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Eating Disorders Among Active Duty Military Personnel

The United States has one of the best militaries in the world, with just over 1.34 million active-duty troops in 2015. They are prepared to meet any threat or challenge facing the country. However, many Americans are unaware of the personal and mental health challenges facing members of the nation’s armed forces. One of these challenges is the prevention and treatment of eating disorders among the ranks of U.S. military service personnel. Recent studies by the U.S. military indicate that eating disorder diagnoses for members of the armed forces have increased by 26 percent over a period of five years. The same study hints that the actual incidence of these illnesses is likely even greater.

According to research, it is estimated that roughly 30 million Americans will experience some type of eating disorder. Similar studies have shown that there are elevated rates of this disease among the nation’s active duty military members. In particular, the disease appears at higher proportions for women who are enlisted for active duty in the military. This data is not a new phenomenon. Back in 1999, researchers at the Mayo Clinic studied the eating behaviors of 423 women on active duty at Madigan Army Medical Center in Fort Lewis, Washington. This study reported that 8 percent of the women were diagnosed with an eating disorder. For comparison, the incidence of this disease for non-military women is estimated at only 1 to 3 percent of the total population. Active duty service members, including West Point graduates, reported that they feeling pressure from family, school and peers to “make the uniform look good.” This pressure can create a cycle of binging and purging with soldiers feeling like they can never be thin or in shape enough. The same disease also occurs among male active duty service members.

In all of the armed forces, more women than men are diagnosed with diseases like anorexia, bulimia and binge eating. More than two-thirds of cases involved female troops and the overall incidence rate among women, at 11.9 cases per 10,000, was more than 11 times that of males. Interestingly, the overall incidence rate of eating disorders among female Marine Corps members was nearly twice the amount when compared to women Army members. For male active duty service members, the rates were highest in the Army and Marines. Potential reasons for the increased risk for developing an eating disorder while in the military is likely due to exposure to trauma, as well as the need to routinely meet physical fitness and body weight requirements. These factors likely elevate the risk of eating disorders developing among both women and men. Children of military families also reported similar conditions at a significantly higher rate than the civilian population.

Research published in the U.S. Military’s Defense Health Agency’s Medical Surveillance Monthly Report found that incidence rates had risen steadily from 2013 to 2016 before decreasing slightly in 2017. Diagnoses for eating disorders increased from 2.3 per 10,000 to 3 per 10,000 in 2016, before dropping to 2.9 per 10,000 in 2017. “Results of the current study suggest that service members likely experience eating disorders at rates that are comparable to rates in the general population, and that rates of these disorders are potentially rising among service members,” the report states. “These findings underscore the need for appropriate prevention and treatment efforts in this population.”

The need for prevention and treatment of military members and their families suffering eating disorders has not been unnoticed. The U.S. Department of Defense’s (DOD) Peer Reviewed Medical Research Program (PRMRP) has allocated funding for eating disorders research, intervention and treatment programs. Congress first made the topic of eating disorders eligible for funding in 2017. In 2018 Congress is expected to allocate $5 million towards the prevention and treatment of eating disorders. However, federal funding for research on eating disorders is limited, with only $0.93 per person affected by eating disorders compared to other diseases such as autism receiving $44 per person affected.

To complicate matters, there is still a stigma surrounding the reporting of diseases such as eating disorders. Members of the Armed Forces are less likely to seek treatment, making prevention programs and access to treatment an imperative need across all branches. The occurrence of these diseases may, in fact, be much greater among active duty military members.

For additional questions about this topic, contact the staff at River Centre Clinic. Their programs provide a full range of treatment options for women and men with a primary diagnosis of an eating disorder. For immediate and confidential feedback, take River Centre Clinic’s EAT-26 (Eating Attitudes Test) assessment.

Follow us on Twitter:  @River_Centre

Active-Duty Military Personnel, Eating Disorders

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Body Weight and the Diet Cycle

According to research from Harvard Medical School, eating disorders such as anorexia, bulimia and binge eating, afflict more than 30 million Americans, while millions more experience disordered eating and weight control behaviors. This statistic is even more sobering when one considers the fact that eating disorders have the highest mortality rate of any psychiatric disorder in the United States. Numbers like these have real consequences on people’s health and overall quality of life. Often people are trapped in a vicious cycle of weight gain and severe dieting. In many instances, dieting does not produce permanent weight loss. Instead, it creates an unhealthy diet cycle where a person’s body weight quickly cycles up and down. What is needed is a holistic understanding of health that does not stigmatize body weight. People should focus on healthy behaviors and physical well-being instead of body weight.

The central idea behind the act of dieting tends to create problems. Extreme diets can actually damage people’s metabolism as well as their mental perception of food and eating. This means that individuals can end up in a worse place versus when they started the diet. The diet cycle can start here, with people’s weight gain and loss having a yo-yo appearance. The rise and fall of body weight creates the appearance that people are actually at war with their food (and weight). What is more beneficial for people is an active and healthy lifestyle, as well as an acceptance of their physical appearance and body weight.

