The Eating Disorders Sourcebook: A Comprehensive Guide to the Causes, Treatments, and Prevention of Eating Disorders (Sourcebooks) - Softcover

Costin, Carolyn

Softcover

ISBN 10: 0071476857 ISBN 13: 9780071476850

Publisher: McGraw Hill, 2007

Synopsis

Sound, sensitive advice for overcoming an eating disorder

Anorexia, bulimia, binge eating, exercise addictions . . . these disorders can be devastating, but they are in no way unbeatable. Therapist Carolyn Costin, herself recovered from anorexia, brings three decades of experience and the newest research in the field together, providing readers with the latest treatments, from medication and behavioral therapy to alternative remedies.

Whether you are living with an eating disorder or you are a loved one or professional helping someone who is, The Eating Disorder Sourcebook will help you:

• Recognize and identify eating disorders
• Discover and work with the underlying causes of an eating disorder
• Make the right choices when comparing treatment options
• Understand what is expected in individual, group, and family therapy
• Know when outpatient treatment is not enough and what else can be done

About this title

About the Author

Carolyn Costin, M.A., M.Ed., M.F.T., has been a specialist in the field of eating disorders for nearly thirty years. She directs the Monte Nido Residential Treatment Facility in Malibu, California, and all of its affiliates. She is also the clinical advisor to the Parent Family Network of the National Eating Disorder Association and an editor of Eating Disorders: The Journal of Treatment and Prevention.

From the Back Cover

Sound, sensitive advice for overcoming an eating disorder

Anorexia, bulimia, binge eating, exercise addictions . . . these disorders can be devastating, but they are in no way unbeatable. Therapist Carolyn Costin, herself recovered from anorexia, brings three decades of experience and the newest research in the field together, providing readers with the latest treatments, from medication and behavioral therapy to alternative remedies.

Whether you are living with an eating disorder or you are a loved one or professional helping someone who is, The Eating Disorder Sourcebook will help you:

• Recognize and identify eating disorders
• Discover and work with the underlying causes of an eating disorder
• Make the right choices when comparing treatment options
• Understand what is expected in individual, group, and family therapy
• Know when outpatient treatment is not enough and what else can be done

Excerpt. © Reprinted by permission. All rights reserved.

The Eating Disorders Sourcebook

A Comprehensive Guide to the Causes, Treatments, and Prevention of Eating Disorders

By Carolyn Costin

The McGraw-Hill Companies, Inc.

Copyright © 2007 Carolyn Costin
All rights reserved.

ISBN: 978-0-07-147685-0

Contents

Acknowledgments
Contributors
Introduction
1 From Diet to Disorder: Problems and Prognosis
2 Young, White, and Female: Myth or Reality?
3 Activity Disorder: When a Good Thing Goes Bad
4 Genes or Jeans: What Causes Eating Disorders?
5 Eating Disorder Behaviors As Adaptive Functions
6 To Those Who Love Them: Guidelines for Family and Significant Others
7 Assessing the Situation
8 Treatment Philosophy and Approaches
9 Individual Therapy: Putting the Eating Disorder Out of a Job
10 Sharing the Pain and the Promise in Group
11 Family Therapy: Working with Families and Significant Others
12 Enough About Your Mother, What Did You Eat Today?
13 Medical Assessment and Management
14 The Psychiatrist's Role and Psychotropic Medication
15 When Outpatient Treatment Is Not Enough
16 Alternative Approaches to Treating Eating Disorders
17 Increasing Awareness and Prevention
Appendix: Eating Disorder Organizations and Websites
Suggestions for Further Reading
Bibliography
Index

Excerpt

CHAPTER 1

From Diet to Disorder: Problems and Prognosis

Disordered eating is alarmingly common, and having an eating disorder is oftenseen—except by those who have one or their family members—as a dietstrategy, a phase, or a trendy thing to do. In 2005 a television comedy seriescalled "Starved" included scenes in which eating disorder behavior was mockedand shown to be, according to the producer, "tragically comic." In one episode,a character pours detergent all over a dessert to avoid eating it, then laterretrieves it from the trash for a binge. Another scene portrays a policemanwho's been diagnosed with bulimia letting a deliveryman out of a ticket inexchange for Chinese food, on which he then binges and purges in an alley,accidentally vomiting on a homeless man. Is this funny? Is it entertainment?Would we accept a comedy about a skid-row alcoholic or heroin addict?

