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My Rebuttal to “Surefire Ways”

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

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

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

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

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

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

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

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

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

Language is a funny thing.

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

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

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

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

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

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

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

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

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

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

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

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

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

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Got Hope?

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

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

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

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

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

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

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

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

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

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

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

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Attachment to Theories

It is human nature to concoct theories in attempt to explain various phenomenon. As human beings, we have the capacity to problem-solve, to think critically and creatively about issues which impact us. For centuries, people have constructed theories as a means of “making sense” of things.

The need to create theories arises most often when the reason or cause of an event or circumstance is not readily apparent. For example, in ancient Greek mythology, the god Apollo rode his chariot across the sky every day, carrying the sun from east to west. Now we have modern science to explain the earth’s rotation on its axis every 24 hours, thus creating the appearance of the sun moving overhead from east to west, so the myth of Apollo is no longer necessary.

In modern times, science has replaced mythology and theory as our means of understanding various phenomena. While modern science has helped us understand many phenomenon, we still do not know what happens to us after death. This explains the popularity of major world religions which offer theories to answer these questions, such as heaven in Christianity or reincarnation in Hinduism.

In contrast to physics, chemistry, and biology, which have existed for millennia, psychology is a relatively new science. Relatively little is known about the causes of, and effective treatments for, mental illnesses. Therefore, numerous psychological theories have been proposed over the past century in attempt to explain psychological disorders. For example, in the 1950’s mental health professionals believed that autism and schizophrenia were caused by emotionally frigid “refrigerator mothers.”

With the advent of better science in recent decades, we have learned that parenting style plays no role whatsoever in the development of autism nor schizophrenia. While the precise causes of these brain disorders are unknown, we do know that autism and schizophrenia are neuro-biological disorders with strong heritability components, and that the patient’s parents can be extraordinarily valuable resources in treatment if they are given the right professional support.

While our current understanding of mental illness is in its infancy, recent scientific research has shed some light on factors that influence the development of mental illnesses. We also have some scientific data demonstrating that certain types of treatment are more effective than others for certain populations. In light of our current understanding of the etiology and effective treatment of mental illness, I am profoundly disappointed when I read about well-meaning but misinformed psychologists who cling to antiquated theories of mental illness and practice antiquated treatments.

For example, psychologist and author Judy Scheel, Ph.D., LICSW, believes that eating disorders are rooted in unhealthy or disrupted attachments to parents. In her recent Psychology Today blog post, she writes:

“For many individuals, eating disorders are attempts to fix externally what is internally vulnerable in an individual. Yet the cause of an eating disorder can often be traced back to attachment patterns that are weak or failing in childhood, which leave someone vulnerable to a whole host of self-esteem, self-worth and relationship issues later in life.”

This theory has a familiar odor. It reeks of refrigerator mothers, castration anxiety, and unconscious conflicts. In 1950, this was all we had. But now, in 2011, we know so much more.

Why do some psychologists cling to antiquated theories which have been disproven? Similarly, one may ask why many people cling to the theory of creationism when we have solid scientific evidence to support evolution. For some people, the notion that “we came from monkeys” is insulting and offensive and clashes with their existing belief system. The story of creationism is a foundation of Judeo-Christian religions, and (at least in its literal interpretation) is incongruent with Darwin’s theory of evolution.

The same is true with psychological theories. Many people who have been trained in psychodynamic or relational approaches feel that the new science runs counter to everything they have been taught and undermines the type of treatment they practice. They cling to their theories and defend them with religious fervor. The new science threatens their religion.

The problem here is that psychology is not a religion; it is a science. In the United States, we all enjoy freedom of religion – the freedom to believe whatever we wish and practice any religion we choose without persecution. We should not have freedom of science. As experts in the field of psychology with doctoral-level degrees, we should not have the freedom to write and publish whatever we happen to believe, and practice whatever method of treatment we wish, without accountability.

