Eating Disorders Review
November/December 2016
Volume 27, Issue 6
Scott Crow, MD, Editor-in-Chief


Feminist Psychodynamic Psychotherapy: A Perspective from Practice, Part 1.

by Kathryn J. Zerbe, MD

Recently Gloria Steinem, iconic spokesperson and author who helped transform what is now commonly known as ‘Second-Wave Feminism,’ said, “People in hard times need a witness.”1 In this interview Ms. Steinem was not overtly lauding psychotherapy as one road that an individual may take in order to find a witness ready to assist in bearing hard times and cultivating new paths to traverse them. Nonetheless, I find myself sharing this quotation often in my practice. Patients and students, no less than each of us who has toiled in the field for quite a few years, have a need to remind ourselves of the reasons and context in which we recommend an undertaking that is a time-, financial-, and labor-intensive commitment.

What Offers Hope

For those of us to whom much is disclosed that is often heart-wrenching and perplexing, the question about what offers hope often pops up as we do the work. Sometimes thinking through a well-tread, fundamental theoretical idea or applying a new perspective or even hearing an example in the press of a celebrated person who has benefited from efforts like our own can be helpful. For example, Ms. Steinem has been courageous in various publications about the benefit she derived from psychotherapy.2, 3 After doing quite a bit of reading about her and her life as I planned a speaking engagement, I was truly inspired by the breadth of her vision and knowledge. I now routinely reference her autobiographical books for those in my practice undergoing similar midlife and later-life transitions. These books have a lot to teach us about staying active and involved in life, for all of our life, and especially after undergoing significant loss and personal travail.

This opportunity also led me to step back and ask myself some tough questions. Was I, a psychoanalyst who considered herself to be practicing and writing from a contemporary, feminist persuasion, up to date or in need of an update? Could I push the ‘refresh button’ and hear some new voices and rethink some older ones that would revitalize my passion for doing feminist psychodynamic psychotherapy? Writing this essay for EDR provides another chance to pull some of these fragments of learning together, and is an example of why I recommend to students in our field the importance of putting pen to paper or presenting one’s ideas to peers at a conference. Sometimes we only know what we really think when we write it down, and we most certainly discover a lot that we don’t know! Writing helps inform - and transform - our practices.

Inquiring about Culture and Sexuality

The list of feminist contributors to psychodynamic treatment is long, and they each have complementary, and sometimes contradictory, things to say about facets of therapy. One fact that remains central in working from within a feminist psychodynamic perspective is the important role that gender and sex play in life, even if these issues are not the core concerns of the patient when he/she enters treatment for an eating problem. The therapist using a feminist psychodynamic approach will take time to question how the patient perceives gender roles in her family system and how this has influenced her individual point of view. Time will also be spent looking into perceptions about culture and how the patient believes cultural norms may have influenced the development of her particular struggles with eating and self-image.

The philosophy of this ‘spirit of inquiry’4 is not to suggest any bedrock issue that the individual must embrace but rather to create an atmosphere wherein assumptions and conflicts can be talked about and perhaps ultimately challenged. For example, feminist psychoanalyst Gohar Homayounpour5 notes that in her practice in Tehran sexual issues and conflicts are frequently brought up by her patients and become a focus of the therapy early on. She contrasts this to Western countries like the United States and Great Britain, where problems with basic attachment, mood dysregulation, charged interpersonal relationships, and development of a sense of self have received a great deal of attention in the psychodynamic literature for decades. Dr. Homayounpour thus explicitly makes the point about how essential it is for the clinician to recognize and to “own” cultural differences in treatment and how these variations impact the psychological depth of the human being and what the clinician is likely to hear in psychotherapy.

Coming to Terms with Trauma

Recognition and treatment of a wide array of traumas, including but not limited to physical and sexual abuse, have reshaped the mental health field in the past 4 decades. Research has shown that a significant number of our eating disordered patients come to us with these histories, and although there are many new and encouraging therapies for the residual symptoms of these developmental derailments, feminist psychodynamic psychotherapy also contributes an important point of view to assist patients. In addition to acknowledging that the abuse occurred and assisting the patient in giving voice to the dissociated or split-off self states that have had few if any safe places to explore the multiple meanings of the abuse to the individual, clinicians working within a feminist psychodynamic framework will be attuned to the impact of the abuse on relationships. In addition the therapist will be aware of the tendency to attempt to master what has ‘been done’ by unwittingly and unconsciously becoming ‘a doer.’6

(Part 2 continues in the January-February 2017 issue; the references will follow Part 2.)

