Patients and Their Carers: Different Perspectives and Family Support

*Anorexia and Bulimia Nervosa*

2014;**33**(6):1046-1053

2004;**9**(1):76-80

1997;**82**(2):571-576

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[88] Pals KL et al. Effect of running intensity on intestinal permeability. Journal of Applied Physiology (Bethesda, MD: 1985).

anorexia in mice. Clinical Nutrition.

[87] Monteleone P et al. Intestinal permeability is decreased in anorexia nervosa. Molecular Psychiatry.

[89] Kishi T, Elmquist JK. Body weight is regulated by the brain: A link between feeding and emotion. Molecular Psychiatry. 2005;**10**(2):132-146

[90] Raevuori A et al. The increased risk for autoimmune diseases in patients with eating disorders. PLoS One.

[91] Devkota S et al. Dietary-fat-induced taurocholic acid promotes pathobiont expansion and colitis in Il10−/− mice. Nature. 2012;**487**(7405):104-108

**100**

Chapter 7

Abstract

Patients' and Carers' Perspectives

Interventions Targeting Anorexia

In clinical practice, patients with anorexia nervosa (AN), their carers and clinicians often disagree about psychopharmacological treatment. We developed two corresponding questionnaires to survey the perspectives of patients with AN and their carers on psychopharmacological treatment. These questionnaires were distributed to 36 patients and 37 carers as a quality improvement project on a specialist unit for eating disorders at the South London and Maudsley NHS Foundation Trust. Although most patients did not believe that medication could help with AN, the majority thought that medication for AN should help with anxiety (61.1%), concentration (52.8%), sleep problems (52.8%) and anorexic thoughts (55.6%). Most of the carers shared the view that drug treatment for AN should help with anxiety (54%) and anorexic thoughts (64.8%). Most patients had concerns about potential weight gain, increased appetite, changes in body shape and metabolism during psychopharmacological treatment. By contrast, the majority of carers were not concerned about these specific side effects. Some of the concerns expressed by the patients seem to be AN-related. However, their desire for help with anxiety and anorexic thoughts, which is shared by their carers, should be taken seriously by clinicians when choosing a medication or planning psychopharmacological studies.

Keywords: anorexia nervosa, psychopharmacological treatment, treatment effects,

Anorexia nervosa (AN) is an eating disorder. According to the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [1], its diagnostic criteria are significantly low body weight, intense fear of weight gain, and disturbed body perception. The prevalence of AN is up to 1% among women with a men-towomen ratio of 1–10 [2]. The peak incidence is at an age between 14 and 17 years [3]. The course is often chronic, and it can lead to persistent disability [4]. A recent

of Psychopharmacological

Amabel Dessain, Jessica Bentley, Janet Treasure,

Ulrike Schmidt and Hubertus Himmerich

Nervosa Symptoms

side effects, opinion survey, patients, carers

1. Introduction

103

1.1 Anorexia nervosa

#### Chapter 7

## Patients' and Carers' Perspectives of Psychopharmacological Interventions Targeting Anorexia Nervosa Symptoms

Amabel Dessain, Jessica Bentley, Janet Treasure, Ulrike Schmidt and Hubertus Himmerich

### Abstract

In clinical practice, patients with anorexia nervosa (AN), their carers and clinicians often disagree about psychopharmacological treatment. We developed two corresponding questionnaires to survey the perspectives of patients with AN and their carers on psychopharmacological treatment. These questionnaires were distributed to 36 patients and 37 carers as a quality improvement project on a specialist unit for eating disorders at the South London and Maudsley NHS Foundation Trust. Although most patients did not believe that medication could help with AN, the majority thought that medication for AN should help with anxiety (61.1%), concentration (52.8%), sleep problems (52.8%) and anorexic thoughts (55.6%). Most of the carers shared the view that drug treatment for AN should help with anxiety (54%) and anorexic thoughts (64.8%). Most patients had concerns about potential weight gain, increased appetite, changes in body shape and metabolism during psychopharmacological treatment. By contrast, the majority of carers were not concerned about these specific side effects. Some of the concerns expressed by the patients seem to be AN-related. However, their desire for help with anxiety and anorexic thoughts, which is shared by their carers, should be taken seriously by clinicians when choosing a medication or planning psychopharmacological studies.

Keywords: anorexia nervosa, psychopharmacological treatment, treatment effects, side effects, opinion survey, patients, carers

#### 1. Introduction

#### 1.1 Anorexia nervosa

Anorexia nervosa (AN) is an eating disorder. According to the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [1], its diagnostic criteria are significantly low body weight, intense fear of weight gain, and disturbed body perception. The prevalence of AN is up to 1% among women with a men-towomen ratio of 1–10 [2]. The peak incidence is at an age between 14 and 17 years [3]. The course is often chronic, and it can lead to persistent disability [4]. A recent longitudinal cohort study showed that only about 30% of patients with AN have recovered after 9 years [5]. AN has also been reported to be associated with a significantly increased mortality with a standardized mortality ratio (SMR) of 5.21 [6]. Thus, novel approaches such as psychopharmacological options should be considered to improve the treatment outcome and the care for people with AN.

treatment is considered, patients with AN are more interested in whether this medication might help with certain psychological symptoms including anxiety,

Patients' and Carers' Perspectives of Psychopharmacological Interventions Targeting…

Weight gain can thus only be a first treatment step to reverse the acute effects of starvation. Relying on weight outcomes alone in drawing conclusions from RCTs could inflate the interpretation of positive results [14]. Instead, weight gain and psychological improvement should be considered as important treatment outcomes

Psychopharmacological agents have potential side effects, including an increase in appetite, weight gain, binge eating, alterations in metabolism, cardiac problems, nausea, haematological changes, tiredness, mood changes and other psychological effects. It is important to share these potential side effects with the patients when obtaining their consent to treatment, as sharing this knowledge helps the process of shared decision-making about a psychopharmacological treatment and contributes

As carers can support their loved ones towards recovery [19], it makes sense to involve them in medical and specifically psychopharmacological decisions. They can support patients when they take their medication, and they can observe and report beneficial and adverse effects. Thus, we surveyed the carers' views and expectations towards psychopharmacological treatment for AN. In this chapter, the term 'carer' is used quite broadly. It can be anyone caring for a person with an

This study was performed to survey the patients' and carers' perspectives of psychopharmacological interventions targeting symptoms of AN. Therefore, a questionnaire was developed to gather the patients' views and another questionnaire, with questions of similar content, was developed to gather the carers' views. In this book chapter, we present both these questionnaires on the patients' and the carers' views on psychopharmacological treatment for AN, and we report on the

In order to perform a quality improvement (QI) project in the Eating Disorders Service of the South London and Maudsley NHS Foundation Trust (SLaM), we developed a questionnaire for such a project. The QI project team consisted of patients and psychiatrists from the eating disorders inpatient ward, the 'step-up' service (a day-hospital service) and the outpatient unit of SLaM. The questionnaire has three main sections. The first section provides basic information on the patient or the carer and their experience with medication prescribed to them or their loved one respectively. The second section asks about what therapeutic effects a psychopharmacological medication should have to help with symptoms of AN. The third

Initially, the questionnaires were distributed to a group of 17 patients with AN

and 16 carers between June 2016 and January 2017. The answers given were

eating disorder, such as a parent, a sibling, a partner or a friend.

mood, and problems with concentration and sleep [10, 16].

DOI: http://dx.doi.org/10.5772/intechopen.86083

in their own right [14].

to drug safety [17, 18].

1.6 Aim of this study

statistical results of the survey.

2.1 Development of the questionnaires

section is about concerns of potential side effects.

2. Methods

105

1.5 The carers' perspective

#### 1.2 Carers' help for patients with anorexia nervosa

Family members, partners and friends are usually highly motivated to care for patients with AN, but they are also often suffering. AN can make them feel guilty or anxious which is neither justified nor helpful. Family therapy for AN can tackle these feelings, can identify interpersonal difficulties maintaining the disorder, teach psychosocial and communication skills, and thus enable the carers to help the patients work towards recovery [7, 8]. The carers' help may also include supporting psychopharmacological treatment.

#### 1.3 Psychopharmacological treatment for anorexia nervosa

The discovery of psychopharmacological treatment options in the 1950s led to a massive breakthrough in the treatment of schizophrenia and depression. Patients who previously had to live in asylums became enabled to lead a self-determined and autonomous life with their families, and resume taking up employment [9]. Patients with AN, however, did not benefit from this success, as the antipsychotics and antidepressants developed did not prove to be effective in AN.

Psychiatric researchers have unsuccessfully tried for decades to apply these medications to the treatment of AN, which is why there is no single medication approved for use in AN [10]. Part of the problem is the difficulty in conducting randomized controlled trials (RCTs) in AN. Most of these RCTs chose weight gain as their main outcome criterion. However, this is what patients with AN fear, and this fear is indeed a symptom of their disorder. Therefore, recruitment for psychopharmacological studies in AN has been a significant challenge [11]. Despite these obstacles, RCTs have been performed and published, although the recruitment rate of these RCTs has been so low that the results may not be generalizable.

The lack of effective psychopharmacological treatment has left patients with AN in a situation where clinical treatment outcomes are very modest. End-of-treatment remission rates of RCTs in adult patients with AN range between 13 and 43% [12]. This is a sobering figure highlighting the pernicious nature of AN and its mortality rate, which is—as already mentioned above—five to six times greater than in the general population [6, 13, 14].

The biological mechanisms leading to AN are not completely understood. Therefore, currently it is not possible to design a drug that would specifically target the biological cause of this psychiatric disorder [10]. However, clinicians could consider prescribing medication that targets certain symptoms which are important or frequent in patients with AN.

#### 1.4 The patients' perspective

During the psychiatric history taking and examination, patients with AN often report that they use self-starvation to cope with stress, difficulties and overwhelming emotions. Thus, AN could be seen as a strategy for coping with underlying problems such as stress, anxiety or low mood [15]. Therefore, a medication that induces appetite and increases weight could be perceived by patients with AN as a way of re-exposing them to these underlying problems. Therefore, when drug

Patients' and Carers' Perspectives of Psychopharmacological Interventions Targeting… DOI: http://dx.doi.org/10.5772/intechopen.86083

treatment is considered, patients with AN are more interested in whether this medication might help with certain psychological symptoms including anxiety, mood, and problems with concentration and sleep [10, 16].

Weight gain can thus only be a first treatment step to reverse the acute effects of starvation. Relying on weight outcomes alone in drawing conclusions from RCTs could inflate the interpretation of positive results [14]. Instead, weight gain and psychological improvement should be considered as important treatment outcomes in their own right [14].

Psychopharmacological agents have potential side effects, including an increase in appetite, weight gain, binge eating, alterations in metabolism, cardiac problems, nausea, haematological changes, tiredness, mood changes and other psychological effects. It is important to share these potential side effects with the patients when obtaining their consent to treatment, as sharing this knowledge helps the process of shared decision-making about a psychopharmacological treatment and contributes to drug safety [17, 18].

#### 1.5 The carers' perspective

longitudinal cohort study showed that only about 30% of patients with AN have recovered after 9 years [5]. AN has also been reported to be associated with a significantly increased mortality with a standardized mortality ratio (SMR) of 5.21 [6]. Thus, novel approaches such as psychopharmacological options should be considered to improve the treatment outcome and the care for people with AN.

Family members, partners and friends are usually highly motivated to care for patients with AN, but they are also often suffering. AN can make them feel guilty or anxious which is neither justified nor helpful. Family therapy for AN can tackle these feelings, can identify interpersonal difficulties maintaining the disorder, teach psychosocial and communication skills, and thus enable the carers to help the patients work towards recovery [7, 8]. The carers' help may also include supporting

The discovery of psychopharmacological treatment options in the 1950s led to a massive breakthrough in the treatment of schizophrenia and depression. Patients who previously had to live in asylums became enabled to lead a self-determined and autonomous life with their families, and resume taking up employment [9]. Patients with AN, however, did not benefit from this success, as the antipsychotics and

Psychiatric researchers have unsuccessfully tried for decades to apply these medications to the treatment of AN, which is why there is no single medication approved for use in AN [10]. Part of the problem is the difficulty in conducting randomized controlled trials (RCTs) in AN. Most of these RCTs chose weight gain as their main outcome criterion. However, this is what patients with AN fear, and this fear is indeed a symptom of their disorder. Therefore, recruitment for psychopharmacological studies in AN has been a significant challenge [11]. Despite these obstacles, RCTs have been performed and published, although the recruitment rate

The lack of effective psychopharmacological treatment has left patients with AN in a situation where clinical treatment outcomes are very modest. End-of-treatment remission rates of RCTs in adult patients with AN range between 13 and 43% [12]. This is a sobering figure highlighting the pernicious nature of AN and its mortality rate, which is—as already mentioned above—five to six times greater than in the

The biological mechanisms leading to AN are not completely understood. Therefore, currently it is not possible to design a drug that would specifically target the biological cause of this psychiatric disorder [10]. However, clinicians could consider prescribing medication that targets certain symptoms which are important

During the psychiatric history taking and examination, patients with AN often report that they use self-starvation to cope with stress, difficulties and overwhelming emotions. Thus, AN could be seen as a strategy for coping with underlying problems such as stress, anxiety or low mood [15]. Therefore, a medication that induces appetite and increases weight could be perceived by patients with AN as a way of re-exposing them to these underlying problems. Therefore, when drug

of these RCTs has been so low that the results may not be generalizable.

1.2 Carers' help for patients with anorexia nervosa

1.3 Psychopharmacological treatment for anorexia nervosa

antidepressants developed did not prove to be effective in AN.

psychopharmacological treatment.

Anorexia and Bulimia Nervosa

general population [6, 13, 14].

or frequent in patients with AN.

1.4 The patients' perspective

104

As carers can support their loved ones towards recovery [19], it makes sense to involve them in medical and specifically psychopharmacological decisions. They can support patients when they take their medication, and they can observe and report beneficial and adverse effects. Thus, we surveyed the carers' views and expectations towards psychopharmacological treatment for AN. In this chapter, the term 'carer' is used quite broadly. It can be anyone caring for a person with an eating disorder, such as a parent, a sibling, a partner or a friend.

#### 1.6 Aim of this study

This study was performed to survey the patients' and carers' perspectives of psychopharmacological interventions targeting symptoms of AN. Therefore, a questionnaire was developed to gather the patients' views and another questionnaire, with questions of similar content, was developed to gather the carers' views. In this book chapter, we present both these questionnaires on the patients' and the carers' views on psychopharmacological treatment for AN, and we report on the statistical results of the survey.

#### 2. Methods

#### 2.1 Development of the questionnaires

In order to perform a quality improvement (QI) project in the Eating Disorders Service of the South London and Maudsley NHS Foundation Trust (SLaM), we developed a questionnaire for such a project. The QI project team consisted of patients and psychiatrists from the eating disorders inpatient ward, the 'step-up' service (a day-hospital service) and the outpatient unit of SLaM. The questionnaire has three main sections. The first section provides basic information on the patient or the carer and their experience with medication prescribed to them or their loved one respectively. The second section asks about what therapeutic effects a psychopharmacological medication should have to help with symptoms of AN. The third section is about concerns of potential side effects.

Initially, the questionnaires were distributed to a group of 17 patients with AN and 16 carers between June 2016 and January 2017. The answers given were

evaluated and the main results have been published in a scientific letter [16]. The feedback received from SLaM patients, carers and colleagues suggested minor alterations to the wording of a few questions and the addition of three further questions. Therefore, we made these changes accordingly and distributed the questionnaires to a second cohort of 19 patients and 21 carers between March and September 2018. Thus, taking both cohorts together, we obtained completed questionnaires from 36 patients and 37 carers.

of the carers believed that patients with AN should consider drug treatment. Most of the patients agreed or strongly agreed with the statement that they did not want medication for treatment with AN, whereas the carers had more diverse opinions in this respect with 40% of neutral opinion and 65% of carers believing that medication should be taken if recommended. However, patients were more cautious

Patients' and Carers' Perspectives of Psychopharmacological Interventions Targeting…

The results revealed that 50% of patients agreed or strongly agreed with each of the following target symptoms of psychopharmacological treatment: anxiety (61.1%; sum of 'agreed' plus 'strongly agreed'), concentration (52.8%), sleep problems (52.8%) and anorexic thoughts (55.6%). Most of the carers shared the view that drug treatment should help with anxiety (54%) and anorexic thoughts

In both patients and carers, 75% stated that more research on drug treatment for AN is needed. As much as 40% of patients expressed their willingness to take part in such research, and 25% of patients were undecided about whether they

Detailed information on the frequencies and percentages of answers concerning the therapeutic effects of a medication for the treatment of AN can be found in

More than 90% of patients agreed or strongly agreed that they had concerns about potential weight gain during psychopharmacological treatment, and about the same number of patients also expressed concerns about appetite increase during drug treatment. Furthermore, the majority of patients were afraid of binge eating,

Most of the patients were also concerned about potential side effects not related

By contrast, a majority of carers were not concerned about weight gain, appetite increase, and changes in body shape nor metabolism. However, most of the carers feared binge eating as a side effect and adverse effects related to mood, tiredness,

Detailed information on frequencies and percentages of answers concerning the

Taken together, we have developed questionnaires for patients with AN and for carers to express their opinion on psychopharmacological treatment for AN. Most patients did not think that medication could help with AN. However, the majority of patients thought that medication for AN should help with anxiety, concentration, sleep problems and anorexic thoughts. In this respect, most of the carers shared the view that drug treatment for AN should help with anxiety and anorexic thoughts. Almost all patients who participated in the survey had concerns about potential weight gain and increased appetite during psychopharmacological treatment, and most of them also feared changes in body shape and metabolism. The majority of

to appetite or weight regulation. These included changes in mood, tiredness or sleepiness, problems with the heart or the heart rhythm, nausea, decreased concen-

heart problems, nausea, concentration, laboratory parameters and sleep.

potential side effects of a medication for the treatment of AN can be found in

3.2 Concerns about side effects of medication for anorexia nervosa

changes in body shape and changes in metabolism.

tration, changes in laboratory parameters and sleep problems.

about this statement, with 42% expressing a neutral view on this.

DOI: http://dx.doi.org/10.5772/intechopen.86083

(64.8%).

Table 1.

Table 2.

107

4. Discussion

4.1 Summary of findings

should take part or not.

The patient and the carer questionnaires used in the second cohort are depicted in the appendix of this article.

#### 2.2 Study sample

The total sample of people who completed the questionnaires included 36 patients and 37 carers.

Patients were all females between 18 and 44 years of age; mean age: 27.64 years 6.85 standard deviation (SD); seven were treated as outpatients, five as day-patients and 24 as inpatients in our specialist unit at the time of the survey. The duration of treatment ranged between 1 week and 15 years; mean duration of treatment: 50.12 weeks 136.62 SD. The duration of their AN was between 1 year and 24 years; mean 9.03 years 6.67 SD. Twenty-four of these patients were currently receiving psychopharmacological treatment.

The carers were 21 males and 16 females between 21 and 71 years; mean age: 51.40 years 11.11 SD. Their close others with AN were two male and 35 female patients between 18 and 44 years old, mean age: 24.62 years 6.71 SD. Of these close others with AN, 12 were treated as outpatients, three as day-patients and 22 as inpatients in our unit at the time of the survey. The duration of treatment of these patients ranged from 'not yet started' to 52 weeks; mean duration of treatment: 11.60 weeks 12.20 SD. The duration of their AN was between 1 and 20 years; mean 7.01 years 6.64 SD. A total of 27 of these patients were currently on medication for mental health problems.

#### 2.3 Data evaluation and statistics

The questionnaires were statistically evaluated using IBM SPSS statistics version 24. We used descriptive statistics to evaluate the questionnaires.

For consistency, the additional questions in the new version of both the patients' and the carers' questionnaires were excluded from statistical evaluation. Thus, the questions on appetite increase and improved gastrointestinal symptoms as potentially desired effects of medication for AN were not included, nor was the question about concerns of changes in the way of thinking as a potential side effect. The evaluation of free text answers was not part of the current publication.

#### 3. Results

#### 3.1 Opinions about therapeutic effects of a medication for anorexia nervosa

Regarding the overall opinion on drug treatment for AN, most patients disagreed in our survey with the view that medication could help with AN, whereas the majority of carers were undecided in this regard. Approximately one third of patients were also neutral about this. In terms of the question on whether patients with AN should consider medication for treatment, a proportion of almost 40% of patients and carers expressed no particular point of view. However, more than half

Patients' and Carers' Perspectives of Psychopharmacological Interventions Targeting… DOI: http://dx.doi.org/10.5772/intechopen.86083

of the carers believed that patients with AN should consider drug treatment. Most of the patients agreed or strongly agreed with the statement that they did not want medication for treatment with AN, whereas the carers had more diverse opinions in this respect with 40% of neutral opinion and 65% of carers believing that medication should be taken if recommended. However, patients were more cautious about this statement, with 42% expressing a neutral view on this.

The results revealed that 50% of patients agreed or strongly agreed with each of the following target symptoms of psychopharmacological treatment: anxiety (61.1%; sum of 'agreed' plus 'strongly agreed'), concentration (52.8%), sleep problems (52.8%) and anorexic thoughts (55.6%). Most of the carers shared the view that drug treatment should help with anxiety (54%) and anorexic thoughts (64.8%).

In both patients and carers, 75% stated that more research on drug treatment for AN is needed. As much as 40% of patients expressed their willingness to take part in such research, and 25% of patients were undecided about whether they should take part or not.

Detailed information on the frequencies and percentages of answers concerning the therapeutic effects of a medication for the treatment of AN can be found in Table 1.

#### 3.2 Concerns about side effects of medication for anorexia nervosa

More than 90% of patients agreed or strongly agreed that they had concerns about potential weight gain during psychopharmacological treatment, and about the same number of patients also expressed concerns about appetite increase during drug treatment. Furthermore, the majority of patients were afraid of binge eating, changes in body shape and changes in metabolism.

Most of the patients were also concerned about potential side effects not related to appetite or weight regulation. These included changes in mood, tiredness or sleepiness, problems with the heart or the heart rhythm, nausea, decreased concentration, changes in laboratory parameters and sleep problems.

By contrast, a majority of carers were not concerned about weight gain, appetite increase, and changes in body shape nor metabolism. However, most of the carers feared binge eating as a side effect and adverse effects related to mood, tiredness, heart problems, nausea, concentration, laboratory parameters and sleep.

Detailed information on frequencies and percentages of answers concerning the potential side effects of a medication for the treatment of AN can be found in Table 2.

#### 4. Discussion

evaluated and the main results have been published in a scientific letter [16]. The feedback received from SLaM patients, carers and colleagues suggested minor alterations to the wording of a few questions and the addition of three further questions. Therefore, we made these changes accordingly and distributed the questionnaires to a second cohort of 19 patients and 21 carers between March and September 2018. Thus, taking both cohorts together, we obtained completed ques-

The patient and the carer questionnaires used in the second cohort are depicted

The total sample of people who completed the questionnaires included 36

27.64 years 6.85 standard deviation (SD); seven were treated as outpatients, five as day-patients and 24 as inpatients in our specialist unit at the time of the survey. The duration of treatment ranged between 1 week and 15 years; mean duration of treatment: 50.12 weeks 136.62 SD. The duration of their AN was between 1 year and 24 years; mean 9.03 years 6.67 SD. Twenty-four of these patients were

The carers were 21 males and 16 females between 21 and 71 years; mean age: 51.40 years 11.11 SD. Their close others with AN were two male and 35 female patients between 18 and 44 years old, mean age: 24.62 years 6.71 SD. Of these close others with AN, 12 were treated as outpatients, three as day-patients and 22 as inpatients in our unit at the time of the survey. The duration of treatment of these patients ranged from 'not yet started' to 52 weeks; mean duration of treatment: 11.60 weeks 12.20 SD. The duration of their AN was between 1 and 20 years; mean 7.01 years 6.64 SD. A total of 27 of these patients were currently on

The questionnaires were statistically evaluated using IBM SPSS statistics version 24. We used descriptive statistics to evaluate the questionnaires.

3.1 Opinions about therapeutic effects of a medication for anorexia nervosa

Regarding the overall opinion on drug treatment for AN, most patients disagreed in our survey with the view that medication could help with AN, whereas the majority of carers were undecided in this regard. Approximately one third of patients were also neutral about this. In terms of the question on whether patients with AN should consider medication for treatment, a proportion of almost 40% of patients and carers expressed no particular point of view. However, more than half

evaluation of free text answers was not part of the current publication.

For consistency, the additional questions in the new version of both the patients' and the carers' questionnaires were excluded from statistical evaluation. Thus, the questions on appetite increase and improved gastrointestinal symptoms as potentially desired effects of medication for AN were not included, nor was the question about concerns of changes in the way of thinking as a potential side effect. The

Patients were all females between 18 and 44 years of age; mean age:

currently receiving psychopharmacological treatment.

medication for mental health problems.

2.3 Data evaluation and statistics

3. Results

106

tionnaires from 36 patients and 37 carers.

in the appendix of this article.

Anorexia and Bulimia Nervosa

2.2 Study sample

patients and 37 carers.

#### 4.1 Summary of findings

Taken together, we have developed questionnaires for patients with AN and for carers to express their opinion on psychopharmacological treatment for AN. Most patients did not think that medication could help with AN. However, the majority of patients thought that medication for AN should help with anxiety, concentration, sleep problems and anorexic thoughts. In this respect, most of the carers shared the view that drug treatment for AN should help with anxiety and anorexic thoughts. Almost all patients who participated in the survey had concerns about potential weight gain and increased appetite during psychopharmacological treatment, and most of them also feared changes in body shape and metabolism. The majority of


carers, in contrast, was not concerned about weight gain, appetite increase, changes in body shape and metabolism. All the addressed side effects were of concern to patients. For the carers, for most of the questions on side effects, between 20 and

Frequencies and percentages of answers regarding the overall opinion on drug treatment for AN, important

Patients (N = 36) Carers (N = 37) Frequency Percent (%) Frequency Percent (%)

Strongly disagree 1 2.8 1 2.7 Disagree 9 25.0 6 16.2 Neutral 7 19.4 17 45.9 Agree 14 38.9 9 24.3 Strongly agree 5 13.9 2 5.4

Patients' and Carers' Perspectives of Psychopharmacological Interventions Targeting…

Strongly disagree 1 2.8 1 2.7 Disagree 4 11.1 3 8.1 Neutral 12 33.3 17 45.9 Agree 11 30.6 10 27.0 Strongly agree 8 22.2 3 8.1

Strongly disagree 1 2.8 0 0 Disagree 3 8.3 2 5.4 Neutral 12 33.3 9 24.3 Agree 15 41.7 18 48.6 Strongly agree 5 13.9 6 16.2

Strongly disagree 0 0 1 2.7 Disagree 1 2.8 0 0 Neutral 7 19.4 5 13.5 Agree 14 38.9 13 35.1 Strongly agree 13 36.1 15 40.5

Strongly disagree 5 13.9 2 5.4 Disagree 7 19.4 6 16.2 Neutral 10 27.8 18 48.6 Agree 8 22.2 7 18.9 Strongly agree 6 16.7 2 5.4

Medication should help to improve concentration

DOI: http://dx.doi.org/10.5772/intechopen.86083

Medication should help with sleep

Medication should weaken anorexic thoughts

Table 1.

109

More research on drug treatment for anorexia nervosa is needed

Willingness to take part in research for drug treatment for anorexia nervosa

40% of had no particular opinion and thus gave a neutral answer.

For the exact wording of the questions, see questionnaire 1 and 2 in the appendix of this chapter.

target symptoms, relevance of psychopharmacological research and willingness to take part.


Patients' and Carers' Perspectives of Psychopharmacological Interventions Targeting… DOI: http://dx.doi.org/10.5772/intechopen.86083

#### Table 1.

Patients (N = 36) Carers (N = 37) Frequency Percent (%) Frequency Percent (%)

Strongly disagree 1 2.8 0 0 Disagree 18 50.0 1 2.7 Neutral 11 30.6 21 56.8 Agree 6 16.7 12 32.4 Strongly agree 0 0 2 5.4

Strongly disagree 3 8.3 0 0 Disagree 5 13.9 1 2.7 Neutral 14 38.9 14 37.8 Agree 12 33.3 20 54.1 Strongly agree 2 5.6 1 2.7

Strongly disagree 2 5.6 7 18.9 Disagree 8 22.2 8 21.6 Neutral 7 19.4 14 37.8 Agree 14 38.9 6 16.2 Strongly agree 5 13.9 1 2.7

Strongly disagree 1 2.8 0 0 Disagree 3 8.3 0 0 Neutral 15 41.7 10 27.0 Agree 16 44.4 24 64.9 Strongly agree 1 2.8 1 2.7

Strongly disagree 2 5.6 0 0 Disagree 4 11.1 3 8.1 Neutral 8 22.2 11 29.7 Agree 16 44.4 17 45.9 Strongly agree 6 16.7 3 8.1

Strongly disagree 3 8.3 0 0 Disagree 7 19.4 3 8.1 Neutral 9 25.0 15 40.5 Agree 8 22.2 14 37.8 Strongly agree 9 25.0 3 8.1

Patients with anorexia nervosa should consider medication for treatment

Medication could help with anorexia nervosa

Anorexia and Bulimia Nervosa

I do not want medication for anorexia nervosa

Medication should be taken if recommended

Medication should help with anxiety

Medication should help with low mood

108

Frequencies and percentages of answers regarding the overall opinion on drug treatment for AN, important target symptoms, relevance of psychopharmacological research and willingness to take part.

carers, in contrast, was not concerned about weight gain, appetite increase, changes in body shape and metabolism. All the addressed side effects were of concern to patients. For the carers, for most of the questions on side effects, between 20 and 40% of had no particular opinion and thus gave a neutral answer.


Patients (N = 36) Carers (N = 37) Frequency Percent (%) Frequency Percent (%)

Concerns about tiredness or sleepiness during drug treatment

DOI: http://dx.doi.org/10.5772/intechopen.86083

Concerns about problems with the heart or the heart rhythm

Concerns about decreased concentration during drug treatment

Concerns about changes in laboratory parameters during drug treatment

Concerns about sleep problems during drug treatment

Table 2.

111

Concerns about nausea during drug treatment

Strongly disagree 0 0 1 2.7 Disagree 3 8.3 2 5.4 Neutral 8 22.2 8 21.6 Agree 14 38.9 16 43.2 Strongly agree 11 30.6 7 18.9

Patients' and Carers' Perspectives of Psychopharmacological Interventions Targeting…

Strongly disagree 1 2.8 0 0 Disagree 1 2.8 0 0 Neutral 10 27.8 3 8.1 Agree 14 38.9 8 21.6 Strongly agree 10 27.8 23 62.2

Strongly disagree 0000 Disagree 3 8.3 1 2.7 Neutral 12 33.3 5 13.5 Agree 14 38.9 18 48.6 Strongly agree 7 19.4 10 27.0

Strongly disagree 0000 Disagree 0000 Neutral 8 22.2 10 27.0 Agree 16 44.4 15 40.5 Strongly agree 12 33.3 10 27.0

Strongly disagree 1 2.8 1 2.7 Disagree 4 11.1 1 2.7 Neutral 12 33.3 6 16.2 Agree 12 33.3 15 40.5 Strongly agree 7 19.4 11 29.7

Strongly disagree 0 0 1 2.7 Disagree 1 2.8 0 0 Neutral 3 8.3 4 10.8 Agree 19 52.8 20 54.1 Strongly agree 12 33.3 10 27.0

Frequencies and percentages of answers regarding the overall opinion on side effects of drug treatment for AN.

For the exact wording of the questions, see questionnaire 1 and 2 in the appendix of this chapter.


Patients' and Carers' Perspectives of Psychopharmacological Interventions Targeting… DOI: http://dx.doi.org/10.5772/intechopen.86083

#### Table 2.

Frequencies and percentages of answers regarding the overall opinion on side effects of drug treatment for AN.

Patients (N = 36) Carers (N = 37) Frequency Percent (%) Frequency Percent (%)

Strongly disagree 0 0 3 8.1 Disagree 1 2.8 10 27.0 Neutral 2 5.6 11 29.7 Agree 9 25.0 6 16.2 Strongly agree 24 66.7 5 13.5

Strongly disagree 0 0 2 5.4 Disagree 2 5.6 11 29.7 Neutral 1 2.8 13 35.1 Agree 13 36.1 3 8.1 Strongly agree 20 55.6 4 10.8

Strongly disagree 1 2.8 1 2.7 Disagree 2 5.6 1 2.7 Neutral 3 8.3 7 18.9 Agree 8 22.2 13 35.1 Strongly agree 22 61.1 10 27.0

Strongly disagree 1 2.8 2 5.4 Disagree 0 0 5 13.5 Neutral 2 5.6 17 45.9 Agree 14 38.9 4 10.8 Strongly agree 19 52.8 4 10.8

Strongly disagree 0 0 1 2.7 Disagree 1 2.8 4 10.8 Neutral 2 5.6 14 37.8 Agree 11 30.6 9 24.3 Strongly agree 22 61.1 5 13.5

Strongly disagree 1 2.8 0 0 Disagree 1 2.8 2 5.4 Neutral 4 11.1 6 16.2 Agree 18 50.0 18 48.6 Strongly agree 12 33.3 8 21.6

Concerns about weight gain during drug treatment

Anorexia and Bulimia Nervosa

Concerns about appetite increase during drug treatment

Concerns about binge eating during drug treatment

Concerns about changes in body shape during drug treatment

Concerns about changes in metabolism during drug treatment

Concerns about mood changes during drug treatment

110

#### 4.2 Patients perspective on medication—not suitable to treat anorexia nervosa but of concern because of weight gain as a side effect

currently no medication is approved for the treatment of AN [10]. Therefore, clinicians could abstain from using psychopharmacological treatment at all and also from informing patients about this opportunity. However, there is positive evidence from clinical studies for a few drugs, and clinicians may share the results of

Patients' and Carers' Perspectives of Psychopharmacological Interventions Targeting…

RCTs [28–31] in AN regarding weight gain. It has also been shown to have a beneficial influence on anxiety [32, 33] and sleep [34] in patients with psychosis. Helping with anxiety and sleep were important features of a psychopharmacological drug for patients with AN in our survey. Thus, the high number of people giving a neutral answer in our survey may point to the need for more information to be shared with patients and their carers about the psychopharmacological options.

For example, olanzapine was found to be superior to placebo in four published

Most patients had concerns about potential weight gain, increased appetite, and changes in body shape and metabolism. This is understandable, because these are

However, the last three decades have seen substantial scientific efforts to examine the metabolic side effects of psychopharmacological agents, specifically antipsychotic agents. Weight gain, high blood glucose levels, impaired insulin sensitivity and changes in lipid metabolism have been found to be unfavourable [35]. However, these results were first and foremost obtained in patients with schizophrenia. In patients with AN, however, we have a diametrically opposite metabolic 'starting situation' compared to patients with schizophrenia, as AN patients are significantly underweight, are at risk of severe hypoglycaemia and hypertriglyceridemia, and have been found to have an increased insulin sensitivity [36, 37]. Therefore, the side effects of certain antipsychotics, including olanzapine which increase blood glucose levels, lower insulin sensitivity, elevate triglyceride levels and lead to weight gain

The evidence from RCTs, however, is insufficient in AN to make firm recommendations; and there are no medications approved for the treatment of AN. Therefore, the above-mentioned conclusions should be drawn with caution, even

Our survey has several limitations. First of all, the applied questionnaires were developed during this QI project and are not established measures for examining patients' and carers' opinions on psychopharmacological treatment. At approximately halfway through the study, we decided to make some minor amendments to the questionnaires, which led to constraints in the statistical evaluation of the survey. Secondly, the sample size of 36 patients and 37 carers is relatively low. However, we hope that by sharing the questionnaires in this book chapter, other scientists will use them for their research which will lead to a broader database. Thirdly, a major shortcoming of this survey is the inclusion of adult patients with AN only, whereas AN is a disorder that starts in childhood and adolescence.

We developed two corresponding questionnaires to survey the perspectives of people with AN and their carers on psychopharmacological treatment for AN.

[35], do appear to be less problematic in patients with AN.

though they may appear obvious.

4.6 Limitations

5. Conclusion

113

these studies with their patients and carers.

DOI: http://dx.doi.org/10.5772/intechopen.86083

4.5 Side effects

AN-related fears.

The most obvious discrepancy within the patients' answers is that they did not believe medication could help with AN, and were at the same time concerned about appetite increase and weight gain as potential side effects of medication. This finding is of great relevance, as the primary outcome criterion in the majority of clinical studies in AN is an increase in body weight [10, 11, 20]. However, patients may not perceive weight gain as the core problem of AN, because—as stated earlier—self-starvation is their own way to attenuate negative affective states and aversive emotions [12]. Therefore, drug treatment to gain weight alone cannot be perceived as a good treatment option from the patients' perspective.

It is of course necessary for patients with AN to gain weight due to the medical risk associated with extremely low body weight. However, this weight gain should be supported by addressing the underlying difficulties of anxiety and anorexic thoughts.

#### 4.3 Anxiety and anorexic thoughts as outcome parameters for future treatment studies

Our survey showed that anxiety is an important symptom that patients with AN and their carers want to be addressed during psychopharmacological therapy. This is not unexpected, as AN has been found to be closely associated with anxiety disorders [21].

Therefore, questionnaires for anxiety and depression should be used to measure the outcome of RCTs in AN. However, there are many different questionnaires available, which all have their advantages and disadvantages. Thus, the suggestions below may seem arbitrary, however, we would like to provide the reader with some specific suggestions as to how anxiety, depression and anorexic psychopathology can be measured.

The Brief Psychiatric Rating Scale (BPRS) assesses 24 different psychiatric symptoms, among them anxiety, depression, unusual thought content and emotional withdrawal [22]. The Depression Anxiety Stress Scales (DASS) is an instrument designed to measure the three related negative emotional states of depression, anxiety and stress [23]. There is a 21-item as well as a 42-item available. Both these questionnaires could be applied in clinical practice to measure the level of anxiety in a patient with AN or used in future RCTs to test psychopharmacological therapies with regard to their effectiveness in reducing anxiety. In children, the Revised Children's Anxiety and Depression Scale (RCADS), a 47-item questionnaire that measures the frequency of various symptoms of anxiety and low mood, may be used [24]. However, our study sample did not include children and adolescents.

To measure anorexic thoughts, the Yale-Brown-Cornell Eating Disorders Scale (YBC-EDS) [25], the Eating Disorder Examination-Questionnaire (EDE-Q) [26] and the Revised Beliefs about Voices Questionnaire (BAVQ-R) [27], could be used. The YBC-EDS measures core preoccupations and rituals related to eating disorders, the EDE-Q assesses key behavioural features and associated psychopathology of eating disorders and the BAVQ-R is a self-reported measure of patients' beliefs, emotions and behaviour about auditory hallucinations.

#### 4.4 Information on pharmacological treatments for patients and carers

The fact that a large proportion of patients and carers were neutral about certain statements regarding psychopharmacological treatment for AN is not surprising, as Patients' and Carers' Perspectives of Psychopharmacological Interventions Targeting… DOI: http://dx.doi.org/10.5772/intechopen.86083

currently no medication is approved for the treatment of AN [10]. Therefore, clinicians could abstain from using psychopharmacological treatment at all and also from informing patients about this opportunity. However, there is positive evidence from clinical studies for a few drugs, and clinicians may share the results of these studies with their patients and carers.

For example, olanzapine was found to be superior to placebo in four published RCTs [28–31] in AN regarding weight gain. It has also been shown to have a beneficial influence on anxiety [32, 33] and sleep [34] in patients with psychosis. Helping with anxiety and sleep were important features of a psychopharmacological drug for patients with AN in our survey. Thus, the high number of people giving a neutral answer in our survey may point to the need for more information to be shared with patients and their carers about the psychopharmacological options.

