Sound, sensitive advice for overcoming an eating disorder
Anorexia, bulimia, binge eating, exercise addictions . . . these disorders can be devastating, but they are in no way unbeatable. Therapist Carolyn Costin, herself recovered from anorexia, brings three decades of experience and the newest research in the field together, providing readers with the latest treatments, from medication and behavioral therapy to alternative remedies.
Whether you are living with an eating disorder or you are a loved one or professional helping someone who is, The Eating Disorder Sourcebook will help you:
- Recognize and identify eating disorders
- Discover and work with the underlying causes of an eating disorder
- Make the right choices when comparing treatment options
- Understand what is expected in individual, group, and family therapy
- Know when outpatient treatment is not enough and what else can be done
About the Author
Carolyn Costin, M.A., M.Ed., M.F.T., has been a specialist in the field of eating disorders for nearly thirty years. She directs the Monte Nido Residential Treatment Facility in Malibu, California, and all of its affiliates. She is also the clinical advisor to the Parent Family Network of the National Eating Disorder Association and an editor of Eating Disorders: The Journal of Treatment and Prevention.
Read an Excerpt
The Eating Disorders Sourcebook
A Comprehensive Guide to the Causes, Treatments, and Prevention of Eating Disorders
By Carolyn Costin
The McGraw-Hill Companies, Inc.Copyright © 2007 Carolyn Costin
All rights reserved.
From Diet to Disorder: Problems and Prognosis
Disordered eating is alarmingly common, and having an eating disorder is often seen—except by those who have one or their family members—as a diet strategy, a phase, or a trendy thing to do. In 2005 a television comedy series called "Starved" included scenes in which eating disorder behavior was mocked and shown to be, according to the producer, "tragically comic." In one episode, a character pours detergent all over a dessert to avoid eating it, then later retrieves it from the trash for a binge. Another scene portrays a policeman who's been diagnosed with bulimia letting a deliveryman out of a ticket in exchange for Chinese food, on which he then binges and purges in an alley, accidentally vomiting on a homeless man. Is this funny? Is it entertainment? Would we accept a comedy about a skid-row alcoholic or heroin addict?
Groups such as the National Eating Disorder Association (NEDA) and the Association of Anorexia Nervosa and Related Disorders (ANAD) led a public outcry. Sponsors pulled out under the pressure, and the show was cancelled. Both "Starved" and the grassroots organizations that protested against it are evidence that eating disorders are now part of our culture and are increasingly earning respect as illnesses rather than lifestyle choices as the Pro Ana (short for pro Anorexia) websites would have us believe. As difficult as it is to understand the growth of websites promoting this illness, their proliferation proves that eating disorders have come out of the closet and into our living rooms, and few of us can remain unaware or untouched.
Elementary school girls continue to starve and purge as an acceptable method of weight loss. Binge eating disorder (BED), although still not yet listed as a separate diagnosis in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV), is increasingly discussed as an illness. Sadly, eating disorders have become mainstream on both ends of the spectrum. In our current cultural climate, instead of asking, "Why do so many people develop eating disorders?" one wonders, "How is it that anyone, especially a female, does not develop one?"
Are Eating Disorders More Common Now or Have They Just Been Hiding?
The first hint that eating disorders were a serious problem came from Hilde Bruch, who in 1973 introduced the first major work in the field, Eating Disorders: Obesity, Anorexia Nervosa, and the Person Within. This book was geared toward professionals and not readily available to the public. Bruch followed it up in 1978 with her pioneering work The Golden Cage, which continues to this day to provide a compelling, passionate, and empathetic understanding of the nature of eating disorders, particularly anorexia nervosa. With the book and television movie The Best Little Girl in the World, Steven Levenkron brought an awareness of knowledge of anorexia nervosa into the average home. And in 1985, when Karen Carpenter died from heart failure due to anorexia nervosa, the picture of the emaciated singer haunted the public from the cover of People magazine.
