We are excited to announce our low-cost eating disorder therapy program. Via our designation as a practicum site we are now able to train advanced graduate students in psychology in evidence-based treatment for eating disorders. This allows us to further our mission of helping to disseminate evidence-based treatments and to bring them to people in California who need them. We are also able to offer a true low-cost treatment option. Our psychology externs will be able to provide individual psychotherapy for adults with bulimia nervosa and binge eating disorder and teens and adults with disordered eating and body image concerns.
Beginning in August, 2021, the cost for sessions with our psychological externs is $60 per therapy hour. Sessions are available in-person in our office in mid-Wilshire area of Los Angeles and virtually with individuals throughout California.
As of June 2021, EDTLA has developed a memorandum of understanding with two local doctoral programs in clinical psychology— the California School of Professional Psychology at Alliant International University and Pepperdine University’s Clinical Psychology Doctoral Program of the Graduate School of Education and Psychology.
Each year, up to two advanced-level doctoral students are carefully selected through an interview process to be psychological externs at EDTLA. Psychological externs provide individual and group therapy to adults and adolescents.
All of the psychological externs receive extensive training through EDTLA’s training seminars and supervision program in order to provide quality therapy at lower fees than is typically found in Los Angeles.
All Psychological Externs work directly under Dr. Muhlheim (PSY15045), meaning that treatment decisions and progress are monitored on a weekly basis by an experienced licensed psychologist.
To inquire about receiving treatment from one of our psychology externs, please complete this form (and put Psychology Extern) under “Requested Clinician.”
You can read more about our current psychology externs here.
In August, 2014, a Los Angeles psychologist who was in the process of taking the licensing exam reached out to me and asked to schedule a meeting. She was interested in pursuing more training and work in the field of eating disorders. We met and there was an immediate recognition that we were aligned. She practiced in the same way I did and had a passion for evidence-based treatment of eating disorders. We discovered we even used all the same patient education materials. And she was an early proponent of Health at Every Size ®. She wanted to know if she could work with me in my practice, but I had no plan to start a group practice. I told this therapist—Dr. Elisha Carcieri—to keep in touch as she completed her licensing.
But I was intrigued, and I didn’t want to lose the opportunity to work with such a capable colleague. So the wheels started to turn. Very soon, I decided to start a group so I could hire her. In December I emailed her back, “I’m starting to think about expanding my practice if you are at all interested… .”And in December, 2014, the seeds of Eating Disorder Therapy LA were planted.
It took time to bloom—because of various family obligations and credentialing issues, Dr. Carcieri finally joined the practice in October 2015. She was well-liked by patients and colleagues alike and we worked really well together, collaborating on other projects as well. After a year and a half with EDTLA, her family moved to South Carolina and she had to leave the practice. Since then, we have continued to grow and add wonderful new colleagues, but I grieved the loss of the colleague who was there at the beginning.
Fast forward to 2020 and the growth of telehealth. I am really excited to share that Dr. Elisha Carcieri is back—joining us via telehealth and will be seeing California patients. She has immediate openings for early morning appointments.
Update June 2021: We are so excited to have our own low-cost option. Please read more here.
This NEDAwareness week, I’ve been thinking a lot about the theme of “Let’s Get Real.” One stubborn myth about eating disorders is that they affect primarily white, upper-middle-class females.
It would take you just one afternoon at my own Los Angeles practice to discover how untrue this is. My clients are all genders, ages, and ethnicities. I accept some private insurance and one public insurance. Among my patients with eating disorders are non-native English speakers, immigrants from low SES backgrounds, and people on public assistance.
The myth that eating disorders affect only the wealthy not only makes it more difficult for patients who don’t meet the stereotype to recognize that they have a problem but affects the entire system of treatment.
Throughout the US, there is a shortage of publicly funded specialized treatment programs for eating disorders. And specialized eating disorder treatment is expensive! The residential treatment complex only serves the economically privileged.
Carolyn Becker, Ph.D. recently brought attention to the presence of eating disorders in food insecure populations. The research on which she collaborated studied adults receiving food at San Antonio area food banks. Those who had hungry children in their households (representing higher levels of food insecurity) had higher levels of binge eating, dietary restraint, weight self-stigma, worry, and overall ED pathology when compared to participants with lower levels of food insecurity
Within Los Angeles County, eating disorders are a covered diagnosis by the Department of Mental Health (DMH). However, according to a DMH district chief, there are no specialized services for eating disorders within the DMH system. I recently led a training on eating disorders at one of the county community mental health centers and a staff member there told me, “Most patients with eating disorders are seen in primary care and none of us are trained specifically in this… What we need is training in evidence-based treatment.”
A clinical staff member at another DMH clinic said, “Honestly, we don’t have a lot of access to resources for people with eating disorders and aren’t equipped to adequately handle serious cases at this clinic. Referrals have always been difficult and there are no reliable referral sources for our patient population. We have really only been able to connect a few of our most severe cases to any treatment at all.”
I searched the Alliance for Eating Disorder Awareness list of Medicare/Medicaid providers and facilities within 50 miles of Los Angeles and came up with only one Medicare provider and no Medicaid providers or facilities.
This blog post was inspired because as a provider for Anthem Medi-Cal, I am receiving calls from county clinics with referrals of other (non-Anthem) Medi-Cal patients with eating disorders that I can’t see. So, when faced with a patient with an eating disorder and no insurance in LA County, what’s a provider to do? Here’s what I’ve been able to find. If you have other resources, I’d love to hear about them!
CHLA takes California Medicaid for patients under age 25 needing medical stabilization.
