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Insights on Insight

Patient “insight” is a much-discussed topic in psychotherapy. Most clinicians believe that developing insight is a crucial aspect of recovery from a mental illness. Many clinicians believe that insight is a necessary prerequisite for change. There are some types of treatment, such as psychoanalysis and psychodynamic psychotherapy, which are based entirely on the development of insight. These types of treatment are predicated on the assumption that increased insight naturally leads to positive behavior change and recovery from mental illness.

These assumptions originated with Sigmund Freud, who believed that mental illness was the result of unconscious psychic conflict. He believed by bringing this conflict into the patient’s conscious awareness, it would no longer have power over the patient and the neurotic or psychotic symptoms would disappear.

The notion that exploration into one’s innermost psyche leads to healing is alluring and romantic. It makes for great novels, memoirs, and movies. The problem is, it rarely works this way in real life. While most people suffering from mental illnesses do indeed experience tremendous inner psychological conflict, there is no evidence that this inner conflict is the cause of any mental illness or that gaining insight into the conflict will promote recovery. Insight, as discussed in psychoanalytic theory or pop psychology, refers to something along the lines of “why I am the way I am” or “why I developed this mental illness.”

There are several reasons why this type of insight alone rarely leads to recovery:

1.) Contrary to popular belief, we do not know what causes most mental illnesses. We may know what factors may trigger, perpetuate, or exacerbate the illness. For example, a loss of some sort often triggers or exacerbates depression, and dieting often triggers or exacerbates an eating disorder. We may know what types of treatment are effective for certain illnesses. For example, we know that DBT is effective in treating borderline personality disorder. But any notion about causality is, at this point in time, largely speculative. So if we don’t really know what causes mental illness, insight into the supposed cause will not promote recovery.

2.) The “insights” encouraged by the therapist are often based upon antiquated theories of mental illnesses which have no empirical support (e.g., that depression is “anger turned inward”). These theories may feel good, or make intuitive sense, or seem to validate the patient’s suffering, but that doesn’t make them accurate or useful in terms of recovery.

3.) We learn and mature emotionally through experience. Thoughts and feelings follow from behavior, not the other way around. Simply knowing why you think the way you think, or why you feel the way you feel, does not change your thoughts or feelings. What does help change your thoughts and feelings is by acting opposite to them. So, for example, if you are feeling depressed and lethargic, sitting around the house all day by yourself trying to figure out why you’re depressed doesn’t make you less depressed. However, dragging yourself off the couch to go for a brisk walk outside, and then inviting some friends over to watch a funny movie, may very well lift your spirits, at least a little bit.

4.) Our neural pathways are rewired not through developing insight, but through consistent, repetitive practice of new behaviors. You will not become a good athlete by watching sports or reading about sports. Rather, you develop and hone your athletic skills by consistent practice and physical conditioning. This is why the behavioral therapies such as CBT, DBT, ACT, and FBT are so much more effective than insight-oriented therapies such as psychodynamic therapy.

5.) Some mental illnesses, such as schizophrenia, bipolar disorder, and anorexia nervosa, involve a symptom called anosognosia, which is a brain-based lack of insight. Because of abnormalities in brain function, individuals with anosognosia are unable to recognize that they are ill even when loved ones are extremely worried. For instance, a person with anorexia nervosa may feel great and perceive her body as normal and healthy, even when she is markedly underweight and clearly suffering from the physical and psychological effects of malnourishment. And an individual with bipolar mania may perceive himself as “on top of the world” and vehemently resist intervention as loved ones stand by and watch him make one self-destructive decision after another. Individuals with anosognosia should not be expected to seek treatment on their own, or to “want to recover,” because they will not have the insight to do so until they are well on their way to recovery.

The types of insights described above are relatively useless. However, there is another type of insight which results from successful treatment and is one of many markers of a psychologically healthy individual. Insight, as I conceptualize it, is best described by both the dictionary definition and the wikipedia definition. Thus, in order to successfully manage or overcome a mental illness, one must be able to discern the true nature of their mental illness and must understand cause and effect insofar as it applies to their symptoms. The following insights are extremely important to recovery:

1.) Insight into the fact that one has a mental illness. This element of insight includes acceptance of the fact that the illness is, to some extent, out of the person’s control, and cannot simply be wished away or overcome by willpower.

2.) Insight into the symptoms of one’s mental illness and how they manifest. This insight includes the ability to recognize signs and symptoms in oneself and the skills to eliminate, manage, or cope with the symptoms when they occur.

3.) Insight into the effects of following, or not following, the treatment plan and clinician’s recommendations. This insight involves understanding not only what the clinician is doing or recommending, but why she is doing or recommending it. That is, understanding the mechanism of change.

4.) Understanding how various choices one makes impact the course of one’s illness. For example, a person with a mood disorder needs to learn that by getting 8-9 hours of sleep nightly, exercising regularly, taking medication daily, and monitoring mood changes on a daily basis are essential to stabilizing moods. She will also need to learn that getting drunk on her 21st birthday, traveling across time zones for vacation without making up missed sleep, missing her medication for two days because she forgot to get refills on time, or burning the candle at both ends during final exams, will likely trigger a return of symptoms, even though “normal people” do these things all the time without a second thought. “But that sucks!” They exclaim. “That’s not fair!” They are correct on both counts.

I believe that a patient must develop all four of these insights during treatment. It is the clinician’s responsibility to assist the patient in developing these insights. It is also the clinician’s responsibility to ensure that the patient’s family members develop these insights during treatment, as it is often a parent or a spouse who will first notice the signs of relapse and encourage a return to treatment. This is especially true in disorders characterized by anosognosia.

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Why Psychodynamic Therapy is Harmful for Eating Disorder Patients

1.) The approach is based upon theory rather than empirical data.

Decades ago, when psychologists and psychiatrists first began treating eating disorders, psychodynamic therapy was the only tool they had. Science has come a long way since then. While there is still so much about the illness that we don’t understand, we have learned a great deal in the past decade about the etiology of eating disorders and how to treat them more effectively. Why use theory-based practice when we have evidence-based practice?

2.) It confuses symptoms with causes.

For example, one psychodynamic theory posits that girls develop anorexia nervosa due to their fear of growing up and their desire to remain child-like. In reality, the ammenorhea and boyishly-thin bodies of anorexic girls are symptoms of the illness.

3.) Insight and motivation are over-emphasized, especially early in treatment.

Insight and motivation are crucial to sustaining wellness later in the recovery process. But patients with anorexia nervosa suffer from anosognosia, a brain-based inability to recognize that they are ill. The problem with emphasizing insight and motivation early in treatment is the presumption that the patient must “choose” to get well and that, if she does not make that “choice,” no one else can make it for her. Precious weeks, months, even years are wasted trying to form an alliance, cultivate motivation, and develop insight.

4.) It presumes that the patient’s family dynamics are at least partially to blame for the eating disorder, and that correcting the family dysfunction will help the patient recover.

There is no reliable scientific evidence to support these theories. Families of eating disorder patients do typically present for treatment with high levels of conflict and tension. The conflicted parent-child relationship, however, is most likely the result of the eating disorder rather than the cause. Having a child with any serious illness creates enormous strain on even the healthiest, most functional families.

5.) It presumes that there is a “deeper meaning” in symptoms which are the result of malnourishment and/or faulty brain chemistry.

