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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Tag: anorexia nervosa

Monday, April 14th, 2014

Weight Gain Predicts Psychological Improvement in Anorexia Nervosa

A recent study published in the journal Behavior Research and Therapy demonstrated that weight gain was a significant predictor of improved psychological functioning in adolescents undergoing treatment for anorexia nervosa (AN). In other words, adolescents who gained more weight during treatment did better mentally than those who gained less weight. This study also showed that weight gain early in the course of treatment had a greater impact on psychological recovery than weight gain later in the course of treatment.

This finding is extremely relevant not only to clinicians who treat adolescent AN, but also to the adolescent patients themselves and their families. The process of re-feeding and restoring weight often feels agonizing for patients and may cause tremendous stress to caregivers. Psychological recovery lags behind physical recovery, so patients often feel worse before they start to feel better. This study provides objective evidence that it is in the patient’s best interest – both physically and psychologically – to eat more and gain weight as soon as possible after diagnosis.

Weight gain is an essential component of treatment for patients with AN. The knowledge that full nutrition is necessary to repair the physical damage caused by AN – including weakened heart, low blood pressure, hypothermia, osteoporosis, stress fractures, lanugo, amenorrhea, infertility, and risk of premature death – helps many patients and families to persevere through the difficult days of re-feeding. Now, patients and families can hold onto hope that weight restoration will bring about psychological improvement as well. This study provides families with direct scientific evidence that gaining weight gives their loved one a greater chance of recovering mentally, emerging from the fog of depression, and reclaiming a meaningful life free from food and weight preoccupation.

Patients in this study were randomly assigned to receive either Family-Based Treatment (FBT) or Adolescent Focused Treatment (AFT). The authors of this study found that weight gain predicted psychological recovery regardless of the type of treatment (FBT vs. AFT) the patient received. This finding may be especially relevant to clinicians who treat adolescent AN using individual therapy. A common criticism of FBT (usually made by clinicians who reject FBT without really understanding it) is that it focuses on weight gain at the expense of the adolescent’s psychological wellbeing. This study clearly demonstrates that weight gain and improved psychological functioning are not mutually exclusive. On the contrary, weight gain and improved psychological functioning are strongly correlated!

It is clear that FBT supports the adolescent’s psychological wellbeing indirectly by promoting regular nutrition and steady weight gain, which help to repair the brain damage caused by malnutrition. I would also argue that FBT has a direct impact on the adolescent’s psychological wellbeing by externalizing the illness, removing any sense of self-blame the adolescent may have, supporting her emotionally, and relieving her of the burden of fighting this deadly illness alone.

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Thursday, February 20th, 2014

Exercise Caution: Physical Activity and Eating Disorder Recovery

Compulsive exercise is often a symptom of eating disorders. It is common for a child who is developing an eating disorder to take a sudden interest in running and other vigorous forms of exercise. Given that exercise is a symptom which is directly related to the energy imbalance that triggers and maintains a restrictive eating disorder, it is important for clinicians and caregivers to monitor and manage patients’ exercise during treatment and recovery.

When a patient has an active eating disorder, it is generally ineffective to use exercise or sports as an “incentive” to get him to eat more or gain weight. Even the patient who absolutely loves soccer, and says he would do anything to keep playing, probably won’t be able to eat enough to make that happen. The malnourished anorexic brain is just not capable of overriding symptoms, no matter how alluring the reward may be.

For people with eating disorders, exercise poses numerous medical risks including stress fractures, osteoporosis, muscle wasting, and heart arrhythmia. Further, exercise can be counterproductive to treatment goals when a patient needs to restore weight. For these reasons, I recommend that patients with Anorexia Nervosa or Bulimia Nervosa abstain from all physical activity until they meet the following criteria:

a.) Complete weight restoration
b.) Complete abstinence from binge/purge behaviors for at least two weeks
c.) Consistently eating complete, balanced meals with little resistance
d.) Sufficient hydration
e.) Willingness and ability to increase nutrition and hydration to compensate for activity
f.) Medically cleared to exercise by physician

Explaining the dangers of exercise to the eating disordered patient is important but rarely sufficient to curb the compulsion. Patients with exercise compulsion need an authoritative source to tell them directly, in no uncertain terms, that all exercise must be stopped until the above criteria are met. In my practice, the hiatus from exercise typically lasts for several months, but this varies widely based upon the patient’s severity of illness and response to treatment.

Abstaining from all physical activity means stopping sports, dance classes, martial arts, and any other extracurricular activity that involves movement. It also means no PE at school, no bike riding, no home workouts, no yoga, and no long-distance walking.

Parents can do a number of things to help prevent their ill child from exercising. They can obtain a doctor’s note to except him from PE class, they can call the coach to inform him that the child will not be able to play for the rest of the season, they can give him a break from his usual chore of walking the dog.

When the exercise compulsion is strong, more serious measures must be taken. Some parents may need to get rid of home exercise equipment, terminate their child’s gym membership, or hide her running shoes. Parents must be extremely vigilant in protecting their child from secretly exercising.

Any time spent behind closed doors presents an opportunity for the patient to succumb to the exercise compulsion. It is not unusual for anorexic patients to exercise in the middle of the night, to sneak out of the house to go running, or to do calisthenics on the bathroom floor. Sometimes it is necessary for parents to sleep in the same room with their child and provide round-the-clock supervision for weeks or months at a time in order to break the exercise compulsion.

Full nutrition and weight restoration often help tremendously in lessening the compulsion to exercise. Many recovering kids will lose interest in exercise once the compulsion has faded. These are often the kids who first began exercising in the context of their eating disorder, but never really enjoyed their activity. Once recovered, these kids will often return to lives that are not particularly active, and decide to pursue other interests instead, such as music, art, or a very busy social life.

For some children, exercise has been a part of their lives since they were very young, but took on a new intensity when the eating disorder arrived. For example, a 12-year-old girl who loves to dance and has taken ballet since preschool may suddenly start taking eight dance classes a week instead of her usual four. As another example, a teenage basketball player may begin rising at 4:00 AM to go jogging in addition to afternoon practices with his team. These kids suffer tremendously as the activities they love become tools for their eating disorder to use against them.

In my experience, these patients are often able to return to the sports and activities they previously enjoyed without compromising their recovery, so long as they are physically and mentally ready to do so, and so long as their activity is monitored and limited. The young dancer described above may return to her studio, once weight-restored and back in school, for three or four classes per week. The recovering teenage basketball player may be permitted to practice with his team, but would not be allowed to exercise outside of scheduled practices.

