Tracking Down Body Image Distortions

Courtesy of Eating Disorders Review

Two studies examine how individual perceptions can be altered.

Body perception problems are among the most striking manifestations of anorexia nervosa (AN). In two recent studies, researchers in Australia and the US used different approaches to determine the origins of distorted body image among AN patients.

Visual adaptations after exposure

Dr. Kevin R. Brooks and colleagues at Macquarie University, Sydney, Australia, designed a unique study to test the effect of manipulated images on a group of female undergraduates (Frontiers in Neuroscience 2016; doi:10.3389/fnins.2016.00334). This is one of the few studies designed to explore how neural mechanisms affect body perception.

Dr. Brooks’ group chose 24 Caucasian female undergraduate psychology students for the experiment. First, full-body digital photos were taken of each participant. The women were photographed while standing and wearing bicycle shorts and a form-fitting top, with feet shoulder-width apart and arms straight at their sides. Then, the original photographs were manipulated in Adobe Photoshop to produce 7 final images depicting the subjects at from -30% to +30% of their original size. Weight and height were recorded to establish body mass index (BMI, kg/m2) for each participant.

Next, each student was shown a photograph of the face of another individual whose BMI and age closed matched hers. Each participant was then tested to see whether she thought the individual in the image was larger or smaller than non-manipulated images viewed at an earlier stage of the experiment. Looking at the digitally manipulated images for as little as 1 minute was enough to change the perception of images seen afterward. For example, after a student looked at images that had been manipulated to make a person appear thinner, people in non-manipulated images seemed heavier than normal.

Neural differences in self-perception during and after weight recovery

In healthy populations, several brain areas, including the medial prefrontal cortex, the posterior cingulate cortex, and the temporal parietal junction, are connected to self-perception and evaluation. Neural activations during self-perception are thought to be altered in AN patients (J Science and Neuroscience 2014; 39:178). But, does this factor normalize with recovery or do the neural activations persist?    

To answer this question, Dr. Carrie J. McAdams and colleagues traced neural pathways that they theorized affected self-perception during illness and after weight recovery among women with AN (Social Cognitive and Affective Neuroscience 2016; 1825-1851.) Dr. McAdams and her colleagues used the Social Identity V2 task (McAdams and Krawak, 2014) and the Faces task to evaluate three groups: 19 healthy women, 22 women with AN, and 18 women in long-term weight recovery after AN. The Social Identity Task involves the subject in different interactions with images of themselves, friends, and reflected images personalized with the name of a female friend. The subjects then responded to 48 statements that related to social interactions, presented three times. In the Faces task, each subject viewed 15 images of her face and 15 images of a stranger. The stranger’s images closely matched those of the subject except that the head was tilted differently in each image. Both ill and weight- recovered AN participants had substantially different medial prefrontal cortex activation as compared to controls. Compared with controls, those with AN had different performance on the Faces task. The reactions were very similar among those with restored weight and controls.

Thus, successful weight recovery from AN seems to be associated with some aspects of self-perception, but not to others. Much more needs to be learned, but both studies add hope for possible ways to better understand the complexities of and treatment for patients with AN.                                                                                                                                                                             

The Effect of Weight Gain/Restoration on Bone Mineral Density in Anorexia Nervosa

Courtesy of Eating Disorders Review

Diminished bone density is a common complication that needs much more thorough investigation.

Diminished bone mineral density (BMD) is a common medical complication of anorexia nervosa (AN). Since AN often begins in the teen years, causing bone mineral loss at a time when BMD normally rapidly increases, the long-term implications are significant.

Dr. Marwan El Ghoch, an expert in bone health and eating disorders, and his colleagues recently conducted a systematic review of the association between weight gain/weight restoration and BMD in adolescents with AN (Nutrients. 2016; 8:769). Noting that nearly 85% of females with AN have very low BMD and a 7-fold increased risk of spontaneous fractures compared to healthy controls, Dr. El Ghoch and his team conducted a systematic literature review of the association between weight gain/weight restoration and BMD in teens with AN.

