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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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A Seat at the Table: Understanding and Helping the Siblings of Eating Disorder Patients

I feel honored to serve on the Professional Advisory Panel for FEAST, a nonprofit organization which provides support and information to the parents and families of people with eating disorders. Last weekend, I had the privilege of presenting at the second annual FEAST conference in Alexandria, VA. I spoke to a group of parents about understanding and helping their other children while also caring for their eating disordered child. Below are some of the major points from my presentation.

Eating disorders can impact the patient’s siblings from various angles:

• Through their parents. When a child is ill with an eating disorder, her siblings often receive less attention from their parents. The parents may be physically absent from the home, traveling to faraway treatment centers and attending many different appointments locally. Parents often feel worried, stressed, and irritable, and these emotions can easily spill over into their relationships with their other children.

• By impacting family life. Family meals with an eating disordered person can be tense or explosive. For this reason, siblings may begin to dread family meals or avoid them altogether. Family trips may be cancelled or ruined by the eating disorder. The financial burden of ED treatment impacts the entire family, including siblings.

• Through their social environment. Parents may not be available to drive siblings to their lessons, sports events, and social activities when they are spending long hours preparing and supervising meals and driving the ill sibling to appointments. Siblings may feel embarrassed to invite friends over when their ill sister or brother is acting particularly bizarre. Siblings may have to deal with gossip from friends and neighbors. They may feel conflicted about telling their friends about their family’s situation, and they have to deal with the stigma of mental illness.

• Through the change in eating habits. Parents are encouraged to serve their anorexic children high-calorie foods to restore their weight. Sometimes siblings over-indulge in these foods and gain unneeded weight.

• Through their genes. Biological siblings of eating disorder patients are 10 times more likely to develop an eating disorder compared to the general population. Additionally, siblings of eating disorder patients may inherit genes that predispose them to other psychiatric illnesses, including depression, OCD and other anxiety disorders, substance abuse, ADHD, and autism.

Brothers and sisters may experience a variety of emotions while their sibling is ill with an eating disorder. They may worry that their sibling will get sicker or die. They may grieve for the loss of their sibling’s true personality while she is consumed by the illness, and they may miss her terribly if she is away from home for a lengthy hospitalization or residential treatment stay. They may worry about their own risk for developing an eating disorder. They may feel angry at their sibling for putting the family through hell or making mealtimes miserable. They may feel jealous because of all of the attention their ill sibling is getting. Siblings may react by withdrawing from friends and family members, having difficulty at school, or acting out. They may feel sad or hopeless. They may have difficulty concentrating. Very young siblings may manifest their distress through physical symptoms (e.g., tummy aches, trouble sleeping).

It may not be possible for parents to shield siblings completely from the impact of the eating disorder. However, there are some steps that parents can take to minimize the damage and help siblings cope:

• Immediately upon diagnosis, provide siblings with age-appropriate information on their sibling’s diagnosis, symptoms, and treatment. Explain that the disorder is biologically-based and that the child did not chose to have it. I have a Sibling reading list, as well as a list of Q & A for siblings of AN patients. Even preschool-age siblings can understand a few basic points: “Your sister has a disease in her brain called anorexia which has made her very sick. She is acting different because of her sick brain; it is not her fault. We need to help her get better. Mommy and Daddy will be very busy taking care of her, but we still love you very much.”

• Be frank with siblings about the seriousness of the eating disorder, including the possibility of death. This honesty helps siblings understand why it is so important that the family intervenes immediately and aggressively, and why other activities have to take a back seat for now.

• Be honest with siblings about the reality of dealing with the eating disorder. Acknowledge that, for a period of time, the whole family will be under stress, family life will change, and you may not be able to spend as much time with them.

• Bring siblings to some Family-Based Treatment (FBT) sessions so that the therapist can explain the eating disorder to them, describe the treatment process, answer their questions, and tell them how they can support their ill sister or brother.

• Make a point of scheduling one-on-one time with each sibling and talking with them about their lives apart from the eating disorder.

• Talk with siblings about their feelings and reactions to the eating disorder. Let them know that it is totally normal and understandable for siblings to feel worried, angry, jealous, resentful, or sad in this type of situation.

• Ensure that siblings remain in a support role, rather than taking on a parent’s role. Lock and LeGrange, authors of the FBT manual, call this process “maintaining intergenerational boundaries.” Siblings can help their ill sister by providing her with distraction before, during, and after meals, by being good listeners and providing empathy, and by engaging her in normal sibling activities. Siblings can help by taking over kitchen chores that the eating disordered person is not well enough to do, such as setting the table or doing the dishes. Do not involve siblings in the actual process of re-feeding or supervising meals, as this can put them in a delicate position of being torn between “loyalty” to their ill sister and the responsibility of reporting ED behaviors to their parents.

An eating disorder can also impact siblings in a positive way. For example, they may grow closer to their ill sibling and value her more after almost losing her. They may feel needed and important in the process of supporting their ill sister or brother. Siblings may become more aware of EDs and other psychiatric illnesses in their friends and try to intervene whenever they see concerning behaviors. They may have improved body image after witnessing the disturbing body image distress of their ill sibling. Often, siblings benefit from having more frequent family meals and structured eating habits. They may grow and mature from the experience, developing more autonomy when parents’ focus is on the eating disorder treatment. Siblings benefit from strengthened parental unity. If a sibling develops an eating disorder or another illness in the future, their parents tend to intervene immediately and are much more equipped to deal with it.

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Navigating Phase III

Last week, I blogged about navigating Phase II of Maudsley Family-Based Treatment (FBT). Today I present a roadmap for Phase III, which is equal to Phase II in its importance as well as its ambiguity.

A common but ill-informed criticism of FBT is that it only addresses eating and weight. This is a misconception. Phase I focuses on establishing normal eating habits and restoring normal weight and Phase II focuses on helping the patient eat on her own in an age-appropriate way, but Phase III has nothing to do with food or weight at all. A wonderful thing about FBT is that the life-threatening eating disordered behaviors are treated first, which frees up the therapist, the patient, and the family to focus on any remaining issues in Phase III.

The goal of Phase III is establishing a healthy adolescent identity. An eating disorder engulfs an adolescent’s identity, creates extreme stress for the entire family, and strains the relationships between family members. Phase III is about restoring healthy, age-appropriate family relationships and returning the adolescent to normal life. Anything that stands in the way of these goals must be dealt with in order for the patient to recover fully.

Phase III begins when the patient is able to eat normally, with age-appropriate independence, while maintaining a healthy weight and not engaging in any eating disorder behaviors. Essentially, once all food issues have been resolved, the patient is ready for Phase III.

The authors of the FBT manual (Locke & Le Grange, 2001) advise that Phase III entails a handful of sessions scheduled several weeks apart. In my clinical experience, many patients do quite well with just a few sessions in Phase III, but others continue to struggle with anxiety, depression, body image, perfectionism, or other problems. Therefore, I offer to provide patients and families with an extended version of Phase III when I believe it is warranted. Length of illness, severity of illness, and co-morbid conditions all influence whether a patient may benefit from more treatment than the FBT manual prescribes.

In my practice, Phase III typically addresses the following issues:

1.) Returning the patient to normal development.

An eating disorder can interrupt normal adolescent development. Often, when a patient enters Phase III, she is at the same developmental level as when the illness first began. Phase III entails helping the patient develop the maturity and social-emotional skills that were lost as a casualty of ED. Depending on the age of the patient, this may entail returning to sports or other activities, getting a driver’s license, going out with friends, dating, returning to college, or developing new hobbies and interests.

2.) Re-establishing healthy relationships amongst family members.

An eating disorder can wreak havoc on family life. It is not uncommon for spouses to have major marital conflict emerge as a result of ED. Siblings may feel neglected by their parents or jealous of the patient. The patient and her parents may develop a codependent relationship over the course of treatment, which can be advantageous in the first two phases, but must be corrected in Phase III so that the patient and parent can each return to their own lives. Healthy boundaries amongst family members can be damaged by ED, and it is crucial for these boundaries to be re-established at the end of treatment.

3.) Addressing any remaining psychological symptoms of the eating disorder.

