Posted on

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Focusing on the biological basis of eating disorders DOES mean:

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

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

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

Posted on

Giving Thanks

In my work as a clinical psychologist, I am faced daily with stories of tragedy, trauma, illness, conflict, and loss. Each therapy session is a window into private suffering.

“Isn’t it hard?” people ask me. “Isn’t it awful to listen to people’s problems all day long? Doesn’t it make you depressed?” My answers to these questions are: “Yes,” “No,” and “Quite the opposite.” It is painful to witness people suffering, but it is endlessly rewarding to help them triumph.

Rather than letting other people’s pain drag me down, I feel honored that they have shared it with me and privileged that I am in a position to help them cope with it. I am intimately aware of the obstacles people face – and overcome – every single day. Being a clinical psychologist provides me with daily opportunities to participate in stories of healing, strength, opportunity, resolution, and empowerment.

As Thanksgiving approaches, many Americans begin to think about expressing gratitude for the things we take for granted the rest of the year. Consider these:

If you get out of bed next Thursday, give thanks.
There are those with depression who cannot do so without herculean effort.

If you are preparing to host relatives in your home, give thanks.
There are those with crippling social anxiety for whom a house full of guests would be unthinkable.

If you are planning to travel across several time zones to spend the holiday with relatives, give thanks.
There are those with mood disorders for whom jet lag can trigger an episode of mania or depression.

If you are looking forward to Thanksgiving dinner, give thanks.
There are those with anorexia nervosa for whom a holiday feast is an object of fear, loathing, and guilt.

If you set the table next Thursday in under five minutes, give thanks.
There are those with OCD who cannot relax unless every napkin, fork, and knife is lined up precisely.

If you sit on the couch after dinner to watch football with your uncles and cousins, give thanks.
There are those with bulimia nervosa who will be pacing around the house, waiting for an opportunity to purge unnoticed.

If you settle into bed with a good book later that evening, give thanks.
There are those who will be cutting their forearms with a razor to numb themselves from the intolerable emotions triggered by the day’s events.

If you go to bed Thanksgiving night satiated and content, give thanks.
There are those whose restless worry keeps them up until sunrise.

If you have never even considered feeling grateful for these ordinary things, give thanks.
Our mental health, and that of our family, should not be taken for granted.

Posted on

The Thin Ideal and Anorexia Nervosa: Case in Point

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Posted on

Summary of Treatment Outcomes

My blog posts from June through November 2013 have been devoted to describing my patients’ treatment outcomes. I’ve been advised that my recent posts have been too data-heavy and too detailed, but hey – that’s how I roll. I like to be thorough, meticulous, and transparent. Prospective patients and their families deserve to have access to this information. But for those who prefer brevity, I’ve summarized my treatment outcomes below. Click on the headings in bold for details.

    Outcomes for Patients with Anorexia Nervosa


Fifty-seven percent of my former patients with Anorexia Nervosa (AN) completed treatment. Of the “treatment completers,” 94% reached full remission and the remaining 6% reached physical remission. Patients required, on average, 28 sessions over the course of 17 months to complete treatment.

Forty-three percent of my former patients with AN did not complete treatment with me. Of the “treatment non-completers,” 23% were referred to other treatment settings which could better meet their needs; 15% moved to other geographic locations during treatment and thus were referred for treatment near their new homes; and the remaining 62% dropped out of treatment prematurely.

    Outcomes for Patients with Bulimia Nervosa and Eating Disorder Not Otherwise Specified


Thirty-three percent of my former patients with Bulimia Nervosa (BN) and Eating Disorder Not Otherwise Specified (EDNOS) completed treatment. One-hundred percent of those who completed treatment reached full remission. On average, patients took 15 sessions over the course of 10 months to complete treatment. Amongst patients with BN, 44% made significant progress prior to discontinuing treatment prematurely. For patients with EDNOS, 17% made significant progress prior to discontinuing treatment prematurely.