Only 19 of the 1156 articles the authors initially reviewed met inclusion criteria for the study. Further, a review of these studies produced only 2 clear findings. First, weight restoration was associated with stabilization of BMD in 6 of 8 teens with AN after one year. Second, 7 studies with follow-up periods longer than a year showed the same trend to stabilization of BMD, followed by significant improvements in BMD. Only one study found that improved BMD can be achieved 30 months after weight restoration. Finally, another single study showed that teenage males with AN who remain underweight may have continued BMD loss.

The authors caution that these seemingly encouraging results must be viewed in light of the fact that weight restoration was achieved only in 9 of the 19 studies. The studies also offered varied definitions of normal weight cutoff points; for example, the cutoff points ranged from 17.5 kg/m2 to more than 19 kg/m2, and 15 of the studies were uncontrolled. And, none of the studies took into account the rate of weight gain or specific eating disorder behaviors than might have had an effect on BMD gain and weight restoration.

Still needed: guidelines for management of bone loss in teens

This represents a large body of work, but the authors point out that much more research is needed. For example, there is a need for full clarity on the extent of repair of bone that can occur with weight restoration. And, when BMD is not adequately restored with weight gain, adequate treatment is needed. Finally, much more research may help clarify how the existing findings about weight gain and bone health applies to teenage males with AN.

Help for Patients Who Just Can’t Recover

Courtesy of Eating Disorders Review

A Swedish study applies the case management approach for enduring eating disorders.

Some patients with severe eating disorders just don’t get better despite long-term treatment, and may go on to develop severe and enduring eating disorders (SEED). An eating disorders center in Stockholm is currently testing a case management system to help such patients (J Eat Disord. 2016; 4:24).

In 2014, the Stockholm Centre for Eating Disorders at the Karolinska Institute designed a new treatment unit, Eira, especially designed for SEED patients. A team at the Karolinksa Institute recently described their ongoing study investigating whether an individualized case management program approach could improve SEED patients’ quality of life, help control their healthcare costs, reduce eating disorder symptoms, and improve access to and voluntary use of available health care.

Patients who are candidates for case management often are seriously ill and in distress because of physical and financial strain, social problems, combined with anxiety, depression and compulsive behaviors. Ironically, some SEED patients appear to be well and thus are ambivalent about treatment. For some clinicians, a patient who has “tried everything” without a positive result may appear “unmotivated” and subsequently dismissed from treatment.

Case management systems

In the past, case management approaches have been aimed at adult patients with severe mental disabilities such as schizophrenia, severe addictive disorders, and psychoses. The case management method offers individualized care, which may last a few months to several years, and there is no time limit for the intervention.

The Eira unit accepts patients who have had an ED for at least 10 years and who have failed at least three treatment programs. All patients undergo a semi-structured diagnostic interview, a qualitative interview, and then complete several self-report questionnaires. Data from medical records are also collected. The program is designed so that the diagnostic interview and self-report assessments are done at follow-ups after 1, 2, and 3 years in the program.

The program can manage up to 30 patients simultaneously. The main activity involves clinical contact with a clinical case manager through supportive conversations. The case manager also has a role in treatment, for example, by providing social training, ways to control symptoms, and family support. According to the authors, the individual patient’s needs and references drive the frequency, setting, and form of the meetings. With the patient’s consent, relatives are invited to participate in the intervention, and special lectures for family members (without the patient) are offered twice a year. According to the authors, clinical outcome and cost-effectiveness will be carefully analyzed at the end of the current study.

The authors also note that the program offers an alternative to more traditional treatment, which is aimed at reducing the patient’s symptoms; instead, the case management approach prioritizes function and quality of life. It will be of great interest to see the final outcomes of this study.

Child Abuse and Development of EDs

Courtesy of Eating Disorders Review

The type of abuse had later effects on individual disorders.

A history of trauma during childhood is more common among patients with eating disorders than among the general population, and this relationship has been extensively studied. Results from a recent study at the University of Montpellier in southern France, add new information about early abuse and its effect on EDs (Scientific Reports; published online before print, doi: 10:1038/srep35761).

