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 trained scientist-practitioner, and 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: eating disorder treatment

Monday, December 14th, 2009

Eating Disorders: Prevention and Early Intervention Tips for Parents

There is a fair amount of internet advice for parents on how to prevent eating disorders in their children. The majority of this advice centers around teaching children about healthy eating habits, moderate exercise, positive body image, and media literacy. This is great advice for parents to follow, but it does not prevent eating disorders. It may help to prevent body dissatisfaction and dieting, but these things are not the same as an eating disorder.

Ironically, many children and adolescents who are in treatment for anorexia nervosa or bulimia nervosa report that their illness was triggered by a health or nutrition class at school, training for a sport, or a general desire to adopt the much-touted principles of “healthy eating and exercise.” Unfortunately, most of the information children receive on the benefits of “healthy eating and exercise” is really our fat-phobic society’s disguised attempt to shield our precious children from this horrible “obesity epidemic.” To make matters worse, this information is delivered to children by teachers, physicians, coaches, and parents – supposedly knowledgeable authority figures whose job is to educate, protect, and nurture them. Children who are predisposed to eating disorders are usually compliant, rule-bound, anxious, obsessive, perfectionistic, driven, and eager to please. They are virtual sponges who soak up this “healthy eating and exercise” information and follow it to the letter. The obesity hysteria terrifies them, and their obsessive, perfectionistic temperament makes them stellar dieters. This is the perfect storm for the development of an eating disorder.

I do not believe we should stop educating children about nutrition and exercise out of fear that they will develop eating disorders, much as I don’t believe we should stop educating adolescents about safe sex and contraception out of fear that they will become sexually active. More information is usually better than less, as long as the information is accurate, useful, and effective. The middle school and high school syllabi on sex education provide information which is accurate, useful, and effective (whether kids act on that information is another story). The information kids receive on “healthy eating and exercise” has not succeeded in improving their overall health, preventing eating disorders, or combating this alleged “obesity epidemic.”

I believe that, in terms of nutrition, kids should be taught about what to embrace rather than what to avoid. They should learn the importance of eating lots of fruit, vegetables, dairy products, protein, fat, and grains, and drinking plenty of water. They should be taught to enjoy their favorite snacks and deserts as well. They should not be taught about calories or the evils of sugar and fat; they should not be advised to avoid any foods, they should not learn to label foods as “good” or “bad,” and they should not be taught about the dangers of obesity or the virtue of thinness. Most importantly, I believe children should be taught about the dangers of dieting, much as they are taught about the dangers of drugs, alcohol, and unprotected sex. The dangers of dieting are grossly underrated.

Even if nutrition education is accurate, useful, and effective, it will not prevent eating disorders. That being said, what steps can parents take to prevent their children from developing eating disorders? In my opinion, it all boils down to three basic principles: 1.) accurate information, 2.) vigilance, and 3.) immediate, aggressive, effective intervention.

Accurate information
The pop-psychology literature will have you believe that if you have a healthy body image yourself, encourage healthy body image in your children, nurture positive self-esteem, and preach the importance of healthy eating habits and exercise, your child will not develop an eating disorder. This assumption is simply untrue. Parents need to know that seemingly healthy, well-adjusted children with positive body images and excellent parents develop eating disorders all the time. Good parenting does not make your child immune. It can, however, improve your child’s chances of full recovery.

If your child develops an eating disorder, let go of guilt, shame, and self-blame. While it is natural for parents to blame themselves, guilt is a hindrance to effective action. Of course you have made mistakes in parenting – everyone has! You may be an imperfect parent, but this does not mean you caused your child’s illness. Despite what you may have heard in the media, there is no reliable scientific evidence to suggest that parents cause eating disorders. If your child’s pediatrician, dietician, or therapist suggests that the eating disorder is your fault, this is an indication that he or she is not aware of recent research on the etiology of eating disorders and effective treatments. Get a second opinion. Anorexia nervosa and bulimia nervosa are biologically-based brain disorders, just like autism and schizophrenia. Although you are not to blame for causing your child’s eating disorder, it is your responsibility as a parent to ensure that she gets proper treatment. This responsibility includes protecting your child from outdated, ineffective treatments, which can often do more harm than good.

