An excellent new study validates psychotherapy for the successful treatment of anorexia nervosa, a disease with a 20% mortality rate. Despite this apparent success, roughly 25% of the participants did not show rapid results and these subjects continued to show full anorexia at the one-year follow-up.

The Anorexia Nervosa Treatment of Out Patients (ANTOP) study was conducted at ten German university eating disorder centers and was designed by the departments for psychosomatic medicine at the university hospitals of Heidelberg (Director: Prof. Wolfgang Herzog) and Tübingen (Director: Prof. Stephan Zipfel) - results were published in The Lancet (reference below).

The study compared three different therapeutic approaches:

1. Focal psychodynamic therapy addresses the way negative associations of relationships and disturbances affect the way patients process emotions. The working relationship between the therapist and the patient plays a key role in this method. The patients are specifically prepared for everyday life after conclusion of the therapy.

2. Cognitive behavior therapy has two focuses: normalization of the eating behavior and weight gain, as well as addressing the problem areas connected to the eating disorders, such as deficits in social competence or in problem-solving ability. The patients are also assigned "homework" by their therapists.

3. Standard psychotherapy was conducted as optimized treatment as usual by experienced psychotherapists selected by the patients themselves. The patients' family physicians were included in the treatment. The patients also visited their respective study center five times during the study.

Both the psychodynamic and the cognitive behavioral approaches were more successful than the "standard psychotherapy" during the 10 months of therapy, as well as at the one-year follow-up. However, overall the psychodynamic model proved more effective.

"Overall, the two new types of therapy demonstrated advantages compared to the optimized therapy as usual," said Prof. Zipfel. "At the end of our study, focal psychodynamic therapy proved to be the most successful method, while the specific cognitive behavior therapy resulted in more rapid weight gain." Furthermore, the patients undergoing focal psychodynamic therapy required additional in-patient treatment less often.

These results are heartening for those of us who practice a relational version of psychodynamic therapy.


Full Citation: 
Zipfel, S, Wild, B, Groß, G, Friederich, HC, Teufel, M, Schellberg, D, Giel, KE, de Zwaan, M, Dinkel, A, Herpertz, S, Burgmer, M, Löwe, B, Tagay, S, von Wietersheim, J, Zeeck, A, Schade-Brittinger, C, Schauenburg, H, Herzog, W. (2013). Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): Randomised controlled trial. The Lancet, 2013; DOI: 10.1016/S0140-6736(13)61746-8

Largest therapy trial worldwide: Psychotherapy treats anorexia effectively

Posted By News On October 21, 2013

A large-scale study has now shown that adult women with anorexia whose disorder is not too severe can be treated successfully on an out-patient basis. Even after conclusion of therapy, they continue to make significant weight gains. Two new psychotherapeutic methods offer improved opportunities for successful therapy. However, one quarter of the patients participating in the study did not show rapid results. These are the findings of the world's largest therapy trial on anorexia nervosa published in the renowned medical journal The Lancet. The Anorexia Nervosa Treatment of OutPatients (ANTOP) study was conducted at ten German university eating disorder centers and was designed by the departments for psychosomatic medicine at the university hospitals of Heidelberg (Director: Prof. Wolfgang Herzog) and Tübingen (Director: Prof. Stephan Zipfel).

Psychotherapy has been recognized as the treatment of choice for anorexia nervosa and in Germany, is covered by health insurance. However, to date there have been no large-scale clinical studies that examine the efficacy of different treatment methods on a comparative basis, constituting a glaring research gap considering the severity of the disease.

Anorexia nervosa – the most lethal mental disorder

"In the long-term course, in up to 20 percent of the cases, anorexia leads to death, making it the most lethal of all of the mental disorders. Patients with anorexia often suffer from the psychological or physical consequences of the disease their entire lives," explained Prof. Zipfel. To date, no convincing studies on specific therapy programs have been available in adults. Furthermore, randomized controlled studies comparing promising therapy methods are rare. "Well-controlled, clinical studies with a high level of reliability are rare, especially for out-patient therapy, creating enormous problems," said Prof. Herzog.

Around 1 percent of the population has anorexia nervosa, with the disorder affecting nearly only girls and young women. Patients with anorexia are very underweight due to their long-term food restriction and, in many cases, their urge to over-exercise. Self-induced vomiting, the use of laxatives, diuretics or appetite suppressants exacerbate the weight loss. The patients' body weight is no more than 85 percent of normal weight (body mass index (BMI) of less than 17.5 kg/m²). Patients with anorexia have an intense fear of gaining weight and their perception of their own figure is distorted. They often have other mental disorders such as depression, anxiety and compulsive disorders.

Treatment by experienced psychotherapists in cooperation with family physicians

The ANTOP study, which accompanied 242 adult women over a period of 22 months (10 months of therapy, 12 months of follow-up observation) now allows scientific conclusions to be drawn about the efficacy of different types of psychotherapy for the first time. Three groups of either 82 or 80 patients each underwent a different method of out-patient psychotherapy. The therapy involved two new psychotherapy methods that were specially developed for out-patient treatment of anorexia and an optimized form of the currently practiced standard psychotherapy ("optimized treatment as usual"). For the specific therapies, treatment manuals were developed in conjunction with international eating disorder experts. The therapy comprises 40 out-patient individual therapy sessions over a period of 10 months.

For all 242 patients, specially trained psychotherapists conducted the therapy with the patients. The patients' family physicians were informed about the therapy and were involved in the treatments and the patients were examined by their family physician at least once a month. Around one third of the patients had to be admitted for in-patient treatment temporarily due to their poor state of health. Approx. one quarter of the patients discontinued their participation before the trial had ended.

Three psychotherapy methods were compared:

1. Focal psychodynamic therapy addresses the way negative associations of relationships and disturbances affect the way patients process emotions. The working relationship between the therapist and the patient plays a key role in this method. The patients are specifically prepared for everyday life after conclusion of the therapy.

2. Cognitive behavior therapy has two focuses: normalization of the eating behavior and weight gain, as well as addressing the problem areas connected to the eating disorders, such as deficits in social competence or in problem-solving ability. The patients are also assigned "homework" by their therapists.

3. Standard psychotherapy was conducted as optimized treatment as usual by experienced psychotherapists selected by the patients themselves. The patients' family physicians were included in the treatment. The patients also visited their respective study center five times during the study.

Specific psychotherapies offer realistic chances for cure

The patients with anorexia in all three groups had made significant weight gains after the end of therapy and at a 12-month follow-up visit. Their BMI had increased by 1.4 BMI points on average (the equivalent of an average of 3.8 kg). "Overall, the two new types of therapy demonstrated advantages compared to the optimized therapy as usual," said Prof. Zipfel. "At the end of our study, focal psychodynamic therapy proved to be the most successful method, while the specific cognitive behavior therapy resulted in more rapid weight gain." Furthermore, the patients undergoing focal psychodynamic therapy required additional in-patient treatment less often. While the acceptance of the two new psychotherapy methods by the patients was very high, at 1 year after the end of therapy, approx. one quarter of the patients continued to have full syndrome anorexia nervosa.

The scientists from Tübingen and Heidelberg drew the following conclusion: The specific therapies give adult patients a realistic chance of recovery or long-term improvement. However, great challenges for the prevention and early treatment of anorexia nervosa remain.

~ Source: Heidelberg University Hospital

The Unseen Battle of Eating Disorders

Last week there was a new study released on how the brains of women with eating disorders (anorexia and obesity) are different. This research showed that the reward circuits in the brain are sensitized in anorexic women and desensitized in obese women - a finding that suggests eating behavior is related to brain dopamine pathways involved in addictions.

Snag Films also posted a video this week on the unseen battle of eating disorders.

Brain circuitry is different for women with anorexia and obesity

Posted On: May 14, 2012

AURORA, Colo. (May 14, 2012) - Why does one person become anorexic and another obese? A study recently published by a University of Colorado School of Medicine researcher shows that reward circuits in the brain are sensitized in anorexic women and desensitized in obese women. The findings also suggest that eating behavior is related to brain dopamine pathways involved in addictions.

