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2017 Music Therapy for Eating Disorders: A Manual for the Use of Music Therapy as an Integrative Therapy for the Treatment of Individuals with Eating Disorders Leah Elizabeth Powers

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COLLEGE OF MUSIC

MUSIC THERAPY FOR EATING DISORDERS:

A MANUAL FOR THE USE OF MUSIC THERAPY AS AN INTEGRATIVE THERAPY

FOR THE TREATMENT OF INDIVIDUALS WITH EATING DISORDERS

By

LEAH POWERS

A Thesis submitted to the College of Music in partial fulfillment of the requirement for the degree of Master of Music

2017 Leah Powers defended this thesis on June 21, 2017. The members of the supervisory committee were:

Lori Gooding Professor Directing Thesis

Jayne Standley Committee Member

Diane Gregory Committee Member

The Graduate School has verified and approved the above-named committee members, and certifies that the thesis has been approved in accordance with university requirements.

ii

This thesis is dedicated to my parents, Don and Beth, for teaching me the value of hard work, the importance of the arts, and the strength of humility. Thank you for showing me that a life of service and of music is the best life to live.

iii ACKNOWLEDGMENTS

Thank you to my family and friends, for pushing me forward and learning about music therapy with me. Thank you for being almost as proud of me as I am of you all. Flor, thank you so much for your guidance and support throughout my internship and writing process, and life in general. Kevin, Annie, and Joseph, thank you for always listening when I complained about formatting. Your sacrifice is greatly appreciated. Thank you to Dr. Standley and Professor Gregory. Your love of music therapy and of the students at Florida State shows every day and has changed many lives, including mine. Thank you, Dr. Gooding, for your infinite wisdom and assistance in this entire process. I quite literally couldn’t have done it without you.

iv TABLE OF CONTENTS

List of Tables ...... vii List of Figures ...... viii Abstract ...... ix

1. INTRODUCTION ...... 1

2. HISTORY OF EATING DISORDERS ...... 4

Anorexia Nervosa...... 4 Bulimia Nervosa...... 8 Eating Disorders Not Otherwise Specified ...... 11

3. ETIOLOGY OF EATING DISORDERS ...... 13

Consumerism and Media Influence ...... 13 Thin Ideal Internalization ...... 15 Normative Discontent ...... 16 Fat Talk ...... 17 Personality ...... 18 Current Diagnoses ...... 20

4. TREATMENT OF INDIVIDUALS WITH EATING DISORDERS ...... 24

Individual Therapy Treatment Approach ...... 25 Family Therapy ...... 27 Nutrition Therapy ...... 28

5. MUSIC THERAPY IN MENTAL HEALTH ...... 30

Current Psychiatric Music Therapy Research ...... 31 Depression, Anxiety, and Obsessive-Compulsive Disorders ...... 33 Post-Traumatic Stress Disorder and Substance Use Disorders ...... 34

6. MUSIC THERAPY FOR EATING DISORDERS ...... 36

Autonomy ...... 38 Emotional Regulation...... 42 Anxiety ...... 45 Motivation for Treatment ...... 46 Further Research ...... 47

v References ...... 49

Biographical Sketch ...... 62

vi LIST OF TABLES

Table 1: Key Features of Feeding and Eating Disorders ...... 21

Table 2: Current Music Therapy Interventions for Eating Disorder Populations ...... 36

Table 3: Shake it Off Songwriting Sample Session ...... 39

Table 4: Who I am Lyric Analysis Sample Session ...... 42

Table 5: Identifying Emotions/ Under the Bridge Lyric Analysis Sample Session ...... 43

Table 6: Singing Sample Session ...... 45

Table 7: Music Games Sample Session ...... 47

vii LIST OF FIGURES

Figure 1: Cognitive Behavioral Therapy Diagram ...... 26

Figure 2: Shake it Off Fill-in-the-Blank Lyric Worksheet ...... 40

Figure 3: Body Outline Worksheet ...... 41

Figure 4: Identifying Emotions Worksheet...... 44

viii ABSTRACT

An eating disorder is a psychological disorder that affects one’s eating habits. According to a 2011 study, approximately 20 million women and 10 million men in the United States suffer from a clinical eating disorder at some point in their lives (Wade, Keski-Rahkonen, & Hudson, 2011). Eating disorders include anorexia nervosa, bulimia nervosa, binge eating disorder, and other disorders (DSM V, 2013). Recent research has indicated that the prevalence of anorexia nervosa is 0.3% in males, 0.9% in females, and 0.3% in adolescents (Hoek, 2006). In 2007, the first national survey to include eating disorders found the prevalence of bulimia nervosa to be 1.5% in the United States (Hudson, Hiripi, Kessler, 2007). The fifth edition of Diagnostic and Statistical Manual of Mental Disorders (2013) was revised to include binge eating disorder, which has a prevalence rate of 2.6% in white women and 4.5% in African American women (DSM V, 2013; Pike, Dohm, Striegel-Moore, & Fairburn, 2001; Striegel-Moore, Wilfley, & Pike, 2000). Though overall prevalence rates are low, eating disorders impact millions of Americans each year, and eating disorders have the highest mortality rate of all psychiatric disorders(Neumarker, 2000). Music therapy, defined as the use of musical interventions to address non-musical goals, has its roots in mental health care (Silverman, 2015). While music therapy is one of the treatment options for individuals with eating disorders, very little research is available regarding music therapy with this population (Hilliard, 2001). This manual provides an overview of music therapy for the treatment of eating disorders with the purpose of better equipping music therapists with the knowledge and tools to serve the growing eating disorder population.

ix CHAPTER 1

INTRODUCTION

The role that music has played in healing expands across both centuries and cultures. Ancient cave paintings dating back at least 26,000 years highlight that the use of music for healing while other records suggest that shamans have used music to promote healing for 30,000 years (McCaffrey, 2015). From Arab nations to Central Asia to the Greek and Roman empires, there is historical evidence that music was used for healing and to promote well-being (McCaffrey, 2015). Though the relationship between music and well-being is quite established, much of this relationship stemmed from “philosophical and literary traditions,” (28) (McCaffrey, 2015) which promoted a mystic and mysterious viewpoint of music in healing. By the 19th and 20th centuries there was renewed interest in the use of music in healthcare, which prompted the need for research on the scientific applications of music in healthcare. Most early research occurred in psychiatric settings (McCaffrey, 2015), and documentation began to emerge on the first systematic use of music therapy in asylums in the late 1800s. By the 1940s the field of music therapy had begun to develop and the first university degree programs were created. Research on music therapy’s effectiveness was still limited, however. By the early 21st century, advances in neuroscience and brain imaging technology led to a better understanding of how music and music therapy affects the brain. Neuroscientific studies have shown that music is capable of affecting neurobiological processes (Lin et al., 2011), and imaging studies have shown that music activates various pathways in the brain (Lin et al, 2011). The data have also shown differing brain responses to various music properties (i.e., unpleasant and pleasant music), and MRI studies have shown areas associated with motor movement responding to music (Lin et al, 2011). Because music can impact neurobiological processes, music interventions can be a beneficial treatment for individuals who suffer from various neurocognitive disorders. Music therapy for individuals with depression has proven to increase their mood state as well as their willingness to participate in group therapy settings (Lin et al, 2011). Reactions to musical stimuli can also increase dopamine release in the striatal system, which causes feelings of euphoria associated with other pleasurable stimuli, such as food or sex (Salimpoor, Benovoy, Larcher, Dagher, & Zatorre, 2011). Individuals with depression may also abuse substances or have other 1 poor coping habits that elicit the same feelings of euphoria. Since music can induce a euphoric release, music therapy can be used to “rewire” an individual to use music instead of a substance or bad habit. Anxiety and depressive disorders are commonly diagnosed in individuals with eating disorders. Roughly 80% of individuals with eating disorders have been diagnosed with another additional psychiatric disorder at some point in their lives (Fichter & Quadflieg, 1997) Comorbid disorders in individuals with eating disorders include but are not limited to: obsessive- compulsive, autism spectrum, anxiety, bipolar, substance use and mood disorders (American Psychological Association, 2013). The elevated suicide risk for these two disorders exists as well, with some reports of 12 people per 100,000 for anorexia nervosa (APA, 2013). In a study examining fifteen adolescent females with anorexia nervosa and fifteen adolescent controls, the females with anorexia nervosa had significantly higher levels of depression and anxiety (Lule, Schulze, Bauer, Scholl, Muller, Fladung, & Uttner, 2014). Another study in Australia reported that out of 100 women being treated for an eating disorder, 65% also had at least one anxiety disorder. 69% of those women reported that the anxiety disorder preceded the onset of the eating disorder (Swinbourne, Hunt, Abbott, Russell, St Clare, & Touyz, 2006). The comorbidity between eating disorders and anxiety disorders is extremely high (Swinbourne et al, 2006). Low self-esteem, debilitating perfectionism, and relationship issues are possible by- products of depression and/or eating disorders (Shafran, Cooper & Fairburn, 2002). Various therapies, including cognitive-behavioral, nutritional, and family therapies can be utilized in individuals with eating disorders’ recovery (Beck-Ellsworth, 2015). However, motivating and engaging individuals in therapy may be difficult (Silverman, 2015). This is where music therapy can be beneficial. Individuals who participated in music therapy versus traditional “talk therapy” have higher levels of participation and engagement in the session. They also reported the music therapy sessions as relaxing and uplifting, stating also that they would engage in music therapy in the future (Patterson, Duhig, Darbyshire, Counsel, Higgins, & Williams, 2015). Music therapy is rooted in psychiatric and mental health care (Silverman, 2015). It seems only natural that it should be expanded to include more and more eating disorder treatment centers. In 2001, Hilliard implemented a cognitive-behavioral based music therapy program at the Renfroe Center, a residential eating disorder treatment center in Tampa, Florida (Hilliard, 2001). The patients, families, and therapists at the facility reported a positive reaction to the use

2 of music therapy (Hillard, 2001). Based on this and other supporting research, one can infer that similar interventions and programs would be highly beneficial in the treatment of eating disorders.

3 CHAPTER 2

HISTORY OF EATING DISORDERS

Eating disorders are defined as eating habits that are maladaptive or different from the norm. Over the course of history, eating disorders have been examined, researched, and treated in many different ways. The earliest accounts of eating disorders are tied to religion or status, rather than low self-esteem or fear of weight gain (Bemporad, 1996). In the 17th and 18th centuries, eating disorders were sometimes viewed as a symptom of hysteria, a popular diagnosis for women at the time (Silverman, 1997). It was not until the late 19th or early 20th century that the modern etiology and treatment of eating disorders began to emerge (Silverman, 1997). In the 1980s, the DSM III included the diagnosis of bulimia nervosa, which was vital to understanding and treating eating disorders (American Psychiatric Association, 1980; Bulik, Sullivan, & Kendler, 2000). In 2013, the DSM V made several beneficial changes to the eating disorder diagnosis, including deleting amenorrhea as a criterion and adding binge eating disorder as a separate disorder (American Psychiatric Association, 2013; Beck-Ellsworth, 2015). New cases of eating disorders have been steadily increasing since 1950, with approximately 20 million women and 10 million men suffering from an eating disorder in the United States (Hudson, Hiripi, Pope & Kessler, 2007; Streigel-Moore & Franko, 2003; Wade et al., 2011)