Parents also need to know that eating disorders are not limited to rich, white teenage girls. This stereotype is antiquated and dangerous, as it prevents individuals outside these demographic categories from being diagnosed and properly treated. Eating disorders strike children, adolescents, and adults; girls and boys, men and women; people of all ethnic, cultural, and economic backgrounds. Several years ago, during my training, I treated a severely underweight teenage boy with anorexia nervosa whose previous pediatrician had told him: “If you were a girl, I’d say you were anorexic.” As a result of this doctor’s failure to intervene, the patient’s condition rapidly deteriorated over the next two years, and by the time he presented in my office, he was in horrible shape.

Vigilance
Here are some concrete steps that parents can take to help prevent eating disorders. You may notice that, unlike other prevention tips you may have read, these tips center around proper nutrition and exercise. This is because all the feminist, feel-good, positive-body image talk in the world is not going to prevent eating disorders. Remember, anorexia nervosa has existed for centuries, long before thinness became fashionable. Eating disorders are triggered by an energy imbalance (consuming fewer calories than you expend) and perpetuated by malnutrition. If a child never becomes malnourished, she is extremely unlikely to develop an eating disorder.
• Make family meals a priority. As a parent, it is your job to prepare and serve nutritious foods. It is far better for a family to sit down to a balanced breakfast of cereal, milk, fruit, juice, and yogurt instead of grabbing a nutrigrain bar and running out the door.
• Closely monitor any changes in your child’s eating habits. Even seemingly “positive” dietary changes such as skipping desert, becoming vegetarian, or reducing fat intake can signal the onset of an eating disorder.
• Adopt a zero-tolerance policy towards any level of malnutrition. Do not allow your child to diet, skip meals, or cut out entire food groups. Children and teenagers need to eat three substantial, nutritious, well-balanced meals every day. Supervised, supported full nutrition is the best defense against an eating disorder.
• Be aware that eating disorders are sometimes triggered by unintentional malnourishment (for example, weight loss due to physical illness, depression, anxiety, stress, or surgery; fasting for religious purposes; side effects of a medication; intense physical exercise without a commensurate increase in nutrition). This type of malnourishment must be taken equally seriously. Dieting is not the only pathway to eating disorders (although it is the most common pathway in modern Western cultures).

Parents need to be on guard for early signs of eating disorders, especially during early adolescence, when most eating disorders develop. Since eating disorders are genetically transmitted, your child is much more vulnerable to developing an eating disorder if you or a relative has suffered from an eating disorder. Family histories of major depression and other mood disorders, anxiety disorders, OCD, and addictions are also risk factors for developing eating disorders. If you have a family history of eating disorders or other mental illnesses, you should know that your child is at greater risk for developing an eating disorder, and you should be extra vigilant.

Some early signs of eating disorders masquerade as “healthy” behaviors or extreme dedication, or can easily be dismissed as typical teenage behavior. However, parents know their kids well. Most parents recognize, long before formal diagnosis, that something is “not quite right” with their child, but they aren’t sure what is wrong or they don’t know what to do. Here are some early signs and symptoms:
• Change in eating habits. This can take many forms, including following a formal diet plan, skipping meals, eating only at certain times, refusing to eat with other people, or anxiety around food. Even seemingly positive dietary changes, such as becoming vegetarian, reducing fat intake, skipping snacks and deserts, and eating only organic foods, can be early signs of an eating disorder.
• Increased preoccupation with food: taking about food, reading diet books, collecting recipes, cooking, serving food to others, sudden interest in what other people are eating.
• Change in mood or behavior. Parents often notice dramatic changes in their child’s personality, such as irritability, anxiety, depression, moodiness, frequent crying, restlessness, withdrawal, changes in sleeping patterns, or loss of interest. Increased dedication to schoolwork, sports, or other extracurricular activities and obsessive behavior in other areas can also be early signs.
• Increase in exercise. The child may begin solo running, take up a new sport, or show increased dedication to her current sports. If she is an athlete, she may begin training excessively outside of team practices. If she is a dancer, she may begin practicing at home, signing up for more dance classes, and auditioning for every possible performance opportunity.
• Weight loss, failure to gain weight, or failure to make expected gains in height. ANY weight loss in a child or adolescent, even a few pounds, may be cause for alarm. ANY failure to grow or gain weight as expected warrants further examination.
• Loss of menstrual periods.
• Signs of binge eating (for example, large amounts of food disappearing overnight).
• Signs of purging (for example, discovering laxatives in your child’s purse or smells of vomit in her bathroom).

