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Understanding Teen Eating Disorders: Warning Signs, Treatment Options, and Stories of Courage Interview

Cris E. Haltom, Cathie Simpson, and Mary Tantillo joined us for an interview on their book Understanding Teen Eating Disorders: Warning Signs, Treatment Options, and Stories of Courage. What follows are our questions in italics, and their thoughtful responses.

(Please note Cris E. Haltom and Mary Tantillo provided the responses to this Book Interview)

Designed as a “learning tool” for professional and family members, your book, Understanding Teen Eating Disorders: Warning Signs, Treatment Options, and Stories of Courage, presents the experiences of 7 teenagers with their eating disorder diagnoses. Why choose this format?

Stories are excellent teaching tools. They can be used to illustrate what we know about the scientific nature,

development, treatment, and prevention of eating disorders.  We started our stories by describing the development of seven different eating disorders that invade the lives of seven teens and tweens. We illustrated the myriad of problems and the distress eating disorders created for these young people and their families.  We believed readers could relate to the stories of patients and their real-life dilemmas. The tension in each story builds as family members and patients realize the seriousness of their problems, whether interpersonal, psychological, nutritional, and/or medical.  Each story ends with descriptions of different evidence-based treatment paths to recovery.

In writing our stories, our mission was to educate by keeping the conversation about eating disorders going and in the public eye as effectively as possible. We believed readers would be more likely to understand and remember individual stories of courage and recovery than they would be to recall less interesting, albeit important, abstract facts or statistics. We have found people are drawn to stories they can relate to in their own lives. In this context, they are more likely to digest and retain facts about eating disorders.

The description of Julie in Chapter 1 highlights some of the details that can be relevant in a diagnosis of restrictive anorexia. In addition to perfectionism and conflict avoidance, what are some of the other traits that were active in Julie that contributed to her eating disorder?

Julie was ambitious, competitive, and self-driven. Yet she was sensitive, humble, and outwardly people pleasing. She suppressed and avoided exposing her own feelings while being over-focused on the needs of others. Over time, she became intolerant of vulnerability, both in herself and in others.  She believed that in order to achieve her ambitions she needed to inhibit weakness. She demanded self-control at all costs, even if it meant lack of self-care.  Determined to improve her cross-country running skills, she became compulsive and single-mindedly persistent about improving her running times.

There is ample evidence that strong cognitive control mechanisms seen in Julie, e.g., cognitive inflexibility, anxiety, obsessiveness, perfectionism, poor set shifting (perseverative responses), and inability to “see the big picture” (weak central coherence) are risk factors for the onset of anorexia nervosa. Additive genetic predisposition to these characteristics combined with environmental factors, e.g., a harsh, critical cross-country coach, likely contributed to the development and maintenance of anorexia nervosa in Julie.

Julie also showed a high degree of sensitivity to criticism and punitive social feedback. For example, she was oddly both attracted to and hurt by harsh feedback from her coach. On the one hand she interpreted her coach’s criticism as a sign of preferential treatment. On the other hand she felt so vulnerable to his criticism she turned to an eating disorder to numb her reactions.   By contrast, Julie was relatively insensitive to positive social feedback. Brain imaging studies show that those with anorexia are both under-reactive to positive interactions and over-reactive to negative interactions.  One set of researchers described those with anorexia as biased toward negative, disapproving faces and biased against warm, caring faces. These traits in Julie likely predisposed as well as perpetuated her illness.

As Julie’s story unfolded she showed increased signs of poor interoceptive awareness (perception of internal body sensations) and alexithymia (difficulty identifying emotions), both of which have been found to have specific brain signatures in those with anorexia compared to healthy controls. Julie, for example, was able to tune out negative feedback from her body when she was exhausted from running. And she relied upon disconnection from her emotions to withstand distress. Although these traits may have resulted from rather than were caused by disordered eating, they perpetuated the eating disorder by allowing Julie to persevere and excel.

Julie’s cognitive inflexibility, distorted interceptive awareness, poor regulation and recognition of emotions, and impaired social connections predisposed her to disconnection from herself (intrapersonal disconnection) as well as from others (interpersonal disconnection). Since eating disorders are diseases of disconnection and disconnection is a maintaining mechanism for eating disorders, one of the keys to recovery for Julie was fighting her way back to meaningful mutual connections with others, starting with her family relationships during Family Based Treatment.

Claire, the college student, is challenged with her life adjustment. In brief, what does research tell us about transitional times in the lives of teens and this connection to eating disorders?

Family Life Cycle Theory posits that difficult life cycle transitions through developmental stages like teens leaving home for college or children entering middle school are stressful .  Research confirms these life transitions may be precipitating factors for different forms of psychopathology including eating disorders.

