Dr. Sarah Ravin - Psychologist | Eating Disorders |Body Image Issues | Depression | Anxiety | Obsessive-Compulsive Disorders | Self-Injury
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Dr. Sarah Ravin

Welcome to my professional blog. I am a Florida Licensed Psychologist and trained scientist-practitioner. In 2008, I received my Ph.D. in clinical psychology. A major component of my professional identity is staying informed about recent developments in the field so that I may provide my clients with scientifically sound information and evidence-based treatment. There is a plethora of information on the internet about Eating Disorders, Depression, Anxiety, Psychotherapy. Unfortunately, much of this information is unsubstantiated and some of it is patently false. It is my hope that by sharing my thoughts and opinions on psychological issues, with scientific research and clinical experience sprinkled in for good measure, I can help to bridge the gap between research and treatment.

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Biologically-Based Mental Illness Category

Thursday, June 2nd, 2011

Blame it on the Brain

There is much debate amongst mental health professionals as to whether mental illnesses should be called “brain disorders.” A large part of the disagreement, as I see it, comes from a lack of consensus as to the meaning of the term “brain disorder.”

I conceptualize a brain disorder as a disease or disorder that originates in the brain and influences mood, thinking, learning, and/or behavior. By my definition, all disorders listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) are brain disorders, including autism, ADHD, major depression, bipolar disorder, OCD, anorexia nervosa, bulimia nervosa, reactive attachment disorder, Alzheimers, and schizophrenia.

To me, “brain disorder” does NOT mean:
• Environment does not play a role in its development
• Environment does not play a role in recovery
• It is 100% biologically based
• It is 100% genetically inherited
• It can only be treated by physician or with a pill
• Psychological interventions won’t help
• The patient can’t do anything to influence the outcome

None of the above is true for ANY brain disorder, whether we’re talking about one that is commonly accepted as “biologically based” or not. In fact, I don’t know of any physical disease or medical condition in which any of the above is true.

Some people in my field are willing to apply the term “brain disorder” to some illnesses which are widely accepted to have a neurobiological basis (e.g., schizophrenia, autism, Alzheimers) but adamantly resist using this term to describe eating disorders, depression, or anxiety disorders, which they perceive to be something else. The underlying assumptions here, which few people would openly admit, are that some mental disorders are legitimate diseases whereas others are choices or responses to the environment; some mental illnesses are serious and deserve to be treated (and funded by insurance) whereas others are the patient’s or the family’s fault, so treatment is optional.

Clinicians who oppose the use of the term “brain disorder” to describe certain mental illnesses typically fall into one or more of the following categories:
• They don’t have a strong science background
• They lack basic knowledge of biology and genetics
• They suffer from (or have suffered from) the mental disorder in question and are personally offended by the term because they believe it invalidates their personal experience
• They feel that their professional identity, the work they have done for many years, is threatened by acknowledgment of the neurobiological basis of mental illness
• They believe that family dynamics or socio-cultural forces are the root cause of mental disorders, and that changing family dynamics or socio-cultural forces will cure or prevent mental disorders.

My clinical work is grounded in the knowledge that all mental illnesses are brain disorders. I believe my patients benefit from knowing that they have a neurobiologically-based, genetically inherited illness which they did not choose and their family did not cause. In order to get well, they must have a profound appreciation of their unique vulnerabilities and how to make healthful choices in order to keep themselves well. It is important for me, as a psychologist, to understand how the brain works – the mind-body-behavior connection – and it is important for me to educate my patients and their families about these issues as well.

It’s a two-way street – brain function affects thoughts, emotions, and behavior; in turn, psychological and behavioral interventions change brain function. The fact that mental illnesses are brain-based does not necessarily mean that medication is required. Research has shown that, for many brain disorders, certain types of psychotherapy are more effective than medication (e.g., mild or moderate depression, panic disorder, social anxiety disorder, anorexia nervosa). For other brain disorders, a combination of psychotherapy and medication produces better outcomes than either treatment alone (e.g., severe major depression, OCD). Less than half of my current patients are taking any psychotropic medication. Many of my patients recover fully without medication, and those who do need medication can often take fewer medications and/or lower doses once they have had good psychological intervention.

One of my college-aged patients who suffers from severe depression and anxiety recently shared the following insight, which beautifully captures the clinical utility of the “brain disorder” concept:

“With my last therapist, we just talked about what went wrong in my family that made me so screwed up. We spent the whole summer trying to figure out why I’m depressed, and it didn’t make me any better. My relationship with my parents just got worse – I got angrier at them and they felt guilty. Now I know I have a brain disorder and I know how to treat it. I come to therapy, I take my meds, and I’m OK. It works.”

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Saturday, October 16th, 2010

We’ll Always Have Fiji

I do not believe that the media plays a major role in the etiology of eating disorders. And yet, in much of the eating disorder world, it has become accepted as an unspoken, self-evident truth that patients with anorexia and bulimia have developed their illnesses in large part due to their desire to emulate “the thin ideal” which our media promotes. Those who espouse this idea cite the Fiji Study, which demonstrated dramatically increased rates of body dissatisfaction and disordered eating amongst Fijian adolescent girls within the first few years after television was first introduced to the island.

I, along with several of my like-minded colleagues, have raised concern over NEDA’s choice of Naomi Wolfe as the conference’s keynote speaker. As a feminist, I am a huge fan of Wolfe’s work. In her groundbreaking book The Beauty Myth, she presents convincing arguments about the myriad ways in which our culture and society are toxic to women. I couldn’t agree more.

Our culture and society are harmful to all women and men, and certainly the media plays a huge role in triggering body dissatisfaction and disordered eating. (Incidentally, the media is a major culprit in the perpetuation of myths about eating disorders.) But disordered eating is not the same as an eating disorder. The Fiji study measured body dissatisfaction and disordered eating, not eating disorders.

The disordered eating / eating disorder distinction is not just a matter of semantics. In fact, I believe that eating disorders are quantitatively AND qualitatively distinct from disordered eating, much as major depression is both quantitatively AND qualitatively different from sadness. Anorexia nervosa has existed for centuries, long before the advent of television and internet and fashion magazines, and long before disordered eating became the norm.

I think it would benefit our profession tremendously to arrive at a consensus regarding the definition of “disordered eating” and how it differs from eating disorders.

The confusion between eating disorders vs. disordered eating is a major contributor to society’s (and some professionals’) lack of understanding of eating disorders. People who engage in disordered eating are, on some level, responding to their environment in choosing to engage in certain eating behaviors, whereas people with eating disorders are caught in the grips of a terrifying mental illness which will not allow them to do otherwise.

