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: thin ideal

Wednesday, November 6th, 2013

The Thin Ideal and Anorexia Nervosa: Case in Point

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Saturday, February 25th, 2012

A New Awareness

Tomorrow, National Eating Disorders Awareness Week (NEDAW) begins.

NEDAW is a public health initiative designed to educate people about eating disorders. While I applaud the good intentions and effort that go into planning and executing NEDAW, I will not be participating in any of the events. I do not believe that the messages conveyed during NEDAW are particularly helpful: instead of correcting the myths and misconceptions associated with eating disorders, NEDAW just seems to perpetuate them.

For example, the National Association of Anorexia Nervosa and Associated Disorders (ANAD) posted the following on their website in under the heading Eating Disorders Awareness Week 2012:

“Through intentional activities, conversations and events we can all help create an environment that redefines outdated thinking, reduces the stigma associated with weight, body shape, or size, and inspires someone to reconsider an unhealthy attitude or behavior.”

There are several assumptions imbedded in this sentence:
• The environment causes eating disorders by making people feel dissatisfied with their bodies.
• People develop eating disorders because they are insecure, vain, shallow, appearance-focused, or overly influenced by the media.
• By altering the messages people receive from their environment and eliminating the “thin is in” culture, we can prevent or cure eating disorders.
• Overcoming an eating disorder is about reconsidering unhealthy attitudes or behaviors.
• If you have a friend or family member suffering from an eating disorder, you should try to inspire him/her to reconsider his/her unhealthy attitudes and behaviors.
• The unhealthy attitudes and behaviors associated with eating disorders are willful and consciously chosen.

Of course, none of these statements are explicit, but they don’t need to be – the public will draw these conclusions on their own.

I wholeheartedly agree that our culture is toxic and that the messages we receive about body image, beauty, food, and sexuality are horrific and damaging. I do not object to these principles at all – quite the contrary – but I do object to focusing on these messages during National Eating Disorders Awareness Week.

The current public health message associated with eating disorders awareness week is something akin to “Girls are dying to be thin, so let’s all love our bodies!” The themes of NEDAW revolve around thinness, body image, and the media. The concept of psychiatric illness is lost. Of course, it does not help that most eating disorder treatment professionals, eating disorder organizations, tabloid magazines, and recovering eating disorder patients espouse the same body-image centered messages.

I would like to change the public health mantra to something along the lines of “Eating disorders are highly heritable brain-based illnesses with severe psychiatric and medical symptoms.” My ideal public health message for EDAW would also contain the following points:

• Most symptoms of anorexia nervosa and bulimia nervosa are triggered or perpetuated by malnutrition. For those who are biologically vulnerable, dieting can trigger a cascade of self-perpetuating symptoms which lead to life-long psychiatric disability or death.
• Body dysmorphia is a symptom, not a cause, of an eating disorder. It is not present in all eating disorder patients, and it bears little relation to the typical woman’s body image distress.
• Early, aggressive intervention offers the best hope for full recovery.
• An eating disorder is a brain disease, not a weight problem.
• There are a variety of methods for treating eating disorders. Most of the eating disorder treatment available is NOT based on current science or evidence-based practice. Patients and parents must be proactive in finding effective treatment.
• Anosognosia – a neurologically-based inability to recognize one’s illness – is a symptom of Anorexia Nervosa. Therefore, patients should not be expected to “want to get well.” It is up to the patient’s loved ones and clinicians to ensure that he/she gets appropriate treatment as soon as possible.

These are the points that the public needs to hear. These are the points that will truly change the way eating disorders are perceived.

There are many eating disorder treatment professionals out there who will participate in a NEDAW walk or rally, or wear a “Love your body” T-shirt, or attend a screening of “America the Beautiful,” and then head to the office to practice outdated, ineffective treatment.

Next week, I will be promoting eating disorders awareness by providing my patients with the most current, evidence-based information and treatment, and by spreading scientifically-sound information through my blog and through my conversations with people. Please join me!

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Monday, December 12th, 2011

The Thin Ideal and Anorexia Nervosa: It’s Not What You Think

It is commonly assumed in popular culture that the “thin ideal” is responsible for causing Anorexia Nervosa (AN). In other words, girls develop AN by embarking on an extreme diet in attempt to look like their favorite celebrity, and if we just showed “real women” in the media, AN would become obsolete.

