Cover Story

In recent months, the media shocked the nation with reports of pro-anorexic Web sites, vehicles through which young women share self-starvation strategies. Amid the public outrage that followed, most of the sites shut down. But there persists an older, less publicized problem--the sharing of starvation tips in inpatient clinics, the very places patients go to put the weight back on.

The phenomenon has not been researched. The low incidence of anorexia nervosa and inconsistency in its treatment make such study difficult. Still, this issue of "contagion" among inpatients has come under increased scrutiny as more clinicians raise concerns about a problem not unlike prisoners trading lock-picking advice.

"Just as antisocial kids teach each other about making weapons, anorexic patients can learn from each other negative tricks of the trade," says Eric Stice, PhD, an eating disorders researcher at the University of Texas at Austin. "You can even get competition on wards to outdo each other maintaining low body mass."

Stice notes that the alternative of outpatient treatment is one way to curb the problem, but other experts say the focus should rather be on suppressing it in inpatient treatment through increased awareness, stricter rules and better communication.

Trading tips

Patients can learn from each other indirectly through modeling or directly through advice--for example, a patient demonstrates how to dump cafeteria food into a potted plant. This, in fact, was the ward experience of a patient who later received outpatient treatment from psychologist Pamela Raizman, PhD, an eating disorders researcher and clinician at the New York State Psychiatric Institute at Columbia Presbyterian Medical Center. Patients used the method to dupe staff who checked their trays for evidence of food consumption, explains Raizman, but she notes that such behavior is not meant to offend staff but rather reflects an internal struggle patients have between recovery and illness.

Typically patients pick up destructive behaviors just by watching others or gossiping, she says. They may learn ways to burn calories by exercising on the sly, for example--performing sit-ups late at night, pacing or even furtively flexing muscles while sitting. "Of particular concern," says Raizman, "are the patients who before were just restrictive and now learn about purging."

In a particularly disturbing case, notes Raizman, a patient vomited into small cups after meals and hid them in the coils of her mattress. Often, however, weight-loss techniques may not be practiced until after a patient's release from the hospital. A recent study involving 193 anorexic patients suggests that, while most patients maintain improvement on short-term follow-up after being released, those who gain the most weight on the unit lose the most once they leave. One implication of this may be that they gained weight to get out, says psychologist Michael Lowe, PhD, an MCP Hahnemann University eating disorders researcher who conducted the study with Rachel Annunziato, and Dara Lucks, also at MCP Hahnemann, and Bill Davis, PhD, at the Renfrew Center in Philadelphia. (Lowe presented the findings in a conference paper, and a journal submission is pending.)

And once out of the hospital, some will use starvation tips learned while there, says Raizman. This isn't to say that treatment is not effective. On the contrary, the research literature indicates that 80 percent of those who undergo inpatient treatment will eventually recover fully.

But at the same time, the relapse rate is high, with most patients in and out of treatment for an average of eight years, says Craig Johnson, PhD, a University of Tulsa psychology professor and the director of the eating disorders program at Laureate Psychiatric Hospital and Clinic. For some, contagion can be a complicating factor, he says.

BECOMING PARTNERS IN RECOVERY

Of course, there are those who doubt that contagion happens all that frequently among anorexics--psychiatrist James Lock, MD, PhD, of Lucille Packard Children's Hospital believes, for example, that anorexics are too private and inward-focused to influence one another much.

But in Johnson's view, anorexics' perfectionist tendencies actually fuel contagion. This is particularly true for adolescents, who are generally more impressionable, more attuned to peers and more competitive than adult patients, says Johnson. Indeed, it doesn't take much more than one rebellious patient to set a pro-anorexic tone on a ward, he says, adding that the type who wishes to be "the best anorexic on the unit" is particularly damaging. Some will push staff to the limit, being kept alive intravenously and still exercising and purging.

"One of the peculiar aspects of anorexia is that, in its acute phases, people are trying to pursue their illness, as opposed to an illness like schizophrenia," says Johnson. "Their goal is to be the thinnest person, and they can be very exhibitionist about their success." The best way to counteract such pro-anorexic behavior is to move the culture of the ward from that of "partners in illness" to "partners in recovery" says Johnson. Specifically he advises that wards control:

  • Weight chats, in which patients compare notes on body size.

  • Revealing clothes that emphasize sunken bellies and gauntness.

  • Provocative food behavior, such as food refusal or vomiting.

  • Exercising, including rocking, flexing, leg swinging and other such behaviors consciously or unconsciously intended to burn calories.

In addition, says Johnson, top treatment programs will help patients identify "nonrecovery thoughts and behaviors" and will promote:

  • Small treatment groups separated by age. Contagion is less common and easier to contain in small groups. It is also less likely to be passed from adults to adolescents if they are separated.

  • Communication. Frequent, even daily, meetings build trust and encourage patients to disclose and surmount pro-anorexic behaviors.

  • Cognitive change. Ongoing inpatient psychotherapy helps to dismantle the anorexic belief system.

  • Discharge. Though a last resort, releasing a recalcitrant patient from treatment shows other patients that pro-anorexic behaviors will not be tolerated.

"The key is to be in tune with patients and to recognize that contagion is a very predictable phenomenon with this patient population," says Johnson. "Staff need to be aware and to design safeguards."