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, and 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

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Sunday, December 6th, 2009

Emotional Anorexia

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Posted in Biologically-Based Mental Illness, Eating Disorders, Psychotherapy | 2 Comments »

Sunday, September 6th, 2009

Palliative Care for Anorexia Nervosa?

I recently read an article in the International Journal of Eating Disorders entitled Managing the Chronic, Treatment-Resistant Patient with Anorexia Nervosa (Strober, 2004). Though eloquently written and artfully persuasive, this was probably the most depressing journal article I have ever read. The author, Michael Strober, seeks to help readers “resolve the paradox of caring for patients who seem so decidedly opposed to change.” Essentially, Strober advises psychologists to avoid pushing, or even encouraging, full nutrition and weight restoration in chronically ill patients with AN because these attempts will backfire by upsetting the patient emotionally and thus leading to premature termination of therapy. Instead, he argues, therapists “can expect little, should seek nothing, and must largely defer to the patient in regards to the objective of the time shared together.”

Strober states that the therapist’s attempts to encourage re-feeding “will feel like an assault” to the patient and are “certain to induce peril.” He warns therapists that their efforts to coerce patients into hospitalization or other much-needed medical care will result in “a potentially dangerous exacerbation of symptoms.” The article presents two tragic case studies of women in their late 20’s who have been chronically ill with AN since early adolescence. Each story is presented as a cautionary tale describing the deleterious effects of requiring full nutrition and weight restoration in these types of patients. Finally, Strober admonishes therapists to be aware of their counter-transference with such patients and advises them to “concede the reality that there may be little to do to drastically alter the course of a patient’s illness,” and notes that “this is neither failure nor inferiority.”

I view this entire philosophy as a manifestation of both failure and inferiority. Failure on the part of professionals who fear an emaciated patient’s wrath more than they fear her death. Failure on the part of a profession which espouses the dogma that avoiding premature termination of treatment is more important than avoiding premature termination of the patient’s life. Failure on the part of a philosophy that values nurturing the therapeutic relationship more than it values giving a patient a fighting chance at life, health, and happiness. These patients have not failed treatment. Treatment has failed them.

Strober argues that there is a place in our field for palliative care for treatment-resistant anorexics. I disagree. Anorexia nervosa is, by definition, resistant to treatment. The “peril” that ensues during re-feeding is real and universal. Re-feeding is agonizing for the patient herself, her friends and family, and her treatment team. Anyone who has ever made the heroic journey from AN to recovery will tell you that. I have never met an anorexic who gladly relinquished rigid control over her diet, voluntarily prepared and consumed high-calorie meals, and excitedly welcomed weight restoration without struggle. A person such as this would not have been diagnosed with AN in the first place. Chronically ill patients with AN are not resistant to treatment. Treatment is resistant to them.

Towards the end of the article, Strober warns therapists to keep their counter-transference in check by not pushing patients too hard, not expecting recovery, and resigning themselves to the reality that these patients are destined for a lifetime of illness and misery followed by a premature death. He notes that many therapists are not well-suited for providing palliative care to treatment-resistant anorexics. I, for one, am certainly not cut out for that type of work. I am not able to sit impassively with a patient who has been ill for fifteen years without taking draconian measures to propel her towards health. I recognize that responsibility for her recovery, at least initially, lies with me and with her family. I would not expect a patient with that level of illness to embrace recovery. That’s my job, not hers.

Individuals with AN are almost universally brilliant, talented, sensitive, and intense. They have so much potential, so many gifts to offer the world. They are physicians and nurses and lawyers, scientists and professors and teachers. They are outstanding athletes, writers, singers, dancers, actresses, and artists. Consider three-time Grammy-winning singer Karen Carpenter who died of AN at age 33 and world-class gymnast Christy Henrich, who died of AN at age 22. These women were beloved daughters, loyal sisters, caring friends.