While it’s rarely effective to use sports as an incentive for a sick patient to get well, sports can be a great incentive for a recovered patient to stay well. Many patients, once physically and psychologically recovered, feel motivated to do whatever it takes to maintain their exciting new life. I have found that exercise contracts work well for these patients.

For example, my former patient, whom I will call Andy, played on a competitive year-round traveling soccer team. When Andy developed Anorexia Nervosa at age 14, his parents and I agreed that he would need to take five months off from soccer to restore his weight and focus on his recovery. Once he was feeling better, Andy became excited to rejoin his team.

Andy’s family and I supported his return to soccer so long as it did not interfere with his recovery. We developed a written contract which stated that Andy may participate in club soccer so long as he maintained his weight, ate all of his meals and snacks, drank 8 glasses of water per day, abstained from exercise outside of team practices, and attended monthly therapy sessions. We also agreed that he would drink a smoothie after each soccer practice and that one of his parents would travel with him to all tournaments to ensure that he ate enough to fuel his activity.

Certain solo long-distance endurance activities, such as cross country running and competitive swimming, pose particular risks for patients predisposed to eating disorders. This is in part due to their very high energy requirements, in part due to their solitary nature, and in part due to the extreme rigor of the activity which demands a high level of dedication. Not only do these factors attract young people who are competitive, driven, and dedicated (read: predisposed to eating disorders); they also create the perfect formula for triggering and perpetuating an eating disorder.

If a recovered person who had been a runner or a swimmer prior to getting sick expresses a desire to return to athletics, it may be preferable for him to choose a different sport. Team sports such as volleyball or basketball may be more conducive to sustained remission.

Activities with an artistic or aesthetic element, such as gymnastics, dance, figure skating, and diving, can pose a risk for those in recovery from eating disorders, particularly if body dissatisfaction and drive for thinness were major symptoms of the patient’s illness. If a former dancer/gymnast/athlete wishes to return to these activities, certain factors must be considered. In addition to the criteria for resuming exercise that I listed above, these young people should attain a certain level of body acceptance prior to returning to their activity. They need to feel at least somewhat comfortable in a leotard, and they must be strong enough to challenge or ignore any negative body thoughts that may arise. If a young person experiences a noticeable increase in eating disordered thoughts or behaviors upon returning to her activity, this is an indication that she likely needs more time off to recover before she can safely return.

It is important for dancers and athletes to return to a nurturing environment that does not encourage food restriction, weight loss, or winning at all costs. It is helpful for parents to speak with coaches and trainers to alert them of their child’s vulnerability and ensure that the atmosphere is conducive to health and well-being. There are dance teachers and coaches who encourage full nutrition, healthy body image, self-care, and a balanced approach to life. These adults can be positive forces in helping a young dancer or athlete sustain remission.

It is of utmost importance that family members and treatment professionals convey, through their words and their actions, that the patient’s physical and mental health are the number one priority. Participation in activities that jeopardize health or fuel emotional distress should be avoided. Participation in activities that bring joy and enhance well-being should be encouraged.

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Sunday, February 9th, 2014

Exercise and Eating Disorders: It’s Not What You Think

Exercise very often plays a role in the development of restrictive eating disorders, particularly Anorexia Nervosa (AN). Some people view exercise as “a form of purging” or “a way to get rid of calories.” These explanations seem to make sense in light of modern western society’s views on exercise, similar to the theory that people with AN restrict their calories in order to conform to society’s thin ideal. But like the thin ideal theory, the “exercise purging” theory is an erroneous attempt to make sense of a puzzling symptom in the context of modern society.

In AN, excessive exercise, just like food restriction, is a biologically-based symptom, driven by something beyond conscious control or awareness. Patients do not exercise “to burn calories,” although they may insist that burning calories is their motivation. Consider, for example, the fact that even patients who know they are too thin are motivated to gain weight (yes, such patients do exist), often cannot stop themselves from moving unless they are forced to do so. Young children with AN are especially susceptible to the drive to exercise even though they have no idea what calories are or how to burn them.

A little history may help to put this into context. People did not really exercise for the purposes of physical fitness and attractiveness prior to the “exercise boom” of the 1970’s and 1980’s. However, hyperactivity was a symptom of AN long before Jane Fonda’s exercise videos found their way into American living rooms.

The nineteenth-century British Physician William Gull, the first clinician to describe AN medically, was surprised by the seemingly boundless energy that his anorexic patients possessed despite their emaciated state. In his 1874 paper entitled Anorexia Nerovsa, he wrote the following description of a young anorexic girl: “The patient complained of no pain, but was restless and active…it seemed hardly possible that a body so wasted could undergo the exercise which seemed agreeable.” Clearly, this young woman was not motivated by the pursuit of a thinner body, as the idea of exercising to “burn calories” would not emerge until a century later.

Animal research has shown that the hyperactivity commonly associated with AN is rooted in neurobiology and may serve an adaptive evolutionary purpose. For example, activity-based anorexia can be experimentally induced in rats which, like humans, evolved as opportunistic omnivorous foragers. When food-deprived lab rats are given free access to a running wheel, they become hyperactive, lose large amounts of weight, and will often die unless they are removed from these experimental conditions. I highly doubt that these rats were running excessively to purge calories, ward off obesity, or pursue some unrealistic standard of rodent beauty.

So why would AN, which leads to numerous health problems, infertility, and death, remain in our gene pool for tens of thousands of years? Shan Gusinger, an evolutionary biologist and a psychologist, posits that AN has evolved in humans as a means of helping us flee from food-depleted environments. The restless energy, grandiosity, and lack of awareness of one’s starved body allowed prehistoric anorexics to lead their tribes in migrations from food-depleted areas to plentiful ones.

Once the anorexic leader and her tribe arrived in a plentiful environment, the tribe feasted, pressuring the anorexic leader to indulge in food with them. In the absence of modern society’s thin ideal and without our modern obesity hysteria, prehistoric anorexics may have been able to allow their families to feed them, restoring their health and fertility. Even if the anorexic herself died of her condition or was rendered infertile, her close genetic relatives survived and reproduced, thus ensuring the continuity of AN into the next generation.

