Clinical Handbook of Mindfulness (73 page)

and others are examples of describe statements.

• Following an observe exercise like the ones above, clients can be asked to

describe their experience, without adding on judgments, interpretations,

and so forth.

Participate

• Activities can be brought into group sessions and clients asked to fully par-

ticipate in them. For example, using a word puzzle or a maze, clients can

be asked to throw themselves completely into the solving of the puzzle

for a certain period of time. After the exercise is over, they can be asked if

judgments went through their mind about themselves or the exercise.

• Any activity that tends to prompt self-consciousness offers abundant

opportunity for practicing the skill of participate. Popular choices include

singing (e.g., typical rounds such as “Row Row Row Your Boat”), dancing,

or laughing out loud in a “laugh club.”

• Another interesting participate exercise is to do an exercise that will likely

draw self-consciousness, like those listed above. Afterwards, ask clients

to imagine what they would have looked like doing the exercise had

they done it with no self-consciousness. Then repeat the exercise, allow-

ing them additional opportunity to practice throwing themselves into

participating.

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14

Mindfulness-Based Approaches

to Eating Disorders

Ruth Q. Wolever and Jennifer L. Best

Worries go down better with soup

∼Jewish Proverb

Introduction

Eating disorders (ED) are complex multidimensional behavioral syndromes

characterized by pervasive core deficits in the self-regulation of food intake,

affect, and cognition
(Dalle Grave, Di Pauli, Sartirana, Calugi & shafran, 2007;

Deaver, Miltenberger, Smyth, Meidinger & Crosby, 2003;
Shafran, Teachman, Kerry, & Rachman,
1999;
Spoor, Bekker, Van Heck, Croon, & Van Strien,

2005).
Disturbance in self-regulation of food intake is linked to difficulty in recognizing physiological signals of hunger and satiety as well as in discerning these signals from somatic signals of emotion. Disturbance in emotion

regulation reflects deficits in identifying, managing and adaptively utilizing

emotion. Disturbance in cognition reflects extreme rigidity seen in cogni-

tive restraint around eating behaviors, perfectionism and distorted thinking

about weight and shape. ED frequently persist even in the face of signifi-

cant deterioration in psychological and physiological wellness. Given their

increasing prevalence, and the associated high risk of relapse and concur-

rent psychopathology, greater attention is warranted to improve the efficacy

of existing treatments. Mindfulness approaches can intervene by improving

self-regulation and the emerging evidence demonstrates the potential utility

of these approaches.

Eating Disorders: An Overview of Diagnostic

Characteristics, Epidemiology, Course and Outcome

Individuals suffering from ED are typically driven by an intense desire to

achieve a thin body ideal
(Thomsen, McCoy, & Williams, 2001)
and are frequently characterized by distorted body images
(Cash & Deagle, 1997),

preoccupations with thoughts related to food
(Powell & Thelen, 1996),
and self-concepts that are overly invested in body weight and shape
(APA
,
2000).

Additionally, recovery from ED is often further complicated by comorbid

Axis I and/or Axis II pathology
(Fernandez-Aranda et al., 2008).
Development of ED is related to the confluence of biopsychosocial factors: dominant

sociocultural values and peer influences
(Hutchinson & Rapee, 2007),
family
259

260

Ruth Q. Wolever and Jennifer L. Best

of origin interpersonal dynamics
(Felker & Stivers
,
1994),
and individual differences in temperament and personality style (Franco-Paredes, Mancilla-Diaz, Vazquez-Arevalo, Lopez-Aguilar, & Alvarez-Rayon,
2005),
in conjunction with established biological vulnerabilities (Becker, Keel, Anderson-Fye,

& Thomas,
2004).
Prevalence of clinically significant eating disturbances now traverse socioeconomic and demographic lines (e.g., ethnic minorities, males, middle-aged women:
Brandsma, 2007;
Harris & Cumella, 2006;

Striegel-Moore, Wilfley, Pike, Dohm, & Fairburn, 2000).
The three primary ED recognized in the clinical and scholarly communities include anorexia

nervosa (AN), bulimia nervosa (BN) and binge eating disorder (BED)
(APA,

2000).

