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.

Iatrogenic Effects

The year is 1892. Emily, age 14, is the second of six children in a Midwestern farming family. One evening in March, Emily’s mother catches a glimpse of her daughter undressing and is taken aback by how slim she looks. Over the next few days, mother notices that Emily eats very little at family meals. She mostly just pushes her food around the plate and slips pieces of her food under the table to the family’s two dogs.

Later that week, Emily’s older sister, Cora, confides in her mother that Emily is no longer getting her monthly cycles. Now mother is greatly concerned, and she has a talk with her husband, who is equally worried. Both parents sit down with Emily and express their concern over her poor eating habits, weight loss, and absence of menstrual cycles. In response to her parents’ talk, Emily bursts into tears. “I just can’t eat,” she cries. “I just can’t.” Mother and father hug their daughter, comfort her, and let her know that they will be taking her to the family doctor the next morning.

When Dr. Benson examines Emily the following day, he is alarmed by his young patient’s gaunt appearance and flat affect. She is no longer the bubbly, robust young girl he has known since birth. Emily’s pulse is much lower than normal, her muscles have wasted, and her adolescent figure has shrunken to a pre-pubescent one.

“Emily is gravely ill and melancholy,” Dr. Benson tells the worried parents. “She is malnourished, and she will need lots of food and rest to recover. She needs complete bed rest for the next three months, plenty of food at each meal, and six tall glasses of milk per day. I will see her again next week.”

Emily cries heavily all the way home, burying her head in her mother’s skirt. As soon as the family gets back to their house, her mother prepares her a large plate of food with extra bread and butter and a tall glass of milk. Mother sits beside Emily and strokes her daughter’s hair as she stares – terrified – at the heaping plate of food. “You will not be doing any chores this spring,” her father tells her firmly. “Cora will do your indoor chores and Ethan will take over your outdoor chores. You will not be returning to school this year – the 2-mile walk is too strenuous for you in this condition. Cora will speak with your teachers and bring home your assignments. You will study from home. You will return to school and chores when you are well.”

“But Papa…” pleads Emily. “I have to –“

“That’s enough, young lady. You know better than to take that tone with me. This is final.” With that, Emily’s father abruptly leaves the room. Tears stream down Emily’s cheeks as she weeps silently. Mother strokes her back and whispers: “Come on, sweetie. Eat.” Hands shaking, Emily picks up her fork and takes a bite. Mother waits with her at the table for the next two hours as she finishes every last bite of food and every last drop of milk.

19th century family

Dr. Benson makes house calls weekly over the next few months. Emily is always lying on her bed, reading and sipping a glass of milk, when he arrives. He watches the young girl slowly put on weight, regain her strength and stamina, begin to smile again, and then blossom into the cheerful teenager she was meant to be. By the time June rolls around, Emily has resumed her monthly cycle and returned to her normal weight. At this point, Dr. Benson gives her permission to begin doing some light chores around the house.

By September, Emily is eating with gusto. She has had three monthly cycles in a row and has regained her curvy figure. She returns to school and resumes all of her farm chores. Her parents are relieved to have their daughter back.

The vignette above illustrates how Anorexia Nervosa (AN) would have been treated several generations ago. Quite a stark contrast from how AN is treated today, isn’t it? The illness itself has remained basically the same throughout time, but the way that people conceptualize it and respond to it has changed dramatically. Consider the following differences between Emily’s treatment in 1892 and the treatment Emily’s great-great-granddaughter Marissa received in modern times:

1.) Emily’s parents are immediately concerned by her weight loss and dwindling food intake. They view weight loss in a growing adolescent as a sign of illness and take her to the doctor immediately. Marissa’s parents are pleased when they notice her becoming slimmer shortly after her 14th birthday. They praise her for foregoing desserts and snack foods. They encourage her interest in athletics and bring her jogging with them in the morning.

2.) Emily’s family doctor is immediately concerned by his young patient’s weight loss, lack of menses, and changed demeanor. At her 15-year-check-up, Marissa’s pediatrician commends her on her 12-pound weight loss. When Marissa’s mother expresses concern to the pediatrician about her daughter’s low heart rate and absence of menses for the past three months, the doctor explains that it is common for female athletes to lose their monthly cycle, and that Marissa’s low heart rate is also due to being a runner.

3.) The prescribed treatment for Emily – full nutrition and complete bed rest – is commenced immediately and aggressively. Eating more food is not recommended, or even suggested, for Marissa. Marissa continues running with the blessing of her doctor and the encouragement of her coach.