#### 4.5 Side effects

4.2 Patients perspective on medication—not suitable to treat anorexia nervosa

The most obvious discrepancy within the patients' answers is that they did not believe medication could help with AN, and were at the same time concerned about appetite increase and weight gain as potential side effects of medication. This finding is of great relevance, as the primary outcome criterion in the majority of clinical studies in AN is an increase in body weight [10, 11, 20]. However, patients may not perceive weight gain as the core problem of AN, because—as stated earlier—self-starvation is their own way to attenuate negative affective states and aversive emotions [12]. Therefore, drug treatment to gain weight alone cannot be

It is of course necessary for patients with AN to gain weight due to the medical risk associated with extremely low body weight. However, this weight gain should be supported by addressing the underlying difficulties of anxiety and anorexic

4.3 Anxiety and anorexic thoughts as outcome parameters for future treatment

Our survey showed that anxiety is an important symptom that patients with AN and their carers want to be addressed during psychopharmacological therapy. This is not unexpected, as AN has been found to be closely associated with anxiety

Therefore, questionnaires for anxiety and depression should be used to measure

the outcome of RCTs in AN. However, there are many different questionnaires available, which all have their advantages and disadvantages. Thus, the suggestions below may seem arbitrary, however, we would like to provide the reader with some specific suggestions as to how anxiety, depression and anorexic psychopathology

The Brief Psychiatric Rating Scale (BPRS) assesses 24 different psychiatric symptoms, among them anxiety, depression, unusual thought content and emotional withdrawal [22]. The Depression Anxiety Stress Scales (DASS) is an instrument designed to measure the three related negative emotional states of depression, anxiety and stress [23]. There is a 21-item as well as a 42-item available. Both these questionnaires could be applied in clinical practice to measure the level of anxiety in a patient with AN or used in future RCTs to test psychopharmacological therapies with regard to their effectiveness in reducing anxiety. In children, the Revised Children's Anxiety and Depression Scale (RCADS), a 47-item questionnaire that measures the frequency of various symptoms of anxiety and low mood, may be used [24]. However, our study sample did not include children and adolescents. To measure anorexic thoughts, the Yale-Brown-Cornell Eating Disorders Scale (YBC-EDS) [25], the Eating Disorder Examination-Questionnaire (EDE-Q) [26] and the Revised Beliefs about Voices Questionnaire (BAVQ-R) [27], could be used. The YBC-EDS measures core preoccupations and rituals related to eating disorders, the EDE-Q assesses key behavioural features and associated psychopathology of eating disorders and the BAVQ-R is a self-reported measure of patients' beliefs,

emotions and behaviour about auditory hallucinations.

4.4 Information on pharmacological treatments for patients and carers

The fact that a large proportion of patients and carers were neutral about certain statements regarding psychopharmacological treatment for AN is not surprising, as

but of concern because of weight gain as a side effect

perceived as a good treatment option from the patients' perspective.

thoughts.

studies

Anorexia and Bulimia Nervosa

disorders [21].

can be measured.

112

Most patients had concerns about potential weight gain, increased appetite, and changes in body shape and metabolism. This is understandable, because these are AN-related fears.

However, the last three decades have seen substantial scientific efforts to examine the metabolic side effects of psychopharmacological agents, specifically antipsychotic agents. Weight gain, high blood glucose levels, impaired insulin sensitivity and changes in lipid metabolism have been found to be unfavourable [35]. However, these results were first and foremost obtained in patients with schizophrenia. In patients with AN, however, we have a diametrically opposite metabolic 'starting situation' compared to patients with schizophrenia, as AN patients are significantly underweight, are at risk of severe hypoglycaemia and hypertriglyceridemia, and have been found to have an increased insulin sensitivity [36, 37]. Therefore, the side effects of certain antipsychotics, including olanzapine which increase blood glucose levels, lower insulin sensitivity, elevate triglyceride levels and lead to weight gain [35], do appear to be less problematic in patients with AN.

The evidence from RCTs, however, is insufficient in AN to make firm recommendations; and there are no medications approved for the treatment of AN. Therefore, the above-mentioned conclusions should be drawn with caution, even though they may appear obvious.

#### 4.6 Limitations

Our survey has several limitations. First of all, the applied questionnaires were developed during this QI project and are not established measures for examining patients' and carers' opinions on psychopharmacological treatment. At approximately halfway through the study, we decided to make some minor amendments to the questionnaires, which led to constraints in the statistical evaluation of the survey. Secondly, the sample size of 36 patients and 37 carers is relatively low. However, we hope that by sharing the questionnaires in this book chapter, other scientists will use them for their research which will lead to a broader database. Thirdly, a major shortcoming of this survey is the inclusion of adult patients with AN only, whereas AN is a disorder that starts in childhood and adolescence.

#### 5. Conclusion

We developed two corresponding questionnaires to survey the perspectives of people with AN and their carers on psychopharmacological treatment for AN.

Although most patients did not believe that medication could help with AN, the majority thought that medication for AN should help with anxiety, concentration, sleep problems and anorexic thoughts. Most of the carers shared the view that drug treatment for AN should help with anxiety and anorexic thoughts. Therefore, these symptoms should be given attention when prescribing psychopharmacological agents for people with AN or when planning RCTs for AN.

Duration of illness

DOI: http://dx.doi.org/10.5772/intechopen.86083

5. For how many years have you had anorexia nervosa?

Patients' and Carers' Perspectives of Psychopharmacological Interventions Targeting…

6. I have been treated with a psychiatric medication (medication for your mental health). 7. I have been treated with antipsychotic medication (such as olanzapine, quetiapine). 8. I have been treated with antidepressant medication (such as sertraline, fluoxetine).

relating to anorexia nervosa? Please specify which.

11. Do you feel the medication helped?

12. I think a drug could help treat my anorexia

15. I would take medication if it is recommended by my therapist or medical doctor. 16. I would like medication to help me with my

17. I would like medication to help me with my

18. I would like medication to help improve my

19. I would like medication to help increase my

20. I would like a medication to help improve my

21. I would like a medication to help me with gastrointestinal symptoms such as

22. I would like medication to help weaken the anorexic voice or anorexic thoughts.

13. I would consider taking medication for treatment of anorexia nervosa. 14. I don't want to take any medication.

nervosa.

anxiety.

mood.

appetite.

sleep.

115

constipation.

concentration.

9. Are you currently taking/have you previously taken prescribed medication

10. Have you experienced side effects from this medication? Please specify.

Opinion about therapeutic effects of a medication for anorexia nervosa

Strongly disagree

Disagree Neutral Agree Strongly

Previous drug treatment for anorexia nervosa

Years

Yes No

agree

Most patients had concerns about potential weight gain, increased appetite, changes in body shape and metabolism. However, psychopharmacological drugs may actually help with metabolic peculiarities in patients with AN, including hypoglycaemia.

No psychopharmacological treatment is currently approved for AN, and scientific data on effects and side effects in individuals with AN is scarce. Therefore, although far-reaching conclusions should not be drawn, the available data and information should be shared with patients and their carers to reach the best possible decision on whether drugs should be used for the treatment of AN.

### Acknowledgements

The authors would like to thank all patients, carers and colleagues at the South London and Maudsley NHS Foundation Trust and King's College London, who were involved in the fruitful and helpful discussions concerning the development of the questionnaires.

#### Conflict of interest

The authors declare that there is no conflict of interest.

#### Appendix. Questionnaires

#### A.1 Questionnaire 1: patient views on medication targeting anorexia nervosa symptoms

This questionnaire has been created to help develop research around the use of psychopharmacological medication in anorexia nervosa. Your input will help refine future research projects. Please answer the questions according to what you think. Insert own text if required. Thank you for your participation.

#### Personal information



Patients' and Carers' Perspectives of Psychopharmacological Interventions Targeting… DOI: http://dx.doi.org/10.5772/intechopen.86083

#### Duration of illness

Although most patients did not believe that medication could help with AN, the majority thought that medication for AN should help with anxiety, concentration, sleep problems and anorexic thoughts. Most of the carers shared the view that drug treatment for AN should help with anxiety and anorexic thoughts. Therefore, these symptoms should be given attention when prescribing psychopharmacological

Most patients had concerns about potential weight gain, increased appetite, changes in body shape and metabolism. However, psychopharmacological drugs may actually help with metabolic peculiarities in patients with AN, including

No psychopharmacological treatment is currently approved for AN, and scientific data on effects and side effects in individuals with AN is scarce. Therefore, although far-reaching conclusions should not be drawn, the available data and information should be shared with patients and their carers to reach the best possible decision on whether drugs should be used for the treatment of AN.

The authors would like to thank all patients, carers and colleagues at the South London and Maudsley NHS Foundation Trust and King's College London, who were involved in the fruitful and helpful discussions concerning the development of the

A.1 Questionnaire 1: patient views on medication targeting anorexia

This questionnaire has been created to help develop research around the use of psychopharmacological medication in anorexia nervosa. Your input will help refine future research projects. Please answer the questions according to what you think.

agents for people with AN or when planning RCTs for AN.

The authors declare that there is no conflict of interest.

Insert own text if required. Thank you for your participation.

Outpatient, Day-care, SEED, Step-up, Inpatient):

1. My age Years

4. Duration of my current treatment in the above-mentioned service:

2. My gender Female/male/other

3. My current treatment: I am currently treated in the following service (FREED,

hypoglycaemia.

Anorexia and Bulimia Nervosa

Acknowledgements

Conflict of interest

Appendix. Questionnaires

nervosa symptoms

Personal information

114

questionnaires.

5. For how many years have you had anorexia nervosa?

Years

#### Previous drug treatment for anorexia nervosa



11. Do you feel the medication helped?

#### Opinion about therapeutic effects of a medication for anorexia nervosa



Personal information

DOI: http://dx.doi.org/10.5772/intechopen.86083

Inpatient):

Duration of illness

quetiapine).

fluoxetine).

specify.

1. My own age Years

Patients' and Carers' Perspectives of Psychopharmacological Interventions Targeting…

3. Age of my loved one with anorexia nervosa Years

7. For how many years has your loved one had anorexia nervosa?

8. My loved one has been treated with medication for their mental health problem. 9. My loved one has been treated with antipsychotic medication (such as olanzapine,

10. My loved one has been treated with antidepressant medication (such as sertraline,

11. Is your loved one currently taking/has your loved one previously taken prescribed medication relating to anorexia nervosa or other mental health

12. Has your loved one experienced side effects from this medication? Please

Opinion about therapeutic effects of a medication for anorexia nervosa

Strongly disagree

Disagree Neutral Agree Strongly

agree

Previous drug treatment for anorexia nervosa

problems? Please specify which.

14. I think medication could help my loved one

consider taking medication for treatment of

15. Patients with anorexia nervosa should

16. I don't want my loved one to take

with anorexia nervosa.

anorexia nervosa.

medication.

117

13. Do you feel the medication helped them?

2. My own gender Female/male/other

4. Gender of my loved one with anorexia nervosa Female/male/other

5. Current treatment: My loved one is currently receiving eating disorder treatment in the following service (FREED, Outpatient, Day-care, SEED, Step-up,

6. Duration of my loved one's current treatment in the above-mentioned service:

Years

Yes No

25. In your own words, what else would you like medication to help with in overcoming anorexia nervosa?

#### Views on side effects of a medication for anorexia nervosa

Which of the following potential side effects would you be concerned about in taking a new medication?


39. In your own words: What side effect do you fear most?

40. Further comments and suggestions for research around medication targeting anorexia nervosa symptoms.

#### Thank you for taking part in this survey and answering the questions.

#### A.2 Questionnaire 2: carer views on medication targeting anorexia nervosa symptoms

This questionnaire has been created to help develop research around the use of psychopharmacological medication in anorexia nervosa. Your input will help refine future research projects. Please answer the questions according to what you think. Insert own text if required. Thank you for your participation.

Patients' and Carers' Perspectives of Psychopharmacological Interventions Targeting… DOI: http://dx.doi.org/10.5772/intechopen.86083

#### Personal information

Strongly disagree

25. In your own words, what else would you like medication to help with in

Which of the following potential side effects would you be concerned about in

Strongly disagree

Views on side effects of a medication for anorexia nervosa

39. In your own words: What side effect do you fear most?

Insert own text if required. Thank you for your participation.

40. Further comments and suggestions for research around medication targeting

This questionnaire has been created to help develop research around the use of psychopharmacological medication in anorexia nervosa. Your input will help refine future research projects. Please answer the questions according to what you think.

Thank you for taking part in this survey and answering the questions.

A.2 Questionnaire 2: carer views on medication targeting anorexia

23. There should be more research on drug treatments in anorexia nervosa. 24. I would take part in a trial to assist in research into drug treatment for anorexia

nervosa.

Anorexia and Bulimia Nervosa

overcoming anorexia nervosa?

29. Changes in my body shape

harder to burn calories

32. Tiredness or sleepiness

35. Decreased concentration 36. Changes in my bloods 37. Sleep problems

38. Changes in the way you think

anorexia nervosa symptoms.

nervosa symptoms

116

30. My metabolism could change, making it

33. Problems with my heart or heart rhythm.

taking a new medication?

26. Weight gain 27. Appetite increase 28. Binge eating

31. Mood changes

34. Nausea

Disagree Neutral Agree Strongly

Disagree Neutral Agree Strongly

agree

agree



#### Duration of illness

7. For how many years has your loved one had anorexia nervosa?

Years

#### Previous drug treatment for anorexia nervosa



#### Opinion about therapeutic effects of a medication for anorexia nervosa



Strongly disagree

Patients' and Carers' Perspectives of Psychopharmacological Interventions Targeting…

41. In your own words: What side effect do you fear most for your loved one?

Thank you for taking part in this survey and answering the questions.

42. Further comments and suggestions for research around medication targeting

, Janet Treasure1,2, Ulrike Schmidt1,2

39. Sleep problems

Author details

Amabel Dessain<sup>1</sup>

119

and Hubertus Himmerich1,2

\*, Jessica Bentley<sup>2</sup>

provided the original work is properly cited.

1 South London and Maudsley NHS Foundation Trust, London, UK

\*Address all correspondence to: amabel.dessain@slam.nhs.uk

2 Department of Psychological Medicine, King's College London, London, UK

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

40. Changes in the way they think

DOI: http://dx.doi.org/10.5772/intechopen.86083

anorexia nervosa symptoms.

Disagree Neutral Agree Strongly

agree

27. In your own words, what else would you like medication to help your loved one with in overcoming anorexia nervosa?

#### Views on side effects of a medication for anorexia nervosa

Which of the following potential side effects would you be concerned about, if your loved one takes medication?


Patients' and Carers' Perspectives of Psychopharmacological Interventions Targeting… DOI: http://dx.doi.org/10.5772/intechopen.86083



Thank you for taking part in this survey and answering the questions.

#### Author details

Strongly disagree

27. In your own words, what else would you like medication to help your loved

Which of the following potential side effects would you be concerned about, if

Strongly disagree

Views on side effects of a medication for anorexia nervosa

17. My loved one should take medication if it is recommended by a therapist or medical

18. I would want any medication to help my loved one with their anxiety. 19. I would want any medication to help my loved one with their low mood. 20. I would want any medication to help my loved one improve their concentration. 21. I would want any medication to help my loved one increase their appetite. 22. I would want any medication to help my loved one to sleep better.

23. I would want any medication to help my loved one with gastrointestinal symptoms

24. I would want any medication to help weaken the anorexic voice or anorexic thoughts my

26. I would encourage my loved one to take part in a clinical trial on drug treatment for

one with in overcoming anorexia nervosa?

your loved one takes medication?

28. Weight gain 29. Appetite increase 30. Binge eating

33. Mood changes

36. Nausea

118

31. Changes in body shape

34. Tiredness or sleepiness

37. Decreased concentration 38. Changes in bloods

harder to burn calories

32. The metabolism could change, making it

35. Problems with the heart or heart rhythm.

such as constipation.

anorexia nervosa.

loved one was experiencing. 25. There should be more research on drug treatments in anorexia nervosa.

doctor.

Anorexia and Bulimia Nervosa

Disagree Neutral Agree Strongly

Disagree Neutral Agree Strongly

agree

agree

Amabel Dessain<sup>1</sup> \*, Jessica Bentley<sup>2</sup> , Janet Treasure1,2, Ulrike Schmidt1,2 and Hubertus Himmerich1,2

1 South London and Maudsley NHS Foundation Trust, London, UK

2 Department of Psychological Medicine, King's College London, London, UK

\*Address all correspondence to: amabel.dessain@slam.nhs.uk

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### References

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[2] Keski-Rahkonen A, Mustelin L. Epidemiology of eating disorders in Europe: Prevalence, incidence, comorbidity, course, consequences, and risk factors. Current Opinion in Psychiatry. 2016;29:340-345. DOI: 10.1097/YCO.0000000000000278

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[4] Schmidt U, Adan R, Böhm I, Campbell IC, Dingemans A, Ehrlich S, et al. Eating disorders: The big issue. Lancet Psychiatry. 2016;3:313-315. DOI: 10.1016/S2215-0366(16)00081-X

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[8] Chen EY, Weissman JA, Zeffiro TA, Yiu A, Eneva KT, Arlt JM, et al. Familybased therapy for young adults with anorexia nervosa restores weight. The International Journal of Eating Disorders. 2016;49:701-707. DOI: 10.1002/eat.22513

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[24] Chorpita BF, Moffitt CE, Gray J. Psychometric properties of the revised child anxiety and depression scale in a clinical sample. Behaviour Research and

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[26] Luce KH, Crowther JH. The reliability of the eating disorder examination-self-report questionnaire version (EDE-Q). The International Journal of Eating Disorders. 1999;25: 349-351. DOI: 10.1002/(SICI) 1098-108X(199904)25:3<349::AID-

[27] Chandwick P, Lees S, Birchwood M.

The revised beliefs about voices questionnaire (BAVQ-R). The British Journal of Psychiatry. 2000;177:229-232.

[28] Kafantaris V, Leigh E, Hertz S, Berest A, Schebendach J, Sterling WM, et al. A placebo-controlled pilot study of adjunctive olanzapine for adolescents with anorexia nervosa. Journal of Child and Adolescent Psychopharmacology. 2011;21:207-212. DOI: 10.1089/

[29] Brambilla F, Garcia CS, Fassino S, Daga GA, Favaro A, Santonastaso P, et al. Olanzapine therapy in anorexia nervosa: Psychobiological effects.

Psychopharmacology. 2007;22:197-204. DOI: 10.1097/YIC.0b013e328080ca31

DOI: 10.1192/bjp.177.3.229

0022-3956(94)90002-7

EAT15>3.0.CO;2-M

cap.2010.0139

International Clinical

[25] Mazure CM, Halmi KA, Sunday SR, Romano SJ, Einhorn AM. The Yale-Brown-Cornell eating disorder scale: Development, use, reliability and validity. Journal of Psychiatric Research.

[16] Himmerich H, Joaquim M, Bentley J, Kan C, Dornik J, Treasure J, et al. Psychopharmacological options for adult patients with anorexia nervosa: The patients' and carers' perspectives. CNS Spectrums. 2018;23:251-252. DOI:

[17] Stübner S, Grohmann R, Schmauß M. Drug safety in clinical practice—Part 1: Psychopharmacological treatment. Fortschritte der Neurologie-Psychiatrie. 2012;80:468-480. DOI: 10.1055/s-0032-

[18] Stübner S, Grohmann R, Schmauß M. Drug safety in clinical practice—Part 2: Psychopharmacological treatment. Fortschritte der Neurologie-Psychiatrie. 2013;81:715-727. DOI: 10.1055/s-0033-

[19] Treasure J, Nazar BP. Interventions for the carers of patients with eating disorders. Current Psychiatry Reports. 2016;18:16. DOI: 10.1007/s11920-015-

[20] Dold M, Aigner M, Klabunde M, Treasure J, Kasper S. Second-generation antipsychotic drugs in anorexia nervosa:

[21] Godart NT, Flament MF, Perdereau F, Jeammet P. Comorbidity between eating disorders and anxiety disorders: A review. The International Journal of Eating Disorders. 2002;32:253-270. DOI:

[22] Overall JE, Gorham DR. The brief psychiatric rating scale. Psychological

A meta-analysis of randomized controlled trials. Psychotherapy and Psychosomatics. 2015;84:110-116. DOI:

10.1159/000369978

10.1002/eat.10096

121

Reports. 1962;10:799-812

10.1017/S1092852917000529

1313085

1355883

0652-3

[9] Thuillier J. Ten years which changed psychiatry. In: Healy D, editor. The Psychopharmacologists. London: Arnold; 2000. pp. 543-559

[10] Himmerich H, Treasure J. Psychopharmacological advances in eating disorders. Expert Review in Clinical Pharmacology. 2018;11:95-108. DOI: 10.1080/17512433.2018.1383895

[11] Miniati M, Mauri M, Ciberti A, Mariani MG, Marazziti D, Dell'Osso L. Psychopharmacological options for adult patients with anorexia nervosa. CNS Spectrums. 2016;21:134-142. DOI: 10.1017/S1092852914000790

[12] Brockmeyer T, Friederich HC, Schmidt U. Advances in the treatment of anorexia nervosa: A review of established and emerging interventions. Psychological Medicine. 2018;48: 1228-1256. DOI: 10.1017/ S0033291717002604

[13] Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Archives of General Psychiatry. 2011;68: 724-731. DOI: 10.1001/ archgenpsychiatry.2011.74

[14] Murray SB, Loeb KL, Le Grange D. Treatment outcome reporting in anorexia nervosa: Time for a paradigm shift? Journal of Eating Disorders. 2018; 6:10. DOI: 10.1186/s40337-018-0195-1

[15] Brockmeyer T, Holtforth MG, Bents H, Kämmerer A, Herzog W, Friederich

Patients' and Carers' Perspectives of Psychopharmacological Interventions Targeting… DOI: http://dx.doi.org/10.5772/intechopen.86083

HC. Starvation and emotion regulation in anorexia nervosa. Comprehensive Psychiatry. 2012;53:496-501. DOI: 10.1016/j.comppsych.2011.09.003

References

APA Publishing; 2013

Anorexia and Bulimia Nervosa

[1] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: [8] Chen EY, Weissman JA, Zeffiro TA, Yiu A, Eneva KT, Arlt JM, et al. Familybased therapy for young adults with anorexia nervosa restores weight. The International Journal of Eating Disorders. 2016;49:701-707. DOI:

[9] Thuillier J. Ten years which changed psychiatry. In: Healy D, editor. The Psychopharmacologists. London: Arnold; 2000. pp. 543-559

[10] Himmerich H, Treasure J. Psychopharmacological advances in eating disorders. Expert Review in Clinical Pharmacology. 2018;11:95-108. DOI: 10.1080/17512433.2018.1383895

[11] Miniati M, Mauri M, Ciberti A, Mariani MG, Marazziti D, Dell'Osso L. Psychopharmacological options for adult patients with anorexia nervosa. CNS Spectrums. 2016;21:134-142. DOI:

10.1017/S1092852914000790

1228-1256. DOI: 10.1017/ S0033291717002604

724-731. DOI: 10.1001/ archgenpsychiatry.2011.74

[12] Brockmeyer T, Friederich HC, Schmidt U. Advances in the treatment of anorexia nervosa: A review of

[13] Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Archives of General Psychiatry. 2011;68:

[14] Murray SB, Loeb KL, Le Grange D. Treatment outcome reporting in anorexia nervosa: Time for a paradigm shift? Journal of Eating Disorders. 2018; 6:10. DOI: 10.1186/s40337-018-0195-1

[15] Brockmeyer T, Holtforth MG, Bents H, Kämmerer A, Herzog W, Friederich

established and emerging interventions. Psychological Medicine. 2018;48:

10.1002/eat.22513

[2] Keski-Rahkonen A, Mustelin L. Epidemiology of eating disorders in Europe: Prevalence, incidence,

risk factors. Current Opinion in Psychiatry. 2016;29:340-345. DOI: 10.1097/YCO.0000000000000278

DOI: 10.1002/eat.22467

[4] Schmidt U, Adan R, Böhm I, Campbell IC, Dingemans A, Ehrlich S, et al. Eating disorders: The big issue. Lancet Psychiatry. 2016;3:313-315. DOI: 10.1016/S2215-0366(16)00081-X

[5] Eddy KT, Tabri N, Thomas JJ, Murray HB, Keshaviah A, Hastings E, et al. Recovery from anorexia nervosa and bulimia nervosa at 22-year followup. Journal of Clinical Psychiatry. 2017;

[6] Himmerich H, Hotopf M, Shetty H, Schmidt U, Treasure J, Hayes RD, et al. Psychiatric comorbidity as a risk factor for mortality in people with anorexia nervosa. European Archives of Psychiatry and Clinical Neuroscience. 2019;269:351-359. DOI: 10.1007/

78:184-189. DOI: 10.4088/

JCP.15m10393

s00406-018-0937-8

10.2147/AHMT.S115775

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[7] Rienecke RD. Family-based treatment of eating disorders in adolescents: Current insights. Adolescent Health, Medicine and Therapeutics. 2017;8:69-79. DOI:

comorbidity, course, consequences, and

[3] Javaras KN, Runfola CD, Thornton LM, et al. Sex- and age-specific incidence of healthcare-registerrecorded eating disorders in the complete Swedish 1979-2001 birth cohort. The International Journal of Eating Disorders. 2015;48:1070-1081.

[16] Himmerich H, Joaquim M, Bentley J, Kan C, Dornik J, Treasure J, et al. Psychopharmacological options for adult patients with anorexia nervosa: The patients' and carers' perspectives. CNS Spectrums. 2018;23:251-252. DOI: 10.1017/S1092852917000529

[17] Stübner S, Grohmann R, Schmauß M. Drug safety in clinical practice—Part 1: Psychopharmacological treatment. Fortschritte der Neurologie-Psychiatrie. 2012;80:468-480. DOI: 10.1055/s-0032- 1313085

[18] Stübner S, Grohmann R, Schmauß M. Drug safety in clinical practice—Part 2: Psychopharmacological treatment. Fortschritte der Neurologie-Psychiatrie. 2013;81:715-727. DOI: 10.1055/s-0033- 1355883

[19] Treasure J, Nazar BP. Interventions for the carers of patients with eating disorders. Current Psychiatry Reports. 2016;18:16. DOI: 10.1007/s11920-015- 0652-3

[20] Dold M, Aigner M, Klabunde M, Treasure J, Kasper S. Second-generation antipsychotic drugs in anorexia nervosa: A meta-analysis of randomized controlled trials. Psychotherapy and Psychosomatics. 2015;84:110-116. DOI: 10.1159/000369978

[21] Godart NT, Flament MF, Perdereau F, Jeammet P. Comorbidity between eating disorders and anxiety disorders: A review. The International Journal of Eating Disorders. 2002;32:253-270. DOI: 10.1002/eat.10096

[22] Overall JE, Gorham DR. The brief psychiatric rating scale. Psychological Reports. 1962;10:799-812

[23] Brown TA, Chorpita BF, Korotitsch W, Barlow DH. Psychometric properties of the depression anxiety stress scales (DASS) in clinical samples. Behaviour Research and Therapy. 1997;35:79-89

[24] Chorpita BF, Moffitt CE, Gray J. Psychometric properties of the revised child anxiety and depression scale in a clinical sample. Behaviour Research and Therapy. 2005;43:309-322. DOI: 10.1016/j.brat.2004.02.004

[25] Mazure CM, Halmi KA, Sunday SR, Romano SJ, Einhorn AM. The Yale-Brown-Cornell eating disorder scale: Development, use, reliability and validity. Journal of Psychiatric Research. 1994;28:425-445. DOI: 10.1016/ 0022-3956(94)90002-7

[26] Luce KH, Crowther JH. The reliability of the eating disorder examination-self-report questionnaire version (EDE-Q). The International Journal of Eating Disorders. 1999;25: 349-351. DOI: 10.1002/(SICI) 1098-108X(199904)25:3<349::AID-EAT15>3.0.CO;2-M

[27] Chandwick P, Lees S, Birchwood M. The revised beliefs about voices questionnaire (BAVQ-R). The British Journal of Psychiatry. 2000;177:229-232. DOI: 10.1192/bjp.177.3.229

[28] Kafantaris V, Leigh E, Hertz S, Berest A, Schebendach J, Sterling WM, et al. A placebo-controlled pilot study of adjunctive olanzapine for adolescents with anorexia nervosa. Journal of Child and Adolescent Psychopharmacology. 2011;21:207-212. DOI: 10.1089/ cap.2010.0139

[29] Brambilla F, Garcia CS, Fassino S, Daga GA, Favaro A, Santonastaso P, et al. Olanzapine therapy in anorexia nervosa: Psychobiological effects. International Clinical Psychopharmacology. 2007;22:197-204. DOI: 10.1097/YIC.0b013e328080ca31

[30] Bissada H, Tasca GA, Barber AM, Bradwejn J. Olanzapine in the treatment of low body weight and obsessive thinking in women with anorexia nervosa: A randomized, double-blind, placebo-controlled trial. American Journal of Psychiatry. 2008;165: 1281-1288. DOI: 10.1176/appi. ajp.2008.07121900

[31] Attia E, Kaplan AS, Walsh BT, Gershkovich M, Yilmaz Z, Musante D, et al. Olanzapine versus placebo for outpatients with anorexia nervosa. Psychological Medicine. 2011;41: 2177-2182. DOI: 10.1017/ S0033291711000390

[32] Tollefson GD, Sanger TM. Anxiousdepressive symptoms in schizophrenia: A new treatment target for pharmacotherapy? Schizophrenia Research. 1999;1(35 Suppl):13-21. DOI: 10.1016/S0920-9964(98)00164-9

[33] Temmingh H, Stein DJ. Anxiety in patients with schizophrenia: Epidemiology and management. CNS Drugs. 2015;29:819-832. DOI: 10.1007/ s40263-015-0282-7

[34] Kluge M, Schacht A, Himmerich H, Rummel-Kluge C, Wehmeier PM, Dalal M, et al. Olanzapine and clozapine differently affect sleep in patients with schizophrenia: Results from a doubleblind, polysomnographic study and review of the literature. Schizophrenia Research. 2014;152:255-260. DOI: 10.1016/j.schres.2013.11.009

[35] Himmerich H, Minkwitz J, Kirkby KC. Weight gain and metabolic changes during treatment with antipsychotics and antidepressants. Endocrine, Metabolic & Immune Disorders Drug Targets. 2015;15:252-260. DOI: 10.2174/ 1871530315666150623092031

[36] Ilyas A, Hübel C, Stahl D, Stadler M, Ismail K, Breen G, et al. The metabolic underpinning of eating disorders: A systematic review and meta-analysis of

insulin sensitivity. Molecular and Cellular Endocrinology. 2018. DOI: 10.1016/j.mce.2018.10.005

[37] Winston AP. The clinical biochemistry of anorexia nervosa. Annals of Clinical Biochemistry. 2012; 49(Pt 2):132-143. DOI: 10.1258/ acb.2011.011185

**123**

**Chapter 8**

**Abstract**

bulimic patients.

psychology) [1].

**1. Introduction: what is storytelling?**

Nervosa

*and Ignacio Jáuregui Lobera*

Storytelling as a Therapeutic Tool

for Family Support in Bulimia

*José Vicente Martínez Quiñones, Mar Martínez Gamarra*

Telling stories (storytelling) is, above and beyond, a form of communication. It is a natural, universal, and well-known way of interaction among human beings. Storytelling, orally as well as in writing, is the sharing of personal narratives, a sort of story-sharing. With regard to chronic disease self-management, storytelling has been reported to be an exciting approach to patients and families. In this regard, families are considered very important in the management and treatment of eating disorders. Living with an eating disorder is an experience which deserves to be expressed in order to improve emotional support always necessary for patients' families. Bearing in mind that eating disorders can be chronic illnesses that lead to challenging and troublesome experiences for patients and their families, this chapter aims to think over the everyday interactions that typify family life in the context of eating disorders and specifically in the case of bulimia nervosa. We propose this text as a reflection based on different experiences when working with

**Keywords:** storytelling, eating disorders, bulimia nervosa, family support, narratives

Storytelling (ST) is a well-known tradition in human culture since people tend to tell stories for many reasons such as entertaining, transfer of knowledge between generations, maintenance of cultural heritage, warning others of dangers, etc. Telling stories with serious (non-entertainment) objectives has emerged as a new way for potential applications in different contexts (e.g., medicine or

Above and beyond ST is a communication tool among human beings with a core aspect which is the emotions. "Serious" ST is an earnest narrative, a way to tell stories outside the context of entertainment. ST has different components such as narrative, perspective, interactivity, and medium. *Narrative* is the actual content of the story, which includes times-contexts, causes-effects, sequence, etc. *Perspective* refers to the fact that in each story the author conveys a subjective point of view of a certain aspect of the story. Perspective includes facets such as cognition, emotions, encoding-decoding, meaning, memory, etc. *Interactivity* is essential in ST, including

#### **Chapter 8**

[30] Bissada H, Tasca GA, Barber AM, Bradwejn J. Olanzapine in the treatment of low body weight and obsessive thinking in women with anorexia nervosa: A randomized, double-blind, placebo-controlled trial. American Journal of Psychiatry. 2008;165: 1281-1288. DOI: 10.1176/appi.

Anorexia and Bulimia Nervosa

insulin sensitivity. Molecular and Cellular Endocrinology. 2018. DOI:

10.1016/j.mce.2018.10.005

acb.2011.011185

[37] Winston AP. The clinical biochemistry of anorexia nervosa. Annals of Clinical Biochemistry. 2012; 49(Pt 2):132-143. DOI: 10.1258/

[31] Attia E, Kaplan AS, Walsh BT, Gershkovich M, Yilmaz Z, Musante D, et al. Olanzapine versus placebo for out-

patients with anorexia nervosa. Psychological Medicine. 2011;41:

[32] Tollefson GD, Sanger TM. Anxiousdepressive symptoms in schizophrenia:

[33] Temmingh H, Stein DJ. Anxiety in

Epidemiology and management. CNS Drugs. 2015;29:819-832. DOI: 10.1007/

[34] Kluge M, Schacht A, Himmerich H, Rummel-Kluge C, Wehmeier PM, Dalal M, et al. Olanzapine and clozapine differently affect sleep in patients with schizophrenia: Results from a doubleblind, polysomnographic study and review of the literature. Schizophrenia Research. 2014;152:255-260. DOI: 10.1016/j.schres.2013.11.009

[35] Himmerich H, Minkwitz J, Kirkby KC. Weight gain and metabolic changes during treatment with antipsychotics and antidepressants. Endocrine, Metabolic & Immune Disorders Drug Targets. 2015;15:252-260. DOI: 10.2174/

[36] Ilyas A, Hübel C, Stahl D, Stadler M, Ismail K, Breen G, et al. The metabolic underpinning of eating disorders: A systematic review and meta-analysis of

1871530315666150623092031

122

2177-2182. DOI: 10.1017/ S0033291711000390

A new treatment target for pharmacotherapy? Schizophrenia Research. 1999;1(35 Suppl):13-21. DOI: 10.1016/S0920-9964(98)00164-9

patients with schizophrenia:

s40263-015-0282-7

ajp.2008.07121900

## Storytelling as a Therapeutic Tool for Family Support in Bulimia Nervosa

*José Vicente Martínez Quiñones, Mar Martínez Gamarra and Ignacio Jáuregui Lobera*

#### **Abstract**

Telling stories (storytelling) is, above and beyond, a form of communication. It is a natural, universal, and well-known way of interaction among human beings. Storytelling, orally as well as in writing, is the sharing of personal narratives, a sort of story-sharing. With regard to chronic disease self-management, storytelling has been reported to be an exciting approach to patients and families. In this regard, families are considered very important in the management and treatment of eating disorders. Living with an eating disorder is an experience which deserves to be expressed in order to improve emotional support always necessary for patients' families. Bearing in mind that eating disorders can be chronic illnesses that lead to challenging and troublesome experiences for patients and their families, this chapter aims to think over the everyday interactions that typify family life in the context of eating disorders and specifically in the case of bulimia nervosa. We propose this text as a reflection based on different experiences when working with bulimic patients.

**Keywords:** storytelling, eating disorders, bulimia nervosa, family support, narratives

#### **1. Introduction: what is storytelling?**

Storytelling (ST) is a well-known tradition in human culture since people tend to tell stories for many reasons such as entertaining, transfer of knowledge between generations, maintenance of cultural heritage, warning others of dangers, etc. Telling stories with serious (non-entertainment) objectives has emerged as a new way for potential applications in different contexts (e.g., medicine or psychology) [1].

Above and beyond ST is a communication tool among human beings with a core aspect which is the emotions. "Serious" ST is an earnest narrative, a way to tell stories outside the context of entertainment. ST has different components such as narrative, perspective, interactivity, and medium. *Narrative* is the actual content of the story, which includes times-contexts, causes-effects, sequence, etc. *Perspective* refers to the fact that in each story the author conveys a subjective point of view of a certain aspect of the story. Perspective includes facets such as cognition, emotions, encoding-decoding, meaning, memory, etc. *Interactivity* is essential in ST, including

story features such as engagement, modification/decision of narrative flow, etc. Finally, *medium* includes mediation, channels, forms, etc. When ST is defined as a narrative, two components must be considered: the narrative content (story) and the narrative form (discourse). Stories and discourses build a fundamental way for humans to make sense of the world (**Table 1**) [2].

Serious ST refers to a non-entertainment context, where stories are part of the real world. It aims to create mental models about different areas in which narrative elements such as engagement, conflict, characters, emotionality, meaning, causeeffect relations, and time and space constraints are adapted to convey experiences [1]. A narrative is a vehicle to trigger emotional and cognitive responses to achieve certain serious goals within their context of solicitation. In addition, interaction becomes a matter for decision processes, knowledge creation, communication of nonquantifiable facts, and altering narrative flow to achieve serious contextual goals. Context, course, content, and channel are the four essential components of serious ST. The context is basically the application of circumstances (e.g., medical or psychological problems); the course would be how content evolves in a causeeffect relationship as part of the application context; the content is the actual ideas contained in the narrative; and the channel is the kind of way to communicate stories [1, 2].

With respect to the context, the applications of serious ST in well-being, health, medicine, and psychology are good examples of the multiple possibilities in this field of study [3, 4]. From a scientific point of view, and following Dahlstrom et al., we prefer using the concept of "scientific storytelling" when we apply it in medical investigation [5].

The objectives of our reflection were to propose ST as a tool to offer family support in eating disorders (ED) and to describe the development of the story-based interventions targeted to families (developing communication strategies). It must be noted that ST is a way to communicate (mainly emotional narratives) but not a specific therapy for ED.

With respect to the method, due to the fact that this chapter is based on a future review, which we are developing ("storytelling and health education"), the main data of our reflection are taken from a search using PubMed/MEDLINE and PsycInfo, considering those articles mainly focused on ED and specifically on bulimia nervosa.


**125**

*Storytelling as a Therapeutic Tool for Family Support in Bulimia Nervosa*

The effectiveness of ST as a communication tool in healthcare has been sup-

Within the healthcare context, ST might be seen as a way of assistance in learning about and managing one's disease or a relative's disease. ST aimed to disease management is based on the fact that each person has his or her own unique experiences living with and managing a disease; the same applies for relatives. Thus, patients and patient relatives' stories are a relevant information source to both

In this way, storytellers are patients and patients' relatives who suffer together a disease or disorder. By identifying with the storyteller, participants can become invested in the content and be positively influenced by the self-management actions described. Telling stories, emotional stories, is a very good tool to break down cognitive resistance to messages promoting lifestyle and behavioral changes [7] or, many times, to get involved in adequate care and support. Through ST, patients increase their receptivity to the health information contained in the stories as it

In sum, ST is a way to motivate both patients and families [6]. In this regard, ST, as a mechanism for reduction in change resistance, is related to health outcomes [7]; it makes patients and families more inclined to follow strategies that have worked for others (and perhaps they have previously avoided) [8]; it reports mutual benefit (discovery and exploration of new information, practical management strategies and skills, opportunities for adoption of resolutions, etc.) when patients/families

When ST is developed in a group format, several authors have reported different

• ST might establish a network of trust and equality among participants, and

• ST can naturally facilitate peer support and enable a support network to form.

• The peer support obtained by means of ST might encourage participants to examine their emotions, problem-solving skills, and goal setting and exchange social support, all of which are core self-management components within

In summary, ST focuses on the patient's perception of their unique needs and their ability to self-manage their disease and similarly occurs when ST is applied to patients' families. Consequently, ST facilitates both patients and families to develop

Chronic diseases usually require regular contact between patients/families and therapists. In this particular way, ST could be a good approach for both patient self-management and family management. For this proposal, core principles of

• ST tends to reduce stigma associated with diseases, and it facilitates the

*DOI: http://dx.doi.org/10.5772/intechopen.86195*

**2.1 Storytelling in medicine and psychology**

ported by evidence from several disciplines [6].

**2. Results**

patients and families [7].

occurs among patients' families.

health-related contexts.

**2.2 Storytelling in chronic diseases**

benefits [12–15]:

exchange their health-related stories [9–11].

it would be a way of cohesion among participants.

development of relationships among the participants.

strategies to manage their illness and suffering, respectively [16].

#### **Table 1.**

*Basic components of storytelling.*

*Storytelling as a Therapeutic Tool for Family Support in Bulimia Nervosa DOI: http://dx.doi.org/10.5772/intechopen.86195*

### **2. Results**

*Anorexia and Bulimia Nervosa*

stories [1, 2].

investigation [5].

bulimia nervosa.

specific therapy for ED.

