By Madalyn Vanarthos, MusicWorx Intern

The National Eating Disorder Association states, “At any given point in time, 1.0% of young women and 0.1% of young men will meet diagnostic criteria for bulimia nervosa.” This data is drawn from the UK, US and Europe. The combined population of these regions is 1,136,250,000 individuals, which means that 11,362,500 young woman and 1,136,250 young men could have Bulimia Nervosa at some point during their lives. Every individual with whom we, as music therapists, work with has a unique relationship with food, whether healthy or unhealthy. As music therapists, and as responsible friends and family, we need to be responsible about our “food language” and how we engage with individuals who are diagnosed with eating disorders, especially as we approach the holidays. I will discuss Bulimia Nervosa (BN) primarily, which is one of the top three most common eating disorders along with Anorexia Nervosa and Binge Eating Disorder. If you want to learn more about these disorders, and how you can advocate for individuals with them, I encourage you to visit the National Eating Disorders (NED) Website to learn more.

Overview

Individuals diagnosed with Bulimia Nervosa binge on large quantities of food and then purge or perform compensatory behaviors to rid themselves of the extra calories (Mayo Clinic, 2017). The DSM-5’s diagnostic criteria for the disorder include “eating large amounts of food in a discrete amount of time,” a “sense of lack of control over eating during an episode” and purging (2013). It must occur, on average, at least once a week for 3 months typically to be formally diagnosed. Individuals with BN have been known to eat up to 20,000 calories at a time (Harvard Health, 2014). Purging bulimia means self-induced vomiting, whereas non-purging bulimia involves excessive exercise, dieting, laxatives, suppositories, enemas or fasting. Frequency of binging can range from several times a week to several times a day (Harvard Health, 2014).

Binge eating and purging leads to a lot of emotional and physical strain. The individual might experience an immediate relief of tension, but will most likely feel extremely guilty, depressed or fearful of discovery afterwards (Comer, 2015, 11.2). Vomiting only expels half of the calories consumed in one sitting, so an unhealthy number of calories are retained.

Everyone who has an eating disorder is skinny or looks sickly.

Individuals with BN are often at a normal weight or even overweight (Ouellette, 2015). Consistent purging can also lead to dehydration, kidney failure, heart irregularities, tooth decay, gum disease, digestive problems or suicide (Mayo Clinic, 2017). Self-harm is a common comorbid condition that affects 34% of individuals with BN. In addition, individuals with BN have an increased risk of suicide, which is a frequent cause of death (Ouellette, 2015).

Causes

Many factors could play a role in BN’s development such as societal pressure, low self-esteem, biological abnormalities or poor emotional health. A few leading symptoms of this disorder are extreme concern or dissatisfaction with body weight or image, self-criticism, or high levels of anxiety or depression.

Eating disorders are triggered simply from external factors like nagging parents, peer pressure, or societal dieting trends.

While these factors can impact and individual, research suggests that biology plays a key role in triggering these unhealthy responses to food (Weir, 2016). One study even stated that women with BN have an “altered intrinsic brain architecture,” which suggests that it is a large-scale problem extending to multiple regions of the brain (Wang et al., 2017, 414).

Demographic

The group most likely to be affected by BN is females. Eighty-five to 90% of those with BN are female (Harvard Health, 2014). BN usually develops in the late teens or early adulthood between 15 and 20 years of age (Comer, 2015, 11.2).

Individuals with BN are young, white, privileged women.

In reality, lifetime prevalence for BN is higher in Latinx and African-American populations (Marques et al., 2010, 412).

Treatment

Numerous forms of treatment are available, apart from music therapy, for individuals with BN. Nutritional counseling and Psychotherapy are highly recommended. Medication has also been known to reduce the binge eating and purges in some cases, but it is advised that some form of psychotherapy accompany medication for better results (Mayo Clinic, 2017). Individuals with BN should regularly receive maintenance treatment even after they have avoided binge eating or purging for longer than three months to prevent relapse.

Music Therapy Goals

Refer to the literature review below to analyze the existing research on music therapy and eating disorders. We desperately need more research to confirm the promising results from these studies. The following goals and objectives were gleaned from this research.

Increasing autonomy and control and decreasing impulsivity are prevalent goals for this population. Another goal is increasing self-esteem, which is an innate desire to be recognized, appreciated and reinforced. Individuals with eating disorders do not always believe or trust in their own qualities and talents and have a hard time believing that others do. The therapist needs to provide consistent verbal and nonverbal affirmation and actively listen to counter that negative thought cycle. Individuals with BN can feel “irritable, unreal, and powerless” before an episode (Comer, 2015, 11.2). Establishing healthy coping skills during sessions is a great goal for those with BN. Other goals that Siegel mentions are to “learn relapse prevention skills,” “establish healthy interpersonal relationships,” and “increase body awareness” (2007, 170).