When people are informed that they are overweight, there are unintended consequences. This information can reduce people’s satisfaction with their body and create other negative emotions and behavior. This is due to the fact that modern society tends to reinforce the message that “thin” is beautiful and good. People who struggle with their weight tend to also have lower self-esteem. The stigma of being overweight can help to set up a cycle for additional weight gain or the development of eating disorders like bulimia or anorexia. Individuals at all body weights often respond to stress and anxiety by eating. This emotional-induced eating will likely only encourage more weight gain. An increase in body weight can create a feeling of lower self-esteem and anxiety in a person. People quickly become trapped in an unhealthy feed back loop of weight gain and dieting.

More has to be done in order to make it safe to be a larger-bodied person. Most eating disorders are often accompanied by trauma, but body shaming and fat loathing only make these diseases worse. Actions from the fashion and food industry, as well as pop culture, almost seem to encourage eating disorders. However, attempts have been made to address the issues surrounding perceptions of physical imperfections, body weight and fat shaming. A few examples from fashion and marketing are from lingerie retailer Aerie and the increasing popularity of plus-size models. Since 2014, the ad campaigns of lingerie retailer Aerie (American Eagle) reportedly uses non-airbrushed photos of women of various body shapes and colors. Successful Fashion designer Chris Siriano has stated that there have “always been customers of different sizes since day one.” Currently, one half of Siriano’s fashion collection is made in extended sizes. These are positive steps in the right direction, but body weight fears and stigma surrounding fat is still a common occurrence.

For additional questions about the connection between body image, body weight and the diet cycle, contact the staff at River Centre Clinic. Their programs provide a full range of treatment options for children and adults with a primary diagnosis of an eating disorder. For immediate and confidential feedback, take River Centre Clinic’s EAT-26 (Eating Attitudes Test) assessment.

Follow us on Twitter:  @River_Centre

Body Weight, Diet Cycle

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LGBTQ+ and Advice to Eating Disorder Treatment Providers

Guest contributor:  Lee R.

When asked to write this blog post, I turned immediately to my good friend Google to look up some statistics and check out the latest research. What I found, or what I did not find, was revealing, albeit not entirely surprising to me. Google Scholar turned up 1,360 results for the search “LGBT eating disorder” in the last 10 years, whereas simply “eating disorder” racked up over 59,000 hits for the same time period.

It is not clear whether or not the LGBTQ+ (Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, etc.) community is underrepresented in eating disorder research, but it certainly is not prominent, appearing in only 2.3% of the research references. But that should not be interpreted as meaning that the disease does not impact the LGBTQ+ community. In fact, it’s quite the opposite.

The Trevor Project and NEDA (National Eating Disorder Association) came together in 2018 to research the prevalence of eating disorders in LGBTQ+ youth1 and the results were staggering. About 54% of the sample had been diagnosed with an eating disorder, and an additional 21% suspected they had an eating disorder due to disordered eating habits. In another study2, it was found that nearly 16% of transgender college students had been diagnosed with an eating disorder in the past year, as opposed to approximately 2.5% of their straight, cisgender counterparts.

Though the research on LGBTQ+ eating disorders is scarce, what does exist speaks volumes. Eating disorders run rampant through this community, yet it is rarely spoken about in the LGBTQ+ community itself, and even less frequently in the mainstream eating disorder treatment community. Where there is currently silence, there needs to grow a discussion on how LGBTQ+ eating disorders develop and progress, how they present, and the best treatment modalities to help sufferers receive the best care possible.

That is not to say that mainstream providers cannot appropriately serve the LGBTQ+ community. However, if providers were educated specifically on how eating disorders impact the LGBTQ+ community, there may be an even greater success rate for recovery. As a start, here are 5 things I, and a few others in the community, wish treatment providers were more aware of:

  1. Gender dysphoria exists and can make it difficult for a person to live in their own body. Gender dysphoria is the feeling of distress that occurs when someone’s gender does not match the one they were assigned at birth. It can often focus on specific parts of the body that society reads as one sex or another. It can result in restriction of food, compensatory behaviors, or binge eating. Providers need to be aware of gender dysphoria, because of the added complications to recovery. Poor body image or body dysmorphia is not the only physical hurdles in those who experience gender dysphoria. Additionally, gender dysphoria is not necessarily due to poor body image, though one may trigger the other.
  2. Internalized homophobia is also a thing that exists. Internalized homophobia refers to the prejudices that members of the LGBTQ+ community turn inward after seeing and hearing the prejudices in society. This can lead to negative views and even shame of their own sexuality. This shame and negativity can then lead to further flawed thinking and disordered eating habits.
  3. Language is important. Using my pronouns is not just a suggestion. While I’ll probably present it as a timid request and tell you “it’s fine” when you mess them up, my pronouns are actually very important to me. They help me feel more at peace with who I am, especially in such a tumultuous time as the beginning stages of eating disorder recovery. By using the correct pronouns for me, you not only convey that you respect who I am, you also help me build trust and rapport. Additionally, using gender-neutral language is imperative. People of all genders can have eating disorders, using female-centric language is outdated. Help everyone feel at home by neutralizing your language.
  4. Do not assume we are just confused. I identify as a queer non-binary person. I am not confused about who I love or what gender I am; I am completely confident in both aspects. And it is quite possible your clients will be too. When they do come out to you, know that this means they trust you. Do not insist that it’s “a phase” or that it’s due to their eating disorder. In fact, it’s likely the other way around: eating disorders often develop and progress due to minority stress, internalized homophobia, and gender dysphoria. If your client is in the beginning stages of exploring their gender and/or sexuality, do not diminish their journey by crediting the eating disorder.
  5. Having culturally sensitive resources available to us is so important. Whether it’s an LGBTQ+ process group, a therapist who is a member of the LGBTQ+ community, or even something as simple as gender-inclusive bathrooms, having resources readily available to us helps us feel included and heard. Knowing that a treatment team is culturally competent can be a great relief for LGBTQ+ people who may otherwise have felt like they needed to keep their identity a secret.

This list is by no means extensive; it really is just a beginning. Every client is unique, and the best way to get to know what they want you to know is to open an honest conversation with them.

I have found in my experience that the staff at the River Centre Clinic is willing to have those honest conversations with their patients. When I first arrived at RCC in 2014, I was unsure if I wanted to come out as genderqueer. I began by talking about it with several of the other patients who then encouraged me to tell the staff. Once I did come out to everyone, the support I received from the staff and my peers did not waver. The staff was willing to learn more about my identity and use the pronouns I chose. Even when I returned in 2016, they remembered my identity and treated me with the same respect and compassion with which they treated everyone else. I believe that the acceptance I received was a vital component in making my recovery as strong as it is today.

Follow us on Twitter:  @River_Centre

 

1 – National Eating Disorder Association. (2018). Eating Disorders Among LGBTQ Youth [Press release]. Retrieved from https://www.nationaleatingdisorders.org/sites/default/files/nedaw18/NEDA -Trevor Project 2018 Survey – Full Results.pdf

2 – Diemer, E. W., Grant, J. D., Munn-Chernoff, M. A., Patterson, D., & Duncan, A. E. (2015). Gender identity, sexual orientation, and eating-related pathology in a national sample of college students. Journal of Adolescent Health, 57(2), 144-149.

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Muscle Dysmorphia, Eating Disorders & Males

The term eating disorder is commonly associated with younger women, even though research has shown that eating disorder symptoms and behaviors also occur in women over 50. However, this stereotype that eating disorders only appear in females is a misconception. Studies have shown that eating disorders do not discriminate, with males also suffering from this potentially lethal disease. Some studies have shown that males account for an estimated 5 to 15 percent of patients with anorexia or bulimia. Symptoms of binge-eating disorder are displayed in 35 percent of males. In males, especially boys and young men, these illnesses create a distorted sense of body image. For males, this distortion is often in the form of muscle dysmorphia, a type of disorder characterized by an extreme concern with becoming more muscular.

For boys and young men with muscle dysmorphia and related disorders, they want to lose weight or gain weight in order to “bulk up.” Young men who believe they are physically too small may actually start using anabolic steroids or other dangerous substances in an attempt to increase their body’s muscle mass. Eating disorders and muscle dysmorphia are listed separately in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders. However, the occurrence of these disorders is often seen as a collection of related behaviors. Both are the direct result of over-evaluating an idealized body type, which fuels either a drive for leanness, muscle mass or both. These eating disorders and body image distortions can give rise to disordered eating behaviors in boys, young males or even older men. Yet, in pop culture and society at large, muscular bodies are encouraged for boys. In American sports, being lean and muscular is seen as a beneficial attribute for nearly all sports. In fact, in certain athletic activities such as wrestling and gymnastics, severe weight and eating control is almost encouraged. So how do parents and loved one identify what is healthy versus unhealthy eating in boys and young men?

One question to ask is whether the person with the potential eating disorder is prone to anxiety, depression and perfectionistic tendencies. Other warning signs include people who have been bullied, felt too skinny or have struggled with their weight. These are all contributing factors for boys to develop some type of eating disorder. People should also consider their family’s personal history when considering whether or not a loved one is struggling with some form of muscle dysmorphia or related eating disorder. Risks are increased if there is a family history of eating disorder behaviors or anxiety issues. What are the family norms surrounding food and body image? Adults in a family are often the role models for their children. If discussions of weight and body shaming are frequent topics, kids will notice. From a mental health standpoint, the goal is to have a healthy sense of self and body. Excessive behaviors are usually a sign of a deeper issue. With this in mind, here are four warning signs to watch for in boys and young males:

  • Engaging in extreme dieting.
  • Quickly losing or gaining body weight.
  • Obsessing over dieting.
  • Binge eating and vomiting.

