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: Eating Disorders

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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Wednesday, January 29th, 2014

Effective Treatment for Bulimia Nervosa: A Good Start

A randomized controlled trial recently published in the American Journal of Psychiatry found that Enhanced Cognitive Behavioral Therapy (CBT-E) was far more effective than psychoanalytic therapy in the treatment of Bulimia Nervosa (BN).

In this study, 70 adults with BN were randomly assigned to either the CBT-E group or the psychoanalytic therapy group. Those in the CBT-E group received 20 sessions over the course of 5 months, whereas those in the psychoanalytic therapy group received weekly sessions for 2 years.

CBT-E for bulimia nervosa directly targets bulimic symptoms of dietary restriction, binge eating, and purging by modifying self-defeating behaviors, identifying and challenging distorted thoughts and beliefs about food, body shape, and weight, and learning skills to regulate moods and deal with setbacks. For example, patients learn to moderate their food intake by consuming regular, satisfying meals and snacks throughout the day rather than fasting, which often leads to nighttime binges.

In contrast, psychoanalytic therapy helps patients work through emotions and resolve inner conflicts which are believed to be at the root of their eating disorder.

After five months of treatment, 42% of patients receiving CBT-E had stopped bingeing and purging, compared to only 6% of patients in the psychoanalytic therapy group. After two years, 44% of patients in the CBT-E group had remained abstinent from bingeing and purging, compared to 15% of patients in the psychoanalytic group. It is important to note that the 2-year assessment represents a 19-month post-treatment follow-up for patients in the CBT-E group, but an end-of-treatment assessment for the psychoanalytic therapy group. Thus, patients in the CBT-E group had maintained their remission 19 months after treatment ended.

I draw the following conclusions from this study:

1.) Treatments which directly target bulimic symptoms are likely to be much more effective than treatments that deal with underlying emotions and psychic conflicts.

2.) Bulimic patients who receive CBT-E experience symptom relief much more quickly than those who receive psychoanalytic therapy.

3.) CBT-E is more efficient and cost-effective. If a psychologist charges $150 per hour, twenty sessions of CBT-E over the course of 5 months would cost a total of $3000. Weekly psychoanalytic sessions for two years would cost a total of $15,600.

4.) The benefits of CBT-E are long-lasting for those who recover

5.) Psychoanalytic therapy can be effective for a small fraction of bulimic patients

6.) CBT-E should be a front-line treatment for bulimia nervosa because, statistically, patients are much more likely to benefit from it than from other treatment approaches.

Bulimia nervosa wreaks havoc on the brain as well as the rest of the body. Insufficient or erratic nutrition caused by restrictive dieting, fasting, bingeing, laxative abuse, purging, and dehydration have a direct and immediate impact on brain function. I suspect that a primary reason for the superiority of CBT-E is that it targets the symptoms of dieting, bingeing, and purging immediately, thereby helping patients achieve medical stability and brain healing. When a person is receiving consistent balanced nutrition and keeping it down, he or she is better able to process emotions, refrain from impulsive behaviors, and do the hard work that is necessary for full recovery.

Perhaps patients in the psychoanalytic therapy group did not have the tools necessary to recover. It is one thing to gain insight into one’s emotions and beliefs; it is another thing entirely to halt a destructive and addictive cycle of restricting, bingeing, and purging.

The authors of this study conclude that it “provides one of the clearest examples of the superiority of one well-implemented psychological treatment over another.” However, CBT-E is not a magic bullet: more than half of the patients who received CBT-E did not recover. Therefore, we need to improve existing treatments for BN and develop new, more effective treatments for this devastating illness.

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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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Sunday, July 14th, 2013

Correlates of Treatment Outcome for Patients with BN & EDNOS

My previous post described the treatment outcomes of my 21 former patients with diagnoses of Bulimia Nervosa (BN) or Eating Disorder Not Otherwise Specified (EDNOS). Treatment was very successful for these patients, with 100% of those who completed treatment (n = 7) achieving full remission. However, the attrition rate was very high, with two-thirds of patients (n = 14) discontinuing treatment prematurely for various reasons. Nineteen percent (n = 4) of patients were referred to other providers or treatment settings because I was unable to meet their needs, 5% (n = 1) moved to another geographic area, and 43% (n = 9) quit before finishing treatment.