I was a graduate student relatively recently (2001 – 2008), and I was taught many things in my training that I no longer believe to be accurate. This is not a failure of my training; this is a reality of an evolving science. New developments occur in medicine all the time, and physicians who have been in practice for 20 years have had to learn and re-learn new ways of practicing as the science of medicine has evolved. This is expected. It is taken for granted by most patients.

As psychologists, we have a responsibility to educate ourselves about the latest scientific developments in our field and utilize our expertise to help people in need. Clinging to unproven theories, in the face of new science, is irresponsible, lazy, and potentially harmful. When challenged on their ideas, many old-school psychologists will use phrases such as “everyone’s opinion is valuable” or “can’t we agree to disagree” or “there is no right way to treat eating disorders” or “I feel unsafe.”

Here is the problem – this is not group therapy. We cannot sit around and validate one another’s feelings and hold hands and sing Kumbaya. Yes, all people are equal, but all ideas are not equal. Some ideas are supported by reliable scientific evidence and others are not. There may not be one right way to treat eating disorders but there are many wrong ways, and there are methods and techniques which clearly work better than others for most people.

We must let go of unhealthy, dysfunctional attachments to old ideas. Clearly, these attachments to antiquated theories contribute to the development of unhelpful psychotherapy. Perhaps today’s unhelpful psychotherapy is an attempt to validate one’s early training.

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Defeating the Monster: Helping Little Girls Overcome Anorexia Nervosa

Over the past two years, I have had an influx of very young girls with Anorexia Nervosa (AN) come to me for treatment. This trend mirrors recent media coverage of the rise in AN among pre-teens. When I tell friends and acquaintances about my work, they are shocked and horrified to learn that many of my AN patients are between 9-12 years old. The typical response is first incredulity, then a remark about how “sad” it is that little girls are under such pressure to be thin and perfect. I am not sad about this at all – in fact, a very young child presenting for AN treatment represents an ideal scenario.

Let me explain. First, there are no good data to support the popular notion that the prevalence of AN has increased over the past few decades (in contrast, the prevalence of bulimia nervosa and binge eating disorder has skyrocketed in recent decades, but that is beyond the scope of this post). Most data in fact suggest that the incidence of AN has remained constant throughout recorded history. Second, we do not yet know how to prevent AN, nor do we know whether AN is possible to prevent.

We do know that children are being diagnosed with and treated for AN at much younger ages now compared to a generation ago. Research has also shown that the prognosis for AN is inversely correlated with age and duration of illness prior to the start of effective treatment. In other words, the younger the patient, the better her chance for full recovery.

The 5th and 6th grade girls who are diagnosed with AN today would most likely have developed AN anyway, but in previous generations the illness would not have been triggered, diagnosed, or treated until later in adolescence, when it is more difficult to treat. Therefore, I view younger age of onset as a positive thing.

AN is triggered by an energy imbalance – that is, a period of time in which a person’s caloric intake is lower than her body’s energy needs. My theory is that kids are developing AN at younger ages because there are more opportunities for energy imbalance to occur in younger children now compared to generations past.

Several factors contribute to this trend of children developing AN at younger ages:

1.) National hysteria about the “obesity epidemic” and well-intentioned but misguided government programs aimed at children.

Children who are predisposed to AN tend to be anxious, sensitive, perfectionistic, rigid, and overly compliant with rules. These are the kids who actually take the “obesity prevention” messages to heart and follow them to the letter. They avoid “unhealthy foods” (e.g., those high in calories) in favor of “healthy foods” (e.g., those low in calories and fat), thus creating a negative energy balance and triggering AN. The irony here is that it is very unhealthy for a growing child to eat a low-fat or restricted-calorie diet.

2.) Earlier puberty.

This generation of children tends to enter puberty earlier than their parents or grandparents. The hormonal changes of puberty, combined with the increased energy needs of the pubertal growth spurt, provide a perfect opportunity for a negative energy balance. Add to that the tendency of girls to begin dieting to counteract their body’s pubertal changes to conform to the thin ideal, and you have a perfect storm.

