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After Weight Restoration: What About Body Image?

Body image disturbance is one of the most insidious and painful symptoms of Anorexia Nervosa (AN). In many cases, body dissatisfaction is the last symptom to abate. However, the relationship between body image and recovery from Anorexia Nervosa (AN) is fairly complex. Many individuals with Anorexia Nervosa (AN) do not experience body image problems as a symptom of their illness. Most people with AN, however, do have some degree of body image disturbance which changes in intensity over the course of their illness and recovery.

A recent randomized controlled trial of adolescent AN treatment found that weight and shape concerns did not change significantly over the course of treatment. The authors of the study point out that, on the one hand, these results suggest that weight and shape concerns do not get worse over the course of treatment. This finding may come as a relief to patients who are terrified that they will hate their bodies if they gain weight. The authors conclude that “weight restoration alone is not sufficient to ameliorate the weight and shape concerns characteristic to AN.”

While the authors’ conclusion may be accurate in some cases, my clinical experience with AN patients as well as my knowledge of statistics leads me to a different conclusion. I have observed that the relationship between weight restoration and body image varies dramatically from person to person. When it comes to AN and body image, people tend to fall into one of the following categories:

1.) Those who do not have significant weight or shape concerns.

2.) Those who present for treatment with significant weight and shape concerns, which gradually abate over the course of weight restoration and may even disappear by the end of treatment.

3.) Those who become increasingly dissatisfied and distressed by their weight or shape as they restore weight.

My hypothesis is that the authors of the study found no significant change in body image over the course of treatment because patients in group 2 and group 3 essentially cancelled each other out, while those in group 1 did not impact the results in either direction.

As you can see from the groupings above, body image disturbance may not even be relevant for the patient (group 1), and if it is, weight restoration alone may be sufficient to improve body image (group 2). For this reason, I typically postpone addressing body image until after weight restoration has been accomplished and the patient has re-established normal eating patterns. By postponing body image work until the end of treatment, the patient and her family save a lot of time, money, and stress, as a substantial proportion of patients do not need it.

Individuals in group 3, however, may benefit from working on their body image in therapy. Helping these individuals improve their body image will be the topic of my next blog post.

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After Weight Restoration: The Role of Motivation

Motivation is the process that initiates, guides, and maintains goal-oriented behaviors. It involves the biological, emotional, social, and cognitive forces that activate behavior. Basically, motivation is what drives us to act.

In eating disorder circles, motivation generally refers to an inner drive to achieve or maintain recovery. Given that anosognosia is a primary symptom of Anorexia Nervosa (AN), most patients have little or no insight or motivation while they are ill. When a person does not perceive herself as ill, she will not be motivated to recover. When a person perceives himself as superior while undernourished, emaciated, and hyperactive, he will be highly motivated to maintain his AN.

Fortunately, motivation is not necessary to begin recovering from AN. In Family-Based Treatment (FBT), motivation is neither expected nor required of patients during Phase I (re-feeding and weight restoration). So long as the parents are highly motivated to return their child to good health (as most parents certainly are), patient motivation is unnecessary.

There are two types of motivation:

Extrinsic motivation is a drive to perform an activity to attain a particular outcome. Extrinsic motivations come from outside the individual. For example, a student is motivated to study in order to earn good grades and gain admission to an elite college.

Intrinsic motivation is an inner drive to perform an activity for personal reasons, based on interest or enjoyment of the task itself. Intrinsic motivation exists even in the absence of external reward. For example, a young artist who is passionate about painting spends hours in the studio completely immersed in her art.

Parenting often involves the use of extrinsic motivation early on, as a pathway to developing intrinsic motivation. A toddler is motivated to use the toilet by getting a star on her chart; a preschooler is motivated to follow her parents’ rules to avoid getting a time-out; a teenager is motivated to be home by curfew to avoid getting grounded.

The ultimate goal of parenting, of course, is for the children to grow into independent adults who are no longer dependent on extrinsic motivation to exist in society. Eventually, the child feels intrinsically motivated to use the toilet because sitting in soiled underpants is uncomfortable; she is kind to her friends and siblings because it is the morally correct thing to do and she wants to maintain good relationships with them; she comes home at a decent hour so that she can get a good night’s sleep and function well the following day.

Similarly, a long-term goal of treatment for Anorexia Nervosa is for the patient to be intrinsically motivated to stay healthy and remain in recovery. But while we wait for intrinsic motivation to develop, it is perfectly fine and, in many instances, absolutely necessary, to impose external motivations in order to nudge the person along towards recovery.

Patients with Anorexia Nervosa often have little or no intrinsic motivation to recover during their acute phase of illness. In fact, most patients are highly motivated to continue engaging in eating disorder behaviors because there are powerful biological, psychological, and social forces compelling them to do so. For this reason, it is often essential to use extrinsic motivations of some sort to get patients to engage in recovery-oriented behavior such as eating meals, gaining weight, refraining from purging, and attending appointments with their treatment team.

