Loss+In+Recovery

= **//Individuals in Recovery from an Eating Disorder//** = = = Facts and Definitions: According to recent research, 4 out of 10 Americans have either suffered or know someone who has an eating disorder ; suggesting 8 to 11 million currently suffer. Anorexia is the 3rd most common chronic illness among adolescents (obesity and asthma are 1 and 2) and has the highest mortality rate of all psychological disorders (The Alliance, 2012). While active eating disorders may be categorized by the diagnostic criteria below, researchers and clinicians have noted the lack of standardization regarding what constitutes "recovery" (Fitzsimmons, 2010). In this presentation, "recovery" will be referred to using physical, psychological, and behavioral components as potential definitions are considered.

//DSM-IV-TR// Criteria for **Anorexia Nervosa (AN)**: 1. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less 85% of that expected; or failure to make expected weight gain during a period or growth, leading to body weight less than 85% of that expected. 2. Intense fear of gaining weight or becoming fat, even though underweight. 3. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight. 4. In postmenarchial females, the absence of at least three consecutive menstrual cycles.

//DSM-IV-TR// Criteria for **Bulimia Nervosa (BN)**:  1. Recurrent episodes of binge eating characterized by BOTH of the following:  a. Eating in a discrete amount of time (within a 2 hour period), an amount that is definitely larger than most people would eat during a similar time period.  b. Sense of lack of control over eating during an episode.  2. Recurrent inappropriate compensatory behavior in order to prevent weight gain (self-induced vomiting, misuse of laxatives or diuretics, starvation, or compulsive exercising).  3. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for three months.  4. Self-evaluation is unduly influenced by body shape and weight. <span style="font-family: Georgia,serif;"> 5. The disturbance does not occur exclusively during episodes of anorexia nervosa

<span style="font-family: Georgia,serif;">Over the last few years, clinicians have utilized the **Eating Disorder Not Otherwise Specified (EDNOS)** diagnosis when someone displays distorted eating and meets several but not all criteria for AN or BN.

<span style="font-family: Georgia,serif;">//DSM-IV-TR// Criteria for **EDNOS** <span style="font-family: Georgia,serif;">**Eating Disorder Not Otherwise Specified includes disorders of eating that do not meet the criteria for any specific eating disorder, however require proper treatment. Examples include:** <span style="font-family: Georgia,serif;"> 1.For females,all of the criteria for Anorexia Nervosa are met except that the individual has regular menses. <span style="font-family: Georgia,serif;"> 2.All of the criteria for Anorexia Nervosa are met except that, despite significant weight loss the individual's current weight is in the normal range. <span style="font-family: Georgia,serif;"> 3.All of the criteria for Bulimia Nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less than twice a week or for duration of less 3 months <span style="font-family: Georgia,serif;"> 4.The regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food. <span style="font-family: Georgia,serif;"> 5.Repeatedly chewing and spitting out, but not swallowing, large amounts of food. <span style="font-family: Georgia,serif;"> 6.Binge Eating Disorder: recurrent episodes of binge eating in the absence if the regular use of inappropriate compensatory behaviors characteristic of Bulimia Nervosa. <span style="font-family: Georgia,serif;"><span style="color: #000000; font-family: Georgia,serif;">//This population is of interest to me as I have spent more than six years in recovery from a ten-year battle with anorexia and bulimia. As awareness of eating disorders expands, my hope is that treatment becomes more available and affordable to those who want to choose recovery. At this time, limited insurance coverage is offered for eating disorders and one day of treatment averages $500-$2000// (The Alliance, 2012). <span style="color: #0000ff; display: block; font-family: Georgia,serif; text-align: center;">**Losses Related to this Population:** <span style="display: block; font-family: Georgia,serif; text-align: center;"> **Primary Loss:** The loss of the eating disorder (binging, purging, and/or restricting behaviors).<span style="color: #ff0000; font-family: Georgia,serif;">**Secondary Losses:** <span style="font-family: Georgia,serif;">Loss of identity associated with being bulimic or anorexic  <span style="color: #000000; display: block; font-family: Georgia,serif; text-align: center;">Loss of coping mechanisms/numbing affec;tLoss of perceived sense of control; Loss of rigid weight management mechanisms; Loss of relationships (friends or family who have active eating disorders); Loss of occupation or hobbies conducive to eating disorder behavior