While women with a preexisting history of poor self-image, dieting behaviors, and other eating disorder behaviors are especially likely to amplify these behaviors in college,research shows that for women, in general, there is a trend for increased eating disorder behaviors over the course of their first year of college. As in the story of Claire, important transitions during adolescence, like entering college, often involve first-time experiences like being free from parental controls, exploration of alcohol and recreational drugs, new and different sexual experiences, and stepped-up academic pressures related to fears for future success. Like Claire, lack of needed support and inadequate coping skills can contribute to poor transition adjustment and onset of disordered eating behaviors.  Abrupt movement to a higher degree of independence, loss of support from former school friends and lack of family support, especially the day-to-day support of living at home with family, can precipitate disordered eating.

The constant availability of tasteful food and pressures to combine eating with socializing challenge young people transitioning to college to self-regulate their food intake in ways they were not required to when living at home. Overwhelmed with the freedoms of college, they are often unsuccessful at regulating eating. Add this to body dissatisfaction promoted by a college culture in which students are pressured to conform to body size and shape ideals, and transition to college can trigger an eating disorder in at-risk individuals.

Each chapter includes some common questions parents and professionals are likely to ask. You then follow with informed answers. Please share 3 of these questions.

Based on our own clinical experiences, we selected three questions from our book that are commonly asked by carers about those with eating disorders.

  1. Question:

I’m afraid if my son is part of a (treatment) group focused on eating disorders, the eating disorder behavior of other participants will be contagious. Will he get ideas from being in a group and become sicker?

  1. Question:

Binge eating disorder in teens gets less attention than anorexia and bulimia.  I know it is more common. Is it as serious?

  1. Question:

As a parent how can I tell when my daughter’s sports practice has turned into compulsive exercise and put her at risk for an eating disorder?

Nick’s experience with an eating disorder is presented, as well as his family’s participation in multifamily group therapy (MFGT). What are the benefits for members of a multifamily group?

MFGT creates a caring and competent community (a “therapeutic village of support”) that promotes healing, wholeness, and recovery from eating disorders. Not only do patients and families gain knowledge about eating disorders and the most effective ways to manage them, they learn emotional and relational skills to interrupt the unwitting perpetuation of eating disorders. Because MFGT is comprised of patients AND their family members, it can capitalize on the use of everyone’s perspectives and maximize the strengths, resources, and adaptive coping strategies of its members when identifying and working through challenges to recovery. One of the biggest advantages to MFGT is its ability to quickly promote a sense of universality (that members are not alone in what they experience) and externalize the eating disorder – separating it from the patient and realigning patients and families alongside each other and the MFGT therapists in order to work together and eliminate illness. The universality and connection fostered by MFGT can decrease the distress and burden of care often created by eating disorders. This experience allows patients and families to see how eating disorders are “diseases of disconnection,” pushing patients to disconnect from their genuine thoughts, feelings and needs and from loved ones.

MFGT teaches patients and families emotional and relational strategies to name and repair disconnections. It helps patients listen to what goes on inside of themselves and in relationships with others and helps family members learn how to reconnect with patients when the eating disorder tries to foster conflict, tension, guilt, and shame. In MFTG,activities are introduced that promote the strengthening and deepening of relationships among patients, their families, and therapists. With this comes a growing sense of mutual trust, empathy and empowerment (perceived mutuality) among all group members —patients, families, and therapists. It is this sense of perceived mutuality that can sustain connection in the face of the eating disorder because patients and families have learned to embrace different thoughts, intense feelings, and needs that characterize these times and learned to remain connected to themselves and others while experiencing these differences. This process allows patients to use connections with family and friends to cope and solve problems instead of turning to the eating disorder.

MFGT is an interpersonal laboratory of sorts, offering many opportunities with one’s own and other families to practice “being in connection” when the eating disorder attempts to disrupt connection. MFGT provides a forum for growth and development in recovery from eating disorders that is often helpful in our overall growth and development. When it may feel too threatening to acknowledge something to ourselves or others, witnessing another patient and family work through a similar experience is helpful. When it is difficult to hear constructive feedback from our own loved ones, it may be easier to hear it from another patient or a member of another family.

The sad fact of abuse in teen partner relationships is revealed in May’s story. Her case exposes the damaging presence of shame that is often part of the eating disorder experience. Can you speak to this?

May had deep shame about her relationship with her boyfriend, Jarold.  Like a moth to the flame, she was drawn into a destructive dynamic in which she was vulnerable to Jarold’s fear-based, angry need to “possess” her.  Jared painted a picture of his miserable home life, and May was attracted to saving him.  All the while Jared criticized May and attempted to control her. He humiliated her in public, monopolized her time, became angry if May didn’t meet his expectations, isolated her from friends, and interrogated her when she disobeyed. Like May, most girls don’t report their emotional or physical dating partner abuse.  They are ashamed they both suffered and tolerated abuse. As a result, they become secretive.