Patients with AN are often compliant, rule-abiding people-pleasers. We can harness these traits in a positive way to promote recovery. It is common for patients to report that they are eating and gaining weight to make their parents happy or to please their doctors. It is even more common for patients to comply with re-feeding and maintain their ideal weight in order to avoid hospitalization or continue playing the sport they love.

Parents often worry that, if left to her own devices, their child would most certainly eat too little, exercise too much, start purging again, and fall down the rabbit hole once more. This worry is completely valid, and this is precisely why patients need a very high level of support and monitoring for a long time after diagnosis. Incidentally, the need for a high level of support and monitoring continues for much, much, much longer than what is provided by most treatment programs or paid for by most insurance companies. One of the reasons why patients need such high levels of support for so long is that intrinsic motivation is neither realistic nor possible for most patients until they are further along in recovery.

While acutely ill patients often lack the motivation to recover, many patients who are weight-restored and further along in their psychological recovery feel very motivated to stay well. I believe that there are several reasons for this shift in motivation in the later stages of recovery:

1.) The ability to think more clearly, thanks to a well-nourished brain and body.

2.) Maturity. Patients get older and more mature as they progress through recovery, and thanks to a more developed prefrontal cortex, they can think ahead, make plans, and follow through with their intentions.

3.) Perspective. Patients in the later stages of recovery have often been through hell and back. They have reclaimed their lives, and while they may not remember much of the acute phase of their illness, they know it was awful and they have no intention of going back.

4.) Parental intervention. Parents who have helped their children recover from AN tend to be extremely motivated to help them stay well. Perhaps more importantly, they feel empowered to use the tools and strategies they’ve learned through treatment to maintain an environment conducive to ongoing recovery and to set limits, without hesitation, on any behavior that jeopardizes recovery.

Motivation seems to be the natural consequence of restored health and improved insight. Once an adolescent or young adult is no longer encumbered by AN, he begins to realize how sick he once was, and how much AN ruined his life. As he returns to school, sports, hobbies, and an active social life, he begins to build a life worth living. This new life motivates him to stay in recovery and deters him from engaging in behaviors that could lead to relapse.

I have found that older adolescents and young adults are often motivated to stay in recovery in order to achieve their goals. For example, they want to go away to college or graduate school, they want to study abroad, they want to get married and have children, they want to travel the world, they want to have a rich and meaningful life that is not dominated by intrusive thoughts about carbs or calories or the circumference of their thighs.

How can you enhance motivation in someone who is recovering from AN? Well, intrinsic motivation, by definition, must grow and flourish from within. It cannot be imposed upon someone from the outside. However, there are a few things that family members and clinicians can do which may facilitate development of intrinsic motivation:

1.) Help the person build a full, rich, meaningful life.

2.) Remind the person periodically (not forcefully or frequently) that his new life would not be possible without continued recovery.

3.) Highlight and enhance the personal characteristics that have helped the person achieve and maintain recovery (e.g., “You are such a strong, courageous, dedicated person to have overcome this illness”).

4.) Help the person identify his core values and support him in living a life that is congruent with these values. What is most important in life? How does he want to be remembered by loved ones after he dies? Unless the person is acutely ill with AN, he is unlikely to say that being thin, exercising excessively, or avoiding sugar and flour his core values.

Staying focused on core values and pursuing a meaningful life are powerful motivators and potent antidotes to the anorexic thoughts that come to visit from time to time.

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After Weight Restoration: The Role of Insight

One of the hallmark symptoms of Anorexia Nervosa (AN) is anosognosia, or a brain-based inability to recognize that one is sick. For this reason, most patients have little or no insight when they first present for treatment. Even months into effective treatment, most patients with AN continue to demonstrate anosognosia from time to time, if not consistently. The irony here is that most patients with AN do not believe they are sick until after they have gotten well.

I am outspoken in my belief that insight is unnecessary, not to mention unlikely, in early recovery from Anorexia Nervosa (AN). I do not expect my patients to have any insight whatsoever early on in their treatment with me. I expect kids with AN to present in my office denying that they have a problem. Their lack of insight does not delay or undermine treatment one bit.

In Family-Based Treatment (FBT), the patient is not required to demonstrate any insight at all during Phase I (Re-feeding and weight restoration). Phase II (returning control of eating to the adolescent) and even Phase III (establishing a healthy adolescent identity) can be successfully completed with a relatively small amount of insight on the patient’s part.

The re-feeding and weight-restoration components of treatment can be achieved without the patient’s consent or compliance. Through FBT and similar family-centered approaches, parents can feed their children complete, balanced nutrition and ensure that they maintain a healthy weight for as long as necessary. In theory, a patient could exist in an externally-maintained state of physical health forever, which would be far better than suffering the long-term medical and psychological consequences of AN. But this is not recovery.

Children and younger teens tend to lack the maturity to develop good insight even after their AN has been in remission for quite some time. Lack of insight is completely normal at this stage of development, even for kids who have never had a brain disorder. It is not necessarily problematic for recovering adolescents to lack insight as long as they are living safely under their parents’ roof.

