A fashion piece called "Celebrities Without Makeup" can make an effective social education for young girls at risk for eating disorders. I first saw something like this from a ad put together by Dove Campaign for Real Beauty and posted about it.

Here is a heads up for parents of kids vulnerable to eating disorders. There is a growing support network on the Internet to help young girls "improve" on their eating disorders. Connecting with others feels supportive, especially those who are like minded. But in fact, the "Pro-Ana" (Pro-Anorexia) groups encourage unhealthy behavior and feed the preoccupation with being thin and losing weight. About 15% of those diagnosed with Anorexia die from complications of starvation.

Image via Wikipedia

Newsweek.com

A 2006 study that she coauthored found that 96 percent of teens diagnosed with eating disorders who visited pro-eating disorder Web sites learned new dieting and purging techniques, and almost 50 percent of teens who visited sites ostensibly devoted to eating disorder recovery also learned new weight-loss tips.

[..]Facebook doesn't track how often it deletes pro-ana (pro-anorexia ) pages, but the groups violate the site's terms of use by promoting self-harm or harm to others. A team of Facebook employees actively searches for and deletes pro-ana groups along with groups promoting everything from bigotry to self-mutilation, according to company spokesman Barry Schnitt. In response to increased scrutiny and criticism, many pro-ana groups are now private and can't be found in a search, and still others omit the term "pro-ana" from their titles.

Most of the anti-pro-ana groups try to warn people away from pages that promote anorexia and educate them about alternatives, says Angela Ross, 19, who has recovered from an eating disorder and created the 1,400-member Stop Pro-Ana page. Ross says she discovered pro-ana sites one day while feeling depressed about her weight and surfing the Web. The sites, she says, fueled her fledgling eating disorder. Similarly, a 15-year-old high school student in Philadelphia happened upon the pro-ana community while flipping through Facebook. "I was looking through groups and I found [a pro-ana group]," she says. "I was like, 'Wow, these girls kind of know what I'm saying.'" Now, using a different account, she's joined dozens of the groups and downloaded Facebook applications that allow her to share thinspiration pictures with friends. She spends about 45 minutes on her pro-ana account every day, although some of her friends will stay online for as much as five hours daily, posting in groups and chatting with other pro-ana Facebookers, she says.

Marcia Herrin, a Dartmouth professor who has written several books on eating disorders, finds the public nature of the discussions of anorexia on Facebook encouraging, because it shows that teens are less afraid of confronting eating disorders. "To me, that illustrates or indicates that teens these days are so wise," she says. "They've seen so much, they know so much, compared to when I was a teenager in the '60s, that not all of them are wrapped up in eating disorders. Girls are concerned about other girls in their social group who they see toying with an eating disorder. They may talk to them directly, they may talk to a school counselor, they may talk to the girls' parents."

Rose actually hoped some of her friends would see the groups she was joining and talk to her about them. "I wanted one of my close friends to see it and rescue me," she says. But unfortunately, no one did. At one point, she was so involved in the Facebook pro-ana community that she started her own group in defense of it; eventually she deleted that group and stopped posting in others. She couldn't get over her guilt at "helping someone kill themselves" by supporting them in their fasting, and she realized that the groups weren't truly helping her. "Even though the pro-ana sites provided a way for me to communicate with people, it wasn't real-life connections and it wasn't real friendships," she says. "It was us telling people, 'Oh, stay strong.' I was not getting better. I was venting the frustrations. I just wanted to talk to people with similar experiences; they really didn't help at all." Rose says she has since recovered from anorexia and she rarely visits pro-ana Facebook groups. When she does, she says, she's mostly relieved to no longer be part of that world.

Rose sums it up pretty well. The pressure we all feel inside ourselves often attributed to "anxiety" or "depression" is in fact the motivation to act or change. When a person with eating disorders finds reassurance and support for their unhealthy habits, their motivation to change is used up in the social exchange.

On-line relationships are complicated even more so by the fact that they aren't anywhere as meaningful or rewarding as "real life" relationships. They give a satisfying feel of intimacy, but there is no way of assuring yourself that what you see on the screen is the real person. In fact there is good reason to believe that much of what we see in on-line social networks is a highly superficial if not completely false presentation of the real person. But the on-line's relationships are satisfying enough to divert a persons energy from more productive pursuits.

Shame has been a particular interest for me. It has appeared repeatedly as a major barrier in therapy, especially in those for whom therapy has failed in the past. It takes a lot of courage to re-enter therapy after feeling it was previously insufficient. Fortunately, a person returning to therapy after a less than satisfactory experience is significant motivated to try new ideas.

