Wednesday, March 18, 2020

Self-Screening Tools for Detecting Eating Disorders among College Students

Vol. 31 / No. 1  

 Disappointing results from a large study.
Since the peak time of the onset of an eating disorder is usually between adolescence and early adulthood, a self-screening questionnaire targeted at this age group would have obvious benefits.  But screening in a way that identifies those with an eating disorder while not mis-identifying those without may be a challenge. Selecting the correct screening instrument may be the key. However, when Japanese researchers recently studied the screening accuracy of the Eating Attitudes Test(EAT-26) and self-reported body frame, followed by a semi-structured interview with the  Structured Clinical Interview for DSM-IV Axis 1 Disorders(SCID)  among new college students, the test results were disappointing (BMC Res Notes. 2019; 12:613).
Earlier studies in Japan using the EAT-26to detect eating disorders and abnormal eating behaviors among high school and college students have yielded inconsistent results. Dr. Norika Hayakawa and four colleagues at Nagoya University designed a larger-scale anonymous study of new college students from 2012 to 2015; the survey was administered during the students’ college entrance medical checkup. The 5275 students who agreed to participate provided self-reported body weight and height and completed the EAT-26. Then, the SCID ED module was conducted among 131 students to provide an eating disorder diagnosis.
Among the 131 students who completed the semi-structured interview, no student with a high EAT-26 score was diagnosed as having an eating disorder based on the SCID. Conversely, 3 students were diagnosed with an eating disorder but none had an elevated EAT-26 score.  One limitation of the study was that only 1.7% of new students were included in the semi-structured interviews, and it is unclear if these were randomly selected.
After assessing their results, the authors concluded that when the EAT-26 alone is used, it is not possible to identify individuals with an eating disorder. Another interpretation of the findings is that a measure such as the EAT-26 is best used for identifying disordered eating attitudes or behaviors, but not to make diagnoses.

Knowledge of Nutrition Needs Can Be Lacking among Those with Eating Disorders

Vol. 31 / No. 1  

Two studies point to a need for improvement.
Recently, Polish nutritionists wondered, how much do people with eating disorders know about nutrition? Do age, education, type of eating disorder, or body mass index (BMI, kg/m2) play a role? (Rocz Panstw Zaki Hig. 2019; 70:41).
Dr. Beata Calyniuk and colleagues at the Medical University of Silesia, Kantowice, Poland, assessed knowledge of nutrition using a survey questionnaire designed by Dr. Calyniuk. The 33-question instrument was published on the Internet in one of the social media portals in the “Eating disorders-tackling” group, which includes people with all types of eating disorders.
The authors found that the least-informed group were people younger than 20 years of age, and those who lived in medium-sized cities with populations between 20,000 and 100,000. Respondents with a vocational education were least informed about nutrition, and those with normal body mass indexes scored highest on knowledge of nutrition in eating disorders. Overall, the authors reported, their study showed that nutrition knowledge was selective and not enough to provide appropriate food choices to meet nutritional needs.
Their findings echoed those of an earlier 6-month study of 182 adolescents with and without eating disorders and their parents (Int J Adolesc Med Health2015; 27:11). The study was conducted in a suburban adolescent medicine office. Eighteen basic questions about nutrition were presented to the teens and their parents. Neither teens with or without an ED correctly answered more than 50% of the questions. Also, fewer than 16% of respondents in either group correctly answered questions about appropriate intake of fats, carbohydrates, and proteins.
Both studies findings underscored the importance of teaching patients about healthy lifestyles and nutrition and thoroughly discussing all nutrients, their functions, and effects on the body.