Anorexia Nervosa Identifying the history of anorexia nervosa as an eating disorder has proven difficult (Keel, 2005). Based on historic records, we know that the first few cases of anorexia nervosa likely occurred in the fourth or fifth century, with accounts of a twenty year old woman who reportedly died from self-starvation found as early as the fourth century (Bemporad, 1996). Though the condition was not referred to as anorexia nervosa, individuals presented with similar behaviors and symptoms. The reasons behind these behaviors, however, have shifted drastically over the course of history. Many early cases of self-starvation were blamed on demonic possession and believed to be cured by exorcism (Bemporad, 1996). Between the 12th and 17th centuries restrictive eating practices were used to promote religious or spiritual goals (Keel, 2005). Priests and other church leaders saw restricting food intake as a rejection of worldly pleasures (Beumont, Al-Alami & Touyz, 1987). Self-starvation was used as a way to rehearse 4 extreme self-discipline and/or to be closer to God (Bell, 1985). All of these early accounts of anorexia nervosa had a running religious theme, but none alluded to any form of treatment (Beumont et al, 1987). In 1689, Richard Morton wrote and published a magnum opus entitled Phthisiologia seu Exercitationes de Phthisi, which was translated to Phthisiologia, a Treatise of Consumptions in English in 1694 (Silverman, 1997). He outlined what is considered the first medical account of anorexia nervosa, labeling it “nervous consumption” (3) (Silverman, 1997). He attributed nervous consumption to “sadness” and “anxious cares” (3) (Silverman, 1997). Characteristics included loss of hunger, amenorrhea, emaciation, and lack of concern over the disorder (Keel, 2005). Here we see the beginnings of a similar symptomology to modern anorexia nervosa. Morton saw and attempted to treat two patients, one male and one female, ages 16 and 18, respectively (Silverman, 1997). Both patients had suffered for approximately two years before seeking treatment with Morton. (Silverman, 1997). In the treatment of each patient, Morton utilized what would be considered pharmacotherapy today (Silverman, 1997). Unfortunately, the female patient died mid-treatment and no records show the outcome of the male subject (Silverman, 1997). Almost a century later, Robert Whytt, a professor of the theory of medicine at the University of Edinburgh, reported seeing patients with similar symptomatology (Silverman, 1997). The next year De Valangin, a professor at the Royal College of Physicians in London, reported successful treatment of anorexia nervosa symptoms in conjunction with a physician (Silverman, 1997). Restrictive eating for religious purposes was still present in 18th and 19th century America and Europe. During this period fasting was quite popular among females (Bemporad, 1996; Brumberg, 2000; van Deth & Vandereycken, 1994). Often these were adolescents who simply refused to eat (Keel, 2005). Sarah Jacobs, a twelve year old girl from Wales, was publically supported by her parents for her fasting behaviors because a local religious figure endorsed it (Bemporad, 1996; Brumberg, 2000; van Deth & Vandereycken, 1994). She became a religious attraction but raised concerns within the medical community. After a week, Sarah grew frail but her parents refused to feed her and she herself did not ask for food (Bemporad, 1996; Brumberg, 2000; van Deth & Vandereycken, 1994). She died after only ten days (Bemporad, 1996; Brumberg, 2000; van Deth & Vandereycken, 1994).

5 In 1860, Dr. Louis-Victor Marcé of the Hôspital Biçetre of Paris published a report entitled, “Note sur une Forme de Délire Hypochondriaque Consécutive aux Dyspepsies et Caractérisée Principalement par le Refus d’Aliments. This report clearly outlined a disorder that would be labeled anorexia nervosa, yet did not give a name to the disorder. (Silverman, 1997). In 1873, anorexia nervosa became the official diagnosis of the symptoms and disorder. Two physicians, separate of each other, were responsible for naming the disorder anorexia nervosa (Silverman, 1997). In Paris, Charles Laségue explored the psychopathology of anorexia nervosa in his paper “De l’Anorexie Hystérique” (4) (Silverman, 1997). The second of the two contributors was Sir William Gull, a leading clinician in London (Silverman, 1997). He introduced the term anorexia nervosa to describe girls with intentional weight loss (Keel, 2005). Three of these girls, labeled Misses A, B, and C, fully recovered from their disorder (Silverman, 1997; Keel, 2005). Gull expressed that the root of most anorexia nervosa cases stems from corruptions in one’s ego (Silverman, 2007). Gull’s description of the disorder included extreme weight loss, amenorrhea, and bradycardia, similar to the diagnosis criteria today (Keel, 2005). Simultaneously, in America, doctors began to note the difference between anorexia nervosa and the broader diagnosis of hysteria (Vandereycken & Lowenkopf, 1990). Cases of anorexia nervosa emerged all around the world, including Australia, Germany, Italy, and Russia (Keel, 2005). Gull’s explanation of anorexia nervosa became the most well-known and well-used (Keel, 2005). His studies showed the first examples of how we diagnose anorexia nervosa today (Keel, 2005). However, the primary focus remained food restriction to achieve moral high ground, rather than out of the fear of fatness (Keel, 2005). Varying viewpoints of the disorder began to emerge at the end of the 19th century and into the 20th. It was not until the early 20th century that the fear of becoming fat became part of the diagnosis (Silverman, 1997). Pierre Janet split anorexia nervosa, which he believed to be solely a psychological disorder, into two subcategories: hysterical and obsessional (Silverman, 1997). The hysterical type was seen as much less common. It was described as a general loss of appetite. The obsessional type included the fear of becoming fat, extreme body dissatisfaction, and self-loathing, indeed similar to anorexia nervosa as described today (Silverman, 1997). In 1914, the root cause of anorexia nervosa shifted from psychological to physiological when Morris Simmonds reported “pituitary insufficiency” (6) as a widespread cause of weight

6 loss (Silverman, 1997). For the next fifteen years, doctors took a more endocrinological approach to treating anorexia nervosa (Silverman, 1997). In 1930, Berkman clearly recounted that the physical aspects were secondary to the psychological disturbances he saw within his patients, and the focus shifted back to anorexia nervosa as a psychological disorder (Silverman, 1997). From a psychoanalytical perspective, Waller, Kaufman, and Deutsch attributed anorexia nervosa symptoms to the unconscious fears and feelings of “oral impregnation” (Silverman, 1997). Despite many contributions from physicians and researchers around the world, Hilde Brunch, Arthur Crisp, and Gerald Russell supplied the most important insights into the etiology of anorexia nervosa (Garner, 1985). Bruch (1962, 1973, 1978) suggested food restriction stems from an inner struggle to achieve autonomy and self-control (Silverman, 1997). She noted that there are three areas of cognitive distortions found within individuals with anorexia nervosa, including: inaccurately judging one’s own body size, inaccurately judging one’s own satiety and emotional states, and a general feeling of lack of control (Silverman, 1997). Brunch asserted that the best path to psychotherapy encompasses intentional reframing of cognitive distortions (Silverman, 1997). She advised that therapists assist their clients by debunking these distortions and reinforcing behaviors that reflect the individual’s true self (Silverman, 1997). This view and method of treatment is the precursor for the cognitive therapy approach used today (Garner & Bemis, 1982). In his studies, Arthur Crisp (1967, 1980) asserted that the central cause of anorexia nervosa is the biological and psychological experiences one goes through during adolescence (Silverman, 1997). He believed that anorexia nervosa served as a coping mechanism to handle puberty. He assessed that psychotherapy should focus on first renourishment, and then confronting one’s phobia of weight gain (Silverman, 1997). Eating disorders as a coping mechanism is incorporated into how we view, classify, and treat eating disorders currently. Similar to Crisp, Gerald Russell (1970, 1985) focused on the extreme fear of weight gain as the main cause of anorexia nervosa (Silverman, 1997). These three individuals were crucial in the modern explanations, psychopathology, and treatment of anorexia nervosa today (Silverman, 1997). Regardless of the point in history, the primary characteristic of anorexia nervosa is the same: self-inflicted food restriction (Silverman, 1997). Originally, individuals with anorexia nervosa were viewed favorably as ascetics abstaining from gluttony or self-indulgence. As society and anorexia nervosa simultaneously progressed, the obsession with thinness and fear of

7 weight gain replaced the ascetic profile as the more frequent reason for the disorder (Casper, 1983).

Bulimia Nervosa As more and more individuals with anorexia nervosa presented symptoms of binging and even purging, more research was needed to better understand the psychopathological differences in these individuals. In the early 1990s, DaCosta and Halmi noted differences between individuals with anorexia nervosa and individuals with anorexia nervosa with the binging and purging subtype (DaCosta & Halmi, 1992). They discovered that patients with bulimic, or binge and purge symptoms, showed higher instances of emotional dysregulation and social and familial dysfunction (DaCosta & Halmi, 1992). Binging and purging behaviors remained under- researched and subsequently classified as subtypes of anorexia nervosa. The word “bulimia” comes from the Greek words bou, meaning bull or ox, and limos, meaning hunger (Parry-Jones & Parry-Jones, 1991). The history of bulimia nervosa is harder to piece together than that of anorexia (Silverman, 1997). There are many accounts of bulimic type behaviors among the research on anorexia nervosa, but bulimia was considered a subtype of anorexia nervosa until the 1970s and 1980s. (Russell, 1979; Silverman, 1997). Because of this, historical accounts or case studies involving bulimia nervosa is quite limited (Silverman, 1997). Similar to anorexia nervosa, early historical accounts of bulimic type behaviors (binging and purging) do not encompass the same psychopathology of the disorders today (Silverman, 1997). Perhaps different from early reports of anorexia nervosa and common presumptions about bulimia nervosa today, most historical binge/purge type behaviors were found in men (Keel, 2005). These binging and purging behaviors were rooted in religious and health reasons. Today, the fear of weight gain and loss of inhibitions criteria is included the modern definition of the disorder (Silverman, 1997; Beck-Ellsworth, 2015). Stories of induced vomiting can be traced back to ancient Egypt, Greece, Rome, and Arabia (Nasser, 1993). Ancient Egyptians would purge once a month for three days straight because they believed that food itself held diseases that plagued humans (Nasser, 1993). Physicians in these countries would prescribe emetics and vomiting as a remedy (Silverman, 1997). Perhaps more well-known are the tales of vomitoriums in ancient Rome (Silverman, 1997). Roman emperors would gorge themselves during extravagant feasts, displaying

8 intentional gluttony, and then purge so that they could continue binging (Crichton, 1996). The Roman philosopher, Seneca, stated succinctly “Men eat to vomit and vomit to eat” (as cited in Pullar, 1972). Crichton asserts that Roman emperors Claudius and Vitellius exhibited bulimic behaviors in the beginning of the first millennium A.D. The two emperors led lush and gluttonous lifestyles, feasting, drinking, and vomiting heavily and habituality. Again, however, the obsession with thinness is absent, making this a historical variation of bulimia rather than a precursor to the modern disorder (Crichton, 1996). Many fasting saints of the twelfth to seventeenth century reportedly participated in binging and self-induced vomiting (Bell, 1985; Keel, 2005). These saints, such as Saint Mary Magdalen de Pazzi, would often blame these binging episodes on the devil. (Bell, 1985). They believed that over-indulging after a period of pious self-starvation was the result of Satan leading them to temptation. This led some saints like Saint Catherine of Siena to view self-starvation and self-induced vomiting as punishment and atonement for her sins (Bell, 1985; Silverman, 1997). In 1380, Saint Catherine died of starvation and emaciation at age 33 (Bell, 1985). Several centuries later, there were still no records of modern bulimia nervosa, only accounts of binging or purging behaviors as a result of self-starvation. Historical accounts also included binging and purging as a way to display one’s social status, such as the Roman emperors (Crichton, 1996). During the later half of the 20th century, researchers began a retrospective review of examples of bulimia in literature prior to the late 1970s (Silverman, 1997). Casper (1983) was one of the pioneer researchers who searched for the split from anorexia nervosa in history (Silverman, 1997). She asserted that patient descriptions including overeating, vomiting, and a fear of weight gain were examples of modern bulimia (Casper, 1983). She noted that statements involving the obsession with thinness did not emerge until the 1940s (Casper, 1983; Silverman, 1997). In 1989, Habermas used similar research methods as Casper, but his criteria included patients of normal body weight with bulimic symptoms and a fear of weight gain. (Habermas, 1989). Van Deth and Vandereycken (1995) examined 19th century medical accounts of vomiting, again to find that patient’s concern about weight loss or gain was absent. In the 1970s, case reports that mimicked those that had earned the retrospective diagnosis of bulimia began to emerge (Silverman, 1997). Brusset and Jeammet (1971) outlined three patients who alternated between under and over eating. One patient participated in self-induced