Guido Frank, MD, assistant professor director of the Developmental Brain Research Program at the CU School of Medicine and his colleagues used functional magnetic resonance imaging (fMRI) to examine brain activity in 63 women who were either anorexic or obese. Scientists compared them to women considered "normal" weight. The participants were visually conditioned to associate certain shapes with either a sweet or a non-sweet solution and then received the taste solutions expectedly or unexpectedly. This task has been associated with brain dopamine function in the past.

The authors found that during these fMRI sessions, an unexpected sweet-tasting solution resulted in increased neural activation of reward systems in the anorexic patients and diminished activation in obese individuals. In rodents, food restriction and weight loss have been associated with greater dopamine-related reward responses in the brain.

"It is clear that in humans the brain's reward system helps to regulate food intake" said Frank. "The specific role of these networks in eating disorders such as anorexia nervosa and, conversely, obesity, remains unclear."

Scientists agree that more research is needed in this area. The study was published in Neuropsychopharmacology.

Source: University of Colorado Denver

* * * * * * *

Shadows and Lies: The Unseen Battle of Eating Disorders 

Synopsis

Anorexia nervosa and bulimia have claimed many lives, as well as headlines, in the past two decades. About five percent of urban teenage girls are affected by eating disorders. Another twenty percent dabble in unsafe weight control practices. Dieting activity can start as early as fourth grade, with some girls as young as nine having serious problems. The emotional and psychological impacts of eating disorders are felt not only by these young women themselves, but by their families and loved ones as well. This powerful and honest documentary profiles four women who are working themselves free from the deadly grip of eating disorders, and from the overwhelming physical and psychological complications associated with these deadly diseases.

Film Credits

Director: Karen Pascal

Producer: Windborne Productions

Mark Schwartz, Clinical Co-Director of Castlewood Treatment Center, Accused of Implanting False Memories of Satanic Abuse

I was sad to hear about this story - Mark Schwartz is not to be confused with Richard Schwartz (I mistakenly thought they were brothers), founder of the Internal Family System Therapy model of parts work. Mark is clinical co-director at Castlewood Treatment Center, where Richard Schwartz also works on occasion.

Mark has been accused of implanting false memories of satanic abuse in a former patient with the intent of collecting more money from insurance. If these allegations are true, it's a sad commentary on putting money above the well-being of the clients.

As many commentators on this story have suggested, the eating-disordered clients seen at Castlewood are particularly vulnerable to manipulation through hypnosis - getting them into a hypnotic state is easier due to the ease with which they already dissociate.

It's also important to know that only Schwartz is being accused here, although Castlewood is of course named in the lawsuit. Richard Schwartz and the IFS model are not implicated in the allegations.

Here is a version of the story from MSNBC (via the AP) - it has received a lot of attention, including several UK papers.

Woman: Psychologist implanted horrific memories

By JIM SALTER

updated 12/2/2011 7:54:41 PM ET

ST. LOUIS — The memories that came flooding back were so horrific that Lisa Nasseff says she tried to kill herself: She had been raped several times, had multiple personalities and took part in satanic rituals involving unthinkable acts. She says she only got better when she realized they weren't real.

Nasseff, 31, is suing a suburban St. Louis treatment center where she spent 15 months being treated for anorexia, claiming one of its psychologists implanted the false memories during hypnosis sessions in order to keep her there long-term and run up a bill that eventually reached $650,000. The claims seem unbelievable, but her lawyer, Kenneth Vuylsteke, says other patients have come forward to say they, too, were brainwashed and are considering suing.

"This is an incredible nightmare," Vuylsteke said.

Castlewood Treatment Center's director, Nancy Albus, and the psychologist, Mark Schwartz, deny the allegations. Albus pledged to vigorously fight the lawsuit, which was filed Nov. 21 in St. Louis County and seeks the repayment of medical expenses and punitive damages. As in repressed memory cases, which typically involve allegations of abuse that occurred during childhood, the outcome will likely hinge on the testimony of experts with starkly different views on how memory works.

Nasseff, who lives in St. Paul, Minn., stayed at Castlewood from July 2007 through March 2008 and returned for seven months in 2009. She was struggling with anorexia and as a resident of Minnesota, which requires insurers to cover long-term eating disorders, she could afford to stay at the center, which sits on a high bluff in the suburb of Ballwin overlooking a park and meandering river. Most states, including Missouri, don't require such coverage.

In her lawsuit, Nasseff claims Schwartz used hypnotic therapy on her while she was being treated with psychotropic drugs, and her lawyer says Schwartz gave her books about satanic worship to further reinforce the false memories. She says she was led to believe she was involved in a satanic cult whose rituals included eating babies, that she had been sexually abused and raped multiple times, and that she had exhibited 20 different personalities.

Vuylsteke said the trauma was too much to bear, and that Nasseff tried to get hold of drugs to kill herself during her stay.

"Can you imagine how you would feel if you thought you had participated in all these horrible things?" Vuylsteke asked.

Eventually, Nasseff learned from other women treated at Castlewood that they, too, had been convinced through therapy that they were involved in satanic cults, Vuylsteke said. And, he said, those women were also from Minnesota, allowing insurance to pay for their treatment.

"It seems like quite a coincidence that all of this cult activity was in Minnesota," he said.

Nasseff returned to Minnesota, where she works part-time in public relations and has her eating disorder in check, her lawyer said.

In her lawsuit, she claims Schwartz warned her in October 2010 to return to Missouri for additional treatment or she would die from her disorder. She says he left a phone message this October warning that if she sued, all of her memories of satanic rituals and abuse would be revealed.

Schwartz, reached by phone at the center, where he is its clinical co-director, denied any wrongdoing but declined to discuss the case further because he hadn't hired a lawyer yet. He previously told ABCNews.com that he never hypnotized Nasseff, that they had never discussed satanic cults and that she never told him she had committed criminal acts.

Albus didn't respond to requests for comment, but she told Courthouse News Service that Castlewood "strongly believes that all of these claims are without merit and we intend to defend these claims vigorously."

Some experts, including University of California, Irvine, professor Elizabeth Loftus, question the validity of repressed memory cases, which became more commonplace in the 1990s.

"Where is the proof you can be raped in satanic rituals and have absolutely no awareness of it, then reliably recover those memories later?" she asked.

However, neither Loftus nor Jim Hopper, a clinical instructor of psychology at Harvard Medical School, would speculate about whether Schwartz may have implanted false memories. Both agreed people can have memories of events that didn't really happen and that the power of suggestion can play a role in producing false memories.

Loftus cited several medical malpractice cases won over memories that proved to be false. Hopper said he believes memory is complex.

"Something that happened years ago can be encoded in the brain in various ways, and various combinations of those memory representations may be retrieved, or not, in various ways, for various reasons, at any particular time," he said.

Since this story originally aired, other women have come forward to support the original claims or add new ones to the situation now facing Schwartz and Castlewood.

From St. Louis Today:

Other women come forward in Castlewood center complaint

BY BLYTHE BERNHARD • bbernhard@post-dispatch.com > 314-340-8129 | Posted: Saturday, December 10, 2011 

In the lush hills overlooking Castlewood State Park, a secluded clinic attracts people from across the country who have tried and failed to overcome an eating disorder.

Pictures of Castlewood Treatment Center in west St. Louis County show a homelike sanctuary where residents practice yoga, sit around a fireplace and sleep under down comforters.

That idyllic image was shattered last month when a Minnesota woman filed suit against Castlewood and its director, psychologist Mark Schwartz, alleging she was brainwashed into believing she had multiple personalities and was implanted with false memories of sexual abuse and satanic cult activity while under hypnosis during her 15-month stay at the center for anorexia. Other women have since come forward to support the woman's claims and to report similar experiences.

"They definitely pushed the idea that I had been abused as a child on me," said Dara Vanek, 28, of Philadelphia, who stayed at Castlewood for several months in 2007 and 2008. "To all of a sudden have this huge amount of doubt about what happened in my childhood was incredibly damaging and shaming for me."

In her malpractice lawsuit against Castlewood, Lisa Nasseff, 31, also alleges that Schwartz wanted to keep her at the treatment center because she had insurance that would pay her medical bills that totaled $650,000.

The lawsuit against Castlewood came as a relief, Vanek and other women say.