A great deal of time and money is wasted attempting to discern this deeper meaning. Meanwhile, the patient’s brain and body are failing, placing him or her at risk of permanent medical and psychiatric problems. I advise patients and families: Don’t waste time on “why.” The reality is that we don’t know exactly what causes anorexia nervosa or bulimia nervosa.

We still do not know the cause of many types of cancer, but we begin aggressive cancer treatment immediately upon diagnosis because the longer it goes untreated, the more grim the prognosis becomes. We can remove a tumor or give chemotherapy without knowing how the tumor originated. The same principles apply with eating disorders – the patient’s nutrition and weight must be normalized immediately, and dangerous behaviors must be stopped right away. The patient will benefit from these interventions, both physically and mentally – even if the “reason” for the eating disorder is unknown.

6.). Too much attention is paid to early experiences, often at the expense of solving problems in the here and now.

Psychodynamic theory presumes that psychiatric disorders stem from early childhood experiences. In reality, childhood experiences are generally irrelevant to the patient’s eating disorder. Even in instances in which early experiences are relevant to the current illness, there is no evidence that an ill patient can overcome her eating disorder “exploring” or “processing” such experiences.

7.) Too much value is placed on the relationship between therapist and patient.

While I completely agree that the therapeutic relationship is very important to the healing process (and there is solid research supporting this), I believe that this relationship must take a backseat to treating the eating disorder aggressively. This means that in order to be optimally effective, the therapist must listen to the patient’s basic needs rather than her expressed wishes (translation: the ED’s wishes), consistently nurturing her relationships with family members when she (translation: the ED) wants them to leave her the f*** alone, and setting firm limits on her ED behavior immediately rather than waiting for her to develop the motivation and insight to do so herself. In my experience, this often means that the patient (translation: the ED) will hate me at the beginning of treatment, then gradually grow to trust, admire, and respect me as treatment progresses and her brain returns to healthy functioning. Most patients eventually express gratitude for that early toughness and understanding of what had to be done, recognizing that they wouldn’t have been able to recover without it.

8.) It undermines the relationship between the patient and his or her parents.

Psychodynamic therapy involves deep exploration of childhood experiences and family relationships in attempt to uncover the seeds of the patient’s current mental conflict. The typical result of this type of therapy is that the patient begins to distrust and resent her parents for making her ill, and the parents back off even further out of fear of making problems worse. This results in further exacerbation of existing family conflict and the creation of new problems, once the patient “realizes” how pathological her family really is.

We now know, through research on family-based treatment, that empowering parents to help their children overcome eating disorders is actually the most effective way to help them recover. I believe that nurturing positive relationships between the patient and her family members is essential for full recovery and ongoing relapse prevention, as family members are usually the first to notice signs of struggle, and the first ones to intervene.

9.) It is extremely difficult to undo the damage done by psychodynamic treatment.

A substantial amount of the trauma that patients and families endure is not the result of the eating disorder itself, but rather the result of bad treatment and protracted illness. Often, patients and their families come to me for family-based treatment after months or years of traditional therapy which has not been effective. Even a newly-diagnosed patient will struggle with re-feeding, but having a history of traditional treatment makes the process much more tumultuous. It is extremely difficult for the patient to accept meal support from their parents when they have been conditioned to believe that separation/individuation issues are at the root of their illness, or that they have developed their eating disorder as a way to survive in a dysfunctional family, or that they will recover when they choose. Further, parents struggle enormously to become empowered to act on their child’s behalf when they have been blamed for causing the illness, either overtly or subtly, by their child’s previous clinicians.

10.) It does not bode well for relapse prevention.

Unfortunately, eating disorders have a very high rate of relapse, in part because the underlying biological vulnerability stays with the patient for life. In order to maintain full recovery, it is extremely important for the patient to maintain his or her optimally healthy body weight, practice excellent self-care, manage stress adaptively, and eat a complete, well-balanced diet. The beliefs that one’s eating disorder resulted from internal conflict, or that “it’s not about the food,” are not terribly conducive to these protective measures.

As science has progressed and newer, more effective treatments have been developed, there has been a backlash from the “old school.” Those who remain entrenched in outdated, unproven psychodynamic theories will defend their beliefs like a lioness defends her cubs because – let’s face it – these theories are their babies. They have built careers on these ideas; written books about them; conceptualized their own recovery through these lenses. But that does not make these theories correct, or evidence-based, or useful, or effective in treatment.

Let’s welcome a new generation of clinicians who use evidence-based treatment that strengthens family relationships, treats deadly symptoms rather than hypothesized causes, and promotes full and lasting recovery for all patients. Let’s welcome a new generation of patients and families who are not blamed for the illness, but are empowered to pursue aggressive, effective treatment upon initial diagnosis. Let’s welcome treatment that actually works and refuse to support treatment that doesn’t.

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Healing After the Crisis

Many people who have recovered from anorexia nervosa (AN) continue to exhibit anxiety, depression, moodiness, perfectionism, or other psychological issues. In fact, the anxious personality style that persists after full recovery is the norm, rather than the exception. Walter Kaye’s research shows that 60-70% of people with histories of AN have anxious, obsessive, perfectionistic, rigid, harm-avoidant personality traits that were present before AN and persist after recovery. These traits are largely genetic and neurobiological in origin.

Individuals who have experienced AN, regardless of how long it has been since their most recent episode, and regardless of how fully recovered they are, need to be mindful of managing their underlying predisposition. For those with histories of AN, having an anxious, obsessive, perfectionistic personality style combined with a biologically-driven tendency to restrict food creates the perfect storm for relapse. Even if anorexia nervosa never returns, these individuals are at greater risk of developing bulimia nervosa and of experiencing depression, anxiety, and related disorders.

Here are some basic guidelines for continued healing after the crisis of AN blows over:

1. Get evaluated for an accurate target weight

You may be “weight-restored” according to your therapist, nutritionist, or doctor. But what exactly does that mean? Are you really at YOUR ideal body weight?

The vast majority of doctors, nutritionists, and therapists tend to set target weights too low. There are several reasons for this: overblown concern about the obesity epidemic, their own personal beliefs about the value of thinness, ignorance of the research on appropriate target weight and recovery from eating disorders, and concern about upsetting patients who negotiate for lower weights. Whatever their motive, the common practice of setting target weights too low perpetuates the illness, increases risk of relapse, and holds most patients in a state of semi-recovery.

In order to recover fully, you need to get to YOUR body’s ideal weight, which has nothing to do with what’s “on the charts.” If you have a biological predisposition to AN, being even 5 pounds below YOUR optimal weight can trigger symptoms of anxiety, obsessiveness, depression, and irritability. The best way to determine your accurate target weight is to obtain copies of your historic growth charts and schedule an appointment with a physician who is knowledgeable about eating disorders. Your physician can examine your historic growth charts and use them to make an educated guess of where your weight would be if you had never developed an eating disorder.

Your ideal weight is not a “magic number;” it is a range of approximately 5-10 pounds at which your body feels good and functions optimally. If you are at your ideal weight, you should be getting regular menstrual periods without taking birth control pills. Your body will gravitate towards your ideal weight range when you are eating normally without restriction and exercising regularly. Research has shown that the vast majority of young adults with AN must maintain a body mass index (BMI) of at least 20 in order for their brain and body to recover fully. Many people require higher BMI’s than that, depending on their bone structure, muscularity, build, and genetics. Many parents find that their child’s last lingering psychological symptoms disappear she gains those last five pounds and returns to her historic growth curve.

