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Continuing Education

Welcome to the continuing education course for Marriage and Family Therapists (MFTs) and Licensed Clinical Social Workers (LCSWs). Rader Programs is pleased to be board certified to offer continuing education credit for MFTs and LCSWs by the California Board of Behavioral Sciences. Our provider number is PCE 1842. This course meets the qualifications for two hours of continuing education credit for MFTs and LCSWs as required by the California Board of Behavioral Sciences. The course content is on the understanding of the eating disorders. The Objectives of the course are to enable the participant to identify and understand the psychological and physical components of an eating disorder.

Once you have reviewed the course below, you will be asked to print and complete a short quiz. Please send the competed quiz to Rader Programs by fax to 818-880-3750 or mail to 26560 Agoura Rd. #108, Calabasas CA 91302. Within one week of receiving the quiz you will then be e-mailed or mailed your certificate of course completion for the two hours of continuing education.

Continuing Education Course for Marriage and Family Therapists

What Are Eating Disorders?

Eating disorders are characterized by severe disturbances in eating behavior. The practice of an eating disorder can be viewed as a survival mechanism. Just as an alcoholic uses alcohol to cope, a person with an eating disorder can use eating, purging or restricting to deal with their problems. Some of the underlying issues that are associated with an eating disorder include low self-esteem, depression, feelings of loss of control, feelings of worthless, identity concerns, family communication problems and an inability to cope with emotions. The practice of an eating disorder may be an expression of something that the eating disordered individual has found no other way of expressing. Eating disorders are usually divided into three categories: Anorexia Nervosa, Bulimia Nervosa and Compulsive Overeating.

Society is changing its values towards the male body. Societal pressures to obtain the "ideal" body image are no longer gender specific. To attest to this you only have to peruse a magazine rack to notice the proliferation of men's magazines whose focus is on looks, fitness, and nutrition. Only a decade ago you could only find one or maybe two magazines dedicated to these issues, now there are over 20.

Anorexia Nervosa

Anorexia is a disorder where the main characteristic is the restriction of food and the refusal to maintain a minimal normal body weight. Any actual gain or even perceived gain of weight is met with intense fear by the Anorexic. Not only is there a true feeling of fear, but also once in the grasp of the disorder, Anorexics experience body image distortions. Those areas of the body usually representing maturity or sexuality including the buttocks, hips, thighs and breast are visualized by the Anorexic as being fat. For some Anorexics, weight loss is so severe there is a loss of menses. In the obsessive pursuit of thinness, Anorexics participate in restrictive dieting, compulsive exercise, and laxative and diuretic abuse. Weight loss is usually achieved through the significant reduction of total food intake. The restriction of nutrition usually begins with the avoidance of high calorie foods, but quickly progresses to the adherence of a diet that is limited to only a few food items. The restricted diet is often eaten in a ritualistic manor. Examples include; strict weighing of all food items prior to consumption, drinking water after each bite of food, and eating only one type of food at a time, This ritualistic behavior gives the Anorexic an additional sense of control over their food. Weight loss is perceived as an act of achieved self-discipline and renewed control. Any weight gain, on the other hand is considered failure and unacceptable. Medical complications from the disorder can be severe. If left untreated, Anorexia Nervosa can be fatal. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM, IV) lists the diagnostic criteria for Anorexia Nervosa as follows:

* A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected).

* B. Intense fear of gaining weight or becoming fat, even though underweight.

* C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.

* D. In postmenarcheal females, amenorrhea, i.e., the absence of at least amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.)

The DSM, IV further classifies Anorexia Nervosa into two types, Restricting and Binge-Eating/Purging. For the Restricting type of Anorexia the individual does not regularly participate in binge-eating or purging behavior. For the Binge-Eating/Purging type the Anorexic does regularly participate in binge-eating or purging behavior.

