). By focusing on weight increase and not food intake, this
technique will likely minimize distracting and useless arguments.
Hospitalization
Hospitalization of anybody for a mental disorder
can often be a confusing and emotion-wrought decision. Family members or
significant others may need to intervene in the patient’s life to ensure they
do not starve themselves to death. In these cases, hospitalization is not only
necessary, but a prudent treatment intervention. Family members should be aware
that individuals who suffer from anorexia nervosa will often resist treatment
of any sort, especially hospitalization. It is important, therefore, to come to
an agreement about the need for such a step and not be swayed by the patient’s
pleas for seeking alternative treatment options. Often these have already been
tried to no success.
A behaviorally-oriented token economy often exists
in psychiatric inpatient units specializing in eating disorders. This program
rewards patients for eating regular meals and ensuring they do not purge
afterwards. As the patient gains weight, additional hospital privileges may be
granted. A specific target weight should be set as the treatment goal, upon
which time the patient (ideally), should graduate from the hospital into an
outpatient program consisting of individual therapy, group therapy, or simply a
support group. Often this is not possible because of financial limitations.
Treatment will usually then continue in an outpatient modality. If such a
behavioral program is not implemented in the inpatient treatment facility the individual
is in, treatment progress will likely be much slower and less steady.
Daily fluid intake and weight should be tracked. If
the person vomits after meals, they should be watched for a few hours after
each meal to ensure no vomiting occurs. The individual’s diet should begin
between 1,500 and 2,000 calories per day. This calorie intake can increase
gradually as the patient makes treatment gains. The patient should have six
equal feedings throughout the day, although this may not always be possible.
Severely anorexic patients can be started on a liquid food supplement (e.g.,
Sustagen) or an IV, if necessary.
Inpatient programs (especially) should be careful
not to overemphasize the importance of a person’s weight, however. Weight is
only the symptom in this disorder of poor body image and self-esteem problems.
These primary difficulties should be the focus of any treatment approach for an
eating disorder. Weight gain can be used as an objective measure as to
treatment progress.
Medications
Some medications can be extremely helpful in
treatment a person who suffers from anorexia nervosa. As always, the medication
should be carefully monitored, especially since the patient may be vomiting,
which may impact on the medication’s effectiveness. A trusting and honest
relationship must be established between the physician and the individual or
mediation compliance will almost certainly become an issue.
Antidepressants (such as amitriptyline) are the
usual drug treatment and may speed up the recovery process. Chlorpromazine may
be beneficial for those individuals suffering from severe obsessions and
increased anxiety and agitation.
Electroconvulsive therapy (ECT) is never an
appropriate treatment option for a person suffering from an uncomplicated eating
disorder.
Self-Help
Self-help methods for the treatment of this
disorder are often overlooked by the medical profession because very few
professionals are involved in them. Self-help support groups are an especially
powerful and effective means of ensuring long-term treatment compliance and
decrease the relapse rate. Individuals find they can bounce ideas off of one
another, get objective feedback about body image, and just gain increased
social support. Many support groups exist within communities throughout the
world which are devoted to helping individuals with this disorder share their
commons experiences and feelings.
Treatment Settings and Levels of Care
Several types of treatment centers and
levels of care are available for treating eating disorders. Knowing the terms
used to describe these is important because insurance benefits (and the
duration of benefits) are tied not only to a patient’s diagnosis, but also to
the type of treatment setting and level of care.
Treatment is delivered in hospitals,
residential treatment facilities, and private office settings. Levels of care
consist of acute short-term inpatient care, partial inpatient care, intensive
outpatient care (by day or evening), and outpatient care. Acute inpatient
hospitalization is necessary when a patient is medically or psychiatrically
unstable. Once a patient is medically stable, he/she is discharged from a
hospital, and ongoing care is typically delivered at a subacute care
residential treatment facility. The level of care in such a facility can be
full-time inpatient, partial inpatient, intensive outpatient by day or evening,
and outpatient. There are also facilities that operate only as outpatient
facilities. Outpatient psychotherapy and medical follow-up may also be delivered
in a private office setting.
Treatment setting and level of care
should complement the general goals of treatment.
Typical
Goals:
-Medically
stabilize the patient
-Help the patient to
stop destructive behaviors (i.e. restricting foods, binge eating,
purging/nonpurging)
-Address and resolve
any coexisting mental health problems that may be triggering the behavior
Patients with severe symptoms often begin treatment as
inpatients and move to less intensive programs as symptoms subside.