The presence of these behaviors could indicate that an eating disorder is developing. If this is the case, it is better for an individual to receive treatment as soon as possible. Earlier treatment has a better likelihood of success since these disordered behaviors will have less time to become entrenched habits. The concern is not only for the boy’s emotional health, but also for his physical health. Good physical fitness is great, but obsessive behaviors and perfectionism are not. If all signs point to a problematic body image and the existence of an eating disorder, it is beneficial to see a mental health professional who specializes in treating these conditions. Sadly, this topic is rarely talked about among young males. There is still a stigma surrounding publicly discussing mental illness. An additional stigma exists due to the fact that eating disorders are still seen as a women’s issue.

For additional questions about eating disorders in boys and young men, contact the staff at River Centre Clinic. Their programs provide a full range of treatment options for children and adults with a primary diagnosis of an eating disorder. For immediate and confidential feedback, take River Centre Clinic’s EAT-26 (Eating Attitudes Test) assessment. It is a widely cited standardized self-report screening measure that can help determine whether an individual has an eating disorder that requires professional treatment.

Follow us on Twitter:  @River_Centre

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Social Media and Orthorexia

Social media’s pervasiveness throughout society is well-established. Individuals from a variety of backgrounds read and actively use some type of social media channel. The mass adoption of this new communication form is starting to generate questions and concerns. One of these questions ask as to whether the use of social media makes people more susceptible to developing an eating disorder? A new study suggests that specific social media channels might actually lead to unhealthy obsessions with healthy eating.

Incidents of depression have been linked to heavy social media use. For example, there is an increasing amount of evidence that connects the amount of time spent on Facebook with the occurrence of depression. Other studies have also suggested that the extensive use of social media by young adults has a negative impact on body image, depression, social comparison, and disordered eating. Beyond these negatives, social media sites that offer the newest superfood or latest diet fad may be just as damaging. Studies are beginning to see a correlation between disordered eating – particularly orthorexia, or an obsession with eating healthy foods that can lead to unhealthy consequences like nutrient deficiencies, social isolation and anxiety.

Although not formally recognized in the Diagnostic and Statistical Manual, awareness about orthorexia is on the rise. Being concerned with the nutritional quality of the food is not a problem and is actually a good habit to develop. However, individuals with orthorexia become so fixated on what is considered healthy eating that they actually start to damage their own well-being. Studies have shown that many individuals with orthorexia also have obsessive-compulsive disorder. High orthorexia nervosa prevalence has been found in populations who take an active interest in their health and body and is frequently comorbid with anorexia nervosa. In particular, there seems to be a link between Instagram users and signs of orthorexia symptoms.

In 2017, a study in Eating and Weight Disorders found that a whopping 49 percent of people who followed health food accounts on Instagram had orthorexia. By contrast, less than 1 percent of the general population has the “condition,” which, by the way, isn’t an official diagnosis or classified eating disorder. The correlation between Instagram users and the increased symptoms of orthorexia nervosa is surprising. Especially, due to the fact that higher Instagram use was associated with a greater tendency towards orthorexia, but no other social media channels had this effect. Additional analysis indicated that Twitter showed a small positive association with orthorexia symptoms. Other features such as Body mass index (BMI) and age had no association with orthorexia. As a reminder, the prevalence of orthorexia nervosa among the study population was 49 percent, which is substantially higher than the general population which is less than 1 percent.

Understandably, people use social media to discover healthy eating tips or to stay accountable to a fitness plan. But the pursuit of nutritious eating can become an unhealthy preoccupation. The pursuit of the perfect diet can lead to self-punishment and interfere with social activities. Eating disorders and disordered eating behaviors do not discriminate; they can affect women, men, girls and boys. For some people, especially women, healthy eating becomes practically synonymous with deprivation. This means that the typical warning signs for eating disorders, distressing thoughts, compulsive behaviors and self-created rules around food, often go unnoticed or are even praised. This is despite the fact that restrictive diets are sometimes precursors to clinical eating disorders. According to the National Eating Disorders Association (NEDA), food inflexibility can lead to guilt or self-loathing if a “bad” food is consumed, as well as anxiety about food planning and isolation from social events with food and drinks.

The signs of orthorexia include compulsively checking nutrition labels, an inability to eat any food that is not designated pure, obsessively following healthy lifestyle bloggers or social media figures, and showing an unusual interest in what kind of food others are eating. Naturally, people can read nutrition labels and follow fitness experts on Instagram without being orthorexic. But, when the action becomes compulsive and obsessive, this may indicate something beyond following a healthy food plan is occurring. Does the individual feel required to check labels, perhaps even multiple times, even though they have purchased this item in the past and already know the nutritional content? When eating food, does the person feel anxious about eating in general? These are perhaps symptoms of an eating disorder like orthorexia. If untreated, orthorexia can lead to anorexia nervosa, since eating disorders are rooted in compulsivity and obsession surrounding food. According to NEDA, orthorexia is characterized by being consumed with good vs. bad or healthy vs. unhealthy food, while anorexia is characterized by obsessive caloric restriction and weight loss.

