Podcast: Supporting Effectively Diagnosing and Treating Eating Disorders

Jeff talks to Dr. David J. Alperovitz about how anorexia, bulimia, binge eating disorder, and ARFID are diagnosed and treated. David also provides an overview of eating disorders, shares tips for recognizing key warning signs, and answers audience questions.

David J. Alperovitz, PsyD, is currently the program director of McLean’s Klarman Eating Disorders Center. He also has over 25 years of experience working at McLean Hospital, primarily with individuals with OCD, eating disorders, trauma histories, and dissociative symptoms.

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Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Jeff: Welcome and thanks for joining us. My name is Jeff Bell. And on behalf of McLean Hospital, I’d just like to say how much we appreciate your interest in our educational webinar series.

Today we set our sights on eating disorders, how they’re diagnosed, how they’re treated, what you should know about anorexia, bulimia, binge eating disorder, and related conditions.

While treatable, these disorders are serious mental health challenges, and unfortunately, there are a lot of misconceptions about them. So our goal for this webinar is to help you separate fact from fiction when it comes to understanding eating disorders.

And to that end, we have brought in an expert. Dr. David Alperovitz has over 25 years of experience working at McLean Hospital, primarily with individuals with OCD, eating disorders, trauma histories, and dissociative symptoms. He’s currently the program director of McLean’s Klarman Eating Disorders Center.

David, thanks so much for your time today.

David: Oh, thanks, Jeff. Wonderful to be here. Appreciate it.

Jeff: Well, we’re thrilled to have you with us. And we have a lot of ground to cover today, so I want to start by asking you about eating disorders in general.

We’re going to break them down individually over the course of the next hour, but how would you best define the umbrella term itself? What exactly is an eating disorder?

David: Oh. So it’s a very general question, and there, you know, there are different permutations of different eating disorders, but generally speaking it’s, you know, a disturbance in eating and feeding.

Coupled most often with the disturbance in the perceptions around body shape and size, often with significant anxiety and fear attached to it. And I say this, you know, eating disorders are not classified as an anxiety disorder, but it is a very significant component.

And it’s very rare when someone who has an active eating disorder doesn’t have anxiety. So I think that’s important to note when we think about eating disorders, that that is a large part for most people.

Significant anxiety around the relationship with food, around the relationship with their bodies, or the relationship around the change of their bodies, and the consequences connected with all of those things.

Jeff: Is there always a component of appearance or weight concern, or sometimes are those not the driving factors?

David: They’re not always the driving factors. Very often they are. There are some instances where people, you know, for one reason or another, may engage on some restrictive eating behaviors. Maybe with very good intentions.

And maybe not so much around appearance, but maybe more around overall sort of umbrella of better health, so to speak. And often, you know, with that becomes, you know, a situation that arises where people really begin to lose perspective, and then the appearance may not be so present.

But then the prospect of gaining weight, now the appearance is a presence, and that becomes anxiety ridden. There are also instances where people struggle with different relationships where food has nothing to do very much with appearance.

It might be really around distaste or aversion, even disgust, or fear of the consequences of what they’re eating. Not so much about appearance or the fear of gaining weight. There’s a newer diagnosis that I’m sure we’ll talk about that is avoidant/restrictive feeding disorders that is more and more prevalent.

Certainly needs a lot more research, but is a very real thing and is less about appearance, although there is some bridging to anorexia and other eating disorders even with ARFID.

Jeff: David, I want to ask you about BDD, body dysmorphic disorder. We’re not going to be focusing on that today. Why is it distinct from eating disorders in general?

David: Great question. And, you know, I think they often get lumped together. You know, BDD extensively is, you know, obsessive thoughts and repetitive behaviors really in response to a perceived, and I’ll emphasize that word, perceived appearance flaw.

And the, you know, the distinguishing factors from an eating disorder is, you know, eating disorders are primarily comprised of disturbances of thoughts and behaviors related directly to eating, to weight, and shape and size. So they’re much more broad, and they, you know, include the component of food and weight.

Whereas BDD can be very, very idiosyncratic for different people. And it’s focused generally on specific body parts, with repetitive behaviors such as checking, comparison, often multiple surgeries as well to alter appearances and things like that. It falls more neatly into, you know, an obsessive-compulsive diagnostic realm.

Jeff: And we should mention that we have a lot of information about BDD on the McLean website, for those of you who’d like to learn more about that. Back on eating disorders in general, what can you tell us about their prevalence?

What kind of stats do we know these days in terms of how many people are impacted by eating disorders and what that trend line looks like over the past many years?

David: Another great question, and I wish I had a better answer for you. I can give you some statistics on prevalence. it’s roughly, you know, between 2 and 3%. Maybe 2.5% will have a lifetime prevalence of having an eating disorder.

Certainly there is good evidence to suggest that roughly two times as many women than men will develop eating disorders. But this gets to some of the myths around eating disorders as well. And I think, you know, over time there has been developed this notion that it really affects white girls who are, you know, fairly affluent.

And that’s really a myth. It affects people of all shapes and sizes, all genders, all ages, and all socioeconomic conditions. And I think that’s very important to note. Yes, it does tend to affect women more than men. About twice as much. But the reason I don’t have a great answer is the prevalence statistics, we need to do more research.

You know, there’s some from the early 2000s, and there’s some updates in around 2020, which are pre-pandemic. And, you know, anecdotally I think the prevalence of eating disorders has actually increased significantly over the last four years.