In our modern world, where children are encouraged to exercise more and make “healthy” (e.g. lower calorie) food choices as early as kindergarten, it is no wonder that AN is still around. During the pre-teen years, when rapid vertical growth and pubertal development demand extra energy, girls and boys are hit hard with the social pressures to be thin (for girls) or lean and ripped (for boys). The rapid weight gain that is necessary for growth and development is feared and despised in these growing children (and often, sadly, in their parents and pediatricians).

Adding add fuel to the fire, the pre-teen years are when intense and time-consuming athletic training begins. Competitive sports provide socially-applauded outlets for the young anorexic’s hyperactivity. No one bats an eye at the 12-year-old dancer who spends hours each evening at her studio in preparation for her next audition, or the 11-year-old boy who plays multiple back-to-back games each weekend with his elite travelling soccer team. Meanwhile, these children are making “healthy food choices,” consuming too few calories and fats to keep up with normal growth, let alone intense daily exercise.

In these vulnerable children, their vertical growth is stunted, their pubertal development is halted, and their intense athletic drive is praised by adults. And before you know it, they have fallen down the rabbit hole and developed full-blown AN. In this way, hyperactivity serves as both a precipitating factor and a perpetuating factor in the development of AN.

In my next post, I will discuss the role of exercise in eating disorder recovery.

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Saturday, January 18th, 2014

Expanding Our Minds: Towards a Biologically-Based Understanding of Eating Disorders

I read the abstract of a recently published journal article which illustrates one of the major problems in the field of mental health treatment in general, and eating disorder treatment in particular. The article, authored by Jim Harris and Ashton Steele and published in the latest issue of Eating Disorders: The Journal of Treatment and Prevention is provocatively titled Have We Lost Our Minds? The Siren Song of Reductionism in Eating Disorder Research and Theory.

The authors state that, over the past decade, “the focus of eating disorder research has shifted from the mind to the brain.” I disagree with this assertion on two levels. First, the statement implies that the mind and the brain are separate entities. They are not. The “mind” is simply a range of conscious functions which are carried out by the brain: for example, thoughts, beliefs, emotions, intentions, motivations, and behaviors. These mental functions originate in the brain, are executed in the brain, and are interpreted by the brain.

Indeed, recent developments in genetics and neuroimaging techniques have allowed scientists to study the structure, function, and circuitry of the brain in far greater detail than was possible before. Researchers have utilized this new technology to generate and test novel hypothesis about the biological underpinnings of eating disorders. The results of these studies have indicated that eating disorders are genetically inherited, biologically-based brain disorders, similar to bipolar disorder and schizophrenia.

However, while research in the area of genetics and neuroimaging has proliferated in the eating disorders field, there has been no shortage of research on psychosocial factors or non-medical treatments for eating disorders, such as FBT and DBT. Contrary to Harris and Steele’s assertion, we have not “lost our minds.” We’ve simply expanded our minds and deepened our realm of investigation to study the biological underpinnings of mental functions as new technology has allowed us to do so.

Harris and Steele assert that the brain disorder model of eating disorders necessitates that treatment targets the underlying neurobiological abnormality; namely, medication. The authors then conclude that the brain disorder model of eating disorders is misguided because no pharmacological intervention has been shown to significantly benefit patients with anorexia nervosa.

This simplistic assumption and its corollary reflect a lack of basic understanding of the relationship between the brain and the symptoms of psychiatric illness. The authors fail to recognize the fact that certain non-medical interventions HAVE been consistently shown to benefit patients with biologically-based brain illnesses.

For example, it is widely accepted amongst medical and psychological professionals, as well as the general public, that autism is a biologically-based brain illness. There are no medications which have shown to consistently benefit children with autism. The gold-standard of treatment for autism is early intervention with applied behavior analysis (ABA), which is a form of behavior therapy focused on skills building, parent training, and modifying environmental contingencies. Most children with autism do extremely well with this type of treatment, and many of them can be mainstreamed in classrooms with typically developing children.

Sound familiar? It should, because that is precisely what is happening in the world of eating disorder treatment. The treatment approaches which have shown the most promise in the world of eating disorders are psychological and behavioral treatments such as Family-Based Treatment (FBT) for anorexia nervosa and Cognitive-Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) for bulimia nervosa.

There are a number of misconceptions about these types of treatments. For example, many people believe that FBT is merely re-feeding. This is not so. FBT is a psychological and behavioral treatment – a form of psychotherapy – and parental control of re-feeding is but one component of the first phase of this three-phase treatment model.

As another example, some people believe that CBT and DBT are merely “learning skills.” Again, this is a misconception. CBT and DBT are forms of psychotherapy which involve a relationship with a therapist who instills hope, provides support and feedback and accountability, promotes awareness of thoughts and feelings, and teaches adaptive skills for managing life’s challenges.

Contrary to popular belief, psychotherapy does not consist of lying on a couch and talking about your mother. That myth stems from psychoanalysis, an antiquated form of treatment commonly practiced in the mid-20th century which has no evidence base. Modern evidence-based psychotherapy is entirely different: it is active, directive, and believe it or not, effective.

I get a bit irritated when uninformed people make sweeping generalizations on either side of the fence, such as “psychotherapy doesn’t work for eating disorders,” or, on the flip side, “psychotherapy is the best way to treat eating disorders.” The truth is more specific: evidence-based psychotherapies are effective in the treatment of eating disorders.

From my perspective, focusing on the biological basis of psychiatric illnesses does NOT mean:

• That the illness can only be treated with a pill
• That psychological and social factors are irrelevant
• That environment doesn’t matter
• That the patient can’t do anything about it
• That the psychologist’s job is obsolete

Focusing on the biological basis of eating disorders DOES mean:

• That eating disorders are illnesses, no different from cancer or diabetes or schizophrenia
• That patients do not, and in fact cannot, choose to develop eating disorders
• That eating disorders are not caused by family dynamics or social pressures
• That prevention efforts aimed at improving body image are unlikely to be effective
• That a person must have a certain genetic predisposition in order to get an eating disorder
• That biological relatives of eating disorder patients are at risk for developing the disorder themselves
• That medication can be helpful, though not curative, in some cases
• That full nutritional restoration, and thereby correcting the brain-based symptoms of starvation, is a necessary first step in treatment
• That psychotherapy focused on resolving underlying issues or gaining insight into the origins of one’s illness is unlikely to be effective in resolving eating disorder symptoms
• That behaviorally-based psychological treatments focused on symptom management and skills building can be very effective, in large part because they change the brain
• That last century’s theories about the causes of eating disorders are inaccurate

I wish that Harris and Steele, and all professionals involved researching or treating eating disorders, could grasp these points. If the general population had this basic understanding of eating disorders, then patients and their families would be viewed with compassion and understanding rather than judgment or smug clichés (e.g. “she needs to learn to love herself;” “it’s all about control”).

