Slavery to Addiction as Meaning of Dropout in Eating Disorders: Psychological Aspects among Women That Have Interrupted Treatment at a Specialized Service in Brazil
Author(s)
Flávia Machado Seidinger-Leibovitz1,2*,
Celso Garcia Junior1,2,
Carla Maria Vieira2,
Luís Fernando Tófoli2,
Egberto Ribeiro Turato2
Affiliation(s)
1 Eating Disorders’ Clinical and Research Program(GETA), Clinical Hospital, Department of Medical Psychology and Psychiatry, Faculty of Medical Sciences, State University of Campinas (Unicamp), Campinas, Brazil. 2 Laboratory of Clinical-Qualitative Research (LPCQ), Department of Medical Psychology and Psychiatry, Faculty of Medical Sciences, State University of Campinas (Unicamp), Campinas, Brazil.
1 Eating Disorders’ Clinical and Research Program(GETA), Clinical Hospital, Department of Medical Psychology and Psychiatry, Faculty of Medical Sciences, State University of Campinas (Unicamp), Campinas, Brazil. 2 Laboratory of Clinical-Qualitative Research (LPCQ), Department of Medical Psychology and Psychiatry, Faculty of Medical Sciences, State University of Campinas (Unicamp), Campinas, Brazil.
ABSTRACT
This study investigated the narratives of women who dropped out of treatment from a specialized outpatient unit for eating disorders (ED). Psychodynamics aspects involved were discussed regarding the issue of adherence and dropout, since it was found to be directly affected by addictive aspects. A qualitative approach was used to identify interpretative matrices that led to a broad understanding of the clinical phenomena observed. Our aim was to identify contributions to the clinical management of barriers to treatment regarding the challenge of adherence to addiction and eating disorders treatments. The sample consisted of eight in-depth interviews fully recorded and transcribed. The emergent categories indicated elements from the experience of the disorders in psychological meanings assigned to dropout by patients. Findings are discussed under a theoretical framework focused on anorexia and bulimia as addictions. The discussion aims to make a contribution to the ED treatment approach and also understand them in their addictive dimension in order to enhance compliance and retention in treatment. The psychodynamic elements from addictive experiences described by patients may contribute to supporting the discussion about eating disorders as “addictive behaviors” beyond the “addiction model of eating disorders” as a physiological model of “addictive” or “toxic” food dependence. Eating disorders experienced as addiction were found affecting the response to treatment.
This study investigated the narratives of women who dropped out of treatment from a specialized outpatient unit for eating disorders (ED). Psychodynamics aspects involved were discussed regarding the issue of adherence and dropout, since it was found to be directly affected by addictive aspects. A qualitative approach was used to identify interpretative matrices that led to a broad understanding of the clinical phenomena observed. Our aim was to identify contributions to the clinical management of barriers to treatment regarding the challenge of adherence to addiction and eating disorders treatments. The sample consisted of eight in-depth interviews fully recorded and transcribed. The emergent categories indicated elements from the experience of the disorders in psychological meanings assigned to dropout by patients. Findings are discussed under a theoretical framework focused on anorexia and bulimia as addictions. The discussion aims to make a contribution to the ED treatment approach and also understand them in their addictive dimension in order to enhance compliance and retention in treatment. The psychodynamic elements from addictive experiences described by patients may contribute to supporting the discussion about eating disorders as “addictive behaviors” beyond the “addiction model of eating disorders” as a physiological model of “addictive” or “toxic” food dependence. Eating disorders experienced as addiction were found affecting the response to treatment.
KEYWORDS
Anorexia Nervosa, Bulimia Nervosa, Qualitative Research, Patient Dropouts, Behaviour, Addictive
Anorexia Nervosa, Bulimia Nervosa, Qualitative Research, Patient Dropouts, Behaviour, Addictive
Cite this paper
Seidinger-Leibovitz, F. , Garcia Junior, C. , Vieira, C. , Tófoli, L. & Turato, E. (2015). Slavery to Addiction as Meaning of Dropout in Eating Disorders: Psychological Aspects among Women That Have Interrupted Treatment at a Specialized Service in Brazil. Psychology, 6, 788-799. doi: 10.4236/psych.2015.66078.
Seidinger-Leibovitz, F. , Garcia Junior, C. , Vieira, C. , Tófoli, L. & Turato, E. (2015). Slavery to Addiction as Meaning of Dropout in Eating Disorders: Psychological Aspects among Women That Have Interrupted Treatment at a Specialized Service in Brazil. Psychology, 6, 788-799. doi: 10.4236/psych.2015.66078.