2. Get evaluated and treated for co-morbid conditions

Co-morbid diagnoses which are made while a patient is underweight, re-feeding, or actively bingeing and purging are notoriously inaccurate. Most acutely ill patients with eating disorders exhibit symptoms of major depression, anxiety disorders, and obsessive-compulsive disorder, but in many cases these symptoms are the direct effects of a malnourished, chaotically nourished, or re-feeding brain. Giving a false diagnosis is worthless at best and counterproductive at worst. It does not make sense, medically or practically or financially, to provide a patient with a medication or a psychological treatment when her symptoms are best addressed through full nutrition.

However, not all psychological symptoms disappear with weight restoration. The truth is that many people with a history of AN have co-morbid psychological disorders which exist independently of their eating disorder. The most common disorders which co-occur with AN are OCD, social anxiety disorder, generalized anxiety disorder, major depression, ADHD, and Asperger’s syndrome. Every eating disorder patient should be evaluated for co-morbid disorders after they have reached and maintained their ideal body weight for several months.

If you are diagnosed with another psychological disorder, it is important to get treatment for it. Evidence-based psychological treatments, such as Cognitive Behavioral Therapy, Dialectical-Behavior Therapy, and Acceptance and Commitment Therapy, are helpful in treating a wide variety of psychological problems. Psychotropic medication may also be included as an adjunct to psychological treatment.

3. Create a relapse prevention plan which involves family, friends, and clinicians

Unfortunately, with eating disorders, relapse is the norm rather than the exception. Therefore, relapse prevention planning is crucial. The best relapse prevention plans are those that involve not only the patient but also her friends, family, and clinicians.

Central to developing a relapse prevention plan is a thorough understanding of the brain-disease model of mental illness. If you were therapized to believe that your eating disorder was the result of striving to be thin, a need for control, or family dysfunction, you are in for a rude awakening several years from now when relapse rears its ugly head. The problem with these myths about etiology (in addition to being false) is that they presume that, once “underling issues” have been addressed, relapse is no longer a possibility. Not true. Not by a long shot.

I have worked with many teenagers who have sworn that they would never develop AN again because they will never go on a diet. This is great, but the problem is that AN can creep back into a person’s life if she becomes stressed or malnourished for any reason. A nasty breakup, a move across the country, a stressful job, a bout with the stomach flu, an episode of depression, or a major surgery – any of these situations can trigger a relapse. One need not intentionally diet in order to fall back into AN.

Developing a relapse prevention plan is a three-step process:
A.) In collaboration with your loved ones and clinicians, generate a written list of early signs of relapse. Some of these signs may first be noticeable to those around you, before you even realize that there is a problem. This is why it is important to have other people involved.
B.) Decide what you will do to cope with any signs of impending relapse so that you can nip them in the bud before they become problematic. Also, decide what your loved ones can do to help if they notice these signs.
C.) Write out the entire plan, including signs of relapse and exactly what to do if said signs occur. Distribute copies of this plan to your family members, closest friends, and clinicians.

4. Learn to manage your personality style so that it works for you

We cannot change our basic personality style. Some people are simply “wired” to be more anxious, and that’s not inherently a bad thing. We’ve evolved this way for good reason. Many people who are very successful in life have anxious personality styles – their drive, conscientiousness, and attention to detail allow them to excel in school, sports, and various careers.

Every personality style has its benefits and its liabilities. People who are disorganized and scatterbrained and have difficulty learning in traditional ways can be extremely gifted artists. People with argumentative natures or short tempers can channel that passion into a career in law, or become champion boxers. People with ADHD may not be well-suited for a dull desk job that requires hours of concentration, but thrive in an active job that requires multitasking, creativity, and interacting with many different people.

Become aware of what your personality style is and how it manifests. Accept and embrace your natural temperament. Identify the ways in which your personality style benefits you or others, and structure your life accordingly. Identify the ways in which your personality style works against you, or prevents you from achieving your goals, or interferes with your wellbeing. Do whatever you can to learn to manage these vulnerabilities.

People with anxious personality styles do best when they have plenty of sleep (8-9 hours per night) and plenty of exercise (approximately 1 hour per day). In addition to cardiovascular exercise to relieve pent-up stress and anxiety, I recommend incorporating a regular yoga practice into your weekly routine to help release tension and develop mind-body awareness. Those with anxious personalities should limit caffeine to one cup per day and eat balanced meals throughout the day to stabilize blood sugar, which in turn helps to stabilize mood. People who are prone to stress benefit greatly from having some personal down time each day to relax and decompress. Bubble baths, reading for pleasure, meditation, and journaling are all good ways to unwind. If you are prone to anxiety, do whatever you can to simplify your life. Eliminate unnecessary commitments. Don’t let yourself get overscheduled. Learn to say no!

Finally, develop skills to cope with anxiety. Self-help books such as The Anxiety and Phobia Workbook and The Relaxation and Stress Reduction Workbook are helpful for those who are motivated to work through their issues on their own. Structured, evidence-based therapies, such as Cognitive Behavioral Therapy and Acceptance and Commitment Therapy, focus on building skills to tackle the every day challenges of life.

5. Get your life back on track

Eating disorders are completely disruptive to every facet of your life. They cause conflict and tension within your family; they alienate you from your friends; they cause you to miss school or work while you seek treatment; they wreck your body and ravage your brain; they change your fundamental view of who you are and what you want from life. It may take many months or even years to recover from all this damage.

Once the storm has passed, it is very important for you to rebuild your relationships with family members and friends, or to make new friends if your old ones are no longer in the picture. You may need to get involved in different activities if your old ones were triggering your disorder. You may discover that all of your goals and strivings were not yours at all, but ED’s. Your new life, post-recovery, may feel foreign, forced, or fake. This experience can be disillusioning, confusing, and deflating.

Now is the time to ask yourself: Who are you, now that ED has been kicked to the curb? What are you about? What do you want from life? If you have recovered from your eating disorder and addressed steps 1-4 listed above, you are ready to answer these questions genuinely and embark on your new, healthy, meaningful, fulfilling life.

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About the Food

“It’s not about the food.”

This phrase, used widely in eating disorder recovery, is misleading and potentially harmful.

Here’s the truth – anorexia nervosa (AN) is not “about” anything other than being born with a certain neurobiological predisposition to this particular brain disorder, which lays dormant until activated by insufficient nutrition. Given that food restriction has a calming and mood-elevating effect in people with this type of brain chemistry, anorexics may restrict their food intake (either consciously or unconsciously) as a way of coping with uncomfortable feelings or stressful events.

So it isn’t JUST about the food; it’s about feelings and circumstances as well. People with AN must learn healthy ways to regulate their emotions. Most of them will require psychotherapy to help them tackle anxiety and perfectionism, build healthy relationships, challenge their distorted thoughts and beliefs, or treat coexisting conditions such as depression or OCD. But it is the disturbance in eating behavior and weight, rather than feelings or events per se, which cause immense physical and psychological damage.

An initial period of low nutrition sets the disorder in motion. Continued low nutrition and low body weight perpetuate the symptoms. Sustained full nutrition and weight restoration are essential for mental and physical recovery. Continued good nutrition and maintenance of a healthy body weight for life protect patients against relapse. At every step of the process, nutrition (or lack thereof) plays a functional role.