3.) Participation in intense athletics at younger ages.

It used to be that athletically-inclined kids did not begin intense athletic training until high school. These days, 6-year-old kids begin practicing for their sport multiple nights per week and traveling to games on the weekends. These kids have extremely high energy needs, as they must consume enough food to fuel their sports in addition to keeping up with normal growth and development. Kids who are predisposed to AN are not able to eat enough to fuel their body’s needs. Further, thinness is considered an advantage in many sports such as gymnastics, track and field, cross country, dance, cheerleading, and diving.

4.) Increased stress.

The modern lifestyle is fast-paced, rushed, overscheduled, and pressured for all of us, even children. Every time I listen to an elderly person talk about their childhood, I am struck by how different life was in the 1940’s and ‘50’s and how much more laid back things were for children then. Stress can trigger loss of appetite, which creates a negative energy balance, which can be the beginning of AN in a vulnerable child.

5.) Decrease in family meals.

For a number of reasons, including busy schedules, families are eating together less often now. If a young child is responsible for fixing her own breakfast, packing her own lunch, or microwaving her own dinner, it is much easier for her to skip meals or restrict her food intake without her parents knowing.

6.) Ignorant pediatricians.

In most cases, pediatricians are the first healthcare professionals to spot (or miss) early signs of an eating disorder. I cannot count the number of patients I have seen whose pediatrician was completely unconcerned by a child or adolescent’s weight loss or failure to gain weight. They will often say things such as “Don’t worry, she’s still in the normal weight range for her age” or “she could lose 10 more pounds and still be fine.” Even worse, many pediatricians will congratulate a child for losing weight. It is as if pediatricians have become so consumed with “fighting childhood obesity” that they have forgotten that kids are supposed to grow and gain weight from birth until age 20. Weight loss is not normal or healthy for any child or adolescent. Generations ago, people understood this, and any weight loss in a child was cause for alarm. You know how grandparents always want to feed you a lot, and say “you’re looking thin” as if it were a bad thing?

Like many diseases, AN in children presents differently than in teens or adults. Here are some key differences I have observed in the young children I treat:

1.) Young children are much less likely than teenagers to fall into AN through dieting. In little girls, the negative energy balance is more likely to result from unintentional weight loss through illness, athletic training, or “healthy eating.”

2.) Fear of fat, drive for thinness, and body dysmorphia – which are considered the hallmark cognitive symptoms of AN – are often absent in young children. Eating provokes extreme fear and resistance, but they often cannot articulate why.

3.) Young children are more likely to present with dehydration as well as malnourishment. Whereas teenage anorexics drink large quantities of water, diet soda, and black coffee, little kids sometimes cannot grasp the concept of calories. Many little kids with AN will fear and avoid anything that enters the mouth- including water, gum, vitamins, and medicine.

4.) Teens and adults with AN usually have a list of “safe foods” which are low calorie and low fat – such as salads, fruit, rice cakes, and nonfat yogurt – and they tend to fear high calorie foods such as ice cream and pizza. However, sometimes young children’s food rules and food fears make no caloric sense. For example, I have worked with children who will willingly consume any beverage, including milkshakes, but who refuse to take a bite of solid food, even a carrot stick. Other kids will have a narrow list of safe foods which are familiar but not low-calorie (e.g., chicken nuggets, pop tarts, and grilled cheese sandwiches).

5.) Young children become medically and mentally unstable much more quickly than teenagers. Post-pubescent teen girls and women, even slender ones, start out at a higher body mass and have reserves of fat. Prepubescent children are already light and very lean. A loss of even a few pounds is enough to cause severe medical problems and extreme cognitive distortions in a child. It is not uncommon for a child to go away to summer camp completely healthy and return three weeks later in grave danger.

