The Exploration of Factors Influencing Recidivism in

Eating DisordersGretchen Kempf

Practice ScenarioO Mentor: Amy EthridgeO Occupational therapist for 11 yearsO Penn State Milton S. Hersey Medical

Center Adolescent Medicine and Eating Disorders Clinic

O Outpatient facilityO Individual and Group therapy

PICOO For clients with a diagnosis of an

eating disorder who are 14 years of age or older and have successfully completed an inpatient program, which of the following three factors is most effective in reducing the rate of recidivism: motivation to change, the presence of support systems, or the demonstration of healthy coping skills?

Working DefinitionsO Anorexia Nervosa:O Refusal to maintain body weight at or above a minimally normal

weight for age and height, for example, weight loss leading to maintenance of body weight less than 85% of that expected or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected.

O Intense fear of gaining weight or becoming fat, even though underweight.

O Disturbance in the way one's body weight or shape is experienced, undue influence of body weight or shape on self evaluation, or denial of the seriousness of the current low body weight.

O In postmenarcheal females, amenorrhea, i.e., the absence of at least 3 consecutive menstrual cycles. A woman having periods only while on hormone medication (e.g. estrogen) still qualifies as having amenorrhea.

Working DefinitionsO Bulimia NervosaO Recurrent episodes of binge eating characterized by both (1)

eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances, and (2) a sense of lack of control over eating during the episode (such as a feeling that one cannot stop eating or control what or how much one is eating).

O Recurrent inappropriate compensatory behavior to prevent weight gain, such as self- induced vomiting, misuse of laxatives, diuretics, enemas, or other medications, fasting, or excessive exercise.

O The binge eating and inappropriate compensatory behavior both occur, on average, at least twice a week for 3 months.

O Self-evaluation is unduly influenced by body shape and weight.O The disturbance does not occur exclusively during episodes of

Anorexia Nervosa.

Working DefinitionsO Eating Disorder Not Otherwise SpecifiedO This diagnosis includes disorders of eating that do not meet the

criteria for the above two eating disorder diagnoses. Examples include: (1) For female patients, all of the criteria for Anorexia Nervosa are met except that the patient has regular menses; (2) All of the criteria for Anorexia Nervosa are met except that, despite significant weight loss, the patient's current weight is in the normal range; (3) All of the criteria for Bulimia Nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur less than twice a week or for less than 3 months; (4) The patient has normal body weight and regularly uses inappropriate compensatory behavior after eating small amounts of food (e.g., self-induced vomiting after consuming two cookies); (5) The patient engages in repeatedly chewing and spitting out, but not swallowing, large amounts of food; and (6) Binge-eating disorder: recurrent episodes of binge eating in the absence of regular inappropriate compensatory behavior characteristic of Bulimia Nervosa.

Search StrategyO Databases: CIHNAL and Google ScholarO Key words: eating disorders and adolescents, adolescents with

eating disorders, teens with eating disorders, motivation to change, social support systems, healthy coping skills, and recidivism

O Journals: European Eating Disorder Review, International Journal of Eating Disorders, Journal of Clinical Child & Adolescent Psychology, Eating Disorders, and Journal of Clinical Psychology

O Inclusion criteria:O Subjects must have a diagnosis of an eating disorder according to

criteria set forth in DSM-IV-TRO Studies must involve only adolescent participants who are fourteen

years of age or olderO Studies must focus on one or more of the following factors:

motivation to change, social support, and/or healthy coping skillsO Subjects must have successfully completed an inpatient treatment

program for their eating disorder

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SynthesisO Scarce literatureO No direct comparative studies of all

three factorsO Factors of recidivism are almost

impossible to isolateO Complex relationship of all three factors

O Some factors may influence one another to ultimately lead to recidivism or a full recovery

SynthesisO Several studies conclude that the presence of a

motivation to change appears to be a necessary element in preventing recidivism after recovery from an eating disorder

O Researchers have concluded that lack of internal motivation to recover may lead to premature termination of the treatment. O May also be due to having social supportO not clear from cases if treatment was terminated

too early in order to please an unsupportive family member or partner of the subject participant

SynthesisO several studies showed evidence of

other factors that may result in recidivism even in the presence of a motivation to change:O Fear of change, ambivalence,

professional rigidity and media influence

O Glen Waller- Any research result that stems from reliance on stated expressions of motivation by subject participants should be viewed with a high degree of suspicion.

SynthesisO Importance of the parent-adolescent social

relationship as a factor in recovery was examined in a study conducted by Kathy Dowell and Benjamin OglesO Compared a child-only intervention to a

combined child-parent intervention for eating disorders.

O parent participation in child psychotherapy treatments added moderate improvements to the outcomes of the child’s treatment

SynthesisO In one study, participants stated that their treatment

outcome was influenced by developing healthy coping skills

O Treatment focused solely on weight loss was damaging

O Treatments that focused on healthy coping skills and healthy eating habits were much more helpful and informative.

O evidence in the literature to support the hypothesis that healthy coping skills lessen eating disorder symptomatologyO increases the subject participant’s motivation to change,

which ultimately leads to better outcomes for recovery

ConclusionO InconclusiveO Despite lack of direct comparison,

the literature appears to indicate that all three factors (namely, motivation to change, social support, and healthy coping skills) play a critical, but complicated, role in maintaining a successful recovery from an eating disorder.

Implications for OTO Each case of an eating disorder must be treated in a

unique manner in order to have a good treatment outcome

O Occupational therapists can provide valuable assistance to the client in areas such as:O time use analysis, keeping a balance in life, the

identification and development of coping skills, grocery shopping and meal planning advice, eating in a public place such as a restaurant or school cafeteria, creating a plan for a return to work or school, and finding enjoyable healthy activities to replace eating disorder behaviors.

O Occupational therapists promote health and participation in life through engagement in occupations