Health Effects of Anorexia Nervosa
Introduction
An eating disorder (ED) is a psychological disorder characterized by abnormal eating habits (Allakbari et al, 2014). Eating pathology is another term for used for eating disorder. There are different forms of eating disorders, such as anorexia nervosa, and bulimia nervosa. Anorexia nervosa (AN) is characterized by a fear of weight gain which leads to faulty eating patterns, malnutrition, and typically excessive weight loss (Mahn and Lordly, 2015). Bulimia nervosa (BN) is an eating disorder involving distortion of body image; typically, extreme overeating is followed by self-induced vomiting, purging, or fasting (Mahn and Lordly, 2015).
Shame is a painful feeling of humiliation or distress caused by the consciousness of wrong or foolish behavior (Kelly and Carter, 2013). Shame can be categorized in many ways, the most common being internalized shame, externalized shame, and bodily shame. As defined by Redshaw and Troop (2012), internalized shame is how one sees or judges the self and external shame is how one perceives how others see the self. Bodily shame, according to Redshaw and Troop (2012), is typically a negative attitude toward one’s weight or size. Bodily shame has subcategories in itself: current and anticipated bodily shame. Current bodily shame involves the negative thoughts one has about his or her own body in its current physical condition. When a person experiences guilt at the thought of gaining weight, it is defined as anticipated bodily shame. People with eating disorders often have prevalent feelings of shame, which fuels their disorder further.
To counteract feelings of shame, medica professionals have developed a therapy program specifically to combat eating pathologies. This type of therapy is called Compassion Focused Therapy. Compassion Focused Therapy (CFT) targets diminishing feelings of shame
and producing feelings of compassion toward the self. One of the ways this is done, is by allowing the family of the patient to get involved in the treatment. The purpose of the family’s involvement is to offer support, empathy, and even another outlet for the patient to help battle their illness. (Goss and Allan, 2014). Another way, is by exposing the patient to self-accepting behaviour. If the patient is taught to accept the way his or her body is and to understand he or she must not feel guilt by his or her form, then the patient will start the process of remission.
The purpose of the studies conducted was to identify the health effects of different eating disorders, to identify how the different types of shame correlate with the development of eating pathologies, and to determine whether Compassion Focused Therapy was more effective with short-term inpatient treatment, or with long-term outpatient treatment. The objective of this report was to identify the health risks eating disorders pose, to establish how feelings of shame can manifest within a person with an ED, and to determine whether compassion focused therapy is a functional treatment method for eating pathologies.
Discussion
The individual types of shame (internal, external and bodily) produce different results in people with eating disorders. In the studies examined, it has been determined that a person is more likely to develop anorexia if they show signs of internal shame. If a person indicates signs of external shame, it is more likely to result in bulimia. The study by Bariairi, Kelly and Carter (2014), and the experiment by Kelly and Carter (2012) are compared to determine that short- term inpatient programs are more effective than long-term outpatient programs.
Health Effects of Anorexia Nervosa
There are multiple health risks, both mentally and physically, that anorexia poses. Some of the major health risks being low bone mass density, heart failure, and depressive and obsessive tendencies.
In the research conducted by Elamin, Erwin, McGovern, Montori, Swiglo, and Sim it is determined that AN is characterized specifically by low bone mass density (BMD) in adolescents and adults. Low BMD, also termed osteoporosis, causes bones to become thin and weak increasing the risk of broken bones. Simple activities such as walking or even standing still can cause fractures. As well as osteoporosis, Elamin and colleagues found that people with AN have serious cardiac problems. Heart failure in patients with anorexia has numerous causes; researchers found the most common cause of heart failure to be muscle loss. The body as a whole begins to lose muscle mass, resulting in the heart reducing in size and strength. As the muscle walls of the heart diminish it is no longer able to pump blood efficiently, and as a result, induces stress that the heart cannot handle. In this study the mortality rate of AN was recorded to be 20%, leading causes being cardiac arrest or suicide. The physical health effects of anorexia were so extreme due to the fact the body being denied essential nutrients and therefore is no longer functioning properly.