Given that treatment completion always led to full remission, attrition appears to be the biggest challenge for this population. Therefore, my post will focus on the differences between those who completed treatment and therefore achieved full remission (aka “treatment completers”) versus those who did not (“treatment non-completers”).

Neither age at intake nor duration of illness before intake predicted treatment outcome. Both treatment completers and treatment non-completers averaged approximately 19 years old at intake, with an average duration of illness of 4.5 years.

Patients who completed treatment and achieved full remission did so through a variety of treatment modalities: 43% (n = 3) received individual therapy with no family involvement, 29% (n = 2) received Family-Based Treatment (FBT), 14% (n = 1) received individual therapy with a high level of family involvement, and 14% (n = 1) received individual therapy with moderate family involvement.

Patients receiving FBT (n = 7) were significantly less likely than those receiving individual therapy to quit treatment prematurely. Only 14% of patients receiving FBT (n = 1) quit treatment prematurely. I referred 43% of them (n = 3) to other treatment settings due to my inability to help them progress in treatment. Twenty-nine percent (n = 2) completed treatment with me and 14% (n = 1) moved to another geographic area and continued her treatment there.

Of the 14 patients who received individual therapy, 57% (n = 8) quit treatment prematurely. The remainder of patients either completed treatment and achieved full remission (36%; n = 5) or were referred to other treatment settings (7%; n = 1).

Interestingly, treatment completers did not differ from treatment non-completers on duration of treatment or on number of sessions attended. For treatment completers, duration of treatment ranged from 1-38 months, with an average duration of 10 months. For treatment non-completers, duration of treatment ranged from 1-28 months, with an average duration of 10 months. Treatment completers attended an average of 15 sessions, while treatment non-completers attended an average of 20 sessions. Thus, it appears that treatment completers did not necessarily remain in treatment longer, but rather reached remission more quickly. Anecdotally, I recall that a number of patients who quit treatment prematurely actually did quite well in their first 6-9 months of treatment and nearly reached remission, but then began to regress, got discouraged, and quit.

Rates of treatment completion and treatment outcome differed based on diagnosis. Amongst patients with BN, 22% (n = 2) completed treatment and achieved full remission, while 44% (n = 4) made significant progress prior to discontinuing treatment. For patients with EDNOS, 42% completed treatment and achieved full remission, while 17% (n = 2) made significant progress prior to discontinuing treatment.

Prior history of untreated Anorexia Nervosa (AN) was associated with treatment dropout and poor outcome. Only 18% (n = 2) of those with a prior history of AN completed their BN/EDNOS treatment with me, and both of those patients had been successfully treated for AN years before. None of the patients with a prior history of untreated AN completed their treatment with me.

Patients with a co-morbid disorder were much less likely to complete treatment. While two-thirds of patients in this sample (n = 14) had a co-morbid disorder, only 29% of them (n = 4) completed treatment and achieved remission.

Taking psychotropic medication during treatment was not related to treatment completion. Thirty-six percent of those who took medication during treatment (n = 4) completed treatment and achieved full remission, compared with 30% (n = 3) of those who did not take medication during treatment.

This sample of patients was 71% Caucasian (n = 15), 24% Hispanic (n = 5), and 5% multi-racial (n = 1). Hispanic patients were much more likely to complete treatment and achieve remission than Caucasian patients. Eighty percent (n = 4) of Hispanic patients in this sample completed treatment and achieved remission, compared with only 20% (n = 3) of Caucasian patients.

I work on a sliding fee scale, offering reduced rates based on patient’s ability to pay. Those who paid my full rate were more likely to complete treatment and achieve remission compared with those who paid a reduced rate. Forty-six percent of those who paid my full rate completed treatment (n = 6), compared with 25% of those who paid a reduced rate (n = 2).