"I feel like it validates that I'm not crazy, that it's something else that was going on," she said. "Satanic ritual abuse was talked about a lot in group therapy. It's kind of ironic (because) Castlewood itself almost seemed at times like a cult. It was implied that you could not recover unless you dedicated your life to Castlewood."

A LAST RESORT FOR SOME
Castlewood is a last resort for patients looking for healing after spending years of their lives in other medical facilities, according to a statement from executive director Nancy Albus.

Its treatment "is marked by compassion, respect and empowerment," according to Albus.

Albus said more than 1,000 clients have been treated at Castlewood since it opened more than 10 years ago. A second, castlelike facility opened recently nearby, and the two homes are licensed for 26 residents as well as outpatient services.

The sprawling Castlewood campus includes a swimming pool, hot tub, dance studio, art room and gym, according to state records. Residential stays cost $1,100 a day over an average of two to four months, and are sometimes covered by insurance, according to Castlewood's website. The facility doesn't accept Medicare or Medicaid patients, so it doesn't receive any government funding.

The private equity firm Trinity Hunt Partners of Dallas, funded by the Hunt family that owns the Kansas City Chiefs, bought majority control of Castlewood in 2008, expanded it in 2010 and announced plans to open similar facilities in other cities. The purchase was part of the firm's $25 million move into behavioral health care.

Former Castlewood patients said their days were spent making collages and writing in journals that they would share in individual and group therapy sessions. On the weekends, residents go on outings to movies, the Butterfly House and the zoo. Therapists supervise clients at meal times, and take them to restaurants and grocery stores to talk about healthy eating habits.

The Missouri Department of Mental Health licenses the facility and found only minor record-keeping deficiencies in its most recent inspection last summer. In their interviews with state inspectors, three Castlewood clients said they felt respected by staff, and another said the program saved her life.

Castlewood also meets the standards set by the Commission on the Accreditation of Rehabilitation Facilities, which conducts regular site visits and interviews with patients and staff.

A Florissant woman who asked only to be identified as Laura because she is still seeing a therapist from Castlewood said her inpatient experience in 2003 and 2004 was positive and that her therapy sessions never included discussions of cult activity or childhood sexual abuse.

"If I didn't go there I wouldn't be here," said Laura, 34. "Castlewood is a good place to go if you're very sick."

Schwartz declined an interview through his attorney. Albus said in her statement that Schwartz is internationally respected in the field of eating disorders.

Former patients of Schwartz, 60, said he is down-to-earth with a magnetic but mysterious personality. He looks like "an old hippie" with long hair, as one patient described him, and another said he has fertility statues and dead bugs behind glass hung in his office.

Schwartz is licensed as a psychologist in Missouri and has no discipline record with the state. He holds a doctorate in science degree from Johns Hopkins University and is an adjunct professor of psychiatry at St. Louis University, according to his résumé.

A spokeswoman for SLU said Schwartz gave a presentation at the medical school years ago but does not teach or supervise students.

THE TREATMENT
The main treatment strategy at Castlewood is called internal family systems. The technique is based on the theory that "the eating disorder actually protects (people) from re-experiencing or thinking about difficult things from their pasts," according to Castlewood's website.

Clients are encouraged to think of themselves as having many "parts" or emotions. Through therapy, they focus on improving the destructive parts of themselves, such as the perfectionist part, that can prevent them from fully enjoying life, as explained on the site.

Several local mental health practitioners said internal family systems therapy has not been rigorously studied for its effectiveness.

Therapists practicing the technique must take extra care with patients with eating disorders, who can be particularly vulnerable to having their memories and personalities twisted, in part because they are malnourished, experts said.

Some residents of Castlewood are so ill that they require feeding tubes, while others are so weak that they use wheelchairs, former patients said.

"People who are suggestible in certain ways can take a suggestion from a therapist and begin to split themselves into parts that they then name, and they will begin to think of themselves as having multiple personalities," said Dr. Lynne Moritz of the St. Louis Psychoanalytic Institute. "The issue is you don't want to encourage that in susceptible people."

Instead of encouraging a client to think about parts, "you want to integrate the whole person who has many different ways of thinking and feeling all at the same time," Moritz said.

Today, experts believe cases of multiple personality disorder are rare, if not nonexistent.
"I've never had a case of multiple personality in 40 years of practice," Moritz said.

REPRESSED MEMORIES
The mental health care field took a hit to its reputation in the 1990s after a rash of cases involving patients who reported memories of childhood sexual abuse that they had previously repressed. In many of the cases, the memories were found to be suggested by a therapist, and the concept of repressed memories grew more controversial.

Schwartz has written that the controversy over memory should not scare therapists away from asking about a client's past, especially because a history of sexual abuse is common in people with eating disorders. The psychologist was affiliated with Dr. William H. Masters and Virginia Johnson, famed local sex researchers of the 1960s and 1970s, and he operated a sex therapy clinic in their name before opening Castlewood.

"Certainly, eating disorders therapists have every reason to suspect the presence of sexual trauma in their patients," Schwartz wrote in the introduction to his 1996 book "Sexual Abuse and Eating Disorders."

"Individuals who actually believe that memories are created by therapists are, for their own reasons, motivated to not know and not see the extent to which abuse actually exists in our culture," Schwartz wrote. "If the statistics are accurate, then our friends and neighbors are having incestuous relationships with their daughters and sons, and by ignoring it, so are we."

Meagan McKay of Vermont said she was at Castlewood at the same time as Lisa Nasseff, the woman who is suing the center.

McKay recalled that when Nasseff left Castlewood, Schwartz told the other residents that she had returned to her cult.

That's when McKay realized something wasn't right.

She started questioning all the times she saw women shaking and screaming, saying they were having flashbacks of abuse. She wondered now about the woman who drew monkeys to represent her multiple personalities. And she thought back to all the times she heard someone say they would die if they left Castlewood.

"I was there for about seven months altogether and saw an awful lot of people who were brainwashed," she said. "I started saying things to people like, 'I think the only cult anybody's ever been in is the one we're in right now."

 

Food and Addiction - Environmental, Psychological and Biological Perspectives

Here are three lectures from UCTV that deal with food addiction. The first one looks at environment factors in obesity, the second one deals with foods that might trigger an addictive process, and the last one deals with calorie restriction for longevity purposes. Good information.

Food and Addiction

UCtelevision — May 06, 2010 — What environmental factors contribute to obesity? Kelly Brownell of Yale University is the Public Health Director at the Rudd Center for Food Policy and Obesity. He explores causes and prevention of obesity and other nutrition problems. He integrates information from many disciplines and specialties ranging from the basic physiology of body weight regulation to world politics and legislation affecting issues such as agriculture subsidies and international trade policies. Series: Food and Addiction: Environmental, Psychological and Biological Perspectives [5/2010]

* * * *

Food and Addiction - What it is, How it is Measured in Humans

UCtelevision — May 13, 2010 — Ashley Gearhardt is a clinical psychology doctoral student at Yale University exploring the possibility that certain foods may be capable of triggering an addictive process. She examines cognitive and neural processes associated with symptoms of food addiction. Series: Food and Addiction: Environmental, Psychological and Biological Perspectives [5/2010].

* * * *

Food and Addiction: The Other Side - Caloric Restriction

UCtelevision — May 13, 2010 — Paul McGlothin practices and researches a calorie restriction diet. Proponents of the calorie-restriction diet claim that restricting calories slows the aging process, reduces the risk of various chronic diseases and leads to a longer life. Series: Food and Addiction: Environmental, Psychological and Biological Perspectives [5/2010].

Tags: Food and Addiction, What it is, How it is Measured in Humans, Ashley Gearhardt, addictive process, Environmental, Psychological, Biological Perspectives, Paul McGlothin, Caloric Restriction, Psychology, brain, eating disorders, food, obesity, Kelly Brownell, physiology of body weight regulation, environmental factors

A Person Is Not the Disease - One Mother's Approach to Anorexia

A mom accidentally stumbles onto the basic truth about mental illness - the person is not the disease, and the more we can separate them and see the disease as a part, the more successful treatment becomes.