UCLA takes California Medicaid for patients under age 25 needing hospitalization for eating disorders.
“To The Bone,” Marti Noxon’s semi-autobiographical film about her experience as a young adult living with anorexia, was released today on Netflix and has already stirred up much controversy within the eating disorder community. As a general rule, I do not see things in black and white. As with anything, I see this film in shades of grey – it handles some things well and some things poorly. Many concerns have already been aired widely in both mainstream and social media. Foremost among these concerns is the movie’s reinforcement of the anorexia nervosa stereotype by portraying an emaciated white female and the weight loss that lead actress Lily Collins underwent to play the role. I will not rehash these here; instead, I hope to shed light on some other important issues and to provide an educational piece to accompany the film.
This film may be triggering. It shows images of severe emaciation and may either be upsetting to those vulnerable to eating disorders, or inspire a competitive desire to be “as skinny”. Often, people with eating disorders don’t feel “sick enough”; anorexia nervosa can be a competitive illness. (Reports are that pro-ana sites are already using images of Lily from the film. While it’s concerning that the film adds to the available library of these sorts of images, this library is already huge – if they didn’t use this image, it would be easy to find another.) Those susceptible must exercise caution when viewing this film and if they are triggered, they should contact their treatment team or contact an organization such as the National Eating Disorders Association for help.
It is difficult to make a film that accurately portrays eating disorders. To depict eating disorders on film, behaviors must be shown. Yet much of the suffering from an eating disorder is internal and harder to depict. This film is not an educational film – it is a piece of entertainment. Nevertheless, I think it does bring eating disorders into the mainstream. The film portrays some things accurately – with others it takes great liberties. Even with these departures, I do think it has virtues that can do some good. I will discuss these more below.
This is one person’s story. Marti Noxon’s aim is to tell her story and she has a right to do so. She has been public that many years ago she suffered from an eating disorder and wanted to both shed light on and draw more attention to the issue. And that she has done! Based on the talkback I attended with Marti Noxon and actors Lily Collins and Alex Sharp, Marti recognizes that she can neither represent the diversity of all people with eating disorders nor speak for the range of people affected. She hopes that her work will open the door for others to tell their own stories, a hope I share. For those interested in a more diverse story about eating disorders, check out the work of Tchaiko Omwale, who is working to complete her film Solace. If you are committed to helping bring more diverse voices forward, you can contribute to help her complete her film.
To The Bone accurately portrays some of the aspects of living with an eating disorder. I do not believe the film overly glamorizes anorexia. It illustrates the mindset and some of the mental anguish of someone with an eating disorder. The film displays a number of common eating disorder behaviors. We see Ellen and her peers engaging in behaviors such as calorie-counting, dietary restriction, overexercise, bingeing and purging, and chewing and spitting. Chewing and spitting is displayed in a restaurant scene in which Ellen goes out to eat with Lucas, her friend from treatment. Chewing and spitting is a lesser-known, but significant eating disorder behavior that is not commonly talked about or assessed by professionals. It is a frequently associated with more severe eating disorder symptoms and suicidal ideation. However, the behavior is more likely to occur in private than in public. It can occur in the context of anorexia nervosa as well as bulimia nervosa or other disorders.
Eating disorders are serious mental illnesses and can be life-threatening. The movie shows Ellen and some of her peers needing medical attention and carefully balances showing the gravity of their situation with building hope for recovery.
To the Bone paints a very Hollywood picture of recovery. While the movie adequately portrays Ellen’s ambivalence about treatment, it implies that things shift when Ellen “decides” she wants to recover. It disturbs me greatly that Dr. Beckham tells Ellen, “I’m not going to treat you if you aren’t interested in living.” Many people with anorexia nervosa have anosognosia, a symptom that causes patients to deny their illness and refuse treatment as a result. We now know that enough food, weight gain, and a cessation of eating disorder behaviors are prerequisites for recovery from anorexia nervosa. Usually some physical restoration is required before a patient can really want to recover – Dr. Ovidio Bermudez calls this a “brain rescue.”
The movie does not model modern eating disorder treatment practices. But realistic treatment would probably not make a good Hollywood story. For starters, I would never suggest a therapy patient change his/her name! More seriously, in eating disorder treatment we prioritize nutritional recovery. This refers not to specific nutrients, but to the development of healthy eating habits including regular meals and adequate amounts of food. This applies to people with all eating disorders, not just anorexia nervosa. People with eating disorders need as a primary element of treatment food – balanced, sufficient, and regular eating. The movie portrays the patients in the residential treatment center as each able to choose their own food. While some patients eat some portion of the meals served, other patients eat nothing (or the one character with BED repeatedly eats only peanut butter out of the jar). I know of no treatment setting that would not have a primary focus on structured regular meals and patients having requirements for meals that can become less restrictive as they progress in treatment.
I worry that the portrayal of Ellen’s family reinforces old myths about eating disorders being caused by families. To reiterate, families do not cause eating disorders. Ellen’s father is unavailable (and never even appears), her mother has had mental health problems (and is involved in a new relationship) and no one is really there for Ellen, except her stepmother who takes her to treatment and her half-sister. I do love the portrayal of the relationship between Ellen and her half-sister. I think this relationship captures the mixture of love, concern, and anger experienced by siblings.