Orthorexia is not yet officially recognized by the DSM-5. However, Healthcare practitioners skilled at recognizing eating disorders will know the signs of orthorexia and can connect patients with the appropriate therapists and medical doctors. Doctors and therapists who specialize in eating disorders and mental health, such as those at the River Centre Clinic (RCC) in Ohio, are aware of orthorexia’s prevalence and risks. For additional questions about this topic or other behavioral health issues – please contact us.

 

Eating Attitudes Test (EAT-26)

The EAT-26 is the most widely cited standardized self-report screening measure that may be able to help you determine if you have an eating disorder that needs professional attention. Take the EAT-26 now and get immediate and anonymous feedback.

Follow us on Twitter:  @River_Centre

 

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Eating disorders: From Pop Stars to Everyday People

From famous entertainers to the average person on the street, eating disorders are the silent battle that many people fight alone. Recently, pop stars like Demi Lovato and Kesha have both disclosed their struggles with eating disorders. Lovato told Insider that she is open about the challenges she faces with weight control and maintaining a positive body image. In a recent article in Cosmopolitan, Kesha shared a similar story but spoke of her success with overcoming body issues. However, there are numerous other people who do not have the spotlight of a pop star to share their pain and triumphs. They are not as well-known, but their everyday struggles with eating disorders are just as real.

Currently, there are over 30 million people who suffer from some type of eating disorder. There are still stigmas around mental illness, and this is true for eating disorders. Whether in Michigan, Iowa, or Ohio; the stories are very similar. These are stories of individuals confronting the pain of this affliction. In a story from Michigan, one woman reflects back on high school and remembers feeling proud that she “hadn’t eaten anything that day.” Eventually, she realized that something had to change. A mother in Iowa shares a similar story about her battles with and recovering from anorexia. “Eating disorders are a lot about control, and there was a lot in my life that was out of control. This was something I could control. And I grew up feeling like I wasn’t good enough or really worthy.”

In Ohio, an anorexia survivor has even created a short film that documents the doubt and isolation that is part of this mental illness. In this instance, the individual who has struggled with anorexia is a male, even though the disease is mistakenly thought of as a women’s disorder. He remembers thinking that “I could never tell people what I was going through because they never would believe me, or maybe it wasn’t even real.” His short film is intended to raise awareness and remind people that they are not alone and help is available. Recovery is possible. On a side note, males make up about 25 percent of eating disorder diagnoses.

Young man sitting

People from all walks of life suffer from Eating Disorders – River Centre Clinic

Across the nation, eating disorders plague a wide-variety of people. Yet, treatment options are available that can bring hope to those who are suffering in silence. For additional information, or if you have questions about eating disorders and recovery solutions, please contact the staff at River Centre Clinic (RCC). With decades of experience, their Eating Disorders Programs provide a full range of treatment options for adolescents and adults with a primary diagnosis of an eating disorder. The levels of care provided at the RCC are designed to meet the needs of most patients with eating disorders, but it is important to note that treatment is individualized for each case. We follow a well-established therapy model for treating eating disorders that integrates individual, group, and family therapy. The River Centre Clinic is located in a modern, spacious and tranquil setting in Sylvania, Ohio.

Eating Attitudes Test (EAT-26)

The EAT-26 is the most widely cited standardized self-report screening measure that may be able to help you determine if you have an eating disorder that needs professional attention. Take the EAT-26 now and get immediate and anonymous feedback.

Follow us on Twitter:  @River_Centre

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Body Image in Eating Disorders

What is Body Image Disturbance?

Body image disturbance is one of the most common clinical features attributed to eating disorders. Most contemporary theories consider body dissatisfaction to be the most immediate or proximal antecedent to the development of an eating disorder and empirical studies indeed confirm this association.

It is generally agreed that the body image construct is multidimensional, involving attitudinal as well as perceptual components. The perceptual deficit was best described by Hilde Bruch in her seminal publications based on years of clinical experience (1) and almost 40 years ago, one of us (DG) published one of the first empirical studies documenting size estimation in anorexia nervosa(2).

While size overestimation generated tremendous interest over the years, it has had limited impact in the understanding and the treatment of the disorder.

Nevertheless, recent research has linked body image disturbance to both psychopathology measured by the Eating Disorder Inventory(3) and temperamental characteristics confirming Bruch’s early observations regarding the relationship of body image disturbance to other core features such as poor interceptive awareness and feelings of ineffectiveness(4).

Eating Disorders Without Body Dissatisfaction

Although body dissatisfaction may be one of the most common modes of entry into an eating disorder, early case descriptions of anorexia nervosa and evidence from non-Western cultures indicate that some patients voluntarily reach an emaciated weight for a variety of psychological reasons body but do not show the characteristic body dissatisfaction.