Of course, it is not a simple issue - sometimes all the disease wants is to kill the person. Anorexia in particular is one of the most challenging dis-eases to heal. Even though this mother was successful, many more trying the same thing would not be - so if your child has anorexia, PLEASE find a good therapist and do not try to handle it yourself.

Mom Discovers When to Be Tough With Anorexia

After Struggling For 10 Years, a Mother's Ultimatum Reached Her Daughter

By LAUREN COX

Emily Troscianko's anorexia was so severe that when she was 26 she was barred from a treatment program because her weight had dropped so low. Therapists said she was a medical liability; they were afraid she might collapse at any time.

Her mother, Susan Blackmore, tried everything she could. Then, by accident, she spoke some honest, harsh words.

"Your anorexia is not welcome at my house… I'm not having your anorexia wrecking my new home," Blackmore says she told her daughter, who is now 28. Emily was finishing her postgraduate studies in German at Oxford University at the time, and often came home during breaks.

When Blackmore and her partner, Adam Hart-Davis, moved from Emily's childhood home she decided she wanted Emily in her new house, but did not want to shelter her anorexia.

"For both of us it was a really pivotal statement, a turning point," said Blackmore."I liken it to the dementors in Harry Potter -- she would walk through the house and you could feel the cold.... you felt as though all the energy was being sucked out of you because of this waif."

At the time Troscianko didn't take her comment well. "I thought 'She's being stupid, how could she think that there is a me that isn't an anorexic me' because that was my whole identity then," said Troscianko. "It did make me think and it did make me upset and scared of alienating the closest member of my family."

Troscianko gradually began to eat again. She went from 83 pounds to 145 and feels she's finally healthy today.

The family shared their story with the U.K.'s Daily Mail, and Troscianko also writes about recovering from anorexia in her blog, A Hunger Artist, for Psychology Today.

Despite their success fighting anorexia, Blackmore said she'd hesitate to give other parents advice. For years she felt meetings with psychiatrists, in seminars and in treatment groups, didn't give a single good answer. Meanwhile she watched other parents "turn their lives upside down" trying to find the right treatment. A few mothers even quit their jobs to help with their children's treatment.

Parents Can Feel Helpless Over Anorexia

"My very strong impression is that no one knows what to do," said Blackmore."Nobody knows how to help anorexics get out of it because they don't want to get out of it."

Susan Blackmore is shown with her daughter Emily Troscianko on vacation in 2008. Troscianko, then 26, had been battling anorexia for 10 years.

(Courtesy of Emily Troscianko)

Experts interviewed by ABCNews.com wouldn't go as far to say there's no parental influence -- but they do agree treating an eating disorder can be one of the toughest challenges in therapy.

Too Tough, or Too Soft, Means Nothing to an Anorexic

"The statistics say somewhere between 20-21 percent (of patients) will die of their eating disorder," said Tyler Wooten, a child, adolescent and adult psychiatrist at UT Southwestern Medical Center in Dallas, Texas. Those deaths can be caused by heart irregularities, starvation and suicide.

Wooten thought Blackmore's conversation with her daughter was an example of saying the right thing at the right time, but not so-called tough love.

Emily Troscianko, 28, gained weight after 10 years with anorexia.

"They are telling an adult that we love you and we would love to have you in the house for visiting, but if you do not get treatment… you cannot come into our house," said Wooten. "That is an effective thing at her age.

"But to say that tough love will work for anorexia is a big misconception because it does not work," said Wooten. According to Wooten, neither does pouring love and attention over someone suffering from anorexia.

Tough Love or Too Much Love?

Wooten said he often sees parents go to extremes when they realize a child suffers from anorexia. One family tried duct-taping food over a child's mouth only to have child services remove her from their care.

At the other extreme, Wooten said parents "walk on eggshells, they don't want to upset anything because if she gets mad she won't eat, if she gets scared she won't eat."

"They often end up sleeping with the kid in the bed at night and what happens is that the kid starts to get really regressed," said Wooten.

In Troscianko's case, her parents didn't go to either extreme at first -- they sent her to a child psychiatrist.

"I was 15 and-a-half when I started to skip breakfast and I started to lie about other meals. Looking back at my diary, there were the (predictable) things about feeling fat and ugly and wanting to lose weight," said Troscianko. "But there were more complex things -- learning how addictive hunger can be."

Anorexia Had False Appeal

Troscianko said she literally got a "high" by feeling dizzy and lightheaded when she was hungry. There was also the feeling of success and an idea that she was stronger compared to others because she could resist eating.

Her parents noticed something was wrong when she returned from a summer trip abroad looking very thin at age 16 and-a-half.

"I think they were just quite confused and quite desperate -- my father was a lot more proactive with trying to force me to eat and trying to scare me with stories of what would happen if I didn't eat," said Troscianko.

At first, she said, friends admired her stamina, or complimented the way she looked. But within a few years Troscianko started to see how anorexia had taken over her life.

When Anorexia Turned Lonely

"I really liked skiing and I didn't have the muscles or the energy to enjoy it," said Troscianko. "Also, social situations -- you avoid situations that involve food, which is quite a lot of them."

Troscianko was so busy with anorexia in college that she barely made any friends. She said her father's warnings about her health had temporary effects, but since she hadn't had heart trouble yet or hadn't been on the brink of death yet the warnings "lost their potency."

Once, in 2003, her father threatened to bring her back from study abroad in Germany unless she started eating. Troscianko said that prompted her into eating more, but she soon fell into her old ways until 2008.

"I wouldn't say that I had been fighting against anorexia for all those years, I was in thrall to it," said Troscianko. "The main struggle was actually before making the decision to get better -- it was trying to make myself want to get better."

Troscianko said she couldn't imagine life being any different than her 10 years as anorexic, and she didn't believe her life would get better if she decided to start eating.

Once Troscianko made the decision to eat, it took just under five months to get back to a healthy weight. She now has a boyfriend, friends and is still flourishing in her academic career.

Therapists who treat anorexia said parents may have more influence over their anorexic children if they catch it in early adolescence.

Some Parents Find Success Stopping Anorexia

"The consequences you might set with an adult child that might be ill and you've been down many roads with are different than the consequences you might set for a 13-year-old, whose been sick for three months," said Jennifer E. Wildes, an Assistant Professor of Psychiatry at the University of Pittsburgh Medical Center.

In children younger than 17, Wildes said therapists can teach parents how to keep their children on "refeeding" plans to increase their calorie count. When the child doesn't eat, Wildes said parents have to form a unified, consistent and reasonable front and not back down.

She said families might run into trouble swaying back and forth. "Parents might say earlier in the week, 'You'll be grounded for the rest of your life if you don't eat!' and Saturday she's off to prom with no change in behavior," said Wildes.

Wooten agreed, and has recommended families take away cars if their teenage daughters don't follow eating plans.

But no matter what the age of the child, experts say separating the person from anorexia is a useful tactic. In part, it finally worked for Troscianko.

Emily Troscianko, 28, says she feels she's been through the worst of her struggle with anorexia.

"To the extent that parents can separate the illness from the child, that can be helpful -- you can love the child but not the anorexia," said Wildes.

Tags: eating disorders, Psychology, Health, anorexia, Mom Discovers When to Be Tough With Anorexia, ABC News, Lauren Cox, Susan Blackmore, parts, Emily Troscianko, A Hunger Artist, Psychology Today

FORA.tv - Janet Treasure: Eating Disorders

Useful.

Janet Treasure: Eating Disorders

Summary

A lecture to investigate the problems of eating disorders such as bulimia and anorexia, by Professor Janet Treasure of the Institute of Psychiatry at King’s College London.

Professor Janet Treasure - Director of the Eating Disorder Unit at the Institute of Psychiatry, King's College London, and at the South London Maudsley Hospital NHS Trust. The unit is active in research and development in all aspects of eating disorders treatment, biology, clinical problems etc. She is also Professor of Psychiatry at Guys Hospital, Kings & St Thomas Medical School, London.

Professor Treasure is a psychiatrist who has specialized in the treatment of eating disorders for over twenty years.

The Eating Disorder Unit at the South London Maudsley Hospital NHS Trust is a leading centre in clinical management and training of eating disorders. The unit provides eating disorder services for a population of 2 million in south East London and accepts specialists referrals from throughout out the United Kingdom.