Dr. S. Guillaume and his colleagues report that while many studies of child abuse have focused upon sexual or physical abuse, far fewer have examined the effects of emotional abuse and neglect during childhood. The authors’ results indicate that more severe eating disorder symptoms may be related to specific types of childhood trauma. In their study, emotional abuse during childhood independently predicted higher Eating Disorders Examination Questionnaire (EDE-Q) scores for eating, weight, and shape concerns, along with poorer daily functioning. In contrast, sexual and physical abuse predicted greater EDE-Q eating concerns.

In their study, the researchers examined 192 consecutive young adult female patients admitted to an outpatient treatment unit (102 with anorexia nervosa, 64 with bulimia nervosa, and 26 with binge-eating disorder). For the clinical assessment, the psychiatrists administered the EDE-Q, and the Functioning Assessment Short Test (FAST). The FAST’s 24-item questionnaire assesses impairment or disability in 6 specific areas of functioning: autonomy, occupational functioning, cognitive functioning, financial issues, interpersonal relationships and leisure time (Clin Pract Epidemiol Ment Health. 2007; 3:5). Childhood trauma was evaluated with the French version of the Childhood Trauma Questionnaire, which retrospectively examines 5 types of trauma through self-reports: sexual abuse, physical abuse, physical neglect, emotional abuse, and emotional neglect (J Am Acad Child Adolesc Psychiatry. 1997; 36:340).

Depression was the most common comorbidity

The most common lifetime comorbidities were major depressive disorders (77%) and anxiety disorders (42%). More than three-fourths of patients were college educated, and the mean age was 25 years. When evaluated for childhood trauma, 42% reported none, while 21% of the subjects had experienced at least 3 types of trauma. Emotional neglect was most common, reported by 36% of the women. Moderate-to-severe trauma was more common among patients with BN than among those with AN. The proportion of patients with physical and sexual trauma did not differ among the three groups. However, those found to have high scores for EDE-Q restraint had more psychiatric disorders, such as major depressive illness, bipolar disorder or substance abuse disorder, and were more likely to have had a lifetime history of suicide attempts than were patients with lower restraint scores.

One goal of the study was to scrutinize the impact of psychiatric comorbidities on the relationship between trauma during childhood and the subsequent severity of ED symptoms. The authors concluded that not all subtypes of abuse have the same impact upon patients. Instead, different types of abuse act additively to exacerbate “the severity of a wide range of ED features, including clinical and neuropsychological dimensions and daily functions.”

When Patients Resist Treatment

Courtesy Eating Disorders Review

Clues to motivating patients who avoid or refuse treatment

Just like Lord Byron’s fictional prisoner of Chillon, some eating disorders patients have “chains” that keep them from seeking treatment. Researchers at the University of Adelaide report that “a cultural context of care” can play an important role in a patient’s decision to avoid or refuse treatment (J Eat Disord. 2016; 4:36).

Of the 1 million persons with eating disorders throughout Australia, only about 30% seek treatment. A movement toward recovery-oriented practice and service delivery in Australia is a central theme in the Australia and New Zealand College of Psychiatrists Clinical Practice Guidelines for Treating Eating Disorders. This framework of recovery takes into account the patient’s experiences beyond the typical framework and guidelines of medical and clinical recovery.

Dr. Connie Musolino and her colleagues used observations, ethnographic fieldwork, and psychological evaluation to study 28 women with disordered eating. Twenty eight women from 19 to 52 years of age participated, and 90% met the criterion for an eating disorder; most fell into the Other Specified Feeding or Eating Disorder (OSFED, formerly EDNOS) category and 2 met the criteria for anorexia nervosa.  Of these, 28, 21 completed the EDE and the mean Global EDE was 3.48—so severity was high.