9 vomiting while the other two abused laxatives. Two of the three patients expressed shame and fear of weight gain (Silverman, 1997). A few years later, Boskind-Lodahl (1976) shed light on bulimic habits by examining 138 individuals who responded to a newspaper article. The subjects disclosed fasting, vomiting, and laxative abuse behaviors, as well as a distorted body image. (Boskind-Lodahl, 1976). Despite the importance of these two articles, they had little impact on the medical community’s recognition of bulimia as a disorder. This is perhaps due to Brusset and Jeammet and Boskind-Lodahl’s focus on etiological explanations of the disorder rather than clinical data (Silverman, 1997). In 1979, a study by Russell with 30 patients exhibiting bulimic behaviors reached even closer to the diagnosis of bulimia we have today (Silverman, 1997).These patients reported using self-induced vomiting (Silverman, 1997). They stated that they vomited in order to compensate for the large amounts of food they consumed. Russell concluded there were three tenets of the disorder: “(1) intractable urges to overeat; (2) avoidance of the fattening effects of food by vomiting and/or abusing purgatives; and (3) a morbid fear of becoming fat” (19) (Russell, 1979; Silverman, 1997). Slowly but surely, researchers and clinicians developed the diagnosis as we know it today. They decided that the above three tenets were all fueled by the fear of weight gain. They also noted that a majority of the patients had previous struggles with anorexia nervosa. This led Russell to name the disorder bulimia nervosa (Russell, 1979, Silverman, 1997). While the specific diagnosis of anorexia nervosa launched in the late 19th century, bulimia nervosa was not recognized as a disorder until a century later (Keel, 2005). When the third edition of the Diagnostic and Statistical Manual of Mental Disorders was published in 1980, it established bulimia as a separate eating disorder and added an “atypical eating disorder” category (American Psychiatric Association, 1980; Bulik, Sullivan, & Kendler, 2000). However, absent from the new diagnosis was any cognitive or psychological distortions associated with bulimia, namely the obsession with thinness. It also left out individuals whose episodes of bulimia were associated with anorexia nervosa (APA, 1980; Silverman, 1997). So, these criteria were added to the revised 3rd edition as well as the 10th revision of the International Classification of Diseases (APA, 1987; ICD-10, 1992). Since then, there has been widespread agreement on the diagnosis criteria of bulimia nervosa and its validity as a disorder (Silverman, 1997).

10 After the addition of bulimia nervosa into the DSM III and DSM III-R, there was a significant increase in cases. In a meta-analysis conducted by Keel & Klump (2003), they noted that all studies in the late 20th century revealed a significant increase in the disorder. A study in 1995 indicates that the incidence of bulimia nervosa rose to 26.5 cases per 100,000 women per year (Soundy, Lucas, Suman, & Melton, 1995). While it may seem that bulimia nervosa suddenly appeared in the late 1970s or early 1980s, patients cited a long history with the disorder (Lucas & Soundy, 1993). This suggests that the rise can be contributed to the solidification of the disorder in the DSM III-R and ICD 10, as well as a seeking out of individuals with the proper symptomatology for research. Researchers and clinicians argue if bulimia nervosa is a new, 20th century disease or if it was simply not documented beforehand.

Eating Disorders Not Otherwise Specified While the literature on historical accounts of anorexia nervosa and bulimia nervosa is moderately extensive, the most common diagnosis is Eating Disorders Not Otherwise Specified, or EDNOS (Fairburn & Bohn, 2005). EDNOS was the diagnosis given to individuals who exhibited disordered eating behaviors, but did not meet the criteria for anorexia nervosa or bulimia nervosa (Beck-Ellsworth, 2015). The previous edition of the DSM, the DSM-IV-TR, included anorexia nervosa, bulimia nervosa, Eating Disorders Not Otherwise Specified (APA, 2000). The most recent edition of the DSM, the DSM V, changed the label EDNOS to Other Specified Feeding or Eating Disorders (OSFED) and added the new diagnosis of binge eating disorder (APA, 2013). The DSM V classifies binge-eating disorder as a separate disorder, however, binge-eating was first seen as a symptom of anorexia nervosa (American Psychiatric Association, 2013; Silverman, 1997). Even Sir William Gull in 1874 reported episodes of overeating in a patient with anorexia nervosa (Silverman, 1997). There were very few reports of binge eating within anorexia nervosa before the 20th century (Casper, 1983). The rise in binge eating may be due to the changing psychopathology of anorexia nervosa (Casper, 1983). Binge eating disorder was formerly a subcategory under the EDNOS criteria, but now is considered a separate disorder (APA, 2013; Beck-Ellsworth, 2015). The majority of the research still refers to both binge eating disorder and OSFED as EDNOS. In this paper, OSFED and EDNOS will be used interchangeably, while binge eating disorder will be separate.

11 Other specified feeding or eating disorders and Binge eating disorder are difficult to research and treat for several reasons. The most obvious one being that both diagnostic criterion are relatively new, regardless of how long individuals have been suffering (APA, 2013; Beck- Ellsworth, 2015). Second, individuals with either one of these eating disorders may or may not have a traditional appearance of someone with an eating disorder. Similar to someone with bulimia nervosa, an individual with OSFED or BED may be of a healthy weight and still be dealing with the unhealthy symptoms and comorbidities of an eating disorder. Lastly, stigmatization of these particular eating disorders and our societal obsession with weight loss may prevent an individual from speaking up or seeking treatment.

12 CHAPTER 3

ETIOLOGY OF EATING DISORDERS

According to Danielle Beck-Ellsworth in Understanding Eating Disorders, the institutions of media, society, and family have long contributed to body dissatisfaction, body image distortions, and ultimately eating disorders (Beck-Ellsworth, 2015). Although eating disorders are more common in Western cultures, the rise of body image and eating issues is not simply due to the idealization of a tall and thin frame (Keel, 2005). An individual’s personality, temperament, or comorbid disorders may also put them at risk for an eating disorder (Beck- Ellsworth, 2015). Even in 18th and 19th centuries, adolescent girls were influenced by the fasting culture of saints (Brumberg, 1989). The story of St. Catherine of Siena, a saint who died from starvation, was included in an inspirational book for girls (Keel, 2005). The religious fasting culture affected the youth of that time period, just as our current culture influences us. How then do we know that eating disorders are related to Western culture? Due to its remote location, the island of Fiji did not have access to television until 1995 (Beck-Ellsworth, 2015). Prior to 1995, there were no documented cases of eating disorders in Fiji. Three years after television broadcasting was introduced, 11% of girls reported vomiting in efforts to control their weight, and 62% admitted to dieting (Becker, 2004; Becker, Burwell, Herzog, Hamburg, Gilman, & Stephen, 2002). Fijian women were susceptible to Western images and ideals, despite the longstanding cultural traditions favoring eating and full-figured bodies (Beck- Ellsworth, 2015). Incidences of eating disorders in Asian countries have also increased as Western culture spreads and infiltrates their society (Beck-Ellsworth, 2015).

Consumerism and Media Influence Eating disorders are a complicated and multifaceted symptom of our culture, historically and presently (Beck-Ellsworth, 2015). They emerge from a dark storm of social expectations, anxieties about the body, and consumer culture. Consumer culture is incredibly contradictory, in the way that one’s mother or father prepares exorbitant amounts of delicious food and subsequently is offended when one refuses seconds. Then later, the mother or father warns one that he/she is “filling out.” Consumerism pushes hedonism and indulgence while simultaneously condemning being fat or out of shape (Beck-Ellsworth, 2015).

13 Consumer culture is nothing new. From the 1750s until the end of the Nineteenth century, Western women’s fashion was centered on waist-squeezing garments commonly known as corsets (Dasler Johnson, 2011). Corsets were an early way to impose bodily ideals on women. A corset was seen as a way to make a woman’s figure more the “natural” shape, as if the shape she had was unnatural to begin with (Dasler Johnson, 2011). Corsets caused all sorts of health issues, ranging from bruising to infertility. The influence of advertising and consumerism only worsens. Businesses profit by convincing consumers that they will feel bad about themselves unless they have that particular product. In 1989, 681,000 cosmetic surgical procedures were performed. That number multiplied to 8.5 million procedures in 2001 (Espinoza & Neil, 2002). According to data discovered in 2007, the business of weight loss brings in approximately sixty billion dollars a year in the United States (Marketdata Enterprises, 2007) A study in 2009 found that children between the ages of two and eleven were exposed to approximately ten food advertisements per day (Powell, Szcypka, & Chaloupka, 2010). In 2016, an advertisement in London caused controversy. The advertisement read “Are you beach body ready?” coupled with a picture of what most would consider an unrealistic body type. The mayor of London, Sadiq Khan, found it so absurd that he banned the advertisement and any others that could send destructive messages to women (Eun Kyung Kim, 2016). Even though we have made significant advances as a society to embrace and protect all body types, the advertising industry’s tactic of scaring consumers into buying their product is still alive, well, and incredibly dangerous. As technology has increased, the exposure to media has also increased. By 1955, half of all American homes owned a television set, further increasing their exposure to media images (Stephens, 2000). Television became a way for Americans to receive news, entertainments, and advertisements. It was a win-win for everyone involved. Companies paid the television networks to broadcast advertisements for their products which in turn raises the sales of their products. Never before could they reach such a broad audience at once. Not surprisingly, the prevalence of eating disorders increased in the second half of the 20th century and into the 21st (Keel, 2005). Because early advertisements and standards of beauty were mainly targeted at white women, it is not surprising that the first clinical patients with eating disorders were also white, middle to upper class females (Beck- Ellsworth, 2015) Since privileged white women were the first to seek treatment (most likely because they were the only people with the money to do so),

14 their eating disorder behaviors became the standard for diagnosis and explanation (Beck- Ellsworth, 2015). The stereotypical emaciated, perfectionist, spoiled white female with a dysfunctional family became the paradigm for anorexia nervosa. Perhaps most important to this view of anorexia nervosa was the extreme skeletal appearance paired with a cognitive distortion of never being skinny enough (Beck-Ellsworth, 2015). This new diagnosis left other types of people out of the equation. Women who were anything but white and men of all backgrounds were viewed as immune from disordered eating or distorted body image (Bordo, 2003). Countless women of varying ages and ethnicities were secretly vomiting or using laxatives in an effort to control their weight (Beck-Ellsworth, 2015). Because a person can have these behaviors and maintain a healthy weight, bulimia nervosa remained a subset under anorexia nervosa. Diagnosing individuals still required them to have a dysfunctional family and “anorexic thinking” (Beck-Ellsworth, 2015). But thin was not always the desired look. The body type that women and men strive for seems to be almost totally dependent on what the media is portraying. In the 1950s, Marilyn Monroe was extremely popular and so was her “hourglass” figure. Magazines began to advertise ways to gain weight, usually involving the idea that men do not want a skinny woman. In the 1960s and 1970s, however, the tall and slender body type became the coveted look. Some think the rise of feminism after the 1950s caused a rejection of the plump, domestic motherly stereotype. In short, society exchanged one idea of a perfect body for a different one (Bordo, 2003).