Immediate, Aggressive, Effective intervention
I have never heard a parent say: “I wish I had waited longer before getting my child into treatment.” Most parents whose children are in treatment for eating disorders regret not intervening sooner. In addition, many parents report that they wish they had sought out evidence-based treatment immediately, rather than continuing with ineffective treatment as their child’s health declines. If you notice any of the signs or symptoms listed above, take action immediately. Here’s how:
• Educate yourself about eating disorders and evidence-based treatment. FEAST (Families Empowered and Supporting Treatment for Eating Disorders) is an excellent resource for parents.
• Do not praise your child for her “healthy eating” habits or willpower around food. Instead, tell her that you have noticed a change in her eating habits and that you are concerned. For example: “I notice that you’re not enjoying ice cream with our family anymore. What has changed?”
• Be prepared for your child to insist that she is just trying to eat healthily, exercise more, or improve her performance in sports or dance. Many eating disorders begin this way but quickly spiral into deadly obsessions.
• Be prepared for your child to be in denial or to resist your efforts to intervene. Teenagers never say: “Mom, I think I’m developing anorexia nervosa, and I’m worried about my recent weight loss.” Denial, resistance, and lack of insight are symptoms of this disease, NOT indications that everything is OK. Don’t back down.
• Don’t waste time on “why.” When your child is developing an eating disorder, it is tempting to try to understand the reasons for it. Resist this temptation and tackle the symptoms immediately. The very foundation of ineffective eating disorder treatment begins with endless search for the “root cause” while the child continues to starve, binge, purge, and over-exercise as her physical and mental health deteriorate. A patient with an active eating disorder is generally unable to make effective use of psychotherapy because her brain is not functioning properly. Eating disorders are life-threatening illnesses with serious mental and physical risks. Think of your child’s eating disorder as a tumor. It must be removed immediately, or it will grow and metastasize. The surgeon does not need to know the reason for the tumor in order to operate and remove it. The sooner you intervene, the better your child’s chances for complete recovery. There will be plenty of time for psychological work, including an exploration of potential triggers, later on in recovery, once your child is well-nourished and physically healthy.
• As soon as you suspect a problem, take your child to the pediatrician for a complete physical exam. Unfortunately, most physicians do not have specialized training in eating disorders and are unlikely to notice an eating disorder until it is in its advanced stages. Thus, you cannot always trust your child’s pediatrician to spot a problem. I have had many patients whose physicians have completely overlooked telltale signs such as weight loss, missed menstrual periods, or failure to grow. Consider taking your child to a pediatrician or adolescent medicine physician who specializes in eating disorders. Remember, trust your parental instincts. If you think there is something wrong with your child, you are probably right. It is far better to intervene immediately and later discover that everything is fine, rather than waiting until your child is in the acute phase of a life-threatening mental illness.
• If you intervene at the first sign of an eating disorder, your child may not meet full criteria for anorexia nervosa or bulimia nervosa. Thus, she may be diagnosed with Eating Disorder Not Otherwise Specified, or she may not be diagnosed with an eating disorder at all. This does not mean that your child’s problem isn’t serious or that immediate, aggressive intervention isn’t necessary. It simply means that your child is in the beginning stages of what is likely to become a severe, life-threatening mental illness if left untreated (or improperly treated). Your child is most likely to achieve complete, lasting recovery treatment begins immediately, rather than waiting for her to develop full-syndrome anorexia nervosa or bulimia nervosa and the myriad of psychological and physical problems these illnesses entail.
• If your child has been in therapy for a while and she continues to restrict her diet, lose weight, binge, or purge, therapy is not working. In early recovery, it does not matter if your child has a good relationship with her therapist, enjoys speaking with her, or trusts her. The therapeutic relationship is only therapeutic insofar as it promotes health, wellness, and recovery. Insight, self-exploration, and rapport are useless in the wake of malnutrition. Speak with your child’s therapist about taking a different approach. If your child’s therapist refuses to talk to you, or if you are not satisfied with the results of treatment, find a different therapist.
• Seek evidence-based psychological treatment for your child and your family. Most therapists, even ones who specialize in eating disorders, are not up-to-date on the latest research and most effective treatments. I have worked with many families who have taken their child to multiple eating disorders specialists over a period of several years and seen no symptom improvement whatsoever. This is usually because the therapists were not aware of recent scientific research on eating disorders and were not using evidence-based treatments. For children and adolescents, the strongest evidence base is for Maudsley Family-Based Treatment (FBT). Maudsley FBT is a highly practical, empirically-validated treatment method which empowers the family to help the patient recover and focuses on immediate restoration of nutritional and physical health before tackling psychological issues. Research has shown that 75-90% of adolescents treated with Maudsley FBT recover within 12 months and maintain their recovery at 5-year follow-up. In contrast, traditional treatment generally takes 5-7 years and only 33% of patients achieve full recovery.
• Remember that you are an essential member of your child’s treatment team. Your child’s treatment will be most effective if you are fully informed and actively involved. Interview any potential physicians, dieticians, therapists, and psychiatrists without your child present before your child meets them. Make sure that you are comfortable with their philosophy of eating disorders and their approach to treatment. Insist on being informed about your child’s progress in treatment and ask what you can do to help her recover. If the therapist will not inform you or include you in treatment decisions, find a new therapist.
• Recognize that your child’s eating disorder is neither her fault nor her choice. Do not wait for her to “choose” recovery, because she can’t. It is your job to choose recovery for her until she is well enough to take ownership of her treatment. Try to separate the disorder from the child you know and love. She is in there somewhere, and some day, she will thank you.

