**6. Medical ramifications of weight management in the treatment of DE and ED**

A heavy burden of medical comorbidities across multiple body systems, attributable to both the malnutrition of AN and the purging behaviors of BN, contribute to the high mortality rates of these illnesses [25]. Restoration of weight and nutritional status are key elements in the treatment of AN [26]. Nutritional and medical treatment of extreme undernutrition present two very complex and conflicting tasks: the need to avoid "refeeding syndrome" caused by a too fast correction of malnutrition and "underfeeding" caused by a too cautious refeeding [27]. Metabolic, endocrinological, and gastronomic consequences that may develop during the refeeding process for ED individuals in recovery need to be understood and addressed in treatment. For the most part, but not in all cases, adverse consequences are reversible with recovery:


*Discretion or Disorder? The Impact of Weight Management Issues on the Diagnosis… DOI: http://dx.doi.org/10.5772/intechopen.92152*

Establishing and maintaining a goal-weight range is but one of many integrative physiological, neurobiological, nutritional, cognitive, emotional, and environmental factors contributing to a complete and sustainable ED recovery.


Issues complicating the achievement of full weight restoration matter a great deal, as halting the process of weight restoration at much lower levels than needed for full and sustainable recovery increases the rate of treatment dropout [33] and relapse [34]. The restoration of nutrient status and weight needs to start slowly and gradually, accelerating as tolerated. The refeeding process needs to focus on modifying the disordered dietary patterns that AN patients commonly practice, which might include slow and irregular eating, vegetarianism, and the consumption of a restricted range of foods. Severely malnourished AN patients often need to be admitted to a hospital in order to receive more aggressive treatment, with extra care and monitoring required to prevent the occurrence of refeeding syndrome [26], a clinical complication involving kidney dysfunction [30]. A person may finally be considered "in remission" after maintaining a stable weight for a number of years and experiencing the natural resumption of mensuration, as well as other normal hormonal, metabolic, and gastroenterological processes. Sustained remission is marked by the return of the reintegrated core self, following its fragmentation by the encroachment of the ED "pseudo-self."

### **7. Discovering and managing the roots of weight management problems in current or past trauma**

Trauma in the form of sexual abuse occurs in 30–65% of women with ED [35]. The vast majority of women and men with AN, BN, and BED report a history of

dysfunctions, always with attention to the possibility of past or current trauma. Studies that include partial or subclinical forms of posttraumatic stress disorder (PTSD) show that well over half of individuals with BN have PTSD or significant PTSD symptoms [24]. In light of the prevalence of trauma in the background of ED patients, trauma investigation needs to become a central focus within the initial inquiry. The diagnostician does well to become self-aware of personal propensities towards countertransference responses or cultural biases (reflecting weightism). The latter are forces which might preclude the clinician's recognition that many overweight and genetically large individuals who eat healthfully and exercise regu-

**6. Medical ramifications of weight management in the treatment of DE**

A heavy burden of medical comorbidities across multiple body systems, attributable to both the malnutrition of AN and the purging behaviors of BN, contribute to the high mortality rates of these illnesses [25]. Restoration of weight and nutritional status are key elements in the treatment of AN [26]. Nutritional and medical treatment of extreme undernutrition present two very complex and conflicting tasks: the need to avoid "refeeding syndrome" caused by a too fast correction of malnutrition and "underfeeding" caused by a too cautious refeeding [27]. Metabolic, endocrinological, and gastronomic consequences that may develop during the

refeeding process for ED individuals in recovery need to be understood and addressed in treatment. For the most part, but not in all cases, adverse

• Efforts of AN patients to restore weight within the refeeding process risk

• During initial phases of weight restoration, particularly for restricting ED patients who begin treatment at lower weights, the metabolic rate may overshoot normal levels in a "hypermetabolic" phase in which patients easily lose weight and need to eat an even larger amount of food to gain and sustain weight. This phenomenon is due to increased diet-induced thermogenesis (with calories dissipated as heat) as well as a variety of neuroendocrine alterations [26]. Despite the urgent need for the body to use restored energy efficaciously to replenish fat reserves and repair tissues in the early weeks and months of refeeding following prolonged semi-starvation, metabolic function may not normalize for 3–6 months following weight restoration [28].