The relationship between food and AN is analogous to the relationship between alcohol and alcoholism. To state that AN “isn’t about the food” is like stating that alcoholism “isn’t about drinking.” A person may be born with a predisposition to developing alcoholism due to her genetic makeup and her particular brain chemistry. However, if that person never takes a sip of alcohol, the disease will never be activated in the first place. Similarly, a person predisposed to AN will not develop the disorder in the absence of a nutritional deficit.

I like to think about the development of eating disorders in terms of the “four P’s:”

Predisposing factors
Recent research indicates that 50-80% of the risk of developing AN is genetic. Individuals with AN have a certain genetically-transmitted neurobiological predisposition. Personality traits which make an individual more susceptible to developing AN include anxiety, perfectionism, obsessiveness, behavioral inhibition, and cognitive rigidity. Most patients with AN have exhibited one or more of these traits since early childhood, long before the development of an eating disorder. These traits tend to be exacerbated during bouts of malnutrition and persist long after recovery, albeit to a lesser degree.

Precipitating factors
Anorexia nervosa is always precipitated by a period of low nutrition. The precursor to the low nutrition will vary from person to person. In modern American culture, where most girls and young women experience a drive for thinness, dieting is the most common pathway to AN.

Not every episode of AN is triggered by dieting, however. A simple desire to “eat healthy,” participation in sports without appropriate caloric compensation, a bout with the stomach flu, or simply loss of appetite during a period of stress – any one of these unintentional, seemingly benign periods of low nutrition can trigger AN in a vulnerable child.

Weight and shape concerns are culturally mediated phenomenon and are not necessarily part of the symptom picture for all anorexics. In medieval times, fasting for religious purposes triggered what we now call anorexia nervosa. AN is seen in cultures as diverse as China, where sufferers report loss of appetite or physical complaints, and Ghana, where sufferers view their self-starvation in terms of religion and self-control.

Puberty, which involves dramatic hormonal, neurological, and physical changes coupled with new social and academic demands, is often a precipitating factor for AN. Neurobiological researchers have hypothesized that puberty-related hormonal changes may exacerbate serotonin dysregulation, explaining why AN usually begins in adolescence.

Perpetuating factors
Continued malnutrition is largely responsible for the self-perpetuating cycle of eating disorder symptoms. A starved brain is a sick brain, and people who are undernourished for any reason display many of the symptoms commonly associated with AN: preoccupation with food, unusual food rituals, social withdrawal, irritability, and depression.

In addition to these symptoms of starvation, body dysmorphia, drive for thinness, and fear of weight gain serve as perpetuating factors. Individuals with AN are unable to recognize how thin they are and may perceive themselves as normal or fat, despite emaciation. They are terrified of eating and morbidly afraid of gaining weight. They cope with these fears by continuing to restrict their diet and remaining underweight, which of course perpetuates the symptoms of starvation. It is a vicious cycle.

Psychological problems such as depression, anxiety, post-traumatic stress, ADHD, and bipolar disorder may also serve as perpetuating factors. Food restriction and compulsive exercise act as a “drug” for certain individuals, providing them with temporary relief from anxiety and negative moods. An anorexic who is suffering from other psychological problems may use her eating disorder symptoms in attempt to alleviate her intolerable emotions. This makes re-feeding and recovery excruciatingly difficult, as the anorexic is required to face extremely painful thoughts and feelings as she endures the two things she fears most: eating more and gaining weight.

Prognostic factors
Research indicates that full nutrition and prompt weight restoration as soon as possible after AN diagnosis is a predictor of good outcome. Likewise, prolonged periods of time spent at a sub-optimal weight are associated with a protracted course of illness and increased risk of irreparable damage such as infertility, osteoporosis, and suicide.

A recent study of inpatients with AN found that the best predictors of weight maintenance during the first year post-discharge were the level of weight restoration at the conclusion of acute treatment and the avoidance of weight loss immediately following intensive treatment. Another study found that nutrient density and variety (eating a wide range of foods, including those that are high-calorie and high-fat) were significant predictors of positive long-term outcome in weight-restored anorexics.

All of the available data suggest that eating a complete, well-balanced diet and maintaining ideal body weight are of utmost importance in recovery from AN and in preventing relapse. Full nutrition and weight restoration alone will not cure AN, but full recovery cannot occur without these essential components.

In sum, nutrition plays a functional role in all stages of AN, from the initial onset and maintenance of symptoms to physical and mental recovery to relapse prevention.

Maybe it is about the food after all.

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A Dangerous Precedent

Earlier this week, a federal judge ordered the Pittsburgh Public Schools to pay $55,000 to settle a lawsuit filed by a mother, who claimed her adolescent daughter was bullied into anorexia.

According to the lawsuit, the plaintiff’s daughter, now 15, was bullied relentlessly at school in 6th and 7th grades. A group of boys taunted her and made degrading remarks of a sexual nature, insinuating that she was fat and ugly. The girl stopped eating lunch at school in attempt to avoid being teased by these boys, who ridiculed her for eating and being fat. Although the girl’s teacher, principal, and guidance counselor were aware of the bullying, they did nothing to intervene. The girl began losing weight, and by the middle of her 7th grade year, her weight was dangerously low and she was diagnosed with anorexia nervosa, for which she was treated at an inpatient psychiatric clinic. The plaintiff, whose daughter now attends private school, sued the school district, her daughter’s middle school, and her principal, claiming that her daughter developed anorexia as a result of their inaction.

I disagree with this ruling, and I think it sets a dangerous precedent.

Before I state my points of contention, I will make several points very clear:
• Bullying has the potential to cause extreme distress. It is cruel, harmful, and absolutely inexcusable.
• All schools should have clear, written policies about bullying and sexual harassment. All students, parents, and faculty must be aware of these policies. School faculty and administrators must enforce these policies to the best of their abilities.
• School faculty and administrators have a responsibility to provide a safe learning environment for all students, and have a duty to intervene at the first sign of bullying.
• Students who engage in bullying behavior should be punished appropriately. If the bullying continues, they should be expelled.

In this particular case, the bullies did some terrible things; they must be held responsible for their actions and punished appropriately. The school faculty and administration were certainly negligent; they must be held accountable for their inaction and punished appropriately. The school district was remiss not to have a bullying policy, and they should be compelled to create one. The victim suffered horribly as a result, and she deserves to heal from this trauma and to attend school in a safe environment. And the buck stops here. I do not believe that the bullies or the negligent school personnel are responsible for this child’s mental illness.

To create a legal precedent in which school officials are held legally or financially liable for a child’s mental illness is dangerous on several levels:
• It implies that the actions of children can cause another child to develop a mental illness.
• It implies that the actions or inactions of adults can cause a child to develop a mental illness.
• It implies that anorexia nervosa is (or can be) the result of teasing or bullying.
• It reinforces the popular but antiquated and unsupported notion that anorexia nervosa is the result of some deep-seated trauma.
• It implies that this child would not have developed anorexia nervosa if she had not been bullied.
• It neglects the horrific experiences of tens of thousands of other children who have been bullied and have suffered silently, but have not developed anorexia nervosa.
• It invalidates the experiences of the tens of thousands of children and adults who have never been bullied or traumatized in any way, but nonetheless have developed anorexia nervosa.

Imagine being a prepubescent boy and being held responsible for causing a classmate’s severe mental illness. Don’t get me wrong – I am in no way defending the behavior of these bullies. They did cruel things and they must be punished. But they did not make this girl develop a life-threatening brain disorder. They couldn’t have, even if they wanted to! Similarly, the school faculty and administrators were obviously negligent and made some terrible mistakes, but they did not cause this child to develop a mental illness.