The Author

Kathryn J. Zerbe, MD, a long-time member of EDR’s Editorial Board, has a private practice in Portland, OR. She is Professor of Psychiatry at Oregon Health and Science University, and Training and Supervising Analyst, Oregon Psychoanalytic Center, and the Institute of Contemporary Psychoanalysis, Los Angeles. Dr. Zerbe is the author of numerous articles and books, including The Body Betrayed and Integrated Treatment of Eating Disorders: Beyond the Body Betrayed.

UPDATE: Teenage Boys with EDs Have a High Psychiatric Burden

Adolescent boys with eating disorders have a higher level of psychiatric comorbidity, particularly depression, and often seek treatment later than their female peers, according to Dr. Samuel Ridout, of Butler Hospital, Providence, RI. Dr. Ridout reported his findings at the American Psychiatric Association’s 2016 annual meeting in Atlanta. Dr. Ridout and his colleagues conducted a retrospective chart review of 127 adolescent girls and 21 adolescent boys (mean age: 15 years) who had been hospitalized for an eating disorder.

The researchers found that the teenage boys had premorbid illness for a longer time than did the teenage girls (348 days vs 172 days, respectively) and that the boys had lost more weight than their female counterparts before being hospitalized (34 lb vs 19 lb, respectively). Substance abuse, comorbid depression, and a history of suicidal ideation were also more commonly found among the boys than the girls. Though it was a small study, the findings pointed to the need for early detection and intervention for all individuals with eating disorders, regardless of gender, and also the need to be vigilant for eating disorders and comorbidities in the young male population, according to Dr. Ridout.

Maricarmen Diaz Juárez, Our ‘Spanish Voice’

For more than a year, EDR has offered readers a Spanish edition of our newsletters. Our translator, Mariecarmen Diaz, is a lawyer and fulltime professor at a private university in Mexico City, the Instituto Tecnológico de Estudios Superiores de Monterrey, at the Law and International Relations Department in Campus Estado de Mexico. Maricarmen received her law degree, a masters in higher education, and also did PhD studies at the University of Salamancia, in Spain.

Maricarmen says she loves teaching and has been in the academic world all her professional life. She notes that in law language is very important, so she is passionate about good Spanish. Her English fluency comes from attending a British school in Mexico since she was a child, and she has family living in the Chicago area. She also tells us that she enjoys the process of translating EDR and helping more people in Latin America learn about eating disorders.

Parents with BED, and Emotional Effects upon Their Children

Maladaptive scores were highest when both parents were diagnosed with BED.

Little is known about the effects of binge eating disorder (BED) in parents and BED-related emotional and behavioral effects upon their children. Psychologist Silvia Cimino and researchers at the universities of Rome and Padua, Italy, recently reported that a diagnosis of BED in one or both parents seems to influence the degree of maladaptive parent-infant exchanges during feeding, a factor that might impact emotional-behavioral problems for their children (Front Psychol. 2016; 7:850). According to the authors, this is the first observational study to recruit families where both the mother and the father have diagnoses of BED.

The study included 204 families divided into 4 groups: Group 1, BED in both father and mother (n=102); Group 2, BED in the mother only (n=103); group 3, BED in the father only (n=100); and group 0, a healthy control group (n=102). Each group was balanced with regard to the child’s age and gender, and 91% of the children came from intact families. The groups were assessed at two time points, 18 and 36 months of age.

Dr. Cimino and colleagues used the Scale for the Assessment of Feeding Interactions (SVIA), an Italian adaptation of the Feeding Scale (Chatoor et al., 1997) normally used for children between 1 to 3 years of age. They also administered the Child Behavior Check-List, a questionnaire completed by parents and caregivers that assesses the child’s abilities and his/or specific behavioral/emotional characteristics. Results from the 100-item questionnaire are then used to determine four syndrome subscales: Emotionally Reactive, Anxious/Depressed, Somatic Complaints, and Withdrawn.

Higher maladaptive scores occurred when both parents had BED

Overall, Group 1, which included both fathers and mothers with BED, had significantly higher scores than those of all other categories. The high scores in Group 1 remained significantly higher than those in other groups at the second assessment. According to the authors, this suggests that feeding time may be difficult both for parents with BED and for their children. This is characterized by “unattuned interactions, lack of parental sensitivity, and a generally negative emotional climate,” according to the authors.