6.) It is easier for young children to externalize their illness. They often describe feeling “taken over” by a voice or by some evil force beyond their control. They love to name their illness and refer to it in the third person, unlike teenagers who tend to balk at this exercise, or who experience their illness as more ego-syntonic. My young patients have come up with various names for their illness – the monster, the beast, the devil, Scary Larry, and Voldemort are a few that come to mind.

In my experience, young children tend to make a full recovery more quickly and more easily than teens or young adults. Because they fall into AN so quickly and because they are still so dependent on their parents, they are brought into treatment very early in the course of the illness. Their AN thoughts and behaviors are not as engrained as, say, a 16-year-old who has suffered from AN for two years.

Young children are more dependent on their parents than teens. Thus, it is far easier for both parent and child to adjust to the “magic plate” technique of parents preparing and supervising all meals and snacks – this is not so different from what most parents do for their healthy 10-year-olds anyway. It is extremely difficult for teens and especially young adults to accept the amount of parental support and supervision required for successful re-feeding.

I love treating little girls with AN. Each time I get a call from a terrified parent whose little girl who is showing signs of AN, I breathe a sigh of relief, grateful that they have come to my attention so early in the course of the illness. Although these children and their families are in for a harrowing journey, I have complete confidence that they will defeat the monster. These kids can enter their teen years fully recovered and able to enjoy high school and college unencumbered by this horrible illness.

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Leaving the Nest: 10 Tips for Parents

It’s back to school time! A new crop of 18-year-olds are leaving home to begin pseudo-independent lives in college. This is the time of year when my inbox is flooded with emails from other clinicians who are using professional list-serves to assemble treatment teams for their patients who are going off to universities in other cities or states.

“Looking for psychologist and psychiatrist in Atlanta for student entering freshman year at Emory. Bipolar disorder diagnosed in February 2011; has been stable on new meds since suicide attempt in June. Patient is very insightful but needs close monitoring.”

“Need treatment team in Boston for incoming freshman at Boston University with 4 year history of bulimia and major depression. Weight is normal but patient engages in binge/purge symptoms 3-4 times per week. Patient has delightful personality but is very entrenched in ED symptoms.”

“20-year-old patient with anorexia nervosa, social anxiety, and OCD just released from our day treatment program needs multidisciplinary treatment team in Chicago as she returns for her junior year at Northwestern University. Patient was discharged at 90% of ideal body weight and is compliant with meal plan. Needs nutritionist, psychologist, psychiatrist, and internist familiar with EDs.”

“23-year-old patient with major depression and alcoholism is entering graduate school at UMass Amherst and needs treatment team. Has 2 months sobriety.”

As I read vignettes such as these, I can’t help but wonder whether it is in the best interest of these vulnerable young people to be away at college. Adjectives like “compliant” and “insightful” and “delightful” seem to be inserted to justify the decision to send the patient away to school and/or to entice clinicians to take on these challenging cases. Qualifiers like “2 months sober” and “90% of ideal body weight” do nothing to quell my apprehension. Frankly, they frighten me more.

Let me be frank: a psychiatric diagnosis is a game changer. Any artificial deadlines, such as an 18th birthday or the start of the school year, are irrelevant. Psychiatric disorders are serious, potentially disabling (think major depression, which is a leading cause of lost productivity in the workplace), even deadly (think anorexia nervosa, which carries a 20% mortality rate). Individuals with psychiatric diagnoses can and do recover and go on to lead productive, fulfilling lives, but this requires prompt, effective treatment and a supportive, low-stress environment for a sustained period of time.

The transition to college presents numerous challenges to even the healthiest and most well-adjusted young people: leaving their hometown, family, and friends; living independently in a different city or state; adjusting to dorm life; navigating new peer relationships and social pressures; managing one’s time and money; choosing a career path and taking academically rigorous courses; assuming full responsibility for nutritional intake, sleep schedule, physical activity, and medical care.