Some reasons for avoiding treatment

The participants were asked to describe their reasons for avoiding treatment. Many of the women described their eating disorders as “a safe place.” When interviewed, the women expressed a feeling of safety with their disorders, for example, by using the same plate at all meals, eating “safe foods,” and maintaining the same daily routine. For example, a 27-year old woman who had diagnoses of EDNOS and AN explained that even though she was panicky and anxious, adopting a rigid routine made her feel calm. Others described their eating disorder as “a safe and familiar place.” Some hid the disorder in a cultural context, turning to the benefits of being lean and dieting. Others claimed that they had food allergies, needed special diets, or were intolerant of a special list of foods. Among others there was a sense of pride in taking care of the problem themselves.

To maintain their disordered eating patterns, participants used high levels of self-discipline and found a sense of safety and pride in starving themselves, and using binge eating and purging. Their definition of care was, for example, adopting a strict vegan diet to avoid obesity or starving to shrink their bodies to avoid unwanted sexual attention. These actions posed real obstacles to seeking any treatment that might lead to recovery. The women’s cultural understanding of healthy eating and exercise, directed from constant bombardment of cultural imagery promoting health and self-discipline, seemed morally superior and made the very concept of recovery seem contradictory and defeating.

One implication, according to the authors, is the importance of working to develop a shared understanding with patients about the underlying function of their eating disorder. This path might help avoid conflicts and provide a pathway for patients to seek and accept treatment. Discussing how disordered eating practices are embedded in self-care, health, eating and body practices may enhance the patient-therapist relationship.

Interestingly, considering ED symptoms form a self-care perspective might be viewed as dovetailing with recent, often neurobiologically oriented research examining negative and positive reinforcement as processes that maintain eating disorder symptoms

How Common Is Binge Eating Disorder in the US?

courtesy of Eating Disorders Review

Changing the definition increased the prevalence by nearly 30%.

Binge-eating disorder (BED) was first described by the late Dr. Albert J. Stunkard in 1959, but it was not declared an official eating disorder until 2013, when it was included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The DSM-5 criteria for BED differ from earlier definitions, such as those in the DSM-IV-TR, by diminishing the required frequency of BE events from twice per week to once per week, and reducing the required duration from 6 to 3 months. Both the inclusion of BED as well as the specific criteria changes could serve the committee’s goal to “shrink EDNOS.”

Nichole Crossrow, MPH, PhD and a team of researchers designed a study comparing the two DSMBED definitions, in part to see if changing frequency and duration criteria do actually change the prevalence of BED. The authors noted that although studies have assessed the implications of the newer DSM-5 criteria for BED, no large-scale survey had yet used the newer diagnostic criteria “to assess BED prevalence or to draw a demographic or clinical profile of afflicted individuals.” The team designed a comparison study of criteria from the DSM-IV-TR and DSM-5 using a large US community sample (J Clin Psychiatry. 2016; 77:8).

To better estimate the prevalence, the authors used an Internet survey to analyze a representative sample of US adults who participated in the 2012 or 2013 National Health and Wellness Survey. This self-administered nationwide Internet survey is completed by approximately 75,000 US adults each year. The 22,397 respondents to the authors’ survey (a 32% response to their email ads) provided information about demographics, psychiatric symptoms, and psychological features. All respondents were asked if they had been given a diagnosis for one of several psychiatric and medical conditions, such as attention deficit hyperactivity disorder (ADHD), anxiety, depression, and bipolar disorder. Responses to questions representing the DSM-5 or DSM-IV-TR BED symptoms were then used to assess whether individuals met diagnostic criteria for BED across 3-month, 12-month, and “ever” time frames. This information was used to estimate the respective prevalence, with one exception: the DSM-IV-TR BED definition outlines a duration criterion of 6 months. The respondents completed several online questionnaires assessing self-esteem, major depressive disorder, mood disorders, and ADHD symptoms.

BED prevalence estimates were higher using DSM-5 criteria

The authors reported that 12-month and lifetime BED prevalence estimates based on DSM-5 criteria (1.64% vs. 2.03%, respectively) were higher than estimates based on DSM-IV-TR criteria (1.15% and 1.52%, respectively). The differences were particularly marked among men. And, of the survey respondents who met DSM-5 criteria for BED, only a very small percentage—3.2%–had ever received a formal diagnosis of BED from a healthcare professional. Those who had a DSM-5diagnosis of BED also were significantly more likely to report having lifetime depression, lifetime anxiety, and ADHD than were respondents who did not meet the diagnostic criteria for BED (after controlling for age, sex, and body mass index.

