Hostility during refeeding

Admittedly, this isn't research. It's an observation by author and anthropologist Sharman Apt Russell in her book Hunger: An Unnatural History. Although only a chapter is spent looking at anorexia nervosa in particular, the book is haunting and well worth a read.

Russell spends much time on events that took place during World War II: the Minnesota Starvation study, the Dutch Hunger Winter, and the tragedies in the Warsaw Ghetto. This excerpt is from Russell's summaries of the refeeding portion of the Starvation Study- the most important part. After all, the purpose of the study was not just to learn what exactly happened when people starved (that was generally well known). It was also to learn how to most effectively refeed a group of starving people on the lowest amounts of calories, funded by the war effort to help keep Europe out of Communist hands after the Nazis surrendered.*

But the men were not initially allowed free access to food. Their calories were only increased slowly, much to the chagrin of the men who thought that their ordeal would finally be over. They got irritable, cranky, desperate.

From Russell:

By the end of the sixth week of refeeding, almost all the subjects were in active rebellion. Many "grew argumentative and negativistic." Some questioned the value of the project, as well as the motives and competence of the researchers. A few admitted that their desire to help the relief effort had completely disappeared. At the same time, unnoticed by the subjects themselves, their energy was returning. They became more responsive, albeit in a negativistic way. They were annoyed at the restrictions still imposed on them. They rejected the buddy system, which was removed "in the face of imminent wholesale violation." They resisted going back to a regular work schedule. At times, the experimenters felt they were watching "an overheated boiler, the capacity of the safety values an unknown variable."

Later, the researchers compared this with what they learned about refeeding camps after the war, where aid workers also noted a growing aggressiveness and surprising "lack of gratitude" in men and women who had previously been dull and apathetic with hunger.

So it seems from these anecdotal cases that some of the resistance seen by eating disordered children during refeeding seems almost purely organic and NOT related to the eating disorder. Perhaps the brain is reawakening and is not happy. Perhaps the person is unable to process what the hell just happened. The anxiety around food that is, of course, related to the eating disorder, seems only to make this worse.

But the negativity and hostility may also be the intrinsic response of a starving brain.

*I thought this was fascinating- obviously, because I included it.

FBT for bulimia in single-parent families

Despite its efficacy in studies, family-based treatment isn't for every family. For single-parent families, FBT can be "ruled out" as a treatment approach because of the time-intensive nature of treatment. Every meal, every snack, every day.

Of course, single-parent families can make it work. The other parent may be nearby and willing to help. Other caring adults can pitch in, or other family members. The parent may be able to take time off of work to care for their sick child until s/he is able to manage better on their own.

But the efficacy of FBT in single- vs. double-parent families hadn't been studied. In the International Journal of Eating Disorders, Daniel LeGrange and the team at the University of Chicago found that single-parent families were able to help their teens with bulimia nervosa as effectively as double-parent families.

Writes LeGrange in the introduction of the paper:

Given the emphasis in FBT on the involvement of the entire family in helping to reduce binge eating and purging behaviors, it could be that single-parent families demonstrate poorer outcomes than two-parent families receiving FBT. Although there is no research indicating that individuals from single-parent families have poorer outcomes in FBT for BN, there are several lines of indirect evidence to suggest that family status may relate to treatment outcomes.

First, single parent families may have less time, fewer social supports, or fewer financial resources than two-parent families. This could predispose single parents toward premature autonomy-granting or decrease their ability to provide adequate parental monitoring.

He also cites unconscious therapist bias against single parents being able to make FBT work, as well as evidence from AN treatment. Single-parent families battling AN benefit from 12 month FBT as opposed to the shorter-course 6 month treatment.

However, LeGrange et al. found:

There were no statistically significant differences between two-parent and single-parent groups on any of the treatment variables at post-treatment or 6-month follow-up...Patients in both groups showed significant reductions in eating disorder behavior and depressive symptoms as well as increases in self-esteem.

Part of the reason that FBT is just as effective in single-parent families is that in dual-parent families, responsibility isn't always shared equally between parents.

The study concluded:

Despite the reliance on parental intervention to reduce bulimic symptoms and normalize eating patterns, the results of this study suggest that FBT is an appropriate and efficacious treatment for single-parent families as well as two-parent families.