Thursday, September 15, 2016

A 12-Item, Short-Form Questionnaire Results from the EDE-QS correlated well with those from the EDE-Q.

Reprinted from Eating Disorders Review
September/October Volume 27, Number 5
©2016 IAEDP
The Eating Disorders Examination Questionnaire (EDE-Q), a 28-item self-report questionnaire, is very widely used and considered a good alternative to the Eating Disorder Examination (EDE). It offers a shorter version that is easy for patients to complete. Why, then, develop an even shorter version of the EDE-Q
Dr. Nichole Gideon and colleagues recently reported their development of the EDE-QS, a 12-item short form of the EDE-Q (PLOS ONE, May 3, 2016). The authors developed the shorter questionnaire to address two problems they identified with the EDE-Q. According to Dr. Gideon, some study populations have not supported the EDE-Q's four-factor structure (Restraint, Eating Concern, Shape Concern, and Weight Concern), and patients consistently score higher on the EDE-Q than on the EDE. And, according to the authors, other inconsistencies between the two measures have been observed in the self-report assessment of features such as objective binge eating behaviors, laxative use, and self-induced vomiting. Even though the administration time for the EDE-Q is markedly shorter than that of the EDE, they contend that it is not ideal for use as a session-by- session outcome measure. 

Two studies to evaluate the questionnaire

Two studies were used to compare the two questionnaires. The goal of the first study was to develop a psychometrically and conceptually sound short form of the EDE-Qthat could be used to measure session-by-session changes. Data from 489 patients attending three eating disorders services in the United Kingdom between April 2008 and January 2013 were included; all data were anonymous when analyzed. 
The second study tested the questionnaire in two study populations, those with and those without EDs. To obtain their study population, the authors sent out an email appeal providing a link to an online survey to all students at a London university. The same link was advertised on the website of Beat (Beating Eating Disorders; https://www.b-eat.co.uk/ ), a charity supporting current and former ED patients. 
The survey included several online questionnaires, and was completed by 559 men and women. Of these, 54 (9%) currently had an eating disorder. Twenty-five had seen the study though the university email appeal and the rest were recruited through the Beat advertisement. All participants completed the EDE-QS, the EDE,and the Clinical Impairment Assessment (CIA), which analyzes impairment in psychosocial functioning secondary to an eating disorder. In addition they filled out the Short Evaluation of Eating Disorders (SEED), the SCOFF questionnaire, the Generalized Anxiety Disorder Questionnaire, the Patient Health Questionnaire, and the World Health Organization Quality of Life Questionnaire.

Was the shorter form effective?

Fewer men than women reported having an eating disorder, and those with an eating disorder reported lower levels of education. There also was a close correlation with the CIA because this questionnaire measures psychosocial impairment secondary to an eating disorder. The EDE-QS showed a positive association with other measures of eating disorder pathology in both groups, just as the authors had hypothesized. There was only a medium correlation between the EDE-QS and the SEED questionnaire.
The authors reported that the brevity and revised response categories on the EDE-QSbetter permit ongoing progressive monitoring, which has been shown to improve patient outcome. The availability of weekly session by session feedback data also may be more appropriate for mental health settings. One more bonus of the shorter instrument may be reduced burden on patients and staff.

The second study did have some limitations, including its small sample size and convenience sampling method. Also, the use of diagnostic assessment or interviews would have been preferable to the online method. The number of people who identified themselves as having eating disorders was relatively small. Finally, the authors noted that it would be a good step to establish clinically significant changes or cutoff points for the EDE-QS, to differentiate between nonclinical and clinical impairment in EDs.

Self-Control and its Connection to Disordered Eating Focusing on strict goals may miss deeper concerns.

Reprinted from Eating Disorders Review
September/October Volume 27, Number 5
©2016 IAEDP
Hilde Bruch was among the pioneers who defined anorexia nervosa (AN) as a struggle for control and a sense of identity, greater competence, and effectiveness. To Dr. Bruch, the symptoms of AN were manifestations of an individual's attempts to compensate for an underlying sense of ineffectiveness and lack of control in other parts of his or her life. Control over eating becomes a focus in an individual's life because it is seen as a success in the context of perceived failures.

A study from Australia

Psychologist Franzisca V. Froreich and researchers at the University of Southwest Australia, Sydney, recently studied the role of self-control in a group of 175 females with AN, who completed self-report questionnaires that addressed measures of control, eating disorders pathology and obsessive-compulsive symptoms (J Eat Disord. 2016; 4:14). The focus of the Australian study was to determine which form of individual self-control was most strongly associated with disordered eating. Another part of the study was exploring the relationship between self- control and obsessive-compulsive symptoms.