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Posted in Eating Disorders, Maudsley Approach, Psychotherapy | 8 Comments »

Wednesday, November 18th, 2009

Force feeding?

The idea of force-feeding in eating disorder treatment is highly controversial. It is ironic that the idea of requiring sustenance, which all living things need to survive anyway, has the power to create such extreme revulsion. Perhaps it is not so surprising that old-school treatment professionals object to force-feeding. You know the types – those who believe that eating disorders are “not about food,” that sufferers are the victims of over-controlling parents or a size-0 obsessed society or a fear of growing up. The idea that eating disorder patients have willfully chosen self-starvation, and will begin to eat again once their “underlying issues” have been resolved, follows logically from these unsubstantiated theories.

What really boggles my mind is that the very mention of force-feeding creates a visceral reaction even in well-informed clinicians who practice evidence-based treatment and parent advocates of Maudsley Family-Based Treatment. These individuals are fully aware that eating disorders render victims temporarily unable to nourish themselves, and they know from empirical literature and personal or clinical experience that re-feeding is the essential first step in successful eating disorders treatment. To me, it seems to follow logically from this knowledge that most patients with eating disorders cannot choose to eat and therefore must be forced to eat in order to recover. And yet, when confronted with the term “force-feeding,” Maudsley parent advocates and clinicians reframe the statement or circumvent the issue altogether. For example, a parent advocate whom I greatly admire states that “It is not forcing them to eat, it is letting them eat and live.” A clinician who practices Maudsley FBT writes that “Describing what we do in the Maudsley approach as “force feeding” is very misleading and I hope that we are able to continue to get the word out that this is a misconception.”