Individuals with a history of intensive eating disorder treatment were less likely to complete treatment than those without such a history. Amongst treatment non-completers, 50% (n = 7) had been hospitalized for their eating disorder or a related psychiatric issue, 21% (n = 3) had a history of residential treatment, and 21% had been in partial hospitalization, day treatment, or intensive outpatient programs. Amongst treatment completers, 29% (n = 2) had a prior history of hospitalization, 14% (n = 1) had a history of residential treatment, and none had a history of partial hospitalization, day treatment, or intensive outpatient treatment. The need for hospitalization during treatment with me was not related to treatment completion or treatment outcome.

In sum, the only variables that were related to treatment completion and remission were diagnosis of EDNOS and payment of my full fee for services. The following variables were associated with treatment non-completion: presence of a comorbid diagnosis, history of untreated AN, and prior history of intensive eating disorder treatment. Surprisingly, neither age at intake, duration of illness before intake, type of treatment received, number of sessions attended, duration of treatment, nor need for hospitalization during treatment were related to treatment completion.

These findings are specific to my practice and my patients, and are not intended to be generalized to other clinicians or other populations.

My next post will explore similarities and differences in treatment outcome among patients with AN, BN, and EDNOS.

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Sunday, June 30th, 2013

A Preview of My Treatment Outcome Data

As a scientist-practitioner, I am well aware that therapists aren’t always good at judging their patients’ outcomes. That’s why I love statistics. Numbers offer an objective, quantitative view. Numbers paint a clear picture that words cannot.

I believe strongly in evidence-based treatment. I also believe in therapist transparency – that is, that therapists should explain to patients and their families what interventions they are using, why they are using them, and what evidence is behind them.

For these reasons, I have chosen to collect data on my own patients and measure their response to treatment. I want prospective patients and their families to have access to these data to assist them in choosing a clinician. After four years in private practice, I have finally seen enough patients to collect treatment outcome data with a decent-sized sample. I am compiling these data for the purpose of improving the quality of my own practice. The results of my patients’ treatment outcomes are not intended to be used to generalize to other populations.

Since opening my practice in 2009, I have evaluated 138 patients. Eighty-nine percent (n = 123) of these patients were female and (n = 15) 11% were male. They ranged in age from 7-64, with a median age of 18 and a modal age of 15. The majority of patients were between the ages of 10 and 25.

The patients’ primary diagnoses were as follows:
• 54% (n = 75) had eating disorders, including anorexia nervosa, bulimia nervosa, and EDNOS
• 22% (n = 30) had mood disorders, such as major depressive disorder or bipolar disorder
• 10% (n = 14) had anxiety disorders, such as OCD or social anxiety disorder
• 8% (n = 11) did not meet criteria for any psychiatric disorder, but rather came to me for help with a specific problem, such as coping with parents’ divorce or stress management.
• 6% (n = 8) had an assortment of other primary diagnoses, including borderline personality disorder, adjustment disorder, or body dysmorphic disorder.

I work on a sliding scale based on the patient’s ability to pay. Sixty-three percent (n = 87) paid my full rate and 37% (N = 51) paid a reduced rate due to their financial circumstances (e.g., unemployment, low income, single parent supporting children alone, or college student paying for his/her own treatment). I saw 16% of these patients (n = 22) for evaluation and/or consultation only. The remaining 84% (n = 116) attended at least one treatment session with me.

All former patients who attended at least one treatment session with me are included in this sample. In addition, four patients who have completed their treatment but have opted to continue seeing me two or three times per year for “check-ups” were included as well. Patients who are currently in treatment with me were not included.

Over the next few weeks, I will be blogging about the end-of-treatment outcomes of my former patients, categorized by primary diagnosis. I am also in the process of conducting a follow-up study, and I hope to publish those data by the end of the summer. All data will be reported in aggregate form so that no individual patients will be identifiable.

Randomized controlled trials (RCTs) are the gold standard in treatment outcome research. However, other types of studies can be quite useful as well. My study tells a different story from the RCTs – the story of clinical practice in the “real world,” with all of the freedoms and confounds that come with it. While I do use evidence-based treatments such as Family-Based Treatment (FBT) and Cognitive Behavioral Therapy (CBT), I frequently make modifications to the manualized form of treatment based on the needs of the individual patient and family.

