Medical Complications of Eating Disorders
Joel P. Jahraus, MD
Primary Care Medicine
Remuda Programs for Eating Disorders
The Remuda Review: The Christian Journal of Eating Disorders
Winter 2003, Vol 2, Issue 1
Abstract. This article discusses the medical complications of eating disorders and the role of the primary care provider in eating disorder treatment teams. The medical complications of eating disorders is a complex topic. This article is an overview based on the existing research and the experience of Remuda’s medical staff in treating 5000 eating disorder patients over the past 13 years. It is intentionally written to be readily understood by the non-medical healthcare provider.
When asked about the consequences of eating disorders, many people think of the emotional devastation and lifestyle disruption that eating disorders cause. Few realize the serious medical complications associated with eating disorders and the risk of significant harm to the body or even death. Psalm 139:13-16 tells us that we are "...fearfully and wonderfully made...". Science confirms what Scripture has long suggested—that the intricacies of human physiology are astounding. Starvation, self-induced vomiting, laxative abuse, and other behaviors associated with eating disorders can completely disrupt the fine tuning of the human body.
In this article, we focus specifically on the medical complications of anorexia and bulimia, including the effects of malnutrition and purging. These symptoms can occur individually or in combination.
Malnutrition
Patients with anorexia, by definition, weigh less than 85% of their medically appropriate weight. Malnutrition is expected in this population. However, malnutrition is often underestimated in patients with bulimia who are at or above normal body weight. The absolute amount and rapidity of weight loss is sometimes more important to the development of medical complications than whether the resultant weight is normal or abnormal for the individual. Weight loss is often perceived as beneficial and individuals may receive positive feedback from friends and others at the same time that their bodies are being compromised by malnutrition.
The relative balance between, and time spent in, bingeing and purging determines weight gain or loss. If bingeing is predominant, such that a significant amount of time is spent bingeing before vomiting, the individual absorbs more nutrients and may evidence stable weight or weight gain. Nevertheless, depending on the content of the binge, malnutrition may still result. For those individuals who spend more time vomiting, weight loss often ensues and malnutrition may eventually be in evidence. It is important to treat each individual separately to best understand the unique impact of the eating disorder on the individual’s physical status.
The primary physical manifestations of malnutrition, particularly evident at low body weight, result from disruption and decrease of the body’s normal metabolism. This is a natural protective mechanism that the body uses, mediated by a change in thyroid hormone production that reduces the body’s caloric requirements.
The maintenance of normal body temperature, pulse, and blood pressure requires a high number of calories. Lowered metabolism leads to a decrease in body temperature with the development of cold intolerance and a progressive drop in pulse and blood pressure. The result is that the individual will often complain of feeling cold, lack of energy, difficulty concentrating, hair loss, constipation, lack of menstrual period, light-headedness, black-out spells, and other symptoms.
Malnourished individuals also change physically over time, with a general diminishment in organ size and function. The heart may lose up to 25% of normal muscle mass, compromising cardiovascular function. The brain decreases in size, as do the uterus, ovaries, and kidneys. A paradoxical fatty replacement of tissue may affect the liver and result in abnormal liver function. Bone deteriorates and osteopenia--a weakening of bone--or osteoporosis ensues. Upon return to healthy body weight, the individual’s organs will usually return to normal size and function. There is insufficient research to determine whether or not the brain is restored. Once bone is lost, most studies show that it does not replenish itself after weight restoration, even with the use of medications such as hormone therapy or calcium and vitamin supplementation. Nevertheless, efforts at preventing further bone loss should be undertaken.
Prepubertal and pubertal children are at particular risk of complications from eating disorders. If the eating disorder strikes during a critical growth period, malnutrition may stunt the child’s growth permanently. Aggressive treatment is warranted. In these cases an ideal weight determination is based not only on the menstrual weight but also on historical information from growth charts. The average weight percentile documented over time in the patient's medical history is extrapolated to obtain an appropriate weight range for the patient’s current age.
Purging
With normal body weight, the physical effects of purging are often not visible. For secretive patients, only the medical provider or dentist may come to suspect that an individual is struggling with an eating disorder.
Although most people equate vomiting with purging, there are other means of purging as well, such as the use of laxatives, diuretics, diet pills, or even compulsive exercise. The individual symptom or combination of symptoms determines the specific physical complications that an individual is likely to face.
For those who vomit, the effects are primarily related to fluid and electrolyte loss (particularly potassium) and local irritation in the mouth, esophagus, and stomach from constant exposure to stomach acid. There may be tears in the stomach and esophagus from the irritation of constant retching. The teeth may deteriorate with the development of cavities or enamel erosion. The salivary glands may swell to accommodate the body’s increased need for digestive salivary juices. Potassium and other electrolyte loss may eventually lead to muscle cramping and even fatal heart rhythm disturbances.
Laxative abuse also leads to fluid and electrolyte loss. It can eventually cause the bowel to lose its normal movement leading to constipation. The continued use of laxatives perpetuates the cycle, continually increasing the individual’s need for laxatives.