Anorexia Nervosa

A diagnosis of AN reflects: (1) a rigid refusal to maintain body weight of at

least 85% of the expected weight based on age and height; (2) an overriding

fear of weight gain or becoming fat; (3) the undue influence of body weight

or shape on self-evaluation; and (4) the absence of at least 3 consecutive

menstrual cycles in post-menarcheal females
(APA
,
2000).
Individuals diagnosed with AN may be further classified as either a restricting type or as a

binge eating/purging type
(APA, 2000).
The current point prevalence of AN

is estimated to be 0.3% in the United States and Western Europe (Hoek, &

van Hoeken,
2003)
with a lifetime prevalence of roughly 0.5–3.7% among

women
(APA Work Group on Eating Disorders, 2000).
AN has an average age

of onset occurring between ages 14 and 18
(APA, 1994),
although symptoms of disordered eating and poor body image are emerging at an alarming rate

in pre-pubescent cohorts
(Rohinson, Chang, Haydel, & Killen, 2001).

Due to its hallmark clinical features of extreme weight loss and chronic

malnutrition, AN poses significant long-term health risks (Office on Women’s

Health,
2000;
NIMH, 2001)
and is considered among the most lethal psychiatric disorders
(Sullivan, 1995).
Long-term prognosis is equivocal (see

Berkman, Lohr, & Bulik, 2007
for an extensive review); for instance, ten-year recovery rates range from 27% in a US sample (Halmi, Eckert, Marchi,

Sampugnaro et al.,
1991)
to 69% in a German sample (Herpertz-Dahlmann,

Muller, Herpertz, & Heussen,
2001).
Given this grim picture, a recent systematic review of randomized controlled trials (RCTs) underscored the consider-

able need to enhance the modest support for efficacy of cognitive-behavioral

therapy and family therapy in preventing relapse among weight-restored

adults with AN and in resolving AN symptoms in adolescent samples respec-

tively
(Bulik, Berkman, Brownley, Sedway, & Lohr, 2007).

Bulimia Nervosa

BN is defined by (1) recurrent episodes of binge eating (consuming large

quantities of food within a discrete period of time coupled with the per-

ception of loss of control); and (2) recurrent inappropriate compensatory

behaviors with the intent to avoid weight gain. Such behaviors may include

self-induced vomiting, fasting, excessive exercising and/or the misuse of lax-

atives, diuretics or other medications that promote weight loss
(APA, 2000).

The binge-compensatory behavioral cycle must occur on average at least

twice a week for three months in order to reach diagnostic severity. Although

Chapter 14 Mindfulness-Based Approaches to Eating Disorders

261

both patients with AN and BN tend to develop self-concepts principally

based on body weight and shape, BN patients by definition must not be

underweight
(APA, 2000).

The current prevalence of BN is roughly 1% in women and 0.1% in men in

the Western world
(Hoek, & van Hoeken, 2003)
with a lifetime prevalence estimated between 1.1 and 4.2% in women (APA Work Group on Eating Disorders,
2000).
However, a significantly higher proportion of the population suffers from subclinical symptoms of the disorder (i.e. 5.4% partial syndrome;

Hoek, & van Hoeken, 2003).
Onset tends to occur in adolescence or young adulthood (e.g., among college-aged samples) and a substantial number of

individuals with AN subsequently develop BN following weight restoration

(Office on Women’s Health, 2000).
Health consequences of BN center on

complications of chronic purging behavior, with the most serious potential

complication being cardiac arrest
(Office on Women’s Health, 2000).
Average mortality rate has been reported as
<
1%
(Keel & Mitchell, 1997;
Steinhausen,
1999).
Recovery rates are variable, ranging from 22 to 77%, with a high probability of relapse
(Fairburn, Cooper, Doll, Norman, & O’Connor,