Groups such as the National Eating Disorder Association (NEDA) and theAssociation of Anorexia Nervosa and Related Disorders (ANAD) led a publicoutcry. Sponsors pulled out under the pressure, and the show was cancelled. Both"Starved" and the grassroots organizations that protested against it areevidence that eating disorders are now part of our culture and are increasinglyearning respect as illnesses rather than lifestyle choices as the Pro Ana (shortfor pro Anorexia) websites would have us believe. As difficult as it is tounderstand the growth of websites promoting this illness, their proliferationproves that eating disorders have come out of the closet and into our livingrooms, and few of us can remain unaware or untouched.

Elementary school girls continue to starve and purge as an acceptable method ofweight loss. Binge eating disorder (BED), although still not yet listed as aseparate diagnosis in the Diagnostic and Statistical Manual for MentalDisorders, Fourth Edition (DSM-IV), is increasingly discussed as an illness.Sadly, eating disorders have become mainstream on both ends of the spectrum. Inour current cultural climate, instead of asking, "Why do so many people developeating disorders?" one wonders, "How is it that anyone, especially a female,does not develop one?"

Are Eating Disorders More Common Now or Have They Just Been Hiding?

The first hint that eating disorders were a serious problem came from HildeBruch, who in 1973 introduced the first major work in the field, EatingDisorders: Obesity, Anorexia Nervosa, and the Person Within. This book wasgeared toward professionals and not readily available to the public. Bruchfollowed it up in 1978 with her pioneering work The Golden Cage, which continuesto this day to provide a compelling, passionate, and empathetic understanding ofthe nature of eating disorders, particularly anorexia nervosa. With the book andtelevision movie The Best Little Girl in the World, Steven Levenkron brought anawareness of knowledge of anorexia nervosa into the average home. And in 1985,when Karen Carpenter died from heart failure due to anorexia nervosa, thepicture of the emaciated singer haunted the public from the cover of Peoplemagazine.

Since then, women's magazines and television journalists have presented us withstories of people who we thought had everything—beauty, success, power,and control—but who were lacking something else, as they began to admitthat they too had eating disorders. Olympic gold medal gymnast Cathy Rigbyrevealed a struggle with anorexia and bulimia that almost took her life, andseveral others followed suit, including Gilda Radner, Princess Diana, SallyField, Elton John, Tracy Gold, Paula Abdul, and more recently Mary Kate Olson,Felicity Huffman, Jamie-Lynn DiScala, and Portia de Rossi to name just a few. Inher recent autobiography, Jane Fonda describes having led a double lifesuffering secretly from anorexia and bulimia throughout most of it even with allof her success and fame. Talk shows on eating disorders continue to feature themedia's fascination with every possible angle one can imagine: "Anorexics andTheir Moms," "A Ten-Year-Old Boy with Anorexia," and "Eating Disordered Twins."

Similar to chemical dependency in the 1970s and 1980s, eating disorder treatmentis a growing business, with hospital and residential eating disorder programsrapidly on the rise. Large corporations are now "investing" in this industry asa result of their market research. This can only mean that it is a growingproblem. The passage of the federal Mental Health Parity Act fueled the growthof this treatment industry by mandating that insurance companies cover majormental illness just as they would physical illness. However, the legislationallows each state the freedom to determine what constitutes a major mentalillness, and eating disorders are most often left out. To date, only 12 states(California, Connecticut, Delaware, Maine, Maryland, Minnesota, Rhode Island,New York, North Dakota, Vermont, Washington, and West Virginia) have state-mandatedinsurance coverage for the treatment of eating disorders, but thepressure is on to change this. To further exacerbate the struggle, for the mostpart, only medically necessary cases of anorexia nervosa and bulimianervosa—as diagnosed under DSM-IV—are insured for inpatient daytreatment and sometimes even outpatient settings. Clients with atypical or lesssevere cases often get no coverage at all.

When people ask, "Are eating disorders really more common now, or have they justbeen in hiding?" the answer is both, however, the overall trend shows that thenumber of individuals with eating disorders has been increasing continuallysince their recognition, paralleling society's growing obsession with beingthin, losing weight, and fear of fat.

Is It Disordered Eating or an Eating Disorder?

Eating disorders may seem more common today because even though individuals whohave them are reluctant to admit it, they do so more readily than in the past.People are more likely to know that they have an illness, the possibleconsequences of that illness, and that they can get help for it. The trouble isthey often wait too long. Determining when problem eating has become an eatingdisorder is difficult. There are far more people with eating or body imageproblems than those with full-blown eating disorders. The more we learn abouteating disorders, the more we realize that individuals may have varyingpredispositions to developing them. A person's particular genetic makeup mayaccount for a heightened sensitivity to the current cultural climate, thusincreasing the likelihood that he or she will cross the line between disorderedeating and an eating disorder. But when is this line crossed?