• Target weights offer invalid markers of metabolic normalization, providing false indicators of ED recovery progress. It has been shown that ED patients forced to gain weight in hospital settings typically plan to lose it upon discharge [29]. Attempting to attain a target weight that is not reflective of the body's self-determined set point is predictive of a poor long-term prognosis.

derailment due to the irrational fear that normal eating behaviors will ultimately lead to overweight or obesity following weight restoration. A psychoeducational discussion of optimal set point weight can potentially diminish fears through the knowledge that the body will maintain this optimized weight by using the same energy intake as had been needed for weight restoration. With metabolic normalization and biological functions coming back on line after their dormancy during weight restriction, the extra energy used previously for weight gain becomes expended on usual day-to-day functions [28].

larly are physically fit, healthy, and strong.

consequences are reversible with recovery:

**and ED**

*Weight Management*

**170**

interpersonal trauma, with approximately one-third of women with BN meeting criteria for lifetime PTSD [36]. Unresolved trauma and/or PTSD can be an important perpetuating factor in the maintenance of ED symptoms [24]. DE and ED behaviors typically serve the patient as coping tools and distractions that numb the ongoing effects of traumatic memories. A trauma-focused approach to ED treatment facilitates the resolution of traumatic experience that lies at the root of behavioral, emotional, and neurobiological dysfunctions [37].

*For decades under the care of dietitians treating Charles' disordered eating, dieting efforts failed, leaving him intractably obese at 100 pounds overweight. Still "feeling fat" following bariatric surgery, he came to therapy struggling to lose weight through old patterns of food restriction, leading to junk food binges. At the start of our treatment, history-taking revealed past trauma at the root of his current eating dysfunction. Since childhood, Charles' family had been forced to flee a war-torn country with only a day's notice, leaving their previously comfortable lives and extended family behind. Moving from country to country, they struggled to survive as refugees, grieving their losses and experiencing years of fear, hunger, and social isolation. In response to the combined work of ED recovery and trauma resolution, within the context of our quality therapy relationship, Charles began to experience a sense of grounded integration and selfhood, evidenced in his growing capacity for self-regulation and self-care. Within several months of treatment, he became a normalized healthy eater and started to exercise regularly. Change in his distorted body image perception as a fat person became apparent when he reported, "During an exercise class, I noticed myself in the mirror and thought, 'Who is that normal weight person? Could that be me?' Despite his weight management problems and eating compulsions, the healthy personality at his core had resurfaced through psychotherapy. In completing his treatment, he described himself as having become*

*Discretion or Disorder? The Impact of Weight Management Issues on the Diagnosis…*

*DOI: http://dx.doi.org/10.5772/intechopen.92152*

*"a happy and gratified human being, enjoying a fulfilled existence."*

initial time-extended single-session weight management assessment.

*tainable change for her would now be in the offing.*

**8. Conclusion**

**173**

In some instances, a skilled practitioner may be capable of discovering trauma and shepherding the start of the trauma resolution process within the context of the

*It was the sudden recurrence of compulsive bingeing habits that she'd assumed were "in remission" that brought this middle-aged woman with BED to treatment. "This is the one area of my life that has always remained just beyond my grasp … . all I know is that my hunger is insatiable." In probing for the possibility of past trauma, our discussion during that initial session uncovered the source of her erratic eating compulsions in feelings of shame, emptiness, and emotional lability originating in early childhood trauma, a connection that had remained outside of her consciousness for 45 years. Her memories of neglect, alienation, and hunger that she suffered at the hands of her parents throughout her growing-up years, having been buried for decades within her limbic brain, now began to surface. Her brain's rapidly firing neuronal connections brought forth immediate new insights into herself, her current feelings, and past emotions, evoking an enlightened clarity about her previously "incomprehensible, over-reactive responses" (sobbing tears, sleeplessness, irrational fears) in the face of certain types of stressful experiences throughout her life. She wept with relief and gratitude upon leaving, recognizing that significant and sus-*

Weight management anomalies signify the patient's unhealthy relationship with

predisposed clinical eating disorders and the metabolic, endocrinological, or gastrointestinal consequences that characterize them. Uncovering the origins of weight management dysfunctions in DE or ED pathology, in providing a direction for treatment, enhances the efficacy and sustainability of healing. From the perspective of a hammer, all things look like a nail; in assessing weight management issues

food, potentially giving rise to chronic disease or the onset of genetically

Unprocessed traumatic memories stored in the mid-brain region become recycled when triggered, creating undischarged energy in the nervous system. Any traumatic assault on, or insult to, the brain impairs brain integration. High stress levels that lead to an overactive amygdala and hippocampus suppress the activities of the prefrontal cortex, the thinking brain that helps to regulate emotions. Body dysmorphic disorder, a common occurrence in ED individuals traumatized by sexual abuse, represents a mind, brain, and body disconnection within the disparate nervous system. BN and AN pathology reflects the disintegration of the structure of the self within the distributed nervous system, resulting in the patient's inaccurate sensing of self-based experience and perception of self. Psychosomatic expressions of traumatic experience are held as bodily sensations. ED heal in the same way as trauma heals, through the neurophysiological and neurobiological reintegration of the distributed nervous system, marking the return of the patient's reintegrated core self [38]. Because traumatic memories are encoded subcortically, the process of healing ED that originate in trauma requires accessing, and gaining leverage within, the structural coding of the brain and nervous system.