4.) The doctor views Emily’s parents as competent agents to re-feed their starving daughter and enforce bed rest for a prolonged period of time. Marissa’s parents are advised to “stay out of the food business” and admonished not to be the “food police.”

5.) Dr. Benson monitors Emily’s condition weekly and supports the family throughout the recovery process. Emily’s menstrual periods return naturally as she restores a healthy weight. Marissa’s pediatrician does not see her again until she develops a stress fracture 5 months later. Marissa has now lost a total of 20 pounds, and her pediatrician gently suggests that she tries to eat a little more. The pediatrician also refers her to a gynecologist, who prescribes birth control pills to re-start her periods.

6.) Emily is expected to comply with the prescribed treatment, and parents are expected to enforce it. Marissa restricts her food intake even more. She is now eating nothing but fruit, vegetables, and chicken breast. Scared to make matters worse, her parents say nothing.

7.) Emily eats hearty meals with her family every day for breakfast, lunch, and dinner, plus plenty of whole milk in between. Unable to watch her daughter starve herself any longer, Marissa’s mother takes her to a local therapist who was recommended by a neighbor. This therapist begins meeting with Marissa weekly, and also refers them to a family therapist and a dietitian. Marissa is now attending multiple appointments each week and following a 1600-calorie exchange plan created by her dietitian. She prepares her own meals, weighing and measuring everything.

8.) The doctor recommends chamomile tea with honey to soothe Emily’s nerves. Neither Emily nor her parents are blamed for her AN. The etiology of the illness is not discussed with Emily or her family, as it is not known. Marissa’s weight does not change, but her mood deteriorates. The therapist refers Marissa to a psychiatrist, who prescribes Lexapro and Klonopin. The family therapist suggests that Marissa’s AN is a cry for attention, as her father works long hours at his law firm and her mother is very preoccupied caring for her younger son with autism.

9.) Emily’s weight was restored to her normal range within three months of commencing treatment. She remains home with her family throughout and maintains good physical and mental health for the rest of her teenage years. By her 16th birthday, Marissa has lost 4 more pounds (a total loss of 24 pounds in 2 years). Her therapist recommends residential treatment at a well-marketed eating disorder treatment center in another state. Marissa spends 3 months at this residential treatment center. The psychiatrist there prescribes two additional psychotropic medications. Within a month of returning home, Marissa relapses and returns to the center for another 3 months.

10.) Emily maintains good relationships with her parents and siblings. She trusts her family to help her when she needs them. By the time she turns 18, Marissa has had three psychiatric hospitalizations, four stays in residential eating disorder treatment, and is taking five different psychotropic medications in addition to Ambien for sleep and birth control pills to regulate periods. She barely speaks to her parents and refuses to sign consents to allow them to access her healthcare information.

Emily and Marissa developed the same illness at the same age but received very different treatments and thus had very different outcomes. Emily’s AN was completely resolved within 6 months, whereas Marissa remains gravely ill and in intensive treatment four years later. Marissa experienced the iatrogenic effects that are so prevalent in modern eating disorder treatment. Iatrogenic effects are harmful outcomes caused by a medical intervention. In other words, a treatment which is intended to help a patient ends up making her condition worse or creating a new problem that wasn’t there before.

Marissa’s story is all too common. The adults around her – with good intentions – inflicted harm by prolonging her state of semi-starvation, prioritizing her adolescent autonomy above her physical health, disempowering her parents, alienating her from her family, subjecting her to time-consuming, costly, and ineffective therapies, prescribing powerful psychotropic drugs that may not have been necessary, isolating her from her primary support system, and surrounding her with other mentally ill teenagers.

modern girl

Clearly, some teenagers with Anorexia Nervosa have complicated presentations with multiple comorbidities which require a team of professionals and specialized care. But there are also many cases in which a simple and straightforward intervention would be far more effective and efficient than the iatrogenic treatments that so many kids and families endure. This is precisely why Family-Based Treatment (FBT) is so effective: it minimizes the iatrogenic effects of other eating disorder treatments. Mainstream eating disorder treatment often morphs Emilys into Marissas.

What would have happened to Marissa if she had been provided with the same treatment as her great- great-grandmother Emily? Would she, too, have regained full health in a matter of six months, and bounced back into a vibrant adolescent life? It’s impossible to know for sure, but it seems likely that she could have. It’s definitely worth a try. Our 21st century Marissas need and deserve treatment that is AT LEAST as effective as 19th century Emilys.