In contrast, Allakbari, Campbell, and Noordenbos (2014) identified the mental effects of AN. Anorexia is identified as an addiction-type illness; because of this people with anorexia tended to develop obsessive compulsive behaviour. In this study, individuals with AN reported having schedules and systems of which they strictly abided by. Similarly, Kelly and Carter (2012) also found that participants adhered to specific rules that were set for themselves. Both research groups reported not yet having been able to identify whether the systems these patients adhere to are to punish or alleviate themselves.
Collecting information from these various studies have proven anorexia is a toxic, and at times, fatal disease that overwhelms the patient’s body and mind. It can lead to numerous serious health risks, however, the most prominent have shown to be osteoporosis, heart failure and obsessive tendencies.
Health Effects of Bulimia Nervosa
Similarl to anorexia, bulimia can cause intense problems with the psyche and the physical body. Some problems include hearing internal voices, and esophageal perforation.
During interviews conducted by Allakbari, Campbell and Noordenbos (2012), patients with BN reported hearing an inner voice which commands them to restrict their eating habits and weight gain. The voices were insistent that the patient must expel whatever contents filled his or her stomach as quickly as possible. Also concluded in the interviews, the voices began as conscious thoughts but over time became supervisory commands. The researchers are puzzled as to why the voices turn from intentional to uncontrollable. The internal voices compromise the patient’s health due to the fact they are demanding physical damage to the body.
As well as hearing internal voices, Mahn and Lordly (2015) found rupturing of the esophagus to be a health risk of BN. The esophagus is a tube which connects the oral cavity to the stomach. Rupture of the esophagus is a serious complication of bulimia, the root cause is repetition of violent vomiting. Although the esophagus consists of multiple cutaneous layers, stomach acid can still corrode through it. When the esophagus has a perforation stomach acid exits the tear and leaks into other parts of the body. If this condition is left untreated it is fatal. Through their studies, Mahn and Lordly (2015) found the mortality rate of BN to be 3.9%, with suicide being the leading cause.
These studies are in agreement that the effects of BN can be detrimental to a person’s health. The major physical health risk of bulimia being esophageal perforation, and the major mental concern being the onset of aggressive internal voices.
The Relationship between Feelings of Shame and Eating Disorders
Typically, people modify their behaviour so as to reduce the feelings of shame they experience (Redshaw, et al 2012). This is why number of studies have found positive relationships between feelings of shame and eating pathologies.
In the research conducted by Kelly and Carter (2012), it was proven that people who experience external bodily shame are more likely to develop bulimia nervosa. Meaning patients who suffer from BN are ashamed of how they appear to others more so than how they appear to themselves. Anorexia, however, was found to be the opposite. People with AN more commonly encounter internal bodily shame. Results also demonstrate that shame builds in diseases such as BN because of the cycle it produces; the patients who induced binging and purging behaviours formed worsening feelings of shame.
Similarly, in the research performed by Redshaw and Troop (2012) the intent was determine the contribution shame had to both anorexic and bulimic symptoms. Participants in this study were individuals who self-reported having an eating disorder and were recruited from the Eating Disorder Unit, Institute of Psychiatry in London. Although 341 names were originally enlisted, only 55 women completed both baseline and follow-up assessments, meaning there was a 25% follow up rate. The study only shows results for the 25% of members who completed both evaluations. 56% of the 55 participants were self-reported anorexics, and 44% were bulimics. The average age for this study was recorded to be 36.4 years of age. The SEED, a self-report questionnaire, was given to measure behavioural symptoms of eating disorders. Results showed
behavioural eating habits were dependent on whether the person suffered from bulimia or anorexia. Three more questionnaires were given as a baseline measure and a follow up measure. These questionnaires were: The Bodily Shame Scale (BSS), The Personal Feelings Questionnaire (PFQ), and The Other as Shamer Scale (OSS). First of all, the BSS was used to determine the feelings, thoughts and behaviours that relate to shame directed toward the body. Secondly, the PFQ was a measurement of shame and proneness to guilt by rating which feelings they felt more strongly on a regular basis. As well as BSS and PFQ, OSS was used as a measure to establish feelings of shame in relation to an outsider’s perspective. These results indicated that bodily shame predicted an increase in anorexic symptoms but not in bulimic symptoms, and that general shame made no additional contribution. The results also concluded that current bodily shame proved to be a strong predictor of binge-eating and purging, whereas anticipated bodily shame was a strong indicator of behaviour related to weight avoidance.