Hospitalization may be required for complications of the disorder, such as
electrolyte imbalances, irregular heart rhythm, dehydration, severe
underweight, or acute life-threatening mental breakdown. Partial
hospitalization may be required when the patient is medically stable, and not a
threat to him/ herself or others, but still needs structure to continue the
healing process. Partial hospitalization programs last between 3 and 12 hours
per day, depending on the patient’s needs. Psychotherapy and drug therapy are
available in all the care settings. Many settings provide additional care
options that can be included as part of a tailored treatment plan. Support
groups may help a patient to maintain good mental health and may prevent
relapse after discharge from a more intensive program.
The intensity and duration of treatment depends on:
-Insurance coverage
limits and ability to pay for treatment
-Severity
and duration of the disorder
-Mental
health status
-Coexisting
medical or psychological disorders
A health professional on the treatment team will make
treatment recommendations after examining and consulting with the patient.
Criteria for Treatment
Setting and Levels of Care: These criteria summarize typical medical
necessity criteria for treatment of eating disorders used by many healthcare
facilities, eating disorder specialists, and health plans for determining level
of care needed.
-Inpatient
-The patient is
medically unstable as determined by:
-Unstable
or depressed vital signs
-Laboratory
findings presenting acute health risk
-Complications due to coexisting
medical problems such as diabetes
-The
patient is psychiatrically unstable as determined by:
-Rapidly
worsening symptoms
-Suicidal
and unable to contract for safety
-Residential
-The patient is medically stable
and requires no intensive medical intervention
-The patient is psychiatrically
impaired and unable to respond to partial hospital or outpatient treatment
-Partial
Hospital
-The
patient is medically stable but:
-Eating disorder impairs
functioning, though without immediate risk
-Needs daily assessment of
physiologic and mental status
-The
patient is psychiatrically stable but:
-Unable to function in normal
social, educational, or vocational situations
-Engages in daily binge eating,
purging, fasting or very limited food intake, or other pathogenic weight
control techniques.
-Intensive
Outpatient/Outpatient
-The patient is medically stable
and no longer needs daily medical monitoring
-The patient is psychiatrically
stable and has symptoms under sufficient control to be able to function in
normal social, educational, or vocational situations and continue to make
progress in recovery
Confidentiality
Issues
Parents of children of legal age or
friends of a person with an eating disorder may want to help navigate insurance
issues and finding treatment facilities, or participate in treatment, but
cannot talk with health professionals or facilities on a patient’s behalf
without the patient’s permission because of certain regulations protecting
medical privacy. The Health Insurance Portability and Accountability Act of
1996, or HIPAA, protects individuals’ medical records from becoming public
knowledge. HIPAA states that under normal circumstances, medical records are
private and that anyone with access to them, like healthcare professionals,
healthcare facilities, or insurers, cannot share that medical information with
anyone but the patient.
HIPAA protection also extends to human
resources (HR) departments at employers. If a person discloses his/her medical
condition to HR personnel when talking about health insurance benefits, HR is
required to maintain confidentiality. If HR divulges information without
permission, the harmed party can file a civil rights complaint. HIPAA requires companies
to have policies that provide for sanctions against any HR person who releases
confidential medical information. The Americans with Disabilities Act may
provide recourse for anyone fired from a job because of a medical condition.
If a friend or family member is helping
a patient through the treatment process, the patient can give oral permission
for that person to see the patient’s records and participate when talking with
healthcare providers or insurers. That person may also make doctors’ appointments
for the patient. A friend or family member cannot see a patient’s medical files
or transport the files or lab samples if the patient is absent, even if
permission has been given orally.
To grant a friend or family member
access to medical records, the patient must provide a durable power of attorney
(POA) document. This document varies by state so it’s best to have a lawyer
create it. Anyone with a POA can sign legal documents for the patient and read
or transport medical records in the patient’s absence.
Other documents worth knowing about
include a medical POA, which lets someone make medical decisions about the
patient’s healthcare if the patient is incapable of making these decisions. The
rules about medical POAs vary by state and it’s best to consult a lawyer to
write one. Advanced directives are another set of documents that the patient
authorizes for future treatment in case the patient cannot make decisions at
that time. Most hospitals have forms for patients to fill out to specify
instructions.