For older adolescents and young adults, however, there comes a point later in recovery, after physical health is restored and most mental symptoms have subsided, when a patient does need to develop some insight about their illness and “own their recovery.” Patients do not need insight to get well, but they certainly do need insight in order to live a healthy, fulfilling, independent life.

As a side note here, the type of insight I am referring to here has nothing to do with “discovering the root cause” or “learning to love yourself” or “finding your voice” or any of the other talking points commonly referenced in ED recovery circles. The important insights to gain, in my opinion, are the following:

1.) Acknowledging and accepting that you have (or had) an eating disorder, which is a biologically-based brain illness that you did not choose to have and your parents did not cause

2.) Acknowledging and accepting the possibility of relapse

3.) Ability to recognize eating disordered thoughts, feelings, and behaviors in yourself

4.) Understanding the necessity of maintaining full nutrition, every day, for life

5.) Accepting the necessity of maintaining your ideal body weight in order to reduce the risk of relapse

How do you help a person who is recovering from AN to develop insight? It’s tricky, and it varies considerably based upon the patient’s own unique experience of having AN. Unlike full nutrition and weight restoration, insight cannot be thrust upon someone against their will. The patient must be an active participant in the process.

I find it helpful, as a therapist, to have frank conversations with patients and their parents about the biological basis of AN, potential triggers, vulnerability to relapse, and the importance of practicing good self-care. A single conversation at the start of treatment is rarely sufficient. Instead, I integrate these conversations into most of our sessions to help the patient absorb and internalize this information. For the first few months of treatment, these discussions are primarily for the benefit of the parents, as most kids are too malnourished and shut-down to process this information. However, after weight restoration and brain healing, these discussions can have a powerful impact on recovering kids.

Parents often have these insight-building conversations with their recovering teens at home. Often, teens will get defensive, shut down, or lash out when parents bring up these topics. But sometimes kids actually listen!

Many weight-restored patients go through a phase of romanticizing their AN, longing to return to the days of extreme thinness, perpetual motion, and hyper-focus on academics and athletics. While these feelings are understandable and typical at a certain stage of recovery, they need to be counterbalanced with conversations about the negative impact AN had on their bodies, their minds, and their lives. Otherwise, it is all too easy for recovering people to view AN through “rose-colored glasses.”

Bear in mind that the development of insight can take years. Recovered teens who initially presented for treatment at age 13-14 (the typical age of onset) will often show a blossoming of insight around age 17-18, just as they are preparing to leave home for college. This newfound insight is often the result of a variety of factors, including consistent full nutrition, brain healing, normal adolescent developmental processes, maturity, frontal lobe development, and successful therapy. I have worked with many adolescents for whom this happens beautifully, organically, and right on time. These kids go off to college in other states and thrive.

In other cases, however, the timing may be far less convenient. Those who develop AN at 16 or 17 years of age may not be sufficiently recovered to develop the insight needed to manage their illness independently at that magical age of 18. Similarly, who relapse during their junior or senior year of high school may have a setback in the process of insight development and thus may not be ready for independence right after high school.

In some cases, kids are diagnosed in childhood or early adolescence but don’t receive effective treatment until late adolescence. In these cases, it may take even longer for insight to develop if the illness has become entrenched and emotional maturity lags far behind chronological age.

Further, teens who have suffered through months or years of ineffective treatment may have built up an arsenal of bogus myth-based insight that has nothing to do with the reality of their illness. For example:

• “I developed AN as a way to cope with feeling out of control in life.”

• “I have to want to get better on my own. I have to do this for myself.”

• “Re-feeding doesn’t help us discover the root cause of your illness.”

• “I am enmeshed with my parents and this is keeping me sick. I need to become more independent.”

These myth-based “insights” very often result in parental alienation and protracted illness.

As you can see, all insight is not equal. The insights worth having are those that are based in empirical science, those that empower parents to help their offspring recover, and those that serve to help patients achieve and maintain their physical and mental health while living a full and meaningful life.

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After Weight Restoration: Envisioning Recovery

In making a post weight-restoration recovery plan, I find it helpful to envision what full recovery will look like for this particular individual, and then break it down into small steps to help her achieve these ends. In my opinion, full recovery from AN involves all of the following:

• Ability to feed oneself the appropriate quantity, quality, and balance of nutrition.
• Ability to maintain one’s optimal body weight with an age-appropriate level of independence.
• Ability to accept and tolerate one’s body size, shape, and weight.
• Complete absence of eating disordered behaviors such as fasting, food restriction, binge eating, and purging.
• Ability to enjoy regular physical activity without compulsion.
• Engaging fully in all aspects of life, including school, family life, social life, and recreational activities. For older patients, this may also include employment, dating and romantic relationships.
• Freedom from constant preoccupation with food, weight, and body image.
• Mindful awareness of one’s predisposition towards AN and ability to avoid or manage potential triggers.