What is your approach?

Four main schools of thought exist concerning music therapy treatment for clients with eating disorders.

1. Behavioral music therapy “uses music to shape maladaptive behaviors” (Siegel, 2007, 171). Often rewards systems are set-up to affirm appropriate behavior. One possible intervention would be to allow the patient to choose their preferred music type to listen to after eating a healthy meal without participating in any binging and purging behaviors (Siegel, 2007). Another possible intervention could be centered around mindfulness and relaxation. The patient could practice meditation and deep breathing to decrease impulsivity and anxiety and promote self-regulation.

2. Cognitive music therapy hinges on the idea of modifying negative or faulty thoughts, consequently emphasizing the need to change false beliefs about body size, shape, etc. The goal is to support rational and uplifting thoughts. Interventions could include writing and singing songs about “self-acceptance, gratitude, and serenity” (Siegel, 2007, 171). Group improvisation is another wonderful intervention that promotes self-awareness and healthy interpersonal communication (Siegel, 2007).

3. The Psychodynamic Approach aids patients in dealing with internal conflict either from their childhood or in the present. Instrumental improvisation gives a voice to internal distress (Siegel, 2007). Asking the clients to assign specific instruments, and consequently distinct sounds, timbres, notes and chords, to family members or other close relationships can help the therapist get a sense of their attitude towards that distinct person, whether positive or negative.

4. Medical Music Therapy emphasizes the need to “take control of the stress response…by influencing cortisol output” (Siegel, 2007, 172). By encouraging the patient to gain control over their negative and anxiety-inducing thoughts, the therapist is, in turn, teaching them skills that can help reduce their stress-response to specific stimuli.

Our Responsibility

Weissman et. al (2016), discussed “Terms that should be avoided in the eating disorder field.” As clinicians, the following list should be considered:

• Avoid using “bulimic” or “anorexic” as adjectives. Use person-first language!
• Replace “bulimic episode” or “binging” with “binge-eating episode.”
• Avoid using abbreviated forms of the disorder such as “anorexia.” Instead use, “Anorexia Nervosa”
• Reconsider saying that an individual “suffers from” or “struggles with” BN. Reframe by saying, “An individual diagnosed with BN.”

As we approach the holiday season, let’s be aware of and reframe the phrases listed below. The following phrases are easy to utter in our homes and seem harmless, but what we say behind closed doors often tends to creep into our day-to-day speech, and consequently could be heard by someone who has an eating disorder. This article delves into the following phrases and more.

• “I’m having seconds…don’t judge me.”
  • This phrase demonizes the idea of wanting or being hungry for more food! Personally, as someone who has a high metabolism, I am quick to jump up for seconds or thirds! Instead say, “I’m having seconds, anyone want anything while I am up?”
• “You’re so skinny, you can eat whatever you want.”
  • For anyone who has an eating disorder, this phrase could be triggering, and in general, this often is untrue. Skinny does not equal healthy and should not be glorified.
• “It’s fine, we’ll work it off in the gym tomorrow”
  • This phrase insinuates that weight gain or loss is directly tied to exercise. Living a healthy lifestyle involves so much more than exercise and food. Mental health, hormone levels, underlying illness and stress levels are just a few examples of factors that can influence our physical and overall health. We can talk about moderation, but let’s not oversimplify it.
• “Ugh…I can’t believe I ate that much. I am so fat.”
  • We can respond to these comments by saying, “You look just as great to me!” I will be the first to admit that I have said this phrase many times, and in all honesty, I have either said it as a joke, or as a quick way to boost my confidence in hopes for a compliment. I often do not consider how it makes the people around me feel. Does this phrase make them feel shame about their body? Let’s ask these questions before we say something like this.

We should not avoid conversations about food or eating healthy! Not only am I passionate about this topic, but I am excited that medical communities and society in general are taking a critical look at how our diet impacts our health. That being said, we need to be conscious about the people around us and the patients we see as music therapists. Main take-away: Everyone’s response to food is different, so let’s use affirming language as we approach the holidays!

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Bauer, S. (2010). Music therapy and eating disorders-A single case study about the sound of human needs. Voices, 10(2).

Bibb, J., Castle, D., & Mcferran, K. S. (2019). Reducing anxiety through music therapy at an outpatient eating disorder recovery service. Journal of Creativity in Mental Health, 1–9 doi: 10.1080/15401383.2019.1595804

Bibb, J., Castle, D., & Newton, R. (2016). ‘Circuit breaking’ the anxiety: Experiences of group music therapy during supported post-meal time for adults with Anorexia Nervosa. Australian Journal of Music Therapy, 27, 1-11.