Finding patients through the Internet

The authors found their study participants in a somewhat unique way, through Amazon Mechanical Turk l (MTurk), a crowdsourcing website. Females who were registered with MTurk and living in the US, and who were between 18 and 40 were eligible to participate. A final study group of 175 women aged 19 to 40 years signed up for the study. After reading an introductory information page and giving consent, participants completed questionnaires, beginning with control-related questionnaires, presented in randomized order. 

A positive connection between ED symptoms and fear of losing self-control 

Just as the authors had hypothesized, eating disorder symptoms and obsessive-compulsive symptom severity were positively associated with external locus of control, negative sense of control, feelings of ineffectiveness, and fear of losing self-control. All were negatively associated with sense of mastery.
The authors report that although a number of control dimensions are related to disordered eating behaviors, ineffectiveness and fear of losing self-control are the strongest predictors of eating pathology. They also noted that none of the items in any of the control scales administered in this study directly referred to eating or weight or shape. Thus, the underlying control beliefs are not disorder-specific but more general in nature; in addition, the direction of causality between control and eating disorders cannot be determined by the results of this study, according to the authors. Instead, the results of this study add some evidence that ineffectiveness and fear of losing self-control are important to consider in the maintenance and treatment of disordered eating behaviors. 
Thus, treatment that focuses on stringent behavioral goals, such as reducing control over eating, weight and shape, may not address the deeper problems that underlie and often maintain these very symptoms. A more successful approach may be to help the individual re-establish adaptive mechanisms of personal control and effectiveness, and thus reduce the need to rely on weight and shape control.

Loss of Control Eating Can Be a Problem for Teens Planning Bariatric Surgery Problematic eating behaviors may affect up to 25% of these young patients.

Reprinted from Eating Disorders Review
September/October Volume 27, Number 5
©2016 IAEDP
Before undergoing bariatric surgery, severely obese teens may present with problematic disordered eating behaviors. Disordered eating is common among teens undergoing bariatric surgery; 20% to 48% report binge eating, eating faster than usual, and feeling guilty about eating, eating until uncomfortably full, eating without hunger, and preferring to eat alone (J Clin Psychiatry. 2012; 73:1351). Some may meet the diagnostic criteria for an eating disorder. 
Loss of control (LOC) eating is a subjective sense of being unable to stop or control eating, regardless of the food involved. According to members of the Teen Longitudinal Assessment of Bariatric Surgery (Teen-LABS) Consortium, LOC eating may be more clinically relevant than binge eating among adolescents, and may also be a better marker of eating-related psychopathology in teens than are objective binge-eating episodes (OBEs). (The Teen-LABS study is an ongoing cohort study of teens aged 13 to 19 who were enrolled and underwent bariatric surgery from 2007 to 2012.)

A study to identify teens with LOC eating

Dr. Linsey M. Utzinger, of the Neuropsychiatric Research Institute, Fargo, ND, and her colleagues analyzed data from the Teen-LABS study to identify candidates for their study (Int J Eat Disord. 2016; E-pub before print). Teens completed baseline assessments within 30 days of their bariatric surgery date. They also completed the following questionnaires: Questionnaire of Eating and Weight Patterns-Revised(QEWP-R), the Night Eating Questionnaire (NEQ), the Beck Depression Inventory(BDI-II), and the Impact of Weight on Quality of Life-Kids (IWQOL-Kids).
Two-hundred and forty-two teens (mean age: 17.1 years) participated in the study. One-hundred and eighty-three were females, and 59 were males. The median body mass index (BMI, mg/kg2) was 50.5. (One of the requirements for adolescent bariatric surgery is a BMI above 40, or a BMI between 35 and 40 when there is a serious comorbidity.)

Nearly one-fourth had LOC eating problems

The most common problematic eating behavior reported among the 242 teens was LOC eating, which was reported by 65 teens, or nearly 24% of the study group. Before they underwent bariatric surgery, nearly 7% of the teens met current criteria for binge eating disorder, or BED. Two teens met the criteria for bulimia nervosa, and 12 met the criteria for night-eating syndrome.
Compared to teens without LOC eating, those with LOC eating showed greater impairment on almost all psychosocial variables. This included greater depression and more marked impairment in weight-related quality of life. Unlike earlier studies showing that LOC eating in youth is associated with maladaptive family function, this was not the case in this study. It is still unknown whether the high rates of disordered eating behaviors in teen candidates for bariatric surgery persist or develop after surgery.