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22 Responses to Iatrogenic Effects

  1. Chris says:

    Maybe before prescribing “complete bed rest” for three months, that Dr. Benson should read this paper: Parry, The impact of extended bed rest on the musculoskeletal system in the critical care environment, Extrem Physiol Med 2015 Oct 9; 4:16 (free, full text on http://www.pubmedcentral.gov)

    In this thorough, scientific, review, the authors conclude: “Bed rest was first introduced as a medical treatment in the 19th century to minimize the metabolic demand on the body and enable a focus on healing and rest to promote recovery. However, lack of physical activity and prolonged bed rest have significant consequences on musculoskeletal, cardiovascular, respiratory, integumentary and cognitive systems and may be associated with harm.”

    One of the advantages of FBT is that it is parents, not MD’s, who determine the recovery plan.

    I have never heard of a parent requiring that their kid remain on complete bed rest for three months while recovering from anorexia nervosa.

    • Dr. Ravin says:

      I agree with you completely, Chris. But this vignette takes place in the 19th century, when complete bed rest was commonly prescribed and the research you cite was not yet conducted.

      At least some things have changed for the better since Dr. Benson’s time!

      • Chris says:

        For more evidence of iatrogenic effects, read this: DiVasta, The effect of bed rest on bone turnover in young women hospitalized for anorexia nervosa: a pilot study, J Clin Endocrinol Metab 2009 May; 94(5):1650-5 http://www.ncbi.nlm.nih.gov/pubmed/19223524
        (best rest associated with suppressed bone formation and resorption and an imbalance of bone turnover.) Another reason to recover at home and stay out of the hospital if at all possible.

  2. Chris says:

    Many parents I know learned the hard way that most of the professional treatments for anorexia nervosa have serious iatrogenic effects. This is one reason the majority of families do not seek treatment from professionals when their child or teenager receives a diagnosis of anorexia nervosa. Examples of iatrogenic effects include long-term hospitalization. In the Gowers TOUCAN study, for example, the anorexia patients assigned to hospital treatment ended up, at the end of the treatment period, in much worse condition psychologically than those who continued to live at home with their parents and families. Professional psychotherapy itself also appears to have serious iatrogenic effects. For example, in a randomized controlled trial testing Mandometer against psychological “treatment as usual,” the patients given the psychological treatments actually had worse psychological symptoms at the end of the treatment period than those sufferers who received Mandometer. Mandometer does not conceptualize anorexia nervosa as a psychiatric or psychological disorder and therefore does not involve traditional psychotherapy.
    It is to be hoped that many of the professionals selling these ineffective and dangerous psychological treatments ultimately will be forced out of business. It is possible that some states might actually make some of these treatments illegal, as is the case with “conversion therapy,” a type of psychotherapy designed to convert LGBT kids to heterosexual, that has been shown to be both ineffective and damaging, much like many of the professional treatments for anorexia nervosa. In many states, including California, it is a crime for a professional psychotherapist to use “conversion therapy” on a minor. It is also to be hoped that parents will bring professional malpractice lawsuits against the purveyors of the many ineffective and dangerous treatments for anorexia nervosa, including, at minimum, psychoanalysis and family systems therapy. If enough of these professionals receive malpractice judgments against them, they will be unable to obtain malpractice liability insurance and therefore their licenses will be revoked.

  3. Mary says:

    This is very distressing to read as a parent. It feels like parent blaming. I read it, slept on it, and read it again before commenting, to be sure I am not reacting, based on my experience as a parent of a daughter who has suffered from bulimia for 10 years. I am not sure how constructive it is to compare a modern approach to what would have been done 100 years ago. It over-simplifies eating disorders! Basically 100 years ago, Emily could have had cancer and the doctor would have prescribed the same treatment because besides a few vials of some herbs in his bag, what else did he have to help her? So he wasn’t treating her AN per se, just doing what was done for all illnesses, and clearly for some illnesses it was “iatrogenic” to do nothing but treat with bed rest and food. Just as then, there are young AN girls today who do well with early intervention and FBT, but this a small percentage of those suffering with EDs. EDs are complex disorders and to propose one simple solution as effective makes parents feel terrible that they may have missed the boat and exposed their child to harm. I understand you are promoting FBT for young ANs, we get it, would it only be so easy for the majority of those that suffer with EDs.

    • Mary says:

      …. in addition, Emily grew up in a simple time, with a stay home mom and an intact family system. Things are much more complex for families today. We have to be careful about setting up a picture of a an ideal or perfect treatment approach that modern families may not be able to replicate. It’s complex, there is no one size fits all.