Since then, women's magazines and television journalists have presented us with stories of people who we thought had everything—beauty, success, power, and control—but who were lacking something else, as they began to admit that they too had eating disorders. Olympic gold medal gymnast Cathy Rigby revealed a struggle with anorexia and bulimia that almost took her life, and several others followed suit, including Gilda Radner, Princess Diana, Sally Field, Elton John, Tracy Gold, Paula Abdul, and more recently Mary Kate Olson, Felicity Huffman, Jamie-Lynn DiScala, and Portia de Rossi to name just a few. In her recent autobiography, Jane Fonda describes having led a double life suffering secretly from anorexia and bulimia throughout most of it even with all of her success and fame. Talk shows on eating disorders continue to feature the media's fascination with every possible angle one can imagine: "Anorexics and Their Moms," "A Ten-Year-Old Boy with Anorexia," and "Eating Disordered Twins."
Similar to chemical dependency in the 1970s and 1980s, eating disorder treatment is a growing business, with hospital and residential eating disorder programs rapidly on the rise. Large corporations are now "investing" in this industry as a result of their market research. This can only mean that it is a growing problem. The passage of the federal Mental Health Parity Act fueled the growth of this treatment industry by mandating that insurance companies cover major mental illness just as they would physical illness. However, the legislation allows each state the freedom to determine what constitutes a major mental illness, and eating disorders are most often left out. To date, only 12 states (California, Connecticut, Delaware, Maine, Maryland, Minnesota, Rhode Island, New York, North Dakota, Vermont, Washington, and West Virginia) have state-mandated insurance coverage for the treatment of eating disorders, but the pressure is on to change this. To further exacerbate the struggle, for the most part, only medically necessary cases of anorexia nervosa and bulimia nervosa—as diagnosed under DSM-IV—are insured for inpatient day treatment and sometimes even outpatient settings. Clients with atypical or less severe cases often get no coverage at all.
When people ask, "Are eating disorders really more common now, or have they just been in hiding?" the answer is both, however, the overall trend shows that the number of individuals with eating disorders has been increasing continually since their recognition, paralleling society's growing obsession with being thin, losing weight, and fear of fat.
Is It Disordered Eating or an Eating Disorder?
Eating disorders may seem more common today because even though individuals who have them are reluctant to admit it, they do so more readily than in the past. People are more likely to know that they have an illness, the possible consequences of that illness, and that they can get help for it. The trouble is they often wait too long. Determining when problem eating has become an eating disorder is difficult. There are far more people with eating or body image problems than those with full-blown eating disorders. The more we learn about eating disorders, the more we realize that individuals may have varying predispositions to developing them. A person's particular genetic makeup may account for a heightened sensitivity to the current cultural climate, thus increasing the likelihood that he or she will cross the line between disordered eating and an eating disorder. But when is this line crossed?
Diagnostic Criteria for Eating Disorders
To be officially diagnosed with an eating disorder, one has to meet the clinical diagnostic criteria delineated in the current edition of the Diagnostic and Statistical Manual for Mental Disorders IV TR (2000), but the specific definitions therein do not encompass all of the syndromes health professionals treat. In fact, the DSM-IV TR criteria can be confusing, complicated, and restrictive.
There is an ongoing, passionate discussion among experts in the field about changing what is considered by many to be an outdated system of classification. The current DSM-IV TR diagnoses for eating disorders include anorexia nervosa (AN); bulimia nervosa (BN); and eating disorders not otherwise specified (EDNOS), which includes binge eating disorder (BED) as well as a variety of subclinical or more appropriately "atypical" eating disorder presentations. Clinicians and researchers alike are proposing alternatives to this model for a variety of reasons. One model proposes a general diagnosis of "eating disorder," with a corresponding list of symptoms or features from which the clinician can choose. This would alleviate the problem of changing the diagnosis when clients develop new symptoms or gain or lose a certain amount of weight.
Furthermore, the severity of an eating disorder has historically been measured by how well the client meets the full diagnostic criteria. Clinicians in the trenches know that this is not the reality. I once treated a young woman who began dieting when she weighed 200 pounds. At the time of her first visit, she was eating only 300 calories a day and had lost 70 pounds in one year. She was fearful of eating, could not eat with anyone or in public, was terrified of gaining weight, and met all the criteria for anorexia nervosa except that her weight was 130 (she was 5?4?). This young woman had one of the most entrenched eating disorders I had ever treated, yet with a diagnosis of EDNOS, I could not get her approved for residential care because she did not meet criteria for anorexia or bulimia.
