Taking a New Look at Old
Boundaries in Eating Disorders
Reprinted from Eating Disorders Review
July/August Volume 24, Number 4
©2013 Gürze Books
The International Conference on Eating Disorders (ICED) in May offered a program filled with practical and research-oriented presentations. Following this year’s theme, “Crossing Disciplinary Boundaries in Eating Disorders,” sessions included a keynote address reminding the audience about the challenges of overlap and similarities among eating disorders, a look at how emotions can drive eating disorders, and an analysis of why male patients are so infrequently involved in eating disorders treatment.
Developing a Transdiagnostic Approach
In his keynote address, David Barlow, PhD, ABPP, professor of psychology and psychiatry, and founder and director emeritus of the Center for Anxiety and Related Disorders at Boston University, told audience members that a transdiagnostic approach to psychiatric and psychologic disorders is slowly but surely developing.
“We have thousands of protocols,” Dr. Barlow noted, adding that the “time has passed for one protocol after another with only a slight twist.” There is no way that such an approach can ultimately be useful, he said. At the present time there may be effective treatment but there is plenty of room for improvement, he said, adding that there are still too many protocols and manuals, and these protocols are still relatively complex, which interferes with effective dissemination.
He also pointed to work by Dr. Chris Fairburn and colleagues a decade ago, which marked the beginnings of taking a transdiagnostic approach to eating disorders. By honing in on overvaluation of shape and weight and control, the researchers hypothesized that the remaining disorders follow this same pattern. Research on the comorbidity of anxiety with bulimia nervosa is another example. Various researchers showed a high comorbidity rate of anxiety with bulimia nervosa.
Intolerance of uncertainty (IU) is a characteristic predominantly associated with generalized anxiety disorder (GAD); however, emerging evidence indicates that IU may be a shared element of emotional disorders, Dr. Barlow said. He explained that a synergy of several types of vulnerabilities leads to stress, and in turn to generalized anxiety, and depression. It is thought that the vulnerabilities come together, perhaps triggered by stress, to find their phenotypical outlet as anxiety and/or depression, the flip side of generalized anxiety, he said. Dr. Barlow said that emotions are not meant to be suppressed; instead, they are present to motivate us to engage in certain behaviors. If the vulnerability is not present, mood recovers naturally and more quickly in response to stress, he said.
Dr. Barlow also shared a unified protocol approach illustrating the principal of transdiagnostic unified treatment for anxiety. This approach features eight treatment modules, including: motivation enhancement for treatment engagement; psychoeducation and treatment rationale; emotional awareness training; cognitive appraisal and reappraisal; interoceptive awareness and tolerance; situational exposures; and relapse prevention.
Dr. Barlow also addressed a question about the interdependence between biological vulnerability and psychological vulnerability. Splitting apart biological and psychological vulnerability does have empirical support, he said because there are recognizable differences in the brain. The fact that specific brain circuits are activated is an argument for keeping disorders separate, as in the case of obsessive-compulsive disorders. However, he added, his group wonders if these vulnerabilities are continually influencing each other.
Emotion’s Role in Eating Disorders
In a plenary session, Steve Wonderlich, PhD, Director of Clinical Research at the Neuropsychiatric Institute, Fargo, ND, said that the study of emotion may be very important to the diagnosis and treatment of persons with eating disorders. The role of emotion in eating disorders is still being debated, and “emotion” is a slippery term, Dr. Wonderlich said. Very significant questions have to do with the possible functional relationship between emotion and eating disorder behaviors. Do emotions precipitate or modulate disordered eating behaviors?
Dr. Wonderlich, a Past President of the Academy for Eating Disorders and a member of the EDR Editorial Advisory Board, described a technique, ecological momentary assessment (EMA), that his group and others have used to collect data about patients in a real-world environment. Patients use a handheld computer or a cell phone to record current states, events, and emotions and thus are able to record events as they occur.