In addition, rather than fitting all patients into a 10-session or 20-session protocol, the length of treatment varied based on individual needs. Essentially, patients could stay in treatment until they were completely well. Insurance constraints were not an issue, as I don’t participate on insurance panels, and finances were not a deterrent from completing treatment, as I am very flexible with my sliding scale.

So what do treatment outcomes look like in the real world? You’ll have to keep reading my blog to find out!

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Friday, February 1st, 2013

My Rebuttal to “Surefire Ways”

An essay written by a clinical social worker titled “Surefire Ways to Give Your Kid an Eating Disorder” has received a lot of attention in the blogosphere over the past week, including brilliant rebuttals by Laura Collins and Carrie Arnold. I wrote a reply to this essay on Ms. Lewis’ blog, but unfortunately she did not post it. I am not sure why my reply wasn’t posted, but I did notice that there are no posted replies from clinicians who strongly disagreed with the essay. Therefore, I have chosen to post my reply on my own blog. If you have attempted, unsuccessfully, to post a reply on Ms. Lewis’ blog, please feel free to post here. As a general policy, I post all replies except spam.

As a psychologist specializing in the treatment of eating disorders in children and adolescents, I was profoundly disappointed to read this essay. I have grown accustomed to hearing myths about eating disorders from lay people and from the media, but I hold professionals to a higher standard. Professionals who write articles for public consumption have an obligation to be accurate, up-to-date, and straightforward.

Ms. Lewis’s essay confuses the common problems of body dissatisfaction, perfectionism, and poor self-esteem with the psychiatric illnesses called eating disorders. Without question, parents have a major influence on their child’s self-esteem and body image, for better or for worse. Parents influence their children’s development in a variety of ways, and bad parenting can cause tremendous pain to impressionable children. However, there is no reliable evidence to indicate that parents cause eating disorders. The Academy for Eating Disorders recent position paper on The Role of the Family in Eating Disorders concluded that “There appears to be no consistent structure or pattern of functioning in families with a member who suffers from an eating disorder; rather, eating disorders evolve in a multiplicity of family contexts.”

For decades, psychologists and psychiatrists theorized that cold, withholding parents caused their children to develop autism, that erratic parenting caused schizophrenia, and that overbearing or perfectionistic parenting caused eating disorders. More recently, these theories have been disproven. While the precise causes of these illnesses are unknown, we do know that these are highly heritable, biologically-based brain disorders that are definitively not caused by any particular type of parenting.

A parent who is a “neat freak” – who uses hand sanitizer before every meal and requires his child to clean his room thoroughly twice a week – cannot give his child OCD. A child cannot acquire a parent’s mental illness by imitating his behavior.

By stating that encouraging perfectionism, withholding emotionally, and using food for rewards and punishments are “surefire ways to give your kid an eating disorder,” Ms. Lewis reveals her ignorance about her own area of expertise. She conflates body dissatisfaction with eating disorders and thereby inadvertently trivializes the most deadly of all psychiatric illnesses.

I respectfully urge Ms. Lewis to educate herself on the most recent scientific knowledge about eating disorders and to revise her essay to reflect this knowledge.

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Saturday, May 19th, 2012

Brain-Based Language and Eating Disorders (by guest blogger Carrie Arnold)

The following is a guest blog post from Carrie Arnold, science writer and blogger, who attended the International Conference on Eating Disorders with me earlier this month.

Language is a funny thing.

I’m a writer–every day, I see (and use!) the power of words to explain very esoteric subjects, to comfort a friend, and even to entertain. The language we use to talk about eating disorders is also important. It was refreshing to have a psychotherapist describe me not as “an anorexic,” but as “someone with anorexia.” Anorexia was a diagnosis. It wasn’t me.

The issue of language in eating disorders goes far deeper than whether or not to use anorexic or bulimic to describe someone. It cuts right to the heart of how we understand eating disorders and how we treat them. One of the sessions at the 2012 International Conference on Eating Disorders in Austin, Texas discussed the use of brain language in regards to eating disorders. Laura Collins, founder and executive director of FEAST, spoke about how the biological language can be empowering to parents and sufferers. Brett Deacon, a psychologist from the University of Wyoming, spoke of the power of the biopsychosocial model of mental illness, and the potential dangers of biological language. Anne Becker, an anthropologist and ED expert from Harvard University, talked about how language affects our perception of EDs. Lastly, Kelly Klump, a behavioral geneticist from Michigan State University, asked the crucial question: is it time for new language or new data?