Musicians and Eating Disorders

Vol. 31 / No. 1  

A recent study shows perfectionism is one underlying factor.
Karen Carpenter is one of the best-known pop singers to have been overcome by longtime anorexia nervosa, and her death at age 32, in 1983, shocked most fans worldwide. Other well-known actresses and singers, such as Jane Fonda, Britney Spears, Elton John, and Lady Gaga, are just a few of the many celebrities who report having dealt with bulimia nervosa.
A recent report from London has shown that eating disorders are surprisingly common among musicians. The key elements increasing risk could be: perfectionism, stress, anxiety, and depression—all components of performing before a live audience (Eat Weight Disord. 2019; 24:54).
Drs. Marianna E. Kapsetaki and Charlie Easmon of Imperial College London and University College London investigated eating disorders among 303 musicians.  The authors had noted that eating disorders are not uncommon among performing artists and hypothesized that eating disorders would have a high prevalence among musicians. The authors sought to pinpoint factors that might be involved, including the type of music, the musician’s income, the stage in his or her career, the time of year, their age, gender, and risk factors, such as parental or peer pressure, social isolation, and perfectionism. They wanted to see if musicians believed eating disorders affected performance and diet, and if the musicians used any particular foods or substances to enhance their performance.
The participants were females and males 18 years of age or older, at all stages in their musical careers. They were asked about any eating disorders in the past, and current eating disorders. General mental health was assessed with the Depression Anxiety Stress Scale(DASS-21).  Body mass index was calculated from self-reported height and weight. All the questions were uploaded on UCL Opinio 7.3online survey software in English, and the survey was then sent worldwide to the musicians.
Musicians in every type of music were affected
A total of 119 males and 182 females participated, and the median age was 27 years. All types of music were represented, from classical to pop, folk, and rock.  Of the participants, 83% were instrumentalists, 31% were singers, 5% were composers, 2% were musicologists, 2% were conductors; and 2% described themselves as “other.” The EDE-Q Global Score (EDE-QGS)showed pathological values in 19% of the musicians, and when asked about lifetime history of an eating disorder, 32% of the participants answered positively. EDE-Q subscale scores were in the pathologic range in 13% to 35% of participants, with the highest percentage being seen on the shape concern subscale.
The authors noted that most of the participants spent much time traveling within one country (85%) versus traveling overseas. Most reported that their eating habits did not affect either their career or their performance; however, some reported that their career affected their eating habits—many reported that they would change their diet if they had higher incomes and about 20% were dependent on or addicted to certain food or drinks, usually caffeine-containing drinks.                      
Pinpointing possible risk factors
Music students, professional musicians, soloists and musicians who traveled overseas had a higher percentage of pathological scores on the EDE-QGSand there was a positive correlation between scores on the EDE-QGSand risk factors of perfectionism, depression, anxiety, stress, peer pressure, and social isolation. There was added stress when an individual was a soloist compared to singing or playing in a small or large group.
The authors note that an increased prevalence of eating disorders among musicians could be due to increased levels of perfectionism (especially in classical or professional musicians) because their goal is to perform perfectly.  The authors also suggest that one reason singers report more eating disorders than do instrumentalists is that there is an ambivalent association with their primary instrument, that is, their bodies make the music.
It is common to think that certain groups are at high risk for eating disorders; endurance athletes or dancers come to mind.  This study suggests that musicians are at similarly elevated risk.

Access to Treatment, and Mortality in Eating Disorders

Vol. 31 / No. 1  

The study model also showed a high prevalence of eating disorders in the general population.
Having a better understanding of the prevalence of eating disorders over the lifetime “could help decision-makers and clinicians better target policies and programs,” according to a team of public health  researchers led by Zachary J. Ward, MPH, of Harvard’s Center for Health Decision Science, Boston (JAMA Network Open. 2019; 2[10]:e1912925).
Given the effort that studies providing data on prevalence across the lifespan would entail, the team designed an analytical model study to simulate clinical and epidemiologic eating disorders data, using a simulated nationally representative cohort of 100,000 individuals (50% male) modeled from birth to age 40 for anorexia nervosa, bulimia nervosa, binge-eating disorder, and other specified feeding and eating disorders (OSFED). The authors also sought to estimate how increasing access to treatment for eating disorders might diminish mortality. Estimates of prevalence, remission and relapse rates as well as excess mortality were drawn from the existing literature.
Eating disorders by age
The study results showed that the estimated prevalence of eating disorders was high: the highest estimated mean annual prevalence of eating disorders overall occurred at approximately 21 years of age for both males and females. The mean lifetime prevalence increased to approximately 1 in 7 males and approximately 1 in 5 females by age 40. The types of eating disorders followed a similar pattern, peaking in the late 20s and then decreasing slowly in later adulthood; in this study, most cases involved OSFED. In the model, 95% of those developing an ED did so by 25 years of age.
Treatment prevented approximately 41.7 deaths per 100,000 persons; however, increasing coverage to provide treatment to all with EDs would prevent 70.5 deaths per 100,000. Of note: total prevention of all EDs was estimated to prevent 213 deaths per 100,000.
This modeling highlights the prevalence of EDs and the mortality burden associated with ED and underscores the potential benefits of improved access to treatment.