To gain a richer view of a patient’s life, the device signals the patient to record their behavior and emotions 6 to 10 times a day. Thus binges, components of meals, and emotions can be recorded at or near the time they occur. According to Dr. Wonderlich, the real beauty of such devices is that the connection between emotion and behavior can be studied at a very precise point in time, which will help establish whether emotions are driving the behavior, or vice versa. This method also establishes a record of emotions and behaviors for longitudinal study. In a 2007 study of 131 adult female volunteers diagnosed with DSM-IV criteria for BN, 90% of the time patients responded within 45 minutes or less. Other researchers who examined the trajectories of emotion before and following the bulimic behavior found that during the 6 hours before a binge episode, a steady increase in negative affect occurred, and culminated in a binge.
Do different emotions have specific relationships to bulimic behavior? Dr. Wonderlich also briefly described the work of Dr. Kelly C. Berg et al., who explored the connection between four negative emotions–guilt, fear, sadness, and hostility– and bulimic behavior. Guilt was linked to the highest degree of negative affect, and was significantly associated with binge eating; this was not the case with the other emotions. Another question concerned individual differences, and whether certain characteristics of people with specific forms of disordered eating made them more vulnerable to behaviors triggered by negative affect. Increasing evidence suggests that negative emotional states may play a role in precipitating eating disorders behavior across diagnoses, he said.
What are the implications for treatment? Some implications for treatment include:
- Consider treatments that directly reduce the intensity of emotion (example, psychotropic drugs).
- Promote more adaptive regulation of high-risk emotion moments. This may be accomplished by targeting events that increase negative affect in persons with eating disorders and\or to enhance their ability to clarify, accept, and tolerate negative affect states (distress tolerance), and
- Promote inhibition of impulsive behavior, especially in times of heightened negative affect.
Does it matter if the eating disorder behavior reduces the negative affect or produces negative reinforcement? Dr. Wonderlich quoted B. F. Skinner, who said, “Although antecedent conditions help to establish a behavior, consequences maintain it.” However, Dr. Wonderlich asked, if this is true, why does a person who pursues low weight engage in behaviors such as binge-eating, which directly interfere with attaining the goal of low weight? Biologically induced binge eating counteracts a physiological state connected with starving, as Ancel Keys noted.
Binge eating and other disordered eating behaviors are maintained because they help the person escape from or avoid the precipitating negative emotional states. If eating disorder behaviors actually function to reduce/avoid a negative emotional state, clinicians have two treatment options, he said. The first would be to identify and help patients develop alternative behaviors that promote the same emotional reward; the second option would be extinction of the behavior.
He described a 2008 study evaluating extinction as a functional treatment for binge eating (Behavior Modification 2008; 32:556). Dr. Ray Miltenberger and colleagues at the University of South Florida trained bulimic patients first in the lab and then at home. Patients listened to a tape recording they had made after a previous binge, one that made them feel badly about the binge. As a result, some of the trainees became abstinent and remained so, Dr. Wonderlich said. He also cited a very recent paper by Dr. Tim Walsh and colleagues that described AN as a well-entrenched habit and reported that with habit acquisition, rather than reward, the brain shifts. Thus, habit formation appears to be critical to the persistence of the dieting behavior. (Am J Psychiatry. 2013; 170:477-484. doi:10.1176/appi.ajp.2012.12081074 ).
Finally, Dr. Wonderlich offered several conclusions about emotion and eating disorders. First, emotion variables and eating disorder behaviors co-vary at a momentary level. Next, antecedent emotional states may be meaningful clinical targets for eating disorders treatment, but the impact of eating disorder behaviors on emotional states still needs much study. Finally, he noted that eating disorder treatment interventions may benefit from a greater focus on specific situations, affects and actions that occur in a momentary timeframe and promote conditioning or reinforcement that perpetuates eating disorder behaviors.
Where Are All the Men?
Men face a number of barriers to obtaining treatment, according to two clinicians who specialize in treating men with eating disorders. In a special plenary session on eating disorders in men, Roberto Olivardia, PhD, and Mark Warren, MD, PhD, FAED, explored some of the reasons that men with eating disorders are often overlooked or never seek treatment.