References
[1] American Psychiatric Association (APA) (2003). Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. Washington DC: American Psychiatric Association. [2] American Psychiatric Association (APA) (2013). Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington DC: American Psychiatric Association. [3] Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality Rates in Patients with Anorexia Nervosa and Other Eating Disorders. A Meta-Analysis of 36 Studies. Arch Gen Psychiatry, 68, 724-731.
http://dx.doi.org/10.1001/archgenpsychiatry.2011.74 [4] Bell, L. (2003). What Can We Learn from Consumer Studies and Qualitative Research in the Treatment of Eating Disorders? Eating and Weight Disorders, 8, 181-187. [5] Brisman, J., & Siegel, M. (1984). Bulimia and Alcoholism: Two Sides of the Same Coin? Journal of Substance Abuse Treatment, 1, 113-118. [6] Brusset, B. (1999). Anorexia mental e bulimia do ponto de vista de sua gênese. In R. Urribarri (Ed.), Anorexia e Bulimia (pp. 51-60). Sao Paulo: Editora Escuta. [7] Brusset, B. (2003). Psicopatologia e metapsicologia da adiccao bulimica. In: B. Brusset, C. Couvreur, & A. Fine (Eds.), A Bulimia (pp. 137-171). Sao Paulo: Editora Escuta. [8] Casper, R. C., Eckert, E. D., Halmi, K. A., Goldberg, S. C., & Davis, J. M. (1980). Bulimia. Archives of General Psychiatry, 37, 1030-1035.
http://dx.doi.org/10.1001/archpsyc.1980.01780220068007 [9] Cassin, S. E., & von Ranson, K. M. (2007). Is Binge Eating Experienced as an Addiction? Appetite, 49, 687-690.
http://dx.doi.org/10.1016/j.appet.2007.06.012 [10] Davis, C., & Carter, J. C. (2009). Compulsive Overeating as an Addiction Disorder. A Review of Theory and Evidence. Appetite, 53, 1-8.
http://dx.doi.org/10.1016/j.appet.2009.05.018 [11] Davis, C., & Claridge, G. (1998). The Eating Disorders as Addiction: A Psychobiological Perspective. Addictive Behaviors, 23, 463-475.
http://dx.doi.org/10.1016/S0306-4603(98)00009-4 [12] Eivors, A., Button, B., Warner, W., & Turner, K. (2003). Understanding the Experience of Drop-Out from Treatment for Anorexia Nervosa. European Eating Disorders Review, 11, 90-107.
http://dx.doi.org/10.1002/erv.492 [13] Fenichel, O. (1945). Psychoanalytic Theory of Neurosis. New York: Norton. [14] Fontanella, B. J., Ricas, J., & Turato, E. R. (2008). Saturation Sampling in Qualitative Health Research: Theoretical Contributions. Cadernos de Saude Publica, 24, 17-27.
http://dx.doi.org/10.1590/S0102-311X2008000100003 [15] Fossey, E., Harvey, C., McDermott, F., & Davidson, L. (2002). Understanding and Evaluating Qualitative Research. Australian and New Zealand Journal of Psychiatry, 36, 717-732.
http://dx.doi.org/10.1046/j.1440-1614.2002.01100.x [16] Goodman, A. (1990). Addiction: Definition and Implications. British Journal of Addiction, 85, 1403-1408.
http://dx.doi.org/10.1111/j.1360-0443.1990.tb01620.x [17] Gracia-Arnaiz, M. (2010). Fat Bodies and Thin Bodies. Cultural, Biomedical and Market Discourses on Obesity. Appetite, 55, 219-225.
http://dx.doi.org/10.1016/j.appet.2010.06.002 [18] Halmi, K. A., Falk, J. R., & Schwartz, E. (1981). Binge-Eating and Vomiting: A Survey of a College Population. Psychological Medicine, 11, 697-706.
http://dx.doi.org/10.1017/S0033291700041192 [19] Hay, P. J., Mond, J., Buttner, P., & Darby, A. (2008). Eating Disorder Behaviors Are Increasing: Findings from Two Sequential Community Surveys in South Australia. PLoS ONE, 3, e1541.