Most families encounter extreme resistance during re-feeding. I have heard stories of previously sweet, compliant, well-behaved young girls hurling swear words and spewing horrid insults at their parents during re-feeding. I myself have been on the receiving end of my share of f-bombs and hateful remarks from patients when I maintain an uncompromising stance of full nutrition and complete weight restoration. I have heard stories of girls running away from home, throwing ravioli across the room, smashing plates, locking themselves in rooms, and attempting to jump out of moving vehicles – all in response to the intolerable anxiety of re-feeding. And these scenarios are the norm, not the exception. I believe that families need to be fully informed of what is likely to happen during re-feeding so that they can prepare themselves to deal with what lies ahead. They need to know that what they are encountering is not evidence that they are doing something wrong, but rather is par for the course with this illness. But I digress.

The process of re-feeding an anorexic very often involves force. It has to, because most anorexics are not able to eat unless they are given no other alternative. In hospitals, this may require nasogastric tubes or IV nutrition. In residential or day treatment settings, it may involve earning privileges by finishing meals. In home-based re-feeding, it may involve not leaving the table until the meal or snack is 100% complete. The patient cannot choose to eat, but she will eat when she is forced. And she absolutely must eat a sufficient amount and variety of foods in order to recover. For those who have never experienced or witnessed the agony of an eating disorder, the idea of forcing someone to eat may sound inhumane. For those of us who have been in the trenches, we know that it is quite the opposite.

Our society values an individual’s right to make her own decisions. Respect for individual autonomy and self-determination is a cornerstone of democracy. In addition, our society embraces paternalism, which is the belief that it is ethical, at times, to intervene in the life of another person who does not desire such intervention because intervening will protect the person from harm, much in the way a loving father would intervene against his child’s wishes in order to protect the child. Our healthcare system and our government embrace the ethics of self-determination as well as the ethics of paternalism. For example, mandated reporter laws require physicians, therapists, social workers, and teachers to report cases of suspected child abuse and elder abuse, even if the victim doesn’t want the abuse to be reported. Laws allow for the temporary involuntary hospitalization of individuals who are suicidal, homicidal, or floridly psychotic. Many newer state laws require drivers to wear seatbelts and to abstain from text-messaging while driving. Hospitalized patients who engage in self-injury are forced into physical or chemical restraints. Children are forced to attend school at least through the age of 16. Suffice it to say that our great country, which was founded on the values of liberty and independence, recognizes that autonomy is not limitless. Children are forced to get an education and forcibly removed from abusive or neglectful homes. People are forced into hospitals for their own protection when they are a danger to themselves or others. Drivers are forced to wear seatbelts and forced to wait until they reach their destination before sending that oh-so-important text message.

Remember the 13-year-old cancer patient who skipped town with his mother last spring in order to escape court-ordered chemotherapy and radiation treatment? Well, the police eventually found him and forced him into treatment. He has just finished his last round of radiation and he is now cancer-free. This boy’s type of cancer has a 90% cure rate in children when treated with chemo and radiation. His doctors reported that he probably would have died if he hadn’t received these treatments.

Anorexia nervosa is also deadly and disabling disorder. Research shows us that most cases of adolescent anorexia nervosa can be successfully treated with a combination of full nutrition, weight restoration, family support, and evidence-based psychotherapy. Without treatment, or with “traditional” treatment which doesn’t aggressively push full nutrition, only 33% of patients ever fully recover.

I think I understand why people are frightened or repulsed by the idea of force-feeding. The idea of pushing full nutrition immediately after eating disorder diagnosis is still controversial, and to many people, the word “force” seems punitive or even abusive. It may conjure up images of physical torture and it may seem to conflict with the aforementioned democratic values. Eating disorder treatment should never be punitive or abusive (although it may feel punitive and abusive to the patient). Re-feeding is only one component of successful treatment. Cognitive, emotional, and behavioral symptoms and co-morbid conditions must be addressed as well. We all want to help patients recover rather than inflict further anguish. The illness itself is pure hell, and the recovery process can be even worse. But allowing the patient to engage in eating disorder symptoms is far more inhumane than force-feeding a patient to save her life, improve her health, and propel her towards full recovery.

