Eating Disorders: New Directions in Treatment and Recovery, 2nd ed.

Whether or not you are a psychotherapist, unless you are an expert on the subject, it would behoove you to read Eating Disorders. Like Candid Camera, an eating disorder can strike when you least expect it, be it in your office or your own home. A complex entity, it is devastating for family members to deal with, and no less a hardscrabble for those who try to treat its victims. This array of articles, written by a group of healers (only two of 14 are M.D.s) from the Wilkins Center for Eating Disorders in Connecticut, will help. Not all the articles are perfect, but I would like to think this is in part deliberate as a metaphorical message to patients with eating disorders that you do not have to be perfect to justify your existence.

These authors make it absolutely clear that it is a grave error for any psychiatrist to attempt to be the sole treater of a patient with an eating disorder. Rather, a team approach, involving close collaboration among internist, nutritionist, psychotherapist, and group therapist, is a sine qua non for ultimate therapeutic success. Individual chapters are written by members of each of these disciplines, with appropriate references to back them up. One of the writers is a therapist who has recovered from anorexia; she offers remarkable insights into the recovery process and how her pregnancy affected not only her patients with eating disorders but herself as well. The improvements in recognition, treatments, and prevention programs for eating disorders since the 1990s are reflected in the great sense of hope permeating, and generated by, these articles. The collection of wisdom by these obviously vetted clinicians is presented in clear, straightforward language and would undoubtedly be helpful to those who suffer from eating disorders, their families, and their therapists.

In industrialized societies, one out of 100 young women suffers from anorexia nervosa; the incidence of bulimia is 10 times higher. No other psychiatric disorder in women has a higher death rate than anorexia nervosa, a rate approximately 12 times greater than the rate for comparison groups. Even though there may be no external warning signs, the medical complications of anorexia and bulimia can be life-threatening. Thus, the first step in any treatment program is for a complete medical evaluation, preferably by an internist who understands how to relate to an eating disorder patient.

Chapter 1 succinctly focuses on the medical aspects of eating disorders and reminds us how vital a daily normal intake of food is to heart, circulatory, lung, brain, hormonal, bone marrow, and metabolic functions. Magnetic resonance imaging studies indicate that brain changes caused by improper nutrition may not all be reversible; full recovery, even in well-managed adolescent anorexia nervosa, can take 5–7 years. Because of bone marrow changes, dual-energy X-ray absorptiometry is strongly indicated, in part to motivate individuals with typical anorexia for help, plus to initiate high calcium/vitamin D supplementation. I would personally underline how imperative it is to regulate the patient’s electrolytes and nutrition, because such irregularities can impair the patient’s judgment to the point that it is not possible for a therapist to deal with the patient.

Chapter 2 describes nutritional counseling, delineating nine important lessons the nutritionist must help the patient with, e.g., daily caloric need and metabolic rate, hydration, exercise, prevention of binge eating/purging, hunger, and expectations. Two case examples are offered. Chapter 3, which focuses on psychiatric consultation with eating disorder patients, emphasizes that “medication is at best a useful adjunct to treatment” but not a substitute for counseling. I would add that a nutritionist and an internist are key figures as well.

Chapter 4, “A Family Systems Perspective on Recovery,” is based on the theory that all parts of a system are interrelated. Since families are emotionally connected, this approach implies a confidence that a family member can be an agent of change. One thesis throughout this book is that eating disorders are an indirect way of dealing with stress resulting from unacceptable feelings, with a food obsession acting as a smoke screen; therefore, family therapy attempts to uncover and correct underlying tensions in the family.

In the fifth chapter, Suzan Ryan offers five case examples to illustrate the thesis that the eating disorder patient’s relationship to food is a metaphor for how the patient relates to the world. Sarita Broden, in chapter 6, advocates the appropriate use of humor, offered with sensitivity, as one effective way to deal with these difficult-to-reach patients. Chapter 7 is an attempt to illustrate the author’s treatment with a young woman with bulimia. Appropriately, the eighth chapter addresses the encroachment of managed care on health care, which particularly affects eating disorder patients, who require long-term treatment for complete recovery. Chapter 9 follows up on this theme of the necessity for cost-effective, short-term approaches by discussing cognitive behavior therapy and briefly mentioning interpersonal psychotherapy and other short-term psychological treatments. Chapter 10 is about the nurse’s role, and the succeeding chapter concerns long-term individual psychotherapy. The complicating role of coexisting comorbid disorders must always be recognized. Chapter 12 presents recurring themes in young adult women with eating disorders. I have already alluded to the spotlight on recovery in chapter 13. Diane Mickley, M.D., concludes this book with some final thoughts, including one survey showing that greater than 60% of eating disorder patients with the best outcomes had at least 2 years of individual psychotherapy. Dr. Mickley acknowledges that more work needs to be done on the neurobiology of eating disorders, the genetic vulnerabilities to their development, advocacy for insurance coverage, and prevention.

Advances in eating disorder research have progressed rapidly in recent years. New treatment developments seem to have emerged daily since this edition was compiled. For instance, olanzapine has been used successfully with treatment-resistant anorexia nervosa (1, 2).

All of the chapter authors preach patience and perseverance to both patients and therapists, pointing out that treatment is hard work and that it takes a long time to achieve healthy results. The goals of treatment include not only improved weight but the promotion of overall well-being, better relationships, self-esteem, and better coping mechanisms. My misgivings about Eating Disorders are as follows: 1) A chapter by a more vetted psychoanalyst (rather than a social worker) about the psychotherapy of an eating disorder patient would have been an improvement. 2) It is relatively easy to make a case for psychodynamics when there is a background history of alcoholic, abusive parents, and/or multiple losses, but none of the case studies in these chapters attempts to deal with the issue of an eating disorder patient with a benign past history. 3) What about eating disorder victims who cannot afford treatment, or no treatment openings, day treatment programs, or hospitalization opportunities are available? 4) Medication use is only cursorily mentioned. I personally have had experience with a diet-adherent eating disorder patient who developed several strokes, with residua, while taking phenelzine—a potential side effect that was not in Physician’s Desk Reference—until the patient herself figured out that phenelzine’s chemical formula has a hydrazine-like nucleus, which is a known possible cause of a lupus-like illness. Needless to say, until this discovery was made, the stress on the patient, family, and therapist was astronomical.

I hope I have conveyed both the importance and value of reading Eating Disorders as well as the imperative of the team approach in dealing with this very painful, debilitating, and challenging clinical entity.