Thin Ideal Internalization Regardless of what type of body has been historically considered “perfect,” media has always contributed to the rise of body dissatisfaction and subsequently, eating disorders. Obviously, there are not very many, if any, advertisements that directly endorse disordered eating behaviors. However, media and all it encompasses can cause what researchers refer to as “thin ideal internalization” (Thompson & Heinberg, 1999). The “thin ideal” is somewhat self- explanatory, meaning the belief that being thin is the ultimate symbol of success and attractiveness. The internalization of this ideal happens when an individual believes the cultural definitions of beauty and engages in behaviors in an attempt to achieve that beauty (Thompson & Heinberg, 1999). Thin ideal internalization directly correlates to body dissatisfaction and

15 disordered eating because that perfect body is unrealistic for the majority of women and men (Thompson & Heinberg, 1999). Research has indicated that frequent subjection to thin-ideal body images in the media is linked to body dissatisfaction, thin-ideal internalization, and disordered eating behaviors (Grabe, Ward & Hyde, 2008). Viewing advertisements containing thin women, essentially the thin-ideal, led to a decrease in mood and self-esteem (Bessenoff, 2006). Grabe et al. conducted a meta- analysis of 77 experimental and correlational research studies examining the effects of media on women’s body image issues. Most of the experimental studies have exhibited that women had higher levels of body dissatisfaction after viewing images of thin models versus images of neutral, average women (Grabe, et al, 2008). This also proved true for television advertisements, where commercials containing thin-ideal images increased body dissatisfaction and disordered eating habits more than commercials unrelated to appearance. Fifty-seven percent of these studies show correlation between exposure to media and body dissatisfaction (Grabe, et al., 2008).

Normative Discontent While the media certainly have played a role in contributing to body image disturbances and disordered eating behaviors, they are not solely to blame. One’s cultural environment usually includes the media, family, and peers. These entities also have the potential to endorse the thin ideal and in turn, disordered eating behaviors. In Western culture, body dissatisfaction is so familiar that it was deemed “normative discontent” (392) (Rodin, Silberstein, & Striegel-Moore, 1985; Tantleff-Dunn, Barnes, Larosa, 2011). This phenomenon was coined over thirty years ago, but still holds true today. Rodin et al. (1985) used the word “normative” to explain that the discontent is a stereotypical behavior or attitude in Western society. However, recent research indicates that women may exhibit body image concerns because they believe their peer group will approve of that particular attitude or behavior (Britton, Martz, Bazzini, Curtin, and LeaShomb, 2006). Normative discontent indicates that negative feelings towards one’s body are more common than not (Tantleff-Dunn et al., 2011). A survey of 472 college-age adults examined the students’ perceptions and attitudes toward body image and eating behaviors (Tantleff-Dunn et al., 2011). A large portion of participants stated that they believe more than half of American

16 women and men possess body dissatisfaction characteristics, such as anxiety about physical appearance and restriction of fat and calories (Tantleff-Dunn et al., 2011). Researchers concluded that individuals that endorse disturbed body image may perceive other individuals to share similar thoughts. This evidence supports that normative discontent is overwhelming present in our American culture. In addition, the study found that stereotype agreement was positively related to eating disorder behaviors (Tantleff-Dunn et al., 2011).

Fat Talk Perhaps the most profound way individuals perpetuate normative discontent is by engaging in “fat talk.” (Nichter & Vuckovic, 1994). Fat talk is also one of more prominent ways that one’s social environment can contribute to body image concerns and subsequently, disordered eating behaviors. Similar to media exposure, fat talk may contribute to thin ideal internalization. (Grabe, et al., 2008; Groesz, Levine, & Murnen, 2002; Levine & Murnen, 2009). Fat talk was originally termed as a way to describe when individuals, usually women, speak negatively about their bodies in an effort to help one’s own or a friend’s body dissatisfaction (Nichter & Vuckovic, 1994). This includes conversations about eating habits, exercise routines, weight gain, diet plans, and the appearance of others (Nichter, 2000; Ousley, Cordero, 2008). Fat talk can serve a variety of social purposes, such as “absolving oneself of guilt, marking group affiliation, providing social validation, masking other underlying issues, and enabling social control” (2) (Mills & Fuller-Tyszkiewicz , 2016). An individual engaging in fat talk may utilize it as a way to cope with negative feelings and also seek affirmation from peers (Nichter, 2000). An example of fat talk may resemble one individual exclaiming “I am so fat!” and a peer or friend immediately stating “No you’re not, I’m the one who is fat” (167) (Arroyo & Harwood, 2012). The friend’s immediate response of “No you’re not, I’m the one who is fat” (167) is socially validating to the individual with negative self-perception (Arroyo & Harwood, 2012). The correlation between fat talk and body dissatisfaction is bidirectional, meaning that individuals with high body dissatisfaction are more likely to participate in fat talk but fat talk also increases body dissatisfaction and the thin ideal (Arroyo & Harwood, 2012; Salk & Engeln-Maddox, 2011). Engaging in fat talk has also been shown to increase the likelihood of mental health issues, such as low self-esteem or depression (Arroyo & Harwood, 2012). Fat talk can be a translator of deeper mental health problems

17 (Arroyo & Harwood, 2012). For example, when an individual exclaims “I feel fat,” they are most likely feeling sadness or dissatisfaction, as “fat” is not typically a word used to describe emotions. Due to the varying stressors and pressures put on undergraduate students, much of the research on fat talk has involved subjects from the college population (Arroyo & Harwood, 2012). College women, in particular, have been shown to be at an increased risk for body image concerns and disordered behaviors (Hudson, et al., 2007). In a study of 186 women, age 18-23, 93% of them reported engaging in fat talk with their friends, even though 84% of the women were in the normal weight range (Salk & Engeln-Maddox, 2011). The women also reported that they thought other groups of friends engaged in fat talk more frequently than they do within their own groups. This reinforces the notion that fat talk is a result of normative discontent in Western society (Salk & Engeln-Maddox, 2011; Britton, et al., 2006, Tompkins, Martz, Rocheleau, & Bazzini, 2009).

Personality While media exposure and societal pressure have proven to be vital in developing body dissatisfaction and disordered eating behaviors, one’s own personality can also contribute. Eating disorder pathology is not immune to the nature vs. nurture argument (Beck-Ellsworth, 2015). Genetics and family history can influence one’s predisposition to an eating disorder, but it would be unfair to place sole blame on biology. Varying personality traits and temperament styles have been associated with eating disorder (Beck-Ellsworth, 2015). Temperament is defined as how one reacts to their environment and personality traits are constructed from these reactions (Kim, 2009). Temperament is inherited biologically, and when coupled with environmental influences, creates one’s personality (Rotella, Fioravanti, Ricca, 2016). One’s mix of temperament and personality can make him or her e more susceptible to eating disorders. Over the past few decades, researchers have examined three facets of personality associated with eating disorders: personality traits, temperaments, and personality disorders (Rotella, et al., 2016) In 1993, Cloninger et al., noted that there are four dimensions of temperament, including novelty seeking, harm avoidance, reward dependence, and persistence. (Cloninger, Svrakic, & Przybeck, 1993; Atiye, Miettunen, Raevuori-Heklamaa, 2014). Using self-report questionnaires and inventories, Cloninger and other researchers have identified how temperament predisposes

18 or affects one’s disordered eating behaviors (Atiye et al., 2014). In a meta-analysis comparing temperament among various eating disorders, individuals with anorexia nervosa, bulimia nervosa, or eating disorder not otherwise specified had much higher levels of persistence than control groups (Atiye et al., 2014). Individuals suffering from anorexia nervosa were found to have higher levels of persistence than other eating disorders, indicating a tendency to continue behavior regardless of reward. All eating disorders exhibited high levels of harm avoidance, with levels in anorexia nervosa being significantly elevated. High harm avoidance explains why individuals with anorexia nervosa are extremely disciplined at avoiding food and weight gain (Magnuson, 2016). High harm avoidance indicates a stronger tendency towards anxiety and neuroticism in individuals with eating disorders (Atiye et al., 2014; Magnuson, 2016). High levels of novelty seeking were associated with bulimia nervosa and binge eating disorder, explaining the binging component and impulsive behaviors associated with those two disorders (Atiye et al., 2014; Magnuson, 2016) In addition to temperaments, different personality traits are common in individuals with eating disorders. Some of the most common traits include perfectionism, impulsivity, neuroticism, and emotional dysregulation (Lilenfeld, Wonderlich, Riso, Crosby, & Mitchell, 2006; Beck-Ellsworth, 2015; Magnuson, 2016; Preyde, Watson, Remers, & Stuart, 2016). These traits have been shown to influence how an individual develops, reacts to, and recovers from an eating disorder (Lilenfeld et al., 2006). Maladaptive perfectionism, or unrealistically high standards for oneself, is positively correlated to anorexia nervosa, bulimia nervosa, binge eating disorder, and EDNOS (Cassin & Von Ranson, 2005; Farstad, McGeown, & von Ranson, 2016). Much like a novelty seeking temperament, higher levels of impulsivity are associated with bulimia nervosa and binge eating disorder (Farstad, et al., 2016). Individuals with eating disorders, particularly anorexia nervosa, tend to have higher levels of neuroticism, or negative emotionality (Magnuson, 2016). Personality disorders are commonly diagnosed among individuals with eating disorders, the most common being Cluster B and C personality disorders (Rotella et al., 2016). In the DSM V, Cluster B personality disorders refer to borderline, narcissistic, histrionic, and antisocial personality disorders (APA, 2013). Individuals with Cluster B disorders often struggle with emotional regulation and impulse control (Hoermann, Zupanick, & Dombeck, 2013). Cluster C

19 refers to avoidant, dependent, and obsessive-compulsive personality disorders (APA, 2013). High levels of anxiety are common among Cluster C personality disorders (Hoermann et al, 2013). Individuals with anorexia nervosa restricting type have frequently reported Cluster C personality disorders including avoidant, dependent, and obsessive-compulsive (APA, 2013; Rotella et al., 2016). Borderline personality disorder and other Cluster B types are more typical of individuals who exhibit binge/purge behaviors, while avoidant personality disorder is most common in individuals with binge eating disorder (Sansone & Levitt, 2006). Personality disorders may lead to poorer treatment outcomes for individuals with eating disorders (Beck- Ellsworth, 2015). In a study of 34 patients with eating disorders, 91% of the patients met the criteria for a personality disorder at the beginning of treatment (Murcia, Cangas, Pozo, Sanchez, Perez, 2009). Patients with schizoid and avoidant personality disorders were the most resistant to treatment (Murcia, et al., 2009).

Current Diagnoses When the DSM V was published in 2013, a few much needed changes were made to the feeding and eating disorders category (Beck-Ellsworth, 2015). The fifth edition removed the criteria of amenorrhea, the loss of one’s menstrual cycle, from the anorexia nervosa diagnosis. This made it easier for men suffering from anorexia nervosa to get properly diagnosed and subsequently, proper treatment. As mentioned previously, the DSM V added the new disorder labeled binge eating disorder (APA, 2013). This also allowed for individuals suffering with binge eating disorder to gain better access to treatment. The DSM V additionally changed the name Eating Disorder Not Otherwise Specified to Other Specific Feeding or Eating Disorder (Beck-Ellsworth, 2015). OSFED now allows individuals who do not fit the criteria for other eating disorders to have a diagnosis. Unfortunately, insurance companies are still slow to cover OSFED because it is not believed to be as severe as anorexia or bulimia nervosa (Beck- Ellsworth, 2015). Currently, there are eight diagnoses listed in the Eating and Feeding Disorders category, including: Anorexia Nervosa, Bulimia Nervosa, Pica, Rumination Disorder, Avoidant/Restrictive Food Intake Disorder, Binge Eating Disorder, Other Specified Feeding or Eating Disorder, and Unspecified Feeding or Eating Disorder (APA, 2013). Table 1 briefly explains each disorder.

