Family Therapy for the Teen with Bulimia Nervosa A three-phase approach using family- based treatment may be a helpful option for adolescents with bulimia nervosa (BN), according to an ongoing study at the University of Chicago (Am J Psycho- therapy 2003;57:237).. Still uncharted territory Although much information is avail- able about the causes and treatment op- tions for adults with BN, much less is known about effective treatment for ado- lescents diagnosed with BN. For example, although cognitive behavioral therapy (CBT) and interpersonal therapy (ITP) have been helpful for adults, no clinical trials of CBT or IPT have yet been de- signed for teens. Dr. Daniel LeGrange and colleagues at the University of Chicago have had good preliminary results with a family therapy approach for adolescents with BN. There are several strong arguments for including the family in treatment of teens with BN, according to the research- ers, For example, information about BN can be shared with the parents and their child, and issues about meals and the impact of the eating disorder on family relationships can be addressed. Addition- ally, the intrinsic denial of the alarming nature of bulimic symptoms makes many teens incapable of appreciating how serious the disorder may be. This ‘makes it necessary for the parents to be- come involved to make certain that the teen gets adequate treatment. ‘A manualized approach for BN Based on an earlier manual developed forfamily treatment for anorexia nervosa (AN), the researchers developed a manual for BN that reflects three clearly defined phases of treatment. Whereas in AN the first and main focus of treatment is em- powering the parents to succeed in refeeding their starving daughter or son, the treatment focus for adolescents with BN is helping parents help their son or ‘daughter regain control overeating and preventing the child from turning to binge-eating and purging, Just as in AN, it is only after the eating disorder has been successfully addressed that parents can hand control over eating back to their child. kh Phase 1. Regulating food intake (ses- sions 1-10). In the first phase, treatment is almost entirely focused on the eating disorder, in order to enable parents to help their child to regulate eating and stop purging. A family meal with the therapist early in treatment start the pro- cess of parental involvernent, and lets the therapist directly observe the family's in- teractions to eating. The therapist helps parents relieve their guilt, so they stop thinking that they caused the eating problem. The emphasis is on the posi- tive aspects of parenting. Families are en- ‘couraged to work out for themselves how best to stabilize the bulimic child's eat- ing. The initial session also helps edu- cate the family about the nature and challenge of treating bulimia, especially the secretiveness and shame associated with binge eating and purging. Phase 2. Negotiating a new pattern of relationships (sessions 11-17). The second phase can begin once the patient hhas agreed to her parents’ demands that she normalize food intake and abstain from binge eating and purging, and when the therapist detects a change in the mood of the family (eg, relief after taking charge of the problem). Although symptoms are the center of discussions, regular, stress-free meals are now encour- aged. This second phase also marks the return of control over eating to the ado- lescent. Parents monitor eating but al- low the teen to make her own food choices. Other family issues can now be brought forward for review. Phase 3. Adolescent issues and ter- ‘mination (sessions 18-20). Once the patient maintains a stable weight and binge/purge symptoms have disap- peared, the therapist and family work to ‘establish a healthy adolescent or young adult relationship with the parents. In this relationship, the illness is not the center of attention. This stage also in- volves working toward increased per- sonal autonomy for the adolescent, more appropriate family boundaries, and ad- dressing the need for independence. According to the authors, their ‘manualized treatment approach is still in the preliminary stages, but family therapy for adolescents with BN may ‘enable patients to recover without pro- tracted outpatient treatment or hospital admission. Racial Teasing and Its Effect on Body Image Among South Asian- American Women Acculturation and loss of ethnic identity have been proposed as risk factors for eating and body image disturbances among women of color. Now two re- searchers have added another risk factor: being teased about racial or ethnic fea- tures (Int J Eat Disord 2003; 34:142). Drs. Dana Sahi Iyer and Nick Haslam report that women from South Asian backgrounds have been overlooked in studies of minority women and eating disorders. This is unfortunate because these women are culturally, economi- cally, and historically distinct from ‘women in other ethnic groups and have markedly different cultural practices, including artanged marriages and re- ligion, What is racial teasing? In typical childhood teasing, the com- ‘ments are directed at children thought to be different or who are disliked. In contrast, “racial teasing” focuses on the target's ethnically distinct attributes. In a 1988 study by Kelly and Cohn, racial teasing was the most prevalent form of teasing among 10- to 17-year-olds in England, Both forms can have long-last- ing and detrimental effects upon the tar- get child, Researchers have shown the connection between being teased and development of aggressiveness, depres- sion, low self-esteem, eating problems and body image dissatisfaction Racial teasing might also adversely af- fect body image because it selects appear- ance-related features. By drawing hurt- ful attention to their distinct features, racial teasing might lead minority women to adopt the beauty norms of the dominant culture, misidentify with their host culture, and experience identity problems, distress and self-denigration, all of which can promote eating and body image problems. SEPTEMBER/OCTOBER 2003 = EATING DISORDERS REVEWThe study Participants in this study included 122 American undergraduate women (mean age: 20.6 years) of South Asian descent who were recruited from 5 states. Most (89%) were Asian