The past decade represents a monumental shift in the way expert clinicians view eating disorders. In fact, it will be 10 years ago this fall that I saw my very first eating disorder patient. As a bright-eyed graduate student hungry for hands-on clinical experience, I chose a training rotation at an adolescent eating disorders clinic. On my first day at the clinic, not much older or wiser than the teenagers I was about to start treating, I was introduced to “the Maudsley Approach,” a promising new treatment method from the UK. And the rest, as they say, was history.

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Thursday, November 21st, 2013

Giving Thanks

In my work as a clinical psychologist, I am faced daily with stories of tragedy, trauma, illness, conflict, and loss. Each therapy session is a window into private suffering.

“Isn’t it hard?” people ask me. “Isn’t it awful to listen to people’s problems all day long? Doesn’t it make you depressed?” My answers to these questions are: “Yes,” “No,” and “Quite the opposite.” It is painful to witness people suffering, but it is endlessly rewarding to help them triumph.

Rather than letting other people’s pain drag me down, I feel honored that they have shared it with me and privileged that I am in a position to help them cope with it. I am intimately aware of the obstacles people face – and overcome – every single day. Being a clinical psychologist provides me with daily opportunities to participate in stories of healing, strength, opportunity, resolution, and empowerment.

As Thanksgiving approaches, many Americans begin to think about expressing gratitude for the things we take for granted the rest of the year. Consider these:

If you get out of bed next Thursday, give thanks.
There are those with depression who cannot do so without herculean effort.

If you are preparing to host relatives in your home, give thanks.
There are those with crippling social anxiety for whom a house full of guests would be unthinkable.

If you are planning to travel across several time zones to spend the holiday with relatives, give thanks.
There are those with mood disorders for whom jet lag can trigger an episode of mania or depression.

If you are looking forward to Thanksgiving dinner, give thanks.
There are those with anorexia nervosa for whom a holiday feast is an object of fear, loathing, and guilt.

If you set the table next Thursday in under five minutes, give thanks.
There are those with OCD who cannot relax unless every napkin, fork, and knife is lined up precisely.

If you sit on the couch after dinner to watch football with your uncles and cousins, give thanks.
There are those with bulimia nervosa who will be pacing around the house, waiting for an opportunity to purge unnoticed.

If you settle into bed with a good book later that evening, give thanks.
There are those who will be cutting their forearms with a razor to numb themselves from the intolerable emotions triggered by the day’s events.

If you go to bed Thanksgiving night satiated and content, give thanks.
There are those whose restless worry keeps them up until sunrise.

If you have never even considered feeling grateful for these ordinary things, give thanks.
Our mental health, and that of our family, should not be taken for granted.

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Wednesday, November 6th, 2013

The Thin Ideal and Anorexia Nervosa: Case in Point

I’ve blogged previously about the role of the “thin ideal” in Anorexia Nervosa (AN). Conventional wisdom holds that young girls develop AN as a result of excessive dieting in pursuit of thinness, which is considered beautiful in western culture. I don’t believe that the thin ideal causes, or even contributes much, to the development of AN. However, I do believe that the thin ideal delays diagnosis, makes recovery more challenging, and normalizes and trivializes life-threatening symptoms.

I had a recent experience with a patient’s family which illustrates the way in which the thin ideal can interfere with recovery from AN. The patient, whom I will call Norah, presented in my office for eating disorder treatment at the age of 17. I diagnosed Norah with AN and began treating her with Family-Based Treatment (FBT). Norah turned out to have a relatively mild, short-lived case of AN (yes, such cases do occur, though they are not the norm), which responded quickly to a brief course of FBT.

Within a few months, Norah was virtually symptom-free and doing quite well overall. Her vital signs were good, she was getting regular periods, she no longer body-checked or weighed herself compulsively, her mood had improved, and she ate three solid meals each day with her parents or friends, consuming a wide variety of foods with no resistance. Sounds great, right?

There was just one problem: Norah’s weight had plateaued about 5 pounds below the target weight I had set for her based on her historic growth curves. This happened despite the fact that she was eating quite well, not purging, and engaging in minimal physical activity. Many teens in recovery from AN have huge nutritional requirements during re-feeding, so this was not entirely surprising. Besides, Norah had always been petite and naturally thin with a fast metabolism. Most likely, she just needed a lot more food.

Norah is a senior in high school who is planning to go away to college next year. I strongly recommended to Norah’s parents that they require her to reach full weight restoration prior to leaving for college, and that they increase her daily caloric intake to help her reach that goal. I explained that full weight restoration and return to normal growth and development are essential to recovery, and I provided them with literature on this subject. Given how tiny Norah is, a loss of even a few pounds would be enough to push her over the edge. In fact, it only took a loss of a few pounds to send her spiraling down into AN in the first place. In order to be well enough to live independently, I explained, Norah needs to gain these last five pounds and learn to maintain her optimal body weight.

Upon hearing this recommendation, Norah had a fit. She screamed and cried and lamented the injustice of it all. Why should she have to weigh “more than I’ve ever weighed before in my whole life?” (yes, one whole pound more than her historic high). I was not entirely surprised by Norah’s reaction. Although Norah had been unusually compliant in treatment thus far (and yes, such cases do exist, though they are not the norm), even a compliant anorexic has her limits.

Norah’s tantrum was foreseeable. After all, she has Anorexia Nervosa. Of course she would not want to eat more or gain more weight. Plus, Norah is a teenager with big dreams – a high school senior desperate to leave town, escape from her parents’ watchful eyes, and explore greener pastures. The mere possibility that she might not be allowed to go away devastated her.

What was not foreseeable was her mother’s reaction. Norah’s mother did not agree with my recommendation: she did not wish to require Norah to eat more food or gain more weight. Sure, she would like for Norah to gain more weight, but she was not willing to make that happen. She did not think it was fair to Norah, who had worked so hard in school and in recovery, to have to gain more weight in order to be allowed to go away for college. “After all,” said Norah’s mother, “Norah was not happy with her body at that weight, and that’s something we all need to take into consideration.”

No. Actually, we don’t need to take that into consideration.