In my opinion, full recovery from AN does not necessarily involve any of the following:
• Ability to eat intuitively
• Ability to eat spontaneously
• Ability to eat sweets or “junk food”
• Return to the eating habits one had prior to the onset of the eating disorder
• Loving one’s body
• Not caring about one’s weight at all
• Complete absence of eating disordered thoughts
• Freedom from monitoring (for example, going for long periods without being weighed)

Of course, it would be wonderful if a person recovered from AN could do any or all of the above. If one of my patients does one of these things, I view it as a very positive sign, an indication that a person has reached a new level of freedom from AN. Parents of recovering kids often long for them to walk into the kitchen and grab a handful of chips, eat candy with abandon, or ask to go out for ice cream.

If a person in recovery does these things, that is fantastic, and it should be celebrated! Often, these things happen naturally after a year or two or three of weight restoration. But these things may not be realistic for some people with a history of AN. And if these things never happen, that is OK.

What is most important, in my opinion, is for a person in recovery to do whatever it takes to live a rich, happy, healthy, fulfilling and productive life. This is what recovery means to me.

Sometimes parents and clinicians worry that a patient’s avoidance of sweets, or inability to eat intuitively, or adherence to a structured plan of meals and snacks is “part of the disorder.” This may be true. But this is not inherently a bad thing.

Some recovered people may never want to be weighed again, because it reminds them of what it was like when they were ill. Some recovered people may resent having to eat three balanced meals every day, or not being able to diet like their friends, or not getting to participate in fasting for religious reasons like their families. Sometimes they just long to be “normal.” These feelings are completely understandable. However, this does not change the reality that people recovered from AN often have special needs which require them to be careful about their health in ways that other people are not. We cannot rewind time to the days before the illness began. We should not pretend AN never happened.

I find it helpful to assess a person’s stage of recovery using the following question:

“Can this person maintain good physical and mental health, and live a meaningful, productive, independent life, while _______________________.”

Then, fill in the blank with the issue in question to help determine whether it is in the patient’s best interest to accept it or change it.

For example:
• Can this person maintain good physical and mental health, and live a meaningful, productive, independent life, while also getting weighed every week at the doctor’s office? YES
• Can this person maintain good physical and mental health, and live a meaningful, productive, independent life, while being 5 pounds underweight? NO
• Can this person maintain good physical and mental health, and live a meaningful, productive, independent life, while never eating dessert or snack foods? YES
• Can this person maintain good physical and mental health, and live a meaningful, productive, independent life, while restricting dietary fat or carbohydrates? NO
• Can this person maintain good physical and mental health, and live a meaningful, productive, independent life, while being tormented by frequent thoughts about food and weight? NO
• Can this person maintain good physical and mental health, and live a meaningful, productive, independent life, while wishing she had thinner legs and having occasional thoughts about restricting food? YES
• Can this person maintain good physical and mental health, and live a meaningful, productive, independent life, without being able to eat intuitively or spontaneously? YES

Keep in mind that accepting something is not the same as liking it, and acceptance does not mean abandoning hope that things will improve. Rather, acceptance is about acknowledging reality and embracing it without judgment, while doing what works, in this moment, to maintain wellness.

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After Weight Restoration: What’s Next?

Scientific research has established that consistent full nutrition and weight restoration are the essential first steps in recovery from Anorexia Nervosa (AN). A recent study by Accurso and colleagues – the subject of my previous blog post – demonstrated that weight gain is a catalyst for broader recovery in Anorexia Nervosa (AN). The necessity of normalizing eating patterns and restoring weight applies to all patients with AN: male and female, young and old, chronic and acute, inpatient and outpatient, mild and severe. While the task of supporting weight restoration in a patient with AN is daunting and exhausting, it is very straightforward.

After weight restoration, the next steps in recovery are less certain, more varied, and highly dependent on individual differences. The best way forward is often ambiguous for someone who is well-nourished but deeply entrenched in the illness. For some people with AN, weight restoration alone is sufficient to bring about full remission. But for others, weight restoration is merely the first step in a long journey towards wellness. Unfortunately, there is little scientific research to guide us in terms of how to help people with AN who are weight-restored but still suffering mentally.

Parents are often quite adept at determining what their child needs in order to move forward. For this reason, parents continue to be essential participants on their loved one’s treatment team even after her weight is restored. Although their role on the treatment team may change a bit, and their degree of involvement may be modified, they continue to be their loved one’s greatest resource in recovery.

After weight restoration, I collaborate with the patient and her family to figure out how we can work together to support her towards full recovery. This typically involves a written treatment plan that we all agree upon. I find it incredibly helpful to have a written treatment plan, as this eliminates confusion and keeps everyone on the same page, working towards common goals.

It is not always clear what the patient needs next, so treatment after weight-restoration is very often a process of trial and error. We create a plan, implement it, and see how the patient does. If she moves forward in recovery, fantastic! If she remains stuck or regresses, we reassess her situation and modify her plan based on lessons learned from her struggles.

My next few blog posts will examine various aspects of treatment and recovery for weight-restored patients with AN. Please feel free to leave a comment if there are any particular issues you’d like me to cover on this topic in my next series of posts.