Problematic Internet Use and Prediction of Eating Disorders

Vol. 31 / No. 1  
A new link between Internet use and eating disorders
According to Statista, the German online portal for statistics, in 2018, the average American spent 24 hours a week online. Smartphones and social networks have increased the level of Internet addiction and eating disorders among university students, according to a recent study by researchers at the University of Granada (Nutrients. 2019; 11:2151).
Problematic Internet Use is one reflection of uncontrolled use of technology, and recent studies are showing a link between Internet addiction and eating disorders.  Problematic Internet Use is categorized as a “behavioral addiction” (Comput Hum Behav. 2016; 55:76). Dr. Francisco-Javier Hinojo-Lucena and colleagues in Granada, Spain, conducted a meta-analysis of the literature on Problematic Internet Use and EDs using two databases, Scopusand Web of Science. The researchers included journal articles, empirical research, papers written in either English or Spanish, to study the association of  Problematic Internet Use with an eating disorder among students. They excluded proceeding of meetings and congresses, book chapters, books, or non-peer-reviewed publications, theoretical papers or reviews, Problematic Internet Use not associated with a particular eating disorder, and non-student populations. The researchers identified 12 articles in the systemic analysis and 10 in the meta-analysis. Seventy-five percent of the articles were published since 2014; the first articles on Problematic Internet Use and eating disorders were published in 2009.
Some conclusions were made
The authors evaluated articles and documents that included 16,520 students from different countries. A number of eating disorders were associated with Problematic Internet Use: AN, BN, BED, food preoccupation, loss of control eating, and dieting. Most cases involved BN (92% of cases) and highlighted the interest in AN (50%), food preoccupation and loss of control eating (both 42%), and BED (17%). Overall, those with Problematic Internet Use were more likely to have an ED or disordered eating. The authors also noted that most studies involved university students, the group at highest risk. Problematic Internet Use presents many challenges because it may encourage sedentary behavior and may facilitate ordering food online. An additional danger from the social networks is the risk of social comparisons, which can also lead to the development of eating disorders such as AN or BN.
Finally, the authors suggest that since university students are at the greatest risk, preventive measures should be introduced earlier, at lower educational levels.

The Importance of Restoring Body Fat Mass in the Treatment of Anorexia Nervosa: An Expert Commentary.

The Eating Disorder Journal
(February 2020, Vol. 21, No.2)
Anorexia nervosa is a severe mental disorder that is characterised by dietary restriction, low weight and widespread endocrine abnormalities. Whilst the importance of weight restoration has been recognised in recent guidelines, the significance of normalising body fat mass has received less attention. A recent systematic review and meta-analysis found that a minimum of 20.5% body fat mass is necessary for regular menses in women with anorexia nervosa of reproductive age. This has significant implications for both treatment and research. It is important to help the patient and carers understand that a certain level of body fat percentage is essential for optimal health, such as the return of menstruation. Further research is needed into how best to use this information to help motivation to change as part of treatment. The benefit of the return of menstruation goes beyond improved fertility: it signals the normalisation of sexual hormones, which have a widespread impact on the body and multiple pathways in the brain. Given the complex functions of adipocytes in various organs of the body, the metabolic effects of the normal body fat tissue should not be underestimated. Further research is needed to elucidate the mechanisms behind the link between minimum body fat mass, menstruation, bone and brain health in anorexia nervosa. J Popul Ther Clin Pharmacol. 2019 Sep 4;26(3):e9-e13. doi: 10.15586/jptcp.v26i3.629.

Physical and psychological aspects of anorexia nervosa based on duration of illness: a cross-sectional study.

The Eating Disorder Journal
(February 2020, Vol. 21, No.2)
BACKGROUND: We evaluated physical and psychological features of patients with anorexia nervosa (AN) who differed by duration of illness. METHODS: Data were obtained from 204 female patients with AN, divided into two groups based on illness duration: short-term illness duration (less than 5 years; n = 118); and long-term duration (5 years or more; n = 86). Physical parameters were measured using blood serum testing and psychological aspects were assessed using various instruments. RESULTS: A significantly higher proportion of restricting type AN was observed in the short-term group while the proportion of binge eating/purging type AN was higher in the long-term group. There was no difference in body mass index (BMI) between the groups. Serum total protein, albumin, potassium, chloride, and calcium in the long-term group were significantly lower than in the short-term group. Overall scores on the Eating Disorder Inventory as well as most of the subscales, except maturity fears, were higher in the long-term group than in the short-term group. The care subscale of the Parental Bonding Instrument (PBI) was lower in the long-term group than in the short-term group, while the overprotection subscale of the PBI was higher in the long-term group than in the short-term group. Results of a multiple regression analysis indicated that the overprotection subscale of the PBI was the only significant predictor of duration of illness. CONCLUSIONS: Duration of illness may be associated with physical and psychological features of AN; thus, adapting therapeutic approaches to illness duration might be necessary. Biopsychosoc Med. 2019 Dec 23;13:32. doi: 10.1186/s13030-019-0173-0. eCollection 2019.