Professor Treasure was chairman of the Physical treatment section of the UK NICE guideline committee. She is the Chief Medical Officer for the Eating Disorder Association (the main UK eating disorder charity) and is the trustee of the Sheffield eating disorders association. She is on the Academy of eating disorders accreditation committee. She has also been active in both research over this time and has over 150 peer reviewed papers. In 2004 was honoured to be awarded the Academy for Eating Disorders (AED) Leadership Award in Research (This award honors an individual who has over substantial period of time ( i.e., 10 years or more) developed through research new knowledge about eating disorders that is internationally respected and that has had a measurable impact on the field, either by significantly furthering our understanding of the etiology of eating disorders, by changing treatment or by fostering new lines of research).

Professor Treasure has been a co-coordinator of a multicentre European study that is examining the genetic and environmental factors in the management of eating disorders. Professor Treasure was also Vice Chairman of a European project examining the effectiveness of treatment of eating disorders in over 20 countries.

Professor Treasure has edited four texts on eating disorders "Neurobiology in the Treatment of Eating Disorders" Ed Hoek K, Treasure J, Katzman M (1997) & "Handbook on Eating Disorders," Szmukler G, Dare C & Treasure (1995) (edition 1 &2) Wiley and, Owen, Treasure & Collier (2001) "Animal Models of Eating behaviour and body composition," Kluwer Academic Publishers The Netherlands. She has authored 2 self help books, one on bulimia nervosa "Getting better bit(e) by bit(e): A Survival Kit for Sufferers of Bulimia Nervosa and Binge Eating Disorders" and one for parents and teachers as well as sufferers themselves on anorexia nervosa "Anorexia nervosa; a survival guide for families, friends and sufferers".

She is working on developing manuals & CD Roms to describe working with individuals and families of people with anorexia nervosa. The ethos of both the research and clinical practice is to work collaboratively with carers and users and to use new technology to further this endeavour.

The web site http://eatingresearch.com hosts information for all stakeholders, users, carers and professionals

Tags: FORA.tv, Janet Treasure, Eating Disorders, Psychology, food, bulimia, anorexia, brain, behavior, neuroscience, genetic factors, environmental factors, binge eating

University of Arizona Campus Health Service Presents: "Love Your Body Day"

Hmmm . . . . a former Miss America talking about loving your body. Well, that's one way to draw a crowd. She looked pretty skinny here when she won the title in 2008, which is not my idea of a healthy body. Maybe she will talk about the destructive nature of beauty pageants on female body image?

One of the sponsors is Sierra Tucson, an in-patient treatment facility that works with eating disorders, among many other things.

The University of Arizona Campus Health Service Presents: "Love Your Body Day"

MONDAY, FEBRUARY 22

6 PM

Student Rec Center, 1400 E 6th Street

Kirsten Haglund

Miss America 2008

"FREEDOM FROM PERFECTION:Overcoming Body Wars, Diet Culture, and Taking Back our Souls"

Q & A to follow talk

Sponsors include:

Campus Health Service, Campus Rec, Remuda Ranch

Rosewood Centers for Eating Disorders and

Sierra Tucson Treatment Center

For More information: welter@email.arizona.edu

Tags: University of Arizona, Campus Health Service, Love Your Body Day, Kirsten Haglund, Miss America 2008, Freedom from Perfection, Overcoming Body Wars, Diet Culture, Taking Back our Souls, culture, beauty, body image, eating disorders, health

Psychological Treatments of Binge Eating Disorder (Research Review)

The Archive of General Psychiatry recently posted the following article, which I want to talk about a little bit since binge eating disorder (BED) is something about which I have some strong opinions.

Psychological Treatments of Binge Eating Disorder

G. Terence Wilson, PhD; Denise E. Wilfley, PhD; W. Stewart Agras, MD; Susan W. Bryson, MA, MS

Arch Gen Psychiatry. 2010;67(1):94-101.

Context Interpersonal psychotherapy (IPT) is an effective specialty treatment for binge eating disorder (BED). Behavioral weight loss treatment (BWL) and guided self-help based on cognitive behavior therapy (CBTgsh) have both resulted in short-term reductions in binge eating in obese patients with BED.

Objective To test whether patients with BED require specialty therapy beyond BWL and whether IPT is more effective than either BWL or CBTgsh in patients with a high negative affect during a 2-year follow-up.

Design Randomized, active control efficacy trial.

Setting University outpatient clinics.

Participants Two hundred five women and men with a body mass index between 27 and 45 who met DSM-IV criteria for BED.

Intervention Twenty sessions of IPT or BWL or 10 sessions of CBTgsh during 6 months.

Main Outcome Measures Binge eating assessed by the Eating Disorder Examination.

Results At 2-year follow-up, both IPT and CBTgsh resulted in greater remission from binge eating than BWL (P < .05; odds ratios: BWL vs CBTgsh, 2.3; BWL vs IPT, 2.6; and CBTgsh vs IPT, 1.2). Self-esteem (P < .05) and global Eating Disorder Examination (P < .05) scores were moderators of treatment outcome. The odds ratios for low and high global Eating Disorder Examination scores were 2.8 for BWL, 2.9 for CBTgsh, and 0.73 for IPT; for self-esteem, they were 2.4 for BWL, 1.9 for CBTgsh, and 0.9 for IPT.

Conclusions Interpersonal psychotherapy and CBTgsh are significantly more effective than BWL in eliminating binge eating after 2 years. Guided self-help based on cognitive behavior therapy is a first-line treatment option for most patients with BED, with IPT (or full cognitive behavior therapy) used for patients with low self-esteem and high eating disorder psychopathology.

Trial Registration clinicaltrials.gov Identifier: NCT00060762

Author Affiliations: Rutgers, The State University of New Jersey, Piscataway (Dr Wilson); Washington University School of Medicine in St Louis, St Louis, Missouri (Dr Wilfley); and Stanford University School of Medicine, Stanford, California (Dr Agras and Ms Bryson).

Binge eating disorder (BDE) was added the DSM-IV as a new (and provisional) diagnosis in 1994. Since then, as the article points out, the diagnosis has shown itself to be a reliable and valid diagnosis.

From the introduction:

Binge eating disorder is characterized by frequent and persistent episodes of binge eating accompanied by feelings of loss of control and marked distress in the absence of regular compensatory behaviors. The disorder is associated with specific eating disorder psychopathology (eg, dysfunctional body shape and weight concerns),⁴ psychiatric comorbidity, and significant health and psychosocial impairments.⁵ Binge eating disorder is also linked with overweight and obesity.⁶

In general, as with most diagnoses, cognitive behavioral therapy (CBT) is the most widely used therapeutic approach, and the most tested. In this study they used CBT with a "guided self help" twist on the model, alongside behavioral weight loss approaches (BWL - this is what you might get from a nutritionist, focusing on nutrition, calorie restriction, and exercise), and interpersonal psychotherapy (IPT), which like CBT is a "reliably effective in eliminating binge eating and reducing associated psychopathology in the short- and longer-term."

Here is how they define the IPT model they used:

Interpersonal psychotherapy for BED was formulated by Wilfley.^{7, 26} It was based on the treatment developed by Klerman et al²⁷ for depression, and Fairburn²⁸ later adapted it for the treatment of bulimia nervosa. The treatment is manualized. The first phase is composed of 4 sessions and is devoted to a detailed analysis of the interpersonal context within which the eating disorder developed and was maintained. This leads to a formulation of the current interpersonal problem areas, which then form the focus of the second stage of therapy aimed at helping the patient make interpersonal changes in the specific area or areas identified. The last 3 sessions are devoted to a review of the patient's progress and an exploration of ways to handle future interpersonal difficulties. Although links are made throughout treatment between interpersonal events and binge eating, the therapy does not contain any of the specific behavioral or cognitive procedures that characterize CBT. In the current study, all sessions were individual and 50 to 60 minutes long except for the first, which was 2 hours long. The first 3 sessions were scheduled during the first 2 weeks and were followed by 12 weekly sessions and the final 4 sessions at 2-week intervals, for a total of 19 sessions during 24 weeks. The total therapy time was the same as that for BWL.