The statements from both of these studies are in agreement about the fact that shame specifically contributes to the growth and upkeep of both anorexia and bulimia. Although results slightly differ between whether bodily shame or general shame generates which eating disorder, they do both recognize that different feelings of shame create either anorexia or bulimia categorically.
The Utilization of Compassion-Focused Therapy
Compassion focused therapy (CFT) was developed specifically to assist those who suffer from eating disorders due to feelings of shame, self-criticism and self-hostility (Goss et al, 2014). According to Borairi, Carter and Kelly (2014), people who are exposed to neglect and abuse early in life are more prone to self-criticism, and eventually psychopathology. In support of this, studies performed by Goss and Allan (2014) provide evidence that when individuals allow
compassion toward themselves to grow it significantly relieves a range of mental health illnesses. Empathy towards those with eating disorders is also a strong antithesis to feelings of guilt and shame.
According to a study conducted by Goss and Allan (2014) the development and practice of compassion would be the remedy to eating disorders caused by shame. This involved three courses of action: being open to compassion from others, being compassionate towards others, and developing compassion towards oneself. They found that other courses of treatment were not as effective as CFT, due to the fact they limited the patients ability to use a soothing method to stop feelings that, for example, caused purging. CFT however, enhanced the use of soothing systems. It also focused specifically on helping patients foster the ability to experience gratifying emotions as well as manage feelings of anxiety and guilt. It was discovered that individuals who could not balance their emotions tend to become overly competitive; the results from this study suggested that people with anorexia are especially focused on ambitiousness. Compassion is often inhibited in people who have a highly ambitious mentality, because of this, they tend to be socially isolated. The treatment they found effective was a two-stage process consisting of psycho-education, and capacity building. It was also found more effective when delivered in a group format. Firstly, the psycho-education is used solely as an individual learning approach to the patient’s disorders and what may have led to their development. Secondly, the group capacity building aimed to practice giving and receiving compassion. Group work was also effective due to the fact it assisted with social isolation.
In agreement with Goss and Allan, the research performed by Carter and Kelly (2013) aimed to prove that inhibiting feelings of shame in highly self-critical individuals was prudent to the recovery from their eating disorders. Therefore, their purpose was to prove that CFT was the
most effective treatment program. Their study suggests the most adequate way to regulate shame is to encourage compassion. The more self-critical the patient then the more likely it is that shame plays a role in the maintenance of their eating disorder. A compulsive focus on weight is viewed as an isolating approach to managing shame. Their methods to recovery were similar to that of Allan and Goss, in that they focused on peer and family group building, and establishing shame-withstanding behaviours. Kelly and Carter (2014) noted that when the patient’s family involved themselves in the recovery process, the patient had a quicker remission rate.
From the comparison of these two studies it can be concluded that compassion focused therapy is an adequate treatment program due to the fact it directly targets the root cause of eating disorders. When an eating disorder is developed due to feelings shame, shame acts as a catalyst. Logically, the best course of action would be to isolate and remove the catalyst to prevent any further progression of the illness.
Short-term Inpatient versus Long-term Outpatient Treatment
There are two types of Compassion Focused Therapy (CFT) to prevent relapse of eating disorders. They are short term inpatient treatment, and long term outpatient treatment.