The movie misses the opportunity to depict the family as important allies in treatment. No one is really involved in Ellen’s treatment beyond the family session, and Dr. Beckham states there is no need for any future family sessions on the basis of how badly it went. None of the young people in this house have their parents involved in their treatment (at least that we see). This is very unrealistic in this day and age. Almost every treatment center involves family members to a greater or lesser degree. In reality, parents can play a central role in the treatment of adolescents and young adults, are usually included in treatment, and can even drive the treatment when their youngsters are incapable of seeking treatment on their own or have anosognosia. Parents can also help with nourishing their youngsters back to health (but not in the dramatic way it was portrayed in the film…with a baby bottle). Family-based treatment (also referred to as the Maudsley method and mentioned in passing in the scene where the moms are in the waiting room waiting for their daughters to have an intake with Dr. Beckham as something they have tried) is actually the leading treatment for adolescents and is also effective for many young adults. It focuses on empowering the family to be an important part of the treatment team and able to fight for recovery on behalf of an unwilling or unmotivated youngster and also provide meal support.
Three Things I really like about the film:
I love that Dr. Beckham says, “There is never one cause.” This is true.
I love that it builds hope for recovery by showing Lucas as doing well and actively working on recovery.
I love that it shows a male and an African-American with eating disorders.
Truth #1: Many people with eating disorders look healthy, yet may be extremely ill.
Truth #2: Families are not to blame, and can be the patients’ and providers’ best allies in treatment.
Truth #3: An eating disorder diagnosis is a health crisis that disrupts personal and family functioning.
Truth #4: Eating disorders are not choices, but serious biologically influenced illnesses.
Truth #5: Eating disorders affect people of all genders, ages, races, ethnicities, body shapes and weights, sexual orientations, and socioeconomic statuses.
Truth #6: Eating disorders carry an increased risk for both suicide and medical complications.
Truth #7: Genes and environment play important roles in the development of eating disorders.
Truth #8: Genes alone do not predict who will develop eating disorders.
Truth #9: Full recovery from an eating disorder is possible. Early detection and intervention are important.
Produced in collaboration with Dr. Cynthia Bulik, PhD, FAED, who serves as distinguished Professor of Eating Disorders in the School of Medicine at the University of North Carolina at Chapel Hill and Professor of Medical Epidemiology and Biostatistics at the Karolinska Institutet in Stockholm, Sweden. “Nine Truths” is based on Dr. Bulik’s 2014 “9 Eating Disorders Myths Busted” talk at the National Institute of Mental Health Alliance for Research Progress meeting.
The Eating Disorder SIG (EDSIG) is an active group of Los Angeles County Psychological Association (LACPA) professionals interested in eating disorders, body image, and related issues. The group, founded in 2012, by Stacey Rosenfeld, Ph.D., is now led by Lauren Muhlheim, Psy.D. Through presentations and discussion, the EDSIG helps LACPA members explore the field of eating disorders and provides them support as they interact with eating-disordered clients, families, and the community.
To date, the EDSIG has attracted national-level speakers as guests, including Dr. Abigail Saguy (author of What’s Wrong with Fat?), Stephanie Covington Armstrong (author of Not All Black Girls Know How to Eat), and Lisa Kantor, JD, an attorney who won the first published eating disorder decision in California, as well the first federal court ruling that mandated insurance companies to pay for medically necessary treatment for mental illnesses. Other speakers include: Dr. Kathleen Kara Fitzpatrick (Clinical Assistant Professor at Stanford University), Aimee Liu (author of several novels as well as Gaining: The Truth of Life After Eating Disorders and Restoring Our Bodies, Reclaiming Our Lives: Guidance and Reflections on Recovering from Eating Disorders), Ragen Chastain (a thought leader in the fat acceptance movement), Dr. Richard Achiro (author of a recent study on over-the-counter workout supplement use in gym-active men that received international recognition from several news sources), Pia Guerrero, founder of Adios Barbie and body image activist, Dagan VanDemark, founder and policy director of Trans Folx Fighting Eating Disorders, TFFED), Dr. Stephanie Knatz Peck (program director for the Intensive Family Treatment Programs at the UCSD Eating Disorders Treatment and Research Center), Jessica Raymond, founder and director of Recovery Warriors and Rise Up + Recover app.
Equally qualified and exciting speakers have already committed to speaking to our group in the coming year, so watch the listserv for details. EDSIG Meetings are geared toward eating-disorder specialists but many talks are likely to be of interest to the more general psychological community. Meetings are held every 1-2 months, typically on a weekday evening, in the Hollywood area. Events are posted on the LACPA calendar and sent out to the email listserv. For questions or to recommend a speaker or request a topic, Dr. Muhlheim at firstname.lastname@example.org.
SIG meetings are open to all LACPA members. Non-members wishing to attend may join LACPA by visiting our website www.lapsych.org.
For a complete list of topics and speakers to date, see below:
January 2012: Introduction to group and topic discussion
February 2012: Intuitive Eating — Brooke Glazer, RD
March 2012: Psychopharmacological Treatment of EDs — Hope Levin, MD
May 2012: Overview of FBT — Lauren Muhlheim, PsyD
July 2012: Current Topics in EDs
October 2012: The One-Hour Medical School — Linda Schack, MD
January 2013: Viewing of the film, Someday Melissa
April 2013: What’s Wrong with Fat? — Abigail Saguy, PhD
June 2013: Difficulties in the Treatment of Overweight Eating Disorder Patients – Swimming Against the Current — Wendy Rosenstein, MD
October 2013: Yoga, Feminism, & Body Image — Melanie Klein, MA
February 2014: Eating Disorders Affect us All: Eating Disorders in Diverse Populations — Stephanie Covington Armstrong
March 2014: Yoga, Body Image, and Eating Disorders — Chelsea Roff
April 2014: Working with Insurance Companies to Obtain Coverage — Lisa Kantor, JD
June 2014: Intuitive Eating with BED — Aaron Flores, RDN
August 2014: Does Every Woman Have an Eating Disorder? – Stacey Rosenfeld, Ph.D.