In most states parents have medical POA
over their children as long as the children are younger than age 18 although
the exact regulations depend on the state. Parents do not have medical or
durable POA over children who are older than age 18, even if the children are
covered under the parents’ health insurance policy. If a child is in college,
is over age 18, but is still covered by the parents’ insurance, then the
parents and child must go through the usual legal process to set up POA. This
can be a problem if the child does not want treatment or is at odds with the
parents, which is sometimes the case. Parents have no legal authority to force
a legally adult child into treatment.
Recreation Therapy
For Women Suffering With Eating Disorders
By: Kathleen Hofer, MSTRS
Quality of life is intimately associated with leisure
experience and opportunities for self-development and self-expression. Play,
recreation, and leisure experiences are an important aspect of the quality of
human existence. If we are to affirm our humanness and enjoy genuine happiness,
we must play. True quality of life is not found simply in improved functioning,
but in the discovery of our humanity through experiences of joyful freedom that
bring meaning and value to life. The purpose of recreation therapy is to
facilitate the development, expression, and maintenance of a healthy leisure
lifestyle.
Women who use eating disorders as a way to cope with life
have physical, mental, social, emotional, and spiritual limitations which
prevent the quality of life inherent in a healthy leisure lifestyle. Upon
admission to the inpatient program at Center for Change, an expressive therapy
assessment is completed for each patient. During the assessment, the patient
describes how the disorder has affected her leisure lifestyle. She identifies
active and creative leisure interests; perceptions of personal strengths, as
well as areas that need improvement; career ideas; feelings about spirituality;
and desires for treatment outcomes. It becomes apparent that the
obsessive/compulsive/addictive cycle of an eating disorder is leisure
dysfunction, a desperate attempt at relieving stress, fear, anxiety, shame,
guilt, anger, loneliness, insecurity, emptiness, and emotional pain. The
addiction gives a temporary false sense of euphoria and control - a counterfeit
transcendence. This is followed by increased guilt, shame, disgust,
discouragement, and spinning out of control. The eating disorder sufferer
becomes hostage to a dark self-destructive power.
When asked in the assessment interview, "What do your
active and creative leisure interests do for you?" patients have given the
following responses:
Stress release, takes away frustrations; Gets me back to
myself; Feel better about myself, sense of accomplishment; Express emotions;
Have fun, get away from routine; Challenge, perspective; Relaxation, express my
individuality; Adrenalin rush; I feel happy and calm; Capture nature and share
the excitement of dance; Uplifting, motivating; It's me, it's my creative,
happy self; Feel alive; Reminds me of my talents and abilities; Gets my mind
off things; Peaceful; Freedom, communication, invigorating, outdoors; Time for
myself; Confidence, forget painful emotions; Peace of mind.
When asked, “How does your eating disorder affect your
leisure interests and lifestyle?” patients responded with the following:
I don't have fun anymore; Less energy; Lost desire and
enjoyment; I gave up the things I like to do to have time to purge; It ruins my
singing voice; I passed out, lost interest; When I binge, I don't want to do
anything else; I'm always fatigued; No more joy, stopped doing anything else; I
canceled dates and socializing; Lost concentration. Had to stop playing sports;
It numbs me. No emotions; The eating disorder destroyed my life; I love water
sports and I'm too scared to wear a swimsuit; Nothing is fun anymore, I'm
grouchy, apathetic; I'm too cold. I isolate; It kills my creative energy.
Experiential recreation therapy interventions are planned to
break the addictive cycle and facilitate self-awareness and self-expression.
Experiential therapy differs from traditional psychotherapy in that an
"experience" is planned which can provide a learning "body
experience". Concepts such as pushing past the fear, teamwork,
communication, assertiveness, leadership, confidence, self-compassion,
acceptance of self and others, relying on higher power, and trust can be
experienced with the whole self (body, mind, and spirit). The Ropes Challenge
Course provides an experience where residents and their family members can
overcome physical challenges which then relate back to emotional challenges. A
patient could spend weeks talking about the concept of trust and not really
understand it until it becomes a personal body, mind, and spirit experience. A
recreation therapist is trained to help process planned experiences,
facilitating an in-depth examination of beliefs, thought processes, emotions,
and behavior patterns, helping patients experience how learning from experience
can create positive changes. Patients move out of their "comfort"
zone and into their "courage" zone.