The most recent scientific evidence strongly suggests that anorexia nervosa is a biologically-based, genetically transmitted brain disorder which is triggered by malnutrition and then becomes self-perpetuating. Children with anorexia come from all walks of life. Some are popular, confident, social, happy, and well-adjusted before their illness begins. Others are depressed, anxious, introverted, teased, or unstable before they develop anorexia. Some children develop anorexia after a stressful event, which could be as benign as a starting middle school or as serious as rape. For many children, the onset of anorexia nervosa does not coincide with a major stressor, but rather spirals out of control during an attempt to “eat healthy,” get in shape for sports, or lose a few pounds for prom.

My point is that some children are simply “wired” for anorexia nervosa, which can be triggered by relatively minor stressors or relatively benign bouts of under-nutrition. It doesn’t make sense to “sue the trigger” when it is just that – a trigger. If we can sue a school district – and win tens of thousands of dollars – for allowing a child to be bullied into anorexia, where does it end? If a child develops an eating disorder after reading a book on nutrition, do we sue the publisher? If an 18-year-old becomes anorexic while struggling to adapt to the social and academic challenges of college life, do we sue the university?

If a teenager develops and eating disorder after being raped, the rapist should be tried and convicted and incarcerated. But the eating disorder, in my opinion, is irrelevant to the outcome of the trial. The rapist should be incarcerated for the same length of time (for life, in my opinion) regardless of whether the victim develops any mental illness afterwards, because he committed a violent crime. The crime is no more or less heinous based upon the particular pre-existing neurological makeup of his victim.

It is well-known amongst mental health professionals that a psychotic break can be triggered by “high expressed emotion,” such as bullying or family conflict, in a person who has the underlying neurobiological predisposition. Do we then sue the school for allowing a child to be “bullied into schizophrenia?” Do we sue the parents for arguing too much and thus causing their son’s psychosis?

I have the deepest sympathy for this plaintiff, and especially for her daughter. No doubt, they have both suffered horribly. This mother is only doing what she believes is best for her dear child, and I’m sure she believes she is helping other children in the process. The judge who approved of this settlement is, likewise, only trying to ensure that justice is served. He or she probably has no intimate knowledge of the etiology of anorexia nervosa, and probably has no idea what some of the negative ramifications of his ruling could be.

If the lawsuit had been simply about protecting children from bullying, I would have supported it 100%. I cannot, however, support a lawsuit which enshrines bullying as a legally valid cause of anorexia.

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Controversy

I love controversy.

So naturally, I was thrilled to read the recent news article in the Sun Sentinel with a headline describing Maudsley as “a controversial treatment.”

This article gives an overview of the Maudsley Method and describes the experiences of two families – one with a 12-year-old girl and one with an 18-year-old boy – who used this approach to help their children recover from Anorexia Nervosa (AN). In a fair and balanced way, the article also lists some of the criticisms of the Maudsley Method that make it so controversial.

I believe that controversy is healthy part of living in a free society. Without controversy, there cannot be progress in the areas of ethics, morals, politics, or social norms. We must challenge old ideas and new ideas alike. We must approach life with an open mind as well as a healthy degree of skepticism. Some of the best ideas in the history of humanity, such as racial integration, freedom of religion, and equal rights for both genders, were born amidst extreme controversy. Thousands of people devoted their lives to the pursuit of these ideas. People died fighting for these causes. And to my generation, they seem so obvious and self-evident that we take them for granted.

Controversy accelerates progress in the aforementioned areas by shedding new light on old ideas. On the contrary, controversy tends to hinder progress in science. This happens because controversy over scientific ideas generally arises when people criticize or oppose scientific discoveries on the grounds of theology, politics, morality, or philosophy. Many scientific truths were initially met with extreme controversy. Galileo was tried – and convicted – by the Vatican for his scientific explanation of a heliocentric universe. And although Darwin’s theory of evolution has been almost universally supported by the modern scientific community, it was (and still is, in some communities) highly controversial for cultural, theological, and political reasons.

All viewpoints have equal merit in debating different perspectives on morality, philosophy, or politics. The winning idea is the one which is shared by the majority of people, which is then often supported by legislation and reinforced by social norms. This is what happened with racial integration, religious freedom, and gender equality. In debates over science, however, some answers are clearly superior to others. Ideas supported by scientific research are superior to ideas not supported by scientific research. Scientists conduct reliable studies, interpret the data, and present the results to their peers. Eventually, these results are disseminated into the public domain. Personal beliefs and political viewpoints and religious doctrines have no place in scientific inquiry. They obscure the truth.

In this vein, we have the controversy over the Maudsley Approach. Some clinicians say that they “don’t believe in Maudsley” just as some people say they don’t believe in God or Santa Clause or evolution. Maudsley, like evolution, is not a “belief” to be accepted or rejected. Maudsley, like evolution, is supported by a wealth of scientific literature which should be evaluated empirically and used effectively to understand and advance the human condition. To treat Maudsley as a socio-political issue like gay marriage that one sides “for” or “against” muddies the waters, misses the point, and makes one look scientifically illiterate.

Those who criticize Maudsley are doing so on philosophical, rather than scientific, grounds. They have not devised reliable, valid studies yielding data to the contrary. Rather, they cite antiquated and unproven ideas about eating disorders, they make criticisms that show a clear ignorance of the scientific process, or they ask irrelevant questions.

Some day soon, the Maudsley Approach will join the ranks of Darwin’s evolution and Galileo’s heliocentric solar system as a scientifically accepted truth. Some day soon, all therapists will approach psychology as a science – like biology and astronomy – which is guided by empirical data and impervious to personal beliefs.

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Rethinking Residential Treatment: Less is More

I am not a fan of residential treatment for eating disorders as it exists today. I am not aware of any scientific research suggesting that residential treatment is superior to outpatient treatment, with the exception of marketing materials from residential treatment centers (which have an obvious bias and financial incentive). We do know that hospital admissions and stints in residential treatment are poor prognostic factors – patients who remain at home and recover through outpatient treatment are more likely to recover than those who go through residential care. To be sure, the relationship between residential treatment and prognosis may be correlational rather than causal. Patients who are sent away to residential treatment generally have longer duration of illness, greater severity of illness, more psychiatric comorbidity, and a history of unsuccessful outpatient treatment.

There is one recently published randomized controlled trial of outpatient vs. residential treatment. Results of this study demonstrated that adolescents who were randomly assigned to outpatient treatment fared just as well as those who were randomly assigned to residential treatment. Given that outpatient treatment is less expensive and less disruptive to the adolescent’s life, the authors conclude that outpatient treatment is preferable.

I am a firm believer in evidence-based outpatient treatments which keep family members fully informed and actively involved whenever possible. Patients who receive treatment which prioritizes nutritional rehabilitation, weight restoration, and cessation of restricting/bingeing/purging behaviors as the essential first step, are more likely to achieve full recovery in less time. In an ideal situation, a skilled therapist can utilize the strengths and resources of the family and coach them in understanding eating disorders, refeeding their loved one, and interrupting her eating disorder behaviors. Families can also be coached in how to maintain a home environment which is conducive to recovery while their loved one participates in therapy to acquire healthy coping skills, learn how to prevent relapse, and manage any comorbid conditions. This is how the Maudsley Method of Family-Based Treatment works. At this time, the Maudsley method is the only empirically-supported treatment for adolescent anorexia nervosa, and has also been shown to be equally effective in treating adolescent bulimia nervosa. Empirical studies on the use of a modified Maudsley approach in treating young adults with eating disorders have not yet been published. However, anecdotal evidence suggests that many young adults respond favorably to a modified Maudsley approach – even those who have been ill for many years and have had numerous stays in inpatient or residential treatment. And, let’s face it: we don’t really have a good alternative treatment for young adults with anorexia nervosa.