A particularly interesting phenomenon exists for those of low body weight who use solely compulsive exercise as their form of purging. In these cases, individuals may be eating what appears to be sufficient calories for their size, yet they continue to lose weight due to the imbalance of calories taken in and calories purged through exercise. The net effect of such weight loss is the same as in pure caloric restriction, but with an additional slowing of heart rate due to the combination of the conditioning effect of exercise and the decreased metabolism related to low body weight.
Refeeding
The process of refeeding can be challenging and may result in medical complications. Individuals with very low body weight are particularly at risk and much care is taken to monitor them in an intensive treatment environment. Daily calories are frequently limited to 800-1200 initially, then advanced over the next few weeks as tolerated. Depending on the degree of malnutrition some of the calories may be given with high caloric supplements either orally or using a feeding tube placed through the nose into the stomach (a "nasogastric tube"). Potential complications include a dilated stomach that loses normal movement (gastroparesis), edema, refeeding hepatitis, and electrolyte imbalances including low phosphorus and magnesium. The heart muscle itself can be weakened from longstanding malnutrition and may be unable to maintain a normal cardiac output resulting in congestive heart failure. Low phosphorus may result in muscle breakdown leading to kidney failure. Vital signs and laboratory values are therefore monitored frequently in addition to daily weights and accurate assessments of intake and output.
In individuals of normal or above normal body weight the degree of malnutrition is often underestimated. In addition, if the individual has vomited frequently or used laxatives or diuretics, sudden abstinence from these behaviors may result in significant fluid retention. Refeeding these individuals often involves starting caloric intake at a slightly higher initial level than those of very low body weight. Careful monitoring is required to avert the potential fluid retention and electrolyte issues.
The next issue of The Remuda Review will offer more details on the refeeding process.
The Primary Care Provider and the Eating Disorder Treatment Team
Primary care providers who see eating disorder patients need to be alert to the medical complications of eating disorders, since patients may not voluntarily seek urgent treatment and their symptoms may go unnoticed for too long. The classic image of the individual of very low body weight, pale and lethargic, bundled up in layered clothing yet refusing to acknowledge her illness, is frequently seen. Occasionally, patients may experience blackouts, chest pain, or even blood in the vomitus, which scare them and lead them to seek medical attention. It is only infrequently, however, that such patients would acknowledge the relationship between their symptoms and malnutrition.
An alert non-medical provider who questions patients about their well-being may help patients to develop a better understanding of how the eating disorder impacts their physical status and to seek medical evaluation. When referring a patient to a primary care provider, it is helpful to provide certain objective information. This includes the patient’s recent physical symptoms, such as weakness, complaints of cold and tiredness, light-headedness, chest pain, apparent weight-loss, swelling of the parotid glands of the face, dental cavities, hair loss, dry skin, and blueness of the hands. It also includes behavioral symptoms, such as extensive dieting; increased isolation; immediate and prolonged trips to the bathroom after meals; increased preoccupation with food, weight, or body image; label reading; calorie and fat gram counting; and frequent weighing.
The primary care provider’s role is to regularly assess and monitor the individual’s physical status and weight and to educate the individual about the medical consequences of eating disorders. The primary care provider also monitors the refeeding process. The frequency of office visits is every week initially with a goal of every other week or eventually monthly after the first two to four weeks, depending on the individual’s response to treatment. Deterioration in vital signs or the development of serious blood abnormalities signifies medical instability and mandates more intensive treatment, typically in an inpatient or residential setting. The primary care provider is instrumental in identifying these medical issues that may necessitate transfer to a higher level of care.
Consistency is important during medical examination, especially when obtaining the individual’s weight. The weight is ideally obtained at approximately the same time of the day, in only a gown and underwear and after voiding. Blood pressure and pulse are obtained in both lying down and standing positions to check for orthostasis, an exaggerated rise in pulse and/or drop in systolic blood pressure which is indicative of malnutrition and/or dehydration. An electrocardiogram is obtained initially along with full blood chemistries to evaluate electrolytes, kidney and liver function, thyroid function, and bone marrow response with a hemoglobin and white blood cell count. A urinalysis is also obtained. Follow-up office visit labs are done if the individual remains entrenched in symptoms with purging and/or low body weight.
Because eating disorders occur in a bio-psycho-social-spiritual context wherein these several dimensions interact dynamically, the primary care provider must also structure treatment to include a multidisciplinary team. In outpatient settings, the team should include at a minimum a dietitian and therapist; often a psychiatrist is needed as well. Patients will need to sign appropriate releases of information to allow for effective communication among team members. Inpatient teams may additionally include nurses, psychologists, and specialty therapists. The primary care provider must play an active role in providing the team with up-to-date medical information communicated in a manner that is understandable to non-medical professionals. The primary care provider must also be accessible to receive communication from other team members, who often have key information about patient symptoms and behaviors. Without this collaborative communication, due to the secrecy that characterizes eating disorders important data can be overlooked. Splitting among team members can also become a serious problem, and a miscommunication about medical status or weight may escalate into a major impediment to the individual’s recovery.
In summation, primary care medicine is an essential component of eating disorder treatment due to the physical devastation associated with eating disorders. Because of these physical consequences, all patients with eating disorders should be evaluated by a primary care provider. Early detection of eating disorders may prevent some of the medical consequences and/or allow for a more complete recovery from these consequences. Healthcare, pastoral, and education professionals can refer to "Signs of an Eating Disorder" in this issue of The Remuda Review to assist in the early identification process. Professionals can refer individuals at risk for eating disorders to a provider who has the specialized training and treatment team in place to assess and address the person’s needs across the bio-psycho-social-spiritual spectrum.