So I’m very curious to see where the prevalence numbers are now. And I think there’s a real call to do more research and learn more about how prevalent eating disorders are in this day and age.

Jeff: How about causes? What do we know about the causes of eating disorders?

David: Another excellent question. And, you know, multifactorial causes, right? I mean, I think we have biological causes that are fairly well identified. We have psychological causes, and we have social causes, right?

I think I mentioned anxiety as one of the sort of comorbid, almost, conditions behind an eating disorder, or very often behind an eating disorder, but there’s also psychosocial consequences.

You know, eating disorders are more prevalent in younger adolescents in early adulthood, and they correlate often with difficult psychosocial situations, especially bullying, traumatic events, family discord, multiple life changes.

You know, essentially things that, you know, inherently might cause stress through development are very clearly associated with eating disorders. So there’s this bio-psychosocial sort of coming together that really underlies most eating disorders.

Jeff: Let’s talk briefly, because we can circle back and get into this in more detail, but pressures from the media. Peer pressures, pressures to look a particular way. Those are factors for eating disorders.

David: Yeah, and I think in some ways that’s one of the unfortunate distinguishing factors of an eating disorder. In very harmful and hurtful ways, they may be culturally supported. And whether that’s through social media, or, I mean, I think there’s more sensitivity to this now.

There was actually a very interesting study about the island of Fiji before they had Western television there. And, you know, they sort of looked at before and after.

And when Western television came and things like “Dynasty” and “Dallas” were on television people were watching, a large number of body disturbance and eating disorders arose when there hadn’t been very much before that.

So there is this sort of culturally reinforced, socially reinforced desire, and purposely, thin is good. And I think that’s, you know, both dangerous, you know, on a media standpoint, but really dangerous from a social media perspective, where people may present sort of altered pictures or the best aspects of themselves.

They don’t tend to put pictures of themselves that aren’t flattering. And it creates this false impression that, you know, this is the way the rest of the world is, and I don’t quite measure up. So there’s this inherent pressure. And that’s different than most other psychiatric diagnosis that are not sort of reinforced culturally in that same way.

And it’s very dangerous and I think very confusing for people as well, although I do think there’s more information out there and certainly more to come. But it’s certainly a very important and quite powerful, unfortunately, factor in supporting eating disorders.

Jeff: So David, one of the messages that we want to get out there today, I know this is important to you, is that these conditions are treatable. There are approaches that can be used to treat these disorders.

That said, I think it’s sobering and important for us to put out as well that these conditions can be deadly.

David: They can. And well, I’ll start with the first part. Yes, absolutely. They are treatable, right? And I think the large majority of the people that engage in eating disorders and receive treatment do well, often into remission and full recovery.

And, you know, there’s maybe 50% of the people that engage in treatment will actually arrive at a full recovery. Another 30% will see marked and significant improvement from treatment. And there is a 20% percentage of folks who will sort of develop a more chronic eating disorder and live with that.

But as you mentioned, this is a very serious acute and fatal illness as well. You know, the statistics are back and forth, but the most recent one suggests that it is the most fatal of all psychiatric diagnosis with around a, I think around a 10% fatality rate.

And that’s sort of bimodal. Probably of that 10% that will die from eating disorder, roughly 20% of them will die from suicide, and the other 80% usually some sort of organ failure or cardiac condition. So it is very serious and potentially deadly.

And the other thing is, you know, the statistics around recovery from eating disorder are general. So if you look at people who receive treatment earlier on in their illness, the success rates are even higher.

So there’s a real importance on being able to assess and identify eating disorders early on. People do better. They engage better in treatment. Versus people that have been struggling for many years, perhaps without treatment.

Jeff: Yeah, really speaks to the importance of awareness. And we’ll talk a little bit later about awareness campaigns and some of all that. But is it your sense, David, that more people are aware today than they were, say, five or 10 years ago about the dangers of these disorders and the fact that there is in fact treatment for them?

David: I do think more people are aware, but I want to be cautious when I say that because I think there’s still more awareness that’s needed. You know, that there is, I think, more of a mindfulness in sort of Hollywood and media markets and advertising and fashion that may have been beginning to evolve five years ago, even earlier.

But really I think is beginning to shift a little bit more. There is more that is needed. I think the more recent statistics around the harms associated with social media, not just with eating disorders, but I think that eating disorders are especially vulnerable to social media in terms of both reinforcement and sustaining of eating disorders.

I think there’s a lot that needs to be done legislatively around social media and a lot of awareness. I think some of the big companies are very clear that they know the dangers of these platforms. And the next step, in my mind, in my bias, is some change, some outright change.

Jeff: So David, we’re going to entertain some questions from our audience throughout the next hour as well. But right now what I would like to do first is sort of break down those main eating disorders, disorder by disorder, and talk about what sets them apart from one another.

Let’s start with the one that I think most of us are most familiar with: anorexia.

David: Sure. Yeah, I think most of us are familiar with it. Ostensibly, it really, in simplistic terms, is a restriction of energy intake, which is kind of a fancy word for nourishment or food, leading to a significant low body weight, you know, in the context of age and sex and their developmental trajectory.

But, you know, a restriction of food with a markedly low body weight. And this is actually an evolved diagnosis that has been a bit more broadened and inclusive in recent years, which is great.

It used to be based specifically on a percentage of ideal body weight, and they’ve broadened it to just say significantly low weight, which I think is great because I think it catches more people that are at risk and really are suffering from an eating disorder.