The majority of patients who are treated with Maudsley do achieve and maintain full recovery. Simply put, Maudsley works, and there aren’t any great alternatives. Thus, Maudsley should typically be the first-line treatment, especially for adolescents with anorexia nervosa, and should commence immediately following diagnosis. That being said, Maudsley may not be appropriate in a minority of cases. For example, families who are unable to find evidence-based treatment providers near their home, families in which neither parent has the necessary time or energy due to very demanding careers or caring for other small children, families in which parents cannot agree to Maudsley and refuse to compromise or work together, families in which there is abuse or addiction, or families in which one or both parents suffers from a physical or mental illness which impairs their ability to parent their child effectively.

Despite the promise of the Maudsley Method, it is not necessarily effective or appropriate for all patients (this statement, while often cited by critics of Maudsley, is annoying and virtually meaningless because NO form of treatment for any psychological or medical illness is ever appropriate and effective for 100% of patients. This is not a weakness of a particular treatment method; this is just reality). For the aforementioned reasons, there is, and probably always will be, a need for residential treatment for eating disorders.

Residential treatment for eating disorders, as it exists today, has several benefits and several drawbacks. The benefits include:
• Supported nutrition to promote appropriate weight restoration
• Round-the-clock monitoring to prevent patients from engaging in bingeing, purging, restricting, and substance use
• Protection from self-harm and suicide
• Providing the patient with a respite from the stresses of school, work, sports, and everyday life
• Providing the family with a respite from the daily strain of caring for their loved one

The drawbacks to residential treatment, as it exists today, include:
• Prolonged separation from the family and home environment
• Prolonged absence from school, friends, extracurricular activities, and normal routines
• Exposure to other eating disorder patients, which can result in acquisition of new symptoms, solidification of identity as an “eating disorder patient,” and competitiveness with other patients about who is sicker or thinner
• Artificial environment – a “bubble” – which does not translate to real-world living
• Exposure to outdated and unproven theories about the etiology and treatment of eating disorders (e.g., blaming “family dysfunction,” search for “root causes,” exploration of supposed “underlying issues”)
• Failure to plan adequately for a smooth transition home
• Insufficient family involvement (weekly phone sessions and “family weekend” pay lip service to family involvement, but they often play the blame game, focus on presumed family dysfunction, advise parents to “back off” and not be the “food police,” and fail to educate families as to how to help their loved one recover. In essence, many family sessions send all the wrong messages and fail to send the helpful ones).
• Over-diagnosis of and over-medication for supposed comorbid disorders which are largely, if not entirely, the result of malnourishment and / or refeeding
• Attempts to use psychotherapy of any kind on patients who are not able to benefit cognitively or emotionally.

These last two points are particularly striking to me (granted, these problems occur with less-informed outpatient treatment as well). I have had many patients who were diagnosed with and medicated for severe mental illnesses such as major depression, bipolar disorder, or even borderline personality disorder, while they were underweight or re-feeding in residential treatment. In many patients, these symptoms decrease substantially or disappear altogether once the patient has reached and maintained a healthy body weight for a number of months. I have several patients who arrived at my office after years of ineffective treatment, with multiple psychiatric diagnoses, taking multiple medications. After weight restoration and maintenance along with evidence-based psychological interventions, these patients no longer required medication for any psychiatric symptoms and no longer met criteria for ANY mental disorder. Sometimes, less is more.

What many psychiatrists and other mental health professionals fail to understand is that all people who are malnourished or re-feeding, even those without eating disorders, exhibit symptoms that mimic certain mental disorders (see Minnesota Starvation Study). Diagnoses made while a patient is underweight or re-feeding are often inaccurate. Medicating a patient for a presumed mental illness which is actually the direct result of a malnourished and / or refeeding brain is at best ineffective and at worst quite harmful. Obviously, many patients with eating disorders do have genuine comorbid psychiatric issues, and clearly these need to be identified and treated. But even those patients with legitimate comorbidities may find that their other symptoms are more manageable, or require less medication, when their eating disorder is under control.

Nearly all patients in residential treatment for eating disorders are there because they are significantly malnourished or actively engaging in frequent binge/purge behaviors. These are patients with significant (though temporary) brain damage which renders them unable to process emotions, think rationally, perceive other people’s intentions, or think logically about food, weight, or body image. We know that this brain damage is reversible only after months of full nutrition, weight restoration, and abstinence from eating disorder symptoms. I understand the rationale that, since patients are in residential treatment, they should be given every possible type of treatment available from equine therapy to process groups to CBT to psychoanalysis to making pretty necklaces. I understand that the directors of residential treatment centers want to provide patients with every possible tool for recovery. But what if the patients are not yet equipped to use these tools? And what if some of these tools can be harmful? Again, this may be a case of less is more.

In my ideal world, residential treatment would retain the benefits it currently has while eliminating the drawbacks. Here’s how it would work:
• The immediate focus would be on full nutrition, full time so that patients can restore their weight as quickly as is medically safe and can break the binge/purge cycle (if applicable). This would include three meals and three snacks per day, carefully monitored. “Magic plate” would be employed, and patients would be required to eat 100% of their meals and snacks. There would be no “rewards” for eating well or “punishments” for eating too little. Eating disorder patients are punished enough by their illness, so the last thing they need is a punitive external measure. Rather, there would be no alternative other than to consume full nutrition, preferably through food, but otherwise through a supplement or nasogastric tube.
• Patients would be carefully monitored and prevented from hiding food, bingeing, or purging.
• Patients would be monitored for urges to self-injure or commit suicide and kept safe from any possible means of self-harm.
• No new diagnoses would be made and no new medications prescribed.
• No individual therapy, family therapy, or group therapy of any kind would be provided. However, a psychologist specializing in eating disorders would be available daily to provide supportive counseling for patients who request it.
• Patients would spend their days participating in relaxing, rejuvenating activities such as reading, watching movies, playing board games, getting massages, taking nature walks and practicing gentle yoga (when medically appropriate).
• Patients would be educated about the genetic and neurobiological basis of eating disorders as well as the role of under-nutrition and compulsive exercise in the development and maintenance of these illnesses. They would be provided with scientifically valid information on effective treatments for eating disorders and relapse prevention.
• Through phone conferences and/or in-person sessions, family members would be educated about the genetic and neurobiological basis of eating disorders as well as the role of under-nutrition and compulsive exercise in the development and maintenance of these illnesses. They would be provided with scientifically valid information on effective treatments for eating disorders and skills to help their loved one continue on the path to recovery at home.
• Family members would be provided with daily updates on their loved one’s progress, regardless of the patient’s age. Family members would also be encouraged to contact the treatment center at any time with questions or concerns.
• Family members and friends of the patient would be strongly encouraged to call and visit the patient whenever possible.
• A physician would set an accurate target weight range for each patient, taking into account her pediatric growth charts, weight/build history, and genetics. The target range would represent the patients’ ideal, healthiest weight, not some arbitrary minimum BMI. Research shows that the vast majority of adult patients require a BMI of at least 20 in order to achieve complete physical and mental recovery, so that would be a good starting point.