Compared with non-BED respondents, those who met DSM-5 criteria for BED were younger and had higher BMI and lower self-esteem.

The study had several strengths and limitations. The main strength of the study is that it included a large representative sample of US adults of different ages, genders, and race/ethnicities. One limitation was that all survey data were self-reported, and the diagnosis of BED could not be clinically confirmed.

According to the authors, changing the criteria for BED increased the official prevalence of BED in the US by about 30%. One particularly striking was that healthcare providers identified only about 3.2% of BED patients. Clearly we have a long ways to go in educating healthcare providers about BED.

Feminist Psychodynamic Psychotherapy, Part 2: A Perspective from Practice

By Kathryn J. Zerbe, MD

Coming to Terms with ‘Bad Objects’

Manifestations of the compulsion to repeat what has been harmful is clinically observed in our patient’s attempt to self-regulate by turning to her eating disorder symptoms or other forms of self-harm despite many therapeutic options suggested and the patient’s conscious desire to stop. Important interpersonal relationships can also derail when those who want to be supportive or understanding are experienced as inflicting pain, and they can quickly resurface as ‘bad objects’ for our patient. Simply knowing that we clinicians are often placed into the ‘bad object’ role, and owning our tendency to want to dodge this experience, embracing our imperfections, and acknowledging the ‘bad objects’ that we, like all people, carry within us, are first steps in helping our patients come to friendlier terms with their own ‘bad objects.’ Only very slowly do these bad objects that internally persecute our patient in the form of symptomatic and interpersonal expressions diminish, because they are often lifelong patterns.

Yet, feminist psychodynamic psychotherapy does not stop here. That is, the crucial objective of identifying and owning split-off self-states and bad objects that wreak such havoc in living life to the fullest is only the start of easing the inner anguish and bodily tensions caused by such insidious forces. Clinical case studies demonstrate how often ruptures and breakdowns in the therapeutic process are brought about by these pathological entities. The patient is assisted by repeatedly working over the common defense of projecting and evacuating bad objects into others. A temporary reprieve from angst occurs when one can psychologically deposit that feeling into another, but there are also consequences. The person who is subject to forceful negative projections may become angry, beleaguered, confused, or simply worn out by what is experienced as personal attack. An important relationship can then easily break down.7, 8

When this process happens in a well-established psychotherapy process, there is an opportunity to catch the rupture as it is happening or soon thereafter and to attempt to slow down and observe what has transpired. This step not only preserves the therapeutic relationship but serves as an ‘in-vivo’ demonstration of what often transpires in relationships outside the office setting. The therapist’s owning her part in what may have caused the rupture, in essence being human, real, and acknowledging mis-attunements, helps to repair the therapeutic rupture. Working through the ‘Disruption-Repair Cycle’ time after time is proving to have robust effects in psychotherapy.

Interestingly, investigation into the Disruption/Repair Cycle in therapy is derived from studies of caretaker/infant dyads.9 What is more feminist in scope than taking seriously our earliest bonds and their lifelong influence on our lives? Psychotherapists practicing with a feminist orientation have always paid particular attention to the role of the mother in fostering development and regulating autonomy and dependency. Infant researchers have concluded that those multiple, tiny disruptions that occur between a mother and her child and the adequate repair that happens in milliseconds between them sets the stage for later resiliency and growth. In the treatment of eating problems, simply knowing psychotherapy will be fraught with disruptions because the patient may keep secrets, move slowly, not follow advice, or act self destructively, and because the therapist will be caught off guard, have flaws, and inadvertently make errors of commission and omission, suggests that the need to repair disruption is essential for forward movement.