Narrative Content (story)

humans to make sense of the world (**Table 1**) [2].

story features such as engagement, modification/decision of narrative flow, etc. Finally, *medium* includes mediation, channels, forms, etc. When ST is defined as a narrative, two components must be considered: the narrative content (story) and the narrative form (discourse). Stories and discourses build a fundamental way for

Serious ST refers to a non-entertainment context, where stories are part of the real world. It aims to create mental models about different areas in which narrative elements such as engagement, conflict, characters, emotionality, meaning, causeeffect relations, and time and space constraints are adapted to convey experiences [1]. A narrative is a vehicle to trigger emotional and cognitive responses to achieve certain serious goals within their context of solicitation. In addition, interaction becomes a matter for decision processes, knowledge creation, communication of nonquantifiable facts, and altering narrative flow to achieve serious contextual goals. Context, course, content, and channel are the four essential components of serious ST. The context is basically the application of circumstances (e.g., medical or psychological problems); the course would be how content evolves in a causeeffect relationship as part of the application context; the content is the actual ideas contained in the narrative; and the channel is the kind of way to communicate

With respect to the context, the applications of serious ST in well-being, health, medicine, and psychology are good examples of the multiple possibilities in this field of study [3, 4]. From a scientific point of view, and following Dahlstrom et al., we prefer using the concept of "scientific storytelling" when we apply it in medical

The objectives of our reflection were to propose ST as a tool to offer family support in eating disorders (ED) and to describe the development of the story-based interventions targeted to families (developing communication strategies). It must be noted that ST is a way to communicate (mainly emotional narratives) but not a

With respect to the method, due to the fact that this chapter is based on a future review, which we are developing ("storytelling and health education"), the main data of our reflection are taken from a search using PubMed/MEDLINE and PsycInfo, considering those articles mainly focused on ED and specifically on

**Elements Meaning Instruments**

Perspective Subjective point of view Cognition

Interactivity Story features Engagement

Medium Means of communication Mediation

Time-context Cause-effect Sequence

Emotion Encoding-decoding Meaning Memory

Modification Narrative flow

Channels Forms

Form (discourse)

**124**

**Table 1.**

*Basic components of storytelling.*

#### **2.1 Storytelling in medicine and psychology**

The effectiveness of ST as a communication tool in healthcare has been supported by evidence from several disciplines [6].

Within the healthcare context, ST might be seen as a way of assistance in learning about and managing one's disease or a relative's disease. ST aimed to disease management is based on the fact that each person has his or her own unique experiences living with and managing a disease; the same applies for relatives. Thus, patients and patient relatives' stories are a relevant information source to both patients and families [7].

In this way, storytellers are patients and patients' relatives who suffer together a disease or disorder. By identifying with the storyteller, participants can become invested in the content and be positively influenced by the self-management actions described. Telling stories, emotional stories, is a very good tool to break down cognitive resistance to messages promoting lifestyle and behavioral changes [7] or, many times, to get involved in adequate care and support. Through ST, patients increase their receptivity to the health information contained in the stories as it occurs among patients' families.

In sum, ST is a way to motivate both patients and families [6]. In this regard, ST, as a mechanism for reduction in change resistance, is related to health outcomes [7]; it makes patients and families more inclined to follow strategies that have worked for others (and perhaps they have previously avoided) [8]; it reports mutual benefit (discovery and exploration of new information, practical management strategies and skills, opportunities for adoption of resolutions, etc.) when patients/families exchange their health-related stories [9–11].

When ST is developed in a group format, several authors have reported different benefits [12–15]:


In summary, ST focuses on the patient's perception of their unique needs and their ability to self-manage their disease and similarly occurs when ST is applied to patients' families. Consequently, ST facilitates both patients and families to develop strategies to manage their illness and suffering, respectively [16].

#### **2.2 Storytelling in chronic diseases**

Chronic diseases usually require regular contact between patients/families and therapists. In this particular way, ST could be a good approach for both patient self-management and family management. For this proposal, core principles of

ST, when applied to health contexts, have been reported to be social cognitive and ecological theories of health behavior, caring and healing, and narrativeautobiographical approaches [17–20]. There are two main objectives of ST in health interventions: (a) to get patients/families to reflect the illness experience and (b) to create meaning from it [20].

As Gucciardi et al. have reviewed, health conditions such as diabetes mellitus, cancer, multiple sclerosis, or psychiatric disorders are frequent diseases in which ST has been applied [20]. Sessions of ST are based on informal-spontaneous sharing of stories by means of a nondirective facilitation approach. Sessions do not consist of didactic delivery of information even though "facilitators" (doctor, nurse, dietitian, etc.) can respond to the shared stories and they can also provide information if required. In this context facilitators play a role of equality but not of experts. Finally, ST must have some elemental rules such as trust, respect, empathy, and no judgment [12, 20, 21]. Sometimes it is possible to use "peer facilitators" (e.g., patients' relatives) previously trained as health promoters and, of course, in ST [12].

Sessions of ST applied to chronic diseases tend to be given over 5–15 weeks, with each session lasting 1–2 hours. The environment usually is an open atmosphere, thus giving everyone the opportunity to speak about their experiences. It is convenient to select topics in advance in order that participants prepare the session with the story (or stories) they want to share in the group (e.g., diagnosis experience, course of the disease, family stress linked to the therapeutic aspects, etc.) [22]. The way to share stories is diverse: verbally, by means of action-oriented activities (e.g., cooking, exercising, etc.), using pictures, writing, trough songs, poems, and readings. ST is not a mere colloquium; it is a participant-centered technique of communication where patients and families are encouraged to self-reflect on their personal experiences.

In the context of chronic diseases, ST is not a way of simple catharsis. Telling stories about illness experiences seems to be therapeutic due to its potential to facilitate learning and coping with the disease. As it was noted by Gucciardi et al., ST is a process of unearthing meaning in the lived experience of illness [20]. Telling stories triggers the reflection and understanding of oneself and the disease [23]. The process of ST starts as a single story (my story), and then stories are elaborated by group participants thus becoming a shared experience [21]. Different ages, groups, ethnicities, socioeconomic status, or gender are potential participants of ST applied to health problems. With respect to ideal number of sessions, basing on participants' preferences and bearing in mind the complexity of the self-management of the disease are better. As it was abovementioned, the use of verbal and written formats is the main strategy along with pictures or photographs [20].

The role of narratives has grown in relevance since the 1980s due to the importance of illness experiences. It must be noted that narratives reflect the nature of the chronic disease experiences but also can be a part of it [24].

#### **2.3 Storytelling and eating disorders: families**

Traditionally, families are considered to play a key role in the management and treatment of ED. Families do not suffer from an ED, but they live with an ED. In this regard families' stories are a way to create experiences, experiences linked to the emotions which usually accompany a life with an ED.

In the field of ED, families have been associated with relationship alteration within the family, problems between partners, great stress experience, problems to cope successfully, uncertainty regarding recovery progress, parental blaming, etc. [25–30]. ED, as it occurs generally in chronic diseases, might be described as a form of biographical disruption which breaks individual or family-anticipated

**127**

**Figure 1.**

*Storytelling as a Therapeutic Tool for Family Support in Bulimia Nervosa*

life paths. As a consequence, narratives lose coherence and meaning and identity becomes lost. The result is a new narrative incoherence which will imply a narrative reconstruction. Stories, ST, will provide new coherences thus giving meaning to ED

Frank [33] considered three narrative types with respect to stories of illness: restitution, chaos, and quest. The first seems to be dominant, and, in sum, it consists of sentences such as "yesterday I was healthy, today I am sick, tomorrow I will be healthy again." On the contrary, chaos narrative is the opposite of restitution, something like "life never will go better again." In this case there is not a narrative coherence to explain the illness. Finally, the quest narrative implies that patients see illness as an opportunity to believe that something is to be gained from the illness experience. Telling stories such as restitution, chaos, or quest narratives has not the same results. Each one shapes experiences. Thus, restitution narratives are usually associated with the fact to pursue, be hopeful, and expect recovery. If the narrative of storytellers shapes their own experiences, the same occurs with regard to the listeners, who, in turn, would also modify their illness experiences [33, 34].

It has been established that ED affect all facets of life and they are a challenging experience for the whole family [34]. It is frequent that parental understandings of illness can remain couched in restitution. Nevertheless, when family members construct ED differently to each other, the consequence is the conflicting narratives and, finally, frustration, anger, and altered communication [34]. Considering the three narratives as suggested by Frank [33], it is possible to observe a process during

ED are usually chronic disorders, thus being both a challenge and a source of family problems. Within the family system, a process of meaning-making will emerge which is absolutely necessary to cope with the illness. This process is guided

When patients with ED are the storytellers, it is possible to distinguish two very

The discourse of patients with anorexia nervosa is built upon three pillars: intensification, circularity, and polarization. This discourse presents a defined reality

different narratives: the discourse of anorectic and bulimic patients [35, 36].

by culturally dominant illness narratives as stated by Frank [33].

*DOI: http://dx.doi.org/10.5772/intechopen.86195*

the therapeutic work in ED (**Figure 1**).

**2.4 Storytelling and eating disorders: patients**

characterized by excess, conflict, and closing [35].

*Therapist working with ED. Adapted from Papathomas et al. [34].*

[31, 32].

*Anorexia and Bulimia Nervosa*

create meaning from it [20].

personal experiences.

ST, when applied to health contexts, have been reported to be social cognitive and ecological theories of health behavior, caring and healing, and narrativeautobiographical approaches [17–20]. There are two main objectives of ST in health interventions: (a) to get patients/families to reflect the illness experience and (b) to

As Gucciardi et al. have reviewed, health conditions such as diabetes mellitus, cancer, multiple sclerosis, or psychiatric disorders are frequent diseases in which ST has been applied [20]. Sessions of ST are based on informal-spontaneous sharing of stories by means of a nondirective facilitation approach. Sessions do not consist of didactic delivery of information even though "facilitators" (doctor, nurse, dietitian, etc.) can respond to the shared stories and they can also provide information if required. In this context facilitators play a role of equality but not of experts. Finally, ST must have some elemental rules such as trust, respect, empathy, and no judgment [12, 20, 21]. Sometimes it is possible to use "peer facilitators" (e.g., patients' relatives) previously trained as health promoters and, of course, in ST [12].

Sessions of ST applied to chronic diseases tend to be given over 5–15 weeks, with each session lasting 1–2 hours. The environment usually is an open atmosphere, thus giving everyone the opportunity to speak about their experiences. It is convenient to select topics in advance in order that participants prepare the session with the story (or stories) they want to share in the group (e.g., diagnosis experience, course of the disease, family stress linked to the therapeutic aspects, etc.) [22]. The way to share stories is diverse: verbally, by means of action-oriented activities (e.g., cooking, exercising, etc.), using pictures, writing, trough songs, poems, and readings. ST is not a mere colloquium; it is a participant-centered technique of communication where patients and families are encouraged to self-reflect on their

In the context of chronic diseases, ST is not a way of simple catharsis. Telling stories about illness experiences seems to be therapeutic due to its potential to facilitate learning and coping with the disease. As it was noted by Gucciardi et al., ST is a process of unearthing meaning in the lived experience of illness [20]. Telling stories triggers the reflection and understanding of oneself and the disease [23]. The process of ST starts as a single story (my story), and then stories are elaborated by group participants thus becoming a shared experience [21]. Different ages, groups, ethnicities, socioeconomic status, or gender are potential participants of ST applied to health problems. With respect to ideal number of sessions, basing on participants' preferences and bearing in mind the complexity of the self-management of the disease are better. As it was abovementioned, the use of verbal and written

The role of narratives has grown in relevance since the 1980s due to the importance of illness experiences. It must be noted that narratives reflect the nature of the

Traditionally, families are considered to play a key role in the management and treatment of ED. Families do not suffer from an ED, but they live with an ED. In this regard families' stories are a way to create experiences, experiences linked to the

In the field of ED, families have been associated with relationship alteration within the family, problems between partners, great stress experience, problems to cope successfully, uncertainty regarding recovery progress, parental blaming, etc. [25–30]. ED, as it occurs generally in chronic diseases, might be described as a form of biographical disruption which breaks individual or family-anticipated

formats is the main strategy along with pictures or photographs [20].

chronic disease experiences but also can be a part of it [24].

**2.3 Storytelling and eating disorders: families**

emotions which usually accompany a life with an ED.

**126**

life paths. As a consequence, narratives lose coherence and meaning and identity becomes lost. The result is a new narrative incoherence which will imply a narrative reconstruction. Stories, ST, will provide new coherences thus giving meaning to ED [31, 32].

Frank [33] considered three narrative types with respect to stories of illness: restitution, chaos, and quest. The first seems to be dominant, and, in sum, it consists of sentences such as "yesterday I was healthy, today I am sick, tomorrow I will be healthy again." On the contrary, chaos narrative is the opposite of restitution, something like "life never will go better again." In this case there is not a narrative coherence to explain the illness. Finally, the quest narrative implies that patients see illness as an opportunity to believe that something is to be gained from the illness experience. Telling stories such as restitution, chaos, or quest narratives has not the same results. Each one shapes experiences. Thus, restitution narratives are usually associated with the fact to pursue, be hopeful, and expect recovery. If the narrative of storytellers shapes their own experiences, the same occurs with regard to the listeners, who, in turn, would also modify their illness experiences [33, 34].

It has been established that ED affect all facets of life and they are a challenging experience for the whole family [34]. It is frequent that parental understandings of illness can remain couched in restitution. Nevertheless, when family members construct ED differently to each other, the consequence is the conflicting narratives and, finally, frustration, anger, and altered communication [34]. Considering the three narratives as suggested by Frank [33], it is possible to observe a process during the therapeutic work in ED (**Figure 1**).

ED are usually chronic disorders, thus being both a challenge and a source of family problems. Within the family system, a process of meaning-making will emerge which is absolutely necessary to cope with the illness. This process is guided by culturally dominant illness narratives as stated by Frank [33].

#### **2.4 Storytelling and eating disorders: patients**

When patients with ED are the storytellers, it is possible to distinguish two very different narratives: the discourse of anorectic and bulimic patients [35, 36].

The discourse of patients with anorexia nervosa is built upon three pillars: intensification, circularity, and polarization. This discourse presents a defined reality characterized by excess, conflict, and closing [35].

**Figure 1.** *Therapist working with ED. Adapted from Papathomas et al. [34].*

Intensification leads to derealization, thus showing a distorted world with regard to its dimensions. On the one hand, it is a vehicle to express very intense feelings; on the other hand, intensification does not end up with this expressive function since it serves as a strategy to legitimate specific behaviors [35].

The amplified image of reality triggers the alarm; it expresses an obsessive fear to gain weight. Thus, body image is perceived to the limit of bearable, and this seems to justify the obsessive desire to lose weight. Maybe the discourse shows the object: the distorted image acts generating fear, thus becoming a relevant factor which maintains the disorder. The dichotomic vision of reality reinforces anorectic behaviors since that vision implies a fight between contrary parts. The result is an experience of a fragmentary world and a split-off vision with respect to the own conscience. Antithesis, paradoxes, and generally the dialectical approach keep alive and reinforce the awareness of both external and internal confrontation, and, as we have seen, once the conscience is divided between opposing parts, it is always defeated in this war of no one [35, 36].

Circularity, showed linguistically by a high degree of recurrence, creates a net of words which envelops and imprisons. As the water of a fountain reflects the image of Narcissus, anorectic discourse throws an image which locks one inside; that discourse shows a conscience turned on itself, tightly centered and closed on the conflict. From this point of view, anorectic discourse is both an expression and an instrument of the disease. At the same time, that discourse has the keys which might neutralize the disease effects. If the discourse catches and it makes the person sick, it is possible to build another different discourse to create and legitimate a healthy behavior.

Considering positive and negative elements of anorectic discourses, it would be possible to include the analysis of discourse within the whole treatment program. By means of the analysis of recordings and texts, it is possible to think over with a critical point of view about the patients' thinking schemes. Then it would be possible to build an alternative discourse, a new healthy discourse [35].

In the case of bulimia nervosa, as a feature that defines the discourse, its openness from the thematic point of view and also some peculiarities in what refers to the global construction of the discourse should be noted. From the thematic point of view, stories usually show a universe open to others, with a central theme, which is dependent on affection and recognition of others [36].

Following the studies of Márquez [35, 36], considering bulimia nervosa, perhaps the most outstanding feature, along with the fragmentary character of the discourse, is the polyphony: voices of the same person or of the others, real or imagined, that give life to the story, make it rich and complex, and, at all events, show a consciousness inhabited by others, confused with them.

In the syntactic plane, the global organization of the discourse is defined by its scattered character: broken syntax with unfinished structures, suspended utterances, and sudden alterations in rhythm show a specific type of thought which is built on impulses.

Verbalization of experiences, reflection, and reconstruction of memories are emerging to consciousness in a choppy way, in various attempts that are not usually alternatives to saying the same thing (or different ways of approaching a fact), since the first tend to be unsuccessful. Stories are characterized by impulsivity, ruptures, advances, and setbacks, which, in short, express precipitation, lack of a necessary prior time for reflection and planning, lack of containment, and difficulties in adjusting to limits.

Intensification presents facts and sensations as endowed with an extreme force; as a result, reality is constructed with such intensity that it is uncontainable within its natural channels. Thus considered, this resource serves as legitimization of the

**129**

*Storytelling as a Therapeutic Tool for Family Support in Bulimia Nervosa*

illness behaviors. Vocalic lengthening and sudden changes in the language rhythm, as well as precipitation and slowing down, also show the presence of emotions that overflow the consciousness, sensations, and affects that are difficult to conduct and

In short, a broken speech seems to reflect the lack of a coherent internal organizing center, a broken voice, a word that has its justification and its center abroad, as

From a dialogical view of change, it is possible to consider change and resistance to change. Resistance to change derives from the slavery of repeating, which traps the dialogical self. The tension between change (liberty of reborn) and resistance to change (self-determination to repetition) can be also represented as voices discussing and contrasting in the context of a personal arena, in the dynamic of a dialog

It is usual to work with families when an ED patient begins his/her process of treatment. There are two facts which we can observe at this point. Firstly, families tend to express that they never imagined a son or daughter with an ED. Second, it is frequent that families talk about their "fault." Novelty and fault build a recurrent

It has been said that healthy relationships are like the tides: they ebb and flow, especially when it comes to verbal interaction. Ebbing and flowing give as a result a balance. But when a family member suffers from an ED, this balance is very hard to maintain. When this occurs, the patient becomes quite self-centered, self-absorbed. Now, relationships as well as dialogs need to be rebalanced. Once an ED affects a family member, many times siblings are victims of that ED since parents focus much more of their time, thoughts, and energy on that affected member. Verbal interactions and relationships are strongly modified. From the point of view of siblings, the patient gets all the love, all the attention, while other members get ignored and overlooked. In order to attract parents' attention, siblings may start

ED often is an enemy of healthy relationships. As an ED develops and progresses, it often takes the place of wholesome relationships that may have once existed in one's life. Typically, as the ED roots within a person, relationships with family members, friends, partners, etc. become strained and gradually altered [39]. Altered relationships within the family tend to create a different discourse. The coherent healthy discourse becomes a broken discourse stained by feelings of doubt, guiltiness, and many times lack of hope. This way a new story emerges. Patients, siblings, parents, partners, etc. have their new particular stories to tell or, sometimes, shut up. During the therapeutic process of ED, there are very different elements that parents refer to as having a great impact on their lives. Examples of these elements would be family unification or disintegration, inability to cope with the disease, inconsiderate comments from significant others, social isolation, and financial impacts, among others. The chronicity of ED causes stress for the family as a unit, by affecting the family's coping mechanisms and the family's relationships

some unhealthy behaviors such as rebelling, acting out, etc. [38].

with significant others leading to isolation of the family unit [28].

Isolated parents give few insights into the ED experience across the whole family unit. Illness experiences may be analyzed through thematic analyses. Although these content-driven approaches can be useful, they offer scarce for the social construction of the ED experience. Specifically, how personal interpretations of illness are shaped through social and cultural narrative auspices is rarely addressed. It is in this regard how ST would be an appropriate tool to understanding illness. The role of narratives,

*DOI: http://dx.doi.org/10.5772/intechopen.86195*

**2.5 Work with families in eating disorders**

finally become not contained.

an echo [36].

between parts [37].

question: Why?

*Storytelling as a Therapeutic Tool for Family Support in Bulimia Nervosa DOI: http://dx.doi.org/10.5772/intechopen.86195*

*Anorexia and Bulimia Nervosa*

defeated in this war of no one [35, 36].

healthy behavior.

built on impulses.

adjusting to limits.

Intensification leads to derealization, thus showing a distorted world with regard to its dimensions. On the one hand, it is a vehicle to express very intense feelings; on the other hand, intensification does not end up with this expressive function since it serves as a strategy to legitimate specific behaviors [35].

The amplified image of reality triggers the alarm; it expresses an obsessive fear to gain weight. Thus, body image is perceived to the limit of bearable, and this seems to justify the obsessive desire to lose weight. Maybe the discourse shows the object: the distorted image acts generating fear, thus becoming a relevant factor which maintains the disorder. The dichotomic vision of reality reinforces anorectic behaviors since that vision implies a fight between contrary parts. The result is an experience of a fragmentary world and a split-off vision with respect to the own conscience. Antithesis, paradoxes, and generally the dialectical approach keep alive and reinforce the awareness of both external and internal confrontation, and, as we have seen, once the conscience is divided between opposing parts, it is always

Circularity, showed linguistically by a high degree of recurrence, creates a net of words which envelops and imprisons. As the water of a fountain reflects the image of Narcissus, anorectic discourse throws an image which locks one inside; that discourse shows a conscience turned on itself, tightly centered and closed on the conflict. From this point of view, anorectic discourse is both an expression and an instrument of the disease. At the same time, that discourse has the keys which might neutralize the disease effects. If the discourse catches and it makes the person sick, it is possible to build another different discourse to create and legitimate a

Considering positive and negative elements of anorectic discourses, it would be possible to include the analysis of discourse within the whole treatment program. By means of the analysis of recordings and texts, it is possible to think over with a critical point of view about the patients' thinking schemes. Then it would be pos-

In the case of bulimia nervosa, as a feature that defines the discourse, its openness from the thematic point of view and also some peculiarities in what refers to the global construction of the discourse should be noted. From the thematic point of view, stories usually show a universe open to others, with a central theme, which

Following the studies of Márquez [35, 36], considering bulimia nervosa, perhaps

In the syntactic plane, the global organization of the discourse is defined by its scattered character: broken syntax with unfinished structures, suspended utterances, and sudden alterations in rhythm show a specific type of thought which is

Verbalization of experiences, reflection, and reconstruction of memories are emerging to consciousness in a choppy way, in various attempts that are not usually alternatives to saying the same thing (or different ways of approaching a fact), since the first tend to be unsuccessful. Stories are characterized by impulsivity, ruptures, advances, and setbacks, which, in short, express precipitation, lack of a necessary prior time for reflection and planning, lack of containment, and difficulties in

Intensification presents facts and sensations as endowed with an extreme force; as a result, reality is constructed with such intensity that it is uncontainable within its natural channels. Thus considered, this resource serves as legitimization of the

the most outstanding feature, along with the fragmentary character of the discourse, is the polyphony: voices of the same person or of the others, real or imagined, that give life to the story, make it rich and complex, and, at all events, show a

sible to build an alternative discourse, a new healthy discourse [35].

is dependent on affection and recognition of others [36].

consciousness inhabited by others, confused with them.

**128**

illness behaviors. Vocalic lengthening and sudden changes in the language rhythm, as well as precipitation and slowing down, also show the presence of emotions that overflow the consciousness, sensations, and affects that are difficult to conduct and finally become not contained.

In short, a broken speech seems to reflect the lack of a coherent internal organizing center, a broken voice, a word that has its justification and its center abroad, as an echo [36].

From a dialogical view of change, it is possible to consider change and resistance to change. Resistance to change derives from the slavery of repeating, which traps the dialogical self. The tension between change (liberty of reborn) and resistance to change (self-determination to repetition) can be also represented as voices discussing and contrasting in the context of a personal arena, in the dynamic of a dialog between parts [37].

#### **2.5 Work with families in eating disorders**

It is usual to work with families when an ED patient begins his/her process of treatment. There are two facts which we can observe at this point. Firstly, families tend to express that they never imagined a son or daughter with an ED. Second, it is frequent that families talk about their "fault." Novelty and fault build a recurrent question: Why?

It has been said that healthy relationships are like the tides: they ebb and flow, especially when it comes to verbal interaction. Ebbing and flowing give as a result a balance. But when a family member suffers from an ED, this balance is very hard to maintain. When this occurs, the patient becomes quite self-centered, self-absorbed. Now, relationships as well as dialogs need to be rebalanced. Once an ED affects a family member, many times siblings are victims of that ED since parents focus much more of their time, thoughts, and energy on that affected member. Verbal interactions and relationships are strongly modified. From the point of view of siblings, the patient gets all the love, all the attention, while other members get ignored and overlooked. In order to attract parents' attention, siblings may start some unhealthy behaviors such as rebelling, acting out, etc. [38].

ED often is an enemy of healthy relationships. As an ED develops and progresses, it often takes the place of wholesome relationships that may have once existed in one's life. Typically, as the ED roots within a person, relationships with family members, friends, partners, etc. become strained and gradually altered [39].

Altered relationships within the family tend to create a different discourse. The coherent healthy discourse becomes a broken discourse stained by feelings of doubt, guiltiness, and many times lack of hope. This way a new story emerges. Patients, siblings, parents, partners, etc. have their new particular stories to tell or, sometimes, shut up. During the therapeutic process of ED, there are very different elements that parents refer to as having a great impact on their lives. Examples of these elements would be family unification or disintegration, inability to cope with the disease, inconsiderate comments from significant others, social isolation, and financial impacts, among others. The chronicity of ED causes stress for the family as a unit, by affecting the family's coping mechanisms and the family's relationships with significant others leading to isolation of the family unit [28].

Isolated parents give few insights into the ED experience across the whole family unit. Illness experiences may be analyzed through thematic analyses. Although these content-driven approaches can be useful, they offer scarce for the social construction of the ED experience. Specifically, how personal interpretations of illness are shaped through social and cultural narrative auspices is rarely addressed. It is in this regard how ST would be an appropriate tool to understanding illness. The role of narratives,

the role of telling stories, would lead to the deepest personal illness experiences. Narrative therapy for ED is well known since the 1980s. By means of telling stories, therapists work with patients, who create a sort of "anti-anorexia" and "anti-bulimia" stories. These stories aim to depict a separation between the person and the disorder, thus setting up space for patients (and families) to re-envision their relationship with their ED. Patients will create a new personal story "without the ED."

#### **2.6 Bulimia nervosa: patients and families. Dialogical analysis with ST**

Along with bulimia nervosa, it has been reported that 61.5% of youth with this ED could be considered to have one or more comorbid disorders (especially mood disorders, anxiety disorders, and personality disorders) [40]. In this particular way, ST might be applied not only in the case of bulimia nervosa but also when comorbidities are present. Thus, using narrative therapy in a group of women with long-course ED with comorbid depression, a reduction in both ED and levels of depression was obtained. It seems necessary to work with different facets: (a) externalize the ED, thus creating distance between herself (patient) and the disorder; (b) explore the person's ED, in which values belong to the patient and which belong to the ED; and (c) develop an alternative story to support the client's sense of self (not just with respect to eating but in other areas of her life); it is not the same "to be" a bulimic patient than "to suffer from bulimia nervosa" [41].

ST is a way of communication, a way to change the discourse, thus contributing to change our mind. Many patients usually say "I can't start again" and "it is impossible to change." But if the patient does not change, the result is the permanence. The same applies to families. Between change and permanence emerges the conflict, and the discourses serve the conflict becoming broken, incoherent. Stories may be based on change and on no change. The consequent discourse is a speech aimed to express the deep desire of change or, on the contrary, the conviction to permanence, the change being impossible. As Marquez stated [35, 36], change vs. non-change is something like an inner dialog between voices, but not only "inner" since external components appear (family, partner, friends, etc.). As stated by Salvini et al. [37], the dialog between voices implies that when one party speaks, the other party is required to be silent. This way, it is common that a dominant discourse emerges (interactional dominance), the dialog being asymmetrical. Therapists must consider this phenomenon because the more symmetrical the dialog is, the more opportunity it provides for mutual influence; the more asymmetrical it is, the more it constrains the exchange of views and experiences. When symptoms are the core part of the discourse and this discourse becomes dominant, patients and families are imprisoned. Following the analysis of Márquez [36], in bulimia nervosa stories are characterized by impulsivity, ruptures, advances, and setbacks, which, in short, express precipitation, lack of a necessary prior time for reflection and planning, lack of containment, and difficulties in adjusting to limits. This style usually leads to a chaos narrative [33].

Based on the study of Hermans et al. [42], Salvini et al. [37] considered the trend toward discursive change during the therapeutic process according to the following four dimensions: (a) interactional dominance, (b) topic dominance, (c) amount of talk, and (d) strategic movements. In a process of scientific ST, it is relevant to analyze linguistic variations probably linked to a transition from a dysfunctional narrative to a new more coherent one. Among a group of bulimic patients (here bulimic storytellers), one of them could be dominant, and the dialog starts being very asymmetrical. With respect to the topics, diets, body image, emotional instability, binge episodes, purging, and other altered behaviors (e.g., self-injuries) are usually highlighted by group members. At the beginning the amount of talk and strategic

**131**

*Storytelling as a Therapeutic Tool for Family Support in Bulimia Nervosa*

movements might be summarized as a scarce of true dialog with different attempts to impose one over others. Each member seems to search for a top position in the group, thus polarizing and dominating the other voices [37]. As the sessions go on, a more reciprocal interaction is favored. The topics remain but they are less strong than before. In order to understand these changes, it is necessary to bring here the concept of metaposition, something like a "third voice." This third voice has a reflexive function. Some auxiliary verbs (*I have to be treated*, *I want to get better*, etc.) are contrasted by more verbs which imply personal conditions (*I feel happy*, *I do not like*, etc.). With the progression of the ST process, the preferred tense is the past, thus distinguishing between a previous condition and the current state (*when I binged*, *once I felt frustrated and I used laxatives*, etc.). Step by step a passage from a condition of dysfunctional self-narratives to more organized ones is observed. As reported by Marquez [36], the discourse may have a relevant role in maintaining the problem, but it is possible to pass from a broken discourse to another healthier one. The discourse reveals psychological profiles as well as interaction styles. In the field of ED, and particularly in bulimia nervosa, working with ST should aim to introduce a "language of change" for both patients and families.

Characteristics of bulimia nervosa involve the sufferer bingeing on large amounts of food, during which patients experience feelings of extreme loss of control. Bingeing leaves the patients feeling guilty, disgusted with themselves, and afraid of weight gain. Patients try to compensate for this by vomiting, by exercising, by fasting, by abusing laxatives, or often by some combination of these behaviors. The life of bulimic patients is usually chaotic: dieting, bingeing, purging, fear to weight gain, feeling of being fat, etc. As result, patients have a negative view of themselves which usually leads to avoiding social interactions. Low mood and poor

2.Effects of bulimia nervosa in my life (physical, psychological, and social

6.Coping with problems and emotions (anxiety, depression, fear, etc.)

11. Bulimia nervosa has many disadvantages for me but has it any advantages?

*DOI: http://dx.doi.org/10.5772/intechopen.86195*

**2.7 Topics to listen from bulimic storytellers**

quality of life complete this framework.

1.What is bulimia nervosa?

5.What are thinking errors?

7.Body dissatisfaction

9.How is my future?

10. Can I help myself?

8.Assertiveness

facets)

3.Dieting

In a ST group, some topics will emerge soon:

4.Is it possible to change my way of thinking?

*Storytelling as a Therapeutic Tool for Family Support in Bulimia Nervosa DOI: http://dx.doi.org/10.5772/intechopen.86195*

movements might be summarized as a scarce of true dialog with different attempts to impose one over others. Each member seems to search for a top position in the group, thus polarizing and dominating the other voices [37]. As the sessions go on, a more reciprocal interaction is favored. The topics remain but they are less strong than before. In order to understand these changes, it is necessary to bring here the concept of metaposition, something like a "third voice." This third voice has a reflexive function. Some auxiliary verbs (*I have to be treated*, *I want to get better*, etc.) are contrasted by more verbs which imply personal conditions (*I feel happy*, *I do not like*, etc.). With the progression of the ST process, the preferred tense is the past, thus distinguishing between a previous condition and the current state (*when I binged*, *once I felt frustrated and I used laxatives*, etc.). Step by step a passage from a condition of dysfunctional self-narratives to more organized ones is observed.

As reported by Marquez [36], the discourse may have a relevant role in maintaining the problem, but it is possible to pass from a broken discourse to another healthier one. The discourse reveals psychological profiles as well as interaction styles. In the field of ED, and particularly in bulimia nervosa, working with ST should aim to introduce a "language of change" for both patients and families.

#### **2.7 Topics to listen from bulimic storytellers**

Characteristics of bulimia nervosa involve the sufferer bingeing on large amounts of food, during which patients experience feelings of extreme loss of control. Bingeing leaves the patients feeling guilty, disgusted with themselves, and afraid of weight gain. Patients try to compensate for this by vomiting, by exercising, by fasting, by abusing laxatives, or often by some combination of these behaviors. The life of bulimic patients is usually chaotic: dieting, bingeing, purging, fear to weight gain, feeling of being fat, etc. As result, patients have a negative view of themselves which usually leads to avoiding social interactions. Low mood and poor quality of life complete this framework.

In a ST group, some topics will emerge soon:


*Anorexia and Bulimia Nervosa*

the role of telling stories, would lead to the deepest personal illness experiences. Narrative therapy for ED is well known since the 1980s. By means of telling stories, therapists work with patients, who create a sort of "anti-anorexia" and "anti-bulimia" stories. These stories aim to depict a separation between the person and the disorder, thus setting up space for patients (and families) to re-envision their relationship with

their ED. Patients will create a new personal story "without the ED."

be" a bulimic patient than "to suffer from bulimia nervosa" [41].

**2.6 Bulimia nervosa: patients and families. Dialogical analysis with ST**

Along with bulimia nervosa, it has been reported that 61.5% of youth with this ED could be considered to have one or more comorbid disorders (especially mood disorders, anxiety disorders, and personality disorders) [40]. In this particular way, ST might be applied not only in the case of bulimia nervosa but also when comorbidities are present. Thus, using narrative therapy in a group of women with long-course ED with comorbid depression, a reduction in both ED and levels of depression was obtained. It seems necessary to work with different facets: (a) externalize the ED, thus creating distance between herself (patient) and the disorder; (b) explore the person's ED, in which values belong to the patient and which belong to the ED; and (c) develop an alternative story to support the client's sense of self (not just with respect to eating but in other areas of her life); it is not the same "to

ST is a way of communication, a way to change the discourse, thus contributing to change our mind. Many patients usually say "I can't start again" and "it is impossible to change." But if the patient does not change, the result is the permanence. The same applies to families. Between change and permanence emerges the conflict, and the discourses serve the conflict becoming broken, incoherent. Stories may be based on change and on no change. The consequent discourse is a speech aimed to express the deep desire of change or, on the contrary, the conviction to permanence, the change being impossible. As Marquez stated [35, 36], change vs. non-change is something like an inner dialog between voices, but not only "inner" since external components appear (family, partner, friends, etc.). As stated by Salvini et al. [37], the dialog between voices implies that when one party speaks, the other party is required to be silent. This way, it is common that a dominant discourse emerges (interactional dominance), the dialog being asymmetrical. Therapists must consider this phenomenon because the more symmetrical the dialog is, the more opportunity it provides for mutual influence; the more asymmetrical it is, the more it constrains the exchange of views and experiences. When symptoms are the core part of the discourse and this discourse becomes dominant, patients and families are imprisoned. Following the analysis of Márquez [36], in bulimia nervosa stories are characterized by impulsivity, ruptures, advances, and setbacks, which, in short, express precipitation, lack of a necessary prior time for reflection and planning, lack of containment, and difficulties in adjusting to limits. This style usually leads to

Based on the study of Hermans et al. [42], Salvini et al. [37] considered the trend toward discursive change during the therapeutic process according to the following four dimensions: (a) interactional dominance, (b) topic dominance, (c) amount of talk, and (d) strategic movements. In a process of scientific ST, it is relevant to analyze linguistic variations probably linked to a transition from a dysfunctional narrative to a new more coherent one. Among a group of bulimic patients (here bulimic storytellers), one of them could be dominant, and the dialog starts being very asymmetrical. With respect to the topics, diets, body image, emotional instability, binge episodes, purging, and other altered behaviors (e.g., self-injuries) are usually highlighted by group members. At the beginning the amount of talk and strategic

**130**

a chaos narrative [33].


In ST "emotional meanings" are essential. Patients with ED assign different meanings to their disorder. Those meanings are reflected in their narratives, their illness experiences told in their particular stories. Patients with bulimia nervosa usually have maladaptive thoughts and emotions related to eating habits and body weight. They also have low self-esteem, and they seem to be sure that a welldesigned body would be a remedy for their problems of personal insecurity. In this regard, their behaviors aim an idealized body through diets, purging rituals, and often strenuous exercise. The chaos is based on the fact that the desire to lose weight is associated with a personal disorganization. As a result, regulation and control over eating become an attempt to organize and stabilize the chaotic mental state [43]. ST is a good instrument to communicate emotional experiences and a way to access patient's difficulties and internal conflicts. In fact, narratives can be seen as expressions of the self and the living experience for the individual who narrates. The link between individuals and their "bulimic (or anorectic) voice" could explain their ambivalence to change [44–46].

Apart from the abovementioned topics related to the patient's current problems and family-related features, there are different meanings with respect to the onset of the disorder. Low self-esteem, clusters of stressful events, new experiences/ difficulties emerged with the disorder, feelings experienced after the onset of the disorder, etc. are usually core parts of the patients' narratives [43].

As other therapeutical approaches, ST aims to produce changes. Patients and families could expect changes to happen such as more dialog, closeness and affection between family members, fewer conflicts between siblings, greater family participation in treatment, more family togetherness, less critical comments, etc. Considering families, the desire to change family dynamics seems to facilitate a healthier environment and consequently a clear improvement in the therapeutic progress. Generally, family emerges as the main source of patients' social support.

#### **3. Discussion and conclusions**

ST is a communication tool among human beings with a core aspect which is the emotions. Narratives are a vehicle to trigger emotional and cognitive responses to achieve certain serious goals within their context of solicitation. With respect to the context, the applications of scientific ST in well-being, health, medicine, and psychology are good examples of the multiple possibilities in this field of study. Considering health contexts, storytellers are patients and patients' relatives who suffer together a disease or disorder. In this particular way, ST is a manner to motivate both patients and families, ST being a mechanism for reduction in change resistance, which is usually related to health outcomes. In the context of chronic

**133**

English.

*Storytelling as a Therapeutic Tool for Family Support in Bulimia Nervosa*

family emerges as the main source of patients' social support.

the inner highness of the affected person.

*And I tried to be Artemisa or Apollo.*

*When the failed transformation occurred.*

*Y quise ser luna menguante para no ser sol.*

*And I wanted to be waning moon just not to be sun. And I imagined myself to be fine and delicate rainfall. And I was a beautiful Caladium with a slender stem.*

*All the figures that my mind reflected were slimline. Until I did not want to be, until I did not think. Because I was just looking for perfection.*

*I WISHED TO BE…*

*Y QUISE SER…*

ST is above and beyond a useful form of communication. ST is not a specific therapy, and its great advantage is to improve the existing therapies by means of a better communication between therapists and patients as well as between family members and patients. With respect to ED, a patient (that is to say a "storyteller") could summarize, in a delightful poem, the process of changing of someone who starts suffering from anorexia or bulimia nervosa (and still is sure to control it) until they reach a point of no return. The capital letter of each verse wants to reflect

Due to the original language in which the poem has been written down, we have decided to maintain the Spanish version as well as to translate the poem into

*And I dreamt of being a horse chestnut tree with an upright and leafy trunk.*

*And ceased being an Alpha Canis Majoris when my shine dimmed.*

*But I became a goldfinch that could not sing and my colors faded without my knowing why.*

diseases, ST is not a way of simple catharsis. Telling stories about illness experiences seems to be therapeutic due to its potential to facilitate learning and coping with the disease. ED are usually chronic disorders, thus being both a challenge and a source of family problems. Within the family system, a process of meaningmaking will emerge which is absolutely necessary to cope with the illness. This process is guided by culturally dominant illness narratives as stated by Frank, and it was abovementioned [33]. As reported by Marquez [36], the discourse may have a relevant role in maintaining the problem, but it is possible to pass from a broken discourse to another healthier one. The discourse reveals psychological profiles as well as interaction styles. In the field of ED, and particularly in bulimia nervosa, working with ST should aim to introduce a "language of change" for both patients and families. As it was abovementioned, impulsivity, ruptures, advances, and setbacks, which, in short, express precipitation, lack of a necessary prior time for reflection and planning, lack of containment, and difficulties in adjusting to limits, are a cluster which define the interaction between family members and a patient diagnosed with BN. This style usually leads to a chaos in both narrative and relationships (in the case of anorexia nervosa, the circularity—manifested linguistically in the high degree of recurrence—weaves with words a network that envelops and imprisons; the discourse projects an image that encloses the subject within himself; the discourse shows an awareness turned inward, hermetically centered and closed on the conflict, thus affecting a clear dialog with others) [35, 36]. In sum, ST aims to produce changes, in both discourse and relationships. Patients and families could expect changes to happen such as more dialog, closeness and affection between family members, fewer conflicts between siblings, greater family participation in treatment, more family togetherness, less critical comments, etc. Considering families, the desire to change family dynamics seems to facilitate a healthier environment and consequently a clear improvement in the therapeutic progress. Generally,

*DOI: http://dx.doi.org/10.5772/intechopen.86195*

#### *Storytelling as a Therapeutic Tool for Family Support in Bulimia Nervosa DOI: http://dx.doi.org/10.5772/intechopen.86195*

*Anorexia and Bulimia Nervosa*

16. Is this a healthy life?

relationships, etc.?

their ambivalence to change [44–46].