Patients would be discharged from my ideal treatment facility only after the following criteria were met:
• The patient has achieved 100% of her ideal body weight.
• The patient eats 100% of her meals and snacks with little resistance.
• The patient reports a significant decrease in urges to restrict, binge, or purge.
• The patient is not experiencing suicidal ideation or urges to self-harm.
• The patient expresses readiness for discharge and willingness to work towards recovery.
• The family has been well-educated about eating disorders and feels confident to manage their loved one’s symptoms at home.
• The patient and her family members have collaboratively developed a specific, written outpatient treatment plan. This plan includes referrals for evidence-based psychological treatment for the individual patient and her family as well as regular medical monitoring. In addition, the plan contains specific strategies for dealing with the patient’s eating disorder behaviors and for creating a pro-recovery home environment.

Although it exists only in my imagination, I would predict that a residential treatment center such as the one I described would be more effective than most currently existing treatment centers. It would also be much cheaper, since far fewer staff would be required. Granted, patients may have a longer duration of residential treatment than they do now, since the goal is 100% weight restoration, but patients would be less likely to relapse. Since this treatment center would be cheaper anyway, and patients would be less likely to require repeated admissions, the overall cost to the patient’s family and to society would be much lower.

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Recovery Timeline for Maudsley FBT

I recently conducted an informal survey of parents who had used the Maudsley Method of Family-Based Treatment to help their children recover from eating disorders. My intention was to gather some preliminary data on recovery milestones which I could share with patients and families who are just embarking on the recovery journey. Then I realized that other people may benefit from this information as well.

The following data were collected from parents of some of my patients (past and present) as well as from parents on FEAST’s caregiver forum, Around the Dinner Table. A total of 22 parents submitted responses. The patients (20 female, 2 male) ranged in age from 10 – 24 years when their family started Maudsley (mean age = 15.3 years).

The patients in my sample varied dramatically with regard to the length of their illness. Some parents reported that they began Maudsley within a month after their child’s first eating disorder symptoms appeared. Other parents had watched their child continue to suffer from the devastating effects of ED through many years of ineffective treatment and numerous hospitalizations before finally turning to Maudsley as a last resort.
Granted, this is not good science, but it is a start.

Length of time from onset of symptoms to beginning of refeeding
Mean = 18.8 months
Median = 6.25 months
Range = 1 – 132 months

Length of time from start of refeeding to weight restoration
Mean = 6.7 months
Median = 4.5 months
Range = 2 – 24 months

Length of time from weight restoration to acknowledgement of having ED
Mean = 1.1 months
Median = 0 (acknowledged having ED when he/she became weight restored)
Range = 0 – 16 months
(90 % of the sample acknowledged having ED at or before weight-restoration)

Length of time from weight restoration to developing motivation to recover
Mean = 4.6 months
Median = 0 months (motivation developed at the time of weight restoration)
Range = 0 – 24 months

Length of time from weight restoration to eating independently while maintaining weight
Mean = 7.8 months
Median = 6.5 months
Range = 0 – 36 months

Length of time from weight restoration to mood normalization
Mean = 3.3 months
Median = 2 months
Range = 0 – 12 months

Length of time from weight restoration to normalization in anxiety (return to pre-ED level)
Mean = 6.5 months
Median = 3 months
Range = 0 – 36 months

Length of time from weight-restoration to absence of body dysmorphia
Mean = 6.9 months
Median = 4 months
Range = 0 – 24 months

Clearly, more rigorous research is necessary in order to draw definitive conclusions. However, I’ve drawn some preliminary conclusions based on my data:

1.) The Maudsley Method can be effective for children, adolescents, and adults. It can be effective for both males and females.
2.) The Maudsley Method can be effective even for young adults who have been ill for 10 years or more.
3.) Most patients who are beginning Maudsley treatment have anosognosia – they do not recognize that they are ill and do not have motivation to recover. The patient does not have to “want to get better” in order for treatment to begin.
4.) The majority of patients develop insight and motivation to recover around the time that they reach a healthy body weight. For some patients, insight and motivation develop gradually after a number of months at ideal body weight.
5.) Patients generally require continued meal support for an average of 6 months after weight restoration.
6.) The manualized Maudsley approach (Lock, LeGrange, Agras, & Dare, 2001) recommends beginning to hand control of eating back to the patient when she reaches 90% of ideal body weight. This is probably too soon for most patients.
7.) The majority of patients must sustain a healthy body weight for 3-6 months before depression, anxiety, and body dysmorphia abate.

This is interesting food for thought (pun intended). I am interested in conducting a much larger survey on families that have used Maudsley. I’d like to gather enough participants and enough data points to be able to do some actual complex statistical analyses – maybe some ANOVA’s or multiple regressions. Through this study, I’d like to examine which variables contribute to recovery time. For example, what features differentiate patients who are able to eat independently at weight restoration vs. those who need continued meal support? What differentiates the patients whose psychological symptoms melt away with weight restoration vs. those who continue to struggle? Most importantly, I would like to use data from this future study to find ways in which the Maudsley method could be improved.

What questions would you like to see answered? I welcome any and all suggestions!

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Palliative Care for Anorexia Nervosa – Part 2

Last fall, I blogged about palliative care for anorexia nervosa (AN). In light of a recently published article on the topic, and considering how riled up I have become as a result, I believe this subject deserves another post.

An article by Lopez, Yager, and Feinstein entitled Medical Futility and Psychiatry: Palliative Care and Hospice Care as a Last Resort in the Treatment of Refractory Anorexia Nervosa was published in this month’s issue of the International Journal of Eating Disorders. The authors describe a 30-year-old female with an 11-year history of AN who presented in their clinic at an extremely low weight with numerous medical complications. Over the course of her chronic illness, this woman had been through two stints in residential treatment, multiple hospitalizations, and several years of participation in a day treatment program. At the time of intake, she continued to engage in caloric restriction (consuming fewer than 300 calories per day) and exercise compulsions (running 2 hours daily).

The treatment team recommended residential treatment, but the patient was unwilling to go voluntarily and the treatment centers were unwilling to accept her involuntarily. The team concluded that “no viable treatment options existed” and consulted the medical center’s ethics committee.
The patient’s family refused guardianship. When the idea of pursuing court-ordered guardianship was presented, the hospital attorneys rejected it on the grounds that the patient would most likely not meet criteria. In the end, “the treatment team and ethics committee determined that her physical and psychiatric impairments were likely to lead to her death, despite any plausible attempts at aggressive intervention” (p. 373).

A palliative care approach was pursued for this patient, despite her firm belief that she was not going to die. So she continued her extreme caloric restriction, purging, laxative abuse, and compulsive exercise. She sustained numerous stress fractures, abrasions, and bruises from falls while running. Her weight, blood pressure, and heart rate dropped even lower. During this time, she attended regular outpatient therapy sessions, during which her eating disorder was never discussed. She eventually became so weak that she was moved to an inpatient hospice, where she died three weeks later.

What is wrong with this picture? The premature death of a young person is always a heartbreaking tragedy. But when a young person dies from a treatable illness, it is even worse. This patient’s family and treatment team abandoned her in her most desperate time of need. The ethics board washed their hands of her; law did not protect her.