Disordered eating is very widespread in our country, especially among women. I define disordered eating as a persistent pattern of unhealthy or overly rigid eating behavior – chronic dieting, yo-yo dieting, binge-restrict cycles, eliminating essential nutrients such as fat or carbohydrates, obsession with organic or “healthy” eating – coupled with a preoccupation with food, weight, or body shape.

By this definition, I think well over half of the women in America (and many men as well) are disordered eaters.

The way I see it, disordered eating “comes from the outside” whereas eating disorders “come from the inside.” What I mean is this: environment plays a huge role in the onset of disordered eating, such that the majority of people who live in our disordered culture (where thinness is overvalued, dieting is the norm, portion sizes are huge, etc) will develop some degree of disordered eating, regardless of their underlying biology or psychopathology.

In contrast, the development of an eating disorder is influenced very heavily by genetics, neurobiology, individual personality traits, and co-morbid disorders. Environment clearly plays a role in the development of eating disorders, but environment alone is not sufficient to cause them. The majority of American women will develop disordered eating at some point, but less than 1% will fall into anorexia nervosa and 3% into bulimia nervosa.

The Fiji study was indeed groundbreaking. It demonstrated the enormous impact of the media on teenage girls’ feelings about their bodies and attitudes towards food. But the study did not demonstrate a causal link between the media and eating disorders. Furthermore, our knowledge that the media makes girls dislike their bodies, while important in its own right, has not yielded useful information with regards to developing effective treatments for eating disorders. And isn’t that the whole point?

I would like for our field to accept the Fiji study for what it is – a fascinating sociological study which confirmed empirically what we already knew intuitively – and push forward towards a deeper understanding of eating disorders so that we may develop and implement more effective treatments.

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Wednesday, August 11th, 2010

About the Food

“It’s not about the food.”

This phrase, used widely in eating disorder recovery, is misleading and potentially harmful.

Here’s the truth – anorexia nervosa (AN) is not “about” anything other than being born with a certain neurobiological predisposition to this particular brain disorder, which lays dormant until activated by insufficient nutrition. Given that food restriction has a calming and mood-elevating effect in people with this type of brain chemistry, anorexics may restrict their food intake (either consciously or unconsciously) as a way of coping with uncomfortable feelings or stressful events.

So it isn’t JUST about the food; it’s about feelings and circumstances as well. People with AN must learn healthy ways to regulate their emotions. Most of them will require psychotherapy to help them tackle anxiety and perfectionism, build healthy relationships, challenge their distorted thoughts and beliefs, or treat coexisting conditions such as depression or OCD. But it is the disturbance in eating behavior and weight, rather than feelings or events per se, which cause immense physical and psychological damage.

An initial period of low nutrition sets the disorder in motion. Continued low nutrition and low body weight perpetuate the symptoms. Sustained full nutrition and weight restoration are essential for mental and physical recovery. Continued good nutrition and maintenance of a healthy body weight for life protect patients against relapse. At every step of the process, nutrition (or lack thereof) plays a functional role.

The relationship between food and AN is analogous to the relationship between alcohol and alcoholism. To state that AN “isn’t about the food” is like stating that alcoholism “isn’t about drinking.” A person may be born with a predisposition to developing alcoholism due to her genetic makeup and her particular brain chemistry. However, if that person never takes a sip of alcohol, the disease will never be activated in the first place. Similarly, a person predisposed to AN will not develop the disorder in the absence of a nutritional deficit.

I like to think about the development of eating disorders in terms of the “four P’s:”

Predisposing factors
Recent research indicates that 50-80% of the risk of developing AN is genetic. Individuals with AN have a certain genetically-transmitted neurobiological predisposition. Personality traits which make an individual more susceptible to developing AN include anxiety, perfectionism, obsessiveness, behavioral inhibition, and cognitive rigidity. Most patients with AN have exhibited one or more of these traits since early childhood, long before the development of an eating disorder. These traits tend to be exacerbated during bouts of malnutrition and persist long after recovery, albeit to a lesser degree.

Precipitating factors
Anorexia nervosa is always precipitated by a period of low nutrition. The precursor to the low nutrition will vary from person to person. In modern American culture, where most girls and young women experience a drive for thinness, dieting is the most common pathway to AN.

Not every episode of AN is triggered by dieting, however. A simple desire to “eat healthy,” participation in sports without appropriate caloric compensation, a bout with the stomach flu, or simply loss of appetite during a period of stress – any one of these unintentional, seemingly benign periods of low nutrition can trigger AN in a vulnerable child.

Weight and shape concerns are culturally mediated phenomenon and are not necessarily part of the symptom picture for all anorexics. In medieval times, fasting for religious purposes triggered what we now call anorexia nervosa. AN is seen in cultures as diverse as China, where sufferers report loss of appetite or physical complaints, and Ghana, where sufferers view their self-starvation in terms of religion and self-control.

Puberty, which involves dramatic hormonal, neurological, and physical changes coupled with new social and academic demands, is often a precipitating factor for AN. Neurobiological researchers have hypothesized that puberty-related hormonal changes may exacerbate serotonin dysregulation, explaining why AN usually begins in adolescence.

Perpetuating factors
Continued malnutrition is largely responsible for the self-perpetuating cycle of eating disorder symptoms. A starved brain is a sick brain, and people who are undernourished for any reason display many of the symptoms commonly associated with AN: preoccupation with food, unusual food rituals, social withdrawal, irritability, and depression.

In addition to these symptoms of starvation, body dysmorphia, drive for thinness, and fear of weight gain serve as perpetuating factors. Individuals with AN are unable to recognize how thin they are and may perceive themselves as normal or fat, despite emaciation. They are terrified of eating and morbidly afraid of gaining weight. They cope with these fears by continuing to restrict their diet and remaining underweight, which of course perpetuates the symptoms of starvation. It is a vicious cycle.

Psychological problems such as depression, anxiety, post-traumatic stress, ADHD, and bipolar disorder may also serve as perpetuating factors. Food restriction and compulsive exercise act as a “drug” for certain individuals, providing them with temporary relief from anxiety and negative moods. An anorexic who is suffering from other psychological problems may use her eating disorder symptoms in attempt to alleviate her intolerable emotions. This makes re-feeding and recovery excruciatingly difficult, as the anorexic is required to face extremely painful thoughts and feelings as she endures the two things she fears most: eating more and gaining weight.