http://dx.doi.org/10.1371/journal.pone.0001541 [20] Jeammet, P. (1999a). A abordagem psicanalitica dos transtornos das condutas alimentares. In R. Urribarri (Ed.), Anorexia e Bulimia (pp. 29-49). Sao Paulo: Ed Escuta. [21] Jeammet, P. (1999b). As condutas bulimicas como modalidade de acomodacao das desregulacoes narcisistas e objetais. In R. Urribarri (Ed.), Anorexia e Bulimia (pp. 113-136). Sao Paulo: Ed Escuta. [22] Kahn, C., & Pike, K. M. (2001). In Search of Predictors of Dropout from Inpatient Treatment for Anorexia Nervosa. International Journal of Eating Disorders, 30, 237-244.
http://dx.doi.org/10.1002/eat.1080 [23] Katz, J. L. (1990). Eating Disorders: A Primer for the Substance Abuse Specialist: 1. Clinical Features. Journal of Substance Abuse Treatment, 7, 143-149.
http://dx.doi.org/10.1016/0740-5472(90)90014-H [24] Kaye, W. H., Wierenga, C. E., Bailer, U. F., Simmons, A. N., Wagner, A., & Bischoff-Grethe, A. (2013). Does a Shared Neurobiology for Foods and Drugs of Abuse Contribute to Extremes of Food Ingestion in Anorexia and Bulimia Nervosa? Biological Psychiatry, 73, 836-842.
http://dx.doi.org/10.1016/j.biopsych.2013.01.002 [25] Krahn, D. D. (1991). The Relationship of Eating Disorders and Substance Abuse. Journal of Substance Abuse, 3, 239-253.
http://dx.doi.org/10.1016/S0899-3289(05)80039-2 [26] Leavey, G., Vallianatou, C., Johnson-Sabine, E., Rae, S., & Gunputh, V. (2011). Psychosocial Barriers to Engagement with an Eating Disorder Service: A Qualitative Analysis of Failure to Attend. Eating Disorders, 19, 425-440.
http://dx.doi.org/10.1080/10640266.2011.609096 [27] Mahon, J. (2000). Dropping out from Psychological Treatment for Eating Disorders: What Are the Issues? European Eating Disorders Review, 8, 198-216. [28] Mahon, J., Winston, A. P., Palmer, R. L., & Harvey, P. K. (2001). Do Broken Relationships in Childhood Relate to Bulimic Women Breaking off Psychotherapy in Adulthood? International Journal of Eating Disorders, 29, 139-149.
http://dx.doi.org/10.1002/1098-108X(200103)29:2<139::AID-EAT1003>3.0.CO;2-I [29] Malterud, K. (2001). Qualitative Research: Standards, Challenges, and Guidelines. The Lancet, 358, 483-488.
http://dx.doi.org/10.1016/S0140-6736(01)05627-6 [30] Masson, P. C., Perlman, C. M., Ross, S. A., & Gates, A. L. (2007). Premature Termination of Treatment in an Inpatient Eating Disorder Programme. European Eating Disorders Review, 15, 275-282.
http://dx.doi.org/10.1002/erv.762 [31] McDougall, J., & Fine, A. (2003). Sobre a bulimia. Entrevista com Joyce Mc Dougall. In B. Brusset, & A. F. Couvrer (Eds.), A Bulimia (pp. 185-196). Sao Paulo: Editora Escuta. [32] Nordbø, R. H. S., Espeset, E. M. S., Gulliksen, K. S., Skarderud, F., Geller, J., & Holte, A. (2012). Reluctance to Recover in Anorexia Nervosa. European Eating Disorders Review, 20, 60-67.
http://dx.doi.org/10.1002/erv.1097 [33] Ronel, N., & Libman, G. (2003). Eating Disorders and Recovery: Lessons from Overeaters Anonymous. Clinical Social Work Journal, 31, 155-177.
http://dx.doi.org/10.1023/A:1022962311073 [34] Santonastaso, P., Bosello, R., Schiavone, P., Tenconi, E., Degortes, D., & Favaro, A. (2009). Typical and Atypical Restrictive Anorexia Nervosa: Weight History, Body Image, Psychiatric Symptoms, and Response to Outpatient Treatment. International Journal of Eating Disorders, 42, 464-470.
http://dx.doi.org/10.1002/eat.20706 [35] Seidinger, F. M. (2014). Significados psicologicos do abandono do tratamento ambulatorial nos transtornos alimentares: Um estudo clinico-qualitativo. Master Degree, State University of Campinas, Sao Paulo.
http://www.bibliotecadigital.unicamp.br/document/?code=000931464 [36] Sly, R. (2009). What’s in a Name? Classifying “The Dropout” from Treatment for Anorexia Nervosa. European Eating Disorders Review, 17, 405-407.