    Outcomes for Patients with Mood Disorders


Twenty-nine percent of patients my former patients with primary diagnoses of mood disorders completed treatment. Of the patients who completed treatment, 83% achieved full remission and the remaining 17% made significant progress. On average, patients took approximately 23 sessions over the course of 11 months to complete treatment.

Thirty-eight percent of mood disorder patients quit treatment prematurely, 24% were referred to other treatment providers who could better meet their needs, and 9% moved to other geographic locations during their treatment and were referred for treatment near their new homes.

    Outcomes for Patients with Anxiety Disorders


All of my former patients with primary diagnoses of anxiety disorders who attended more than two sessions experienced substantial improvement in anxiety symptoms as well as significant improvement in functioning, even if they did not complete a full course of treatment. Patients with anxiety disorders attended an average of 10 sessions over the course of 6 months.

Amongst those who completed a full course of treatment, 75% achieved full remission and the remaining 25% made significant progress.

Posted on

A Comparison of Treatment Outcomes: AN, BN, and EDNOS

My previous posts described treatment outcomes and correlates of my patients with various eating disorder diagnoses, including Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Eating Disorder Not Otherwise Specified (EDNOS). Some findings were similar across diagnostic groups:

• The vast majority of patients with any diagnosis who completed treatment achieved full remission.

• The attrition rate, overall, was high.

• Family-Based Treatment (FBT) was associated with treatment retention, meaning that patients who participated in FBT were less likely to discontinue treatment prematurely than those receiving individual therapy.

• Patients who paid a reduced rate for services were much less likely to complete treatment and much less likely to achieve remission than those who paid full rate.

• Hospitalization during treatment with me was not related to treatment completion or treatment outcome, regardless of diagnosis.

• History of intensive eating disorder treatment (e.g., residential treatment, day treatment) was related to treatment non-completion and poorer outcome for patients across diagnoses.

Quite surprisingly, the differences among the diagnostic groups outnumbered the similarities:

• Patients with AN who completed treatment attended more sessions, over a longer period of time, than patients with BN or EDNOS. Completing treatment for AN involved an average of 28 sessions over 17 months, whereas completing treatment for BN or EDNOS involved an average of 15 sessions over 10 months.

• Type of treatment had a significant impact on outcome for patients with AN but not for patients with BN or EDNOS. All AN patients who achieved remission did so through FBT. However, patients with BN and EDNOS achieved remission through various means, including individual therapy with no family involvement, individual therapy with family involvement, and FBT.

• Younger age at intake and shorter duration of illness predicted treatment completion and remission for patients with AN. However, neither age nor duration of illness affected treatment outcome for patients with BN or EDNOS.

• All “treatment non-completers” with AN (those who quit prematurely, moved away, or were referred to other treatment settings) discontinued treatment within the first six months. In contrast, a number of “treatment non-completers” with BN or EDNOS remained in treatment for more than a year.

• Among patients with AN, those who completed treatment attended significantly more sessions than those who did not (28 sessions vs. 8 sessions) and remained in treatment for a much longer time than those who did not (17 months vs. 3 months). In contrast, for patients with BN and EDNOS, treatment completers and non-completers both remained in treatment for an average of 10 months, and treatment non-completers actually averaged more sessions than treatment completers (20 sessions vs. 15 sessions). Thus, it appears that for BN and ENDOS, treatment completers did not remain in treatment longer, but rather reached remission more quickly.

• Caucasians with AN were slightly more likely than Hispanics with AN to complete treatment and achieve remission. In contrast, Hispanics with BN or EDNOS were significantly more likely than Caucasians with these diagnoses to complete treatment and achieve remission.

• The presence of a comborbid disorder was not related to treatment completion or treatment outcome for patients with AN. However, the presence of a comorbid disorder was a significant predictor of treatment dropout and poorer outcome for patients with BN and EDNOS.