Coupled with this, you know, and we’ve spoken a little bit about this, there’s a real fear of gaining weight, becoming fat. Even when people are significantly underweight, that fear is still very pronounced.

And I think, often not for everyone, but coupled with that is a fairly pronounced sense of loss of control that if they were to eat more, that they might not retain the ability to control their appetite, to control their eating behaviors, and that they might gain weight in a way that felt beyond their control.

And then the last component of the diagnosis is that there’s really a disturbance in the way one’s shape or body is experienced, and it’s really unduly influenced by aspects of shape or weight, as well as a denial of the seriousness of low body weight with anorexia.

That’s very common. There are people maybe at a very significant, even very risky weight, but not have an awareness. And that’s not sort of they’re just lying about it. No, I think that’s really ego-syntonic, that they really perceive this.

And it’s one of the things that makes these illnesses dangerous, is that it can, you know, influence their ability to get help, because they think they’re doing okay, right? And they don’t see the disturbance that other people might see and might be quite concerned about, loved ones, family, peers, as well.

Jeff: How about bulimia? What sets it apart from anorexia?

David: Bulimia, and again, I’ll say that there are often instances where people will develop anorexia and merge into bulimia, and vice versa. But bulimia is different than anorexia in that it’s really about eating, you know, a large amount of food, a significantly large amount of food, in a specific time period, usually two hours.

And the way they define that is it’s not just eating a little bit more. And I think there’s this concept of a subjective binge. And we’ve all experienced eating a little bit more than we would like. And we might even use sort of the word, oh, I’m binging.

But no, this is really definitely a larger amount of food than people would eat under the same amount of time and similar circumstances. So it’s marked. And this is also coupled with that sense of lack of control. Sort of the feeling that you can’t stop or can’t control how much you would eat.

And then the secondary very important part of the bulimia nervosa diagnosis is the compensatory behaviors. And that’s really aimed at preventing weight gain. And that can take various forms. People think very commonly about compensatory vomiting, sometimes misuse of laxatives or diuretics, sometimes medications, excessive exercise as a compensatory action.

And the other thing I’ll say about bulimia, and anorexia, actually, is that the bulimia episode is not occurring in the context of an episode of anorexia. It’s separate, but it’s its own entity, although people can move between the two diagnoses. But they are separate entities. Yeah.

Jeff: Binge eating disorder, what should we know about that?

David: So again, similar to bulimia in the first part. Eating the markedly large amounts of food in a specific amount of time, usually two hours, a similar sense of that feeling of lack of control, feeling like you can’t stop, but without the compensatory behaviors, right?

Binge eating disorder is the most common eating disorder, and it affects men and women, not quite equally, but much more equally than bulimia and anorexia. So a significant number of men also will struggle with binge eating.

It’s often underdiagnosed. And I think there’s a lot of shame people associate with binge eating, potentially due to weight gain, potentially due to that sense of lack of control. So, you know, again, this speaks to more research in terms of prevalence, but we do know that it is the most common of the eating disorders and the most people struggle with it.

Jeff: So David, there is this acronym out there, ARFID, I think a lot of folks might not be familiar with. What does that stand for? What is this particular disorder? And is it part of the eating disorder family?

David: It is. Yeah. And it’s a newer diagnosis. ARFID stands for avoidant/restrictive food intake disorder. It’s kind of a mouthful there. And it really takes three primary different courses.

It’s sort of measured by either a feeding or eating disturbance that has to do with the lack of interest in food, or avoidance maybe because of sensory characteristics of food. And often that will include real, marked disgust and fear of being overstimulated by the food in a way that is aversive and quite negative.

And then, thirdly, the other component of ARFID is a real fear around the consequences of eating, and that, you know, it’s measured by a persistent failure to eat adequate nutritionally. But those consequences might include a real fear of vomiting, or emetophobia.

And associated with all of this, you know, whether it’s a lack of interest and avoidance because of sensory reasons or, you know, fears of the adverse consequences, is a real loss of weight. Now, it does not include, you know, in the diagnosis, a fear around body image.

That can develop, and we often see people who will develop that in the course of having ARFID, but it’s not part of the formal diagnosis, and it’s not the driving force.

It’s not about losing weight or about appearance. It’s really about the lack of interest or the fear of the consequences or sensory aspects of the eating that make it challenging.

Jeff: Okay, one more acronym to deconstruct here: OSFED, O-S-F-E-D. What does that mean?

David: Jeff, I’m really glad you asked that because that’s another evolution in eating disorders and a shift in nomenclature. It used to be that the old DSM had a diagnosis called EDNOS, which was eating disorders not otherwise specified.

And it really was sort of a catchall for other aspects of eating disorders that didn’t really fall neatly into the constructed boxes that we’ve talked about, right? And it wasn’t particularly useful, and I think it was somewhat problematic in that it suggested that these were in some way less important, less serious, less significant.

And so with the most recent diagnostic and statistical manual, they included OSFED, other specified feeding and eating disorders. And those would include things like an atypical anorexia where, you know, all the criteria of a more typical anorexia were met maybe despite significant weight loss.

And weight might be in a normal range, but all the other characteristics were there. And it was making a marked negative impact on their life and interfering with their ability to function.

Similarly, like binge eating disorder, maybe the duration or frequency of binging wouldn’t fully meet the criteria of a binge eating disorder, but was also having a significant impact on their lives.

