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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 inthe 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 participant
s 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.



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