Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Tuesday, December 11, 2007

Why Don’t You Just Eat: The Failure of the Medical Model in the Treatment of Anorexia Nervosa and Bulimia Nervosa – Kristin Tyman

The purposeful restriction of caloric intake by individuals has been documented throughout history, from religious fanatics to sorority sisters. Yet it was not until 1973 and the publication of Hilde Bruch’s book, Eating Disorders: Obesity, Anorexia Nervosa and the Person Within, that the term Anorexia Nervosa was first introduced to the public as a legitimate psychiatric disease with physical manifestations and complications (1). The Diagnostic and Statistical Manual of Mental Health Disorders, DSM-IV-TR, classifies Anorexia Nervosa as an intense fear of weight gain despite weight at or below eighty five percent of ideal body weight, amenorrhea in postmenarcheal females, distorted body image and the inability to recognize the seriousness of the disorder. Bulimia Nervosa is defined as eating large amounts in a discrete period of time (within any two hour period), a feeling of lack of control, use of compensatory behaviors to control weight, binge eating at least two times per week over a three month period, and self loathing (2). In the United States, it is estimated that ten million women and one million men struggle with Anorexia Nervosa or Bulimia Nervosa. However, it is known that only one third of those struggling with Anorexia Nervosa are treated for the mental health component and even more shockingly, only six percent of people with Bulimia Nervosa receive mental health treatment (3). While war has been declared on obesity and its potential physical and mental health side effects, the “significant rise in the incidence of eating disorders – more than 500% - over the past two decades” (4) has received much less attention. No war has been waged.

Why Don’t You Listen: Ignoring the Psychological Component

The assumption that a healthy body weight is directly associated with a healthy mind is flawed. The failure of the medical model to recognize the significant psychological nature of eating disorders compromises the recovery process.

Eating disorders are extremely complicated illnesses, “in fact, due to a variety of medical causes and suicide, the mortality rate for this illness is among the highest of any psychiatric illness (3).” Misconceptions and confusion surrounding criteria, foundation and presentation of the disorder remain. Too many people still regard Anorexia Nervosa and Bulimia Nervosa diseases of choice among Caucasian, upper class teenagers. Part of the blame can be placed on the media and its influence over culture, but another significant player in the perpetration of this frame of thinking is the medical field itself. The focus on the medical stabilization of patients with Anorexia Nervosa and/or Bulimia Nervosa, specifically the focal point on body weight as the primary indicator of health, disregards the mental incapacitations of the disease and the need for a broader based approach.

The medical model is failing people with eating disorders because it assumes that once weight is restored, behaviors will stop and health will be achieved. “Historically, medical stabilization, weight restoration, and the promotion of psychological recovery have been the goals of…hospitalization, but lengthy inpatient stays no longer are feasible in the current care environment (5).” An eating disordered person has limited choices for inpatient level of care treatment. A person is discharged once weight has been restored to 85% of normal body weight. The thinking behind this is that once weight is “normal” then a person will have the ability to think rationally and will want to begin the recovery process, rather than allowing him/her to retreat into the disorder. The medical field’s reliance on specific, measurable goals such as weight restoration and proper nourishment for brain activities makes sense scientifically. However, this reliance on the Health Belief Model and particularly hospitalization and forced tube feeding as cues to action, completely disregards the importance of self-efficacy in the recovery process. “The medical model has a deep professional, economic, and philosophical stake in preserving the integrity of what it has demarcated as its domain, and the result has frequently been blindness to the obvious (6).” By ignoring the relevance of the acceptance of self, and how it can affect one’s intention and in turn change behavior does call into question “the merits of hospitalization (1).”

The goal for most patients when they enter a hospital is to leave a healthier person. However for most patients with an eating disorder, a hospital stay is an interruption of unhealthy behaviors. Usually, patients’ goals are to leave as soon as possible and resume life with the eating disorder. It is vital that medical staff understand these complexities when treating eating disordered patients, in particular “experience in the handling of such patients is needed, otherwise there is the danger that the personnel and the other patients will become overwhelmed (1).” Beyond self-efficacy, another concept that appears to aid individuals that are ready to recover is modeling, in particular surrounding oneself with people who have healthy relationships with their bodies and food. Social Learning Theory states that “people are influenced by observing others, and their health behavior is affected by knowledge (7).” The medical hospital setting is not an environment where patients can model the staff and their approaches. Usually patients are confined to beds, fed intravenously and prohibited from exercising or using bathrooms alone. This strict control and enforcement of rules is typically not something that they will encounter once discharged. And, in fact, for many eating disorder patients, this very concept of feeling controlled and having no voice or validity is a primary reason why they have an eating disorder. If modeling is to occur in the medical hospital setting, then “it is critical that these patients receive care and advice from competent primary care providers” (8) that understand the extent of the disorder on both the physical body and emotional self.