Let’s face it: the typical college lifestyle does not promote physical or mental health. Late nights spent studying or partying, daytime napping, chronic sleep deprivation, erratic eating habits consisting mostly of processed snacks and caffeinated beverages in lieu of balanced meals. Most college students drink alcohol socially, and many drink to excess multiple times a week. Widespread use of illicit drugs as well as rampant abuse of black market prescription drugs as study aids (e.g. Adderall) or sleep aids (e.g., Xanax) is a mainstay of university life. Casual sex with multiple partners, often unprotected and usually under the influence of alcohol, is the norm on most campuses.

Navigating these challenges successfully requires a certain level of mental and emotional stability. Maintaining good self-care in an environment where virtually everyone else practices unhealthy habits requires a maturity and strength of character that is beyond the reach of most 18, 19, and 20 year olds.

I have treated patients before, during, and after college, and have counseled their parents throughout this process. I worked at three different university counseling centers during my doctoral training. During that time I worked with dozens of students struggling with psychiatric illnesses and gained an intimate understanding of what universities do, and don’t do, to support students with mental health problems.

Now, as a psychologist in private practice near two large universities, I treat a number of college students as well as high-school students who hope to go away to college in the near future. I also have a few patients who had attempted to go away to college in the past, but experienced a worsening of symptoms, a full-blown relapse, or in some cases life-threatening complications which rendered them unable to live independently. These are young people who have returned home to the safety of their families and are now going through treatment to repair the damage with hopes of living independently in the future.

I have developed the following professional recommendations for parents of young people with psychiatric illnesses based on these clinical experiences as well as the latest scientific research:

1.) If your child is a junior or senior in high school and hopes to go away to college in the future, begin working with her and her treatment team now to establish criteria to assess her readiness for going away to college. I recommend collaboratively establishing a written plan which includes specific, measurable criteria which the child must meet before she is permitted to leave home.

2.) If your child has had life-threatening symptoms (suicide attempt, drug/alcohol abuse, eating disorder), ensure that her condition is in full remission for at least 6 months prior to letting her go away to college. For example:
– A child with bipolar disorder should have at least 6 months of mood stability without any manic or major depressive episodes.
– A child who has attempted suicide should have a minimum of 6 months without any suicidal behaviors, gestures, or urges.
– A child with a substance abuse problem should have at least 6 months of complete sobriety.
– A child with anorexia nervosa should have at least 6 months of eating independently without restriction while maintaining 100% full weight-restoration with regular menstrual periods.
– A child with bulimia nervosa should have at least 6 months of normalized eating with complete abstinence from all binge/purge behaviors.

3.) A young person going off to college should have, at most, minimal or mild mental/emotional symptoms. For example, a child with an anxiety disorder who has occasional panic attacks, or who feels somewhat anxious at parties around new people, may be able to function well at college, but a child who has panic attacks multiple times a week or who avoids most social situations is not yet ready to go away.

4.) Ensure that your child has effective tools to manage any symptoms that may arise. This may include CBT or DBT skills to manage feelings of depression or anxiety.

5.) Work with your child and her treatment team to develop a self-care plan that includes plenty of sleep, physical activity, time management, and balanced meals and snacks at regular intervals.

6.) Do not rely upon university services (student health center or student counseling center) to provide therapy, psychiatric, or medical services for your child. University counseling centers are not equipped to manage the needs of students with major mental health issues. Most student counseling centers are over-worked, under-staffed, and underfunded. By necessity, most have limits on the number of sessions each student can attend, and most will not support parental involvement in treatment decisions or even communicate with parents at all.