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Weight Gain Predicts Psychological Improvement in Anorexia Nervosa

A recent study published in the journal Behavior Research and Therapy demonstrated that weight gain was a significant predictor of improved psychological functioning in adolescents undergoing treatment for anorexia nervosa (AN). In other words, adolescents who gained more weight during treatment did better mentally than those who gained less weight. This study also showed that weight gain early in the course of treatment had a greater impact on psychological recovery than weight gain later in the course of treatment.

This finding is extremely relevant not only to clinicians who treat adolescent AN, but also to the adolescent patients themselves and their families. The process of re-feeding and restoring weight often feels agonizing for patients and may cause tremendous stress to caregivers. Psychological recovery lags behind physical recovery, so patients often feel worse before they start to feel better. This study provides objective evidence that it is in the patient’s best interest – both physically and psychologically – to eat more and gain weight as soon as possible after diagnosis.

Weight gain is an essential component of treatment for patients with AN. The knowledge that full nutrition is necessary to repair the physical damage caused by AN – including weakened heart, low blood pressure, hypothermia, osteoporosis, stress fractures, lanugo, amenorrhea, infertility, and risk of premature death – helps many patients and families to persevere through the difficult days of re-feeding. Now, patients and families can hold onto hope that weight restoration will bring about psychological improvement as well. This study provides families with direct scientific evidence that gaining weight gives their loved one a greater chance of recovering mentally, emerging from the fog of depression, and reclaiming a meaningful life free from food and weight preoccupation.

Patients in this study were randomly assigned to receive either Family-Based Treatment (FBT) or Adolescent Focused Treatment (AFT). The authors of this study found that weight gain predicted psychological recovery regardless of the type of treatment (FBT vs. AFT) the patient received. This finding may be especially relevant to clinicians who treat adolescent AN using individual therapy. A common criticism of FBT (usually made by clinicians who reject FBT without really understanding it) is that it focuses on weight gain at the expense of the adolescent’s psychological wellbeing. This study clearly demonstrates that weight gain and improved psychological functioning are not mutually exclusive. On the contrary, weight gain and improved psychological functioning are strongly correlated!

It is clear that FBT supports the adolescent’s psychological wellbeing indirectly by promoting regular nutrition and steady weight gain, which help to repair the brain damage caused by malnutrition. I would also argue that FBT has a direct impact on the adolescent’s psychological wellbeing by externalizing the illness, removing any sense of self-blame the adolescent may have, supporting her emotionally, and relieving her of the burden of fighting this deadly illness alone.

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Exercise Caution: Physical Activity and Eating Disorder Recovery

Compulsive exercise is often a symptom of eating disorders. It is common for a child who is developing an eating disorder to take a sudden interest in running and other vigorous forms of exercise. Given that exercise is a symptom which is directly related to the energy imbalance that triggers and maintains a restrictive eating disorder, it is important for clinicians and caregivers to monitor and manage patients’ exercise during treatment and recovery.

When a patient has an active eating disorder, it is generally ineffective to use exercise or sports as an “incentive” to get him to eat more or gain weight. Even the patient who absolutely loves soccer, and says he would do anything to keep playing, probably won’t be able to eat enough to make that happen. The malnourished anorexic brain is just not capable of overriding symptoms, no matter how alluring the reward may be.

For people with eating disorders, exercise poses numerous medical risks including stress fractures, osteoporosis, muscle wasting, and heart arrhythmia. Further, exercise can be counterproductive to treatment goals when a patient needs to restore weight. For these reasons, I recommend that patients with Anorexia Nervosa or Bulimia Nervosa abstain from all physical activity until they meet the following criteria:

a.) Complete weight restoration
b.) Complete abstinence from binge/purge behaviors for at least two weeks
c.) Consistently eating complete, balanced meals with little resistance
d.) Sufficient hydration
e.) Willingness and ability to increase nutrition and hydration to compensate for activity
f.) Medically cleared to exercise by physician

Explaining the dangers of exercise to the eating disordered patient is important but rarely sufficient to curb the compulsion. Patients with exercise compulsion need an authoritative source to tell them directly, in no uncertain terms, that all exercise must be stopped until the above criteria are met. In my practice, the hiatus from exercise typically lasts for several months, but this varies widely based upon the patient’s severity of illness and response to treatment.

Abstaining from all physical activity means stopping sports, dance classes, martial arts, and any other extracurricular activity that involves movement. It also means no PE at school, no bike riding, no home workouts, no yoga, and no long-distance walking.

Parents can do a number of things to help prevent their ill child from exercising. They can obtain a doctor’s note to except him from PE class, they can call the coach to inform him that the child will not be able to play for the rest of the season, they can give him a break from his usual chore of walking the dog.

When the exercise compulsion is strong, more serious measures must be taken. Some parents may need to get rid of home exercise equipment, terminate their child’s gym membership, or hide her running shoes. Parents must be extremely vigilant in protecting their child from secretly exercising.