      • Chris says:

        FBT isn’t only for anorexia nervosa. It has also been tested for bulimia. For example, in a randomized trial published a few months ago, FBT was found to be more effective than Cognitive Behavioral Therapy (CBT) for the treatment of bulimia nervosa in adolescents. The study is published in the November 2015 issue of the Journal of the American Academy of Child and Adolescent Psychiatry: LeGrange, Randomized Clinical Trial of Family-Based Treatment and Cognitive-Behavioral Therapy for Adolescent Bulimia Nervosa, J Am Acad Child Adolesc Psychiatry 2015 Nov; 54(11): 866-94. In the study, the group treated with FBT had roughly double the rate of recovery at the end of the treatment, and six months later. Twelve months after the completion of treatment, the adolescents treated with FBT had a 50% higher rate of remission. The full study can be purchased for $12 on the website of the Journal of the American Academy of Child and Adolescent Psychiatry. This study has provided strong evidence for the use of FBT as first-line treatment for BN. Some parents might want to retain a professional therapist to help them with FBT; others might decide to proceed with treatment without involving a professional in the process.

        • Mary says:

          I am familiar with that study. We do need a lot more research of this kind. Unfortunately, while there were short term improvements for the FBT group, “by 12-month follow-up, there were no statistically significant differences between the 2 treatments.” As a parent, it is not surprising that there would not be big gains for young adolescents with CBT alone. Also, the subjects were included if they had one or more b/p episodes a week. There was no stratification for severity, once a week is very different than several times a day. Still, more research of this kind is needed for sure.

    • Dr. Ravin says:

      Hi Mary,

      I appreciate your feedback. I read your comments carefully and I take them seriously. I do not think you are over-reacting. I think I can understand where you are coming from and why you are distressed. I am very sorry that you perceived the article as parent blaming, and I am sorry for the distress it caused you. Please know that it was absolutely NOT my intention to blame parents in any way. In terms of my own philosophy, I do not blame parents in any way for their children’s eating disorders or other illnesses, and I believe that parents are their child’s best resource in recovery.

      My intention in writing this article was not to place any blame on parents, but rather, to criticize the way that eating disorders are often treated today, which often involves unnecessary, expensive, and potentially harmful interventions (interventions which often blame parents or blame the patient). I was criticizing the modern American eating disorder treatment industry.

      I agree that the article oversimplifies eating disorders (at least in Emily’s case). This was part of my point – my point being that sometimes the eating disorder treatment industry makes eating disorders more complicated than they need to be, which prolongs treatment and causes more pain and suffering. I also agree with you that many cases of eating disorders are complicated and require more intensive interventions. I did mention this in the last two paragraphs of the article.

      One major point of my article was to illustrate that it is impossible to know at the outset which cases are going to be severe and / or complicated, but that any case can become severe and / or complicated when a teenager is allowed to remain in a malnourished state for a prolonged period of time. Many symptoms and complications of EDs are actually the result of prolonged malnutrition on a developing adolescent brain. In the vignette about Marissa, you’ll notice that the AN symptoms which are most likely to cause long-term irreversible damage (malnutrition, low weight, and amenorhea) are not addressed at all until she has been suffering from AN for a prolonged period of time. This is NOT her parents’ fault, as they are simply following the advice of their doctors and therapists, with whom they entrusted their daughter’s care.

      In many cases (though certainly not all cases) it is possible to prevent long-term damage by ensuring that the adolescent is re-fed to a healthy weight as soon as possible and provided with the support he or she needs to remain at a healthy weight throughout adolescence. In the case of bulimia, the important early intervention would be to support the adolescent in establishing normalized eating patterns and preventing binge-purge episodes.

      In Marissa’s case, it is not possible to know whether she would have been able to recover in a relatively short time like Emily, or whether her illness would become chronic regardless. But my point is that Marissa potentially could have recovered much more quickly, and maintained a good relationship with her family, if her physician had immediately recognized her malnutrition, weight loss, low heart rate, and lack of menses as problematic, and made it clear to Marissa and her family that is is imperative that she eats more and regains the weight she lost. Similarly, if the therapists and dietitian whom Marissa saw later had prioritized full nutrition and weight restoration, and empowered Marissa’s parents to support her recovery at home, this could have shortened the duration of Marissa’s illness.