20 Table 1: Key Features of Feeding and Eating Disorders

Diagnoses Main Diagnostic Prevalence Risk Factors Common Criteria Comorbidities

Pica Eating of Unclear, Environmental: Autism Spectrum nonfood but higher neglect, Disorder, Intellectual substances that is in developmental delay Disability, inappropriate to populations Schizophrenia, developmental with Obsessive- stage or culture intellectual Compulsive Disorder disability

Rumination Repeated Unclear, Environmental: Generalized Anxiety Disorder regurgitation of but higher neglect, Disorder, Intellectual food for at least in understimulation, life Disability 1 month, not populations stressors, parental related to a with relationships gastrointestinal intellectual or other medical disability conditions

Avoidant/ Lack of interest Unlisted in Temperamental- Anxiety Disorders, Restrictive in eating, the DSM V anxiety, Autism Obsessive- Food avoidance due to Spectrum Disorder, Compulsive Intake sensory OCD, ADHD Disorder, Autism Disorder characteristics, Environmental- Spectrum Disorder, or concern about familial anxiety, Attention- eating mothers with eating Deficit/Hyperactivity consequences disorders Disorder, Intellectual that causes Genetic/Physiological Disability failure to meet - gastrointestinal appropriate conditions, nutritional gastroesophageal guidelines reflux, vomiting

Anorexia Persistent energy 12 month Temperamental- Bipolar/depressive/ Nervosa intake restriction, prevalence anxiety, obsessive anxiety disorders, intense fear of in young behaviors Obsessive- weight gain, females- Environmental- Compulsive disturbance in 0.4%; association with Disorder, Substance self-perception prevalence settings that value Use Disorder of weight/shape unknown in thinness males

21 Table 1 - continued

Diagnoses Main Diagnostic Prevalence Risk Factors Common Criteria Comorbidities

Genetic/Physiological - first degree relatives also with AN, brain abnormalities that still remain unclear

Bulimia Recurrent 12 month Temperamental- Bipolar/depressive/ Nervosa episode of binge prevalence weight concerns, low anxiety disorders, eating, recurrent in young self-esteem, Social Anxiety compensatory females- depressive symptoms, Disorder, Substance behaviors to 1-1.5%, social anxiety Use Disorder, prevent weight prevalence Environmental- thin Borderline gain, disturbance unknown in ideal internalization, Personality Disorder in self-perception males sexual/physical abuse of weight/shape Genetic/ Physiological: childhood obesity, early pubertal maturation

Binge Recurrent 12 month Genetic/Physiological Bipolar/depressive/ Eating episodes of binge prevalence - appears to run in anxiety disorders, Disorder eating, a lack of among U.S. families Substance Use self-control adult Disorder during binge females- eating episodes, 1.6%, binge eating is males- not accompanied 0.8% by compensatory behaviors

Other Symptoms that Unlisted Unlisted Other Eating Specified cause clinical or Disorder, other Feeding or social psychiatric disorders Eating impairment but associated with Disorder do not meet the eating disorders full criteria for any other eating disorders. Includes:

22 Table 1 - continued

Diagnoses Main Diagnostic Prevalence Risk Factors Common Criteria Comorbidities

Atypical anorexia nervosa, bulimia nervosa (low frequency), binge eating disorder (low frequency), purging disorder, night eating syndrome

Unspecified Symptoms that Unlisted Unlisted Other Eating Feeding or cause clinical or Disorder, other Eating social psychiatric disorders Disorders impairment but associated with do not meet the eating disorders full criteria for any other eating disorders. Used when there is insufficient information *Adapted from Diagnostic and Statistical Manual of Mental Disorders (5th ed.) (p.329-354), by American Psychiatric Association, 2013, Arlington, VA: American Psychiatric Publishing

23 CHAPTER 4

TREATMENT OF INDIVIDUALS WITH EATING DISORDERS

The treatment of individuals with eating disorders is a complicated and multifaceted process. Since eating disorders have been shown to have the highest mortality rate of any psychiatric disorder, treatment and recovery is extremely important (Arcelus, Mitchell, & Wales, 2011). In a meta-analysis of 36 published studies, researchers indicated that the weighted mortality rate of anorexia nervosa was 5.1 per 1000 person-years. This means that 0.51% of anorexia nervosa patients die per year (Smink, van Hoeken, & Hoek, 2012). Out of the deaths from anorexia nervosa, 20% of those individuals died by suicide (Arcelus et al, 2011). The weighted mortality rates were 1.7 for bulimia nervosa and 3.3 for eating disorder not otherwise specified, meaning that 0.17% and 0.33% of bulimia nervosa and EDNOS patients die per year (Arcelus et al, 2011; Smink et al, 2012). In a study in 2010, Keel and Brown concluded that binge eating disorder had a mortality rate of 2.9% (Keel & Brown, 2010). Mortality rates can be difficult to measure due to discrepancies between diagnoses and the number of follow up years (Smink et al, 2012). Recovery from an eating disorder is possible, but many individuals suffering from an eating disorder may never fully regain normal, healthy eating behaviors and cognitions (Beck- Ellsworth, 2015). Recovery rates for anorexia nervosa and bulimia nervosa are 52-69% and 55%, respectively (Smith, van Hoeken, & Hoek, 2013). Since binge eating disorder is a new diagnosis in the DSM-V, research is limited, but rates of remission appear to range from 19-65% (Smith et al., 2013). These percentages imply that approximately half of individuals suffering from an eating disorder will not recover. This is why effective research a effective treatment is incredibly vital. There are many variables to consider in the treatment of an individual with an eating disorder. Treatment can include ranging levels of care facilities and varying clinicians and therapists (Beck-Ellsworth, 2015). Treating an individual with an eating disorder has proven difficult for many reasons, perhaps most importantly an individual’s denial of any problems (Beck-Ellsworth, 2015). Usually, an individual will wait until the disordered eating behaviors have caused issues requiring attention from a medical doctor before seeking treatment. Hopefully, that doctor will recognize the symptoms and refer the individual to the rest of the

24 treatment team (Beck-Ellsworth, 2015). Treatment also varies depending on the individual’s age and independence level (Beck-Ellsworth, 2015). It is essential that treatment is selected on a case by case basis, centers around the individual’s needs, and incorporates evidence based practices (Garfinkel & Dorian, 2001). The first step in treatment is assessment (Beck-Ellsworth, 2015). Age at assessment is a significant predictor of mortality rates for anorexia nervosa, so it is important to seek treatment sooner rather than later (Arcelus et al, 2011). Assessments usually include an interview, self- report, and/or questionnaire. Clinicians utilize assessments in hopes that they will provide insight into the individual’s attitudes towards food and dieting, body image, risk factors, and social history (Beck-Ellsworth, 2015). Common assessments include the Body Dysmorphic Disorder Questionnaire and the Eating Disorder Inventory-3 (Garner, Olmstead, & Polivy 1983; Brohede, Wingren, Wijma, & Wijma, 2013) The Eating Disorder Inventory-3 compares an individual’s levels of body dissatisfaction, fear of fatness, and perfectionism to those of other eating disorder patients as well as the general population (Garner et al., 1983; Beck-Ellsworth, 2015). It can also be used at varying stages in an individual’s treatment to measure progress (Beck-Ellsworth, 2015). After assessing an individual, the clinician designs a treatment plan and decides on a level of care (Beck-Ellsworth, 2015). Level of care refers to the type of facility and therapy needed to treat an individual with an eating disorder. The highest level is inpatient treatment, wherein the client lives in a hospital and receives individual/group therapy, nutrition therapy and has access to 24 hour doctors (Beck-Ellsworth, 2015). While the clinician and patient decide on the level care, it can ultimately fall into the hands of the patient’s insurance company. If a patient’s eating disorder is considered moderately severe by his/her insurance company, they may only qualify for a lower level of care, such as partial hospitalization or intensive outpatient treatment. The lowest level of care is outpatient therapy, where an individual receives one or two hours a week of individual, family, and nutritional therapy (Beck-Ellsworth, 2015).

Individual Therapy Treatment Approaches Different facilities and different clinicians employ a variety of treatment approaches. Individuals with an eating disorder usually participate in individual, family, and nutritional therapy (Beck-Ellsworth, 2015). Individual therapy often utilizes evidence-based behavior

25 models, such as cognitive- behavioral therapy (CBT), dialectical-behavioral therapy (DBT), and acceptance commitment therapy (ACT) (Beck-Ellsworth, 2015). In the 1970s and 1980s, CBT was the primary approach used in eating disorder treatment (Agras, Walsh, Fairburn, Wilson, & Kraemer, 2000). Since then, DBT and ACT have been integrated as behavioral therapies for eating disorders (Hayes, 2004). These two therapies incorporate cognitive-behavioral techniques while also focusing on mindfulness and self-acceptance (Beck-Ellsworth, 2015). Most likely, clinicians and therapists do not strictly practice one type of behavioral therapy or the other, but rather integrate them together to better suit the needs and treatment goals of each individual (Beck-Ellsworth, 2015). The most prominent contributors to CBT were Albert Ellis and Aaron Beck (Beck- Ellsworth, 2015). CBT is based on the premise that one’s emotions, thoughts, and behaviors all influence each other. Figure 1 shows a diagram explaining the cognitive-behavioral viewpoint. One study noted that cognitive-behavioral therapy had significantly better results with individuals with eating disorders when compared to interpersonal therapy (Agras et al, 2000). Through cognitive-behavioral interventions, an individual can change a maladaptive behavior and/or thought process. One of the most common interventions used with individuals with eating disorders is cognitive restructuring (Beck-Ellsworth, 2015). An example may be that a client writes down a recurring negative or irrational thought that he or she has about their body, and then writes down different emotions evoked by that particular thought. Then a therapist may challenge the rationality of that thought process, asking for facts that support it. After that, the client can write down a new thought that is more grounded in reality and positive (Beck- Ellsworth, 2015).

Figure 1: Cognitive Behavioral Therapy Diagram

26 Dialectical behavioral therapy (DBT) was initially developed for the treatment of individuals who exhibited suicidal thoughts or behaviors (Linehan, 1987). DBT developed out of cognitive- behavioral therapy. However, it is based on the idea that individuals who are raised in dysfunctional environments will develop maladaptive coping skills to handle that environmental stress. These maladaptive coping skills could include substance abuse, self-injurious behaviors, or other dangerous behaviors, including disordered eating (Beck-Ellsworth, 2015). There are four principles of DBT: emotional regulation, distress tolerance, mindfulness, and interpersonal effectiveness (Linehan, 1987; Beck-Ellsworth, 2015). Dialectical behavioral therapy uses these core ideas to assist individuals in developing new, healthy coping skills (Beck-Ellsworth, 2015). It has been proven to decrease disordered eating behaviors and depressive symptoms in women with eating disorders (Lenz, Taylor, Fleming, & Serman, 2014). The newest effective treatment approach, acceptance commitment therapy (ACT), relies heavily on the concept of mindfulness (Beck-Ellsworth, 2015). ACT aims to normalize hardship and suffering as a part of the human experience (Hayes, Pistorello, & Levin, 2012). As the name suggests, ACT leads individuals to accept all of their thoughts and feelings. One of the more popular ACT techniques is known as cognitive defusion. Cognitive defusion explains that one’s thoughts are comprised of words, and those words only have significance if the individual’s places meaning on them (Begley, 2007). Another important tenet of ACT is psychological flexibility. This tenet states that an individual must accept and acknowledge that life is made of good and bad experiences (Beck-Ellsworth, 2015). Some individuals with eating disorders use the disorder to avoid stressful feelings or thoughts, so accepting all of their emotions through ACT techniques has proven effective (Manlick, Cochran, & Koon, 2013). Using psychological flexibility and acceptance techniques has been shown to reduce disordered eating behaviors (Deming & Lynn, 2010)

Family Therapy While individual therapy is vital in treating an individual with an eating disorder, it is also important to remember that everyone in that person’s family is affected by the eating disorder (Dare, Eisler, Russell, & Szmukler, 1990) Family therapy is another important component of eating disorder treatment (Beck-Ellsworth, 2015). Much like how different approaches work for different individuals in individual therapy, the level of family involvement

27 in treatment varies (Beck-Ellsworth, 2015). Family therapy is most often used when the person with an eating disorder is a child, teenager, or young adult (Beck-Ellsworth, 2015). The most extensively researched family therapy is known as the Maudsley Method (Beck-Ellsworth, 2015). The Maudsley Method was created in the 1980s at the Maudsley Hospital in London, England (Russell, Szmukler, Dare, & Eisler, 1987; Beck-Ellsworth, 2015). It is based on the premise that a family member’s eating disorder affects everyone in the family, therefore everyone must participate in therapy (Dare et al., 1990). Helping the child or adolescent retain a healthy weight is the primary goal of family therapy (Dare et al., 1990). The first controlled trial of the Mausley Method compared family-based treatment to a strictly individual therapy approach (Russell et al., 1987). Using the Morgan and Russell scales (1975), results indicated that ninety percent of participants with anorexia nervosa had good to intermediate outcomes using the Maudsley Method, while only eighteen percent showed the same results with individual therapy (Morgan & Russell, 1975; Russell et al., 1987). Considering adults with anorexia nervosa or bulimia nervosa, family therapy was not significantly better than individual therapy (Russell et al., 1987). Family therapy trials with adolescents with bulimia nervosa are fairly limited (Schmidt, Lee, Beecham, & Perkins, 2007). In a study comparing family therapy and CBT in individuals 13-20 years old, there was no significant different between the two approaches (Schmidt et al, 2007). However, there does appear to be significant decrease in bulimic behaviors when comparing family therapy to psychotherapy (Le Grange, Crosby, Rathouz, 2007). In short, an eclectic combination of all the individual and family treatment options is best. The treatment team should always base the treatment of an individual with an eating disorder on evidenced- based interventions and the individual’s specific needs (Beck-Ellsworth, 2015).