While previous studies of mothers with eating disorders and their children have shown similar problematic interactions during feeding (Stein et al., 2013), this study adds specific effects of BED upon parents and highlights the characteristics of father-infant exchanges, underscoring the fact that without treatment the risk of relational difficulties does not spontaneously lessen over time.

These results emphasize the familial impact of BED and the potentially broad benefits of effective treatment.

Turning to the Brain to Explain Lack of Behavioral Inhibition in BN

Two studies add data from adults and teens.

There is new evidence for disinhibition of behavior in bulimia nervosa (BN), but it is unclear if this is specific to eating behavior or is more generalized. At University Hospital, Heidelberg, Germany, Dr. Mandy Skunde and colleagues have used functional magnetic resonance imaging (fMRI) to search for possible underlying neural links between impaired general and food-specific behavior inhibition in adult women with BN. Their initial findings suggest that diminished frontostriatal brain activation may underlie disinhibition of eating but that it may also be generalized (J Psychiatry Neurosci. 2016; 41:E69).

Inhibitory control in bulimic-type eating disorders has been analyzed in numerous studies and is not limited to binge eating. It often includes other impulsive behaviors, such as excessive drinking and substance abuse. The final study group included 28 adult women (mean age: 28 years) who met DSM-5 diagnostic criteria for BN and 29 healthy controls (mean age: 27 years).

No greater action noted in the limbic system

Contrary to their original hypothesis, the authors found no significant brain differences during tests of behavioral inhibition to general and food-specific stimuli in the BN group compared with controls. There also was no greater inactivation in the limbic system during exposure to food-specific stimuli. However, significant differences in the frontostriatal networks were noted in a subgroup of patients with more severe symptoms (3 or more binge-eating episodes per week).

The clinical implications of the team’s findings, according to Dr. Skunde, is that better insight into neural mechanisms underlying behavioral inhibition problems among BN patients may help lead to brain-directed treatment, such as neuromodulation with transcranial magnetic stimulation (Eur Eat Disord Rev. 2013;21:436; Neuroimage Clin. 2015; 8:611).

Brain findings in younger patients with BN

In a second study, the first to use fMRI to investigate attentional brain networks in patients with BN, a team at the universities of Aachen, Aachen, Germany, HWTH, Maastricht, the Netherlands, and JARA-BRAIN, Mainz, Germany, demonstrated altered activation of brain regions involved with attention in adolescent and young adult patients with BN (PLOS One, September 8, 2016; doi:10.1371/jurnalk.pone.0161329).

The authors used a modified version of the Attention Network Task to investigate the neural substrates for alerting, reorienting, and executive attention, and correlated brain activation in these areas with symptoms of attention deficit hyperactivity disorder and eating disorders. Some of these symptoms included alterations in activity in parieto-occipital regions, anterior and posterior cingulate regions, and the default mode network.

Dr. Jochen Seitz and colleagues concluded that altered neurotransmission in the sensorimotor frontostriatal network may contribute to behavioral dysfunction in BN patients through increasing attention/preoccupation with eating disorder thoughts, and by increasing the likelihood of inattentive/impulsive behaviors.

Helping Men Recover from an Eating Disorder

One unfortunate trend: Males waited longer to seek help.

In one of the few studies to examine how men recover from an eating disorder, Drs. Gunn Pettersen, Karin Wallin, and Tabita Björk recently interviewed a small group of Norwegian males from 19 to 52 years of age who had recovered from anorexia nervosa (n=10), bulimia nervosa (n=4), or EDNOS (n=1) (BMJ Open. 2016; 6:e010760).

The researchers wondered whether males with eating disorders might have different recovery rates than female ED patients, perhaps owing to different factors such as feelings of shame at having a ‘female illness,’ or lack of treatment facilities. A majority of the few, and mostly small, studies examining men who have recovered from eating disorders have focused on factors like barriers to seeking help and delay in seeking treatment due to shame or an inability to recognize the signs of an ED.

Participants in the current study were former patients who had completed their treatment for an eating disorder diagnosed with the DSM-IV and who had recovered from the eating disorder. Seventeen males were identified; and 15 gave consent for the study.