References
Garner, D. M., & Garfinkel, P. E. (1997). Handbook of treatment for eating disorders, 2nd Edition. New York: Guilford Press.
Kaplan, A. S., & Garfinkel, P. E. (1993). Medical issues and the eating disorders: The interface. Levittown, PA: Brunner/Mazel.
Mehler, P. S., & Andersen, A. E. (1999). Eating disorders: A guide to medical care and complications. Baltimore: Johns Hopkins University Press.
Remuda Review •
Introduction Fall 2002, Vol 1, Issue 1
Welcome to the inaugural issue of The Remuda Review. This quarterly journal will offer a Biblically-based and scientifically-valid approach to the integration of Christianity and patient care in the treatment of eating disorders. The goal is to present practical information for those who provide eating disorder treatment from a Christian perspective or who work with Christian patients.
Our first article, Bio-Psycho-Social-Spiritual: Completing the Model, demonstrates a scientific foundation for integrating patient care and Christianity. Our second article, Five Biblical Factors in Eating Disorder Development, offers a Biblically-based foundation for this integration. Using the model presented in this initial issue, future issues of The Remuda Review will focus on practical treatment methods and applications.
In short, The Remuda Review is a clinicians’ primer of Biblically-based and scientifically-valid eating disorder conceptualization, treatment, and practice.
Editorial Staff
“See to it that no one takes you captive through hollow and deceptive philosophy, which depends on human tradition and the basic principles of this world rather than on Christ.”
Colossians 2:8
Remuda Review •
Five Biblical Factors in Eating Disorder Development
A. David Wall, PhD and Marian Eberly, RN, MSW, CISW
Remuda Programs for Eating Disorders
The Remuda Review: The Christian Journal of Eating Disorders
Fall 2002, Vol 1, Issue 1
Note: This article presents a Biblical view of eating disorders. Its primary goal is to assist those who work with Christian patients to effectively and compassionately treat the eating disorder in a manner consistent with the patient’s faith.
Abstract. In the understanding of many Christians, the Bible indicates that human beings consist of a union of body, soul, and spirit, and exist in an influential social context. The broken condition of the world resulting from the fall of man has created vulnerabilities in each aspect of human nature. Human beings also make personal sinful choices. Eating disorders arise from these five sources of vulnerability in combination. Vulnerabilities specific to each of these five areas are explored in relation to eating disorder development. Christians sometimes place inordinate emphasis on personal sin in the development of eating disorders. A balanced Biblical view recognizes the vulnerabilities of the human condition and therefore emphasizes God's grace, forgiveness, and redemption along with the need for restorative, evidence-based treatment to address the whole person. A restorative treatment model emphasizing God's grace is therefore presented for dealing with each area of vulnerability that affects human nature.
“My father says I am just sinning and I don’t need all this treatment. Is that true?”
A young Christian woman with anorexia nervosa tearfully expressed this statement about her father’s views and her anguish that he might be right. Those who work with Christian eating disorder patients will inevitably encounter this tension in their patients: Is the eating disorder a result of sin, disease, genes, or something else? For Christians and those who work with Christian patients, it is important to have a Biblical answer to this question. This article therefore provides a Biblically-based understanding of human nature, illness, and the restorative work of patient care. This Biblical model has been carefully developed during Remuda Ranch's thirteen year history by Christians from many backgrounds. Remuda has applied this model effectively in its work with Christian eating disorder patients. We hope that presenting this model may assist others who work with Christian patients to more fully grasp, and effectively and compassionately treat, the complexity of eating disorders.
Biblical View of Human Nature
In the understanding of many Christians, the Bible indicates that human beings are a trinity, like the God in whose image we were made. Genesis lays the foundation for this point-of-view. “The LORD God formed the man from the dust of the ground...” We are physical; Adam can mean from the earth. The passage continues, “...and breathed into his nostrils the breath of life...” We therefore also have a spirit. “...and the man became a living being.” Finally, we have a soul, which the Bible tells us consists of emotions, thoughts, and will/moral conscience (Romans 2:15). This trinitarian view is confirmed by multiple New Testament Scriptures (e.g., Matthew 10:28; Acts 2:31; Romans 8:10; Ephesians 4:4; James 2:26; 1 Peter 2:11), and is expressed frequently in Christian theology.
But human beings are not made up of three segregated parts. In Hebrew thought, humans are unified, indivisible beings, paradoxically or dialectically encompassing all three aspects. All are necessary to form a human being. And each impacts the other within a unified whole (The New Unger's Bible Dictionary, 2002).
The Bible also adds one more dimension. Human beings do not exist in isolation from one another. People have an impact on one another, and the people of God were designed to function harmoniously and in unity. “Now you are the body of Christ, and each one of you is a part of it... If one part suffers, every part suffers with it; if one part is honored, every part rejoices with it” (1 Corinthians 12:27,26). In short, our trinitarian human nature is also deeply affected by our social context--family, church, society, and culture.