7.) Prior to your child’s departure for college, establish a treatment team off-campus.
– Interview the clinicians over the phone and schedule a family meeting in person with the clinician before the school year starts, during the time you are helping your child move into the dorms. If the clinician is reluctant to talk with you over the phone or refuses to meet with you in person, this is a red flag.
– I recommend selecting a clinician who welcomes individualized, appropriate parental involvement in college students’ mental healthcare. This means working collaboratively with parents based upon the individual patient’s needs in light of her diagnosis, history, and developmental stage, irrespective of her chronological age.
– Ensure that your child signs releases of information allowing you to communicate with the clinician regarding your child’s care (law requires that persons over 18 must provide written permission for a mental health professional to release information to anyone, including parents).
– Use the initial family meeting to provide the clinician with any relevant history about your child’s condition. Written psychological evaluations or discharge summaries from previous treatment providers are very helpful in this regard.
– Work collaboratively with the new clinician and your child to establish frequency of contact, and nature of communication, between you and the new clinician. For instance, I often work out a plan wherein I call parents every two weeks, or once a month, with a general progress report on the patient, without revealing the specific content of sessions (e.g., “Mary is adjusting well to dorm life. She’s had some mild anxiety but she seems to be managing it well.” Or “Annie has been struggling with an increase in depressive symptoms over the past week. I will keep you posted and notify you right away if there is any indication of suicidality or deterioration in functioning.”) Be very clear about the type of information that will be shared between clinician and parents. It is important for the patient to establish a trusting relationship with the clinician and to feel secure that, in general, “what happens in therapy stays in therapy.” It is equally important for the parents to be reassured that they will be notified promptly if the child’s condition deteriorates.

8.) Have a safety net in place. Decide exactly what extra supports will be provided, and under what circumstances, if the child should experience an increase in symptoms while away at college. For example: an increase in symptoms lasting longer than one week may result in the child coming home for the next weekend, or perhaps a parent would travel to stay with the child in a hotel for a week or two.

9.) Have a plan B.
– Work collaboratively with your child and her new treatment team to establish what conditions would warrant a more serious intervention.
– Some situations, in my opinion, warrant a medical leave and an immediate return to the safety of home. For example, a suicide attempt or gesture, an episode of alcohol poisoning, a weight loss of more than 5 pounds (in the case of anorexia nervosa) or a recurrence of binge/purge symptoms lasting longer than a couple of weeks (in the case of bulimia).

10.) Always remember, and reiterate to your child: whatever happens is feedback, not failure.
– A medical leave of absence is not the end of the world. Nor is it permanent. It is simply an indication that your child temporarily needs more support than can be provided in the college setting. It is no different from a young person taking a leave of absence for major surgery or cancer treatment (try getting that done in the student health center!).
– Many young adults recover more swiftly from a relapse compared to the first time they were ill – the benefit of maturity and the motivation of wanting to return to college and independent living can be very helpful in this regard. If your child does well at home and recovers from the relapse, she may be able to return to school away from home the following semester or the following year.
– Depending on the circumstances and the course of your child’s illness, it is possible that the best scenario for her would be to live at home and attend college locally, or transfer to a school in-state and come home each weekend. Again, this is not the end of the world. If her recovery is robust after college, she will still have the opportunity to go away to graduate school or start the career of her dreams somewhere else.

Attending college is a privilege and a gift, not an inalienable right. It is not something that one must automatically do right after graduating from college. Living away from home, apart from one’s primary support system, to attend a faraway school is a privilege unique to American culture, and is not a prerequisite for success in any way. In most other countries, young people who do attend college (and not everyone does) do so locally while living at home until they are married.

Take your child’s psychiatric diagnosis very seriously, and do the right thing for her health. As her parent, it is not only your right but your duty to make these decisions, and you should be supported by a treatment team that empowers you to do so.

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When Books are Wrong

A new book on eating disorder treatment entitled When Food is Family will be published later this year. The book is written by a therapist with over 25 years of experience treating eating disorders who is also the founder and director of an eating disorder clinic.