      In conclusion, please accept my heartfelt apology for writing something that made you feel blamed and distressed. I do not blame you in any way for your daughter’s eating disorder, nor do I blame any parent for their child’s eating disorder. I hope that this clarification helps you to understand my perspective on iatrogenic effects. I would welcome any further feedback, questions, or concerns that you have.

      • Mary says:

        Thank you for your kind reply. This is a great discussion, so important on many levels. To be honest, in all my years as a mom, I have never met a family who achieved the result you described for Emily, within months, navigated solely by the family under the care of a family physician. That said, I have seen and experienced first hand the iatrogenic effects of poorly trained professionals. Months and years and thousands of dollars spent with no impact on symptom use, been there. My D found recovery (early) in the hands of trained professionals in RTC with a treatment philosophy and level of support (um 24-7) that was right for her individually, followed up with outpatient care and tons of family support. 10 year process and still going. I know so many families who have battled even more than we have. So that is why is is hard to read about a simple timely approach resulting in something like a cure. I think we are all on the same page. We need research and training and early intervention. Thank you for all you do!

        • Chris says:

          I don’t think most parents who succeeded with FBT would say it’s a simple approach. Refeeding an anorexic teenager and re-establishing normalized patterns of eating behavior requires a lot of intelligence, motivation, experience, emotional stability, and insight. Parents generally tend to have these qualities; most eating disorder psychotherapists don’t.

        • Dr. Ravin says:

          Hi Mary,

          I can understand how it must be frustrating to read about relatively short recoveries when your child has suffered for so long. Eating Disorders, like most other illnesses, occur on a spectrum of severity. Some cases are relatively mild and straightforward to treat (like Emily’s), while others take years to recover. I have worked with families whose child recovered in a relatively short period of time, like Emily, with minimal professional involvement (e.g., 10 – 15 FBT sessions with me + medical monitoring with the family physician), so I know these cases do exist. However, most patients take much longer to recover, even with FBT.

          I have seen many cases in like Marissa’s in which professional interventions (e.g., years of therapy without weight restoration; multiple stints in residential treatment without aftercare, excluding parents from their child’s treatment, prescribed powerful psychotropic drugs to treat conditions they do not even have) have caused iatrogenic effects and prolonged treatment unnecessarily.

          In writing this article, I was deliberate in depicting straightforward treatment and recovery for Emily while depicting poorly executed treatment and protracted illness in Marissa. This stark contrast represents two extremes. Lots of people are somewhere in the middle.

          I have also seen many cases in which the family does everything “right” – catches the illness right away, stages an early intervention, seeks out evidence-based treatment, provides meal support and post-meal support, ensures that their child is fully weight restored within a few months and continues to gain and grow throughout adolescence -and still the patient takes a year or two or three to recover fully. We don’t always know why some patients recover in a matter of months while others take years. Some patients take longer to heal for reasons unknown. There’s still a tremendous amount about eating disorders that we don’t know.

          Given that there is so much we DON’t know, it is very important for us not to ignore what we DO know. Here’s what we do know:
          – In AN, full weight restoration must happen as soon as possible.
          – In BN and binge-purge type AN, binge eating and purging behaviors must be curtailed as soon as possible.
          – Normalizing eating habits is a top priority in both AN and BN
          – Most kids with eating disorders need meal support for a long time (many months, if not a year or two or three) before they are able to eat independently while maintaining their health
          – Alienating parents from their children, or separating children from their parents, harms families and hinders recovery
          – Parents do not cause eating disorders and patients do not choose to have them
          – Parents have special skills and insights into their child, know their child better than anyone else, and are more invested in their child’s outcome than anyone else, and thus can play an essential role in their child’s recovery

          I am glad to hear that your daughter was able to get better with a treatment approach that worked for her. Each patient is unique, and we cannot expect the same approach to work for everyone. Best wishes to you and your daughter!

  4. Leslie says:

    Dr. Ravin,
    Your point is right on and well taken by this mother whose daughter suffered for years under treatment remarkably similar to “Marissa’s.” Against common sense and our better instincts, we followed the advice of well-meaning but misdirected clinicians until you helped us fully understand and implement the principles of FBT.

    Iatrogenic effect? We know it well. Thanks again — this time for putting words to our experience

  5. Michele says:

    Dr. Ravin,

    What advice do you give to the parents of a child who discovered the AN quickly, kept her home and restored her weight within 3 months, but now grapple with “whack a mole” negative coping mechanisms in its place and a deep depression?