Feasibility of Implementing a Family-Based Inpatient Program for Adolescents With Anorexia Nervosa: A Retrospective Cohort Study.

The Eating Disorder Journal
(February 2020, Vol. 21, No.2)
Background: Manualized Family Based Therapy (FBT) is the treatment of choice for adolescent anorexia nervosa, but it is an outpatient treatment. Very little research has examined whether or how the principles of FBT might be successfully adapted to an inpatient setting, and there is little other evidence in the literature to guide us on how to best treat children and adolescents with eating disorders (EDs) while in hospital. This paper describes and provides treatment outcomes for an intensive inpatient program that was designed for the treatment of adolescents less than 18 years of age with severe anorexia nervosa, based on the principles of FBT. Each patient's family was provided with FBT adapted for an inpatient setting for the duration of the admission. Parents were encouraged to provide support for all meals in hospital and to plan meal passes out of hospital. Methods: A retrospective cohort study was conducted that examined the outcomes of 153 female patients admitted over a 5-year period. Outcome data focused primarily on weight change as well as psychological indicators of health (i.e., depression, anxiety, ED psychopathology). Results: Paired t-tests with Bonferroni corrections showed significant weight gain associated with a large effect size. In addition, patients showed improvements in scores of mood, anxiety, and ED psychopathology (associated with small to medium effect sizes), though they continued to display high rates of body dissatisfaction and some ongoing suicidality at the time of discharge. Conclusion: This study shows that a specialized inpatient program for adolescents with severe EDs that was created using the principles of FBT results in positive short-term medical and psychological improvements as evidenced by improved weight gain and decreased markers of psychological distress. Front Psychiatry. 2019 Dec 3;10:887. doi: 10.3389/fpsyt.2019.00887. eCollection 2019.

Mortality and risk assessment for anorexia nervosa in acute-care hospitals: a nationwide administrative database analysis

The Eating Disorder Journal
(February 2020, Vol. 21, No.2)
Anorexia nervosa (AN) is a common eating disorder with the highest mortality rate of all psychiatric diseases. However, few studies have examined inpatient characteristics and treatment for AN. This study aimed to characterise the association between mortality and risk factors in patients with AN in acute-care hospitals. METHODS: We conducted a nationwide, retrospective analysis of the Japanese Diagnosis and Procedure Combination inpatient database. Data extraction occurred from April 2010 to March 2016. We estimated in-hospital mortality and identified independent risk factors, using multivariate logistic regression analysis to examine patient characteristics and physical and psychological comorbidities. RESULTS: We identified 6937 patients with AN aged ≥12 years in 885 acute-care hospitals. Of these, 361 (5.2%) were male. Male and female participants' median ages at first admission were 34 (17-65) and 28 (17-41) years, respectively. In total, 195 in-hospital patient deaths, including 22 (6.1%) men and 173 (2.6%) women, it was observed that the unadjusted odds ratio of mortality for male patients was more than twice that for female patients (OR: 2.40, 95% CI: 1.45-3.81). Multivariate logistic regression analysis demonstrated an adjusted odds ratio of 2.19 (95% CI: 1.29-3.73). Age at first hospital admission, percentage of ideal body weight, comorbidities, and hypotension were significantly associated with increased mortality risk, but the frequency of hospitalization, bradycardia, and other psychiatric disorders were not. Treatment in a university hospital was associated with lower mortality risk (odds ratio: 0.45, 95% CI: 0.30-0.67). CONCLUSION: The results highlighted sex differences in mortality rates. Potential risk factors could contribute to improved treatment and outcomes. These retrospective findings indicate a need for further longitudinal examination of these patients. BMC Psychiatry. 2020 Jan 13;20(1):19. doi: 10.1186/s12888-020-2433-8.