Diagnostic Criteria for Eating Disorders

To be officially diagnosed with an eating disorder, one has to meet the clinicaldiagnostic criteria delineated in the current edition of the Diagnostic andStatistical Manual for Mental Disorders IV TR (2000), but the specificdefinitions therein do not encompass all of the syndromes health professionalstreat. In fact, the DSM-IV TR criteria can be confusing, complicated, andrestrictive.

There is an ongoing, passionate discussion among experts in the field aboutchanging what is considered by many to be an outdated system of classification.The current DSM-IV TR diagnoses for eating disorders include anorexia nervosa(AN); bulimia nervosa (BN); and eating disorders not otherwise specified(EDNOS), which includes binge eating disorder (BED) as well as a variety ofsubclinical or more appropriately "atypical" eating disorder presentations.Clinicians and researchers alike are proposing alternatives to this model for avariety of reasons. One model proposes a general diagnosis of "eating disorder,"with a corresponding list of symptoms or features from which the clinician canchoose. This would alleviate the problem of changing the diagnosis when clientsdevelop new symptoms or gain or lose a certain amount of weight.

Furthermore, the severity of an eating disorder has historically been measuredby how well the client meets the full diagnostic criteria. Clinicians in thetrenches know that this is not the reality. I once treated a young woman whobegan dieting when she weighed 200 pounds. At the time of her first visit, shewas eating only 300 calories a day and had lost 70 pounds in one year. She wasfearful of eating, could not eat with anyone or in public, was terrified ofgaining weight, and met all the criteria for anorexia nervosa except that herweight was 130 (she was 5?4?). This young woman had one of the most entrenchedeating disorders I had ever treated, yet with a diagnosis of EDNOS, I could notget her approved for residential care because she did not meet criteria foranorexia or bulimia.

Changes in official diagnostic criteria happen slowly. There are ongoing debatesand calls for more research. Eventually we will have more clarity, but theclinical descriptions taken from DSM-IV TR are the currently accepted standards.

Cases of Anorexia Nervosa

Despite its increase over the last decade or so, anorexia nervosa is not a newillness nor is it solely a phenomenon of our current culture. For an interestinghistory of this illness, read Joan Brumberg's Fasting Girls: The History ofAnorexia Nervosa (1989). The case of anorexia nervosa most often cited as thefirst in the medical literature was that of a 20-year-old girl treated in 1686by Richard Morton and explained in his work Phthisiologia: Or a Treatise ofConsumptions (1694). Morton's description of what he termed nervous atrophy ornervous consumption sounds eerily familiar:

I do not remember that I did ever in my entire Practice see one that was soconversant with the Living so much wasted with the greatest degree ofConsumption, (like a Skeleton only clad with Skin) yet there was no Fever, buton the contrary a Coldness of the whole Body ... Only her Appetite wasdiminished, and Digestion uneasy, with Fainting Fitts, [sic] which didfrequently return upon her.

The first case study in which we have descriptive detail from the patient'sperspective is that of a woman known as Ellen West (1900–1933). Ellencommitted suicide at age 33 to end the desperate struggle that had manifesteditself through an obsession with thinness and food. Ellen kept a diary thatcontains perhaps the earliest record of the inner world of an eating disordersufferer:

Everything agitates me, and I experience every agitation as a sensation ofhunger, even if I have just eaten.

I am afraid of myself. I am afraid of the feelings to which I am defenselesslydelivered over every minute.

I am in prison and cannot get out. It does no good for the analyst to tell methat I myself place the armed men there, that they are theatrical figments andnot real. To me they are very real.

Like Ellen West, people suffering from anorexia today exhibit rigid control oftheir "out of controlness," making an effort to deny or to purge not just foodbut yearnings, ambitions, and sensual pleasures. Emotions are feared andtranslated into somatic (body) experiences and eating disorder behaviors, whichserve to eliminate the feeling, needing aspect of self. Through their strugglewith their bodies, individuals with anorexia nervosa pursue a mind-over-mattermentality, perfection, and mastery of self—all accomplishments that oursociety praises and applauds. This, of course, entrenches these patterns intothe very fabric of each individual's identity. Indeed, people with anorexianervosa seem not simply to have this disorder but to become it.