So technically it wouldn’t meet the diagnosis, but it was significant behaviorally and significant psychologically in its impact. And what I like about this new sort of category of diagnosis is that it really emphasizes that these two are serious conditions.

And they deserve and merit attention and treatment rather than sort of being this catchall or this sub-threshold, that they can be very impactful and important to assess and also to treat.

Jeff: So one of my takeaways from your overview here, David, is that these are very complex conditions. It’s got to be tough to tease out exactly what’s what for a provider. Talk a little bit about the diagnostic tools that are used.

David: So yeah, there are some measures that we can use to suss out and diagnose and differentially diagnose eating disorders. And there were some challenges in doing that. And I sort of have alluded to sort of aspects of secrecy and shame sometimes attached to eating disorders.

So I think when folks are trying to assess, and I think about this in the context of primarily primary care doctors, for instance, maybe school teachers as well, and family members, being mindful that people are not always forthcoming, due to reasons of shame and secrecy.

And they may not always be honest. And, you know, even with themselves. Again, if there’s a perceptual disturbance, they may not even see what others are seeing. So that’s the caveat there.

So what with that, I always say that, you know, being curious and asking direct questions in a non-threatening way really elucidates the best answers. It’s not a perfect method. Sometimes people will be very well defended or may not even see things that they’re struggling with.

And that can happen for a number of reasons, either because there’s that disturbance, and they’re seeing things differently than others, or because this is a way of life that they have grown accustomed to, and it is what they know.

So they don’t see it really as different, even though people around them may have pronounced concerns about how they’re doing, may notice that a weight loss, may notice, you know, binging and purging activities. But this has become a way of life, and this is sort of what they do, and they don’t really sort of begin to see it as serious.

They can be quite defended against entering treatment. And I don’t want to sort of stereotype, because I think there are other people that really are quite disturbed by these very same symptoms and much more forthcoming and outgoing and willing to seek treatment.

But there is that aspect of shame and secrecy that I think people that are trying to assess and diagnose eating disorders really need to be mindful of. And certainly not to inject more shame or fear than is already there.

Jeff: We’re about to segue into some of the treatment approaches for eating disorders. But I want to ask a broad question on behalf of one of our attendees. Can people naturally grow out of an eating disorder?

David: Yeah, I mean, again, it depends on the significance and serious of an eating disorder. Yes, people can. I think the more entrenched they are in the eating disorder, and again, the longer they have had the eating disorder, the harder that is. But yes, people can with time.

And it’s not really, I wouldn’t say, grow out, because I think they may, what I’ll say is they may be doing more independent work or independent therapeutic work. So it is like, you know, they may not seek a residential level of treatment, or they may not work with a therapist.

I’m pro both of those things when needed, but there are instances when people can work with themselves in a therapeutic way to work through an eating disorder over time. It is more challenging.

And again, I think the more severe the eating disorder, the harder it is. I want to be very clear about this, that they’re not doing it in isolation. That they may have very important and meaningful relationships with people around them that help them in their recovery, even if they’re not talking directly about the eating disorder.

I’ve always believed that recovery does not occur in isolation. It always occurs in the context of relationships. Most importantly, therapeutic relationships, but also important, meaningful, and loving relationships.

So, you know, that is possible, and I think, you know, I want to say that, but I think the far better course is not to be alone and directly involved in some therapeutic component of a relationship with someone who’s really focused on helping support recovery around eating disorders.

Jeff: I want to ask you next, David, to walk us through the primary treatment approaches for eating disorders. And I realize that they’re going to be distinct for different forms of eating disorders as well.

So if you would sort of break down for us along the way whether or not a particular eating disorder, like anorexia or bulimia, responds better to a particular treatment approach than the other.

David: Sure. So this gets into something that I was talking about a little bit earlier. And the, you know, the gold standard for all treatments is evidence-based treatment. And unfortunately, eating disorders, they do have some evidence-based treatment, but we have a lot of evidence-informed treatment.

We have a lot of evidence of what kinds of treatment works, both anecdotally through clinical experience and through some research. That said, a lot more is needed to really sort of solidify and build upon therapeutic practice and even new therapies that may, you know, evolve and be helpful with eating disorders.

Just as an aside, to give you a sense of the scale of research money, eating disorders is one of the least funded psychiatric diagnoses. You know, they get about 73 cents in comparison to $87 for schizophrenia, so-

Jeff: Wow, that’s a big difference.

David: It’s a huge difference. And eating disorder treatment is fairly available. I mean, there are a lot of centers, and in the last 20 years a lot more have evolved nationwide, actually, all over the world.

You know, even in Boston there are four or five treatment centers. That wasn’t the case 20 years ago. But the research really has lagged behind. So there’s more to do in terms of the efficacy of treatment, refining treatment, developing new treatments, and really reinforcing what we do and some of what we know already.

So in terms of types of treatments, there’s a lot of them. I don’t know how much you want me to go into them. They’re kind of like the alphabet soup.

There’s acceptance and commitment therapy, or ACT, A-C-T. There’s CBT, cognitive behavioral therapy, with an enhanced version specifically designed for eating disorders. Dialectical behavioral therapy. There’s, you know, interpersonal therapies.

There’s, I think, a real need for family-based treatment, which I’ll say a little bit more about, sometimes referred to as the Maudsley approach, which is essentially most often a home-based therapy. And it’s been shown to be very effective.

This is sort of evidence supported, but it’s primarily with adolescents with anorexia and bulimia. And it doesn’t really focus so much on the cause of the eating disorder. It’s more of a behavioral intervention and really focusing on refeeding.