Prognostic factors
Research indicates that full nutrition and prompt weight restoration as soon as possible after AN diagnosis is a predictor of good outcome. Likewise, prolonged periods of time spent at a sub-optimal weight are associated with a protracted course of illness and increased risk of irreparable damage such as infertility, osteoporosis, and suicide.

A recent study of inpatients with AN found that the best predictors of weight maintenance during the first year post-discharge were the level of weight restoration at the conclusion of acute treatment and the avoidance of weight loss immediately following intensive treatment. Another study found that nutrient density and variety (eating a wide range of foods, including those that are high-calorie and high-fat) were significant predictors of positive long-term outcome in weight-restored anorexics.

All of the available data suggest that eating a complete, well-balanced diet and maintaining ideal body weight are of utmost importance in recovery from AN and in preventing relapse. Full nutrition and weight restoration alone will not cure AN, but full recovery cannot occur without these essential components.

In sum, nutrition plays a functional role in all stages of AN, from the initial onset and maintenance of symptoms to physical and mental recovery to relapse prevention.

Maybe it is about the food after all.

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Friday, August 6th, 2010

A Dangerous Precedent

Earlier this week, a federal judge ordered the Pittsburgh Public Schools to pay $55,000 to settle a lawsuit filed by a mother, who claimed her adolescent daughter was bullied into anorexia.

According to the lawsuit, the plaintiff’s daughter, now 15, was bullied relentlessly at school in 6th and 7th grades. A group of boys taunted her and made degrading remarks of a sexual nature, insinuating that she was fat and ugly. The girl stopped eating lunch at school in attempt to avoid being teased by these boys, who ridiculed her for eating and being fat. Although the girl’s teacher, principal, and guidance counselor were aware of the bullying, they did nothing to intervene. The girl began losing weight, and by the middle of her 7th grade year, her weight was dangerously low and she was diagnosed with anorexia nervosa, for which she was treated at an inpatient psychiatric clinic. The plaintiff, whose daughter now attends private school, sued the school district, her daughter’s middle school, and her principal, claiming that her daughter developed anorexia as a result of their inaction.

I disagree with this ruling, and I think it sets a dangerous precedent.

Before I state my points of contention, I will make several points very clear:
• Bullying has the potential to cause extreme distress. It is cruel, harmful, and absolutely inexcusable.
• All schools should have clear, written policies about bullying and sexual harassment. All students, parents, and faculty must be aware of these policies. School faculty and administrators must enforce these policies to the best of their abilities.
• School faculty and administrators have a responsibility to provide a safe learning environment for all students, and have a duty to intervene at the first sign of bullying.
• Students who engage in bullying behavior should be punished appropriately. If the bullying continues, they should be expelled.

In this particular case, the bullies did some terrible things; they must be held responsible for their actions and punished appropriately. The school faculty and administration were certainly negligent; they must be held accountable for their inaction and punished appropriately. The school district was remiss not to have a bullying policy, and they should be compelled to create one. The victim suffered horribly as a result, and she deserves to heal from this trauma and to attend school in a safe environment. And the buck stops here. I do not believe that the bullies or the negligent school personnel are responsible for this child’s mental illness.

To create a legal precedent in which school officials are held legally or financially liable for a child’s mental illness is dangerous on several levels:
• It implies that the actions of children can cause another child to develop a mental illness.
• It implies that the actions or inactions of adults can cause a child to develop a mental illness.
• It implies that anorexia nervosa is (or can be) the result of teasing or bullying.
• It reinforces the popular but antiquated and unsupported notion that anorexia nervosa is the result of some deep-seated trauma.
• It implies that this child would not have developed anorexia nervosa if she had not been bullied.
• It neglects the horrific experiences of tens of thousands of other children who have been bullied and have suffered silently, but have not developed anorexia nervosa.
• It invalidates the experiences of the tens of thousands of children and adults who have never been bullied or traumatized in any way, but nonetheless have developed anorexia nervosa.

Imagine being a prepubescent boy and being held responsible for causing a classmate’s severe mental illness. Don’t get me wrong – I am in no way defending the behavior of these bullies. They did cruel things and they must be punished. But they did not make this girl develop a life-threatening brain disorder. They couldn’t have, even if they wanted to! Similarly, the school faculty and administrators were obviously negligent and made some terrible mistakes, but they did not cause this child to develop a mental illness.

The most recent scientific evidence strongly suggests that anorexia nervosa is a biologically-based, genetically transmitted brain disorder which is triggered by malnutrition and then becomes self-perpetuating. Children with anorexia come from all walks of life. Some are popular, confident, social, happy, and well-adjusted before their illness begins. Others are depressed, anxious, introverted, teased, or unstable before they develop anorexia. Some children develop anorexia after a stressful event, which could be as benign as a starting middle school or as serious as rape. For many children, the onset of anorexia nervosa does not coincide with a major stressor, but rather spirals out of control during an attempt to “eat healthy,” get in shape for sports, or lose a few pounds for prom.

My point is that some children are simply “wired” for anorexia nervosa, which can be triggered by relatively minor stressors or relatively benign bouts of under-nutrition. It doesn’t make sense to “sue the trigger” when it is just that – a trigger. If we can sue a school district – and win tens of thousands of dollars – for allowing a child to be bullied into anorexia, where does it end? If a child develops an eating disorder after reading a book on nutrition, do we sue the publisher? If an 18-year-old becomes anorexic while struggling to adapt to the social and academic challenges of college life, do we sue the university?

If a teenager develops and eating disorder after being raped, the rapist should be tried and convicted and incarcerated. But the eating disorder, in my opinion, is irrelevant to the outcome of the trial. The rapist should be incarcerated for the same length of time (for life, in my opinion) regardless of whether the victim develops any mental illness afterwards, because he committed a violent crime. The crime is no more or less heinous based upon the particular pre-existing neurological makeup of his victim.

It is well-known amongst mental health professionals that a psychotic break can be triggered by “high expressed emotion,” such as bullying or family conflict, in a person who has the underlying neurobiological predisposition. Do we then sue the school for allowing a child to be “bullied into schizophrenia?” Do we sue the parents for arguing too much and thus causing their son’s psychosis?

I have the deepest sympathy for this plaintiff, and especially for her daughter. No doubt, they have both suffered horribly. This mother is only doing what she believes is best for her dear child, and I’m sure she believes she is helping other children in the process. The judge who approved of this settlement is, likewise, only trying to ensure that justice is served. He or she probably has no intimate knowledge of the etiology of anorexia nervosa, and probably has no idea what some of the negative ramifications of his ruling could be.