There are numerous psychological symptoms related to an eating disorder. For example, body dysmorphia, perfectionism, poor self-esteem, anxiety, and cognitive rigidity may predispose people to AN and perpetuate the illness once it has begun. For many patients, these symptoms abate or resolve on their own during the first two phases. For many others, however, targeted treatment is needed at this phase. Cognitive-behavioral therapy (CBT) can be helpful in this regard.

4.) Working through the trauma of experiencing an eating disorder.

While many treatment programs address traumatic experiences that precipitated an eating disorder, few acknowledge that the experience of having eating disorder is itself very traumatic. Caring for a child with an eating disorder can be almost as traumatic as experiencing one. In many cases, the patient or her parents (or both) experience post-traumatic stress reactions at this point, such as disturbing nightmares, intrusive memories, and avoidance of stimuli associated with the eating disorder.

It is not uncommon for parents, drained and burnt out from the exhausting work of Phase I and Phase II, to have their own breakdowns at this point. Their child is well enough that they are no longer operating in crisis mode and they have some room to breathe. Once the survival instinct is no longer employed on a constant basis, parents have permission to experience their own reactions. Some parents fall into a depression; others feel disillusioned and cynical; still others suffer from extreme anxiety or lash out in anger. These are all normal, expected reactions to the trauma of almost losing a child. It is important for parents to get their own therapeutic support at this juncture if needed.

5.) Addressing grief.

Another often neglected aspect of eating disorder treatment is grieving what the eating disorder has taken. Not all patients and families experience this grief, but some do. I believe that when there is grief associated with the eating disorder, it should be discussed openly and addressed as part of the healing process. Patients often lose friends to their illness. They may have to take a hiatus from their favorite sport, or give it up altogether. Some patients miss a semester of school. Most are isolated from society for some time. At this stage, patients can feel the pain and injustice of losing a piece of their youth irretrievably.

Some parents may mourn the loss of their child’s innocence. They mourn the loss of life as they knew it. Many parents take time off from work and become isolated from their social circle as they help their child recover. Some parents mourn the loss of dreams they once had for their child which have been thwarted by ED.

No one emerges from the hell of an eating disorder unscathed. That said, some people are able to close that chapter in their lives and move forward, whereas others remain trapped by anger, sadness, or bitterness. It is important for patients and parents to work through their grief so that they can move forward in a life unencumbered by ED.

6.) Relapse prevention.

It is important for the patient and her parents to be aware of possible signs of impending relapse and to know what to do if these signs emerge. I find it very useful to discharge patients with a written relapse prevention plan which I have developed in collaboration with the patient and family.

7.) Evaluating the patient for co-morbid conditions.

Many patients with eating disorders experience co-morbid psychiatric conditions. Patients who continue to struggle with emotional or behavioral problems after the eating disorder has been resolved should be evaluated to determine whether they suffer from a comorbid disorder. The most common comorbid disorders are the anxiety disorders (including OCD, generalized anxiety disorder, panic disorder, PTSD, and social anxiety disorder), followed closely by mood disorders (depression and bipolar disorder). Other comorbid conditions may include autism spectrum disorders (such as Asperger’s), ADHD, substance abuse, and personality disorders.

8.) Getting the patient appropriate treatment for co-morbid conditions.

If the patient does indeed suffer from a co-morbid condition, it is important for her to get treatment for it. Treatment for a co-morbid disorder may include individual therapy, psychotropic medication, or a combination thereof. Cognitive behavioral therapy (CBT) in particular has been found to help many people recover from anxiety disorders, mood disorders, and numerous other conditions.

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Why Clinicians Are Resistant to Maudsley FBT

Research has shown that the Maudsley Method of Family-Based Treatment (FBT) is more effective than any other treatment for anorexia nervosa (AN) or bulimia nervosa (BN) in patients under age 18. Despite this fact, many clinicians who treat eating disorders are very resistant to using FBT to treat their patients. There are a variety of reasons for this resistance – some legitimate, some personal, some inexcusable, and some bred from ignorance.

Here are some of the most common reasons why clinicians who treat eating disorders are resistant to using FBT, along with my rebuttals to each:

1.) “I work with adults. FBT is not applicable to most adults.”

While FBT has not been adequately studied in adults, the reality is that there are no evidence-based treatments for adults with AN yet. I believe that patients over age 18 need to have loved ones fully informed about their illness and actively involved in their treatment just as much as young patients. The basic principles of FBT (with some age-appropriate modifications) are now being applied to older patients with very promising results.

As Cynthia Bulik’s recent study on Uniting Couples Against Anorexia Nervosa demonstrated, the principles of FBT can be applied very successfully to adults, using spouses or significant others for support rather than parents.

Also, there is some preliminary evidence that a modified version of FBT can be useful for college-aged patients who are temporarily living at home with parents during recovery. There may very well be a time in the not-too-distant future in which a modified form of FBT is an evidence-based treatment for adults.

2.) “Some families can’t do it.”

This statement is absolutely true – some families can’t do it. However, I believe that the true percentage of families who “can’t do it” is actually much smaller than one may think. FBT can be successful in divorced families, step-families, single-parent families, families with many children, families where both parents work full time, and families in which a parent suffers from a mental illness.

The only real contraindications for FBT in patients under18 are cases in which the patient has been physically or sexually abused by a parent, or both parents are so mentally or physically ill that they are unable to care for their children. Both of these contraindications are relatively rare, and even in these cases, one would hope that the patient would be living in a safe environment with other adults (e.g., relatives, foster parents) who could participate in FBT with the patient.

What happens too often is that parents don’t purse FBT because they aren’t aware it exists, or aren’t aware of the evidence behind it. It is also common for parents to be discouraged from doing FBT with their child because the child’s clinician (who is not really familiar with FBT or who doesn’t agree with it) tells the parent that it won’t work for their particular child for some reason.

In sum, I would estimate that maybe 10 % of families really can’t do it (I have no data to support this percentage; it is just an educated guess). The majority of families can do it if they have the proper clinical support and encouragement. The majority of parents love their children immensely and will do anything to help them recover if given the opportunity. It is up to us, the clinicians, to give families that opportunity.

3.) “Some adolescents don’t improve with FBT.”

I have no counterpoint to this one. The reality is that FBT is not effective for everyone. This is not a shortcoming unique to FBT, as there are no treatments that work for 100% of patients. I doubt that there will ever be one treatment that works for everyone in the same diagnostic category, because each individual patient is unique and has their own set of circumstances. Therefore, we must continue to research other forms of treatment and work to improve upon the existing treatments. When a patient does not improve with FBT, we must offer something else – residential treatment, day treatment, cognitive behavioral therapy – whatever is most appropriate for that particular patient and that particular family.

4.) “My training and inclination is as an individual therapist. Making the switch to working with families is intimidating. Learning FBT would be like starting from scratch.”

I don’t see it as starting from scratch. Rather, I see it as adding another (very effective) tool to your existing toolbox. You certainly don’t need to abandon individual therapy just because you’ve added a new treatment to your repertoire.

While some patients will recover fully with FBT and never need individual therapy, most patients do have co-morbid disorders or other issues which need to be addressed with individual therapy. In these cases, individual therapy comes after FBT. Many times I have transitioned to individual therapy with a patient after the patient has successfully recovered with FBT. The great thing about this approach is that the eating disorder has already been fully addressed through FBT, so you and the patient can focus all your time and energy on other things, such as depression, OCD, body image issues, perfectionism, and social difficulties.

5.) “My training is in psychodynamic therapy and relational approaches. FBT is pretty concrete and behavioral. Adopting FBT would seem to remove the very things that made me want to become a therapist in the first place – the focus on depth and the therapeutic relationship.”

FBT is more concrete and behavioral than other types of therapy, and I believe that is part of why it is so effective in treating these malignant illnesses which demand immediate behavioral management in order to save the patient’s health. That being said, the therapeutic relationship is just as essential in FBT as it is in other types of treatment. The parents and the therapist must develop trust in one another, and mutual respect is key, because the parents and therapist are allies working together against the illness on behalf of the child. It is extremely rewarding to be able to offer this kind of assistance and support to terrified, confused, guilt-stricken parents, who blossom with confidence as you educate them about the illness and empower them to do what needs to be done to help their child recover.