There is no doubt that the ideal female body is much too thin and unrealistic for the vast majority of people. And yes, the majority of girls and women, as well as many men, aspire to be thinner and attempt to diet in order to lose weight. But the thin ideal plays a different, and more peripheral, role in AN than most people think.

The thin ideal does not cause AN. Contrary to popular belief, AN has existed for centuries, long before television or internet or fashion magazines, long before thinness was associated with attractiveness or health. Girls do not “become anorexic” in order to look like supermodels. Many girls have tried to “become anorexic” and failed. You cannot choose to “become anorexic” any more than you can choose to become schizophrenic or autistic or epileptic. It is impossible to develop AN if you do not have the genes for it. Dieting, while ubiquitous in American society, does not cause AN. In fact, it’s quite the opposite – dieting reliably predicts weight gain. At least 95% of dieters regain all of the weight they lost within a few years, and research suggests that the rise in obesity in recent decades is at least in part the result of repeated dieting.

Although the thin ideal does not cause AN, it impacts AN in other very important ways:

• It delays diagnosis and treatment.

Since the population is so consumed with dieting and losing weight, children and adolescents in the early stages of AN are usually praised for their willpower around food, for their strenuous exercise regimens, for their avoidance of “fatty foods.” Parents, friends, and even pediatricians will commend kids for losing weight and compliment them on their slim appearance. In their own zest for thinness, adults seem to have forgotten that it is neither normal nor healthy for a child or teenager to lose weight. In this “thin is in” culture, a patient’s AN is often not recognized until he or she is emaciated and visibly ill. By that point, the illness is very entrenched and treatment is much more difficult. It would save so much time, energy, suffering, and money (yes, money) to diagnose and treat AN at its first manifestation, before it spirals into dramatic weight loss.

• It prevents full recovery.

Clinicians often set a target weight range that is much too low for full physical and mental recovery. Eating disorder thoughts and behaviors, as well as the associated anxiety and depression, begin to melt away only when a patient has reached and maintained his or her unique optimal weight range.

Clinicians themselves are often so afraid of weight gain that they settle for, or even worse, actively encourage patients to stop at, a “low normal” weight. We seem to have forgotten that there is a natural diversity of body sizes. Some people are genetically built to be thin; others to be average; some to be muscular; some to be stocky; some to be large-framed. Each individual is optimally healthy at his or her ideal weight range.

Recovering patients who have reached that magical BMI of 18.5 (at which they are no longer considered “underweight” on the charts) are often complimented for their thinness, which is considered desirable and attractive and healthy. The thin ideal feeds into patients’ disordered belief that they should maintain a “low normal” weight even if their own body is healthiest at a higher weight.

• It exacerbates patients’ suffering.

The ever-present chatter about diets and calories and weight loss and exercise programs creates an unhealthy environment for recovery. When the vast majority of the population is trying to eat less, exercise more, and lose weight, it exacerbates the suffering of a patient who has received doctor’s orders to eat more, exercise less, and gain weight despite her compulsive urges to do the opposite. Patients who do achieve their healthy weight goals tend to see themselves as colossal failures – unattractive, ugly, and disgusting – as they have moved away from the societal ideal that everyone else is striving to achieve.

• It trivializes the illness.

As a result of our society’s thin ideal, patients with anorexia are often viewed as vain, superficial, spoiled rich girls who starve themselves for the sake of beauty and fashion. Anyone who has witnessed AN up close will testify that nothing could be further from the truth.

• It creates an environment of fear and guilt around food and fat.

Most people these days make moral judgments of themselves and others based on dietary intake and body size. How many times have you heard people say things like: “I was so bad last night – I had 2 cookies” or “I was really good yesterday – I only had a salad for lunch.” Extreme fear of eating and gaining weight is a symptom of AN. So is extreme guilt after eating, or when not exercising. This societal moralizing around food and weight validates the symptoms of AN in its early stages and triggers their recurrence when a patient is trying to recover.

If our society’s ideal female body were a plump, voluptuous figure, would AN still exist? Absolutely. Would the incidence of AN be reduced? Probably not. But I believe that patients would be diagnosed sooner, treated earlier, restored to higher (and healthier) weights, and feel somewhat less triggered to restrict after remission. Perhaps the public would also be more apt to see AN for what it really is: an agonizing, life-threatening mental illness that destroys a person’s physical and emotional health. The broader context in which AN occurs would be less validating of the anorexic symptoms and more supportive of full recovery.

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