Nutrition Therapy The third component of eating disorder treatment is nutrition therapy. According to Hinds (2015), the aims of nutrition therapy include: healthy relationships with food and exercise; eliminate fears surrounding foods; stop ruminations about weight and food; restore health; reverse medical complications, if possible; and maintain a healthy body weight” (243). The main clinician on the nutritional treatment team is the Registered Dietitian (Hinds, 2015). Dietitians

28 not only counsel individuals on meal planning and medical complications, but also work to straighten out an individual’s dysfunctional relationship with food. The dietitian may focus on the client’s use of food for emotional control or self-punishment (Hinds, 2015). They also provide psychoeducation for the individual about the danger of their disordered eating habits (Hinds, 2015). Perhaps most importantly, the dietitian works with other members of the treatment team to decide which method of nutrition treatment is best for each client. Much like the varying modalities of individual therapy, there are different methods of nutritional therapy as well (Hinds, 2015). The first phase is mechanical eating, which is designed for individuals to treat food as medicine (Hinds, 2015). Mechanical eating involves specific times, places, and foods for every meal. This is often the hardest phase for an individual battling an eating disorder. After mechanical eating is established, various meal planning systems can be explored (Hinds, 2015). One meal planning method is the exchange method, modified from the American Diabetes Association (Hinds, 2015). In this method, each category of food is assigned a quantity based on the individual’s caloric needs. Similar foods can be exchanged, allowing for more flexibility than mechanical eating. The exchange method may prove difficult in patients with anorexia due to obsessive tendencies (Hinds, 2015). Some dietitians assign a specific number of calories and individuals are allowed to eat freely as long as they reach that assigned calorie level. Another method is the plate model, where a diagram of a plate is used to illustrate a balanced diet. Dietitians in treatment centers often use the normal meal approach, where individuals are given meals that they may encounter in an everyday routine (Hinds, 2015). This means that the meal may be missing the balanced diet component, but may better prepare an individual for situations outside of the treatment center. The approach of individualized menus uses what the individual is already comfortable eating and slowly builds on it (Hinds, 2015). Many dietitians regard Intuitive Eating as the final goal for individuals (Tribole & Resch, 2010, Hinds, 2015). Intuitive eating means that an individual can understand and honor hunger and satiety cues, as well as rid themselves of any irrational fears of certain foods (Hinds, 2015). Some individuals, however, may never reach this stage (Hinds, 2015). No two individuals with an eating disorder are alike, so it is important to find the best menu planning option based on each individual’s recovery process.

29 CHAPTER 5

MUSIC THERAPY IN MENTAL HEALTH

As mentioned previously, music has played a healing role throughout mankind’s history. During the Renaissance period, clinicians in Italy and France employed music to treat a variety of mental illnesses (Davis & Gfeller, 2008). In the eighteenth century, the first empirical endeavors were attempted to study how music affects the body and brain (Silverman, 2015). An article published in Columbian Magazine in 1789 claimed that music could change one’s emotional or expressive state (Silverman, 2015). A few years later, an article in New York Weekly Magazine described a French music teacher who was experiencing psychosis symptoms. According to the article, these symptoms would disappear when she would go to a concert and return once the concert was finished (Heller, 1987; Silverman, 2015). Early researchers understood that music could change one’s mood but could not pinpoint why music was helpful (Gfeller & Davis, 2008). By the early twentieth century, music programs at psychiatric hospitals were largely used to enhance the mood of the patients (Silverman, 2015). Early psychiatric music programs included singing, dancing, music appreciation, and music education (Van de Wall, 1936). Between 1920 and 1950, programs similar to music therapy were present in many psychiatric hospitals. Clinicians noted the use of music to facilitate socialization, entertainment, and pride within the patients, but music therapy was not yet a profession (Silverman, 2015). In the 1940s, World War II veterans returned home, many with psychiatric needs. This coupled with the advancement of psychotropic medications created a platform for psychiatric music therapy to flourish (Silverman, 2015). Music therapy was used to assist veterans dealing with a variety of issues, including alcoholism, psychosis, and post-traumatic stress disorders (Michel, 1951; Forsdyke, 1967; Silverman, 2015). As advances in the medical field were made, the music therapy profession continued to develop in order to be consistent with current models of behavioral health care (Silverman, 2015). In 1944, Michigan State University was the first to offer a music therapy degree program, followed closely by the development of the National Association of Music Therapy in 1950 (American Music Therapy Association, 2017; Silverman, 2015).

30 Music therapy, as defined by the American Music Therapy Association (AMTA), is the “clinical use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program” (53) (Silverman, 2015). In short, music therapists utilize music and music interventions to address nonmusical goals (American Music Therapy Association, 2012; Silverman, 2015). Music therapy is an evidence-based profession and has the largest research base of any creative arts therapy (Silverman, 2015). In order to practice as a music therapist in the United States, one must finish a university program accredited by AMTA, achieve 1,200 clinical practice hours, and pass an examination given by the Certification Board of Music Therapists (Silverman, 2015). There are 7,000 music therapists currently board certified in the United States (American Music Therapy Association, 2017) While music therapy is offered in a variety of settings, mental and behavioral health was the first population to benefit from music therapy (Silverman, 2015). It also remains one of the most prominent populations served. Music therapists working on behavioral health goals can work in community mental health centers, group homes, outpatient or inpatient facilities, and long-term state hospitals (Silverman, 2015). In a 2005 survey, AMTA found that twenty-one percent of music therapists work in a behavioral or mental health setting (American Music Therapy Association, 2005; Silverman, 2007). The most common goals reported in the survey for psychiatric music therapy included: “socialization, communication, self-esteem, coping skills, and stress reduction/management” (388) (Silverman, 2007). These goals were addressed using various music therapy interventions such as “music assisted relaxation, improvisation, songwriting, lyric analysis, and music and movement” (388) (Silverman, 2007). A 2016 Workforce Analysis by AMTA revealed that the percentage of music therapists in working in mental health settings had increased slightly to twenty-two percent (American Music Therapy Association, 2016). Other than a category labeled “all others,” mental health settings had the highest percentage rate (American Music Therapy Association, 2016).

Current Psychiatric Music Therapy Research Although psychiatric music therapy is typically one of the broadest areas of practice for music therapy professionals, research is difficult to obtain and therefore lacking (Silverman, 2007). However, the data that is available proves promising for the effectiveness of music

31 therapy. In a meta-analysis examining music therapy with individuals with schizophrenia and other related disorders, researchers found that music therapy assisted in improving their mental state and socialization skills (Mossler, Chen, Heldal, & Gold, 2012). In a survey of behavioral health inpatients, Silverman (2006) found that individuals rated music therapy more helpful than other types of therapies. Over half of the participants reported that music therapy was their favorite group or therapy (Silverman, 2006). In another study by Silverman (2012), patients dealing with substance abuse exhibited higher levels of motivation than patients in the control group. These three studies represent just a small portion of research supporting the effectiveness of psychiatric music therapy. Music therapy works best when added to traditional, standard care (Mossler et al, 2012). The majority of music therapists working in behavioral health settings report that most of their sessions are group sessions (Silverman, 2007). This means that individuals with varying diagnoses would all attend the same group. Although diagnoses are quite different, many of them share overlapping symptomatology and require similar treatment goals. In order to combat diagnostic limitations and cater to a wide range of symptoms and issues, Fairburn, Cooper and Shafran (2003) suggested the use of transdiagnostic theory. This was originally intended for eating disorder treatment, but has been broadened to meet the needs of various behavioral health patients. The transdiagnostic theory lessens the emphasis on the actual diagnosis and instead addresses specific behaviors and goals that overlap in individuals with varying psychiatric disorders (Fairburn, Shafran & Cooper, 2003). This theory can be easily transferred to music therapists working in psychiatric group settings (Silverman, 2015). In a study of 2,436 females in the hospital for an eating disorder, ninety-seven percent of the patients had one or more comorbid disorders (Blinder, Cumella & Sanathara, 2006). Ninety- four percent of participants suffered from depression while fifty-six percent had diagnosed anxiety disorders (Blinder et al, 2006). In addition, the study indicated that approximately one fifth of the over 2400 participants were diagnosed with either obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), or substance use disorder. (Blinder et al, 2006). The following paragraphs highlight existing research on the effectiveness of music therapy with the aforementioned comorbid disorders often present in individuals suffering from an eating disorder.

32 Depression, Anxiety, and Obsessive-Compulsive Disorders Music therapy can be incredibly beneficial to individuals dealing with depressive disorders. Possibly different from traditional talk therapy or taking medications, no negative effects of music therapy have been reported thus far (Edwards, 2006). In a review of nine studies comparing the effects of music therapy versus traditional talk therapy, all of the studies noted that music therapy had a more positive and significant impact than traditional treatments (Lee & Thyer, 2013). One of those studies revealed that anhedonia, defined as the loss of pleasure in daily life and often a symptom of depression, is positively affected by music therapy (Castillo- Perez, Gomez-Perez, Velasco, Perez-Campos & Mayoral, 2010). Erkkilä et al. (2011) found that improvisational music therapy decreased patients’ depressive symptoms immediately and at the three month follow up. Another study examining music therapy for individuals with depression found music therapy improved mood states and motivated individuals in their treatment (Maratos, Gold, Wang, & Crawford, 2008). Depressive and anxiety disorders are often comorbid. Silverman (2011) utilized song- writing interventions to address coping skills in an acute inpatient setting. Though results were not statistically significant, the music therapy group reported a better understanding of coping skills and higher attendance levels that the control (Silverman, 2011). Another study by Silverman (2011b) revealed that percussion interventions and lyric discussions reduced anxiety levels in short term patients. In a recent study by Gutierrez and Carmarena (2015), the authors examined the effect of music therapy on patients with generalized anxiety disorder whom, despite persistent treatment for over a year, were still presenting with the symptoms. The authors employed music therapy in CBT interventions, such as cognitive reframing and emotion identification, and noted that anxiety levels were significantly lower after the twelve-week program (Gutierrez & Carmarena, 2015). Blinder et al (2006) found that one fifth of individuals with eating disorders in their study had co-occurring obsessive compulsive disorder or obsessive personality traits. Obsessive- compulsive disorder (OCD) is defined by repetitive and intrusive thoughts that usually result in compulsions or rituals that an individual feels are pertinent to relieving anxiety (APA, 2013). Obsessive-compulsive personality traits include the need for control, inflexibility, unrealistic high standards for oneself, competitiveness, self-discipline, anxiety and the strive for perfectionism (Magnuson, 2015). Of the eating disorder population, obsessive-compulsive traits

33 are found mostly in individuals with anorexia nervosa, but they affect the non-eating disorder population as well (APA, 2013; Bidabadi & Mehryar, 2014). When Bidabadi & Mehryar (2014) studied the effects of music therapy as supplemental to traditional treatment, they reported that music therapy decreased anxiety and depressive symptoms that typically accompany OCD and OCD behaviors. Participants also experience an overall decrease in obsessive behaviors (Bidabadi & Mehryar, 2014).