• History of hospitalization for an eating disorder or related psychiatric issue was related to poorer outcome for patients with BN and EDNOS, but not for patients with AN.

• Taking psychotropic medication during treatment was related to treatment completion and positive outcome for patients with AN but not for patients with BN or EDNOS.

Please bear in mind that these findings are specific to my practice and my patients, and are not intended to be generalized to other treatment settings or other patients.

Posted on

Correlates of Treatment Outcome for Patients with Anorexia Nervosa

In my last blog post, I described the end-of-treatment outcomes of my former patients (N = 30) with Anorexia Nervosa (AN). In sum, 57% of patients completed treatment (n=17) and 43% of patients (n = 13) did not complete treatment. The former group is referred to as “treatment completers” and the latter as “treatment non-completers.”

As expected, end-of-treatment results differed dramatically between the two groups. By the end of treatment, 94% percent of treatment completers had achieved full remission and 6% (n = 1) had achieved physical remission. In contrast, none of the treatment non-completers achieved remission, although 46% of them made significant progress (n = 6).

Bear in mind that I set the bar very high for my patients in terms of defining remission. In most published studies of AN treatment outcome, the patients whom I categorized as having made significant progress would be categorized as “recovered” or “in remission.” If I used the (completely inadequate) definitions of remission that other studies have used, a full 77% of my sample would have completed treatment and made a full recovery. But I digress.

These data clearly demonstrate that my approach to treating AN is effective. Patients with AN who have completed treatment with me always achieved physical remission and almost always achieved psychological and behavioral remission as well.

The 43% attrition rate is disheartening, given that patients are likely to achieve remission if they remain in treatment long enough. Attrition is a major problem in AN treatment in general, and in AN treatment for adults in particular. The validity of most AN treatment outcome studies is compromised by the high rates of attrition. It is not surprising that many adults discontinue AN treatment prematurely, given that treatment is very difficult, anxiety provoking, and lengthy.

This raises the question of what is “long enough” in terms of AN treatment? In my opinion, “long enough” is as long as it takes to bring the patient to full remission, which varies considerably based on individual differences. Among the treatment completers, the length of time to full remission ranged from 2 months to 4 years, with a mean of 17 months. The number of sessions attended by treatment completers ranged from 3 – 82, with a mean of 28 sessions. There were a handful of the young patients who achieved full remission in 12 sessions or less, although this was not the norm.

The rates of treatment completion versus non-completion in my sample beg the question of how these two groups differed. What was it that made treatment completers stick it out until the end, while the treatment non-completers either quit or regressed to the point that they required more intensive treatment? Cause and effect cannot be determined from this type of study. However, a careful examination of the similarities and differences between treatment completers and non-completers may yield useful information and hypotheses which can be tested in future studies.

The patients who completed treatment and reached remission differed in several important ways from those who discontinued treatment prematurely.

Variables That Had a Significant Impact on Treatment Outcome:

1.) Type of Treatment

In my practice, all children and adolescents under age 18 with AN receive FBT (Family-Based Treatment, also known as the Maudsley Method). Some adolescents also receive individual therapy as an adjunct to FBT after weight restoration. Some children and adolescents transition to individual therapy with me after FBT is complete; this may be the case for those who have comorbid disorders or other ongoing issues. Patients over 18 with AN are strongly encouraged to do FBT whenever appropriate, although it is not always possible for logistical reasons, and some young adults are staunchly opposed to it. In my sample, 66.7% of patients (n = 20) received FBT alone, 16.7% (n = 5) received FBT plus individual therapy, and 16.7% (n = 5) received individual therapy alone.

In my sample, all of the patients who received individual therapy alone were 20 or older. Six of the 11 young adults in my sample (n = 55%) participated in FBT, either alone or in conjunction with individual therapy. All of the patients under age 18 received FBT, and two of these patients also received individual therapy.