And the kids! It is nothing short of amazing to watch the therapeutic relationship evolve and unfold so quickly as recovery progresses. In the first few sessions, the kid typically presents as catatonically depressed, curled up in a fetal position under a blanket, sobbing quietly; or the kid reacts with extreme anger and resistance, yelling and hurling insults and dropping f-bombs before running out of the room. Entire tissue boxes are gone through in one session; stuffed animals need to be placed back on the shelves after being thrown. And within a few months, the kid is smiling, laughing, so happy to see you, chattering on about their trip to Disney World or their new boyfriend or how much they love ‘90’s music exclaiming “Wow, Dr. Ravin, it must have been so cool to be a teenager back in the ‘90’s!” The transformation is astounding.

Furthermore, there is lots of room for a tremendous amount of depth when continuing to work with the patient individually after FBT has been successfully completed. In fact, is even more feasible to go into greater depth in these cases, because the eating disorder is in remission and health-threatening behaviors have long-since been eliminated, so treatment can focus exclusively on other (often more interesting!) issues.

6.) “FBT is agnostic on etiology, and I think etiology is very important.”

Yes, FBT is agnostic with regards to etiology. In other words, the clinician states clearly at the outset of treatment that we don’t know exactly what causes eating disorders, and that it is not relevant for the purposes of this treatment. I believe this agnostic stance is one of the strengths of FBT: it does not waste time on “why” but instead focuses on “how” to help the patient recover.

I agree that etiology is very important because our ideas about etiology (for better or for worse) have a huge impact on how we treat patients. Therefore, clinicians and researchers must continue to have professional discussions about etiology amongst themselves.

My concern is not the discussion of etiology amongst professionals in the field. Rather, my concerns are 1.) When clinicians have a particular presumption about etiology which is not consistent with recent scientific evidence, 2.) When that particular presumption guides the use of treatments that are less effective, and 3.) When those presumptions about etiology cause harm to patients and their families by subtly or overtly blaming the patient or the family.

In my opinion, when clinicians discuss etiology with patients and their families, these discussions should be limited to the following points:

A.) Clarifying that neither the patient nor the family is to blame for the illness.

B.) Dispelling common myths about etiology (e.g., media, control issues, overprotective parents)

C.) Discussing the “Four P’s:” predisposing factors (e.g., genetic predisposition), precipitating factors (e.g., weight loss through dieting or illness), perpetuating factors (e.g., malnutrition has a calming and mood-elevating effect on those who are vulnerable to eating disorders), and prognostic factors (e.g., importance of early and aggressive intervention, maintenance of optimal body weight).

This is all the information patients and families need to know about etiology, because let’s be frank: this is all we really know about etiology. Anything else is just a distraction.

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We’ll Always Have Fiji

I do not believe that the media plays a major role in the etiology of eating disorders. And yet, in much of the eating disorder world, it has become accepted as an unspoken, self-evident truth that patients with anorexia and bulimia have developed their illnesses in large part due to their desire to emulate “the thin ideal” which our media promotes. Those who espouse this idea cite the Fiji Study, which demonstrated dramatically increased rates of body dissatisfaction and disordered eating amongst Fijian adolescent girls within the first few years after television was first introduced to the island.

I, along with several of my like-minded colleagues, have raised concern over NEDA’s choice of Naomi Wolfe as the conference’s keynote speaker. As a feminist, I am a huge fan of Wolfe’s work. In her groundbreaking book The Beauty Myth, she presents convincing arguments about the myriad ways in which our culture and society are toxic to women. I couldn’t agree more.

Our culture and society are harmful to all women and men, and certainly the media plays a huge role in triggering body dissatisfaction and disordered eating. (Incidentally, the media is a major culprit in the perpetuation of myths about eating disorders.) But disordered eating is not the same as an eating disorder. The Fiji study measured body dissatisfaction and disordered eating, not eating disorders.

The disordered eating / eating disorder distinction is not just a matter of semantics. In fact, I believe that eating disorders are quantitatively AND qualitatively distinct from disordered eating, much as major depression is both quantitatively AND qualitatively different from sadness. Anorexia nervosa has existed for centuries, long before the advent of television and internet and fashion magazines, and long before disordered eating became the norm.

I think it would benefit our profession tremendously to arrive at a consensus regarding the definition of “disordered eating” and how it differs from eating disorders.

The confusion between eating disorders vs. disordered eating is a major contributor to society’s (and some professionals’) lack of understanding of eating disorders. People who engage in disordered eating are, on some level, responding to their environment in choosing to engage in certain eating behaviors, whereas people with eating disorders are caught in the grips of a terrifying mental illness which will not allow them to do otherwise.

Disordered eating is very widespread in our country, especially among women. I define disordered eating as a persistent pattern of unhealthy or overly rigid eating behavior – chronic dieting, yo-yo dieting, binge-restrict cycles, eliminating essential nutrients such as fat or carbohydrates, obsession with organic or “healthy” eating – coupled with a preoccupation with food, weight, or body shape.

By this definition, I think well over half of the women in America (and many men as well) are disordered eaters.

The way I see it, disordered eating “comes from the outside” whereas eating disorders “come from the inside.” What I mean is this: environment plays a huge role in the onset of disordered eating, such that the majority of people who live in our disordered culture (where thinness is overvalued, dieting is the norm, portion sizes are huge, etc) will develop some degree of disordered eating, regardless of their underlying biology or psychopathology.

In contrast, the development of an eating disorder is influenced very heavily by genetics, neurobiology, individual personality traits, and co-morbid disorders. Environment clearly plays a role in the development of eating disorders, but environment alone is not sufficient to cause them. The majority of American women will develop disordered eating at some point, but less than 1% will fall into anorexia nervosa and 3% into bulimia nervosa.

The Fiji study was indeed groundbreaking. It demonstrated the enormous impact of the media on teenage girls’ feelings about their bodies and attitudes towards food. But the study did not demonstrate a causal link between the media and eating disorders. Furthermore, our knowledge that the media makes girls dislike their bodies, while important in its own right, has not yielded useful information with regards to developing effective treatments for eating disorders. And isn’t that the whole point?

I would like for our field to accept the Fiji study for what it is – a fascinating sociological study which confirmed empirically what we already knew intuitively – and push forward towards a deeper understanding of eating disorders so that we may develop and implement more effective treatments.

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Controversy

I love controversy.

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

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

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

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

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

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

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

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

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How to Help Your Depressed Teenager: Tips for Parents

If your child is depressed, it is important to act now. Untreated depression causes tremendous suffering and can lead to serious medical and emotional problems, including suicide. Adolescents with untreated depression have difficulty learning and making and keeping friends. They are also more likely to abuse drugs and engage in self-injury. You must intervene now in order to help your teenager blossom into the wonderful person she was meant to be.

1. Educate yourself on depression in adolescents.

Learn the signs and symptoms of depression and know how to differentiate between normal sadness or “teen angst” and clinical depression. All teenagers are moody and irritable at times, and sadness is a natural and healthy response to a loss or disappointment. Depression is a serious but treatable mental illness which affects between 2-5% of adolescents at any point in time.

Depression involves a pervasively sad or irritable mood that lasts at least two weeks, but usually several months or more, and causes a noticeable change in functioning. Depressed adolescents also experience physiological symptoms such as changes in appetite and weight, lack of energy, insomnia or hypersomnia, and physical aches or pains. They tend to have poor self-esteem and irrationally negative thoughts, lose interest in activities and friends, isolate themselves, and feel guilty or worthless for no good reason. Many depressed teens feel hopeless and have recurrent thoughts of death or suicide.

2. Take your child to the pediatrician for a complete physical exam to rule out organic causes of depression.

In some cases, depression is the result of a general medical condition such as hypothyroidism or mononucleosis. Depression can also be a side effect of certain medications. Some teens may exhibit depression as a result of abusing alcohol, drugs, or prescription or over-the-counter medications. Finally, simple things like sleep deprivation, too much stress, and nutritional deficiencies can manifest as depression. It is important that your child receives a complete physical exam in order to rule out any of these potential causes.

3. Let go of guilt and blame.

Depression is no one’s fault. Your child did not choose it and you did not cause it. We know that depression is a heritable brain disorder which is often (though not always) triggered by stressful life events and brain changes during puberty. It is unhelpful, even counterproductive, to blame yourself or your child for her depression. While your child is depressed, her moods and behaviors are to some degree out of her control. She cannot “choose to be happy” or “snap out of it.”