September 2014: Pregnancy and Eating Disorders – Maggie Baumann, MFT, CEDS
October 2014: Transgender Issues and Eating Disorders – Dagan VanDeMark
December 2014: The Stages of Recovery – Aimee Liu
February 2015: Adios Barbie: Body Image, Intersectionality, Healing and Advocacy – Pia Guerrero
March 2015: B.E.A.U.T.Y: Paint Me A Soul — Nikki DuBose
April 2015: Temperament, neurobiology, and implications for adult eating disorder treatment — Stephanie Knatz, Ph.D.
May 2015: Misophonia – Jaeline Jaffe
June 2015 – Modernizing Recovery Resources for the Millennial Generation– Jessica Raymond
July 2015: Advocacy and the Eating Disorder World: Why Clinicians Matter– Kathleen MacDonald
August 2015: Shift Happens: Cognitive development, flexibility and remediation in eating disorders– Kara Fitzpatrick, Ph.D.
September 2015: Full Metal Apron: Fighting Eating Disorders from the Kitchen Table — JD Ouellette
November 2015: Medico-Legal Aspects of Eating Disorders Treatment Including Denial of Care — David Rudnick, MD
December 2015: When Fit Becomes Foe: Excessive Workout Supplement Use as an Emerging Eating Disorder in Men — Richard Achiro, Ph.D.
January 2016: Elimination is Oppression: The Ill-Advised War Against Obesity– Ragen Chastain
January 2016: Unraveling the Enigma of Male Eating Disorders (CE event) — Stuart Murray, Ph.D.
March 2016: When OCD and Eating Disorders Collide: Assessment and Treatment Planning for OCD and co-existing Eating Disorders – Kimberly Quinlan, LMFT
April 2016: Medical Complications in Eating Disorder Treatment – Lyn Goldring, RN
May 2016: Dieting, stress, and weight stigma – Janet Tomiyama, Ph.D.
July 2016: It’s All Relative: Eating Disorders and Genetics – Stephanie Zerwas, Ph.D.
November 2016: DBT for Eating Disorders – Charlotte Thomas, LCSW
November 2016: in conjunction with the Couples SIG – Panel Discussion: The Impact of Particular Addictive/Compulsive Behaviors on a Couple’s Relationship, and How to Help – Hoarding, Gambling, and Eating Disorders– Regina F. Lark, PhD, Cristin Runfola, PhD, and Margaret Altschul, MBA, MA, LMFT
December 2016: The Healing Power of the Paw: How Animals Can Play a Vital Role in Eating Disorder Recovery — Shannon Kopp
January 2017: The Dangers of Dieting – Glenys Oston, RDN
February 2017: When an Athlete Gets an Eating Disorder – Abby McCrea, LMFT (in conjunction with the Sports and Performance Psychology SIG)
March 2017: Thinking Critically and Cautiously About the Phrase “Eating Disorders Are Biologically-Based Mental Illnesses – Michael Levine, Ph.D., FAED
April 2017: Medical Complications of Eating Disorders – Margherita Mascolo, MD
September 2017: Psychopharmacological Treatment of Eating Disorders – Hope Levin, MD
October 2017: Media and Body Image: How Media Literacy Can Help Counteract Unrealistic Body Ideals – Bobbi Eisenstock, Ph.D.
December 2017: Body Image in Anorexia Nervosa and Body Dysmorphic Disorder: Clinical and Neurobiological Features – Jamie Feusner, MD
January 2018: Avoidant/restrictive food intake disorder: Assessment, neurobiology, and treatment – Jennifer Thomas, Ph.D.
April 2018: Understanding Brain Development in the Treatment of Eating Disorders – Ovidio Bermudez, MD
May 2018: Polycystic Ovary Syndrome and Eating Disorders: What’s the Connection? – Gretchen Kubacky, Psy.D.
July 2018: Men Struggle, Too: My Journey with Binge Eating Disorder – Ryan Sheldon
December 2018: Eating Disorders and the Impact on Siblings – Kym Piekunka
February 2019: Weight Stigma and Disordered Eating: A Multi-Method Approach – Jeffrey Hunger, PhD
April 2019: Historical Trauma and Modern Day Oppression: How Does This Relate to Eating Disorders? – Gloria Lucas
May 2019: Mindfulness-Based Eating Awareness Training (MB-EAT): Research and Clinical Application – Sheila Forman, PhD (with the Mindfulness and Spirituality SIG)
Two experiences this week inspired this blog post. The first occurred when I passed a billboard for Soylent while driving through Hollywood. The billboard read, “Juice is sweet; Soylent is complete.” My initial thought was that consuming Soylent would just be depressing.
Soylent is a “nutritionally complete, ready-to-drink, meal in a bottle” developed by engineers. Its main ingredients are oat flour and maltodextrin and a mix of vitamins, minerals, protein, and carbohydrates. Soylent creator Rob Rhinehart was working at a tech startup and began to resent the physical requirement of eating, “Food was such a large burden,” he told a reporter at The New Yorker. It was also expensive. He developed Soylent to save time and money. In interviews he said he was not interested in creating something tasty, only something efficient and nutritious.
A New York Times reporter who tried it said it was “a punishingly boring, joyless product.” I have read about Soylent but never tried it. When I passed the billboard my thought was that Soylent was bottled sadness; food lacking any variety in taste and texture. In other words: food without any of the good parts!