Welcoming the Worst and the Worrisome 

Literally hundreds of research articles summarized in EDR over the past decades have highlighted the eating disorder person’s struggle to acknowledge, name, regulate, and come to terms with the expression of affect in treatment. These articles have offered concrete, cutting-edge tools to assist clinicians in this undertaking. Behind the goal of improved affect expression resides an underlying psychodynamic formulation that eating disorders are themselves attempts to regulate feelings that were not expressed, processed, or adequately ‘held’ within the family or cultural environment.

Feminist psychodynamic psychotherapy takes this concept one step further by privileging communications that include ‘The Disagreeable Passions,’ such as anger, fear, frustration, envy, betrayal, mourning, greed, appetite, deprivation, and rage.10 Helping patients to reveal and to own their painful affect states, in essence refusing to collude with swallowing one’s selfhood for the comfort of another, is the daily task of the feminist psychodynamic psychotherapist.

Many young clinicians who treat eating disorders with manualized techniques they learned during residency or graduate training are often shocked in workshops to learn how neatly feminist psychodynamic concepts overlap with what they are already doing and that they have already unknowingly incorporated a technique they may have taken for granted into their practice. Patricia Gherovici,11 a feminist psychoanalyst who practices in Paris and Philadelphia, describes how bulimic symptoms helped one of her patients manage severe anxiety, and to ‘neutralize’ miscreant feeling states and overwhelming human needs before she could adequately individuate and curtail the binge/purge cycle. Like many of our patients, other psychiatric symptoms remitted while eating problems did not budge until her patient found new ways to transform disagreeable passions into healthier activities (e.g., cooking), and to differentiate her personal desires from those imposed from others in her culture and family of origin.

Inhabiting Rooms of One’s Own

Attachment research, neurobiology studies, meditative practice observations, and evolutionary biology discoveries, now have hard-won scientific evidence that buttresses the psychotherapeutic practice of valuing private space that promotes reflection, creativity, and personal health for men and women. Feminist thinkers have opined for decades that one’s subjectivity can be harnessed only by a balance between what one learns within a group or with others (appropriating the Native American term ‘talking circle’) and the individual practice of seeking repose (having a room of one’s own). Most recently, feminist historian Omnia El Shakry12 has brought to the world’s attention the contributions of Arabic intellectuals in the last century who sought to interweave long-established spiritual practices with Freudian psychotherapeutic ideas. One assertion of El Shakry’s work is the confluence in both of these seemingly divergent traditions of the human need for contemplative time. Honoring this requirement of personal time and space–essentially inhabiting rooms of one’s own–allows us to reflect on, think about, and eventually integrate spiritual, social, and psychological aims for greater fulfillment in life.

With eating disorder patients, clinicians appropriate this approach and call it by many new names (e.g., mentalization; primary reflective function; self-regulation; emotional muscle training) that actually have deep, ancient roots. For the feminist psychodynamic psychotherapist, the treatment hour is an essential but insufficient room wherein the individual safely experiences empathy for oneself and others, bears misfortune and trauma, and ultimately transcends the eating disorder symptoms by finding new purpose and meaning in life. The patient must then continue his/her personal odyssey by experiencing solace and solitude in rooms of one’s own. Small wonder that many therapeutic traditions now converge in prescribing exercises such as journaling, meditation, prayer, and ongoing self-analysis. All share the same goal of improved self-regulatory functioning in the quest for greater vitality and perspicacity in making decisions and taking ownership for them.

Conclusion: Evolving and Transforming Psychodynamic Psychotherapy

Western and non-Western scholars and psychotherapists are currently augmenting and transforming the ways that feminist psychodynamic psychotherapy is practiced. These voices will increasingly be integrated into the treatment of eating disorders because they emphasize facets of subjectivity, self- creation, ethics, and cultural responsibility snuffed out when an eating and body image problem takes hold of an individual life.

The role of the therapist as witness will remain central regardless of tweaks to and enlargements of feminist theory and its multidisciplinary contributors. As one wise patient with anorexia summed up midway through her many years of feminist psychodynamic psychotherapy, “When you finally realize you are in the fight of your life, it sure helps to have someone there to listen, ear to ear. You just don’t help ‘hold and process’ my emotions like you say. You also help me to hear me, those thoughts I am actually saying to myself.”