Agreeing to therapy is a humbling experience in and of itself. The American culture so values individualism, asking for help is often viewed as a sign of weakness, perhaps more likely by those who need help the most. I have previously written about the pervasiveness of shame in many long term issues I've seen in therapy. It's almost as if the person attempts to punish himself into change. But the misery extends well beyond what is helpful in motivating change into a self-imposed purgatory. Eventually, the person becomes so desperate to escape that they engage in self-destructive compulsive and addictive behaviors to temporarily escape the pain. Unfortunately, once the consequences of the escape behaviors becomes apparent, misery returns worse than before. This pattern of habitual and cyclical self-recrimination and escape could explain life long patterns of substance abuse and chronic maladjustment including depression. I've been finding some fascinating research that explores shame in therapy that has motivated some intensive research.

Hook and Andrews (2005) reviewed the literature on shame in therapy. They found that shame has recently been found associated with onset and course in depression, especially in chronic and recurrent depression. Personality traits that evoked shame were "as likely to be consequences or concomitants of depression as they were to be precursors." They speculated that "feeling ashamed of personal qualities and behaviors may lead to a chronic course of the disorder by affecting disclosure of the issues involved, thereby impeding therapeutic progress".

Hook and Andrews (2005) also studied questionnaire data of self-described persons who suffered from depression to "examine relationships between shame, disclosure in therapy, and current symptoms...." Of the study's 85 respondents, 54% withheld significant information from their therapist, 42% withheld information related to depressive symptoms and behaviors. Nearly 3/4 of respondents who withheld information said they did so because of shame. Most intriguing, those who were no longer in therapy who also had not disclosing depressive symptom/behaviors had significantly higher depressive symptoms currently than other participants. The study combined with the article's review of the literature, found that "significant relationships have been established between shame-proneness and non-disclosure of symptoms/behaviors in both therapy groups, and of this type of non-disclosure and current depression symptoms in those no longer in therapy."

This is the kind of research I can bring back to work tomorrow and use. It also appears to be a research approach and topic I may be able to emulate. One point they make in the discussion is that while many authors have spoken against assessing shame directly, "if one does not ask, one does not find out about such experiences". And the information that might be withheld otherwise would likely involve depressive symptoms and related behaviors. This finding replicates a previous study of women with eating disorders, which found a significant association between non-disclosure in therapy and shame that involved eating disorder symptoms. I have tended to teach my clients to expect that they will find that those things they most wish not to share are likely to be need disclosure and work to assure a good outcome in therapy.

Another interesting twist in the discussion was an attempt at explaining why "disclosure of symptoms may be more important for depression recovery than disclosure of other upsetting issues and experiences. One explanation is suggested by evidence from Pennebaker and Beall’s (1986) study that disclosure of feelings confers more benefit on long-term health than disclosure of purely factual information." Does that sound clinically sound or what? Ever had a client not want to share the details of a particularly shameful event? I've had some good success encouraging them to share the feelings about the event and how it affected them later, while leaving out the details.

This article is both inspiring of my interest in research as well as immediately practical in clinical applications. I'm going to be digging through this bibliography next week.

Hook, A., Andrews, B. (2005). The relationship of non-disclosure in therapy to shame and depression. British Journal of Clinical Psychology, 44(3), 425-438. DOI: 10.1348/014466505X34165

Sort of contagious. You see, there are a lot of symptomatic behaviors that are subject to imitation. Drug abuse, cutting, suicidal behavior and eating disorders are just a few examples. When like minded people get together, they inspire imitative behavior in each other. It is unlikely that they are sharing the behavior in each other's presence, but they are seruptitiously comparing notes.

Therapists are very much aware of this potential for contagion. They do what they can to minimize the chance it will happen. If you know of such imitation going on in a therapy experience, be sure you let the therapist know immediately. Thanks to the heads up and link from The Corpus Callosum. Here is a excerpt from his blog. There is also a link to the study abstract.

According to a study published in the medical journal, Pediatrics, girls and young women who visit eating disorder oriented websites may be harmed by the activity. The funny thing is, is does not matter if the sites encourage eating disorder behavior, or discourage it. Persons who visit such sites are more likely to end up in the hospital for treatment of their disorder, and are more likely to have along duration of active illness. Furthermore, they are likely to spend less time on schoolwork.

Although it is not possible to say that the use of such sites exacerbated the disorders, persons who do access the sites report that they learn new techniques for dieting and attempted weight loss. Some of these techniques are pathological.

Eating Disorders include Anorexia, Bulimia, and Binging Disorder. Unfortunately, most often, eating disorders, even with rigorous studies, have been studied as if they are related disorders. While there appears to be some relationship, between them, there are important differences.

Anorexia is one of the most deadly forms of mental illness. The mortality rate is about 10%.