The Center's Leisure Education Services are based on the
assumption that behavior can change and improve as the patient acquires new
leisure abilities, knowledge, skills, and attitudes. Leisure activities are
planned as a means of learning healthy coping skills. Active involvement in social
outings and creative leisure skills can provide new resources and promote
development of inherent talents. Service projects are planned as a means of
reaching out to others, discovering the joy of helping others. Patients are
encouraged to take increasingly more responsibility for their leisure mental
health. As patients become more focused on their strengths, gifts, and talents
they become empowered. Perceptions shift toward perceived freedom, competency,
problem-solving abilities, conflict resolution, successful experiences, and
internal motivation. Life as an adult woman begins to be viewed as exciting
rather than as terrifying. Eventually, patients can honestly believe "I
can be a responsible adult who has choices and options; life is an adventure;
it's never too late for a happy childhood."
Leisure Counseling as an aftercare service has been created
to help discharged patients transition, re-establish a social support network,
and re-integrate into their community. The recreation therapist acts as a guide
or a personal coach to support the recovery needs of the individual. True
leisure is only possible if a person is at peace with self. During re-creation,
they may begin to realize what it means to be truly human, truly alive. As the
recovering patient chooses life over death, chooses hope over despair, chooses
health over illness, chooses light over darkness, she begins to be
"re-created". A healthy sense of self and a clear and accurate
appreciation of who she is as a unique individual is critical to the experience
of healing. Healing leisure experiences promote a sense of connectedness to a
greater whole (environment and community). Recreation therapy addresses the
total needs of the woman suffering with an eating disorder, and those needs can
find fulfillment through leisure experiences. Recreation therapy can bring
women a sense of joy, laughter, belonging, and a renewed sense of wholeness.
The Recreational
Therapist Role in Prescribing Exercise to the Eating Disorder Patient
By Jon Mitchell, CTRS, CLC and Robyn
Eisenbach
University of Iowa Hospitals and Clinics
University of Iowa Hospitals and Clinics
Anorexia nervosa and bulimia are
psychiatric disorders that often lead to serious medical complications.
Anorexia nervosa is primarily a disorder, which involves restriction of food
intake to the point of starvation and weight loss. Bulimia is a syndrome of
binge eating, usually followed by some form of purging, which may be
self-induced vomiting, laxative use, or associated behaviors such as diuretic
use, diet pill use, or excessive exercise. Morbidity and mortality rates among
patients with eating disorders are among the highest recorded for psychiatric
disturbances. Using the specific recreational therapy intervention for eating
disordered clients, exercise prescription, this intervention will assist in the
role modeling of healthy levels of exercise, balance of lifestyle choices, and
improve the client's physical and psychological health. The distinctive feature
of recreational therapy, that makes it different from other therapies, is the
use of recreation activities as a mode of treatment. The recreational therapist
has a unique perspective regarding the leisure and social needs of a client
with an eating disorder. Recreational therapy can assist eating disordered
clients in assuming greater control over their leisure lifestyle, and is a
useful and effective addition to the treatment of the eating disordered client.
There are generic principles that are common to every training program, when these principles are applied to a particular individual, the principles are said to be the person's exercise prescription. Perhaps the best way to prescribe exercise to patients with an eating disorder is to first redefine what exercise is. Common definitions describe exercise as an activity for training or developing the body or mind. The average person with Anorexia or Bulimia Nervosa may interpret exercise as a way to cope with stressors or burn calories to help reduce weight. This sounds fine and may closely resemble what the rest of society has come to believe, but looking closely at what this really means to the person with an eating disorder, we see this distorted. Their intense fear of gaining weight, refusal to maintain a minimally normal body weight, and significant disturbance in the perception of the shape or size of his or her body drives these patients to over exercise. To these people exercise becomes an obsession. The client becomes obsessive in thought and compulsive in deed. Since society accepts exercise as a means of improving health, to persons with an eating disorder, it represents their freedom to engage in self-degrading behaviors under the guise of a socially accepted vehicle for improved wellness. A preoccupation with appearance may grow out of a preoccupation with health. This is one of many negative feedback cycles eating disordered patients face that yields stressed out, fatigued, and isolated individuals with low self-esteem.