So why is this Biblical understanding of human nature important for dealing with eating disorders?
Human Nature and Eating Disorders
According to Scripture, we live in a broken world due to the fall of man in the Garden of Eden: "Sin entered the world through one man, and death through sin" (Romans 5:12). We are surrounded and impacted by this brokenness in the world: "for the creation was subjected to frustration…" (Romans 8:20). We experience this brokenness within our very organisms: "For in my inner being I delight in God's law; but I see another law at work in the members of my body …" (Romans 7:22-23). This brokenness is often referred to as the fallen or sinful condition of the world. As a condition, it is not the same as the committing of individual, personal sins. Confusing the two can be the source of hurtful ideas that emphasize judgment and condemnation instead of God's loving redemption.
The fallen or broken condition of the world creates vulnerabilities in every aspect of our humanity: body, soul, spirit, and interpersonal relations. We explore these vulnerabilities below.
1. The Body
Vulnerabilities: Scientific research has revealed genetic predispositions to problematic behaviors such as alcoholism, aggression, unhealthy urges, and obsessions. In addition to genes, toxic aspects of our environment--such as stress, nutritional deficiencies, and chemical exposure--can produce biochemical abnormalities within us that dramatically alter our behavior and emotions. Our bodies are also vulnerable to intentional abuse and accidental injuries, including injuries to the brain that result in emotional and behavioral changes. Neuroscience tells us that the developing brain forms an internal map of its environment. Adam and Eve’s internal map reflected a creation in total harmony with God—a peaceful and safe environment. Our brains, on the other hand, may grow to reflect a harsh and dangerous environment. In short, many biochemical underpinnings of mental illness--including eating disorders and related pathologies--have been adequately demonstrated and cannot be ignored. Christians often deny this evidence, while secularists may overstate it. A balanced Biblical view accepts that these many physiological problems exist because our bodies are part of the fallen world. Physiological problems are not, in themselves, necessarily the results of personal sin, although they may increase the likelihood that certain personal sins will occur.
Restoration: The biochemistry of an individual with an eating disorder may be out-of-balance due to the several factors that arise from our fallen world. It is therefore important to treat the body through proper nutrition, exercise, and self-care, as well as the judicious use of medications where indicated. This helps to accomplish the necessary reparative work and to restore the body to an optimal level of functioning.
2. The Soul
Vulnerabilities: Scripture tells us that the soul incorporates three aspects--emotions, thoughts, and will/moral conscience (e.g., Romans 2:14-15). Like the body, the soul is vulnerable to the broken conditions of the fallen world. First, the soul exists in union with a fallen body. Therefore, the physical apparatus through which the soul perceives and interacts with the world may distort reality, promoting negative emotional reactions, thinking patterns, and choices. The soul is also shaped according to what we are taught and the choices/beliefs that have been punished, reinforced, or modeled by others. We are all exposed to and reinforced for unhealthy emotional expressions, negative thinking, and self-centered choices. Shaped by these dysfunctional social influences, the soul may operate according to the distorted principles and beliefs that derive from a fallen world.
Restoration: In working with an eating disorder patient, it is important to address problems in all three aspects of the soul: unhealthy emotional functioning, distorted thoughts, and poor choices. First, providers compassionately validate patients' emotional pain and the reality of the resulting consequences. Constricted patients may need help recognizing and expressing their emotions openly. Emotionally dysregulated or labile patients may need help with emotion regulation skills. Second, providers employ cognitive restructuring to challenge dysfunctional beliefs and thoughts. Patients often need to examine their beliefs and the social context in which they arose in order to change unhealthy beliefs to those that are consistent with Scripture. A cultural worldview sees the person merely as “a body” and teaches that one’s primary value comes from appearance or ability to perform. Therapists may offer a Biblical worldview that values who the person was created uniquely to be by a loving God, helping the Christian patient to establish her true identity in Christ. Finally, treatment is tailored to the patient’s motivational level, so that the patient’s will is maximally engaged in choosing steps for recovery.
3. The Spirit
Vulnerabilities: According to Scripture, at birth our spirits are separated from God’s Spirit. This results from the fall in the Garden of Eden, where our spiritual aspect--created to connect us to God--lost its vitality due to the introduction of sin. Apart from God, the human spirit cannot be a source of life or health (Romans 5:12-17). In addition, the human spirit is beset by evil influences that seek to separate us from God and lead us into destructive choices. “For our struggle is not against flesh and blood, but against the rulers, against the authorities, against the powers of this dark world and against the spiritual forces of evil in the heavenly realms” (Ephesians 6:12-13).
Restoration: To address the needs of the human spirit, it is important to acknowledge that the human spirit can be reborn from above into a living relationship with God (John 3:3-8). Through the indwelling of the Holy Spirit and ongoing sanctification, human beings can flourish in the life-giving fruit of the Spirit (Galatians 5:22-23). To promote sanctification and spiritual health, providers can incorporate Scripture and prayer into every component of treatment, and encourage patients' regular participation in corporate praise and worship. Providers who are committed Christians can model the benefits of an active faith and a personal relationship with Jesus Christ. They can pray for patients throughout the course of treatment. Providers can also invite patients into a deeper relationship with the Father, Son, and Holy Spirit so that patients may continually grow in the grace and knowledge of God.