Bulimia Nervosa

Bulimics are caught in the devastating and addictive binge-purge cycle. The Bulimic eats compulsively and then purges through self-induced vomiting, use of laxatives, diuretics, strict diets, fasts, vigorous exercise, or other compensatory behaviors to prevent weight gain. Binges usually consist of the consumption of large amounts of food in a short period of time. Binge eating episodes are often triggered by dysphoric mood, stress, dietary restraint, body image concerns, or boredom. The binge eating usually occurs in secret and there is a feeling of lack of control over the binge behavior. The type of foods eaten during a binge vary but are usually high caloric food with a high content of fat. The binge behavior is terminated by uncomfortable feelings of fullness, interruption by others, or purging behavior. The binge is then followed by feelings of guilt, shame, and remorse. To compensate for the binge and the associated feelings, Bulimics participate in purging behavior. The most common form of purging is self-induced vomiting. The purging behavior temporarily reduces the feeling of fullness and the fear of gaining weight. But this temporary relief is followed by feelings of guilt, shame and disgust for participating in the purging behavior. Bulimics, like Anorexics, are also obsessively involved with their body shape and weight. Constant weighing and emphasis on body self-evaluation is a hallmark of the disorder. The medical complications of the binge-purge cycle can be severe and like Anorexia can be fatal. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM, IV) lists the diagnostic criteria for Bulimia Nervosa as follows:

* A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

1. eating , in a discrete period of time (e.g., within any two hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances

2. a sense of lack control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)

* B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.

* C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for three months.

* D. Self -evaluation is unduly influenced by body shape and weight.

* E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa.

The DSM, IV further classifies Bulimia Nervosa into two types, Purging and Nonpurging. Purging classification of Bulimia refers to when an individual with Bulimia regularly engages in self-induced vomiting, or the misuse of laxatives, diuretics or enemas. Nonpurging Bulimia refers to the use of other compensatory measures such as strict dieting and excessive exercise as the main method of weight loss.

Compulsive Overeating

Compulsive Overeaters are often caught in the vicious cycle of binge eating and depression. They often use food as a coping mechanism to deal with their feelings. Binge eating temporarily relieves the stress of these feelings, but is unfortunately followed by feelings of guilt, shame, disgust, and depression. Binge eating, like Bulimia, often occurs in secret. It is not uncommon for Compulsive Overeaters to eat normally or restrictively in front of others and then make up for eating less by bingeing in secret. For other Compulsive Overeaters, binges consist of "grazing" on foods all day long. Like the other eating disorders, Compulsive Overeaters are constantly struggling and unhappy with their weight. It is not uncommon for the number on the scale to determine how they feel about themselves. Medical complications can also be severe and even life threatening for Compulsive Overeaters.

Prevalence and Outcome

Each year, millions of people in the United States succumb to potentially life-threatening eating disorders. Estimates of people afflicted with Anorexia Nervosa and Bulimia Nervosa in the United States range from 2% to 6%. This implies that between 5 and 16 million people suffer from these disorders. Approximately 90% of those afflicted with these disorders are women. The potentially fatal disease, Anorexia Nervosa, occurs within the population at approximately .5% to 2%. Estimates for the occurrence of Bulimia Nervosa range between 1% to 4% of the population. Although eating disorders can affect people of all ages, 86% of individuals afflicted with these disorders report the onset before the age of 20. The occurrence of eating disorders among college age women can almost be considered epidemic. Between 19% and 30% of this age group display bulimic behavior. The current trend is that eating disorders are affecting younger and younger individuals. It is estimated that currently 11% of high school students may have a diagnosable eating disorder. Athletes and dancers may face a greater risk for developing an eating disorder. In ballet, for example, success may depend on the attainment of a wiry and extremely thin body type. For athletes, particularly women in "appearance sports" which include gymnastics and figure skating, appearance also seems to play a key role in success. Of females who participate in these types of athletic activities, as well as track and cross-country, 62% have been reported to have eating disorders.

Course and Outcome of Eating Disorders:

The onset for Anorexia Nervosa and Bulimia Nervosa is usually during late adolescence or early adulthood. The illnesses usually begin following a stressful life event. Many eating disordered individuals feel out of control with their life and through the practice of the eating disorder get a false sense of control. They often went through a period of being overweight and being teased or felt left out because of their weight. Their first attempts at weight loss were often met with success and positive comments from their family and peers. Of individuals with eating disorders, 77% usually practice their eating disorders between 1 and 15 years. Eating disorders are among the deadliest mental disorders with up to 10% succumbing to death as a result of starvation, cardiac arrest, or suicide. Eating disorders are most successfully treated with early diagnosis. For anorexics that receive treatment, 40% recover completely, 40% make only partial recovery, and 20% have chronic problems. For bulimics, 50% recover completely, 35% have some bulimic episodes, and 15% still have chronic problems with their bulimia.