There are generic principles that are common to every training program, when these principles are applied to a particular individual, the principles are said to be the person's exercise prescription. Perhaps the best way to prescribe exercise to patients with an eating disorder is to first redefine what exercise is. Common definitions describe exercise as an activity for training or developing the body or mind. The average person with Anorexia or Bulimia Nervosa may interpret exercise as a way to cope with stressors or burn calories to help reduce weight. This sounds fine and may closely resemble what the rest of society has come to believe, but looking closely at what this really means to the person with an eating disorder, we see this distorted. Their intense fear of gaining weight, refusal to maintain a minimally normal body weight, and significant disturbance in the perception of the shape or size of his or her body drives these patients to over exercise. To these people exercise becomes an obsession. The client becomes obsessive in thought and compulsive in deed. Since society accepts exercise as a means of improving health, to persons with an eating disorder, it represents their freedom to engage in self-degrading behaviors under the guise of a socially accepted vehicle for improved wellness. A preoccupation with appearance may grow out of a preoccupation with health. This is one of many negative feedback cycles eating disordered patients face that yields stressed out, fatigued, and isolated individuals with low self-esteem.
Exercise becomes a perceived need and
is often a determining factor for allowing them to feel like a success or
failure. If their busy day didn't allow them to get their exercise done, they
state an increase in stress and don't feel productive. Persons with Anorexia or
Bulimia may feel they need to exercise, especially after eating. This perceived
need also ties into the belief that their worthiness depends on how productive
they are and since exercise is generally accepted as productive, the more of it
the better. The person repeatedly exercises beyond the requirements for good
health. Cardiovascular health requires that 2,000 to 3,500 calories be burned
each week in aerobic exercise. After 3,500 calories are burned per week, the
health benefits decrease, and the risk of injury increases. It should also be
identified that many persons with an eating disorder also suffer from OCD or
OCD traits, which further complicates these exercisers ability to regulate
appropriate frequency, intensity, and time during their regime. The client may
keep detailed records, scrupously observe a rigid diet, and constantly focus on
an unattainable goal. Many times exercise becomes part of their daily rituals,
in which they feel compelled to complete a specific number of repetitions,
minutes, or miles depending on the activity.
There are a number of ways that the
Recreational Therapist plays a distinct role in prescribing appropriate
exercises and actually establishing a prescription. Of course, we must mention
incorporating fun and play into the routine. The client focuses on challenge,
and forgets that physical activity can be fun. Eating disorder clients'
exercises of choice tend to be walking, running, and a multitude of house
chores accompanied by vast quantities of sit-ups. These venues are usually
pursued alone, to a high intensity, follow a rigid pattern, are a means for
suppressing feelings, and allow few opportunities for breaks. This isn't a
particularly healthy form of exercise, nor is it as fun as being in a group or
with a partner.
As inherently social beings, we benefit
significantly from participating in exercises with friends or any other people.
Not only is exercising with others safer it yields opportunities for growth,
emotional support, and healthy competition. Especially beneficial to exercising
with friends is a potential sounding board for sorting out problems, rather
than avoiding them and literally running away from them, as the typical over
exerciser would do. Sociologists say we live in an age of narcissism, or
self-absorption in our bodies and ourselves. Both men and women are expected to
achieve perfect or near-perfect bodies: slim, toned, strong, agile, and
aesthetically appealing. The closer people get to the cultural ideal, the more
they notice the flaws that remain. They define self-worth in terms of
performance. We all have at times experienced having ourselves being our worst
enemy. This can especially be true when your standards are as high as those of
the typical eating disorder. There is constant competition involved during the
exercise routine for these people. Unfortunately, it is usually against
themselves and unaccompanied by any joy or praise for successes. In this way,
we see patients with eating disorders exercises as self-esteem vacuums, where
they are working hard, failing to meet expected (but unattainable) goals for
themselves and therefore not deserving of external praise. This is justified in
their mind as helping them to be thinner, more attractive, and therefore
deserving of attention from others. The problem with this can be summed up in
the adage, "you cannot, by doing something external, solve a problem that
is internal". It isn't hard to see how this isolative, high-energy
demanding, indirect approach to coping with problems is ineffective and tiring,
thereby lowering self-esteem.