Indian-Americans and most came from affluent families (67% had family incomes above $60,000 per year). All the women completed seven self-report questionnaires and a demo- graphic information sheet Results In this group, only a history of hurtful racial teasing, but not acculturation or loss of ethnic identity, was associated with disturbed eating behavior and body image dissatisfaction. Racial teasing, which was reported by 86% of the ‘women, was not correlated with ethnic identification, and only weakly corre- lated with acculturation. ‘Associations are still unclear Just how and why racial teasing is as- sociated with disturbed body image and disordered eating is still unclear. The au- thors hypothesize that being teased about visible signs of being ethnically dif- ferent might make some girls dissatisfied with their appearance, and they may then tum to disordered eating in an at- tempt to change it. Another possibility isthat racial teasing may create or deepen sense of not belonging in the surround- ing culture, The results of the study strongly sup- port the role of racial teasing in disor- dered eating behavior and body image problems. This indicated that racial teas- ing might be an important but neglected factor in eating and body image distur- bance among minority women. Researchers and theorists interested in studying eating disturbances among eth- nic minorities may need to look beyond women’s relations to the dominant cul- ture and their culture of origin. Ifa his- tory of being cruelly taunted about one’s ethnic appearances associated with eat- ing and body image disturbances, then itmay be the majority culture's response to the minority individual, not just her accommodation to it or estrangement from her own ethnic origins, that plays a role in the development of these dis- turbances. EATING DISORDERS REVIEW = SEPTEMBER/OCTORER 2003, The Psychology of Bulimia ‘Nervosa: A cognitive perspective (By Myra Cooper, PhD. Oxford University Press; 2003, 337 pages, $49.50) ‘though $49.50 may seem a lotto spend (on a paperback book, this informative re- view and synthesis nicely delivers what it promises—a very scholarly introduction to psychological aspects of bulimia nervosa, primarily cognitive theoretical and treatment approaches. | suspect that it developed from ‘an advanced seminar for psychology gradu- ate students at Oxford. For someone new to the field, this book will provide an excel- lent way to step into the current scene. For those who've been in the field for a while, this book offers a careful review, and con- tains interesting discussions from which | ‘even veterans can learn something new. At the very outset, | was grabbed by the historical introduction, in which Dr. Cooper resurrects “kynorexia” (a term from antiq- ity and the Middle Ages referring to “insa- tiable hunger lke that of a dog") and “bu- limia emetica,” from Cullen's 1780s classi- fication of three types of bulimia, in which ‘vomiting followed excessive eating. Next, after a detailed review of the status. ‘and controversies concerning nosology and key clinical features, Dr. Cooper turns to her main focus, thorough discussions of psycho- | logical issues. In each area, she presents | and eiiques the evidence, pointing out dif- ficulties in interpretation, gaps in knowledge, | the ned for future researc, and treatment | implications. She begins with internal states BOOK REVIEW and their cognitive associations, involving self-esteem, body image, impulsivity, sexu- ality and perfectionism. Then, she turns to ‘external and developmental factors, includ ing abuse, attachment, emotional regula- tion, development ofthe self, fami issues, life events, coping, and social suppor. There are reviews of epidemiology, cul- tural issues, and a brief but helpful survey cof non-cognitive psychological theories, in- cluding psychodynamic: (ego-psychology, object relations, self-psychology and rela- tional theories), sociocultural, feminist, fam ily/systems, and behavioral theories. ‘When we finally gat to cognitive theories, ‘about halfway through the book, we've been well prepared for an in-depth discussion. Her review ofthe basic assumptions offered by major theorists inthe field is focused and edifying - Garner and Bemis; Fairburn; Young; Vitousek and Hollon; Guidano and Lotti; Cooper et al, eto. She then addresses some of the newer ideas in cognitive theory, associating cognition with attention and ‘memory, cognitive-affective interactions; and others. The final sections perceptively analyze ‘treatments based on these various psycho logical models. | particularly appreciated the discussions of outcomes, future issues in systems of care (such as self-help, manualized care, and stepped care), new ‘topics on the horizon such as schema-fo- cused theory and therapy, and an exami ration of what might actually be the effec tive elements in treatment. wy. BMI and Length of Disease Predict Bone Turnover in AN Long-term anorexia nervosa (AN) and a low body mass index (BMI) lead to a breakdown of the essential balance of bone formation and resorption (European J Clin Nutr 2003; 57:1262), according to the results of a recent case-controlled study. University of Bonn scientists dis- covered this pattern after evaluating 51 ‘women with ANand 51 control subjects matched for age, sex, and height. AN patients had lower BMIs, lower fat mass, lower fat-free mass, and lower muscle mass than women in the control group. In addition, serum levels of osteocalcin (a marker of bone formation) were lower, and serum levels of C- telopeptide (CTx, a marker of bone re- sorption) were higher in patients than in controls. Finally, a ratio of these two ‘markers, which providesan index reflect- ing the balance of bone formation and remodeling, was elevated among patients but not controls. The AN patients had enhanced serum calcium and cortisol levels, and reduced serum levels of sev- eral hormones, including thyroid hor- mones, insulin, and leptin. BMI and duration of disease were in- dependent predictors of the CTx/ osteocalcin ratio in the patients with AN. Use of oral contraceptives had no effect upon the ratio in patients or controls.Copyright of Eating Disorders Review is the property of Gurze Books and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.