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Anorexia Symptoms are Reduced by Massage Therapy

Anorexia Nervosa is diagnosed as body weight 15% below normal in individuals who
are fearful of weight gain despite being underweight, disturbed over their body weight
or shape, and, among females, if there are disruptions in the menstrual cycle resulting
in amenorrhea. With the rapid growth in cultural expectations that women’s bodies should be
very thin, concerns about body shape and eating emerge as early as adolescence and may
contribute to the “almost epidemic rise” in the incidence
of eating disorders, now striking 1% of adolescent females and resulting in
death in 2 to 10% of cases.

Women who have anorexia consistently report comorbidity of eating and affective disorders,
and high depression and anxiety levels are observed in these women.
Eating disorders also affect body image. For example one study found that
dysphoria significantly covaried with women’s negative evaluations of their
bodies and in another study, mood and eating symptoms were linked to
body-image concerns, perfectionism, impulsivity, self-criticism and
perceptions of anorexic families as incohesive.

Due to limited food intake, anorexic individuals can experience biochemical changes including
electrolyte imbalances as well as renal and liver dysfunction.  The energy requirements of the
body can shift into a catabolic state in which energy is released through the breakdown of
materials in the body, including muscle and other structural proteins, to provide glucose.  The
production of glucose from alternative substrate sources has been associated with increased
cortisol levels, with higher cortisol
levels being associated with lower body weight and depression.

Anorexic individuals do not respond readily to treatment.  Recent reviews on the status of
treatments for eating disorders report that encouraging findings on treatments for bulimia have
not been matched in parallel studies on anorexia, with the exception of one study which found
that the tricyclic antidepressant, cyproheptadine, was marginally associated with decreases in
anorexia symptoms.  Psychotherapy has had limited success with outpatients, and studies on
inpatients suggest that anorexia is often a chronic condition requiring repeated hospitalization.
One study on a clinical population reported that almost one half of inpatients with a diagnosis
of anorexia were readmitted to a psychiatry unit within five years,  and another study on a
non-clinical population reported that women’s scores on the Eating Disorder Inventory  were
highly stable over a one year period.

Anorexic individuals also report a strong desire for more tactile nurturance. Compared with a
non-clinical sample, anorexics have reported greater touch deprivation during
their current lives as well as their childhood.  These studies suggest that the inclusion
of positive touch experiences such as massage therapy may be important for successful
treatment.  Studies have shown that elderly individuals and hospitalized depressed children
showed decreased anxiety, depression and stress hormones following massage. Bulimic
adolescents have also benefited from massage therapy. Massaged patients reported improved
attitudes on the Eating Disorder Inventory, including drive for thinness, bulimia, body
dissatisfaction, ineffectiveness, perfectionism, interpersonal distrust, interoceptive awareness
and maturity fears.  Additionally, they reported
lower depression and anxiety levels and they exhibited less anxious behavior and
more positive affect.  Following a month of treatment, massaged subjects showed
lower cortisol, again suggesting reduced stress, and increased dopamine.  The
present study investigated the effectiveness of massage therapy for women
with anorexia nervosa.

MethodSample

Nineteen females currently undergoing treatment for anorexia were randomly assigned
to a massage therapy or a standard treatment only control group. Participants’ body
mass index (BMI; weight in kg/square of height in meters) suggested body weight at least
15% below normal range. Six of the 10 participants in the massage therapy
group and 5 of the 9 subjects in the control group were in-patients at a center for
eating disorders.  Outpatient subjects were recruited from college treatment
centers serving women with eating disorders.  In- and out-patients did not differ
on the BMI, the EDI or demographic variables.  Subjects in the massage and
control groups also did not differ on BMI, EDI or the demographic variables.


Treatment Procedures

Massage Therapy.  The massage therapy subjects received a massage two days
per week for 5 weeks, for a total of 10 massages.  The massage covered the
entire body, including 15 min in a supine position and 15 minutes in a prone
position. It consisted of first exerting traction upon the neck with the patient
in a supine position, followed by smooth strokes across the forehead, jaw
and face, and depressing the shoulders. The therapist then moved each arm
one at a time and exerted traction, followed by massage of the hand and
smooth strokes over the length of the arm. The torso was gently rocked,
and then the same movements used with the arms were used with the legs
and feet, one at a time. In a prone position the Achilles tendon was stretched,
and long strokes were made from the hip to the toes. The strokes on the back  
included lumbar stretching, strokes that connect the back and arms, grasping
top of shoulders and squeezing, friction alongside the spine, sacral traction
and long, soothing strokes from the head to the feet.

Assessment procedures

Immediate effects measures (Pre/Post therapy sessions)
The immediate effects measures included: (1) the State Anxiety Inventory (2) The Profile of
Mood States Depression Scale (3) saliva cortisol

Longer-Term effects measures (First Day/Last Day)
The longer-term effects measures included: (1) Eating Disorders Inventory (EDI); (2) The
Center for Epidemiological Studies Depression Scale (CES-D) ratings of depression; (3) urine
samples collected from the subjects prior to the end of the first and last day therapy sessions.
An aliquot of urine was frozen and sent to Duke University to be assayed for cortisol,
serotonin (5HIAA), creatinine, and catecholamines (dopamine, epinephrine and
norepinephrine).  

Results

Immediate Effects
Group analyses revealed that the massage group score on the STAI and the POMS
and cortisol levels decreased, suggesting an immediate reduction in anxiety and
stress hormone levels and an improved mood following the massage sessions.

Longer-Term Effects
Analyses of the longer-term measures revealed that after the 5-week treatment period the
massage group showed decreased EDI scores. Dopamine also
increased in the massage group following the five-week treatment period.

Discussion
The anorexic women in this study reported decreased anxiety and improved mood
immediately following the massage therapy sessions.  In parallel with the self-report
data, decreases in saliva cortisol levels further suggested reduced stress.  These
findings support previous reports on the benefits of massage therapy for bulimic
women. The increased dopamine levels and the increased norepinephrine levels
were unexpected and certainly warrant further research.

By the last day of the study, massaged women reported less body dissatisfaction
on the Eating Disorder Inventory.  That the EDI scores of subjects in the control
group were unchanged, despite being in standard treatment, supports reports on
the stability of EDI responses and confirms observations that anorexia does not
respond readily to traditional therapies. The massage therapy may have been
more successful because of the desire for tactile nurturance in anorexic women.
Further studies are needed to explore associations between body satisfaction,
the need for tactile nurturance, and massage therapy.  By helping women
feel more comfortable with their bodies, massage therapy may have
facilitated close physical contacts in intimate relationships, thereby
satisfying the need for tactile nurturance. Continued research is needed
to determine the relationship between body image and the need for
tactile nurturance among anorexic women receiving massage therapy.

Touchpoints
Touch Research Institutes
Department of Pediatrics (D-820)
University of Miami School of Medicine
P.O. Box 016820
Miami, FL 33101