Clients and Clinicians Facing Fears: Exposure Therapy for Eating Disorders

By Kelsey E. Clark, MS Posted in Gurze Eating Disorders Review 2/2/20
Fear is a normal emotional response that occurs when we feel threatened. We perceive a threat, and to protect ourselves we try to avoid the feared situation. In some cases, fear and avoidance lead to significant distress and interfere with our daily lives. For example, they can get in the way of work/school or damage our relationships. When this happens, this may indicate a person has a mental illness. Many individuals with eating disorders have fears related to eating, shape, and weight. A person may fear fatness or may fear perceived consequences of fatness, such as social rejection. Such fears are often behind eating disorder thoughts and behaviors.
Exposure therapy immerses individuals in situations so they confront experiences they fear or avoid. This facilitates learning new associations with the feared/avoided things. Exposure therapy is strongly supported by research for treating anxiety and fear-based disorders such as specific phobias, obsessive-compulsive disorder, post-traumatic stress disorder, panic disorder, and social anxiety disorder. For example, imagine exposure therapy for someone who has a specific phobia of spiders: The therapy client and clinician would work together to decide on situations so the client can face their fear. They might look at photographs of spiders, videos of spiders, be in the same room as a spider, and even hold a spider. This way, the client’s feared expectancies about what will happen can be challenged. Clients can see that they are able to tolerate anxiety, distress, and uncertainty.
Exposure therapy also has a growing evidence base for treating eating disorders. In eating disorders treatment, exposure therapy looks different from one person to another. A client might eat feared/avoided foods, induce urges to binge eat, induce urges to use inappropriate compensatory behaviors such as purging, or induce physical sensations such as feelings of fullness. They could also break eating rituals, confront their reflection in the mirror, imagine and describe in detail the experience of gaining weight, or stop using a body checking behavior. This explores and challenges the client’s feared outcomes. Feared outcomes look different from one person to another. Clients might fear they will immediately or ultimately gain weight, will be unable to stop eating, will experience unrelenting physical discomfort, or will experience never-ending emotional distress. Facing these fears violates these expectancies! Clients then learn they can tolerate and make it through these uncomfortable situations. By riding out the wave of fear, clients can reach treatment goals and live the life they want to live.
The Problem
Despite strong research support, many clinicians do not use exposure therapy. Research has found that many clinicians are nervous about exposure therapy. Apprehension is understandable—at first glance, exposure therapy sounds like the opposite of what clinicians want to do! Exposure therapy makes clients uncomfortable and distressed, when clinicians’ goal is to help clients to feel better and live by their values. Many clinicians fear that exposure therapy will cause clients to drop out of treatment, that they won’t be able to complete exposures, or that it will be intolerable to clients. Prior studies have debunked such concerns that exposure therapy is infeasible or unacceptable. Yet, exposure therapy remains underused.
The Research Study
As part of a larger eating disorders treatment study, we developed a novel three-session exposure therapy module. This treatment is individualized to address clients’ core fears. The treatment also provides opportunities for clients to practice skills they learn in treatment: emotion awareness, emotion regulation, and emotion tolerance. The present study aims to explore the feasibility and acceptability of this eating disorders exposure therapy module and explore the concerns of clinicians. We predicted that the exposure therapy would be feasible—that is, practical to use and able to be fully delivered as planned. We predicted that it would be acceptable—that is, judged as suitable and useful, and that clients would respond positively to it. A sample of adults with bulimia nervosa completed the exposure module. The treatment module included three exposures and one mood induction exercise intended to heighten emotions for the exposure. We used a mixed methods approach to comprehensively examine qualitative and quantitative data. We completed video coding of therapy sessions and analyzed questionnaires clients and clinicians answered before and after each session.
The Results
Broadly, our results indicated that the treatment is feasible and acceptable, as we hypothesized. On average, clinicians were able to complete the exposures as planned. Clients brought necessary supplies with them for exposures most of the time. We found that no clients dropped out of treatment immediately following the exposure sessions. We found that clients appeared to understand the rationale behind exposures and believed it was helpful. Clients expressed strong satisfaction with the exposure session content and strong satisfaction with their clinicians. One client stated that exposure was an “uncomfortable experience but also powerful.” Another client reported that exposure therapy was “extremely helpful, because [they] had to learn to sit with negative feelings.” These results support that it is possible to treat eating disorder clients with exposure therapy and that clients will judge it positively. With these initial results, we will be able to update and refine the treatment before examining the treatment in future research studies and disseminating it on a larger scale.
The Research Implications
Our findings support previous research and indicate that exposure therapy has untapped potential in treating eating disorders. Future work will continue to explore the efficacy of exposure therapy and explore why exposure therapy works. We will also explore how to spread the word about exposure therapy so that more clients and clinicians are aware of it. We will learn how best to address myths and misconceptions about this type of treatment. Our results indicate that instead of avoiding exposure therapy, clinicians should approach exposure therapy with the same degree of psychological flexibility they aim to foster in their clients.
The idea of facing our fears certainly sounds frightening! This is true for clients and clinicians alike! However, exposure therapy is based on the idea that continually avoiding things we fear robs us of the chance to learn that our fears won’t necessarily come true. This avoidance perpetuates our problems when fear/avoidance get in the way of the life we want to live. By approaching the things we fear instead of avoiding them, we learn how to accept the discomfort and uncertainty that are a normal part of life.