Requirements for surgery

Before being considered for bariatric surgery, teens must meet a number of requirements, beginning with a BMI of 35 to 40. Both patient and parent/guardian must provide consent for the procedure; the patient, and a parent/guardian must undergo psychological evaluation to be certain he or she is prepared for pre- and post-surgery requirements, including a supportive family environment, willingness to commit to strict diet, exercise and weight loss support groups, and physician follow-up for the rest of their lives. They also must have reached physical and skeletal maturity (Tanner Scale IV or V). Teen girls must be willing to avoid pregnancy for at least 1 year, and preferably 2, after the weight-loss surgery. Finally, prospective patients must agree to participate in a clinically supervised weight loss program, and to fail to lose weight on such program for at least 6 months.

The authors point out that it is important for clinicians to identify LOC eating problems among teens scheduled for bariatric surgery, and to make appropriate treatment referrals for these young patients.

Predicting Relapse Risk with Weight Gain Patterns

Reprinted from Eating Disorders Review
September/October Volume 27, Number 5
©2016 IAEDP

Fewer than half of patients treated for anorexia nervosa (AN) maintain their initial recovery, and up to 63% relapse after treatment. By identifying individual patterns of weight gain during inpatient treatment, clinicians might better evaluate an anorexic patient's treatment response, noncompliance, and risk of relapse, according to researchers from the University of Maryland, Stanford University School of Medicine, and Johns Hopkins School of Medicine. At the recent International Conference on Eating Disorders (ICED) meeting in San Francisco, Saniha H. Makhzoumi and colleagues reported identifying 3 distinct weight gain patterns in their study of 211 female inpatients with AN or subthreshold AN. 
The women had a mean age of 28.5 years, mean admission body mass index (BMI, mg/kg2) of 16.14, and had been ill with AN for a mean of nearly 11 years. The researchers assessed frequency of ED behaviors, and clinical variables on admission, such as BMI, age, target weight, behavioral subtype and number of prior hospitalizations for ED treatment. They also administered the Eating Disorder Inventory, the Eating Disorder Recovery Self-Efficacy Questionnaire, and the NEO Five Factor Inventory. The research team identified 3 distinct patterns of weight gain and response to treatment. Women with the highest risk of relapse were more likely to have purging subtype AN, and to have higher lifetime BMIs (and higher weight suppression), along with past hospitalizations for AN treatment.

BED: Overcoming Barriers to Diagnosis A new screening tool fits well with primary care settings.

Reprinted from Eating Disorders Review
September/October Volume 27, Number 5
©2016 IAEDP
Although binge eating disorder (BED) is the most common eating disorder, it often is unrecognized and undiagnosed, and thus untreated. BED was not formally recognized as a distinct eating disorder until 2013, when it was included in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Estimates of the lifetime prevalence of BED range from 1.9% to 2.8%, but treatment rates remain low, as reflected by World Health Organization (WHO) data. According to WHO, fewer than 40% of patients with BED ever have treatment (Biol Psychiatry. 2013; 73:904). Two recent studies have addressed ways to detect BED.

Overcoming barriers from clinicians and patients

According to Susan Kornstein, MD, and her colleagues, BED's low diagnosis and treatment rates can be traced to barriers posed by clinicians as well as patients (Prim Care Companion CNS Disord; 2016; 18:4088). First, clinicians may be unfamiliar with the newly available DSM-5 diagnostic criteria and treatment options. Then, shame, embarrassment, and also a lack of awareness of the disorder may make individuals with BED reluctant to seek help. To find possible solutions, the authors conducted a comprehensive search of Pub Med articles from January 2008 to December 2014. 

Suggestions to improve diagnosis

The authors' research showed several ways that the diagnosis can be improved. In many primary care practices, routine patient visits do not include assessment of weight and body mass index. Routinely adding a question about eating habits and following changes in body weight as part of a complete patient history would be a helpful first step, according to the authors. And, a patient's reluctance to discuss his or her eating habits, reflecting underlying shame and embarrassment, may serve as a red flag for possible disordered eating. BED often co-occurs with obesity and type 2 diabetes, and binge eating is one of the predictors for this comorbidity. Thus, according to the authors, primary care physicians should routinely assess individuals with diabetes for an undetected eating disorder. 