4. Don’t be too quick to medicate.

Psychotropic medication has its place, and under certain circumstances, it may be a very helpful adjunct to psychological treatment for depression. Far too often, however, psychiatrists and other physicians use medication as the first line of defense against depression. This is especially dangerous for children and adolescents, whose brains are still developing and who are more likely to suffer from serious side effects.

In addition to the risk of side effects and the lack of evidence about the long-term effects of antidepressants on a developing brain, there are other dangers to using medicating as the first, or only, line of treatment.

First, there has been very little research on the effects of antidepressants in youth. Second, there is only one antidepressant medication (Prozac) which has been FDA-approved to treat depression in adolescents, but doctors regularly use other medications “off-label” to treat them. Third, psychotherapy is more effective than medication for most adolescents with mild-to-moderate depression. Fourth, a child who receives medication without psychotherapy will not learn the necessary skills or make the necessary life changes needed to sustain lasting improvement and prevent relapse. The effects of medication expire when the medication is stopped, whereas the effects of good psychotherapy are longer-lasting.

In order to protect your child from being prescribed unnecessary or harmful medication, I recommend first taking your child to a psychologist (Ph.D. or Psy.D.) rather than a psychiatrist (M.D.). Psychologists perform psychological assessments and conduct psychotherapy but do not prescribe medication. Most psychiatrists, on the other hand, prescribe medication to the vast majority of patients they see, while conducting little (if any) psychotherapy.

If it becomes evident later on that your child could benefit from medication as an adjunct to psychotherapy, you can always ask your child’s psychologist or pediatrician to refer you to a child psychiatrist with whom he/she has a working relationship.

5. Seek evidence-based psychological treatment.

All therapy is not created equal. Some psychological treatments have been shown to work, while others have not. Research supports the effectiveness of three different types of psychotherapy for depressed adolescents: individual cognitive-behavioral therapy (CBT), group CBT, and interpersonal psychotherapy for adolescents (IPT-A). All three of these treatments are relatively short-term, usually consisting of 12-16 weekly sessions over the course of 3-4 months.

CBT focuses on the relationships among thoughts, feelings, and behaviors. CBT directly targets the adolescent’s present symptoms, without much emphasis on the past. The CBT therapist helps the adolescent identify patterns of thinking and acting which are contributing to her depression and teaches her new ways of thinking and behaving that facilitate positive feelings. CBT be delivered individually, with your child meeting 1-on-1 with a therapist, or in a group consisting of one or two therapists and 6-12 other adolescents who are experiencing depression.

IPT-A focuses on the adolescent’s social functioning and her current relationships with important people in her life. Through IPT-A, the adolescent develops her social skills, learns more effective ways of communicating, identifies connections between certain relationship patterns and her depressive symptoms, and learns to cope effectively with life transitions.

Be conscientious and selective in your search for an appropriate therapist for your child. Try to find a psychologist who has experience in treating adolescent depression. Speak with the psychologist briefly over the phone before making an appointment. Ask her about her philosophy of treatment, and make sure she practices evidence-based treatment.

6. Insist upon being fully informed and actively involved in your child’s treatment.

There is quite a bit you can do to help your child recover from depression, so don’t let any professional tell you otherwise. Treatment works best when you are fully informed and actively involved. Your child will probably be meeting with the therapist individually during most sessions. However, you should be involved in the initial evaluation and treatment planning. You should expect the therapist to check in with you on a regular basis to provide updates on your child’s progress. The therapist should always return your calls in a timely fashion and should definitely tell you if your child is engaging in dangerous behavior.

At the start of treatment, have a frank conversation with the therapist about confidentiality and boundaries. You, the therapist, and your child should come to a clear agreement about what types of information will and will not be disclosed to you as the parent. It is important that your child forms a comfortable, trusting relationship with her therapist. It is even more important, however, that you are made aware of any harmful behaviors (e.g., drug or alcohol use, unprotected sex, eating disorders, cutting) and involved in the process of helping your child overcome these issues.

7. Be willing to consider antidepressant medication under certain circumstances.

Antidepressants are vastly over-prescribed. They should not typically be used as a first-line treatment and should not be prescribed unless the patient is also in psychotherapy. However, there are certain circumstances under which medication may be beneficial and even life-saving:
• If your child has been in evidence-based psychotherapy for two or three months but has not shown any improvement, consider adding an antidepressant to your child’s treatment plan as an adjunct to psychotherapy.
• Depression has a strong genetic component. If your child has a first-degree relative (mother, father, or sibling) who suffers from a mood disorder, this suggests that your child’s depression is likely to be genetic and biologically-based. In this situation, it is more likely that your child will benefit from antidepressants.
• Research has shown that severe depression responds best to a combination of psychotherapy and antidepressant medication. In contrast, mild- to moderate depression can typically be successfully treated with psychotherapy alone. Most cases of depression are mild or moderate, so check with your child’s psychologist to determine the severity of her illness. Adolescents with severe depression are often too ill to engage in psychotherapy without the added benefit of medication to normalize their brain chemistry.
• Your child’s medication should be prescribed and monitored by a board-certified child and adolescent psychiatrist, not by her pediatrician. While pediatricians are able to prescribe antidepressants, they do not have the expertise necessary to monitor your child’s progress and ensure that she is on the correct dose of the right medication.
• You and your child should meet with the psychiatrist for a thorough evaluation before any medication is prescribed. Be sure to ask the psychiatrist about any potential side effects or drug interactions of which you should be aware.
• Your child should be closely monitored by her psychiatrist while she is on the medication, especially during the first month and after a change in dosage. After that, the psychiatrist should follow up with your child at least monthly to monitor her progress and change her dosage if necessary.

8. Create a home environment conducive to overall physical health and mental wellbeing.

Basic self-care habits such as sleep, nutrition, exercise, and stress release are extremely important for someone suffering from depression. Teenagers are notorious for staying up late, eating lots of junk food, and guzzling soda at all hours of the day. While most teens can “get away with” these habits for a few years, teens recovering from depression cannot afford to take shortcuts with their health. Depressive symptoms can be caused or exacerbated by sleep deprivation, poor nutrition, inactivity, and chronic stress.

Prioritize health and well-being above all else. Establish regular bedtimes to ensure that your child gets a minimum of 8 hours of sleep every night. Many adolescents need 9-10 hours of sleep or even more in order to function optimally. Require your child to eat nutritious, balanced meals with the entire family. Supplement her diet with multivitamins and Omega-3 essential fatty acids, which have been shown to improve mood, memory, and general mental functioning. Encourage her to enjoy some physical activity every day. Minimize the stress and tension in your household. Help your child create a balance of study time, personal time, friend time, and family time.

9. Encourage healthy social relationships and fun activities.

Depression causes adolescents to withdraw from their friends and family and lose interest in activities they once enjoyed. Unfortunately, social isolation and inactivity only exacerbate depressive symptoms. Ensure that your child stays connected to the family by sharing meals with the family every day and involving her in a weekly family outing or game night. Encourage her to go out with her friends or invite them over to the house.

See to it that your child is involved in activities that create a sense of purpose, nurture her talents and burgeoning self-concept, and help her connect with other like-minded kids and adults. If your child is artistic, sign her up for art lessons or encourage her to audition for a play. If she is musical, encourage her to join the marching band or take dance classes. If she is athletic, encourage participation on a sports team. Many adolescents find a sense of meaning in volunteer work or involvement in religious activities.

Depressed adolescents often lose motivation and lack the interest and energy to initiate activities on their own. However, once they become involved and engaged in activities, they usually begin to feel a little bit better. Remind your child of this when she expressed reluctance to do something fun or social.

10. Provide your child with plenty of nurturing, comfort, and physical contact.

No parent wants their child to suffer. It will be very difficult to and heart-wrenching to watch your child struggle with depression. However, it is important that you remain calm, steady, compassionate, and optimistic.

Depressed adolescents often feel worthless and guilty for worrying their parents. Tell your child that you love her infinitely and unconditionally, regardless of whether she is happy or depressed. Ensure your child that she is not to blame for being depressed and that she has done nothing wrong. Let her know that you are concerned about her depression, that you are here to support her, and that you will take all the necessary steps to get her good treatment and help her recover.