Medical Complications of Eating Disorders

The following is a list of possible medical complications that accompany Eating Disorders. If left untreated the physical complications can become life threatening.

* Low blood pressure
* Electrocardiogram abnormalities
* Hypovolemia
* Myocardiopathy and CHF (especially with use of ipecac)


* Uric acid elevated
* Cholesterol is abnormal(elevated or depressed)
* Carotene is elevated
* Deficiencies of trace minerals
* Low blood glucose
* Hypochloremic metabolic alkalosis


* Increased dental caries
* Highly sensitive teeth from gingival deterioration
* Pyorrhea
* Lacerations and contusions of the oral cavity from use of objects to induce emesis


* T-3 deficiency(leading to bradycardia, hypercarotenemia, sluggish reflexes, dry skin, cold intolerance and various abnormalities of the hair)
* Abnormal calcium levels and symptoms
* Hypogonadism
* Addisons disease or hyperaldosteronism
* Partial diabetes insipidus condition and the inability to concentrate urine normally


* Dry skin
* Loss of subcutaneous tissues and fat in general
* Scars (such as on knuckles due to inducing emesis)
* Acrocyanosis
* Fine lanugo hair


* Lack of REM sleep
* EEG abnormalities
* Affected hypothalamus(lower body temperature, cold intolerance, loss of shivering response and malfunction of entire temperature regulating system) due to chronic malnutrition


* Abdominal pain, bloating, and fullness
* Irritable bowel syndrome
* Esophageal perforations and lacerations(Mallory-Weiss Syndrome)
* Malabsorption of nutrients leading to hypoalbuminemia, hypoproteinemia and calcium deficiency
* Ulceration of the bowel
* Fatty infiltration of the liver
* Pancreatitis
* Esophagitis
* Exacerbation of hemorrhoids
* Melanosis coli
* Gastric ulceration
* Gastritis


* Effects of resultant metabolic alkalosis, potassium and chloride deficiencies
* Diminished reflexes
* Skeletal muscle weakness
* Abnormal gastrointestinal motility
* Paresthesia
* Cramps
* Polyuria and oliguria
* Nocturia
* Constipation
* CNS abnormalities
* Cardial effects(conduction abnormalities, irregular rhythms and sudden death)
* Emotional lability and lassitude
* Impaired kidney function
* Potassium increase due to diuretic abuse causing cardiac abnormalities
* Dehydration
* Depletion of sodium(hyponatremia)


* Anemia
* Thrombocytopenia
* Leukopernia
* Bone marrow may be deficient or hypocellular


* Menstrual irregularity
* Infertility
* Amenorrhea
* Breast atrophy
* Atrophic vaginitis and loss of sexual appetite


* Dark circles, puffiness under the eyes
* Transient blurred vision


* Tubular and collecting system abnormalities due to electrolyte abnormality
* Prerenal and renal azotemia due to diminished renal pertusion and chronic dehydration
* Predisposition to renal stones


* Loss of muscle mass leading to muscular weakness
* Osteoporosis


* Aspiration pneumonia


* Bacterial and fungal infections
* Bilateral parotid gland swelling

Neurochemistry in Eating Disorders

Findings from the study of the neuroendocrine system have led to the development of medicine therapies that help eating disordered individuals overcome their mental illness. Researchers have found that the neurotransmitters serotonin and neuroepinephrine are significantly decreased in acutely ill patients suffering from Anorexia and Bulimia Nervosa. These neurotransmitters also function abnormally in individuals afflicted with depression. This leads some researchers to believe there may a link between these two disorders. Besides creating a sense of physical and emotional satisfaction, the neurotransmitter serotonin also produces the effect of feeling full and having had enough food. These effects support the use of certain antidepressant medications for the treatment of eating disorders. The most commonly used antidepressants for Bulimia include imipramine (Tofranil), desipramine (Norpramin), and fluoxetine (Prozac). Other medications that effect serotonin that have been used for Bulimia Nervosa include Zoloft and Paxil. An herb that has been used for the treatment of eating disorders is St. John's Wort, also known as hypericum (hypericum perforatum). Hypericum seems to work as a serotonin reuptake inhibitor. Similar to Prozac, hypericum may allow additional serotonin to be available, therefore providing the person with a sense of fullness and a more general feeling of well-being. Some physicians are using Naltrexone, a medication that blocks the production of natural opioids. The belief is that the drug will prevent pleasure experienced during binges for the bulimic and restricting for the anorexic.

