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Anorexia Nervosa Symptoms are Reduced by Massage Therapy SYBIL HART, TIFFANY FIELD, MARIA HERNANDEZ-REIF, and GRACIELA NEARING Touch Research Institutes, Miami, Florida, USA SEANA SHAW University of Miami School of Medicine, Miami, Florida, USA SAUL SCHANBERG and CYNTHIA KUHN Duke University Medical School, Durham, North Carolina, USA Nineteen women (M age = 26) diagnosed with anorexia nervosa were given standard treatment alone or standard treatment plus massage therapy twice per week for five weeks. The massage group reported lower stress and anxiety levels and had lower cortisol (stress) hormone levels following massage. Over the five-week treatment period, they also reported decreases in body dissatisfaction on the Eating Disorder Inventory and showed increased dopamine and norepinephrine levels. These findings support a previous study on the benefits of massage therapy for eating disorders. Anorexia nervosa is one of the most disabling psychiatric disorders affecting women (Walsh & Devlin, 1998) with a nearly three-fold rise in incidence in the past 40 years for women between 20 and 30 years of age (Pawluck & Gorey, 1998). The diagnostic features of anorexia nervosa include (1) a refusal to maintain normal body weight, (2) fear and an irrational preoccupation with weight gain, body size, and image, despite being underweight, and (3) among females, a disturbance in the menstrual cycle resulting in amenorrhea (American Psychiatric Association [APA], 1994) . Women with anorexia nervosa consistently show a comorbidity of affective disorders (Steiger, Leung, Puentes-Neuman, & Gottheil, 1992) , including depression and anxiety (Fornari, Kaplan, Sandberg, Matthews, Skolnick, & Katz, 1992) and obsessive-compulsive disorder (Walsh & Devlin, 1998) . Unfortunately, medications that have been effective for treating depression and obsessive-compulsive disorders (e.g., fluoxetine) are only modestly effective for treating these disorders in patients with anorexia nervosa (Walsh & Devlin, 1995, 1998) . Due to limited food intake, individuals with anorexia nervosa often experience biochemical changes, including electrolyte imbalances as well as renal and liver dysfunction (Turner & Shapiro, 1992) . They also may experience higher cortisol (stress hormone) levels, which have being associated with lower body weight (Turner & Shapiro) and depression (Faustman, Faull, Whiteford, Borchert, & Csernansky, 1990). In addition, lower serotonergic and dopamine levels have been associated with anorexia nervosa (Ninan & Kulkarni, 1998; Yang et al., 1999) and may explain the comorbidity of depression and obsessive-compulsive disorders, respectively. A multicomponent intervention program is recommended for the treatment of anorexia (Loeb & Wilson, 1998; Mantero, Ruggiero, Papa, & Penati, 1998). Treatment should include daily caloric intake between 2,000 and 4,000 calories, psychological counseling, and a supervisor during exercise and meals so the patient can attempt to resume normal physical and nutritional conditions (Sunday & Halmi, 1997; Walsh & Delvin, 1998). When necessary, hormone therapy may be prescribed to treat bone loss (Grinspoon, Herzog, & Klibanski, 1997) and although not very effective, fluxoetine (Prozac) is often administered for treating depression and obsessive-compulsive disorders (Walsh & Delvin, 1998) . Surprisingly, individuals with anorexia nervosa report a strong desire for more tactile nurturance (Gupta & Schork, 1995) . This may be due, in part, to reports or perceptions of greater touch deprivation during childhood (Gupta, Gupta, Schork, & Watteel, 1995). Current research reveals that massage therapy effectively attenuates many of the symptoms associated with anorexia nervosa. For example, massage has been shown to reduce anxiety and depression and lower salivary cortisol stress hormone levels for women who were sexually or physically abused (Field et al., 1999). Depressed adolescent mothers showed behavioral, physiological, and stress hormone changes, including a decrease in anxious behaviors, pulse, and cortisol levels following a month of massage therapy (Field, Grizzle, Scafidi, & Schanberg, 1996) . Moreover, a recent study on massage therapy effects for adolescents with bulimia nervosa revealed improved eating disorder attitudes, including less drive for thinness, bulimia, body dissatisfaction, ineffectiveness, perfectionism, and interpersonal distrust (Field et al., 1998) . Additionally, in the bulimia study, those who received massage therapy reported lower depression and anxiety levels, showed more positive affect, and had lower cortisol stress hormone levels than the control group. Anorexia and Massage 291 The mechanism underlying the positive effects of massage therapy has been associated with greater parasympathetic arousal. Evidence for this hypothesis stems from the reduction in cortisol stress hormones and catecholamines following massage therapy in psychiatric patients (Field et al., 1992) and an increase in vagal tone, suggestive of heightened parasympathetic state (Field, 1998) . Moreover, massage therapy has been associated with an increase in serotonin (Field, Grizzle, Scafidi, & Schanberg, 1996; Hernandez- Reif, Dieter, Field, Swerdlow, & Diego, 1998) and dopamine (Field et al., 1999; Field et al., 1998) that might explain the improved mood in some of the massage studies. The goals of the present study included evaluating massage therapy for women with anorexia nervosa for (1) reducing stress and stress hormone levels, (2) decreasing depression, (3) improving mood, (4) reducing eating disorder symptoms, and (5) increasing dopamine values. METHOD Participants Nineteen women (M age = 25.7) who were undergoing treatment for anorexia nervosa were stratified for treatment center (inpatient or outpatient) and then randomly assigned to a massage therapy (N = 10) or a standard treatment only control group (N = 9) . A power analyses based on previous massage findings revealed that only 10 subjects were required per group for 50% power to detect the effects of massage at an alpha of .05 (two-tailed) . Since our hypotheses may be stated directionally, the power was sufficient for detecting moderate effects. Twenty participants had been recruited but one assigned to the control group failed to return for the last day’s assessments. Participants were diagnosed by a psychiatrist or through structured interviews and met the diagnostic criteria for anorexia nervosa as described in the DSM-IV (APA, 1994) including (1) refusal to maintain expected body weight for their age and height, (2) intense fear of gaining weight, (3) irrational preoccupation with body weight or shape, and (4) amenorrhea. Participants’ body mass index (BMI; weight in kg/square of height in meters) suggested body weight at least 15% below normal range (M = 17.8). Six of the 10 participants in the massage therapy group and 5 of the 9 subjects in the control group were inpatients at a center for eating disorders. Inpatients were seen at the Renfrew Center and outpatient participants were recruited from a university’s treatment center that served students with eating disorders. All participants were approached at the beginning of treatment and were screened for eligibility within two weeks of recruitment. In- and outpatients did not differ on diagnostic, the BMI, baseline scores on the Eating Disorder Inventory, or demographic variables (see Table 1). 292 S. Hart et al. Procedure STANDARD CARE All participants were receiving care as inpatients or outpatients. Participants in the inpatient program were residing at the Renfrew Treatment Center and were under the care of a psychiatrist during their residential treatment. The inpatients participated in daily individual and group therapy sessions, worked with a dietician who instructed them on nutrition and principles of physiology and metabolism, and engaged in other activities, such as movement therapies. The women in the outpatient program were under the care of a psychiatrist and attended group therapy. MASSAGE THERAPY Participants assigned to the massage therapy group received a 30-minute massage two days per week for five weeks, for a total of ten massages. The massage therapy sessions were always conducted in the late afternoon by trained female massage therapists at the Renfrew Center or at our wellness center for the outpatients. To promote relaxation, the therapists were instructed to refrain from talking during the massage and to instruct the participant to relax and discourage her from talking. The full body massage sequence described in the Appendix has been used in other studies to promote relaxation. The steps are standard swedish massage techniques. DISCUSSION In this study, women diagnosed with anorexia nervosa who received massage therapy reported decreased anxiety and improved mood immediately following their first and last massage. A reduction in salivary cortisol (stress) values following the first massage corroborated the self-reports of reduced anxiety. These findings also parallel previous massage therapy findings for adolescents diagnosed with bulimia (Field et al., 1998) , suggesting that touch therapy has positive and immediate benefits for attenuating stress levels, stress hormones, and depressed mood in girls and women with eating disorders. The present study also revealed an increase in dopamine values for the women receiving massage therapy, as had been reported in the massage therapy study on adolescents diagnosed with bulimia (Field et al., 1998) . Dopamine depletion has been associated with a decrease in food intake and has been implicated in anorexia nervosa and feeding behaviors (Ninan & Kulkarni, 1998). Although weight gain resulting from massage therapy has image, and biochemical abnormalities for women diagnosed with anorexia nervosa. Although this study was limited by a small sample size, the compelling findings, along with previous findings on massage therapy effects for adolescents with bulimia (Field et al., 1998), suggest that massage therapy added to standard care may be effective for healing mind and body issues for individuals with eating disorders. |