Physical contact through affection, hugging, kissing can be very comforting to a distraught adolescent. If your child resists being touched, use a soothing voice and reassuring words to comfort her and let her know that you are always available for a hug whenever she needs one. Express empathy towards your child and be willing to listen to her thoughts and feelings. However, you must keep in mind that depressed adolescents may have many irrational thoughts and negative perceptions about themselves and others. For example, your child may be extremely self-critical, believe that no one likes her, tell you her life is a living hell, or fear that you are angry with her. You can gently explain to your child her depression is causing her to see things through a “negative filter” such that many of her perceptions are colored by the depression and are not necessarily accurate.

11. Be patient and realistic.

Recovery from depression takes time. Your child will not feel better right away, nor should you expect her to. It takes weeks for the effects of psychotherapy and medication to become evident. Your child may begin to feel hopeless and worry that she will be depressed forever. This hopelessness is a symptom of depression, rather than an accurate assessment of her situation. You must remain hopeful and optimistic regardless of your child’s attitude. Reassure your child that recovery takes time; that she will begin to feel better soon; that she must stick with treatment.

It is often helpful to lower your standards while your child is depressed. This is difficult for many parents to accept. However, it is important to recognize that depression is a very real and very disabling condition that will have a major impact on your child’s functioning, personality, and behavior. Depression in teens can manifest in a variety of ways. Some teens may suffer a decline in academic performance due to inability to concentrate. Many depressed teens will become quiet and withdrawn; others will become angry and volatile. Some depressed adolescents will act out, abuse drugs, cut themselves, or get into trouble at school. However your child’s depression manifests, be aware of one thing: your child will NOT seem like herself while she is depressed. Just be aware of this fact and accept it. This is not to say that you must tolerate blatant disrespect, delinquency, or dangerous behavior. Continue to maintain appropriate boundaries and limits to keep everyone safe. However, recognize that your child is suffering from a serious mental illness that impairs her ability to function. If her grades slip, or she doesn’t do her chores, or she mouths off to you more than usual, show compassion and empathy, and try to maintain perspective.

Some adolescents experience one episode of depression and that’s it. However, more than half of adolescents who experience major depression will go on to have more episodes in the future. This does not mean that treatment didn’t work, or that your child failed, or that you failed your child. This is simply the nature of major depressive disorder. The good news is that if your child has been successfully treated the first time, you know exactly what to do if she begins to develop symptoms again. With the knowledge, insight, skills, and professional contacts gained the first time around, relapse should be briefer and easier to manage.

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In Defense of Helicopter Parenting

Last month, Time Magazine ran an article about the dangers of over-involved, over-protective parenting (otherwise known as “helicopter parenting” because these parents tend to hover over their children). The article is well-researched, well-written, and very interesting. As a therapist who frequently encounters this phenomenon in the parents of my adolescent and young adult patients, and as a product of this type of parenting myself, I have a few thoughts and observations on the issue.

I agree wholeheartedly with the author that today’s parents are far too over-involved and over-protective, and this is particularly true amongst middle- to upper-class families with well-educated parents. According to psychologist Eric Ericson, the primary developmental task of middle adulthood (ages 30-50) is seeking satisfaction through productivity in career, family, and civic interests. This is precisely the age at which adults are parenting young children and adolescents, and for helicopter parents, their striving for productivity is channeled into their children. Parents’ intentions are good, but the outcome can be problematic. You see, the middle adulthood psychosocial task of productivity stands in diametric opposition to the adolescent developmental task of identity formation. Children need to play, explore, relax, and interact with their surroundings in creative, imaginative ways. Adolescents need to loaf, “hang out,” date, experience “teen angst,” spend quality time with family and friends, develop their social skills, make their own choices (within reason), make mistakes, and learn from them.

Ideally, a healthy person will emerge from adolescence with a solid self-identity, resilience, confidence, good problem-solving skills, and the ability to tolerate discomfort and failure. Having worked in several college counseling centers, I can attest that many kids arrive at college without these skills and attributes. Their lives have been geared entirely towards achievement in academics, arts, and athletics, often not for the love of science or music or soccer, but because their parents pushed them and/or because they believed it would improve their chances of gaining admission to a prestigious college. Quite often, they don’t know how to structure their time, study properly, deal with disappointment, or make decisions independently. Sadly, many of them do not know who they are or what they enjoy.

Helicopter parenting has the potential to be quite harmful to children by increasing their stress and anxiety and preventing them from developing self-confidence, resourcefulness, problem-solving skills, distress tolerance skills, emotion regulation skills, and creativity. Children and adolescents are over-scheduled, over-worked, and pushed to succeed, often at the expense of their emotional health. There is not enough unstructured time for kids to play, explore, or create. There is little room for adolescent identity formation in between AP classes, Princeton Review SAT prep courses, college applications, three varsity sports, band practice, clubs, and mandatory community service hours.

These issues notwithstanding, one problem I have seen far too often in my profession is the tendency for therapists to blame helicopter parents for causing their child’s eating disorder. It is easy to look at over-involved parents and an adolescent’s misguided search for control and identity through self-starvation and conclude that the former caused the latter. But the belief that over-involved, controlling, or enmeshed parents cause children to develop anorexia nervosa (AN) or bulimia nervosa (BN) lacks solid scientific evidence. What’s worse, this belief has the potential to undermine treatment, disempower parents, confuse children, perpetuate deadly symptoms, erode physical and mental health, destroy families, and turn an acute illness into a chronic and disabling one.

There is a correlation between over-involved, over-protective parenting and the development of AN, but correlation does not necessarily indicate causation. If variable A (helicopter parenting) and variable B (child’s development of AN) are correlated, there are several possible explanations for the relationship between these two variables:

1.) A causes B
2.) B causes A
3.) Variable C causes both A and B
4.) Variables D, E, F, G, H, I, J, K, L, M, and N work together in complex ways to influence the development of both A and B.

Let’s examine each possible explanation.

1.) Explanation 1: Helicopter parenting causes children to develop AN. There is no reliable scientific evidence to support this explanation. Ironically, this explanation is touted far more frequently than the others, even by clinicians who specialize in treating eating disorders.
2.) Explanation 2: A child’s AN causes parents to become over-involved or over-protective. There is some evidence to support this explanation. If parents were not anxious, cautious, protective, or hovering before their child developed AN, you’d better believe they will be once their child becomes ill. This phenomenon is not unique to AN. Parents of children with any illness or medical condition naturally worry about their child and do whatever they can to protect her.
3.) Explanation 3: A third variable causes both helicopter parenting and AN in children. There is a wealth of evidence to support the genetic transmission of AN as well as related personality traits. The personality traits that predispose people to developing AN – anxiety, obsessiveness, perfectionism, and harm-avoidance – are largely genetic. In an adolescent female, these traits are likely to manifest as an eating disorder. In a middle-aged, middle-class, intelligent, well-educated parent, these traits are likely to manifest as over-involvement, over-protection, and over-investment in their child.
4.) Explanation 4: A complex interaction of other variables work together to produce both helicopter parenting and AN in children. This is the most thorough, and probably the most accurate explanation. As stated in explanation #3, genetics plays a major role in the development of AN. A wealth of environmental variables are also believed to influence the development of parenting style as well as AN (e.g., level of education, income, culture, peer group, family background, exposure to stressful life events).

I love working with adolescent children of helicopter parents. I require parents to be fully informed and actively involved in their child’s treatment, and helicopter parents slide seamlessly into this role. They are excellent candidates for Maudsley Family-Based Treatment because their anxiety level is high enough to propel them towards action, they thoroughly educate themselves on their child’s condition, they seek out the best treatment and resources, they are vigilant and persistent, they maintain a very high level of involvement and supervision, and they are tremendously invested in their child’s recovery. Misguided, ill-informed, old-school therapists argue that these characteristics caused the child’s AN, and they advise parents to “back off” and allow the child to make her own choices about food and weight and treatment. This approach rarely leads to lasting recovery.

While helicopter parenting certainly has the potential to cause harm, it can also be used to the child’s advantage in recovery if channeled properly. Helicopter parents tend to be wildly successful in Maudsley Phase I (re-feeding / weight restoration), and largely successful in Phase II (helping the adolescent eat properly on her own). Some of these parents are eager to step back in Phase III as their child deals with psychological and social issues and develops a healthy adolescent identity. Other parents struggle to let go when the time comes. With proper guidance from a good therapist, however, most helicopter parents can learn to manage their own anxiety enough to allow their children to blossom and develop as healthy, independent young adults. This does not come naturally for them, but never underestimate the power of the helicopter parent. If the therapist who helped save their beloved child from a life threatening illness coaches them to step back and let go, they’ll do it.