Why Don’t You Just Get Help: Barriers to Treatment

The strict criteria for eating disorder diagnosis as well as the lack of specialty care outside of major metropolitan areas in conjunction with limited insurance coverage leads to far too few people receiving adequate care.

The mental health of a person with an eating disorder is compromised from the onset of the disorder no matter what the person’s weight, body size or engagement in behaviors is. The reliance on the medical model as well as the belief that eating disorders are not widespread disorders restricts the available care. Due to economic, geographic and cultural barriers, treatment remains very limited. Most people who have insurance coverage receive mental health benefits to allow for therapy and, depending on diagnosis, inpatient, partial or residential care stays. Based on criteria, as determined by manuals such as the DSM-IV, insurance companies have the power to cover or refuse coverage for certain treatments. For example, a person who fits all criteria for Anorexia Nervosa, except is currently over 85% of normal body weight is not termed anorexic. Without diagnosis there are no funds available for treatment. In Massachusetts, eating disorders are not classified as biological disorders and therefore insurance companies do not have to provide coverage. Despite the fact that other disorders closely related to eating disorders such as Depression and Obsessive Compulsive Disorder have parity, patients with eating disorders often must pay out of pocket if treatment is prolonged. Current studies state that the usual stay in an inpatient hospital setting is seven days but adequate care would call for a forty-five day stay. “The cost of the usual care treatment package is $36,200 per subject and the cost of the adequate care treatment package is $119,200 per subject” (9) but “there is evidence that length of stay and the amount of weight restoration achieved during length of stay are diminishing. Further it appears that such shortened lengths of stay are associated with a diminished likelihood of successful treatment (9).” The problem is simple - patients who are receiving treatment are being discharged too soon, which in turn puts them at greater risk to relapse and return to treatment.

It is difficult to put a timeframe on how long it should take one to recover from an eating disorder, but this is exactly what insurance companies and the facilities with which they contract are deciding. “The intensity of treatment for each member, the focus, and its length vary considerably (1).” Many eating disorder treatment programs must force people to leave programs once their insurance runs out, despite knowing that medically and emotionally they are still fragile. For many people with eating disorders the option of self-pay for inpatient care is not a reality. Recently a State Representative in Massachusetts introduced Bill H989 – An Act Requiring Equitable Insurance Coverage for Eating Disorders. The bill would include eating disorders as biologically based illnesses that deserve full coverage. There is also a movement to refine language in the next publication of the DSM. Beyond this more treatment options and specialists must be made available. Currently most facilities in Massachusetts are clustered in the Greater Boston region. Most hospitals are at full capacity and are forced to place eating disordered patients on floors that are not equipped to handle them. Nearly all centers do not currently accept MA Health despite “anorexia and bulimia…appearing in increasingly diverse populations of women (6).” This lack of resources hinders the validity of the disorder and the recovery process.

Why Don’t You Just Ignore Everyone: Society’s Role

The media, while not the sole reason someone develops an eating disorder, plays a large role in perpetuating the idea that Anorexia Nervosa and Bulimia Nervosa are disorders based out of a fear of weight gain. Unfortunately the current medical model contributes to this false reality.

In a culture of abundance, it can seem unbelievable that there is a large percentage of the population controlling weight by restricting and/or purging. “Why don’t you just eat?” is a common phrase that eating disorder clients hear from those not understanding the complete mental shutdown that occurs. An eating disordered person never thinks that they are “enough:” they feel they are not good enough, smart enough, perfect enough, happy enough, hungry enough or worthy enough. The idea that an underweight person needs only to gain weight, just enough to put them above 85% of ideal body weight, in order to achieve happiness and fulfillment is not only bogus, but it downplays the seriousness of the illness. “Weight gain in itself is not a cure for anorexia nervosa (1).” The strict criteria used to diagnose individuals sets people up for failure. For many people, they are not a good enough Anorexic or Bulimic until they have been labeled according to diagnostic criteria, despite many times showing signs of the disorder previously. Today the uses of the terms anorexic and bulimic have become quite colloquial. Often times the terms are used in the media to highlight a celebrity who has lost significant weight and speculate about his or her mental status. In schools, many adolescents use these terms to put down a fellow classmate or poke fun at his or her mental health. “Culture provokes, exacerbates, and gives distinctive form to an existing pathological condition (6).” The media has helped to portray eating disorders as simply being about weight and when medical professionals and insurance companies use these same criteria as a measure of health, society is left with a complete misunderstanding of the disease.