Stigma and shame prevented May from admitting both the seriousness of the eating disorder and her abusive treatment by Jarold. When confronted with dieting and purge behavior in treatment, May was defensive. As with the abuse, she perpetuated her shame with denial and secrecy. Meanwhile, the eating disorder thrived on May’s shame and embarrassment.

May worked tirelessly to protect her vulnerabilities. Her biggest fear, when her psychotherapist prepared her for her parents knowing her self-harm secrets, was that her parents would force her to break up with Jarold. As ashamed as she was, she was terrified of losing both the eating disorder and Jarold.

May’s shame was both expressed and managed through symptoms of bulimia nervosa. The eating disorder functioned as a secretive form of self-punishment, a place to hide and a salve for her pain. When May became overwhelmed by emotional distress, she avoided and numbed her feelings with dietary restraint, binge eating, and vomiting.  May’s story provides an example of what research has long confirmed – that young women who have experienced dating partner abuse are more likely to demonstrate eating disorder symptoms. As in May’s case, shame may be a key link between dating partner abuse and eating disorder symptoms.

Your last chapter address eating disorder prevention. What are some of the recommendations you mention?

Eating disorder prevention interventions are intended to reduce eating disorder behaviors as well as reduce or stabilize the risk factors, e.g., body dissatisfaction, associated with eating disorders.  Our chapter on eating disorder prevention offers tips in several categories. The first of these promotes increasing teens’ media literacy in order to prevent low body-esteem. Body dissatisfaction is created when teens feel pressured to conform to media ideals for body appearance. Examples of these tips include, first, raising consciousness and awareness of media-fueled size and weight prejudice and, second, exposing media’s profit motive to promote manufactured, unrealistic body ideals, e.g., photo-shopped images of female models promoting thin idealization.

A second group of prevention tips in our book addresses problems with – and alternatives to – dieting.  Tips are borrowed from evidence-based eating disorder prevention programs.  They suggest it is important for teens to know that dieting is largely ineffective and can lead to weight gain, cycles of restricting and binge eating, and malnutrition. An anti-diet approach to healthy eating and weight encourages adults to role model (for teens) body acceptance, eating without guilt, zero tolerance for weight and shape prejudice, moderate exercise, balanced nutrition, and rejection of fad diets.

Our book includes a third group of prevention tips adapted from successful healthy weight programs. They advance a positive relationship with food and eating, and they promote acceptance of natural, genetically determined weight.  They propose food is enjoyable and not the enemy. They argue that food can be consumed in its diversity, in a balanced and moderate way, free of harsh categorization as good or bad, and consumed at regular intervals during the day. To prevent an eating disorder, our tips encourage people to listen to their natural body cues for hunger and satiety, and they urge people to accept naturally determined weight without pursuit of idealized weight or shape. In all, prevention tips in our book educate and influence people to develop positive and healthful attitudes towards food and eating.

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About the authors:

Cris E. Haltom, PhD, CEDS is a Certified Eating Disorders Specialist who has treated eating disorders in her private practice in Ithaca, NY, for over 30 years. She has presented workshops at national and local conferences. She is past Education and Prevention Liaison of the Western New York Comprehensive Care Centers for Eating Disorders and she authored A Stranger at the Table: Dealing with Your Child’s Eating Disorder(2004, Ronjon Publishing). She published research on her co-authored eating disorder education program, the Parent Partner ProgramTM. In addition to her clinical psychology practice, she is part-time faculty at Ithaca College in the Department of Psychology.

Cathie Simpson, PhD, lives and works in Ithaca, NY, where she is a psychotherapist and editor. Her interests are diverse. She coauthored the book American Dresses 1780-1900with Elsie Frost McMurry (2001, Cornell University) and published the book Remembering Infancy: Adult Memories of the First Months of Life (2014, Scholars’ Press). Once a month, she facilitates the local pet-loss group.

Mary Tantillo, PhD, PMHCNS-BC, FAED, CGP, is a fellow of the Academy for Eating Disorders, Professor of Clinical Nursing at the University of Rochester School of Nursing, and Clinical Professor in the Department of Psychiatry at the University of Rochester School of Medicine and Dentistry. She has directed the Western NY Comprehensive Care Center for Eating Disorders since 2005 and founded The Healing Connection Inc. in 2010. Dr. Tantillo has treated eating disorders across all levels of care for over thirty years. She has presented and published research and clinical work on a relational/motivational approach to eating disorder treatment with a special focus on the use of Multifamily Therapy Group.


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