Imbedded in Norah’s mother’s comment are several assumptions:

1.) That it is perfectly normal and rational for a teenage girl who has always been small and thin to dislike her body and aspire to be thinner

2.) That the rational solution to this teenager’s drive for thinness is to allow her to remain even thinner than before, thus interrupting normal adolescent growth and development

3.) That requiring the teenager to reach her optimal body weight – even when her optimal body weight conforms to the societal ideal – will somehow harm her psyche

None of these assumptions are true, of course. But the thin ideal makes these assumptions seem reasonable to parents and pediatricians and therapists and dieticians alike.

In an ideal world, these assumptions would always seem ludicrous to sensible adults, regardless of the patient’s size or weight. It should not be considered normal or rational for a teenager of any size or shape to dislike her body and aspire to be thinner. Losing weight should never be seen as a solution to body dissatisfaction, especially when weight loss disrupts normal adolescent growth and development. And requiring a teenager to reach and maintain her optimal body weight should not harm her psyche, regardless of whether her optimal weight lies within the realm of what society considers beautiful.

Sadly, we do not live in an ideal world. I am a member of society, just like everyone else, and I’m not immune to the impact of the thin ideal. Norah’s case seems particularly striking to me precisely because her body has always conformed to the thin ideal, and would still conform to the thin ideal after complete weight restoration. Therefore, it seemed particularly dangerous – and ridiculous – not to require her to achieve full weight restoration, because – hey – even at her optimal body weight she’d still be thin.

Here’s where the thin ideal colors my thinking. If Norah had been a large girl whose healthy body naturally gravitated towards a higher weight, her mother’s reaction might have made sense to me. If the poor girl had a stocky body type that placed her on the higher end of the growth charts, it may have seemed rational to allow her to stop five pounds short of full weight restoration. Her body dissatisfaction and drive for thinness would have seemed legitimate rather than disordered. I may have “taken into consideration” the fact that Norah “wasn’t happy with her body before.” Mother’s remark would not have changed my recommendation, but it would have given me pause. I’m not proud of this, but there you have it.

In response to Norah’s mother’s comment, I reminded Norah’s parents, as I had done at the start of treatment, that they are the leaders of Norah’s treatment team and I am a consultant to them. My job is to use my expertise in adolescent AN to guide them, inform them, and empower them to make the right decisions for their daughter. Along with these explanations, I also acknowledged that any recommendation I make is only as good as the parents’ willingness and ability to carry it out.

Ultimately, Norah’s parents chose to reject my recommendation. I suspect that the thin ideal played an important role in their decision. As for me, this situation highlighted the role of the thin ideal in my own belief system and shed light on an important point: an anorexic patient’s body dissatisfaction, drive for thinness, and resistance to weight restoration are symptoms of a serious illness, regardless of her size or weight. And that is something we all need to take into consideration.

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Monday, November 4th, 2013

Summary of Treatment Outcomes

My blog posts from June through November 2013 have been devoted to describing my patients’ treatment outcomes. I’ve been advised that my recent posts have been too data-heavy and too detailed, but hey – that’s how I roll. I like to be thorough, meticulous, and transparent. Prospective patients and their families deserve to have access to this information. But for those who prefer brevity, I’ve summarized my treatment outcomes below. Click on the headings in bold for details.


Fifty-seven percent of my former patients with Anorexia Nervosa (AN) completed treatment. Of the “treatment completers,” 94% reached full remission and the remaining 6% reached physical remission. Patients required, on average, 28 sessions over the course of 17 months to complete treatment.

Forty-three percent of my former patients with AN did not complete treatment with me. Of the “treatment non-completers,” 23% were referred to other treatment settings which could better meet their needs; 15% moved to other geographic locations during treatment and thus were referred for treatment near their new homes; and the remaining 62% dropped out of treatment prematurely.


Thirty-three percent of my former patients with Bulimia Nervosa (BN) and Eating Disorder Not Otherwise Specified (EDNOS) completed treatment. One-hundred percent of those who completed treatment reached full remission. On average, patients took 15 sessions over the course of 10 months to complete treatment. Amongst patients with BN, 44% made significant progress prior to discontinuing treatment prematurely. For patients with EDNOS, 17% made significant progress prior to discontinuing treatment prematurely.


Twenty-nine percent of patients my former patients with primary diagnoses of mood disorders completed treatment. Of the patients who completed treatment, 83% achieved full remission and the remaining 17% made significant progress. On average, patients took approximately 23 sessions over the course of 11 months to complete treatment.

Thirty-eight percent of mood disorder patients quit treatment prematurely, 24% were referred to other treatment providers who could better meet their needs, and 9% moved to other geographic locations during their treatment and were referred for treatment near their new homes.


All of my former patients with primary diagnoses of anxiety disorders who attended more than two sessions experienced substantial improvement in anxiety symptoms as well as significant improvement in functioning, even if they did not complete a full course of treatment. Patients with anxiety disorders attended an average of 10 sessions over the course of 6 months.

Amongst those who completed a full course of treatment, 75% achieved full remission and the remaining 25% made significant progress.

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Thursday, July 18th, 2013

A Comparison of Treatment Outcomes: AN, BN, and EDNOS

My previous posts described treatment outcomes and correlates of my patients with various eating disorder diagnoses, including Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Eating Disorder Not Otherwise Specified (EDNOS). Some findings were similar across diagnostic groups:

• The vast majority of patients with any diagnosis who completed treatment achieved full remission.

• The attrition rate, overall, was high.

Family-Based Treatment (FBT) was associated with treatment retention, meaning that patients who participated in FBT were less likely to discontinue treatment prematurely than those receiving individual therapy.

• Patients who paid a reduced rate for services were much less likely to complete treatment and much less likely to achieve remission than those who paid full rate.

• Hospitalization during treatment with me was not related to treatment completion or treatment outcome, regardless of diagnosis.

• History of intensive eating disorder treatment (e.g., residential treatment, day treatment) was related to treatment non-completion and poorer outcome for patients across diagnoses.

Quite surprisingly, the differences among the diagnostic groups outnumbered the similarities:

• Patients with AN who completed treatment attended more sessions, over a longer period of time, than patients with BN or EDNOS. Completing treatment for AN involved an average of 28 sessions over 17 months, whereas completing treatment for BN or EDNOS involved an average of 15 sessions over 10 months.

• Type of treatment had a significant impact on outcome for patients with AN but not for patients with BN or EDNOS. All AN patients who achieved remission did so through FBT. However, patients with BN and EDNOS achieved remission through various means, including individual therapy with no family involvement, individual therapy with family involvement, and FBT.

