Eating Disorders - fieldi

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Introduction 3 needs of patients whose eating difficulties coexisted with other psychiatric problems, including substance abuse, personality disorders, or the effects of trauma. The primary focus of the Wilkins Center has always been clinical treatment but that has expanded to include research and prevention. Affiliations were formed primarily with colleagues at Yale University, but also with those at Harvard University and Columbia University. Wilkins staff served as founders and leaders of national advocacy groups, government task forces, and professional organizations. The staff donated time to public education, at local schools, through media interviews and in television appearances. Although the Wilkins Center initially targeted anorexic and bulimic patients who were typically close to normal weight or underweight, we were approached by an increasing number of patients who were overweight. Some seemed to have a biological problem—a genetic tendency to be heavy—compounded by an American lifestyle high in calories and low in exercise. Others, however, especially “compulsive overeaters,” shared many features of our bulimic patients. They were preoccupied with the pursuit of thinness, often with endless cycles of dieting and then bingeing. Depression (and sometimes alcoholism) was common in such patients and their families. A new category of eating disorder was proposed in 1992: binge eating disorder (Spitzer et al. 1993). These men and women binge but they do not purge. They tend to fail traditional weight-loss programs but seem to benefit from treatments similar to those developed for bulimia (McCann and Agras 1990). People who fulfill the criteria for the “binge eating disorder” represent up to 2 percent of the general population, from 30 percent to 50 percent of patients in hospital weight-loss programs, and up to 70 percent of people in Overeaters Anonymous. Thus treatment developed in the past decade for bulimia may benefit a far larger population than originally envisioned. With skilled specialists and expanding treatment options, the majority of patients with eating disorders can hope to get better. Treatment for eating disorders is not magical. It takes sophisticated care, hard work, and time, often far longer than we wish. Unfortunately the current revolution in health care may significantly restrict access to experts and limit both intensity and length of treatment. Yet with sufficient care, large numbers of patients can and do
4 Introduction recover. Many resolve adolescent issues, develop heightened selfesteem, improve relationships, and expand coping skills in ways that provide lifelong benefits. This book is an effort to share some of what we have learned from our patients and one another, as well as some of the advances in the field of eating disorders during a pioneering era. <strong>Eating</strong> disorders are complex syndromes occurring in diverse people and settings. They vary in the physical toll they take. Some patients are physically stable, others are in acute medical danger or developing chronic health problems. Some are fairly well nourished, others restrict or binge to the exclusion of any normal eating. Psychological well-being also varies widely. <strong>Eating</strong> disorders may be precipitated by the developmental needs of adolescence or by an acute crisis. They may compound long-term difficulties with low self-esteem, obsessionalism, or depression. They may coexist with anxiety, panic attacks, or personality disorders. They may worsen in seeming paradox despite recovery from alcoholism, acceptance at college, or a wonderful social relationship. Patients come with different attitudes toward treatment. Some may feel they have no problem or can recover “on their own”; others have had so much treatment that they have lost hope. One person may long to resolve basic difficulties in psychotherapy, while another, convinced that the problems are biological, may seek medication. Some wish to come alone; some prefer to be with parents or spouse; some seek the sharing and support of a group. Families, too, vary in their understanding of eating disorders, past experience with treatment, and perceptions of what is best for their daughter. They may seek a suitable inpatient program or hope that intensive outpatient care will avert the need for hospitalization. Parents may have to juggle the demands of a child’s illness with the needs of their own marriage, their careers, aging grandparents, and other offspring. Emotional and financial resources and burdens differ from family to family. To complicate this picture further, professionals, too, may vary in their approaches or may offer conflicting advice. If parents suspect an eating disorder, where can they go for evaluation? If a person seeks treatment, what kind and what setting is best? If a patient is in
Page 1 and 2: editor BARBARA P. KINOY EATING DISO
Page 4 and 5: Eating Disorders New Directions in
Page 6: To our patients’ children and gra
Page 9 and 10: viii Contents 3. Psychiatric Consul
Page 11 and 12: x Foreword Although serious deficie
Page 14 and 15: preface In 1994, in the first editi
Page 16 and 17: Preface xv psychological hazards to
Page 18 and 19: Preface xvii partial, complete, or
Page 20 and 21: acknowledgments We wish to acknowle
Page 22 and 23: contributors Debra Bader, CSW, BCD:
Page 24 and 25: Eating Disorders
Page 26 and 27: Introduction diane w. mickley I am
Page 30 and 31: Introduction 5 therapy or on medica
Page 32 and 33: 1 Medical Aspects of Anorexia and B
Page 34 and 35: Medical Aspects of Anorexia and Bul
Page 42 and 43: 2 Recovery Through Nutritional Coun
Page 44 and 45: Recovery Through Nutritional Counse
Page 46 and 47: Lesson 1: Daily Caloric Need and Me
Page 54 and 55: ical activity to a normal level. If
Page 56 and 57: patient who binges, it may be helpf
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Page 60 and 61: Figure 2.3 Typical Hunger and Food
Page 62 and 63: herself. She frequently feels hopel
Page 74 and 75: 3 Psychiatric Consultation with Eat
Page 76 and 77: Psychiatric Consultation 51 standab
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Psychiatric Consultation 53 difficu
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Psychiatric Consultation 55 Obsessi
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4 A Family Systems Perspective on R
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A Family Systems Perspective on Rec
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she calls her mother and tells her
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5 Relationship to Food as to the Wo
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iors—somehow to integrate the fra
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treatment, Theresa wanted to see an
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Relationship to Food as to the Worl
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6 The Therapeutic Use of Humor in t
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The Therapeutic Use of Humor 91 Amy
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The Therapeutic Use of Humor 93 was
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The Therapeutic Use of Humor 95 ass
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The Therapeutic Use of Humor 97 Ron
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Jodie’s Story 99 capacity to make
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Jodie’s Story 101 house and a ter
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Jodie’s Story 103 She did not do
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adness. The dream also revealed tha
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8 Eating Disorders and Managed Care
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Eating Disorders and Managed Care 1
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Eating Disorders and Managed Care 1
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Cognitive-Behavioral Therapy and Ot
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10 The Nurse’s Role in a Pilot Pr
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The Nurse’s Role in a Pilot Progr
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The Nurse’s Role in a Pilot Progr
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11 Individual Psychotherapy: A Long
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Individual Psychotherapy 135 Such p
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Individual Psychotherapy 137 empath
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weight and shape, as well as change
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Individual Psychotherapy 141 vomiti
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Individual Psychotherapy 143 During
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Individual Psychotherapy 145 and re
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Individual Psychotherapy 147 Mitche
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Young Adult Women 149 to surface an
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Young Adult Women 151 with their at
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Young Adult Women 153 ing; in fact,
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Young Adult Women 155 doomed, and a
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part of a treatment team where the
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13 Recovery margaret goldkopf-woodt
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Recovery 161 I can appreciate both
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Recovery 163 meant. I certainly cou
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Recovery 165 ate other uncomfortabl
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Recovery 167 connection between my
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Recovery 169 safe place, and our ow
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Recovery 171 My pregnancies and mot
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Recovery 173 They seem to be living
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Recovery 175 Self-disclosure remain
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nel. All that I feared, the hurts I
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Afterword 179 surprisingly rapidly
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Afterword 181 With eating disorders
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Treatment helped me to face life, i
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AA/BA. See American Anorexia/Bulimi
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37; prevention of, 29-31; rigid die
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problems and, 19; events triggering
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Keel, P. K., 180 Keller, H., 133 Ke
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Psychoeducational group therapy, 12
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112-20; IPT, 121-22; psychoeducatio
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