Enhanced cognitive behavior therapy: A single treatment for all eating disorders
Eating disorders (EDs) including anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified (ED NOS) are serious illnesses with a high burden of disease and significant psychiatric and medical comorbidity. Anorexia has the highest mortality rate of any psychiatric disorder, and bulimia and EDNOS are also associated with medical instability (Crow et al. 2009) Because approximately half of the individuals presenting with EDs fail to meet the strict criteria of the Diagnostic and Statistical Manual of Mental Disorders (4th ed. text rev. DSM IV TR; American Psychiatric Association [APA] 2000) for anorexia or bulimia, the most common ED diagnosis in clinical settings is EDNOS. It is highly likely that professional counselors will encounter EDs in their practice, even in clients presenting with other problems. Studies have found that up to 15% of women will suffer from a diagnosable ED in their lifetime (Wade, Bergin, Tiggemann, Bulik, Fairburn, 2006) Moreover, although it has traditionally been believed that only one in 10 ED cases occurs in a male, a recent community study of over 10,000 teenagers, ages 13 to 18, found equal numbers of males and females with anorexia (Swanson, Crow, Le Grange, Swendsen, Merikangas, 2011) It is likely that male ED cases often go undetected or undiagnosed, making accurate estimation of prevalence difficult. Anorexia tends to develop in adolescence, with peaks in onset at ages 14 and 18, whereas bulimia tends to develop in later adolescence or early adulthood (Hudson, Hiripi, Pope, Kessler, 2007) However, EDs can also present in children and develop or persist into late adulthood. Indeed, EDs tend to persist in a majority of cases, although their form may vary over time (Wade et al. 2006) Approximately 50% of individuals with anorexia will go on to experience bulimia or EDNOS, and individuals with bulimia may also shift to EDNOS over time (Steinhausen, 2009) In terms of prognosis, approximately 50% of individuals with anorexia and bulimia may be expected to recover, 20% 30% will present with persistent subclinical symptoms, 20% 25% will have a chronic disorder, and up to 10% may die as a result of the disorder (Steinhausen, 2009) Medical complications in EDs are wide ranging and have an effect on major organs of the body, particularly the skeletal, gastrointestinal, cardiovascular, and endocrine systems (Kaplan Noble, 2007) Individuals with EDs can experience severe medical problems and may require one or multiple hospital admissions. In addition, they frequently present with psychiatric comorbidities, including depression (45% 86% O'Brien Vincent, 2003) anxiety disorders such as social anxiety and obsessive compulsive disorder (64% Kaye et al. 2004) and personality disorders (58% Rosenvinge, Martinussen, Ostensen, 2000) Because medical and psychiatric comorbidities are common when working with EDs, treatment guidelines recommend the regular monitoring of clients' mental and physical status (APA, 2006; National Institute for Clinical Excellence [NICE] 2004) Several risk factors for developing an ED have been identified. Gender and sociocultural factors, such as the media and Western culture, clearly play a role. Repeated exposure to fashion magazines (which often use technology to modify images) has been found to predict increases in ED symptoms among adolescent girls valuing a thin ideal (Stice, Spangler, Agras, 2001) In a comprehensive review, Jacobi, Hayward, de Zwaan, Kraemer, and Agras (2004) concluded that low self esteem and elevated weight and shape concern substantially increase the risk of an ED. Early childhood feeding and gastrointestinal problems, such as pica, indigestion, and picky eating, can also elevate risk. Adverse life experiences, such as sexual abuse or loss of a first degree relative, are risk factors for developing a psychiatric disorder and may predispose some individuals to an ED (Jacobi et al.