One-hundred percent of treatment completers (n = 17) received FBT, either by itself (n = 15) or in conjunction with individual therapy (n = 2). In other words, all patients who achieved remission did so through FBT. One-hundred percent of the patients who did individual therapy alone (n = 5) ended treatment prematurely, either because they moved (n = 2), they quit (n = 2), or I referred them to a higher level of care (n = 1). In other words, individual therapy by itself never resulted in treatment completion or remission.

2.) Subtype of AN

This sample contained 5 patients with the Binge-Purge subtype of AN (AN – BP) and 25 patients with the Restricting subtype of AN (AN – R). One-hundred percent of treatment completers had a diagnosis of AN-R. None of the AN-BP patients completed treatment.

Among the AN-BP patients, 2 were referred to higher levels of care after regressing during treatment with me. One patient moved to another state after making some progress in treatment with me. Two patients quit treatment prematurely after making significant progress with me.

The patients in my sample with AN-BP were more likely to have a history of impulsivity, self-injury, and suicidal gestures compared to those with AN-R. I hypothesize that this cluster of symptoms made these patients more difficult for me to treat effectively as an outpatient solo practitioner, and more likely to benefit from a more structured, comprehensive treatment approach such as day treatment or residential treatment.

3.) Age

On average, those who completed treatment and achieved remission were significantly younger at intake than those who did not complete treatment (p <.01). Treatment completers ranged in age from 10 – 24 at intake, with a median age of 14. Treatment non-completers ranged in age from 10 – 37, with a median age of 20. However, it is important to note that there was a broad range of ages in both groups, with some young adults achieving full remission and some children and adolescents discontinuing treatment prematurely. 4.) Fee Paid for Services I believe that neither finances nor insurance issues should prevent people from accessing high-quality healthcare services. Therefore, I do not participate on any insurance panels. I am flexible with my fees and I work on a sliding scale based on a patient's ability to pay. If a family’s financial status changes during the course of treatment, I will change my fee for them accordingly. I work with many patients for very low hourly fees. Thus, I can only assume that the patients who discontinued treatment prematurely did not do so for financial reasons. Among the patients in this AN sample, 87% (n = 26) paid my full fee and 13% (n = 4) paid a reduced rate. The rate of reduced-pay patients in this sample is significantly lower than in my other diagnostic groups. I hypothesize that this may be due to the fact that the majority of patients in this sample received family-based treatment and had at least one parent who was a working professional, or who at least was employed full-time. In contrast, many of my patients with other diagnoses were college students supporting themselves, who were therefore eligible for a low fee. In this sample of AN patients, those who paid a reduced rate were significantly less likely to complete treatment compared to those who paid a full rate. Only 25% of reduced fee patients (n = 1) completed treatment, versus 62% of full fee patients (n = 16). It is unclear why reduced rate patients were less likely to complete treatment. However, the reduced rate patients differed from the full rate patients in several important ways. First, and most obviously, they had lower incomes, and likely dealt with the host of stressors that accompany being of lower socio-economic status. Second, they were all over the age of 18, which statistically reduces their likelihood of full recovery. Third, they were more likely to receive individual therapy than the full-rate patients. All of the low-rate patients received individual therapy, either alone (n = 2) or in combination with FBT (n = 2). Observing my patients with other diagnoses, I have noticed that those who pay full rate are much more likely to attend all of their sessions and to complete treatment, whereas those who pay lower rates are more likely to cancel sessions, no-show for sessions, and drop out prematurely. While I’m sure that the reasons for these differences are complex, I can’t help but wonder if people who pay more for something tend to value it more and take it more seriously. Variables That Had a Minor Impact on Treatment Outcome:

1.) Length of illness before intake.

Among treatment completers, length of illness before intake ranged from 3 months to 13 years (mean = 27 months). Amongst treatment non-completers, length of illness before intake ranged from 3 months to 21 years (mean = 67 months). However, this difference was not statistically significant (t = 1.63; p = 0.11).