The premise of When Food is Family is that early childhood relationships play a significant role in the development of an eating disorder. The book is based on attachment theory, which posits that “emotional support, understanding, empathy, and acceptance during a child’s development are the foundation of self-esteem and self-worth throughout life.” The author asserts that children develop eating disorders in part because they do not receive the emotional support and nurturing they need from their families, so they develop a “relationship with food” as a substitute for the intimate familial relationships they crave.

According to the online synopsis, When Food is Family “provides family members a step-by-step approach to understanding what attachment means, why connection to each other is important, how relationship breakdowns can lead to an eating disorder, how food becomes the relationship of choice, and how to go about repairing these relationships so that food (and the eating disorder) is replaced by healthy relationships within the family.”

My primary concern with this book is that it seems to set our field back about 20 years. There is no reliable scientific evidence to support the theory that disrupted attachments or dysfunctional family relationships lead to eating disorders. Nor is there any reliable evidence that treatment approaches predicated on these attachment theories help patients achieve recovery.

I absolutely agree that “emotional support, understanding, empathy, and acceptance during a child’s development are the foundation of self-esteem and self-worth throughout life.” Of course childhood environment is important in the development of self-esteem and emotional well-being. Of course “relationship breakdowns” within a family cause emotional suffering for everyone. Disrupted attachments are bad. Healthy attachments are good. But I am not aware of any evidence that disrupted attachments can lead to eating disorders.

The fact that some eating disorder patients come from dysfunctional families does not indicate that said family dysfunction caused their eating disorder. Correlation does not equal causation. Despite decades of research and millions of dollars spent on cross-sectional and longitudinal studies, researchers have not been able to identify anything that parents do, or don’t do, to cause eating disorders in their children.

The theories espoused by this book are not only unfounded and incongruent with our modern scientific understanding of eating disorders, but also potentially harmful to young patients and their families who are seeking treatment for these life-threatening illnesses.

When parents have a child with a poorly-understood, stigmatized, confusing, life-threatening illness such as anorexia nervosa or bulimia nervosa, they do not need to be told by an expert that family dysfunction is at the root of her illness. The family unit is not well-served when parents are told by an expert that they have failed to bond properly with their children, and this failure to bond has resulted in their child developing a serious illness. Parents with an anorexic or bulimic child do not need to be taught skills to develop healthy attachments with their children. They need well-informed professional support which empowers them to take aggressive action to help restore their child to health.

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The Price of Assumption

Recently, there have been heated debates between clinicians and parent advocates regarding the role of environmental and family issues in eating disorders. Some people insist that family dynamics and environmental factors play a role in the development of an eating disorder. Others bristle at the possibility. Some people say “families don’t cause eating disorders, BUT…” Others fixate on the “but” and disregard everything else.

My views on this issue are complex. Thankfully, my views became much clearer to me as I was watching an episode of the E! True Hollywood Story entitled Britney Spears: The Price of Fame. Now I am able to articulate my views on this topic in a way that most people can understand.

Numerous magazine and newspaper articles have reported that Britney Spears has been diagnosed with bipolar disorder. According to unnamed “sources close to the pop star,” Spears was suffering from untreated bipolar disorder during her public meltdown and psychiatric hospitalization in 2008. While I have not treated Britney and thus cannot ethically make a diagnosis, I will say that her erratic behavior circa 2006-2008 could be explained by a bipolar diagnosis, and that the rate of bipolar disorder is thought to be quite high amongst people in the creative and performing arts.

Scientists now know that bipolar disorder is a neurobiologically-based, genetically transmitted disease. However, rather than focusing on the neurobiology or genetics of bipolar disorder, The E! True Hollywood Story explored various influences in Britney’s life that fueled her self-destructive behavior. Clearly, this type of commentary is far more interesting to the typical E! viewer than neurobiology, my own preferences notwithstanding. Several mental health professionals were interviewed and gave their opinions as to the influence of early stardom, family problems, a stage mom, excessive fame, and extreme wealth on the pop star’s behavior. Sadly, though, the viewer is led to believe that these environmental and family issues are the cause of Britney’s downfall.