Some of earliest 19th century clinical descriptions of anorexia nervosa do not even mention body dissatisfaction as a clinical feature of the disorder. Cases of apparent anorexia nervosa from China and India lack the “fear of becoming fat” or the body dissatisfaction so prominent in Western cases.

Some Patients Began Restricting Food Intake Because of “Spiritual” Concerns
Even in Western culture, research studies as well as clinical experience indicate that there is a small minority of patients who present with a very low weight but who deny body dissatisfaction at any point during the development of their disorder.

Some of these patients began restricting their food intake because of “spiritual” concerns, fears of choking, aversion to the texture of certain foods, food allergies, or a brief phase of physical illness. These cases have been traditionally classified as “atypical”; however, the diagnostic designations may be too restrictive as evidenced by the changes to the DSM-5.

Body Dissatisfaction is Still a Major Risk Factor

Nevertheless, to point out the exceptions is not to deny the overwhelming evidence that body dissatisfaction is one of the most important risk factors for restrictive dieting which, in turn, predicts the onset and the maintenance of serious eating disorders.

It is a major predictor of relapse in both anorexia and bulimia nervosa; patients who do recover report that body image is one of the major impediments to lasting change. The most challenging problem is how to affect lasting change in body dissatisfaction among those with eating disorders.

Methods to Correct Distorted Body Size

Various methods have been used to attempt to correct distorted body size estimation. One method has been to provide corrective feedback to anorexia nervosa patients with the aim of improving accuracy over time. This can be accomplished in several ways.

One strategy involves providing feedback on standardized measures of size estimation. Another involves directing patients to study their body in a mirror and try to develop a more objective or realistic view of their weight or shape.

Confronting patients With Their Own Distorted Self-perception has Little Therapeutic Effect
Some studies have shown that this exercise may have value in helping patients overcome denial of the severity of their disorder. However, most clinicians agree that directly changing body size perceptions has very limited role in the treatment of anorexia nervosa.

It is not surprising that confronting patients with their own distorted self-perception has little therapeutic effect since most patients have a long history of feedback by friends, family and therapists that they are too thin and must gain weight. This alone seems to have little impact.

A Cognitive Approach to Re-Interpreting Body Image

In our treatment setting, we prefer a cognitive approach aimed at re-interpreting the meaning of body size overestimation rather than trying to change it directly. Body size overestimation can be thought of as a perceptual anomaly that is often observed in eating disorders.

This is similar to other situations where people are encouraged to not rely on a particular perceptual state but rather defer to a higher-order judgment regarding the perception – for instance a person trying to decide whether or not to drive a car after drinking alcohol.

Accordingly, patients are encouraged to view their body-size misperception as an unfortunate perceptual disability (like being a color-blind person trying to coordinate his or her wardrobe). In this case, it is preferable to rely on objective data or a trustworthy person, rather than self-perception to determine actual body size.

Body image usually does not improve early in the process of recovery from anorexia nervosa, and in fact, it often becomes worse during weight gain. If it does improve, it is often in the later stages of recovery.

Treatment For Anorexia Nervosa

There has been remarkable advancement in recent years in the technology for treating body dissatisfaction in those at risk for eating disorders, and for obese individuals. The application of these approaches to anorexia nervosa has been less fully developed.

Treatment for anorexia nervosa requires increasing weight and weight gain is not uncommon in those with bulimia nervosa which predictably increases body dissatisfaction in the short-term.

Cognitive restructuring can be focused on identifying the idiosyncratic meaning that “being thin” and “weight control” has for the patient, and then finding more elegant personal and interpersonal solutions that do not require the life-long physical, psychological and interpersonal disadvantages of maintaining anorexia nervosa.

Within the context of a broader cognitive approach to anorexia nervosa (5), we have found group therapy focused on the “appearance assumptions” from Cash’s workbook particularly useful (6).

Avoiding Self-Defeating Practices

Developing a more positive body image often involves avoiding certain self-defeating practices (e.g. weighing, looking in the mirror, wearing revealing clothing and compulsive exercise) that provide short-term relief, but become rituals that only accentuate anxiety, discontentment and dysphoria.

These can be replaced by body image enhancement activities (yoga, movement, pleasure walks, listening to music,) that emphasize the body as a source of pleasure rather than a vehicle for control, mastery or self-definition. We emphasize the importance of viewing the functional aspects of the body rather than the ascetic features.

Finally, one of the most potent set of interventions derives from education about discrimination related to obesity (7) and the important advancements in advocating Health at Every Size as it’s health and civil rights implications (8).

Addressing Peer Relationships to Promote Change

It is also vital to understand the role of the interpersonal context in body dissatisfaction and to address peer relationships in promoting change. Recent evidence indicates that girls tend to select friends who are similar to themselves in terms of body dissatisfaction and bulimic symptoms but dissimilar in terms of dieting (9) and that body dissatisfaction is predicted by peer conversations about dieting, body consciousness and thin idealization (10).