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Eating Disorders: Prevention and Early Intervention Tips for Parents

There is a fair amount of internet advice for parents on how to prevent eating disorders in their children. The majority of this advice centers around teaching children about healthy eating habits, moderate exercise, positive body image, and media literacy. This is great advice for parents to follow, but it does not prevent eating disorders. It may help to prevent body dissatisfaction and dieting, but these things are not the same as an eating disorder.

Ironically, many children and adolescents who are in treatment for anorexia nervosa or bulimia nervosa report that their illness was triggered by a health or nutrition class at school, training for a sport, or a general desire to adopt the much-touted principles of “healthy eating and exercise.” Unfortunately, most of the information children receive on the benefits of “healthy eating and exercise” is really our fat-phobic society’s disguised attempt to shield our precious children from this horrible “obesity epidemic.” To make matters worse, this information is delivered to children by teachers, physicians, coaches, and parents – supposedly knowledgeable authority figures whose job is to educate, protect, and nurture them. Children who are predisposed to eating disorders are usually compliant, rule-bound, anxious, obsessive, perfectionistic, driven, and eager to please. They are virtual sponges who soak up this “healthy eating and exercise” information and follow it to the letter. The obesity hysteria terrifies them, and their obsessive, perfectionistic temperament makes them stellar dieters. This is the perfect storm for the development of an eating disorder.

I do not believe we should stop educating children about nutrition and exercise out of fear that they will develop eating disorders, much as I don’t believe we should stop educating adolescents about safe sex and contraception out of fear that they will become sexually active. More information is usually better than less, as long as the information is accurate, useful, and effective. The middle school and high school syllabi on sex education provide information which is accurate, useful, and effective (whether kids act on that information is another story). The information kids receive on “healthy eating and exercise” has not succeeded in improving their overall health, preventing eating disorders, or combating this alleged “obesity epidemic.”

I believe that, in terms of nutrition, kids should be taught about what to embrace rather than what to avoid. They should learn the importance of eating lots of fruit, vegetables, dairy products, protein, fat, and grains, and drinking plenty of water. They should be taught to enjoy their favorite snacks and deserts as well. They should not be taught about calories or the evils of sugar and fat; they should not be advised to avoid any foods, they should not learn to label foods as “good” or “bad,” and they should not be taught about the dangers of obesity or the virtue of thinness. Most importantly, I believe children should be taught about the dangers of dieting, much as they are taught about the dangers of drugs, alcohol, and unprotected sex. The dangers of dieting are grossly underrated.

Even if nutrition education is accurate, useful, and effective, it will not prevent eating disorders. That being said, what steps can parents take to prevent their children from developing eating disorders? In my opinion, it all boils down to three basic principles: 1.) accurate information, 2.) vigilance, and 3.) immediate, aggressive, effective intervention.

Accurate information
The pop-psychology literature will have you believe that if you have a healthy body image yourself, encourage healthy body image in your children, nurture positive self-esteem, and preach the importance of healthy eating habits and exercise, your child will not develop an eating disorder. This assumption is simply untrue. Parents need to know that seemingly healthy, well-adjusted children with positive body images and excellent parents develop eating disorders all the time. Good parenting does not make your child immune. It can, however, improve your child’s chances of full recovery.

If your child develops an eating disorder, let go of guilt, shame, and self-blame. While it is natural for parents to blame themselves, guilt is a hindrance to effective action. Of course you have made mistakes in parenting – everyone has! You may be an imperfect parent, but this does not mean you caused your child’s illness. Despite what you may have heard in the media, there is no reliable scientific evidence to suggest that parents cause eating disorders. If your child’s pediatrician, dietician, or therapist suggests that the eating disorder is your fault, this is an indication that he or she is not aware of recent research on the etiology of eating disorders and effective treatments. Get a second opinion. Anorexia nervosa and bulimia nervosa are biologically-based brain disorders, just like autism and schizophrenia. Although you are not to blame for causing your child’s eating disorder, it is your responsibility as a parent to ensure that she gets proper treatment. This responsibility includes protecting your child from outdated, ineffective treatments, which can often do more harm than good.

Parents also need to know that eating disorders are not limited to rich, white teenage girls. This stereotype is antiquated and dangerous, as it prevents individuals outside these demographic categories from being diagnosed and properly treated. Eating disorders strike children, adolescents, and adults; girls and boys, men and women; people of all ethnic, cultural, and economic backgrounds. Several years ago, during my training, I treated a severely underweight teenage boy with anorexia nervosa whose previous pediatrician had told him: “If you were a girl, I’d say you were anorexic.” As a result of this doctor’s failure to intervene, the patient’s condition rapidly deteriorated over the next two years, and by the time he presented in my office, he was in horrible shape.

Vigilance
Here are some concrete steps that parents can take to help prevent eating disorders. You may notice that, unlike other prevention tips you may have read, these tips center around proper nutrition and exercise. This is because all the feminist, feel-good, positive-body image talk in the world is not going to prevent eating disorders. Remember, anorexia nervosa has existed for centuries, long before thinness became fashionable. Eating disorders are triggered by an energy imbalance (consuming fewer calories than you expend) and perpetuated by malnutrition. If a child never becomes malnourished, she is extremely unlikely to develop an eating disorder.
• Make family meals a priority. As a parent, it is your job to prepare and serve nutritious foods. It is far better for a family to sit down to a balanced breakfast of cereal, milk, fruit, juice, and yogurt instead of grabbing a nutrigrain bar and running out the door.
• Closely monitor any changes in your child’s eating habits. Even seemingly “positive” dietary changes such as skipping desert, becoming vegetarian, or reducing fat intake can signal the onset of an eating disorder.
• Adopt a zero-tolerance policy towards any level of malnutrition. Do not allow your child to diet, skip meals, or cut out entire food groups. Children and teenagers need to eat three substantial, nutritious, well-balanced meals every day. Supervised, supported full nutrition is the best defense against an eating disorder.
• Be aware that eating disorders are sometimes triggered by unintentional malnourishment (for example, weight loss due to physical illness, depression, anxiety, stress, or surgery; fasting for religious purposes; side effects of a medication; intense physical exercise without a commensurate increase in nutrition). This type of malnourishment must be taken equally seriously. Dieting is not the only pathway to eating disorders (although it is the most common pathway in modern Western cultures).

Parents need to be on guard for early signs of eating disorders, especially during early adolescence, when most eating disorders develop. Since eating disorders are genetically transmitted, your child is much more vulnerable to developing an eating disorder if you or a relative has suffered from an eating disorder. Family histories of major depression and other mood disorders, anxiety disorders, OCD, and addictions are also risk factors for developing eating disorders. If you have a family history of eating disorders or other mental illnesses, you should know that your child is at greater risk for developing an eating disorder, and you should be extra vigilant.

Some early signs of eating disorders masquerade as “healthy” behaviors or extreme dedication, or can easily be dismissed as typical teenage behavior. However, parents know their kids well. Most parents recognize, long before formal diagnosis, that something is “not quite right” with their child, but they aren’t sure what is wrong or they don’t know what to do. Here are some early signs and symptoms:
• Change in eating habits. This can take many forms, including following a formal diet plan, skipping meals, eating only at certain times, refusing to eat with other people, or anxiety around food. Even seemingly positive dietary changes, such as becoming vegetarian, reducing fat intake, skipping snacks and deserts, and eating only organic foods, can be early signs of an eating disorder.
• Increased preoccupation with food: taking about food, reading diet books, collecting recipes, cooking, serving food to others, sudden interest in what other people are eating.
• Change in mood or behavior. Parents often notice dramatic changes in their child’s personality, such as irritability, anxiety, depression, moodiness, frequent crying, restlessness, withdrawal, changes in sleeping patterns, or loss of interest. Increased dedication to schoolwork, sports, or other extracurricular activities and obsessive behavior in other areas can also be early signs.
• Increase in exercise. The child may begin solo running, take up a new sport, or show increased dedication to her current sports. If she is an athlete, she may begin training excessively outside of team practices. If she is a dancer, she may begin practicing at home, signing up for more dance classes, and auditioning for every possible performance opportunity.
• Weight loss, failure to gain weight, or failure to make expected gains in height. ANY weight loss in a child or adolescent, even a few pounds, may be cause for alarm. ANY failure to grow or gain weight as expected warrants further examination.
• Loss of menstrual periods.
• Signs of binge eating (for example, large amounts of food disappearing overnight).
• Signs of purging (for example, discovering laxatives in your child’s purse or smells of vomit in her bathroom).