Some telltale signs

Other telltale signs that can point to BED include childhood obesity and family eating problems, as well as having a parent with a mood or substance use disorder. The authors noted that patients who are not obese may binge eat, and thus may be candidates for the diagnosis of BED. Patients with BED often gain weight during the year before they seek treatment. Therefore, primary care physicians who provide weight management programs for patients are in a good position to recognize BED. The authors found the Eating Disorder Examination-Questionnaire and the Questionnaire of Eating and Weight Patterns-Revised were among the most helpful self-report instruments.

A seven-item BED screening test

In a separate study, researchers developed the 7-item Binge-Eating Disorder Screener (BEDS-7), a patient self-report instrument (Prim Care Companion CNS Disord. 2016; 18:doi:10.4088/PCC.15m0896). Dr. Barry K. Herman and associates developed the screening tool based on DSM-5 diagnostic criteria for BED, comparisons with existing diagnostic questionnaires, and the results of face-to-face interviews with subjects who had self-reported BED symptoms. 
First, the researchers tested a 13-item pilot test in a cross-sectional study of 97 adults with BED. Seven of the 13 questions yielded 100% sensitivity and 39% specificity, so the test was shortened to 7 primary questions and includes statements such as, “I have no control over eating” and “I eat faster than normal.” Patients were able to indicate the strength of symptoms from “never or rarely” to “always”; another option was “missing.” 

According to the authors, the screening instrument is brief enough to be easily incorporated into a regular patient visit. Using the BEDS-7 test, 16 of the 97 adults were found to have BED. The individuals detected with BED also had poorer Behavior Evaluation Scale (BES) scores and RAND 36-Item Health Survey scores than did those identified as true negatives.

BED: Overcoming Barriers to Diagnosis A new screening tool fits well with primary care settings.

Reprinted from Eating Disorders Review
September/October Volume 27, Number 5
©2016 IAEDP
Although binge eating disorder (BED) is the most common eating disorder, it often is unrecognized and undiagnosed, and thus untreated. BED was not formally recognized as a distinct eating disorder until 2013, when it was included in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Estimates of the lifetime prevalence of BED range from 1.9% to 2.8%, but treatment rates remain low, as reflected by World Health Organization (WHO) data. According to WHO, fewer than 40% of patients with BED ever have treatment (Biol Psychiatry. 2013; 73:904). Two recent studies have addressed ways to detect BED.

Overcoming barriers from clinicians and patients

According to Susan Kornstein, MD, and her colleagues, BED's low diagnosis and treatment rates can be traced to barriers posed by clinicians as well as patients (Prim Care Companion CNS Disord; 2016; 18:4088). First, clinicians may be unfamiliar with the newly available DSM-5 diagnostic criteria and treatment options. Then, shame, embarrassment, and also a lack of awareness of the disorder may make individuals with BED reluctant to seek help. To find possible solutions, the authors conducted a comprehensive search of Pub Med articles from January 2008 to December 2014. 

Suggestions to improve diagnosis

The authors' research showed several ways that the diagnosis can be improved. In many primary care practices, routine patient visits do not include assessment of weight and body mass index. Routinely adding a question about eating habits and following changes in body weight as part of a complete patient history would be a helpful first step, according to the authors. And, a patient's reluctance to discuss his or her eating habits, reflecting underlying shame and embarrassment, may serve as a red flag for possible disordered eating. BED often co-occurs with obesity and type 2 diabetes, and binge eating is one of the predictors for this comorbidity. Thus, according to the authors, primary care physicians should routinely assess individuals with diabetes for an undetected eating disorder. 

Some telltale signs

Other telltale signs that can point to BED include childhood obesity and family eating problems, as well as having a parent with a mood or substance use disorder. The authors noted that patients who are not obese may binge eat, and thus may be candidates for the diagnosis of BED. Patients with BED often gain weight during the year before they seek treatment. Therefore, primary care physicians who provide weight management programs for patients are in a good position to recognize BED. The authors found the Eating Disorder Examination-Questionnaire and the Questionnaire of Eating and Weight Patterns-Revised were among the most helpful self-report instruments.

A seven-item BED screening test

In a separate study, researchers developed the 7-item Binge-Eating Disorder Screener (BEDS-7), a patient self-report instrument (Prim Care Companion CNS Disord. 2016; 18:doi:10.4088/PCC.15m0896). Dr. Barry K. Herman and associates developed the screening tool based on DSM-5 diagnostic criteria for BED, comparisons with existing diagnostic questionnaires, and the results of face-to-face interviews with subjects who had self-reported BED symptoms. 
First, the researchers tested a 13-item pilot test in a cross-sectional study of 97 adults with BED. Seven of the 13 questions yielded 100% sensitivity and 39% specificity, so the test was shortened to 7 primary questions and includes statements such as, “I have no control over eating” and “I eat faster than normal.” Patients were able to indicate the strength of symptoms from “never or rarely” to “always”; another option was “missing.” 