    She is back to her normal percentile in weight, has her periods and has for nearly 3 years. But the depression and anxiety are worse than ever. It’s like ever since her brain was affected by the AN, she’s not been the same.

    She’s in week 7 of the distress tolerance model of a DBT skills group, and we are switching this week from a ED therapist (mostly talk) to a DBT therapist to provide more exposure to that therapy weekly. And then seeing our regular ED dietician to remain on top of that in the meantime.

    Her dad and I are at a loss with whether we are doing the right thing or not. Her ED T was very knowledgeable but after three years, I believe she’s struggling more in some ways than ever. Thanks for your thoughts.

    Suggestions? We are in Wisconsin.

    • Dr. Ravin says:

      Hi Michele,

      Based on the information you’ve given, it sounds as though your daughter has co-morbid depression and anxiety. Since her bout with AN was relatively short, she recovered quickly and has been physically healthy for the past three years, you can be reasonably sure that the depression and anxiety she is currently experiencing are neither symptoms of AN nor residual effects of AN.

      As I’m sure you are aware, it is common for individuals with AN to have a co-morbid mood disorder and/or anxiety disorder. Your goal at this point, then, should be to address the depression and anxiety separately from the AN. In light of her current symptoms, it sounds as though the DBT skills group and DBT individual therapy are more appropriate for her than an ED therapist.

      I think it is important to conceptualize and treat the anxiety and depression as illnesses separate from the AN. The symptoms of depression and anxiety may have first emerged in the context of AN, or were first diagnosed alongside the AN, but the fact that they have persisted for so long after full weight restoration strongly suggests that they are distinct disorders.

      I conceptualize depression, anxiety, and AN as biologically-based brain disorders, not “negative coping mechanisms.” There is convincing scientific evidence that all three of these conditions are highly heritable and related to differences in the way the brain processes information. That being said, individuals who struggle with depression and anxiety often experience very intense, painful emotions, and it can be helpful for them to learn more adaptive coping skills. The DBT skills group can help with this.

      My suggestions for your daughter are:

      1.) Make sure you have an accurate diagnosis or diagnoses. I’d recommend a complete psychological evaluation, if she hasn’t already had one, or another psychological evaluation if she hasn’t had one since her AN diagnosis.

      2.) Consider psychotropic medication if she isn’t already on it. Evidence suggests that severe depression is best treated with a combination of therapy and medication. Psychotropic meds should be prescribed and closely monitored by a psychiatrist, not by the family doctor or pediatrician. If she is already on meds, consider a medication re-evaluation. She may need a larger dose or a different medication if she is not responding to her current regimen.

      3.) I think you are headed in the right direction with DBT. Active, directive, behaviorally-oriented therapies (Such as CBT and DBT) are typically most effective for depression and anxiety. If your daughter doesn’t make progress after a few months in DBT, consider CBT as an alternative.

      4.) Make sure she eats well, maintains her healthy weight, and continues to grow and gain as expected for her stage of adolescence. This will help prevent relapse of AN. If any eating or weight issues emerge, address them right away.

      Best of luck to you in supporting your daughter’s recovery.

      • Chris says:

        Talk therapy and medications are not the only treatments for anxiety or depression. For example, there is substantial evidence that lack of sleep causes or contributes to anxiety and depression in teenagers. Most teens need 8-9 hours of sleep per night; most get much less than that. Increasing the amount of sleep has been shown to have very positive benefits for overall mental health. In addition, lack of exposure to natural sunlight can cause changes in mood. In a study conducted at University of North Carolina, it was found that exposure to natural light improved mood as much as anti depressive medications. Exercise too has been proven to have beneficial effects, particularly taking walks in forests and other natural environments. People can go on http://www.pubmed.gov Enter anxiety or depression in the search bar. Thousands of scientific studies that have been done on both anxiety and depression will be displayed. Parents are in a good position to read these studies for themselves and determine the best way of approaching their teenager’s psychological problems, based on a combination of scientific evidence and the parent’s unique knowledge of their kid, and the parents’ natural motivation to help their kids recover.