• Younger age at intake and shorter duration of illness predicted treatment completion and remission for patients with AN. However, neither age nor duration of illness affected treatment outcome for patients with BN or EDNOS.

• All “treatment non-completers” with AN (those who quit prematurely, moved away, or were referred to other treatment settings) discontinued treatment within the first six months. In contrast, a number of “treatment non-completers” with BN or EDNOS remained in treatment for more than a year.

• Among patients with AN, those who completed treatment attended significantly more sessions than those who did not (28 sessions vs. 8 sessions) and remained in treatment for a much longer time than those who did not (17 months vs. 3 months). In contrast, for patients with BN and EDNOS, treatment completers and non-completers both remained in treatment for an average of 10 months, and treatment non-completers actually averaged more sessions than treatment completers (20 sessions vs. 15 sessions). Thus, it appears that for BN and ENDOS, treatment completers did not remain in treatment longer, but rather reached remission more quickly.

• Caucasians with AN were slightly more likely than Hispanics with AN to complete treatment and achieve remission. In contrast, Hispanics with BN or EDNOS were significantly more likely than Caucasians with these diagnoses to complete treatment and achieve remission.

• The presence of a comborbid disorder was not related to treatment completion or treatment outcome for patients with AN. However, the presence of a comorbid disorder was a significant predictor of treatment dropout and poorer outcome for patients with BN and EDNOS.

• History of hospitalization for an eating disorder or related psychiatric issue was related to poorer outcome for patients with BN and EDNOS, but not for patients with AN.

• Taking psychotropic medication during treatment was related to treatment completion and positive outcome for patients with AN but not for patients with BN or EDNOS.

Please bear in mind that these findings are specific to my practice and my patients, and are not intended to be generalized to other treatment settings or other patients.

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Sunday, July 7th, 2013

Correlates of Treatment Outcome for Patients with Anorexia Nervosa

In my last blog post, I described the end-of-treatment outcomes of my former patients (N = 30) with Anorexia Nervosa (AN). In sum, 57% of patients completed treatment (n=17) and 43% of patients (n = 13) did not complete treatment. The former group is referred to as “treatment completers” and the latter as “treatment non-completers.”

As expected, end-of-treatment results differed dramatically between the two groups. By the end of treatment, 94% percent of treatment completers had achieved full remission and 6% (n = 1) had achieved physical remission. In contrast, none of the treatment non-completers achieved remission, although 46% of them made significant progress (n = 6).

Bear in mind that I set the bar very high for my patients in terms of defining remission. In most published studies of AN treatment outcome, the patients whom I categorized as having made significant progress would be categorized as “recovered” or “in remission.” If I used the (completely inadequate) definitions of remission that other studies have used, a full 77% of my sample would have completed treatment and made a full recovery. But I digress.

These data clearly demonstrate that my approach to treating AN is effective. Patients with AN who have completed treatment with me always achieved physical remission and almost always achieved psychological and behavioral remission as well.

The 43% attrition rate is disheartening, given that patients are likely to achieve remission if they remain in treatment long enough. Attrition is a major problem in AN treatment in general, and in AN treatment for adults in particular. The validity of most AN treatment outcome studies is compromised by the high rates of attrition. It is not surprising that many adults discontinue AN treatment prematurely, given that treatment is very difficult, anxiety provoking, and lengthy.

This raises the question of what is “long enough” in terms of AN treatment? In my opinion, “long enough” is as long as it takes to bring the patient to full remission, which varies considerably based on individual differences. Among the treatment completers, the length of time to full remission ranged from 2 months to 4 years, with a mean of 17 months. The number of sessions attended by treatment completers ranged from 3 – 82, with a mean of 28 sessions. There were a handful of the young patients who achieved full remission in 12 sessions or less, although this was not the norm.

The rates of treatment completion versus non-completion in my sample beg the question of how these two groups differed. What was it that made treatment completers stick it out until the end, while the treatment non-completers either quit or regressed to the point that they required more intensive treatment? Cause and effect cannot be determined from this type of study. However, a careful examination of the similarities and differences between treatment completers and non-completers may yield useful information and hypotheses which can be tested in future studies.

The patients who completed treatment and reached remission differed in several important ways from those who discontinued treatment prematurely.

Variables That Had a Significant Impact on Treatment Outcome:

1.) Type of Treatment

In my practice, all children and adolescents under age 18 with AN receive FBT (Family-Based Treatment, also known as the Maudsley Method). Some adolescents also receive individual therapy as an adjunct to FBT after weight restoration. Some children and adolescents transition to individual therapy with me after FBT is complete; this may be the case for those who have comorbid disorders or other ongoing issues. Patients over 18 with AN are strongly encouraged to do FBT whenever appropriate, although it is not always possible for logistical reasons, and some young adults are staunchly opposed to it. In my sample, 66.7% of patients (n = 20) received FBT alone, 16.7% (n = 5) received FBT plus individual therapy, and 16.7% (n = 5) received individual therapy alone.

In my sample, all of the patients who received individual therapy alone were 20 or older. Six of the 11 young adults in my sample (n = 55%) participated in FBT, either alone or in conjunction with individual therapy. All of the patients under age 18 received FBT, and two of these patients also received individual therapy.

One-hundred percent of treatment completers (n = 17) received FBT, either by itself (n = 15) or in conjunction with individual therapy (n = 2). In other words, all patients who achieved remission did so through FBT. One-hundred percent of the patients who did individual therapy alone (n = 5) ended treatment prematurely, either because they moved (n = 2), they quit (n = 2), or I referred them to a higher level of care (n = 1). In other words, individual therapy by itself never resulted in treatment completion or remission.

2.) Subtype of AN

This sample contained 5 patients with the Binge-Purge subtype of AN (AN – BP) and 25 patients with the Restricting subtype of AN (AN – R). One-hundred percent of treatment completers had a diagnosis of AN-R. None of the AN-BP patients completed treatment.

Among the AN-BP patients, 2 were referred to higher levels of care after regressing during treatment with me. One patient moved to another state after making some progress in treatment with me. Two patients quit treatment prematurely after making significant progress with me.

The patients in my sample with AN-BP were more likely to have a history of impulsivity, self-injury, and suicidal gestures compared to those with AN-R. I hypothesize that this cluster of symptoms made these patients more difficult for me to treat effectively as an outpatient solo practitioner, and more likely to benefit from a more structured, comprehensive treatment approach such as day treatment or residential treatment.