Any time spent behind closed doors presents an opportunity for the patient to succumb to the exercise compulsion. It is not unusual for anorexic patients to exercise in the middle of the night, to sneak out of the house to go running, or to do calisthenics on the bathroom floor. Sometimes it is necessary for parents to sleep in the same room with their child and provide round-the-clock supervision for weeks or months at a time in order to break the exercise compulsion.

Full nutrition and weight restoration often help tremendously in lessening the compulsion to exercise. Many recovering kids will lose interest in exercise once the compulsion has faded. These are often the kids who first began exercising in the context of their eating disorder, but never really enjoyed their activity. Once recovered, these kids will often return to lives that are not particularly active, and decide to pursue other interests instead, such as music, art, or a very busy social life.

For some children, exercise has been a part of their lives since they were very young, but took on a new intensity when the eating disorder arrived. For example, a 12-year-old girl who loves to dance and has taken ballet since preschool may suddenly start taking eight dance classes a week instead of her usual four. As another example, a teenage basketball player may begin rising at 4:00 AM to go jogging in addition to afternoon practices with his team. These kids suffer tremendously as the activities they love become tools for their eating disorder to use against them.

In my experience, these patients are often able to return to the sports and activities they previously enjoyed without compromising their recovery, so long as they are physically and mentally ready to do so, and so long as their activity is monitored and limited. The young dancer described above may return to her studio, once weight-restored and back in school, for three or four classes per week. The recovering teenage basketball player may be permitted to practice with his team, but would not be allowed to exercise outside of scheduled practices.

While it’s rarely effective to use sports as an incentive for a sick patient to get well, sports can be a great incentive for a recovered patient to stay well. Many patients, once physically and psychologically recovered, feel motivated to do whatever it takes to maintain their exciting new life. I have found that exercise contracts work well for these patients.

For example, my former patient, whom I will call Andy, played on a competitive year-round traveling soccer team. When Andy developed Anorexia Nervosa at age 14, his parents and I agreed that he would need to take five months off from soccer to restore his weight and focus on his recovery. Once he was feeling better, Andy became excited to rejoin his team.

Andy’s family and I supported his return to soccer so long as it did not interfere with his recovery. We developed a written contract which stated that Andy may participate in club soccer so long as he maintained his weight, ate all of his meals and snacks, drank 8 glasses of water per day, abstained from exercise outside of team practices, and attended monthly therapy sessions. We also agreed that he would drink a smoothie after each soccer practice and that one of his parents would travel with him to all tournaments to ensure that he ate enough to fuel his activity.

Certain solo long-distance endurance activities, such as cross country running and competitive swimming, pose particular risks for patients predisposed to eating disorders. This is in part due to their very high energy requirements, in part due to their solitary nature, and in part due to the extreme rigor of the activity which demands a high level of dedication. Not only do these factors attract young people who are competitive, driven, and dedicated (read: predisposed to eating disorders); they also create the perfect formula for triggering and perpetuating an eating disorder.

If a recovered person who had been a runner or a swimmer prior to getting sick expresses a desire to return to athletics, it may be preferable for him to choose a different sport. Team sports such as volleyball or basketball may be more conducive to sustained remission.

Activities with an artistic or aesthetic element, such as gymnastics, dance, figure skating, and diving, can pose a risk for those in recovery from eating disorders, particularly if body dissatisfaction and drive for thinness were major symptoms of the patient’s illness. If a former dancer/gymnast/athlete wishes to return to these activities, certain factors must be considered. In addition to the criteria for resuming exercise that I listed above, these young people should attain a certain level of body acceptance prior to returning to their activity. They need to feel at least somewhat comfortable in a leotard, and they must be strong enough to challenge or ignore any negative body thoughts that may arise. If a young person experiences a noticeable increase in eating disordered thoughts or behaviors upon returning to her activity, this is an indication that she likely needs more time off to recover before she can safely return.

It is important for dancers and athletes to return to a nurturing environment that does not encourage food restriction, weight loss, or winning at all costs. It is helpful for parents to speak with coaches and trainers to alert them of their child’s vulnerability and ensure that the atmosphere is conducive to health and well-being. There are dance teachers and coaches who encourage full nutrition, healthy body image, self-care, and a balanced approach to life. These adults can be positive forces in helping a young dancer or athlete sustain remission.

It is of utmost importance that family members and treatment professionals convey, through their words and their actions, that the patient’s physical and mental health are the number one priority. Participation in activities that jeopardize health or fuel emotional distress should be avoided. Participation in activities that bring joy and enhance well-being should be encouraged.

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Exercise and Eating Disorders: It’s Not What You Think

Exercise very often plays a role in the development of restrictive eating disorders, particularly Anorexia Nervosa (AN). Some people view exercise as “a form of purging” or “a way to get rid of calories.” These explanations seem to make sense in light of modern western society’s views on exercise, similar to the theory that people with AN restrict their calories in order to conform to society’s thin ideal. But like the thin ideal theory, the “exercise purging” theory is an erroneous attempt to make sense of a puzzling symptom in the context of modern society.