Four possible factors linked to recovery

The authors suggest there were four main factors related to recovery in males: (1) a need for change, (2) making a commitment to put the ED behind them, (3) making interpersonal changes, and (4) searching for a new life without an ED.

Many of the men took a long time to understand and admit that they had an ED, and some described having a protracted and very private struggle with their disorder. To these men, admitting to having an ED included admitting that food, weight, and body appearance controlled or dominated all parts of their lives. Some had quit their jobs or dropped out of college because of the effects of living with their eating disorder. Before seeking help, the men recalled their life with an ED as meaningless or chaotic. Few had contacted healthcare professionals, and most reported having been pushed into getting help by a close family member or friend.

A realization they needed help

Some began their recovery process with hospitalization, dieting, or severe weight loss and avoidance of food, leading to hospitalization, while others did contact their primary care physicians for help. No matter how they got help, the primary motivation was the same: realizing they could no longer manage the situation by themselves.

Most of the men acknowledged the importance of stabilizing their eating patterns, seeking better nutrition, and reaching healthier weights during the early phases of recovery. Most also found the structure of in-hospital treatment very helpful. Another common thread in the recovery process was finding a new balance and identifying new coping strategies and leaving their ED behind. Despite the serious effects, most of the men reported that the eating disorder had acted as a functional coping mechanism for many years, and some even described the ED as their ‘best friend.’ Thus, one challenge for the therapists was helping the men let go of the ‘advantages’ their ED seemed to represent.

Recovery similar to that of females, or different?

The authors noted that their findings concur with many of the important themes identified among females recovering from an ED, which might point to a universal nature of change and recovery from an eating disorder. Much of the difference between the course of eating disorders (and treatment seeking) in males may relate to differences in case-finding, perceived stigma, and availability of treatment services for males, rather than to innate gender differences.

Restrictive eating among men

A second study highlights barriers to prompt diagnosis of EDs in males. This retrospective chart review of males with restrictive eating disorders revealed that certain laboratory study results and vital signs had suggested the diagnosis early on (J Adolesc Health. 2016; 59:397) and in some cases had been overlooked.

The men were first seen at an outpatient eating disorder program. The men were from 11 to 25 years of age, had a mean percentage of median body mass index (BMI) of 88.8%, and many had a history of being overweight or obese. Half had a history of a psychiatric disorder; 42% had a history of overweight or obesity; and 12% had a family history of an eating disorder. Studying the patients’ vital signs and results of lab tests revealed that the most prominent abnormality was bradycardia (a heart rate below 60 beats per minute, or bpm). The mean heart rate was 58.7 bpm, and the orthostatic heart rate change was 22 bpm; 51.5% of the men met Society for Adolescent Health and Medicine hospital admission criteria. Nearly a third were anemic.

A lack of treatment options for men

In an accompanying editorial, Mark A. Goldstein, MD of Harvard Medical School and his colleagues noted that a standard vital sign, a lower-than normal pulse rate, could be a “red flag” for males, signifying a need for further evaluation (J Adolesc Health. 2016; 59:371). In their editorial, Dr. Goldstein and colleagues also pointed to another major problem: lack of treatment options. Although 100% of residential-based programs in the US accept females, only about 20% accept males, and a much smaller subset of programs offer male-only treatment (Int J Eat Disord. 2006; 49:434; Eat Disord. 2012; 20:444).

The editorialists also raise another point to ponder: Most successful ED prevention programs have been developed for females, and focus on perceived pressure to be thin, body dissatisfaction, and the cultural thin ideal, which may not be as salient for males. Instead, more helpful approaches for men might focus on body dissatisfaction, size, shape, and muscularity.

Refeeding Hospitalized Adolescents with Restrictive Eating Disorders

Higher-than-currently-recommended caloric levels were safe.

Correcting malnutrition in adolescents with anorexia nervosa has a special urgency because of impaired growth, loss of menses, and negative effects on bone health. A team of researchers led by nutritionist Elizabeth K. Parker, at the Westmead Hospital, Sydney, Australia, report that higher-caloric refeeding is safe for teens hospitalized with restrictive eating disorders (J Nutr Rehab. 2016; article ID 5168978, published online before print).