Collins, B., McDowell, J. E., Miller, S., Breithaupt, L., Thompson, J., & Fischer, S. (2017). The impact of acute stress on the neural processing of food cues in Bulimia Nervosa: Replication in two samples. Journal of Abnormal Psychology, 126(5), 540-551. doi:10.1037/abn0000242.supp

Comer, Ronald. (2015). Abnormal psychology. New York, New York: Worth Publishers.

Cyr, M., Yang, X., Horga, G., & Marsh, R. (2018). Abnormal fronto-striatal activation as a marker of threshold and subthreshold Bulimia Nervosa. Human Brain Mapping, 39(4), 1796-1804. doi:10.1002/hbm.23955

Fabello, M. A. (2017, December 23). 7 Food-Related Phrases You Should Ban From Your Vocabulary This Month (and Forever). Retrieved from https://www.self.com/story/food-related-phrases-to-stop-using

Harvard Health Publishing. (2014, December). Bulimia: Symptoms, diagnosis and treatments. Retrieved April 14, 2018, from https://www.health.harvard.edu/mind-and-mood/bulimia-symptoms-diagnosis-and-treatments

Lejonclou, A., & Trondalen, G. (2009). “I’ve started to move into my own body”: Music therapy with women suffering from eating disorders. Nordic Journal of Music Therapy, 18(1), 79-92.

Marques, L., Alegria, M., Becker, A. E., Chen, C., Fang, A., Chosak, A., & Diniz, J. B. (2010). Comparative prevalence, correlates of impairment, and service utilization for eating disorders across US ethnic groups: Implications for reducing ethnic disparities in health care access for eating disorders. International Journal of Eating Disorders, 44(5), 412-420. doi:10.1002/eat.20787

Mathisen, T. F., Rosenvinge, J. H., Friborg, O., Pettersen, G., Stensrud, T., Hansen, B. H., & …

Sundgot‐Borgen, J. (2018). Body composition and physical fitness in women with bulimia nervosa or binge‐eating disorder. International Journal of Eating Disorders, 51(4), 331-342. doi:10.1002/eat.22841

Mayo Clinic. (2017, August 23). Bulimia Nervosa. Retrieved April 14, 2018, from https://www.mayoclinic.org/diseases-conditions/bulimia/symptoms-causes/syc-20353615

Ouellette, J. (2015, January). Statistics on Bulimia. Retrieved from https://mirror-mirror.org/facts-staticstics/statistics-on-bulimia

Siegel, S. (2007). Music therapy practice for clients with eating disorders. In C. Colwell & B. Crowe (Eds.), Effective clinical practice in music therapy: Music therapy for children, adolescents, and adults with mental disorders (pp. 165-174). Silver Spring,

MD: American Music Therapy Association, Inc. Statistics & Research on Eating Disorders. (2020, May 08). Retrieved from https://www.nationaleatingdisorders.org/statistics-research-eating-disorders

Valenzuela, F., Lock, J., Grange, D. L., & Bohon, C. (2018). Comorbid depressive symptoms and self-esteem improve after either cognitive-behavioral therapy or family-based treatment for adolescent Bulimia Nervosa. European Eating Disorders Review. doi:10.1002/erv.2582

Wang, L., Kong, Q., Li, K., Li, X., Zeng, Y., Chen, C., . . . Si, T. (2017). Altered intrinsic functional brain architecture in female patients with bulimia nervosa.  Journal of Psychiatry & Neuroscience,42(6), 414-423. doi:10.1503/jpn.160183’

Weir, K. (2016, April). New Insights on Eating Disorders. Retrieved from https://www.apa.org/monitor/2016/04/eating-disorders

Weissman, R. S., Becker, A. E., Bulik, C. M., Frank, G. K., Klump, K. L., Steiger, H., . . .

Walsh, B. T. (2016). Speaking of that: Terms to avoid or reconsider in the eating disorders field. International Journal of Eating Disorders, 49(4), 349-353. doi:10.1002/eat.22528

Note During COVID

Many of us will not be around extended family for the holidays. In fact, I would encourage everyone reading to avoid large gatherings to prevent exposure and protect the vulnerable in our communities. That being said, just because we are not meeting, does not mean the problems that individuals with BN face disappear. One source states,

“If an eating disorder could choose its favorite environment, it could do no better than the stay-at-home orders issued in many states to combat the coronavirus. Fear over health? Check. Fear around food? Double-check. Social isolation? Triple-check. Combine all this with economic volatility and an international sense of dread, and eating disorder behaviors seem to have a big advantage over recovery. In short, coronavirus quarantine and eating disorders: it’s a perfect storm.”

Continue reading for more insight on how our friends/family members with BN could be struggling during COVID, and this holiday season.