Stice (2002)

Eating disorders are one of the most common psychiatric problems faced by women and girls and are characterized by chronicity and relapse. Anorexia nervosa involves emaciation, fear of becoming fat, disturbed perception of body shape, undue influence of shape on self-evaluation, denial of the seriousness of low body weight, and amenorrhea. Bulimia nervosa is marked by uncontrollable binge eating, compensatory behavior to prevent weight gain (e.g., vomiting), and undue influence of shape on self-evaluation. Binge eating disorder entails uncontrollable binge eating in the absence of compensatory behaviors. Eating disorders are marked by psychosocial impairment and co-morbid psychopathology and have the highest levels of treatment seeking, inpatient hospitalization, suicide attempts, and mortality of the most common psychiatric syndromes. Furthermore, eating pathology increases the risk for onset of obesity, depression, and substance abuse.

Unlike most mental illness that have higher rates in the higher stressed lower socio-economic populations, Anorexia nervosa and other eating disorders are more common in Caucasian women who are high academic achievers and have a goal-oriented family or personality. Partly for that reason, and partly because of those theorists who emphasis the role of nurture in mental illness, some experts believe that conflicts within the family may contribute or even cause the disorder. For example, a child to draw attention away from marital problems, and bring the family back together. Some theorists have gone so far as to assert that the families that produce children with eating disorders are perfectionistic and over controlling. Supposedly power struggles between the parents and the child occur in one of the few places that parents require a certain cooperation with the child, at the dinner table. The child rebels by refusing to eat.

Clearly the problem is not that simple. Instead it is apparent that there is a myriad of etiological factors involved. Causal factors may be best divided into those that increase the risk of the disorder and those that help maintain the disorder once it's begun.
Stice (2002) describes a number of risk and maintenance factors:

• being overweight leading to excessive dieting;


• perceive pressure from peers and family to lose weight;


• body dissatisfaction;


• contagion from family or friends who are eating disordered;


• internalization of the thin ideal and overvaluation of the importance of appearance;


• negative affect, including low self-esteem;


• perfectionism and presumably other obsessive-compulsive traits;

Interestingly Stice could find little evidence to support other commonly associated factors such as sexual abuse, dysfunctional families, or deficits in parental affection. Stice notes however, that his study probably doesn't say much anorexia, so much as bulimia and other eating disorders. Few of the studies he reviewed separated out anorexia as a separate diagnosis and so the symptoms of bulimia and other eating disorders being more prevalent, overwhelmed the data. However, it's just as important to note that all of the above factors have also been associated with Anorexia. Stice makes a convincing point that all eating disorders probably involve complex relationships with many factors including all of the above plus possibly a few more not yet identified.

The major problem is that there is no clear course for treatment. Perhaps that makes sense, since eating disorders involve multiple interacting factors that all require intervention. However, the deadly Anorexia needs a clearer map for treatment. WebMD gives a typical list of treatments you'll find on various sites on the net. They include individual therapy where emotional regulation, distress tolerance can be taught, group therapy, family therapy, and medical treatment. If weight falls 30% below normal, hospitalization, tube feeding and supervised meals may be necessary to bring weight back to normal. Nutritional counseling is necessary to teach healthy eating habits.

Here we run into the paradoxical nature of "state of the art" treatment strategies for eating disorders. Families are encouraged to show support, avoid power struggles, focus as little as possible on food and eating, and paying attention to the needs of all family members. But then if weight falls to dangerous levels, families are encouraged to parents are helped to temporarily take control over their child's eating to make sure she gains weight.

The real conflict is maintaining the treatment plan within the two separate conditions. Some families will find it very hard to give the child most of the responsibility up until the point her weight becomes dangerous. Then taking charge of the child's eating will create HUGE power struggles. There are some claims that this approach is helpful. There is a real challenge again is in the transition from total control to giving the child control.

Harriet Brown in the New York Times from November 26th, wrote a touching and deeply personal account of her struggle with this method of intervention with her own anorexic daughter. Most notable was what she found in her own research about the disorder.

I came across one from 1997, a follow-up to an earlier study on adolescents that assessed a method developed in England and was still relatively unknown in the United States: family- based treatment, often called the Maudsley approach. This treatment was created by a team of therapists led by Christopher Dare and Ivan Eisler at the Maudsley Hospital in London, in the mid-1980s, as an alternative to hospitalization. In a hospital setting, nurses sit with anorexic patients at meals, encouraging and calming them; they create a culture in which patients have to eat. The Maudsley approach urges families to essentially take on the nurses' role. Parents become primary caretakers, working with a Maudsley therapist. Their job: Finding ways to insist that their children eat.

[...]On Day 2 of refeeding Kitty, our younger daughter, Lulu (also her nickname), turned 10. We had cake, a dense, rich chocolate cake layered with raspberry filling — one of Kitty's favorites. Of course she refused it. I told her that if she didn't eat the cake, we'd go back to the hospital that night and she would get the tube. I hated saying this, but I hated the prospect of the hospital more. The tube felt like the worst thing that could happen to her, though of course it was not. Five minutes after Kitty was born, I fed her from my own body. Now the idea of forcing a tube down her throat, having a nurse insert a "bolus" every so often, seemed a grotesque perversion of every bit of love and sustenance I'd ever given her.