Some have recommended a conservative average weekly weight gain of 0.5 kg to 1 kg (for example, following the NICE Guidelines). More recently, others have suggested more rapid weight gains, such as 1 kg to 2 kg per week. The reason for the limited rate of weight gain is, of course, to avoid the refeeding syndrome, which can cause fluid and electrolyte shifts. Low serum phosphate levels, in particular, can lead to complications including cardiac failure and death. However, according to the authors, the recommended slow refeeding may also produce an unintended consequence, the “underfeeding syndrome,” among patients with AN. Thus, standard guidelines for ‘starting low and going slow’ may actually put already malnourished patients at risk for further clinical deterioration and longer hospital stays.

A 3-year retrospective study

To study the benefits of higher initial feeding rates, the authors conducted a 3-year retrospective chart review of 247 consecutive patients with restrictive EDs admitted to an adolescent ED unit between January 2011 and December 2013.

Patients with bradycardia were monitored on a cardiology ward with continuous telemetry measurements for the first 24 to 48 hours or until their resting heart rate was more than 50 bpm. Some patients admitted with bradycardia received continuous nasogastric (NG) feeding with a 1 kcal/mL formula at 100 mL per hour, to provide 2400 kcal per day while restricting oral ingestion to sips of water for 24 to 48 hours. The rationale for continuous NG feeding was to provide medically unstable patients with a constant, controlled supply of carbohydrates for the first 24 to 48 hours.

Phosphate supplementation was started early

Before starting nutritional rehabilitation, all patients were given 1 g of a phosphate supplement and a daily multivitamin, and then a minimum of 500 mg phosphate twice a day during the first week of admission, and supplementation was halted if phosphate levels became abnormally elevated. Blood tests, particularly to measure serum phosphate levels, were done prior to starting nasogastric (NG) feeding, 6 hours after starting NG feeding, and then daily for the first week.

Once hospitalized, all patients received some type of nutrition support within the first 24 hours, including an oral diet only (7.4%); continuing NG tube feeding (54.3%); or a combination of oral diet and a cyclic overnight NG feeding. Slightly more than half of the patients had bradycardia, and were started on an oral diet with overnight NG feeds. Of 7 patients who developed peripheral edema only1 also developed mild hypomagnesemia; the remaining 6 had normal electrolytes.

Once the patients were medically stable, they were treated on an adolescent medical ward, and their NG feeding was decreased to cyclic overnight feeding of 100 mL per hour of a 1 kcal/mL formula over 10 hours. In addition to NG feeds, a meal plan of 1800 kcal was provided during the day, and nursing staff supervised meals. Patients who had not finished the prescribed meal plan were given a nutrition supplement meal replacement. This resulted in a mean caloric intake at admission of 2612 kcal, which rose to 3775 kcal by week 4. Mean weight gain was 2.1 kg per week.

Adequate monitoring and dietary supplements helped avoid the refeeding syndrome

Overall, the findings suggest that with adequate patient monitoring and appropriate supplementation rapid weight regain can be achieved without producing the refeeding syndrome. Among the 52 patients who had overnight NG feeding, only 3.8% received medication to relieve anxiety about the feeding tube. Nearly 12% experienced nose bleeds, and 29% reported nasal irritation. A small number of patients, 3.8%, were discharged before they completed their inpatient treatment.

The authors concluded that a more rapid refeeding protocol with phosphate supplementation can be safely used for teens with restrictive eating disorders, without producing the refeeding syndrome. Parker and colleagues also suggest that prophylactic phosphate supplementation and careful monitoring of electrolytes be stressed more in the guidelines for preventing refeeding syndrome, rather than restricting caloric intake in this already-malnourished patient population.

(Note: Clearly, it will be important to replicate this sort of work before changing guidelines, but this paper adds to our knowledge about rates of refeeding when coupled to prophylactic phosphorus supplementation in adolescents. Also see the article, “Prophylactic Phosphate Supplementation for Anorexic Inpatients,” in the November/December 2016 issue.)

BOOK REVIEW: Managing Severe and Enduring Anorexia Nervosa: A Clinician’s Guide

(Stephen Touyz, Daniel LeGrange, Hubert Lacey, and Philipa Hay, Eds. Routledge (Taylor & Francis, New York, NY, 2016))

Severe and enduring anorexia nervosa (AN) is probably the greatest challenge currently facing eating disorder clinicians. A new volume edited by Drs. Touyz, LeGrange, Lacey, and Hay provides a valuable new resource for approaching the treatment of people with severe and enduring AN.