Other brain chemicals have been explored for their possible role in eating disorders. Individuals with eating disorders have been shown to have a higher than normal level of the hormones vasopressin and cortisol. Both these hormones are normally released in response to physical and possible emotional stress, and may contribute to some of the dysfunction seen in eating disordered individuals. Other research has found high levels of the neuropeptide-Y and peptide-YY to be elevated in patients with Anorexia and Bulimia. These chemicals have been shown to stimulate eating behavior in laboratory animals. The hormone cholecystokinin (CCK) has been found to be low in women with Bulimia and has caused laboratory animals to feel full and stop eating.

Body Image and Eating Disorders

To understand the body image dysfunction of eating disordered individuals, it is helpful to look at our first experiences in learning about our bodies. During infancy, physical sensations of the body are the way we begin to formulate the separate sense of ourselves from an otherwise seemingly shapeless and boundless space. How we feel about our bodies developed in direct response to how our caregivers treated our bodies during infancy and childhood. The ways in which we were touched, held, caressed and nurtured even before we could communicate sent us the message about how we should feel about our bodies. Individuals who were touched apathetically, held insecurely and neglected often develop poor and distorted body images later in life.

During childhood we explored our bodies. If we were told that touching ourselves was "bad" we could have inferred the message that our bodies were something to be ashamed of. Comments about weight and teasing by family members can also lead to negative feelings about one's body. Not only the messages we received about our own bodies but how our parents related to their own bodies influenced our level of body image acceptance. Parents who displayed dissatisfaction with their bodies were likely to have children with body image disturbances.

During adolescence the influence of peers became important. Self monitoring and comparing ourselves to others becomes central to our psyche. This may have been a time when we were particularly vulnerable to images in the media and the pressures from our peers. As our bodies developed and changed, how we and others reacted to these changes influenced our eventual body perception. Other possible catalysts to a poor body image could have included sexual abuse, physical abuse, domineering coaches and controlling relationships.

Individuals with eating disorders often exhibit discomfort and dissatisfaction with the parts of their body usually associated with body shape change or increased "fatness" at puberty i.e., hips, thighs, buttocks and breasts. Although body image distortions are a main component of both Anorexia and Bulimia, some eating disordered individuals may have an overall concept of their body size but still be obsessed and dissatisfied with certain body parts. Obsessive weighing is used a means to evaluate not only their body, but often their self-worth.

Treatment for eating disorders individuals includes the confrontation of the body image distortions, and helping the individual to begin to develop a more positive body image. The eating disordered individual is helped to de-program themselves from the negative messages they have internalized over the years. This is accomplished by facilitating the individual in connecting with, taking ownership of, and appreciating their body. The use of video, art, and writing are all techniques that are used to combat the obsession and distortions. One therapeutic tool utilized is having the eating disordered individual make a list of the parts of their body they like and the amazing things they can do with their body. This is in direct contrast to their usual relationship with their body of discounting and concentrating on those aspects that they dislike. Eating disordered individuals are taught that constantly weighing themselves sets them up for a negative experience that can lead to dissatisfaction and obsession. Many individuals who have moved into recovery of an eating disorder have chosen to smash their scales and in the process have freed themselves from having their emotions tied to a number that has nothing at all to do with who they really are. It is also important for the eating disordered individual to re-program themselves by replacing any false messages they have received about how they should look with realistic goals that take into account their own personal beauty and uniqueness. Some recovering individuals facilitate this by choosing to avoid and not purchase fashion magazines that promote a body type that fits less then three percent of the population.

Media and Eating Disorders

The influence of the media on the proliferation of eating disorders cannot be refuted. From an early age we are bombarded with images and messages that reinforce the idea to be happy and successful we must be thin. Today, you cannot read a magazine or newspaper, turn on the television, listen to the radio, or shop at the mall without being assaulted with the message that fat is bad. The most frightening part is that this destructive message is reaching kids. Today even elementary school aged children are obsessed with their weight. The following are statistics and facts that document how obsessed we are as a society with the pursuit of thinness.

* One out of three women and one out of four men are on a diet at any given time.

* In one study, three out of four women stated that they were overweight although only one out of four actually were.

* Two out of five women and one out of five men would trade three to five years of their life to achieve their weight goals.