Immediate, Aggressive, Effective intervention
I have never heard a parent say: “I wish I had waited longer before getting my child into treatment.” Most parents whose children are in treatment for eating disorders regret not intervening sooner. In addition, many parents report that they wish they had sought out evidence-based treatment immediately, rather than continuing with ineffective treatment as their child’s health declines. If you notice any of the signs or symptoms listed above, take action immediately. Here’s how:
• Educate yourself about eating disorders and evidence-based treatment. FEAST (Families Empowered and Supporting Treatment for Eating Disorders) is an excellent resource for parents.
• Do not praise your child for her “healthy eating” habits or willpower around food. Instead, tell her that you have noticed a change in her eating habits and that you are concerned. For example: “I notice that you’re not enjoying ice cream with our family anymore. What has changed?”
• Be prepared for your child to insist that she is just trying to eat healthily, exercise more, or improve her performance in sports or dance. Many eating disorders begin this way but quickly spiral into deadly obsessions.
• Be prepared for your child to be in denial or to resist your efforts to intervene. Teenagers never say: “Mom, I think I’m developing anorexia nervosa, and I’m worried about my recent weight loss.” Denial, resistance, and lack of insight are symptoms of this disease, NOT indications that everything is OK. Don’t back down.
• Don’t waste time on “why.” When your child is developing an eating disorder, it is tempting to try to understand the reasons for it. Resist this temptation and tackle the symptoms immediately. The very foundation of ineffective eating disorder treatment begins with endless search for the “root cause” while the child continues to starve, binge, purge, and over-exercise as her physical and mental health deteriorate. A patient with an active eating disorder is generally unable to make effective use of psychotherapy because her brain is not functioning properly. Eating disorders are life-threatening illnesses with serious mental and physical risks. Think of your child’s eating disorder as a tumor. It must be removed immediately, or it will grow and metastasize. The surgeon does not need to know the reason for the tumor in order to operate and remove it. The sooner you intervene, the better your child’s chances for complete recovery. There will be plenty of time for psychological work, including an exploration of potential triggers, later on in recovery, once your child is well-nourished and physically healthy.
• As soon as you suspect a problem, take your child to the pediatrician for a complete physical exam. Unfortunately, most physicians do not have specialized training in eating disorders and are unlikely to notice an eating disorder until it is in its advanced stages. Thus, you cannot always trust your child’s pediatrician to spot a problem. I have had many patients whose physicians have completely overlooked telltale signs such as weight loss, missed menstrual periods, or failure to grow. Consider taking your child to a pediatrician or adolescent medicine physician who specializes in eating disorders. Remember, trust your parental instincts. If you think there is something wrong with your child, you are probably right. It is far better to intervene immediately and later discover that everything is fine, rather than waiting until your child is in the acute phase of a life-threatening mental illness.
• If you intervene at the first sign of an eating disorder, your child may not meet full criteria for anorexia nervosa or bulimia nervosa. Thus, she may be diagnosed with Eating Disorder Not Otherwise Specified, or she may not be diagnosed with an eating disorder at all. This does not mean that your child’s problem isn’t serious or that immediate, aggressive intervention isn’t necessary. It simply means that your child is in the beginning stages of what is likely to become a severe, life-threatening mental illness if left untreated (or improperly treated). Your child is most likely to achieve complete, lasting recovery treatment begins immediately, rather than waiting for her to develop full-syndrome anorexia nervosa or bulimia nervosa and the myriad of psychological and physical problems these illnesses entail.
• If your child has been in therapy for a while and she continues to restrict her diet, lose weight, binge, or purge, therapy is not working. In early recovery, it does not matter if your child has a good relationship with her therapist, enjoys speaking with her, or trusts her. The therapeutic relationship is only therapeutic insofar as it promotes health, wellness, and recovery. Insight, self-exploration, and rapport are useless in the wake of malnutrition. Speak with your child’s therapist about taking a different approach. If your child’s therapist refuses to talk to you, or if you are not satisfied with the results of treatment, find a different therapist.
• Seek evidence-based psychological treatment for your child and your family. Most therapists, even ones who specialize in eating disorders, are not up-to-date on the latest research and most effective treatments. I have worked with many families who have taken their child to multiple eating disorders specialists over a period of several years and seen no symptom improvement whatsoever. This is usually because the therapists were not aware of recent scientific research on eating disorders and were not using evidence-based treatments. For children and adolescents, the strongest evidence base is for Maudsley Family-Based Treatment (FBT). Maudsley FBT is a highly practical, empirically-validated treatment method which empowers the family to help the patient recover and focuses on immediate restoration of nutritional and physical health before tackling psychological issues. Research has shown that 75-90% of adolescents treated with Maudsley FBT recover within 12 months and maintain their recovery at 5-year follow-up. In contrast, traditional treatment generally takes 5-7 years and only 33% of patients achieve full recovery.
• Remember that you are an essential member of your child’s treatment team. Your child’s treatment will be most effective if you are fully informed and actively involved. Interview any potential physicians, dieticians, therapists, and psychiatrists without your child present before your child meets them. Make sure that you are comfortable with their philosophy of eating disorders and their approach to treatment. Insist on being informed about your child’s progress in treatment and ask what you can do to help her recover. If the therapist will not inform you or include you in treatment decisions, find a new therapist.
• Recognize that your child’s eating disorder is neither her fault nor her choice. Do not wait for her to “choose” recovery, because she can’t. It is your job to choose recovery for her until she is well enough to take ownership of her treatment. Try to separate the disorder from the child you know and love. She is in there somewhere, and some day, she will thank you.

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Emotional Anorexia

Most patients with anorexia nervosa (AN) experience an ostensible “loss of appetite,” if you will, for all human needs. During refeeding, some patients with AN become uncharacteristically violent and hostile towards their parents, shunning all attempts at comfort or affection. Some therapists have referred to this phenomenon as “emotional anorexia.” While I’m not aware of any empirical literature on this topic, I do have some hypotheses of my own.

Like AN and other mental illnesses, the etiology of emotional anorexia is complex and multifaceted. I believe that the factors which contribute to emotional anorexia are, in order of relevance: 1.) Genetic predisposition, 2.) Neurobiological changes associated with malnutrition and refeeding, 3.) Psychological symptoms of AN, and 4.) Developmental and familial issues. Let’s examine each of these issues in turn.

GENETIC PREDISPOSITION. Between 50%-80% of the risk of developing AN is genetic. It is very likely, then, that genes play the most significant role in the development of emotional anorexia as well. The character traits which predispose people to AN: anxiety, obsessiveness, perfectionism, and harm avoidance, are present at birth and are determined primarily by genetics. People with this character structure tend to exercise restraint not just with their food, but also in other areas of their lives. They tend to be emotionally inhibited, most likely because they tend to be overly fearful of making mistakes.

Further, recent research has demonstrated that individuals with AN have difficulty processing emotional information. They tend to misperceive others’ emotions (for example, they are likely to think someone is angry with them when in reality the person is concerned about them), and they avoid emotionally intense situations. This type of personality creates the perfect template for the development of emotional anorexia.

Brain imaging studies have shown that individuals with AN have alterations in their anterior insula, a region of the brain which is critically important for interoception (the self-awareness of internal bodily signals). During the acute phase of their illness, individuals with AN are literally unable to sense hunger, fullness, tiredness, and changes in body temperature. Additionally, they have an imbalance between circuits in the brain that regulate reward and emotion (the ventral or limbic circuit) and circuits that are associated with consequences and planning ahead (the dorsal or cognitive circuit).

This combination of difficulty processing emotional information, disrupted interoceptive awareness, and disregulated reward-emotion circuitry renders anorexics incapable of experiencing pleasure from food, rest, sex, physical affection, or fun activities the way healthy people do. A hug may feel the same as a slap in the face; a smile may look like a sneer; a piece of chocolate cake may be as punishing as a tablespoon of cod liver oil; words of encouragement may sting like salt in a wound. People with AN feel safer and calmer when they shrug off affection and shun human contact as well as food.