If the lawsuit had been simply about protecting children from bullying, I would have supported it 100%. I cannot, however, support a lawsuit which enshrines bullying as a legally valid cause of anorexia.

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Thursday, June 24th, 2010

A False Dichotomy

One of the things that bothers me most about my field is the false dichotomy between biology and psychology. On the one hand, there are psychiatrists who over-diagnose and overmedicate without taking the time to get to know patients and truly understand their symptoms. They spend very little time with patients and try to solve everything with a pill, rather than providing psychotherapy or referring patients to a psychotherapist. These psychiatrists do not take into account the role of environmental stressors, lifestyle (nutrition, sleep, substance use), and learned patterns of thinking that can be successfully treated without medication.

On the other hand, there are therapists who over-pathologize and overanalyze. These therapists are married to unscientific, unsupported psychodynamic theories about the etiology of psychological problems which tend to attribute symptoms to supposed family dysfunction and internal conflicts. These therapists fail to take into account the powerful role of genetics and neurobiology in contributing to the patient’s symptoms. They ignore or discount the recent scientific advances in our field, and they do not employ empirically-supported treatments which have been demonstrated to be effective. They rely instead on their opinions and “clinical judgment.”

Neither side of this dichotomy serves its patients well, as both sides fail to appreciate the true complexity of the human experience. One side places all eggs in one very small proverbial basket (a pill), effectively abnegating the patient of any responsibility for behavioral, psychological, or environmental change. The other side places an unfair amount of blame on the patient and / or her family, searching for root causes that may not exist, traumas that may never have occurred, or dysfunction in normal thoughts and behaviors. Consequently, it is implied, if not blatantly asserted, that biologically-driven thoughts and behaviors are freely chosen and can be un-chosen just as freely with enough insight into said root causes, traumas, and dysfunction.

I am often disappointed by those mental health professionals who have so little scientific understanding of the interaction between genes and environment, between biology and psychology, between experience and neurodevelopment. They seem to forget that the mind is an abstraction of the brain, and the brain is part of the body. Their thinking is so dichotomous – disorder X was caused by either genes OR environment; treatment must be medication OR psychotherapy; it’s a neurobiological illness OR it is caused by environmental factors. They don’t seem to understand that, with mental illness, it’s rarely a question of “nature or nurture.” Rather, it is nature AND nurture, both of which come in many forms. Biology, psychology, and environment are constantly interacting, with each of these components profoundly impacting the other two.

I would like to see all mental health professionals develop a full understanding of and appreciation for biopsychosocial models of mental illness and evidence-based treatments. It is my hope that psychologists, psychiatrists, and mental health professionals from all disciplines will begin taking a more well-rounded approach to treating psychiatric disorders and helping people achieve mental health.

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Friday, May 7th, 2010

Palliative Care for Anorexia Nervosa – Part 2

Last fall, I blogged about palliative care for anorexia nervosa (AN). In light of a recently published article on the topic, and considering how riled up I have become as a result, I believe this subject deserves another post.

An article by Lopez, Yager, and Feinstein entitled Medical Futility and Psychiatry: Palliative Care and Hospice Care as a Last Resort in the Treatment of Refractory Anorexia Nervosa was published in this month’s issue of the International Journal of Eating Disorders. The authors describe a 30-year-old female with an 11-year history of AN who presented in their clinic at an extremely low weight with numerous medical complications. Over the course of her chronic illness, this woman had been through two stints in residential treatment, multiple hospitalizations, and several years of participation in a day treatment program. At the time of intake, she continued to engage in caloric restriction (consuming fewer than 300 calories per day) and exercise compulsions (running 2 hours daily).

The treatment team recommended residential treatment, but the patient was unwilling to go voluntarily and the treatment centers were unwilling to accept her involuntarily. The team concluded that “no viable treatment options existed” and consulted the medical center’s ethics committee.
The patient’s family refused guardianship. When the idea of pursuing court-ordered guardianship was presented, the hospital attorneys rejected it on the grounds that the patient would most likely not meet criteria. In the end, “the treatment team and ethics committee determined that her physical and psychiatric impairments were likely to lead to her death, despite any plausible attempts at aggressive intervention” (p. 373).

A palliative care approach was pursued for this patient, despite her firm belief that she was not going to die. So she continued her extreme caloric restriction, purging, laxative abuse, and compulsive exercise. She sustained numerous stress fractures, abrasions, and bruises from falls while running. Her weight, blood pressure, and heart rate dropped even lower. During this time, she attended regular outpatient therapy sessions, during which her eating disorder was never discussed. She eventually became so weak that she was moved to an inpatient hospice, where she died three weeks later.

What is wrong with this picture? The premature death of a young person is always a heartbreaking tragedy. But when a young person dies from a treatable illness, it is even worse. This patient’s family and treatment team abandoned her in her most desperate time of need. The ethics board washed their hands of her; law did not protect her.

Imagine, now, that this patient suffered from severe mental retardation (MR) instead of AN. A patient with MR would not be permitted to engage in self-injurious behaviors. If she could not eat on her own, her family or her nurse or her homecare worker would prepare her meals and spoon feed her. If she engaged in repetitive physical activities that posed a danger to her health, as many intellectually challenged persons do, she would be restrained for her own safety. If her family were unable or unwilling to provide her with the care she needed, she would be placed in a residential treatment center or a group home or an assisted living facility of some type. The cost of these services, even in the United States, would be subsidized by the government. Allowing a person with MR to starve to death would be considered cruel and inhumane. But for a person with AN, it is OK?

The irony here is overwhelming. Both AN and MR are biologically-based brain disorders which result in an inability to meet one’s basic physical needs. MR is, by definition, a life-long, incurable condition which causes marked impairment in functioning. AN is treatable, and many people recover from it completely. Unlike most people with MR, people with AN are able to form intimate relationships, pursue higher education, have meaningful careers, function independently, and make enormous contributions to society.

We, as a society, have done a great service to those with MR. We have medical ethics, legal guidelines, and government programs to protect them and ensure that their needs are met. They are not offered palliative care. Regardless of their family circumstances and finances, they are offered tremendous support for as long as they need it, which is usually for their entire lives. But with AN, the treatment ends when the insurance runs out. Or when the parents and treatment team are fed up. Or when a judge decides that further treatment isn’t worth it.