<span style="font-family: Georgia,serif;">2. Sadness <span style="font-family: Georgia,serif;">3.Anger <span style="font-family: Georgia,serif;">4.Resentment <span style="font-family: Georgia,serif;">5. Guilt || # <span style="font-family: Georgia,serif;">Learning to identify, use, and value emotions.
 * ||< <span style="display: block; font-family: Georgia,serif; text-align: center;">**Stressor** || <span style="display: block; font-family: Georgia,serif; text-align: center;">**Process**  ||
 * =<span style="font-family: Georgia,serif;">**Grief-Oriented** = ||< <span style="font-family: Georgia,serif;">1. Feeling
 * 1) <span style="font-family: Georgia,serif;">Crying, alternative forms of therapy (art, music, etc.)
 * 2) <span style="font-family: Georgia,serif;">Finding ways to address emotional pain and what lead to wanting numbness; Journaling
 * 3) <span style="font-family: Georgia,serif;">Confronting unhealthy relationships, establishing boundaries, self-reflecting, and acceptance.
 * 4) <span style="font-family: Georgia,serif;">Seeking medical care to attend to physical damage of eating disorder, budgeting to deal with financial burden of treatment, acceptance, and turning guilt into motivation to choose recovery. ||

<span style="font-family: Georgia,serif;">2. How to develop healthier coping mechanisms <span style="font-family: Georgia,serif;">3. How to develop healthier eating and exercise habits <span style="font-family: Georgia,serif;">4. How to deal with potential weight-gain <span style="font-family: Georgia,serif;">5. How to create healthier relationships <span style="font-family: Georgia,serif;">6. How to deal with high cost and limited insurance coverage of eating disorder treatment <span style="font-family: Georgia,serif;">7. How to deal with occupation or hobbies conducive to eating disorder <span style="font-family: Georgia,serif;">8. How to create a new assumptive universe. ||< <span style="font-family: Georgia,serif;">1. Apply CBT, DBT, REBT, and Mindfulness practices. <span style="font-family: Georgia,serif;">2. Journaling, establishing a support system, and using creative outlets. <span style="font-family: Georgia,serif;">3. Employ intuitive eating and exercise. <span style="font-family: Georgia,serif;">4. Use positive affirmations, acceptance, redefine beauty, health, and identity. <span style="font-family: Georgia,serif;">5. Establish boundaries and eliminate toxic relationships <span style="font-family: Georgia,serif;">6. Seek treatment scholarships, financial assistance, and use as motivation for choosing recovery. <span style="font-family: Georgia,serif;">7. Modify or change occupations or hobbies more conducive to recovery. <span style="font-family: Georgia,serif;">8. Explore interests and create a new identity. ||
 * <  ||< <span style="font-family: Georgia,serif;">**Stressors**  ||< <span style="font-family: Georgia,serif;">**Process**  ||
 * < =<span style="font-family: Georgia,serif;">**Life-Oriented** = ||< <span style="font-family: Georgia,serif;">1. How to employ emotional regulation.


 * <span style="font-family: Georgia,serif;">The charts listed above include adaptive forms of grieving the loss of an eating disorder. Common forms of maladaptive behaviors may involve isolation, substance abuse, and continued reliance on a rigid exercise and diet regimen that falls short of diagnostic criteria.

=<span style="color: #808080; font-family: Georgia,serif;">Key Concepts and Implications for Social Workers: =

<span style="font-family: Georgia,serif;">1.The following is an excerpt from a qualitative study conducted by Patching & Lawlery (2009) that offers insight pertinent to working with women and men in recovery:

//<span style="font-family: Georgia,serif;"> Three themes- control, connectedness and conflict emerged as significant in the development, experience of, and recovery from an eating disorder. The development of the condition was attributed to a lack of control, a sense of non-connectedness to family and peers and extreme conflict with significant others. Recovery occurred when the women re-engaged with life, developed skills necessary for conflict resolution and rediscovered their sense of self. Rather than viewing the development of and recovery from an eating disorder as separate and discrete events, the data from the life-history interviews suggest they are better viewed as one entity—that is, the journey of an individual attempting to discover and develop their sense of self. This perspective challenges some current constructs of eating disorders; it is not a condition in and of itself but a symptom of deeper issues that if addressed, when the individual is ‘ready’ to make that choice, will lead to recovery. //

<span style="font-family: Georgia,serif;">2. Similarly, artificial secondary control of food intake and exercise regimen is an attempt to compensate for a lack of primary control over life events and social relationships. <span style="font-family: Georgia,serif;">3. Deriving a positive identity from having an eating disorder may contribute to resistance or ambivalence to treatment (Giles, 2006). This ambivalence may be exacerbated when met by perceived dismissiveness of family and friends who do not view the condition as serious and in need of medical attention. In addition, only 1 in 10 individuals with an eating disorder obtain treatment, with 35 percent receiving specialized and most receiving nominal treatment from primary caregivers with limited knowledge of eating disorders (Ison, 2010).