The Familial Red Flag

By Kate Funk, MFT, LMFT
Posted in Gurze Eating Disorder Review 2/2/20
I was in treatment for an eating disorder and remember having zero insight into what caused my eating disorder. I had no clue how my family dynamics may have contributed to my behaviors or cognitions. I had no idea how my Dad’s anger and frequent travel or my Mom’s depression and disordered eating affected me. I remember the other clients dreading family therapy and I questioned what was so hard about it. I didn’t have any understanding that my family could be a part of the problem. I couldn’t imagine anything being involved in the development of my eating disorder other than my low self-esteem and a desire to be thin. As I soon learned, the reality is that eating disorders are much more complex than self-esteem or a society placing importance on a specific physique. Our environments, experiences and culture all influence the development of eating disorders and must be addressed in order to successfully heal from them.
My parents had known each other since they were 11 years old and decided to announce their divorce post my leaving residential treatment. Coincidence? Probably not. In no way am I blaming my parents for my eating disorder or my recovery on their divorce, but I do believe that the environment in which I grew up played a role in the development of the disorder. The family therapy we went through helped my parents gain insight into their own work, which allowed them to see how their marriage wasn’t what it once was. Eating disorders can be red flags that something in the family system isn’t working. That was certainly the case for my family. My illness served as the official announcement that we needed help as a family and it was the catalyst for family therapy and my parents own individual therapeutic work.
I remember my Dad struggling with guilt in a family session pleading, “I gave you everything – vacations, cars, clothes, everything you ever wanted and now I am to blame!” It’s not about blame, but is about how certain environments can hide or nurture the eating disorder. My parents had given me every opportunity a parent could dream of giving. But, I came to learn I am very sensitive and pick up on everyone’s emotions and feel things quite deeply. I internalized my parents’ problems as my own. I worried about my Mom’s mental health and internalized my Dad’s anger to be about me, and my eating disorder was the perfect escape. I remember telling my Dad things that happened may not have affected others the way they affected me, but with my temperament my parents’ unhappiness became my own. The development of the disorder requires the perfect storm of temperament, biology, personal psychology, environment, and events that occur in our lives. Those realizations were probably the most important part of my treatment; they allowed me to let go of the guilt and recognize I wasn’t broken beyond repair … that everyone in my family had a role to play and that we could all work as a team together to heal. No one person causes an eating disorder, but the perfect storm of events must occur to create one.
These stereotypical nuclear family anecdotes are most likely not helpful for older adults with eating disorders, but more than likely the seeds of the eating disorder were there much before adulthood. Striving for perfection, comparison in the family, feelings of not being good enough, and family secrets can certainly impact the way we grow and become adults. Adults with eating disorders often find themselves in family dynamics that contribute to or hide the disorder, as well. High achieving couples, emotional avoidance, physical or emotional distance, and traditional gender roles can certainly impact the development or maintenance of the eating disorder. Often adults in recovery are able to change their cognitions and extinguish their behaviors but the same environments where the disorder thrived is certainly not likely to promote change and wellness.
It is important and highly recommended that family therapy be a part of treatment for adolescents, but family therapy is imperative for any person in recovery. If someone is being asked to change everything about the way they think and behave in their daily life, how are they going to sustain these changes if everything around them is exactly the same? It is possible, but the odds are certainly against them. Secrecy, shame and certain family dynamics that maintain the secrecy and shame are breeding grounds for eating disorders and it’s critical for recovery to move beyond them. I encourage all people with eating disorders to have family therapy to help each member of the family learn their role in order to help themselves and the client heal.
Eating disorders are an opportunity for all family members (whoever they might be – significant others, close friends, extended family, etc.) to reflect on their role in any dynamics that may have contributed to the development of the eating disorder. Taking the time to do this provides the space for each participant to consider the shifts needed to support healthy changes. I believe family therapy is the most effective way to establish these healthy changes for the entire family system.