* Diet and diet-related products are a 33 billion dollar a year industry.

* In 1970 the average age a girl started dieting was 14; by 1990 the average age dropped to 8.

* One half of 4th grade girls are on a diet.

* While only one out of ten high school girls are overweight, nine out of ten high school juniors and seniors diet.

* Following viewing images of female fashion models, seven out of ten women felt more depressed and angrier than prior to viewing the images.

* When preschoolers were offered dolls identical in every respect except weight, they preferred the thin doll nine out of ten times.

* A study asked children to assign attractiveness values to pictures of children with various disabilities. The participants rated the obese child less attractive than a child in a wheelchair, a child with a facial deformity, and a child with a missing limb.

* A study found that women overestimate the size of their hips by 16% and their waists by 25%, yet the same women were able to correctly estimate the width of a box.

* In a Glamour survey, 61% of respondents said they were ashamed of their hips, 64% were ashamed of their stomachs and 72% were ashamed of their thighs.

* 30% of women chose an ideal body shape that is 20% underweight and an additional 44% chose an ideal body shape 10% underweight.

* In 1950 mannequins closely resembled the average measurements or women. The average hip measurement of mannequins and women were 34 inches. By 1990 the average hip measurement was 37 inches, while the average mannequins hip measured only 31 inches.

* If today's mannequins were actual human women, based on their theoretical body-fat percentages they would have probably ceased to menstruate.

* 50% of women wear size 14 or larger, but most standard clothing outlets cater to sizes 14 or smaller.

* Over the last three decades fashion models, Miss Ameri ca contestants, and Playboy centerfolds have grown steadily thinner, while the average woman's weight has actually risen.

* Twenty years ago the average fashion model weighed 8% less than the average woman. Today she weighs 23% less.

* Kate Moss is 5'7" and weights 95 pounds. That is 30% below ideal body weight.

* Pamela Anderson is 5'7" and weights 120 pounds. She is supposed to be the voluptuous ideal yet she is 11% below ideal body weight. In contrast, a generation ago Marilyn Monroe set the beauty standard at 5'5" and weighed 135 pounds. Today her agent would probably tell her she had to lose weight!

Changing society's view cannot happen overnight, but here are a few suggestions to help defend against negative messages:

* Be Realistic - Women's bodies are designed to store fat for a developing child. Those models and actors you admire starve themselves, punish themselves with extreme workouts and endure surgery to look the way they do.

* Variety is the spice of life - If we all looked exactly the same life would be boring. Get into the uniqueness of you.

* Appreciate your body - Reestablish a positive relationship with your body. Your body is the most valuable asset you will ever own. All of Bill Gates money could not recreate you. Learn to appreciate the amazing things you can do with your body. Make a list of those things you like about your body.

* Pamper your body - Take a long hot bath and sooth yourself. Spoil yourself by getting a massage.

* Exercise - Studies have shown that when people participate in even moderate exercise, such as walking, they feel more connected and better about their bodies.

* You can't judge a book by its cover - There is a lot more to you than what you look like. Make a list of your traits that you really like. Think about the people you admire and look up to. You admire these individuals because of who they are, not because of what they look like.

* Be a good role model - Your children will have enough pressure from the media and peers. Try not to express dissatisfaction with your body in front of your children. Studies have shown that parents who displayed dissatisfaction with their body were more likely to have children with body image disturbances when they became adults.

Abuse and Eating Disorders

Some studies have shown the significant occurrence of both sexual and physical abuse among eating disordered individuals. We have found that over 80 percent of our clients have had some type of abusive experience. The development of an eating disorder, in some instances, can almost be viewed as a survival mechanism to attempt to shield the individual from further harm. For compulsive overeaters, they may unconsciously make themselves larger to separate and protect themselves from others. Anorexics may unconsciously make themselves smaller, losing their secondary sexual characteristics (breasts, hips, and buttocks) to avoid a sexual identity, almost achieving a prepubescent state. Some survivors of abuse even act out sexually to unconsciously conquer their abusive experience. For survivors of abuse, the obsessions and compulsions about weight and body image may be an attempt to regain control of their bodies. This unconscious drive to achieve a "perfect " body may be a response to the feeling of having their control stripped from them through the abuse experience.