2.) Use of Medication During Treatment

Individuals who took psychotropic medication during treatment with me were somewhat more likely to complete treatment and achieve remission. Fifty-nine percent of treatment completers (n = 10) took medication during treatment, compared with 38% of treatment non-completers (n = 5).

3.) Ethnicity

This sample of 30 patients was comprised of 60% White Non-Hispanic individuals (n = 18) and 40% White Hispanic Individuals (n = 12). These percentages are roughly similar to the ethnic makeup of Coral Gables, Florida, the Miami Suburb in which my office is located. The treatment completers group was comprised of 71% White Non-Hispanic individuals (n = 12) and 29% White Hispanic individuals (n = 5). The treatment non-completers group included 46% White Non-Hispanics (n = 6) and 54% White Hispanics (n = 7). Therefore, White Non-Hispanics were slightly more likely to complete treatment and achieve full recovery than White Hispanics.

4.) History of intensive eating disorder treatment.

History of residential, day treatment, or intensive outpatient treatment had a minor impact on treatment outcome. Twelve percent of treatment completers (n = 2) and 23% of treatment non-completers (n = 3) had a history of residential eating disorders treatment prior to beginning treatment with me. Twenty-four percent of treatment completers (n = 4) and 31% of treatment non-completers had a history of partial hospitalization, day treatment, or intensive outpatient eating disorder treatment.

Variables that Had No Impact on Treatment Outcome:

1.) Comorbid disorders

The presence of comorbid disorders did not differ significantly between the two groups. Fifty-three percent of treatment completers (n = 9) had a comorbid diagnosis, as did 46% of treatment non-completers.

2.) Gender.

Given that only 7% of the sample was male (n = 2), I cannot draw any conclusions about gender differences in treatment response. Incidentally, both of the males in my sample achieved full recovery.

3.) Hospitalization before treatment.

Being hospitalized for AN or a related psychiatric issue prior to beginning treatment with me did not have a significant impact on treatment outcome. Thirty-five percent of treatment completers (n = 6) had been hospitalized at least one prior to beginning treatment with me, as had 31% percent of treatment non-completers (n = 4).

4.) Hospitalization during treatment.

The need for hospitalization during the course of treatment with me did not have a significant impact on treatment outcome. Eighteen percent of treatment completers (n = 3) needed to be hospitalized during the course of their treatment, compared with 15% (n = 2) of treatment non-completers.

These data, taken together, suggest that a patient with AN-R who enters treatment with me and receives FBT is very likely to achieve full remission within 28 sessions over the course of 17 months, regardless of gender, comorbid diagnosis, or history of hospitalization. A patient under age 18 has a greater likelihood of achieving full remission, although a patient over 18 is also likely to achieve full remission, provided that he or she is treated with FBT.

Please bear in mind that these results are specific to my practice and my patients. These data are not intended to be generalized to other clinicians or other patient populations.

Posted on

End of Treatment Outcomes for Patients with Anorexia Nervosa

Since opening my practice in 2009, I have evaluated 49 patients with primary diagnoses of Anorexia Nervosa (AN). All patients who attended an evaluation and at least one treatment session with me, and who are no longer in treatment with me, were included in this sample. In addition, there were several patients who have completed their treatment but have elected to see me two or three times per year for check-ins; these patients were included in this sample as well. Patients who are currently in treatment with me were not included. Patients who saw me for an evaluation and / or consultation only, but did not attend any treatment sessions, were not included either. Thirty patients met criteria for inclusion in this sample. The remaining 19 did not meet criteria, either because they saw me for evaluation and consultation only or because they are currently in treatment with me.

Please bear in mind that this is not a randomized, controlled study. The results I am posting are specific to my practice and my patients. They are not intended to be generalized to other clinicians or other patients. While many of my patients are referred to me by their pediatrician or psychiatrist, the majority of my patients are self-selecting. That is, their families researched their treatment options on their and chose to work with me for a specific reason. The self-selecting nature of many of these families also limits the generalizability of the results.