This image the billboard conjures contrasts sharply with the experience of food as depicted in the movie City of Gold, which I viewed only a few days later. This documentary, about Los Angeles-based Pulitzer Prize-winning food writer Jonathan Gold, is a celebration of food, Los Angeles, and ethnic diversity. (I highly recommend it, by the way!).
In the movie, Los Angeles is described as a crossroads where people of many different ethnicities have settled and brought their unique cuisines. Immigrants to LA developed food stands and inexpensive restaurants to serve the palates of their own ethnic communities. These were not restaurants designed to serve the assimilated American majority – they were part of the daily life of the immigrants. There are Korean restaurants, Mexican restaurants, and Chinese restaurants in abundance. Jonathan Gold, unlike many food critics, writes about these strip mall burrito and hotdog stands; as others have described, “democratizing” food. It further shows how the collision of ethnicities in Los Angeles brings these tastes and traditions to broader groups and creates crossovers such as Korean tacos, the iconic Korean-Mexican fusion which originated in Los Angeles as street food.
Juxtaposing City of Gold with the Soylent billboard, I wondered how anyone in Los Angeles would choose Soylent over the real food traditions described in the movie. Food expresses culture and offers the opportunity for connection. By eating Soylent, something artificial and without heritage, one is opting out of a greater connection to others and to life. The idea of consuming the same food day after day when there are so many different cuisines to sample – that is what depressed me. And, of course, I thought about my work.
One of my favorite aspects of working as an eating disorder professional is helping clients recover from devastating illnesses that make them fear and avoid food – the very sustenance they need to survive – and progress to a place where they can rediscover the joys of food. Jonathan Gold is a great role model for the love of food and positive engagement with the world. My hope for my patients is that they will get to a similar place where they embrace the varieties of food available and open themselves to experience culture in this way.
Despite being widely thought of as a disorder primarily affecting females, we know that people of all genders experience eating disorders. The experiences of males with eating disorders may be different so read on to learn more.
It is difficult to know exactly how many males are affected, partly because they have not been researched as much and partly because they are less likely to get diagnosed and treated.
Although it is widely quoted that only 10% of people with eating disorders are male, this is a likely underestimation. More likely, approximately 25% of individuals with anorexia nervosa and bulimia nervosa are male. Males make up even a larger percentage of the people with two more newly recognized diagnoses, Avoidant Restrictive Food Intake Disorder (ARFID) and Binge Eating Disorder. It is estimated that 40 percent of people with binge eating disorder are male. As many as 67 percent of children with ARFID may be male.
Eating disorders in males have been noted since 1689, when Richard Morton, an English physician, described 2 cases of “nervous consumption,” one in a male patient. Males later fell off the radar of eating disorders. Less than 1% of the papers on eating disorders focus on males.
Males have been largely excluded from the literature and research on eating disorders due to a variety of factors including stigma and biased assessment measures. Men may be less likely to endorse symptoms of what is commonly seen as a female illness and reluctant to ask for help. Because eating disorder awareness efforts typically target only girls, boys and men also may be less aware of eating disorders and less likely to recognize their problem as one. For these various reasons, males are likely underreported in prevalence statistics.
Additionally, since all of the available measures used to assess eating disorders were designed for females, they may not capture males with eating disorders. For example, the Eating Disorders Inventory has a question, ” I think my thighs are too large. ” This item is less likely to be endorsed by males because it does not reflect their body image concerns. A male-specific eating disorder assessment tool is the Eating Disorder Assessment for Males (EDAM). For example, a corresponding item on the EDAM might be something similar to, “I check my body several times a day for muscularity, ” which is more oriented toward males’ concerns.
One of the most striking differences between males and females with eating disorders is the difference in body image concerns. This seems to be a reflection of the difference between perceived ideal female and male bodies. While women are encouraged to be thin, males are encouraged to be muscular. There is research indicating that while the ideal body shape for females has gotten thinner over the years, corresponding research shows the ideal for men has gotten bulkier and more muscular.
Whether an eating disorder presents as a desire for thinness or muscularity appears to be related primarily to gender role identification; that is, feminine self-identification appears to be a risk factor for the development in men of thinness-oriented eating disorder psychopathology, while masculine self-identification is linked with the drive for muscularity and may contribute toward the development in men of muscularity-oriented body image concerns.
There is a question as to whether muscle dysmorphia is a type of body dysmorphia (itself a type of obsessive-compulsive and related disorders) or an eating disorder. Dr. Stuart Murray’s research supports that it is an eating disorder because it typically includes both compulsive exercise practices and disordered eating. Disordered eating practices are usually central to muscle dysmorphia, which is why it is not just body dysmorphia. As with female eating disorders, the compulsive exercise practices associated with muscularity-oriented eating disorders are often driven by appearance rather than health or performance.
Muscularity disordered eating may look quite different than the disordered eating more commonly seen in females. Girls and women with eating disorders usually restrict intake of high calorie food items. Males with eating disorders may increase their intake, especially of protein sources, and may also use appearance-enhancing substances such as supplements, steroids, growth hormone, and clenbuterol.
Other Differences Between Male and Female Eating Disorders
Exercise is more central to male presentations of bulimia nervosa than is purging or laxative use. Male eating disorders most typically involve two dimensions for male body image: leanness and muscularity. These may often be mutually exclusive. This can cause a cyclical nature to male eating disorders of bulking (weight gain) followed by cutting (weight loss). Males with bulimia may also not engage in typical binge eating, but may instead have “cheat meals.”