3.) Age

On average, those who completed treatment and achieved remission were significantly younger at intake than those who did not complete treatment (p <.01). Treatment completers ranged in age from 10 – 24 at intake, with a median age of 14. Treatment non-completers ranged in age from 10 – 37, with a median age of 20. However, it is important to note that there was a broad range of ages in both groups, with some young adults achieving full remission and some children and adolescents discontinuing treatment prematurely.

4.) Fee Paid for Services

I believe that neither finances nor insurance issues should prevent people from accessing high-quality healthcare services. Therefore, I do not participate on any insurance panels. I am flexible with my fees and I work on a sliding scale based on a patient's ability to pay. If a family’s financial status changes during the course of treatment, I will change my fee for them accordingly. I work with many patients for very low hourly fees. Thus, I can only assume that the patients who discontinued treatment prematurely did not do so for financial reasons.

Among the patients in this AN sample, 87% (n = 26) paid my full fee and 13% (n = 4) paid a reduced rate. The rate of reduced-pay patients in this sample is significantly lower than in my other diagnostic groups. I hypothesize that this may be due to the fact that the majority of patients in this sample received family-based treatment and had at least one parent who was a working professional, or who at least was employed full-time. In contrast, many of my patients with other diagnoses were college students supporting themselves, who were therefore eligible for a low fee.

In this sample of AN patients, those who paid a reduced rate were significantly less likely to complete treatment compared to those who paid a full rate. Only 25% of reduced fee patients (n = 1) completed treatment, versus 62% of full fee patients (n = 16). It is unclear why reduced rate patients were less likely to complete treatment. However, the reduced rate patients differed from the full rate patients in several important ways. First, and most obviously, they had lower incomes, and likely dealt with the host of stressors that accompany being of lower socio-economic status. Second, they were all over the age of 18, which statistically reduces their likelihood of full recovery. Third, they were more likely to receive individual therapy than the full-rate patients. All of the low-rate patients received individual therapy, either alone (n = 2) or in combination with FBT (n = 2).

Observing my patients with other diagnoses, I have noticed that those who pay full rate are much more likely to attend all of their sessions and to complete treatment, whereas those who pay lower rates are more likely to cancel sessions, no-show for sessions, and drop out prematurely. While I’m sure that the reasons for these differences are complex, I can’t help but wonder if people who pay more for something tend to value it more and take it more seriously.

Variables That Had a Minor Impact on Treatment Outcome:

1.) Length of illness before intake.

Among treatment completers, length of illness before intake ranged from 3 months to 13 years (mean = 27 months). Amongst treatment non-completers, length of illness before intake ranged from 3 months to 21 years (mean = 67 months). However, this difference was not statistically significant (t = 1.63; p = 0.11).

2.) Use of Medication During Treatment

Individuals who took psychotropic medication during treatment with me were somewhat more likely to complete treatment and achieve remission. Fifty-nine percent of treatment completers (n = 10) took medication during treatment, compared with 38% of treatment non-completers (n = 5).

3.) Ethnicity

This sample of 30 patients was comprised of 60% White Non-Hispanic individuals (n = 18) and 40% White Hispanic Individuals (n = 12). These percentages are roughly similar to the ethnic makeup of Coral Gables, Florida, the Miami Suburb in which my office is located. The treatment completers group was comprised of 71% White Non-Hispanic individuals (n = 12) and 29% White Hispanic individuals (n = 5). The treatment non-completers group included 46% White Non-Hispanics (n = 6) and 54% White Hispanics (n = 7). Therefore, White Non-Hispanics were slightly more likely to complete treatment and achieve full recovery than White Hispanics.

4.) History of intensive eating disorder treatment.

History of residential, day treatment, or intensive outpatient treatment had a minor impact on treatment outcome. Twelve percent of treatment completers (n = 2) and 23% of treatment non-completers (n = 3) had a history of residential eating disorders treatment prior to beginning treatment with me. Twenty-four percent of treatment completers (n = 4) and 31% of treatment non-completers had a history of partial hospitalization, day treatment, or intensive outpatient eating disorder treatment.

Variables that Had No Impact on Treatment Outcome:

1.) Comorbid disorders

The presence of comorbid disorders did not differ significantly between the two groups. Fifty-three percent of treatment completers (n = 9) had a comorbid diagnosis, as did 46% of treatment non-completers.

2.) Gender.

Given that only 7% of the sample was male (n = 2), I cannot draw any conclusions about gender differences in treatment response. Incidentally, both of the males in my sample achieved full recovery.

3.) Hospitalization before treatment.

Being hospitalized for AN or a related psychiatric issue prior to beginning treatment with me did not have a significant impact on treatment outcome. Thirty-five percent of treatment completers (n = 6) had been hospitalized at least one prior to beginning treatment with me, as had 31% percent of treatment non-completers (n = 4).

4.) Hospitalization during treatment.

The need for hospitalization during the course of treatment with me did not have a significant impact on treatment outcome. Eighteen percent of treatment completers (n = 3) needed to be hospitalized during the course of their treatment, compared with 15% (n = 2) of treatment non-completers.

These data, taken together, suggest that a patient with AN-R who enters treatment with me and receives FBT is very likely to achieve full remission within 28 sessions over the course of 17 months, regardless of gender, comorbid diagnosis, or history of hospitalization. A patient under age 18 has a greater likelihood of achieving full remission, although a patient over 18 is also likely to achieve full remission, provided that he or she is treated with FBT.

Please bear in mind that these results are specific to my practice and my patients. These data are not intended to be generalized to other clinicians or other patient populations.

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Monday, July 1st, 2013

End of Treatment Outcomes for Patients with Anorexia Nervosa

Since opening my practice in 2009, I have evaluated 49 patients with primary diagnoses of Anorexia Nervosa (AN). All patients who attended an evaluation and at least one treatment session with me, and who are no longer in treatment with me, were included in this sample. In addition, there were several patients who have completed their treatment but have elected to see me two or three times per year for check-ins; these patients were included in this sample as well. Patients who are currently in treatment with me were not included. Patients who saw me for an evaluation and / or consultation only, but did not attend any treatment sessions, were not included either. Thirty patients met criteria for inclusion in this sample. The remaining 19 did not meet criteria, either because they saw me for evaluation and consultation only or because they are currently in treatment with me.