Post Traumatic Stress Disorder and Substance Use Disorders Post-Traumatic Stress Disorder (PTSD) affects approximately one fourth of individuals with eating disorders (Blinder et al, 2006). PTSD occurs after an individual experiences a traumatic event, such as military combat, sexual or physical abuse, a motor vehicle accident, or the death of a loved one (APA, 2013). Symptoms of PTSD include flashbacks, insomnia, hyper vigilance, anxiety, negative self- beliefs, or partial amnesia about the traumatic event (APA, 2013). Often, individuals with PTSD use disordered eating behaviors to cope with the stress and symptoms of PTSD (Hudson et al, 2007). In this regard, eating disorders may be compared to the use of substances as a negative coping mechanism or a way to self-medicate. Music therapy has been proven highly effective with individuals suffering from PTSD (Silverman, 2015). A 2011 study revealed that patients with PTSD receiving music therapy services reported significant decreases in PTSD symptoms and depression (Carr et al., 2011). Patients also viewed music therapy as valuable in their treatment process (Carr et al, 2011). Several studies have been conducted examining music therapy with veterans experiencing PTSD symptoms, but little research has been done with nonmilitary PTSD. Sexual abuse or trauma is a huge predictor and risk factor for the onset of eating disorder psychopathology and symptoms (Holzer, Uppala, Wonderlich, Crosby & Simonich, 2008; Fischer, Stojek & Hartzell, 2010). Trauma increases eating disorder risk in women as well as men (Magnuson, 2016). Perhaps one of the most extensively researched populations in psychiatric music therapy is individuals with substance use disorders. Due to the similarities and comorbidities between eating disorder and substance use pathology, current research on the effectiveness of music therapy for individuals with substance use can be transferred and applied to individuals with eating disorders. One of the most important benefits of music therapy for those in substance use treatment is the effect it has on an individual’s’ willingness to seek and follow up with treatment.

34 In a study of 99 patients in a detoxification facility, Silverman (2012) found that patients who participated in group songwriting activities exhibited a significantly higher level of motivation in treatment than the control. Dingle, Gleadhill, & Baker (2008) found that music therapy activities such as lyric analysis, songwriting, improvisation, and singing increased patient’s motivation in treatment. They also found that attendance was higher in the music therapy group and patients reported high levels of enjoyment (Dingle et al, 2008). Ross et al. (2008) also found music therapy to be motivational to individuals with a dual diagnosis. One of the symptoms and/or causes of a substance use disorder is one’s inability to process and handle emotions in a healthy manner (Silverman, 2015). Individuals with eating disorders often share this issue (Magnuson, 2016). Often, individuals with substance use disorder uses the substances to induce or suppress emotions (Jones, 2005). Research indicates that group music therapy, specifically songwriting and lyric analysis, assisted patients in experiencing positive emotions without the use of substances (Jones, 2005; Baker, Gleadhill, & Dingle, 2007). Additionally, a study of ten females in a substance use rehabilitation center revealed that music activities and games decreased depression, stress, anxiety, and anger in the participants (Cevasco, Kennedy, & Generally, 2005).

35 CHAPTER 6

MUSIC THERAPY FOR EATING DISORDERS

While there is limited research on the effect of music therapy on individuals with eating disorders (McFerran, 2005), the research suggests that music therapy is beneficial in treating some of the co-occurring disorders and symptoms experienced by those with eating disorders. According to transdiagnostic theory (Silverman, 2015), music therapists should be concerned with cognitive, behavioral, and affective features and patterns that maintain illness. Many features associated with eating disorders have been researched using music therapy, though not specifically with individuals with eating disorders. This may be due to the delicate nature of the population, privacy concerns, time constraints or a combination of all of the above. This author found 6 studies conducted in the 21st century that specifically examined the effects of music therapy on individuals with eating disorders. All the articles revealed positive and promising results for music therapy as a supplemental therapy for eating disorder treatment. These studies can be divided into four primary treatment goals: increase autonomy/self-confidence, increase emotional regulation, reduce stress and anxiety, and increase motivation for treatment. Table 2 provides a brief overview of each study. The following section provides more information on music therapy interventions as they relate to each of the four primary treatment goals for individuals with eating disorders. A brief summary is provided for each area followed by a sample session plan. In order to integrate tenets of cognitive-behavioral therapy, each sample plan provides examples of ways the patients can implement the interventions outside of the group setting and monitor any behavior changes themselves (Beck-Ellsworth, 2015).

Table 2: Current Music Therapy Interventions for Eating Disorders Populations Author(s) Population Interventions Results and Impact Used Hilliard -Residential Facility -Song writing Participants and staff members (2001) -All females -Singing reported an increase in feelings of -Varying eating -Drumming empowerment, disorder diagnoses -Lyric Analysis communication among patients, -Ages 14-45 -Musical games self-confidence, positive thinking, and motivation for treatment.

36 Table 2-continued

Author(s) Population Interventions Results and Impact Used Bibb et al -Inpatient Eating -Singing Results showed that subjects in the (2015) Disorder Program -Music listening music therapy group had -17 females, 1 male -Song Writing significantly lower levels of -Anorexia nervosa -Lyrics Analysis anxiety post-meal than subjects in diagnoses the standard therapy group. -Ages 20-58

McFerran et -Children’s hospital- -Individual song Analysis of the patients’ song al (2006) inpatient eating writing lyrics revealed that the lyrics disorder unit -Lyric analysis centered on the themes of identity -15 females (28.2%), relationships (17.3%), -Anorexia Nervosa aspirations (16.6%), reference to diagnoses disorder (15.2%), emotional -Ages 12-17 awareness (17.2%), and seeking emotional support (5.4%).

Pavlakou -Community Center -Group singing Participants reported group singing (2009) -8 females helped to increase relaxation and -2 subjects body awareness. They also diagnosed bulimia reported a decrease in anxiety and nervosa, 1 with stress in their everyday activities. anorexia nervosa, 5 subjects with disordered eating behaviors and no diagnosis -Ages 18-62 Lejonclou & -Inpatient Eating -Music Participants reported increased Trondalen Disorder Unit improvisation self-confidence and emotional (2009) -2 separate case -Song writing awareness. studies: 1 woman -Music and with anorexia, 1 movement women with bulimia nervosa -Ages 19 and 25, respectively Trondalen -Music therapy -Music Participant reported increased self- (2003) office improvisation confidence, autonomy, and -Case study- 1 -Self listening emotional regulation. woman with anorexia nervosa - Age 26

37 Autonomy The Merriam-Webster dictionary website (https://www.merriam- webster.com/dictionary/autonomy) defines autonomy as “self-directing freedom and especially moral independence.” Achieving autonomy involves developing a strong sense of self by defining your personal beliefs and values. Because low self-esteem and obsession with appearance are part of the pathology of eating disorders, obtaining self-confidence and empowerment is often difficult (Beck-Ellsworth, 2015). Almost all of the aforementioned studies addressed increasing self-awareness and autonomy in some way, whether purposefully or as a byproduct of the music therapy itself. In 2001, Hilliard began a cognitive-behavior based music therapy program at a residential treatment facility for individuals with eating disorders in Florida (Hilliard, 2001). The participants were all females between the ages of 14-45 who had an eating disorder severe enough to seek residential treatment. These individuals also had diagnosed comorbid disorders including bipolar disorder, depression, anxiety, dissociative identity disorder, panic disorder, self-injurious behaviors, and substance use disorder (Hilliard, 2001). Hilliard implemented music therapy techniques such as song-writing, singing, drumming and lyric analysis to address goals such as motivation, self-confidence, and cognitive distortions (Hilliard, 2001). Hilliard used what he referred to as “diva” sessions (112) to focus on and increase confidence and empowerment within the women (Hilliard, 2001). In one of the sessions, the patients collectively wrote a rap about their struggles and triumphs with an eating disorder. This offered individual empowerment and built community strength within the group. Another study examined the effects of individual songwriting and lyric analysis on adolescents struggling with eating disorders (McFerran, Baker, Patton, & Sawyer, 2006). These clinicians noted that songwriting was frequently more popular than more passive interventions such as music listening. They concluded that songwriting provided a medium through which the adolescents could reflect on their emotions and express themselves freely (McFerran et al, 2006). Self –expression through song writing creates autonomy because the individual can see their work and be proud of it. Twenty-eight percent of the content of the songs that patients wrote centered on forming their own identity (McFerran et al, 2006). Three case studies involving adult women, two with anorexia nervosa and one with bulimia nervosa, also revealed that music therapy aided in developing autonomy (Trondalen,

38 2003; Lejonclou & Trondalen, 2009). One study utilized listening to music improvisation sessions recorded by the patient previously while the other two employed movement to music and dancing (Trondalen, 2003; Lejouclou & Trondalen, 2009). Improvising and dancing to music provided a way for the individuals to enjoy themselves without fear or preoccupation of how their bodies looked (Trondalen, 2003; Lejouclou & Trondalen, 2009). This allowed them to feel more confident in their abilities and their bodies. The patients stated that music improvisation provided a sense of control that they later could use to aid in controlling and regulating their emotions (Trondalen, 2003).

Table 3: Shake it Off Songwriting Sample Session Activity Shake it Off Songwriting Procedure 1. Introduce yourself (if new patients) then introduce the group. 2. Explain the group, stating that we are going to talk about self-image. If desired, can prompt the group by asking to define self or body image. 3. Pass out body outline sheets. 4. Instruct patients to take 3-5 minutes and write down negative words they feel about themselves or negative things people have said inside the body outline. Ask them to briefly share. 5. Instruct patients to take 3-5 minutes and write down positive words they feel about themselves or positive things people have said inside the body outline. Ask them to briefly share. 6. Instruct them to hold on to the outline, then pass out Shake it Off lyric sheets. Sing the song with guitar accompaniment or listen to the recording, whichever you feel is best. 7. Briefly discuss the song lyrics. 8. Pass out lyric rewrite sheets. Use negative words that the patients wrote on the body outlines for the first verse and the positive words for the second verse. Use positive affirmations or mantras for the chorus. 9. Play the new version of the song with guitar accompaniment. Materials -body outline worksheet (Figure 3) - lyric sheets -writing utensils -guitar or iPad/Bluetooth speaker -Fill-in-the-Blank lyric sheet (Figure 2) Goals/Group Autonomy, self-concept, positive thinking/cognitive distortions, positive Topics body image, self confidence Suggestions for Encourage the patients to keep a journal in which they write down at least follow-up one positive statement about themselves daily. Instruct them to bring the journal to the next session. 39

[Verse 1]

I ______I ______That’s what people say, mmm, That’s what people say, mmm

I ______I ______At least that’s what people say, mmm That’s what people say, mmm

[Pre-Chorus] But I keep ______Can’t stop won’t stop ______G It’s like I got this music in my mind, Saying ______

[Chorus]

C Cause the players gonna play, play, play, play, play. And the haters gonna hate, hate, hate, hate, hate

I’m just gonna shake, shake, shake, shake, shake. Shake it off, I shake it off C Heart breakers gonna break, break, break, break, break. And the fakers gonna fake, fake, fake, fake, fake

I’m just gonna shake, shake, shake, shake, shake Shake it off, I shake it off

[Verse 2]

I ______I ______. And that’s what they I’ see, mmm That’s what they I’ see, mmm I ______I ______.