http://dx.doi.org/10.1002/erv.964 [37] Smink, F. R., van Hoeken, D., & Hoek, H. W. (2013). Epidemiology, Course, and Outcome of Eating Disorders. Current Opinion in Psychiatry, 26, 543-548.
http://dx.doi.org/10.1097/YCO.0b013e328365a24f [38] Speranza, M., Revah-Levy, A., Giquel, L., Loas, G., Venisse, J. L., & Jeammet, P. (2012). An Investigation of Goodman’s Addictive Disorder Criteria in Eating Disorders. European Eating Disorders Review, 20, 182-189.
http://dx.doi.org/10.1002/erv.1140 [39] Surgenor, L. J., Maguire, S., & Beumont, P. J. V. (2004). Drop-Out from Inpatient Treatment for Anorexia Nervosa: Can Risk Factors Be Identified at Point of Admission? European Eating Disorders Review, 12, 94-100.
http://dx.doi.org/10.1002/erv.539 [40] Turato, E. R. (2000). Introducao à metodologia da pesquisa clinico-qualitativa: Definicao e principais caracteristicas. Revista Portuguesa de Psicossomática, 2, 93-108. [41] Umberg, E. N., Shader, R. I., Hsu, L. K., & Greenblatt, D. J. (2012). From Disordered Eating to Addiction: The “Food Drug” in Bulimia Nervosa. Journal of Clinical Psychopharmacology, 32, 376-389.
http://dx.doi.org/10.1097/JCP.0b013e318252464f [42] Vandereycken, W., & Pierloot, R. (1983). Drop-Out during In-Patient Treatment of Anorexia Nervosa: A Clinical Study of 133 Patients. British Journal of Medical Psychology, 56, 145-156.
http://dx.doi.org/10.1111/j.2044-8341.1983.tb01542.x [43] WHO, World Health Organization Regional Office for Europe (2005). Mental Health: Facing the Challenges, Building Solutions. Report from the WHO European Ministerial Conference.
http://www.euro.who.int/data/assets/pdf_file/0008/96452/E87301.pdf [44] Wilson, G. T. (1991). The Addiction Model of Eating Disorders: A Critical Analysis. Advances in Behavior Research and Therapy, 13, 27-72.
http://dx.doi.org/10.1016/0146-6402(91)90013-Z
[1] American Psychiatric Association (APA) (2003). Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. Washington DC: American Psychiatric Association. [2] American Psychiatric Association (APA) (2013). Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington DC: American Psychiatric Association. [3] Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality Rates in Patients with Anorexia Nervosa and Other Eating Disorders. A Meta-Analysis of 36 Studies. Arch Gen Psychiatry, 68, 724-731.
http://dx.doi.org/10.1001/archgenpsychiatry.2011.74 [4] Bell, L. (2003). What Can We Learn from Consumer Studies and Qualitative Research in the Treatment of Eating Disorders? Eating and Weight Disorders, 8, 181-187. [5] Brisman, J., & Siegel, M. (1984). Bulimia and Alcoholism: Two Sides of the Same Coin? Journal of Substance Abuse Treatment, 1, 113-118. [6] Brusset, B. (1999). Anorexia mental e bulimia do ponto de vista de sua gênese. In R. Urribarri (Ed.), Anorexia e Bulimia (pp. 51-60). Sao Paulo: Editora Escuta. [7] Brusset, B. (2003). Psicopatologia e metapsicologia da adiccao bulimica. In: B. Brusset, C. Couvreur, & A. Fine (Eds.), A Bulimia (pp. 137-171). Sao Paulo: Editora Escuta. [8] Casper, R. C., Eckert, E. D., Halmi, K. A., Goldberg, S. C., & Davis, J. M. (1980). Bulimia. Archives of General Psychiatry, 37, 1030-1035.
http://dx.doi.org/10.1001/archpsyc.1980.01780220068007 [9] Cassin, S. E., & von Ranson, K. M. (2007). Is Binge Eating Experienced as an Addiction? Appetite, 49, 687-690.
http://dx.doi.org/10.1016/j.appet.2007.06.012 [10] Davis, C., & Carter, J. C. (2009). Compulsive Overeating as an Addiction Disorder. A Review of Theory and Evidence. Appetite, 53, 1-8.
http://dx.doi.org/10.1016/j.appet.2009.05.018 [11] Davis, C., & Claridge, G. (1998). The Eating Disorders as Addiction: A Psychobiological Perspective. Addictive Behaviors, 23, 463-475.