And it’s a therapy where all of the family members are really a part of the team, they’re considered essential parts of the treatment team. And it’s really breaking patterns of behavior, reestablishing healthy eating, restoring weight, and then interrupting any compensatory behaviors that might be occurring.

But that’s, again, more for children and adolescents, less so for adults. What else?

Psychodynamic therapy I think also is a big player. And I think most of the eating disorder therapists that I’ve met tend to formulate through a psychodynamic lens and maybe treat a little bit more eclectically, using some cognitive behavioral, some ACT.

And I can talk more about or less about any of those methods. But I’m not sure how much would be useful.

Jeff: Well, okay. let’s see what our listeners would like to, and viewers, would like us to zero in on a little bit here as we go, David. A question from a viewer is this: If a person has co-occurring diagnoses, do they have to be treated separately?

David: The answer is, it really depends, but hopefully not. You know, some of that may be based on the limitations of what’s available around you. But people tend not to fall neatly into diagnostic boxes and may very often have a coexisting or co-occurring mental health disorder.

With eating disorders, those the most common coexisting disorders are, you know, certainly a history of trauma or PTSD symptoms, OCD, sometimes substance abuse, personality disorders. So if all of those things needed to be treated separately, it would really get in the way of entering into treatment.

So the best treatment is to focus on what’s really the most important thing in the moment. If we’re thinking an eating disorder is the driving factor and it is really acute, that needs to sort of be the area of most attention.

And the sort of analogy I’ll use when folks come into our program is, you know, okay, someone comes in and they’ve got OCD, and they’ve got a significant anorexia.

It’s like, all right, you’re going to be majoring in the anorexia, because we need to really sort of get you to a healthier place physically. We need to have some nourishment. But simultaneously, we’re going to engage in some exposure and response therapy for your OCD.

The nourishment will reinforce your strength to do that. It’ll help your brain to incorporate some of the challenges of ERP. And both can happen simultaneously. But that would be more of a minoring in the OCD and a majoring in the eating disorder, because the nutritional needs are more severe and more acute.

Jeff: A viewer would like me to ask you to comment on alternative treatments and their efficacy: eye movement desensitization and reprocessing, EMDR, and perhaps psychedelics.

David: Oh God, I’m so interested in psychedelics, and I’ve just been reading more and more about them. There’s so much good evidence for substance abuse and psychedelics for trauma as well.

I don’t know as much about eating disorders and psychedelics. I am very curious to learn more. I’m glad that there’s a ton of research being done. And, full disclosure, I was really afraid of psychedelics and somewhat opposed to them in the realm of psychiatric treatment.

But I’ve been doing a lot of reading and have been really impressed by how helpful they can be to people. So I don’t know the answer to how helpful that will be with eating disorders. I’m hopeful that we will learn more, and I really am hopeful that there’s a place for them.

I’m really about anything that, that can help and support and work. I don’t know how helpful they will be in this realm or not. Jeff, what was the first part of the question?

Jeff: EMDR.

David: EMDR. Sure. Eye movement rapid desensitization. You know, very clearly there’s evidence to suggest that this is a helpful treatment, particularly for single-episode traumas. I think they’re finding more and more areas where it can be useful.

Personally have not found it all that useful directly with eating disorders, but it may be, you know, a part of an adjunctive treatment if someone has some traumatic experiences that may be interfering or getting in the way of their life, or maybe sort of crossing over into their eating disorder.

But for eating disorders specifically, I’ve not found EMDR to be a specific help. But admittedly, I have not had a lot of experience in observing that either.

Jeff: I want to ask you about levels of care for eating disorders. You mentioned some in-home work. What about hospitalization, residential, outpatient, or intensive outpatient options?

What are some of the guidelines regarding when it is appropriate for someone to be hospitalized with an eating disorder, for example?

David: Right. Another good question. Maybe I’ll sort of work through the continuum from the lowest levels of sort of like, you know, we have outpatient treatment, which is working individually with a therapist.

And actually, I should broaden this, and probably should have spoken to this earlier, that you introduced me as an expert, right? And I sort of said, “Whoa, am I an expert?” And I think eating disorders are a field that scares a lot of people off because you have this perception that you need to be an expert in all these areas.

And the reality is, I know very little about sort of nutritional aspects and very little about the medical aspects of treatment of eating disorders. I have some working knowledge because I’ve been in it for a while. But I really rely on working as a team.

And that’s important with eating disorders especially, that there is this team approach. So ideally you’re having, you know, an individual therapist, a dietician, a psychiatrist, a primary care doctor, maybe even a family therapist, and you’re not holding all the responsibility for something that’s very acute and potentially life-threatening.

It’s held as a team that has different areas of expertise. So I think that scares a lot of people off from working with these eating disorders. And there’s a lot more need for people to be able to gain competency and work with eating disorders, but they don’t need to be this expert in all the areas.

And I just always want to say that because I think, you know, there’s so many people that could be really doing good work, but are sort of a little timid to get involved with eating disorders because they feel like they got to hold everything.

So outpatient therapy is, you know, sort of working with a therapist and potentially an outpatient team that I’ve discussed.

There is what’s called intensive outpatient therapy, which essentially is like a day program, but it’s modified. It’s usually three or four days a week. Usually half days. And it’s a combination of groups and individual work with some nutritional work as well.