The Recreational Therapist working
closely with persons having an eating disorder will also be able to assist them
in encouraging that their exercise activities are properly motivated. These
people will tell you outright that many times when they exercise or have
exercised, it was primarily to burn calories and fat, deal with guilt from
eating, or to avoid feelings. This is a form of purging and should not be
called exercise. They will even say that they "need" to exercise
rather than they "want" to exercise. If the exercise is motivated by
eating disorder driven guilt, perceived "need", obsessive urge, or
solely to burn fat (for below minimum target weight individuals) it needs to be
called something other than exercise. To me, a better word for activities driven
this way would be punishment. When you discuss this with eating disorder
patients, they can relate and are usually surprised by the accuracy of this
concept. This is a core concept for our exercise education groups and has
helped eating disorder patients closely look at their use of the word exercise
as a distortion of the true behaviors…purging and self-punishment. Teaching
these persons that they are deserving of praise and are productive even in the
absence of exercise and busy work is a challenging but necessary aspect of
their treatment. Dr. Arnold E. Andersen, an internationally renowned physician
who heads the program at the University of Iowa Hospitals and Clinics, likes to
tell our patients that they are human beings, not human-doings.
Another significant concept to assist
prescribing exercise to persons with Anorexia or Bulimia Nervosa is the idea of
considering total daily physical activity. Many of our subjects are students,
workaholics, or not in work or school at all, but are active most of the day.
Even though they may have walked to work or school, remained on their feet,
participated in P.E. and after school sports, and fulfilled compulsive chores,
they haven't "exercised" until they have visited the gym for at least
60 minutes of increased intense cardiovascular work. It should be mentioned
here that a contributory factor to this belief is the health related media, in
a nation dominated by predominantly obese and sedentary individuals. For many
of us, our jobs may entail sitting at a desk or in front of a computer for
eight hours per day, sitting in traffic jams, and then finally collapsing into
a vegetative state at the TV or computer. This working majority of us could be
said to "need" exercise in order to prevent or combat obesity, low
energy, low cardio respiratory functioning, and many other associated concerns.
Eating disorder patients however, have expended significant calories throughout
their day and maintained a heart rate and respirations above resting rate,
thereby eliminating the "need" for exercise.
Recreational Therapists play a significant role as ambassadors to promote stress management indirectly or directly to our clients. This topic warrants its own article, but can be touched on with regards to utilizing physical exercises as techniques many of us do use exercise to lower stress or to cope with stressors in our lives. To many persons with an eating disorder, relaxation or passive self-nurturing activities have disappeared from their lives. Replacing these means of reducing stress are active and seemingly "productive" asocial activities, devoid of pleasure or fun. In order to cope with their problems, we often see our clients avoid their situations, "stuff" their emotions, and attempt to externally control their internal struggles by exercising, restricting food intake, or purging. As any good stress management programs will emphasize, in order to relieve perceived stress, clients must tune into these problems, instead of stuffing their feelings or running away from the problem. These problems are in a sense "sent to the back burner", and as the pressure from these unresolved issues fester, stress boils to an overflow, leaving the person feeling overwhelmed. This stress "boil" can often be the driving force for excessive exercise. It may present itself as misplaced anger, guilt, disappointment, or dissatisfaction.
Recreational Therapists play a significant role as ambassadors to promote stress management indirectly or directly to our clients. This topic warrants its own article, but can be touched on with regards to utilizing physical exercises as techniques many of us do use exercise to lower stress or to cope with stressors in our lives. To many persons with an eating disorder, relaxation or passive self-nurturing activities have disappeared from their lives. Replacing these means of reducing stress are active and seemingly "productive" asocial activities, devoid of pleasure or fun. In order to cope with their problems, we often see our clients avoid their situations, "stuff" their emotions, and attempt to externally control their internal struggles by exercising, restricting food intake, or purging. As any good stress management programs will emphasize, in order to relieve perceived stress, clients must tune into these problems, instead of stuffing their feelings or running away from the problem. These problems are in a sense "sent to the back burner", and as the pressure from these unresolved issues fester, stress boils to an overflow, leaving the person feeling overwhelmed. This stress "boil" can often be the driving force for excessive exercise. It may present itself as misplaced anger, guilt, disappointment, or dissatisfaction.
We have to bear in mind the compromised
physical and mental capacities of persons with an eating disorder. Many have
exercised and restricted to the point of exhausting their necessary stores of
body fat. This prompts their body to break down muscle, organ, and tissues to
provide the body with energy. The compromised heart and skeletal muscles
reduces the functional capacity for the person's body to perform at, and
recover from, an optimal level of physical activity. A decrease in cardiac
chamber size, cardiac wall thickness, myocardial oxygen uptake, bradycardia,
and hypotension are all possible associated secondary conditions to the
clients' eating disorder. These secondary conditions can inhibit the exercise
prescription, and could potentially be a life-threatening situation. The
ability of anorectic patients to exercise at the level they do is surprising in
view of their decreased cardiac capacity to respond to exercise demand. Most of
these secondary conditions are reversible with weight gain.