The book is organized conceptually around a trial that was conducted in Australia and recently published (Psychol Med. 2013; 43:2501), which reported on a comparison of cognitive behavioral therapy (CBT) versus use of Specialist-Supportive Clinical Management (SSCM) for patients with AN. The study enrolled individuals with AN with a mean duration of illness of 17.7 years. Improvement was seen in both groups, which underscores both the potential for recovery in long-lasting AN and the need for a book of this sort.

The book discusses specific strategies for clinicians who encounter such patients, such as the use of CBT, the use of SSCM, and the use of medications. There is also coverage of relatively unique topics highly pertinent to this group. Examples include the role of hospitalization, the role of involuntary treatment, and how and when one might contemplate palliative care. Finally, one major question when treating such individuals is what causes AN symptoms to persist and to be resistant to intervention, and both of these are covered as well.

This is a relatively short, highly readable, and valuable volume that will guide eating disorders clinicians working with people with severe and enduring AN. Clinicians working with this group of patients often feel discouraged and uncertain about how to proceed; this book emphasizes the fact that there are ways forward.

— SC

A Relapse Prevention Program for Anorexia Nervosa Patients

The goal: getting ahead of relapse.

Relapse is common following treatment for AN, and new methods to prevent this are needed. A group in the Netherlands has developed a new program designed to prevent AN relapse, the Guideline Relapse Prevention Anorexia Nervosa (GRP) (BMC Psychiatry. 2016; 16:316).

Tamara Berends and colleagues at Altrecht Eating Disorders Rintveld, the Netherlands, designed a cohort follow-up study of 83 patients successfully treated for AN. The study group included inpatients and outpatients 12 years of age and older who met DSM-IV criteria for a diagnosis of AN or of eating disorder not otherwise specified (EDNOS) that had been “clinically referred to as AN.”

Treatment at the study site addressed three major areas: (1) eating habits, body weight, and body image; (2) psychological aspects of function, such as self-esteem, perfectionism, and trauma; and (3) social functioning. All patients who started the relapse prevention program had completed previous outpatient treatment. Patients were only eligible for the relapse prevention program when remission was reached. Full relapse was defined as a body mass index (BMI, kg/m2) less than 18.5 for adults and SD BMI <-1 for younger patients.

Program content and goals

The primary aim of the GRP program was to enhance cooperation between the professional, the patient, and her relatives, to gain better understanding of each patient’s process of relapse, including triggers and early warning signs. The cooperating parties then formulate actions that they can take in the face of a new and impending relapse. This information is then summarized in a “Relapse Prevention Plan” so that appropriate action can be taken when early warning signs point to relapse.

Once the prevention plan is developed, the aftercare program starts, and continues for at least 18 months. In a series of aftercare visits, the patient, therapist, and family monitor and discuss the patient’s status. Dr. Berends and colleagues described two very common scenarios. In the first, the patient is stable, and thus the focus of the visits is on maintaining stability by promoting good physical health and optimal personal and social function. Real or possible stressful life events in the near future are discussed and anticipated. In the second scenario, the patient has one or more early warning signs of impending relapse. When this happens, the main focus during the aftercare visits is getting a thorough understanding of the actual triggers of relapse and how to deal with these to promote recovery.

The frequency of visits depends on the patient’s condition and the need for treatment and care. Stable patients generally come to the center for a visit 4 to 6 months after initial recovery. If the patient is less stable, visits are planned every 2 months. Working together, patient and therapist can decide whether a longer aftercare period is needed when the patient is vulnerable to relapse. Follow-up lasts for 5 years.

What an aftercare visit looks like

The typical 45-minute visit is attended by the patient and her family. At each visit, there is a weigh-in and the patient’s overall physical condition is evaluated. Two main topics are always on the agenda: psychosocial and social functioning, including discussion of school, friends, sports, and overall moods; and the presence of AN symptoms, such as anorectic cognitions, return of abnormal eating habits or excessive exercise. At the end of each visit, a new appointment is made for the next visit.

How effective was the aftercare program?

Full relapse occurred in 11% of the participants and partial relapse in 19%. Of those who did relapse, about a fifth recovered again during follow-up. Patients were most vulnerable to relapse between months 4 and 16. As intended by the program, contact in case of relapse often occurred within a week.

