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Living With Food: The Science Supporting Eating Disorder Treatment

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Is Obesity an Eating Disorder?

Posted by Sarah Emerman on Fri, Mar 26, 2010 @ 10:11 AM
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By Dr. Lucene Wisniewski 
 
There are people who think that if you’re obese, then by definition you must have a pathological relationship with food. Just as everyone who has a low body weight does not have anorexia, the notion that all individuals who have a higher body weight have an abnormal relationship with food is false. Weight doesn’t tell you anything about whether or not a person has an eating disorder. So if you’re overweight you may or may not have an eating disorder. One of things we do know is that 1/3 of people who show up to weight loss clinics meet the diagnostic criteria for Binge Eating Disorder. The probability, therefore, is that an overweight individual does not meet criteria for an eating disorder, and their weight may instead be a consequence of an interaction between environment and genetics, or that the individual is eating past the point where they are full.
 
Binge Eating Disorder falls under the category of an unspecified eating disorder in the current DSM IV. Proposed changes to the DSM V, however, qualify Binge Eating Disorder as its own category based on the following diagnostic criteria:
 
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
  1. eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances
  2. a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)
B. The binge-eating episodes are associated with three (or more) of the following:
  1. eating much more rapidly than normal
  2. eating until feeling uncomfortably full
  3. eating large amounts of food when not feeling physically hungry
  4. eating alone because of being embarrassed by how much one is eating
  5. feeling disgusted with oneself, depressed, or very guilty after overeating
C. Marked distress regarding binge eating is present.
 
D. The binge eating occurs, on average, at least once a week for three months.
 
E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior (i.e., purging) and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.

When we define binge eating we’re talking about eating a large amount of food in a consolidated period of time. This isn’t to say that an individual with a healthy eating pattern doesn't eat past the point they are full once in a while. The differentiation is in the feeling that one has lost control over their eating. That is to say that the person who is binge eating couldn’t have stopped, even if they wanted to. Additionally, along with a loss of control, following a binge a person typically feels a high degree of guilt and shame. One indicator of a normalized eating pattern is eating when you're hungry and stopping when you're full. Its also normal to have variability in your hunger and fullness depending on things like activity, stress, and caloric intake.
 
Its important to note that while the majority of people who meet criteria for binge eating disorder are overweight, this is not true for all. For some people, their bodies are more efficient in metabolizing and storing caloric energy. If a person is binge eating then it requires different treatment than a person would receive if they were obese without the presence of binge eating. If you have binge eating disorder and you’re overweight, focusing just on the weight will probably not be adequate. There are many empirically founded treatments that are thought to be helpful for binge eating disorder. Cognitive behavioral therapy, Interpersonal Therapy, and Dialectical Behavioral Therapy have all shown to be helpful. CBT, however, should be the first line of treatment (Grilo & Masheb, 2005). While behavioral weight control and a restrictive diet may help decrease binging episodes temporarily, CBT will be a better long term intervention.  

For more information on binge eating disorder visit: 
 
Grilo, C. M. & Masheb, R. M. (2005). A randomized controlled comparison of guided self-help cognitive behavioral therapy and behavioral weight loss for binge eating disorder. Behaviour Research and Therapy, 43, 1509-1525. 
 
Contributions by Sarah Emerman 

The Relationship Between the Media and Eating Disorders

Posted by Mark Warren on Fri, Mar 19, 2010 @ 02:43 PM
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The media has a very complicated relationship with eating disorders. There are many different crosscurrents in the ways the media treats food, bodies, individuals with eating disorders, and weight issues. Any conversation about the media and eating disorders must take into account that at any given moment there are many levels of complexity in the conversation.
 
We know that the images presented in the media are highly distorted, extreme, and often present an image that is frankly disordered. In general, the thin female ideal is almost universal in media images. At the same time, food advertisers devote vast amounts of time and energy to encourage people to overeat. Shows such as Man v. Food present unrealistic expectations of what people can cook and consume. While, on shows like Dr. 90210 and The Swan, plastic surgeons and dermatologists suggest ongoing surgical modifications of whatever body type you happen to have. The media, therefore, is both triggering and confusing and will leave almost anyone unhappy with their body and convinced there is something they need to do to change how they look.
 
However, when someone is ill with an eating disorder, or dies from an eating disorder, the media usually turns away. Recent deaths of celebrities tend to focus on drugs, alcohol consumption, sexual behaviors, incompetent physicians, Hollywood pressures, and other issues without ever asking the question “could an eating disorder have caused or contributed to this death?” Given the extraordinarily high mortality of eating disorders, the highest of any other mental illness, and the prevalence in our culture, this is a glaring omission.
 
There’s no easy answer to understanding how to resolve the multiple deficits of the media world. Certainly we have found that some reporters and journalists are very proactive and are our allies in the fight for accurate representation of female and male body types. Hopefully many more members of the media will work to change how people with eating disorders are portrayed and to reduce the triggers and the images that we see. As professionals, our role is to educate and try to provide a counterbalance to some of the terrible imagery and falsehoods that are spread, and to keep working to create a supportive culture for those who suffer from eating disorders.
 