And that’s really for folks that are struggling a little bit more, and the eating disorder, in one way or another, has gotten in the way of their life such that they’re struggling to function, whether it’s work or school. But they don’t totally need to be removed from their life. They can do a little bit of both concurrently.

And then the next step up from that would be like a partial hospital, which is, you know, five days a week, full days. You know, there’s no immediate medical risk. They’re medically stable, but they’re psychiatrically unstable. They’re really not able to attend to the educational, social, work responsibilities in their life, and they need more support and more robust support. Go on.

Jeff: Yeah, David, we’ve had a number of questions come in that essentially boil down to this one. So let me just sort of consolidate them.

What do you do when someone simply denies that there is a problem and you are left to watch that person slowly disappear? This is a tough one.

David: Yeah, it’s a tough one, and it’s a really scary one. You know, I think, again, the more modalities of perspective that you can engage. So, you know, you never really know what is going to break through denial.

And I’m not a proponent of sort of fighting, because I think that entrenches people more in their denial. It’s really trying to be more open and curious. And bring in people who really care, and the individual who’s suffering, but maybe thinks they’re not, knows that they care, and to, in a non-threatening way, express their concerns.

It may be a tincture of repetition and time. And it may need to be that they continue to struggle. And maybe one of the conditions, if you have a son or a daughter who’s struggling, but really is in denial, that they may have to agree to do some things that they think are silly because they don’t think they’re struggling.

“Well, we want you to get some regular labs and weights, just to make sure everything’s okay. I know you think it’s silly, but we want to just, we’ll be overly cautious.”

And that might be an inroad, again, not in a confrontational way, but an inroad into sort of helping them begin to see a little bit more of what others are seeing. And not just others. People who care and love about them are seeing.

But the more I think people fight and push, you know, which is not uncommon, because when people care, they get really anxious, and anxiety often manifests in sort of frustration and anger.

I think when that happens, it tends to pull people apart rather than together, and it makes it harder for the individual to actually see what is going on and what other people are concerned about. It becomes more of a fight than a helpful and useful intervention.

Jeff: Yeah, David, before I forget to circle back to this, we are going to talk about resources for our viewers. But family members who are confused about how to approach a conversation like that about a loved one, where would you point them? How can they educate themselves to get up to speed?

David: Yeah, So again, I think consultation is wonderful. There are some very good resources available online. MEDA is one that I’m a huge fan of, which is the Multi-Service Eating Disorder Association. It’s actually a national organization, but it’s based in Massachusetts.

But it’s wonderful. The website itself has a lot of knowledge-based statistics. There’s some blogs on there. There are certainly links to other resources. Within that there’s the contact to reach out to MEDA itself and to do in-person, virtual sessions.

They have a lot of free resources as well, and they actually have scholarships for people that are unable to afford some of the resources. And they’re very inclusive. So I’m a huge fan of them.

They’re a nonprofit. I think they’re very well organized and a really, really valuable source of information for people that may know nothing and are just sort of coming at this with very little awareness or knowledge. It’s a great starting point.

Similarly, NEDA, the National Eating Disorder Association, has a very nice platform and resources for people to call, to chat online, as well as a lot of written material and seminars, didactic stuff as well.

Jeff: I’m always pleased to see a question like this come in, because I know teachers are such an important frontline for students developing mental health challenges and how they navigate them.

What can schools do to best support students when they’re seeing more disordered eating or behaviors amongst their student population?

David: Yeah, I think, you know, the first thing is talking with the families and trying to see, are these behaviors also replicating themselves in other platforms? At home, you know, on the weekend with friends.

You know, maybe it’s just the school food that’s really awful and there isn’t a problem. But I think it’s always better to be cautious and reach out and ask to see whether this is something that parents are noticing.

They may not be noticing it, but it may open their eyes to being more mindful and aware that there potentially is something going on. And as I said earlier, if there is, the earlier that people begin to get support, the better outcome there is, the less severe the eating disorder will become, and the greater the ability to move beyond it into recovery.

So again, direct and curious questions in a caring manner. Bringing in people who are observing in different areas to see what they’re seeing as well. Yeah.

Jeff: Another school-related question. A viewer wants to know, can adolescents and young adults be in school and successful in a treatment program? Or should the person be in a treatment program solely?

David: It really depends. I mean, I’m all about not interrupting life, if one can avoid it. So if, you know, the eating disorder is something that can be managed on an outpatient basis, I actually think it’s more important for folks to stay in school and connected with family and friends and all those good things.

If the eating disorder is too severe, or there’s too much risk, or if they’re medically compromised, then those would need to be separated. They might be able to do some schoolwork from the context of a residential program or a hospital, but they shouldn’t be expected to be doing school full-time in those instances.

I very much believe in the treatment of eating disorders that the more people can simultaneously engage in the important and meaningful aspects of their life, the better.

I think there’s some who may say that, “Oh, you’ve got to really sort of be in recovery or be substantially better with your eating disorder to begin to reengage in those things that the eating disorder may have taken away or made difficult.” I disagree.

I think that the two things actually work best when they’re occurring concurrently. So that when people are engaged in meaningful life and doing treatment, it underscores the rationale for why they’re doing this hard work.

Because I want to get back to these good things: my friends, my family, my school. And if they’re in isolation from that, if the work is so challenging and takes so much courage, it’s sometimes hard to see the rationale if you’re not simultaneously engaged with it.

And I think it also propels people. You know, if there’s concurrent anxiety or depression, and they’re doing these things that are, you know, in theory, very enjoyable and fulfilling, it makes the work a little bit easier.