Perhaps we are splitting hairs or just arguing over semantics. The American Heritage Dictionary provides several definitions of the verb “force,” including 1.) to compel to perform an action, 2.) to move something against resistance, and 3.) to produce with effort. Anyone who has witnessed, experienced, or been involved with the process of re-feeding an anorexic would undoubtedly agree that it involves 1.) compelling them to perform an action (eating), 2.) moving against resistance (the eating disorder thoughts, feelings, and behaviors, and 3.) an extreme amount of effort for both the caregiver and the patient. Call it whatever you want – supported nutrition, letting them eat, helping them recover, empowering parents to combat eating disorder symptoms – all of these labels are quite accurate and descriptive. So is force-feeding. And I don’t believe it is a bad thing.

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Posted in Anxiety, Eating Disorders, Maudsley Approach | 5 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 »

Wednesday, July 29th, 2009

10 Common Mistakes in Eating Disorder Treatment

Eating disorders are notoriously difficult to treat and have the highest mortality rate of any psychiatric illness. With traditional treatment, average time to recovery is 5-7 years, relapse is the norm, and many patients continue to suffer from chronic physical and mental illness for decades. Fortunately, new research has shed light on how we can help patients recover more quickly, prevent relapse, and live healthy, fulfilling lives. Below are 10 of the most common mistakes I’ve observed in the treatment of eating disorders.

1.) Setting target weight too low.

Physicians and dieticians will often set a patient’s minimum target weight at the low end of the statistically-determined “ideal” range. The minimum target weight thereafter becomes the maximum allowable weight in the patient’s mind, and she will do whatever she can to avoid going above it. There is no such thing as a universal minimum target weight. People vary dramatically in terms of body build, muscle mass, bone structure, body shape, and natural weight. Professionals need to take these factors into consideration when setting target weight ranges. The minimum target weight is often not sufficient to promote brain healing and repair the damage caused by malnutrition. “Out of immediate medical danger” does not translate to optimal physical and mental health. Many patients are left to struggle with ongoing depression, fatigue, anxiety, and preoccupation with food and weight because they haven’t reached their optimal body weight.

For children and adolescents, setting minimum target weight too low is especially dangerous because it fails to take into account the natural growth and physical development that occurs throughout adolescence. The ideal weight for a 13-year-old is not ideal for a 22 year-old. A 13-year-old patient who becomes fixated on her “minimum target weight” and maintains such a weight for a number of years is placing an indefinite moratorium on her physical, psychological, and sexual development. Another problem that is particularly disconcerting is that the minimum target weight set by professionals is often significantly lower than the patient’s pre-eating disorder weight, even if the patient was at a healthy weight before. Think about the subtle message this sends and how the ill patient may interpret it: “You were too big before, so you were right to start dieting.” This just feeds into the eating disorder. We need to send a different message: complete weight restoration is not negotiable.

2.) Discharging patients from inpatient or residential programs prematurely.

By “prematurely,” I mean several things: before the patient has reached her ideal body weight, before she has developed the skills to manage her symptoms, before other comorbid conditions have been diagnosed and treated, before the patient’s family has the knowledge and tools they need to support continuing recovery, or before a solid relapse-prevention plan is in place. According to my standards, then, the majority of patients are discharged prematurely. With treatment as usual, relapse is the norm, and repeated admission to hospitals and residential facilities is expected. It doesn’t have to be this way, and relapse may not be such a major problem if patients were treated fully and successfully the first time around. Of course, this will require healthcare reform and better insurance coverage in order to pay for a much longer duration of treatment, but I digress.

3.) Blaming parents for their child’s eating disorder.

Parents have traditionally been excluded from their children’s eating disorders treatment in large part because professionals have blamed them for causing the eating disorder. This viewpoint is based in psychoanalytic theory, not empirical fact, and to date there has been no reliable scientific evidence that parents cause eating disorders. Blaming parents is harmful to the entire family. It disempowers parents, angers and confuses the patient and her siblings, and interferes with the recovery process. Only a generation ago, parents were blamed for causing their children’s autism and schizophrenia. We now know that these illnesses are biologically-based brain disorders, and the idea of a “refrigerator mother” causing her son’s autism is ludicrous. I look forward to the day when the general public has the same sentiment about parents causing eating disorders.