These findings point to the importance of controlling for friendship selection when examining the role of peers in adolescent body image and eating problems. These findings can be extrapolated to group therapy in clinical settings by underscoring the importance of healthy and unhealthy group affiliations and their impact on recovery and relapse.

Changing Parental Attitudes Toward Weight

It has been our experience that promoting healthy group norms is one of the most important targets of intervention over the course of therapy.

Additionally, a major impediment to change can be parental attitudes toward weight and shape or parents’ overvaluation of thinness that can have a detrimental effect on the treatment of their children.

This issue must be approached with sensitivity to the historical factors influencing parental attitudes; however, treatment must focus on changing the family imperatives that interfere size acceptance as well as respect for individual differences of a wide array of attributes.

Psycho-Educationally Oriented Prevention Programs

Finally, the remarkable advancement in recent years in the technology for treating body dissatisfaction in those at risk for eating disorders, and for obese individuals can be applied in treatment of serious eating disorders. Psycho-educationally oriented prevention programs can reduce body dissatisfaction and reduce ameliorate disorder symptoms in college women that are sustained over a two-year follow-up (11).

Although the application of these approaches to those with clinical eating disorders has been less fully developed, we rely heavily upon psycho-education as well as cognitive approaches to challenging body image disturbance (12) and these have led to clinically and statistically significant changes in body dissatisfaction over the course of our Adult Partial Hospitalization and Adolescent Residential Programs.

Sources:

1. Bruch, H., Perceptual and conceptual disturbances in anorexia nervosa. Psychosomatic Medicine, 1962. 24(2): p. 187-&.

2. Garner, D.M., et al., Body image disturbances in anorexia nervosa and obesity. Psychosom Med, 1976. 38(5): p. 327-36.

3. Garner, D., Eating Disorder Inventory-3 Professional Manual. Psychological Assessment Resources, Inc, 2004.

4. Zanetti, T., et al., Clinical and Temperamental Correlates of Body Image Disturbance in Eating Disorders. European Eating Disorders Review, 2013. 21(1): p. 32-37.

5. Garner, D.M., K. Vitousek, and K.M. Pike, Cognitive Behavioral Therapy for Anorexia Nervosa, in Handbook of Treatment for Eating Disorders1997.

6. Cash, T.F., The body image workbook1997, Oakland, CA: New Harbinger.

7. Garner, D.M. and S.C. Wooley, Confronting the failure of behavioral and dietary treatments for obesity. Clinical Psychology Review, 1991. 11(6): p. 729-780.

8. Bacon, L., et al., Size acceptance and intuitive eating improve health for obese, female chronic dieters. Journal of the American Dietetic Association, 2005. 105(6): p. 929-936.

9. Rayner, K.E., et al., Adolescent Girls’ Friendship Networks, Body Dissatisfaction, and Disordered Eating: Examining Selection and Socialization Processes. Journal of Abnormal Psychology, 2013. 122(1): p. 93-104.

10. Lee, K., Engaging in peer conversation about slimming predicts body dissatisfaction in Chinese college women: A study in Hong Kong. Social Influence, 2013. 8(1): p. 1-17.

11. Stice, E., et al., Efficacy Trial of a Selective Prevention Program Targeting Both Eating Disorders and Obesity Among Female College Students: 1- and 2-Year Follow-Up Effects. Journal of Consulting and Clinical Psychology, 2013. 81(1): p. 183-189.

12. Garner, D.M. and C.D. Keiper, Anorexia and bulimia, in Handbook of clinical psychology competencies, J.C. Thomas and M. Hersen, Editors. 2010, Springer: New York. p. 1429-1459.

Contributed by the following River Centre Clinic Staff:

David M. Garner, Ph.D. is the Owner and Administrative Director

Julie J. Desai, M.A. is the Director of the Adult Partial Hospitalization Program

Meggan Desmond, LISW is the Director of the Adolescent Residential Program

The River Centre Clinic has almost two decades of experience providing innovative treatment to adults and adolescents suffering from eating disorders. It has developed a ground-breaking approach to treatment, based on extensive experience and research, designed to reduce costs without compromising high quality of care.