4. The Social Context
Vulnerabilities: We live in a social environment that is hostile to human health because of the pervasive presence of sin in the world. It is not uncommon for patients with eating disorders to have experienced some form of physical, sexual, emotional, and/or spiritual abuse or neglect. Without the sins of others perpetrated against them, it is possible to surmise that the eating disorder may not have developed. In this case, whose sin created the eating disorder? There are also cultural forces which exert tremendous pressures on young women regarding body image and weight control. These pressures sometimes occur even within the church. Wounds perpetrated by others and by cultural forces against the eating disorder patient may therefore play a major role in the development and maintenance of her problems. These wounds are not the result of personal sin, but of a fallen world.
Restoration: Because the social environment can be hostile, the patient is taught how to deal with others more assertively and effectively, to protect herself with healthier boundaries, and to adapt more productively. Healthy, assertive, and emotionally honest relationships can be modeled by providers and supported by other patients in group settings. Because some patients have been deeply wounded by others, it is important to help them grieve losses, begin the forgiveness process, and to talk with their families in a context of truth and love (Ephesians 4:15). Education regarding healthy marriage and family life is often needed. Families and marriages also require family therapy to change the systemic relationship patterns that may serve to sustain the patients’ eating disorder. Furthermore, patients can be taught how to locate a faith community that will offer the possibility of healthy fellowship and sound Biblical doctrine.
5. Personal Sin
Vulnerabilities: Finally, individuals make personal, sinful choices. According to Scripture, we are all born with a sinful nature that is set in rebellion against God. We make choices to maximize pleasure and avoid pain, even when these choices may harm others or ourselves. We all have these tendencies and they make us vulnerable to choosing sin (Romans 7:14-20).
Restoration: Because patients have made and will continue to make some sinful choices, counseling should emphasize God’s continual offer of loving forgiveness and the life-changing power of repentance. Many eating disorder patients live isolated lives filled with shame and guilt, and believe that they have failed God to the point where He cannot love them anymore. This separation from God is extremely painful. It is therefore essential to help patients understand the concept of grace, to grow beyond a legalistic and judgmental perception of God, and to embrace a Christian life walking in God’s beneficent love. From this context of grace, acceptance, and forgiveness, repentance can occur. Patients can embrace truth, rather than denial about past ineffective choices and actions, and they can take responsibility for recovery, rather than continue in the role of helpless victim. This must occur with wisdom, focusing on responsibility for healing rather than blame for causing the eating disorder. This process is assisted by understanding that eating disorders are almost always unhealthy and irrational ways of meeting rational, human needs, such as the needs for love and acceptance. It is not productive to blame people for their attempt to meet basic human needs. These underlying needs can be validated, while patients are encouraged at the same time to take responsibility for choosing healthier methods to meet their needs. In short, eating disorder patients recover when they allow themselves to experience the grace of God’s unconditional forgiveness and love, and--in this cradle of security and hope--responsibly transform their lives through healthy choices and the continual counsel of the Holy Spirit and caring people.
Views of Human Nature: Implications
In a Biblical view, eating disorders result from all five factors, present in varying degrees for different individuals. A thorough assessment, including a spiritual assessment, can reveal which factors predominate for each individual patient and in what proportion and combination. We cannot automatically point to just one element of this complex situation in our efforts to understand an eating disorder. Doing so would overlook critical information about what it means to be human in the present fallen world.
Without realizing it, some Christians subscribe to a non-Biblical view of human nature. They believe that our behaviors and emotions are controlled exclusively by our soul or mind. They therefore endow the soul or mind with a pre-eminence over the body, spirit, and society. From this perspective, any deviant, pathological, or harmful behaviors are seen purely as personal sins. As such, eating disorders are perceived as sinful, plain and simple. In this case, the patient is believed to be completely responsible for the onset and continuation of her pathological behavior. You cannot medicate sin. You cannot change sin with psychotherapy or treatment. From this perspective, the only thing needed is repentance.
Many Christian patients will either believe this about themselves and/or come from families or churches that do. We need to be prepared to deal with this core belief, because it creates inappropriate shame and guilt and makes the eating disorder more difficult to treat.
On the other hand, some secular authorities remove the soul and spirit completely from the picture and ascribe to a materialistic view of human beings that reduces us to our physical nature alone, like primitive animals. This extreme secular perspective has for the most part removed sin from psychopathology, and focuses exclusively on genes, biochemistry, learning contingencies, and the like. This removal of sin from the equation essentially takes away personal responsibility for one’s behavior, because sin involves personal freedom and choice which have no part in such a deterministic model.
Either of these extremes compounds the eating disorder. The first view may engender crippling shame, guilt, and perfectionism. The second may lead to passivity, a victim mentality, and an abrogation of personal responsibility in the healing process. But a Biblical view can offer the possibility of comprehensive restoration because it reveals the full complexity of eating disorder pathology.
Conclusions: Practical Integration
So is the eating disorder a sin?