In AN, excessive exercise, just like food restriction, is a biologically-based symptom, driven by something beyond conscious control or awareness. Patients do not exercise “to burn calories,” although they may insist that burning calories is their motivation. Consider, for example, the fact that even patients who know they are too thin are motivated to gain weight (yes, such patients do exist), often cannot stop themselves from moving unless they are forced to do so. Young children with AN are especially susceptible to the drive to exercise even though they have no idea what calories are or how to burn them.

A little history may help to put this into context. People did not really exercise for the purposes of physical fitness and attractiveness prior to the “exercise boom” of the 1970’s and 1980’s. However, hyperactivity was a symptom of AN long before Jane Fonda’s exercise videos found their way into American living rooms.

The nineteenth-century British Physician William Gull, the first clinician to describe AN medically, was surprised by the seemingly boundless energy that his anorexic patients possessed despite their emaciated state. In his 1874 paper entitled Anorexia Nerovsa, he wrote the following description of a young anorexic girl: “The patient complained of no pain, but was restless and active…it seemed hardly possible that a body so wasted could undergo the exercise which seemed agreeable.” Clearly, this young woman was not motivated by the pursuit of a thinner body, as the idea of exercising to “burn calories” would not emerge until a century later.

Animal research has shown that the hyperactivity commonly associated with AN is rooted in neurobiology and may serve an adaptive evolutionary purpose. For example, activity-based anorexia can be experimentally induced in rats which, like humans, evolved as opportunistic omnivorous foragers. When food-deprived lab rats are given free access to a running wheel, they become hyperactive, lose large amounts of weight, and will often die unless they are removed from these experimental conditions. I highly doubt that these rats were running excessively to purge calories, ward off obesity, or pursue some unrealistic standard of rodent beauty.

So why would AN, which leads to numerous health problems, infertility, and death, remain in our gene pool for tens of thousands of years? Shan Gusinger, an evolutionary biologist and a psychologist, posits that AN has evolved in humans as a means of helping us flee from food-depleted environments. The restless energy, grandiosity, and lack of awareness of one’s starved body allowed prehistoric anorexics to lead their tribes in migrations from food-depleted areas to plentiful ones.

Once the anorexic leader and her tribe arrived in a plentiful environment, the tribe feasted, pressuring the anorexic leader to indulge in food with them. In the absence of modern society’s thin ideal and without our modern obesity hysteria, prehistoric anorexics may have been able to allow their families to feed them, restoring their health and fertility. Even if the anorexic herself died of her condition or was rendered infertile, her close genetic relatives survived and reproduced, thus ensuring the continuity of AN into the next generation.

In our modern world, where children are encouraged to exercise more and make “healthy” (e.g. lower calorie) food choices as early as kindergarten, it is no wonder that AN is still around. During the pre-teen years, when rapid vertical growth and pubertal development demand extra energy, girls and boys are hit hard with the social pressures to be thin (for girls) or lean and ripped (for boys). The rapid weight gain that is necessary for growth and development is feared and despised in these growing children (and often, sadly, in their parents and pediatricians).

Adding add fuel to the fire, the pre-teen years are when intense and time-consuming athletic training begins. Competitive sports provide socially-applauded outlets for the young anorexic’s hyperactivity. No one bats an eye at the 12-year-old dancer who spends hours each evening at her studio in preparation for her next audition, or the 11-year-old boy who plays multiple back-to-back games each weekend with his elite travelling soccer team. Meanwhile, these children are making “healthy food choices,” consuming too few calories and fats to keep up with normal growth, let alone intense daily exercise.

In these vulnerable children, their vertical growth is stunted, their pubertal development is halted, and their intense athletic drive is praised by adults. And before you know it, they have fallen down the rabbit hole and developed full-blown AN. In this way, hyperactivity serves as both a precipitating factor and a perpetuating factor in the development of AN.

In my next post, I will discuss the role of exercise in eating disorder recovery.

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Effective Treatment for Bulimia Nervosa: A Good Start

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

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

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

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

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

I draw the following conclusions from this study:

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

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

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

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

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

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

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

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

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

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Expanding Our Minds: Towards a Biologically-Based Understanding of Eating Disorders

I read the abstract of a recently published journal article which illustrates one of the major problems in the field of mental health treatment in general, and eating disorder treatment in particular. The article, authored by Jim Harris and Ashton Steele and published in the latest issue of Eating Disorders: The Journal of Treatment and Prevention is provocatively titled Have We Lost Our Minds? The Siren Song of Reductionism in Eating Disorder Research and Theory.

The authors state that, over the past decade, “the focus of eating disorder research has shifted from the mind to the brain.” I disagree with this assertion on two levels. First, the statement implies that the mind and the brain are separate entities. They are not. The “mind” is simply a range of conscious functions which are carried out by the brain: for example, thoughts, beliefs, emotions, intentions, motivations, and behaviors. These mental functions originate in the brain, are executed in the brain, and are interpreted by the brain.