Please bear in mind that this is not a randomized, controlled study. The results I am posting are specific to my practice and my patients. They are not intended to be generalized to other clinicians or other patients. While many of my patients are referred to me by their pediatrician or psychiatrist, the majority of my patients are self-selecting. That is, their families researched their treatment options on their and chose to work with me for a specific reason. The self-selecting nature of many of these families also limits the generalizability of the results.

The sample described in this post contains 30 patients. These patients ranged in age from 10 – 37 (median age = 15). Eighty-three percent of these patients (n = 25) met criteria for restricting subtype (AN-R) and the remaining 17% (n = 5) met criteria for binge-purge subtype (AN-BP). Half of these patients (n = 15) had a co-morbid diagnosis, with the most common being Major Depressive Disorder and Depressive Disorder Not Otherwise Specified. Fifty-three percent of patients (n = 16) took some type of psychotropic medication during their treatment with me.

The patients varied widely in terms of length of illness and severity of symptoms. Duration of illness before intake ranged from 3 months to 21 years (median duration = 19 months). Importantly, these figures reflect the duration since the onset of illness, which is typically longer (and often much longer) than the duration since diagnosis. For the purpose of calculating duration of illness, onset of illness was defined as the period of time in which patient began engaging in behavioral symptoms of AN (e.g., restricting, compulsive exercise, purging) as reported by the patient and/or parents.

The majority of these patients arrived at my office with some history of treatment. Seventy percent of patients (n = 21) had already received some type of treatment before beginning therapy with me. As expected, most of those who were new to treatment had a much shorter duration of illness. One-third of patients (n = 10) had been hospitalized for their eating disorder or a related psychiatric issue (e.g., suicide attempt) prior to their evaluation with me. Seventeen percent of the patients (n = 5) had previously been in residential treatment and 27% (n = 8) had previously been in partial hospitalization, day treatment, or intensive outpatient treatment eating disorder treatment.

Duration of treatment with me ranged from one week to 48 months (median duration of treatment = 11 months). Number of treatment sessions with me ranged from 1 – 82. For those whose treatment lasted 18 months or longer, the duration of treatment can be explained by either a relapse after a period of remission or continued treatment to address a comorbid condition, such as anxiety or depression. Seventeen percent of patients (n = 5) had to be hospitalized during their treatment with me.

Prior to reporting end-of-treatment outcomes, it is important to clarify how I defined outcomes. I created the following definitions, each with specific criteria, in order to categorize patient outcomes:

1. Patient must meet ALL of the following criteria to be classified as in full remission:
a.) Patient is 100% weight-restored. Target weights were calculated based on patient’s individual historic growth chart and parent input. Patients under age 20 were expected to return to their historic percentiles for height, weight, and BMI. For patients age 20 and up, target weights were calculated based on the patient’s height, body build, weight history, menstrual history, and parental input (when available).
b.) Patient has started or resumed menstrual periods (for females ages 14 +).
c.) Patient is medically healthy.
d.) Complete abstinence from binge/purge behaviors, laxatives, and diet pills.
e.) Patient eats regular, balanced meals most of the time or always , as reported by patient and parent (when applicable)
f.) For children under 18 – child eats independently in an age-appropriate way most of the time or all of the time. For patients ages 18 and up, patient is able to eat independently while maintaining his/her weight.
g.) No more than mild preoccupation with food, weight, body image, or fear of weight gain

2. Patient is classified as in physical remission if he/she meets criteria a, b, c, d, and e under full remission, but does not meet criteria f or g under full remission. Essentially, a patient in physical remission is physically well and free of eating disorder behaviors, but cannot eat well independently, and/or continues to be preoccupied with thoughts about food, weight, and body image.

3. Patient is classified as having made significant progress if:
a.) Patient has made significant improvement in dietary habits (e.g., eats regular, balanced meals and snacks and has expanded the variety of foods he/she eats) as reported by patient and parents (when applicable)
b.) Patient has restored some weight and is at least 90% of ideal body weight (as defined in criterion a under full remission)
c.) Patient is medically healthy
d.) If patient has a history of bingeing, purging, laxatives, or diet pills, the frequency of these behaviors has been reduced to once per week or less.

4. Patient is classified as having made some progress if:
a.) Patient has improved dietary habits since intake, but needs more improvement
b.) Patient has restored some weight but remains more than 10% below target weight (as defined in criterion a under physical remission).
c.) Patient is a female age 14 or older but is not menstruating
d.) If patient has a history of bingeing, purging, laxatives, or diet pills, he/she has reduced the frequency of these behaviors since intake but still engages in them more than once per week.

5. Patient is classified as having made no progress if he/she has not improved dietary habits, has not restored any weight, and/or has not reduced the frequency of bingeing or compensatory behaviors.

6. Patient is classified as regressed if he/she meets ANY of the following criteria:
a.) Patient has lost weight since starting treatment
b.) Patient has been eating less since intake (in terms of frequency, quantity, and variety)
c.) Frequency of bingeing or compensatory behaviors has increased since intake
d.) Patient has become medically unstable

Fifty-seven percent of patients (n = 17) completed treatment and will be referred to as “treatment completers.” Treatment completers ranged in age from 10 – 24 at intake, with a median age of 14. Duration of treatment for treatment completers ranged from 2 months to 48 months (median duration = 15.5 months).

Ninety-four percent of treatment completers (n = 16) met criteria for full remission at end of treatment. The remaining 6% (n = 1) met criteria for physical remission at end of treatment. For the treatment completers, weight restoration was achieved in an average of 3 months (range = 1 – 7 months). Two of the treatment completers were fully weight-restored (though not in full remission) at the start of treatment with me, having already been in eating disorder treatment elsewhere.

Forty-three percent of patients (n = 13) did not complete treatment and will be referred to as “treatment non-completers.” Treatment non-completers ranged in age from 10 – 37, with a median age of 20. Duration of treatment for the non-completers ranged from one week to six months (median duration = 3 months). Of the treatment non-completers, I referred 23% (n = 3) to other providers because they required something I could not provide (e.g., residential treatment) or my treatment approach was not helping them. Fifteen percent of non-completers (n = 2) moved to other parts of the country during their treatment and thus were referred to other providers near their new homes. Sixty-two percent of treatment non-completers (n = 8) dropped out of treatment prematurely.

Of the treatment non-completers, 46% (n = 6) had made significant progress by their last session with me. Fifteen percent had made some progress, 23% (n = 3) had made no progress, and 15% (n = 2) had regressed.

Stay tuned for my next blog post, in which I will examine and interpret the differences between treatment completers and treatment non-completers.

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