Neurophysiological effects of past trauma that are revealed in the present become accessible and available for remediation [38]. Trauma resolution lies in creating a psychophysiological state associated with decreased adrenergic activity, decreased muscular neuromuscular arousal, and cognitive quieting [39]. The introduction of neurophysiological (sensorimotor) and neurobiological (interpersonal, attachment-based) treatment interventions into mainstream clinical treatment for ED increases exposure to mindful embodied movement experience, fostering mind, brain, and body connectivity. By stimulating integrative neuronal firing and synaptic activity, these "top-down" and "bottom-up" transactions enhance acuity in selfsensing, self-perception, and body image coherence, supporting the unification of the disparate self [38].

Trauma resolution becomes enhanced through a mindful, quality connection between the therapist and patient. Rapid resolution therapy (RRT) is a body-based talk therapy technique shown to alleviate negative effects of trauma and PTSD without requiring the patient to recollect painful memories [40]. Trauma resides in the limbic system and in the perceptual world within a neural network, which has sufficient functional boundary thresholds to largely "disintegrate" it from the rest of the nervous system. When negative feelings become dissociated or "split off" (as they do within the bulimic "pseudo-self"), the potential exists to reintegrate them through the patient's connection with his/her best and resourceful self, through solution discovery, or rediscovery, both past and present [40]. Trauma resolution accesses neuroplasticity, through which neural networks that become litup 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 reinterprets new combinations of neural connections to create meaning [40]. By creating connections within the distributed nervous system in the context of a trusted human relationship, the technique connects problems to solutions through consolidating memories of human strengths and resourcefulness.

*Discretion or Disorder? The Impact of Weight Management Issues on the Diagnosis… DOI: http://dx.doi.org/10.5772/intechopen.92152*

*For decades under the care of dietitians treating Charles' disordered eating, dieting efforts failed, leaving him intractably obese at 100 pounds overweight. Still "feeling fat" following bariatric surgery, he came to therapy struggling to lose weight through old patterns of food restriction, leading to junk food binges. At the start of our treatment, history-taking revealed past trauma at the root of his current eating dysfunction. Since childhood, Charles' family had been forced to flee a war-torn country with only a day's notice, leaving their previously comfortable lives and extended family behind. Moving from country to country, they struggled to survive as refugees, grieving their losses and experiencing years of fear, hunger, and social isolation. In response to the combined work of ED recovery and trauma resolution, within the context of our quality therapy relationship, Charles began to experience a sense of grounded integration and selfhood, evidenced in his growing capacity for self-regulation and self-care. Within several months of treatment, he became a normalized healthy eater and started to exercise regularly. Change in his distorted body image perception as a fat person became apparent when he reported, "During an exercise class, I noticed myself in the mirror and thought, 'Who is that normal weight person? Could that be me?' Despite his weight management problems and eating compulsions, the healthy personality at his core had resurfaced through psychotherapy. In completing his treatment, he described himself as having become "a happy and gratified human being, enjoying a fulfilled existence."*

In some instances, a skilled practitioner may be capable of discovering trauma and shepherding the start of the trauma resolution process within the context of the initial time-extended single-session weight management assessment.

*It was the sudden recurrence of compulsive bingeing habits that she'd assumed were "in remission" that brought this middle-aged woman with BED to treatment. "This is the one area of my life that has always remained just beyond my grasp … . all I know is that my hunger is insatiable." In probing for the possibility of past trauma, our discussion during that initial session uncovered the source of her erratic eating compulsions in feelings of shame, emptiness, and emotional lability originating in early childhood trauma, a connection that had remained outside of her consciousness for 45 years. Her memories of neglect, alienation, and hunger that she suffered at the hands of her parents throughout her growing-up years, having been buried for decades within her limbic brain, now began to surface. Her brain's rapidly firing neuronal connections brought forth immediate new insights into herself, her current feelings, and past emotions, evoking an enlightened clarity about her previously "incomprehensible, over-reactive responses" (sobbing tears, sleeplessness, irrational fears) in the face of certain types of stressful experiences throughout her life. She wept with relief and gratitude upon leaving, recognizing that significant and sustainable change for her would now be in the offing.*

#### **8. Conclusion**

interpersonal trauma, with approximately one-third of women with BN meeting criteria for lifetime PTSD [36]. Unresolved trauma and/or PTSD can be an important perpetuating factor in the maintenance of ED symptoms [24]. DE and ED behaviors typically serve the patient as coping tools and distractions that numb the ongoing effects of traumatic memories. A trauma-focused approach to ED treatment facilitates the resolution of traumatic experience that lies at the root of