Males with eating disorders have a later age of onset, a greater likelihood of previous overweight status, greater psychiatric comorbidity, and a greater risk for suicidality. They are also less likely to seek treatment and when they do, it is common after a longer period of illness, which reduces the likelihood of a full recovery. Males suffer from many of the same medical issues as females with eating disorders but also may experience decreased testosterone and problems with sexual functioning.
Treatment for male patients with eating disorders must be gender-sensitive and address the stigma of being seen for what is commonly known as a female disorder. Clinicians should explore with male clients what it means for them to be male and how their body reflects that. Treatment with males often focuses more tightly on addressing exercise, which is often the first symptom to present and the last to remit.
Although maligned by Atkins and many others, I’m not really the bad guy.
This is why:
I contain the falsely feared primary energy source in the diet: carbohydrate. My carbohydrates along with those found in the fruit & milk groups should make up 50-65% of total calories consumed. I supply 4 calories per gram. If you are very physically active I encourage you to use my power and consume me to reach the higher percentage so you have plenty of energy to soar!
As a carbohydrate, I am the preferred source of energy or fuel for biologic work in humans:
I contribute to the mechanical work of muscle contraction
I provide chemical work that synthesizes cellular molecules
I help transport various substances in the intracellular & extracellular fluids
I provide fuel for the central nervous system.
I enable metabolism of dietary fat (the other macronutrient you likely fear).
I prevent protein (likely the only macronutrient you perceive as safe) from being used for energy thereby allowing protein to be used for what it’s intended –building & repairing body tissue & making antibodies, hormones, and enzymes.
I become glycogen (stored glucose) for readily-available energy to support physical activity.
I’m in your favorite meals and come around often frequently since so many foods include me. It’s hard to get rid of me!
Meals are not the same without me & you know it!
The foods that contain me provide vitamins/minerals/phytochemicals that you have been taking via a daily multi-vitamin pill. Actually, my nutrients are in food form and are therefore better absorbed & utilized such as: B Complex Vitamins, Vitamin A/E/C, Choline, Inositol, Calcium, Cooper, Iron, Magnesium, Phosphorus, Potassium, Selenium, Zinc.
Without me, you may experience strong urges to binge. I help to create satiation. Blood sugar regulation requires all three of us macronutrients: carbohydrates, protein, & fat in just the right combination. We help each other out to help you have the most optimal blood sugar & metabolism. We also together prevent the HANGRY feeling!
Believe it or not, some vegetables also include me even though many think they escape me. Thank goodness I still have a presence in people’s lives even if they don’t acknowledge me.
The average recommended number of daily servings of starch for adults ranges from 9-12 exchanges for a 2000 to 2500 calorie meal plan.
Check out these excellent starch foods.
Each serving or one “exchange” of a bread/grain/cereal/starchy vegetable listed equals 15 grams of carbohydrates:
1 regular slice of bread (white, pumpernickel, whole wheat, rye)
½ English muffin
½ hamburger bun
1/4 bagel or 1 ounce (can vary)
½ pita-6 inches across
1/3 cup cooked rice, brown or white
½ cup cooked pasta
½ cup cooked legumes (beans, peas, lentils)
½ cup cooked barley or couscous
½ cup cooked bulgur
3oz potato, sweet or white
½ cup mashed potato
½ cup sweet potatoes, plain
1 cup winter squash (acorn or butternut )
½ cup corn
1 tortilla -6 inches across
½ cup cooked cereal
¾ cup dry cereal
3 cups popcorn
¾ ounce pretzels
1 plain roll-1oz
Recipes Featuring Starch
Some easy & quick ways to make sure you get enough starch (notice that the other macronutrients -protein & fat- just come around naturally):
Microwavable French Toast
¼ cup milk
1.5 TB syrup
1 tsp cinnamon
1.5 slices any bread
1 TB butter
Spread butter on bread and slice into cubes. Put cubes into mug and whisk together wet ingredients and then pour them over the bread and stir to cover bread cubes with liquid. Microwave on high for 2 minutes. Top with sliced bananas or berries and it’s a balanced breakfast.
Tuna Pesto English Muffin Open Faced Sandwich
1 whole separated English Muffin
Mayo to taste-I like Trader Joes Mayo with expeller pressed oils
Himalayan pink salt & lemon-pepper to taste
Pesto to taste
Lettuce of choice-2 leaves
Make tuna salad by adding mayo, salt, lemon pepper to taste in bowl.
Toast the separated English muffin to preferred goldenness.
Spread a layer of pesto on each half of toasted muffin.
Add the tuna salad to the English muffin with pesto.
Garnish with a lettuce leaf and sliced tomato.
Katie Grubiak, RD is a Registered Dietitian and Director of Nutrition Services at Eating Disorder Therapy LA. You can read more about her here.
I recently began volunteering at the Best Friends Neonatal Kitten Nursery. Best Friends Los Angeles opened its neonatal kitten nursery in February 2013. The nursery is staffed with a dedicated coordinator and supported by volunteers who sign up for two hour feeding shifts 24 hours a day to help the kittens grow and thrive.
If you were an abandoned kitten in the Los Angeles area, or even a kitten with a mother, you’d be lucky to make your way to the Best Friends Neonatal Kitten Nursery.
The most vulnerable animals in the Los Angeles shelters are newborn kittens, often abandoned at birth, or turned into shelters from accidental litters. Because the kittens cannot feed themselves, they will die without someone to bottle feed them.
In the mommy and me section of the nursery, mothers nurse their kittens. In the other sections, kittens are bottle-fed, tube-fed, or syringe-fed until they are able to eat gruel on their own. Kittens are weighed before and after each feeding. If their weights are not steadily going up, the interventions increase. They are very fragile at this age.