The sample described in this post contains 30 patients. These patients ranged in age from 10 – 37 (median age = 15). Eighty-three percent of these patients (n = 25) met criteria for restricting subtype (AN-R) and the remaining 17% (n = 5) met criteria for binge-purge subtype (AN-BP). Half of these patients (n = 15) had a co-morbid diagnosis, with the most common being Major Depressive Disorder and Depressive Disorder Not Otherwise Specified. Fifty-three percent of patients (n = 16) took some type of psychotropic medication during their treatment with me.

The patients varied widely in terms of length of illness and severity of symptoms. Duration of illness before intake ranged from 3 months to 21 years (median duration = 19 months). Importantly, these figures reflect the duration since the onset of illness, which is typically longer (and often much longer) than the duration since diagnosis. For the purpose of calculating duration of illness, onset of illness was defined as the period of time in which patient began engaging in behavioral symptoms of AN (e.g., restricting, compulsive exercise, purging) as reported by the patient and/or parents.

The majority of these patients arrived at my office with some history of treatment. Seventy percent of patients (n = 21) had already received some type of treatment before beginning therapy with me. As expected, most of those who were new to treatment had a much shorter duration of illness. One-third of patients (n = 10) had been hospitalized for their eating disorder or a related psychiatric issue (e.g., suicide attempt) prior to their evaluation with me. Seventeen percent of the patients (n = 5) had previously been in residential treatment and 27% (n = 8) had previously been in partial hospitalization, day treatment, or intensive outpatient treatment eating disorder treatment.

Duration of treatment with me ranged from one week to 48 months (median duration of treatment = 11 months). Number of treatment sessions with me ranged from 1 – 82. For those whose treatment lasted 18 months or longer, the duration of treatment can be explained by either a relapse after a period of remission or continued treatment to address a comorbid condition, such as anxiety or depression. Seventeen percent of patients (n = 5) had to be hospitalized during their treatment with me.

Prior to reporting end-of-treatment outcomes, it is important to clarify how I defined outcomes. I created the following definitions, each with specific criteria, in order to categorize patient outcomes:

1. Patient must meet ALL of the following criteria to be classified as in full remission:
a.) Patient is 100% weight-restored. Target weights were calculated based on patient’s individual historic growth chart and parent input. Patients under age 20 were expected to return to their historic percentiles for height, weight, and BMI. For patients age 20 and up, target weights were calculated based on the patient’s height, body build, weight history, menstrual history, and parental input (when available).
b.) Patient has started or resumed menstrual periods (for females ages 14 +).
c.) Patient is medically healthy.
d.) Complete abstinence from binge/purge behaviors, laxatives, and diet pills.
e.) Patient eats regular, balanced meals most of the time or always , as reported by patient and parent (when applicable)
f.) For children under 18 – child eats independently in an age-appropriate way most of the time or all of the time. For patients ages 18 and up, patient is able to eat independently while maintaining his/her weight.
g.) No more than mild preoccupation with food, weight, body image, or fear of weight gain

2. Patient is classified as in physical remission if he/she meets criteria a, b, c, d, and e under full remission, but does not meet criteria f or g under full remission. Essentially, a patient in physical remission is physically well and free of eating disorder behaviors, but cannot eat well independently, and/or continues to be preoccupied with thoughts about food, weight, and body image.

3. Patient is classified as having made significant progress if:
a.) Patient has made significant improvement in dietary habits (e.g., eats regular, balanced meals and snacks and has expanded the variety of foods he/she eats) as reported by patient and parents (when applicable)
b.) Patient has restored some weight and is at least 90% of ideal body weight (as defined in criterion a under full remission)
c.) Patient is medically healthy
d.) If patient has a history of bingeing, purging, laxatives, or diet pills, the frequency of these behaviors has been reduced to once per week or less.