Indeed, recent developments in genetics and neuroimaging techniques have allowed scientists to study the structure, function, and circuitry of the brain in far greater detail than was possible before. Researchers have utilized this new technology to generate and test novel hypothesis about the biological underpinnings of eating disorders. The results of these studies have indicated that eating disorders are genetically inherited, biologically-based brain disorders, similar to bipolar disorder and schizophrenia.

However, while research in the area of genetics and neuroimaging has proliferated in the eating disorders field, there has been no shortage of research on psychosocial factors or non-medical treatments for eating disorders, such as FBT and DBT. Contrary to Harris and Steele’s assertion, we have not “lost our minds.” We’ve simply expanded our minds and deepened our realm of investigation to study the biological underpinnings of mental functions as new technology has allowed us to do so.

Harris and Steele assert that the brain disorder model of eating disorders necessitates that treatment targets the underlying neurobiological abnormality; namely, medication. The authors then conclude that the brain disorder model of eating disorders is misguided because no pharmacological intervention has been shown to significantly benefit patients with anorexia nervosa.

This simplistic assumption and its corollary reflect a lack of basic understanding of the relationship between the brain and the symptoms of psychiatric illness. The authors fail to recognize the fact that certain non-medical interventions HAVE been consistently shown to benefit patients with biologically-based brain illnesses.

For example, it is widely accepted amongst medical and psychological professionals, as well as the general public, that autism is a biologically-based brain illness. There are no medications which have shown to consistently benefit children with autism. The gold-standard of treatment for autism is early intervention with applied behavior analysis (ABA), which is a form of behavior therapy focused on skills building, parent training, and modifying environmental contingencies. Most children with autism do extremely well with this type of treatment, and many of them can be mainstreamed in classrooms with typically developing children.

Sound familiar? It should, because that is precisely what is happening in the world of eating disorder treatment. The treatment approaches which have shown the most promise in the world of eating disorders are psychological and behavioral treatments such as Family-Based Treatment (FBT) for anorexia nervosa and Cognitive-Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) for bulimia nervosa.

There are a number of misconceptions about these types of treatments. For example, many people believe that FBT is merely re-feeding. This is not so. FBT is a psychological and behavioral treatment – a form of psychotherapy – and parental control of re-feeding is but one component of the first phase of this three-phase treatment model.

As another example, some people believe that CBT and DBT are merely “learning skills.” Again, this is a misconception. CBT and DBT are forms of psychotherapy which involve a relationship with a therapist who instills hope, provides support and feedback and accountability, promotes awareness of thoughts and feelings, and teaches adaptive skills for managing life’s challenges.

Contrary to popular belief, psychotherapy does not consist of lying on a couch and talking about your mother. That myth stems from psychoanalysis, an antiquated form of treatment commonly practiced in the mid-20th century which has no evidence base. Modern evidence-based psychotherapy is entirely different: it is active, directive, and believe it or not, effective.

I get a bit irritated when uninformed people make sweeping generalizations on either side of the fence, such as “psychotherapy doesn’t work for eating disorders,” or, on the flip side, “psychotherapy is the best way to treat eating disorders.” The truth is more specific: evidence-based psychotherapies are effective in the treatment of eating disorders.

From my perspective, focusing on the biological basis of psychiatric illnesses does NOT mean:

• That the illness can only be treated with a pill
• That psychological and social factors are irrelevant
• That environment doesn’t matter
• That the patient can’t do anything about it
• That the psychologist’s job is obsolete

Focusing on the biological basis of eating disorders DOES mean:

• That eating disorders are illnesses, no different from cancer or diabetes or schizophrenia
• That patients do not, and in fact cannot, choose to develop eating disorders
• That eating disorders are not caused by family dynamics or social pressures
• That prevention efforts aimed at improving body image are unlikely to be effective
• That a person must have a certain genetic predisposition in order to get an eating disorder
• That biological relatives of eating disorder patients are at risk for developing the disorder themselves
• That medication can be helpful, though not curative, in some cases
• That full nutritional restoration, and thereby correcting the brain-based symptoms of starvation, is a necessary first step in treatment
• That psychotherapy focused on resolving underlying issues or gaining insight into the origins of one’s illness is unlikely to be effective in resolving eating disorder symptoms
• That behaviorally-based psychological treatments focused on symptom management and skills building can be very effective, in large part because they change the brain
• That last century’s theories about the causes of eating disorders are inaccurate

I wish that Harris and Steele, and all professionals involved researching or treating eating disorders, could grasp these points. If the general population had this basic understanding of eating disorders, then patients and their families would be viewed with compassion and understanding rather than judgment or smug clichés (e.g. “she needs to learn to love herself;” “it’s all about control”).

The past decade represents a monumental shift in the way expert clinicians view eating disorders. In fact, it will be 10 years ago this fall that I saw my very first eating disorder patient. As a bright-eyed graduate student hungry for hands-on clinical experience, I chose a training rotation at an adolescent eating disorders clinic. On my first day at the clinic, not much older or wiser than the teenagers I was about to start treating, I was introduced to “the Maudsley Approach,” a promising new treatment method from the UK. And the rest, as they say, was history.