According to the authors, the screening instrument is brief enough to be easily incorporated into a regular patient visit. Using the BEDS-7 test, 16 of the 97 adults were found to have BED. The individuals detected with BED also had poorer Behavior Evaluation Scale (BES) scores and RAND 36-Item Health Survey scores than did those identified as true negatives.

Sunday, September 4, 2016

The Latest Word on Males and Eating Disorders

By Tom Wooldridge, Psy.D
Recently, I met with a patient who I will call J. As we walked into my office for our first meeting, J’s thin, fragile body and eyes surrounded by dark circles spoke volumes. The family had decided to speak with a mental health provider after J’s mother found her child’s hair, falling away as a result of malnutrition, in the shower drain. In that first meeting, J described being plagued by worries about being “too fat” as well as a brutal exercise regimen, coupled with a diet highly restrictive in both calories and variety, intended to assuage that fear. In many ways, this is a run-of-the-mill description of a patient with an eating disorder. But what if I told you that J’s full name is Josh, and that he is a 14-year-old boy?
You may or may not be surprised. Certainly Josh’s father was. When I spoke with him the following week, he confided, through his tears, that he always thought that only “emotional teenage girls” develop anorexia nervosa. While a number of complex factors prevented the family from seeking treatment earlier, the belief that men and boys do not suffer from eating disorders as well as the stigma and shame associated with that possibility are important ones.
Eating disorders are often thought of as a “female problem.” Even researchers, advocates, and treatment providers who are aware that these disorders affect men and boys are plagued by misinformation. For example, it is often stated that 10% of individuals with EDs are male. As it turns out, this often-repeated statistic is highly problematic. When it was published 25 years ago, it represented the number of men and boys in treatment, not in the general population (Andersen, 1990). In fact, the best available data indicates that males account for 25% of individuals with anorexia nervosa and bulimia nervosa and 36% with binge eating disorder (Hudson et al., 2007).
As outlined in the first author’s book about males with anorexia nervosa (Wooldridge, 2016), the treatment process for patients with eating disorders can be divided into four stages: engagement, alliance building, diagnosis, and finally the ongoing treatment process itself. While we would refer readers to the book for a fuller discussion of each of these stages, here are a few comments about aspects of each particularly relevant to men and boys with eating disorders.
Engagement falters for two reasons. First, many men and boys fail to recognize that their behavior (weight loss, purging, binge eating, compulsive exercise, etc.) is a symptom of an eating disorder. And when they do recognize this, their help-seeking behavior is often hindered by stigma and shame. All too often, friends, family, and medical providers fail to recognize that they need urgent medical treatment. In one study, male patients with anorexia nervosa emphasized the lack of gender-appropriate information and resources for men as an impediment to seeking treatment (Räisänen & Hunt, 2014). Moreover, research shows that males are more likely to seek treatment at a later age than their female counterparts (Gueguen et al., 2012).
While the alliance-building process is crucial, it is also frequently given less attention that it deserves. Indeed, the importance of a strong working alliance has been clearly demonstrated for patients with eating disorders in particular (Antoniou & Cooper, 2013; Elvins & Green, 2008). For example, alliance was related to early weight gain as well as final outcome in adolescents with anorexia nervosa who are taking part in family-based treatment (Pereira, Lock, & Oggins, 2006). There are obstacles to the alliance-building process that are specific to men and boys with eating disorders. Stigma and shame often make the alliance-building process more difficult and should be addressed early in treatment. Stigma must be named and the layers of shame and embarrassment beneath acknowledged. An important aspect of addressing stigma is education.
Traditional constructions of masculinity often make the alliance-building more difficult. For example, men appear to hold more negative attitudes toward mental health treatment than their female counterparts (Andrews, Issakidis, & Carter, 2001). The effort to conform to socially prescribed gender roles prevents the expression of vulnerability and need for help (Galdas, Cheater, & Marshall, 2005). With this in mind, intervention should target normative beliefs (i.e., that other males don’t seek treatment), which are deeply related to the male experience of stigma and, thus, help-seeking behavior (Hammer, Vogel, & Heimerdinger-Edwards, 2013).