It baffles me that, in a society which purports to value human life, we allow these precious lives slip away. The Bush administration placed restrictions on stem-cell research, supposedly out of concern for the sanctity of life. Nearly half of Americans are opposed to abortion. Our society believes that elderly, terminally ill patients in excruciating pain must not be allowed to die, as evidenced by the fact that doctor-assisted suicide is illegal in every state except Oregon. States have laws which allow for the involuntary hospitalization of imminently suicidal and floridly psychotic patients, recognizing that these individuals are not well enough to care for themselves. Psychiatric hospitals use 4-point restraints, sedatives, and padded rooms to prevent patients from injuring themselves. Prisoners are forbidden from having sharp objects and belts in order to protect them from taking their own lives. Death row inmates who attempt suicide are resuscitated. Don’t we owe the same to innocent people who are suffering from a horrible eating disorder?

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Posted in Eating Disorders, Psychotherapy, Suicide | 5 Comments »

Thursday, August 27th, 2009

Food, Safety, and Trust

Earlier this week, I read about a hospital program that provides medical stabilization for patients with eating disorders. The medical director of this program wrote that if a patient “refuses” meals and liquid supplements, the staff observes the patient, without intervention, for approximately 48 hours. If the patient continues to “refuse” nourishment after that point, the physician and psychologist have a discussion with the patient about using a nasogastric tube, but recommend oral feeding instead.

Disheartened to read about this hospital’s approach, I politely asked the medical director to explain the medical or psychological rationale for waiting 48 hours before providing a hospitalized, medically unstable eating disorder patient with some form of nourishment. Her response was that most patients with anorexia “are not at increased at increased medical risk by waiting one or two days to begin serious re-feeding.” Further, she wrote that it is “medically and psychologically safer” for patients to under-eat for a couple of days and then start re-feeding, when they are “fully committed to the process and trusting the treatment staff.”

I don’t have a medical degree, but I do know more than the average person about the medical complications of eating disorders. I’m not aware of any medical reason why it would be safer for a low-weight, medically-compromised anorexic patient to go without any nourishment, or without sufficient nourishment, for ANY period of time, let alone 48 hours. It is my understanding that re-feeding should begin as soon as possible. Clearly, severely malnourished patients who are at risk for re-feeding syndrome should be started on a low-calorie meal plan which is gradually increased by several hundred calories each day until they reach an appropriate caloric level for weight restoration. But still, the re-feeding process should begin immediately, right? Am I missing something here?

I do have a doctorate in psychology and a thorough understanding of eating disorders, and I am well aware of the potential psychological repercussions of this hospital’s approach. Critically ill patients with eating disorders are not “refusing” nourishment. They are suffering from a disease that renders them unable to nourish themselves or accept nourishment from others without a fight. Even if it were the case that people with anorexia “won’t” eat, rather than “can’t” eat, I would still argue that society in general, and the healthcare establishment in particular, has a moral obligation prevent people with mental illness from inflicting damage upon their bodies and brains.

For a person with a mild eating disorder who is being treated on an outpatient basis, it is unacceptable, and counter-productive to recovery, to under-eat for even one meal. Imagine, then, a severely ill, medically compromised patient who is admitted to a hospital, most likely after years of unsuccessful outpatient or residential treatment, being presented with a choice of whether, what, or how much to eat. Eating disorder patients need to be protected from their symptoms, which not only wreak havoc on their bodies, but cause unrelenting psychological anguish as well. Food is not optional for anyone. Full nutrition, as soon as possible and by whatever means necessary, cannot be presented as optional in eating disorder recovery.

The medical director of this hospital program wrote that, after approximately 48 hours of not eating or under-eating, patients can begin re-feeding “fully committed to the process and trusting the treatment staff.” I disagree with this assertion. Patients with eating disorders are rarely, if ever, “fully committed to the process” until they are much further along in their recovery. This anosognosia is a symptom of their illness, and it’s not likely to disappear after two more days of starvation. Further, “trusting the treatment staff” is not a necessary prerequisite for re-feeding. Eating disorders do not “trust” healthcare professionals because the role of healthcare professionals, at least in theory, is to annihilate eating disorders. Gaining the trust of the patient, however, is a different story. I would wonder how a patient could ever trust a staff that stood by as she starved for a couple of days. If you can’t count on a medical stabilization program to ensure full nutrition and protect you from your illness, then who can you rely upon?

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Posted in Eating Disorders | 4 Comments »

Monday, August 17th, 2009

What’s That About?

“It’s about control.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Isn’t it about time?

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Posted in Biologically-Based Mental Illness, Eating Disorders, Psychotherapy | 5 Comments »

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