**3. Discussion and conclusions**

13. What induces me to binge?

14. What triggers diet-binge-purge?

15. Can I remember what is normal eating?

12. What is a vicious cycle (diet-binge-diet; purge-binge-purge, etc.)?

17. Am I aware of the links among feelings, thoughts, mood, behavior,

In ST "emotional meanings" are essential. Patients with ED assign different meanings to their disorder. Those meanings are reflected in their narratives, their illness experiences told in their particular stories. Patients with bulimia nervosa usually have maladaptive thoughts and emotions related to eating habits and body weight. They also have low self-esteem, and they seem to be sure that a welldesigned body would be a remedy for their problems of personal insecurity. In this regard, their behaviors aim an idealized body through diets, purging rituals, and often strenuous exercise. The chaos is based on the fact that the desire to lose weight is associated with a personal disorganization. As a result, regulation and control over eating become an attempt to organize and stabilize the chaotic mental state [43]. ST is a good instrument to communicate emotional experiences and a way to access patient's difficulties and internal conflicts. In fact, narratives can be seen as expressions of the self and the living experience for the individual who narrates. The link between individuals and their "bulimic (or anorectic) voice" could explain

Apart from the abovementioned topics related to the patient's current problems and family-related features, there are different meanings with respect to the onset of the disorder. Low self-esteem, clusters of stressful events, new experiences/ difficulties emerged with the disorder, feelings experienced after the onset of the

As other therapeutical approaches, ST aims to produce changes. Patients and families could expect changes to happen such as more dialog, closeness and affection between family members, fewer conflicts between siblings, greater family participation in treatment, more family togetherness, less critical comments, etc. Considering families, the desire to change family dynamics seems to facilitate a healthier environment and consequently a clear improvement in the therapeutic progress. Generally, family emerges as the main source of patients' social support.

ST is a communication tool among human beings with a core aspect which is the emotions. Narratives are a vehicle to trigger emotional and cognitive responses to achieve certain serious goals within their context of solicitation. With respect to the context, the applications of scientific ST in well-being, health, medicine, and psychology are good examples of the multiple possibilities in this field of study. Considering health contexts, storytellers are patients and patients' relatives who suffer together a disease or disorder. In this particular way, ST is a manner to motivate both patients and families, ST being a mechanism for reduction in change resistance, which is usually related to health outcomes. In the context of chronic

disorder, etc. are usually core parts of the patients' narratives [43].

**132**

diseases, ST is not a way of simple catharsis. Telling stories about illness experiences seems to be therapeutic due to its potential to facilitate learning and coping with the disease. ED are usually chronic disorders, thus being both a challenge and a source of family problems. Within the family system, a process of meaningmaking will emerge which is absolutely necessary to cope with the illness. This process is guided by culturally dominant illness narratives as stated by Frank, and it was abovementioned [33]. As reported by Marquez [36], the discourse may have a relevant role in maintaining the problem, but it is possible to pass from a broken discourse to another healthier one. The discourse reveals psychological profiles as well as interaction styles. In the field of ED, and particularly in bulimia nervosa, working with ST should aim to introduce a "language of change" for both patients and families. As it was abovementioned, impulsivity, ruptures, advances, and setbacks, which, in short, express precipitation, lack of a necessary prior time for reflection and planning, lack of containment, and difficulties in adjusting to limits, are a cluster which define the interaction between family members and a patient diagnosed with BN. This style usually leads to a chaos in both narrative and relationships (in the case of anorexia nervosa, the circularity—manifested linguistically in the high degree of recurrence—weaves with words a network that envelops and imprisons; the discourse projects an image that encloses the subject within himself; the discourse shows an awareness turned inward, hermetically centered and closed on the conflict, thus affecting a clear dialog with others) [35, 36]. In sum, ST aims to produce changes, in both discourse and relationships. Patients and families could expect changes to happen such as more dialog, closeness and affection between family members, fewer conflicts between siblings, greater family participation in treatment, more family togetherness, less critical comments, etc. Considering families, the desire to change family dynamics seems to facilitate a healthier environment and consequently a clear improvement in the therapeutic progress. Generally, family emerges as the main source of patients' social support.

ST is above and beyond a useful form of communication. ST is not a specific therapy, and its great advantage is to improve the existing therapies by means of a better communication between therapists and patients as well as between family members and patients. With respect to ED, a patient (that is to say a "storyteller") could summarize, in a delightful poem, the process of changing of someone who starts suffering from anorexia or bulimia nervosa (and still is sure to control it) until they reach a point of no return. The capital letter of each verse wants to reflect the inner highness of the affected person.

Due to the original language in which the poem has been written down, we have decided to maintain the Spanish version as well as to translate the poem into English.

#### *I WISHED TO BE…*

*And I wanted to be waning moon just not to be sun. And I imagined myself to be fine and delicate rainfall. And I was a beautiful Caladium with a slender stem. And I dreamt of being a horse chestnut tree with an upright and leafy trunk. And I tried to be Artemisa or Apollo. But I became a goldfinch that could not sing and my colors faded without my knowing why. And ceased being an Alpha Canis Majoris when my shine dimmed. When the failed transformation occurred. All the figures that my mind reflected were slimline. Until I did not want to be, until I did not think. Because I was just looking for perfection. Y QUISE SER…*

*Y quise ser luna menguante para no ser sol.*

*Y me imaginé ser lluvia fina y delicada. Y fui hermosa Caladium de tallo esbelto. Y soñé ser un castaño de Indias con el tronco erguido y abundante hojas. Y fingí ser Artemisa o Apolo. Pero me convertí en un jilguero que no podía cantar y perdí mis colores sin saber la razón. Y dejé de ser una Alpha Canis Majoris cuando perdí mi brillo. Cuando sucedió la transformación fallida. Todas las figuras que mi mente reflejaba eran finas. Hasta que no quise ser, hasta que no pensé. Porque solo buscaba la perfección.*

#### **Author details**

José Vicente Martínez Quiñones1 \*, Mar Martínez Gamarra<sup>2</sup> and Ignacio Jáuregui Lobera3

1 Department of Neurosurgery, Mutua de Accidentes de Zaragoza, Zaragoza, Spain

2 Storytelling Spanish Association (ASEST), Spain

3 Department of Molecular Biology and Biochemical Engineering, University of Pablo de Olavide of Seville, Seville, Spain

\*Address all correspondence to: jvmartinez@maz.es

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**135**

*Storytelling as a Therapeutic Tool for Family Support in Bulimia Nervosa*

American women. Health Psychology.

[9] Greenhalgh T, Campbell-Richards D, Vijayaraghavan S, Collard A, Malik F, Griffin M, et al. New models of selfmanagement education for minority ethnic groups: Pilot randomized trial of a story-sharing intervention. Journal of Health Services Research & Policy.

2011;**30**:674-682

2011;**16**:28-36

[10] Cangelosi PR, Sorrell JM.

Storytelling as an educational strategy for older adults with chronic illness. Journal of Psychosocial Nursing and Mental Health Services. 2008;**46**:19-22

[11] Greenhalgh T, Collard A, Begum N. Narrative based medicine: An action research project to develop group education and support for bilingual health advocates and elderly south Asian patients with diabetes. Practical Diabetes International. 2005;**22**:125-129

[12] Greenhalgh T, Collard A, Campbell-Richards D, Vijayaraghavan S, Malik F, Morris J, et al. Storylines of self-

management: Narratives of people with diabetes from a multiethnic inner city population. Journal of Health Services Research & Policy. 2011;**16**:37-43

[13] Holm A-K, Lepp M, Ringsberg KC. Dementia: Involving patients in storytelling—A caring intervention. A pilot study. Journal of Clinical Nursing.

[14] Dale JR, Williams SM, Bowyer V. What is the effect of peer support on diabetes outcomes in adults? A systematic review. Diabetic Medicine.

2005;**14**(2):256-263

2012;**29**:1361-1377

[15] Funnell MM. Peer-based behavioural strategies to improve chronic disease self-management and clinical outcomes: Evidence, logistics, evaluation considerations and needs

*DOI: http://dx.doi.org/10.5772/intechopen.86195*

[1] Lugmayr A, Sutinen E, Suhonen J, Islas Sedano C, Hlavacs H, Suero Montero C. Serious storytelling—A first definition and review. Multimedia Tools and Applications. 2017;**76**:15707-15733

[2] Meadows MS. Pause & Effect: The Art of Interactive Narrative. Indianapolis: Pearson Education, New

[3] Day D. Exercise without failure: Building fitness Apps as narrative game. Model View Culture (Technology, Culture, and Diversity Media)

[Online]. 2015. Available from: https:// modelviewculture.com/pieces/exercisewithout-failure-building-fitness-apps-

[4] Debra Malina P. Narrative Medicine:

Honoring the Stories of Illness. New York: Oxford University Press;

[5] Dahlstrom MF, Scheufele DA. (Escaping) the paradox of scientific

[6] Hartling L, Scott S, Pandya R, Johnson D, Bishop T, Klassen TP. Storytelling as a communication tool for health consumers: Development of an intervention for parents of children with croup. Stories to communicate health information. BMC Pediatrics.

[7] Houston TK, Allison JJ, Sussman M, Horn W, Holt CL, Trobaugh J, et al. Culturally appropriate storytelling to improve blood pressure: A randomized trial. Annals of Internal Medicine.

[8] McQueen A, Kreuter MW, Kalesan B, Alcaraz KI. Understanding narrative effects: The impact of breast cancer survivor stories on message processing, attitudes, and beliefs among African

storytelling. PLoS Biology.

2018;**16**:e2006720

2010;**10**:64-74

2011;**154**:77-84

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Riders Press; 2002

as-narrative-games

2006

*Storytelling as a Therapeutic Tool for Family Support in Bulimia Nervosa DOI: http://dx.doi.org/10.5772/intechopen.86195*

#### **References**

*Anorexia and Bulimia Nervosa*

*Y me imaginé ser lluvia fina y delicada. Y fui hermosa Caladium de tallo esbelto.*

*Cuando sucedió la transformación fallida.*

*Hasta que no quise ser, hasta que no pensé.*

*Porque solo buscaba la perfección.*

*Todas las figuras que mi mente reflejaba eran finas.*

*Y fingí ser Artemisa o Apolo.*

*Y soñé ser un castaño de Indias con el tronco erguido y abundante hojas.*

*Y dejé de ser una Alpha Canis Majoris cuando perdí mi brillo.*

*Pero me convertí en un jilguero que no podía cantar y perdí mis colores sin saber la razón.*

**134**

**Author details**

José Vicente Martínez Quiñones1

and Ignacio Jáuregui Lobera3

provided the original work is properly cited.

Pablo de Olavide of Seville, Seville, Spain

2 Storytelling Spanish Association (ASEST), Spain

\*Address all correspondence to: jvmartinez@maz.es

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

\*, Mar Martínez Gamarra<sup>2</sup>

1 Department of Neurosurgery, Mutua de Accidentes de Zaragoza, Zaragoza, Spain

3 Department of Molecular Biology and Biochemical Engineering, University of

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[3] Day D. Exercise without failure: Building fitness Apps as narrative game. Model View Culture (Technology, Culture, and Diversity Media) [Online]. 2015. Available from: https:// modelviewculture.com/pieces/exercisewithout-failure-building-fitness-appsas-narrative-games

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[7] Houston TK, Allison JJ, Sussman M, Horn W, Holt CL, Trobaugh J, et al. Culturally appropriate storytelling to improve blood pressure: A randomized trial. Annals of Internal Medicine. 2011;**154**:77-84

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[10] Cangelosi PR, Sorrell JM. Storytelling as an educational strategy for older adults with chronic illness. Journal of Psychosocial Nursing and Mental Health Services. 2008;**46**:19-22

[11] Greenhalgh T, Collard A, Begum N. Narrative based medicine: An action research project to develop group education and support for bilingual health advocates and elderly south Asian patients with diabetes. Practical Diabetes International. 2005;**22**:125-129

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[36] Márquez M. La palabra de eco. Rasgos lingüísticos propios de una paciente bulímica. Trastornos de la Conducta Alimentaria. 2006;**3**:208-227

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[27] Highet N, Thompson M, King RM. The experience of living with a person with an eating disorder: The impact on the careers. Eating Disorders.

[28] Hillege SP, Beale B, McMaster R. Impact of eating disorders on family life: Individual parents' stories. Journal of Clinical Nursing. 2006;**15**:1016-1022

[29] Tierney SJ. The treatment of adolescent anorexia: A qualitative research study focusing on the views of parents. Eating Disorders.

[30] Vandereycken W. Introduction. Eating Disorders. 2005;**13**:325-326

[32] Crossley ML. Narrative psychology, trauma and the study of self/identity. Theory & Psychology. 2000;**10**:527-546

[33] Frank AW. The Wounded Storyteller: Body, Illness and Ethics. Chicago, IL: University of Chicago Press; 1995

[34] Papathomas A, Smith B, Lavallee D. Family experiences of living with an eating disorder: A narrative analysis. Journal of Health Psychology.

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[31] Bury M. Chronic illness as biographical disruption. Sociology of Health & Illness. 1982;**4**:167-182

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[20] Gucciardi E, Jean-Pierre N, Karam G, Sidani S. Designing and delivering facilitated storytelling interventions for chronic disease self-management: A scoping review. BMC Health Services

[21] Koch T, Kralik D. Chronic illness: Reflections on a community-based action research programme. Journal of Advanced Nursing. 2001;**36**:23-31

[23] Sandelowski M. We are the stories we tell: Narrative knowing in nursing practice. Journal of Holistic Nursing.

[24] Kleinman A. The Illness Narratives: Suffering, Healing, and the Human Condition. New York: Basic Books; 1988

[22] Greenhalgh T, Collard A, Begum N. Sharing stories: Complex intervention for diabetes education in minority ethnic groups who do not speak English. BMJ. 2005;**330**:628

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**139**

Section 4

Clinical Management:

Monitoring of Physical

and Mental Health and

Providing Psychological

Therapy

### Section 4

Clinical Management: Monitoring of Physical and Mental Health and Providing Psychological Therapy

**141**

**1. Introduction**

**Chapter 9**

**Abstract**

Reclaiming the Lost Self in the

Neurobiological Approach to

Brain, and Body

*Abigail H. Natenshon*

Recovery That Integrates Mind,

The pathology of bulimia nervosa reflects the 'dis-integration' of the structure of the self within the distributed nervous system, resulting in the patient's impaired sense of self and incapacity to sense self-experience. The twenty-first century definition of self as 'an embodied, sensory-based process grounded in kinesthetic experience' not only refutes the long-held myth of mind-body dualism, but also sheds light on the influence of neurobiological factors in disease onset and on how people make recovery changes within psychotherapy. The capacity to create, or reinstate, self-integration is built into the nervous system through the neuroplastic brain's ability to change its structure and function in response to thought, sensation, feeling, and motor activity. The introduction of neurophysiological (sensorimotor) and neurobiological (interpersonal, attachment-based) interventions into mainstream clinical treatment for bulimia nervosa increases exposure to embodied experience, fostering mind, brain, and body connectivity. By stimulating integrative neuronal firing and synaptic activity, top-down and bottom-up transactions enhance acuity in self-sensing, self-perception, and body image coherence, supporting the unification of the disparate self. The current focus of mainstream clinical eating disorder treatment on symptom reduction alone neglects the neurological underpinnings of the disease. This chapter describes a range of treatment options for bulimia nervosa

designed to support sustainable changes at the brain level.

attachment, mind-brain-body connections, vertical integration

**Keywords:** bulimia nervosa, anorexia nervosa, eating disorders, self-image, body image, self-integration, neurobiology, neurobiological interventions, neurophysiological interventions, trauma resolution, interpersonal neurobiology, Feldenkrais Method, sensorimotor interventions, embodied self, disorganized

Bulimia nervosa (BN), described as "an ominous variant of anorexia nervosa" (AN) [1], is a disorder of the brain, the distributed nervous system, and the pathological 'dis-integration' of the core self, all indicators of mind, brain, and body

Treatment of Bulimia Nervosa: A

#### **Chapter 9**

## Reclaiming the Lost Self in the Treatment of Bulimia Nervosa: A Neurobiological Approach to Recovery That Integrates Mind, Brain, and Body

*Abigail H. Natenshon*

### **Abstract**

The pathology of bulimia nervosa reflects the 'dis-integration' of the structure of the self within the distributed nervous system, resulting in the patient's impaired sense of self and incapacity to sense self-experience. The twenty-first century definition of self as 'an embodied, sensory-based process grounded in kinesthetic experience' not only refutes the long-held myth of mind-body dualism, but also sheds light on the influence of neurobiological factors in disease onset and on how people make recovery changes within psychotherapy. The capacity to create, or reinstate, self-integration is built into the nervous system through the neuroplastic brain's ability to change its structure and function in response to thought, sensation, feeling, and motor activity. The introduction of neurophysiological (sensorimotor) and neurobiological (interpersonal, attachment-based) interventions into mainstream clinical treatment for bulimia nervosa increases exposure to embodied experience, fostering mind, brain, and body connectivity. By stimulating integrative neuronal firing and synaptic activity, top-down and bottom-up transactions enhance acuity in self-sensing, self-perception, and body image coherence, supporting the unification of the disparate self. The current focus of mainstream clinical eating disorder treatment on symptom reduction alone neglects the neurological underpinnings of the disease. This chapter describes a range of treatment options for bulimia nervosa designed to support sustainable changes at the brain level.

**Keywords:** bulimia nervosa, anorexia nervosa, eating disorders, self-image, body image, self-integration, neurobiology, neurobiological interventions, neurophysiological interventions, trauma resolution, interpersonal neurobiology, Feldenkrais Method, sensorimotor interventions, embodied self, disorganized attachment, mind-brain-body connections, vertical integration

#### **1. Introduction**

Bulimia nervosa (BN), described as "an ominous variant of anorexia nervosa" (AN) [1], is a disorder of the brain, the distributed nervous system, and the pathological 'dis-integration' of the core self, all indicators of mind, brain, and body

disconnection. Scientists propose that somatic, autonomic, and visceral information is aberrantly processed in people who are vulnerable to developing AN and/or BN [2]. Engaging the distributed nervous system in the treatment of BN through adjunctive interventions that combine top-down and bottom-up neurophysiological mechanisms, and/or through the psychobiological attachment bond of emotional communication and interactive regulation between the patient and therapist, heals neurobiological aberrations at their source by accessing the roots of these disorders, which are embedded in neurobiological dysfunction. By capturing images of the neuroplastic brain as it changes in real time, modern brain-scanning technology reveals that harnessing body-based movement and sensory experience in conjunction with psychotherapy facilitates the neurological convergence of the mind, brain, and body, which fosters the integration of the structure of the healthy self. The current focus of mainstream conventional BN treatment, however, is on the psychological and environmental origins of the disorder, neglecting the neurological underpinnings of disease. Scientific evidence points to the need to expand the parameters of the treatment field to promote the neurobiological reintegration of the recovering bulimic patient's healthy self through treatment modalities that sustain changes at the brain level. Recruiting brain circuitry enhances and promotes the integration of the nervous system. "It is around the concept of the core self that psychology crosses paths with the brain and body" [3].

The etiology of neurobiological disturbances leading to ED onset stems from genetic, metabolic, and other biological factors, in conjunction with ever-changing internal forces and external circumstances, compounded by the influence of cooccurring diagnoses. BN symptomatology, marked by behavioral excess and impulsivity, anesthetizes or otherwise reorganizes the patient's affective and internal states. Symptoms typically include bingeing, self-induced vomiting, fasting, food restriction, promiscuity, self mutilation, stealing, compulsive shopping, compulsive exercise, abuse of substances including alcohol, laxatives, diuretics, and/or diet pills, erratic sleep patterns, and the compulsion to prepare food for others.

Alike in their neurobiological underpinnings, AN and BN patients share disturbances in their capacity to experience the sensation of hunger, and typically relieve distress through symptomatic behaviors that create a sense of control over internal chaos and frightening emotions. Diagnostic distinctions between BN and AN are never well delineated. A subgroup of anorexic patients purges; a subgroup of bulimic patients restricts food in the presence, or absence, of bingeing and/or purging. Although abnormally low body weight is an exclusion for the diagnosis of BN, some 25–30% of individuals with BN have a prior history of AN [4]. The greatest levels of psychopathology are present in patients whose diagnoses cross over from AN to BN, or from BN to AN [5], a phenomenon seen in restricting-type AN patients who attempt to eat normally, then fearing the loss of self-control leading to weight gain, couple restrictive eating behaviors with episodes of bingeing and purging; and in BN patients who stop purging, then in an effort to maintain thinness, turn to food restriction or excessive exercise. The binge-purging behaviors of BN lead to a less favorable prognosis than that of restricting-type AN, as dangerous habit-forming and self-perpetuating behaviors lead to potassium depletion and other physical complications [1]. Fifty to eighty percent of the variance in AN and BN liability can be accounted for by genetic factors [2].

This chapter discusses a range of neurophysiological and neurobiological treatment interventions, which, when used as adjuncts to current traditional psychotherapeutic interventions, hold the potential to improve the efficacy and sustainability of ED healing. Because women are more likely than men to perceive their bodies negatively [6], the chapter's focus is on women, with particular attention, through case examples, to those whom I have treated through my practice of psychotherapy.

**143**

*Reclaiming the Lost Self in the Treatment of Bulimia Nervosa: A Neurobiological Approach…*

My concomitant training as a practitioner of the Feldenkrais Method of Somatic Education© has offered me powerful insights into the usefulness of neurophysiological interventions in facilitating healthy self- and body image development. I share some of these insights with readers through anecdotal case examples from my own practice, in conjunction with mindful meditation techniques and Feldenkrais

"The brains of individuals who exhibit eating ED pathology are 'wired' differently [from non-ED brains], creating the need to define diagnosis by aberrations in brain circuitry and physiology, and then provide treatments aimed at correcting or ameliorating the aberrant circuitry" [7]. Neurocognitive and brain imaging studies suggest that ED patients have impaired neural systems implicated in executive functions, visuospatial processes, self-image perception, emotional regulation and reward processing [8]. "New brain-imaging technology provides insights into ventral and dorsal neural circuit dysfunction—perhaps related to altered serotonin and dopamine metabolism—that contributes to the puzzling symptoms found in people with eating disorders. For example, altered insula activity could explain interoceptive dysfunction, and altered striatal activity might shed light on altered reward modulation in people with AN" [2]. Patients with AN have shown overlapping brain networks involved in reward and behavioral compulsivity [9]. The AN individual's trait toward an imbalance between serotonin and dopamine pathways may play a role in an altered interaction between ventral (limbic) neurocircuits, which are important for identifying the emotional significance of stimuli and for generating an affective response to these stimuli, and dorsal (cognitive) neurocircuits that modulate selective attention, planning and effortful regulation of affective states [2]. Dopamine-related reward circuitry, pathways that modulate the drive to eat, showed reduced activation in this network in BN women; the greater the frequency

of binge-purge episodes, the less responsive was the brain [10].

that affect feeding, emotionality, and other behaviors [2].

Starvation and emaciation have profound effects on the functioning of the brain and other organ systems, causing neurochemical disturbances that could exaggerate premorbidity, giving rise to symptoms that maintain or accelerate the disease process. Restrictive eating behaviors have been shown to create adverse structural changes in brain regions that are part of the reward circuitry, and also cause shrinkage in the overall size of the brain, including both gray and white matter [8]. Studies of patients with AN show widespread gray matter decreases in the neocortex and in areas linked to emotion regulation and reward, such as the anterior cingulate, orbitofrontal cortex, insular cortex, hippocampus/parahippocampus, amygdala and striatum; studies also report gray matter increases in neocortical and limbic regions. Such volume alterations may, or may not, normalize following ED recovery, dependent upon the severity and endurance of pathology [8]. Puberty may play an active role in major reorganization of white matter during adolescence and early adulthood [8], and activation of a genetic predisposition for ED symptoms. Menarche is associated with a rapid change in body composition and neuropeptides modulating metabolism. It has been surmised that the rise in estrogen levels in pubescent females could affect neuromodulatory systems such as serotonin or neuropeptides

Multiple and distributed brain regions have been implicated in the psychopathology of AN, implying a dysfunction of interregional brain connectivity [8]. A study of structural connectivity suggests that people with AN may have impaired "wiring" between parts of the brain that are involved in the formulation of insight

*DOI: http://dx.doi.org/10.5772/intechopen.83844*

**2. The neurobiology of AN and BN**

interventions.

*Reclaiming the Lost Self in the Treatment of Bulimia Nervosa: A Neurobiological Approach… DOI: http://dx.doi.org/10.5772/intechopen.83844*

My concomitant training as a practitioner of the Feldenkrais Method of Somatic Education© has offered me powerful insights into the usefulness of neurophysiological interventions in facilitating healthy self- and body image development. I share some of these insights with readers through anecdotal case examples from my own practice, in conjunction with mindful meditation techniques and Feldenkrais interventions.

#### **2. The neurobiology of AN and BN**

*Anorexia and Bulimia Nervosa*

disconnection. Scientists propose that somatic, autonomic, and visceral information is aberrantly processed in people who are vulnerable to developing AN and/or BN [2]. Engaging the distributed nervous system in the treatment of BN through adjunctive interventions that combine top-down and bottom-up neurophysiological mechanisms, and/or through the psychobiological attachment bond of emotional communication and interactive regulation between the patient and therapist, heals neurobiological aberrations at their source by accessing the roots of these disorders, which are embedded in neurobiological dysfunction. By capturing images of the neuroplastic brain as it changes in real time, modern brain-scanning technology reveals that harnessing body-based movement and sensory experience in conjunction with psychotherapy facilitates the neurological convergence of the mind, brain, and body, which fosters the integration of the structure of the healthy self. The current focus of mainstream conventional BN treatment, however, is on the psychological and environmental origins of the disorder, neglecting the neurological underpinnings of disease. Scientific evidence points to the need to expand the parameters of the treatment field to promote the neurobiological reintegration of the recovering bulimic patient's healthy self through treatment modalities that sustain changes at the brain level. Recruiting brain circuitry enhances and promotes the integration of the nervous system. "It is around the concept of the core self that

The etiology of neurobiological disturbances leading to ED onset stems from genetic, metabolic, and other biological factors, in conjunction with ever-changing internal forces and external circumstances, compounded by the influence of cooccurring diagnoses. BN symptomatology, marked by behavioral excess and impulsivity, anesthetizes or otherwise reorganizes the patient's affective and internal states. Symptoms typically include bingeing, self-induced vomiting, fasting, food restriction, promiscuity, self mutilation, stealing, compulsive shopping, compulsive exercise, abuse of substances including alcohol, laxatives, diuretics, and/or diet pills, erratic sleep patterns, and the compulsion to prepare food for others.

Alike in their neurobiological underpinnings, AN and BN patients share disturbances in their capacity to experience the sensation of hunger, and typically relieve distress through symptomatic behaviors that create a sense of control over internal chaos and frightening emotions. Diagnostic distinctions between BN and AN are never well delineated. A subgroup of anorexic patients purges; a subgroup of bulimic patients restricts food in the presence, or absence, of bingeing and/or purging. Although abnormally low body weight is an exclusion for the diagnosis of BN, some 25–30% of individuals with BN have a prior history of AN [4]. The greatest levels of psychopathology are present in patients whose diagnoses cross over from AN to BN, or from BN to AN [5], a phenomenon seen in restricting-type AN patients who attempt to eat normally, then fearing the loss of self-control leading to weight gain, couple restrictive eating behaviors with episodes of bingeing and purging; and in BN patients who stop purging, then in an effort to maintain thinness, turn to food restriction or excessive exercise. The binge-purging behaviors of BN lead to a less favorable prognosis than that of restricting-type AN, as dangerous habit-forming and self-perpetuating behaviors lead to potassium depletion and other physical complications [1]. Fifty to eighty percent of the variance in AN and

This chapter discusses a range of neurophysiological and neurobiological treatment interventions, which, when used as adjuncts to current traditional psychotherapeutic interventions, hold the potential to improve the efficacy and sustainability of ED healing. Because women are more likely than men to perceive their bodies negatively [6], the chapter's focus is on women, with particular attention, through case examples, to those whom I have treated through my practice of psychotherapy.

psychology crosses paths with the brain and body" [3].

BN liability can be accounted for by genetic factors [2].

**142**

"The brains of individuals who exhibit eating ED pathology are 'wired' differently [from non-ED brains], creating the need to define diagnosis by aberrations in brain circuitry and physiology, and then provide treatments aimed at correcting or ameliorating the aberrant circuitry" [7]. Neurocognitive and brain imaging studies suggest that ED patients have impaired neural systems implicated in executive functions, visuospatial processes, self-image perception, emotional regulation and reward processing [8]. "New brain-imaging technology provides insights into ventral and dorsal neural circuit dysfunction—perhaps related to altered serotonin and dopamine metabolism—that contributes to the puzzling symptoms found in people with eating disorders. For example, altered insula activity could explain interoceptive dysfunction, and altered striatal activity might shed light on altered reward modulation in people with AN" [2]. Patients with AN have shown overlapping brain networks involved in reward and behavioral compulsivity [9]. The AN individual's trait toward an imbalance between serotonin and dopamine pathways may play a role in an altered interaction between ventral (limbic) neurocircuits, which are important for identifying the emotional significance of stimuli and for generating an affective response to these stimuli, and dorsal (cognitive) neurocircuits that modulate selective attention, planning and effortful regulation of affective states [2]. Dopamine-related reward circuitry, pathways that modulate the drive to eat, showed reduced activation in this network in BN women; the greater the frequency of binge-purge episodes, the less responsive was the brain [10].

Starvation and emaciation have profound effects on the functioning of the brain and other organ systems, causing neurochemical disturbances that could exaggerate premorbidity, giving rise to symptoms that maintain or accelerate the disease process. Restrictive eating behaviors have been shown to create adverse structural changes in brain regions that are part of the reward circuitry, and also cause shrinkage in the overall size of the brain, including both gray and white matter [8]. Studies of patients with AN show widespread gray matter decreases in the neocortex and in areas linked to emotion regulation and reward, such as the anterior cingulate, orbitofrontal cortex, insular cortex, hippocampus/parahippocampus, amygdala and striatum; studies also report gray matter increases in neocortical and limbic regions. Such volume alterations may, or may not, normalize following ED recovery, dependent upon the severity and endurance of pathology [8]. Puberty may play an active role in major reorganization of white matter during adolescence and early adulthood [8], and activation of a genetic predisposition for ED symptoms. Menarche is associated with a rapid change in body composition and neuropeptides modulating metabolism. It has been surmised that the rise in estrogen levels in pubescent females could affect neuromodulatory systems such as serotonin or neuropeptides that affect feeding, emotionality, and other behaviors [2].

Multiple and distributed brain regions have been implicated in the psychopathology of AN, implying a dysfunction of interregional brain connectivity [8]. A study of structural connectivity suggests that people with AN may have impaired "wiring" between parts of the brain that are involved in the formulation of insight [9]. An example is brain network connective abnormalities that exist within the caudal anterior cingulate and the posterior cingulate, regions crucial for insight, error detection, conflict monitoring, and self-reflection. One study showed that in AN patients, these regions are poorly connected with the rest of the brain, as compared to healthy participants [9].

Body image distortion may be coded in parietal, frontal, and cingulate regions that assign motivational relevance to sensory events [4]. The parietal cortex mediates perceptions of the body and its activity in physical space. "Recent research extends this concept to suggest that the parietal lobe contributes to the experience of the patient being an 'agent' of her own actions. The well-known distortion of body image in individuals with AN may suggest abnormalities of circuits through the postulated 'self' networks" [4]. Reindl [11] describes BN as a disorder of the self, involving the patient's neurological incapacity to sense self-experience. Bulimic women in recovery report increasing accuracy in "sensing their own voice, sensing that they matter as human beings, sensing what to expect within the change process, and sensing their own curiosity [rather than fear] about their subjective experience" (in [11], pp. 281–282).

*After engaging in treatment for BN, Emma began to develop a sense that her life matters, and that she has needs that deserve to be recognized by others. Feeling safer and stronger now, through her newly emerging sense of self, in response to her controlling husband's insistence that she terminate treatment, she replied, "Therapy has become my world now. It is nothing that I plan to stop soon."*

#### **3. Factors contributing to BN onset: genetics loads the gun; the environment pulls the trigger**

A child with a genetic susceptibility to develop addictions, clinical eating disorders, depression and/or anxiety, having been exposed to the neurobiological effects of chronic early parent/child attachment disturbances, becomes vulnerable to the onset of AN or BN in later life. "The early years of a child's life are the most pivotal time for ground floor development of identity and self-image. Failure of caregivers' appropriate responses to a child's needs deprives the developing child of the essential groundwork for acquiring her own body identity, with a discriminating perceptual and conceptual awareness of her own functions" (in [12], p. 57).

*Emma, having been bulimic for many decades, reports that when, as an adult, she was 100 pounds overweight, she never experienced herself as being "a fat person." Following bariatric surgery, at a normal weight, she was unable to perceive herself as having become thinner, which motivated her to begin restricting her caloric intake. "In an exercise class one day," she reported, "I caught a glimpse of myself in the mirror and was surprised…. "Who is that person?" I thought. "Could that really be me?"*

The awareness of oneself as a separate individual evolves only through *experiences* and *continuous interaction* with one's environment (in [12], p. 57). "Attuned, empathic responses from caregivers to the child's basic narcissistic needs are experienced by the child as part of the self, and are essential for the development of a healthy self-structure. For example, the caregiver needs to soothe when the child needs calming, enliven when the child needs stimulation, affirm when the child needs coherence" (in [11], p. 39). "When the child's narcissistic needs are disregarded, she becomes vulnerable to an experience of fragmentation and depletion

**145**

*Reclaiming the Lost Self in the Treatment of Bulimia Nervosa: A Neurobiological Approach…*

(in [11], p. 39). "By not listening and responding appropriately to a child's needs, parents deprive the child of the opportunity to learn how to listen and respond appropriately to *herself* "(in [11], p. 39). The child whose care-giver uses food as a reward for compliant behavior, or withholds it as punishment, will grow up confused and unable to differentiate her various needs, feeling helpless in controlling her biological urges and emotional impulses (in [12], p. 57). Non-secure relational attachment through neglect or abuse by caregivers in a child's early experience interrupts the production of integrative neuronal fibers within the integrative regions of the brain, which include the amygdala, hippocampus, and prefrontal

When a child's genuine needs and affects are consistently met with chronologically inadequate empathy by caregivers, these "needs and affects become disavowed, repressed, or split off from the total self-structure" within the nervous system (in [11], p. 35). The individual's emotional development, once derailed, is unavailable to be integrated into the adult personality (in [11], p. 36). The child not only fails to internalize a healthy self-structure, but eventually creates a new self-system with the split-off aspects of the self. If the individual later begins to experiment with bulimic behaviors, the biochemical effects of the binge-purge cycle create an altered state, reinforcing the already existing split in the psyche, and further organizing the dissociated needs into a 'bulimic self.' Essentially, the BN individual invents a system by which disordered eating patterns, rather than people,

Without adequate self-structure, the child experiences herself as ineffective in communicating her internal states to others. Feeling worthless and unlovable contributes to the development of a deep sense of shame. Repeated shame-inducing interpersonal experiences in childhood, once internalized, become an enduring, core sense of shame, spreading throughout the self, shaping one's emerging identity. Contained within the experience of shame is the piercing awareness of one's self as fundamentally deficient, in some vital way, as a human being (in [11], p. 15).

*Tess has struggled with BN for decades. Throughout her childhood, she endured her mother's on-going judgment and criticism about her weight. Disagreeing with the pediatrician, Tess' mother considered her daughter "fat," and forbade her to eat the sweet and savory treats offered to her brothers. Tess experienced a searing sense of shame each time her mother warned her not to "let food cross her lips," or forced her to cross her legs to prove that she hadn't yet become too fat to do so. Tess reported, "She informed me in the third grade that when I reached grade five, I could attend Weight Watchers meetings." Decades later, Tess explained, "Having food in my stomach still opens the floodgates of shame and embarrassment from my childhood, bringing me back to those immense feelings of inadequacy and incompetency. My greatest shame of all was in how unworthy I felt to be my mother's child." Early childhood feelings of helplessness and confusion reinforced Tess' continued inability to control her urges and impulses and differentiate her* 

Dysfunctional family systems of BN individuals tend to generate greater mutual neglect, rejection, and blame, and less understanding, nurturance, and support than do more functional families. The obsessions and compulsions connected to BN symptoms provide the individual a protective shield against disintegration and internal collapse within the hostile and critical family environment, as well as a

sense of internal coherence that calms, numbs, or stimulates, as needed.

*Tess reports spending much of her childhood in her closet, hidden and isolated, shut off from her family's chaotic world. "I felt invisible and safe there, muffling* 

cortex, where the capacity for self-regulation is located [13].

are used to meet self-object needs (in [11], p. 36).

*needs and desires well into her adult years.*

*DOI: http://dx.doi.org/10.5772/intechopen.83844*

#### *Reclaiming the Lost Self in the Treatment of Bulimia Nervosa: A Neurobiological Approach… DOI: http://dx.doi.org/10.5772/intechopen.83844*

(in [11], p. 39). "By not listening and responding appropriately to a child's needs, parents deprive the child of the opportunity to learn how to listen and respond appropriately to *herself* "(in [11], p. 39). The child whose care-giver uses food as a reward for compliant behavior, or withholds it as punishment, will grow up confused and unable to differentiate her various needs, feeling helpless in controlling her biological urges and emotional impulses (in [12], p. 57). Non-secure relational attachment through neglect or abuse by caregivers in a child's early experience interrupts the production of integrative neuronal fibers within the integrative regions of the brain, which include the amygdala, hippocampus, and prefrontal cortex, where the capacity for self-regulation is located [13].

When a child's genuine needs and affects are consistently met with chronologically inadequate empathy by caregivers, these "needs and affects become disavowed, repressed, or split off from the total self-structure" within the nervous system (in [11], p. 35). The individual's emotional development, once derailed, is unavailable to be integrated into the adult personality (in [11], p. 36). The child not only fails to internalize a healthy self-structure, but eventually creates a new self-system with the split-off aspects of the self. If the individual later begins to experiment with bulimic behaviors, the biochemical effects of the binge-purge cycle create an altered state, reinforcing the already existing split in the psyche, and further organizing the dissociated needs into a 'bulimic self.' Essentially, the BN individual invents a system by which disordered eating patterns, rather than people, are used to meet self-object needs (in [11], p. 36).

Without adequate self-structure, the child experiences herself as ineffective in communicating her internal states to others. Feeling worthless and unlovable contributes to the development of a deep sense of shame. Repeated shame-inducing interpersonal experiences in childhood, once internalized, become an enduring, core sense of shame, spreading throughout the self, shaping one's emerging identity. Contained within the experience of shame is the piercing awareness of one's self as fundamentally deficient, in some vital way, as a human being (in [11], p. 15).

*Tess has struggled with BN for decades. Throughout her childhood, she endured her mother's on-going judgment and criticism about her weight. Disagreeing with the pediatrician, Tess' mother considered her daughter "fat," and forbade her to eat the sweet and savory treats offered to her brothers. Tess experienced a searing sense of shame each time her mother warned her not to "let food cross her lips," or forced her to cross her legs to prove that she hadn't yet become too fat to do so. Tess reported, "She informed me in the third grade that when I reached grade five, I could attend Weight Watchers meetings." Decades later, Tess explained, "Having food in my stomach still opens the floodgates of shame and embarrassment from my childhood, bringing me back to those immense feelings of inadequacy and incompetency. My greatest shame of all was in how unworthy I felt to be my mother's child." Early childhood feelings of helplessness and confusion reinforced Tess' continued inability to control her urges and impulses and differentiate her needs and desires well into her adult years.*

Dysfunctional family systems of BN individuals tend to generate greater mutual neglect, rejection, and blame, and less understanding, nurturance, and support than do more functional families. The obsessions and compulsions connected to BN symptoms provide the individual a protective shield against disintegration and internal collapse within the hostile and critical family environment, as well as a sense of internal coherence that calms, numbs, or stimulates, as needed.