There is much debate and uncertainty to
the degree of which cognitive functioning and decision-making skills are
compromised. We regularly observe eating disorder patients demonstrate a
limited capacity to choose appropriate exercises, self-regulate
obsessive-compulsive behaviors, and maintain a safe regime. The restricted mood
and flat affect often displayed by persons with eating disorders, combined with
frequent preoccupation with thoughts, can give the impression that there is a
decrease in mental capacity. These patients' minds are actually very busy with
their preoccupied thoughts…calculating calories, keeping mental food logs,
worrying, and focusing on their dissatisfaction with performance or physical
appearance. Theodore Reothke once said, "A mind too active is no mind at
all".
Exercise prescription can also help restore another common medical problem of eating disorder clients, bone density. Decreased bone density very often to the degree of osteoporosis and osteopenia has been noted in women with chronic anorexia nervosa. Fractures or the vertebrae, sternum, and long bones are common complications among the eating disorder patients.
Exercise prescription can also help restore another common medical problem of eating disorder clients, bone density. Decreased bone density very often to the degree of osteoporosis and osteopenia has been noted in women with chronic anorexia nervosa. Fractures or the vertebrae, sternum, and long bones are common complications among the eating disorder patients.
Digressing to the basic physiology of
exercise, it is important to remind the client with an eating disorder what is
happening to their body during exercise. When the muscles are strained, they
are broken down. Over the following 48 hrs or so, the body, utilizing ingested
food and periods of rest, rebuilds the lost tissues. The alarming combination
of over exercising and restricting food intake renders the body helpless
against the process of tearing the body down faster than it can rebuild.
Conforming to the concept of keeping energy input approximate to energy output, we prescribe an exercise with low F.I.T. (Frequency, Intensity, and Time) for the period in which they are restoring weight and until after at least 6 months of attaining their goal weight. It should be understood that at no time do we discuss the number of calories being burned or the client's weight, other than the general guideline of balancing energy input to energy output. We start the patient off with a frequency of only two to three times per week, have limits on intensity that don't allow their heart rate to exceed 55 - 60% of their maximal heart rate, and have a 20 minute limit on continual physical activity. We do also allow a five to ten minute warm-up and a five to ten minute warm-down on the front and back end of the exercise.
Conforming to the concept of keeping energy input approximate to energy output, we prescribe an exercise with low F.I.T. (Frequency, Intensity, and Time) for the period in which they are restoring weight and until after at least 6 months of attaining their goal weight. It should be understood that at no time do we discuss the number of calories being burned or the client's weight, other than the general guideline of balancing energy input to energy output. We start the patient off with a frequency of only two to three times per week, have limits on intensity that don't allow their heart rate to exceed 55 - 60% of their maximal heart rate, and have a 20 minute limit on continual physical activity. We do also allow a five to ten minute warm-up and a five to ten minute warm-down on the front and back end of the exercise.
Upon admission to UIHC, patients with
an eating disorder are required to remain relatively sedentary to interrupt
their focus on physical activities as a primary segment of their day. This
allows the patient having an eating disorder to focus on thought distortion,
family problems, body image, self esteem, and many other core issues that often
sprout the compulsive urges to over exercise or exercise for the wrong reasons.
Equally important, this initial period of exercising at a reduced F.I.T. will
allow the body tissues to restore and replenish. These factors will yield a
mind and body more able to handle stress of exercise and responsibility of
initiating and performing it appropriately.
Specific types of exercise we prescribe
are low impact, low intensity, and have a small risk of falling or collisions.
This prevents significant jarring of bones, damage to joints, tendons, and
muscles that are made weak from these persons' poor nutrition. The exercises
are to be performed with a partner or in a group as often as possible.