Both survivors of abuse and individuals with eating disorders often exhibit discomfort and dissatisfaction with the parts of their body usually associated with body shape change or increased "fatness" at puberty i.e., hips, thighs, buttocks and breasts. Survivors of abuse may be dissatisfied with these aspects of their bodies because they represent sexuality. They often express a desire to return to the prepubescent stage, which occurred before the painful confusion of sexuality. Feelings of distrust, inadequacy, insecurity, disconnection, and worthlessness are common.

Common Roles Played in a Substance Abuse Family

Similar to alcoholic families, eating disordered family members often take on certain roles within the family system. These roles are in no way set in stone and family members often take on different roles at different times in their life. Some of the most common roles are as follows:

Enabler- the enabler is usually the individual emotionally closest to the eating disordered person. They watch over, protect and conceal for the eating disordered individual. Enablers often keep track of eating disordered individuals by listening at bathroom doors and checking the trash for food wrappers. Denial can also be central to the enabler as they often deny to others and even themselves the extent and severity of the eating disorder. Denial of the disorder to others is achieved through the enabler concealing the effects of the eating disorder through taking on responsibilities for the eating disordered individual. These responsibilities include work/schoolwork duties, parenting, and household duties.

Hero- usually the oldest child in the family takes on or is given the role of the hero. They are often perceived as being helpful within the family and as successful in their pursuits. Attention early in their life gives them a partial sense of worth and they often continuously strive to achieve approval and recognition. The hero is often the beacon of the family and represents for the family what is right with the family. Underneath the successful and confident exterior lies a sense of inadequacy and guilt. Part of these feelings are a result of the hero's inability to fix the family and eating disordered individual.

Scapegoat- the scapegoat is often the second child in the family. Since much of the family attention has been directed to the hero, the scapegoat gains attention by acting-out and getting in trouble. Since they perceive they can never get the praise the hero receives, negative attention is better than receiving no attention at all.

Lost Child- the lost child is usually the middle child in the family. By the time the lost child enters the family, the family members are too preoccupied with their own behaviors and roles to allow for quality time. The lost child is often shy, introverted and withdrawn. Since they never had the opportunity to learn to socialize within the family, they find making friends difficult. To cope, the lost child turns inward and develops a fantasy life. The lost child is particularly vulnerable to the development of an eating disorder as they often use food to comfort themselves.

Mascot- the mascot is usually the last one born into the family. The way they receive attention is to be funny, cute, and entertaining. When there is pain in the family they divert attention through making a joke or light of the situation. The mascot finds difficulty with growing up because they have been rewarded for their childlike behavior. Since they have not been taken seriously in the family they often grow up feeling unimportant and inadequate.

Co-dependents who as adults become involved with an eating disordered individual often come from an eating disorder, substance abuse or other dysfunctional family themselves. Usually, they grew up in a family where one parent was missing. This does not have to mean that the one parent is physically missing, but more likely that the one parent was absent in their role as a parent. The parent may be eating disordered, a substance abuser, suffer from an illness, grieving over the loss of a loved one or even a single parent. In all these circumstances the co-dependent feels abandoned, if not physically than emotionally.

The co-dependent learns early in life that there is no room for them to be a child. By the time they enter the family there is usually so much dysfunction, that the parents are not able to give attention to them for being a child. The co-dependent learns that the way to receive the attention that all children need is to drop the role of a child and take on the role of an adult. In this new role the young co-dependent learns there is no room to show feelings. They feel that expressing feelings gets them in trouble or ignored, at best. The young co-dependent becomes a caretaker, almost taking on the role of the unavailable parent. They take care of the present parent and often the other children in the house. Their goal in life becomes one of trying to fix others. Self esteem, identity and ego are all tied into their ability to cure others. Underlying feelings of insecurity and failure are present as a result of not being able to control all negative situations.

As an adult control now becomes central to the individual's life. Co-dependents feel if they can only control the disease, everything will turn out OK. Co-dependents usually start off trying to help the eating disorder person by giving support and trying to reward the desired behaviors. When encouragement and reward do not work, the co-dependent changes strategies and delivers subtle threats. These threats quickly escalate, cumulating into the ultimate threat of all, leaving the relationship. This threat is usually withdrawn, leaving the co-dependent feeling helpless and guilty. The investment in controlling the disease is so great because they not only want to save their loved one but also their self-esteem is at risk.