Did Britney’s family or environment cause her bipolar disorder? No. Neither family nor environment can cause a brain disorder.

Did her family or environment fuel her bipolar disorder? Yes. And here’s how: Let’s say Britney had taken a different path in life, married a plumber instead of Kevin Federline and worked as a preschool teacher instead of a pop star. Let’s say she stayed in her small Louisiana hometown, never dabbled in drugs or heavy drinking, went to bed every night at a decent hour, and maintained close, age appropriate relationships with her family and good friends, making a decent living but nothing more. Would she still have developed bipolar disorder? Yes, I absolutely believe she would have (remember, most people with bipolar disorder are not pop stars, but regular people). However, her disease would have been much more easily diagnosed and treated if she had been surrounded and supported by normal, loving people who could influence her in a positive way. As it happened, her disease was certainly protracted and exacerbated by the lifestyle of a pop star, which includes late nights, insufficient sleep, excessive amounts of alcohol and drugs, and endless amounts of power and money.

If Britney’s therapist had held a family session with Lynne and Jamie Spears and Kevin Federline in attempts to “explore the family dynamics which contributed to the disorder,” that would be a complete waste of time. The elder Spears’ and Mr. Federline – the very people who are in the best position to help Britney recover – would have felt subtly blamed and marginalized. There is nothing to be gained, and everything to be lost, by approaching a brain disorder in this fashion.

The most ideal situation for Britney would be for her parents and K-Fed (and any other people close to her) to work together to provide family-based support to help her recover and to help eliminate any environmental or family factors which may be fueling her disease. It would be most helpful for her family members to be educated about bipolar disorder and understand that it is a biologically-based brain disease that she did not choose and that they did not cause. The family would also need to know that certain environmental factors, such as pregnancy and childbirth, stress, insufficient sleep, drugs and alcohol, medication non-compliance, or excessive emotional distress, can trigger episodes and exacerbate symptoms. The family would need to learn pro-active ways to help Britney manage her environment in a way that is most conducive to achieving mental and physical wellness.

In considering this example, it is important to bear in mind that people with bipolar disorder run the gamut from pop stars to professors to businessmen to truck drivers to homeless panhandlers. Families of people with bipolar disorder also run the gamut – some are amazing and supportive, others are average, and some are downright abusive. If treatment for bipolar disorder is to be successful, the clinician must perform a thorough evaluation of the patient and family, and the information gleaned from that assessment should be used to guide treatment decisions. A good clinician would not presume that the family of a person with bipolar disorder is dysfunctional or abusive, or that family dynamics caused or contributed to the development of the disorder. Similarly, a good clinician would not presume that the family is healthy or that there is nothing the family needs to change. Quite simply, a good clinician would not assume anything – she would simply perform an assessment and tailor her approach to the strengths, limitations, and realities of that particular patient and family, in line with the most recent evidence-based research.

Eating disorders are also neurobiologically-based, genetically transmitted diseases which patients don’t choose and parents don’t cause. Family issues and environment certainly can fuel eating disorders by encouraging dieting or glorifying thinness, by making diagnosis more difficult or treatment less accessible, or by making recovery harder than it needs to be.

All eating disorder patients have a biological brain disease which most likely would have arisen, at some point in time and to some degree, regardless of family or environment. Some patients have family or environmental issues which are fueling their disorder, and some do not. If such familial or environmental issues exist, they usually become quite obvious if you do a thorough assessment. These family or environmental issues will need to be addressed in treatment, not because they caused the eating disorder, but because they can trigger or exacerbate symptoms and interfere with full recovery.

But if there are no obvious familial or environmental issues fueling the disorder, please don’t waste time searching for them. You aren’t doing the patient or the family any good by “being curious,” or “just exploring.” You are simply satisfying your own voyeuristic drive, as I fulfilled mine by watching the E! True Hollywood Story on Britney Spears.

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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.