The term anorexia is of Greek origin—an (meaning "privation" or "lack of")and orexis (meaning "appetite")—indicating a lack of desire to eat. It wasoriginally used to describe the loss of appetite caused by some other ailmentsuch as headaches, depression, or cancer, where the person actually doesn't feelhungry. Normally, appetite is like the response to pain, beyond the individual'scontrol. Ellen West and others like her are not suffering from a loss of hungerbut from hunger and a denial of it that they cannot explain. They may eventuallydevelop a true lack of appetite, but for the most part, it is the strong desireto control their appetite that is a cardinal feature. Thus, the term anorexiaalone is insufficient because people afflicted with this disorder have not justlost their appetites. In fact, they long to eat, obsess and dream about it; someof them even break down and eat uncontrollably. Rather than losing their desireto eat, those suffering from anorexia report spending 70 to 85 percent of eachday thinking about food but denying their bodies even when driven by hungerpangs. They often want to eat so badly that they cook for and feed others, studymenus, read and concoct recipes, and go to bed and wake up thinking about food.They simply don't allow themselves to have it; if they do, they relentlesslypursue any means to get rid of it.

The full clinical term, anorexia nervosa (lack of desire to eat due to a mentalcondition), is a more appropriate name for the illness. This now-common term wasnot used until 1874, when British physician Sir William Gull used it to describeseveral patients who exhibited all the familiar signs we associate with thedisorder today: refusal to eat, extreme weight loss, amenorrhea (absence ofmenses), low pulse rate, constipation, and hyperactivity—all of which hethought resulted from a "morbid mental state." Other early researchers pointedout individuals with these symptoms and began to develop theories about why theywould behave in such a fashion. In 1903, psychiatrist Pierre Janet describes thecase of Nadja, who exhibits mixed features of an eating disorder, including anobsession with thinness. Janet described the syndrome by explaining that "it isdue to a deep psychological disturbance, of which the refusal of food is but theouter expression."

People with anorexia nervosa are afraid of food and of themselves. What often(but not always) begins as a determination to lose weight, progresses andtransforms into a morbid fear of gaining any weight—even when it isnecessary to maintain life. A relentless pursuit of thinness takes hold. Theseindividuals are literally dying to be thin. Being thin, which translates tobeing in control, becomes the most important thing in the world.

In the throes of the disorder, people with anorexia are terrified of losingcontrol, terrified of what might happen if they allow themselves to eat. Thiswould mean a lack of willpower, a complete "giving in," and they fear that oncethey let up on the control they have imposed on themselves, they will never getthat control back. They are afraid that if they allow themselves to eat, theywill not stop, and if they gain one pound today or even this week, that they arenow "gaining." A pound today means another pound later and then another andanother until they are obese. Physiologically speaking, there is a good reasonfor this feeling. When a person is starving, the brain is constantly sendingimpulses to eat. The strength of these impulses is such that the feeling thatone may not be able to stop is powerful. Self-induced starvation goes againstnormal bodily instincts and can rarely be maintained. It is also one reason why30 to 50 percent of individuals with anorexia ultimately end up binge eating andpurging food to the point of developing bulimia nervosa. This is why researchersare looking for differences in the biology of individuals who develop andmaintain anorexia.

People with anorexia fear, as crazy as it may seem when looking at them, thatthey are or will become fat, weak, undisciplined, and unworthy. To them, losingweight is good and gaining weight is bad—period. With the progression ofthe illness, there are eventually no fattening foods but simply the dictum that"food is fattening." The "anorexic" mind-set seems useful at the beginning of adiet when the goal is to lose a few unwanted pounds, but when dieting itselfbecomes the goal, there is no way out. Dieting becomes a purpose and what can bereferred to as "a safe place to go." It's a world that serves to help cope withfeelings of meaninglessness; low self-esteem; failure; dissatisfaction; the needto be unique; and the desire to be special, successful, and in control.Individuals with anorexia create a world in which they can feel they are"successful," "good," and "safe" if they can deny food, making it through theday while eating little, if anything at all. They consider it a threat and afailure if they break down and eat too much, which for them can be as little as300 calories or less. In fact, for some people with anorexia, eating any fooditem of more than 100 calories can cause great anxiety. They often prefer two-digitnumbers when it comes to calories and to their weight. This kind ofovercontrol and exertion of mind over matter goes against our understanding ofall normal physiological impulses and instincts for survival. Of the eatingdisorders, anorexia nervosa is the most tenacious, the most deadly, and the mostrare.

(Continues...)

Excerpted from The Eating Disorders Sourcebook by Carolyn Costin. Copyright © 2007 by Carolyn Costin. Excerpted by permission of The McGraw-Hill Companies, Inc..
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Edition details

• Publisher: McGraw Hill
• Publication date: 2007
• Language: English
• ISBN 10: 0071476857
• ISBN 13: 9780071476850
• Binding: Paperback
• Edition number: 3
• Number of pages: 352