      • Karen says:

        I love your website and think that you provide both scientifically excellent and very kindly framed advice, but I think the recommendation that a psychotropic medication for anxiety or depression should be prescribed and followed only by a psychiatrist is somewhat inappropriate, particularly coming from someone who is not medically trained (though very highly trained in other areas). Many family doctors and pediatricians are quite comfortable with psychotropic medications; some have a significant amount of extra training in their use. Others have completed full fellowships focused primarily on psychosocial and psychiatric concerns. Most (hopefully nearly all) physicians will practice within their scope, and if not comfortable, will refer on. If every child with straightforward anxiety or depression had their psychotropic medication not only initially prescribed but also followed exclusively by a child psychiatrist the shortage of psychiatrists would be drastically worse than it is already. Pediatricians in particular have a strong vantagepoint for evaluating children because they see so many emotionally healthy children, giving them perspective; psychiatrists sometimes have a tendency to overpathologize and overprescribe to children who primarily need simple interventions like family time, adequate sleep and nutrition, time playing outside, meaningful self-esteem building activities, and calming strategies. And psychotropic treatment for children and adolescents with depression or anxiety, from a medical perspective, is actually quite simple compared to many other psychotropic interventions. The child psychiatrists here would be fairly upset at the idea of a psychologist telling patients that they should not be discharged to a family doctor or pediatrician’s care even after they have been successfully started on a medication without experiencing major difficulties. That said, I do very much enjoy your blog and thank you for your very thoughtful and wise posts.

        • Karen,

          Thank you for your interesting comment. You have brought to my attention several issues that I have not previously considered.

          I have definitely witnessed the problem of psychiatrists’ tendency to over-pathologize and over-prescribe. For this reason, I typically don’t refer patients to psychiatrists unless I am relatively certain that they would benefit from medication.

          I had not previously considered that pediatricians could be the best doctors to prescribe psychotropic meds, but upon reflection I can now understand how this may be the case for some kids in some cases. Especially cases in which the pediatrician has extra training or experience in psycho-social issues and psychotropic medication, or when the family does not have access to a psychiatrist.

          I am not sure where you live, but I wonder if there are regional differences in terms of pediatricians’ competence to prescribe medication? In my region (south Florida), I have experienced the opposite of what you describe – the majority of pediatricians and primary care doctors express that they are not comfortable prescribing psych meds in most cases, and are most likely to refer to psychiatrists.

          Just a couple of weeks ago, I attended a seminar in which the presenter – himself a psychopharmacologist – noted that in his experience, it can be problematic when primary care doctors prescribe psychotropic medication because they tend to prescribe very low doses and don’t do frequent or thorough enough follow-up to monitor the effects of the drug. I have observed this problem as well. I’m guessing that it is possible that this situation is unique to certain communities or certain regions of the country.

          I don’t doubt your experience with pediatricians prescribing psych meds. I think it is wonderful, and beneficial to the patient and family, when they can receive prescriptions from a doctor that knows them well and has treated them for years.

          You wrote: “If every child with straightforward anxiety or depression had their psychotropic medication not only initially prescribed but also followed exclusively by a child psychiatrist the shortage of psychiatrists would be drastically worse than it is already.” I agree with on on this, but the case in question doesn’t sound straightforward. The mother who initially asked for my advice stated that her daughter had been suffering from depression and anxiety for 3 years, which seemed to be getting worse.

          • Chris says:

            A study published in the journal Pediatrics last year found that primary care physicians (including pediatricians) were more likely to prescribe psychotropic medications to children than were psychiatrists. Anderson, Outpatient Visits and Medication Prescribing for US Children with Mental Health Conditions, Pediatrics 2015 Nov; 136(5)
            http://www.ncbi.nlm.nih.gov/pubmed/26459647 Therefore, it would seem that the risk of over-prescribing medications would be greater if the pediatrician is making the decision whether to give the kid drugs, as compared with a psychiatrist. Since there is a growing consensus that over-prescribing is a serious problem, we can reasonably question the role of pediatricians in treating childhood anxiety and depression.

            I think most parents are skeptical of both pediatricians and psychotherapists with respect to the issue of psychotropic medications, and the skepticism is warranted. In a large meta-analysis published in 2014, the highly-regarded Cochrane Collaboration reported on all well-designed and conducted studies of the treatment of depressive disorders in children and adolescents. Eleven studies involving 1307 participants were included in the review. The authors analyzed psychological therapies versus antidepressant medications. The results showed that both approaches had only limited effectiveness and for the majority of outcomes there were no statistically significant differences between the two interventions. The conclusion of the paper was that “There is very limited evidence upon which to base conclusions about the relative effectiveness of psychological interventions, antidepressant medication and a combination of these interventions. On the basis of the available evidence, the effectiveness of these interventions for treating depressive disorders in children and adolescents cannot be established. Further appropriately powered randomized controlled trials are required.”
            Cox, Psychological Therapies versus Antidepressant Medication, Alone and in Combination for Depression in Children and Adolescents, Cochrane Database Syst Rev 2014 Nov 30. http://www.ncbi.nlm.nih.gov/pubmed/25433518 Therefore I question Karen’s comment, above, that “psychotropic treatment for children and adolescents with depression or anxiety, from a medical perspective, is actually quite simple compared to many other psychotropic interventions.”To the contrary, the treatment of anxiety and depression in children and teens is not well understood from a scientific perspective, and appears to be extremely complex. As described by Sarah in her post, above, there is also substantial risk of iatrogenic effects arising from whatever treatment the professional uses.