Especially beneficial are modalities such as weight lifting, walking, and
stationary cycling. These can be easily structured to start with lighter
workloads and slowly progress to higher ones. This conditions the clients' bone
density and lean tissue to progress accordingly. Building and maintaining
muscle and bone mass requires weight-bearing exercise. Individual requirements
vary depending on age and level of fitness. Overdoing weight-bearing exercise
can tear down muscle tissue instead of building it, and also damage bones,
joints, cartilage, tendons, and ligaments. Our prescription centers around the
idea that their degraded body tissues and loss of weight need time to recover,
so they will begin with a light work load and gradually progress to a more
moderate one. The patients are able to restore lost weight and participate in
physical activities during their stay, which greatly reduces anxiety from being
sedentary and feel like all they are gaining is fat tissue.
Successful treatment of patients with
eating disorders relies on the joint efforts of a variety of professions in the
human services field. The most effective approach has been to follow a
cognitive behavioral model and utilize a multidisciplinary team. Integral
players in this team are physicians, nurses, dieticians, psychiatrists,
occupational therapists, recreational therapists and social workers. The
recreational therapist has a unique opportunity to allow patients to practice
appropriate physical activities and teach exercises within the parameters of
the prescription. Many of the professionals on our team have frequent
discussion groups to address problems and concerns our patients focus on. The
Recreational Therapist provides hands-on participation in guided activities to
stimulate the patient to function in a similar fashion to that which they would
do outside of the hospitalized setting. We are able to process through
emotional struggles and catch inappropriate behaviors as they arise and even before
they would happen, rather than significantly later than the stress inducing
trigger took place.
Throughout our exercise sessions, we
process how patients can be working on high self-esteem, body image, social
skills, coping skills, and stress management. One of our best exercise groups
to address all of these areas is aquatic therapy. We require the patient to
wear a swimming suit, take them to an area surrounded by fitness equipment and
full-length mirrors, and allow them to experience fun exercises in the water.
Participants are able to improve not only a very safe modality of exercise, but
directly requires the patient to address body image concerns and overcome fears
of looking in the mirror. This has proven to be one of the most rewarding experiences
for our patients as the high degree of initial anxiety yields a high degree of
self-satisfaction upon completion of the activity.
Exercise prescription is one of the
many ways in which the Recreational Therapist can intervene to foster improved
rate of recovery for eating disorder patients. Our efforts in close conjunction
with the multidisciplinary team, are paving the way for eating disorder
patients to enjoy an active and healthy lifestyle in an appropriate balance
with their nutrition and social lives. These individuals are more emotionally
stable, more able to physically function closer to functional capacity, and
demonstrate sounder cognitive skills than prior to beginning treatment. Most
enjoyably, these persons are able to derive more fun out of their daily lives
and can better balance the amount of work with play.
References
Andersen,
Arnold E. Medical consequences and complications of the eating disorders.
Directions in Psychiatry, Vol. 8, Lesson 10. Brotman, Andrew W., Herzog, David
B., & Rigotti, Nancy. (May/June) 1985.
Medical
Complications of eating disorders: outpatient evaluation and management.
Comprehensive Psychiatry, Vol. 26, No. 3, 258-272.
Career
Information. American Therapeutic Recreation Association. [Online]. Wed. July
18, 2001. Available HTTP: http://www.atra-tr.org/careerinfo.htm.
Definitions.
ANRED, Anorexia Nervosa and Related Eating Disorders, Inc. [Online]. Available
HTTP: http://www.anred.com.
Exercise
prescription. ANRED, Anorexia Nervosa and Related Eating Disorders, Inc.
[Online]. Available HTTP: http://www.anred.com.
Jake,
Laurie. Promoting recovery from eating disorders through a healthy leisure
lifestyle. Connections, Vol. 1, Issue 5, 12.
Male
and female obligatory exercise. ANRED, Anorexia Nervosa and Related Eating
Disorders, Inc. [Online]. Available HTTP: http://www.anred.com.
Neiman, David C. Fitness and Sports Medicine. Copyright 1990. Bull Publishing Company. 183.
Neiman, David C. Fitness and Sports Medicine. Copyright 1990. Bull Publishing Company. 183.
Prevention
of eating disorders. ANRED, Anorexia Nervosa and Related Eating Disorders, Inc.
[Online]. Available HTTP: http://www.anred.com
Shangold,
Mona M. Beyond the exercise prescription: making exercise a way of life. The
Physician and Sportsmedicine, Vol. 26, No. 11. (November) 1998. Available HTTP:
http://www.physsportsmed.com/issues/1998/11nov/shangold.htm.
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