http://dx.doi.org/10.1016/S0306-4603(98)00009-4 [12] Eivors, A., Button, B., Warner, W., & Turner, K. (2003). Understanding the Experience of Drop-Out from Treatment for Anorexia Nervosa. European Eating Disorders Review, 11, 90-107.
http://dx.doi.org/10.1002/erv.492 [13] Fenichel, O. (1945). Psychoanalytic Theory of Neurosis. New York: Norton. [14] Fontanella, B. J., Ricas, J., & Turato, E. R. (2008). Saturation Sampling in Qualitative Health Research: Theoretical Contributions. Cadernos de Saude Publica, 24, 17-27.
http://dx.doi.org/10.1590/S0102-311X2008000100003 [15] Fossey, E., Harvey, C., McDermott, F., & Davidson, L. (2002). Understanding and Evaluating Qualitative Research. Australian and New Zealand Journal of Psychiatry, 36, 717-732.
http://dx.doi.org/10.1046/j.1440-1614.2002.01100.x [16] Goodman, A. (1990). Addiction: Definition and Implications. British Journal of Addiction, 85, 1403-1408.
http://dx.doi.org/10.1111/j.1360-0443.1990.tb01620.x [17] Gracia-Arnaiz, M. (2010). Fat Bodies and Thin Bodies. Cultural, Biomedical and Market Discourses on Obesity. Appetite, 55, 219-225.
http://dx.doi.org/10.1016/j.appet.2010.06.002 [18] Halmi, K. A., Falk, J. R., & Schwartz, E. (1981). Binge-Eating and Vomiting: A Survey of a College Population. Psychological Medicine, 11, 697-706.
http://dx.doi.org/10.1017/S0033291700041192 [19] Hay, P. J., Mond, J., Buttner, P., & Darby, A. (2008). Eating Disorder Behaviors Are Increasing: Findings from Two Sequential Community Surveys in South Australia. PLoS ONE, 3, e1541.
http://dx.doi.org/10.1371/journal.pone.0001541 [20] Jeammet, P. (1999a). A abordagem psicanalitica dos transtornos das condutas alimentares. In R. Urribarri (Ed.), Anorexia e Bulimia (pp. 29-49). Sao Paulo: Ed Escuta. [21] Jeammet, P. (1999b). As condutas bulimicas como modalidade de acomodacao das desregulacoes narcisistas e objetais. In R. Urribarri (Ed.), Anorexia e Bulimia (pp. 113-136). Sao Paulo: Ed Escuta. [22] Kahn, C., & Pike, K. M. (2001). In Search of Predictors of Dropout from Inpatient Treatment for Anorexia Nervosa. International Journal of Eating Disorders, 30, 237-244.
http://dx.doi.org/10.1002/eat.1080 [23] Katz, J. L. (1990). Eating Disorders: A Primer for the Substance Abuse Specialist: 1. Clinical Features. Journal of Substance Abuse Treatment, 7, 143-149.
http://dx.doi.org/10.1016/0740-5472(90)90014-H [24] Kaye, W. H., Wierenga, C. E., Bailer, U. F., Simmons, A. N., Wagner, A., & Bischoff-Grethe, A. (2013). Does a Shared Neurobiology for Foods and Drugs of Abuse Contribute to Extremes of Food Ingestion in Anorexia and Bulimia Nervosa? Biological Psychiatry, 73, 836-842.
http://dx.doi.org/10.1016/j.biopsych.2013.01.002 [25] Krahn, D. D. (1991). The Relationship of Eating Disorders and Substance Abuse. Journal of Substance Abuse, 3, 239-253.
http://dx.doi.org/10.1016/S0899-3289(05)80039-2 [26] Leavey, G., Vallianatou, C., Johnson-Sabine, E., Rae, S., & Gunputh, V. (2011). Psychosocial Barriers to Engagement with an Eating Disorder Service: A Qualitative Analysis of Failure to Attend. Eating Disorders, 19, 425-440.
http://dx.doi.org/10.1080/10640266.2011.609096 [27] Mahon, J. (2000). Dropping out from Psychological Treatment for Eating Disorders: What Are the Issues? European Eating Disorders Review, 8, 198-216. [28] Mahon, J., Winston, A. P., Palmer, R. L., & Harvey, P. K. (2001). Do Broken Relationships in Childhood Relate to Bulimic Women Breaking off Psychotherapy in Adulthood? International Journal of Eating Disorders, 29, 139-149.