Unprocessed traumatic memories stored in the mid-brain region become recycled when triggered, creating undischarged energy in the nervous system. Any traumatic assault on, or insult to, the brain impairs brain integration. High stress levels that lead to an overactive amygdala and hippocampus suppress the activities of the prefrontal cortex, the thinking brain that helps to regulate emotions. Body dysmorphic disorder, a common occurrence in ED individuals traumatized by sexual abuse, represents a mind, brain, and body disconnection within the disparate nervous system. BN and AN pathology reflects the disintegration of the structure of the self within the distributed nervous system, resulting in the patient's inaccurate sensing of self-based experience and perception of self. Psychosomatic expressions of traumatic experience are held as bodily sensations. ED heal in the same way as trauma heals, through the neurophysiological and neurobiological reintegration of the distributed nervous system, marking the return of the patient's reintegrated core self [38]. Because traumatic memories are encoded subcortically, the process of healing ED that originate in trauma requires accessing, and gaining leverage within,

Neurophysiological effects of past trauma that are revealed in the present become accessible and available for remediation [38]. Trauma resolution lies in creating a psychophysiological state associated with decreased adrenergic activity, decreased muscular neuromuscular arousal, and cognitive quieting [39]. The introduction of neurophysiological (sensorimotor) and neurobiological (interpersonal, attachment-based) treatment interventions into mainstream clinical treatment for ED increases exposure to mindful embodied movement experience, fostering mind, brain, and body connectivity. By stimulating integrative neuronal firing and synaptic activity, these "top-down" and "bottom-up" transactions enhance acuity in selfsensing, self-perception, and body image coherence, supporting the unification of

Trauma resolution becomes enhanced through a mindful, quality connection between the therapist and patient. Rapid resolution therapy (RRT) is a body-based talk therapy technique shown to alleviate negative effects of trauma and PTSD without requiring the patient to recollect painful memories [40]. Trauma resides in the limbic system and in the perceptual world within a neural network, which has sufficient functional boundary thresholds to largely "disintegrate" it from the rest of the nervous system. When negative feelings become dissociated or "split off" (as they do within the bulimic "pseudo-self"), the potential exists to reintegrate them through the patient's connection with his/her best and resourceful self, through solution discovery, or rediscovery, both past and present [40]. Trauma resolution accesses neuroplasticity, through which neural networks that become litup 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 reinterprets new combinations of neural connections to create meaning [40]. By creating connections within the distributed nervous system in the context of a trusted human relationship, the technique connects problems to solutions through consolidating memories of

behavioral, emotional, and neurobiological dysfunctions [37].

the structural coding of the brain and nervous system.

the disparate self [38].

*Weight Management*

human strengths and resourcefulness.

**172**

Weight management anomalies signify the patient's unhealthy relationship with food, potentially giving rise to chronic disease or the onset of genetically predisposed clinical eating disorders and the metabolic, endocrinological, or gastrointestinal consequences that characterize them. Uncovering the origins of weight management dysfunctions in DE or ED pathology, in providing a direction for treatment, enhances the efficacy and sustainability of healing. From the perspective of a hammer, all things look like a nail; in assessing weight management issues

through a purely behavioral lens, first responders who fail to investigate and probe an underlying emotional landscape are likely to recommend a non-integrative solution, such as dieting, missing the opportunity to address the full complement of impinging psychological, neurobiological, and neurophysiological factors that contribute to weight management dysfunctions. Dieting, and particularly the use of unhealthful weight control behaviors, increase risk for weight gain and later eatingand weight-related problems [21].

It is through a unique use of self within the diagnostic moment that the knowledgeable and informed first responder approaches the uniquely challenging arena of weight management. By "listening with a third ear," the clinician with clear intention and exquisite sensitivity to implied and unspoken issues intuits and then skillfully addresses the possibility of a yet unknown and unnamed condition as part of a wider constellation of symptoms. The proactive diagnostician fosters the patient's self-reflection, self-acceptance, and incentive to heal dysfunctions sustainably at their source; increased self-esteem and positive body image have been shown to be best achieved through self-acceptance rather than weight reduction [41].

Research justifies the need for long-term implementation of interventions that aim to simultaneously prevent the onset of obesity and ED through the prevention of dieting behaviors and the promotion of healthful eating and physical activity as ongoing lifestyle behaviors [21]. Research reveals that fitness center employees, ideally placed to observe clients who exhibit an addiction-like relationship with exercise in an effort to lose weight as part of an ED, require detailed guidelines for intervention, including ways to start conversations to this end [42]. Bottom line, first responders need to determine whether the patient's desire for weight change is based on healthful choices and discretion, or on the dictates of pathological compulsions that underlie and drive dysfunctional eating behaviors. In either case, the diagnostician sets the stage for the patient's immediate and compelling engagement in integrative treatment, creating the potential to save lives and promote life quality.