Assessment and diagnosis of eating disorders in males raises the question of what is an eating disorder and what is not (Darcy & Lin, 2012). The most important aspect of the diagnostic process involves recognizing that eating disorders are applicable, as a diagnostic category, to male patients. Two diagnoses deserve special mention in male populations. In recent years, muscle dysmorphia, a sub-classification of body dysmorphia, has gained attention. The distinguishing feature of muscle dysmorphia is the central role of muscularity-oriented, as opposed to thinness-oriented, body image concerns and behaviors (Murray, Rieger, Touyz, De la Garza Garcia, 2010). This disorder is characterized by an intense fear that one is insufficiently muscular and an excessive drive to enhance the visible appearance of muscularity. These patients are notable for working out and lifting weights excessively, as well as their extreme anxiety in the face of missed workouts (Murray, Rieger, Touyz, & De la Garcia Garcia, 2010).
Second, binge eating disorder is the most common eating disorder and affects more males than anorexia and bulimia combined. Binge eating disorder is characterized by episodes of bingeing and subsequent shame and guilt, after which the cycle repeats. All too often, health professionals address co-morbid symptoms, which include diabetes, high blood pressure and cholesterol, heart disease, gallbladder disease, osteoarthritis, and gastrointestinal problems (Bulik et al, 2003), without recognizing and treating the underlying eating disorder. Similarly, because of misinformation and stigma, men often think of binge eating as “normal guy” behavior.
While eating disorders in men and boys exist across ages and cultures, men and boys who identify as gay, bisexual, and transgender are at a higher risk of developing an eating disorder (Brown & Keel, 2012). The most widespread explanation for the increased incidence of eating disorders in the homosexual population is that gay men experience more body dissatisfaction than heterosexual men (Andersen, Cohn, & Holbrook, 2000). Indeed, the lean and muscular body type, which is difficult to achieve for most, is especially idealized by gay men. In addition, the transgender population merits further investigation as an especially high-risk category. In a recent study of college-aged youth, an eating disorder diagnosis as well as use of diet pills, vomiting, and laxative use were highest among transgender youth compared to heterosexual and homosexual women and women (Diemer, Grant, Munn-Chernoff, Patterson, & Duncan, 2015).
Once males and their families are engaged in treatment, a multidisciplinary and integrative approach to treatment is required to fully address all the factors that contribute to the patient’s eating disorder. Unsurprisingly, evidence clearly demonstrates better outcomes with an experienced multidisciplinary team than with efforts by a single clinician (Halmi, 2009; Mehler & Andersen, 1999). Treatment teams often consist of: psychologists, psychiatrists , social workers, primary care physicians, registered dieticians, and sometimes educators, clergy, even financial advisors to facilitate expensive inpatient treatment. In a similar vein, in an effort to address the complexity of the patient system, treatment should be integrative.  Five relevant domains are identified: systemic, biological, cultural, psychodynamic, and spiritual (Wooldridge, 2016).
This emphasis on integrative treatment often stands in contrast with the emphasis on symptom-focused treatments that, while deeply valuable, may fail to acknowledge the underlying roots of patients’ struggles. Similarly, much has been made of the role of genetic vulnerability in patients with eating disorders. One compelling line of research suggests that the genetic vulnerability to an eating disorder ranges from 50 to 70 percent. Indeed, monozygotic twins share a 50 percent chance of having an eating disorder if one is afflicted (Bulik, Sullivan, Tozzi, Furberg, Lichtenstein, & Pedersen, 2006). At present, though, there is no conclusion as to what is being transmitted that causes genetic vulnerability. Furthermore, too much emphasis on genetic factors may impede the treatment process, as providers may overlook the role of other factors, such as underlying anxiety, depression, etc., dysfunction within family systems or psychodynamic meanings associated with food, weight, and shape, that can be directly addressed in the treatment.
In closing, let us return to Josh. The initial states of treatment consisted of educating Josh and his family about the fact that eating disorders don’t only happen to adolescent girls. A multidisciplinary treatment team, which included a psychiatrist, psychotherapist, and nutritionist, was engaged to address each aspect of Josh’s eating disorder. Josh’s parents were an integral component of the treatment team as well, essential to the process of helping him to normalize his eating and exercise. At the same time, Josh had a lot of work to do on his own. Although it took over a year for Josh’s weight to fully stabilize and several more years of treatment for his attitudes toward food, weight, and shape to fully normalize, Josh did achieve full recovery.