Changes in official diagnostic criteria happen slowly. There are ongoing debates and calls for more research. Eventually we will have more clarity, but the clinical descriptions taken from DSM-IV TR are the currently accepted standards.
Cases of Anorexia Nervosa
Despite its increase over the last decade or so, anorexia nervosa is not a new illness nor is it solely a phenomenon of our current culture. For an interesting history of this illness, read Joan Brumberg's Fasting Girls: The History of Anorexia Nervosa (1989). The case of anorexia nervosa most often cited as the first in the medical literature was that of a 20-year-old girl treated in 1686 by Richard Morton and explained in his work Phthisiologia: Or a Treatise of Consumptions (1694). Morton's description of what he termed nervous atrophy or nervous consumption sounds eerily familiar:
I do not remember that I did ever in my entire Practice see one that was so conversant with the Living so much wasted with the greatest degree of Consumption, (like a Skeleton only clad with Skin) yet there was no Fever, but on the contrary a Coldness of the whole Body ... Only her Appetite was diminished, and Digestion uneasy, with Fainting Fitts, [sic] which did frequently return upon her.
The first case study in which we have descriptive detail from the patient's perspective is that of a woman known as Ellen West (1900–1933). Ellen committed suicide at age 33 to end the desperate struggle that had manifested itself through an obsession with thinness and food. Ellen kept a diary that contains perhaps the earliest record of the inner world of an eating disorder sufferer:
Everything agitates me, and I experience every agitation as a sensation of hunger, even if I have just eaten.
I am afraid of myself. I am afraid of the feelings to which I am defenselessly delivered over every minute.
I am in prison and cannot get out. It does no good for the analyst to tell me that I myself place the armed men there, that they are theatrical figments and not real. To me they are very real.
Like Ellen West, people suffering from anorexia today exhibit rigid control of their "out of controlness," making an effort to deny or to purge not just food but yearnings, ambitions, and sensual pleasures. Emotions are feared and translated into somatic (body) experiences and eating disorder behaviors, which serve to eliminate the feeling, needing aspect of self. Through their struggle with their bodies, individuals with anorexia nervosa pursue a mind-over-matter mentality, perfection, and mastery of self—all accomplishments that our society praises and applauds. This, of course, entrenches these patterns into the very fabric of each individual's identity. Indeed, people with anorexia nervosa seem not simply to have this disorder but to become it.
The term anorexia is of Greek origin—an (meaning "privation" or "lack of") and orexis (meaning "appetite")—indicating a lack of desire to eat. It was originally used to describe the loss of appetite caused by some other ailment such as headaches, depression, or cancer, where the person actually doesn't feel hungry. Normally, appetite is like the response to pain, beyond the individual's control. Ellen West and others like her are not suffering from a loss of hunger but from hunger and a denial of it that they cannot explain. They may eventually develop a true lack of appetite, but for the most part, it is the strong desire to control their appetite that is a cardinal feature. Thus, the term anorexia alone is insufficient because people afflicted with this disorder have not just lost their appetites. In fact, they long to eat, obsess and dream about it; some of them even break down and eat uncontrollably. Rather than losing their desire to eat, those suffering from anorexia report spending 70 to 85 percent of each day thinking about food but denying their bodies even when driven by hunger pangs. They often want to eat so badly that they cook for and feed others, study menus, read and concoct recipes, and go to bed and wake up thinking about food. They simply don't allow themselves to have it; if they do, they relentlessly pursue any means to get rid of it.