The complex relationship between psychopathology, the fallen world, and personal sin was carefully articulated in a 2002 issue of Christian Counseling Today, devoted entirely to this topic. For Christians to perceive eating disorders as chiefly or even exclusively due to personal sin or willful disobedience is to completely misunderstand the complexity of eating disorders in relation to the sinful condition of the world with its ubiquitous impact on us. An inordinate emphasis on personal sin is harmful to the human person and is inconsistent with Scripture.
All sickness, physical and emotional, is ultimately due to the fallen condition of the world, which makes us vulnerable in many ways. Eating disorders result from these vulnerabilities in combination. As caring individuals, we must address each aspect of the eating disorder using the best, evidence-based methods available. We must avoid the blame game, compassionately providing treatment to remedy the effects of a fallen world, and offering appropriate spiritual guidance and education to help patients in making healthier personal choices.
It is essential to rely on evidence-based treatment methods established by scientific research in our efforts to address the whole person. Because scientists sometimes approach their work from an atheistic perspective, some Christians dismiss the scientific research. However, Scripture indicates that God reveals truth not only through the Bible, but also through his creation and the study thereof. The Scripture is eloquent in this regard:
The heavens declare the glory of God; the skies proclaim the work of his hands. Day after day they pour forth speech; night after night they display knowledge... Their voice goes out into all the earth, their words to the ends of the world (Psalm 19:1-2,4).
The heavens proclaim his righteousness, and all the peoples see his glory (Psalm 97:6).
But ask the animals, and they will teach you, or the birds of the air, and they will tell you; or speak to the earth, and it will teach you, or let the fish of the sea inform you ( Job 12:7-8).
For since the creation of the world God's invisible qualities--his eternal power and divine nature--have been clearly seen, being understood from what has been made (Romans 1:20).
By ignoring God’s revelation of truth through nature we may forego knowledge that God intends for us to have--such as medical knowledge that equips the physician to promote better health and healing. All truths cohere because they derive from the one Truth, Jesus Christ. When individual scientific truths are firmly established according to sound principles and harmonize with Scripture, it is prudent to accept their validity and to benefit from their use, since “every good ... gift is from above” (James 1:17), and “every prudent man acts out of knowledge” (Proverbs 13:16).
Our look at the Bible’s understanding of human nature accords with the bio-psycho-social-spiritual model outlined in the companion article published in this issue of The Remuda Review. Scientific research and the Bible both suggest that human beings are multi-dimensional creatures, consisting of body, soul, and spirit, and existing in an influential social context. But what science calls illness or disorder, Scripture explains as the result of the fall of man and the broken condition of the world. Where science may ultimately reduce eating disorders only to illness, Scripture makes it plain that there is often an element of personal sin involved as well. Science offers a variety of useful tools for addressing the bio-psycho-social aspects of eating disorders. When screened and applied according to Biblical principles, many of these tools can be quite effective. But Scripture offers a complete view of human beings and accurate moral guidance.
In sum, Biblical integration supports the judicious use of scientifically-valid treatment methods. It offers a personal relationship with Jesus Christ that can renew the mind through Scriptural truth and restore the soul through a covenant of continual forgiveness. Through Biblical integration with patient care, the needs of the Christian patient--body, soul, spirit, social relations, and personal sin--can be addressed with wisdom, truth, and God's transforming love.
References
1984. The Holy Bible, New International Version. New York: International Bible Society.
2002. Christian Counseling Today, 10. Glen Ellyn, IL: Christian Counseling Resources, Inc.
2002. The New Unger's Bible Dictionary. Chicago: Moody Press.
Remuda Review •
Bio-Psycho-Social-Spiritual: Completing the Model
Edward J. Cumella, PhD
Research Department
Remuda Programs for Eating Disorders
The Remuda Review: The Christian Journal of Eating Disorders
Fall 2002, Vol 1, Issue 1
Abstract. Health professionals conceptualize illness using a bio-psycho-social model. Recently, health professionals have also embraced the role of spirituality in their conceptualizations. Secular authorities typically reduce spirituality merely to psychological beliefs, emotional experiences, and the social support provided by church attendance. But Christians believe that the spiritual dimension of man exists as a distinct reality. Recent scientific studies on the efficacy of prayer and the health benefits of church attendance suggest the reality of the spiritual dimension. Furthermore, a large quantity of research and theory on the integration of spirituality into mental health has occurred in the Christian tradition. Christian conceptualizations and treatments of mental illness are therefore supported by extensive research.
In 1977, Dr. George Engel developed the “bio-psycho-social model” (Engel, 1977). His model has been adopted by the health professions as the primary model within which to conceptualize and treat both physical and mental illness. The bio-psycho-social model recognizes that mental illness arises from an interactive, dynamic process involving 1) genetic and biomedical factors, 2) psychological, emotional, behavioral, and cognitive factors, and 3) social and family factors. Each area may create a vulnerability to, or protect against, the development of specific mental illnesses. Somewhere among complex bio-psycho-social interactions, mental illnesses arise, progress, heal, or fail to develop at all.
The Spiritual Dimension
In the past decade, the health professions have also embraced the role of spirituality in the development of, recovery from, and protection against mental illness. Renowned psychiatric authorities have published books, and prestigious peer-reviewed journals have offered scientific papers on the importance of spirituality in mental health. Many US medical schools have added courses on spirituality to their standard training (Gundersen, 2000).