In the United States, it is nearly impossible not to be affected by culture. “Sociological theory is based on the assumption people do not function and act apart from their culture. Eating behavior and attitudes towards physical build and body image cannot be understood without first understanding the mutual relationship between individuals and their environment (10).” Dove introduced the Campaign for Real Beauty nearly two years ago. The focus of the campaign and in particular the ads that are run on television are to remind people that the struggle to fit in and be deemed beautiful begins much earlier than adolescence and lasts a lifetime. Many of the commercials feature “non-models” with varying body sizes. Unilever, Dove’s mother company, also films commercials for Axe Deodorant featuring scantily clad women reacting wildly to a man’s scent. It is an interesting conundrum. Unilever is trying to sell products and this only further reveals “the instability of the contemporary personality construction, the difficulty of finding homeostasis between the producer and the consumer sides of self (6).” Similarly to Unilever’s multiple product campaigns, Tyra Banks uses her talk show as a forum for women to state what makes them feel good about themselves. Tyra’s “So What” campaign has attracted the attention of many consumers. At the same time, Tyra is the woman who hosts America’s Next Top Model and judges women based on physical appearance.

It is not easy to be a person struggling with body issues in a culture that equates thinness and beauty with perfection. Media outlets have a powerful influence over society, but unfortunately the image they continue to display is one of a disorder that is the passing phase of a person just looking to lose weight. The medical field needs to do a greater job of relaying the graveness of the disorders.

Why We Must Change: Conclusion

It is fairly apparent that the obsession over body size and weight is not diminishing but that should not bar attempts to reframe the way in which we think and speak about eating disorders in this country. The social stigma surrounding Anorexia Nervosa and Bulimia Nervosa must be broken down. The only way that this will occur is if medical doctors begin to treat the disorder as more than an issue about weight. “In the medical model, the body of the subject is the passive tablet on which disorder is inscribed…Within such a framework, interpreting anorexia requires, not technical or professional expertise, but awareness of the many layers of cultural signification that are crystallized in the disorders (6).” There needs to be a greater coming together between the mental health and medical worlds if the patient is to ever “uncover his own abilities, his resources and inner capacities for thinking, judging, and feeling (1).” The length of hospital stay needs to be increased, access to care needs to be expanded, and specialists need to be identified. Patients need “medical stabilization, nutrition rehabilitation … interruption of compensatory behaviors…psychoeducation…identification and management of the psychological aspects of the illness…identification and treatment of the comorbid conditions (11).”

The use of the medical model in the treatment of Anorexia Nervosa and Bulimia Nervosa acts as a band-aid but in no way accomplishes all that must be done to treat these patients. While weight restoration is vital to the health and well-being of patients, the focus on weight diminishes the importance of other factors and signs of the illness. In order for eating disorders to receive the funding for research, treatment and education, the medical model must expand its current criteria and acknowledge that this illness requires more than a one-time visit to the doctor.

References

1. Bruch, H. Eating Disorders: Obesity, Anorexia Nervosa and the Person Within. Basic Books Inc.: Harper Colophon Books, 1973.

2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, DSM-IV-TR, Fourth Edition.

3. National Eating Disorders Association. Statistics. Seattle, WA: NEDA. http://www.nationaleatingdisorders.org

4. Latzer, Y. and Shatz, S. Comprehensive Community Prevention of Disturbed Attitudes to Weight Control: A Three-Level Intervention Program. Eating Disorders: The Journal of Treatment and Prevention Spring 1999; 7:3-31.

5. Butryn, M. and Wadden, T. Treatment of Overweight Children and Adolescents: Does Dieting Increase the Risk of Eating Disorders? International Journal of Eating Disorders May, 2005; 38:285-293.

6. Bordo, S. Unbearable Weight: Feminism, Western Culture, and The Body. University of California Press, 1993.

7. Salazar, M.K. Comparison of Four Behavioral Theories. AAOHN Journal 1991; 39:128-135.

8. Mehler, P. Anorexia and Osteoporosis. Eating Disorders: The Journal of Treatment and Prevention Summer 1999; 7:143-147.

9. Crow, S. and John Nyman. The Cost-Effectiveness of Anorexia Nervosa Treatment. International Journal of Eating Disorders March 2004; 35:155-160.

10. Latzer, Y. and Shatz, S. Comprehensive Community Prevention of Disturbed Attitudes to Weight Control: A Three-Level Intervention Program. Eating Disorders: The Journal of Treatment and Prevention Spring 1999; 7:3-31.

11. Treat, T.., Jill Gaskill, Elizabeth McCabe, Frank Ghinassi, Amanda Luczak, and Marsha Marcus. Short-term Outcome of Psychiatric Inpatients with Anorexia Nervosa in the Current Care Environment. International Journal of Eating Disorders September 2005; 38

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