4. Patient is classified as having made some progress if:
a.) Patient has improved dietary habits since intake, but needs more improvement
b.) Patient has restored some weight but remains more than 10% below target weight (as defined in criterion a under physical remission).
c.) Patient is a female age 14 or older but is not menstruating
d.) If patient has a history of bingeing, purging, laxatives, or diet pills, he/she has reduced the frequency of these behaviors since intake but still engages in them more than once per week.

5. Patient is classified as having made no progress if he/she has not improved dietary habits, has not restored any weight, and/or has not reduced the frequency of bingeing or compensatory behaviors.

6. Patient is classified as regressed if he/she meets ANY of the following criteria:
a.) Patient has lost weight since starting treatment
b.) Patient has been eating less since intake (in terms of frequency, quantity, and variety)
c.) Frequency of bingeing or compensatory behaviors has increased since intake
d.) Patient has become medically unstable

Fifty-seven percent of patients (n = 17) completed treatment and will be referred to as “treatment completers.” Treatment completers ranged in age from 10 – 24 at intake, with a median age of 14. Duration of treatment for treatment completers ranged from 2 months to 48 months (median duration = 15.5 months).

Ninety-four percent of treatment completers (n = 16) met criteria for full remission at end of treatment. The remaining 6% (n = 1) met criteria for physical remission at end of treatment. For the treatment completers, weight restoration was achieved in an average of 3 months (range = 1 – 7 months). Two of the treatment completers were fully weight-restored (though not in full remission) at the start of treatment with me, having already been in eating disorder treatment elsewhere.

Forty-three percent of patients (n = 13) did not complete treatment and will be referred to as “treatment non-completers.” Treatment non-completers ranged in age from 10 – 37, with a median age of 20. Duration of treatment for the non-completers ranged from one week to six months (median duration = 3 months). Of the treatment non-completers, I referred 23% (n = 3) to other providers because they required something I could not provide (e.g., residential treatment) or my treatment approach was not helping them. Fifteen percent of non-completers (n = 2) moved to other parts of the country during their treatment and thus were referred to other providers near their new homes. Sixty-two percent of treatment non-completers (n = 8) dropped out of treatment prematurely.

Of the treatment non-completers, 46% (n = 6) had made significant progress by their last session with me. Fifteen percent had made some progress, 23% (n = 3) had made no progress, and 15% (n = 2) had regressed.

Stay tuned for my next blog post, in which I will examine and interpret the differences between treatment completers and treatment non-completers.

Posted on

Book Review: Food to Eat

There are a number of books that I recommend to the parents of every eating disorder patient I see. When it comes to books for eating disorder sufferers themselves, however, I am much more cautious. Many of the books that are directed at sufferers, while well-intentioned, can be triggering for some patients.

Now all of that has changed. I have finally found a book that I would wholeheartedly recommend to any adult eating disorder patient at any stage of recovery: Food to Eat. I have never read anything quite like this before. Food to Eat, authored by dietician Lori Lieberman and recovering eating disorder patient Cate Sangster, combines practical nutritional advice with quick, easy-to-prepare recipes. The most unique part of Food to Eat is that the pages of recipes and nutritional advice are peppered with dialogue between Lori and Cate. A virtual cognitive restructuring exercise, this dialogue counteracts common eating disorder thoughts with empathic, scientifically-grounded information about nutrition and behavior change.

Food to Eat can be particularly helpful for young adults with eating disorder histories who are transitioning into independent living situations which require them to prepare their own food for the first time. In addition, I would recommend Food to Eat for an adult of any age who is pursuing recovery and wants to develop a certain level of comfort in preparing and eating a variety of foods. Finally, I would recommend Food to Eat for caregivers of eating disorder patients who are responsible for preparing and serving food to the patient, as this book provides unique insight into what the patient is likely thinking when a given recipe is presented.

Full nutrition is the most crucial ingredient of eating disorder recovery. Food to Eat provides a recipe for success in overcoming the cognitive as well as nutritional challenges of eating disorders.