First, a mini-history lesson. As neuroimaging techniques and other brain science has advanced in recent years, scientists studying mental illness have begun to use these tools to explore the biology of mental illness. Without these tools, researchers could only look at the psychosocial factors that contributed to mental illness, and they accumulated a mass of very important data on the subject. But neuroimaging and other techniques have allowed scientists to probe biological variations that might contribute to mental illness. Leading psychiatrists and psychologists like Tom Insel, director of the National Institute for Mental Health, have argued that these significant biological differences mean that “mental illness” should be renamed “brain disease.”

To some, a brain disease by any other name surely doesn’t smell as sweet. To me, the use of “brain disease” or, an alternative, “biologically-based mental illness” seems obvious. Depression, schizophrenia, and eating disorders affect the brain. That’s where they start. Deny that, and you may as well call them Big Toe Disorders or something equally ludicrous. If they’re not brain disorders, then what are they? I’m not asking a rhetorical question-I really would like an answer.

One potential answer that Dr. Deacon suggested was the biopsychosocial model. Mental illnesses are really biopsychosocial illnesses. Which is accurate. My problem with that term is that every disease, from eating disorders to cancer to diabetes, has biological, psychological, and social components. It’s like taking cows, sheep, goats, horses, dogs, and cats and putting them in a barn and trying to tell them apart by figuring out which have four legs.

I don’t know of anyone out there who can support the assertion that EDs are only biological. Genes matter, yes, but so does environment. Laura presented statements from families around the world that biological language like “brain disorder” gave them a way to move forward. Looking for blame didn’t really matter anymore. They could reframe their loved one’s behavior: instead of being a willful teen refusing to eat, they had a sick adolescent who wasn’t able to eat.

One of the main concerns with the biological language is the potential for stigma. If your genes caused your illness, then you’re screwed. After all, your genes are your genes, and they’re not changing unless you stand in front of some gamma rays. Which I wouldn’t recommend. Basically, then, it’s easy to see how biology would support the view of “Once an anorexic/bulimic, always an anorexic/bulimic.” Recovery was a hopeless endeavor.

While it’s true that you’re stuck with the genes you’re born with, your biology isn’t written in stone. To paraphrase biologist PZ Myers, biology isn’t rigid. It’s a bunch of squishy processes making do. Your genes don’t change, but their expression does. It’s a process known as epigenetics, whereby genes are regularly activated and silenced by various environmental factors. It’s entirely possible that the negative energy balance (that is, burning more calories than you’re consuming) that typically precedes anorexia activates genes that perpetuate the food restriction. It’s also entirely possible that nutritional rehabilitation silences these genes or activates other ones that help the brain and body return to normal.

The problem, then, isn’t with the biological language per se, but rather our culture’s generally abysmal level of scientific literacy. These concepts are difficult for even PhD scientists to understand. But as society’s awareness of the biological contributions to brain diseases/ mental illness grows, perhaps the understanding of the complex biology will improve as well. In fact, a study by Cindy Bulik and colleagues at UNC found that biological language actually decreased the stigma of anorexia, rather than increasing it.

Saying things like “brain disease” also doesn’t mean that the only solution is a pill. Although I do benefit from medication, I’m hardly a shill for Big Pharma. Psychotherapy remains one of the best ways to reliably change the brain long-term. Researchers found significant brain changes when a group of people with spider phobia underwent a course of cognitive-behavioral therapy. The authors conclude that “These findings suggest that a psychotherapeutic approach, such as CBT, has the potential to modify the dysfunctional neural circuitry associated with anxiety disorders. They further indicate that the changes made at the mind level, within a psychotherapeutic context, are able to functionally “rewire” the brain.”

At some point, however, all of this “language talk” makes me want to throw up my hands in frustration. Aren’t we just wasting loads of time playing at semantics? Call it Rainbows and Kittens for all I care!