The CBTgsh model they used is described here:

This intervention is derived from manual-based CBT. The primary focus is developing a regular pattern of moderate eating using self-monitoring, self-control strategies, and problem-solving. Relapse prevention is emphasized to promote maintenance of behavioral change. The principal role of the therapist is to explain the rationale for the use of the self-help manual, generate a reasonable expectancy for a successful outcome, and to motivate the patient to focus on using the manual. There were 10 treatment sessions, each lasting approximately 25 minutes, except for the first session, which was 60 minutes long. The first 4 sessions were weekly, the next 2 occurred at 2-week intervals, and the last 4 occurred at 4-week intervals. The therapists were first- or second-year graduate students with no experience in CBTgsh or treating BED, 4 at Rutgers University and 4 at Washington University. Dr Fairburn conducted initial training in CBTgsh in a 3-hour workshop. The therapists did not receive regularly scheduled supervision. As with the other 2 treatments, quarterly meetings across sites were held throughout the study.

This is an interesting study and it proves that a psychotherapy approach is superior to behavior modification in controlling binge eating behavior. In the comment section of the paper they discuss the outcome:

Consistent with some previous studies,^{11, 13} ours found no difference among the 3 interventions at posttreatment on binge eating; specific eating disorder psychopathology of body weight, shape, and eating concern; or general psychopathology. At the 2-year follow-up, however, both IPT and CBTgsh were significantly more effective than BWL in eliminating binge eating. This superiority of a specialty therapy over BWL for BED is supported by 2 recent short-term studies. Munsch et al³⁶ found that CBT was significantly superior to BWL, and Grilo and Masheb¹⁷ showed that a self-help version of CBT was significantly more effective than self-help BWL. Devlin et al,^37-38 in a randomized double-blind placebo-controlled study, found that the addition of CBT—but not antidepressant medication—to BWL treatment significantly enhanced outcomes at posttreatment and 24-month follow-up. Interpersonal psychotherapy was also more successful in retaining patients in the trial than BWL or CBTgsh. Our dropout rate for BWL was consistent with previous research.^{36, 39} The CBTgsh attrition in our study was greater than in others (eg, Grilo and Masheb¹⁷) possibly because it was contrasted with longer, more "face valid" treatments. This might also explain the difference in suitability ratings.

It's good that they compared the three approaches, although the IPT and GBTgsh approaches were not different enough to me to generate significant differences in results. As someone who works with clients on binge eating behaviors, this study proves to me that many of my clients need therapeutic intervention in order to overcome this behavior issue - BWL efforts are not nearly enough.

However, I would recommend a completely different approach. It seems there was very little effort to look at the etiology of the binge behavior in autobiographical details. In general, I think this is necessary, while also acknowledging that the current managed care situation requires very short-term therapeutic approaches such as the ones used in this study.

My sense is that binge behavior is a symptom of pervasive but low-grade depression, dysthymia, often with an early onset (APA, p. 380-381), meaning that the behavior begins in the teen years. Many clients may also exhibit more severe depression, anxiety, or other psychological issues, as well as having experienced childhood trauma, neglect, or abuse.

There has been very little research into the connections between binge-eating disorders (BED) and dysthymia, although Kristin Moerk has conducted a preliminary study that deserves follow-up (Moerk, 2002). She offers the following summary of her dissertation:

Many of the personality traits selected as candidate potentially relating to high comorbidity between BED and depression were linked only to depression and not observed at higher level in the pure BED group than in the control group. These traits included: perfectionism, low self esteem, sociotropy, autonomy, dependency, and self criticism. (Moerk, 2002, p. 7)

These findings are consistent with my sense that binging clients exhibit low self-concept, perfectionism, and self criticism. The Moerk study included dysthymics in the depressed group, so her research can be extended to include this population as well as those more severely depressed. Other researchers have found that dysthymia was more strongly correlated with binge eating and bulimia than major depression (Geist, Davis, & Heinmaa, 1998; Perez, Joiner, & Lewinsohn, 2004).

Dysthymia seems to respond best to a combination of anti-depressants and therapy (Grohol, 2008), with cognitive behavioral therapy (CBT) being the most widely studied psychotherapy approach for this disorder. The study presented above is notable in that there was not a drug group, as is generally the case. I was glad to see that they were willing to avoid the money that comes from drug companies to fund such research.

My bias would be to use Richard Schwartz’s Internal Family Systems Therapy (IFS), which was developed during work with survivors of child abuse and has proven successful with bulimics and anorexics, as well as less challenging clients—he includes a whole chapter detailing his work with a bulimic client in his book (Schwartz, 1995, p. 61-83). Essentially, IFS is a form of parts work, not dissimilar to Ego States work (Watkins & Watkins, 1997) or the Voice Dialogue model (Stone & Stone, 1989).

Using the IFS model, the binging behavior is not seen as the primary issue, but rather as a coping mechanism (what IFS terms “firefighter” behavior in that the binging “part” responds to pain by trying to “put out the fire” through addictive behaviors). In employing the IFS model, the client becomes aware that the behaviors—the parts, schemas, ego states, or subpersonalities—are not who she is as a person but, rather, are merely wounded parts that need to be “unburdened.”

Therapy begins with an exploration of the most dominant parts, often that would include the “Perfectionist” and the “Inner Critic,” parts that are known as “managers” because their role is to keep the self-system functional by pushing out negative feelings, such as depression. The “firefighters” (or binging behaviors) are activated when the managers fail to keep the “exiled” feelings or “parts” out of consciousness. The exiles are the wounded parts that carry the burden of dark emotions, such as sadness and depression (or more significantly, trauma, abuse, and neglect), that the managers are afraid will take over the self-system if they are not exiled.

Therapy consists of systematically negotiating with managers and firefighters to uncover and unburden the exiles. Once the exiles and other parts are unburdened, they typically adopt new and more functional roles in the self-system (Schwartz, p.53).

Finally, the client learns to differentiate her parts from the inner core of Self—also known as Atman, Buddha-nature, Soul, and so on—so that she can learn to become Self-led (Schwartz, 41). When the client can become Self-led, individual parts, even if they are not fully unburdened, no longer are as capable of hijacking the self-system. Developing access to the Self can be an invaluable tool in coping with both the dysthymia (or depression, anxiety, trauma, and so on) and the binge behavior.

It is worth noting that Schwartz also advocates working to create some contact with the Self very early in therapy so that is can act as a co-therapist in the process. In his model, much of the healing comes from the client's Self doing internal attachment work with the wounded and burdened parts (Harryman, in press).

I would really like to see someone put this model up against CBT and pharmaceuticals. I think it will prove superior.

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text Revision). Washington, DC: Author.

Geist, R., Davis, R., & Heinmaa, M. (1998). Binge/purge symptoms and comorbidity in adolescents with eating disorders. Canadian Journal of Psychiatry, 43, 507–512.

Grohol, J. M. (2008). Dysthymia treatment. Retrieved November 28, 2009, from http://psychcentral.com/lib/2008/dysthymia-treatment/

Moerk, K. C. (2002). Personality in binge eating disorder and depression: Do similarities in personality traits partially account for comorbidity findings?. Unpublished doctoral dissertation, State University of New York at Stony Brook, New York.

Perez, M., Joiner, T. E., & Lewinsohn, P. M. (2004). Is major depressive disorder or dysthymia more strongly associated with bulimia nervosa?. International Journal of Eating Disorders, 36(1), 55 - 61.

Schwartz, R. (1995). Internal family systems therapy. New York: Guilford Press.

Stone, H., & Stone, S. (1985/1989). Embracing our selves. Novato, CA: New World Library.

Watkins, J. G., & Watkins, H. H. (1997). Ego states: Theory and therapy. New York: W. W. Norton & Co.