            All this leads most parents I know to take the problem of adolescent anxiety and depression into their own hands, using the parents’ unique knowledge and skill to develop their own plan for how best to address their kid’s condition. This approach parallels the FBT model for treating anorexia nervosa, in which parents, not professionals, are in charge, and professionals play a secondary role, if any.

  6. Nancy says:

    Dr. Ravin –

    I am having lunch today with an acquaintance who suspects her 18 year old son may have anorexia. She shared this with me after I happened to share with her that my daughter had anorexia, but is now in strong recovery. My friend’s eyes filled up with tears when she described how everyone thinks she is crazy because she is worried about her son. Everyone has praised his weight loss and that he runs twice a day. I could so relate to being in that place.

    I came to your blog because it helped me so much when my daughter was sick. I have sent your one about keeping college aged kids home to get into strong recovery to so many people I know. It is what we did with my daughter. She hated us for it at the time, but now says it was the best thing we ever did. This blog post will be such a helpful read to my friend who is so early in this process. I want to inform her, without overwhelming her. I understand the the illustration is purposely simplified, but it is so helpful for the sake of comparison.

    As to some of the other comments on this blog, we were never able to do traditional FBT with my d. However, after a year of being told to back off and not be the food police, my d was just getting worse. As a result of the knowledge I gained from your blog (and a few phone consultations with you) and the FEAST parent support forum, we were able to get my d evidence based treatment that included us. She did choose her food, but she had meal support through her IOP program or with me for months and months after weight restoration. Again, she hated it, but it was necessary. A HUGE investment with DBT helped her with the lifelong anxiety and the crushing depression that came with AN. She has some relationship tendencies that she has been able to recognize and use DBT to work against type to develop healthy and meaningful relationships.

    She is getting to experience studying abroad in South America this semester and trying to embrace every aspect from being homesick and overwhelmed at the prospect of living with a host family and only speaking Spanish to being overwhelmed at the beauty of the sites she is getting to see.

    Thank you for this blog post that I know will help my friend and for all of the support your blog was to me in getting my d well.

  7. Jill says:

    What about when you have a transgender teeenager (born female), who is on the Autistic Spectrum, regularly self-harms, (took an overdose at the age of 12), threatens suicide, and has restrictive anorexia?

    What about if combined with all the above, you are a single parent, working full-time with no family nearby?

    This is my situation. My 17 year old is very frail, but not “ill enough” to be admitted as an inpatient. I can’t get him to put on any weight as he just refuses. How can I administer FBT in my position and is it safe? I feel that I would have to be on suicide watch.

    • Jill,

      Your family situation sounds extremely complicated and isolating. My heart goes out to you.

      I imagine that it would be very difficult, and possibly unsafe, to implement FBT with your son, given his suicidality, his other illnesses, and his behavioral challenges, plus your predicament of being a single parent with little outside support.

      I imagine that having a therapist with expertise in AN as well as ASD, suicidal behavior, and gender/sexuality issues could be really helpful for both you and your son. Unfortunately, it will probably be quite difficult to find someone who fits the bill.

      No matter what sort of professional help you do or don’t have, however, there is still the necessity of getting him fully nourished and weight-restored. So the real question here is not “can I implement FBT” but rather “How can I help my son get fully nourished and weight-restored ASAP?”

      Given that he has a diagnosis of autism, I am thinking that Applied Behavior Analysis may be the most effective approach in dealing with his various problems, including the restrictive eating. This would allow your son to remain at home with you and have a trained ABA therapist come into your home to implement whatever interventions are needed. ABA therapists typically have a lot of experience with food sensitivities and food refusal (not necessarily AN per se, but changing people’s behaviors around food) which could be helpful in increasing his food intake. You probably know a lot more about ABA than I do, given that you have a child who is on the spectrum.

      https://www.autismspeaks.org/what-autism/treatment/applied-behavior-analysis-aba

      I wish you all the best in helping your son recover.

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