Anorexia Nervosa & Social Anxiety Disorder: A Systemic Review

By Michelle L. Miller, BS and Jennifer R. Ferrante, BA, BS
Posted in Gurze Eating Disorders Review February 2, 2020
Individuals with anorexia nervosa often struggle socially, battling fears of public scrutiny and judgement regarding their weight and shape1. Up to 34% of individuals with anorexia nervosa will experience symptoms that meet clinical criteria for social anxiety disorder, and many more will experience subclinical symptoms2. Additionally, study participants are often recruited from treatment programs; this excludes those individuals whose social anxiety may have prevented them from initiating or maintaining treatment, and likely results in an underestimation of the true prevalence of social anxiety in this population. A better understanding of the relationship between social anxiety and anorexia nervosa is crucial for improving diagnosis, treatment, and overall quality of life for individuals with anorexia nervosa.
Among individuals with anorexia nervosa, symptoms of social anxiety are often associated with concerns regarding one’s appearance. For example, social appearance anxiety, or anxiety specifically related to fears of negative evaluation of one’s appearance, is positively associated with symptoms of social anxiety in individuals with anorexia nervosa3. Interestingly, this social appearance anxiety does not appear to be restricted to weight-related concerns, as patients with anorexia nervosa and non-weight-related body image concerns score higher on measures of social anxiety as compared to individuals with anorexia nervosa and exclusively weight-related body image concerns4. Social anxiety related to both weight-related and non-weight related body image concerns may represent the high prevalence of body dysmorphic disorder5 or the increased public self-consciousness6-7 among individuals with anorexia nervosa.
The social anxiety that individuals with anorexia nervosa experience is complex and cannot be solely attributed to concerns regarding one’s appearance. Symptoms of social anxiety among individuals with anorexia nervosa are also positively associated with alexithymia traits, such as difficulty identifying and describing feelings8, as well as internalized shame9. In addition, underlying traits may exist that predispose a person to develop both anorexia nervosa and social anxiety disorder. For example, individuals with anorexia nervosa are more likely to possess certain traits associated with social anxiety, such as public self-consciousness6-7, interpersonal distrust10, perfectionism11-12, doubts about being understood13, doubts about being the same13, and poor interoceptive awareness6 as compared to healthy controls. Conversely, extraversion is negatively associated with symptoms of social anxiety among individuals with anorexia nervosa and may serve as a protective factor against social anxiety in this population6.
Alternatively, social anxiety in itself may represent an underlying vulnerability promoting the development and progression of anorexia nervosa symptoms, as 74% of individuals with an eating disorder report the onset of social phobia as preceding the onset of eating disorder14. Once an individual develops symptoms of both social anxiety and anorexia nervosa, these symptoms may exacerbate each other. For instance, individuals with more severe social appearance anxiety3 and who use more social safety behaviors15 also experience more severe symptoms of anorexia nervosa. Symptoms of social anxiety may allow symptoms of anorexia to progress via preventing individuals from entering and maintaining treatment of their eating disorder. Specifically, increased social anxiety among individuals with anorexia nervosa and bulimia nervosa is associated with less likelihood of entering outpatient eating disorder treatment after an initial intake appointment16.
Even if individuals with comorbid social anxiety and anorexia nervosa enter and maintain adherence to a treatment program, they may face unique challenges during eating disorder treatment. The same traits that may create a vulnerability for the development of comorbid social anxiety and anorexia nervosa, such as interpersonal distrust10 and doubts about being understood13, may also impede the formation of the therapeutic alliances crucial for treatment maintenance and success. An inability to enter, maintain, or benefit from treatment may explain the association between more time ill with anorexia nervosa and more severe social anxiety symptomatology17. Further research is needed to better understand and elucidate the complex relationship between symptoms of anorexia nervosa and social anxiety, with the goal of identifying interventions that will make anorexia nervosa treatment more feasible and effective for individuals with comorbid social anxiety.