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Childhood Eating Problems Program

The River Centre Clinic offers outpatient programming for children with eating difficulties. Childhood can be full of different phases and eating changes. Although this is fairly common behavior, it can leave parents feeling troubled. Disturbances in feeding become problematic when it causes the child to become upset or worry and when he or she is not eating enough to sustain proper nutrition and facilitate proper growth. Complications around eating can take many forms including but not limited to:

  • Trouble with food textures/sensory issues
  • Temper tantrums during meals
  • Refusing to eat
  • Limiting food groups
  • Choking, gagging, or vomiting after eating
  • Body image concerns
  • Anxiety/OCD

Although eating issues during childhood may seem to be just a frustration for parents and caregivers, there are real medical concerns including, nutritional deficiencies or a reliance on liquid supplements and vitamins. The staff at River Centre Clinic are carefully selected, not just for their experience in treating symptoms and underlying causes of eat problems, but also for their compassion and willingness to extend themselves on behalf of all clients. The staff is clinically trained in working with children suffering from:

  • Selective/restrictive eating (picky eating)
  • Food, choking, vomiting phobias (Functional Dysphagia)
  • Lacking interest in food/eating
  • Food avoidance due to sensory issues

River Centre Clinic’s outpatient therapists work with children and families to lessen the stress and anxiety surrounding mealtimes. They work closely with families to ensure that every member is part of the healing process. Many times, changes are necessary to the environment and  routine that will require the assistance of parents and caregivers.

The Clinic’s Childhood Eating Problems Program is based on well-established and evidence-based therapy models that integrate individual and family therapy. The treatment is based on applied behavioral principles, enhanced cognitive behavioral principles and directive play therapy techniques, which integrate individual and family therapy and is applied in an individualized manner for each patient. River Centre Clinic treats eating problems that may be coupled with co-occurring disorders and problems, including but not limited to:

  • ADHD
  • Anger Management
  • Anxiety
  • Autism Spectrum Disorders
  • Behavioral Problems
  • Conduct Disorders
  • Depression

For further information about this program, or to schedule an initial assessment, contact Anna Lippisch, MSW, LSW, Director of Childhood Eating Problems Program, at 419-885-8800.

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Six Tips to Prevent Relapse

A residential treatment program can become a safe space for many patients. It may feel scary going back to your home, job, or school. While in treatment, you have invested time working on your recovery and hopefully whatever environment you are returning to can foster a pro-recovery environment. Despite the environment, many patients have a few slips during the recovery process post-treatment. River Centre Clinic’s hope is that you have learned strategies to prevent those slips from becoming relapse. These five tips are not all-inclusive, but they are some of the best strategies to ensure recovery.

Meal plan.

While in treatment you have learned how to meal plan and it most likely began to feel like a normal process towards the end of your stay. However, directly after treatment, meal planning may feel inflexible. It may be tempting to not follow your plan precisely or to completely stop planning. Rest assured that you will not have to meal plan forever to maintain your recovery. While the timeline differs for each individual as to when they can stop meal planning, patients who stick to their meal plan as ordered are less likely to relapse. Be open and honest with your outpatient therapist regarding your concerns with meal planning and create a strategy that works for both of you.

Connect with your outpatient treatment team regularly.

Before you leave residential treatment, you will have hopefully connected with an outpatient therapist and set up your first appointment post-treatment. Talk to your therapist to determine who else you should connect with to create a team of health professionals that advocate for your recovery. Often a team including a therapist, dietitian and primary care physician, all skilled in treating eating disorders, are highly beneficial for post-treatment care.

Utilize your team.

Connecting with a team of skilled health care professionals post-treatment is a vital part of recovery. Just as important, is connecting with a team of friends and family. Your tribe should include people that you feel comfortable talking to about your eating disorder, meal plan and urges. Take time to talk to these special individuals about the type of support you need. Ask your therapist if you can schedule a designated appointment for your tribe to help them understand your recovery
process and how they can help.

Define one self-care ritual and stick to it!

Stress is inevitable and it can make recovery more difficult. But you can combat stress by taking care of yourself and incorporating self-care into your daily routine. Self-care can look different depending on the individual. Do you enjoy reading, a nice hot bath, journaling, listening to music, meditation? These types of activities can be incorporated into your routine to help manage stress.

Know the difference between a slip and relapse.

A slip usually happens suddenly and may take you by surprise. Maybe you were having a particularly busy day and realized at 4:00 p.m. that you missed your afternoon snack. If you’re able to get right back to your planned meals and squeeze in the missed calories, consider that a slip. While a slip is still a setback, it’s much more minor than relapse. Relapse is when a slip turns into consistent eating disorder behaviors. To prevent this from happening, acknowledge a slip if it occurs. Call someone in your tribe or your therapist, if you are able to, so that they can help prevent guilt and shame that you may feel from your slip. These feelings will only exacerbate the problem. Focus on the progress you have made and brainstorm
solutions to prevent a future slip.

Make your own stoplight list.

How will you know when you are falling back into old eating disordered habits? By creating a personalized red, yellow and green flag list with the help of your therapist, you will have a written set of guidelines which will help you to recognize when you need to reach out for assistance. Look specifically at your own personal relapse cues and recovery behaviors and create a comprehensive list. Being sure to identify high-risk indicators that you are doing poorly (red flags), warning signs that you are slipping back into old habits (yellow flags), and signs that you are living a recovered lifestyle (green flags) is integral to keeping on track. Be sure to include both physical and emotional indicators of each.

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