 
Contributions by Sarah Emerman 
 

The Comorbidity Between Borderline Personality Disorder and Eating Disorders

Posted by Sarah Emerman on Fri, Mar 12, 2010 @ 09:45 AM
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By, Dr. Anita Federici

A significant number of individuals with an eating disorder also meet diagnostic criteria for other mental illnesses (e.g., anxiety disorders, major depression, etc.). One topic that has received increased attention in recent years is the relationship between Borderline Personality Disorder (BPD) and eating disorders. Studies show that 25% to 54% of individuals with an eating disorder also meet diagnostic criteria for BPD (Sansone & Levitt, 2006). The co-occurrance of the two disorders tends to be higher among those who exhibit more impulsive behaviors, such as binge eating and purging.

BPD is listed under axis II of the DSM IV. In order to receive a diagnosis, individuals must meet a minimum five of nine criteria. These criteria may be re-organized into five core areas of dysregulation:

  1. Emotional Dysregulation: Individuals with BPD often experience emotional ups and downs, often in a given day. There may be chronic negative feelings, anxiety, and problems with anger and irritability. Mood changes can happen suddenly and are often triggered by situations in the external environment.
  2. Behavioral Dysregulation: Individuals with BPD often engage in recurrent impulsive and self-destructive behaviors. These may include: suicide attempts, suicide threats, self-injury, alcohol and drug abuse, impulsive sexual behavior, gambling, binge eating and/or purging.
  3. Cognitive Dysregulation: This category refers to increased suspiciousness/mistrust of others and/or dissociation (e.g., feeling like the world around you is not quite real). Typically these symptoms increase under stressful conditions.
  4. Interpersonal Dysregulation: Relationships are often described as intense, unstable, and chaotic. Frantic efforts are made to avoid abandonment and feelings for others can be intense and may change quickly.
  5. Dysregulation in Sense of Self: Individuals with BPD often experience an unstable sense of identity and/or chronic feelings of emptiness.

Some researchers believe that the co-occurance of both disorders may be caused by an inability to tolerate and skillfully manage negative or unpleasant emotions. 

Given the significant overlap between these two disorders, researchers are interested in developing effective treatment for clients who present with both BPD and an eating disorder. Recently, there is exciting and promising evidence for the use of Dialectical Behavior Therapy (DBT). DBT is effective for reducing impulsive and self-destructive behaviors in individuals with a primary diagnosis of BPD. Studies show that DBT reduces, and often eliminates, suicidal and self-injurious behaviors. Early studies also show that DBT is a promising intervention for women with a primary eating disorder diagnosis. DBT has been associated with reduced binge eating and purging behaviors. Studies evaluating DBT for individuals with both disorders are underway. Currently, our center is piloting the feasibility and effectiveness of DBT for individuals with both disorders, including those with multi-diagnostic presentations (such as comorbid PTSD, anxiety disorders, or Obsessive Compulsive Disorder).

For more information on Borderline Personality Disorder check out:

Contributions by Sarah Emerman

 

 

The DSM V and Eating Disorders

Posted by Mark Warren on Fri, Mar 05, 2010 @ 09:36 AM
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Psychiatry, and by extension all mental health fields, are to some degree reliant on the Diagnostic Statistical Manual of the American Psychiatric Association. This manual, currently in its 4th addition, is now being re-evaluated for the upcoming 5th edition, known as the DSM V. The DSM is critical in multiple areas of mental healthcare. Its primary function is to provide a behavioral basis for diagnosis. In doing so, it provides standards by which a diagnosis can be reasonably made, that are considered valid and useful for the patient who is receiving the diagnosis.

The core feature of effective healthcare is the ability to link various treatments to different diagnoses. One of the most important ways to determine if you are receiving effective care is to know that your diagnosis impacts your treatment. A provider who believes one treatment treats all is unlikely to be providing effective care. In developing the DSM V, the American Psychiatric Association is acknowledging the importance of supporting the need for accurate diagnosis and effective treatment based on that diagnosis.

The process of developing accurate diagnoses is complicated. Early DSM versions are primarily informed by a psychodynamic view of the world and are not behaviorally organized. Starting with the DSM III in 1975, greater emphasis has been placed on behaviors and their treatment. The DSM V will be the most recent attempt to be as specific and clear as possible about true diagnostic categories and how best to understand complex psychological presentations. It is the nature of these diagnoses and definitions that they will not be perfect, final, or complete and that modifications will continue to occur. However, each manual has been an improvement of its predecessor and we believe the DSM V will be as well.

For eating disorders, there are some significant changes proposed for the DSM V. These include: 

  • The addition of Binge Eating Disorder as separate diagnosis. At this time, Binge Eating Disorder falls under the diagnosis of a non-specified eating disorder. Binge Eating Disorder, however, is likely the most common eating disorder, has significant medical complications, and may have effective behavioral treatment. Thus, patients will benefit by its having its own separate diagnostic category.
  • The diagnosis for Anorexia Nervosa has been changed with the removal of the criteria for amenorrhea. This particular criteria has historically been used for research but is not considered to be a specific marker for the illness and it is possible to have anorexia while still having a normal menses. Its removal therefore will enable more patients to receive effective care.
  • Bulimia Nervosa has been changed so that the number of episodes per week is no longer a central criteria for a diagnosis. In the DSM IV, the binge/purge cycle had to be present 3-4 times per week. Under the new criteria, the number of episodes per week has been reduced to one. Again, this change will result in more people with BN being able to access effective care.

 

Next week: The comorbidity between borderline personality disorder and eating disorders  

 

Contributions by Sarah Emerman

 

 

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