The full clinical term, anorexia nervosa (lack of desire to eat due to a mental condition), is a more appropriate name for the illness. This now-common term was not used until 1874, when British physician Sir William Gull used it to describe several patients who exhibited all the familiar signs we associate with the disorder today: refusal to eat, extreme weight loss, amenorrhea (absence of menses), low pulse rate, constipation, and hyperactivity—all of which he thought resulted from a "morbid mental state." Other early researchers pointed out individuals with these symptoms and began to develop theories about why they would behave in such a fashion. In 1903, psychiatrist Pierre Janet describes the case of Nadja, who exhibits mixed features of an eating disorder, including an obsession with thinness. Janet described the syndrome by explaining that "it is due to a deep psychological disturbance, of which the refusal of food is but the outer expression."
People with anorexia nervosa are afraid of food and of themselves. What often (but not always) begins as a determination to lose weight, progresses and transforms into a morbid fear of gaining any weight—even when it is necessary to maintain life. A relentless pursuit of thinness takes hold. These individuals are literally dying to be thin. Being thin, which translates to being in control, becomes the most important thing in the world.
In the throes of the disorder, people with anorexia are terrified of losing control, terrified of what might happen if they allow themselves to eat. This would mean a lack of willpower, a complete "giving in," and they fear that once they let up on the control they have imposed on themselves, they will never get that control back. They are afraid that if they allow themselves to eat, they will not stop, and if they gain one pound today or even this week, that they are now "gaining." A pound today means another pound later and then another and another until they are obese. Physiologically speaking, there is a good reason for this feeling. When a person is starving, the brain is constantly sending impulses to eat. The strength of these impulses is such that the feeling that one may not be able to stop is powerful. Self-induced starvation goes against normal bodily instincts and can rarely be maintained. It is also one reason why 30 to 50 percent of individuals with anorexia ultimately end up binge eating and purging food to the point of developing bulimia nervosa. This is why researchers are looking for differences in the biology of individuals who develop and maintain anorexia.
People with anorexia fear, as crazy as it may seem when looking at them, that they are or will become fat, weak, undisciplined, and unworthy. To them, losing weight is good and gaining weight is bad—period. With the progression of the illness, there are eventually no fattening foods but simply the dictum that "food is fattening." The "anorexic" mind-set seems useful at the beginning of a diet when the goal is to lose a few unwanted pounds, but when dieting itself becomes the goal, there is no way out. Dieting becomes a purpose and what can be referred to as "a safe place to go." It's a world that serves to help cope with feelings of meaninglessness; low self-esteem; failure; dissatisfaction; the need to be unique; and the desire to be special, successful, and in control. Individuals with anorexia create a world in which they can feel they are "successful," "good," and "safe" if they can deny food, making it through the day while eating little, if anything at all. They consider it a threat and a failure if they break down and eat too much, which for them can be as little as 300 calories or less. In fact, for some people with anorexia, eating any food item of more than 100 calories can cause great anxiety. They often prefer two-digit numbers when it comes to calories and to their weight. This kind of overcontrol and exertion of mind over matter goes against our understanding of all normal physiological impulses and instincts for survival. Of the eating disorders, anorexia nervosa is the most tenacious, the most deadly, and the most rare.
Excerpted from The Eating Disorders Sourcebook by Carolyn Costin. Copyright © 2007 by Carolyn Costin. Excerpted by permission of The McGraw-Hill Companies, Inc..
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Table of Contents
1 From Diet to Disorder: Problems and Prognosis
2 Young, White, and Female: Myth or Reality?
3 Activity Disorder: When a Good Thing Goes Bad
4 Genes or Jeans: What Causes Eating Disorders?
5 Eating Disorder Behaviors As Adaptive Functions
6 To Those Who Love Them: Guidelines for Family and Significant Others
7 Assessing the Situation
8 Treatment Philosophy and Approaches
9 Individual Therapy: Putting the Eating Disorder Out of a Job
10 Sharing the Pain and the Promise in Group
11 Family Therapy: Working with Families and Significant Others
12 Enough About Your Mother, What Did You Eat Today?
13 Medical Assessment and Management
14 The Psychiatrist's Role and Psychotropic Medication
15 When Outpatient Treatment Is Not Enough
16 Alternative Approaches to Treating Eating Disorders
17 Increasing Awareness and Prevention
Appendix: Eating Disorder Organizations and Websites
Suggestions for Further Reading