*Tess reports spending much of her childhood in her closet, hidden and isolated, shut off from her family's chaotic world. "I felt invisible and safe there, muffling* 

*Anorexia and Bulimia Nervosa*

compared to healthy participants [9].

experience" (in [11], pp. 281–282).

**environment pulls the trigger**

*really be me?"*

[9]. An example is brain network connective abnormalities that exist within the caudal anterior cingulate and the posterior cingulate, regions crucial for insight, error detection, conflict monitoring, and self-reflection. One study showed that in AN patients, these regions are poorly connected with the rest of the brain, as

Body image distortion may be coded in parietal, frontal, and cingulate regions that assign motivational relevance to sensory events [4]. The parietal cortex mediates perceptions of the body and its activity in physical space. "Recent research extends this concept to suggest that the parietal lobe contributes to the experience of the patient being an 'agent' of her own actions. The well-known distortion of body image in individuals with AN may suggest abnormalities of circuits through the postulated 'self' networks" [4]. Reindl [11] describes BN as a disorder of the self, involving the patient's neurological incapacity to sense self-experience. Bulimic women in recovery report increasing accuracy in "sensing their own voice, sensing that they matter as human beings, sensing what to expect within the change process, and sensing their own curiosity [rather than fear] about their subjective

*After engaging in treatment for BN, Emma began to develop a sense that her life matters, and that she has needs that deserve to be recognized by others. Feeling safer and stronger now, through her newly emerging sense of self, in response to her controlling husband's insistence that she terminate treatment, she replied, "Therapy* 

*has become my world now. It is nothing that I plan to stop soon."*

**3. Factors contributing to BN onset: genetics loads the gun; the** 

A child with a genetic susceptibility to develop addictions, clinical eating disorders, depression and/or anxiety, having been exposed to the neurobiological effects of chronic early parent/child attachment disturbances, becomes vulnerable to the onset of AN or BN in later life. "The early years of a child's life are the most pivotal time for ground floor development of identity and self-image. Failure of caregivers' appropriate responses to a child's needs deprives the developing child of the essential groundwork for acquiring her own body identity, with a discriminating perceptual and conceptual awareness of her own functions" (in [12], p. 57).

*Emma, having been bulimic for many decades, reports that when, as an adult, she was 100 pounds overweight, she never experienced herself as being "a fat person." Following bariatric surgery, at a normal weight, she was unable to perceive herself as having become thinner, which motivated her to begin restricting her caloric intake. "In an exercise class one day," she reported, "I caught a glimpse of myself in the mirror and was surprised…. "Who is that person?" I thought. "Could that* 

The awareness of oneself as a separate individual evolves only through *experiences* and *continuous interaction* with one's environment (in [12], p. 57). "Attuned, empathic responses from caregivers to the child's basic narcissistic needs are

experienced by the child as part of the self, and are essential for the development of a healthy self-structure. For example, the caregiver needs to soothe when the child needs calming, enliven when the child needs stimulation, affirm when the child needs coherence" (in [11], p. 39). "When the child's narcissistic needs are disregarded, she becomes vulnerable to an experience of fragmentation and depletion

**144**

*the sounds of my family's screaming and arguing, protecting myself from having to witness my father physically abusing my brothers." Decades later, at the start of treatment, Tess was still seeking refuge from shame and disgrace behind closed (bathroom) doors now, hiding her purging behaviors from her husband and children. "My feelings of disgrace about needing to soothe myself by purging food and feelings have haunted, and followed me, throughout my life."*

The quality of early caregiving "not only affects the child's subjective experience in the moment, but also influences the on-going development of her brain, effecting how her brain will process experience in the future" (in [11], p. 49).

#### **3.1 BN onset typically postdates childhood**

Setting the neurological stage for the onset of BN in later life, early childhood abuse or neglect impairs the structure of the self within the nervous system. The abused or neglected young child does not yet have the emotional, developmental, or environmental wherewithal to engage in compensatory behaviors, such as purging, substance abuse, or excessive exercise, all characteristic of BN pathology. BN onset usually emerges in later years, during adolescence or young adulthood, continuing into later years and decades if untreated and unresolved. Early life experiences that influence the mental and emotional characteristics of the child alter the anatomic, physiologic, and metabolic [neurobiological] characteristics of the adult [12]. As adults, BN individuals who have undergone early attachment disorganization impose various forms of abuse and degradation upon themselves, reminiscent of those sustained in childhood.

Women with BN avoid turning inwards to sense their needs, desires, feelings and aggressive strivings, for fear of encountering annihilating disgrace and inadequacy, compounded by guilt.

*Emma considered engagement in any form of self-care as equivalent to "intolerable selfishness." Incapable of sensing her own needs and self-experience at the start of treatment, Emma could not discern whether her expressions of kindness or consideration towards her friends were based on honest feelings, or if they were merely "self-serving manipulations," designed to insure the friendship of women whose love and favor she felt she did not deserve.*

Profoundly disconnected from their subjective psychic and physical experience, BN individuals feel the need to rely on externally based, rather than internally sensed, gauges to guide their actions.

*Emma said, "Because my judgment about everything is so poor, and my thoughts and opinions are never right or acceptable, I have had to rely on my husband to know what is right for the two of us. For close to 25 years of marriage, I have had to 'suck it up,' accepting what he likes, and doing what he wants…. I am also well aware that if I were ever to cross him, the emotional costs for me would be high."*

As a disorder of the self, BN is characterized by the individual's diminished selfcontrol, self-regulation, self-attunement, self-trust, self-agency, self-reliance, selfperception, self-sensing and self-worth. As an escape from consciousness of the self, and in response to deficits in self-structure and self-regulatory capacities, BN behaviors separate [dissociate] the patient from her painful thoughts and feelings. "Dissociation implies that two or more mental processes or contents are not associated or integrated, with the result that consciousness, memory, identity, and perception are to some extent disconnected and not experienced as a whole" (in [11], pp. 15, 34).

**147**

*Reclaiming the Lost Self in the Treatment of Bulimia Nervosa: A Neurobiological Approach…*

*Despite Tess' substantive progress in her BN recovery, her husband's "surprise attack" over dinner one night felt to her like an undeserved and highly demeaning insult. Tess described her immediate, entirely bodily-centered reaction; "I completely shut-down. I went into "blackout mode," totally disconnecting from him, my feelings, and my self. I purged my dinner, along with my feelings, which I had been completely unable to identify till I felt my stomach completely empty. It was only after the violence of that event that I became calm enough to realize what a fool I'd* 

*been for believing that he values me and the person that I am becoming."*

narrative that contained more constructive options for problem resolution.

**4. Treating the human nervous system reintegrates mind, brain,** 

and where neurons fire, new connections can be made" (in [16], p. 18).

Contained within the nervous system and grounded in perception and kinesthetic experience, body image and self-image are "virtually interchangeable within the brain, each having mental and neurophysiological components embedded in

In describing how nervous system interconnections occur, Daniel Siegel defines the brain as "a *self*-organizing emergent process of electrochemical energy exchange between brain and body, and with other individuals" [14] and the human mind as "a relational and embodied process that regulates the flow of energy and information" [15]. The roots of the embodied mind exist in the somatic reality of the body. When the dynamic interaction between body and brain is activated, the regulation of energy and information flow happens "not only in the circuits and synapses of the skull-based brain, but also within the body, in the distributed nervous system" (in [15], p. 54). Feedback from sensory receptors throughout the body creates and re-creates the embodied self. Patients access the embodied self through sensing it, in response to selfexperience. "The body, as represented in the brain by a map, may constitute the indispensable form of reference for the neural processes that we experience as the mind" [3]. Norman Doidge explains how it all works. "We tend to think of learning as having internal origins within the cranial brain in thoughts, ideas and feelings (top down, and 'from the inside out'). But this is only partly the case. Brain-changing electrical movements also originate in externalized behaviors, through experience and behaviors, affecting the brain 'from the outside in,' addressing different regions [16]. The brain is a feedback loop system, seeking balance and coherence through its own integration in order to achieve and maintain homeostasis [15]. It changes its structure and function with each different activity it performs, continually perfecting its circuits so as to be better suited to any task at hand [17]. "All experience encompassing thought, sensation, feeling, and behavior, be it conscious or unconscious, is embedded in neurons, with neuroplastic change occurring through the movement of ions in and out of brain membranes. Set off by a dynamic flow of electrochemical energy that creates electrical signals and patterns inside neurons, the movement of ions increases the density of brain circuitry within and between various regions of the brain where healing change occurs. Where attention goes, neural firing occurs,

Tess had little access to her thinking brain until after her stomach had had its way with her, a phenomenon demonstrating a rift in the fabric of her self-structure. Nervous system re-integration (i.e., healing) takes place over time and through therapeutic life experience, particularly when long-term dysfunction has been ingrained in neuronal development. Significantly however, Tess' capacity to bring her left-brain online in the face of traumatic memory was becoming appreciably more rapid and consistent. In starting to put words to her feelings, she had begun to create a coherent

*DOI: http://dx.doi.org/10.5772/intechopen.83844*

**and body**

*Reclaiming the Lost Self in the Treatment of Bulimia Nervosa: A Neurobiological Approach… DOI: http://dx.doi.org/10.5772/intechopen.83844*

*Despite Tess' substantive progress in her BN recovery, her husband's "surprise attack" over dinner one night felt to her like an undeserved and highly demeaning insult. Tess described her immediate, entirely bodily-centered reaction; "I completely shut-down. I went into "blackout mode," totally disconnecting from him, my feelings, and my self. I purged my dinner, along with my feelings, which I had been completely unable to identify till I felt my stomach completely empty. It was only after the violence of that event that I became calm enough to realize what a fool I'd been for believing that he values me and the person that I am becoming."*

Tess had little access to her thinking brain until after her stomach had had its way with her, a phenomenon demonstrating a rift in the fabric of her self-structure. Nervous system re-integration (i.e., healing) takes place over time and through therapeutic life experience, particularly when long-term dysfunction has been ingrained in neuronal development. Significantly however, Tess' capacity to bring her left-brain online in the face of traumatic memory was becoming appreciably more rapid and consistent. In starting to put words to her feelings, she had begun to create a coherent narrative that contained more constructive options for problem resolution.

#### **4. Treating the human nervous system reintegrates mind, brain, and body**

In describing how nervous system interconnections occur, Daniel Siegel defines the brain as "a *self*-organizing emergent process of electrochemical energy exchange between brain and body, and with other individuals" [14] and the human mind as "a relational and embodied process that regulates the flow of energy and information" [15]. The roots of the embodied mind exist in the somatic reality of the body. When the dynamic interaction between body and brain is activated, the regulation of energy and information flow happens "not only in the circuits and synapses of the skull-based brain, but also within the body, in the distributed nervous system" (in [15], p. 54). Feedback from sensory receptors throughout the body creates and re-creates the embodied self. Patients access the embodied self through sensing it, in response to selfexperience. "The body, as represented in the brain by a map, may constitute the indispensable form of reference for the neural processes that we experience as the mind" [3].

Norman Doidge explains how it all works. "We tend to think of learning as having internal origins within the cranial brain in thoughts, ideas and feelings (top down, and 'from the inside out'). But this is only partly the case. Brain-changing electrical movements also originate in externalized behaviors, through experience and behaviors, affecting the brain 'from the outside in,' addressing different regions [16]. The brain is a feedback loop system, seeking balance and coherence through its own integration in order to achieve and maintain homeostasis [15]. It changes its structure and function with each different activity it performs, continually perfecting its circuits so as to be better suited to any task at hand [17]. "All experience encompassing thought, sensation, feeling, and behavior, be it conscious or unconscious, is embedded in neurons, with neuroplastic change occurring through the movement of ions in and out of brain membranes. Set off by a dynamic flow of electrochemical energy that creates electrical signals and patterns inside neurons, the movement of ions increases the density of brain circuitry within and between various regions of the brain where healing change occurs. Where attention goes, neural firing occurs, and where neurons fire, new connections can be made" (in [16], p. 18).

Contained within the nervous system and grounded in perception and kinesthetic experience, body image and self-image are "virtually interchangeable within the brain, each having mental and neurophysiological components embedded in

*Anorexia and Bulimia Nervosa*

*the sounds of my family's screaming and arguing, protecting myself from having to witness my father physically abusing my brothers." Decades later, at the start of treatment, Tess was still seeking refuge from shame and disgrace behind closed (bathroom) doors now, hiding her purging behaviors from her husband and children. "My feelings of disgrace about needing to soothe myself by purging food* 

The quality of early caregiving "not only affects the child's subjective experience in the moment, but also influences the on-going development of her brain, effect-

Setting the neurological stage for the onset of BN in later life, early childhood abuse or neglect impairs the structure of the self within the nervous system. The abused or neglected young child does not yet have the emotional, developmental, or environmental wherewithal to engage in compensatory behaviors, such as purging, substance abuse, or excessive exercise, all characteristic of BN pathology. BN onset usually emerges in later years, during adolescence or young adulthood, continuing into later years and decades if untreated and unresolved. Early life experiences that influence the mental and emotional characteristics of the child alter the anatomic, physiologic, and metabolic [neurobiological] characteristics of the adult [12]. As adults, BN individuals who have undergone early attachment disorganization impose various forms of abuse and degradation upon themselves, reminiscent of those sustained in childhood. Women with BN avoid turning inwards to sense their needs, desires, feelings and aggressive strivings, for fear of encountering annihilating disgrace and inad-

*Emma considered engagement in any form of self-care as equivalent to "intolerable selfishness." Incapable of sensing her own needs and self-experience at the start of treatment, Emma could not discern whether her expressions of kindness or consideration towards her friends were based on honest feelings, or if they were merely "self-serving manipulations," designed to insure the friendship of women whose love* 

Profoundly disconnected from their subjective psychic and physical experience,

*Emma said, "Because my judgment about everything is so poor, and my thoughts and opinions are never right or acceptable, I have had to rely on my husband to know what is right for the two of us. For close to 25 years of marriage, I have had to 'suck it up,' accepting what he likes, and doing what he wants…. I am also well aware that if* 

As a disorder of the self, BN is characterized by the individual's diminished selfcontrol, self-regulation, self-attunement, self-trust, self-agency, self-reliance, selfperception, self-sensing and self-worth. As an escape from consciousness of the self, and in response to deficits in self-structure and self-regulatory capacities, BN behaviors separate [dissociate] the patient from her painful thoughts and feelings. "Dissociation implies that two or more mental processes or contents are not associated or integrated, with the result that consciousness, memory, identity, and perception are to some extent

BN individuals feel the need to rely on externally based, rather than internally

*I were ever to cross him, the emotional costs for me would be high."*

disconnected and not experienced as a whole" (in [11], pp. 15, 34).

*and feelings have haunted, and followed me, throughout my life."*

ing how her brain will process experience in the future" (in [11], p. 49).

**3.1 BN onset typically postdates childhood**

equacy, compounded by guilt.

*and favor she felt she did not deserve.*

sensed, gauges to guide their actions.

**146**

neurons. There is no valid distinction to be made between the "mind-self" and the "embodied self" (in [18], p. 18). Body image [and self image] change from action to action, built from sensory and psychic experiences that are constantly being integrated in the central nervous system (in [12], p. 87). "It is through self-awareness/ consciousness of body and brain that we clarify self-image and body image, experiencing both as an inseparable whole. The unity of body and mind is an objective reality. All feelings and emotions have motoric antecedents initiated within the body" [19]. In other words, "emotions themselves are body phenomena," [20] with the body experiencing emotions first, prior to the mental awareness of feelings. Experiencing emotions is therefore synonymous with experiencing body and brain changes; the development of self-regulation becomes synonymous with regulating changes in both the body and the brain. In BN individuals who have experienced trauma, the brain, which interprets the traumatic event as still happening, will become calmed only following the calming of the body, which under the right circumstances, becomes capable of healing itself, along with emotional wounds.

#### **5. Defining mental health as nervous system integration**

The best predictor of positive mental health is nervous system integration [14]. The mind seeks to achieve mental health through "self-organization, optimizing function by linking differentiated parts of the [nervous] system in the quest for harmony, flexibility, resiliency, adaptability, stability, coherence and energy… otherwise known as integration" [15]. In recognizing the body as the first responder to emotional stimuli, the task at hand in healing BN patients is to differentiate emotions from physiological activation. Cognitive self-regulation of emotional responses to aversive events is essential for mental and physical health. Emotion regulation involves a coherent relationship with the self… in other words, the effective, integrative communication between body, mind, and feelings [21]. "A prerequisite for successful emotion regulation is the awareness of emotional states, which in turn is associated with the awareness of bodily signals, or interoceptive awareness" [22]. "The human body needs to sense, process, and integrate different bodily signals in the premotor, temporoparietal, posterior parietal, and extrastriate cortices, in order to achieve self-identification, self-location, and body-part ownership" [23]. "Stimulating interoceptive sensing of body signals facilitates the differentiation of emotions from the physiological component of emotional experience, promoting self-regulation," [22] a process central to healing sub-clinical, as well as clinical, eating disorders and dysfunctions of all kinds. A direct correlation exists between a full and integrative ED recovery, and the achievement of central nervous system integration within the treatment process. A survey of recovered ED patients identified "dimensions of psychological self-adaptability and resilience *within a complete and integrative* mental health model" as the fundamental criteria for having achieved recovery success [24]. In retrospect, it is not unusual for recovered ED individuals to express appreciation and gratitude for having experienced the twicedifficult ordeal of taking on the life-threatening challenges of illness, followed by the life-enhancing challenges of the psychotherapeutic healing process.

#### **6. Integrative disorders require integrative approaches to treatment**

Currently, conventional psychosocial, behavioral and pharmacological treatment interventions for adults with BN and AN have been shown to have limited efficacy [25]. Hilde Bruch, a pioneer in the field of ED treatment, contends that

**149**

*Reclaiming the Lost Self in the Treatment of Bulimia Nervosa: A Neurobiological Approach…*

unsatisfactory treatment results are related to inadequate conceptualizations of the underlying problems (deficits in self-perception and inner controls) (in [12], pp. 378–379). By re-defining the self as "an embodied, sensory-based process grounded in kinesthetic experience" [15], twenty-first century brain research and the field of interpersonal neurobiology have opened new possibilities for the treatment of the impaired BN self, shedding light on *how* people make changes within the context of psychotherapy. In healing the self, therapeutic interventions that access the embodied brain (sensory receptors embedded within, and distributed throughout the body), together with the cranial-based thinking brain, best address the broader neurobiological issues that underlie the inception and maintenance of

"Greater attention to improving the efficacy of existing ED treatment methodologies is critical, given the increasing prevalence of ED, the high risk of relapse, the effects of concurrent psychopathology, the high cost of care, and the greatest mortality rate of all the mental health disorders, which is one in ten patients [25]. Treatment outcome studies for cognitive-behavioral therapy (CBT), currently considered 'best practice' for the treatment of BN, reveal that only 50% of BN subjects stop bingeing and purging even under the very best conditions" [25]. Neurobiological solutions for the impairment of self-structure exist within the patient's learned capacity to sense self-experience, a process defined as "attunement to one's subjective felt experience… a 'felt sense,' being both psychic and bodily, beginning with the body and occurring in the zone between the conscious and the unconscious. Turning inward to consult this 'border zone' leads to the capacity to trust in one's subjective experience, from which emotions, cognitions and memories arise, fostering deep therapeutic changes" (in [11], p. 12), and access to an ever

Clinicians enhance the patient's capacity to integrate self-based consciousness through focusing on body-felt sensations connected to the emotions and underlying

"The more completely a patient accesses and uses her entire muscular apparatus, the more the brain will become activated, with the activated regions further stimulating adjacent areas," [26] increasing exposure to self-experience and the patient's

Providing new ways "to pay attention within the integration of consciousness enables the client with an open and receptive mind to catalyze the integration of new combinations of previously isolated segments of his or her mental reality"

*At one point during a therapy session, I felt I had lost connection with Emma, noticing her eyes beginning to divert from mine, and her increasing discomfort. "What are you feeling right now?" I inquired. Closing her eyes and grimacing, she sat forward on the couch and reported that what we were discussing was making her feel uncomfortable. In response to my inquiry about where in her body she might be sensing this discomfort, Emma replied that it was "in her stomach" and that she was starting to feel nauseated. Previously, she had relinquished responsibility for her purging, blaming her stomach for "dictating" when and where purging would occur. Now she would choose to take responsibility for preventing this from happening. "Why don't we spend a few minutes breathing together," I suggested. The experience altered her emotional state. At this point, with her left-brain on board she began to use words to communicate her feelings of distress, and was relieved to report that her stomach agitation was subsiding. The first stirrings of Emma's feelings of relief, accomplishment, and self-agency were the result of her refusal to succumb to an interruption in the flow of that session by engaging in BN behaviors.*

*DOI: http://dx.doi.org/10.5772/intechopen.83844*

deeper and more complex sense of self" (in [11], p. 99).

issues that bring her to treatment [15].

potential to sense it (in [11], p. 162).

eating disorders.

*Reclaiming the Lost Self in the Treatment of Bulimia Nervosa: A Neurobiological Approach… DOI: http://dx.doi.org/10.5772/intechopen.83844*

unsatisfactory treatment results are related to inadequate conceptualizations of the underlying problems (deficits in self-perception and inner controls) (in [12], pp. 378–379). By re-defining the self as "an embodied, sensory-based process grounded in kinesthetic experience" [15], twenty-first century brain research and the field of interpersonal neurobiology have opened new possibilities for the treatment of the impaired BN self, shedding light on *how* people make changes within the context of psychotherapy. In healing the self, therapeutic interventions that access the embodied brain (sensory receptors embedded within, and distributed throughout the body), together with the cranial-based thinking brain, best address the broader neurobiological issues that underlie the inception and maintenance of eating disorders.

"Greater attention to improving the efficacy of existing ED treatment methodologies is critical, given the increasing prevalence of ED, the high risk of relapse, the effects of concurrent psychopathology, the high cost of care, and the greatest mortality rate of all the mental health disorders, which is one in ten patients [25]. Treatment outcome studies for cognitive-behavioral therapy (CBT), currently considered 'best practice' for the treatment of BN, reveal that only 50% of BN subjects stop bingeing and purging even under the very best conditions" [25]. Neurobiological solutions for the impairment of self-structure exist within the patient's learned capacity to sense self-experience, a process defined as "attunement to one's subjective felt experience… a 'felt sense,' being both psychic and bodily, beginning with the body and occurring in the zone between the conscious and the unconscious. Turning inward to consult this 'border zone' leads to the capacity to trust in one's subjective experience, from which emotions, cognitions and memories arise, fostering deep therapeutic changes" (in [11], p. 12), and access to an ever deeper and more complex sense of self" (in [11], p. 99).

Clinicians enhance the patient's capacity to integrate self-based consciousness through focusing on body-felt sensations connected to the emotions and underlying issues that bring her to treatment [15].

*At one point during a therapy session, I felt I had lost connection with Emma, noticing her eyes beginning to divert from mine, and her increasing discomfort. "What are you feeling right now?" I inquired. Closing her eyes and grimacing, she sat forward on the couch and reported that what we were discussing was making her feel uncomfortable. In response to my inquiry about where in her body she might be sensing this discomfort, Emma replied that it was "in her stomach" and that she was starting to feel nauseated. Previously, she had relinquished responsibility for her purging, blaming her stomach for "dictating" when and where purging would occur. Now she would choose to take responsibility for preventing this from happening. "Why don't we spend a few minutes breathing together," I suggested. The experience altered her emotional state. At this point, with her left-brain on board she began to use words to communicate her feelings of distress, and was relieved to report that her stomach agitation was subsiding. The first stirrings of Emma's feelings of relief, accomplishment, and self-agency were the result of her refusal to succumb to an interruption in the flow of that session by engaging in BN behaviors.*

"The more completely a patient accesses and uses her entire muscular apparatus, the more the brain will become activated, with the activated regions further stimulating adjacent areas," [26] increasing exposure to self-experience and the patient's potential to sense it (in [11], p. 162).

Providing new ways "to pay attention within the integration of consciousness enables the client with an open and receptive mind to catalyze the integration of new combinations of previously isolated segments of his or her mental reality"

*Anorexia and Bulimia Nervosa*

neurons. There is no valid distinction to be made between the "mind-self" and the "embodied self" (in [18], p. 18). Body image [and self image] change from action to action, built from sensory and psychic experiences that are constantly being integrated in the central nervous system (in [12], p. 87). "It is through self-awareness/ consciousness of body and brain that we clarify self-image and body image, experiencing both as an inseparable whole. The unity of body and mind is an objective reality. All feelings and emotions have motoric antecedents initiated within the body" [19]. In other words, "emotions themselves are body phenomena," [20] with the body experiencing emotions first, prior to the mental awareness of feelings. Experiencing emotions is therefore synonymous with experiencing body and brain changes; the development of self-regulation becomes synonymous with regulating changes in both the body and the brain. In BN individuals who have experienced trauma, the brain, which interprets the traumatic event as still happening, will become calmed only following the calming of the body, which under the right circumstances, becomes capable of healing itself, along with emotional wounds.

**5. Defining mental health as nervous system integration**

the life-enhancing challenges of the psychotherapeutic healing process.

**6. Integrative disorders require integrative approaches to treatment**

Currently, conventional psychosocial, behavioral and pharmacological treatment interventions for adults with BN and AN have been shown to have limited efficacy [25]. Hilde Bruch, a pioneer in the field of ED treatment, contends that

The best predictor of positive mental health is nervous system integration [14]. The mind seeks to achieve mental health through "self-organization, optimizing function by linking differentiated parts of the [nervous] system in the quest for harmony, flexibility, resiliency, adaptability, stability, coherence and energy… otherwise known as integration" [15]. In recognizing the body as the first responder to emotional stimuli, the task at hand in healing BN patients is to differentiate emotions from physiological activation. Cognitive self-regulation of emotional responses to aversive events is essential for mental and physical health. Emotion regulation involves a coherent relationship with the self… in other words, the effective, integrative communication between body, mind, and feelings [21]. "A prerequisite for successful emotion regulation is the awareness of emotional states, which in turn is associated with the awareness of bodily signals, or interoceptive awareness" [22]. "The human body needs to sense, process, and integrate different bodily signals in the premotor, temporoparietal, posterior parietal, and extrastriate cortices, in order to achieve self-identification, self-location, and body-part ownership" [23]. "Stimulating interoceptive sensing of body signals facilitates the differentiation of emotions from the physiological component of emotional experience, promoting self-regulation," [22] a process central to healing sub-clinical, as well as clinical, eating disorders and dysfunctions of all kinds. A direct correlation exists between a full and integrative ED recovery, and the achievement of central nervous system integration within the treatment process. A survey of recovered ED patients identified "dimensions of psychological self-adaptability and resilience *within a complete and integrative* mental health model" as the fundamental criteria for having achieved recovery success [24]. In retrospect, it is not unusual for recovered ED individuals to express appreciation and gratitude for having experienced the twicedifficult ordeal of taking on the life-threatening challenges of illness, followed by

**148**

[27]. Studies show that "patients who have been trained to attend to bodily information display greater coherence between subjective experience and visceral responses during emotional episodes" [28]. Because the self, the brain, the mind, and the body are integrated entities, none will heal effectively and sustainably apart from the others.

#### **7. Neurophysiological interventions integrate mind, brain, body, and self**

Logic will not change emotion, but body movement will [13]. Straddling verbal and non-verbal input, and "breaking through to feeling," (in [12], p. 46) neurophysiological interventions use the body to create changes in the brain, and the brain to create changes in the body, through top-down and bottom-up processing. Top-down brain processing refers to perception driven by cognition, including mechanisms initiated via mental processing at the level of the cerebral cortex [29, 30]. "Bottom-up brain processing refers to the processing of sensory information as it is coming in [29]. Bottom-up mechanisms are initiated by stimulation of various somato-, viscero-, and chemo-sensory receptors that influence central neural processing and mental activities via ascending pathways from the periphery to the brainstem and cerebral cortex. All mind-body therapies actually involve a combination of top-down and bottom-up mechanisms, creating 'vertical' integration, which brings the emotional and thinking brain online together [30]. Bidirectional autonomic and neuroendocrine pathways serve as mind-body pathways between the central nervous system and the periphery, facilitating the expression of affective, autonomic, hormonal, and immune responses, enhancing mental and physiological functioning [30].

As adjuncts to traditional ED treatment techniques, top-down and bottom-up "neurophysiological interventions have been shown to diminish symptoms associated with ED" [31], contradicting feelings of helplessness and fear, and facilitating a sense of empowerment [13].

*During her assessment session, it became apparent that Suellyn, who had struggled with BN and major depression for several years, had undergone significant trauma in her past. At 22, she described herself as "always suicidal, feeling way too fat, and frequently being too depressed to get out of bed." She refused to speak of events in her past, believing that doing so would "send her back under the covers." Her mother had recently forced here to leave her home, friends and job, to live temporarily with her father in another state. Seeking a breakthrough to a window of communication, I invited her to consider deep breathing together with me, further awakening her body-felt sensibility through spine twisting, accompanied by differentiated eye movements. Her initial response to the movement was to feel "totally disconnected" from her body, and from me. After about 5 minutes of movement in her chair, she reported, "I am here now," a reality that had become clearly apparent in her eyes and facial expression. She left the session in an elevated mood, planning to return soon.*

Bottom-up interventions have been shown to be more successful in addressing "the repetitive, unbidden, physical sensations, and movement inhibitions, than are top-down interventions" [34]. Providing a non-threatening way to intercept trauma-based memory pathways, bodily-based movement reverses the sensorimotor intrusions of unresolved trauma by conveying to the patients that sensations come and go, leading to their acceptance, and to feeling safer [13].

In the next section, I discuss two types of interventions through which nervous system re-integration fosters the repair of the impaired self. The first involves

**151**

*Reclaiming the Lost Self in the Treatment of Bulimia Nervosa: A Neurobiological Approach…*

*neurophysiological* sensorimotor bodily-based movement *with mindful attention and intention*, (differentiating it from rote, 'mindless' bodily exercise). Examples include the Feldenkrais Method, trauma-informed yoga and EMDR. The second is *neurobiological* in nature, repairing the impaired self within a top-down, bottom-up attachment theory model that harnesses the power of empathy within the interpersonal psychotherapeutic connection through empathic resonance. Within this interpersonal neurobiological model, "the top-down process involves cognitive perspective taking, while the bottomup process, achieved through neuronal mirroring representation systems, plays a key role in the direct sharing of the emotional state of the other" [32]. Rapid Resolution Therapy (RRT) represents a form of neurobiological intervention, specifically designed to achieve the resolution of trauma. Within the context of a trusting relationship, the therapist's focus during RRT is on a neurolinguistic use of oneself within the therapeutic relationship, with the intention of facilitating the patient's self-integration by turning traumatic memories into strengths and resources through memory consolidation [33].

Sensorimotor treatment is a movement-based neurophysiological intervention that combines cognitive and somatic techniques to address physical symptoms of a dissociative nature. Sensorimotor interventions foster healing through the organic, non-reductionist process of 'embodied learning,' which, rather than separating the organism into its anatomical parts, joins those parts into one continuous feedback loop [19]. "In sensorimotor psychotherapy, top-down, cortically mediated functions are harnessed to observe and facilitate sensorimotor processing where patients observe and report the interplay of physical sensation, movements, and impulses, noticing internal reactions as they try out new physical actions. Patients also learn to observe the effects of their thoughts and emotions on their body, recognizing which parts of the body respond to the impact of a particular thought, and/or how the body organizes a particular emotion. Meaning-making emerges from such observation, [resulting in] subsequent transformation of habitual response tendencies" [34]. The process of embodied learning has been shown to "repair and re-integrate perceptual-sensory dysfunction, increase interoceptive attention and/ or proprioceptive awareness (the internal awareness of body parts), and produce a more accurate body perception and undistorted body representation" [35]. "Combining sensorimotor bottom-up processes with top-down processes activates the dynamic state of body and brain interaction where the regulation of energy and information flow happens within the circuits and synapses of the skull-based brain, within the body through the distributed nervous system, [and between the brains of two people in the context of a mindful relationship]…. all are unifying elements

*7.1.1 The Feldenkrais Method of Somatic Education© integrates the self and body* 

Sensory stimuli are closer to our unconscious, subconscious, or autonomous functioning than to any of our conscious understanding: "Words can obscure intentions; kinesthetic truth gets right to our core" [19]. The Feldenkrais Method promotes self-integration by fostering conscious reconnection with one's unconscious sensorimotor repertoire through expanding the movement repertoire [17]. Directed mindful attention brings previously unfamiliar body parts systematically into awareness, moving the individual and brain toward integration, and offering a concrete means by which to change one's state of being. During or following movement sequences, the essentially non-verbal movement experience might be

*DOI: http://dx.doi.org/10.5772/intechopen.83844*

**7.1 Sensorimotor psychotherapy**

of a disparate self" (in [15], p. 54).

*image coherence*

*Reclaiming the Lost Self in the Treatment of Bulimia Nervosa: A Neurobiological Approach… DOI: http://dx.doi.org/10.5772/intechopen.83844*

*neurophysiological* sensorimotor bodily-based movement *with mindful attention and intention*, (differentiating it from rote, 'mindless' bodily exercise). Examples include the Feldenkrais Method, trauma-informed yoga and EMDR. The second is *neurobiological* in nature, repairing the impaired self within a top-down, bottom-up attachment theory model that harnesses the power of empathy within the interpersonal psychotherapeutic connection through empathic resonance. Within this interpersonal neurobiological model, "the top-down process involves cognitive perspective taking, while the bottomup process, achieved through neuronal mirroring representation systems, plays a key role in the direct sharing of the emotional state of the other" [32]. Rapid Resolution Therapy (RRT) represents a form of neurobiological intervention, specifically designed to achieve the resolution of trauma. Within the context of a trusting relationship, the therapist's focus during RRT is on a neurolinguistic use of oneself within the therapeutic relationship, with the intention of facilitating the patient's self-integration by turning traumatic memories into strengths and resources through memory consolidation [33].

#### **7.1 Sensorimotor psychotherapy**

*Anorexia and Bulimia Nervosa*

sense of empowerment [13].

*to return soon.*

the others.

[27]. Studies show that "patients who have been trained to attend to bodily information display greater coherence between subjective experience and visceral responses during emotional episodes" [28]. Because the self, the brain, the mind, and the body are integrated entities, none will heal effectively and sustainably apart from

**7. Neurophysiological interventions integrate mind, brain, body, and self**

Logic will not change emotion, but body movement will [13]. Straddling verbal and non-verbal input, and "breaking through to feeling," (in [12], p. 46) neurophysiological interventions use the body to create changes in the brain, and the brain to create changes in the body, through top-down and bottom-up processing. Top-down brain processing refers to perception driven by cognition, including mechanisms initiated via mental processing at the level of the cerebral cortex [29, 30]. "Bottom-up brain processing refers to the processing of sensory information as it is coming in [29]. Bottom-up mechanisms are initiated by stimulation of various somato-, viscero-, and chemo-sensory receptors that influence central neural processing and mental activities via ascending pathways from the periphery to the brainstem and cerebral cortex. All mind-body therapies actually involve a combination of top-down and bottom-up mechanisms, creating 'vertical' integration, which brings the emotional and thinking brain online together [30]. Bidirectional autonomic and neuroendocrine pathways serve as mind-body pathways between the central nervous system and the periphery, facilitating the expression of affective, autonomic, hormonal, and

immune responses, enhancing mental and physiological functioning [30].

As adjuncts to traditional ED treatment techniques, top-down and bottom-up "neurophysiological interventions have been shown to diminish symptoms associated with ED" [31], contradicting feelings of helplessness and fear, and facilitating a

*During her assessment session, it became apparent that Suellyn, who had struggled with BN and major depression for several years, had undergone significant trauma in her past. At 22, she described herself as "always suicidal, feeling way too fat, and frequently being too depressed to get out of bed." She refused to speak of events in her past, believing that doing so would "send her back under the covers." Her mother had recently forced here to leave her home, friends and job, to live temporarily with her father in another state. Seeking a breakthrough to a window of communication, I invited her to consider deep breathing together with me, further awakening her body-felt sensibility through spine twisting, accompanied by differentiated eye movements. Her initial response to the movement was to feel "totally disconnected" from her body, and from me. After about 5 minutes of movement in her chair, she reported, "I am here now," a reality that had become clearly apparent in her eyes and facial expression. She left the session in an elevated mood, planning* 

Bottom-up interventions have been shown to be more successful in addressing "the repetitive, unbidden, physical sensations, and movement inhibitions, than are top-down interventions" [34]. Providing a non-threatening way to intercept trauma-based memory pathways, bodily-based movement reverses the sensorimotor intrusions of unresolved trauma by conveying to the patients that sensations

In the next section, I discuss two types of interventions through which nervous

system re-integration fosters the repair of the impaired self. The first involves

come and go, leading to their acceptance, and to feeling safer [13].

**150**

Sensorimotor treatment is a movement-based neurophysiological intervention that combines cognitive and somatic techniques to address physical symptoms of a dissociative nature. Sensorimotor interventions foster healing through the organic, non-reductionist process of 'embodied learning,' which, rather than separating the organism into its anatomical parts, joins those parts into one continuous feedback loop [19]. "In sensorimotor psychotherapy, top-down, cortically mediated functions are harnessed to observe and facilitate sensorimotor processing where patients observe and report the interplay of physical sensation, movements, and impulses, noticing internal reactions as they try out new physical actions. Patients also learn to observe the effects of their thoughts and emotions on their body, recognizing which parts of the body respond to the impact of a particular thought, and/or how the body organizes a particular emotion. Meaning-making emerges from such observation, [resulting in] subsequent transformation of habitual response tendencies" [34]. The process of embodied learning has been shown to "repair and re-integrate perceptual-sensory dysfunction, increase interoceptive attention and/ or proprioceptive awareness (the internal awareness of body parts), and produce a more accurate body perception and undistorted body representation" [35]. "Combining sensorimotor bottom-up processes with top-down processes activates the dynamic state of body and brain interaction where the regulation of energy and information flow happens within the circuits and synapses of the skull-based brain, within the body through the distributed nervous system, [and between the brains of two people in the context of a mindful relationship]…. all are unifying elements of a disparate self" (in [15], p. 54).

#### *7.1.1 The Feldenkrais Method of Somatic Education© integrates the self and body image coherence*

Sensory stimuli are closer to our unconscious, subconscious, or autonomous functioning than to any of our conscious understanding: "Words can obscure intentions; kinesthetic truth gets right to our core" [19]. The Feldenkrais Method promotes self-integration by fostering conscious reconnection with one's unconscious sensorimotor repertoire through expanding the movement repertoire [17]. Directed mindful attention brings previously unfamiliar body parts systematically into awareness, moving the individual and brain toward integration, and offering a concrete means by which to change one's state of being. During or following movement sequences, the essentially non-verbal movement experience might be

enhanced through open-ended, insightful verbal cueing that prompts the sensing of self-experience by promoting a coherent narrative within the process, i.e., "Do you sense a place in your body that feels more comfortable and safe…more unfamiliar and unsafe? What is it like for you to explore yet unknown parts of your body and self?"

Within the Feldenkrais sensorimotor movement experience, the clarification of self-image requires the patient's felt-sense during the action, through focused attention on self-awareness (self consciousness), variation (change and novelty), differentiation (the capacity to sense and create differences,) and integration (the capacity to bring the learning to a meaningful coherence). The differentiation and integration of coherent movement coordination provides the critical interface between brain and body, allowing global mapping to be maintained, refreshed and altered by continual motor activity and rehearsal" [3]. Differentiation of the smallest possible sensory distinctions between movements while paying close attention to injured or distorted body parts allows people to subjectively experience these parts through larger, more accurate and refined brain maps (in [18], p. 171).

During Feldenkrais Awareness through Movement [ATM] group classes, conducted on yoga mats, the floor becomes an invaluable feedback system. The practitioner guides participants through scripted sequential movements, facilitating their introspective sensing of self-experience. Feldenkrais Method practice has, through the past eight decades, become increasingly accessible worldwide. It has also become available free-of-charge through easy-to-follow 5 to 20 minute Awareness through Movement© UTube demonstrations presented by expert Feldenkrais practitioners who bring adjunctive sensorimotor movement interventions directly into the clinical treatment office, and/or into patients' homes for independent practice. The Feldenkrais Functional Integration [FI] technique offers hands-on, gentle, pleasurable body movement, promoting self-integration through movement provided through human touch. While the patient lies on the treatment table, the practitioner's nervous system, in connection with the patient's nervous system, imparts sensory information directly to the patient's brain through the patient's embodied sensory receptors. The following examples illustrate the efficacy of the Feldenkrais Method's Awareness through Movement© and Functional Integration© modes as adjuncts to traditional mainstream treatment for patients in recovery from BN.