Except that language really does matter. A recent study in the American Journal of Psychiatry found that people were significantly more likely to believe that someone needed treatment when they were diagnosed with social anxiety disorder versus social phobia. In the state of New Jersey, it was legal for health insurers to deny paying for anorexia treatment because it wasn’t a biologically based mental illness. A recent class action law suit caused this provision to be overturned and anorexia and bulimia treated on par with depression, bipolar disorder, and schizophrenia. Language matters, and it matters a lot.

The talk at ICED didn’t necessarily settle the matter, but then it wasn’t meant to. The most important thing was how it provided a better understanding of what we all mean when we say things like brain disease or biopsychosocial. What I mean when I say brain disease isn’t necessarily what other people mean. I know that talking about the biology of eating disorders doesn’t mean that environment is irrelevant as is psychotherapy. But that’s not necessarily what other people think. Perhaps what the field needs to do is clarify what their terms mean and how they use them in a sentence. Only then can we start to have a meaningful dialogue that will move the field forward.

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Sunday, January 8th, 2012

Got Hope?

“I’ve been in therapy for 18 years, and I’ve still got a pretty significant case of Anorexia.”

Recently, these words were uttered to me over the phone by an adult with Anorexia Nervosa (AN) who was desperate for help. A successful professional and devoted mother to three young daughters, she, like so many who suffer from AN, seems to “have it all.” Her husband was aware of her illness – he had attended a few therapy sessions – but it was never discussed openly. Although he was terrified that she would die, he had no idea how to help her. In fact, he had been advised by her former treatment providers that he should not try to “fix” her – that was her job. Like most men, he was begging for something concrete, a specific job to do, something to latch onto and work towards to help save his precious wife.

“I know my life inside and out,” this woman told me. “I have so much insight. It just hasn’t gotten any better.”

If someone has been in therapy for 18 years – or even 18 weeks – there should be marked, measurable improvement. Even 18 days into treatment, there should be something concrete – a written treatment plan, psycho-education for the patient and family, recommendations of reading materials and resources, development of specific goals. There should be hope. Psychotherapy research has shown that the instillation of hope – which is one common factor present in all types of psychological treatment – is the predominant mechanism of change in the first few weeks of treatment.

If someone who is suffering from a life-threatening, soul-killing mental illness for 18 years without making any improvement, where is the hope? How can someone possibly have hope that their condition will improve when they have been dutifully going to therapy with eating disorder experts for almost two decades? In the amount of time it takes to raise a child from birth through high school graduation, there has been no measurable change. Can you imagine such an interminable, grueling, agonizing battle?

In these chronic cases, inevitably the patient begins to blame herself. Her family, once supportive and nurturing, becomes paralyzed with guilt and fear, with anger and frustration. They, too, lose hope.

Let me tell you this: if you have been in treatment for 18 years, 18 months, even 18 weeks, and your condition has not improved, TREATMENT HAS FAILED YOU. No matter how long you have suffered, no matter how many treatment programs you’ve been through, or how many therapists you have seen, or how many relationships have been destroyed by this horrific illness, THERE IS HOPE.

New science offers hope for people with AN. We know so much more now than we did even 5 years ago. This new knowledge is power – it is ammunition against even the most severe, chronic, “treatment resistant” cases.

If you have been in treatment for a significant period of time without improvement, please do not blame yourself. It is your treatment team’s job to help you get well. Even if you don’t want it. Even if your motivation wavers. Even if you are ambivalent about change. These feelings are symptoms of the illness, and you deserve treatment regardless. If your therapist is kind and warm and empathic and you have wonderful relationship, that is terrific – but these things alone will not get you well.

You need a treatment team that will stand up to AN; a team that will insist upon prompt nutritional restoration, achievement of your optimally healthy body weight, cessation of eating disorder behaviors, skills to cope with unhealthy thoughts and negative emotions, and treatment of any comorbid psychiatric conditions.

If your clinicians have not been able to help you, I beg you, I implore you, to find a second opinion. Find a third, fourth, fifth opinion if needed. You deserve effective treatment, and you need something concrete – a specific plan – to help you reach full recovery.

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