Research was conducted by Borairi, Carter, and Kelly (2014) to prove that eating disorder patients could be in remission within 12 weeks of starting inpatient CFT. They deduced that the more consistently the patient was exposed to stimulation of inner-kindness then the more likely the patient was to remain in remission. Participants in this study were collected from Toronto General Hospital’s inpatient treatment program. The sample group of 97 consisted of 94 women, and the age group varied from 17-57. For a baseline measurement of where the patients were at emotionally, eating disorder symptoms, shame levels, and self-compassion ability were measured through respective questionnaires. Participants completed similar questionnaires four
more times over the duration of the treatment to assess their progress. By the completion of the
12 week treatment, results indicated that the more exposure the patient had to self-compassion treatment, it culminated an observable change in eating disorder symptoms. It was also demonstrated that patients who experienced larger decreases in levels of shame in their first four weeks of treatment, had a faster remission rate overall during the 12 week period. A majority of the patients reported feeling a new calmness within themselves that they had not experienced before. With these facts stated, the hypothesis that short term inpatient treatment of CFT is effective was proven in this study.
In comparison, another study was conducted by Kelly and Carter (2012) to examine the effectiveness of a 13 month long outpatient CFT treatment program. The sample consisted of 51 who were admitted to an intensive hospital-based eating program in Canada. Participants were between the ages of 18-55 years, and 97% of the group was made up of women. Three questionnaires were given to gather a baseline measure of self-criticism and self-assurance, self- esteem, and shame. The scale for self-criticism and self-assurance asked participants to rate how they react when a situation goes wrong for them. Self-esteem was measured by asking the individuals to evaluate how positively they view themselves. The participants were asked to rate how frequently they felt shame at their own actions. The study found that the patients did not overcome their illness quickly, 67% of the sample reported eating disorder symptoms by the end of the 13 month trial period.
By comparing these two studies it is evident that inpatient CFT programs are more effective. Inpatient programs are more effective to treat eating disorders because the patient has a more constant opportunity to build inner-compassion, which in turn, offsets the preservation of an eating disorder. The studies show this inclination, due to the fact the results of the outpatient
program indicated high relapse rates. With the relapse rate being over half the sample size, the effectiveness of outpatient treatment cannot be deemed less effective than inpatient therapy. Conclusion
The intent of this lab was to analyze the health effects of different eating disorders, to establish the link between feelings of shame and eating pathologies, and the comparison of CFT
inpatient versus outpatient program effectiveness.
There were various limitations to these case studies. For instance, there are variables not documented which could have affected the results of the observations. These variables are age, gender, and family involvement.
There was not a specific age group tested. Middle aged people may not respond to treatment in the exact same way a teenager would. In future studies, focusing on specific age groups to document how the disorder develops could prove to be more productive. The studies could also investigate the question of whether older people who suffer from eating disorders have newly developed the illness or if they are relapsing into an existing one.
The research was also based primarily on females. Perhaps a comparison study could be conducted to observe how males and females first react to feelings of shame, and then also how effective CFT treatment is for each gender.
Family and peer involvement is an important aspect of CFT. The support of family members assists in the recovery of an eating disorder patient due to the added moral support. The studies discussed did not mention the level of recovery when the family or peers were not supportive. Seeing as the stability of the patient is dependent on the ability to diminish their
feelings of shame, there is a possibility that without the support of family and friends they are more likely to relapse. Further analysis could help to prove this.
In summary, through comparison of these studies it is proven that different types of shame result in different eating pathologies. Bulimia nervosa is more likely to develop when a person suffers from feelings of external shame; whereas when a person encounters feelings of internal shame they are more likely to generate anorexia nervosa. The health risks are identified and it is confirmed that anorexia and bulimia are illnesses which take over the mind and body. It is also confirmed that inpatient care is more effective than outpatient care when using compassion focused therapy. It was proven more effective because the patient has an opportunity to be more thoroughly exposed to the ideals compassion focused therapy aims for. When patients are taught to treat their shame alongside their eating disorder, they will achieve a much higher success rate against relapse. The dangers produced by eating disorders can be minimized if counteracted by evoking self-accepting behavior