For the record, this is not about people with AN being “more worthwhile” than people with MR and therefore “more deserving” of resources. Quite the contrary. I believe that all human beings, regardless of physical or mental illness, disability, race, gender, religion, or sexual orientation, deserve affordable, effective healthcare services throughout their lifespan.

Why is it that we have failed people with chronic AN but served people with MR so well? Because most people in society, and many in my own profession, believe that AN is a choice. No one, not even children, believes that people choose to have MR. Because many treatment professionals believe that AN patients must be motivated to recover, enter treatment willingly, and manage their symptoms on their own. No one waits around for people with MR to become motivated to recover before providing them with services, and no one expects them to manage their issues alone. Because our legal system believes that an adult with a BMI of 10 who runs 15 miles a day and cannot nourish herself is competent to make her own healthcare decisions.

Come on, world. We can do so much better than this.

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Thursday, December 10th, 2009

Fighting the Wrong Battles

I’ve become increasingly annoyed at the conflation of “body dissatisfaction” with “eating disorder.” The former is a culturally-driven socio-political phenomenon, whereas the latter is a severe, biologically-based mental illness. The former afflicts over 85% of American females, whereas the latter strikes only a small fraction of us (less than 1% for anorexia nervosa and 2-3% for bulimia nervosa).

There has been a great deal of controversy surrounding supermodel Kate Moss’s comment that “Nothing tastes as good as being thin feels,” and around Ralph Lauren’s ridiculously photo-shopped ads. Eating disorder clinicians and activists have been quite vocal about their opposition to these media bytes, arguing that they encourage eating disorders. I know that these professionals and activists have noble intentions, but I believe they are fighting the wrong battles.

I object to underweight models not because I believe they cause eating disorders, but because being underweight is harmful to the models’ physical and mental health, and viewing these images on a regular basis contributes to body dissatisfaction in most people. I refuse to have magazines in my office waiting room not because I believe they cause eating disorders, but because I am opposed to the blatant objectification of women. Besides, I think that fashion magazines are sexist, superficial, and boring.

Hanging in my office is a certificate of membership from NEDA (National Eating Disorders Association) which thanks me for my “support in the effort to eliminate eating disorders and body dissatisfaction.” I really wish they had eliminated those last three words.

I think the conflation of sadness with depression is analogous. The former, in its extreme and persistent form, is one symptom of the latter. The former is a natural, healthy emotional state that every human being experiences from time to time, while the latter is a serious mental illness caused by a combination of neurobiological, psychological, and environmental factors. I remember an incident that illustrates this principle beautifully. I was conducting an initial evaluation with an adolescent girl and her parents. When I asked the father whether he thought his daughter was depressed, he replied: “I don’t believe in depression.” Interesting response, I thought. As if depression were something like God or heaven or Santa Clause, something to be believed in or not. I asked the father to elaborate on his beliefs. He replied: “I think we all get sad sometimes, and that’s OK.” I smiled and gently responded that I agree with him – yes, all of us do get sad sometimes, and yes, that’s OK. However, some people experience prolonged, intense feelings of sadness accompanied by sleep and appetite disturbances, fatigue, thoughts of suicide, loss of interest, and difficulty concentrating. These people are experiencing major depression.”

Imagine if, in exchange for my membership in the National Depression Association, I received a certificate thanking me for my support in the effort to eliminate Major Depressive Disorder and sadness.” Laughable, isn’t it? Well, so is the ED/Body Dissatisfaction comparison. It trivializes the anguish that eating disordered people experience, and it falsely encourages those whose lives have not been touched by eating disorders to think that they “know how it feels.” Well, guess what. They don’t.

Eliminating all sadness in the world would probably not affect the prevalence of Major Depressive Disorder because sadness is but one symptom of depression, whereas depression is not a result of sadness. Likewise, eliminating body dissatisfaction would be fantastic for everyone, but it would not result in the elimination of eating disorders.

Contrary to popular belief (and, sadly enough, the belief of many eating disorders professionals), the media’s glorification of thinness is not responsible for the so-called “epidemic” of anorexia nervosa. Also contrary to popular belief, the incidence of anorexia nervosa has not increased dramatically in recent decades. Cases of what would now be diagnosed as anorexia nervosa have been documented as early as the medieval times, long before thinness was considered fashionable. These fasting saints shunned all sustenance to the point of emaciation not because they wanted to be skinny, but because they believed it brought them closer to God.

Unbeknownst to many, anorexia nervosa occurs in many non-western cultures. For example, recent studies have shown that the prevalence of anorexia nervosa in China and Ghana is equal to its prevalence in the US. The major difference is that patients in non-western cultures relate their starvation to profound self-control, moral superiority, and spiritual wholeness rather than to a desire to be thinner. Today’s American anorexics, like their medieval predecessors and non-western counterparts, all experience prolonged inability to nourish themselves, dramatic weight loss to the point of emaciation, amenorrhea, and denial of the seriousness of their condition. The self-reported reasons for starvation, it seems, are the only things that change across time and culture. I believe that an anorexic’s so-called reasons for starvation are simply her attempts to derive meaning from her symptoms, which are always filtered through a cultural lens. An anorexic does not starve herself because she wants to be thin, or because she wants to be holy, or because she wants to show supreme self-control. She starves herself because she suffers from a brain disease, of which self-starvation is a symptom.

Recent research suggests that anorexia nervosa is not a culture-bound syndrome, but bulimia nervosa is. Anorexia nervosa seems to be a distinct genotype that has been around for centuries and that manifests itself in various cultures and eras. Bulimia nervosa, on the other hand, appears to occur in individuals with a certain genetic / neurobiological predisposition who are exposed to a culture which combines massive amounts of readily available, highly palatable foods with a cultural mandate for thinness. This research implies that reducing or eliminating the cultural glorification of thinness may indeed reduce the prevalence of bulimia nervosa, but will have no effect on the prevalence of anorexia nervosa. I suppose that, once this awful waif model craze blows over, anorexics will simply find another “reason” to starve.

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Sunday, December 6th, 2009

Emotional Anorexia

Most patients with anorexia nervosa (AN) experience an ostensible “loss of appetite,” if you will, for all human needs. During refeeding, some patients with AN become uncharacteristically violent and hostile towards their parents, shunning all attempts at comfort or affection. Some therapists have referred to this phenomenon as “emotional anorexia.” While I’m not aware of any empirical literature on this topic, I do have some hypotheses of my own.