The “faculty at Harvard Medical School ... are teaching medical students how to obtain a spiritual history and how to discuss related concerns with their patients.” Americans are also asking for spiritual issues to be addressed in the clinician-patient relationship. Surveys reported by USA Today and Time Magazine indicate that 2/3 of Americans want their health providers to address religion with them. And perhaps as much as 1/2 of Americans want their doctors to pray with them (Gundersen, 2000).
In short, spirituality has found a place in our bio-psychosocial understanding of mental health and illness. Because spiritual beliefs influence thoughts and choices and are often shaped in a social context such as family or church, mainstream sources have come to recognize spirituality as an important aspect of individual psychology and social/family functioning. Spirituality is therefore seen as a key part of the “psycho-social” in the bio-psycho-social model.
But Christians might take a different view of this situation. While agreeing with the role of spirituality in mental health and illness, Christians might disagree with the reduction of spirituality to its mere psychological and social dimensions. Following Biblical teaching, Christians believe that human beings possess a body, a soul, and a spirit. The body clearly corresponds to the “bio” aspect of the bio-psycho-social model. The soul, translated from the New Testament Greek word, psyche, corresponds to the “psycho” aspect of the model. In keeping with this, Scripture informs us that souls consist of emotions, thoughts, and will--all common aspects of modern scientific psychology. Scripture also reflects man’s relational nature. Biblical concepts such as family, congregation, the communal Body of Christ, and national identity all express the social dimension and correspond readily to the “social” aspect of the bio-psycho-social model. But many Christians also believe that human beings have a spirit that is distinct from their soul. Christians assert the existence of an actual spiritual realm and believe that this spiritual reality interacts dynamically with man’s bio-psycho-social makeup. Christians would therefore propose that spirituality cannot be reduced merely to psychological beliefs, emotional experiences, and church socials. Spirituality exists above and beyond these phenomena.
For a Christian, therefore, human beings are bio-psychosocial-spiritual, and only a complete bio-psycho-social-spiritual model will fully address all the dimensions of mental health and illness.
Science and Spirit
Interestingly, focus on the spiritual dimension of man as a distinct reality is not only an article of Christian faith, but also a point with emerging scientific validity. For instance, in recent years there has been an effort to study prayer using scientific methods. Two separate research investigations have found scientifically valid evidence that Christian prayer affects the physical world.
In 1988, Randolph Byrd, MD, published a research paper on prayer in the Southern Medical Journal (Byrd, 1988). His paper followed the scientific method to establish a cause-and-effect relationship. In the study, a computer randomly assigned 393 coronary care patients at San Francisco General Hospital either to be prayed for by a prayer group or not. Since the patients were randomly assigned to prayer or non-prayer conditions, the scientific method allows us to assume that there was nothing inherently different about the patients in the two groups. Furthermore, neither the patients themselves nor anyone rendering treatment at the hospital knew to which group the patients had been assigned. The prayer groups were given only the patients’ first names. These safeguards created a double-blind study: since no one knew who was receiving prayer, no one could treat the prayer patients differently from the non-prayer patients, nor could the prayer patients benefit psychologically from the personal knowledge that someone was praying for them.
In short, we know that both groups of patients had similar medical histories, received the same medical care, and had similar psychological experiences regarding their medical problem. We must therefore attribute any differences in outcome between the prayer and non-prayer patients to the only known difference between them: the prayer that occurred on behalf of those assigned to the prayer groups. No one possessed enough information to inject any other difference into the groups of patients, so no other cause would present itself in the face of differential outcomes.
After ten months, the results indicated that those receiving Christian prayer were five times less likely to need antibiotics, 2-1/2 times less likely to suffer congestive heart failure, and less likely to suffer cardiac arrest.
Such results suggest that Christian prayer effects some kind of healing power. Since no one knew who was being prayed for (except, presumably, God), the differences between the two groups of patients had to derive from prayer itself and could not have arisen from any human intervention. Only prayer distinguished the groups, and therefore the only cause of the health improvement among those who were prayed for would be prayer itself.
In 1999, William Harris, MD, and his colleagues at Mid-America Heart Institute in Kansas City conducted a replication of Dr. Byrd’s 1988 study (Harris, et al., 1999). Harris et al.’s study used very similar methods to Byrd’s, but more patients— 990. In one methodological change, Harris’ cardiac patients did not even know that they were in a study at all, whereas Byrd's patients knew that there was a 50-50 chance that they were receiving prayer.
Harris et al. used a global measure of clinical outcome, and found that patients who received prayer scored 11% lower on the outcome scale. Lower scores mean better outcomes. The result was statistically significant, again suggesting the healing power of Christian prayer.
A second source of scientific evidence for the reality of the spiritual dimension involves recent scientific investigations into church attendance. One study was conducted at Duke University (Koenig, et al., 1999) with 3968 elderly North Carolina residents. The study found that those elderly persons who attended church at least once per week were 46% less likely to die during the six-year period of the study than those who attended church irregularly or not at all. We know that those who attend church are healthier than average due to less alcohol and tobacco use, and that they have more social support than others due to fellowship opportunities in their churches. Therefore, the authors used statistical techniques to tease out these differences—medical illnesses, health practices, social support measures, and demographics. Even when the effects of these factors were removed from the picture, the authors still found that church attendance decreased mortality by 28%.