Tags: Psychology, eating disorders, therapy, depression, dysthymia, binge eating disorder, APA, Internal Family Systems Therapy, IFS, Richard Schwartz, Psychological Treatments of Binge Eating Disorder, Archive of General Psychiatry, Interpersonal psychotherapy, Behavioral weight loss treatment, guided self-help, cognitive behavior therapy, DSM-IV criteria for BED, JAMA, G. Terence Wilson, Denise E. Wilfley, W. Stewart Agras, Susan W. Bryson, parts work

Tom Venuto - Orthorexia and The New Rules of Clean Eating - Part 1

Orthorexia is a new-ish eating disorder. As far as I can tell, it's pretty much the same as anorexia except that the impetus is not body image as much as it is "purity" of foods - which leads me to see in the OCD spectrum (mental health professionals might likely disagree with this view).

Like anorexics, orthorexics tend to end up frail and malnourished, as you can see in the videos below. And like anorexics, orthorexics have a very limited list of "safe" foods.

Orthorexia and The New Rules of Clean Eating - Part 1

Tom Venuto

Clean eating has no official definition, but it’s usually described as avoiding processed foods, chemicals, preservatives and artificial ingredients. Instead, clean eaters choose natural foods, the way they came out of the ground or as close to their natural form as possible. Vegetables, fruits, legumes, 100% whole grains, egg whites, fish, and chicken breast are clean eating staples. Clean eating appears to be a desirable, sensible, even noble goal. Eating clean is what we should all strive to do to achieve optimum health and body composition isn’t it? Arguably the answer is mostly yes, but more and more people today are asking, “is it possible to take clean eating too far?”

Physician Steven Bratman thinks so. In 1997, Bratman was the first to put a name to an obsession with healthy eating, calling it orthorexia nervosa. In his book, Health Food Junkies, Bratman said that whether they are trying to lose weight or not, orthorexics are preoccupied with eating healthy food and avoiding anything artificial or “toxic.”

Orthorexics are not only fanatical about eating the purest, healthiest, most nutritious (aka “clean”) foods available, says Bratman, they often feel a sense of righteousness in doing so.

Whether orthorexia should be officially classified as an eating disorder is controversial. The term appears in pub med indexed scientific journals, but it’s not listed in the DSM-IV as are anorexia and bulimia. Opponents wonder, “Since when did choosing a lifestyle that eliminates junk food become a disease?”

Media coverage and internet discussions about orthorexia have increased in the past year. John Stossel did a segment on 20-20 (ABC) last year and websites such as the Mayo Clinic, the Huffington Post and the UK-based Guardian added their editorials into the mix in recent months, alongside dozens of individual bloggers.

In most cases, mainstream media discussions of orthorexia have focused on far extremes of health food practices such as raw foodism, detox dieting or 100% pure organic eating, where some folks would rather starve to death than eat a cooked or pesticide-exposed vegetable. In fact, some people do, as seen in the 20-20 video clip below.

But closer to my home, what about the bodybuilding, fitness, figure and physique crowd? Should we be included in this discussion?

Read the rest of Tom's article.

Here is an article by the man who first created this diagnostic disorder, Steven Bratman.

What is Orthorexia?

It’s great to eat healthy food, and most of us could benefit by paying a little more attention to what we eat. However, some people have the opposite problem: they take the concept of healthy eating to such an extreme that it becomes an obsession. I call this state of mind orthorexia nervosa: literally, "fixation on righteous eating."

Such people are sometimes affectionately called "healthfood junkies." However, in some cases, orthorexia goes beyond a mere lifestyle choice. Obsession with healthy food can progress to the point where it crowds out other activities and interests, impairs relationships, and even becomes physically dangerous. When this happens, orthorexia takes on the dimensions of a true eating disorder, like anorexia nervosa or bulimia.

Do you wish that occasionally you could just eat, and not think about whether it’s good for you? Has your diet made you socially isolated? Is it impossible to imagine going through a whole day without paying attention to your diet, and just living and loving? Does it sound beyond your ability to eat a meal prepared with love by your mother – one single meal – and not try to control what she serves you? Do you have trouble remembering that love, and joy, and play and creativity are more important than food? Have you gotten your weight so low that people think you may have anorexia?

If you recognize yourself in these questions, you might have orthorexia.

Are you concerned that you (or someone you care about) may need help recovering from orthorexia? If so, please see my book Health Food Junkies for practical advice on how to overcome health-food obsession. However, if your orthorexia is so severe that you can't even keep up a minimum healthy weight, you really should see an eating disorder specialist. See the comments and suggestions at the end of the story about Kate Finn, on the home page of this site.

— Steven Bratman, M.D.

Tags: eating disorders, Health, Psychology, orthorexia nervosa, anorexia nervosa, The New Rules of Clean Eating, Tom Venuto, nutrition, purity, obsession, Steven Bratman

Cognitive vs. Jungian: Comparing Therapies for the Rule/Role Developmental Stage

I wrote this yesterday for my psych class - the topic of the paper was to compare/contrast cognitive and psychoanalytic therapies. This was supposed to be a 5-6 page paper, but I went over a bit. The last section, dealing with the case study, could be pages longer all on its own.

* * * * *

Cognitive vs. Jungian: Comparing Therapies for the Rule/Role Developmental Stage

There are hundreds, if not thousands, of potential therapeutic models that can be employed for any of the myriad diagnoses to be found in the DSM-IV. Knowing which of these approaches is most applicable to a give situation is at least partially a subjective choice. However, there are certain things one can know about each therapeutic modality that allows for selecting the best option for a give diagnosis. The first step in this process is to determine the developmental stage—as much as possible, which is to say, taking a best guess—at which the dysfunction originated. From there, using the Integral Psychology of Ken Wilber (2000), one can then narrow down the best options for treatment. In this paper, it will be proposed that both the cognitive therapies of Ellis and Beck and the Psychodynamic Therapy of Jung are well-suited to the rule/role stage of development, corresponding to concrete operations in Piaget’s model, Erikson’s industry vs. inferiority conflict, or the conventional stage of Kohlberg’s moral hierarchy.

Wilber uses the term “fulcrum” to represent the complexity of developmental stages in his integral psychology approach, and he defines it as follows [AQAL means all quadrants, all levels, all lines]:

A developmental milestone within the self-identity stream, or the proximate-self line of development. Fulcrums follow a general 1-2-3 process: fusion or identification with one’s current level of self-development; differentiation or disidentification from that level; and integration of the new level with the previous level. AQAL theory, and Integral Psychology in specific, focus on anywhere from nine to ten developmental fulcrums. (Rentschler, 2006, p. 10)

For the purposes of this discussion, fulcrum-4 (F4) and its transition to fulcrum-5 (F5) are the developmental stages of interest. F4 (ages 6-12) is best defined as the stage of rule/role identity, meaning that the self begins to become less egocentric and more capable of taking on the role of other in its experience. According to Wilber, when there is dysfunction at this stage, the result is some form of script pathology, “all of the false, misleading, and sometimes crippling scripts, stories, and myths that the self learns” (Wilber, 2000, p. 96). The movement into F5 (ages 12-adulthood, if it occurs at all), when successful, allows the self-reflexive ego to emerge. With a corresponding shift from “conventional/conformist to post-conventional/individualistic, the self is faced with identity versus role confusion” (Wilber, 2000, p. 96). Resolving this conflict of individuation is another stage where Jungian therapy and cognitive therapies are quite useful.

When it comes to dealing with the dysfunctional scripts of F4—or more generally the way conscious and unconscious thoughts shape self-concept—few therapeutic approaches have proven more effective than the cognitive therapies. Cognitive therapies (especially Cognitive Behavioral Therapy) break issues down into thoughts, feelings, and actions, allowing the client to stop the “vicious circle” that can often escalate into either/or thinking, catastrophizing, or other dysfunctional cognitions (Royal College of Psychiatrists, 2005). On the other hand, Jungian therapy has also shown some considerable success in this realm by taking a nearly opposite approach to working with the same material (dealing with the unconscious rather than the conscious). The Jungian approach also seeks to help the patient define his or her place in the world, as to be expected at the stage of the rule/role self. Jung used discussion of archetypes and complexes, the first often viewed as positive and the later often seen as dysfunctional, as the way into how behavior and thoughts have been hijacked by unconscious material. Consequently, rather than deal with conscious thoughts and beliefs as the cognitive therapies do, Jung believed, like Freud, that dreams and images from the unconscious were the best way into the psyche (Corey, 2001, p. 82).