Like AN and other mental illnesses, the etiology of emotional anorexia is complex and multifaceted. I believe that the factors which contribute to emotional anorexia are, in order of relevance: 1.) Genetic predisposition, 2.) Neurobiological changes associated with malnutrition and refeeding, 3.) Psychological symptoms of AN, and 4.) Developmental and familial issues. Let’s examine each of these issues in turn.

GENETIC PREDISPOSITION. Between 50%-80% of the risk of developing AN is genetic. It is very likely, then, that genes play the most significant role in the development of emotional anorexia as well. The character traits which predispose people to AN: anxiety, obsessiveness, perfectionism, and harm avoidance, are present at birth and are determined primarily by genetics. People with this character structure tend to exercise restraint not just with their food, but also in other areas of their lives. They tend to be emotionally inhibited, most likely because they tend to be overly fearful of making mistakes.

Further, recent research has demonstrated that individuals with AN have difficulty processing emotional information. They tend to misperceive others’ emotions (for example, they are likely to think someone is angry with them when in reality the person is concerned about them), and they avoid emotionally intense situations. This type of personality creates the perfect template for the development of emotional anorexia.

Brain imaging studies have shown that individuals with AN have alterations in their anterior insula, a region of the brain which is critically important for interoception (the self-awareness of internal bodily signals). During the acute phase of their illness, individuals with AN are literally unable to sense hunger, fullness, tiredness, and changes in body temperature. Additionally, they have an imbalance between circuits in the brain that regulate reward and emotion (the ventral or limbic circuit) and circuits that are associated with consequences and planning ahead (the dorsal or cognitive circuit).

This combination of difficulty processing emotional information, disrupted interoceptive awareness, and disregulated reward-emotion circuitry renders anorexics incapable of experiencing pleasure from food, rest, sex, physical affection, or fun activities the way healthy people do. A hug may feel the same as a slap in the face; a smile may look like a sneer; a piece of chocolate cake may be as punishing as a tablespoon of cod liver oil; words of encouragement may sting like salt in a wound. People with AN feel safer and calmer when they shrug off affection and shun human contact as well as food.

NEUROBIOLOGICAL CHANGES ASSOCIATED WITH MALNUTRITION AND REFEEDING. Since the Minnesota Starvation Study, we have known that malnutrition causes biochemical changes in the brain which result in dramatic personality and behavior changes, such as depression, anxiety, irritability, apathy, loss of interest, isolation, and social withdrawal. The neurobiological changes associated with re-feeding are equally profound. Because starvation numbs emotions, many patients experience a resurgence of depression, anxiety, irritability, anger, and loss of control when food is reintroduced. Dr. Walter Kaye hypothesizes that individuals with AN have a shortage of serotonin in the brain, since serotonin is derived partially from food. More serotonin receptors are created in effort to harvest the scanty amount of serotonin available. Thus, when food is reintroduced and serotonin levels rise, the large number of receptors causes too much serotonin to be taken up, making the person feel extremely agitated and irritable. This makes eating a terrible emotional ordeal. It is very difficult to give or receive love and affection when you are struggling with intolerable anxiety and irritability.

PSYCHOLOGICAL SYMPTOMS OF ANOREXIA NERVOSA. So now we have a teenager with the perfect genetic template for emotional anorexia who is experiencing the profound neurobiological effects of malnutrition. In addition to these physiological effects, she is experiencing debilitating depression, feelings of worthlessness and inadequacy, she has lost interest in socializing, she has withdrawn from friends and family, and she has difficulty accurately perceiving emotions. When she isolates herself, she experiences less social reinforcement, which confirms the depressive schema that she is worthless and inadequate. Her athletic performance begins to decline, she has difficulty concentrating, and she is no longer asked out on dates. Her friends are alarmed by the changes in her physical appearance and mood, so they stop talking to her. Parents, teachers, coaches, and friends express extreme concern, which she misinterprets as anger, jealousy, or criticism. All of these things reinforce her feelings of worthlessness and inadequacy. I have had several patients with AN cry to me that their parents didn’t visit them at all while they were away at summer camp or college. Meanwhile, their parents confided to me that they wanted desperately to visit their daughter, but she told them not to, and they wanted to respect her autonomy. The patients insisted that they didn’t want their parents, yet lamented their absence. Clearly, there’s a disconnect here. The patient either a.) is not aware of her emotional needs, b.) doesn’t know how to express these needs, or c.) chooses not to express her needs because she is afraid, embarrassed, or ashamed. I believe that a, b, and c are all true.

One of the core features of AN which has persisted throughout the centuries is a sense of “needlessness,” of being “above” worldly pleasures and bodily needs. Medieval saints experienced this needlessness. They prayed for days on end without food, water, sleep, or socialization. Amongst these fasting saints, there are documented cases of what would today be diagnosed as AN. In certain non-western cultures such as China and Ghana, AN is as prevalent as it is in the US. The major difference is that patients in non-western cultures relate their starvation to profound self-control, moral superiority, and spiritual wholeness rather than to a desire to be skinny. Today’s American anorexics, like their medieval predecessors and non-western counterparts, experience some version of needlessness. Some anorexics have a grandiose sense of being “above” basic needs, including food, sleep, fun, love, and comfort. This grandiosity often stems from the extra burst of energy and euphoria that starvation brings them, coupled with the sense of pride and accomplishment that they have been able to override their body’s needs and diet to the point of emaciation. Other anorexics believe they are unworthy of food, sleep, fun, love, or comfort. These feelings stem from the debilitating depression that is triggered by malnourishment and exacerbated by body dysmorphia and self-loathing. Many anorexics vacillate between these two mind frames, but the end result is the same: emotional anorexia.

The neurobiological changes associated with refeeding cause most patients to experience intense mood swings, irritability, and anger. The psychological trauma of AN adds fuel to the fire. Eating more and gaining weight are an anorexic’s worst nightmares, and this is precisely what is required of her in order to recover. She gains weight, experiences tremendous fear as her appetite kicks into high gear once again, and she is no longer “allowed” to diet. Her body dysmorphia and self-loathing are more intense than ever. Her irritability, agitation, moodiness, and depression are at an all-time high. She withdraws and isolates herself even more, feeling as though she is “too fat” to be seen in public and undeserving of love, comfort, friends, or fun.