#### *7.1.1.1 Feldenkrais Awareness through Movement [ATM] as part of mainstream BN practice*

*Marion, a 43-year-old bulimic woman who grew up in a chaotic, dysfunctional family, was diagnosed with BN restricting-type, bi-polar disorder, dissociation, and self-mutilation after having been gang raped by her brother and his friends when she was 16. For close to two decades, she had been treated in hospital programs for BN and post-traumatic stress disorder (PTSD) before joining an outpatient movement-based ED support/therapy group for adults with clinical ED, which I facilitated. Each group session included a guided Feldenkrais Awareness through Movement© lesson, followed by participants processing their movement experience as it relates to relevant therapeutic issues. Though in a food-restrictive phase of her disorder, attunement to her inner bodily experience during group movement sessions led Marion to report that after group sessions, she would go to a grocery store and bring home "a four course dinner." "While eating, I visualize the food as it enters my body as no longer being 'the enemy.' I imagine it traveling around and throughout my entire body, nourishing and giving life to all my cells and tissues." In reconnecting with parts of herself that had previously seemed unsafe, she experienced her self as becoming increasingly "whole." In individual psychotherapy, she began to access* 

**153**

*Reclaiming the Lost Self in the Treatment of Bulimia Nervosa: A Neurobiological Approach…*

*feelings and issues that she ordinarily would not have felt comfortable facing or disclosing. Describing her Feldenkrais experience, she said, "I know I am safe. I know where I am in my body, and I know that I am learning to know myself better. This work makes me feel that it is okay, and not so scary, to be changing." Following group sessions, she slept more soundly. Ultimately, her purging and cutting behaviors ended* 

*7.1.1.2 Feldenkrais Functional Integration© as part of mainstream BN practice*

*As an adjunct to psychotherapy, I engaged Lana in a hands-on Feldenkrais Functional Integration "lesson," described as such for its being a form of nervous system education. Having spent many months in residential treatment facilities, Lana, who had been sexually abused by her grandfather from ages 3 to 8, suffered from BN-restricting type with co-occurring bi-polar disorder type II, fibromyalgia, substance abuse, promiscuity, and self-mutilation. Though human touch is typically a delicate issue for victims of sexual abuse, through our secure 2-year therapeutic attachment and her trust in the healing process, she described my hands-on work as "a comfort, helping me to feel myself directly, and to feel myself in control." Through these lessons, she began to discern parallels between her undifferentiated expressions of emotional rage, and her body's undifferentiated and painful immobility during fibromyalgia flare-ups. As her body became increasingly flexible, differentiated, and ultimately re-integrated through her movement experiences she became more adept at differentiating and reintegrating her emotions as well, becoming calmer and increasingly regulated. Lana spoke of her Feldenkrais experience as "clearing out the cobwebs in my brain." At the end of one Feldenkrais session, in response to my lifting her leg off the treatment table in order to assess her degree of neuro-skeletal integration, Lana described feeling a sense of "overwhelming relief and gratitude" for the now seemingly apparent weightlessness in her leg, in contrast with her own self-perception. "This is the first time I can remember* 

*feeling good about living inside this body of mine"].*

*7.1.2 Sensorimotor interventions designed to address and heal trauma*

cial results for BN individuals who have experienced trauma.

Lana's sensation of physiological lightness was the result of her brain having uploaded novel sensory information through her newly reorganized nervous system. Embodied learning awakened Lana's sensory epiphany, followed by an increasingly integrated sense of self and identity. Though positive sensorimotor sensations might initially appear to be fleeting, the nervous system's brain and body 'own' these changes, with continued practice deepening the sustainability of learning and healing.

A 2007 study revealed that trauma is significantly associated with the onset of ED, particularly BN and binge eating disorder. Traumatic experiences may include physical and emotional neglect (including food deprivation); physical, sexual, and emotional abuse and assault; teasing; and bullying [37]. The following are two additional forms of sensorimotor movement interventions shown to offer benefi-

The Feldenkrais Method takes adults back to infancy, mobilizing developmental processes at a fundamental level. "Through manualized movement sequencing a process of organic learning is stimulated which enables a sort of post-maturation and leads to the formation and integration of new, more functionally appropriate responses. The progression and promotion of the kinesthetic sense is, as our first and basic ability to perceive, deeply connected with our self-identity" [36].

*DOI: http://dx.doi.org/10.5772/intechopen.83844*

*completely.*

*Reclaiming the Lost Self in the Treatment of Bulimia Nervosa: A Neurobiological Approach… DOI: http://dx.doi.org/10.5772/intechopen.83844*

*feelings and issues that she ordinarily would not have felt comfortable facing or disclosing. Describing her Feldenkrais experience, she said, "I know I am safe. I know where I am in my body, and I know that I am learning to know myself better. This work makes me feel that it is okay, and not so scary, to be changing." Following group sessions, she slept more soundly. Ultimately, her purging and cutting behaviors ended completely.*

The Feldenkrais Method takes adults back to infancy, mobilizing developmental processes at a fundamental level. "Through manualized movement sequencing a process of organic learning is stimulated which enables a sort of post-maturation and leads to the formation and integration of new, more functionally appropriate responses. The progression and promotion of the kinesthetic sense is, as our first and basic ability to perceive, deeply connected with our self-identity" [36].

#### *7.1.1.2 Feldenkrais Functional Integration© as part of mainstream BN practice*

*As an adjunct to psychotherapy, I engaged Lana in a hands-on Feldenkrais Functional Integration "lesson," described as such for its being a form of nervous system education. Having spent many months in residential treatment facilities, Lana, who had been sexually abused by her grandfather from ages 3 to 8, suffered from BN-restricting type with co-occurring bi-polar disorder type II, fibromyalgia, substance abuse, promiscuity, and self-mutilation. Though human touch is typically a delicate issue for victims of sexual abuse, through our secure 2-year therapeutic attachment and her trust in the healing process, she described my hands-on work as "a comfort, helping me to feel myself directly, and to feel myself in control." Through these lessons, she began to discern parallels between her undifferentiated expressions of emotional rage, and her body's undifferentiated and painful immobility during fibromyalgia flare-ups. As her body became increasingly flexible, differentiated, and ultimately re-integrated through her movement experiences she became more adept at differentiating and reintegrating her emotions as well, becoming calmer and increasingly regulated. Lana spoke of her Feldenkrais experience as "clearing out the cobwebs in my brain." At the end of one Feldenkrais session, in response to my lifting her leg off the treatment table in order to assess her degree of neuro-skeletal integration, Lana described feeling a sense of "overwhelming relief and gratitude" for the now seemingly apparent weightlessness in her leg, in contrast with her own self-perception. "This is the first time I can remember feeling good about living inside this body of mine"].*

Lana's sensation of physiological lightness was the result of her brain having uploaded novel sensory information through her newly reorganized nervous system. Embodied learning awakened Lana's sensory epiphany, followed by an increasingly integrated sense of self and identity. Though positive sensorimotor sensations might initially appear to be fleeting, the nervous system's brain and body 'own' these changes, with continued practice deepening the sustainability of learning and healing.

#### *7.1.2 Sensorimotor interventions designed to address and heal trauma*

A 2007 study revealed that trauma is significantly associated with the onset of ED, particularly BN and binge eating disorder. Traumatic experiences may include physical and emotional neglect (including food deprivation); physical, sexual, and emotional abuse and assault; teasing; and bullying [37]. The following are two additional forms of sensorimotor movement interventions shown to offer beneficial results for BN individuals who have experienced trauma.

*Anorexia and Bulimia Nervosa*

body and self?"

enhanced through open-ended, insightful verbal cueing that prompts the sensing of self-experience by promoting a coherent narrative within the process, i.e., "Do you sense a place in your body that feels more comfortable and safe…more unfamiliar and unsafe? What is it like for you to explore yet unknown parts of your

Within the Feldenkrais sensorimotor movement experience, the clarification of self-image requires the patient's felt-sense during the action, through focused attention on self-awareness (self consciousness), variation (change and novelty), differentiation (the capacity to sense and create differences,) and integration (the capacity to bring the learning to a meaningful coherence). The differentiation and integration of coherent movement coordination provides the critical interface between brain and body, allowing global mapping to be maintained, refreshed and altered by continual motor activity and rehearsal" [3]. Differentiation of the smallest possible sensory distinctions between movements while paying close attention to injured or distorted body parts allows people to subjectively experience these parts through larger, more accurate and refined brain maps (in [18], p. 171).

During Feldenkrais Awareness through Movement [ATM] group classes, conducted on yoga mats, the floor becomes an invaluable feedback system. The practitioner guides participants through scripted sequential movements, facilitating their introspective sensing of self-experience. Feldenkrais Method practice has, through the past eight decades, become increasingly accessible worldwide. It has also become available free-of-charge through easy-to-follow 5 to 20 minute Awareness through Movement© UTube demonstrations presented by expert Feldenkrais practitioners who bring adjunctive sensorimotor movement interventions directly into the clinical treatment office, and/or into patients' homes for independent practice. The Feldenkrais Functional Integration [FI] technique offers hands-on, gentle, pleasurable body movement, promoting self-integration through movement provided through human touch. While the patient lies on the treatment table, the practitioner's nervous system, in connection with the patient's nervous system, imparts sensory information directly to the patient's brain through the patient's embodied sensory receptors. The following examples illustrate the efficacy of the Feldenkrais Method's Awareness through Movement© and Functional Integration© modes as adjuncts to traditional mainstream treatment for patients in recovery from BN.

*7.1.1.1 Feldenkrais Awareness through Movement [ATM] as part of mainstream BN* 

*Marion, a 43-year-old bulimic woman who grew up in a chaotic, dysfunctional family, was diagnosed with BN restricting-type, bi-polar disorder, dissociation, and self-mutilation after having been gang raped by her brother and his friends when she was 16. For close to two decades, she had been treated in hospital programs for BN and post-traumatic stress disorder (PTSD) before joining an outpatient movement-based ED support/therapy group for adults with clinical ED, which I facilitated. Each group session included a guided Feldenkrais Awareness through Movement© lesson, followed by participants processing their movement experience as it relates to relevant therapeutic issues. Though in a food-restrictive phase of her disorder, attunement to her inner bodily experience during group movement sessions led Marion to report that after group sessions, she would go to a grocery store and bring home "a four course dinner." "While eating, I visualize the food as it enters my body as no longer being 'the enemy.' I imagine it traveling around and throughout my entire body, nourishing and giving life to all my cells and tissues." In reconnecting with parts of herself that had previously seemed unsafe, she experienced her self as becoming increasingly "whole." In individual psychotherapy, she began to access* 

**152**

*practice*

#### *7.1.2.1 Trauma-informed yoga*

It is not unusual for ED individuals with restrictive eating disorders to attempt to control symptoms by using strenuous exercise to increase caloric expenditure. Trauma-informed yoga offers these individuals a safe avenue for the engagement in physical activity while providing an outlet for disease-associated symptoms [38]. Trauma-informed yoga reprograms the brain through activating novel movement, breathing, and action patterns and their psychological correlates. Facilitating sensorimotor processing and mitigating stress responses through combined topdown and bottom-up influences, yoga practice provides "a non-threatening means by which to unearth previously disavowed emotions stored in the 'emotional' limbic system, then cortically mediates traumatic pathways and thoughts through psychological appraisal methods" [38]. Teaching the use of breath facilitates close attention to present-moment awareness of self, bringing the nervous system from a dysregulated state to a unified, centered state by shifting the sympathetic nervous system to a balanced parasympathetic sense of calm and relaxation, while offering patients a sustainable relationship with the internal body. [39] By associating bodily states with emotional experiences, yoga gives rise to conscious feelings that occur through changes in the nervous system, fostering increased interoceptive awareness, thereby increasing emotional regulation in response to negative affect [22].

#### *7.1.2.2 Eye Movement Desensitization and Reprocessing (EMDR)*

Given the correlation between trauma and the onset of BN, Eye Movement Desensitization and Reprocessing (EMDR) offers an alternative interpersonal, experiential and body-centered therapy approach that treats the BN patient's cooccurring PTSD. Through EMDR, the patient processes and resolves sensations and emotions connected to traumatic memory stored in the limbic brain. The technique uses a unique procedure in which the therapist exposes the patient to rhythmic bilateral stimulation (BLS), using alternating bilateral visual (eye movement), auditory, or sensory stimulation [40], (e.g., tactile stimulation, such as the therapist's sequential touching of the patient's right knee and left knee). The technique relieves affective distress, reformulates negative beliefs and reduces physiological arousal. EMDR allows faster and more highly effective processing for trauma than does psychotherapy, as the neural substrate of rhythmic movement has more direct links to the limbic system than to language-based regions. Once disseminated (dissociated) fragments of traumatic memory have been reconnected, they become capable of integrating a new personal semantic memory network with new cognitive schemas, thus fulfilling the goal of EMDR treatment [41].

#### **8. The neurobiology of mindful human attachment repairs impaired self-structure**

"Energy and information can flow within the brain and between brains, profoundly shaping the flow of energy and information within and between people" [13]. The self-organization of the infant's developing brain occurs in the context of a relationship with another self, another brain" [42]. Allan Schore defines psychotherapy as "an attachment relationship that affects underlying neuronal structure and function" [43]. His developmental model places particular emphasis upon "the experience-dependent maturation of a system in the orbital prefrontal cortex that regulates psychophysiological state and organismic energy balance" [43]. "When the therapist's mind and embodied-self come together in relationship with those

**155**

*Reclaiming the Lost Self in the Treatment of Bulimia Nervosa: A Neurobiological Approach…*

of the patient, implicit systems of the therapist interact with implicit systems of the patient, rendering psychotherapy the 'talking' cure. Talking to neurons alters neuronal networks and the functional sphere of influence of the prefrontal

"By means of reverie and intuition, the sensitive empathic clinician's monitoring of unconscious process, rather than content, calls for right brain attention to matching the patient's implicit affective-arousal states, a process that lies at the core of the therapeutic relationship. Through the subconscious processing of information, the clinician uses an expansive attention mechanism that includes free association, while the left brain, more involved in the conscious processing of information, focuses on local detail" [43]*.* The resulting 'empathic resonance' is an embodied, sensed connection, typically experienced between therapist and patient as a dynamic, spirited, vibrant, and often loving mutual attachment, in which the patient's right brain hemisphere becomes altered in form and function in response to a mindful, energetic connection with the therapist's right brain hemisphere. Resonance exists 'outside our skin,' giving rise to a therapy relationship in which 'a mind is being changed by a mind'" [44] Deeply ensconced in psychophysiology, empathic resonance may be considered 'sharing a common brain,' with the intersubjective field between two individuals including far more than two minds, to include

According to Schore, "emotional healing takes place primarily in the circuitry of the right brain hemisphere, which is dominant for attachment, intense emotionality, and the knowledge of how to be in relationships' [46]. "Right brain to right brain emotional processes are central to emotional development, psychopathology, and psychotherapy. The functions of the emotional right brain foster the selfexploration process of psychotherapy, especially of unconscious affects that can be integrated into a more complex and implicit sense of self. Emotional communication between therapist and patient lies at the psychobiological core of the therapeutic alliance. Therapist affect facilitation is a powerful predictor of treatment success" [47]. Studies show that the more successful the treatment, the greater the

The brain's mirror neuron system is the foundational building block for empathy, a major component of healthy [resonant] psychotherapeutic attachment. Leading to a new theory of empathy that is bottom-up and top-down in nature, "mirror neurons reveal the fundamental integration within the brain of the perceptual and motor systems with limbic and somatic regulatory functions" [27]. It is through the therapist's empathy and genuine caring that patients come to feel listened to, heard, seen for who they are, and even loved, sometimes for the first

*Thinking back, Tess revealed that after our first therapy session, she felt frightened, yet at the same time, compelled to continue treatment. "It was as though you could see right through me. It was terrifying for me to feel so totally transparent to you, with all of my defects. Yet at the same time it was thrilling for me that you actually saw goodness in me, strengths and even excellence in parts of my life, none of which I had ever before recognized. I was afraid that you would eventually see through to my inadequacies and feel repelled by me, rejecting me as your patient. As the weeks passed, I knew in my heart that this would be the only chance I'd ever have, to understand who I am and who I could become, why I am sick, and how to get* 

"It is through the relationship that deficits in internal working models of the self

*better so that my life could become my own for the first time ever"].*

and the world are gradually repaired" [43].

*DOI: http://dx.doi.org/10.5772/intechopen.83844*

lobes" [16].

two bodies" [45].

neuroplastic change [48].

time in their lives.

*Reclaiming the Lost Self in the Treatment of Bulimia Nervosa: A Neurobiological Approach… DOI: http://dx.doi.org/10.5772/intechopen.83844*

of the patient, implicit systems of the therapist interact with implicit systems of the patient, rendering psychotherapy the 'talking' cure. Talking to neurons alters neuronal networks and the functional sphere of influence of the prefrontal lobes" [16].

"By means of reverie and intuition, the sensitive empathic clinician's monitoring of unconscious process, rather than content, calls for right brain attention to matching the patient's implicit affective-arousal states, a process that lies at the core of the therapeutic relationship. Through the subconscious processing of information, the clinician uses an expansive attention mechanism that includes free association, while the left brain, more involved in the conscious processing of information, focuses on local detail" [43]*.* The resulting 'empathic resonance' is an embodied, sensed connection, typically experienced between therapist and patient as a dynamic, spirited, vibrant, and often loving mutual attachment, in which the patient's right brain hemisphere becomes altered in form and function in response to a mindful, energetic connection with the therapist's right brain hemisphere. Resonance exists 'outside our skin,' giving rise to a therapy relationship in which 'a mind is being changed by a mind'" [44] Deeply ensconced in psychophysiology, empathic resonance may be considered 'sharing a common brain,' with the intersubjective field between two individuals including far more than two minds, to include two bodies" [45].

According to Schore, "emotional healing takes place primarily in the circuitry of the right brain hemisphere, which is dominant for attachment, intense emotionality, and the knowledge of how to be in relationships' [46]. "Right brain to right brain emotional processes are central to emotional development, psychopathology, and psychotherapy. The functions of the emotional right brain foster the selfexploration process of psychotherapy, especially of unconscious affects that can be integrated into a more complex and implicit sense of self. Emotional communication between therapist and patient lies at the psychobiological core of the therapeutic alliance. Therapist affect facilitation is a powerful predictor of treatment success" [47]. Studies show that the more successful the treatment, the greater the neuroplastic change [48].

The brain's mirror neuron system is the foundational building block for empathy, a major component of healthy [resonant] psychotherapeutic attachment. Leading to a new theory of empathy that is bottom-up and top-down in nature, "mirror neurons reveal the fundamental integration within the brain of the perceptual and motor systems with limbic and somatic regulatory functions" [27]. It is through the therapist's empathy and genuine caring that patients come to feel listened to, heard, seen for who they are, and even loved, sometimes for the first time in their lives.

*Thinking back, Tess revealed that after our first therapy session, she felt frightened, yet at the same time, compelled to continue treatment. "It was as though you could see right through me. It was terrifying for me to feel so totally transparent to you, with all of my defects. Yet at the same time it was thrilling for me that you actually saw goodness in me, strengths and even excellence in parts of my life, none of which I had ever before recognized. I was afraid that you would eventually see through to my inadequacies and feel repelled by me, rejecting me as your patient. As the weeks passed, I knew in my heart that this would be the only chance I'd ever have, to understand who I am and who I could become, why I am sick, and how to get better so that my life could become my own for the first time ever"].*

"It is through the relationship that deficits in internal working models of the self and the world are gradually repaired" [43].

*Anorexia and Bulimia Nervosa*

*7.1.2.1 Trauma-informed yoga*

It is not unusual for ED individuals with restrictive eating disorders to attempt to control symptoms by using strenuous exercise to increase caloric expenditure. Trauma-informed yoga offers these individuals a safe avenue for the engagement in physical activity while providing an outlet for disease-associated symptoms [38]. Trauma-informed yoga reprograms the brain through activating novel movement, breathing, and action patterns and their psychological correlates. Facilitating sensorimotor processing and mitigating stress responses through combined topdown and bottom-up influences, yoga practice provides "a non-threatening means by which to unearth previously disavowed emotions stored in the 'emotional' limbic system, then cortically mediates traumatic pathways and thoughts through psychological appraisal methods" [38]. Teaching the use of breath facilitates close attention to present-moment awareness of self, bringing the nervous system from a dysregulated state to a unified, centered state by shifting the sympathetic nervous system to a balanced parasympathetic sense of calm and relaxation, while offering patients a sustainable relationship with the internal body. [39] By associating bodily states with emotional experiences, yoga gives rise to conscious feelings that occur through changes in the nervous system, fostering increased interoceptive awareness, thereby increasing emotional regulation in response to negative affect [22].

*7.1.2.2 Eye Movement Desensitization and Reprocessing (EMDR)*

tive schemas, thus fulfilling the goal of EMDR treatment [41].

**8. The neurobiology of mindful human attachment repairs impaired** 

"Energy and information can flow within the brain and between brains, profoundly shaping the flow of energy and information within and between people" [13]. The self-organization of the infant's developing brain occurs in the context of a relationship with another self, another brain" [42]. Allan Schore defines psychotherapy as "an attachment relationship that affects underlying neuronal structure and function" [43]. His developmental model places particular emphasis upon "the experience-dependent maturation of a system in the orbital prefrontal cortex that regulates psychophysiological state and organismic energy balance" [43]. "When the therapist's mind and embodied-self come together in relationship with those

Given the correlation between trauma and the onset of BN, Eye Movement Desensitization and Reprocessing (EMDR) offers an alternative interpersonal, experiential and body-centered therapy approach that treats the BN patient's cooccurring PTSD. Through EMDR, the patient processes and resolves sensations and emotions connected to traumatic memory stored in the limbic brain. The technique uses a unique procedure in which the therapist exposes the patient to rhythmic bilateral stimulation (BLS), using alternating bilateral visual (eye movement), auditory, or sensory stimulation [40], (e.g., tactile stimulation, such as the therapist's sequential touching of the patient's right knee and left knee). The technique relieves affective distress, reformulates negative beliefs and reduces physiological arousal. EMDR allows faster and more highly effective processing for trauma than does psychotherapy, as the neural substrate of rhythmic movement has more direct links to the limbic system than to language-based regions. Once disseminated (dissociated) fragments of traumatic memory have been reconnected, they become capable of integrating a new personal semantic memory network with new cogni-

**154**

**self-structure**

#### **8.1 The therapist's versatile and empathic use of self fosters patient self-reintegration**

For BN individuals who failed to experience the benefits of healthy attachment during childhood, an effective therapeutic attachment offers a second real-time opportunity to feel the intrapersonal gratification that can be derived from a secure and trusting interpersonal attachment relationship with another human being. The healing therapeutic relationship becomes the prototype for healthful, quality relationships, both within, and beyond, the treatment dyad. "The highest human functions… including stress regulation, humor, empathy, compassion… are all right brain functions. An expanded capacity for right, not left, brain processing lies at the core of clinical expertise" [46]. The skillful and knowledgeable psychotherapist needs to maintain a mindful, pro-active and viable presence within each therapy moment, using himself or herself with intention, versatility, flexibility, courage, intuition and creativity [49]. Because ED represent changes within neural systems that mediate reward responses, decision-making, and social behaviors, effective treatment requires individualization based upon the specific constellation of symptoms presented, as well as their neurobiological underpinnings. As psycho-educators, practitioners need to keep patients informed about anticipated neurobiological changes in brain function related to impaired nutrition, such as fatigue, concentration and learning deficits, mood swings, insomnia, and impulsivity [2]. Patients also need to become aware of the positive changes in brain function that occur side-by-side with, and as result of, BN recovery.

The therapist's openness to his or her own bodily state is a crucial requirement for establishing interpersonal attunement with the patient [27]. "The therapist who is not intimidated, and who feels comfortable disclosing his or her own selfexperience in appropriate, boundaried and clearly intentional ways, offers patients the opportunity and permission to bring forward more of their own seemingly intolerable experience. Therapist receptivity assures patients that they need not censor themselves, so that difficult emotions lose some of their threat" [44]. For purposes of role modeling in promoting the patient's learning and self-discovery, the clinician's self-revelation potentially fills gaps in the patient's emotional and self-development. Immediate, in-the-moment inquiry about the patient's countertransferential reactions to the therapist's disclosure enhances the patient's sensing of self-experience and interpersonal trust building. "So, what's it like for you that I have chosen to share this information with you today?" "As an interactive regulator of the patient's psychological state" [47], the therapist's trust in, and acknowledgment of, the patient's strengths, resiliency, and potential to achieve recovery inspires and sustains the patient's belief in herself, fortifying her capacity to withstand the challenges of navigating the BN recovery process…as well as life without an ED.

#### *Secure attachment relationships are based in mutual trust.*

*Emma shared, "You are the first person who has ever really listened to me, seeing beneath the surface to who I really am." Feeling stressed for having to leave town and therapy for several weeks, she texted me from afar about her disappointment in herself for having purged. "I hope I am not intruding on your time in reaching you like this," she wrote. "I genuinely care about you, and am glad to hear from you whenever and however it works best." I replied. "It is important for you to understand that the 'failure' you describe is not a failure at all, but a normal part of every stage of the recovery process. Knowing you as I do, I trust that you will continue to go from strength to strength, just as you've done your entire life, from early childhood onwards. And, if you are assessing the quality of your recovery,* 

**157**

quieting [53].

*Reclaiming the Lost Self in the Treatment of Bulimia Nervosa: A Neurobiological Approach…*

*please don't forget to consider the newfound clarity of your empowered voice in communicating with your husband, and his response, which has been respectful and loving in return. I look forward to one day soon when you will begin to recognize your own growing strengths and much deserved self-trust. She responded, "Thanks.* 

"Because empathy accounts for as much, and probably more, outcome variance than does the specific intervention, the quality of the therapy alliance is more important to treatment outcomes than the particular treatment method or theory embraced by the therapist" [48]. This becomes increasingly so, as patients internal-

*Trust-building secures therapeutic relationships outside the professional office.*

*Tess had planned to observe a religious holiday that would have required a day's fasting. Prior to the holiday, between therapy sessions, it occurred to me that she might consider the alternative of reframing her commitment to observance this year by spending this day eating healthfully, instead. I phoned her to share my thoughts. "You think about me outside our sessions?! That's the best gift you could ever give me!" She was proud to report having been successful at fulfilling this unique challenge.*

The therapist's clearly defined boundaries and skilled navigation of complex transference and countertransference issues are essential in reinforcing the effective use of self in what, in some instances, becomes a process similar to re-parenting. In reinforcing a loving, secure, healthy, and trusted attachment, the therapist re-visits, refreshes, and re-inspires the patient's healthfully continuing self-development.

**9. Trauma resolution occurs through neurobiological reintegration of** 

Independent of its etiology, any traumatic assault on, or insult to, the brain impairs brain integration. A recent study found that "the vast majority of women and men with AN and BN reported a history of interpersonal trauma, with approximately one-third of BN women meeting criteria for lifetime PTSD [50]. Another study reported that sexual abuse occurs in 30–65% of women with ED, and that women with BN and substance dependence disorder had the highest frequency and most severe history of sexual abuse [51]. High stress levels leading to an overactive amygdala and hippocampus suppress the activities of the prefrontal cortex…the

The psychosomatic expressions of trauma experiences are held as bodily sensations, which become embedded in a broad variety of psychopathological and intersubjective phenomena [52]. Unprocessed traumatic memories stored in the mid-brain region become recycled when triggered, creating undischarged energy in the nervous system. Because traumatic memories are encoded subcortically, the process of healing trauma requires gaining leverage within the structural coding of the brain. Psychotherapeutic "'interpretation'" has been shown to have limited effectiveness with pathologies arising from the verbal phase related to explicit memories, and no effect on the pre-verbal phase implicit memories" [52]. Trauma speaks through the body. Trauma has been described as a "disorder of arousal." Its resolution lies in creating a psychophysiological state associated with decreased adrenergic activity, decreased muscular neuromuscular arousal, and cognitive

*DOI: http://dx.doi.org/10.5772/intechopen.83844*

*You're right. I appreciate your thoughts."*

**the distributed nervous system**

thinking brain, that helps to regulate the emotional brain.

ize and own dyadic gains.

*Reclaiming the Lost Self in the Treatment of Bulimia Nervosa: A Neurobiological Approach… DOI: http://dx.doi.org/10.5772/intechopen.83844*

*please don't forget to consider the newfound clarity of your empowered voice in communicating with your husband, and his response, which has been respectful and loving in return. I look forward to one day soon when you will begin to recognize your own growing strengths and much deserved self-trust. She responded, "Thanks. You're right. I appreciate your thoughts."*

"Because empathy accounts for as much, and probably more, outcome variance than does the specific intervention, the quality of the therapy alliance is more important to treatment outcomes than the particular treatment method or theory embraced by the therapist" [48]. This becomes increasingly so, as patients internalize and own dyadic gains.

*Trust-building secures therapeutic relationships outside the professional office.*

*Tess had planned to observe a religious holiday that would have required a day's fasting. Prior to the holiday, between therapy sessions, it occurred to me that she might consider the alternative of reframing her commitment to observance this year by spending this day eating healthfully, instead. I phoned her to share my thoughts. "You think about me outside our sessions?! That's the best gift you could ever give me!" She was proud to report having been successful at fulfilling this unique challenge.*

The therapist's clearly defined boundaries and skilled navigation of complex transference and countertransference issues are essential in reinforcing the effective use of self in what, in some instances, becomes a process similar to re-parenting. In reinforcing a loving, secure, healthy, and trusted attachment, the therapist re-visits, refreshes, and re-inspires the patient's healthfully continuing self-development.

#### **9. Trauma resolution occurs through neurobiological reintegration of the distributed nervous system**

Independent of its etiology, any traumatic assault on, or insult to, the brain impairs brain integration. A recent study found that "the vast majority of women and men with AN and BN reported a history of interpersonal trauma, with approximately one-third of BN women meeting criteria for lifetime PTSD [50]. Another study reported that sexual abuse occurs in 30–65% of women with ED, and that women with BN and substance dependence disorder had the highest frequency and most severe history of sexual abuse [51]. High stress levels leading to an overactive amygdala and hippocampus suppress the activities of the prefrontal cortex…the thinking brain, that helps to regulate the emotional brain.

The psychosomatic expressions of trauma experiences are held as bodily sensations, which become embedded in a broad variety of psychopathological and intersubjective phenomena [52]. Unprocessed traumatic memories stored in the mid-brain region become recycled when triggered, creating undischarged energy in the nervous system. Because traumatic memories are encoded subcortically, the process of healing trauma requires gaining leverage within the structural coding of the brain. Psychotherapeutic "'interpretation'" has been shown to have limited effectiveness with pathologies arising from the verbal phase related to explicit memories, and no effect on the pre-verbal phase implicit memories" [52]. Trauma speaks through the body. Trauma has been described as a "disorder of arousal." Its resolution lies in creating a psychophysiological state associated with decreased adrenergic activity, decreased muscular neuromuscular arousal, and cognitive quieting [53].

*Anorexia and Bulimia Nervosa*

**self-reintegration**

BN recovery.

**8.1 The therapist's versatile and empathic use of self fosters patient** 

For BN individuals who failed to experience the benefits of healthy attachment during childhood, an effective therapeutic attachment offers a second real-time opportunity to feel the intrapersonal gratification that can be derived from a secure and trusting interpersonal attachment relationship with another human being. The healing therapeutic relationship becomes the prototype for healthful, quality relationships, both within, and beyond, the treatment dyad. "The highest human functions… including stress regulation, humor, empathy, compassion… are all right brain functions. An expanded capacity for right, not left, brain processing lies at the core of clinical expertise" [46]. The skillful and knowledgeable psychotherapist needs to maintain a mindful, pro-active and viable presence within each therapy moment, using himself or herself with intention, versatility, flexibility, courage, intuition and creativity [49]. Because ED represent changes within neural systems that mediate reward responses, decision-making, and social behaviors, effective treatment requires individualization based upon the specific constellation of symptoms presented, as well as their neurobiological underpinnings. As psycho-educators, practitioners need to keep patients informed about anticipated neurobiological changes in brain function related to impaired nutrition, such as fatigue, concentration and learning deficits, mood swings, insomnia, and impulsivity [2]. Patients also need to become aware of the positive changes in brain function that occur side-by-side with, and as result of,

The therapist's openness to his or her own bodily state is a crucial requirement for establishing interpersonal attunement with the patient [27]. "The therapist who is not intimidated, and who feels comfortable disclosing his or her own selfexperience in appropriate, boundaried and clearly intentional ways, offers patients the opportunity and permission to bring forward more of their own seemingly intolerable experience. Therapist receptivity assures patients that they need not censor themselves, so that difficult emotions lose some of their threat" [44]. For purposes of role modeling in promoting the patient's learning and self-discovery, the clinician's self-revelation potentially fills gaps in the patient's emotional and self-development. Immediate, in-the-moment inquiry about the patient's countertransferential reactions to the therapist's disclosure enhances the patient's sensing of self-experience and interpersonal trust building. "So, what's it like for you that I have chosen to share this information with you today?" "As an interactive regulator of the patient's psychological state" [47], the therapist's trust in, and acknowledgment of, the patient's strengths, resiliency, and potential to achieve recovery inspires and sustains the patient's belief in herself, fortifying her capacity to withstand the challenges of navigating the BN recovery process…as well as life without an ED.

*Secure attachment relationships are based in mutual trust.*

*Emma shared, "You are the first person who has ever really listened to me, seeing beneath the surface to who I really am." Feeling stressed for having to leave town and therapy for several weeks, she texted me from afar about her disappointment in herself for having purged. "I hope I am not intruding on your time in reaching you like this," she wrote. "I genuinely care about you, and am glad to hear from you whenever and however it works best." I replied. "It is important for you to understand that the 'failure' you describe is not a failure at all, but a normal part of every stage of the recovery process. Knowing you as I do, I trust that you will continue to go from strength to strength, just as you've done your entire life, from early childhood onwards. And, if you are assessing the quality of your recovery,* 

**156**

Rapid Resolution Therapy (RRT), illustrated in the examples in Section 9.1, is a body-based talk therapy technique shown to alleviate negative effects of trauma and PTSD without requiring the patient to recollect painful memories. Within the context of a trusted relationship, the technique connects problems to solutions through the human nervous system by consolidating memories of past and present human strengths and resourcefulness [54]. "Trauma resides in the limbic system (responsible for emotional systems and defensive responses) and in the perceptual world within a neural network that has sufficient functional boundary thresholds to largely 'dis-integrate' it from the rest of the nervous system. When negative feelings become dissociated or 'split off' [as they do with the bulimic pseudo-self], the potential exists to reintegrate them through the patient's connection with a better state, her best self, by sensing and owning her resourceful self through solutiondiscovery, or rediscovery, both past and present" [33]. Trauma resolution "accesses neuroplasticity, through which neural networks that become lit-up at the same time as the neural network associated with the problem, result in the problem's loss of definition. This dynamic allows for a free flow of communication with the rest of the nervous system, as the brain re-interprets new combinations of neural connections to create meaning" [54]. Because the effects of past trauma are revealed in the present, they become accessible, and thereby, available for remediation.

#### **9.1 Sensing, recall, and consolidation of resourcefulness memories heal trauma**

Trauma occupies the right side of the brain where it creates a hyperactive cortisol network; the processing of trauma needs to occur within the left side of the brain, where some form of resolution can be reached. The healing process becomes reinforced through connections to real-life experience, as the therapist guides the patient to access her already existing internal resourcefulness.

*Having grown up in a dysfunctional, chaotic family environment during which her father spent years in prison, Lillian is a highly functioning divorced woman struggling with BN, depression, anxiety, and alcohol addiction. Her impaired self-perception, self-regulation, and distrust in her judgment and decision-making have kept her resentfully tied to a long-term, disorganized relationship with a boyfriend upon whom she relies to provide compensatory external controls. Though considering herself to be "helpless and hopeless," this day she spoke of her excellent performance in her new job, the gratifying relationships she'd established there, and her improved relationship with her adolescent son. "When you are feeling good about such experiences, have you ever sensed where inside your body you notice sensations of pleasure or gratification?" I asked. She had not noticed. I invited her to probe her sensory recall, calling up past fulfilling experiences where she might have sensed an internal body-felt 'lightness of being.' She could not. Upon parting, she randomly commented that the Botanic Garden in which we had walked and talked that day had offered a delightful and uplifting experience. Capturing that opportunity, I replied, "Try to observe where in your body you might be sensing your positive feelings now, right at this moment." Lillian pointed to her heart. "Perhaps the next time you notice yourself feeling inadequate, out of control or fearful, you might want to try to bring up your body's sensory memory of your feelings of contentment right now, in this beautiful place. You might just come to discover that the same body that has long been your worst enemy could possibly become your greatest ally".*

Tapping into old 'feel good' moments facilitates positivity in the experience of now. "Eating disorders, which are dysfunctions of multisensory body integration, are the outcome of primary disturbances in the way the body is "experienced" and

**159**

**10. Conclusion**

*Reclaiming the Lost Self in the Treatment of Bulimia Nervosa: A Neurobiological Approach…*

"remembered" [55]. Memory consolidation puts the experience of body phenomena into the thinking brain, securing it there through the creation and re-creation of healthy neurobiological circuitry and neuronal connections between mind, brain,

*A 6-year-old Honduran child, whose mother had brought him to the U.S. seeking asylum, underwent sustained trauma during his one-month detention in a cage at the country's border, separated from his mother. Having seen a film clip of their reunion on television, Tess watched the agonized child convulsing and crying in anguish and recrimination. "You gave me away. You don't love me. You are not my mom anymore, and I don't want to be your son. I want to go back to the jail." Tess, having been abused and neglected by her own mother, instantaneously succumbed to re-experiencing her own traumatic childhood feelings of rejection. She purged immediately after viewing the program and awoke the following morning with an aching body, and a pain that "took up all the space in my stomach." In an emergency therapy session that morning, Tess sat on my couch with bent knees tightly drawn up to her chin, arms tightly encircling her legs, her body language expressing a somatic narrative that portrayed fear and the need for self-protection. She described her previous night's experience, "where my dissociated bulimic self harangued me about how repulsive, despicable and worthless I am. I became painfully aware that all of my progress in treatment had gone up in smoke, becoming 'unreal' to me, as though it never happened." During our treatment session, Tess became aware of how her mother currently and consistently continues to fuel her shame and psychic pain, into the present. She also became able to recognize her own co-dependent fear and reluctance to erect a viable emotional boundary between them. Having become fully present in the here and now within our secure attachment, our solution-based dialogue during that session countered her right-brain activation by creating a coherent, left-brain narrative, consolidating and reintegrating more recent body-felt remembrances of her healthy Self. Within two hours time, her face and body had visibly relaxed to a state of calm as she shifted out of the past into the fulfillment and gratification of her present life. Tess left that session with a smile on her face,* 

*expressing an overwhelming sense of relief and gratitude.*

ED recovery is to be complete and sustainable.

Tess's successful resolution of this traumatic incident held out the promise of change within her nervous system reflecting a greater and more spontaneous capacity to access her internal resiliency in the face of future resurgences of traumatic memory. The process of trauma resolution in working with BN patients is no different from healing trauma in any other context, with the exception that in light of the integrative nature of an ED, attention to trauma resolution needs to become part of a greater fabric of pathology, all aspects of which demand resolution and healing if

Characterized by biochemical, neuromuscular, and sensory imbalances, BN fosters internal chaos and system rigidity, disrupting the integrity of the patient's core self. Clinicians and patients alike need to understand and anticipate that BN treatment and recovery processes are never linear. Tess describes her treatment as being "highly successful…my eating lifestyle, coping abilities, relationships, life quality, and over-all sense of well-being have all significantly improved…yet my BN is still and always lurking within arm's reach, capable of stopping me in my tracks when I am least expecting it." Integrative disorders demand integrative treatment approaches.

*DOI: http://dx.doi.org/10.5772/intechopen.83844*

and body.

*Reclaiming the Lost Self in the Treatment of Bulimia Nervosa: A Neurobiological Approach… DOI: http://dx.doi.org/10.5772/intechopen.83844*

"remembered" [55]. Memory consolidation puts the experience of body phenomena into the thinking brain, securing it there through the creation and re-creation of healthy neurobiological circuitry and neuronal connections between mind, brain, and body.