4.) Failure to involve parents and other family members in the patient’s treatment.

Parents have a right and a responsibility to be fully informed and actively involved in their child’s treatment. Imagine how confusing and disempowering it is for parents to drop their child off at various appointments without being informed about the treatment and without being given an opportunity to ask questions, voice their concerns, or help with the recovery process. Likewise, adolescents have a right to have their parents fully informed and actively involved in their treatment. No child would have to manage cancer or diabetes independently. Why should it be any different for eating disorders? The research clearly indicates that involving parents in an adolescent’s eating disorder treatment dramatically increases her chance of full recovery.

Some therapists argue that involving parents in an adolescent’s treatment is counterproductive because it interferes with the adolescent’s burgeoning autonomy and encourages the family unit to remain enmeshed. In reality, the opposite is true. The eating disorder itself is disruptive to normal adolescent development and causes the patient to remain dependent on her parents. Family-based treatment approaches, such as the Maudsley Method, are first and foremost respectful of adolescent development. These approaches empower parents to help their children recover so that they may return to normal adolescent life, unencumbered by the illness.

5.) Basing interventions on unsubstantiated theories about the causes of eating disorders.

Our ideas about etiology inform our treatment approach. Consequently, incorrect assumptions about eating disorders tend to result in ineffective treatment. Let’s say, hypothetically, that controlling parents cause eating disorders. Or that media images which glorify thinness are responsible for eating disorders. Or that anorexia nervosa is caused by sexual abuse or is rooted in a desire to avoid growing up. Even if these things were true (and there is no reliable scientific evidence that they are), the first priorities in treatment should still be nutritional rehabilitation, weight restoration, and medical stability. Why? Because the patient’s life and health depend on it. Because research has consistently shown that many of the physical and mental symptoms of eating disorders are caused or exacerbated by malnutrition, restrictive eating, bingeing, and purging, and that these symptoms diminish with normalized eating and weight restoration. Because spending more time at a suboptimal weight, or engaging in food restriction, binge eating, or purging, is causing more physical and emotional damage. Because a weight-recovered, medically stable eating disordered patient who is receiving full nutrition is better equipped to explore and process the issues that may have triggered eating disorder symptoms in the first place.

6.) Viewing the patient’s symptoms as rationally chosen behaviors.

Recent research suggests that eating disorders are genetically-transmitted, biologically based mental illnesses, just like bipolar disorder and schizophrenia. No one would choose the agony and suffering of an eating disorder. I think the general public may get confused about this point because, for healthy people, eating and exercise are voluntary behaviors that are largely under conscious control. For eating disorder patients, restrictive eating, fasting, excessive exercise, bingeing, and purging are compulsive behaviors brought about by a brain condition, perpetuated by malnutrition, and aggravated by emotional stress.

Not only is it incorrect to view eating disorders as choices, but it is dangerous as well. It leads to blaming patients for their illnesses, trying to talk them out of their symptoms, and giving them the responsibility of choosing recovery. Almost invariably, people with anorexia are not able to choose recovery because denial and lack of insight are hallmark symptoms of the illness. People with bulimia are more likely to acknowledge their disorder and enter treatment voluntarily, but they are often unable to interrupt the binge/purge cycle without a major intervention and significant support from others. Insight and motivation are not prerequisites for entering treatment, restoring weight, or stopping unhealthy behaviors. Rather, increased insight and desire to maintain health are natural consequences of full nutrition, improved brain health, abstinence from eating disordered behaviors, and good therapy.

7.) Overemphasizing psychological recovery while underemphasizing physical recovery.

I am not entirely sure why many clinicians work with patients on developing insight and searching for a root cause early in treatment, prior to nutritional restoration and medical stability. We still do not know the causes of many types of cancer, but cancers are treated aggressively as soon as they are diagnosed. A surgeon will operate on a patient to remove a tumor regardless of whether he knows what caused it. It is tragically comical to imagine a doctor and patient searching for the cause of the tumor while it metastasizes.