First, there is a misperception that only women have eating disorders. According to Dr. Olivardia, clinical instructor of psychology at Harvard Medical School and co-author of one of the first books to deal with eating disorders in men, The Adonis Complex, there is a wide misperception that eating disorders only affect women; another misperception is that eating disorders affect only gay men. Sexual orientation can be a huge issue, he said, noting that shame and secrecy also keep many young men from seeking help for an eating disorder. Gay men are more likely to discuss their disorders with peers, while heterosexual men are far more secretive, and even their spouses are often unaware of the problem.
When men do seek help, they may find themselves in treatment centers that cater to women, and they may have problems dealing with a female physician as well. And, since so many treatment centers cater primarily to women, treatment may not be available for men, even if they do want help.
Dr. Olivardia noted that eating disorders can appear in boys as young as 9 or 10, and disorders very often focus on muscle mass rather than with weight alone. They may see themselves as too thin and scrawny, and seek anabolic steroids to “bulk up.” Just as with women, cultural influences are powerful– muscularity is seen as a core element of masculinity, dominance, and attractiveness. For example, in the 1980s, a shift in the movies occurred at which time bigger bodies became important commodities and important currency; this was accompanied by an explosion of “muscle magazines,” men’s fitness magazines, and even video games stressing male bulk. He pointed to an extreme example of newer action figures, wherein even Star Wars action figures were re-mastered to be much more muscular. It is estimated that from 4 to 6 million males are affected, and the onset of these disorders is around the time of puberty. He added that much more data are needed about incidence, race, and socioeconomic status.
Men are less likely to seek treatment because of shame about having what is “a female disorder,” according to Dr. Olivardia. Males with eating disorders are often self-conscious and find themselves in settings with few other male patients. The good news is that once these men get into treatment, they do as well if not better than do women, he said.
Men need to be included in the conversation about eating disorders. Dr. Warren, Medical Director of the Cleveland Center for Eating Disorders, traced the history of eating disorders in men, noting that the first two reported cases of anorexia nervosa involved one female and one male. Our culture focuses on gender, food, and bodies, he said. For example, even the story of Adam and Even featured nakedness and food and how genders are affected. He added that men have been excluded from the current narrative of eating disorders because the criteria, screening tools, and treatment have all been based upon the histories of women patients. He added, “For men to be included in the conversation, we have made many attempts to distinguish how eating disorders are different in men. We need to accept that men have eating disorders and then to find how biology and genetics exist to present a different clinical picture in men.”
Dr. Warren also said that there are compelling reasons to improve studies of eating disorders in men; these problems are serious, potentially life-threatening conditions that are extremely challenging to diagnose and treat and they are increasing. He praised Dr. Arnold Andersen, a longtime member of EDR’s Editorial Board, for his pioneering work in the treatment of men with eating disorders. Dr Warren also shared with the audience that he himself had anorexia nervosa in his teens and knew nothing about the disease at the time. He said that his recovery was a matter of luck and that even now most men recover as a matter of luck rather than as a result of clear diagnosis and treatment. Men started “disappearing from the equation when the focus turned to amenorrhea and “hysteria,” neither of which applied to men. In the late 1970s, Dr. Gerald Russell’s work on bulimia brought men back into the eating disorders world, Dr. Warren said. However, even today most research articles are written exclusively about women, he said, showing that we have not progressed in the way we might want to.
What else can be done? Dr. Warren told the audience that one positive step in the future would be to always include men in every eating disorders study. Clinicians can also ask themselves what it is like to be a man with an eating disorder. In most treatment centers, male patients only see women patients, and a woman clinician typically asks a male patient to discuss his body, feeding, and intake. He added that most males are asked if they are gay before they are asked if they are afraid their illness will kill them.
Shame is such a powerful emotion, he said, which keeps men with eating disorders from seeking help. Health care providers can be more mindful and sensitive to eating disorders in males. They can remember to ask male patients more about their body goals and use gender-neutral language. Treatment centers can be more welcoming, for example, by including men in their ads. Men also need to know about the history and sociocultural beliefs that underlie eating disorders and how culture affects us all, he said. Having a male clinician to talk with and to be validated by is also a powerful way to help a man with eating disorder feel more comfortable about seeking treatment and sticking with it. The chemistry of the treatment team is extremely important, Dr. Warren said.