Posted on

As Serious As Cancer

There are several parallels between Anorexia Nervosa (AN) and cancer. Both diseases are severe and potentially fatal – the mortality rate of AN is similar to that of the most common form of childhood leukemia. Both can become chronic illnesses characterized by periods of remission and periods of relapse. Early, aggressive intervention is crucial in the treatment of AN as well as the treatment of cancer. Both diseases will grow and metastasize if left unchecked. Neither cancer nor AN is the patient’s choice or the parents’ fault. Chemotherapy is an aversive, painful treatment with unwanted side effects. The same can be said of re-feeding and weight restoration in AN – it is extremely anxiety provoking and difficult for the patient, yet it is necessary in order to eradicate the disease. Patients with AN, like patients with cancer, require a tremendous amount of help and support from caregivers for long periods of time.

Blogger Cameron Von St. James, the husband of Mesothelioma survivor Heather Von St. James, wrote the following essay about caring for his wife during her battle with cancer. I think it may resonate with caregivers of patients with AN.

The Hardest Battle Of Our Lives
by Cameron Von St. James

When my wife and I walked into that doctor’s office on November 21, 2005, we didn’t realize that our lives were about to change forever. Until then, we were your average couple. We both worked full-time jobs and had welcomed our first and only child into the world just 3 months prior. As we sat in the doctor’s office together, we watched our lives transform into a chaos and uncertainty before our very eyes. The doctor read the diagnosis: malignant pleural mesothelioma. Cancer, and an extremely deadly one at that. I knew we were in for a long, difficult struggle.

The doctor told us about treatment options. We could go to a local university hospital, a regional hospital that didn’t even have a specialist to deal with my wife’s form of cancer, or Dr. David Sugarbaker in Boston, a renowned specialist in the treatment of mesothelioma. My wife couldn’t even answer, she was so shocked and terrified. She turned to me as if to cry for help. I answered her silent plea by telling the doctor, “Get us to Boston!” That decision turned out to be one of the most important I’ve ever made in my life.

Being a caregiver my wife was extremely taxing and difficult, but it’s a job that I knew I had to do to the best of my ability. I knew I had to be strong for her and be her rock. Inside, though, my life was in turmoil. My wife had to quit her job and required more and more care each day. As a result, I was working full-time, taking care of our infant daughter, and also taking care of my beloved wife too, whisking her to one doctor appointment after another, making travel arrangements to Boston, and making her comfortable at home. It was a full schedule and there were so many times when I felt like giving up, but I knew I needed to press on.

During this time, I dealt with a multitude of fears that will never leave me. Medical bills piled up. I watched the love of my life endure pain and sickness that no one should ever have to endure. I feared what would happen to our daughter if my wife didn’t survive through this. Would she have to spend the rest of her life without a mother? And with a father that was broke because of all the medical bills? It was the hardest, most painful time I’ve ever lived through, and more than once the stress and pressure forced me to the ground in tears. I had bad days, but I never let my wife see my in my moments of weakness. I knew that she needed me to be strong, and I did my best to give her that.

After months of surgery, radiation and chemotherapy treatments, Heather is cancer-free. She beat mesothelioma against all odds, and I am so proud of her. Two years after her diagnosis, I enrolled in school full-time to study Information Technology. I graduated with honors and am thankful to have been given the stage to give the speech at my graduation. It was there that I was able to see the lessons I learned and communicate my gratitude for the fact that my wife had beat cancer.

My own lessons stay with me even today. I learned that I’m strong enough to take care of someone I love, even if it is scary and often painful. I learned to use my own stubbornness to work to my advantage. Most importantly, I learned that time is precious to us all and we should spend it with the people we love so much. It’s seven years later and Heather is cancer free, and we continue to raise our beautiful daughter with the lessons we both learned. It is our hope that our story of triumph over cancer can inspire others in their own battles.

Posted on

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.