The Exploration of

Factors Influencing
Recidivism in Eating
Disorders
Gretchen Kempf
Practice Scenario
O Mentor: Amy Ethridge
O Occupational therapist for 11 years
O Penn State Milton S. Hersey Medical
Center Adolescent Medicine and Eating
Disorders Clinic
O Outpatient facility
O Individual and Group therapy
PICO
O For clients with a diagnosis of an eating
disorder who are 14 years of age or older
and have successfully completed an
inpatient program, which of the following
three factors is most effective in reducing
the rate of recidivism: motivation to
change, the presence of support systems,
or the demonstration of healthy coping
skills?
Working Definitions
O Anorexia Nervosa:
O Refusal to maintain body weight at or above a minimally normal
weight for age and height, for example, 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.
O Intense fear of gaining weight or becoming fat, even though
underweight.
O Disturbance in the way 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.
O In postmenarcheal females, amenorrhea, i.e., the absence of at
least 3 consecutive menstrual cycles. A woman having periods only
while on hormone medication (e.g. estrogen) still qualifies as having
amenorrhea.

Working Definitions
O Bulimia Nervosa
O Recurrent episodes of binge eating characterized by both (1)
eating, in a discrete period of time (e.g., within any 2-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,
and (2) a sense of lack of control over eating during the episode
(such as a feeling that one cannot stop eating or control what or
how much one is eating).
O Recurrent inappropriate compensatory behavior to prevent weight
gain, such as self- induced vomiting, misuse of laxatives, diuretics,
enemas, or other medications, fasting, or excessive exercise.
O The binge eating and inappropriate compensatory behavior both
occur, on average, at least twice a week for 3 months.
O Self-evaluation is unduly influenced by body shape and weight.
O The disturbance does not occur exclusively during episodes of
Anorexia Nervosa.

Working Definitions
O Eating Disorder Not Otherwise Specified
O This diagnosis includes disorders of eating that do not meet the
criteria for the above two eating disorder diagnoses. Examples
include: (1) For female patients, all of the criteria for Anorexia
Nervosa are met except that the patient has regular menses; (2) All
of the criteria for Anorexia Nervosa are met except that, despite
significant weight loss, the patient's current weight is in the normal
range; (3) All of the criteria for Bulimia Nervosa are met except that
the binge eating and inappropriate compensatory mechanisms
occur less than twice a week or for less than 3 months; (4) The
patient has normal body weight and regularly uses inappropriate
compensatory behavior after eating small amounts of food (e.g.,
self-induced vomiting after consuming two cookies); (5) The patient
engages in repeatedly chewing and spitting out, but not swallowing,
large amounts of food; and (6) Binge-eating disorder: recurrent
episodes of binge eating in the absence of regular inappropriate
compensatory behavior characteristic of Bulimia Nervosa.

Search Strategy
O Databases: CIHNAL and Google Scholar
O Key words: eating disorders and adolescents, adolescents with
eating disorders, teens with eating disorders, motivation to change,
social support systems, healthy coping skills, and recidivism
O Journals: European Eating Disorder Review, International Journal
of Eating Disorders, Journal of Clinical Child & Adolescent
Psychology, Eating Disorders, and Journal of Clinical Psychology
O Inclusion criteria:
O Subjects must have a diagnosis of an eating disorder according to
criteria set forth in DSM-IV-TR
O Studies must involve only adolescent participants who are fourteen
years of age or older
O Studies must focus on one or more of the following factors:
motivation to change, social support, and/or healthy coping skills
O Subjects must have successfully completed an inpatient treatment
program for their eating disorder

Matrix
Matrix
Matrix
Matrix
Synthesis
O Scarce literature
O No direct comparative studies of all three
factors
O Factors of recidivism are almost
impossible to isolate
O Complex relationship of all three factors
O Some factors may influence one another to
ultimately lead to recidivism or a full
recovery

Synthesis
O Several studies conclude that the presence of
a motivation to change appears to be a
necessary element in preventing recidivism
after recovery from an eating disorder
O Researchers have concluded that lack of
internal motivation to recover may lead to
premature termination of the treatment.
O May also be due to having social support
O not clear from cases if treatment was
terminated too early in order to please an
unsupportive family member or partner of the
subject participant

Synthesis
O several studies showed evidence of other
factors that may result in recidivism even
in the presence of a motivation to change:
O Fear of change, ambivalence, professional
rigidity and media influence
O Glen Waller- Any research result that
stems from reliance on stated expressions
of motivation by subject participants
should be viewed with a high degree of
suspicion.

Synthesis
O Importance of the parent-adolescent
social relationship as a factor in recovery
was examined in a study conducted by
Kathy Dowell and Benjamin Ogles
O Compared a child-only intervention to a
combined child-parent intervention for
eating disorders.
O parent participation in child psychotherapy
treatments added moderate
improvements to the outcomes of the
childs treatment
Synthesis
O In one study, participants stated that their
treatment outcome was influenced by developing
healthy coping skills
O Treatment focused solely on weight loss was
damaging
O Treatments that focused on healthy coping skills
and healthy eating habits were much more helpful
and informative.
O evidence in the literature to support the hypothesis
that healthy coping skills lessen eating disorder
symptomatology
O increases the subject participants motivation to
change, which ultimately leads to better outcomes
for recovery

Conclusion
O Inconclusive
O Despite lack of direct comparison, the
literature appears to indicate that all three
factors (namely, motivation to change,
social support, and healthy coping skills)
play a critical, but complicated, role in
maintaining a successful recovery from an
eating disorder.


Implications for OT
O Each case of an eating disorder must be treated in a
unique manner in order to have a good treatment
outcome
O Occupational therapists can provide valuable
assistance to the client in areas such as:
O time use analysis, keeping a balance in life, the
identification and development of coping skills, grocery
shopping and meal planning advice, eating in a public
place such as a restaurant or school cafeteria, creating
a plan for a return to work or school, and finding
enjoyable healthy activities to replace eating disorder
behaviors.
O Occupational therapists promote health and
participation in life through engagement in
occupations