Jeff: We’ve had a couple questions come in about ARFID. Let me see if I can combine these. First, what are treatments for ARFID?

And then also, I have been seeing an increase in ARFID in younger children, older elementary, early middle school. I am wondering if this is an increase in prevalence or more of an awareness of the diagnosis.

David: Oh, that last part is a really great question, which I’m not sure I have the answer. I suspect it’s a little bit of both. And again, it’s a newer diagnosis, so I think there is more awareness that certainly will lead to more diagnosis. But again, I think there’s more research that needs to be done.

We may be kind of catching up with something that’s been there for a while as well, because we now have a formal diagnosis for it. It’s a really hard question.

You know, there are, and again, in terms of treatment, there are some really nice treatments developed with some folks at Mass General Hospital. Kamryn Eddy and Jenny Thomas in particular have a really nice manual for treating ARFID.

I won’t go into it in detail, but the gist of it is really trying to have a very flexible approach and increasing the amounts and types of food that people eat in very creative and sequential ways. And, you know, again, with a real mindfulness of also trying to provide adequate nutrition along the way, because a lot of folks with ARFID are really malnourished.

But it’s not about body image. It’s about, you know, the fear or the aversive consequences or, you know, sometimes disgust and distaste. So they will often, you know, pair some of the foods that are harder to eat in small quantities, pair them with other foods.

They really think outside of the box, and it’s a much more flexible approach to broadening someone’s relationship with food. And someone who has ARFID, you know, similar to any eating disorder, they really are in the driver’s seat in terms of like, they’re not being forced to eat things that, you know, that they really just can’t.

They’re given choices, and they actually have a voice in constructing the treatment plan as well. And, you know, they can put the brakes on, they can steer left and right as they need to. So it’s a much more flexible approach. But Jenny Thomas and Kamryn Eddy have done some really wonderful work and have a very nice manual for working with ARFID.

And there’s much more to come. It’s new. You know, there’s I think a lot more that we’re going to learn.

Jeff: Another broad question for you. You touched on this earlier. There are physiological impacts to eating disorders, certainly. We talk about eating disorders as a mental health disorder. Talk about what’s happening physiologically in the body when untreated.

David: You know, again, it depends on the type of eating disorder. I think most commonly we’ll think of anorexia, but bulimia certainly also has significant physical consequences. So does binge eating, particularly when there’s overweight. There can be, you know, increased risk for stroke and heart attack and all of those things.

With anorexia, you know, I think the things that people often worry about the most are cardiac functioning and organ failure. The other piece that I think is significant and a little harder to assess, unless you really know the person, is that I think there’s a cognitive impairment.

You know, I think at our sort of very basic level, we need food not only to move, obviously, and function, but also to think, and that with a deprivation of nourishment, people often get much more concrete, less flexible in their thoughts, have less ability to see a broader perspective.

And in some ways that actually can reinforce the eating disorder, particularly if there’s perceptual disturbances. It’s harder to see the forest through the trees when we get more rigid, and we tend to zero in on the things that we fear the most, and that reinforces the eating disorder.

So I think there’s a significant cognitive aspect associated, particularly with malnourishment. But there can be a lot of varied physical symptoms as well.

Jeff: We’ve had a couple of viewers ask me to ask you to circle back to causes, potential causes here. One question is this: Is there a particular personality type or disposition that is more prone to an eating disorder than others.

David: Hard to know exactly what that means. I think there are subsets that we do see. I mean, I think there’s, again, I’ve mentioned generally that sense of anxiety underlying almost all eating disorders.

Certainly, I think there’s a significant component, I’m not sure of the percentage, but of folks who, coupled with that anxiety, may manifest some symptoms of perfectionism and sort of a real sense or desire to control their environment in very precise and perfect, sometimes idiosyncratic ways that is not uncommon with eating disorders, but is not, you know, present in all eating disorders.

You know, again, it’s a hard question to answer because I want to be careful in that I think, again, some of the work that that MEDA and others are doing right now is really sort of broadening and making eating disorders more inclusive.

Yes, there are specific subtypes of personalities and experiences that we tend to see with eating disorders, but I think if we focus solely on them, we sort of alienate and ignore or give short shrift to the fact that eating disorders occur in all populations. Genders, sexual identities, socioeconomic status, size, shape, weight, genders, all of that.

So, you know, there are, yes, there are some characteristics that we see, but I want to be careful that we don’t ignore that these things are happening in all populations as well.

Jeff: Sure. And the related question there, David, is, what can you tell us a little bit more about some of the genetic components and the research being done around that?

David: Yeah, so there’s definitely genetic vulnerability to anorexia and bulimia. We know that. It’s, you know, a very hard thing to tease out differentially because there’s a environmental component of living in a world that goes along with that.

But there’s enough data to suggest that there’s a genetic component. We are actually involved in a small role, in a very, very large study, that’s looking at the genetic origins and vulnerabilities to eating disorders.

And this is through The Klarman Family Foundation and the Broad Institute. And this is, you know, a study in terms of multiple thousands of individuals. So it’s really, you know, I think we’re hoping to learn a great deal more about genetic origins and vulnerabilities than we do at present.

We know there’s a link, and that’s well established. But they did a similar study several years ago with schizophrenia with I think almost 100,000 participants, where they really were able to elucidate a lot more of the vulnerabilities and origins genetically for schizophrenia.