The other night, the nursery coordinator, Nicole, was tube-feeding some kittens who were ill. As she explained, they were feeling too sick to eat on their own. Although acknowledging that her tube feeding was making them angry, Nicole was resolute. No kitten would starve to death on her watch. Of course, I connected this back to my families working to re-feed their children with anorexia.
In the neonatal nursery, we don’t spend time thinking about why the kitten is not nursing or eating in the expected fashion. If they are sick, they are treated for that, but in the meantime, every kitten is fed around the clock and those who don’t have mothers are bottle fed, those who won’t nurse from their mothers (often when they are too congested) are tube-fed, and those who won’t eat gruel independently are syringe-fed.
How does this relate to parents doing Family Based Treatment (FBT) for Eating Disorders with children who have Anorexia?
Of course, parents do not literally force food down human children’s throats, but they do set up contingencies to require eating even if the child doesn’t feel well and even if they rail and resist and are angry about it.
This is the heart of FBT Phase 1. When children are not able to eat on their own (due to an eating disorder) parents are instructed to nourish their starving child back to health. Parents need to step in and help their children make steady weight gains until they are able to eat on their own. Parents need to be resolute and not worry about their children being angry at them. They also should not spend time exploring why their child is not eating.
For further information on parental direction over eating in FBT, check out this prior blog post.
Binge eating disorder (BED) has been making headlines with the recent announcement that the FDA has approved lisdexamfetamine dimesylate (Vyvanse) for the treatment of BED.
So, what is BED, how is it treated, and what does this new treatment option mean for persons with BED?
What is Binge Eating Disorder
BED is a condition in which a person engages in recurrent episodes of binge eating at least once a week for three months1. Binge eating episodes typically involve eating rapidly until uncomfortably full, and eating when one is not necessarily hungry. Some individuals with BED report feeling unable to stop the episode, and describe themselves as being out of control during a binge. Binge eaters often binge alone and make efforts to hide their behavior from friends, partners, or family members. Episodes of binge eating often end in feelings of guilt, shame, and depressed mood. Unlike other eating disorders, such as bulimia nervosa, people with BED do not vomit or use other methods of compensation (such as excessive exercise or fasting) to shed calories or lose weight after a binge. It should be clear that this is a very different experience than, say, overeating on Thanksgiving, having a second piece of birthday cake, or eating foods that are outside of your normal pattern while on vacation.
Until 2013, BED was not a diagnosable eating disorder. It was instead grouped in with other unspecified eating disorders that didn’t quite meet criteria to be formally diagnosed. After much research, the most recent iteration of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), has included BED as a specific eating disorder distinct from other diagnoses.
Despite only recently being formally acknowledged, BED is the most commonly occurring eating disorder. Prevalence estimates vary, ranging from 1.6-3.5% of women, 0.8-2% of men, and 1.6% of adolescents.1, 2, 3 BED occurs as commonly among women from racial or ethnic minority groups as for white women, 1 and is often seen in people with severe obesity.1, 4 Up to 30% of people seeking bariatric surgery or other interventions for weight loss are suffering from BED5. While it is more common for women to meet all of the criteria for BED, men tend to engage in binge eating as frequently as women2. Like all eating disorders, the causes of BED are complex. There is evidence for genetic, biological, and environmental risk factors. BED is associated with significant chronic health problems. It is also common for individuals with BED to struggle with other mental health disorders at the same time, including depression, anxiety, and substance use disorders.
The good news is that there are established treatments that work for BED. Unfortunately, effective psychological interventions for eating disorders don’t get as much press as pharmaceuticals. Nevertheless, those suffering from BED should be aware of what is available.
Treatment for Binge Eating Disorder
Evidence-based psychological treatments are first-line considerations for the treatment of BED. A psychologist or other mental health professional qualified to treat eating disorders usually conducts psychological treatment for BED on an outpatient basis. Cognitive behavioral therapy (CBT) is the most well studied and established treatment for BED with demonstrated effectiveness.6 The treatment involves reducing episodes of binge eating using tools such as establishing regular eating patterns and self-monitoring of food intake and patterns of eating. CBT also addresses concerns about shape and weight, and examines and challenges patterns of thinking that may be keeping a person stuck in a pattern of binge eating. CBT for BED involves discussion and planning of how to maintain progress, and how to recognize and respond to relapse. Studies have demonstrated improvements lasting up to 12 months post-treatment with CBT.7 Interpersonal therapy (IPT) has also been proven effective for BED with strong research support.8 IPT involves more of a focus on interpersonal (relationship) difficulties with an understanding of how these problems may have precipitated BED, or how they might be keeping the BED going. Finally, there is evidence that dialectical behavior therapy (DBT), which focuses on mindfulness, emotion regulation, and distress tolerance, is effective at treating BED.9
Pharmacological Treatments for Binge Eating Disorder
In addition to psychological treatments, antidepressants and anticonvulsants have proven helpful at reducing the frequency of binge eating in patients with BED.6 The newest and only medication specifically approved by the FDA for BED is Vyvanse, a central nervous system stimulant that has been approved to treat ADHD in children and adults since 2007. The approval for BED came after clinical trials demonstrated that the average number of binge eating days per week among sufferers were decreased in those who took Vyvanse, compared to those who took a placebo.10 Sounds promising…but there are other considerations to keep in mind…side effects, long-term use, and the question of whether a medication can address the complex nature of a serious eating disorder such as BED.