As we have seen, co-dependency often occurs in the family of an eating disordered individual. Its results can be as devastating to the co-dependent as to the eating disordered individual themselves. For this reason, it is imperative to include a family component as part of any eating disorder treatment.

Men and Eating Disorders

"It's a disease, and a disease has no gender, it picks on men and women alike."

The incidence of women with eating disorders is so prevalent that many people believe that eating disorders only affect women. This is a deadly myth. The stigma attached to these disorders may cause millions of men to remain without support, treatment and recovery. Just as women once rarely acknowledged their alcoholism, men are reluctant to admit they suffer from eating disorders. Part of the hesitancy may stem from the fear of seeking support for a "female problem". Men can and do suffer from Anorexia, Bulimia and Compulsive Overeating. Men are resistant to ask for help because since childhood they are told to "be in control", "tough it out", and "handle it themselves" without seeking out help. Not to be able to control something in life is mistaken as a sign of weakness for men. Men are often not given permission to express their feelings and may turn to food to cope with uncomfortable feelings.

The under diagnosis of eating disorders in men is not limited to the lay public but unfortunately also includes physicians and other healthcare providers. The loss of menstrual cycles in anorexic women is not present in anorexic men, which often alerts professionals to the disorder. For men levels of testosterone decrease along with sexual libido, which often go unreported or unnoticed. Bulimia may partly go unrecognized in men, as overeating by men is less likely to evoke concern.

Many of the underlying issues that attribute to an eating disorder; low self-esteem, depression, feeling of loss of control, abuse, identity concerns, inability to cope with emotions and family communication problems are the same for both men and women. There are some variations in these issues that manifest themselves differently in men. Men for example, are more concerned with body size and shape, whereas women are more concerned with weight. Body image concerns are a strong indication of eating disordered behavior in men. Men with eating disorders usually began developing a negative relationship with their bodies as a result of teasing and taunting by their peers. This teasing and rejection by others becomes internalized and leads to the individual becoming disconnected and ashamed of their own body. Our culture values athleticism and pushes the masculine ideal for boys. Eating disordered men report having had difficulty fitting into the masculine values of competitiveness, aggressiveness, strength, athleticism and independence. Boys who later in life develop eating disorders tend to be more passive, non-athletic, and dependent then their non-eating disorder counterparts. It is command to hear the memories of pain and embarrassment of having been the last one chosen for athletic teams.

The pressure of weight restrictions in certain sports is fostering eating disorders among athletic individuals as well. These sports include wrestling, gymnastics, swimming, horse racing, running, rowing, and bodybuilding. Among bodybuilders the dangerous use of steroids can cause serious side effects including, depression, sexual dysfunction, and other physical disorders.

Adolescence, the period in life where identity is developed and defined, is a particularly difficult time for eating disordered males. The development of an eating disorder may be partially the result of an attempt by the individual to unconsciously deal with gender identity conflicts. Confusion and anxiety about becoming a man and sexuality can be temporarily avoided by the practice of an eating disorder. Some males attempt to deal with their sexual impulses by participating in eating disorder behavior as a way to attempt to regain control over their bodies. Starvation, a practice of anorexics, can reduce the production of testosterone and subsequently reduce sexual drive.

Families also play a role in eating disordered behavior. Fathers often relate more with their sons physically then emotionally. Mothers often relate to their daughters through emotions and feelings, fathers on the other hand, tend to relate to sons through the participation in athletic activities. Mothers will often talk to their daughters about what is going on in their life, whereas fathers are more likely to toss a baseball or football. If a son is not proficient at sports, he may feel he ha not only let down his father but also lost a channel of communication. It is also important to note that many eating disordered men identify more closely with their mothers than with their fathers.

Society is changing its values towards the male body. Societal pressures to obtain the "ideal" body image are no longer gender specific. To attest to this you only have to peruse a magazine rack to notice the proliferation of men's magazines whose focus is on looks, fitness, and nutrition. Only a decade ago you could only find one or maybe two magazines dedicated to these issues, now there are over 20.

Quiz and Certification of Completion

Now that you have reviewed the course on line, please complete the short quiz and send to Rader Programs by fax to 818-880-3750 or mail to 26560 Agoura Rd. #108, Calabasas CA 91302. Within one week of receiving the quiz you will then be e-mailed your certificate of course completion for the two hours of continuing education. To begin the course click on the link below.

Download the Rader Programs Eating Disorder Continuing Education Quiz here.