*A 6-year-old Honduran child, whose mother had brought him to the U.S. seeking asylum, underwent sustained trauma during his one-month detention in a cage at the country's border, separated from his mother. Having seen a film clip of their reunion on television, Tess watched the agonized child convulsing and crying in anguish and recrimination. "You gave me away. You don't love me. You are not my mom anymore, and I don't want to be your son. I want to go back to the jail." Tess, having been abused and neglected by her own mother, instantaneously succumbed to re-experiencing her own traumatic childhood feelings of rejection. She purged immediately after viewing the program and awoke the following morning with an aching body, and a pain that "took up all the space in my stomach." In an emergency therapy session that morning, Tess sat on my couch with bent knees tightly drawn up to her chin, arms tightly encircling her legs, her body language expressing a somatic narrative that portrayed fear and the need for self-protection. She described her previous night's experience, "where my dissociated bulimic self harangued me about how repulsive, despicable and worthless I am. I became painfully aware that all of my progress in treatment had gone up in smoke, becoming 'unreal' to me, as though it never happened." During our treatment session, Tess became aware of how her mother currently and consistently continues to fuel her shame and psychic pain, into the present. She also became able to recognize her own co-dependent fear and reluctance to erect a viable emotional boundary between them. Having become fully present in the here and now within our secure attachment, our solution-based dialogue during that session countered her right-brain activation by creating a coherent, left-brain narrative, consolidating and reintegrating more recent body-felt remembrances of her healthy Self. Within two hours time, her face and body had visibly relaxed to a state of calm as she shifted out of the past into the fulfillment and gratification of her present life. Tess left that session with a smile on her face, expressing an overwhelming sense of relief and gratitude.*

Tess's successful resolution of this traumatic incident held out the promise of change within her nervous system reflecting a greater and more spontaneous capacity to access her internal resiliency in the face of future resurgences of traumatic memory. The process of trauma resolution in working with BN patients is no different from healing trauma in any other context, with the exception that in light of the integrative nature of an ED, attention to trauma resolution needs to become part of a greater fabric of pathology, all aspects of which demand resolution and healing if ED recovery is to be complete and sustainable.

#### **10. Conclusion**

Characterized by biochemical, neuromuscular, and sensory imbalances, BN fosters internal chaos and system rigidity, disrupting the integrity of the patient's core self. Clinicians and patients alike need to understand and anticipate that BN treatment and recovery processes are never linear. Tess describes her treatment as being "highly successful…my eating lifestyle, coping abilities, relationships, life quality, and over-all sense of well-being have all significantly improved…yet my BN is still and always lurking within arm's reach, capable of stopping me in my tracks when I am least expecting it." Integrative disorders demand integrative treatment approaches.

*Anorexia and Bulimia Nervosa*

Rapid Resolution Therapy (RRT), illustrated in the examples in Section 9.1, is a body-based talk therapy technique shown to alleviate negative effects of trauma and PTSD without requiring the patient to recollect painful memories. Within the context of a trusted relationship, the technique connects problems to solutions through the human nervous system by consolidating memories of past and present human strengths and resourcefulness [54]. "Trauma resides in the limbic system (responsible for emotional systems and defensive responses) and in the perceptual world within a neural network that has sufficient functional boundary thresholds to largely 'dis-integrate' it from the rest of the nervous system. When negative feelings become dissociated or 'split off' [as they do with the bulimic pseudo-self], the potential exists to reintegrate them through the patient's connection with a better state, her best self, by sensing and owning her resourceful self through solutiondiscovery, or rediscovery, both past and present" [33]. Trauma resolution "accesses neuroplasticity, through which neural networks that become lit-up at the same time as the neural network associated with the problem, result in the problem's loss of definition. This dynamic allows for a free flow of communication with the rest of the nervous system, as the brain re-interprets new combinations of neural connections to create meaning" [54]. Because the effects of past trauma are revealed in the

present, they become accessible, and thereby, available for remediation.

patient to access her already existing internal resourcefulness.

**9.1 Sensing, recall, and consolidation of resourcefulness memories heal trauma**

Trauma occupies the right side of the brain where it creates a hyperactive cortisol network; the processing of trauma needs to occur within the left side of the brain, where some form of resolution can be reached. The healing process becomes reinforced through connections to real-life experience, as the therapist guides the

*Having grown up in a dysfunctional, chaotic family environment during which her father spent years in prison, Lillian is a highly functioning divorced woman struggling with BN, depression, anxiety, and alcohol addiction. Her impaired self-perception, self-regulation, and distrust in her judgment and decision-making have kept her resentfully tied to a long-term, disorganized relationship with a boyfriend upon whom she relies to provide compensatory external controls. Though considering herself to be "helpless and hopeless," this day she spoke of her excellent performance in her new job, the gratifying relationships she'd established there, and her improved relationship with her adolescent son. "When you are feeling good about such experiences, have you ever sensed where inside your body you notice sensations of pleasure or gratification?" I asked. She had not noticed. I invited her to probe her sensory recall, calling up past fulfilling experiences where she might have sensed an internal body-felt 'lightness of being.' She could not. Upon parting, she randomly commented that the Botanic Garden in which we had walked and talked that day had offered a delightful and uplifting experience. Capturing that opportunity, I replied, "Try to observe where in your body you might be sensing your positive feelings now, right at this moment." Lillian pointed to her heart. "Perhaps the next time you notice yourself feeling inadequate, out of control or fearful, you might want to try to bring up your body's sensory memory of your feelings of contentment right now, in this beautiful place. You might just come to discover that the same body that* 

*has long been your worst enemy could possibly become your greatest ally".*

Tapping into old 'feel good' moments facilitates positivity in the experience of now. "Eating disorders, which are dysfunctions of multisensory body integration, are the outcome of primary disturbances in the way the body is "experienced" and

**158**

The capacity for self-correction is built into the nervous system through the brain's ability to integrate sensing, perception, and motor activity. Effective treatment needs to support changes at the brain level, with attention paid to mental, somatic, and relational issues. The creation of neural firing patterns that awaken the brain enables newly established synaptic connections, promoting self-awareness of one's internal world, which modulates and modifies it [27], promoting self-integration.

According to Allan Schore, a significant paradigm shift in psychotherapy is occurring, marked by clinical modes now moving from left brain to right brain, from the mind to the body, and from the central to the autonomic nervous system [52]. "After three decades of cognitive approaches, motivational and emotional processes have roared back into the limelight…cognitive interventions have been proven short-lived in their efficacy, and limited in the problems to which they can be applied" [47]. The right hemisphere is dominant in the change process of psychotherapy. Body-based right brain affect, including specifically unconscious affect, is best accessed through updated, adjunctive psychotherapeutic interventions [47]. Psychobiological attachment-based empathic resonance between the patient and therapist, and the use of adjunctive top-down and bottom-up neurophysiological interventions in appropriate situations and with clarity of intention, address the neurobiological roots of disease, beyond symptoms, in fostering mind, brain, and body connections that promote integration of the structure of the self.

Though we live in an era of psychotherapy research and practice where specific modes of psychotherapeutic treatment have been recognized as targeting specific sites of brain functioning [56], mainstream clinical eating disorder treatment continues to focus on symptom reduction alone, neglecting the neurological origins and underpinnings of these disorders. Clinicians need to become better prepared to resolve these lethal disorders at their source by accessing the brain and distributed nervous system, fostering the sustainability of ameliorative change. In so doing, they stand on the precipice of a new age of treatment, moving patients, the field, and eating disorder research, forward.

#### **Acknowledgements**

Heartfelt thanks and gratitude go to my dear friend and fellow writer, Lyn Haber, whose brilliant edits and much-appreciated tenacity were so supportive and uplifting to me throughout this project.

Many thanks go to 'Tess,' for having provided astute insights and contributions as I put this chapter together. As a soon-to-be psychotherapist herself, and a joy and pleasure to have worked with in treatment, she has my love, respect, and gratitude.

**161**

**Author details**

Abigail H. Natenshon

provided the original work is properly cited.

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Eating Disorder Specialists of Illinois, Highland Park, Illinois, USA

\*Address all correspondence to: abigailnatenshon@gmail.com

*Reclaiming the Lost Self in the Treatment of Bulimia Nervosa: A Neurobiological Approach…*

*DOI: http://dx.doi.org/10.5772/intechopen.83844*

#### **Abbreviations**


*Reclaiming the Lost Self in the Treatment of Bulimia Nervosa: A Neurobiological Approach… DOI: http://dx.doi.org/10.5772/intechopen.83844*

#### **Author details**

*Anorexia and Bulimia Nervosa*

integration of the structure of the self.

uplifting to me throughout this project.

AN anorexia nervosa BN bulimia nervosa ED eating disorders

CBT cognitive-behavioral therapy

PTSD post-traumatic stress disorder

RRT rapid resolution therapy ATM awareness through movement

FI functional integration

BLS bilateral stimulation

EMDR eye movement desensitization and reprocessing

**Acknowledgements**

**Abbreviations**

The capacity for self-correction is built into the nervous system through the brain's ability to integrate sensing, perception, and motor activity. Effective treatment needs to support changes at the brain level, with attention paid to mental, somatic, and relational issues. The creation of neural firing patterns that awaken the brain enables newly established synaptic connections, promoting self-awareness of one's internal

According to Allan Schore, a significant paradigm shift in psychotherapy is occurring, marked by clinical modes now moving from left brain to right brain, from the mind to the body, and from the central to the autonomic nervous system [52]. "After three decades of cognitive approaches, motivational and emotional processes have roared back into the limelight…cognitive interventions have been proven short-lived in their efficacy, and limited in the problems to which they can be applied" [47]. The right hemisphere is dominant in the change process of psychotherapy. Body-based right brain affect, including specifically unconscious affect, is best accessed through updated, adjunctive psychotherapeutic interventions [47]. Psychobiological attachment-based empathic resonance between the patient and therapist, and the use of adjunctive top-down and bottom-up neurophysiological interventions in appropriate situations and with clarity of intention, address the neurobiological roots of disease, beyond symptoms, in fostering mind, brain, and body connections that promote

Though we live in an era of psychotherapy research and practice where specific modes of psychotherapeutic treatment have been recognized as targeting specific sites of brain functioning [56], mainstream clinical eating disorder treatment continues to focus on symptom reduction alone, neglecting the neurological origins and underpinnings of these disorders. Clinicians need to become better prepared to resolve these lethal disorders at their source by accessing the brain and distributed nervous system, fostering the sustainability of ameliorative change. In so doing, they stand on the precipice of a new age of treatment, mov-

Heartfelt thanks and gratitude go to my dear friend and fellow writer, Lyn Haber, whose brilliant edits and much-appreciated tenacity were so supportive and

Many thanks go to 'Tess,' for having provided astute insights and contributions as I put this chapter together. As a soon-to-be psychotherapist herself, and a joy and pleasure to have worked with in treatment, she has my love, respect, and gratitude.

ing patients, the field, and eating disorder research, forward.

world, which modulates and modifies it [27], promoting self-integration.

**160**

Abigail H. Natenshon Eating Disorder Specialists of Illinois, Highland Park, Illinois, USA

\*Address all correspondence to: abigailnatenshon@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[24] de Vos AJ, Lamarre A, Radstaak M, Bijkirk CA, Bohlmeijer E, Westerhof GJ. Identifying fundamental criteria for eating disorder recovery: A systematic review and qualitative meta-analysis. Journal of Eating Disorders. 2017;**5**(1): 1-14. DOI: 10.1186-s40337-017-0164-0

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[26] Riva G. the neuroscience of body memory: From the self through the space to the others. Cortex. 2017;**104**:241-260. DOI: 10.1016/J. Cortx.2017.07.013

[27] Siegel DJ. An interpersonal neurobiology approach to psychotherapy; awareness, mirror neurons, and neural plasticity in the development of well-being. Psychiatric Annals. 2006;**36**(4):248-256

[28] Sze JA, Gyurak A, Yuan JW, Levenson RW. Coherence between emotional experience and physiology: Does body awareness training have an impact? Emotion. 2010;**10**(6):803-814

[29] OpenPSYC. Openpsyc.blogspot. com/2014/06booem

[30] Taylor AG, Goehler LE, Galper DI, Innes KE, Bourguignon C. Topdown and bottom-up mechanisms in mind-body medicine: Development of an integrative framework for psychophysiological research. Explore. 2010;**6**(1):29. DOI: 10.1016/j. explore.2011.12.005

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[32] Janowiak-Siuda K, Rymarczyk K, Grabowska A. How we empathize with others: A neurobiological perspective. Medical Science Monitor. 2011;**17**(1):RA18-RA24. DOI: 10.12659/ msm.881324

[33] Connelly J. The Institute for Rapid Resolution Therapy. https:// www.floridacenterforrecovery. com/addiction-glossary/ rapid-resolution-therapy

[34] Ogden P, Pain C, Fisher J. A sensorimotor approach to the

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[2] Kaye WH, Fudge JL, Paulus M. New insights into symptoms and neurocircuit function of anorexia nervosa. Nature Reviews Neuroscience. 2009;**10**(8): 573-584. DOI: 10.1038/nrn2682

[9] University of Illinois at Chicago. Abnormalities found in 'Insight' Areas of the Brain in Anorexia. ScienceDaily.

2016. www.sciencedaily.com/ releases/2016/07/160719123857.htm

[10] Frank G. Eating disorders impact brain function, new brain research suggests. Science News. University of Colorado Denver; 2011. https://www.sciencedaily.com/ releases/2011/07/110711144944.htm

[11] Reindl SM. Sensing the Self: Women's Recovery from Bulimia. Cambridge, MA: Harvard University

[12] Bruch H. Eating Disorders. Obesity, Anorexia Nervosa and the Person Within. New York: Basic Books, Inc.,

[13] National Institute for the Clinical Application of Behavioral Medicine NICABM. Master Strategies in the Treatment of Trauma: The Latest Interventions can Reduce Symptoms and Speed Healing [Internet]. 2018. Available from: https://www.nicabm. com/tag/treating-trauma-master-series/

[14] Siegel DJ. How to Understand your Mind [Internet]. Leadership Online

[15] Siegel DJ. Mindsight: The New Science of Personal Transformation. New York: Bantam/Random House;

[16] Doidge N. The Brain that Changes Itself: Stories of Personal Triumph from the Frontiers of Brain Science. New

[17] Feldenkrais M. Awareness through Movement: Health Exercises for

Personal Growth. New York: Harper and

Press; 2001

Publishers; 1973

[Accessed:2018-11-07]

Training Program; 2017

York: Viking; 2007

Row; 1972

2010

[3] Russell R. Movement and the development of sense of self. In: Proceedings from the International Conference on the Feldenkrais Method; August 2004; Seattle, Washington.

[4] Kaye W. Neurobiology of anorexia and bulimia nervosa purdue ingestive behavior research center symposium influences on eating and body weight over the lifespan: Children and adolescents. Physiology & Behavior. 2008;**94**(1):121- 135. DOI: 10.1016/j.physbeh.2007.11.037

[5] Mickalide AD, Anderson AE. Subgroups of anorexia nervosa and bulimia: Validity and utility. Journal of Psychiatric Research.

[6] Whiteman H. Why are women more vulnerable to eating disorders? Brain study sheds light. Medical News Today. 2016

[8] Via E, Zalesky A, Sanchez I, Forcano L, Harrison BJ, Pujol J, et al. Disruption of brain white matter microstructure in women with anorexia nervosa. Journal of Psychiatry & Neuroscience. 2014;**39**(6):367-375. DOI: 10.1503/

[7] Moseman S. Understanding Neurobiology and Eating Disorders. Tulsa, Oklahoma: Laureate Eating Disorders Program; 2014. http://www. eatingdisorderhope.com/treatment-foreating-disorders/types-of-treatments/ neurobiology-can-play-key-role-in-

treating-eating-disorders

1985;**19**(2-2):121-128

1979;**9**(3):429-424

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treatment of trauma and dissociation. Psychiatric Clinics of North America. 2006;**29**(1):263-279, xi-xii. DOI: 10.1016/j.psc.2005.10.012

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[36] Laumer U, Bauer M, Fichter M, Milz H. Therapeutic effects of the feldenkrais method (awareness through movement) in eating disorders. IFF Academy: Feldenkrais Research Journal. 2004;**1**:2

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[38] Hall A, Ofei-Tenkorang NA, Machn JT, Gordon CM. Use of yoga in outpatient eating disorder treatment: A pilot study. Journal of Eating Disorders. 2016;**4**(38):1-8. DOI: 10.1186/ s40337-016-0130-2

[39] Kinser P, Goehler L, Taylor AG. How might yoga heal depression? A neurological perspective. Explore. 2012;**8**(2):118. DOI: 10.1016/j. explore.2011.12.005

[40] Korn D, Leeds AM. Preliminary evidence of efficacy of EMDR resource development and installation in the stabilization phase of treatment of complex posttraumatic stress disorder. Journal of Clinical Psychology. 2002;**58**(12):1465-1487

[41] Coubard OA. Eye movement desensitization and reprocessing (EMDR) reexamined as cognitive and emotional neuroentertainment. Frontiers in Human Neuroscience. 2015;**8**:1035. DOI: 10.3398/ fnhum.2014.01035

[42] Mahler MS, Pine F, Bergman A. The Psychological Birth of the Human Infant: Symbiosis and Individuation. New York: Basic Books; 1931

[43] Schore AN. The experiencedependent maturation of a regulatory system in the orbital prefrontal cortex and the origin of developmental psychopathology. Development and Psychopathology. 1996;**8**:59-87

[44] Schore JR, Schore AN. Modern attachment theory: The central role of affect regulation in development and treatment. Clinical Social Work Journal. 2008;**36**(1):9-20. DOI: 10.1007/ s10615-007-0111-7

[45] Schore AN. Early organization of the non-linear right brian and development of the predisposition to psychiatric disorders. Development and Psychopathology. 1996;**8**(1):59-87

[46] Halasz G. In conversation with allan schore. Australian Psychiatry. 2011;**19**(1):30-36. DOI: 10.3109/10398562.2010.530757

[47] Schore AN. Right brain affect regulation: An essential mechanism of development, trauma, dissociation, and psychotherapy. In: Fosha D, Siegel DJ, Solomon M, editors. Papers by YellowBrick Leadership. The Healing Power of Emotion: Affective Neuroscience, Development, and Clinical Practice. New York City: WW Norton; 2009

[48] Germer CK, Siegel RD, Fulton PR. Mindfulness and Psychotherapy. Guilford Press; 2005

[49] Natenshon A. Eating disorders: A treatment apart. In: Jauregui-Lobera, editor. Eating Disorders: A Paradigm of the Biopsychosocial Model of Illness. Intech; 2017. pp. 165-187

**165**

*Reclaiming the Lost Self in the Treatment of Bulimia Nervosa: A Neurobiological Approach…*

*DOI: http://dx.doi.org/10.5772/intechopen.83844*

Smith BN. Comorbidity of partial and subthreshold PTSD among men and women with eating disorders in the National Comorbidity Survey-Replication Study. The International

[51] Deep AL, Lilenfeld LR, Plotnicov KH, Pollice C, Kaye WH. Sexual abuse in eating disorder subtypes and control women: The role of comorbid substance

[52] Ogden P, Pain C, Minton K, Fisher J. In: Schore AN, editor. Including the Body in Mainstream Psychotherapy for Traumatized Individuals. Vol. 25(4). Psychologist-Psychoanalyst. 2005. Retrieved from: http://www. sensorimotorpsychotherapy.org/

[53] Everly GS Jr, Benson H. Disorders of arousal and the relaxation response:

Speculations on the nature and treatment of stress-related diseases. International Journal of Psychosomatics.

[54] Quintal JS. Trauma resolution treatment…and more; rhizomatics and the processes of change. In: Proceedings of the SelahFreedom: Bringing Light into the Darkness of Sex Trafficking. Conference; 8-9 November 2018;

[55] Riva G, Gaudio S. Locked to the wrong body: Eating disorders are the outcome of a primary disturbance in multisensory body integration. Consciousness and Cognition.

[56] Gabbard GO. A neurobiologically informed perspective on psychotherapy. The British Journal of Psychiatry. 2000;**1777**:117-122. www.ncbi.nlm.nih.

dependence in bulimia nervosa. The International Journal of Eating

Disorders. 1999;**25**:1-10

article%20APA.html

1989;**36**(1-4):15-21

Winnetka, Illinois. p. 4

gov/pubmed/11026950

2018;**59**:57-59

Journal of Eating Disorders. 2012;**45**(3):307-315. DOI: 10.1002/

eat.20965

[50] Mitchell KS, Mazzeo SE, Schlesinger MR, Brewerton TD, *Reclaiming the Lost Self in the Treatment of Bulimia Nervosa: A Neurobiological Approach… DOI: http://dx.doi.org/10.5772/intechopen.83844*

Smith BN. Comorbidity of partial and subthreshold PTSD among men and women with eating disorders in the National Comorbidity Survey-Replication Study. The International Journal of Eating Disorders. 2012;**45**(3):307-315. DOI: 10.1002/ eat.20965

*Anorexia and Bulimia Nervosa*

treatment of trauma and dissociation. Psychiatric Clinics of North America. 2006;**29**(1):263-279, xi-xii. DOI: 10.1016/j.psc.2005.10.012

[42] Mahler MS, Pine F, Bergman A. The Psychological Birth of the Human Infant: Symbiosis and Individuation.

New York: Basic Books; 1931

[43] Schore AN. The experiencedependent maturation of a regulatory system in the orbital prefrontal cortex and the origin of developmental psychopathology. Development and Psychopathology. 1996;**8**:59-87

[44] Schore JR, Schore AN. Modern attachment theory: The central role of affect regulation in development and treatment. Clinical Social Work Journal. 2008;**36**(1):9-20. DOI: 10.1007/

[45] Schore AN. Early organization of the non-linear right brian and development of the predisposition to psychiatric disorders. Development and Psychopathology. 1996;**8**(1):59-87

[46] Halasz G. In conversation with allan schore. Australian Psychiatry. 2011;**19**(1):30-36. DOI: 10.3109/10398562.2010.530757

[47] Schore AN. Right brain affect regulation: An essential mechanism of development, trauma, dissociation, and psychotherapy. In: Fosha D, Siegel DJ, Solomon M, editors. Papers by YellowBrick Leadership. The Healing Power of Emotion: Affective Neuroscience, Development, and Clinical Practice. New York City: WW

[48] Germer CK, Siegel RD, Fulton PR. Mindfulness and Psychotherapy.

[49] Natenshon A. Eating disorders: A treatment apart. In: Jauregui-Lobera, editor. Eating Disorders: A Paradigm of the Biopsychosocial Model of Illness.

s10615-007-0111-7

Norton; 2009

Guilford Press; 2005

Intech; 2017. pp. 165-187

[50] Mitchell KS, Mazzeo SE, Schlesinger MR, Brewerton TD,

[35] Eshkebari E, Rieger E, Longo M, Haggard P, Treasure J. Persistent body image disturbance following recovery from eating disorders. The International

[36] Laumer U, Bauer M, Fichter M, Milz H. Therapeutic effects of the feldenkrais method (awareness through movement) in eating disorders. IFF Academy: Feldenkrais Research Journal. 2004;**1**:2

[37] Brewerton TD. Eating disorders, trauma, and comorbidity: Focus on PTSD. Journal of Treatment and Prevention. 2007;**15**(4):285-304 www. nationaleatingdisorders.org/blog/ eating-disorders-trauma-ptsd-recovery

[38] Hall A, Ofei-Tenkorang NA, Machn JT, Gordon CM. Use of yoga in outpatient eating disorder treatment: A pilot study. Journal of Eating

s40337-016-0130-2

explore.2011.12.005

Disorders. 2016;**4**(38):1-8. DOI: 10.1186/

[39] Kinser P, Goehler L, Taylor AG. How might yoga heal depression? A neurological perspective. Explore. 2012;**8**(2):118. DOI: 10.1016/j.

[40] Korn D, Leeds AM. Preliminary evidence of efficacy of EMDR resource development and installation in the stabilization phase of treatment of complex posttraumatic stress disorder.

Journal of Clinical Psychology.

[41] Coubard OA. Eye movement desensitization and reprocessing (EMDR) reexamined as cognitive and emotional neuroentertainment. Frontiers in Human Neuroscience.

2002;**58**(12):1465-1487

2015;**8**:1035. DOI: 10.3398/

fnhum.2014.01035

Journal of Eating Disorders.

2014;**47**:400-409

**164**

[51] Deep AL, Lilenfeld LR, Plotnicov KH, Pollice C, Kaye WH. Sexual abuse in eating disorder subtypes and control women: The role of comorbid substance dependence in bulimia nervosa. The International Journal of Eating Disorders. 1999;**25**:1-10

[52] Ogden P, Pain C, Minton K, Fisher J. In: Schore AN, editor. Including the Body in Mainstream Psychotherapy for Traumatized Individuals. Vol. 25(4). Psychologist-Psychoanalyst. 2005. Retrieved from: http://www. sensorimotorpsychotherapy.org/ article%20APA.html

[53] Everly GS Jr, Benson H. Disorders of arousal and the relaxation response: Speculations on the nature and treatment of stress-related diseases. International Journal of Psychosomatics. 1989;**36**(1-4):15-21

[54] Quintal JS. Trauma resolution treatment…and more; rhizomatics and the processes of change. In: Proceedings of the SelahFreedom: Bringing Light into the Darkness of Sex Trafficking. Conference; 8-9 November 2018; Winnetka, Illinois. p. 4

[55] Riva G, Gaudio S. Locked to the wrong body: Eating disorders are the outcome of a primary disturbance in multisensory body integration. Consciousness and Cognition. 2018;**59**:57-59

[56] Gabbard GO. A neurobiologically informed perspective on psychotherapy. The British Journal of Psychiatry. 2000;**1777**:117-122. www.ncbi.nlm.nih. gov/pubmed/11026950

**167**

**Chapter 10**

Management

be alert to the possibility in all patients.

In it, SEMI was defined as follows:

**1. Introduction**

*agencies."*

*Paul Robinson*

**Abstract**

Severe and Enduring Eating

The concept of severe and enduring mental illness was introduced in 1999 in order to direct resources to patients suffering from long-term serious disorders, and was suggested for eating disorders in 2009. However, the term is still restricted to patients with long-term psychosis. In this chapter, the concept of severe and enduring eating disorder (SEED) is described and its relevance to anorexia nervosa (AN) and bulimia nervosa (BN) is explored. The recovery curve for anorexia nervosa seems to follow an exponential pattern with an asymptote that approaches but does not meet the horizontal, suggesting that recovery is always possible. Symptoms of AN but not BN seem to worsen after 3 years of illness, perhaps a significant threshold. Symptoms of severe and enduring AN (SEED-AN) are debilitating and longstanding as well as potentially fatal. Symptoms of severe and enduring BN (SEED-BN) are also debilitating, especially in social adjustment. In both conditions, family difficulties are prominent. A clinical approach to SEED is described based on improving quality of life, the recovery approach, (rather than cure) for sufferers and their families is described, although full symptomatic recovery can occur at any stage and clinicians should

**Keywords:** anorexia nervosa, bulimia, chronic, severe and enduring, recovery model

The idea of severe and enduring mental illness (SEMI) extends back to 1999 when the UK Department of Health published the National Service Framework [1].

*schizophrenia, bipolar affective disorder or organic mental disorder, severe anxiety disorders or severe eating disorders, have complex needs which may require the continuing care of specialist mental health services working effectively with other* 

Clearly it was intended, rightly, to include non-psychotic disorders such as eating disorders and obsessive-compulsive disorder. Since that time policy has changed, perhaps because of increasing demands on community psychiatric

*"People with recurrent or severe and enduring mental illness, for example* 

Disorders: Concepts and

#### **Chapter 10**

## Severe and Enduring Eating Disorders: Concepts and Management

*Paul Robinson*

#### **Abstract**

The concept of severe and enduring mental illness was introduced in 1999 in order to direct resources to patients suffering from long-term serious disorders, and was suggested for eating disorders in 2009. However, the term is still restricted to patients with long-term psychosis. In this chapter, the concept of severe and enduring eating disorder (SEED) is described and its relevance to anorexia nervosa (AN) and bulimia nervosa (BN) is explored. The recovery curve for anorexia nervosa seems to follow an exponential pattern with an asymptote that approaches but does not meet the horizontal, suggesting that recovery is always possible. Symptoms of AN but not BN seem to worsen after 3 years of illness, perhaps a significant threshold. Symptoms of severe and enduring AN (SEED-AN) are debilitating and longstanding as well as potentially fatal. Symptoms of severe and enduring BN (SEED-BN) are also debilitating, especially in social adjustment. In both conditions, family difficulties are prominent. A clinical approach to SEED is described based on improving quality of life, the recovery approach, (rather than cure) for sufferers and their families is described, although full symptomatic recovery can occur at any stage and clinicians should be alert to the possibility in all patients.

**Keywords:** anorexia nervosa, bulimia, chronic, severe and enduring, recovery model

### **1. Introduction**

The idea of severe and enduring mental illness (SEMI) extends back to 1999 when the UK Department of Health published the National Service Framework [1]. In it, SEMI was defined as follows:

*"People with recurrent or severe and enduring mental illness, for example schizophrenia, bipolar affective disorder or organic mental disorder, severe anxiety disorders or severe eating disorders, have complex needs which may require the continuing care of specialist mental health services working effectively with other agencies."*

Clearly it was intended, rightly, to include non-psychotic disorders such as eating disorders and obsessive-compulsive disorder. Since that time policy has changed, perhaps because of increasing demands on community psychiatric

services due to bed closures and funding restrictions and the most recent definition is very restrictive. In 2018, the National Institute for Clinical and Care Excellence (NICE) [2] released the draft scope for SEMI and stated: "the groups that will be covered are *Adults (aged 18 years and older) with complex psychosis*". Ruggeri et al. [3] provided two sets of criteria that reflect this tension: 1. Diagnosis of psychosis, 2. Duration of service contact ≥2 years, 3. GAF (Global Assessment of Functioning) score' <50 and a second model only including the latter two criteria, hence including non-psychotic disorders (including eating disorders).

In this context in which access to services could be restricted by psychiatric teams on the basis that the patient did not have a severe and enduring mental illness, the author wrote a book entitled Severe and Enduring Eating Disorders [4] partly in an attempt to draw attention to the ongoing major problems experienced by people with long term eating disorders. In this chapter we will examine the SEMI concept as applied to eating disorders, review the symptoms experienced by SEED patients and look at the differences between different eating disorders, which have lasted for many years. In the last section, recommendations for management of SEED will be made.

#### **2. Definitions and concepts**

Eating disorders have been fully described in the DSM 5 [5] and these definitions will not be considered here. However, the questions of duration and severity do give rise to controversy and although the term Severe and Enduring" has been applied to eating disorders [4, 6], the precise length of history and severity required are still undecided.

#### **2.1 Length of illness**

This can be approached in a number of ways. One is to ask the question: At what point do eating disorders become significantly harder to treat? This is an important question, because if we knew the answer, we could make all possible efforts to begin treatment before that point. Unfortunately there is rather little evidence to guide us, although it has been suggested [7] that after 3 years of illness, anorexia nervosa may become more intractable. This is based on a randomised controlled study of anorexia nervosa [8] in which patients with a length of history of restricting anorexia nervosa of <3 years did significantly better in family therapy than patients with a longer history. Another approach is to look at the proportion of patients who still fulfil criteria for the disorder at different times after onset. In **Table 1**, a number of studies in which this proportion is reported are displayed. In each study, the proportion of patients with a "poor outcome" is noted in the 5th column. The proportion includes all deaths, as well as patients with a poor outcome due to reasons other than the eating disorder, so the measure is somewhat flawed. However, the proportion after 9–24 years (average 13.4 years) ranges from 12 to 59%, average 27.9%. This tells us that the proportion of patients initially diagnosed as having anorexia nervosa and who go on to do badly is high, and we can expect around a quarter of patients to follow this course. A more conservative estimate is shown in the 3rd column, namely the proportion of patients still fulfilling diagnostic criteria for anorexia nervosa. The range is from 3 to 37% with an average of 14.4%. The highest estimate in that column, 37% [13] is from a national service which accepted referrals from all over the UK. Hence the severity of disease in patients admitted is likely to be higher and length of illness proportionately longer.

**169**

*Severe and Enduring Eating Disorders: Concepts and Management*

24 Diagnoses not recorded

**Proportion % fulfilling disease criteria**

12 19 Mortality 7.7%, BN

10 3 Adolescents, no

15 13 No deaths, 30% binge

10 6 Community screening,

Average 13.4 14.4 27.9%

**Notes Poor** 

9 17 Mortality 11% 59% Deter et al. [10]

9.5%

deaths, 5% BN, 23% personality disorder

eating

mean age onset 14

18 6 Same cohort as above 12% Wentz et al. [16]

20 37 15% BN, 15% died 36.6% Ratnasuriya et al.

**outcome (ED and other reasons)**

Mortality 12.8% 29% Theander et al. [9]

**Reference**

Herpertz-Dahlmann et al. [12]

[13]

Strober et al. [14]

39.6% Fichter et al. [11]

27% Wentz et al. [15]

Without that centre the average proportion fulfilling criteria at average 14 years is

Four of the above studies [9–11, 16] provided data on outcome of anorexia nervosa at several time points which allows us to draw a survival curve (**Figure 1**). This shows that as time goes on, the number of cases reduces and almost, but not quite, reaches the horizontal, that is the curve seems to represent an asymptote. It should be noted that at no time does the curve ever stop falling, although the gradient does flatten, showing that anorexia nervosa can always recover, at any stage. The graph suggests that significant flattening seems to occur between 5 and 10 years, and in that period after diagnosis recovery does become less likely. **Figure 1** also shows the exponential curve that was derived from the data points shown and this

The proposal by Treasure and Russell [7] that a history of more than 3 years might be accompanied by a decreased responsiveness to treatment was further examined in a study by Gardini [17]. In this audit of routine questionnaires, results in patients with anorexia nervosa with under 3 years history were compared with a group of patients with a history of 3–10 years and a further group with over 10 years duration. A comparable study was performed for patients with a diagnosis of

9.14% which may be a more representative figure.

*2.1.1 The asymptotic pattern of outcome*

*Follow-up studies of anorexia nervosa.*

also suggests an asymptotic pattern.

*2.1.2 Symptoms may increase in severity after 3 years*

bulimia nervosa and the same durations of illness.

*DOI: http://dx.doi.org/10.5772/intechopen.87004*

**Length of follow-up (years)**

**Condition studied**

Anorexia nervosa

Anorexia nervosa

Anorexia nervosa

Anorexia nervosa

Anorexia nervosa

Anorexia nervosa

Anorexia nervosa

Anorexia nervosa

**Table 1.**


*Severe and Enduring Eating Disorders: Concepts and Management DOI: http://dx.doi.org/10.5772/intechopen.87004*

#### **Table 1.**

*Anorexia and Bulimia Nervosa*

disorders).

SEED will be made.

undecided.

**2.1 Length of illness**

**2. Definitions and concepts**

services due to bed closures and funding restrictions and the most recent definition is very restrictive. In 2018, the National Institute for Clinical and Care Excellence (NICE) [2] released the draft scope for SEMI and stated: "the groups that will be covered are *Adults (aged 18 years and older) with complex psychosis*". Ruggeri et al. [3] provided two sets of criteria that reflect this tension: 1. Diagnosis of psychosis, 2. Duration of service contact ≥2 years, 3. GAF (Global Assessment of Functioning) score' <50 and a second model only including the latter two criteria, hence including non-psychotic disorders (including eating

In this context in which access to services could be restricted by psychiatric teams on the basis that the patient did not have a severe and enduring mental illness, the author wrote a book entitled Severe and Enduring Eating Disorders [4] partly in an attempt to draw attention to the ongoing major problems experienced by people with long term eating disorders. In this chapter we will examine the SEMI concept as applied to eating disorders, review the symptoms experienced by SEED patients and look at the differences between different eating disorders, which have lasted for many years. In the last section, recommendations for management of

Eating disorders have been fully described in the DSM 5 [5] and these definitions will not be considered here. However, the questions of duration and severity do give rise to controversy and although the term Severe and Enduring" has been applied to eating disorders [4, 6], the precise length of history and severity required are still

This can be approached in a number of ways. One is to ask the question: At what point do eating disorders become significantly harder to treat? This is an important question, because if we knew the answer, we could make all possible efforts to begin treatment before that point. Unfortunately there is rather little evidence to guide us, although it has been suggested [7] that after 3 years of illness, anorexia nervosa may become more intractable. This is based on a randomised controlled study of anorexia nervosa [8] in which patients with a length of history of restricting anorexia nervosa of <3 years did significantly better in family therapy than patients with a longer history. Another approach is to look at the proportion of patients who still fulfil criteria for the disorder at different times after onset. In **Table 1**, a number of studies in which this proportion is reported are displayed. In each study, the proportion of patients with a "poor outcome" is noted in the 5th column. The proportion includes all deaths, as well as patients with a poor outcome due to reasons other than the eating disorder, so the measure is somewhat flawed. However, the proportion after 9–24 years (average 13.4 years) ranges from 12 to 59%, average 27.9%. This tells us that the proportion of patients initially diagnosed as having anorexia nervosa and who go on to do badly is high, and we can expect around a quarter of patients to follow this course. A more conservative estimate is shown in the 3rd column, namely the proportion of patients still fulfilling diagnostic criteria for anorexia nervosa. The range is from 3 to 37% with an average of 14.4%. The highest estimate in that column, 37% [13] is from a national service which accepted referrals from all over the UK. Hence the severity of disease in patients admitted is likely to be higher and length of illness proportionately longer.

**168**

*Follow-up studies of anorexia nervosa.*

Without that centre the average proportion fulfilling criteria at average 14 years is 9.14% which may be a more representative figure.

#### *2.1.1 The asymptotic pattern of outcome*

Four of the above studies [9–11, 16] provided data on outcome of anorexia nervosa at several time points which allows us to draw a survival curve (**Figure 1**).

This shows that as time goes on, the number of cases reduces and almost, but not quite, reaches the horizontal, that is the curve seems to represent an asymptote. It should be noted that at no time does the curve ever stop falling, although the gradient does flatten, showing that anorexia nervosa can always recover, at any stage. The graph suggests that significant flattening seems to occur between 5 and 10 years, and in that period after diagnosis recovery does become less likely. **Figure 1** also shows the exponential curve that was derived from the data points shown and this also suggests an asymptotic pattern.

#### *2.1.2 Symptoms may increase in severity after 3 years*

The proposal by Treasure and Russell [7] that a history of more than 3 years might be accompanied by a decreased responsiveness to treatment was further examined in a study by Gardini [17]. In this audit of routine questionnaires, results in patients with anorexia nervosa with under 3 years history were compared with a group of patients with a history of 3–10 years and a further group with over 10 years duration. A comparable study was performed for patients with a diagnosis of bulimia nervosa and the same durations of illness.

#### **Figure 1.**

*Percentage of participants who fulfilled diagnostic criteria at each assessment from four follow-up studies of anorexia nervosa. The curve is exponential, derived from these data points.*

#### **Figure 2.**

*EDE-Q scores in three groups of patients with anorexia nervosa (total n = 87) with length of history of <3 years, 3–10 years and >10 years. The p values derive from a Manova comparing the three length of history groups. \**≤*3 years group vs. 3–10 year group p = 0.048, \*\**≤*3 years group vs. 3–10 year group p = 0.017 (post-hoc tests). EDE-Q-G: global score, EDE-Q-R: restraint, EDE-Q-E: eating concern, EDE-Q-S: shape concern, EDE-Q-W: weight concern.*

The results were intriguing. For anorexia nervosa (but not for bulimia nervosa), time had a significant impact on EDE-Q restraint and a borderline significant impact of EDE-Q weight concern and EDE-Q global score. The scores increased between <3 and 3–10 years and then declined after 10 years. The results are summarised in **Figure 2**.

This study provides some evidence for the 3 year threshold proposed by Treasure and Russell [7]. Some eating disorder symptoms significantly increase after 3 years

**171**

alone.

*Severe and Enduring Eating Disorders: Concepts and Management*

illness and this could relate to increasing difficulty in helping patients achieve remission. The increased restraint score could reflect increased resistance to the parents encouraging the patient to consume a weight gaining diet, an essential ele-

In this section, SEED-AN symptoms [18] will be compared with SEED-BN

In SEED-AN, many participants complained of physical problems, but also

*"The worst thing is going to be as I am moving in my latter years being osteoporotic* 

*"Osteoporosis was diagnosed but I think it's controllable ... with Calcium and the* 

In SEED-AN, most participants were depressed, and self esteem was often

*"I felt like I was a horrible, disgusting, person ... I felt like really ugly and disgusting and dirty and therefore to dress myself in things that made me look pretty* 

*"Sometimes I'm just bubbly and happy and in a fun mood and other days I just* 

In SEED-AN, social disruption, lack of intimate relationships and social isola-

*"I felt I just totally failed and dropped out of life. I was too scared to join up the squash club, I was too scared to socialise with people, I lost all my confidence with* 

In SEED-BN most participants were not in relationships and were living

In SEED-BN most participants either did not complain of any physical problem,

*but you know what, there are some fantastic tablets today."*

*right diet, and I think it's not acute."*

*would be like, it would be wrong somehow."*

*"I think a lot of it is dealing with your depression."*

In SEED-BN depression and mood instability were the rule.