These results argue for the use of a relapse prevention plan at the end of treatment, together with interval monitoring. Taking this step may be one way to significantly contribute to lowering reduction rates of relapse for AN patients.

The Mystery of the Trembling Eyelids

Q. One of my patients with binge eating disorder (BED) has been complaining about a problem I haven’t seen before. She describes this as “twitching” of a lower eyelid. We have ruled out fatigue and excess alcohol or caffeine. She has been taking topiramate for a little over a year to treat her binge eating. Any possible connection?

A. Yes, there may be a connection. Topiramate is generally used as an antiepileptic agent, but has also been studied for a variety of other disorders, including trigeminal neuralgia, mood disorders, and obesity, and also for patients with BED.

A recent case of a 47-year-old woman with BED and persistent eyelid twitching, or myokymia (contractions of the orbicularis oculi muscle), comes to mind. As reported in a recent issue of Case Reports in Psychiatry (2016; doi:10.1155/2016/7901085), just like your patient, the female patient was taking topiramate, and had been doing so for the past 16 months. Eyelid myokymia is a mild muscle contraction of the eyelid, and usually affects a single eyelid, more often a lower lid. Patients may tell friends and family that their eyelid is “jumping wildly,” but because the condition is hard to see, their complaint is sometimes discounted. As Dr. Mohammadrasoul Khalkhali of Guilan University of Medical Sciences, Rasht, Iran, reported, the woman was taking 50 mg of topiramate at bedtime. Physical examination was normal, and no abnormalities were found on magnetic resonance imaging studies; laboratory test results were all normal. She had a history of hypertension, which had been was controlled with 25 mg/day. Her vision was not affected by the twitching, and she was advised to continue her medications and to work fewer hours and get more rest.

One month after her visit, her eyelid twitching had worsened, and the movements had moved up to the upper eyelid and periodically to the eyebrow. Although results of physical examination were once more normal, the patient was distressed because she thought others could see the twitching. This time she was advised to halt use of topiramate, and once the medication was stopped the twitching disappeared within 2 weeks. However: when the topiramate was stopped, her appetite increased and with it weight gain resumed. After 2 months she began using topiramate again. Two weeks later, her eyelid myokymia returned.

A number of conditions have been implicated in myokymia, including genetic changes, autoimmune disease, radiation exposure, toxic effects, and hypoxia. Because of the temporal connection between stopping the topiramate and the return of symptoms, and the fact that topiramate acts on calcium and potassium channels related to myokymia, the connection seemed clear.

— SC

A New Year and a New Format for EDR

In the Next Issue
A New Year and a New Format for EDR

Beginning with the first issue of 2017—starting our 28th year—EDR will have an entirely new look, and we think you will like it. Earlier this year we began thinking about ways to make the publication more accessible, and one way to do this was to redesign the EDR website. One major consideration was making the newsletter available to read on mobile phones and other devices. The old EDR was accessible only by computer.

The new website also offers links to our publisher, the International Association of Eating Disorders Professionals (iaedp), and this means that you can earn continuing education credits through a collaboration with iaedp—a link will guide you to the CME programs. Other features include a special section for selected treatment programs and lists of eating disorders organizations, as well as background material on eating disorders. There are many more changes, including a blog and links to social media.

What won’t change, however, is our commitment to bringing you current information about the diagnosis and treatment of eating disorders. You will be able to read the entire issue, as before, or selected articles. Our archives, featuring outstanding authors and all features over the years, will also be easy to access.

Feminist Psychodynamic Psychotherapy: A Perspective from Practice, Part 2
By Kathryn J. Zerbe, MD

Western and non-Western scholars and psychotherapists are currently augmenting and transforming the ways that feminist psychodynamic psychotherapy is practiced. In this final installment of a two-part series, Dr. Zerbe explores more of the dynamics that can improve psychotherapeutic efforts. One example includes what to do when those who want to be supportive or understanding are viewed by the patient as inflicting pain, quickly surfacing as “bad objects” for the patient.


  • Pain and Eating Disorders Among Dancers
  • An Alzheimer’s Drug May Reduce the Urge to Binge Eat
  • Neural Differences In Self-Perception During Illness and After Recovery in Patients with AN
  • Applying Case Management for Outpatients with Severe And Enduring Eating Disorders
  • ARFID and Adult Picky Eaters

Reprinted from: Eating Disorders Review