http://dx.doi.org/10.1002/1098-108X(200103)29:2<139::AID-EAT1003>3.0.CO;2-I [29] Malterud, K. (2001). Qualitative Research: Standards, Challenges, and Guidelines. The Lancet, 358, 483-488.
http://dx.doi.org/10.1016/S0140-6736(01)05627-6 [30] Masson, P. C., Perlman, C. M., Ross, S. A., & Gates, A. L. (2007). Premature Termination of Treatment in an Inpatient Eating Disorder Programme. European Eating Disorders Review, 15, 275-282.
http://dx.doi.org/10.1002/erv.762 [31] McDougall, J., & Fine, A. (2003). Sobre a bulimia. Entrevista com Joyce Mc Dougall. In B. Brusset, & A. F. Couvrer (Eds.), A Bulimia (pp. 185-196). Sao Paulo: Editora Escuta. [32] Nordbø, R. H. S., Espeset, E. M. S., Gulliksen, K. S., Skarderud, F., Geller, J., & Holte, A. (2012). Reluctance to Recover in Anorexia Nervosa. European Eating Disorders Review, 20, 60-67.
http://dx.doi.org/10.1002/erv.1097 [33] Ronel, N., & Libman, G. (2003). Eating Disorders and Recovery: Lessons from Overeaters Anonymous. Clinical Social Work Journal, 31, 155-177.
http://dx.doi.org/10.1023/A:1022962311073 [34] Santonastaso, P., Bosello, R., Schiavone, P., Tenconi, E., Degortes, D., & Favaro, A. (2009). Typical and Atypical Restrictive Anorexia Nervosa: Weight History, Body Image, Psychiatric Symptoms, and Response to Outpatient Treatment. International Journal of Eating Disorders, 42, 464-470.
http://dx.doi.org/10.1002/eat.20706 [35] Seidinger, F. M. (2014). Significados psicologicos do abandono do tratamento ambulatorial nos transtornos alimentares: Um estudo clinico-qualitativo. Master Degree, State University of Campinas, Sao Paulo.
http://www.bibliotecadigital.unicamp.br/document/?code=000931464 [36] Sly, R. (2009). What’s in a Name? Classifying “The Dropout” from Treatment for Anorexia Nervosa. European Eating Disorders Review, 17, 405-407.
http://dx.doi.org/10.1002/erv.964 [37] Smink, F. R., van Hoeken, D., & Hoek, H. W. (2013). Epidemiology, Course, and Outcome of Eating Disorders. Current Opinion in Psychiatry, 26, 543-548.
http://dx.doi.org/10.1097/YCO.0b013e328365a24f [38] Speranza, M., Revah-Levy, A., Giquel, L., Loas, G., Venisse, J. L., & Jeammet, P. (2012). An Investigation of Goodman’s Addictive Disorder Criteria in Eating Disorders. European Eating Disorders Review, 20, 182-189.
http://dx.doi.org/10.1002/erv.1140 [39] Surgenor, L. J., Maguire, S., & Beumont, P. J. V. (2004). Drop-Out from Inpatient Treatment for Anorexia Nervosa: Can Risk Factors Be Identified at Point of Admission? European Eating Disorders Review, 12, 94-100.
http://dx.doi.org/10.1002/erv.539 [40] Turato, E. R. (2000). Introducao à metodologia da pesquisa clinico-qualitativa: Definicao e principais caracteristicas. Revista Portuguesa de Psicossomática, 2, 93-108. [41] Umberg, E. N., Shader, R. I., Hsu, L. K., & Greenblatt, D. J. (2012). From Disordered Eating to Addiction: The “Food Drug” in Bulimia Nervosa. Journal of Clinical Psychopharmacology, 32, 376-389.
http://dx.doi.org/10.1097/JCP.0b013e318252464f [42] Vandereycken, W., & Pierloot, R. (1983). Drop-Out during In-Patient Treatment of Anorexia Nervosa: A Clinical Study of 133 Patients. British Journal of Medical Psychology, 56, 145-156.
http://dx.doi.org/10.1111/j.2044-8341.1983.tb01542.x [43] WHO, World Health Organization Regional Office for Europe (2005). Mental Health: Facing the Challenges, Building Solutions. Report from the WHO European Ministerial Conference.
http://www.euro.who.int/data/assets/pdf_file/0008/96452/E87301.pdf [44] Wilson, G. T. (1991). The Addiction Model of Eating Disorders: A Critical Analysis. Advances in Behavior Research and Therapy, 13, 27-72.
http://dx.doi.org/10.1016/0146-6402(91)90013-Z