And the hope is to replicate that with eating disorders. It’s at the very beginning stages, but it’s a very important and I think going to be a very groundbreaking study.

Jeff: David, I’m watching our time run out, and I want to be really careful that we make sure we have time to talk about some of the myths and misconceptions regarding eating disorders.

Walk us through the ones that are most important to you to kind of debunk.

David: Eating disorders are simple. Just eat. That is not true. If it was true, we wouldn’t be talking right now. There wouldn’t be people working with eating disorders. And I think it, you know, they’re complex, and they’re not as simple as just making a behavioral change.

There’s significant complexities, especially fears, attached to eating and eating with regularity that make it incredibly difficult to fight and work on any sort. Again, that’s part of the rationale for not doing this in isolation. Doing this in the context of important and therapeutic relationships.

You know, I think families can get caught in that, particularly if they don’t have a knowledge base. Hey, I can eat okay, but my son or daughter is not eating. Just eat. And I mean, I wish it was that simple. It really is not. And I think that’s the sort of primary myth that I often sort of want to debunk.

Another myth is that, you know, a comment, perhaps, that a family member made that was hurtful or influential to someone was the cause or the root cause of an eating disorder in an individual. And that’s also a myth. You know, we’re saying things imperfectly all the time, as are others.

Our intent is clearly what’s most important. And I think people can feel a real pervasive sense of guilt. But a stray comment here and there are not causing eating disorders. There are far larger and far more powerful sociocultural influences that are influencing eating disorders, as well as genetics and psychosocial influences.

So that I think, you know, often parents will say, “Oh, you know, I made this comment when she was 11, and it had an impact.” Yeah, perhaps it did have an impact, but it was in the context of these far larger impacts as well.

And your intent was not to cause an eating disorder. That’s apparent and obvious in your relationship with your daughter. So, you know, that’s I think something that really people can get stuck on. I’m trying to think about other-

Jeff: Well, you mentioned early on the myths about who gets an eating disorder as well.

David: Oh yeah. Yeah. It’s not just rich, white, young girls. I think that, you know, with perfectionism, you know, that eating disorders affect everyone. And I think we can get very stuck in that. And even some of the media portrayals of eating disorders have focused in a way too narrow way.

And what is important about this is when someone who doesn’t fit into that myth of the rich, white, young girl, who may be a person of color, who may be in a larger body, it stigmatizes even more their experience, because they don’t feel like they have a place, when actually these things are affecting people of all shapes and sizes, genders, races.

And again, I think there’s some groundbreaking information going on around improving people’s awareness about this.

There’s a lot more to do, but that’s, I think, a real myth that needs debunking, and I think it’s important, you know, prognostically for people that don’t fit into this very narrow lens of the conceptualization, sort of the myth of what an eating disorder looks like.

Jeff: As we start to wrap things up, we’ve covered a lot of ground. We’ve talked about a number of resources. Are there additional resources that you want to put out there? We want to make sure, because we’re going to attach those hyperlinks adjacent to the video that lives on our website so folks can find these resources.

Are there other websites, other favorite books? Anything else you’d like to share?

David: The Academy for Eating Disorders is a really good useful resource. More for professionals, but also for some patients and families. But primarily for professionals, I would say.

I mentioned I think the CBT for ARFID manual that Jenny Thomas and Kamryn Eddy have done at MGH. I think that’s a really good resource, because I know there was a question about treatment of ARFID.

A book I often recommend is called “Surviving an Eating Disorder” and that’s by Siegel, Brisman, and Weinshel, I believe. And that’s, I think, really a good book for both patients, families, and even professionals.

Other resource. Oh, well, Carolyn Costin has some good resources as well. She has an eating disorder source book, which I think has a lot of good information in it as well. I mean, there there are a ton of books.

There’s a lot of books about sort of experiential aspects of eating disorders and experiential aspects of treatment. Those are more or less helpful depending on how well one relates to that particular individual’s experience. So I tend to stay away from recommending those.

But sometimes they can be very helpful if they resonate. But, you know, I think the online platforms also have a lot of those books and resources. So you can kind of peruse and suss out what might be potentially a good match for you.

Jeff: Excellent. And finally, we’d like to wrap up these webinar segments on a hopeful note. And you’ve provided a lot of hope along the way over the past hour.

What message do you have for someone who might be watching the webinar and feeling a little overwhelmed, this can be very daunting, and not knowing where to start, and feeling like there’s not hope for somebody living with or impacted by an eating disorder? What can you share for them?

David: I can honestly say that I’m very hopeful about the future of eating disorders. And I’m personally committed to trying to debunk myths and create better awareness. But I think there’s a collective movement. And the Broad Institute-Klarman Family Foundation study that I mentioned is on a huge scale.

I think that’s going to be a sort of groundbreaking study that will lead to much more research and much more attention, both to the origins, but also ultimately treatment studies and outcome studies, to really develop more solid evidence-based treatment modalities for eating disorders.

So I think the future is bright. I think, yes, there’s work to do and there’s certainly more money to be spent in this area, but I’m very optimistic. And I don’t say that, you know, just off the cuff. I really feel that.

Jeff: That’s a perfect place for us to wrap this up. David, thank you so much for your time and loaning us your expertise as well. We really appreciate both.

David: Jeff, thank you for having me. Really appreciate the opportunity.

Jeff: Excellent. And to those of you who are watching, thank you for your interest in our educational webinar series. We hope you’ll come back for our future sessions and we wish you a wonderful day.

Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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