NEUROBIOLOGICAL CHANGES ASSOCIATED WITH MALNUTRITION AND REFEEDING. Since the Minnesota Starvation Study, we have known that malnutrition causes biochemical changes in the brain which result in dramatic personality and behavior changes, such as depression, anxiety, irritability, apathy, loss of interest, isolation, and social withdrawal. The neurobiological changes associated with re-feeding are equally profound. Because starvation numbs emotions, many patients experience a resurgence of depression, anxiety, irritability, anger, and loss of control when food is reintroduced. Dr. Walter Kaye hypothesizes that individuals with AN have a shortage of serotonin in the brain, since serotonin is derived partially from food. More serotonin receptors are created in effort to harvest the scanty amount of serotonin available. Thus, when food is reintroduced and serotonin levels rise, the large number of receptors causes too much serotonin to be taken up, making the person feel extremely agitated and irritable. This makes eating a terrible emotional ordeal. It is very difficult to give or receive love and affection when you are struggling with intolerable anxiety and irritability.

PSYCHOLOGICAL SYMPTOMS OF ANOREXIA NERVOSA. So now we have a teenager with the perfect genetic template for emotional anorexia who is experiencing the profound neurobiological effects of malnutrition. In addition to these physiological effects, she is experiencing debilitating depression, feelings of worthlessness and inadequacy, she has lost interest in socializing, she has withdrawn from friends and family, and she has difficulty accurately perceiving emotions. When she isolates herself, she experiences less social reinforcement, which confirms the depressive schema that she is worthless and inadequate. Her athletic performance begins to decline, she has difficulty concentrating, and she is no longer asked out on dates. Her friends are alarmed by the changes in her physical appearance and mood, so they stop talking to her. Parents, teachers, coaches, and friends express extreme concern, which she misinterprets as anger, jealousy, or criticism. All of these things reinforce her feelings of worthlessness and inadequacy. I have had several patients with AN cry to me that their parents didn’t visit them at all while they were away at summer camp or college. Meanwhile, their parents confided to me that they wanted desperately to visit their daughter, but she told them not to, and they wanted to respect her autonomy. The patients insisted that they didn’t want their parents, yet lamented their absence. Clearly, there’s a disconnect here. The patient either a.) is not aware of her emotional needs, b.) doesn’t know how to express these needs, or c.) chooses not to express her needs because she is afraid, embarrassed, or ashamed. I believe that a, b, and c are all true.

One of the core features of AN which has persisted throughout the centuries is a sense of “needlessness,” of being “above” worldly pleasures and bodily needs. Medieval saints experienced this needlessness. They prayed for days on end without food, water, sleep, or socialization. Amongst these fasting saints, there are documented cases of what would today be diagnosed as AN. In certain non-western cultures such as China and Ghana, AN is as prevalent as it is in the US. The major difference is that patients in non-western cultures relate their starvation to profound self-control, moral superiority, and spiritual wholeness rather than to a desire to be skinny. Today’s American anorexics, like their medieval predecessors and non-western counterparts, experience some version of needlessness. Some anorexics have a grandiose sense of being “above” basic needs, including food, sleep, fun, love, and comfort. This grandiosity often stems from the extra burst of energy and euphoria that starvation brings them, coupled with the sense of pride and accomplishment that they have been able to override their body’s needs and diet to the point of emaciation. Other anorexics believe they are unworthy of food, sleep, fun, love, or comfort. These feelings stem from the debilitating depression that is triggered by malnourishment and exacerbated by body dysmorphia and self-loathing. Many anorexics vacillate between these two mind frames, but the end result is the same: emotional anorexia.

The neurobiological changes associated with refeeding cause most patients to experience intense mood swings, irritability, and anger. The psychological trauma of AN adds fuel to the fire. Eating more and gaining weight are an anorexic’s worst nightmares, and this is precisely what is required of her in order to recover. She gains weight, experiences tremendous fear as her appetite kicks into high gear once again, and she is no longer “allowed” to diet. Her body dysmorphia and self-loathing are more intense than ever. Her irritability, agitation, moodiness, and depression are at an all-time high. She withdraws and isolates herself even more, feeling as though she is “too fat” to be seen in public and undeserving of love, comfort, friends, or fun.

Enter the old-school therapist. The young patient is absolutely miserable and desperate to feel better. She has little insight into her symptoms and trusts the therapist completely. The therapist searches through the patient’s past to uncover the “root cause” of her AN. Lo and behold, it is discovered that her parents were too controlling, too overbearing, too overprotective, too critical, too mean, too distant, too neglectful, or too abusive (often some combination of the above). The patient, who is in the midst of the neurobiological hurricane that is re-feeding, becomes angry and hostile towards her parents once she “realizes” that they have caused her current misery. Her parents take her to appointments, prepare her food, and insist that she eats it, thus making her even more fat and unlovable. Her parents try to comfort her; she pushes them away. She is, at times, violently angry with them. After all, they made her anorexic, and now they are making her fat. The same pattern also develops with certain members of her treatment team. She views their interpretations as criticisms. She perceives their requirement of weight restoration as their attempts to fatten her up. Her parents and her treatment team are ruining her life as they chip away at the one thing that has ever made her feel good: the AN.

DEVELOPMENTAL ISSUES. The concept of mother is inextricably intertwined with the concept of food. As developing fetuses in our mother’s womb, we receive nourishment from her. We are born with a rooting reflex, which prompts us to suck our mother’s breast or a bottle. Without this reflex, and without a mother or other caregiver to provide the nourishment, we would die. As infants, we cry when we are hungry. Mother comes running; she holds us and feeds us. Throughout our childhood and adolescence, mother is probably responsible for most of the food shopping and meal preparation.

When a teenager develops AN, her mother is often the first to notice a problem. Mother may encourage or require her to begin treatment. Mother often prepares and serves her food during re-feeding. Mother may ask when and what she last ate, and may require that she eat just a little bit more. Is it any wonder, then, that an anorexic’s feelings about food spill over into her feelings about her mother?

Some psychoanalysts postulate that AN develops from a lack of empathic attunement between mother and child. The mother is not attuned to her child’s emotional needs, so the child is unable to meet her own needs, and this is manifested in her inability to feed herself. There are no empirical data to support the theory that lack of maternal empathic attunement causes AN, and in fact, I believe that this theory is 100% false in terms of explaining the etiology of AN. However, I can understand how this principal may operate subconsciously in the mind of an ill patient. Individuals with AN have great difficulty getting their needs met. They may be unaware of their own needs, they may feel as though they don’t deserve to have their needs met, or they may believe they are “above” having needs. This applies to emotional needs as well as nutritional ones.

I suspect that there is a modest correlation (which does NOT imply causation) between a mother’s inability to provide for her child’s physical or emotional needs and the child’s development of AN. Remember, 50-80% of the risk for developing AN is genetic, so it is very likely that a patient with AN has a first-degree relative (often the mother) who also has a history of AN. If the mother is currently struggling with AN, her fear of food and intolerable anxiety may render her unable to provide for her child’s basic physical and emotional needs. Even if the mother is currently healthy but has a personal history of AN, she will likely share the biochemical and temperamental traits of her ill daughter, albeit to a lesser degree. The recovered AN mother’s deficit in interoceptive awareness may spill over onto her child. She may struggle to meet her daughter’s needs because she has difficulty sensing and meeting her own needs.

Teenagers who develop AN tend to be “model children.” They are almost universally intelligent, well-behaved, hard-working, and gifted at athletics or artistic endeavors. They follow all the rules to the letter. They have never caused a problem for their parents or teachers. The development of AN and the process of recovery leads to an examination of one’s life. The experience of having a life-threatening, soul-killing, personality-destroying illness is enough to make any teenager step back and take stock. Teenagers who are recovering from AN may begin to feel resentful that they have lived a “faked existence” and “played by everyone else’s rules.” They may realize that they have missed out on a lot of fun and excitement by being so straight-laced. With their therapist’s encouragement to express their emotions authentically, they unleash their fury onto the people who have been there through it all: their parents.

This is not a cohesive or well-articulated theory, just a compilation of related thoughts. I hope that research will shed some light onto this phenomenon in the near future.