Fearing Fat: A Literature Review of Family Systems Understandings and Treatments of Anorexia and Bulimia.

Sixteen-year-old Karen G. saunters into the office behind her parents, glowering in silent hostility. She positions her 5 foot, 6 inch frame in the chair closest to the door Folding her twig-like arms across her chest, Karen complains that the room is cold. Although Karen is attractive, her gaunt appearance and the dark circles under her eyes are immediately noticeable. The problem, her parents say, is "she won't eat. " Karen weighs 84 pounds. Jennifer M. is a 22-year-old single woman with a 9-year history of bulimia. She has been binge eating and vomiting seven times a week, and has been taking about 40 laxatives per week. Although she possesses an average weight for her body type and height, she expresses strong dissatisfaction with her physical appearance. The eating disorders of anorexia nervosa and bulimia nervosa, as mystifying as they are frightening, first began receiving national attention in the late 1970s. Since that time, medical, psychological, and family therapy research on anorexia and bulimia has exploded, with considerable attention devoted to their etiology. In particular, researchers have examined the association between family functioning and development of an eating disorder. The prevalence of eating disorders, their insidious onset in the adolescent years, and the role family factors play in their occurrence, maintenance, and successful treatment make a thorough understanding of anorexia and bulimia important for family life educators, family therapists, and other mental health practitioners. This article provides a comprehensive review of the role family system variables play in the occurrence and maintenance of anorexia and bulimia. It reviews diagnostic criteria, prevalence and etiology, current family systems treatments for anorexia and bulimia, and the research related to the efficacy of these approaches. DEFINITIONS OF ANOREXIA NERVOSA AND BULIMIA NERVOSA Although anorexia nervosa and bulimia nervosa both are disorders primarily affecting adolescent women (Muuss, 1985), they are distinctive forms of eating orders. Anorexia is a complex emotional disorder characterized primarily by an obsession with food and weight (Gilbert & DeBlassie, 1984; McNab, 1983). Anorectic refers to persons who restrict their diet and do not exhibit symptoms of bulimia. Bulimia, derived from the Greek word for "ox-hunger," is characterized by episodes of overeating or binge eating in which a person may consume 3 to 27 times the recommended daily food allowance (Abraham & Beaumont, 1982). Binges are often followed by purging through self-induced vomiting; the use of diet pills, laxatives or diuretics; or excessive exercise (Muuss, 1986). Bulimic refers to persons exhibiting symptoms of bulimia only. Some patients may alternate between these two eating disorders in a condition labeled bulimarexia (Boskin-White & White, 1983). Subtypes of these disorders are beyond the scope of this article, but information on them may be found elsewhere (e.g., Garner, Garner, & Rosen, 1993; Hall, Blakey, & Hall, 1992; Wilson & Walsh, 1991). There are four Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R; American Psychiatric Association [APA], 1987; see Table 1) criteria for anorexia. Other medical explanations for the weight loss (e.g., diabetes) must be eliminated before diagnosis. Associated medical conditions include hypothermia, dehydration, and the presence of fine lanugo hair over the body (see Herzog Copeland, 1985). Anorectics may experience depressed mood, sleep disturbance, and a loss of libido, and, as the disorder becomes more severe, an inability to concentrate may impede the effectiveness of psychotherapy with anorectics. Although the mortality rate is dropping (Stierlin & Weber, 1989), anorexia remains a life-threatening illness. Stierlin and Weber (1989) recommend that therapists treating anorectic families insist on regular medical care in conjunction with therapy. …