Enter the old-school therapist. The young patient is absolutely miserable and desperate to feel better. She has little insight into her symptoms and trusts the therapist completely. The therapist searches through the patient’s past to uncover the “root cause” of her AN. Lo and behold, it is discovered that her parents were too controlling, too overbearing, too overprotective, too critical, too mean, too distant, too neglectful, or too abusive (often some combination of the above). The patient, who is in the midst of the neurobiological hurricane that is re-feeding, becomes angry and hostile towards her parents once she “realizes” that they have caused her current misery. Her parents take her to appointments, prepare her food, and insist that she eats it, thus making her even more fat and unlovable. Her parents try to comfort her; she pushes them away. She is, at times, violently angry with them. After all, they made her anorexic, and now they are making her fat. The same pattern also develops with certain members of her treatment team. She views their interpretations as criticisms. She perceives their requirement of weight restoration as their attempts to fatten her up. Her parents and her treatment team are ruining her life as they chip away at the one thing that has ever made her feel good: the AN.

DEVELOPMENTAL ISSUES. The concept of mother is inextricably intertwined with the concept of food. As developing fetuses in our mother’s womb, we receive nourishment from her. We are born with a rooting reflex, which prompts us to suck our mother’s breast or a bottle. Without this reflex, and without a mother or other caregiver to provide the nourishment, we would die. As infants, we cry when we are hungry. Mother comes running; she holds us and feeds us. Throughout our childhood and adolescence, mother is probably responsible for most of the food shopping and meal preparation.

When a teenager develops AN, her mother is often the first to notice a problem. Mother may encourage or require her to begin treatment. Mother often prepares and serves her food during re-feeding. Mother may ask when and what she last ate, and may require that she eat just a little bit more. Is it any wonder, then, that an anorexic’s feelings about food spill over into her feelings about her mother?

Some psychoanalysts postulate that AN develops from a lack of empathic attunement between mother and child. The mother is not attuned to her child’s emotional needs, so the child is unable to meet her own needs, and this is manifested in her inability to feed herself. There are no empirical data to support the theory that lack of maternal empathic attunement causes AN, and in fact, I believe that this theory is 100% false in terms of explaining the etiology of AN. However, I can understand how this principal may operate subconsciously in the mind of an ill patient. Individuals with AN have great difficulty getting their needs met. They may be unaware of their own needs, they may feel as though they don’t deserve to have their needs met, or they may believe they are “above” having needs. This applies to emotional needs as well as nutritional ones.

I suspect that there is a modest correlation (which does NOT imply causation) between a mother’s inability to provide for her child’s physical or emotional needs and the child’s development of AN. Remember, 50-80% of the risk for developing AN is genetic, so it is very likely that a patient with AN has a first-degree relative (often the mother) who also has a history of AN. If the mother is currently struggling with AN, her fear of food and intolerable anxiety may render her unable to provide for her child’s basic physical and emotional needs. Even if the mother is currently healthy but has a personal history of AN, she will likely share the biochemical and temperamental traits of her ill daughter, albeit to a lesser degree. The recovered AN mother’s deficit in interoceptive awareness may spill over onto her child. She may struggle to meet her daughter’s needs because she has difficulty sensing and meeting her own needs.

Teenagers who develop AN tend to be “model children.” They are almost universally intelligent, well-behaved, hard-working, and gifted at athletics or artistic endeavors. They follow all the rules to the letter. They have never caused a problem for their parents or teachers. The development of AN and the process of recovery leads to an examination of one’s life. The experience of having a life-threatening, soul-killing, personality-destroying illness is enough to make any teenager step back and take stock. Teenagers who are recovering from AN may begin to feel resentful that they have lived a “faked existence” and “played by everyone else’s rules.” They may realize that they have missed out on a lot of fun and excitement by being so straight-laced. With their therapist’s encouragement to express their emotions authentically, they unleash their fury onto the people who have been there through it all: their parents.

This is not a cohesive or well-articulated theory, just a compilation of related thoughts. I hope that research will shed some light onto this phenomenon in the near future.

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Monday, August 17th, 2009

What’s That About?

“It’s about control.”

This statement has been applied to everything from OCD to eating disorders to self-injury to domestic violence. But, really, what does this statement mean?

When I hear that X is about Y, I generally interpret this statement in one of two ways: 1.) Y is a theme of X or 2.) Y is the most salient feature of X. For example, if someone says that Romeo and Juliet is about undying love, my interpretation is that undying love is a primary theme of Romeo and Juliet. Or if someone says: “My birthday is about me,” I interpret that as “I am the most important person on my birthday” in terms of attention, presents, and deciding how to celebrate.

In regards to the cliché that a certain psychological problem is about control, both of these interpretations make sense to a certain extent. Control is both a theme and a salient feature of OCD insofar as sufferers are overly preoccupied with controlling their external environment, as well as their thoughts and actions related to their particular obsession. For example, a person with OCD may spend hours scrubbing her body and cleaning her home in order to control the spread of germs and prevent herself or others from becoming ill.

Control is both a theme and a salient feature of eating disorders insofar as sufferers become preoccupied with controlling their dietary intake, exercise, and weight. Individuals with anorexia tend to be “over-controlled,” rigid, and perfectionistic not only with food but in other areas of their lives, while individuals with bulimia experience periods of “dyscontrol” of their emotions and food intake, resulting in binge /purge episodes.

Control is both a theme and a salient feature in the lives of individuals who engage in self-injurious behaviors such as cutting. Many, though not all, individuals who cut have experienced physical or sexual abuse, which results in feeling a lack of personal control over one’s life and one’s body. People who cut usually experience overwhelming emotions that they are unable to control. Some people use self-injury as an interpersonal message with an intent to control or manipulate others.

Control is both a theme and a salient feature in cycles of domestic violence. Through subtle and overt messages, abusers control and manipulate their victims. It is easy for abusers to control their victims because the victims are usually smaller and physically weaker than they are. In most cases, abusers have financial and / or emotional control over their victims. And, sadly, victims feel a devastating loss of personal control over their own lives.

I am concerned, however, that people who claim that a mental illness or psychological phenomenon is about control have an entirely different interpretation of this phrase. For most people, I think “It’s about control” translates to “it is caused by a lack of control or a need for control.” This interpretation has no empirical backing and, when espoused by treatment professionals, leads to ineffective treatment.

For instance, many therapists believe that eating disorders are “about control,” meaning that they believe that the etiology of eating disorders is rooted in a subconscious need for control. As a result of this theory, their treatment entails helping the patient gain a sense of personal control in other areas of her life, and advising her parents to “back off” of the power struggle around meals, with the assumption that eventually the patient will no longer feel the need to control her food intake.