<span style="font-family: Georgia,serif;">4. Given the complexity of eating disorders, a multi-disciplinary approach involving a therapist, psychiatrist, medical doctor, and nutritionist is preferred.

<span style="font-family: Georgia,serif;">5. Researchers and clinicians have identified a strong correlation between family environment and eating disorder etiology (Gillett, Harper, Larson, Berrett & Hardman 2009). Depending on the age of one’s client, it would be appropriate to engage the parent(s) in the therapeutic process to address contributing factors that may limit the client’s ability to successfully recover.

=<span style="color: #008080; font-family: Georgia,serif;">**Questions asked by fellow classmates:** =

<span style="color: #008080; font-family: Georgia,serif;">**At what age do most people develop an eating disorder?** <span style="font-family: Georgia,serif;">Although most eating disorders develop in adolescence or young adulthood, some manifest as early as 5 or 6 and in rare cases, 30 or older. Approximately 95 percent of individuals with an active eating disorder are between 12 and 25 (DMH, 2006).

<span style="color: #008080; font-family: Georgia,serif;">**Do teenagers feel that by having an eating disorder, it helps them fit in a specific crowd?** <span style="font-family: Georgia,serif;">Yes, research has correlated peer, parental and media influence to the development of an eating disorder (Peterson, Paulson & Williams, 2007).

<span style="color: #008080; font-family: Georgia,serif;">**Do images of models and society’s idea of what is beautiful have an impact on eating disorders?** <span style="font-family: Georgia,serif;">Yes, the media’s portrayal of an association between a slim body size and positive characteristics such as control, success and attractiveness has been linked to the increased prevalence of eating disorders (Ison, 2010).

<span style="color: #008080; font-family: Georgia,serif;">**What are female vs. male statistics?** <span style="font-family: Georgia,serif;">An estimated 10-15% of people with anorexia or bulimia are male (Carlat, 1997). Among gay men, nearly 14% appeared to suffer from bulimia and over 20% appeared to be anorexic and in general, men are less likely to seek treatment for eating disorders because of the perception that they are “woman’s diseases” (American Psychological Association, 2001).

<span style="color: #008080; font-family: Georgia,serif;">**Does race/ethnicity play a role in eating disorder etiology?** <span style="font-family: Georgia,serif;">While eating disorders were once thought to only impact young, white females, growing research suggests eating disorders affect women and men of all demographics. Despite this trend, accurate statistics have been difficult to produce due to the underreporting among minority women, under and misdiagnosing by the treatment provider, and a cultural bias within the DSM-IV (NEDA, 2005).

<span style="color: #008080; font-family: Georgia,serif;">**What percentages of people with eating disorders die from the disease?** <span style="font-family: Georgia,serif;">According to a study done by colleagues at the American Journal of Psychiatry (2009), eating disorders have the highest mortality rate of any mental disorder. Crude mortality rates were:

<span style="font-family: Georgia,serif;">• 4% for AN

<span style="font-family: Georgia,serif;">• 3.9% for BN

<span style="font-family: Georgia,serif;">• 5.2% for EDNOS

<span style="color: #008080; font-family: Georgia,serif;">**Once in recovery, how does the body react to change?** <span style="font-family: Georgia,serif;">In early recovery, one may experience weight gain as the body attempts to return to a healthy weight and fuel the system which has been starved. Regardless of the type of eating disorder behavior (binging, purging, and/or restricting), prolonged reliance on any of the three may cause significant damage to an individual’s metabolism. However, research has shown that with continued employment of intuitive eating by becoming attuned to natural hunger signals, one’s metabolism can recover and maintain a healthy weight.

<span style="color: #008080; font-family: Georgia,serif;">**How do people with eating disorders view themselves?** <span style="font-family: Georgia,serif;">Individuals with eating disorders most often demonstrate low self-worth and cognitive distortions, most notably regarding body image.

<span style="font-family: Georgia,serif;">**<span style="color: #008080; font-family: Georgia,serif;">For individuals who binge and purge, how many report enjoying the purging ?** <span style="font-family: Georgia,serif;">Some individuals who purge report feeling a release and sense of high when they vomit.