*DOI: http://dx.doi.org/10.5772/intechopen.87004*

ment in family based therapy.

**3. Clinical features of SEED**

(unpublished data).

denied their seriousness:

or felt they were manageable.

*want to be on my own."*

**3.2 Psychological**

extremely low:

**3.3 Social**

tion were common.

*job interviews."*

**3.1 Physical**

*Severe and Enduring Eating Disorders: Concepts and Management DOI: http://dx.doi.org/10.5772/intechopen.87004*

illness and this could relate to increasing difficulty in helping patients achieve remission. The increased restraint score could reflect increased resistance to the parents encouraging the patient to consume a weight gaining diet, an essential element in family based therapy.

#### **3. Clinical features of SEED**

In this section, SEED-AN symptoms [18] will be compared with SEED-BN (unpublished data).

#### **3.1 Physical**

*Anorexia and Bulimia Nervosa*

**Figure 1.**

**170**

**Figure 2.**

marised in **Figure 2**.

*Q-W: weight concern.*

The results were intriguing. For anorexia nervosa (but not for bulimia nervosa),

This study provides some evidence for the 3 year threshold proposed by Treasure and Russell [7]. Some eating disorder symptoms significantly increase after 3 years

time had a significant impact on EDE-Q restraint and a borderline significant impact of EDE-Q weight concern and EDE-Q global score. The scores increased between <3 and 3–10 years and then declined after 10 years. The results are sum-

*EDE-Q scores in three groups of patients with anorexia nervosa (total n = 87) with length of history of <3 years, 3–10 years and >10 years. The p values derive from a Manova comparing the three length of history groups. \**≤*3 years group vs. 3–10 year group p = 0.048, \*\**≤*3 years group vs. 3–10 year group p = 0.017 (post-hoc tests). EDE-Q-G: global score, EDE-Q-R: restraint, EDE-Q-E: eating concern, EDE-Q-S: shape concern, EDE-*

*Percentage of participants who fulfilled diagnostic criteria at each assessment from four follow-up studies of* 

*anorexia nervosa. The curve is exponential, derived from these data points.*

In SEED-AN, many participants complained of physical problems, but also denied their seriousness:

*"The worst thing is going to be as I am moving in my latter years being osteoporotic but you know what, there are some fantastic tablets today."*

*"Osteoporosis was diagnosed but I think it's controllable ... with Calcium and the right diet, and I think it's not acute."*

In SEED-BN most participants either did not complain of any physical problem, or felt they were manageable.

#### **3.2 Psychological**

In SEED-AN, most participants were depressed, and self esteem was often extremely low:

*"I felt like I was a horrible, disgusting, person ... I felt like really ugly and disgusting and dirty and therefore to dress myself in things that made me look pretty would be like, it would be wrong somehow."*

In SEED-BN depression and mood instability were the rule.

*"Sometimes I'm just bubbly and happy and in a fun mood and other days I just want to be on my own."*

*"I think a lot of it is dealing with your depression."*

#### **3.3 Social**

In SEED-AN, social disruption, lack of intimate relationships and social isolation were common.

*"I felt I just totally failed and dropped out of life. I was too scared to join up the squash club, I was too scared to socialise with people, I lost all my confidence with job interviews."*

In SEED-BN most participants were not in relationships and were living alone.

*"I've got some friends that I have online but I haven't actually met them. Because I feel I can totally fake…see it kind of doesn't matter what I say because I haven't met them. Do you know what I mean? Because it doesn't matter if they disappear, they're not actually real friends."*

#### **3.4 Family**

In SEED-AN, the patient sometimes ended up as their parents' carer.

*"I was sort of left; a lot of the family got married and moved away from home."*

In other cases, difficult relationships improved over time.

*"In the last 2 years the relationship with my family has got better. I now have contact with my sister. We often chat on the phone. I don't really see my brothers or hear from them, I often ask my parents about them, they ask about me."*

In SEED-BN, family difficulties were frequent. Some felt their families did not take the eating disorder seriously. One patient after she had confessed her bulimia to her mother, reported that her mother said "*yeah I used to do it. It's so stupid. You kind of don't wanna do that … ,*" which she did not find helpful. Other patients reported that their families were weight obsessed. When one participant had regained a size 12, a member of her extended family exclaimed "*Oh my God what have they been feeding you? You're enormous*!"

#### **3.5 Financial**

For SEED-AN, patients were often poor, living on benefits without paid work. They also described clinical frugality, in which they had extreme difficulty spending money on themselves:

*"I find it very difficult spending money. If you walked into my flat, I've got nothing particular there ... just very-very bare. My shoes, I wear them until they begin to fall into pieces."*

For SEED-BN, the illness was often very costly because of the large quantity of food consumed. One patient interviewed was seeing a debt counsellor to manage loans from 5 different lenders: "*I don't have any savings, and I don't buy anything nice for myself, I just survive*."

#### **3.6 Occupational**

SEED-AN: These patients often reported being out of work and surviving on benefits. "*I completed 1 year of that (teaching) course and then I had to go into hospital so that came to an end. ... I seemed to lose interest in work and it seemed more important that I planned my meals and my walks*."

SEED-BN: These individuals were often in work, and some valued the structure of work to help manage their eating disorder: "*I feel that going to work in the morning 'wipes the slate clean' if I have binged and vomited the night before*." Others found that the eating disorder had an adverse effect on work: "*Last summer I had to take a number of months off work due to my eating disorder and depression, and I still struggle to fulfill all my commitments when my mood is low*."

**173**

*Severe and Enduring Eating Disorders: Concepts and Management*

Outcome research in the area of management of SEED is sparse. There are several examples of publications in which clinicians have expressed their opinion in this area [14, 19, 20]. One question that constantly appears in the area of management is what general approach to use. As already discussed full recovery from an eating disorder is always possible although less likely as the years pass. The patient (and the clinician and family) are thus confronted with the question each time therapy is contemplated: Should I go for a full recovery or for the best quality-of-life

From the point of view of the clinician, there may be a moral dilemma. Funding for services may depend on inpatient units being full. This applies to both the public and private health sectors. There may therefore be perverse incentives to admit the SEED patient for a prolonged hospital stay in pursuit of weight gain. Most professionals in charge of an inpatient eating disorders service will be aware of these pressures, and how they sometimes conflict with patient care. Hospital admission is essential in the case of a patient who presents life threatening physical illness. However the likelihood of long-term recovery after prolonged admission in someone with a long illness is probably small and one is left with a suspicion that some SEED patients may be admitted for long periods without

It seems to the author evident that all patients with SEED to be offered treatment and that fully alleviating disorder. However not all patients benefit from this approach especially if it is provided against the patient's consent and in such cases a harm minimization or recovery approach focused on improving quality of life

This approach [21] that originated amongst service users in the United States posits that improved mental and physical health can be achieved even though the illness at the root of a person's difficulties cannot be cured. Thus a person with schizophrenia who hears voices, believes he is being bugged and has interpersonal difficulties can still be helped to deal with the symptoms through individual family and social interventions even though medication has had

Can a similar approach applied to eating disorders? Here we will go through the different realms indicated by see patients as problematic and identify ways to

The role of medication in the eating disorders is limited and the main group who appear to benefit are those with bulimia nervosa. Antidepressants such as high-dose fluoxetine can be tried with patients who have had at least one evidence-based psychological treatment for bulimia nervosa [22]. Of other drugs olanzapine has been tried in anorexia nervosa [23] and although the evidence is currently weak, some eating disorder specialists believe that the drug reduces anxiety and may have an impact in improving weight gain. Adequate randomised trials are awaited.

*DOI: http://dx.doi.org/10.5772/intechopen.87004*

given that I have a long-term disorder.

**4. Management**

much benefit.

**4.1 Cure or care?**

limited impact.

approach them.

**4.3 Medication**

maybe more humane and helpful.

**4.2 The recovery approach**

#### **4. Management**

*Anorexia and Bulimia Nervosa*

**3.4 Family**

**3.5 Financial**

ing money on themselves:

*fall into pieces."*

*for myself, I just survive*."

*that I planned my meals and my walks*."

*to fulfill all my commitments when my mood is low*."

**3.6 Occupational**

*they're not actually real friends."*

*have they been feeding you? You're enormous*!"

*"I've got some friends that I have online but I haven't actually met them. Because I feel I can totally fake…see it kind of doesn't matter what I say because I haven't met them. Do you know what I mean? Because it doesn't matter if they disappear,* 

In SEED-AN, the patient sometimes ended up as their parents' carer.

In other cases, difficult relationships improved over time.

*"I was sort of left; a lot of the family got married and moved away from home."*

*"In the last 2 years the relationship with my family has got better. I now have contact with my sister. We often chat on the phone. I don't really see my brothers or* 

In SEED-BN, family difficulties were frequent. Some felt their families did not take the eating disorder seriously. One patient after she had confessed her bulimia to her mother, reported that her mother said "*yeah I used to do it. It's so stupid. You kind of don't wanna do that … ,*" which she did not find helpful. Other patients reported that their families were weight obsessed. When one participant had regained a size 12, a member of her extended family exclaimed "*Oh my God what* 

For SEED-AN, patients were often poor, living on benefits without paid work. They also described clinical frugality, in which they had extreme difficulty spend-

*"I find it very difficult spending money. If you walked into my flat, I've got nothing particular there ... just very-very bare. My shoes, I wear them until they begin to* 

For SEED-BN, the illness was often very costly because of the large quantity of food consumed. One patient interviewed was seeing a debt counsellor to manage loans from 5 different lenders: "*I don't have any savings, and I don't buy anything nice* 

SEED-AN: These patients often reported being out of work and surviving on benefits. "*I completed 1 year of that (teaching) course and then I had to go into hospital so that came to an end. ... I seemed to lose interest in work and it seemed more important* 

SEED-BN: These individuals were often in work, and some valued the structure of work to help manage their eating disorder: "*I feel that going to work in the morning 'wipes the slate clean' if I have binged and vomited the night before*." Others found that the eating disorder had an adverse effect on work: "*Last summer I had to take a number of months off work due to my eating disorder and depression, and I still struggle* 

*hear from them, I often ask my parents about them, they ask about me."*

**172**

Outcome research in the area of management of SEED is sparse. There are several examples of publications in which clinicians have expressed their opinion in this area [14, 19, 20]. One question that constantly appears in the area of management is what general approach to use. As already discussed full recovery from an eating disorder is always possible although less likely as the years pass. The patient (and the clinician and family) are thus confronted with the question each time therapy is contemplated: Should I go for a full recovery or for the best quality-of-life given that I have a long-term disorder.

From the point of view of the clinician, there may be a moral dilemma. Funding for services may depend on inpatient units being full. This applies to both the public and private health sectors. There may therefore be perverse incentives to admit the SEED patient for a prolonged hospital stay in pursuit of weight gain. Most professionals in charge of an inpatient eating disorders service will be aware of these pressures, and how they sometimes conflict with patient care. Hospital admission is essential in the case of a patient who presents life threatening physical illness. However the likelihood of long-term recovery after prolonged admission in someone with a long illness is probably small and one is left with a suspicion that some SEED patients may be admitted for long periods without much benefit.

#### **4.1 Cure or care?**

It seems to the author evident that all patients with SEED to be offered treatment and that fully alleviating disorder. However not all patients benefit from this approach especially if it is provided against the patient's consent and in such cases a harm minimization or recovery approach focused on improving quality of life maybe more humane and helpful.

#### **4.2 The recovery approach**

This approach [21] that originated amongst service users in the United States posits that improved mental and physical health can be achieved even though the illness at the root of a person's difficulties cannot be cured. Thus a person with schizophrenia who hears voices, believes he is being bugged and has interpersonal difficulties can still be helped to deal with the symptoms through individual family and social interventions even though medication has had limited impact.

Can a similar approach applied to eating disorders? Here we will go through the different realms indicated by see patients as problematic and identify ways to approach them.

#### **4.3 Medication**

The role of medication in the eating disorders is limited and the main group who appear to benefit are those with bulimia nervosa. Antidepressants such as high-dose fluoxetine can be tried with patients who have had at least one evidence-based psychological treatment for bulimia nervosa [22]. Of other drugs olanzapine has been tried in anorexia nervosa [23] and although the evidence is currently weak, some eating disorder specialists believe that the drug reduces anxiety and may have an impact in improving weight gain. Adequate randomised trials are awaited.

#### **4.4 Psychological therapy**

Patients with anorexia nervosa and bulimia nervosa are in both quantitative and qualitative studies are found to suffer from depression and anxiety. These difficulties often correlate with the severity of the eating disorder symptoms such as lower weight or frequent bingeing and purging and treatments to reduce those are clearly the preferred approach. However patients with SEED have often received one or more courses of psychotherapy and perhaps one or more inpatient or day patient episodes. In anorexia nervosa there is little evidence that any therapy is better than any other although in bulimia nervosa CBT [24] and some other approaches have been found helpful. In a trial in which two therapies were tested in patients with long-standing anorexia nervosa [6] weight gain was modest but significant and there were significant improvements in depression and eating disorder symptoms. The two therapies were SSCM and cognitive behaviour therapy (CBT). SSCM is Specialist Supportive Clinical Management [25] and is a therapy that can be delivered by mental health staff without psychotherapy training. It mostly addresses eating disorder behaviours and has been used as a control therapy in several randomised trials [6, 26, 27] in which the results were surprisingly good, often doing as well as the more complex therapy being studied. Hence it has earned itself a place in the NICE guidelines [28]. Initially it was designed exclusively for anorexia nervosa and a variant (SSCM-ED) has been used in all eating disorders [29]. SSCM and SSCM-ED have no published manual but a manual for the latter can be obtained from the author of this chapter.

#### **4.5 Physical risk monitoring**

This is clearly required in anorexia nervosa of any duration, because without in patients can deteriorate and die from nutritional problems. For bulimia nervosa, the most common serious medical problems are electrolyte disturbances. Who should do the monitoring is a point of debate. When specialist eating disorder services are scarce and expensive, there is an argument for monitoring to be based in primary care. However, the staff in primary care require training in monitoring eating disorders and in what to do when a worrying finding, such as an abnormal ECG, is uncovered. Some general practitioners are reluctant to take on this work, and a possible model in the UK NHS might be to provide funding for primary care staff to provide this service, and a formal link with an eating disorders specialist to provide support and guidance when abnormalities are discovered. Unfortunately, this has not yet been achieved and care is thus often a source of tension between primary and specialist care. Methods for monitoring patients with eating disorders have been documented in MARSIPAN [30] and in Treasure [31]. For monitoring of physical problems which develop over time but do not usually threaten life, such as osteoporosis, the patient and doctor need to decide on whether and how often to monitor the conditions. Some have argued that as the sole effective treatment for osteoporosis due to anorexia nervosa is weight gain, and as we know it will get worse without increase in weight, repeated scans are not required. Others believe that knowing that the condition is deteriorating might provide an incentive to improve weight and secondly alerts patient, physician and family to the increasing possibility of fractures after trivial or no injury.

#### **4.6 Family interventions**

Many patients with SEED-AN and SEED-BN describe difficulties with their families as already described. The problems from the family members' point of view are how to respond to a serious eating disorder which does not seem to be getting better, without suffering from depression and other manifestations of stress, and

**175**

**Acknowledgements**

*Severe and Enduring Eating Disorders: Concepts and Management*

eating disorder, as it is in younger, short history patients [34].

career is possible without the eating disorder becoming more severe.

by individuals, families and society can be alleviated.

A substantial proportion of individuals with eating disorder fail to recover either because they have not had early access to treatment, or because they have not responded to such treatment. As time goes on the chances of recovery reduce but they never seem to reach zero, suggesting an asymptotic function underlying the chances of recovery with time. There is some evidence to suggest that over 3 years, anorexia nervosa, but not, apparently bulimia nervosa, may become more entrenched and resistant to treatment. Both conditions, however, profoundly affect quality of life and although the mortality is lower in bulimia nervosa, both conditions are associated with widespread disruption of physical health and psychological, family and social functioning. In long term eating disorders each of these realms require attention from professionals and from other informed individuals in families, who require adequate training and support, and the general public including ex-sufferers and charities such as BEAT. Severe and enduring eating disorders (SEED) should be recognised by the wider psychiatry community as deserving of attention and resources as much as other severe and enduring mental disorders so that the suffering endured by patients and their families as well as the costs incurred

The author would like to thank Ms. Jessica Jackson, Ms. Maxine Hughes, and Ms. Giulia Guidetti for permission to quote qualitative interview subjects. The author also thanks Professor Elena Tomba and Ms. Valentina Gardini, University of

Bologna, for permission to quote data in **Figure 2** and associated text.

without inadvertently making the eating disorder worse. For these families, collaborative caring [32] has a lot to offer, and has been shown [33] to result in lower distress levels in carers. Single or multiple family therapy might sometimes be indicated to help resolve some difficulties, although naturally the aim of therapy would be improving family functioning and quality of life, rather than curing the

As described above, social isolation is commonly described in patients with long term anorexia nervosa and bulimia nervosa. Patients are reluctant to eat with others and may turn down invitations to go out, preferring to stay at home and binge-eat. Attending a day service for treatment can be a first step in re-socialising and help to find appropriate voluntary work or educational courses can also be a useful aid to recreating a social network. Some patients, especially with anorexia nervosa, find that meeting other patients with the same condition can be more acceptable, because they do not need to explain their behaviour to others. However, while this may be helpful initially, it can result in further entrenchment of the eating disorder and if possible, wider social networks should be sought. The help of occupational therapy and nursing staff can be invaluable in this process. If a patient already has a career, or is mid way through a training, the staff can help them reintegrate and request observer status before going back to work or study. For certain occupations, such as dance or athletics, the patient needs to decide whether pursuing the former

*DOI: http://dx.doi.org/10.5772/intechopen.87004*

**4.7 Social and occupational interventions**

**5. Summary and conclusions**

#### *Severe and Enduring Eating Disorders: Concepts and Management DOI: http://dx.doi.org/10.5772/intechopen.87004*

without inadvertently making the eating disorder worse. For these families, collaborative caring [32] has a lot to offer, and has been shown [33] to result in lower distress levels in carers. Single or multiple family therapy might sometimes be indicated to help resolve some difficulties, although naturally the aim of therapy would be improving family functioning and quality of life, rather than curing the eating disorder, as it is in younger, short history patients [34].

#### **4.7 Social and occupational interventions**

*Anorexia and Bulimia Nervosa*

**4.4 Psychological therapy**

**4.5 Physical risk monitoring**

**4.6 Family interventions**

Patients with anorexia nervosa and bulimia nervosa are in both quantitative and qualitative studies are found to suffer from depression and anxiety. These difficulties often correlate with the severity of the eating disorder symptoms such as lower weight or frequent bingeing and purging and treatments to reduce those are clearly the preferred approach. However patients with SEED have often received one or more courses of psychotherapy and perhaps one or more inpatient or day patient episodes. In anorexia nervosa there is little evidence that any therapy is better than any other although in bulimia nervosa CBT [24] and some other approaches have been found helpful. In a trial in which two therapies were tested in patients with long-standing anorexia nervosa [6] weight gain was modest but significant and there were significant improvements in depression and eating disorder symptoms. The two therapies were SSCM and cognitive behaviour therapy (CBT). SSCM is Specialist Supportive Clinical Management [25] and is a therapy that can be delivered by mental health staff without psychotherapy training. It mostly addresses eating disorder behaviours and has been used as a control therapy in several randomised trials [6, 26, 27] in which the results were surprisingly good, often doing as well as the more complex therapy being studied. Hence it has earned itself a place in the NICE guidelines [28]. Initially it was designed exclusively for anorexia nervosa and a variant (SSCM-ED) has been used in all eating disorders [29]. SSCM and SSCM-ED have no published manual but a manual for the latter can be obtained from the author of this chapter.

This is clearly required in anorexia nervosa of any duration, because without in patients can deteriorate and die from nutritional problems. For bulimia nervosa, the most common serious medical problems are electrolyte disturbances. Who should do the monitoring is a point of debate. When specialist eating disorder services are scarce and expensive, there is an argument for monitoring to be based in primary care. However, the staff in primary care require training in monitoring eating disorders and in what to do when a worrying finding, such as an abnormal ECG, is uncovered. Some general practitioners are reluctant to take on this work, and a possible model in the UK NHS might be to provide funding for primary care staff to provide this service, and a formal link with an eating disorders specialist to provide support and guidance when abnormalities are discovered. Unfortunately, this has not yet been achieved and care is thus often a source of tension between primary and specialist care. Methods for monitoring patients with eating disorders have been documented in MARSIPAN [30] and in Treasure [31]. For monitoring of physical problems which develop over time but do not usually threaten life, such as osteoporosis, the patient and doctor need to decide on whether and how often to monitor the conditions. Some have argued that as the sole effective treatment for osteoporosis due to anorexia nervosa is weight gain, and as we know it will get worse without increase in weight, repeated scans are not required. Others believe that knowing that the condition is deteriorating might provide an incentive to improve weight and secondly alerts patient, physician and

family to the increasing possibility of fractures after trivial or no injury.

Many patients with SEED-AN and SEED-BN describe difficulties with their families as already described. The problems from the family members' point of view are how to respond to a serious eating disorder which does not seem to be getting better, without suffering from depression and other manifestations of stress, and

**174**

As described above, social isolation is commonly described in patients with long term anorexia nervosa and bulimia nervosa. Patients are reluctant to eat with others and may turn down invitations to go out, preferring to stay at home and binge-eat. Attending a day service for treatment can be a first step in re-socialising and help to find appropriate voluntary work or educational courses can also be a useful aid to recreating a social network. Some patients, especially with anorexia nervosa, find that meeting other patients with the same condition can be more acceptable, because they do not need to explain their behaviour to others. However, while this may be helpful initially, it can result in further entrenchment of the eating disorder and if possible, wider social networks should be sought. The help of occupational therapy and nursing staff can be invaluable in this process. If a patient already has a career, or is mid way through a training, the staff can help them reintegrate and request observer status before going back to work or study. For certain occupations, such as dance or athletics, the patient needs to decide whether pursuing the former career is possible without the eating disorder becoming more severe.

#### **5. Summary and conclusions**

A substantial proportion of individuals with eating disorder fail to recover either because they have not had early access to treatment, or because they have not responded to such treatment. As time goes on the chances of recovery reduce but they never seem to reach zero, suggesting an asymptotic function underlying the chances of recovery with time. There is some evidence to suggest that over 3 years, anorexia nervosa, but not, apparently bulimia nervosa, may become more entrenched and resistant to treatment. Both conditions, however, profoundly affect quality of life and although the mortality is lower in bulimia nervosa, both conditions are associated with widespread disruption of physical health and psychological, family and social functioning. In long term eating disorders each of these realms require attention from professionals and from other informed individuals in families, who require adequate training and support, and the general public including ex-sufferers and charities such as BEAT. Severe and enduring eating disorders (SEED) should be recognised by the wider psychiatry community as deserving of attention and resources as much as other severe and enduring mental disorders so that the suffering endured by patients and their families as well as the costs incurred by individuals, families and society can be alleviated.

#### **Acknowledgements**

The author would like to thank Ms. Jessica Jackson, Ms. Maxine Hughes, and Ms. Giulia Guidetti for permission to quote qualitative interview subjects. The author also thanks Professor Elena Tomba and Ms. Valentina Gardini, University of Bologna, for permission to quote data in **Figure 2** and associated text.

*Anorexia and Bulimia Nervosa*

### **Author details**

Paul Robinson1,2

1 Orri, UK

2 University College London, UK

\*Address all correspondence to: drpaulrobinson@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**177**

*Severe and Enduring Eating Disorders: Concepts and Management*

results of previous investigations, compared with those of a Swedish long-term study. Journal of Psychiatric

Research. 1985;**19**(2-3):493-508

1994;**56**(1):20-27

1991;**158**:495-502

[10] Deter HC, Herzog W. Anorexia nervosa in a long-term perspective: Results of the Heidelberg-Mannheim study. Psychosomatic Medicine.

[11] Fichter MM, Quadflieg N, Hedlund S. Twelve-year course and outcome predictors of anorexia nervosa. The International Journal of Eating Disorders. 2006;**39**(2):87-100

[12] Herpertz-Dahlmann B, Muller B, Herpertz S, Heussen N. Prospective 10-year follow-up in adolescent anorexia nervosa—Course, outcome, psychiatric

adaptation. Journal of Child Psychology and Psychiatry. 2001;**42**(5):603-612

[13] Ratnasuriya RH, Eisler I, Szmukler GI, Russell GF. Anorexia nervosa: Outcome and prognostic factors after 20 years. The British Journal of Psychiatry.

[14] Strober M, Freeman R, Morrell W. The long-term course of severe anorexia

[15] Wentz E, Gillberg C, Gillberg IC, Rastam M. Ten-year follow-up of adolescent-onset anorexia nervosa: Psychiatric disorders and overall functioning scales. Journal of Child Psychology and Psychiatry.

[16] Wentz E, Gillberg IC, Anckarsater H, Gillberg C, Rastam M. Adolescent-onset anorexia nervosa: 18-year outcome.

nervosa in adolescents: Survival analysis of recovery, relapse, and outcome predictors over 10-15 years in a prospective study. The International

Journal of Eating Disorders.

1997;**22**(4):339-360

2001;**42**(5):613-622

comorbidity, and psychosocial

*DOI: http://dx.doi.org/10.5772/intechopen.87004*

[1] Department of Health and Social Care. A National Service Framework for Mental Health: Modern standards and service models. UK: Department of

[2] National Institute for Health and Care Excellence (NICE). Draft guideline scope: Rehabilitation in adults with severe and enduring mental illness. 2018. Available from: https://www.nice.org.uk/guidance/ gid-ng10092/documents/draft-scope

[3] Ruggeri M, Leese M, Thornicroft G, Bisoffi G, Tansella M. Definition and prevalence of severe and persistent mental illness. The British Journal of Psychiatry. 2000;**177**(2):149-155

[4] Robinson P. Severe and Enduring Eating Disorder (SEED): Management of Complex Presentations of Anorexia and Bulimia Nervosa. Wiley: Chichester;

[5] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association;

[6] Touyz S, Le Grange D, Lacey H, Hay P, Smith R, Maguire S, et al. Treating severe and enduring anorexia nervosa: A randomized controlled trial. Psychological Medicine. 2013;**43**(12):2512

[7] Treasure J, Russell G. The case for early intervention in anorexia nervosa: Theoretical exploration of maintaining factors. The British Journal

of Psychiatry. 2011;**199**(1):5-7

[8] Russell GF, Szmukler GI, Dare C, Eisler I. An evaluation of family therapy

nervosa. Archives of General Psychiatry.

[9] Theander S. Outcome and prognosis in anorexia nervosa and bulimia: Some

in anorexia nervosa and bulimia

1987;**44**(12):1047-1056

**References**

Health; 1999

2009. p. 184

2013

*Severe and Enduring Eating Disorders: Concepts and Management DOI: http://dx.doi.org/10.5772/intechopen.87004*

#### **References**

*Anorexia and Bulimia Nervosa*

**176**

**Author details**

Paul Robinson1,2

2 University College London, UK

provided the original work is properly cited.

\*Address all correspondence to: drpaulrobinson@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

1 Orri, UK

[1] Department of Health and Social Care. A National Service Framework for Mental Health: Modern standards and service models. UK: Department of Health; 1999

[2] National Institute for Health and Care Excellence (NICE). Draft guideline scope: Rehabilitation in adults with severe and enduring mental illness. 2018. Available from: https://www.nice.org.uk/guidance/ gid-ng10092/documents/draft-scope

[3] Ruggeri M, Leese M, Thornicroft G, Bisoffi G, Tansella M. Definition and prevalence of severe and persistent mental illness. The British Journal of Psychiatry. 2000;**177**(2):149-155

[4] Robinson P. Severe and Enduring Eating Disorder (SEED): Management of Complex Presentations of Anorexia and Bulimia Nervosa. Wiley: Chichester; 2009. p. 184

[5] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013

[6] Touyz S, Le Grange D, Lacey H, Hay P, Smith R, Maguire S, et al. Treating severe and enduring anorexia nervosa: A randomized controlled trial. Psychological Medicine. 2013;**43**(12):2512

[7] Treasure J, Russell G. The case for early intervention in anorexia nervosa: Theoretical exploration of maintaining factors. The British Journal of Psychiatry. 2011;**199**(1):5-7

[8] Russell GF, Szmukler GI, Dare C, Eisler I. An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Archives of General Psychiatry. 1987;**44**(12):1047-1056

[9] Theander S. Outcome and prognosis in anorexia nervosa and bulimia: Some

results of previous investigations, compared with those of a Swedish long-term study. Journal of Psychiatric Research. 1985;**19**(2-3):493-508

[10] Deter HC, Herzog W. Anorexia nervosa in a long-term perspective: Results of the Heidelberg-Mannheim study. Psychosomatic Medicine. 1994;**56**(1):20-27

[11] Fichter MM, Quadflieg N, Hedlund S. Twelve-year course and outcome predictors of anorexia nervosa. The International Journal of Eating Disorders. 2006;**39**(2):87-100

[12] Herpertz-Dahlmann B, Muller B, Herpertz S, Heussen N. Prospective 10-year follow-up in adolescent anorexia nervosa—Course, outcome, psychiatric comorbidity, and psychosocial adaptation. Journal of Child Psychology and Psychiatry. 2001;**42**(5):603-612

[13] Ratnasuriya RH, Eisler I, Szmukler GI, Russell GF. Anorexia nervosa: Outcome and prognostic factors after 20 years. The British Journal of Psychiatry. 1991;**158**:495-502

[14] Strober M, Freeman R, Morrell W. The long-term course of severe anorexia nervosa in adolescents: Survival analysis of recovery, relapse, and outcome predictors over 10-15 years in a prospective study. The International Journal of Eating Disorders. 1997;**22**(4):339-360

[15] Wentz E, Gillberg C, Gillberg IC, Rastam M. Ten-year follow-up of adolescent-onset anorexia nervosa: Psychiatric disorders and overall functioning scales. Journal of Child Psychology and Psychiatry. 2001;**42**(5):613-622

[16] Wentz E, Gillberg IC, Anckarsater H, Gillberg C, Rastam M. Adolescent-onset anorexia nervosa: 18-year outcome.

The British Journal of Psychiatry. 2009;**194**(2):168-174

[17] Gardini V. When do Eating Disorders Become Severe and Enduring?. Unpublished Master degree dissertation, Supervisor Prof. Elena Tomba. Bologna: University of Bologna; 2019

[18] Robinson PH, Kukucska R, Guidetti G, Leavey G. Severe and enduring anorexia nervosa (SEED-AN): A qualitative study of patients with 20+ years of anorexia nervosa. European Eating Disorders Review. 2015;**23**(4):318-326

[19] Yager J. Management of patients with chronic, intractable eating disorders. In: Yager PS, editor. Clinical Manual of Eating Disorders. London: American Psychiatric Publishing; 2007

[20] Wonderlich S, Mitchell JE, Crosby RD, Myers TC, Kadlec K, Lahaise K, et al. Minimizing and treating chronicity in the eating disorders: A clinical overview. The International Journal of Eating Disorders. 2012;**45**(4):467-475

[21] Slade M. Mental illness and well-being: The central importance of positive psychology and recovery approaches. BMC Health Services Research. 2010;**10**:26

[22] Walsh BT, Wilson GT, Loeb KL, Devlin MJ, Pike KM, Roose SP, et al. Medication and psychotherapy in the treatment of bulimia nervosa. The American Journal of Psychiatry. 1997;**154**(4):523-531

[23] Norris ML, Spettigue W, Buchholz A, Henderson KA, Gomez R, Maras D, et al. Olanzapine use for the adjunctive treatment of adolescents with anorexia nervosa. Journal of Child and Adolescent Psychopharmacology. 2011;**21**(3):213-220

[24] Fairburn CG, Cooper Z, Doll HA, O'Connor ME, Bohn K, Hawker DM, et al. Transdiagnostic cognitivebehavioral therapy for patients with eating disorders: A two-site trial with 60-week follow-up. The American Journal of Psychiatry. 2009;**166**(3):311-319

[25] McIntosh VV, Jordan J, Luty SE, Carter FA, McKenzie JM, Bulik CM, et al. Specialist supportive clinical management for anorexia nervosa. The International Journal of Eating Disorders. 2006;**39**(8):625-632

[26] Schmidt U, Renwick B, Lose A, Kenyon M, Dejong H, Broadbent H, et al. The MOSAIC study: Comparison of the Maudsley model of treatment for adults with anorexia nervosa (MANTRA) with Specialist Supportive Clinical Management (SSCM) in outpatients with anorexia nervosa or eating disorder not otherwise specified, anorexia nervosa type: Study protocol for a randomized controlled trial. Trials. 2013;**14**:160

[27] McIntosh VV, Jordan J, Carter JD, Frampton CM, McKenzie JM, Latner JD, et al. Psychotherapy for transdiagnostic binge eating: A randomized controlled trial of cognitive-behavioural therapy, appetite-focused cognitive-behavioural therapy, and schema therapy. Psychiatry Research. 2016;**240**:412-420

[28] National Institute for Health and Care Excellence. Eating disorders: Recognition and treatment. NG69; 2017

[29] Robinson P, Hellier J, Barrett B, Barzdaitiene D, Bateman A, Bogaardt A, et al. The NOURISHED randomised controlled trial comparing mentalisationbased treatment for eating disorders (MBT-ED) with specialist supportive clinical management (SSCM-ED) for patients with eating disorders and symptoms of borderline personality disorder. Trials. 2016;**17**(1):549

**179**

*Severe and Enduring Eating Disorders: Concepts and Management*

*DOI: http://dx.doi.org/10.5772/intechopen.87004*

[30] Royal College of Psychiatrists. MARSIPAN CR189. London; 2014

ac.uk/ioppn/depts/pm/

March 31, 2019]

2007;**15**(1):24-34

GUIDETOMEDICALRISK ASSESSMENT.pdf [Accessed:

[32] Treasure J, Sepulveda AR, Whitaker W, Todd G, Lopez C, Whitney J. Collaborative care between professionals and non-professionals in the management of eating disorders: A description of workshops focussed on interpersonal maintaining factors. European Eating Disorders Review.

[33] Whitney J, Murphy T, Landau S, Gavan K, Todd G, Whitaker W, et al. A practical comparison of two types of family intervention: An exploratory RCT of family day workshops and individual family work as a supplement to inpatient care for adults with anorexia nervosa. European Eating Disorders

Review. 2012;**20**(2):142-150

2015;**28**(6):455-460

[34] Blessitt E, Voulgari S, Eisler I. Family therapy for adolescent anorexia nervosa. Current Opinion in Psychiatry.

[31] Treasure J. A Guide to the Medical Risk Assessment for Eating Disorders. 2009; Available from: https://www.kcl.

research/eatingdisorders/resources/

*Severe and Enduring Eating Disorders: Concepts and Management DOI: http://dx.doi.org/10.5772/intechopen.87004*

[30] Royal College of Psychiatrists. MARSIPAN CR189. London; 2014

*Anorexia and Bulimia Nervosa*

2009;**194**(2):168-174

2015;**23**(4):318-326

2019

The British Journal of Psychiatry.

[17] Gardini V. When do Eating Disorders Become Severe and

[18] Robinson PH, Kukucska R, Guidetti G, Leavey G. Severe and enduring anorexia nervosa (SEED-AN): A qualitative study of patients with 20+ years of anorexia nervosa. European Eating Disorders Review.

[19] Yager J. Management of patients with chronic, intractable eating disorders. In: Yager PS, editor. Clinical Manual of Eating Disorders. London: American Psychiatric Publishing; 2007

[20] Wonderlich S, Mitchell JE, Crosby RD, Myers TC, Kadlec K, Lahaise K, et al. Minimizing and treating chronicity in the eating disorders: A clinical overview. The International

Journal of Eating Disorders.

[21] Slade M. Mental illness and well-being: The central importance of positive psychology and recovery approaches. BMC Health Services

[22] Walsh BT, Wilson GT, Loeb KL, Devlin MJ, Pike KM, Roose SP, et al. Medication and psychotherapy in the treatment of bulimia nervosa. The American Journal of Psychiatry.

2012;**45**(4):467-475

Research. 2010;**10**:26

1997;**154**(4):523-531

2011;**21**(3):213-220

[23] Norris ML, Spettigue W,

Buchholz A, Henderson KA, Gomez R, Maras D, et al. Olanzapine use for the adjunctive treatment of adolescents with anorexia nervosa. Journal of Child and Adolescent Psychopharmacology.

Enduring?. Unpublished Master degree dissertation, Supervisor Prof. Elena Tomba. Bologna: University of Bologna; [24] Fairburn CG, Cooper Z, Doll HA, O'Connor ME, Bohn K, Hawker DM, et al. Transdiagnostic cognitivebehavioral therapy for patients with eating disorders: A two-site trial with 60-week follow-up. The American Journal of Psychiatry.

[25] McIntosh VV, Jordan J, Luty SE, Carter FA, McKenzie JM, Bulik CM, et al. Specialist supportive clinical management for anorexia nervosa. The International Journal of Eating Disorders. 2006;**39**(8):625-632

[26] Schmidt U, Renwick B, Lose A, Kenyon M, Dejong H, Broadbent H, et al. The MOSAIC study: Comparison of the Maudsley model of treatment for adults with anorexia nervosa (MANTRA) with Specialist Supportive Clinical Management (SSCM) in outpatients with anorexia nervosa or eating disorder not otherwise specified, anorexia nervosa type: Study protocol for a randomized controlled trial. Trials.

[27] McIntosh VV, Jordan J, Carter JD, Frampton CM, McKenzie JM, Latner JD, et al. Psychotherapy for transdiagnostic binge eating: A randomized controlled trial of cognitive-behavioural therapy, appetite-focused cognitive-behavioural therapy, and schema therapy. Psychiatry

[28] National Institute for Health and Care Excellence. Eating disorders: Recognition and treatment. NG69; 2017

[29] Robinson P, Hellier J, Barrett B, Barzdaitiene D, Bateman A, Bogaardt A, et al. The NOURISHED randomised controlled trial comparing mentalisationbased treatment for eating disorders (MBT-ED) with specialist supportive clinical management (SSCM-ED) for patients with eating disorders and symptoms of borderline personality disorder. Trials. 2016;**17**(1):549

Research. 2016;**240**:412-420

2009;**166**(3):311-319

2013;**14**:160

**178**

[31] Treasure J. A Guide to the Medical Risk Assessment for Eating Disorders. 2009; Available from: https://www.kcl. ac.uk/ioppn/depts/pm/ research/eatingdisorders/resources/ GUIDETOMEDICALRISK ASSESSMENT.pdf [Accessed: March 31, 2019]

[32] Treasure J, Sepulveda AR, Whitaker W, Todd G, Lopez C, Whitney J. Collaborative care between professionals and non-professionals in the management of eating disorders: A description of workshops focussed on interpersonal maintaining factors. European Eating Disorders Review. 2007;**15**(1):24-34

[33] Whitney J, Murphy T, Landau S, Gavan K, Todd G, Whitaker W, et al. A practical comparison of two types of family intervention: An exploratory RCT of family day workshops and individual family work as a supplement to inpatient care for adults with anorexia nervosa. European Eating Disorders Review. 2012;**20**(2):142-150

[34] Blessitt E, Voulgari S, Eisler I. Family therapy for adolescent anorexia nervosa. Current Opinion in Psychiatry. 2015;**28**(6):455-460

### *Edited by Hubertus Himmerich and Ignacio Jáuregui Lobera*

The prevalence of eating disorders such as anorexia and bulimia nervosa is growing, and these disorders are affecting adolescents and young adults at increasingly younger ages. This has led to a greater number of patients presenting to health services. Although novel therapeutic approaches have been introduced in recent decades, the mortality rates of patients with anorexia and bulimia nervosa remain alarmingly high. The course of anorexia nervosa in particular is often chronic and can lead to persistent disability. This book covers the clinical features and symptoms, neurobiology, pathophysiology, and current and potential future treatment options for both anorexia and bulimia nervosa. It also highlights the important aspects of support for families and their perspectives on these disorders.

Published in London, UK © 2019 IntechOpen © Sanja Cokolic / iStock

Anorexia and Bulimia Nervosa

Anorexia and Bulimia

Nervosa

*Edited by Hubertus Himmerich* 

*and Ignacio Jáuregui Lobera*