While cognitive approaches attempt to reshape conscious thoughts and beliefs, working primarily with rational and concrete thinking, Jungian therapy circumvents the conscious self for the unconscious and its images. Using techniques such as dream analysis and active imagination, Jung sought to bring into light the shadow material that shapes thoughts and beliefs. Once the images were uncovered, he then used explication (direct interpretation of the image) and amplification (association with other similar images) to solve the riddle of these messages from the unconscious (Adams, n.d.). Most importantly, Jung viewed complexes as one of the central elements of dysfunction: “they are either the cause or the effect of a conflict” (Jung, 1955, p. 79). However, while Jung viewed the complex as an obstacle, he viewed obstacles as an opportunity for growth (Jung, 1955, p. 80).

Despite their differences on the surface, both approaches seek to replace dysfunctional thought patterns with healthier thoughts and beliefs. The end result of successful therapy in both models is a move from being stuck developmentally in F4 rule/role conflicts toward growing into an F5 individuation. In Jung’s model, individuation is the specific goal of all analysis: “the cure will bring about no alteration of personality but will be the process we call ‘individuation,’ in which the patient becomes what he really is” (Jung, 1985, p. 10). Likewise, Dr. Robert Ellis felt that clients were shaped by irrational cognitions that need to be replaced with more rational cognitions, with the end result of restoring the autonomy of the individual.

But if the therapist tackles the patient’s basic irrational thinking processes, which underlie all kinds of fear that he may have, it is going to be most difficult for this patient to turn up with a new neurotic symptom some months or years hence. (Ellis, 1962, p. 96)

The removal of neurotic symptoms can reasonably be viewed as a form on individuation in the sense that Jung uses the word in that the patient is no longer captive to irrational thoughts and can be a more self-directed human being.

One profound difference in the two approaches is the length of the therapy, which also suggests a deeper difference on how each views psychological health. Jung’s depth psychology, similar to Freud’s psychoanalytic model, expects a long-term analysis, lasting sometimes for many years of two or three days a week sessions. A typical successful analysis generally lasts about three years, as recounted by Albert Ellis in relation to his own analysis (Ellis, 1962, p. 4). His own model was much briefer, but not as focused the cognitive therapy of Aaron and Judith Beck. In her 10 principles of cognitive therapy, Judith Beck states that it aims to be time limited, with an average of 4 to 14 sessions for the average depression or anxiety client (Beck, 1995, p. 7). In our modern era of HMO health care—and its limited mental health care commitment—cognitive therapy is clearly more likely to be used than depth psychology.

The difference in time allotted to therapy, however, underscores a basic difference in how the inner life of the patient is conceived by each approach. In the Jungian model, the patient is not presumed to be healthy or cured until she or he is operating as a unique, individuated human being. For Jung this included a willing to include the religious and spiritual elements of human culture in the therapeutic process. Jung believed that “all religions, including the primitive with their magical rituals, are forms of psychotherapy which treat and heal the suffering of the soul” (Jung, 1985, p. 16). To say that this is not a part of the cognitive model would be an understatement. Cognitive therapies rely almost solely on the rational dialectic between therapist and patient to dispel irrational thinking. Judith Beck defines cognitive therapy as “goal oriented and problem focused” (Beck, 1995, p. 6), with seemingly very little interest in the patient as a whole person. In fact, so much of cognitive therapy, especially Cognitive Behavioral Therapy, is focused on behaviorist tenets that there is little room for interiority at all—thoughts are treated as objects and not as expressions of subjective experience. Albert Ellis does not hesitate to dismiss the Jungian and psychoanalytic approaches as semi-logical. While discussing therapeutic models such as “abreaction, catharsis, dream analysis, free association, interpretation of resistance, and transference analysis,” he admits that they may sometimes be used successfully; but he then goes on to say, “Are these relatively indirect, semi-logical, techniques of trying to help the patient change his personality particularly efficient? I doubt it” (Ellis, 1962, p. 37). The difference in the two approaches is fairly clear.

Applying the two models to a case study

A. is an 18-year-old female, Asian college student who was referred to counseling at her school by a friend concerned about her weight loss and diet habits, which include excessive exercise. Her body mass index (BMI) of 16.9 marks her as malnourished, a key indicator of an eating disorder, most likely anorexia nervosa. She will not talk about her diet and exercise habits, but freely talked about her controlling parents (they call her daily) and her own stress at meeting everyone’s expectations for her. Her parents want her to be a doctor, while she has no interest in medicine and expresses an interest in interior design. Part of the parents’ desire to know where she is at all times might be traced back to the death of her younger brother when she was three-years-old. Her mother was depressed for several years, and when she came out of it, she focused all of her attention on A.

There is much to be said for the use of rational therapies in this case. Ellis contends that much of our irrational thinking issues from sentences in our heads that we have heard from others, including not only words, but also gestures, intonations, critical looks, and other non-verbal messages (Ellis, 1962, p. 28). For A., her parents instilled in her the belief that she was never good enough, a script that causes her to feel insecure about a 3.7 gpa, about her weight, and about not having chosen a major yet, even though she is in her first year of college. But these are not the priority scripts. The first advances need to be in the area of diet and exercise, where her inner scripts are putting her life at risk. From there, the therapist might move to the identity issues and her desire to “move on” from her parents.

As much as that will be useful, there is deeper trauma here, likely from the death of her baby brother and the ensuing depression in her mother when A. was three. These scripts are pre-rational and may be only marginally verbal, so a rational approach is not likely to reach them. Taking a Jungian approach here, including dream work and active imagination, might be the best route to dealing with the trauma that underlies the current behaviors and beliefs. The therapist will need to identify and single out the complexes involved as well. The part of her that restricts food is doing so to protect her from the pain of being embodied (which would allow the emotional pain to be more present), and that part is likely a complex composed of messages from her parents, but also has a perfectionist tone to it—there may even be some archetypal energy in relation to the ideal of beauty and femininity. Resolving that complex could go a long way toward easing her eating disorder, while the cognitive work might only be a short-term band-aid.

In the end, neither therapy on its own would be sufficient with this client, although together they get closer to becoming useful. Since her primary conflict seems to be identity and role related (F4 and F5 pathologies), they are suited to her stage of dysfunction. However, adding ego states therapy (Watkins & Watkins, 1997), or Internal Family Systems Therapy (Schwartz, 1995) would likely be more beneficial—both of which work well as stand-alone approaches with eating disorders. As much as every model of counseling would like to be self-contained and suited to all approaches, the reality is much different. An eclectic or integral approach is generally much more useful to the client as well as the therapist.

References

Adams, M. V. (n.d.). What is Jungian analysis? Retrieved from http://www.jungnewyork.com/whatisit.shtml

Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford Press.

Corey, G. (2001). Theory and practice of counseling and psychotherapy (6th ed.). Belmont, CA: Wadsworth/Thomson Learning.

Ellis, A. (1962). Reason and emotion in psychotherapy. Secaucus, NJ: Citadel Press.

Jung, C. G. (1955). Modern man in search of a soul. New York: Harcourt, Brace and Company.

Jung, C. G. (1985). The practice of psychotherapy: Essays on the psychology of the transference and other subjects (1st ed.): Princeton Bollingen.

Rentschler, M. (2006). AQAL Glossary. AQAL: Journal of integral theory and practice, 1(3). Retrieved from http://aqaljournal.integralinstitute.org/public/Pdf/AQAL_Glossary_01-27-07.pdf

Royal College of Psychiatrists (2005). Cognitive behavioural therapy (CBT). Retrieved from http://www.rcpsych.ac.uk/mentalhealthinfoforall/treatments/cbt.aspx

Schwartz, R. (1995). Internal family systems therapy. New York: Guilford Press.

Watkins, J. G., & Watkins, H. H. (1997). Ego states; Theory and therapy. New York: W.W. Norton.

Wilber, K. (2000). Integral psychology. Boston: Shambhala Publications.

Tags: Psychology, therapy, eating disorders, Cognitive therapy, Jungian therapy, Rule/Role Developmental Stage, comparison, Albert Ellis, Judith Beck, Carl Jung, Integral Psychology, Ken Wilber