<span style="color: #008080; font-family: Georgia,serif;">**Once in recovery, how do they socialize with others around food?** <span style="font-family: Georgia,serif;">Similar to those in recovery from alcoholism or drug addiction, individuals with eating disorders must address the “triggers” of their disease. Early in recovery, one may avoid social settings based around food or limit the amount of time required at a holiday or family functions. Many treatment programs are set up to help clients address these challenges and provides opportunities to problem-solve solutions. Ideally, as one progresses throughout recovery, old triggers may be weakened and eventually extinguished.

<span style="color: #008080; font-family: Georgia,serif;">**What types of therapy have been shown as successful?** <span style="font-family: Georgia,serif;">As policy changes by managed care have forced treatment facilities to adapt to a fewer number of visits or shorter inpatient stays, support has grown for a more flexible approach of individualized care derived from several treatment modules and theories. Some of these primary theories include CBT, DBT, REBT, and mindfulness (Schaffner, 2008).

=<span style="color: #800080; font-family: Georgia,serif;">**Rewriting their stories while learning to grieve: Personal accounts of grief in recovery from an eating disorder** =
 * <span style="font-family: Georgia,serif;">The first account is by Lisa Tillman, Ph.D., professor and author of A Secret Life in a Culture of Thinness and Body and Bulimia Revisited: Reflections on 'A Secret Life’. **

<span style="font-family: Georgia,serif;">//Moving beyond bulimia meant learning to utilize other discursive resources to develop an effective counternarrative. In the newer story, I honor others’ struggles, bear witness to others’ traumas, and combat others’ oppression without dismissing my own. I see that being able to face, to cope with, and to communicate my loss and grief render me better able to support others.//


 * <span style="font-family: Georgia,serif;">In the end, recovering from an eating disorder is largely rooted in learning to grieve and <span style="color: #800080; font-family: Georgia,serif;">feel . This difficulty, further illustrated in Tillman’s intimate account of her pain in learning her soon-to-be ex-husband has a new lover… **

<span style="font-family: Georgia,serif;">//At last, I reach for a towel, pat my face dry, and stare into the mirror. My brown eyes instantly fill with tears. The wound at my core cracks through its scab. I clutch the edge of the vanity, steadying myself for a deep, heaving sob. Liquid pours from my eyes and nose, into my mouth, and down my throat. I try to swallow but choke and cough. My stomach flips. As I spit into the sink, I realize how familiar this feels: the setting, the position of my body, the grief. The Grief. How very little effort it would take to vomit. But instead of calling up the contents of my stomach, I call up the grief, and I do what I could not at age 15 or 25: I let the grief out. I Let It Out. Out. OUT.//


 * <span style="font-family: Georgia,serif;">The second account is by Meg Hatson, a recovering anorexic. **

<span style="font-family: Georgia,serif;">//The grieving process is not linear; there are still many days when I long for my old body or am tempted to cope with life's stresses in unhealthy ways. But I am learning. I am learning to celebrate my identity as a writer, a daughter, and a sister, instead of a sick woman. To nurture with gratitude a body that can move and make love and, should I choose, bear a child. I am a Recovering Woman who makes a choice for health every day. Because there is no other choice.//



References: American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Carlat, D.J. (1997). Review of bulimia nervosa in males. //American Journal of Psychiatry, 154.// Fitzsimmons, E. M. (2010). Differences in coping across stages of recovery from an eating disorder. //International Journal Of Eating Disorders, 43(8),// 689-693. Gillett, K. S., Harper, J. M., Larson, J. H., Berrett, M. E., & Hardman, R. K. (2009). Implicit family process rules in eating-disordered and non-eating-disordered families. //Journal Of Marital & Family Therapy, 35(2),// 159-174. Hatson, M. (Feb 15, 2011). Truth about recovering from anorexia - A woman's story on eating disorder recovery: What really happens inside an anorexia clinic. //Marie Claire//. Ison, J. (2010). Social identity in eating disorders. //European Eating Disorders Review, 18(6),// 475-485. National Eating Disorder Association (2005) Patching, J., & Lawler, J. (2009). Understanding women’s experiences of developing an eating disorder and recovering: A life-history approach. //Nursing Inquiry, 16(1),// 10-21. Peterson, K. A., Paulson, S., & Williams, K. K. (2007). Relations of eating disorder symptomology with perceptions of pressures from mother, peers, and media in adolescent girls and boys. //Sex Roles, 57(9/10),// 629-639.