She sat in front of the cake, crying. She put down the fork, said her throat was closing, said that she was a horrible person, that she couldn't eat it, she just couldn't. We told her it was not a choice to starve. We told her she could do nothing until she ate — no TV, books, showers, phone, sleep. We told her we would sit at the table all night if we had to.

Still, I was astonished when she lifted the first tiny forkful of cake to her mouth. It took 45 minutes to eat the whole piece. After she'd scraped the last bit into her mouth, she lay her head on the table and sobbed, "That was scary, Mommy!" At age 4, Kitty went for a pony ride and was seated on an enormous quarter horse. When the horse reared, she just held on. Afterward I asked if she'd been scared. "Not really," she said. "Can I go again?" This was the child who was now terrified by a slice of chocolate cake.

That night, when I checked on her in bed, she mumbled, "Make it go away." I now knew what "it" was. It seemed as if she were possessed by a vicious demon she must appease or suffer the consequences. I pictured its leathery wings and yellow fangs inside her. Each crumb Kitty ate was an act of true bravery, defiance snatched from its curved talons. I've heard women joke, "I could use a little anorexia!" They have no idea.

This demon was described nowhere in the books I was frantically reading. It wasn't until I stumbled on a 1940s study led by Dr. Ancel Keys, a physiologist at the University of Minnesota, that I began to understand. During World War II, Keys recruited 36 physically and psychologically healthy men for a yearlong study on starvation. For the first three months they ate normally, while Keys's researchers recorded information about their personalities, eating patterns and behavior. For the next six months their rations were cut in half; most of the men lost about a quarter of their weight, putting them at about 75 percent of their former weight — about where Kitty was when she was hospitalized. The men spent the final three months being refed.

Keys and his colleagues published their study in 1950 as "The Biology of Human Starvation," and his findings are startlingly relevant to anorexia. Depression and irritability plagued all the volunteers, especially during refeeding. They cut their food into tiny pieces, drew meals out for hours. They became withdrawn and obsessional, antisocial and anxious. One volunteer deliberately chopped off three of his fingers during the recovery period. The demon, I thought.

"Starvation affects the whole organism," Keys wrote. Given what I'd seen of Kitty, that made sense to me. But I wondered why — if starvation triggers the cognitive, emotional and behavioral changes that are so uniform in anorexia — the Minnesota volunteers did not develop the intense fear of eating and gaining weight that characterizes the disease. And what about the millions of people around the world who are starving because they don't have enough food — why don't they develop anorexia?MORE

An article on Anxiety, Depression and Substance Abuse Treatments blog points out the Maudsley treatment has been around a long time. Salvador Minuchin talked about a family proactive approach in his book Psychosomatic Families.

The “Maudsley approach” doesn’t banish the parents from the treatment and neither did the family method. Both were started in the eighties and probably pulled from each other as they developed this “family centered approach.” Out-patient treatment can often be tricky if the parents or spouse have chosen to see the disorder before it has gotten out of hand. In these cases family, as well as individual, therapy is required. But, it is most important that the therapist providing treatment to the individual not be the same therapist treating the family. Although a seemingly easy distinction to make, in reality this practice can be quite difficult. Invariably as the anorexic patient begins to get better, the family demands to come into the individual session so that they can plead their case and overpower the patient and the therapist. Both the individual and family therapies are long and exhausting and slow to respond. Perhaps the most important point in treating anorexia is to allow the patient to determine their treatment: at their pace, in their time, as long as they stick to a mutually agreed upon weight gain regime.

I suspect the work of Dr. Ancel Keys (1950), the Biology of Human Starvation may need more attention. The concept that the drive to not eat, as Brown calls it the "demon", is a physiological function of being malnourished, may well be an important insight too long overlooked. He pioneered the persistent hypercaloric diet and noted that his volunteers had much difficulty returning to their original weight requiring active intervention by the project staff. Perhaps the scourge of Anorexia is in part a process of physiological shut down that requires extreme measures to turn around.

Perhaps draconian measures like the Maudsley or Minuchin approach may well be what's necessary. Brown notes that researchers at the University of Chicago are mid way through a research study. Meanwhile, an active family component seems a prudent course, certainly more humane and less expensive than an inpatient hospital setting.

Isn't it sad that our most effective and pervasive education sources (TV) and other media is full of images that are not real, raise expectations for ourselves and others, and sets us up to feel inadequate. Those feelings help create in some girls a frenzied obsession with appearance that sometimes leads to eating disorders, some of which are deadly. And they make a few people rich.

Thanks to Dr. Deb Serani for the link.