There is no scientific basis for this theory or this treatment approach, and I have never met a person who has recovered this way. I’m sure such people exist, I’ve just never seen them. I would presume that these individuals went through years of treatment, suffered numerous medical and psychological problems, and spent many thousands of dollars before finally recovering. Recent scientific evidence suggests that eating disorders are biologically-based, genetically transmitted brain diseases that are triggered by an energy imbalance and perpetuated by malnutrition. There’s no room for “control” in this etiology.

While I’m on the subject of about, there’s another use of the word about that perplexes and frustrates me. Case in point: a very well-regarded eating disorder recovery website has the following mission statement on its homepage:

“We are dedicated to raising awareness about eating disorders… emphasizing always that eating disorders are NOT about food and weight.”

What does this mean? Surely, it cannot mean that food and weight are not themes in eating disorders. Nor can it mean that disturbances in food and weight are not a salient feature of eating disorders. By definition, individuals with eating disorders manifest disturbances in eating behavior, weight loss, or excessive preoccupation with weight. I can only assume, then, that this statement means that eating disorders are not caused by food and weight (or disturbances thereof). If this is the meaning of the mission statement, then the statement is undeniably false.

The latest scientific research tells us that eating disorders are, in fact, set into motion by disturbances in eating and weight. A person with a biological predisposition to anorexia nervosa or bulimia nervosa will not develop the illness unless he or she experiences a disturbance in eating and/or weight. Anorexia nervosa and bulimia nervosa are triggered by under-nutrition, which may initially be intentional (e.g., the decision to diet, “eat healthy,” or exercise more) or unintentional (e.g., the result of an illness, surgery, injury, medication, or another mental illness such as depression). The cycle of starvation in anorexia nervosa is maintained by malnutrition, and the illness is most severe and most deadly when the patient is underweight. The restrict/binge/purge cycle in bulimia nervosa is also self-perpetuating and is triggered or exacerbated by disturbances in eating behavior and preoccupation with weight. Full nutrition, weight restoration, cessation of restricting, bingeing, and purging behaviors, and decrease in preoccupation with weight are essential for full recovery. In conclusion, eating disorders are absolutely about food and weight. To neglect this perfectly obvious fact is to sabotage treatment.

Scientist-practitioner ranting notwithstanding, I think I do understand what that mission statement is intending to communicate. I think it is trying to convey that eating disorders are not just about food and weight; they also entail tremendous psychological suffering. I think the statement is trying to emphasize that correction of disturbances in eating and weight is not sufficient for full recovery, as psychological issues must be addressed as well. Finally, I think the statement hopes to convey that eating disorders are serious mental illnesses that bear little resemblance to typical dieting and body image woes.

While I applaud the website’s attempt to convey the aforementioned messages, I think the way the statement is worded has the potential to create a misunderstanding (or, at the very least, it doesn’t bring people closer to an accurate understanding). I’m guessing that eating disorder sufferers and their families, as well as the general public, will misinterpret the message, most likely in the manner I described. The consequences of such misinterpretation can be tragic.

We have a responsibility to people with eating disorders to provide them, and their families, with accurate information. Further, we have a responsibility to educate the public about eating disorders in order to reduce stigma, garner support, facilitate early detection, and lobby for more effective treatment. To start, let’s make sure the messages about eating disorders that we send, whether in person, in print, or on the internet, are accurate, understandable, easy to interpret, and scientifically-sound.

Isn’t it about time?

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Friday, August 14th, 2009

Maudsley Is As Maudsley Does

Those who know me professionally are well aware that I am an advocate of the Maudsley Method of Family-Based Treatment and that I use this approach to treat my adolescent patients with eating disorders. What they may not know is that Maudsley principles pervade my treatment philosophy for eating disorder patients of all ages, regardless of the treatment approach I employ with them. For example:

• I always externalize the eating disorder and teach my patients to do the same.
• I firmly believe that patients do not choose eating disorders and that parents do not cause them. I make this point explicitly to patients and their families at the start of treatment and as many times as necessary throughout the course of treatment.
• I explanation the etiology of eating disorders as follows: We don’t know definitively what causes eating disorders, and for the purposes of this treatment, the cause isn’t terribly important right now. The most recent scientific research suggests that eating disorders are biologically-based, genetically-transmitted mental illnesses which are triggered by an energy imbalance (for example, through dieting) and perpetuated by malnutrition, with emotional stress (e.g., anxiety, OCD, depression) as an aggravating factor. I mention all of the common myths about the causes of eating disorders (e.g., the media, fear of growing up, need for control, overbearing parents) and dispute each one of them.
• At the start of treatment, I provide patients with psycho-education about the central role of full nutrition, weight restoration, and cessation of binge/purge behaviors in recovery.
• Whenever possible, I involve family members (parents, siblings, spouses, girlfriends, boyfriends) in the patient’s treatment to some extent. In some cases, family involvement may be as simple as providing family members with psycho-education, literature, and internet resources on eating disorders. In other cases, family members may participate in the evaluation or attend some therapy sessions with the patient. Regardless of the patient’s age, I like to empower those who live with her (parents, spouses, significant others) to provide meal support and help stop other symptoms such as excessive exercise, bingeing, and purging.
• I view family members as essential members of the treatment team who can provide nutritional, practical, and emotional support to the patient as she recovers.
• I make physical health (including full nutrition, weight restoration, elimination of purging and other unhealthy behaviors) the most immediate priority in treatment.
• I help patients re-learn how to eat properly on their own once they are physically healthy and psychologically prepared to assume this responsibility.
• I treat patients’ other disorders (e.g., depression, OCD, anxiety) and address their developmental, familial, and interpersonal issues after physical health has been achieved.

In my view, these principles are equally applicable for children, adolescents, college students, and adults. They apply when I am doing individual therapy using a CBT, DBT, ACT, or IPT approach. They apply when I am doing couple’s therapy when one partner has an eating disorder. And, of course, they apply when I am doing Maudsley Family-Based Therapy.

These principles are a central part of my professional identity. I stand behind them when I am giving a lecture, doing a presentation, conversing with colleagues, speaking to potential clients, talking about work with family and friends, or even answering the questions of acquaintances who are interested in what I do.

To date, the Maudsley approach has only been empirically-supported for adolescents with anorexia nervosa and bulimia nervosa. However, preliminary data suggest that Maudsley may be equally effective for pre-adolescent children and young adults. Regardless of what the eventual published data may say about broader applications of Maudsley, I will hold fast to these principles. At least until science or experience convinces me otherwise.

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