And that’s what they don’t know, mmm That’s what they don’t know, mmm [Pre-Chorus 2]

[Chorus]

Figure 2: Shake it Off Fill-in-the-Blank Lyric Worksheet

40

Figure 3: Body Outline Worksheet

41 Table 4: Who I am Lyric Analysis Sample Session

Activity Who am I? Lyric Analysis Procedure 1. Introduce yourself (if new patients) then introduce the group. If desired, MT can start with the prompt “Who are you?” or “Does anybody know who they are?” and discuss how this is a loaded question. 2. State that we are going to be listening to two songs, discussing them, and then doing an activity. Pass out the first song “Some Nights” by Fun and writing utensils. 3. Direct patients to listen quietly to the song and mark any lyrics or ideas that stood out to them. 4. Briefly discuss what everyone interpreted from the song. Then pass out the second song, “Who I Am Hates Who I’ve Been” by Relient K and do the same as the first song. 5. Pass out paper and more writing utensils. 6. Instruct patients to make three columns titled “Who I’m not, Who I am, and Who I want to be” and fill them out. Play background music while they do this. 7. Ask the group to share what they wrote and what insight they have gained from the group. Materials -lyric sheets -blank paper -colored pencils -markers -iPad -Bluetooth speaker Goals/Group Autonomy, self-concept, self-awareness, self-reflection Topics Notes *Alternative songs: Who you are-Jessie J Who am I- Jessica Andrews You Gotta Be-Des’rae Strength, Courage, and Wisdom-India Arie Who I am-Nick Jonas Be Ok-Ingrid Michaelson Suggestions for It may be beneficial to follow up with a goal setting group. If this is not follow-up feasible, encourage patients to make small, attainable goals for each day and keep a log documenting progress. These goals can be everyday tasks or small goals that work towards a statement in the patients’ “Who I want to be” section. Instruct patients to bring the log to the next session.

42 Emotional Regulation Individuals with eating disorders often struggle with emotional dysregulation and avoidance and in turn use their disordered eating behaviors to mismanage uncomfortable or negative feelings (Wildes, Bingham, & Marcus, 2010). Music therapy can effectively help them navigate and express their emotions in a positive way. In the three case studies, the use of music improvisation allowed the patients to have some control while simultaneously allowing them to explore their feelings (Trondalen, 2003; Lejouclou & Trondalen, 2009). After the improvisation sessions, the therapist and patient were able to talk about how the elements of emotional regulation and self-expression through the music can transfer to their daily lives (Trondalen, 2003; Lejouclou & Trondalen, 2009).

Table 5: Identifying Emotions/ Under the Bridge Lyric Analysis Sample Session

Activity Identifying Emotions/ Lyric Analysis Procedure 1. Introduce yourself (if new patients) then introduce the group. 2. If desired, MT can prompt discussion: “We are going to work on expressing ourselves today, does anybody feel like they have issues in that area?” 3. Explain that the group will listen and discuss two songs followed by a brief discussion. 4. Pass out the first song, “Under the Bridge” by Red Hot Chili Peppers. Instruct patients to listen to the lyrics and mark anything that stands out to them. 5. Facilitate small discussion based on the song. 6. Pass out the second song, “True Colors” by Cyndi Lauper and repeat steps 4 and 5. 7. Explain that sometimes one of the best ways to express ourselves is through writing. 8. Pass out emotions worksheet and instruct patients to fill it out for the remainder of the group. Play background music while the patients work. 9. End the session by prompting clients to think about if this method of self-expression worked for them. Materials -iPad -bluetooth speaker -Emotion worksheets -lyric sheets -journals

43 Table 5 – continued Goals/Group Topics Emotional regulation, emotional awareness, self- expression Notes *This session may work best with an adolescent population. Suggestions for Bring multiple copies of the identifying emotions worksheet (figure 4) follow-up and encourage the patients to take extra copies to fill out outside of the group setting. Encourage patients to use the sheet particularly when they are feeling any emotions they find hard to cope with. Instruct patients to bring the worksheet(s) to the next session.

1. I feel ______when ______.

2. I feel ______when ______.

3. I feel ______when ______.

4. I feel ______when ______.

5. I feel ______when ______.

6. I feel ______when ______.

7. I feel ______when ______.

8. I feel ______when ______.

9. I feel ______when ______.

10. I feel ______when ______.

11. I feel ______when ______.

12. I feel ______when ______.

13. I feel ______when ______.

14. I feel ______when ______.

15. I feel ______when ______.

Figure 4: Identifying Emotions Worksheet

44 Anxiety

In 2015, Bibb, Castle, and Newton compared the effects of music therapy versus traditional support therapy on mealtime anxiety levels in patients in a residential facility for individuals with eating disorders. The subjects included seventeen females and one male between the ages of 18-65 with severe anorexia nervosa. They found that music therapy interventions, such as singing, songwriting, and lyric analysis, successfully assisted the patients in coping with the wide spectrum of emotions and anxiety they struggled with after eating a meal (Bibb et al, 2015). The music therapy sessions also provided a positive distraction for the patients (Bibb et al, 2015). Results of the study indicated that anxiety and stress levels were significantly lower in the patients that received post meal music therapy sessions than those who received standard therapy (Bibb et al, 2015). Since music therapy strives to achieve goals mostly through the music than the discussion, it is often perceived as less threatening than talk therapy. Music therapy has been found to decrease anxiety and agitation in many populations, ranging from children in the hospital to older adults with symptoms of dementia (Nguyen, Nilsson, Hellström, & Bengston, 2010; Petrovsky, Cacchione, & George, 2015). Individuals with eating disorders often struggle with high anxiety levels, and music therapy for anxiety is well documented and highly effective (APA, 2013; Beck-Ellsworth, 2015). Pavlakou (2009) organized a choir of eight women with varying eating disorder symptoms. While these women did not have a clinical diagnosis, all reported difficulty in daily functioning due to disordered eating behaviors (Pavlakou, 2009). The physiological aspects of singing, such as breathing and stretching, have been found to relieve feelings of stress and anxiety (Pavlakou, 2009). The women in the choir reported that singing allowed them to feel more positive and relaxed throughout their daily lives (Pavlakou, 2009).

Table 6: Singing Sample Session

Activity Singing Session Procedure 1. Introduce yourself (if new patients) then introduce the group. 2. List the songs on the dry erase board. 3. Instruct patients to pick at least one song from the songs listed. 4. Encourage patients to play instruments and/or sing along as you sing and play the songs they chose. 5. If desired, therapist can prompt discussions based on lyric content.

45 Table 6 - continued Procedure 6. Towards the end of the session, prompt the group to think or discuss about the benefits of singing including: emotional, physical, and social. Materials -guitar -tuner -lyric folders/ sheets - instruments for patients: drums, shakers, bells -dry erase markers -dry erase board (if not provided) Goals/Group Anxiety/stress reduction, relaxation, positive distraction, mood elevation, Topics communication, group cohesion, coping skills

Notes *If the group is 50-60 minutes long, bring approximately 20-30 songs to choose from. *Be wary of songs with lyrics including body image issues. Suggestions for Encourage the patients to be involved in a type of singing activity outside follow-up of the group setting. This may be singing alone or singing in a different group setting. Instruct patients to keep a log of how many times they participate in singing outside the group so that they may bring the log to the next session.

Motivation for Treatment Perhaps the most important use for music therapy with eating disorder populations is increasing their motivation for engaging in treatment. Many individuals with eating disorders are comfortable in their disorder, using it as a coping mechanism. This, along with feeling self – conscious, can make the treatment process incredibly difficult. In all the studies examined, the patients or subjects perceived music therapy as motivating and enjoyable. In particular, Hilliard’s study using a CBT music therapy design showed that the music therapy sessions were favored and well attended by the patients, patients’ families, and staff members of the treatment center (Hilliard, 2001). Engaging adolescents in treatment, whether for disordered eating or a comorbid condition, has proven even more difficult (Golden et al, 2003). Results in a study on adolescents with eating disorders indicated an eighty-three percent participation rate, confirming that music therapy is appealing and engaging to adolescents (McFerran et al, 2006).

46 Table 7: Music Games Sample Session Activity Music Games Procedure 1. Introduce yourself (if new patients) then introduce the group. 2. Briefly discuss the importance of relaxation and positive distractions. 3. Allow group members to chose from a variety of games and facilitate those for the remainder of the session. Materials - ipad -bluetooth speaker - dry erase board/markers - Games: music trivia, music pictionary, crossword puzzles, word searches Goals/Group Motivation for treatment, positive distraction, group cohesion, Topics anxiety/stress reduction, relaxation Notes *This group may work better with group members that are familiar with each other. *It is important for the therapist to be familiar with all of the games and rules so that he/she can adapt them to fit the group members’ needs. Suggestions for Encourage patients to play games/activities outside of the group setting, follow-up at least 3-4 times per week. Instruct them to keep a log of when they participate in games so that they can report these activities at the next session.

Further Research While the results of the aforementioned studies are promising, more research is needed. With more research comes more training for music therapists, awareness of the benefits of music therapy, and more music therapy jobs in eating disorder facilities. Based on existing research, future research should examine the effects of music therapy on adolescents with eating disorders as well as men with eating disorders. According to one longitudinal study of twelve-year old girls, 13% of participants had suffered from an eating disorder by age twenty (Stive, Shaw, & Jaconis, 2010). More adolescent specific research is needed to explore how music therapy can aid in the treatment process. Men with eating disorders are often an underserved population, most likely due to stigma and lack of awareness (Beck-Ellsworth, 2015). Men make up twenty- five percent of individuals with anorexia nervosa and bulimia nervosa, and thirty-six percent of individuals with binge eating disorder (Hudson et al, 2007). General clinical research as well as music therapy research is vital to increase knowledge and services for men suffering from disordered eating behaviors. 47 Continuing education classes, educational symposia, in-services, and surveys are another important aspect needed in further research. A music therapy symposium related to eating disorders was held at the University of Dayton, Ohio to stimulate interest and increase knowledge of eating disorders and various treatment modalities (Gardstrom, Lowe, Schlabig, 2015). The speakers, including a psychologist, a music therapist, a dietitian, and an art therapist, presented statistics, case studies, anecdotes, and other research to an audience of mostly music therapy students and professionals. They hoped this information would expand the audience’s knowledge of eating disorders and better equip them to work with individuals in this population (Gardstrom et al, 20154). A pre- and post- survey revealed that sixty-eight percent of the participants reported an increase in general eating disorder knowledge while eighty-nine percent reported an increase in treatment and therapy knowledge (Gardstrom et al, 2015). If more symposia and secondary education opportunities like this one are provided, awareness of the benefits of music therapy for eating disorder populations will undoubtedly increase. Most importantly, new research studying the effects of music therapy for individuals with eating disorders needs to be more specific, with statistical analyses and quantitative data. The Bibb et al (2015) study on post mealtime anxiety is a strong example of where further research needs to go. That study pinpoints a specific issue within individuals with eating disorders and measures the effects of music therapy on anxiety using an assessment tool. Data gathered from the study was examined using unpaired t-tests and was found statistically significant (Bibb et al, 2015). However, one limitation the authors expressed was that the sample was not randomized (Bibb et al, 2015). Randomized controlled trials are also needed in the music therapy for eating disorders research. Specific and quantitative studies on the effects of music therapy with eating disorders are vital in expanding the knowledge of clinicians and music therapists in order to provide more effective treatment options to individuals suffering from eating disorders and other comorbid disorders.

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61 BIOGRAPHICAL SKETCH

Leah Powers was raised in Thomson, Georgia. She holds a Bachelor of Arts degree in Music from Valdosta State University in Valdosta, Georgia. She began her graduate studies in Music Therapy at Florida State University in 2015. In 2017, she became a board-certified music therapist (MT-BC) and has also received certification to practice music therapy in neonatal intensive care units (NICU-MT). She completed her internship in June 2017 at the Tallahassee Memorial Behavioral Health Center in Tallahassee, Florida, under the supervision of Flor del Cielo Perez, MM, MT-BC. Leah pursued her research in music therapy for eating disorders under the direction of Dr. Lori Gooding. At the end of the Summer 2017 semester, she will graduate from Florida State University with a Master of Music degree.

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