Imagine, now, that this patient suffered from severe mental retardation (MR) instead of AN. A patient with MR would not be permitted to engage in self-injurious behaviors. If she could not eat on her own, her family or her nurse or her homecare worker would prepare her meals and spoon feed her. If she engaged in repetitive physical activities that posed a danger to her health, as many intellectually challenged persons do, she would be restrained for her own safety. If her family were unable or unwilling to provide her with the care she needed, she would be placed in a residential treatment center or a group home or an assisted living facility of some type. The cost of these services, even in the United States, would be subsidized by the government. Allowing a person with MR to starve to death would be considered cruel and inhumane. But for a person with AN, it is OK?

The irony here is overwhelming. Both AN and MR are biologically-based brain disorders which result in an inability to meet one’s basic physical needs. MR is, by definition, a life-long, incurable condition which causes marked impairment in functioning. AN is treatable, and many people recover from it completely. Unlike most people with MR, people with AN are able to form intimate relationships, pursue higher education, have meaningful careers, function independently, and make enormous contributions to society.

We, as a society, have done a great service to those with MR. We have medical ethics, legal guidelines, and government programs to protect them and ensure that their needs are met. They are not offered palliative care. Regardless of their family circumstances and finances, they are offered tremendous support for as long as they need it, which is usually for their entire lives. But with AN, the treatment ends when the insurance runs out. Or when the parents and treatment team are fed up. Or when a judge decides that further treatment isn’t worth it.

For the record, this is not about people with AN being “more worthwhile” than people with MR and therefore “more deserving” of resources. Quite the contrary. I believe that all human beings, regardless of physical or mental illness, disability, race, gender, religion, or sexual orientation, deserve affordable, effective healthcare services throughout their lifespan.

Why is it that we have failed people with chronic AN but served people with MR so well? Because most people in society, and many in my own profession, believe that AN is a choice. No one, not even children, believes that people choose to have MR. Because many treatment professionals believe that AN patients must be motivated to recover, enter treatment willingly, and manage their symptoms on their own. No one waits around for people with MR to become motivated to recover before providing them with services, and no one expects them to manage their issues alone. Because our legal system believes that an adult with a BMI of 10 who runs 15 miles a day and cannot nourish herself is competent to make her own healthcare decisions.

Come on, world. We can do so much better than this.

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Everything I Need to Know I Learned From Adolescents

A 31-year-old woman named Monica recently died from anorexia nervosa (AN) following a 15-year battle with the disease. Her death is an eerie reminder of what we already know: eating disorders are dangerous, deadly, and difficult to treat. Traditional treatment for AN typically takes 5-7 years. Less than half of patients with AN will ever fully recover, and of those who do recover, one-third will relapse. Nearly 20% of patients with AN will die as a result of their illness.

Just a decade ago, only 30% of patients fully recovered, and now nearly 50% will fully recover. The reasons for the improved prognosis include greater awareness about eating disorders, which leads to earlier diagnosis and treatment, and the advent of more effective, evidence-based treatment for adolescent AN, such as Maudsley Family-Based Treatment. But early diagnosis, early intervention, and the Maudsley method primarily benefit adolescents. Consequently, I would presume that the 20% increase in recovery rates over the past decade is primarily due to the recovery of more adolescents, not the recovery of more chronically-ill adults.

Although AN typically begins in early adolescence, those who die from the disease are more often adults who have battled it for many years. The most effective course of action is early diagnosis and aggressive, evidence-based treatment as soon as symptoms appear. Unfortunately, there are countless adults with AN who have struggled for years or even decades. As of this time, there are no evidence-based treatments for adults with AN, nor are there any medications which have been proven to benefit adults with AN. CBT has been shown to be moderately beneficial in preventing relapse in weight-restored AN patients but shows no benefit in underweight anorexics.

A lot of the AN treatment offered today is outdated and ineffective. Fortunately, however, there are more and more clinicians and treatment centers who are adopting modern, evidence-based approaches to treating adolescent AN that have much higher success rates. For example, the Kartini Clinic, the UCSD 5-Day Intensive Family Program, and the Children’s Hospital at the University of Chicago have adopted a highly-practical family-based, evidence-based approach to treating adolescent AN based on the Maudsley Method.

We can learn a lot from the success of these adolescent programs. I believe that we can use the basic principles of Maudsley FBT and the philosophy of these adolescent treatment programs to develop effective treatments for adults. Medicine, psychology, and psychiatry do this all the time in the reverse; that is, they extend effective adult treatments to adolescents. If a particular medication or psychotherapy approach demonstrates effectiveness in adults, clinicians automatically begin using it in adolescents, often without any research data to support its use in this population. Clinical trials are then conducted on adolescents, and research data follows.

Consider the basic principles of Maudsley FBT:
1. Conceptualization of AN as a biologically-based brain disorder of unknown origin
2. Externalizing the illness
3. Viewing family members as vital resources in a patient’s recovery
4. Recognition that most of the symptoms of AN are direct result of malnutrition and thus will abate after weight restoration
5. Focus on nutritional rehabilitation and weight restoration as non-negotiable first priorities in treatment
6. Acknowledgment that patients with AN are unable, in the acute phase of illness, to make healthy decisions regarding food and weight
7. Coaching parents to provide emotional and nutritional support to their child
8. Addressing psychological symptoms and other comorbid disorders after weight restoration

Which of these principles are irrelevant in the treatment of adults?

I see no logical reason why we cannot use Maudsley FBT in the treatment of adults with AN. Based on the patient’s circumstance and living situation, spouses, roommates, friends, or significant others may be enlisted for meal support in lieu of parents. The specific details may need to be tweaked in order to be relevant to an adult patient’s situation, but the general principles would remain the same. After all, the physical and psychological symptoms of AN are the same regardless of whether the patient is an adolescent or an adult. AN stunts growth and development and prevent sufferers from becoming independent, fully-functional beings. Thus, adults with AN are regressed physically, sexually, and socially to the point that they often resemble adolescents anyway.

The differences that do exist between adolescent and adult forms of AN are not inherent to the disease itself or even to the age of the patient. Rather, they are imposed by society. We, as a society, have arbitrarily determined that teenagers are fully responsible for their own healthcare decisions once they reach their 18th birthday. This is the case regardless of whether the patient has an ego-syntonic, anosognosic condition such as AN which impairs their judgment and insight. By virtue of their illness, adults with AN are unable to make healthy decisions for themselves. And yet, the law prohibits parental involvement, even parental notification of treatment, unless the patient signs a release. The law clearly sides with AN, not with the patient.

Family support and family involvement are powerful predictors of good outcome. Unfortunately, most therapists consider parental involvement in an adult patient’s treatment unnecessary or even detrimental. These therapists believe that the etiology of AN is rooted in controlling parents, separation anxiety, and issues related to independence and autonomy. Thus, they keep patients separated from the very people who love them most and who may be best equipped to help them achieve full recovery. This is counterproductive because a patient’s physical and psychological wellbeing must always take precedence over the developmental issues of emerging adults which, incidentally, have never been proven to be causally related to AN. Adult patients’ lives are threatened as a result of ignorant adherence to an unproven theory.

I firmly believe that Maudsley Family-Based Treatment can be effective in young adults. In fact, I have used this approach with young adults in my practice with great success. I have seen patients who have been sick for a decade, hospitalized multiple times, and endured several courses of ineffective residential treatment finally achieve recovery as outpatients through FBT. I look forward to the day when FBT is widely available to adults, as well as adolescents, with AN.