One of the earliest things we’re taught in our clinical training is how to build a positive, trusting relationship with the patient. If the patient doesn’t trust us and feel comfortable with us, the therapy won’t work. Indeed, psychotherapy research across various disorders and types of treatment has demonstrated that the therapeutic relationship is a very powerful predictor of outcome. However, the therapeutic relationship is more complicated in working with eating disorders because success in therapy requires that the patient do the exact opposite of what her disorder wants: eat more and gain weight. Early in treatment, it often seems as though maintaining a positive therapeutic relationship and helping the patient recover are mutually exclusive. So often, well-meaning eating disorder therapists work hard early on to gain a patient’s trust and build a positive therapeutic relationship in the hopes that the patient will eventually develop the insight and motivation to address her symptoms. While this rapport-building is going on, the patient is becoming sicker, weaker, thinner, more depressed, and more entrenched in her symptoms. Allowing the patient to marinate in malnutrition and continue to engage in her symptoms delays recovery, increases her risk of medical complications, and prevents her from being able to engage in the psychological work of recovery.

The therapeutic relationship is only therapeutic insofar as it facilitates health, growth, and recovery. I have found that my relationships with patients improve naturally, and dramatically, once they are no longer engaging in restricting, bingeing, or purging. I would much rather have an angry, tearful adolescent patient hurl vile words at me as I’m pushing full nutrition and weight restoration than a quiet, sweet adolescent patient who enjoys talking with me as her health declines and her vital signs dwindle.

8.) Overemphasizing physical recovery while underemphasizing psychological recovery.

This is the polar opposite of #7. It happens far less often that #7, but it does happen. Full nutrition, weight restoration, medical stability, and cessation of binge/purge behaviors are absolutely necessary, but not sufficient, for recovery. Restoring physical health is only the beginning of a long, difficult process. The psychological aspect of eating disorders cannot be ignored or minimized. Patients need low-stress environments and lots of support from loved ones. Most patients need psychotherapy to address anxiety, depression, perfectionism, social concerns, body dysmorphia, and other issues that may have contributed to the eating disorder. Therapy can help patients develop the skills they need to manage their emotions, cope with stress, stay healthy, and prevent relapse. Some patients need psychiatric medication to treat comorbid conditions such as ADHD, OCD, or major depression. Fully addressing the patient’s psychological needs, as well as her physical and nutritional needs, gives her the best shot at lasting recovery.

9.) Failure to intervene immediately, and aggressively, at the first sign of weight loss or change in eating or exercise behavior.

The research is very clear on this point: early intervention predicts better prognosis. We should not wait for a teenager to develop full-blown anorexia nervosa or bulimia nervosa before stepping in to help her. We should not wait for her to drop to 15% below her ideal body weight, miss 3 consecutive menstrual periods, or develop a dangerously low heart rate. We should not wait until she has binged or purged twice a week for three months. Let’s step in when she is 1% below her ideal body weight, when she has missed one menstrual period, when she has purged one meal. Better yet, let’s step in as soon as we notice body image concerns, changes in eating or exercise habits, or excessive preoccupation with body weight and shape.

10.) Using physical appearance or statistically-determined BMI charts as definitive measures of physical or mental health.

There is a common misconception that all people with eating disorders are emaciated. This is not necessarily true. Certainly, individuals in the acute phase of anorexia nervosa are often shockingly thin. However, most people with eating disorders don’t “look sick.” Individuals with bulimia are usually of normal weight. People with anorexia who are at or near their ideal body weight, but still actively struggling with eating-disordered thoughts and feelings, generally “look normal.” Further, it is impossible to tell whether a person is underweight simply by looking at them. Because ideal body weights are highly individualized based upon bone structure, muscle mass, body shape, and weight history, a person may fall within the “ideal” BMI range and still be significantly malnourished or dehydrated. The danger in using physical appearance as a gauge of mental or physical health is that people who “look normal” may be overlooked. Their eating disorders may not be as easily detected and may not be taken as seriously. These patients don’t believe they deserve treatment because they’re not thin enough, not sick enough, not worthy enough. As professionals, we must not fall prey to this distorted thinking.

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