A similar study tracked 5286 California residents (Strawbridge, Cohen, Shema, & Kaplan, 1997) over a much longer time period, 28 years. This study found a concordant result. People who regularly attended Christian services lived longer than those who did not. Once again, the impact of church attendance persisted even after medical conditions, health practices, and social support were accounted for.
Since it is difficult to fully measure and tease out the effects of health status and social support from the effects of church attendance per se, these studies on church attendance must be seen as less conclusive than the studies on prayer. Nevertheless, the church studies are indeed suggestive and they certainly meet the standards of proof expected of most modern social scientific findings. We cannot therefore dismiss them lightly. Together, they constitute credible evidence for the reality of a spiritual dimension. In conjunction with the demonstrated efficacy of Christian prayer, fair-minded individuals must acknowledge the likelihood that something apparently supernatural seems to exist and is capable of affecting the bio-psycho-social world.
Harold Koenig, MD, associate professor at Duke University Medical School, summarizes the situation thus: “On scientific grounds there is good evidence, in my view, that religious commitment... is associated with better health. And then there’s the tantalizing idea that there’s something beyond the social support, beyond the lifestyle and the meditation. Scientifically, you would say that’s something that we can’t explain. A person of faith would say that’s the hand of God” (quoted in Gundersen, 2000).
Clearly, then, modern science is arriving at the same view of human beings that the Bible has offered for thousands of years. The Bible through direct revelation, and science through an accurate study of the world God made, are both converging on a bio-psycho-social-spiritual understanding of human beings. Even for a purely secular practitioner who may not accept the reality of a spiritual realm and who may explain the impact of spirituality in purely psycho-social terms, it is nevertheless clear that spirituality matters and plays a role in the understanding, treatment, and prevention of mental illness.
Christian Integration
In this light, it becomes important to consider how to incorporate spirituality into our work with mentally ill people.
The prevailing view of mainstream authorities who promulgate the role of spirituality is that any spiritual tradition can be incorporated with equal effectiveness into treatment. And, of course, all mental health practitioners would agree that it is essential to respect and to work within patients’ existing spiritual beliefs. However, of the many spiritual traditions, by far the greatest quantity of research and theory on the integration of spirituality into mental health has occurred in the Christian tradition.
The field of integration studies endeavors to integrate counseling and Christianity into a unified conceptual and treatment model. Accredited universities and seminaries support this work, as do scientific journals dedicated exclusively or predominantly to this work, such as The Journal of Psychology and Christianity and The Journal of Psychology and Theology. Thousands of books have been written on the topic of recovery and healing from a Christian perspective. Therefore, the mental health professional wishing to follow the standards of the field and incorporate spirituality into his or her research or clinical work can draw on an extensive literature and evidenced-based content regarding the integration of patient care and Christianity. For other spiritual traditions, this wealth of resources is not available.
This leads us to a key point: Christian-based mental health programs are not only following the standards of current practice by integrating spirituality into treatment, but they are also doing so in perhaps the most scientifically-defensible and valid manner possible given the present state of knowledge.
In sum, Christian conceptualizations and treatments of mental illness are supported by extensive research. It is from this perspective that The Remuda Review intends to delineate and disseminate a Biblically-based, Christ-centered understanding of the etiology, assessment, and treatment of a specific class of mental illness--eating disorders.
Remuda seeks in its work and through this journal to apply the current scientifically-valid and Biblically-based understandings of mental illness to the specific problems of anorexia, bulimia, and related disorders. In so doing, we follow the currents of mental health practice and the standards of evidenced-based treatment, and we honor a Christ-centered, Biblical tradition.
We have presented in this article a brief summary of the scientific validity of Christ-centered treatment. In the companion article, Five Biblical Factors in Eating Disorder Development, we establish a Biblical basis for scientifically-developed mental health concepts and interventions. The two perspectives harmonize and support each other, both converging on a truly holistic approach to understanding and treating persons with mental illness: a bio-psycho-social-spiritual model.
References
Byrd, R.C. (1988). Positive therapeutic effects of intercessory prayer in a coronary care unit population. Southern Medical Journal, 81, 826-829.
Engel, G.L. (1977). The need for a new medical model: a challenge for biomedicine. Science, 196, 129-136.
Gundersen, L. (2000). Faith and healing. Annals of Internal Medicine, 132, 169-172.
Harris, W. S., Gowda, M., Kolb, J.W., Strychacz, C.P., Vacek, J.L., & Jones, P.G.. (1999). A randomized, controlled trial of the effects of remote, intercessory prayer on outcomes in patients admitted to the coronary care unit. Archives of Internal Medicine, 159, 2273-2278.
Koenig, H.G., Hays, J.C., Larson, D.B., George, L.K., Cohen, H.J., & McCullough, M.E.. (1999). Does religious attendance prolong survival? The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 54, M370-376.
Strawbridge, W.J., Cohen, R.D., Shema, S.J., & Kaplan, G.A. (1997). Frequent attendance at religious services and mortality over 28 years. American Journal of Public Health, 87, 957-961.
Remuda Review •