The potential side effects of Vyvanse include decreased appetite, dry mouth, increased heart rate or blood pressure, difficulty sleeping, anxiety, gastrointestinal problems, feeling jittery, and even sudden death among people with heart problems. The drug is also particularly risky for individuals with a history of seizures or mania. Vyvanse may cause psychotic or manic symptoms in people with no history of mental illness, and has a high potential for abuse, dependence, tolerance, and overdose.
Vyvanse appears to decrease symptoms over a short period of time (about three months) while taking the medication. However, it is unlikely that the medication will result in long-term changes in complex binge eating behavior once the drug is stopped, meaning that one might expect to take Vyvanse for the rest of their lives in order to keep BED at bay. This is problematic considering the chronic nature of BED, 2 and the fact that the negative emotion, distress, shame, and weight or shape concerns that are often related to BED would almost certainly remain unaddressed.
While there are no identified side effects to engaging in psychological treatment of BED, these treatments do take time (often around 20 weeks), and not every person will respond to an intervention the same way. It may take some trial and error to find the right therapist or treatment. However, psychological treatments are more equipped than medication alone to address the binge eating behavior itself, and the different ways binge eating relates to other areas of a person’s life and functioning. Rather than simply masking and reducing symptoms in the short term with a medication, completing a course of evidence-based therapy can provide the insight and tools needed for managing the patterns of disordered eating that are characteristic of BED for life. Many people with BED may benefit from trying a psychological approach before initiating treatment with a serious medication like Vyvanse.
Implications for Patients
All of these factors should be carefully considered when making a decision about treatment for BED. With all eating disorders including BED, it is important to get help sooner rather than later. For many people, turning to their primary care doctor is the first step. Patients should keep in mind that these conversations can be sensitive and difficult, and many providers may not be familiar with BED. Other providers may be familiar with the recent approval of a new drug, and will be eager to explore prescription medication options for treatment.
If you aren’t getting anywhere with your doctor, it is always appropriate to ask for a referral to a medical provider who is more familiar with eating disorders. Your doctor may also be able to provide you with a referral to a mental health provider, such as a psychologist, who can provide one of the therapies discussed above, and to a nutritionist or dietician who specializes in eating disorders for even more comprehensive support. Remember that it is important to seek help from professionals qualified to treat eating disorders, and treatment decisions should be tailored to the unique needs of each person.
1. American Psychiatric Association. (2013). The Diagnostic and Statistical Manual of Mental Disorders: DSM 5. bookpointUS.
2. Hudson, J. I., Hiripi, E., Pope Jr, H. G., & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological psychiatry, 61(3), 348-358.
3. Swanson, S. A., Crow, S. J., Le Grange, D., Swendsen, J., & Merikangas, K. R. (2011). Prevalence and correlates of eating disorders in adolescents: Results from the national comorbidity survey replication adolescent supplement. Archives of General Psychiatry, 68(7), 714-723.
4. Marcus, M. D., & Levine, M. D. (2005). Obese patients with binge-eating disorder. In The management of eating disorders and obesity (pp. 143-160). Humana Press.
5. Kalarchian, M. A., Marcus, M. D., Levine, M. D., Courcoulas, A. P., Pilkonis, P. A., Ringham, R. M., … & Rofey, D. L. (2007). Psychiatric disorders among bariatric surgery candidates: relationship to obesity and functional health status. The American journal of psychiatry, 164(2), 328-334.
6. Brownley, K. A., Berkman, N. D., Sedway, J. A., Lohr, K. N., & Bulik, C. M. (2007). Binge eating disorder treatment: a systematic review of randomized controlled trials. International Journal of Eating Disorders, 40(4), 337-348.
7. Wilson, G. T., Grilo, C. M., & Vitousek, K. M. (2007). Psychological treatment of eating disorders. American Psychologist, 62(3), 199.
8. Wilfley, D. E., Welch, R. R., Stein, R. I., Spurrell, E. B., Cohen, L. R., Saelens, B. E., … & Matt, G. E. (2002). A randomized comparison of group cognitive-behavioral therapy and group interpersonal psychotherapy for the treatment of overweight individuals with binge-eating disorder. Archives of general psychiatry, 59(8), 713-721.
9. Telch, C. F., Agras, W. S., & Linehan, M. M. (2001). Dialectical behavior therapy for binge eating disorder. Journal of consulting and clinical psychology, 69(6), 1061.
10. McElroy S. L., Hudson, J. I., Mitchell, J. E., et al. (2014) Efficacy and Safety of Lisdexamfetamine for Treatment of Adults With Moderate to Severe Binge-Eating Disorder: A Randomized Clinical Trial. JAMA Psychiatry.
Elisha Carcieri, Ph.D., is a licensed clinical psychologist (PSY #26716) practicing in the Los Angeles area. Dr. Carcieri earned her bachelors degree in psychology from The University of New Mexico and completed her doctoral degree in clinical psychology at Saint Louis University. During her graduate training, she conducted research focused on eating disorders and obesity, and was trained in using cognitive behavioral therapy (CBT) for eating disorders and other mental health disorders such as anxiety and depression. Dr. Carcieri completed her postdoctoral fellowship at the Long Beach VA Medical Center, where she worked with Veterans coping with mental illness, disability, significant acute or chronic health concerns, and chronic pain. In addition to cognitive behavioral strategies, she also incorporates alternative evidence-based approaches such as mindfulness, and acceptance and commitment-based strategies, depending on the needs of each client. Dr. Carcieri has experience working with culturally diverse clients representing various aspects of diversity including race/ethnicity, gender, age, disability, and size, and welcomes new clients from all backgrounds. She is a member of the American Psychological Association (APA), the Academy for Eating Disorders (AED), and the Los Angeles County Psychological Association (LACPA).